Table of contents
- 1. Fever without a source
- 2. Sickle Cell
- 3. Febrile Seizures (Pediatric)
- 3.1. Simple vs Complex (Atypical)
- 3.2. Investigations
- 3.3. Management
- 4. Acute Otitis Media
- 5. UTI or Urosepsis
- 6. Arthritis
- 7. Autoimmune
- 8. Infectious
- 8.1. Hand Foot Mouth Disease
- 8.2. Scarlet Fever
- 8.3. Roseola
- 8.4. Fifth Disease
- 8.5. Herpes
- 9. Dehydration
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)
- >1mo (consider low-risk criteria)
Sickle Cell
Febrile Seizures (Pediatric)
- Associated w fever, no evidence of intracrania infection
- Age 6mo-6y
- Tonic-clonic most common
Simple vs Complex (Atypical)
- Typical Features:
- Generalized
- Brief <15min
- Once in 24hrs.
Investigations
- Lab tests (depends on hx)
- Lumbar Puncture if:
- <12mo old w/o fever source OR
- if children with first complex febrile seizure
Management
- Seizure safety (Nothing in mouth, turn on side)
- Treat infection
- Treat fever (antipyretics - not effective in preventing seizure)
- Prophylaxis not indicated.
-
Counselling:
- Simple Febrile Seizure
- Self-limiting seizure
- Does not cause permanent brain damage
- Increased risk of recurrence (30% if >12mo, and 50% if <12mo age)
- Complex Febrile Seizure
- Increased risk of epilepsy
- Not increased risk of recurrence febrile seizures.
- Simple Febrile Seizure
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.
-
- 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
- Something that covers E.coli (80%)
- 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
- Joint Effusion
- 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)
Reactive Arthritis
- Joint inflammation following infections somewhere.
- Joint tap to r/o septic arthritis if: history of fever, inability to wt bear, ESR >40mm/hr, WBC >12.0
- Knees
- Hips
- Ankles
- Elbows
Juvenile Idiopathic Arthritis
- Onset ≤16yo,
- duration ≥6 weeks (retrospective)
- Other causes excluded.
- NOT PAINFUL
- Acute Uveitis can manifest
- red, painful, photophobic eye (10-20% of JIA patients),
- compications: cataracts, synechiae, scarring, glaucoma, vision loss.
- ANA increases risk of uveitis
- Develops 5-7y of JIA (must do regular slit lamp exams)
Systemic JIA
- Also salmon-colored Rash, transient fevers, HSM, lymphadenopathy, serositis, pericarditis
- Acute phase reactants + anemia
Psoriatic Arthritis
- Associated with:
- Nail pitting
- Dactylitis
- Skin lesions (psoriasis)
Enthesitis Related Arthritis
- Males, older age,
- SI joints may be involved
- Many features:
- Enthesitis (Entheses: sites where tendons and ligaments insert into bone)
- Causes plantar spurs (Painful to walk on)+ Achilles Erosions (looks like bite on xray)
- Acute Uveitis (red, painful, photophobic eye) (10-20% of JIA patients), compications: syneciae
Slipped Capital Femoral Epiphysis
- 10-14yo
- Males
- Overweight
- Surgical emergency
Autoimmune
Henoch-Schonlein Purpura (HSP)
- Most common vasculitis in children
- Usually follows respiratory infection
- IgA deposition in small vessels of:
- Kidneys: proteinuria, hematuria, RBC casts, abn renal function(40-50%)
- GI : gi pain (50-75%)
- skin: palpable purpura (100%)
- Joints: arthritis/arthralgias (75%)
- Treatment:
- Supportive
- NSAIDS for symptom relief
- Corticosteroids if severe (symptoms, renal disease, skin)
- Prognosis: usually goes away in 4 weeks, poor prognosis with severe nephritis.
Kawasaki Disease
- Small-medium vessel vasculitis
- 3mo-5y of age
- Usually triggered by infection
- Major concern if coronary artery aneurisms.
- Typical: ≥5 days of fever, plus >4/5 criteria.
- Rash
- Cervical lymphadenopathy >1.5cm
- Peripheral Extremity Changes
- Bilateral non-purulent conjunctivitis
- Oral Mucosal Changes.
- Treatment: (Need to treat within 7-10days after fever)
- IVIG 2g/kg
- ASA (first high dose 80-100 mg/kg/d until afebrile, then 3-5mg/kg/day)
- Treatment reduces coronary artery aneurisms from 20% to 4%.
Infectious
Exanthem (Generalized rash not involving mucous membranes) | Measles Rubella Fifth Disease (Pavrovirus B19) Roseola (HHV-6 and 7) Scarlet Fever |
Enathem (Rash on mucous membranes) | Small pox Measles Chickenpox |
Hand Foot Mouth Disease
- Coxsackie Group A virus
- vesicles, pustules with erythematous base on hand, feet, mouth
- Enanthems: tongue, posteriour pharynx.
Scarlet Fever
- Group A Strep
- Generalized red papules with "sand-paper" texture
- Desquamation
- Enanthems: strawberry tongue, petechiae on palate.
- Give Penicillin or amp or amox x10 days.
- Complications: Pneumonia, pericarditis, meningitis, hepatitis, glomerulonephritis, rheumatic fever
Roseola
- HHV-6
- Fever for 5 days then maculopapular rash
- Symptomatic treatment, self resolving (watch out for febrile seizures).
Fifth Disease
- Pavrovirus B19
- "Slap cheeks", maculopapular lacy rash. Reappears with sun/exercise.
- Symptomatic treatment.
- Careful of STAR complex
Herpes
- HSV1 HSV2
- Presentations:
- Disseminated herpes.
- Perioral herpes (initial presentation in kids can be significant gingival involvement called gingivostomatitis)
- Genital Herpes
- Herpetic witlow (suck on finger, herpes infects causes painful lesion for weeks).
- Eczema herpeticum
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:
Age | Mild(%) | Moderate (%) | Severe (%) |
≤ 2 | 5 (50 ml/kg) | 10 (100 ml/kg) | 15 (150 ml/kg) |
> 2 | 3 (30 ml/kg) | 6 (60 ml/kg) | 9 (90 ml/kg) |
- 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.
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