Description

Pediatrics 2 of 3

Pediatric Respiratory Topics

Disclaimer: Content is for educational exam preparation only and does not constitute medical advice. Medicine changes quickly; always verify with current, local guidelines before applying to patient care.

1. Asthma

Assessment Tool: PRAM (Pediatric Respiratory Assessment Measure) The scoring system ranges from 0 to 12 points. The mnemonic provided is WE SOS.

• W (Wheeze): 0 to 3 points
• E (Air Entry): 0 to 3 points
• S (Suprasternal In-drawing): 0 to 2 points
• O (Oxygen Saturation): 0 points (>94%), 1 point (92 to 94%), 2 points (<92%)
• S (Scalene Retractions): 0 to 2 points

Severity Scoring:

• Mild: 1 to 3 points.
• Moderate: 4 to 7 points.
• Severe: 8 to 12 points, or the presence of cyanosis or altered level of consciousness.

Treatment and Dosing:

• Mild Asthma:
  • Ventolin (SABA): Every 20 minutes. Dose: 4 puffs (<10 kg) or up to 8 puffs (>20 kg). Give three rounds.
  • Dexamethasone (DEX): 0.6 mg/kg PO (give two doses: one now, and one dose to take tomorrow).
• Moderate Asthma:
  • Ventolin and Ipratropium Bromide: Both given every 20 minutes for three rounds.
    • Ipratropium Bromide Nebs: 250 micrograms (<20 kg) or 500 micrograms (>20 kg).
    • Ventolin Nebs: 0.15/kg/dose (5mg) up to 3/hr for continuous
  • DEX is also given.
• Severe Asthma:
  • Continuous nebulized Ventolin and Ipratropium Bromide.
  • DEX or Methylprednisolone.
  • Methylprednisolone Dose: 1 mg/kg.
  • Magnesium: 50 mg/kg (can be repeated every 20 minutes as needed).
  • Other options: Epi, epi infusion, inhaled epinephrine, ketamine, or heliox.

Admission and Discharge Criteria:

• Admission Criteria: Oxygen saturation less than 90%, respiratory distress, social concerns, comorbidities, or requiring a SABA more than every 4 hours.
• Discharge Criteria: The patient must be able to tolerate 4 hours without receiving a round of Ventolin.
• Take-Home Ventolin Dosing: Four puffs every 4 hours for 4 days.

2. Bronchiolitis

Common Age: Less than one to less than three-year-olds.

Scoring System Mnemonic: WE SOS for Real.

• W (Wheeze).
• E (Air Entry).
• S (Substernal In-drawing).
• O (Oxygen Saturation).
• S (Scalene or Abdominal Retractions).
• F (Feeding).
• R (Respiratory Rate): Less than 60 (normal), 60 to 70 (worse), greater than 70 (even worse).

Treatment:

• Oxygen for saturations less than 94%.
• Nasal suctioning.
• Trial of Ventolin (if it works, keep doing Ventolin).
• If Ventolin works, give Steroids.
• Volume repletion (by feeding or IV fluids).
• May also try nebulized or IM epinephrine.

Admission Criteria (CPS): 90 RASCAL.

• 90: Less than 90% oxygen saturation.
• R: Respiratory distress.
• A: Apnea.
• S: Social concerns.
• C: Comorbidities (especially cardiac or pulmonary conditions).
• A: Age less than 3 months or if premature.
• L: Lactation or not tolerating feeds.

3. Croup (Laryngotracheobronchitis)

Common Age: 6 Month to 6 year olds.

Scoring System: Wesley Croup Score. The mnemonic provided is CRIES.

• C (Cyanosis): 0 or 5 points
• R (Retractions): 0 to 3 points
• I (Impaired Consciousness): 0 or 5 points
• E (Air Entry): 0 to 2 points
• S (Stridor): 0 to 2 points

Severity Scoring:

• Mild: 0 to 3 points (stridor only when upset).
• Moderate: 4 to 6 points (stridor at rest).
• Severe: 7 plus points (stridor at rest, severe respiratory distress).

Treatment and Dosing:

• Mild Croup: Dexamethasone: 0.6 mg/kg (one dose now, and one dose to be taken in 24 hours).
• Moderate/Severe Croup (stridor at rest):
  • Dexamethasone 0.6 mg/kg
  • Racemic Epinephrine: 2.25% concentration. Dose: 0.1 mL per kilogram up to 0.5 mL (usually 0.5 mL). Can be repeated every 20 minutes as needed.
    • Monitoring: Due to the dose lasting 2 to 3 hours, patients must be monitored for at least 3 hours after their last dose of racemic epinephrine.
  • Severe Croup may also require intubation or IM/IV epinephrine.

Admission Criteria: Uses the 90 RASCAL mnemonic (similar to bronchiolitis), but also specifically includes stridor despite treatment and does not include apnea.

ENT & Head/Neck Infections

• Epiglottitis
  • Age Group: 5–7 years old or older
  • Common Bugs: H. flu (historically), Group A strep, S. aureus, S. pneumoniae
  • Treatment Specifics: Airway management/ICU monitoring, Ceftriaxone and Vancomycin.
• Tracheitis
  • Age Group: 3–5 years old
  • Common Bugs: Often mixed, potentially predominantly S. aureus
  • Treatment Specifics: Airway management/ICU monitoring, Ceftriaxone and Vancomycin.
• Retropharyngeal Abscess (RPA)
  • Age Group: 6 months to 3 years old
  • Common Bugs: Group A strep, S. pneumoniae, S. aureus, Fusobacterium
  • Treatment Specifics: Ceftriaxone and Clindamycin (due to anaerobes). Requires surgical consult, especially if the abscess is greater than 2 cm in size.
• Peritonsillar Abscess (PTA)
  • Age Group: 15–30 years old
  • Common Bugs: Mixed, Group A strep, S. aureus, Fusobacterium
  • Treatment Specifics: Ceftriaxone or Clindamycin. Needs drainage (needle aspiration or I&D). Maybe safe for discharge home on Amoxicillin/Clavulanate (amoxy clav) for 10 days.
• Lemierre's Syndrome
  • Age Group: 15–24 years old
  • Common Bugs: Group A strep, Fusobacterium (accounts for about a third of infections)
  • Treatment Specifics: Ampicillin/Sulbactam, Piperacillin/Tazobactam, or Carbapenem. Diagnosis via CT neck with contrast.

Lemierre's Syndrome Classic Triad: Pharyngitis, anterior neck tenderness and swelling, and non-cavitary pulmonary infiltrates (from septic emboli).

4. Acute Otitis Media (AOM)

Watch and Wait Criteria (CPS): Must be met for observation to be acceptable.

1. Healthy, immunized, and over 6 months.
2. Well appearing.
3. Temperature less than 39° C.
4. Less than 2 days of symptoms.
5. Able to sleep well with mild pain.
6. Intact tympanic membrane (TM) with no discharge.
7. Unilateral infection.

Treatment (Moderate to Severe AOM): Pain control and antibiotics.

• Antibiotic Duration: 10 days (6 months to 2 years old); 5 days (over 2 years old).
• Amoxicillin Dosing (Most Common): 90 mg/kg per day divided into two doses. Other options include Cefuroxime or Amoxicillin/Clavulanate.
• Ear Tubes: Patients can go home with Ciprodex drops.

5. Pertussis (Bordetella pertussis)

Incubation Period: 12 to 17 days.

Three Phases:

1. Catarrhal Phase: Dry cough, rhinorrhea, mild fever (looks like a mild viral infection).
2. Paroxysmal Phase: Violent coughing paroxysms (8 to 10 coughs) followed by a whoop. This phase lasts 2 to 4 weeks.
3. Convalescent Stage: Gradual improvement, though cough can linger up to 8 weeks.

Treatment: Azithromycin for the patient as well as contacts.

Admission Criteria: Less than 3 months old or premature, or less than a year old with significant symptoms.

Cardiovascular Topics

6. Congenital Heart Disease (General)

Ductal Closure: The PFO closes at about 6 months. The PDA closes within 1 to 3 days.

Prostaglandin E1 (PGE1) Dosing (for ductal-dependent lesions): 0.05 micrograms per kilogram per minute, titrated to effect.

• Side Effects: Apnea, hypotension, seizures, fever.

Specific Diagnostic Testing:

• 4limb Blood Pressure Test: Upper extremity BP greater than lower extremity BP by 20 points is concerning (e.g., for coarctation).
• Pre and Post-ductal Sats: Measure at the right arm and left leg. Concerning if the right arm is less than 90% or if there is a 3% difference between the two limbs.
• Hyperoxia Test (100% O2):
  • Poor Man's Test: Less than 10% increase in saturation is concerning.
  • True Test: Less than 100 mmHg increase in PaO2 is concerning for a right-to-left shunt. Greater than 250 mmHg rules out a right-to-left shunt.

Lesion Categories:

• Cyanotic Lesions: Tetralogy of Fallot (TOF), Truncus Arteriosus, Total Anomalous Pulmonary Vein Connection (TAPVC), Transposition of the Great Arteries (TGA), Tricuspid Atresia, Pulmonary Atresia or Stenosis.
• Obstructive Lesions (Lead to shock/gray baby, present in first few weeks): Severe Aortic Stenosis, Interrupted Aortic Arch, Coarctation of the Aorta, Hypoplastic Left Heart.
• CHF/Mixing Lesions (Present at 1 to 3 months): VSD, large ASD, PDA.

7. Tetralogy of Fallot (TOF) and Tet Spells

The Four Lesions (TET): VSD, RV outflow obstruction, overriding aorta, and RV hypertrophy.

Treatment for TET Spell (right-to-left shunting):

• Decrease Tachycardia: Anxiolysis or knee-to-chest position.
• Increase SVR (Systemic Vascular Resistance): Knee-to-chest position, fluid bolus, or possibly Phenylephrine.
• Decrease PVR (Pulmonary Vascular Resistance): Oxygen.

8. Kawasaki Disease

Diagnosis Mnemonic: WARM CREAM. Diagnosis is clinical, based on fever for 5 or more days PLUS 4 out of 5 of the following criteria:

• C: Conjunctival injection.
• R: Rash (generalized, polymorphous).
• E: Erythematous palms and soles.
• A: Adenopathy (cervical, unilateral, more than 1.5 cm).
• M: Mucous membrane changes (dry cracked lips or strawberry tongue).

Incomplete Kawasaki Disease: Fever for 5 days PLUS 2 or 3 criteria.

• Labs: Order CRP and ESR.
• Diagnostic Values: Elevated CRP (more than 30) or ESR (more than 40).
  • If elevated and 3 criteria met: Treat as Kawasaki and order echo.
  • If elevated and 2 criteria met: Admit, order echo, and draw supplemental labs (including WBC > 15, Platelets > 450, albumin <30).

Treatment and Dosing:

• IVIG: 2 grams per kilogram (single dose).
• Aspirin: 30 to 50 mg/kg daily orally in four divided doses.

9. SVT versus Sinus Tachycardia (Pediatrics)

SVT Rate Thresholds (Faster than Sinus Tachycardia):

• Infants: Over 220 bpm.
• Older Children: Greater than 180 bpm.

Other Differences: SVT is very regular (maintained R-R intervals), unlike sinus tachycardia, which varies with activity or respirations. SVT may lack P waves or have inverted P waves coming after the QRS.

10. Rheumatic Fever (Jones Criteria)

Prerequisite: Documented diagnosis of a Group A Strep infection. Diagnostic Criteria: Two Major OR One Major and Two Minor criteria must be met.

Major Criteria (Jones, where O is the heart):

• J: Joints (Arthritis with swelling).
• O (Heart): Carditis.
• N: Nodules (Subcutaneous nodules).
• E: Erythema Marginatum.
• S: Sydenham Chorea.

Minor Criteria (FAPE):

• F: Fever.
• A: Arthralgia (without swelling).
• P: PR interval prolongation.
• E: ESR or CRP elevation.

Gastrointestinal Topics

11. Neonatal Jaundice (Hyperbilirubinemia)

Bilirubin Thresholds:

• Bilirubin level over 85 can cause jaundice.
• Bilirubin level over 340 is a risk factor for kernicterus.

Indications for Further Investigation:

• Jaundice within the first day of life.
• Jaundice beyond 3 weeks of life.
• Sick appearing infant.
• Elevated conjugated bilirubin (always pathological).
• Rapidly rising bilirubin level.
• Total serum bilirubin not responding to phototherapy and approaching the exchange transfusion threshold.

Neurotoxicity Risk Factors (Lower Threshold for Phototherapy): Isoimmune hemolytic disease, G6PD deficiency, asphyxia, lethargy, temperature instability, sepsis, acidosis, and Albumin less than 30.

Causes of Unconjugated (Indirect) Hyperbilirubinemia (Examples): Physiological jaundice, breast milk jaundice, hemolysis (e.g., ABO incompatibility, G6PD deficiency), GI obstruction (e.g., pyloric stenosis), and metabolic conditions (e.g., Gilbert syndrome).

Causes of Conjugated (Direct) Hyperbilirubinemia (Always Pathological): Infections (e.g., sepsis, TORCH), biliary obstructions (e.g., biliary atresia), and metabolic causes (e.g., cystic fibrosis, alpha 1 antitrypsin deficiency).

12. GI Foreign Bodies

Indications for Urgent Removal/Consultation (Patient Factors):

• Respiratory distress.
• Esophageal obstruction (inability to swallow).
• Intestinal obstruction or perforation.
• Esophageal impaction for more than 24 hours.

Indications for Urgent Removal/Consultation (Object Factors):

• Esophageal button battery.
• Sharp object in the stomach.
• Long object in the stomach (longer than 5 cm).
• Wide object in the stomach (wider than 2 cm).
• Multiple magnets.

13. Specific Pediatric GI Conditions

Meckel's Diverticulum

• Presentation: Painless bleeding (hematochezia). Can lead to intussusception.
• Rule of Twos: Affects 2% of the population, located 2 feet proximal from the ileocecal valve, typically 2 inches in length, common in less than two-year-olds, and has a 2:1 male to female ratio.
• Management: Meckel scan, transfusion, possible surgery.

Midgut Volvulus with Malrotation

• Presentation: Presents in the first month of life with bilious vomiting in a sick infant.
• Diagnosis: Upper GI series with small bowel follow-through (may show corkscrew pattern or double bubble on X-ray).
• Management: Resuscitation, decompression, Antibiotics (Ampicillin, Gentamicin, Flagyl), and surgical consultation.

Necrotizing Enterocolitis (NEC)

• Presentation: Presents in the first month of life, particularly in premature babies. Onset related to starting enteral feeding.
• X-ray findings: Pneumatosis intestinalis, perforation, and dilated loops.
• Management: Decompression, resuscitation, Antibiotics (Ampicillin, Gentamicin, Flagyl), and surgical consultation.

Intussusception

• Common Age: 6 months to 2 years of age.
• Features: Colicky abdominal pain, current jelly stools, right-sided sausage-like mass, and lethargy between pain episodes.
• Diagnosis: Ultrasound shows a target sign.
• Management: Air or barium enema.

Hirschsprung's Enterocolitis

• Pathophysiology: Congenital lack of innervation of the myenteric plexus.
• Suspicion: Delayed meconium passage beyond one day.
• X-ray findings: Cut off sign in the colon, pneumatosis intestinalis, or signs of perforation.
• Management: Biopsy to confirm diagnosis. Enterocolitis treatment requires Ampicillin, Gentamicin, Flagyl, and pediatric surgery consultation.

Pyloric Stenosis

• Presentation: 3 weeks to 2 months of life. Features include projectile non-bilious emesis and a palpable olive-like mass.
• Labs: May show low potassium, low chloride, and alkalosis.
• Ultrasound Diagnostic Values (PI pneumonic): 3 mm by 14 mm by 19 mm (note: one source cites 4 mm instead of 3 mm).
• Management: Hydration, electrolyte correction, and surgical consultation (surgery is not urgent).

Henoch-Schönlein Purpura (HSP)

• Age: 4 to 6 year olds.
• Symptoms Mnemonic: ARENA: Abdominal pain, Rash (palpable purpura), Edema (diffuse), Nephritis, Arthritis.
• Key Lab Finding: Normal platelets despite the purpura.
• Treatment: NSAIDs. Steroids if severe abdominal pain, GI bleeding, hematuria, or severe arthritis. These severe findings also serve as admission criteria.

Disclaimer: Content is for educational exam preparation only and does not constitute medical advice. Medicine changes quickly; always verify with current, local guidelines before applying to patient care.