Transcript Slide 1

PEDIATRIC ISSUES IN ILAC
Stephen F. Darrow, MD
Chief Resident
Internal Medicine-Pediatrics
June 3, 2008
Pearls for the Campo
• Most babies born in the DR are born in a
hospital
• There is a national vaccination program,
so most kids have received their vaccines.
• Parents want to
make sure that their
child is growing well
and is healthy.
Pearls for the Campo
• Make sure you know (or have a chart with
normal vital signs by age)
• Every child should have a weight recorded
(including kilograms) and percentile
– Necessary for medication dosing and to
assess growth
• Be aware of whether your patient is able to
swallow pills (your liquid medication
options will be limited)
Pediatric Fever
• Fever is defined as temperature above
100.4 F or 38 C
• You will have to rely on oral or axillary
temperatures in the campo, which are
frequently lower than the patient’s core
body temperature.
Pediatric Fever
• Any febrile infant less
than one month old
should be transported
to the nearest medical
facility.
– This child will require
further evaluation
including blood and
urine cultures, lumbar
puncture, and IV
antibiotics
Pediatric Fever
• In children older than one month age, use
your history and physical to assess for
localizing signs.
• Remember to look in the ears.
• Examine the skin for abscess/ cellulitis.
• If the child is toilet trained, collect urine for
urinalysis.
Pediatric Fever
• Assess the child for signs of
toxicity:
– Lethargy
– Signs of shock:
• tachycardia, poor perfusion
– Severe dehydration
– Nuchal rigidity
• Any infant who appears toxic should be
transported to the nearest medical facility for
further workup and IV antibiotics.
Common Pediatrics Infections
• Otitis media
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Strep pneumonia, H. influenzae, M. catarrhalis
Amoxicillin 80-90 mg/kg/day div bid or tid
Cefuroxime 30 mg/kg/day div bid
Azithromycin 10 mg/kg x 1 then 5 mg/kg/day x 4 days
Treat for 10 days
• Pharyngitis
– Same as for otitis media. Treat for 10-14 days.
• Thrush – Gentian violet/ nystatin (okay in
infants)
Normal Ear
•
•
•
•
Color = Pearly gray, pink
Position = Neutral
Translucent
Mobile
Otitis Media
• Color
= White plus
erythema
• Position
= Bulging
tympanic membrane
• Translucency
= Decreased
• Mobility
= Decreased
Fluid in the Ear: Infection or Not?
• Air fluid levels are not
necessarily acute
otitis media infection
– Look at other
characteristics
• Could be otitis media
with effusion (no
acute infection)
Common Pediatrics Infections
• Wound Infection and/or Cellulitis
– Surrounding redness, pus around wound site
sign of infection
Common Pediatrics Infections
• Cellulitis
– Group A Strep, Staph aureus
• Cephalexin 50-75 mg/kg/day div tid
• Cloxacillin 50 mg/kg/day div qid
• Clindamycin 10-30 mg/kg/day div tid or qid (side
effect diarrhea)
• TMP/SMX 8 mg/kg/day (TMP component) div bid
(Stevens-Johnson side effect – consider using this
if running low on above meds)
Common Pediatrics Infections:
Urinary Tract Infections
• Organisms: E. Coli, Proteus
• Lab
+ Nitrites, + leukocytes on urine analysis
• Treatment:
– TMP/SMX 8 mg/kg/day (TMP component) div
bid
– Cefixime 8 mg/kg q day
– Treat for 7-10 days
“Parasites”
• Most GI complaints are attributed to
parasites.
• Parents are almost always concerned that
their children do not eat enough and that
this may be due to a parasite.
• If you treat everyone who thinks they have
a parasite, you will run out of medicine!
“Parasites”
• Evaluate for any signs of infection:
– Abdominal pain
– Chronic diarrhea
– Poor Growth
• If you treat one patient, treat the whole
family.
“Grippe”
• “Grippe” encompasses all upper
respiratory symptoms
• Differential diagnosis includes
– Allergies
– Upper respiratory infection
– Sinusitis
• Cold medications are generally not
recommended in children due to poor
efficacy.
“Grippe”
• Treat for allergies if associated with
itching, sneezing, or atopic sequelae on
exam (pale mucosa, allergic shiners)
• Treat for sinusitis if associated with
headache or sinus pain, fever, or
prolonged course
• Remember to look for foreign body!
Cough
• Cough may be a symptom of a mild URI or
may indicate a more serious problem.
• Think asthma if associated with wheezing
or shortness of breath or if it is worse at
night.
– There is often a history of eczema or allergies
in the patient, or a family history of asthma or
allergies.
Cough
• Think pneumonia if associated with fever
or with signs of consolidation on exam
(dullness to percussion)
• Think TB if cough is chronic and if other
family members have a chronic cough.
Dehydration
Degree of Dehydration
Mild
Moderate
Severe
Older Child
3% (30 ml/kg)
6% (60 ml/kg)
9% (90 ml/kg)
Infant
5% (50 ml/kg)
10% (100 ml/kg)
15% (150 ml/kg)
Dehydration
Mild
Moderate
Severe
Skin turgor
Normal
Tenting
None
Skin (touch)
Normal
Dry
Clammy
Buccal mucosa/lips
Moist
Dry
Parched/Cracked
Eyes
Normal
Deep
Sunken
Tears
Present
Reduced
None
Fontanelle
Flat
Soft
Sunken
CNS
Consolable
Irritable
Lethargic/obutunded
Pulse rate
Normal
Slightly increased
Increased
Pulse quality
Normal
Weak
Impalpable
Capillary refill
Normal
2-3 seconds
> 3 sec
Urine output
Normal
Decreased
Anuric
<1.015
1.015-1.025
> 1.025
Oral liquids
Oral liquids + close follow up
next ½ day clinic
Refer to nearest med center
for IV hydration.
Examination
Laboratory
Urine Specific gravity
Treatment
Fluids!
Dehydration
• Mild- Moderate Dehydration can be
treated with oral rehydration therapy
• Pedialyte or WHO oral rehydration solution
• Administer small volumes (5-10 ml at a
time)
• Replace deficit over 4 hours
• Replace ongoing losses
Infestations
• Scabies
– Linear burrows around:
• wrists, ankles, finger
and toe webs, groin, waist
– In infants and toddlers:
head, neck, trunk,
palms and soles are affected
– Very pruritic
Infestations
• Scabies
– Permethrin 5% cream or lindane lotion
– Apply to entire body below neck and leave on
overnight; bathe in am
– Treat entire household
– Wash all clothing and linen
Infestations
• Head Lice
– Pediculosis humanus capitis
– Acquired by close physical contact, sharing
hats/ brushes
– Nits are oval, white 0.5 mm dots stuck on hair
shafts 1-3 cm from scalp. Found especially
above and behind ears.
– Lice are six legged insects visible to the
unaided eye.
Infestations
• Head Lice
– Pruritis is the principle symptom
– Occipital adenopathy is common
– Lindane shampoo; leave on scalp for five
minutes before rinsing, then comb hair with a
fine-tooth comb. Repeat in 7 days.
• Use Permethrin 5% cream in infants
– Treat entire household
– Wash all bedding, clothing, hats
Asthma: Emergency Treatment
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Assess ABC’s
Oxygen as needed
Inhaled beta-agonist
Ipratropium bromide
Corticosteroids, po or IM (2 mg/kg load,
then 1 mg/kg bid)
• Epinephrine SC, 0.01 ml/kg
• Terbutaline SC, 0.01 ml/kg
Asthma Attack
• Retractions
(indentation of chest)
• Accessory muscle
use (neck muscles to
breathe)
• Nasal flaring
High Blood Pressure
• Coarctation of the
aorta can lead to high
blood pressure
• Avoid ACE inhibitors
in pubescent
teenagers
Take Home Points
• Common Things Are Common
– Colds
– Stomach Pain
• Parasites
• Constipation
– Ear infections
– Skin infections
– Scabies/ Lice