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COMMON INFECTIONSOF CHILDHOODJen Avegno MDLSU New Orleans Emergency Medicine rule 1 kids get sick .
2006 National Hospital Ambulatory Medical CareSurvey showed most common ED diagnosis for kids 1 upper respiratory infection kids 2 12 otitis media ear disorders.
In all fever is the most common chief complaint ofkids presenting to the ED about 20 30 all peds rule 2 most kids don t getTHAT sick this lecture is about.
objectives Review pediatric fever guidelines Discuss some common infections in childhood See LOTS of pictures of cute kids case 1.
Mom brings in a 3 week old baby girl with a feverfor 4 hours The child was a normal vaginal deliverywith no complications and has been feeding andgrowing well at home This morning she began to spit up her bottle and had several loose stools .
She has been somewhat sleepy but does respond toher parents Physical exam reveals a child in nodistress with a rectal temperature of 100 8 and anormal exam for age fever 3 mo.
the dreaded neonatal what is the risk of serious bacterial illness SBI inkids less than 3 months with fever SBI UTI bacteremia meningitis osteo pneumonia gastroenteritis cellulitis septic arthritis.
risk is about 6 10 in these kids with those younger than1 month having the highest chance of SBI kids under 3 months may present looking like viralsyndrome but still have SBI in one study kids lessthan 60 days with temp 38 .
22 had RSV 7 with RSV also had concomitant SBI why do neonates get immature immune system exposure to pathogens during delivery esp GBS .
cannot mount immune response to preventlocalized infection from disseminating what does temperature reallymean what IS a fever fever a pyrogen mediated rise in body.
temperature above normal range what is a NORMAL temp the magical 98 6 was set as normal by a German guy inthe 19th century using a 22cm long mercury glassthermometer we now think that his instruments may.
have been OFF by 1 5 2 degrees normal temps can vary by age in kids from 99 5 neonates to 98 older kids temps are influenced by age sex race time of day activitylevel ambient temp site of measurement type of device.
what constitutes a fever NO REAL EVIDENCE to support the hard and fast cutoff of 100 4 38 C evidencesuggests that oral temps 37 2 37 8 maybe considered febrile depending on.
BEST SITE to measure temperature the hypothalamic artery yeah right take home point fever is an ARBITRARYnumber base your workup on overallclinical impression not a particular cutoff.
what about people withoutthermometers oh yeah the mom hands don t blow them off 60 of parents use their hands instead of a thermometerto assess fever.
is this method accurate studies show 74 90 sensitive 76 86 specific 85 94 NPV the exact number or method doesn t matter .
BELIEVING the parents is common infectious pathogens inthe neonateAGE BACTERIAL VIRAL OTHER0 28 days Group B Strep Herpes simplex Bundling.
Listeria Varicella environmentE Coli EnterovirusC trachomatis RSVN gonorrhoeae Flu1 3 months H flu Varicella Bundling.
S pneumo Enterovirus environmentN meningiditis RSVE coli flu length of illness localized symptoms .
pertinent PMH birth hx of both mom baby sick contacts vaccination status any meds ABx physical exam findings.
VITAL SIGNS yes ALL of them ABCs respiratory airway distress signs of shock tachycardia for infants less than 1 year HR should increase 10 beatsfor every 1 C.
TAKE THOSE CLOTHES OFF just remember in non immunocompetent kids neonates fever may be the ONLY presenting signof SBI do not be reassured by a normal exam management of neonatal fever.
standard management again ABCs consider intubation for respiratorydistress hypoxia altered MS fluid resuscitation 20 ml kg IV IO fluids to total of 60 100 ml kg if hypovolemia persists .
cultures prior to Abx if possible sterilization of CSF can occur as quickly as 15 min 2 hrsafter receiving Abx so watch results BROAD SPECTRUM TREATMENT Ampicillin Gentamycin or Cefotaxime avoid Rocephin in.
kids 28 days Vanc Acyclovir major guidelines for fever 90PHILADELPHIA ROCHESTER BOSTONAGE 29 60 d 60 d 28 89 d.
TEMP 38 1 37 9 37 9EXAM well no focus well no focus well no focusLAB VALUES low WBC 15 WBC 5 15 WBC 20risk Band 0 2 band 1500UA 10 wbc UA 10 wbc UA 10 wbc.
CSF 8 wbc CSF 10 wbcneg CXR neg CXRHIGH RISK dispo admit IV Abx admit IV Abx admit IV AbxLOW RISK dispo home no Abx home no Abx home empiric AbxHow good is it 98 42 92 50 NPV 94 6 .
sens spec 14 99 7 12 98 9 these rules miss very few kids with SBI watch out for cancer toxic shock.
autoimmune and or congenital disorders cardiac pulmonary case 2 Dad comes to the ED with little Maria age 2 andreports that she has had a fever for the last 2 days.
up to 103 4 at home The parents have triedTylenol and Motrin to no avail Maria has not eatenmuch but is still drinking water and juice She had a runny nose a few days ago but is not sneezing coughing or vomiting In the ED Maria has a.
temperature of 102 8 She looks droopy butinteracts well with her parents fever 3 36 months only slightly less scary feverbetween 3 36 months.
fever is the most common complaint in this age unlike neonates of young children who presentwith viral illness RSV croup bronchiolitis etc andfever 39 less than 0 5 will also be bacteremic the well appearing febrile child.
3 36 months concern here is for OCCULT BACTEREMIA before HiB and Prevnar the rate of occult bacteremia inthe non focal febrile child was 5 currently it is less than 1 with other pathogens more.
N meningiditis urinary pathogens treating a fever WHY do we treat a fever feel better decrease anxiety.
lower morbidity mortality prevent febrile seizures HOW do we treat a fever ambient temp control light clothing bedding.
fluids sponge bath warm feet potatoes or onions in socks REALLY antipyretics how do you give Tylenol .
Acetaminophen 15 mg kg every 4 6 hours Ibuprofen 10 mg kg every 6 hours alternate evidence shows some minor benefits in reducing feverfaster and lasting longer BUT .
potential for dosage scheduling errors synergistic renaltoxicity difficult to understand and comply detailed information handout at appropriatereading level on administration of antipyreticsshould be given to caregivers .
common infectious pathogens inthe young childAGE BACTERIAL VIRAL OTHER3 36 months S pneumo Varicella LeukemiaN meningiditis Enterovirus Lumphoma.
E coli RSV NeuroblastomaFlu Wilms tumorAdenovirus length of illness localized symptoms .
headache neck pain sore throat pulling ears cough describe wheeze vomiting RASH mental status use of antipyretics defervesence after use doesNOT exclude bacteremia sick contacts.
po intake output vaccination status any meds ABx physical exam findings VITAL SIGNS yes ALL of.
ABCs respiratory airwaydistress signs of shock tachycardia capillary refill is an easy andreliable indicator of perfusion.
TAKE THOSE CLOTHES OFF thorough search for focal algorithm for pediatric notes on the workup most guidelines argue for getting the WBC first .
then CXR if WBC 20k but who does this study showed that rate of pneumococcalbacteremia increased to 0 5 with WBC 10 15k 3 5 with WBC 15 20k 18 with WBC 20k ANC 10k include all immature forms increases risk of.
bacteremia by 10 fold over those with ANC 10k management treatment the post immunization world has resulted in muchlower rates of bacteremia for this age group where bacteremia rates in febrile kids 1 5 the most.
cost effective strategy is a WBC blood CX and empiric Abx Rocephin when rates 0 5 clinical judgment alone for treatment management is most useful to select out high risk groups kids 3 6 mo are still relatively non .
immunocompetent recommendations are for allkids in this age group with temp 39 to have WBC BCx treat all WBC 15k with empiric ABx watch out for CANCER.
autoimmune disease JRA Kawasaki s brain tumors Mom brings in a 15 month old girl who woke uplast night screaming and with fever to 101 2 Shehas not eaten much today but is drinking liquids.
with normal urine output All of her immunizationsare up to date and she is otherwise healthy Onexam you note a mildly ill appearing non toxicchild who responds well to mom The left TM is redand bulging with loss of landmarks .
otitis media epidemiology Most commonly diagnosed disease in kids 15 By age 3 estimated that more than 80 of kidshave had one episode 40 have had 3.
Risk factors Smoking Day care Family history Anatomic abnormalities.
Winter Bottle feeding definitions ACUTE s s of acute infxn WITH effusion aka acute suppurative or prurulent OM.
OME effusion WITHOUT s s of acute infxn aka serous mucoid secretory nonsuppurative CHRONIC chronic ear discharge from perforated RECURRENT 3 episodes in 6 mo or 4 episodes pathophysiology.
It s all about the tube functions ofthe eustachian tube Ventilates middle ear for pressureequilibration Drains middle ear.
Protects ear from NP secretions When the eustachian tube Only open when becomes obstructed yawning chewing swallowingMiddle ear ventilationNegative middle ear cavity.
pressure causes fluid tomove into middle earCHILD transudate and combinewith NP secretions common pathogens in otitis.
S Pneumoniae H flu higher in OME M catarrhalis S aureus S pyogenes.
gram negative bacteria VIRUSES Pulling at ears Vomiting diarrhea Decreased po intake.
Fever may be present in only of cases with lessthan 10 having temp 40 URI sx a normal TMpars flaccida.
pars tensaeustachian tubelight reflex signs symptoms What does the TM look like .
erythematoushemorrhagic more picturesMiddle ear effusionsother indicators of AOM .
lack of TM mobility MOST RELIABLE SIGN cloudy retracted dull TM1 3 of cases may NOT have symptoms diagnosisAAP AAFP guidelines state that the following should be.
present to dx AOM 1 Recent usually abrupt onset of s s2 Presence of middle ear effusion bulging limited TM mobility air fluid level 3 S s of middle ear inflammation.
erythema or otalgia treatment AAP guidelines on management of AOM in Dx by hx of acute onset signs of effusion signs ofmiddle ear inflammation.
Assess for pain if present treat Limited role for observation in select patients 2years must have a ready means of communicationwith clinician If treat with ABx start with amox 80 90.
If treatment failure by 48 72 hours reconsider dxor change ABx OTITIS MEDIA treatmentTemp 39 1 or Initial Tx Clinical failuresevere otalgia or after 48 72 hrs.
BOTH with initial txNO Amox 80 90 mg kg day Augmentin 90 mg kg dayPCN all cefdinir of amox cefuroxime cefpodoxime PCN all Rocephin 3 dayazith clarith tx clinda.
YES Augmentin 90 mg kg day Rocephin 3 days of amox PCN all clinda PCN all Rocephin 1 time tympanocentesisor 3 day tx treatment.
Important points treatment failure lack of clinical improvement and or persistentsigns of AOM Bactrim macrolides often considered 2nd line but resistance ratesapproach 30 40 .
Courses are generally 10 days in patients 2 yrs perf TM andrecurrent OM recommended in patients 6 years NO INDICATION for antihistamines decongestants steroids or tubesin single episode AOM Auralgan may be useful for pain relief.
Tx of OME either alone or following episode of OM iscontroversial ABx Antihistamines Tubes for patients with OME for 4 6 months failed tmt andhearing loss watch out for.
otitis externarule #1: kids get sick. 2006 National Hospital Ambulatory Medical Care Survey showed: most common ED diagnosis for . kids <1 = upper respiratory infection. kids 2-12 = otitis media/ear disorders. In all, fever is the most common chief complaint of kids presenting to the ED (about 20-30% all peds visits)

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