General Peds Topics

Fever without a source

• If <3mo see Neonatal Fever
• Fever in general:
  • Rectal (38) > Oral (37.5)> Axillary (37.3)

• Low Risk Criteria (Rochester Criteria) - for use in infants up to 3mo of age. Age Group ≥60 days old Past Health Born ≥37w gestation Home with or before mother No hospitalizations No perinatal, postnatal or current antibiotics No treatment for unexplained hyperbilirubinemia No chronic disease Physical Exam Rectal temp ≤38.0C Appears well - no evidence of skin/soft tissue/ bone/joint/ear infection. Labs Total WBC 5.0-15.0x109/L Bands <1.5 x109 /L Urine < 10 WBC/HPF Stool (if diarrhea) < 5 WBC/HPF   Risk of Serious Bacterial Infection <1mo 1-3mo Low Risk High Risk Low Risk  High Risk 3-6% 25-35% <1% 10-20%

• Septic Workup if concerned (toxic, irritable, altered LOC, etc..)
  • CBC + diff
  • Blood culture, blood smear
  • Urinalysis + culture
  • LP
  • +/- CXR if resp concern
  • +/- stool microscopy+culture if diarrhea
• If Non-toxic ≤3mo of age without source.
  • >1mo (consider low-risk criteria)
    • Meets low-risk criteria (Urine cultures + re-eval in 24hrs) (blood culture, LP, IV abx OPTIONAL)
    • Does not meet low-risk criteria (Admit, blood+urine culture, LP, IV abx)
  • ≤1mo
    • (Admit, blood+urine culture, LP, IV abx)

Sickle Cell

Febrile Seizures (Pediatric)

• Associated w fever, no evidence of intracrania infection
• Age 6mo-6y
• Tonic-clonic most common

Acute Otitis Media

• (Pasted - most up-to-date in Family Medicine - Acute_Otitis_Media section)
• Organisms:
  • Strep pneumoniae
  • H. influenza
  • Moraxella catarrhalis

Tx:

• 80-90% will resolve with watchful waiting in 48-72hrs..treat fever.  Watch for rash, drowsiness, vomiting, SOB
• To treat or not to treat:

  • Acute Otitis Media Guidelines
    <6mo of age - Antibiotic therapy 6mo-2yrs - Antibiotic therapy if certain of diagnosis.  Observation if uncertain diagnosis >2hrs - Antibiotic therapy if severe illness.  Observation if non-severe or uncertain diagnosis.

    (AAP & AAFP Clinical Practice Guidelines)
• Drugs:
  • 1st line: Amoxicillin 80-90 mg/kg/d divided bid  (use macrolides if penicillin allergy)
  • 2nd line:
    • Cefprozil 30 mg/kg/day divided bid
    • Ceftriaxone 50 mg/kg intramusc. (or IV) x1 dose.
    • Azithromycin 10 mg/kg od x1 dose, then 5mg/kg od x4 doses.
    • Clarithromycin 15 mg/kg/day divided bid
  • If failed initial therapy (no symptom improvement in 2-3 days):
    • Amoxicillin-clavulanate (90mg/kg/d : 6.4 mg/kg/d) divided bid x10 days.
    • if fails again, ceftriaxone 50mg/kg/d IM or IV od x3 doses.  Refer to ENT
• Antipyretics/Analgesics
• If TM perforation, use drops.

Complications

• Perforation and drainage - most common (use ciprodex topical)
• Transient hearing loss/delay
• Mastoiditis (rare) --> fever, tenderness over mastoid bone, +/- anterior displacement of pinna - requires IV abx.
• Rare: bacteremia, meningitis, cerebral abscess.

UTI or Urosepsis

• Kids >3mo
  • Something that covers E.coli (80%)
    • 1st gen not used due to resistance (Keflex)
    • 3rd gen cephalosporins
    • amp-gent
• Infants <3mo
  • Amp-gent because broader spectrum of bugs + higher risk of upper UI tract disease.
• If Urosepsis or recurrent UTI perform U/S to check anatomy
  • Pelviectasis <5mm is considered normal (for the most part).
  • If U/S abnormal or still concerned do VCUG (Voiding cystourethrogram)

Arthritis

• Defined as:
  • Joint Effusion
    OR
  • ≥2 of the following:
    • decreased ROM
    • tenderness or pain on motion
    • increased warmth
• DDx:

  • - Inflammatory JIA, connective tissue (SLE, JDM, scleroderma) Vasculitis (HSP, KD, systemic) - Infection Septic arthritis, reactive arthritis, toxic synovitis - Trauma/Overuse

    - Malignancy Leukemia, neuroblastoma, bone tumors - Hematologic Hemophilia, sickle cell - Developmental Growting pains, SCFE, AVN

• Investigations:
  • CBC, diff, smear
  • ESR, CRP
  • X-rays.
  • Others (depends)

Autoimmune

Infectious

Dehydration

How Dehydrated?

• Mild:
  • Dry mucous membranes
  • Decreased Urine Output
  • Increased thirst
• Moderate
  • Tachycardia, depressed fontanelle
  • Sunken eyes
  • Decreased skin turgor
  • Cool skin
• Severe (Shock)
  • Weak pulse, low BP, anuria
  • Mottled cord extremities

Figure out Deficit:

• IF Severe
  • Send Lytes + give NS (20-40cc/kg) rapidly - want to keep sodium (prevent die from shock)
  • Note: in peds they tend to give D5W NS because high risk of hyponatremia or hypernatremia
  • Maintenance
• If Mild or Moderate:
  • Oral Rehydration Therapy.  (50-100cc/kg over 4 hrs)

Example:

• Dora is 14% dehydrated, "healthy weight 12kg)
• The idea is to correct her with bolus to achieve circulatory stability (this means correct 4% to 10% deficit).  And give the rest with the maintenance fluid over longer term.
• 140ml/kg * 12kg = 1680 mL
• Dora is 1680 mL of fluid behind.
• However, we only do IV up to circulatory stability - 10% dehydration.  So we need to correct 4% of dehydration via IV fluids.
  • 40ml/kg * 12kg = 480mL  (give to 10% right away to get circ stability) over 30min or so.
• Calculate maintenance: 4mL/hr*10kg (40) + 2 ml/hr * 2kg (4ml) = 44mL/hr
• Calculate remaining deficit (10%): 100mL/kg * 12kg = 1200ml/day = 50mL/hr
• Total requirement/hr = 94mL/hr (this will correct deficit within one day), then maintain 44mL/hr for maintenance for days following.

Lytes:

• Potassium needs typically 20-40mmol/L 
• Assumes no renal problems.
• Repeat lytes q6hrs while on IV fluids.