Pediatric_Quick_Notes_full-1.pdf

Pediatric Quick Notes Table of Contents 1 PEDIATRIC CARDIOLOGY..................................................................................................................................5 1.1 Atrial Septal Defect.......................................................................................................................................5 1.2 Coarctation of the Aorta................................................................................................................................ 5 1.3 Patent Ductus Arteriosus.............................................................................................................................. 6 1.4 Tetralogy of Fallot.........................................................................................................................................6 1.5 Transposition of the Great Vessels...............................................................................................................6 1.6 Ventricular Septal Defect.............................................................................................................................. 7 2 PEDIATRIC PULMONOLOGY.............................................................................................................................. 8 2.1 Acute Bronchiolitis........................................................................................................................................8 2.2 Acute Epiglottitis...........................................................................................................................................8 2.3 Croup............................................................................................................................................................9 2.4 Pneumonia...................................................................................................................................................9 2.5 Respiratory Syncytial Virus......................................................................................................................... 11 2.6 Asthma....................................................................................................................................................... 11 2.7 Cystic Fibrosis............................................................................................................................................ 13 2.8 Neonatal Respiratory Distress Syndrome (Hyaline Membrane Disease).................................................... 14 2.9 Foreign Body Aspiration............................................................................................................................. 15 3 PEDIATRIC ENDOCRINOLOGY........................................................................................................................ 16 3.1 Dwarfism..................................................................................................................................................... 16 3.2 Type I Diabetes Mellitus............................................................................................................................. 16 3.3 Type II Diabetes Mellitus............................................................................................................................ 17 3.4 Obesity....................................................................................................................................................... 17 4 PEDIATRIC EENT............................................................................................................................................... 19 4.1 Conjunctivitis.............................................................................................................................................. 19 4.2 Dacryoadenitis............................................................................................................................................ 19 4.3 Strabismus (Tropia).................................................................................................................................... 20 4.4 Otitis Media................................................................................................................................................. 20 4.5 Otitis Externa.............................................................................................................................................. 21 4.6 Oral Candidiasis......................................................................................................................................... 21 4.7 Nasal Polyps............................................................................................................................................... 22 4.8 Pharyngitis & Tonsillitis............................................................................................................................... 23 4.9 Dental Caries.............................................................................................................................................. 26 5 Pediatric GI.......................................................................................................................................................... 27 5.1 Gastritis...................................................................................................................................................... 27 5.2 Pyloric Stenosis.......................................................................................................................................... 27 5.3 Constipation................................................................................................................................................ 27 5.4 Intussusception........................................................................................................................................... 30 5.5 Umbilical Hernia......................................................................................................................................... 31 5.6 Childhood Nutritional Deficiencies.............................................................................................................. 31 5.7 Phenylketonuria.......................................................................................................................................... 32 Page 2 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes 5.8 Lactose Intolerance.................................................................................................................................... 33 5.9 Abdominal Pain.......................................................................................................................................... 33 5.10 Acute Abdominal Pain................................................................................................................................ 35 5.11 Diarrhea...................................................................................................................................................... 39 5.12 Hyperbilirubinemia...................................................................................................................................... 42 6 PEDIATRIC GU................................................................................................................................................... 43 6.1 Cryptorchidism............................................................................................................................................ 43 6.2 Cystitis........................................................................................................................................................ 44 6.3 Orchitis....................................................................................................................................................... 45 6.4 Wilms Tumor.............................................................................................................................................. 45 6.5 Male Circumcision...................................................................................................................................... 45 6.6 Vesicoureteral Reflux.................................................................................................................................. 46 6.7 Vaginitis...................................................................................................................................................... 46 6.8 Dysmenorrhea............................................................................................................................................ 47 6.9 Amenorrhea................................................................................................................................................ 47 7 PEDIATRIC MSK................................................................................................................................................ 49 7.1 Nursemaid’s Elbow (Radial Head Subluxation).......................................................................................... 49 7.2 Slipped Capital Femoral Epiphysis............................................................................................................. 49 7.3 Osteosarcoma............................................................................................................................................ 50 7.4 Juvenile Rheumatoid Arthritis..................................................................................................................... 51 7.5 Osgood-Schlatter Disease.......................................................................................................................... 54 7.6 Scoliosis..................................................................................................................................................... 54 7.7 Pediatric Fractures...................................................................................................................................... 55 8 PEDIATRIC NEUROLOGY................................................................................................................................. 60 8.1 Febrile Seizures.......................................................................................................................................... 60 8.2 Cerebral Palsy............................................................................................................................................ 61 8.3 Headache................................................................................................................................................... 62 8.4 Migraine Headaches................................................................................................................................... 63 8.5 Tension Headaches.................................................................................................................................... 63 8.6 Cluster Headaches..................................................................................................................................... 64 9 PEDIATRIC PSYCHIATRY................................................................................................................................. 65 9.1 ADHD......................................................................................................................................................... 65 9.2 Autism......................................................................................................................................................... 66 9.3 Eating Disorders......................................................................................................................................... 67 9.4 Adjustment Disorder................................................................................................................................... 68 9.5 Child Abuse................................................................................................................................................ 68 10 PEDIATRIC DERMATOLOGY............................................................................................................................ 70 10.1 Dermatitis................................................................................................................................................... 70 10.2 Childhood Exanthems................................................................................................................................. 71 10.3 Dermatophytoses....................................................................................................................................... 74 10.4 Acne Vulgaris............................................................................................................................................. 80 10.5 Molluscum Contagiosum............................................................................................................................ 80 Simplenursing.com 82% or Higher on Your Next Nursing Test Page 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Pediatric Quick Notes 10.6 Verrucae..................................................................................................................................................... 81 10.7 Impetigo...................................................................................................................................................... 81 10.8 Lice............................................................................................................................................................. 82 11 PEDIATRIC HEMATOLOGY............................................................................................................................... 83 11.1 Sickle Cell Anemia...................................................................................................................................... 83 11.2 Acute Lymphocytic Leukemia..................................................................................................................... 84 12 PEDIATRIC INFECTIOUS DISEASE.................................................................................................................. 85 12.1 Diphtheria................................................................................................................................................... 85 12.2 Pinworms.................................................................................................................................................... 85 12.3 Mumps........................................................................................................................................................ 86 12.4 Pertussis..................................................................................................................................................... 86 13 Pediatrics Exam Notes........................................................................................................................................ 87 13.1 The Newborn Infant.................................................................................................................................... 87 13.2 Pediatric Oral Health................................................................................................................................... 91 13.3 Pediatric Physical Exam & Health Maintenance Exams............................................................................. 94 13.4 Immunizations............................................................................................................................................ 98 13.5 Child Development................................................................................................................................... 101 13.6 Common Behavior Problems.................................................................................................................... 105 13.7 Pediatric Nutrition..................................................................................................................................... 107 13.8 Lactation Overview................................................................................................................................... 108 13.9 Childhood Obesity.................................................................................................................................... 110 13.10 Adolescent Medicine........................................................................................................................ 112 13.11 Sports Pre-Participation Physical..................................................................................................... 115 13.12 Pediatric Fever................................................................................................................................. 118 13.13 Pediatric UTI.................................................................................................................................... 119 14 Pediatrics Exam II TRP..................................................................................................................................... 122 14.1 ADHD....................................................................................................................................................... 122 14.2 Pediatric Imaging...................................................................................................................................... 124 14.3 Pediatric Asthma...................................................................................................................................... 128 14.4 Pediatric Snoring and Obstructive Sleep Apnea....................................................................................... 130 14.5 Pediatric GI Problems............................................................................................................................... 131 14.6 Pediatric Labs........................................................................................................................................... 133 14.7 Medical Evaluation for Child Abuse and Neglect...................................................................................... 135 14.8 Pediatric Infectious Disease..................................................................................................................... 138 14.9 Autism....................................................................................................................................................... 148 14.10 The Allergic Child............................................................................................................................. 151 14.11 Dehydration...................................................................................................................................... 154 14.12 Heart Disease in Childhood............................................................................................................. 156 14.13 Pediatric Pharmacology................................................................................................................... 163 14.14 Pediatric Hematology....................................................................................................................... 165 14.15 Pediatric Oncology........................................................................................................................... 169 14.16 Common Pediatric Musculoskeletal Disorders................................................................................. 173 Page 4 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes 1 PEDIATRIC CARDIOLOGY  Acyanotic = left-to-right  Cyanotic = right-to-left NOTE: All left-to-right shunts have the potential to revert to right-to-left shunts due to increasing pulmonary congestion (Eisenmenger’s syndrome). Investigation of suspected heart defect  Most cases are diagnosed prenatally by US screening @ 16-20 weeks  Some defects don’t emerge until several days or weeks have passed since birth due to transition of circulation → adult levels of pulmonary vascular resistance  Neonate will usually have symptoms within 24 hours 1.1 Atrial Septal Defect  Acyanotic Signs & symptoms  May be asymptomatic unless there are other defects  R heart failure  Pulmonary edema  Increased pulmonary vasculature  Midsystolic pulmonary flow or ejection murmur accompanied by a fixed split S2 Management  Refer to pediatric cards for echo  Surgical repair at age 2-3 for most  Small defects in boys don’t need closure if RV size is normal. 1.2 Coarctation of the Aorta  Obstructive Signs & symptoms  Poor perfusion to LEs → diminished femoral pulses, cyanosis, cardiogenic shock, cold extremities, claudication  Association with Turner’s syndrome, Shone’s syndrome, and bicuspid aortic valve Workup  Measure BPs on all 4 extremities → HTN in UEs with low or unattainable BP in LEs  Refer for echo Management  Reopen truncus arteriosus within 4 days of birth with prostaglandins Simplenursing.com 82% or Higher on Your Next Nursing Test Page 5 of 177 © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes 1.3 Patent Ductus Arteriosus  Acyanotic Signs & symptoms  Harsh continuous machine murmur  Usually asymptomatic  May have exertional dyspnea or heart failure Management  Refer to pediatric cards for echo and for meds to make ductal tissue regress or surgical repair 1.4 Tetralogy of Fallot  The most common cyanotic heart defect  Pulmonary stenosis → RV hypertrophy, overriding aorta, VSD  VSD may be right-to-left or left-to-right Signs & symptoms  Progressive  May appear healthy and pink at birth  Cyanotic “tet spells” where child turns blue, squats to valsalva  Harsh systolic ejection murmur  May also have right aortic arch, Down’s or DeGeorge’s syndrome Management  Surgical correction in early infancy Complications  Brain abscess  Stroke  CNS injury 1.5 Transposition of the Great Vessels  Cyanotic  Aorta and pulmonary trunk are switched so that deoxygenated blood gets pumped through the aorta to systemic circulation while the oxygenated blood gets pumped through the pulmonary artery back through the lungs  Coexisting left-to-right shunt must also be present for life ex utero Signs & symptoms  Severe cyanosis at birth  Loud S2 Management  Requires arterial switch for long-term survival Page 6 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes 1.6 Ventricular Septal Defect  The most commonly diagnosed congenital heart defect  May be single or multiple  May be associated with other lesions Signs & symptoms  Holosystolic murmur  May have thrill or diastolic rumble  Heart failure  Down’s syndrome association Management  Most will get smaller and disappear on their own  Surgical repair indicated for intractable CHF, failure to thrive Simplenursing.com 82% or Higher on Your Next Nursing Test Page 7 of 177 © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes 2 PEDIATRIC PULMONOLOGY 2.1 Acute Bronchiolitis  Reserach definition = first episode of wheezing in a child younger than 12 to 24 months who has physical findings of a viral respiratory infection and has no other explanation for the wheezing, such as pneumonia or atopy  Broader definition = an illness in children 70 breaths/minute for infants; RR >50 RR that defines moderate to severe respiratory breaths/minute for older children distress Moderate/severe suprasternal, intercostal, or Mild or absent retractions subcostal retractions (=12 months) No nasal flaring Grunting Nasal flaring Apnea No apnea Significant shortness of breath Mild shortness of breath Normal color Cyanosis Normal mental status Altered mental status Normoxemia (oxygen saturation>=92 percent in Hypoxemia (sustained oxygen saturation 5 years → macrolide, doxycycline  F/u outpatient treatment in 24-48 hours Sequelae  Postinfectious cough for up to 4 months  Moderate DOE for 2-3 months Page 10 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes 2.5 Respiratory Syncytial Virus Highly contagious, transmitted via aerosols or fomites  The most common cause of fatal acute respiratory infections in infants and young children  Causes a spectrum of disease from URTs, LRTs, pneumonia  Most serious disease is in preemies, chronic lung disease, heart defects, asthma, immunocompromised, and the elderly. Management  Supportive  May need hospitalization with fluid and respiratory support  Albuterol trial  Steroids only in older kids, not infants  Ribavirin for select infants 2.6 Asthma Signs & symptoms  Coughing  Wheezing  Chest tightness or pain  SOB  Eczema  Allergies Differential  Anatomic abnormality  Infection  Foreign body  Cystic fibrosis: more likely to see digital clubbing  GERD  Pulmonary edema  Laryngeal dysfunction  Bronchopulmonary dysplasia Workup  PFTs are most useful but can’t usually get good data until age 7-8, and may look normal despite having asthma Management  Patient education: use of spacer, shaking canister, home monitoring, prevention or environment control  SaȕAs: albuterol, levalbuterol  LaȕAs: salmeterol, formoterol  Inhaled steroids: beclomethasone (required trial for Medicaid), fluticasone, budesonide, mometasone, ciclesonide, triamcinolone, flunisolide  Anticholinergics aren’t as helpful in kids  Mast cell stabilizers: cromolyn, nedocromil  Leukotriene inhibitors: montelukast, zileuton, zafirlukast Simplenursing.com 82% or Higher on Your Next Nursing Test Page 11 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes  Refer for acute life-threatening attack, mod-severe asthma, steroid-dependent asthma, complicated asthma, poor response to optimal therapy PCP treatment for pediatric acute exacerbation  Assess severity using Pulmonary Index Score  Mild: SaßA neb up to 3 doses, with oral steroids given after 1st dose if no improvement. st  Moderate oxygen if needed, SaßA + ipratropium neb up to 3 doses, with oral steroids after 1 dose  Systemic steroids: 3-5 days for mild-mod flare, 5 days with taper for mod-severe flare. Follow-up visits  Inquire about missed days of school, # urgent  care or ER visits, # of hospitalizations, days per week with symptoms  Ask about triggers Pediatric Meds: Ages 0-4 Pediatric Meds: Ages 5-11 Page 12 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes 2.7 Cystic Fibrosis  Autosomal recessive inherited defect of protein regulating chloride channels, bicarb, and other ions (CFTR protein) → defective mucociliary clearance → mucus obstruction, inflammation, infection, and fibrosis  Also affects the pancreas and vas deferens  Most commonly affects Caucasians Signs & symptoms  Will be on a continuum depending on % of normal CFTR functioning  No known abnormalities until there is < 10% normally functioning CFTR proteins; < 10% → absence of vas deferens, < 5% → sweat abnormality, < 4.5% → progressive pulmonary infections, < 1% → pancreatic deficiency  Recurrent pulmonary infections with atypical bacteria (Staph aureus in infancy and Pseudomonas in adulthood), poorly controlled asthma, failure to thrive, meconium ileus, pancreatitis, vitamin deficiencies, nasal polyps, sinusitis, fatty liver, liver fibrosis, portal HTN, gallstones, jaundice, osteoporosis or frequent fractures from vit D deficiency, rectal prolapse from thick stools, intestinal strictures, appendicitis, GERD, infertility, delayed puberty, smooth muscle growth around bronchioles, respiratory symptoms, diabetes, enlarged or deficient spleen  Acute exacerbation (will be bronchial rather than pneumonia): increased cough of sputum, sputum color change, dyspnea, fatigue, decreased exercise tolerance, poor appetite, new tachypnea, retractions, wheezing, rhonchi, weight loss, fever, new findings on CXR, PFTs, hypoxia. Simplenursing.com 82% or Higher on Your Next Nursing Test Page 13 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes Workup  Newborn screens detect only severe disease  Genetic screens of 23 most common mutations only identify CF in Caucasians  Buccal DNA swab for other mutations  Sweat chloride test is confirmatory Management  Dietary support: higher BMI associated with better lung functioning, need high caloric intake to combat malabsorption, salt supplements, pancreatic lipase supplements, fat-soluble vitamin supplements  Promote mucus clearance: percussion and chest compression vests, upside-down coughing, huff breathing, oral oscillators, exercise, CPAP, saline mist, albuterol  Infection control: cyclic use of antibiotics against Pseudomonas, intermittent IV antibiotics, oral antibiotics for 2-3 weeks after exacerbation  Frequent office visits with PFTs, sputum culture, diabetes screens, bone densitometry, CBC, PT/PTT, UA, vitamin levels, LFTs, albumin, immunizations Prognosis  Lung function declines at about 2% per year, but this will speed up with increasing exacerbations  Patients are unable to return to previous baseline with each exacerbation  Median survival age is 38 2.8 Neonatal Respiratory Distress Syndrome (Hyaline Membrane Disease)  A result of surfactant deficiency → alveolar collapse and diffuse atelectasis  Typically occurs in preterm infants Prevention  Antenatal glucocorticoid treatment for women at risk for preterm delivery prior to 34 weeks of gestation  If gestation is greater than 30 weeks, the fetal lung maturity may be tested by sampling the amount of surfactant in the amniotic fluid by amniocentesis Signs & symptoms  Respiratory distress and cyanosis soon after birth  Tachypnea  Tachycardia  Chest wall retractions  Abdominal breathing Workup  CXR showing diffuse ground glass appearance with air bronchogram Management  Inpatient with fluid balance, CPAP, exogenous surfactant Page 14 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes 2.9 Foreign Body Aspiration  Most common site is the right lung, followed by left lung, trachea/carina, and larynx Signs & symptoms  Choking episode followed by symptom-free period  Respiratory distress  Cyanosis  AMS  Generalized wheezing  Coughing  Recurrent pneumonia  Diminished breath sounds Workup  Send to ED for bronchoscopy if severe symptoms  CXR is problematic because most swallowed objects are radiolucent. Simplenursing.com 82% or Higher on Your Next Nursing Test Page 15 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes 3 PEDIATRIC ENDOCRINOLOGY 3.1 Dwarfism Etiologies  Achondroplasia: most common, genetic  Growth hormone deficiency: will see delayed puberty  Others:congenital dysplasias, Noonan syndrome, Tuner syndrome, osteogenesis imperfecta, hypothyroidism Workup  Bone x-rays  Referral to endocrinology Workup  Bone x-rays  Referral to endocrinology Management  Growth or thyroid hormone supplementation  Distraction osteogenesis 3.2 Type I Diabetes Mellitus  Accounts for most cases of diabetes in kids under 19  Genetic and environmental influences Signs and symptoms  Polyuria  Polydipsia  Weight loss  Lethargy  DKA is often the initial presentation Workup  Differentiate from DM2 by islet autoantibody screen Management  Formal training and education using a diabetes team  Intensive insulin regimen  Address depression and anxiety  Annual urine microalbumin  Ophtho visits at age 10 or after 3-5 years of diagnosis  Lipid screens  Periodic autoimmune thyroid and celiac screening Page 16 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes 3.3 Type II Diabetes Mellitus Screening  Universal not recommended by AAP nor ADA  Screen at risk children with BMI > 85th percentile and 2+ additional risk factors; screen every 3 years Signs & symptoms  DKA  Hyperglycemia without ketonuria  Polyuria  Polydipsia  Lethargy  Often occurs at onset of puberty as this causes increased insulin resistance Workup  Differentiate from DM1 by presence of excess weight, acanthosis nigricans, HTN, dyslipidemia, PCOS, FH, ethnic group risk factors Management  Treat comorbidities  If asymptomatic → lifestyle changes only with weight loss and increased activity; if no improvement → metformin  If symptomatic with mild hyperglycemia → metformin and lifestyle changes; if no improvement → add basal insulin  If severe → begin insulin then wean off to metformin  Screen for HTN, dyslipidemia, NAFLD  Annual ophtho visits  Annual microalbumin screens  Annual diabetic neuropathy screens 3.4 Obesity  Overweight = BMI 85-95th percentile  Obese = BMI > 95th percentile  Severe obesity = BMI > 120th percentile or BMI > 35  Genetic factors account for 30-50% of variation in adiposity  Endocrine causes account for < 1% of cases Environmental risk factors  High glycemic index foods  Sugar-contained beverages  Large portion sizes  Fast food  Diminished family presence at meals  Decreasing structured physical activity  Shortened sleep duration  Television viewing Simplenursing.com 82% or Higher on Your Next Nursing Test Page 17 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes Screening  BMI should be calculated annually for children older than 2, with plotting to track changes  Overweight children additionally should be screened for dyslipidemia, NAFLD (ALT); utility of insulin resistance screen or vitamin D deficiency screen has not been established Workup  Obesity ROS: delayed development, short stature, headaches, snoring, daytime sleepiness, abdominal pain, hip pain, knee pain, limp, oligomenorrhea or amenorrhea, urinary frequency, nocturia, polydipsia, polyuria, binge eating or purging, insomnia, anhedonia Management  Refer all obese children under 2 to a specialist  Treatment for underlying eating disorders  Firm limits on screen time  Establish habitual physical activity  Educational handouts Sequelae  Pseudotumor cerebri  Sleep apnea  Obesity hypoventilation syndrome  Liver disease  DM  PCOS  Slipped capital femoral epiphysis  Tibia vara Page 18 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes 4 PEDIATRIC EENT 4.1 Conjunctivitis Etiologies  Kids & adults: adenovirus, Strep pneumo, Haemophilus, Moraxella, Pseudomonas  Infant: think Neisseria gonorrhoeae or Chlamydia trachomatis  Allergic = conjunctivitis verno  Conjunctivitis sicca is chronic dry eye related to rheumatic disease  Hard to distinguish bacterial from viral, all etiologies can cause eyes to be stuck together in the morning  Bacterial tends to be consistently purulent throughout the day and is usually unilateral  Viral tends to feel more gritty and usually affects the 2nd eye 24-48 hours later  Allergic will be ITCHY = pathognomonic Workup  Culture if extremely purulent Treatment  All etiologies are usually self-limiting  Throw out contact lenses, wash sheets and hands, will be contagious for 2 weeks  Antibiotics → erythromycin ointment, sulfacetamide drops, FQ drops in contact lens wearers (Pseudomonas)  OTC antihistamine drops for viral causes → Ocuhist, Naphcon-A, Visine AC  Acute allergy → short-term antihistamine/vasoconstrictor drops like Naphcon-A, Opcon-A, Visine-A  Chronic allergy → antihistamine + mast cell stabilizer drops like Patanol or Pataday, Optivar, Alocril, Ketotifen, Alamast, Elestat  Severe allergy: lodoxamide or cromolyn drops  If no response in 2 days or need for steroid drops refer to ophtho 4.2 Dacryoadenitis  Blocked lacrimal glands Etiologies  Viral: EBV  Bacterial: mumps, Staph, gonorrhea  Chronic: sarcoidosis, thyroid eye disease, orbital pseudotumor Signs & symptoms  Swelling of upper lid  Lid redness & erythema  Lid pain  Excess tearing or discharge  Swelling of preauricular nodes Simplenursing.com 82% or Higher on Your Next Nursing Test Page 19 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes Management  Warm compresses  Think malignancy if no improvement 4.3 Strabismus (Tropia) Etiologies  Congenital: pseudostrabismus, prenatal drug exposure, nerve palsy, familial external ophthalmoplegia  Acquired: accommodative strabismus, intermittent exotropia, cataracts, tumors, increased ICP, orbital injury, head trauma, vascular disorders, botulism, myasthenia gravis, nerve palsy, Guillain- Barre, ocular myopathy, multiple sclerosis, infection, drug or toxin, DM, hypoglycemia, thyrotoxicosis Differential  Pseudostrabismus  Ocular instability of infancy (normal in first few months of life) Workup  Affected eye will drift when covered, then moves quickly back if cover is removed  Differentiate congenital from acquired (may be vision-threatening or life-threatening) Management  Refer to ophtho for consistent strabismus at any age, persistent strabismus after 4 months of age, altered light reflex, deviation with cover test, deviation that changes depending on position of gaze, torticollis, parental concern Sequelae  If untreated may lead to amblyopia (vision reduction) or diplopia 4.4 Otitis Media Acute OM  Agents: Strep, H. flu, M. cat, or viral (can’t distinguish)  Signs & symptoms: hearing loss is hallmark, ear pain, ear fullness, drainage with relief if ear drum is perforated, prior URI, pulling at ears, fever, irritability Chronic suppurative OM = frequent AOM with otorrhea as a result of TM perforation or tube placement OM with effusion = fluid behind TM without presence of infection, a result of chronic eustachian tube dysfunction, previous AOM, or barotrauma Page 20 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes Management  If mild, can watchfully wait with NSAIDs for pain relief as long as patient is > 2 years  If infection is obvious or there is a fever, treat with 10-14 d of high dose amoxicillin, erythromycin, Augmentin, Septra, ceftriaxone  Refer for surgical management if there is bilateral effusion > 3 months and bilateral hearing deficiency  Chronic → tx with 10 d of FQ, consider chronic therapy with daily amoxicillin during winter and spring with monthly f/u. 4.5 Otitis Externa Etiology  Bacterial 90% of the time: Pseudomonas, Strep, Staph  Fungal: Aspergillus, Actinomyces, Candida  Eczema if chronic  Malignant otitis externa = osteomyelitis of temporal bone as a result of chronic infection in DM, not cancerous! Signs & symptoms: pain with manipulation of tragus, hearing loss, otorrhea, fullness, itching, recent exposure to water. Management  Bacterial → neo/poly/HC only if TM intact, FQ (use a wick if canal is swollen), systemic therapy if canal is swollen shut or pt is immunocompromised  Fungal → acetic acid/HC drops, clotrimazole drops  Bacterial vs fungal? → CASH powder covers both  Chronic → treat eczema with steroid cream, then use vinegar/water washes and avoid Q-tips  Malignant → emergent referral to ENT 4.6 Oral Candidiasis  Risk factors: inhaled steroid use, AIDS, antibiotic use, radiation therapy Signs & symptoms  Pseudomembranous form is most common: white plaques  Angular cheilitis with chronic lip-lickers  Glossitis with broad spectrum antibiotic use  Cottony feeling in mouth  Loss of taste  Pain with eating and swallowing  May be asymptomatic Workup  KOH prep of mouth scrapings Treatment  Infants: oral nystatin swabs for 7-14 days, boiling of bottle nipples and pacifiers  Older children: oral nystatin rinses or systemic fluconazole if severe Allergic Rhinitis  Typically does not occur in infants under 6 mos  Seasonal or perennial Simplenursing.com 82% or Higher on Your Next Nursing Test Page 21 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes  Samter’s triad = syndrome of aspirin sensitivity, nasal polyposis, and asthma often seen with allergic rhinitis, frequently leading to severe pansinusitis Signs & symptoms: repetitive sneezing, pruritus of nose, eyes, palate, ears, clear rhinorrhea, nasal congestion, postnasal drip, epistaxis, allergic shiners, Dennie’s lines, allergic salute, retracted TMs, serous effusions, swollen or boggy turbinates, hyperplasia of palate or posterior pharynx Differential: sinusitis, rhinitis medicamentosa (Afrin!), polyps, deviated septum, adenoid hypertrophy, FB, vasomotor rhinitis Management  Instruct patients in allergen avoidance: closed windows, bed cases, washing linens weekly, removing stuffed animals, cockroach poison, mold precautions, HEPA filters  Nasal saline sprays or rinses  Oral decongestants  Nasal steroids: fluticasone, flunisolide  1st or 2nd gen antihistamines: cetirizine and fexofenadine ok for infants > 6 mo  Leukotriene inhibitor  Refer to allergist for kids with mod-severe disease, prolonged rhinitis despite intervention, coexisting asthma or nasal polyps, recurrent otitis media orsinusitis 4.7 Nasal Polyps Etiologies  Usually a reaction to bacterial infection in kids  Allergies  Chronic sinusitis Signs & symptoms  Stuffiness  Feelings of pressure or fullness in the face  Trouble smelling Management  Steroid nasal spray  Saline rinses  Refer for surgical excision but may recur Page 22 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes 4.8 Pharyngitis & Tonsillitis Simplenursing.com 82% or Higher on Your Next Nursing Test Page 23 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes 4.8.1 Viral Pharyngitis Agents  Adenovirus, coronavirus, rhinovirus,influenza, parainfluenza, Coxsackie Signs & symptoms  Concurrent rhinorrhea  Erythema, edema, dysphagia, pain, fever, lymphadenopathy, diffusely pink throat, cough, fever Treatment  Salt water gargles  Lozenges or hard candy for kids over 4  Acetaminophen or ibuprofen  Oral rinse with equal parts lidocaine, diphenhydramine, and Maalox  Benzydamine HCl mouth rinse 4.8.2 Strep Pharyngitis Agents  GAS Signs & symptoms  Uncommon in kidsunder 2-3  Sore throat, dysphagia, odynophagia, erythema, airway obstruction, brightbeefy red demarcated splotches  Centor criteria: tender cervical adenopathy, fever > 100.4, no cough, tonsillar exudate  Abdominal pain and vomiting in peds Workup  Distinguish from viral by rapid Strep test ± culture Treatment  Penicillin VK  Cephalosporin  Erythromycin: increasing macrolide resistance 4.8.3 Acute Tonsillitis Agents  Viral (can be mono) or bacterial (usually GAS) Signs & symptoms  Swollen tonsils with white plaques Workup  Rapid Strep  Monospot Treatment  Antibiotics Page 24 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes 4.8.4 Peritonsillar Abscess Signs & symptoms  May follow tonsillitis  Bulging, asymmetrical soft palate, hot potato voice, severe throat pain, dysphagia, trismus, deviated uvula, salivation, fever, severe malaise Treatment  Urgent referral to ENT for I&D 4.8.5 Mononucleosis Agents  EBV or CMV Signs & symptoms  Fatigue, malaise,sore throat with tonsillar edema, erythema, and shaggy white-purple tonsillar exudate, lymphadenopathy, hepatosplenomegaly  Many will have 2° Strep tonsillitis Workup  Monospot (not + early in disease)  CBC to look for atypical lymphocytes Treatment  OTC pain control  ? steroids  Splenic precautions  Treat tonsillitis but avoid ampicillin due to rxn with mono → rash 4.8.6 Fusobacterium Pharyngitis Agents  Fusobacterium necrophorum Signs & symptoms  Adolescents  Severe pharyngitis  Cervical adenopathy  Headache  May have fever  Unilateral neck pain or swollen neck Workup  Very high CRP  ↑ WBCs with leukocytocis Treatment  Treat to avoid Lemierre’s syndrome (septic emboli thrown from internal jugular) with penicillin + clindamycin Simplenursing.com 82% or Higher on Your Next Nursing Test Page 25 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes 4.9 Dental Caries Prevention  Early referral to dentist for kids with breast or bottle feeding > 12 months, frequent consumption of sugary beverages and snacks, prolonged use of sippy cups, use of bedtime bottles, use of liquid meds > 3 weeks, insufficient fluoride exposure, visible plaque on upper front teeth, enamel pits or defects, exposure to second-hand smoke  AAP recommends referral to dentist at age 1, Medicaid begins at age 3  Screen for plaque, white spots, and cavities as soon as first teeth erupt  Instruct parents to clean infant’s gums with soft cloth starting at birth, and to begin brushing teeth when they first appear twice per day  Fluoride varnish: providers in NC may apply from eruption of first teeth up to age 3  Stop pacifiers by age 3, thumb sucking by age 6 Signs & symptoms  Initial presentation is a white spot Page 26 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes 5 Pediatric GI 5.1 Gastritis Differential  H. pylori  Stress, severe illness, or major surgery  Caustic ingestion  Celiac disease  Drugs  Ethanol  Milk sensitivity  Eosinophilic gastroenteritis  Crohn’s disease  Other infection  GERD 5.2 Pyloric Stenosis  Typically in 3-6 week olds, usually firstborn males  Rare after 12 weeks Signs & symptoms  Projectile nonbilious vomiting  Ravenous hunger  Palpable pyloric olive  Poor weight gain  Visible peristaltic waves Workup  KUB showing “caterpillar sign” of distended, hypertrophic stomach  US showing thickened stomach muscle (preferred imaging) Management  Refer for surgical pyloromyotomy 5.3 Constipation ***Encopresis is managed similarly, only without the use of laxatives as long as constipation has been excluded as a cause  Usually begins with an acute episode of constipation then is self-perpetuating as kids may hold stool to avoid painful BMs or going at school → chronic rectal distension → increased threshold for conscious need to defecate Signs & symptoms  Encopresis  UTIs  Chronic abdominal pain  Poor appetite Simplenursing.com 82% or Higher on Your Next Nursing Test Page 27 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes  Lethargy  Rectal skin tags Differential  Imperforate anus  Hirschsprung disease repair  Crohn’s perianal disease  Psychogenic  Hypothyroidism  Tethered cord  Spina bifida  Anterior displacement of the anus  Intestinal pseudo-obstruction  Cystic fibrosis  Celiac  Lead intoxication  Botulism  Cow’s milk constipation Workup  Criteria: symptoms must be present for 1 month in toddlers and infants and 2 months in older children  Labs only for kids not responding to an intervention program Management  Initial disimpaction with enema or Golytely (or lactulose or sorbitol- containing juices in infants) followed by maintenance with Miralax (if > 2 years old, but safety has also been demonstrated in infants)  Adjust maintenance therapy to goal of 1 soft stool per day  “Rescue plan” to use stimulant laxative, enema, or suppository if there are signs of constipation recurrence  Behavioral modification with toileting regimen and bowel training → sit on toilet for 5-10 min after each meal, give sticker or game reward for each effort, record BMs and symptoms with log Rome III criteria for the diagnosis of functional constipation in children Infants and toddlers Children with development age 4 to 18 years At least two of the following present for at least one month At least two of the following present for at least two months Two or fewer defecations per week Two or fewer defecations per week At least one episode of incontinence after the acquisition of toileting skills At least one episode of fecal incontinence per week History of excessive stool retention History of retentive posturing or excessive volitional stool retention History of painful or hard bowel movements History of painful or hard bowel movements Presence of a large fecal mass in the rectum Presence of a large fecal mass in the rectum History of large-diameter stools that may obstruct the toilet History of large-diameter stools that may obstruct the toilet Page 28 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes Pediatric Laxative Dosing Osmotic and lubricant laxatives Laxative Dose Polyethylene glycol 3350 powder (Miralax®) 0.4 to 0.8 gm/kg/day (up to 1.5 gm/kg per day has been useful in some Children cases*) Adults 17 gm of powder per day, in 8 ounces of water Current clinical practice: Younger than: 0.5 to 1 teaspoon once daily 18 months 18 months to 2 to 3 teaspoons once daily 3 years Older than 3 years 2 to 4 teaspoons once daily Lactulose Children 1 mL/kg (up to adult dose), once or twice daily Adults 15 to 30 mL, once daily (maximum 60 mL/day) Sorbitol (syrup, 70 percent solution) 1 to 11 years old 1 mL/kg, once or twice daily 12 years to adults 15 to 30 mL, once or twice daily 1 to 3 mL/kg, once daily (Caution: Should not be used in individuals at Mineral oil risk for aspiration, including infants, neurologically impaired children, or patients with marked gastroesophageal reflu Magnesium hydroxide 1 to 2 mL/kg, once daily (milk of magnesia) Stimulant laxatives Laxative Dose Simplenursing.com 82% or Higher on Your Next Nursing Test Page 29 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes Senna (syrup, 8.8 mg sennosides/5 mL OR Tablets 8.6 mg sennosides/tab) 1 to 2 years old 1.25 to 2.5 mL, once or twice daily 2 to 6 years old 2.5 to 3.75 mL, once or twice daily 6 to 12 years old 5 to 7.5 mL (or 1 to 2 tabs), once or twice daily 12 years and older 1 to 2 tabs, once or twice daily Bisacodyl (10 mg suppositories OR 5 mg tablets) 2 to 12 years old 1/2 to 1 suppository (OR 1 to 2 tablets), once daily 12 years to adult 1 to 3 tablets (OR 1 suppository), once daily 5.4 Intussusception  The most common cause of intestinal obstruction in infants < 1 year  Most cases are between 6 months and 3 years of age  Can occur multiple times Etiologies  Idiopathic: most cases  Viral  Underlying condition: Meckel diverticulum Sings & symptoms  Periodic colicky abdominal pain  Vomiting  Bloody “currant jelly” stools  Palpable mass or “sausage” in RUQ  Lethargy Differential  Malignancy if child is over 3 Workup  Plain films showing SBO  US showing “pseudokidney sign” or “lasagna sign” (test of choice) Management  Refer for emergent reduction via enema or surgical repair Page 30 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes 5.5 Umbilical Hernia  Caused by open umbilical ring, which usually closes in all kids by 5 years but may be slower to close in black children  May interfere with feeding if it contains bowel  Rarely become incarcerated or strangulated in kids Management  Referral for surgical repair indicated when hernia is incarcerated, extremely large, or symptomatic 5.6 Childhood Nutritional Deficiencies -Supplements indicated for children from neglected or deprived environments, anorexia, inadequate appetite, lead poisoning, failure to thrive, limited sunlight exposure, with chronic disease affecting absorption and utilization of nutrients, who are trying to lose weight, or are on restrictive diets. 5.6.1 Vitamin Iron Screening  Hb routinely checked at 12 months, 3 years, annually in teen females, once in teen males  Screen at 15-18 months for high risk infants Signs of deficiency  Anemia  Impaired psychomotor or mental development  Susceptibility to infection  Decreased exercise capacity  Thrombosis Workup  Hb or CBC  Ferritin, Hb electrophoresis, B12, folate  FOBT  Celiac workup  IBD workup Recommendations  Iron supplements for preterm infants until 12 months  Iron-fortified infant formulas  No cow’s milk until 12 months  Supplement as needed with oral iron  Recheck CBC every 4 weeks during therapy 5.6.2 Vitamin D Screening  Screen kids with risk factors (premature, exclusively breast fed, vegetarian diet, high altitude, malabsorption) Simplenursing.com 82% or Higher on Your Next Nursing Test Page 31 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes Signs of deficiency Rickets  Osteomalacia Workup  25-OH vitamin D level Recommendations  At least 400-600 IU daily  Follow supplementation with laboratory testing 5.6.3 Calcium Screening  Ask about milk consumption at well child visits Signs of deficiency  Rickets  Susceptibility to fracture Workup  DEXA scan Recommendations  Whole milk from 1-2 years of age  Kids 1-3 need 700 mg of Ca (~2 cups of milk)  Kids 4-8 need 1000 mg of Ca (~2-3 cups of milk)  Kids 9-18 need 1300 mg of Ca (~3+ cups of milk)  Decrease soda intake (P in it associated with bone fx)  Other sources: white beans, broccoli, fortified OJ, salmon, sweet potatoes  Calcium in spinach is not bioavailable! 5.7 Phenylketonuria  Autosomal recessive disorder  Screened for in newborn metabolic screening  From defective conversion of phenylalanine to tyrosine  Phenylalanine is found in breast milk and standard formulas Signs & symptoms  Intellectual disability  Epilepsy  Abnormal gait, posture, or stance  “Mousy” urine or body odor  Eczematous rash Differential  BH4 deficiency Workup  Elevated serum phenylalanine Page 32 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes Management  Dietary restriction  Frequent phenylalanine and tyrosine monitoring 5.8 Lactose Intolerance  May be primary or secondary due to bacterial overgrowth, enteritis, Celiac disease, IBD, etc.  High prevalence among Native Americans, patients of African descent, and Hispanics Signs & symptoms  Abdominal pain, bloating, farts, diarrhea, and possibly vomiting after ingestion of lactose Management  Avoid milk and ice cream as they have the highest amount of lactose  Lactase supplementation (variable results)  Add Lactaid to milk and let sit overnight before drinking  Utilize yogurt or cheese for dietary calcium needs, or supplement 5.9 Abdominal Pain 5.9.1 Chronic Abdominal Pain = greater than 1-2 months duration  Most digestive tract pain is perceived in the midline, so any lateralizing is usually the gallbladder, kidney, ureter, ascending/descending colon, or ovary. Organic Etiologies Clinical clues Cause The further the pain from the umbilicus, the greater the Quadrant pain likelihood of organic disease Early morning pain, pain awakens at night Peptic origin Early satiety, nausea, sour breath, belching Peptic origin Crampy pain and/or bloating and/or intestinal gas related to meals, dairy products and foods containing dairy Lactose intolerance, giardiasis products Respiratory symptoms, such a chronic cough, wheezing, Gastroesophageal reflux laryngitis Infrequent stooling, incomplete evacuation, encopresis, mass in the left lower abdominal quadrant and hard stool Constipation in rectal vault, diet low in fiber and high in starches, abdominal distension Blood in stool Peptic origin or inflammatory bowel disease Fever, weight loss, no increase in height, joint Inflammation or an infectious disease process complaints and rash Self-induced purging behavior with or without weight loss Gastroesophageal reflux from an eating disorder Weight loss, restrictive eating behavior, and fecal mass Constipation from an eating disorder in left lower abdominal quadrant Medications such as antibiotics for acne Esophagitis Simplenursing.com 82% or Higher on Your Next Nursing Test Page 33 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes Pain with specific physical activity and primarily muscle Muscle strain tenderness on examination Cervical motion tenderness, adnexal tenderness, or Pelvic inflammatory disease, ovarian cyst, ectopic adnexal mass on pelvic pregnancy Functional Etiologies Functional dyspepsia (must include all of the following):  Within the preceding two months, at least weekly occurrence of:  Persistent or recurring pain or discomfort in the upper abdomen, and  No evidence of inflammatory, anatomic, metabolic, or neoplastic process to explain the symptoms, and  Pain or discomfort not relieved by defecation or associated with the onset of a change in stool frequency or form Irritable bowel syndrome (must include all of the following):  Abdominal discomfort or pain with>+2 of the following  Relieved with defecation, and/or  Onset associated with a change in frequency of stool, and/or  Onset associated with a change in form (appearance) of stool, and  No evidence of inflammatory, anatomic, metabolic, or neoplastic process to explain the symptoms Functional abdominal pain (must include all of the following):  Within the preceding two months, at least weekly occurrence of:  Episodic or continuous abdominal pain, and  Insufficient criteria for other functional gastrointestinal disorders, and  No evidence of inflammatory, anatomic, metabolic, or neoplastic process to explain the symptoms Childhood functional abdominal pain syndrome  Within the preceding two months, at least weekly occurrence of:  Childhood functional abdominal pain at least 25 percent of the time and >=1 of the following: o Some loss of daily functioning, and/or o Additional somatic symptoms such as headache, limb pain, or difficulty sleeping Abdominal migraine pain (must include all of the following):  Within the preceding 12 months, >=2 episodes of:  Paroxysmal episodes of intense, acute, periumbilical pain that lasts for >=1 hour, and  Intervening periods of usual health lasting weeks to months, and  The pain interferes with normal activities, and  The pain is associated with >=2 of the following: anorexia, nausea, headache, photophobia, pallor, and no evidence of inflammatory, anatomic, metabolic, or neoplastic process to explain the symptoms Management  Goal is to return to normal function vs. complete elimination of pain  Pain diaries  Biopsychosocial model of care receives higher satisfaction in this setting  Relaxation techniques Page 34 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes  Dietary changes: removing lactose or increasing fiber  Set plan for return to school (may begin part-time but homeschooling is discouraged)  Medications for pain triggers: acid, constipation, altered motility  Refer to GI for alarm symptoms of active or persistent bleeding, weight loss, early satiety with peptic symptoms, loss of appetite, persistent chest pain, persistent vomiting, or failure to improve with medical therapy. 5.10 Acute Abdominal Pain Differential Neonate 3 months - 2 years 2-5 years >5 years Colic Gastroenteritis Gastroenteritis Gastroenteritis Dietary protein allergy Viral illness Viral illness Viral illness Trauma (including inflicted Trauma (including Volvulus Appendicitis injury inflicted injury Necrotizing enterocolitis Incarcerated hernia Appendicitis Trauma Testicular torsion Intussusception Pharyngitis Constipation Adhesions Urinary tract infection Constipation Pharyngitis Pneumonia (lower lobe → Foreign body ingestion Urinary tract infection diaphragm irritation) Sickle cell syndrome Urinary tract infection: may also Pneumonia vasoocclusive crisis cause diarrhea Dietary protein allergy Intussusception Diabetic ketoacidosis Sickle cell syndrome vasoocclusive Tumor Foreign body ingestion crisis Sickle cell syndrome Hirschsprung disease Henoch Schönlein purpura vasoocclusive crisis Henoch Schönlein Adhesions Ovarian torsion purpura Hemolytic uremic Ovarian torsion Testicular torsion syndrome Intraabdominal Toxin Inflammatory bowel disease abscess Meckel's diverticulum Tumor Intraabdominal abscess Hepatitis Adhesions Ruptured ovarian cyst Hemolytic uremic Cholecystitis syndrome Hepatitis Pancreatitis Meckel's diverticulum Urolithiasis Toxin Hepatitis Primary bacterial Meckel's diverticulum peritonitis Perforated ulcer Simplenursing.com 82% or Higher on Your Next Nursing Test Page 35 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes Adhesions Hemolytic uremic syndrome Myocarditis, pericarditis Primary bacterial peritonitis Familial Mediterranean fever Abdominal migraine PE  Should be complete for CC of abdominal pain, including bimanual pelvic exam for sexually active females with lower abdominal pain  Tenderness to percussion, rebound tenderness, and involuntary guarding are often signs of peritoneal irritation Workup  Unnecessary for kids that are otherwise healthy, well-appearing, and have normal Pes  CBC with smear for infection and red cell morphology  Hct for bleeding  Liver enzymes and amylase for suspected hepatitis, cholecystitis, or pancreatitis  BMP for DKA  Urinalysis  Urine HCG for all menstruating females  Rapid Strep test  Imaging for kids with hx of trauma, peritoneal irritation signs, obstructive signs, masses, distension, or focal tenderness or pain (for pediatric appendicitis, consult with pediatric surgeon before ordering imaging) → abdominal film for obstruction, upper GI series with contrast for volvulus, US or contrast enema for intussusception, CT with contrast when a wide variety of dx are being considered, US or non-contrast helical CT for urolithiasis Page 36 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes Acute abdominal pain: males and premenarchal females Simplenursing.com 82% or Higher on Your Next Nursing Test Page 37 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes Acute abdominal pain in postmenarchal girls Management  Pain control with morphine is shown to not affect exam results  Rule out life-threatening etiologies Page 38 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes 5.11 Diarrhea 5.11.1 Chronic = persistent loose or watery stools at least 3x per day for > 2 weeks  In developing countries this is more likely to be due to serial enteric infections and malnutrition  In developed countries this is more likely to be due to underlying disease causing malabsorption or maldigestion Etiologies  Functional diarrhea (aka toddler’s diarrhea) = painless passage of 3+ large unformed stools during waking hours for > 4 weeks without failure to thrive or a definable cause  Postenteritis syndrome: an uncommon sequelae of acute infectious diarrhea  Bacterial: occurs chronically in the immunocompromised as a result of Campylobacter or Salmonella infection, or from C. diff  Parasites: uncommon in developed countries  Immunodeficiency with subsequent opportunistic infection → chronic diarrhea with Crypto, Isospora, Cyclospora, rotavirus  Celiac  IBD  Allergic enteropathy: diarrhea as a result of cow’s milk proteins  Eosinophilic gastroenteritis: sometimes associated with an identifiable dietary antigen  Fat maldigestion: cystic fibrosis or pancreatic insufficiency  Bowel obstruction or dysmotility: Hirschsprung’s or intestinal pseudoobstruction  Congenital diarrhea  Neuroendocrine tumor: ZE syndrome, VIPoma, mastocytosis  Factitious diarrhea Red: life-threatening cause. Green: common cause. * Symptoms typically >1 month in duration. More likely in older children and adolescents. ∆ Only in infants ◊ More likely in infants and young children Simplenursing.com 82% or Higher on Your Next Nursing Test Page 39 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes Workup & Management  Self-limiting  Eliminate sorbitol and juice as the cause  Increase dietary fat  Probiotics  Bacterial cultures  Gluten avoidance 5.11.2 Acute Etiologies  Viral gastroenteritis: the most common cause of acute diarrhea  Extraintestinal infection (OM, UTI, pneumonia)  Antibiotics: amoxicillin  Overfeeding: causes osmotic diarrhea  Lactase deficiency: primary or secondary  Cryptosporidium: from contaminated drinking water  Toxin ingestion: from food bacteria or organophosphate poisoning Not Seriously Ill Page 40 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes Seriously Ill = bloody diarrhea or abdominal tenderness Red: life-threatening conditions. * More likely in older children and adolescents. More likely in infants and young children. Presentation  Dysenteric symptoms = fever, tenesmus, blood and/or pus in the stool  Mild dehydration = increased thirst, moist or slightly dry mucous membranes, normal tear and urine production  Moderate dehydration = irritability, lethargy, postural hypotension, sunken eyes and anterior fontanelle, decreased tear and urine production, decreased capillary refill  Severe dehydration = lethargy, rapid/weak pulse, marked hypotension with poor peripheral perfusion, dry mucous membranes, anuria or oliguria, absent tear production Workup  Ask about travel to a developing area, day care, pets and petting zoos, unsafe foods, swimming in or drinking fresh untreated surface water, knowing other ill people, medications, underlying medical conditions, and contact with reptiles  Stool culture: only order when results would affect treatment (recent travel, h/o blood or mucus in stool, systemically unwell, severe or prolonged diarrhea or with high suspicion of disease outbreak due to low yield Management  Admit for IVF resuscitation with mod-severe dehydration, circulatory compromise, significant electrolyte abnormalities, continuous copious diarrhea, or inability to drink  Oral rehydration solution: 50-100 mL/kg over 3-4 hours (starting with 1 tsp/hour and working up), then maintain as 10 mL for each loose stool, 2 mL for each emesis  Avoid antibiotics unless specific organism has been detected due to risk of HUS  Avoid antimotility agents in kids  May take 10-20 mg zinc for 10-14 days (can reduce severity and incidence of diarrheal episodes) Simplenursing.com 82% or Higher on Your Next Nursing Test Page 41 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes  May have single dose ondansetron for emesis  Back to normal diet ASAP or non-diluted formula 5.12 Hyperbilirubinemia  Jaundice is common in newborns since it is formed at high levels during this time and not cleared as well as in adults  Appearance of jaundice begins in the face and progresses to the chest, abdomen, arms, and then legs  Jaundice within first 24 hours of life is worrisome  Jaundice developing in 72-96 hours is physiologic and resolves in 1-2 weeks  “Breast milk jaundice” begins in the first week after birth, peaks at 2 weeks, and then declines; it is not dangerous and is probably due to the infant’s immature liver and intestines  Hyperbilirubinemia puts infant at increased risk for encephalopathy and kernicterus  Total bili values are compared in percentiles (Bhutani nomogram)  Major risk factors for infants >= 35 weeks’ gestation: predischarge total bili in the high risk zone, jaundice in first 24 hours, positive DAT or known hemolysis, gestational age 35-36 weeks, previous sibling received phototherapy, cephalohematoma or significant bruising, exclusive breastfeeding, East Asian race  Minor risk factors: predischarge total bili in the high intermediate risk zone, gestational age 37-38 weeks, jaundice observed before discharge, previous sibling with jaundice, macrosomic infant of diabetic mother, maternal age > 25 years, male gender  Decreased risk factors: total bili in low risk zone, gestational age > 41 weeks, exclusive bottle feeding, black race, hospital d/c after 72 hours Screening  Usually done routinely at time of metabolic screening prior to discharge (USPSTF grade I); infants with total bili > 95th percentile are at increased risk  Routine follow-up appointments after discharge are timed to assess developing jaundice, with f/u in 3 days for infants d/c before 24 hours (or sooner if high-risk), and later for infants d/c after 48 hours or beyond Management  Calculate risk zone of infant based on risk factors and total bili values  Admit for phototherapy if needed  Admit for exchange transfusion if needed: initiated when phototherapy has failed or infant has signs of neuro dysfunction  Home measures for low-risk infants: increasing frequency and efficacy of breastfeeding, supplementing inadequate breastfeeding with formula Page 42 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes 6 PEDIATRIC GU 6.1 Cryptorchidism  Most undescended testes will descend spontaneously by the time an infant is several months old but will rarely occur after 6 months  Ectopic testes are descended but are in an aberrant position such as the inguinal pouch, suprapubic region, or perineum  Occasionally descended testes can ascend as child grows  Retractile testes and located suprascrotally but can descend to the scrotum and remain there as long as the cremasteric reflex is overcome Management  Refer for testes not descended by 6 months for surgical orchiopexy due to risk of malignant degeneration, subfertility, torsion, or inguinal hernia Enuresis  Not clinically significant until child is > 5 years of age  Contributing factors: nocturnal polyuria, detrusor overactivity, disturbed sleep, maturational delay, genetics, abnormal ADH secretion Differential  Kidney disease  Daytime incontinence  Constipation  Pinworms  Spinal dysraphism or abnormality  Urologic anatomic abnormality Workup  Voiding diary  UA Management  High rate of spontaneous resolution by 15 years of age  Behavioral changes: regular voiding and emptying bladder before bedtime, no fluids after 6pm  Rewards for voiding before bedtime, working up to rewards for staying dry overnight  More active interventions needed as child gets older, social pressures increase, and self-esteem is affected  Enuresis alarms for wetting > twice per week  Desmopressin for children with nocturnal polyuria and normal bladder capacity who have failed alarm trials Simplenursing.com 82% or Higher on Your Next Nursing Test Page 43 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes 6.2 Cystitis  Agents: 90% are E. coli, also Staph saprophyticus,Enterococcus, enterics  Uncomplicated = limited to lower urinary tract, child > 2 years, no underlying medical problems, no underlying anatomic or physiologic abnormalities  Complicated = upper tract disease, MDR pathogen, host with malignancy, DM, or anatomic or physiologic abnormality, indwelling catheter  Risk factors: female, sexual activity, vesicoureteral reflux, polycystic kidneys, dysfunctional elimination syndrome, fecal impaction, paraplegia, sickle cell anemia, kidney transplant, DM, bladder stones, immunodeficiency, recent instrumentation Signs & symptoms  Infants < 1 month: may only have fever  Older kids: dysuria, frequency, urgency, enuresis, abdominal or suprapubic pain, hematuria (fever, chills, flank pain suggest upper tract infection) Differential  Chemical cystitis  Autoimmune cystitis  Drugs  Bladder dysfunction  Vulvovaginitis, cervicitis, or urethritis  Prostatitis or epididymo-orchitis  Nephrolithiasis  Urethral stricture  Neoplasm  Vaginal foreign body Workup  UA with microscopy (catheterized specimen for non-toilet trained children), culture if negative (sensitivity only 88%) Treatment  Admit for infants < 2 months, immunocompromised, vomiting, inability to tolerate orals, lack of outpatient f/u, and failure of outpatient therapy  Ages 2-13 years 2nd or 3rd generation cephalosporin, add amoxicillin if suspecting enterococcal infection  Age > 13 Septra or cephalosporin  First episode in uncomplicated female should be treated 5-7 days  Young children, male adolescents, and children with recurrent, febrile, or complicated cystitis should be treated for 7-14 days  Renal bladder US indicated for first febrile UTI in kids under 2 who did not have normal prenatal screening US, for kids of any age with recurrent UTIs, and kids of any age with UTI, poor growth, HTN, or FH of renal disease  VCUG indicated for evaluation of possible reflux in kids of any age with > 2 febrile UTIs Page 44 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes 6.3 Orchitis  Usually viral: mumps, rubella, coxsackie, echovirus, parvovirus  May be STI if sexually active Signs & symptoms  Scrotal swelling  Pain and tenderness with erythema and shininess of the overlying scrotal skin  May also have epididymis involvement with STI orchitis Differential  Epididymitis  Testicular torsion: absent cremasteric reflex  Appendix testis or appendix epididymis torsion  Trauma  Incarcerated inguinal hernia Management  NSAIDs  ABs if suspecting STI cause  Scrotal support  Ice packs 6.4 Wilms Tumor  A renal cancer that is the 4th most common childhood cancer  Most diagnosed before age 10 Signs & symptoms  Abdominal mass or swelling  Abdominal pain  Hematuria  HTN Management  Refer to surgery and pediatric cancer center  Abdominal US or contrasted CT to differentiate from other masses Prognosis  Good with early disease  Lung is most frequent first site of recurrence 6.5 Male Circumcision  Currently promoted as the health benefits outweigh the risks: reduced UTIs, reduced STI transmission, reduced penile inflammatory and retractile disorders, easier hygiene  Procedural risks are rare  Not covered by Medicaid and typically costs $200 out of pocket  Uncircumcised infants will need parent education on how to care for and clean the penis regularly to prevent phimosis Simplenursing.com 82% or Higher on Your Next Nursing Test Page 45 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes 6.6 Vesicoureteral Reflux  Currently this is treated as it is thought to promote renal scarring and recurrent pyelonephritis  Can occur prenatally and may be seen on prenatal US as hydronephrosis  Graded I-V based on severity Workup  Renal US for infants diagnosed with prenatal hydronephrosis  Contrasted voiding cystourethrogram  Radionuclide cystogram  Serum creatinine  UA  Screen siblings for reflux Management  Grades I and II can be managed with observation  Kids with > grade III reflux are treated  Antibiotic prophylaxis: Septra, trimethoprim, nitrofurantoin  Surgical correction  Annual imaging for medical or observational therapy  Annual growth checks, BP, and UA 6.7 Vaginitis Etiologies  STI  Vaginal polyp or tumor  Atrophic prepubertal tissue (more susceptible to irritants)  Strep pyogenes and other respiratory pathogens  Foreign body  Pinworms  Urethral prolapse: treat with topical estrogen cream for 2 weeks  Lichen sclerosus: treat with topical steroids  Labial adhesions: treat with topical estrogen cream  Systemic illness: measles, varicella, scarlet fever, EBV, Crohn’s, Kawasaki disease  Nonsexually transmitted vulvar ulcers  Urethral prolapse  Ectopic ureter Management  Treat underlying cause  Wear nightgowns to allow air circulation  Cotton underwear  Avoid tights, leotards, and leggings  Bathe in water only for 15 minutes and limit soap to non-genital areas  Dry genital area well after bathes, can use a cool hair dryer  No bubble baths or perfumed soaps  Cool compresses  Use wet wipes instead of toilet paper Page 46 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes  Avoid sitting around in wet swim suits  Antibiotic therapy for purulent discharge that does not respond to hygiene measures 6.8 Dysmenorrhea 6.8.1 Primary = painful menses with normal anatomy  Cause is usually prostaglandins and uterine vasoconstriction  Leading cause of school absences  Incidence decreases after age 20  Cramping pain radiating to back or inner thighs  Associated with heavy flow  Management: NSAIDs beginning 1-2 days before expected menses, OCPs, progesterone, Mirena IUD, acupuncture, thiamine supplementation 6.8.2 Secondary = a result of disease or pathology  Causes: endometriosis, uterine fibroids, adenomyosis, STIs, endometrial polyps  Usually begins well after menarche  Causes pelvic pain unrelated to menses  May have history of pelvic pain beginning at menarche vs. several months or years later  Workup: refer for laparoscopy to differentiate endometriosis from PID  Management: NSAIDs, OCPs, IUD, refer to OB-GYN for uterine artery embolization and evaluation for hysterectomy 6.9 Amenorrhea 6.9.1 Primary Amenorrhea = failure of any menses Differential  Hypothalamic or pituitary dysfunction  Hyperandrogenism  Ovarian causes  Pseudohermaphroditism  Uterine causes  Pregnancy Workup  Begins at 14 if neither menarche or breast development has occurred, or otherwise at age 16  Pelvic and rectal exam  hCG test  FSH, LH, PRL, testosterone, TSH, FT4 (may refer to endocrine for these) Simplenursing.com 82% or Higher on Your Next Nursing Test Page 47 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes 6.9.2 Secondary amenorrhea = absence of menses for 3 consecutive months in women how have passed menarche Differential  Pregnancy  Hypothalamic-pituitary causes: stress, strict diet or exercise  Hyperandrogenism  Uterine causes  Premature ovarian failure (before age 40)  Normal physiologic variation shortly after menarche  PCOS  Meds  Calorie deprivation Workup  bHCG, PRL, FSH, LH, TSH, CMP  Testosterone levels if evidence of virilization  Refer for dexamethasone suppression test if suspecting hypercortisolism  10 day progestin withdrawal trial Treatment  Usually estrogen replacement therapy Page 48 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes 7 PEDIATRIC MSK 7.1 Nursemaid’s Elbow (Radial Head Subluxation)  MOI: being pulled up too hard by hand or wrist → radial head slipping out of annular ligament Signs & symptoms Signs % symptoms  Crying, screaming, holding arm flexed against belly, refusal to use arm Workup  X-ray  Assess neurovascular involvement Treatment  Reduce with flexion and supination of the arm (usually occurs during x-ray positioning) 7.2 Slipped Capital Femoral Epiphysis  MOI: occurs when femoral head is displaced from the femoral neck  Obese, hypogonadic adolescent males are at increased risk Simplenursing.com 82% or Higher on Your Next Nursing Test Page 49 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes Signs & symptoms  Unilateral or bilateral, with many uni cases progressing to bi Limp  Affected leg turns out and appears shorter  Loss of hip flexion, internal rotation, and abduction Workup  X-ray Management  An orthopedic emergency, requires surgical repair 7.3 Osteosarcoma  Arises from primitive bone-forming mesenchymal stem cells  Overall the most common malignant bone tumor  Most occur in the metaphysis region  Peak incidence in 12-25 year olds Signs & symptoms  Pain  Swelling  Palpable mass Differential  Trauma  Infection Management  Biopsy for definitive diagnosis  Bone MRI, chest CT, radionuclide bone scan, and/or PET scan for staging Page 50 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes 7.4 Juvenile Rheumatoid Arthritis  Classification of subtypes is still a work in progress  Most commonly used classification is ILAR, with further classification of each group based on age at onset, duration and pattern, and presence of ANA or rheumatoid factor ILAR Classification of Idiopathic Arthritides of Childhood 7.4.1 Systemic arthritis  An autoimmune condition probably unrelated to other forms of childhood arthritis, requiring different therapy  Accounts for 10-20% of cases  Can present in kids as young as 1 Signs & symptoms  High fever  Macular, salmon pink rash related to fever spikes  Hepatomegaly  Lymphadenopathy  Arthralgias typically in the wrists, knees, and Differential  Postinfectious arthritis  Reactive arthritis  SLE and other connective tissue diseases  Malignancy  Malaria ankles Workup -Diagnosis is clinical, based on presence of intermittent fever for at least 2 weeks and arthritis -Labs will show increased WBCs, thrombocytosis, anemia, high ESR Management  NSAIDs for 6-12 weeks for mild and nondisabling symptoms  Add steroid taper or biologics for severe cases or for those unresponsive to NSAID trial, followed by DMARD  Anticytokine therapy for refractory disease Prognosis  Follows one of three patterns: systemic symptoms and no progressive arthritis, persistent systemic symptoms and progressive arthritis, or resolution of systemic symptoms with progressive destructive arthritis 7.4.2 Polyarthritis  Involves at least 4 joints during first 6 months of illness Signs & symptoms  Younger kids: begins with 1-2 affected joints then spreads  Older kids: rapid onset in multiple joints -Usually symmetric  Sausage fingers  Uveitis Simplenursing.com 82% or Higher on Your Next Nursing Test Page 51 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes Differential  Reactive arthritis  Psoriatic arthritis  Spondyloarthropathy  SLE  Systemic vasculitis  Sarcoidosis  IBD  Epiphyseal dysplasia  Minocycline-induced autoimmunity Workup  No characteristic labs, may have elevated ESR, anemia Management  NSAID trial for 3 weeks, followed by a different NSAID if no response  Methotrexate or biologic Prognosis  Will be chronic and progressive without treatment 7.4.3 Pauciarthritis (oligoarthritis)  Involvement of < 5 joints during the first 6 months of disease onset  May involve more joints over time ( = extended pauciarthritis) Signs & symptoms  Limping without complaint  Usually large joints are affected but not the hips  Swollen, tender joints Differential  Psoriatic arthritis  Enthesitis-related arthritis  Infection  Malignancy Workup  Diagnosis is clinical based elimination of other causes and on presence of arthritis in a single joint for at least 3 months or 2+ joints for at least 6 weeks  ANA is usually +  No rheumatoid factor  Management  NSAIDs  Intraarticular steroids  Methotrexate or biologics rarely required Prognosis  Many cases resolve within 6 months  May recur  Uveitis is the most serious complication and occurs in 20% of cases Page 52 of 177 Simplenursing.com 82% or Higher on Your Next Nursing Test © 2013 SimpleNursing.com All Rights Reserved. Pediatric Quick Notes 7.4.4 Enthesitis- related arthritis  Includes childhood spondyloarthropathies  Arthritis + enthesitis  Arthritis + 2 or more of the following: SI joint tenderness, inflammatory spinal pain, FH, uveitis, + HLA- B27  Gradual onset that may first be recognized following fever or msk trauma Management  NSAIDs for 3-6 months: frequently diclofenac or piroxicam are used  Sulfasalazine, biologics, or DMARDs if no improvement Prognosis  May progress to psoriatic arthritis 7.4.5 Psoriatic arthritis  Psoriasis + arthritis Signs & symptoms  May need to search for hidden psoriasis lesions  Joints tend to be less tender than other inflammatory arthritides  Nail pitting or onycholysis  Pitting edema  Uveitis  Dactylitis Differential  Reactive arthritis  Ankylosing spondylitis Workup  Usually seronegative  No specific tests Management  NSAIDs: typically don’t induce remission  Steroid injections into joints  DMARDs  Add second DMARD or biologic if needed  Monitor for uveitis Prognosis  Clinical remission achieved in most patients after 5 years of treatment Simplenursing.com 82% or Higher on Your Next Nursing Test Page 53 of © 2013 SimpleNursing.com All Rights Reserved. 177 Pediatric Quick Notes 7.5 Osgood-Schlatter Disease  MOI: anterior tibial tuberosity avulsion due tooveruse  Most common in males age 10-14 Signs & sy

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