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

    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.

           

     

    Acute Otitis Media

    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:AOMmanagement.png
      • 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)

    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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