Facilitated by Partners In Healthcare and sponsored by Walgreens

Facilitated by Partners In Healthcare and sponsored by Walgreens
Evidence Based Pediatric Treatment Guidelines 2014: Clinical Practice Strategies for the Retail Clinician Wendy L. Wright, MS, RN, APRN, FNP, FAANP Owner – Wright & Associates Family Healthcare Partner – Partners in Healthcare Education Facilitated by Partners In Healthcare and sponsored by Walgreens Wright, 2014 Wright, 2014

Another Great Resource for Pediatrics
accessed Wright, 2014

Development & Anticipatory Guidance
Developmental Screening 9 months 18 months 30 months Identify those infants and children with developmental disorders accessed Wright, 2014 Wright, 2014

Development & Anticipatory Guidance
Every visit from birth – age 21 Specific guidance is based upon age accessed Wright, 2014

Eye Examinations and Vision
AAP recommendations Begin vision screening as a newborn Formal screening at: Age 3 years Age 4 years Age 5 years Age 6 years Age 8, 10, and 12 years Age 15 and 18 years Wright, 2014

AAP Updates Hearing Screening
Most common congenital developmental abnormality affecting children in the United States Screen before 1 month Repeat by 3 months if abnormal If abnormal, referred to early intervention before age 6 months for formal evaluation Wright, 2014 accessed

AAP Recommendations Universal newborn hearing screening
Screenings for hearing impairment should be performed periodically on all infants and children in accordance with the following schedule Newborn Age 4, 5, 6, and 8 Risk assessments performed at all other well-child visits accessed Wright, 2014

USPSTF Hearing Screening Recommendations
The USPSTF recommends screening for hearing loss in all newborn infants All infants should have hearing screening before 1 month of age Those infants who do not pass the newborn screening should undergo audiologic and medical evaluation before 3 months of age for confirmatory testing These children should undergo periodic monitoring for 3 years accessed Wright, 2014

Dental Examination AAP recommendations Begin at age 12 months
3 years of age 6 years of age Wright, 2014

Autism Screening Universal screening
Formal ASD screening on all children at 18 and 24 months regardless of whether there are any concerns Guidelines stress that providers need to ask/discuss any concerns that parents may have at every well-child visit accessed Wright, 2014

M-CHAT Screening Tool http://www.mchatscreen.com
Conducted at 18 and 24 months Can learn to become certified autism screener Wright, 2014

Look for the Presence of Red Flags
No babbling or pointing or other gesture by 12 months No single words by 16 months No two-word spontaneous phrases by 24 months Loss of language or social skills at any age. accessed Wright, 2014

Lead Screening AAP recommendations
12 months or… 24 months Continued risk factor assessment throughout childhood accessed Wright, 2014

Anemia Screening AAP recommendations
Age 12 months Hemoglobin or hematocrit Continued risk assessment throughout childhood accessed Wright, 2014

Children and Screening
Begin at 10 years of age in children at risk or at the onset of puberty, if earlier than 10 years Repeat every 3 years, if normal Wright, 2014

What Constitutes a Risk Factor in Children?
Overweight (BMI>85th %tile for age and sex, weight for height >85th%tile, or weight >120% of ideal for height) In addition – presence of two or more of the following: Family history of type 2 diabetes in first- or second-degree relative Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander) Signs of, or conditions associated with, insulin resistance including acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, small for gestational age at birth history in the child Maternal history of DM or gestational DM accessed Wright, 2014

General Health Counseling
Seatbelts Helmets Sunscreen Smoke Detectors Pool Safety Carbon Monoxide Guns Domestic Violence Wright, 2014

General Health Counseling
Drugs Alcohol Smoking Remember – School / sport physicals may be the only contact that the child has with a health care professional in a year Wright, 2014

Immunization schedule: aged 0 through 18 years— United States, 2014
Wright, 2014

ACIP Recommendations for Use of Meningococcal Vaccine
Routine vaccination of adolescents with MCV-4 Individuals age Microbiologists who are routinely exposed to isolates of Neisseria meningitidis Military recruits Persons who travel to, or reside in, countries in which N meningitidis is hyperendemic or epidemic Complement-deficient and asplenic patients ACIP Recommendations for Use of Meningococcal Vaccine The Advisory Committee on Immunization Practices (ACIP) recently released its recommendation for the use of Menactra, a new quadrivalent conjugate meningococcal vaccine licensed in January The ACIP believes that recommending immunizations with Menactra vaccine among children 11 to 12 years old might have a positive effect on vaccine coverage during adolescence by strengthening the role of the pre-adolescent well visit. In addition to the indication for adolescents, ACIP also has recommended Menactra vaccine for persons in high-risk groups, including incoming college freshmen living in dormitories, microbiologists who are routinely exposed to isolates of Neisseria meningitidis, persons who travel to, or reside in countries in which N meningitidis is epidemic, military recruits, and complement deficient and asplenic patients. Reference: CDC. Prevention and Control of meningococcal disease. MMWR. 2005;54:1-21. CDC. MMWR. 2005;54(RR-7):13. Wright, 2014 Wright, 2014

ACIP Recommendations – October 2010
ACIP recommends routine vaccination of adolescents with MCV4 beginning at age 11 through 12 years at the pre-adolescent vaccination visit, with a booster dose at age 16 years. For adolescents vaccinated at age 13 through 15 years, a one-time booster dose should be given 3 to 5 years after the first dose. Wright, 2014

Updated ACIP Recommendations
Why Change the Program Now? Data indicates protection wanes within 5 years after vaccination Wright, 2014

HPV4 Protects against 4 strains of HPV
16 and 18 – cause 70% of all cervical cancer 6 and 11 – cause 90% of genital warts CDC just recommended administration as young as 9 but ideally to 11 – 12 year old girls Age limit: < 26 years of age Wright, 2014

HPV Vaccine Series of 3 injections
Day 0, day - 2 months and day - 6 months .5 ml injection IM injection into deltoid Wright, 2014

Additional Indication for HPV4
Indicated to reduce risk of genital warts in males Also: reduction in anal cancers Ages: 9 years - < 26 years of age Universal recommendation for boys: 9 – 21 years Permissive recommendation for boys 22 – 26 years (insurance may not cover) Wright, 2014

Additional Approval HPV4
Prevention of anal cancer and associated precancerous lesions due to human papillomavirus (HPV) types 6, 11, 16, and 18 in people ages 9 through 26 years 78 percent effective in the prevention of HPV 16- and 18-related AIN Wright, 2014

Influenza Wright, 2014

Important Influenza Messages
Begin to vaccinate as soon as flu vaccines are received in clinics Immunity lasts throughout entire flu season, even if vaccines are given in August All healthcare professionals who care for patients in a protected environment (severely immunocompromised) should receive the Trivalent Inactivated Vaccine (TIV) rather than LAIV Wright, 2014

Egg Allergy and TIV 2011 - The recommendation is as follows:
For patients with a history of egg allergy WITHOUT anaphylaxis, there is no need to divide doses or perform skin testing before vaccination There will be no need to confirm the levels of ovalbumin in the flu vaccine because all products will contain less than 0.6 micrograms per dose; Patients with egg allergy should be observed for 30 minutes after vaccination; and Vaccine providers should be equipped and trained to handle anaphylactic emergencies Do not use LAIV (Flumist) Wright, 2014

New Information 2014-2015 strains for influenza vaccine announced
Trivalent or Quadrivalent A/California/7/2009 (H1N1) A/Victoria/361/2011 (H3N2) B/Massachusetts/2/2012 Quad: B/Brisbane/60/2008 accessed

MMR and Travel Before departure, children aged 6–11 months should receive the first dose of MMR vaccine Infants vaccinated before age 12 months must be revaccinated on or after their first birthday with 2 doses of MMR vaccine, separated by at least 28 days accessed Wright, 2014 Wright, 2014

Management of Fever Definition
Temperature > 37.2° C orally or > 98.9° F in am OR….> 37.7° C orally or > 99.9° F in afternoon – pm When child presents with a fever of 5 – 7 days or less, must consider: Viral vs. Bacterial infections Bacteremia Sepsis Wright, 2014

Worrisome Findings: Consider Hospitalization
Altered LOC Abnormal breathing Tachycardia in presence of significant findings Significantly elevated temperature Petechiae Cyanosis Pallor Delayed capillary refill (> 2 seconds) Poor muscle tone Wright, 2014 Wright, 2014

Management of Fever Antipyretics Benefits
May mask signs and symptoms of serious conditions Side effects may occur from these medications Do not alter course of illness Benefits Good when fever is > 103 Always recommend in children with history of febrile seizure May make more comfortable Wright, 2014

Management of Fever Options for treatment (weight/age dosing)
Acetaminophen Ibuprofen Caution regarding cool sponge baths Education: Monitor closely Reinforce when to call or return Avoid aspirin and related products Increase fluids Wright, 2014

Clinical Pearl: Document visual acuity on all eye complaints
Wright, 2014

Hordeolum Etiology History Obstruction of the glands of Zeiss
Staphylococcal aureus is the most common causative organism History Swollen, red, painful lesion on the lid margin Itchiness of the eyelid Wright, 2014

Hordeolum Physical examination Treatment
Erythematous, tender nodule on the margin of the eyelid Surrounding edema Treatment Warm compresses-20 minutes qid Antimicrobial ointment or drops Good eye hygiene and handwashing Wright, 2014

Hordeolum Wright, 2014

Internal Hordeola Wright, 2014

Viral Conjunctivitis Etiology Symptoms
Adenovirus is the most common cause 40 strains identified Recent studies have shown that it can remain viable on plastic and metal surfaces for up to 1 month Symptoms Watery discharge, foreign body sensation, redness URI symptoms are common including sore throat and fever Often bilateral Wright, 2014

Viral Conjunctivitis Signs Treatment
Normal visual acuity, PERRLA, EOMI, Fund nl Mucoid-slightly watery discharge Mild, diffuse injection Preauricular lymphadenopathy Treatment Symptomatic only Cool compresses Strict eye hygiene Wright, 2014

Viral Conjunctivitis Wright, 2014

Bacterial Conjunctivitis
Etiology Staphylococcus aureus Streptococcus pneumoniae/pyogenes Haemophilus influenzae Neisseria gonorrhea Symptoms Redness, swelling, purulent discharge, itching No symptoms until eye complaints began Wright, 2014

Signs Normal visual acuity, PERRLA, EOMI, Fund nl Diffuse injection No ciliary injection Unilateral at onset Treatment Topical antimicrobials x 5-7 days Warm compresses qid x minutes Strict eye hygiene given contagion Wright, 2014

Wright, 2014

Conjunctivitis Viral Bacterial Palpable preauricular node
Watery discharge Mild-moderate conjuctival injection URI symptoms Bilateral Bacterial Non-palpable nodes GC and Chlamydia + Purulent discharge GC-Mucopurulent Moderate conjunctival injection Unilateral at onset Wright, 2014

Allergic Conjunctivitis
Two types of allergic conjunctivitis Seasonal and perennial Seasonal is most common and caused by the following triggers Pollens Grass Ragweed Perennial persists all year and is caused by indoor allergens, such as dust mites Wright, 2014

Signs and Symptoms Symptoms Signs Itching
Watery– stringy-like clear discharge Signs Injected conjunctiva Other physical examination findings such as: Dennie’s lines Allergic shiners Allergic facies Allergic crease Wright, 2014

Wright, 2014

Treatment Systemic and/or topical antihistamines relieve acute symptoms due to interaction of histamine at ocular H1 and H2 receptors Examples of topical antihistamines include: epinastine (Elestat) and azelastine (Optivar) Vasoconstrictors are available either alone or in conjunction with antihistamines to provide short-term relief of vascular injection and redness Common vasoconstrictors include naphazoline, phenylephrine, oxymetazoline, and tetrahydrozoline Wright, 2014

Treatment Mast cell stabilizers include cromolyn sodium and lodoxamide (Alomide), Olopatadine (Patanol), nedocromil (Alocril) Nonsteroidal anti-inflammatory drugs (NSAIDs) act on the cyclooxygenase metabolic pathway and inhibit production of prostaglandins. One example is: ketorolac tromethamine (Acular) Wright, 2014

IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults Clinical Infectious Diseases Advance Access published March 20, 2012 Accessed Wright, 2014

Algorithm for the management of acute bacterial rhinosinusitis
Algorithm for the management of acute bacterial rhinosinusitis. Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging. Chow A W et al. Clin Infect Dis. 2012;cid.cir1043 © The Author Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please Wright, 2014

What Constitutes at Risk for Resistance?
Age < 2 years or > 65 years Daycare Antimicrobial within past 1 month Hospitalization within past 5 days Comorbidities Immunocompromised Accessed Wright, 2014

Goals of Treatment Restore integrity and function of ostiomeatal complex Reduce inflammation Restore drainage Eradicate bacterial infection accessed Wright, 2014

Treatment of Acute Bacterial Rhinosinusitis
Nonpharmacologic Therapies Cold steam vaporizer Increased water intake Intranasal saline irrigations with either physiologic or hypertonic saline are recommended as an adjunctive treatment in adults with ABRS1 1http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html Accessed Wright, 2014 Wright, 2014

Management Strategies in ABRS
Antihistamines or decongestants No longer recommended Topical corticosteroids Intranasal corticosteroids are recommended as an adjunct to antibiotics in the empiric treatment of ABRS, primarily in patients with a history of allergic rhinitis1 Corticosteroids Decongestants should be used in acute rhinosinusitis because they keep the OMC open and prevent bacterial growth in sinus cavity. Do not prescribe antihistamines unless there is an allergy, they have no place in the treatment of infections. Watch out for combination products with antihistamines 1http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html Accessed Wright, 2014 Wright, 2014

Antimicrobial Regimens in Children

Important Changes Macrolides (clarithromycin and azithromycin) are not recommended due to high rates of resistance among S. pneumoniae (30%) TMP/SMX is not recommended due to high rates of resistance among both S. pneumoniae and H. influenzae (30%–40%) Second and third-generation cephalosporins are no longer recommended due to variable rates of resistance among S. pneumoniae. accessed Wright, 2014 Wright, 2014

Length of treatment The recommended duration of therapy for uncomplicated ABRS in adults is 5–7 days In children with ABRS, the longer treatment duration of 10–14 days is still recommended Accessed Wright, 2014

When to Change Treatments
An alternative treatment should be considered if symptoms worsen after 48–72 hours of initial empiric antimicrobial therapy, or when the individual fails to improve despite 3–5 days of antimicrobial therapy Accessed Wright, 2014

When to Refer Accessed Wright, 2014

Ear Conditions Wright, 2014

Wright, 2014

Variations of Tympanic Membrane
Normal TM Acute OM Otitis Media with Effusion Wright, 2014

AAP Updated Guidelines
Diagnosis of AOM: Evidence: 1A Moderate - severe bulging of TM OR…new otorrhea NOT due to otitis externa Evidence: 1B Mild bulging of TM and…. Recent ( < 48 hours) onset of ear pain or…. Intense erythema of TM accessed Wright, 2014

AAP Updated Guidelines (cont.)
Severe AOM: Prescribe antimicrobial for AOM in children 6 months or older with severe signs and symptoms Moderate or severe otalgia for at least 48 hours OR… Temperature: (39 degrees Celsius) accessed Wright, 2014

Nonsevere bilateral AOM in children < 24 months without signs or symptoms: Antibiotics should be prescribed even in the setting of mild symptoms Mild otalgia < 48 hours Temperature < 39 degrees Celsius accessed Wright, 2014

Nonsevere unilateral AOM in children age 6 month – 23 months: Two options: Antimicrobial therapy Observation as treatment option Nonsevere Follow-up must be ensured Start antimicrobials if worsen or no improvement with 48 – 72 hours accessed Wright, 2014

Nonsevere AOM in older children (24 months or older): Two options: Antimicrobial therapy Observation as treatment option Nonsevere Follow-up must be ensured Start antimicrobials if worsen or no improvement with 48 – 72 hours accessed Wright, 2014

Summary: AAP Updated Guidelines (cont.)
AGE Otorrhea with AOM Unilateral or Bilateral AOM with Severe Symptoms Bilateral AOM without Otorrhea Unilateral AOM without Otorrhea 6 months – 2 years Antibiotic Antibiotic therapy or observation > 2 years Antibiotic or observation Antibiotic or observation accessed Wright, 2014

Treatment options: Amoxicillin: first line Provided that: no antibiotics in previous 30 days and No purulent conjunctivitis and Not allergic to PCN accessed Wright, 2014

Treatment options: Amoxicillin/clavulanate Child who has received antibiotics in previous 30 days OR…. Has concurrent purulent conjunctivitis OR…. History of AOM which is unresponsive to amoxicillin accessed Wright, 2014

Initial Immediate or Delayed Antibiotic Treatment
Recommended First line Treatment Alternative Treatment (if Penicillin Allergy) Amoxicillin (80-90 mg/kg/day) in two divided doses OR Cefdinir (14 mg/kg/day) in one – two divided doses Cefuroxime (30 mg/kg/day) in two divided doses Amoxicillin/clavulanate (90 mg/kg/day or amoxicillin) with 6.4 mg/kg/day of clavulanate) in two divided doses Cefpodoxime (10mg/kg/day) in two divided doses Ceftriaxone (50 mg IM or IV) daily for 1 or 3 days accessed Wright, 2014

Antibiotic Treatment After 48-72 hours of Failure of Initial Antibiotic
Recommended First line Treatment Alternative Treatment (if Penicillin Allergy) Amoxicillin/clavulanate (90 mg/kg/day or amoxicillin) with 6.4 mg/kg/day of clavulanate) in two divided doses Ceftriaxone 3 day Clindamycin (30 – 40 mg/kg/day) in three divided doses with or without concomitant third generation cephalosporin Ceftriaxone (50 mg IM or IV) for 3 days Clindamycin (30 – 40 mg/kg/day) in three divided doses with concomitant third generation cephalosporin Tympanocentesis Consult specialist accessed Wright, 2014

Remember… For children with OM and tympanostomy tubes:
You may also utilize topical medications Ofloxacin (Floxin Otic) 0.3% solution Age years: 5 drops into affected ear bid x 10 days Ciprofloxacin (Ciprodex): 6 months and up: 4 drops into the affected ear bid x 7 days Wright, 2014

Duration of Treatment for AOM
Results 10 days: Patients <2 years old or those with severe symptoms 7 days: Age 2-5 years of age with mild – moderate AOM 5 – 7 days: 6 years and older with mild – moderate symptoms accessed Wright, 2014

Otitis Media with Effusion
Fluid in the middle ear No signs and symptoms of AOM Air fluid levels Dullness of TM Decreased movement of TM accessed Wright, 2014

OME Wright, 2014

OME Treatment: Observation as a treatment option
Majority – up to 90% will resolve within 3 months without intervention If still present at 12 weeks – may need hearing evaluation, referral to ENT High risk individuals may be candidates for myringotomy accessed Wright, 2014

Otitis Externa Wright, 2014

Otitis Externa Pathophysiology
Inflammation +/or infection of the external auditory canal Associated with prolonged water exposure, inserting objects into ear, scratching the ear 10-20x more common in the summer Children with eczema, psoriasis, seborrhea are at a greater risk Most common cause: Pseudomonas Wright, 2014

Otitis Externa Symptoms Unilateral ear pain Discharge from the ear
Low grade fever Recent history of swimming or placing something in ear Pain with tragal movement Redness around ear Decreased hearing Wright, 2014

Otitis Externa Signs Erythematous, edematous canal
Pain with tragal/pinna movement Yellow/green discharge Foreign body Pre or postauricular lymphadenopathy Wright, 2014

Otitis Externa Plan Diagnostic Therapeutic None Can check culture
Remove foreign body Irrigate canal Erythromycin (Cortisporin) Otic Ear Solution: 4 drops qid into affected ear x 5 days Ciprofloxacin (Ciprodex) 3 – 4 drops tid into affected ear x 7 days Wright, 2014

Otitis Externa Plan Therapeutic Warm compresses NSAIDS/Tylenol
Prednisone Auralgam Wick Wright, 2014

Otitis Externa Plan Educational
Avoid prolonged water exposure - ear plugs Ear wax removal kits Prevention: Oil into canal; Vaseline on cotton ball No Q tips in ear Try to remove all water after bathing by manipulating ear Wright, 2014

Pharyngitis Wright, 2014

Pharyngitis Epidemiology Group A Beta Hemolytic Strep
Most interest because of its association with severe complications Peritonsillar abscesses, rheumatic fever, post-streptococcal glomerulonephritis - complications Wright, 2014

Pharyngitis Symptoms Group A Beta Hemolytic Strep
Rapid onset of sore throat Fever Swollen glands Children often complain of abdominal pain Usually-no URI symptoms Headache Decreased appetite Dysphagia Irritability Wright, 2014

Exudative pharyngitis
Differentials include: Strep pharyngitis Peritonsillar abscess Mononucleosis Viral pharyngitis Wright, 2014

Pharyngitis Plan Diagnostic
Throat culture: 24 hour is the gold standard Quick strep: % sensitivity; 31-95% specificity Must swab both tonsils for best results Consider mononucleosis Wright, 2014

MUST DO A THROAT CULTURE
Pharyngitis Even with a best case scenario, 1/3 - 1/2 of cases of strep pharyngitis are missed or overdiagnosed using history and physical examination only!!! MUST DO A THROAT CULTURE Wright, 2014

Remember… Children with mono have strep pharyngitis 50% of the time
Wright, 2014

Pharyngitis Plan Therapeutic: Strep Pharyngitis Educational
PCN VK-standard Treatment is for 10 days Warm water gargles Tylenol/NSAID’s Educational Contagion Quick improvement Discard toothbrush Wright, 2014

Peritonsillar Abscess
Generally begins as an acute febrile URI or pharyngitis Condition suddenly worsens Increased fever Anorexia Drooling Dyspnea Trismus Wright, 2014

Physical examination May appear restless Irritable May lie with head hyperextended to facilitate respirations Muffled voice Stridor may be present Respiratory distress Wright, 2014

Physical examination findings Fiery red asymmetric swelling of one tonsil Uvula is often displaced contralaterally and often forward Large, tender lymphadenopathy Wright, 2014

Wright, 2014

If respiratory distress is severe, do not examine the pharynx
Important Reminder If respiratory distress is severe, do not examine the pharynx Wright, 2014

Treatment Aspiration of the abscess may be performed for accurate diagnosis and treatment CT scan of the head and neck Monitor airway at all times ENT consult is essential Usual management IV antibiotics Inpatient management Wright, 2014

Viral Upper Respiratory Infection
Caused by the rhinovirus, adenovirus or coronavirus Transmitted through respiratory droplets Most common ages: 4 – 7 years Begins with sore throat, low grade fever and progresses on to include nasal congestion and a cough Typically lasts 3 – 14 days Wright, 2014

Treatment Mainly symptomatic Consider the following:
Avoid cough and cold medications in individuals < 2 years of age Consider the following: Decongestants First generation antihistamines Cough suppressants Guaifenesin products Chicken soup Wright, 2014

General Signs and Symptoms of Respiratory Distress
Respiratory rate which is > 50% above upper limits of normal for age Intercostal retractions Nasal flaring Substernal retractions Grunting with breathing Cyanosis/pallor Wright, 2014

Asthma and Asthma Exacerbation
Wright, 2014 Wright, 2014

Impact of Asthma Most frequent cause for hospitalization in children (470,000 each year) Emergency room visits and hospitalizations are increasing Most frequent cause of childhood death, particularly amongst certain groups (children, african americans) 5,000 people die yearly from asthma Leads to more than 100 million days per year of restricted activity Most frequent cause for hospitalization in children (470,000 each year) Most frequent cause of childhood death, particularly amongst certain groups Each year-over 5000 people die of asthma and related complications; the majority of this number are children. Increasing incidence of death-amongst inner city children and children of African American ancestry Wright, 2014 Wright, 2014

Asthma is... A disease of: Inflammation Hyperresponsiveness
Primary Process Hyperresponsiveness Airway bronchoconstriction Excessive mucous production A disease of: Inflammation Hyperresponsiveness/Bronchoconstriction Excessive mucous production Wright, 2014 Wright, 2014

Epithelial Damage in Asthma
Disruption of the bronchial epithelium, as shown on this slide, has both structural and functional effects that contribute to inflammation and airway wall remodelling. (Holgate, 1999) Normal Asthmatic Wright, 2014 Jeffery P. In: Asthma, Academic Press 1998. Wright, 2014

Diagnosis of Asthma Diagnosis of Asthma Wright, 2014 Wright, 2014

What is Asthma “A common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation.” National Heart, Lung and Blood Institute; National Asthma Education and Prevention Program; Expert Panel Report 3: Guidelines for Diagnosis and Management of Asthma, Full Report 2007. Wright, 2014

Diagnosis of Asthma History and Physical Examination
Pulmonary Function Tests Monitoring: Peak Flow Meters History and Physical Examination Pulmonary Function Tests Peak Flow Meters Wright, 2014 Wright, 2014

Symptoms and Signs of Asthma in Children
Coughing, particularly at night Wheezing Chest tightness SOB Cold that lingers x months with a persistent cough Coughing, particularly at night Wheezing Chest tightness SOB Tachypnea Restlessness Retractions Associated Symptoms Anxiety-children with asthma more likely to suffer from anxiety symptoms and disorders than non asthmatic children-study by Vila et. Al and Published in Psychosomatics: Sept 1999 Wright, 2014 Wright, 2014

Diagnosis Consider the diagnosis of asthma and perform spirometry if any of these indicators are present. These indicators are not diagnostic by themselves but the presence of multiple key indicators increases the probability of the diagnosis of asthma. Spirometry is needed to make the diagnosis of asthma. National Heart, Lung and Blood Institute; National Asthma Education and Prevention Program; Expert Panel Report 3: Guidelines for Diagnosis and Management of Asthma, Full Report 2007. Wright, 2014

Step 2 Minor limitation None Step 3 and consider short course of oral systemic corticosteroids Persistent Extremely limited Some limitation Interference with normal activity Several times per day Daily >2 days/week but not daily ≤2 days/week SABA use for symptom control (not prevention of EIB) >1x/week 3-4x/month 1-2x/month Nighttime awakenings Throughout the day >2 days/week but not daily Symptoms Severe Moderate Components of Severity Mild Intermittent Impairment Risk Step 1 In 2 to 6 weeks, depending on severity, evaluate level of asthma control that is achieved. If no clear benefit is observed in 4 to 6 weeks, consider adjusting therapy or alternative diagnoses Recommended Step for Initiating Treatment ≥2 exacerbations in 6 mos requiring oral systemic corticosteroids, or ≥4 wheezing episodes/1 year lasting >1 day & risk factors for persistent asthma 0-1/year Exacerbations requiring oral systemic corticosteroids Consider severity and interval since last exacerbation Frequency and severity may fluctuate over time Exacerbations of any severity may occur in patients in any severity category Figure 17-1 Classifying Asthma Severity and Initiating Treatment in Children 0 to 4 Years of Age National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR ). Bethesda, MD. U.S. Department of Health and Human Services. NIH publication Available at: Accessed August 29, 2007.

Stepwise Approach for Managing Asthma in Children Age 0 to 4 Years
Persistent Asthma: Daily Medication Intermittent Asthma Consult with asthma specialist if Step 3 care or higher is required. Consider consultation at Step 2. Step 6 Preferred: High-dose ICS + either LABA or Montelukast and Oral Systemic Corticosteroids Step Up if Needed (first check adherence, inhaler technique, & environmental control) Step 5 Preferred: High-dose ICS + either LABA or Montelukast Step 4 Preferred: Medium-dose ICS + either LABA or Montelukast Step 3 Preferred: Medium-dose ICS Step 2 Preferred: Low-dose ICS Alternative: Cromolyn or Montelukast Step 1 Preferred: SABA PRN Assess Control Step Down if Possible (& asthma is well controlled at least 3 months) Patient Education and Environmental Control at Each Step Quick-Relief Medication for All Patients SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms With viral respiratory infection: SABA q 4-6 hours up to 24 hours (longer with physician consult). Consider short course of oral systemic corticosteroids if exacerbation is severe or patient has history of previous severe exacerbations Caution: Frequent use of SABA may indicate the need to step up treatment. See text for recommendations on initiating daily long-term-control therapy National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR ). Bethesda, MD. U.S. Department of Health and Human Services. NIH publication Available at: Accessed August 29, 2007.

Classifying Asthma Severity and Initiating Treatment in Children 5 to 11 Years of Age
Step 3, med.-dose ICS option, or Step 4 Step 3, medium-dose ICS option Persistent Extremely limited Some limitation Minor limitation None Interference with normal activity Several times per day Daily >2 days/week but not daily ≤2 days/week SABA use for symptom control(not prevention of EIB) Often 7x/week >1x/week but not nightly 3-4x/month 2x/month Nighttime awakenings Throughout the day >2 days/week but not daily Symptoms Severe Moderate Components of Severity Normal FEV1 between exacerbations FEV1 >80% predicted FEV1/FVC>85% FEV1<60% predicted FEV1/FVC <75% FEV1=60%-80% predicted FEV1/FVC= 75%-80% FEV1 80% predicted FEV1/FVC >80% Lung Function Mild Intermittent Impairment Risk Step 2 Step 1 & consider short course of oral systemic corticosteroids In 2 to 6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly Recommended Step for Initiating Treatment Consider severity and interval since last exacerbation Frequency and severity may fluctuate over time for patients in any severity category ≥2/year 0-1/year Relative annual risk of exacerbations may be related to FEV1 Exacerbations requiring oral systemic corticosteroids National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR ). Bethesda, MD. U.S. Department of Health and Human Services. NIH publication Available at: Accessed August 29, 2007.

Stepwise Approach for Managing Asthma in Children Age 5 to 11 Years
Intermittent Asthma Persistent Asthma: Daily Medication Consult w/ asthma specialist if Step 4 care or higher is required. Consider consultation at Step 3. Each Step: Patient education, environmental control, and management of comorbidities Steps 2-4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma Step Up if Needed (first, check adherence, inhaler technique, environmental control, and comorbid conditionals) Step Down if Possible (and asthma is well-controlled at least 3 months) Quick-Relief Medication for All Patients SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: Up to 3 treatments at 20-minute intervals as needed. Short course of oral systemic corticosteroids may be needed Caution: Increasing of use of SABA or use>2 days a week for symptom relief (not prevention of EIB) indicates inadequate control and the need to step up treatment Step 1 Preferred: SABA PRN Step 2 Preferred: Low-dose ICS Alternative: Cromolyn, LTRA, Nedocromil, or Theophylline Step 3 Preferred: Low-dose ICS + either LABA LTRA or Theophylline OR Medium-dose ICS Step 5 Preferred: High-dose ICS + LABA Alternative: High-dose ICS + either LTRA or Theophylline Step 4 Preferred: Medium-dose ICS + LABA Alternative: Medium-dose ICS + either LTRA or Theophylline Step 6 Preferred: High-dose ICS + LABA + Oral Systemic Corticosteroid Alternative: High-dose ICS + either LTRA or Theophylline + Oral Systemic Corticosteroid Assess Control National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR ). Bethesda, MD. U.S. Department of Health and Human Services. NIH publication Available at: Accessed August 29, 2007.

Stepwise Approach for Managing Asthma in Patients Aged≥12 Years
Preferred: SABA PRN Step 2 Preferred: Low-dose ICS (A) Alternative: Cromolyn (A), LTRA (A), Nedocromil (A), or Theophylline (B) Step 3 Preferred: Low-dose ICS + LABA (A) OR Medium-dose ICS (A) Alternative: Low-dose ICS + either LTRA (A), Theophylline (B), or Zileuton (D) Step 5 Preferred: High-dose ICS + LABA (B) AND Consider Omalizumab for Patients Who Have Allergies (B) Step 4 Preferred: Medium-dose ICS + LABA (B) Alternative: Medium-dose ICS + either LTRA (B), Theophylline (B), or Zileuton (D) Step 6 Preferred: High-dose ICS + LABA + Oral Corticosteroid Consider Omalizumab for Patients Who Have Allergies Intermittent Asthma Persistent Asthma: Daily Medication Consult with asthma specialist if Step 4 care or higher is required. Consider consultation at Step 3. Step Up if Needed (first, check adherence, environmental control, and comorbid conditions) Step Down if Possible (and asthma is well controlled at least 3 months) Assess Control Quick-relief medication for all patients SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of systemic oral corticosteroids may be needed Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step up treatment Steps 2-4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma Wright, 2014 National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR ). Bethesda, MD. U.S. Department of Health and Human Services. NIH publication Available at: Accessed August 29, 2007.

Controlling asthma is a major focus of the EPR-3 guidelines
Major Focus in EPR-3 Controlling asthma is a major focus of the EPR-3 guidelines Wright, 2014

Assessing Asthma Control (Youths 12 Years of Age and Adults)
Follow-up Visits: Determine Level of Control and Treatment Needed Components of Control Well-controlled Not Well-controlled Very Poorly Controlled Impairment Symptoms ≤2 days/week >2 days/week Throughout the day Nighttime awakenings ≤2 x/month 1-3x/week ≥4x/week Interference with normal activity None Some limitation Extremely limited Short-acting beta2-agonist use for symptom control (not prevention of EIB) Several times per day FEV1 or peak flow >80% predicted/personal best 60-80% predicted/personal best <60% predicted/personal best Validated Questionnaires ATAQ ACQ ACT ≤0.75* ≥20 1-2 ≥1.5 16-19 3-4 N/A ≤15 Exacerbations 0-1/year ≥2/year (see note) Consider severity and interval since last exacerbation Risk Progressive loss of lung function Evaluation requires long-term follow-up care Treatment-related adverse effects Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk. Wright, 2014 *ACQ values of are indeterminate regarding well-controlled asthma. Key: EIB, exercise-induced bronchospasm; FEV1, forced expiratory volume in 1 second. See figure 3-8 for full name and source of ATAQ, ACQ, ACT.

Monitoring Control in Clinical Practice: Asthma Control Test™ for Patients Aged ≥12 Years1
Level of Control Based on Composite Score2 ≥20 = Controlled 16-19 = Not Well Controlled ≤15 = Very Poorly Controlled Regardless of patient’s self assessment of control in Question 5 Monitoring Control in Clinical Practice: Asthma Control Test™ for Patients Aged ≥12 Years Key Point: Newer patient-centric questionnaires, such as the ACT, are useful in assessing asthma control The questions on the ACT focus on activity limitation; symptoms such as wheezing, coughing, shortness of breath, or chest tightness; and use of rescue medication, as well as overall patient assessment of asthma control1 For each question, patients rate their level of control on a scale of 1 to 5, with 5 indicating better control. The numbers are then added together to calculate a total score, with a maximum value of 251 In patients aged ≥12 years, the NAEPP draft guidelines define “well-controlled” as a composite score of ≥20, not well controlled as a composite score of 16 to 19, and very poorly controlled as a composite score ≤152 It is possible that patients may rate their asthma as well controlled (as seen in question 5) yet have a total control score of <19, indicating suboptimal control. The ACT, therefore, provides physicians with an opportunity to engage patients in a dialogue regarding the importance of control, and what is and is not considered well-controlled asthma1 The results from a study by Nathan et al reinforce the ease and usefulness of the ACT survey3 The ACT was developed with the guidance of a group of primary care physicians and asthma specialists, given the need for a simple method to qualify asthma control. This group developed a list of 22 survey items consistent with asthma treatment guidelines3 To validate this tool and identify those guidelines that correlate best with asthma control, this 22-item survey was conducted via a 4-week recall period to 471 asthma patients across 6 specialty groups3 In addition to the survey, prebronchodilator FEV1 measurements were taken, and physicians interviewed all patients. Based on these assessments, physicians graded patients’ asthma control on a 5-point scale with 1 meaning “not controlled” and 5 indicating “completely controlled”3 Stepwise logistic regression methods were used to identify those items that had the greatest validity in differentiating between patients with different physician-described levels of asthma control. Based on the analysis, 5 items were selected for the ACT. The 5 items were found to have an internal consistency reliability of 0.84 overall3 1. Asthma Control Test™ copyright, QualityMetric Incorporated 2002, All rights reserved. 2. Available at: Accessed February 5, 2007. Wright, 2014 1. Asthma Control Test™. Copyright, Quality Metric Incorporated 2002, All Rights Reserved. 2. NIH; NHLBI; National Asthma Education and Prevention Program. EPR-3. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (January 2007 Draft). Available at: Accessed February 5, 2007. 3. Nathan RA, Sorkness CA, Kosinski M, et al. Development of the Asthma Control Test: a survey for assessing asthma control. J Allergy Clin Immunol. 2004;113:59-65. Wright, 2014 124

Acute Asthma Exacerbation Management
Wright, 2014

Case Study 6 year old who presents with a 2 day history of increasing sob and wheezing Began after developing a URI + nasal discharge, wheezing, cough, fever – 99.6 Denies ST, ear pain, sinus pain, pain with inspiration Meds: none Allergies: NKDA PMH: Bronchiolitis: age 6 months – required hospitalization Wright, 2014

Physical Examination 6 year old who is wheezing audibly and obviously uncomfortable RR: 30 and labored Pulse: 124 bpm Lungs: + inspiratory and expiratory wheezes No use of accessory muscles Remainder of exam is unremarkable Wright, 2014

Acute Asthma Exacerbation
Measure Spirometry vs. Peak Flow FEV1 is most important number >80% predicted 50% – 79% of predicted < 50% of predicted Wright, 2014

What does this mean for our patient?
Spirometry Results FEV1 = 62% of predicted FEV1/FVC = 90% What does this mean for our patient? Wright, 2014

Acute Asthma Exacerbation
Inhaled short acting beta 2 agonist: Up to three treatments of 2-4 puffs by MDI at 20 minute intervals OR a single nebulizer Can repeat x 1 – 2 provided patient tolerates Albuterol or similar via nebulizer Reassess spirometry or peak flow after Wright, 2014

Prednisone Multiple products available Prelone, Orapred, Prednisone
1 mg/kg daily (may split dosage) Example: Prednisone 10 mg bid x days No taper necessary Wright, 2014

Home Nebulizer May be important to order the patient a nebulizer to be delivered to his/her home Will be set up by a respiratory company Patient and parent will be taught appropriate utilization Wright, 2014

Patient Education Have plan in place for next URI
Preventative therapy? Environmental modification Daily peak flows Wright, 2014

Severity of Acute Exacerbations

Bronchiolitis Wright, 2014

Bronchiolitis Bronchiolitis is the most common lower respiratory tract infection in infants and is usually caused by a viral infection Most common cause: respiratory syncytial virus RSV is responsible for > 50% of all cases Other causes: adenovirus and influenza Most commonly seen in the winter and spring Wright, 2014

Bronchiolitis Bronchiolitis
Affects infants and young children most often because their small airways become blocked by mucous more easily than older children Usually occurs between birth and 2 years of age Peak occurrence: 3 – 6 months Wright, 2014

Burden of Illness Typically, bronchiolitis is a mild illness
Risk factors for more severe illness include: Prematurity Heart or lung disease Weakened immune system Wright, 2014

Complications of Bronchiolitis
Hospitalization Respiratory distress Children with this condition are more likely to develop asthma later in life Wright, 2014

Signs and Symptoms Usually presents as the common cold initially
Nasal congestion Runny nose Cough These symptoms typically last for 1 -2 days and then symptoms begin to worsen Fever Vomiting after coughing Wright, 2014

Signs and Symptoms Cough worsens Wheezes frequently occur
High pitched sounds indicating a difficulty with air movement Worsening respiratory distress may occur Retractions Flaring of the nostrils Irritability Tachycardia and tachypnea Wright, 2014

Incubation Period and Duration
Incubation period is: Days – 1 week This is dependent upon which virus is responsible for the infection Duration of symptoms Typically 7 days but children with severe cases may cough for weeks Wright, 2014

Treatment Symptomatic treatment is the most common treatment
Increased fluids Cool mist vaporizer to thin the secretions Tilting the child’s mattress up may be beneficial Antibiotics are not helpful Wright, 2014

Inhaled corticosterioids
Pharmacotherapy Corticosteroids Inhaled corticosterioids Wright, 2014

Bronchitis Wright, 2014

Bronchitis Definition: Inflammatory condition of the tracheobronchial tree Acute bronchitis Most cases of acute bronchitis are viral (90-95%) 5% are bacterial Most frequent cause of bacterial bronchitis – atypical pathogen (i.e. mycoplasma) Wright, 2014

Treatment for Bronchitis
Symptomatic Increase fluids Steam Guiafenesin or similar First generation antihistamine Cough syrup – usually not helpful or effective Wright, 2014

Bronchitis Treatment Antibiotics rarely needed Prednisone
If needed, atypical pathogen coverage Prednisone Short, non-tapering burst is often very effective i.e. 5 days Wright, 2014

Pertussis Wright, 2014

Pertussis: Preventable but Persistent
“There is a relative lack of awareness among health-care providers that pertussis immunity from natural infection or childhood vaccination wanes 5-8 years after the last booster dose. This leaves adolescents and adults vulnerable to pertussis infection, and those infected can transmit risk of life-threatening disease to young infants.”1 Pertussis: Preventable but Persistent “There is a relative lack of awareness among health-care providers that pertussis immunity from natural infection or childhood vaccination wanes 5-8 years after the last booster dose. This leaves adolescents and adults vulnerable to pertussis infection, and those infected can transmit risk of life-threatening disease to young infants.”1 Reference: 1. Healy CM, Rench MA, Castagnini LA, Baker CJ. Pertussis immunization in a high-risk postpartum population. Vaccine. 2009;27(41): Reference: 1. Healy CM, et al. Vaccine. 2009;27(41): Wright, 2014

Pertussis: Highly Communicable, Frequently Overlooked
Acute respiratory tract infection caused by Bordetella pertussis (gram-negative aerobic bacillus)1 Highly communicable (90%-100% secondary attack rate among susceptibles)2,3 Morbidity in all ages, especially infants1,2 The cause of 13%-17% of cases of prolonged cough in adolescents and adults4 Adolescents, adults with unrecognized or untreated pertussis contribute to the reservoir of B pertussis in the community and pose a risk of transmission to others1 Eye of Science /Photo Researchers, Inc. Pertussis: Highly Communicable, Frequently Overlooked Pertussis, or whooping cough, is a highly contagious acute respiratory infection caused by Bordetella pertussis, a gram-negative aerobic bacillus.1 It is easily transmitted from one person to another via coughed aerosol droplets, and has a 90%-100% secondary attack rate among susceptibles.2,3 The disease may occur at any age, but it manifests most severely in infants, in whom it is potentially life-threatening. In serologic studies, 13%-17% of prolonged cough in adults and adolescents has been found to be caused by B pertussis.4 However, diagnosis is often difficult in these age groups; pertussis may be mild or cause moderate to severe symptoms; the only symptoms may be those of a minor, nonspecific upper respiratory tract infection. Infected adolescents and adults constitute a reservoir for infection in infants and young children.1,3 References: 1. Centers for Disease Control and Prevention (CDC). Recommended antimicrobial agents for treatment and postexposure prophylaxis of pertussis: 2005 CDC guidelines. MMWR. 2005;54(RR-14): CDC. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine: recommendations of the Advisory Committee on Immunization Practices and Recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR. 2006;55(RR-17): Long SS: Pertussis (Bordetella pertussis and Bordetella parapartussis.) In:Kliegman RM, Behrman RE, Jenson HB, Stanton BF eds, Nelson Textbook of Pediatrics. 18th edition. Philadelphia, PA: Saunders Elsevier; 2007: Cherry JD. The epidemiology of pertussis: a comparison of the epidemiology of the disease pertussis with the epidemiology of Bordetella pertussis infection. Pediatrics. 2005;115(5): References: 1. Centers for Disease Control and Prevention (CDC). MMWR. 2005;55(RR-14): CDC. MMWR. 2006;55(RR-17): Long SS: Pertussis (Bordetella pertussis and Bordetella parapartussis.) In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds, Nelson Textbook of Pediatrics. 18th edition. Philadelphia, PA: Saunders Elsevier;2007: Cherry JD. Pediatrics. 2005;115(5): Wright, 2014 Wright, 2014

Reported Cases of Pertussis Are Highest in Adolescents and Adults …
~10,000-25,000 cases of pertussis are reported in the US every year1 ~60% of reported cases occur among adolescents and adults2 Reported cases are the tip of the iceberg Estimated actual cases among adolescents and adults: 800, million per year3 Courtesy of the Centers for Disease Control and Prevention (CDC). Reported Cases of Pertussis Are Highest in Adolescents and Adults … Approximately 10,000-25,000 cases of pertussis are reported in the US every year.1 The majority of those cases (about 60% in recent years) occur among adolescents and adults.2 Reported cases, however, represent only a small fraction of actual cases among adults and adolescents in the US, which are estimated at 800, million per year.3 The CDC notes, “Despite increasing awareness and recognition of pertussis as a disease that affects adolescents and adults, pertussis is overlooked in the differential diagnosis of cough illness in this population.”4 References: 1. CDC. Summary of notifiable diseases—United States, (Published July 9, 2009 for Volume 56, 2007). MMWR. 2007;56(53): CDC. Data on file (Pertussis Surveillance Reports), MKT ( ); MKT18596 (2007); MKT (2008). 3. Cherry JD. The epidemiology of pertussis: a comparison of the epidemiology of the disease pertussis with the epidemiology of Bordetella pertussis infection. Pediatrics. 2005;115(5): CDC. Recommended antimicrobial agents for treatment and postexposure prophylaxis of pertussis: 2005 CDC guidelines. MMWR. 2005;54(RR-14):1-16. “Despite increasing awareness and recognition of pertussis as a disease that affects adolescents and adults, pertussis is overlooked in the differential diagnosis of cough illness in this population.”4 References: 1. CDC. (Published July 9, 2009 for 2007). MMWR. 2007;56(53): CDC. Data on file (Pertussis Surveillance Reports), MKT ( ); MKT18596 (2007); MKT (2008). 3. Cherry JD. Pediatrics. 2005;115(5): CDC. MMWR. 2005;55(RR-14):1-16. Wright, 2014 Wright, 2014

The Very Young are Very Vulnerable to Complications of Pertussis
Pertussis complications, hospitalizations, and deaths1 Age No. with pertussisa Hospitalization Pneumonia Seizures Encephalopathy Death <6 months 7203 4543 847 103 15 56 6-11 months 1073 301 92 7 1 1-4 years 3137 324 168 36 3 The Very Young Are Very Vulnerable to Complications of Pertussis Complications of pertussis include pneumonia and neurologic complications, such as seizures and acute encephalopathy. These complications are serious and sometimes fatal, occurring most often in children <6 months of age.1,2 For example, in the United States between 1997 and 2000, among children ≤4 years of age, 88% of pertussis-related hospitalizations occurred among infants <6 months of age.1 Furthermore, complications of pertussis in this age group are more likely to lead to death. In children ≤4 years of age, of the 58 deaths attributable to pertussis complications, 97% of them occurred in children <6 months of age.1 More recently, during the period , young infants again experienced the most serious complications of pertussis.3 For example, 76 of the 100 deaths from pertussis during this period occurred among infants <2 months of age at the onset of illness. The case-fatality ratio among infants <2 months of age was 1.8%.3 Among 12,174 infants younger than 12 months of age, 62.8% were hospitalized, 55.8% experienced apnea, 12.7% had radiographically confirmed pneumonia, and 1.5% suffered seizures.3 References: 1. CDC. Pertussis—United States, MMWR. 2002;51(4): CDC. Recommended antimicrobial agents for treatment and postexposure prophylaxis of pertussis: 2005 CDC guidelines. MMWR. 2005;54(RR-14): CDC. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. Recommendations of the Advisory Committee on Immunization Practices and Recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR. 2006;55(RR-17):1-37. a Individuals with pertussis may have had 1 or more of the listed complications. Data are for “Unvaccinated or incompletely vaccinated infants aged <12 months have the highest risk for severe and life-threatening complications and death.”2 References: 1. CDC. MMWR. 2002;51(4): CDC. MMWR. 2005;54(RR-14):1-16. Wright, 2014 Wright, 2014

Transmitting Pertussis to Infants Is a Family Matter1
Multicenter study in France, Germany, Canada, US Study population: 95 infants ≤6 months of age with lab-confirmed pertussis Household members were responsible for 76%-83% of transmission to infants in 44 cases where a source could be identified Part-time caretaker 2% Grandparent 6% Friend/Cousin 10% Mother 37% Aunt/Uncle 10% Transmitting Pertussis to Infants Is a Family Matter1 A recent multicenter study conducted in France, Germany, Canada, and the United States included 95 index cases and 404 contacts.1 A source of pertussis was identified for 48% of infants in the primary analysis and up to 78% in additional analyses. The authors concluded that the study provided solid evidence that among infants for whom a source case was identified, household members were responsible for 76%-83% of transmission of B pertussis to this high-risk group. Mothers accounted for 37% of known pertussis transmission; fathers, 18%.1 The authors suggested that vaccination of adults and adolescents in close contact with young infants may eliminate a substantial portion of infant pertussis if high coverage rates can be achieved. A follow-up study by the same author concluded that casual transmission of pertussis to infants from sources in the community is also a factor and could account for approximately one-third of infant cases of pertussis.2 References: 1. Wendelboe AM, Njamkepo E, Bourillon A, et al. Transmission of Bordetella pertussis to young infants. Pediatr Infect Dis J. 2007;26(4): Wendelboe AM, Hudgens MG, Poole C, Van Rie A. Estimating the role of casual contact from the community in transmission of Bordetella pertussis in young infants. Emerg Themes Epidemiol. 2007;4:15. Sibling 16% “Implementation of the ACIP recommendation for adult and adolescent [Tdap] vaccination could substantially reduce the burden of infant pertussis, if high coverage rates among those in contact with young infants can be achieved.” Father 18% Reference: 1. Wendelboe AM, et al. Pediatr Infect Dis J. 2007;26(4): Wright, 2014 Wright, 2014

ACIPa Recommendations for Use of Tdapb in Adults and Adolescents
All adults years of age who have not already received Tdap:1 Single dose to those who received their last tetanus and diphtheria toxoid (Td) vaccine ≥10 years ago Interval as short as 2 years since last Td may be used, especially in settings of higher risk (outbreaks, contact with infants) (CHANGED) All adolescents years of age2 Single dose of Tdap instead of Td Preferred timing is years of age ACIP Recommendations for Use of Tdap in Adults and Adolescents The Advisory Committee on Immunization Practices (ACIP) recommends routine use of tetanus, diphtheria, and acellular pertussis (Tdap) vaccine in adults years of age. All adults who received their last tetanus and diphtheria toxoid (Td) vaccine more than 10 years ago should be vaccinated with a single dose of Tdap vaccine.1 Intervals as short as 2 years since the last Td vaccine are acceptable in cases of wound management and in situations when the risk of pertussis transmission is high—for example, during pertussis outbreaks, or when an adult is in contact with infants. Tdap is also recommended for all adolescents years of age who have not already received it. The preferred timing of Tdap vaccination is years of age.2 References: 1. CDC. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC) for use of Tdap among health-care personnel. MMWR. 2006;55(RR-17): CDC. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2006;55(RR-3):1-43. a ACIP = Advisory Committee on Immunization Practices. b Tdap = Tetanus, diphtheria, and acellular pertussis vaccine. Reference: 1. CDC. MMWR. 2006;55(RR-17): CDC. MMWR. 2006;55(RR-3):1-43. Wright, 2014 Wright, 2014

October 2010 – ACIP Recommendations
Tdap – for those over 65 years of age who have not received Tdap previously, those desiring Tdap, or those who to be in contact with infants Ideally, 2 weeks before contact Interval has been removed for time between Td and Tdap Also – Tdap may now be given (off-label) to individuals 7 years of age (as a catch up) for children not immunized Wright, 2014

The ACIP Recommends: Build a Cocoon of Protection Around Infants1
Tdap is recommended for all adults who have or anticipate having close contact with infants <12 months of age Parents, grandparents (<65 years of age), child-care providers, health-care personnel All should receive Tdap at least 2 weeks before beginning contact with the infant The ACIP Recommends: Build a Cocoon of Protection Around Infants1 The ACIP recommendations for Tdap are consistent with the “cocoon” strategy of immunizing adults in order to help protect infants. Adults who have close contact, or expect to have close contact, with infants <12 months of age should receive Tdap vaccine at least 2 weeks prior to beginning contact, according to the recommendations. This includes parents, grandparents <65 years of age, child-care workers, and health-care personnel, among others. An interval as short as 2 years since the last dose of Td vaccine is suggested, in order to reduce the risk for local and systemic reactions post-vaccination; shorter intervals may be used. Reference: 1. CDC. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC) for use of Tdap among health-care personnel. MMWR. 2006;55(RR-17):1-37. Reference: 1. CDC. MMWR. 2006;55(RR-17):1-37. Wright, 2014 Wright, 2014

ACIP Recommendations: Tdap for Mothers
Women are encouraged to receive a single dose of Tdap before conception if they have not already received Tdap1 Maternal antibody affords only limited (<2 months) protection for the infant2,3 For mothers who have not already received Tdap, Tdap is recommended “as soon as feasible” in the immediate postpartum period1 Vaccination should occur before discharge from the hospital or birthing center ACIP Recommendations: Tdap for Mothers The ACIP recommendations encourage women to receive a single dose of Tdap before conception if they have not already received Tdap.1 Maternal antibody offers only limited (<2 months) protection to the newborn.2,3 For women who have not received Tdap previously, Tdap is recommended as soon as feasible in the immediate postpartum period.1 The vaccine should be administered prior to discharge from the hospital or birthing center.1 References: 1. CDC. Prevention of pertussis, tetanus, and diphtheria among pregnant and postpartum women and their infants: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2008;57(RR-4): Healy CM, Munoz FM, Rench MA, et al. Prevalence of pertussis antibodies in maternal delivery, cord, and infant serum. J Infect Dis. 2004;190(2): Shakib JH, Ralston S, Raissy HH, et al. Pertussis antibodies in postpartum women and their newborns. J Perinatol. 2010;30(2):93-97. References: 1. CDC. MMWR. 2008;57(RR-4): Healy CM, et al. J Infect Dis. 2004;190(2): Shakib JH, et al. J Perinatol. 2010;30(2):93-97. Wright, 2014 Wright, 2014

New 2013 Tdap with each pregnancy
Tdap may be administered any time during pregnancy, but vaccination during the third trimester would provide the highest concentration of maternal antibodies to be transferred closer to birth Regardless of interval and previous vaccination with Tdap accessed Wright, 2014

Tdap Issue Remaining What to do with individuals who have received Tdap and are in need of another Td vs. Tdap Tdap revaccination (June 2013) Meeting agenda for June 2013 Decided NOT to universally recommend for all, other than pregnant women Wright, 2014

Diagnostic Tests for Pertussis
NP culture on special media (Regan-Lowe, Bordet-Gengou) PCR Serologic tests Increased WBC with an absolute lymphocytosis DFA—variable sensitivity/specificity Copyright © 2005 Nucleus Medical Art. All rights reserved. The best site to obtain an appropriate clinical specimen is the posterior nasopharynx, either by aspiration of nasopharyngeal secretions or by insertion of a Dacron® or calcium alginate wire swab applicator.1 Samples taken from nasal discharge or by swabbing the throat and tonsils are inadequate.2 Polymerase chain reaction (PCR) is emerging as the diagnostic method of choice on the basis of studies showing it to be more specific and sensitive than culture.3,4 PCR diagnostic tests would provide results % more sensitive than culture.3 Use only a Dacron® swab for this procedure. Serologic testing is not standardized and because of a lack of association between antibody levels and immunity to pertussis, results are difficult to interpret.3,4 Direct fluorescent antibody (DFA) can yield rapid results but has disadvantages of variable sensitivity and specificity.1 References: 1. CDC. Epidemiology and prevention of vaccine-preventable diseases (The Pink Book), 7th ed. US Department of Health and Human Services. 2002: Available at Accessed March 13, 2005. 2. Murphy T, Bisgard K, Sanden G. VPD Surveillance Manual, Chapter 2. Diagnosis and laboratory methods. June 2000; 3. Chia JH, Su LH, Lin PY, et al. Comparison of multiplex polymerase chain reaction, culture, and serology for the diagnosis of Bordetella pertussis infection [abstract]. Chang Gung Med J. 2004;27(6): 4. Wright SW. Pertussis infection in adults. South Med J. 1998;91(8): Wright, 2014 Wright, 2014

Treatment of Cases and Chemoprophylaxis of Close Contacts
Erythromycin estolate or erythromycin ethylsuccinate (EES) mg/kg/day (max 2 g/day) in 2-4 divided doses for 7-14 days1* Azithromycin mg/kg/day (max 500mg/day) 1 dose/day for 5 days† Clarithromycin mg/kg/day (max 1g/day) in 2 divided doses for 7 days While the Advisory Committee on Immunization Practices (ACIP) recommends 14 days of erythromycin in the United States for treatment of cases and close contacts of pertussis, 7 days is the recommended dose in Canada. In Canada, on the basis of results from 4 randomized controlled trials, the recommended treatment for pertussis is 7 days of erythromycin,1 5 days of azithromycin,2 or 7 days of clarithromycin.3 References: 1. Halperin SA, Bortolussi R, Langley J, Miller B, Eastwood B. Seven days of erythromycin estolate is as effective as fourteen days for the treatment of Bordetella pertussis infections. Pediatrics. 1997;100:65-71. 2. Halperin SA. Pertussis Control in Canada [letter]. CMAJ. 2003;168(11): 3. Lebel MH, Mehra S. Efficacy and safety of clarithromycin versus erythromycin for the treatment of pertussis: a prospective, randomized, single blind trial. Pediatr Infect Dis J. 2001;20: Reference: 1. Halperin SA. Pertussis Control in Canada [letter]. CMAJ. 2003;168(11): * Use caution when using macrolides, especially erythromycin, in infants less than 2 weeks old. † Azithromycin may be given as mg/kg/day (max 500 mg/day) on day 1 and 5 mg/kg/day (max 250 mg/day) on days 2-5. Wright, 2014 Wright, 2014

Treatment of Cases and Chemoprophylaxis of Close Contacts (cont’d)
For patients allergic to macrolides: Trimethoprim-sulfamethoxazole 8mg TMP/40mg SMX/kg/day (max 320mg TMP/1600mg/day) in 2 divided doses for 14 days1 All of these agents reduce transmission of B pertussis and ameliorate early symptoms2 No antibiotic lessens the severity or shortens the duration of cough in patients who are already experiencing paroxysmal episodes1 Penicillins/cephalosporins are not effective If patients are allergic to macrolides, trimethoprim-sulfamethoxazole can be given—8mg TMP/40mg SMX/kg/day (max 320mg TMP/1600mg/day)—in 2 divided doses for 14 days.1 All of these agents reduce transmission of B pertussis and ameliorate early symptoms.2 No antibiotic lessens the severity or shortens the duration of cough in patients who are already experiencing paroxysmal episodes.1 Caution must be exercised using macrolides, especially erythromycin, in infants <2 weeks old (pyloric stenosis). Penicillins/cephalosporins are not effective. References: 1. Edwards KM, et al. In: Plotkin SA, et al, eds. Vaccines. 1999: 2. CDC. The Pink Book, 7th ed. 2002: Available at: March 15, 2005. References: 1. Edwards KM, et al. In: Plotkin SA, et al, eds. Vaccines. 1999: 2. CDC. The Pink Book, 7th ed. 2002: Available at: Accessed March 15, 2005. Wright, 2014 Wright, 2014

Websites with Vaccine Information
Wright, 2014 Wright, 2014

Stridor Wright, 2014

Stridor Few conditions in pediatrics are as emergent and potentially life threatening as an upper airway obstruction Rapid identification and treatment is essential Wright, 2014

Differential Diagnosis for Stridor
Laryngotracheobronchitis (croup) Mechanical obstruction (birth) Foreign body aspiration Peritonsillar abscess Epiglottitis Angioedema Wright, 2014

Croup Causes: Characteristics: Usually caused by a virus
RSV, Parainfluenza or Rhinovirus Characteristics: Inflammation and edema of the pharynx and upper airways Narrowing of the subglottic region + laryngospasm is frequently seen Wright, 2014

Croup Subglottic narrowing Wright, 2014

Croup Presentation: Mild URI symptoms x 24 – 48 hours
Rhinorrhea, cough, low grade fever, sore throat Followed by a sudden onset of: Croupy cough, hoarseness of the voice and stridor Stridor usually begins when the child awakens suddenly from a nap or during the night with a fever Wright, 2014

Croup Presentation: May have wheezing on auscultation
Suprasternal and subcostal retractions are most common Tachycardia and tachypnea are frequently present Hypoxemia may occur Severity and course varies significantly but illness usually lasts about 3 days – 1 week Wright, 2014

Croup Treatment: Exposure to a cool night; child often improves on the way to the ED Humidification or mist may be helpful Aerosolized racemic epinephrine can be helpful Very short acting agent delivered via nebulizer Nebulizer with albuterol or beta 2 agonist may offer some benefit Inhaled corticosteroids/prednisone is frequently beneficial Wright, 2014

Treatment Symptomatic treatment is the most common treatment
Increased fluids Cool mist vaporizer to thin the secretions Tilting the child’s mattress up may be beneficial Antibiotics are not helpful Wright, 2014

Severe Croup Airway management may be essential
Possibilities includes tracheostomy vs. intubation depending upon severity Rarely done any longer although may be needed if child is severe Wright, 2014

Pneumonia Definition: Acute infection of the lung parenchyma
Can occur as a result of: Aspiration Viruses Bacteria Children < than 4 years Consider: RSV and parainfluenza Consider S. pneumoniae and H. influenzae Wright, 2014

Pneumonia Children > 5 years Physical Examination
Mycoplasma, S. pneumoniae, Chlamydia pneumoniae Physical Examination Vital signs Respiratory distress Auscultate lungs (egophony, bronchophony) Palpate for tactile fremitus Wright, 2014

Pneumonia Diagnostic Chest Xray is recommended for all suspected cases of pneumonia Wright, 2014

Treatment of CAP < 5 years of age Presumed bacterial pneumonia
Amoxicillin (90 mg/kg/day) in two divided doses OR Amoxicillin/clavulanate (90mg/kg/day) in two divided doses Presumed atypical pneumonia Azithromycin (10 mg/kg on day followed by 5 mg/kg/day on days 2-5) Clarithromycin (15mg/kg/day) in two divided doses x 7-14 days OR Erythromycin (40 mg/kg/day) in four divided doses accessed Wright, 2014

Treatment of CAP > 5 years of age Presumed bacterial pneumonia
Amoxicillin (90 mg/kg/day) in two divided doses OR Amoxicillin/clavulanate (90mg/kg/day) in two divided doses Consider adding macrolide is unclear etiology Presumed atypical pneumonia Azithromycin (10 mg/kg on day followed by 5 mg/kg/day on days 2-5) Clarithromycin (15mg/kg/day) in two divided doses x 7-14 days OR Doxycycline for children > 7 – 8 years of age accessed Wright, 2014

Chest Pain Chest pain in children and adolescents rarely has a cardiac etiology Most frequent causes Musculoskeletal injury vs. overuse Gastrointestinal (i.e. reflux) Lung/pleural etiology Psychogenic causes Wright, 2014

Cause of Chest Pain in Children
Precordial Catch – (Texidor’s twinge) Most common cause of chest pain An innocent cause of chest pain Very typical history: Sporadic (entirely random) LSB (always same place) Quality – sharp Radiation: fingerpoint Mild – severe Lasts < 2 minutes Respirations make it worse!! Wright, 2014

Cardiac Causes of Chest Pain
Congenital heart conditions i.e. cardiomyopathies Arrhythmias must also be considered Pericarditis vs. myocarditis must also be considered Important: Comprehensive history and physical examination Wright, 2014

Murmurs Innocent murmurs will be heard in up to 50% of school aged children Goal to make sure that you do not miss a serious cardiac anomaly Important questions: Any sob with exercise? Any dizziness or syncope with exercise? Any family history of sudden cardiac death? Wright, 2014

Characteristics of Benign Murmurs
No radiation Systolic Grade < III Does not interfere with S1 and S2 Decreases with sitting or standing Equal femoral and radial pulses Normal PMI Normal history and physical examination Wright, 2014

Characteristics of Pathologic Murmurs
Radiation Diastolic Grade > IV Interferes with S1 and/or S2 Increases with sitting or standing Unequal femoral and/or radial pulses Displaced PMI Abnormal history Wright, 2014

Work – up for Pathologic Murmur
Cardiac consultation Echocardiogram If HCM is suspected, must deny sports participation pending additional work-up Increases with standing Systolic in nature Often accompanied by shortness of breath with exercise Wright, 2014

GI/GU Wright, 2014

Acute vs. Chronic Abdominal Pain
Acute gastroenteritis – number one cause of acute abdominal pain in children Other causes of acute pain: RLL and LLL pneumonia, constipation, UTI, appendicitis, mittelschmerz, ectopic pregnancy and ovarian cysts Wright, 2014

Causes of Chronic or Recurrent Pain
Constipation Musculoskeletal pain Lactose intolerance vs. celiac disease Colitis vs. Crohn’s IBS Wright, 2014

Diarrhea Wright, 2014

Statistics Common complaint worldwide
Millions of individuals develop diarrhea every year Young and old individuals at increased risk from this condition Increased risk of dehydration Increased risk of death Wright, 2014

Pathophysiology 4 basic mechanisms causing diarrhea
Retention of water within the intestine Malabsorptive syndrome; lactose intolerance Maalox can produce diarrhea through this mechanism Excessive secretion of water and electrolytes into the intestinal lumen Cholera; E. Coli, Crohn’s disease, laxatives Release of protein and fluid into the intestinal mucosa Ulcerative colitis, Crohn’s disease, Infections Altered intestinal motility resulting in rapid transport through the colon IBS, Scleroderma Wright, 2014

Acute Diarrhea Cause: most likely to be an infectious agent
Most will resolve on own If diarrhea persists for 72 hours or more, is associated with gross blood in stool, evaluation is essential Wright, 2014

History Any other family/friends ill? Any recent trips/camping?
Food intake? Any nonpasturized ciders? Any beef? Uncooked meats? Mayonnaise? Medications? Wright, 2014

Symptoms Sudden onset Frequent bowel movements Loose, watery stools
Bloody stools Abdominal cramping Thirst Decreased urination Dizziness Fatigue Wright, 2014

Physical Examination Generally unremarkable Tachycardia Poor turgor
Orthostatic signs Hyperactive bowel sounds (borborygmi) Tender abdomen Heme positive stool, possibly (E. Coli) Fecal impaction Wright, 2014

Acute Gastroenteritis
Symptoms Abdominal pain described as colicky, diffuse, crampy May have vomiting Headache Fever and chills Profuse diarrhea often helps to differentiate it from appendicitis Please remember that 15% of children with an appendicitis will have significant diarrhea Wright, 2014

Gastroenteritis Signs Temperature Diffuse tenderness
No obturator, psoas or markle’s sign Dehydration No urination or tears in 8 hours constitutes dehydration in children Wright, 2014

Gastroenteritis Diagnosis History and physical examination
Fecal leukocytes Salmonella, Shigella, Amoeba and Campylobacter all invade the intestinal mucosa and therefore cause leukocytes Inflammatory bowel disease (Colitis, Crohn’s) E. coli, viral etiologies do not generally produce these cells Wright, 2014

Gastroenteritis Stools for O&P Stools for C&S C. difficile
Entamoeba histolytica Giardia lamblia Stools for C&S Salmonella or Shigella Need to request specific tests for E. Coli, Yersinia, and Campylobacter C. difficile Previous antibiotic therapy Wright, 2014

Gastroenteritis Treatment Fluids BRATT diet Antibiotics IV rehydration
Avoid lactose Antibiotics Depending upon the pathology-antibiotic regimen varies IV rehydration Hospitalization Anti-motility agents (controversial) Wright, 2014

Constipation Normal frequency of BM’s: 3 / day – 3 per week
Focus is shifting more toward comfort with BM’s rather than number Most common GI complaint in the US Always ask regarding following: Weight loss, blood in stool, abdominal pain, anorexia, vomiting, anemia Wright, 2014

Constipation Options for treatment Fiber intake
Polyethylene glycol (Miralax) Lactulose Milk of Magnesia Behavioral modification Wright, 2014

Don... Don is a 17yowm who presents with an 2 day history of worsening abdominal pain. Woke him from sleep today. Epigastric at onset. Now seems lower in right side of abdomen. Associated with nausea and vomiting for the past 2 hours and a temp of Denies bowel changes, urinary symptoms. Meds: none; Allergies: NKDA What is going on with Don? Don is a 29yowm who presents with an 8 hour history of worsening abdominal pain. Woke him from sleep. Epigastric at onset. Now seems lower in right side of abdomen. Associated with nausea and vomiting for the past 2 hours and a temp of Denies bowel changes, urinary symptoms. Meds: none; Allergies: NKDA What is going on with Don? Wright, 2014 Wright, 2014

Appendicitis Inflammation/Infection of the Appendix Etiology
Can lead to ischemia and perforation of the appendix Etiology Most common age: years Incidence: 1.1/1000 Persons each year Males>females Whites>Nonwhites Summer-most common time of year Midwest-highest incidence Inflammation/Infection of the Appendix Can lead to ischemia and perforation Etiology Most common age: years Incidence: 1.1/1000 Persons each year Males>females Whites>Nonwhites Summer-most common time of year Midwest-highest incidence Wright, 2014 Wright, 2014

Appendicitis Mortality and morbidity rates remain high
Perforation rates: % Perforation has been known to occur within 1st hours of the infection Mortality and morbidity rates remain high Perforation rates: % The younger and the older the individual, the more likely it is to ruptiure- Iolder individuals do not feel the pain as badly as a teenager or young adult. Also-they do not mount such an obvious inflammatory response. Young children can’t describe it. Also-young children do not localize infection Individuals over the age of 60, when presenting with an appendicitis. By the time it is diagnosed, 70% of them are rupture Wright, 2014 Wright, 2014

History of a patient with appendicitis
Careful history is the most important aspect Individual is usually a teen or young adult Classic presentation: awakens in the night with vague periumbilical pain Worsens over the period of 4 hours Subsides as it migrates to the RLQ Worsened with movement, deep respirations, coughing Careful history is the most important aspect Individual is usually a teen or young adult Classic Presentation: Awakens in the night with vague periumbilical pain Worsens over the period of 4 hours Often subsides as it migrates to the RLQ and then picks up again Worsened with movement, deep resipations, coughing Wright, 2014 Wright, 2014

Diarrhea before pain is more likely to be gastroenteritis.
Clinical Pearl The presence of pain before vomiting is highly suggestive of appendicitis. Diarrhea before pain is more likely to be gastroenteritis. The presence of pain before vomiting is highly suggestive of appendicitis Wright, 2014 Wright, 2014

Physical Examination Abdominal Examination
Tenderness at McBurney’s point 1/3 the distance between the anterior iliac spine and the umbilicus Guarding Contraction of the abdominal walls Frequently present Abdominal Examination Tenderness at McBurney’s point 1/3 the distance between the anterior iliac spine and the umbilicus Remember however, that the appendix can be anywhere in the abdomen including the left lower quadrant Guarding Contraction of the abdominal walls Frequently present Can be faked or induced Wright, 2014 Wright, 2014

Physical Examination Rigidity Markle’s sign
Important predictor of appendicitis Involuntary spasm of the abdominal musculature Caused by peritoneal inflammation Markle’s sign Heel-drop jarring test Rigidity Important predictor of appendicitis Involuntary spasm of the abdominal musculature Caused by peritoneal inflammation Markle’s sign Heel-drop jarring test One study involving the Markle sign-this helped to identify appendicitis and more specifically peritoneal inflammation approximately 92% of the time Wright, 2014 Wright, 2014

Physical Examination Rebound tenderness Rovsing’s Sign Psoas Sign
Press on area above the pain Suddenly withdraw fingers Rovsing’s Sign Pain felt in RLQ when examiner presses firmly in the LLQ and suddenly withdraws Psoas Sign Patient is placed in a supine position Ask patient to life thigh against your hand that you have placed above the knee Rebound tenderness Press on area above the pain Suddenly withdraw fingers Rovsing’s Sign Pain felt in RLQ when examiner presses firmly in the LLQ and suddenly withdraws Psoas Sign Patient is placed in a supine position Ask patient to life thigh against Wright, 2014 Wright, 2014

Physical Examination Obturator Sign Internal Examination
May be or may not be positive Patient is positioned in supine position with the right hip and knee flexed Internally rotate the right leg Internal Examination Consideration to an ovarian cyst Rectal Examination May be considered Obturator Sign May be or may not be positive Patient is positioned in supine position with the right hip and knee flexed Internally rotate the right leg internally Internal Examination Rectal Examination This is essential to assist with the diagnosis Wright, 2014 Wright, 2014

Laboratory/Radiologic Testing
CBC with differential Normal wbc count doesn’t rule-out the diagnosis White blood cell count may actually decrease Look for wbc left shift Elevated wbc Elevated neutrophils Elevated bands CBC with differential Normal wbc count doesn’t rule-out the diagnosis White blood cell count may actually decrease Look for wbc left shift Elevated wbc Elevated neutrophils Elevated bands Myelocytes and metamyelocytes do not belong in the periphery. Normally found in the bone marrow. Wright, 2014 Wright, 2014

Laboratory/Radiologic Testing
Urinalysis CT Scan vs. Ultrasound Emerging evidence that US may be as effective as CT scan for individuals with appendicitis Many hospitals are moving to US first approach to reduce radiation exposure Urinalysis-To r/o UTI CT Scan Within past 2 years, new focused appendiceal CT technique has been developed Will decrease the laparoscopy rate Ultrasound can be performed; seems to be best for children and women of childbearing age Ultrasound-is still utilized particularly in women of childbearing age-as ovarian cysts can sometimes mimic an appendicitis accessed Wright, 2014 Wright, 2014

UTI Gram negative bacilli are the most common pathogens (Escherichia coli) Staphylococcus saprophyticus – more likely in young, sexually active women Preschoolers and young children will likely present with symptoms similar to an adult Dysuria, urgency, frequency Must r/o or consider pyelonephritis Wright, 2014

UTI Urinary dipstick findings Treatment Leukocytes Nitrites RBC’s
Trimethoprim/sulfamethoxazole (8 – 10 mg/day of trimethoprim Cefixime (Suprax) in children > 6 years Cefpodixime (Vantin) Treatment: 7 days – 10 days Wright, 2014

Enuresis Definition: involuntary urination at night after 5 years of age in girls and 6 years of age in boys Small percentage have diurnal enuresis Differentials (particularly if dry in past) Urinary tract infection Emotional issues (divorce, new baby) Type 1 diabetes Neurologic abnormalities Constipation Wright, 2014

Enuresis Treatment Options
Desmopressin (DDAVP )(Nasal spray no longer approved for this indication) Tricyclic antidepressants (caution advised) Bed wetting alarm Bladder training Constipation treatments Wright, 2014

School Physical Examination
Help to maintain the health and safety of the young athlete by... Detecting conditions that may predispose to injury (obesity, recurrent ankle sprains) Detect conditions that may be life threatening (hypertrophic cardiomyopathy) Goal to not to exclude an individual from sport’s participation But…to find any problems that might worsen with particular activities Wright, 2014

Millions of Young Athletes
Millions of young athletes are involved in a variety of activities Wright, 2014

Goals of the Preparticipation Physical Examination
Pre-participation physical is also not a substitute for routine primary care However, the preparticipation physical examination is the only contact with a health care provider for 78% of all athletes Wright, 2014

Kids Just Want to Have Some Fun!!
Wright, 2014

AAP recommends examinations every 2 years
Frequency AAP recommends examinations every 2 years Many schools have different recommendations accessed Wright, 2014

Preparticipation Physical Examination
Guidelines issued by AHA, AAFP and AAP Standardized forms recommended to include history and physical examination Biggest concern Cardiac pathology Most common abnormality Orthopedic abnormality accessed Wright, 2014

Wright, 2014

Sprains/strains Most frequently encountered in children:
Ankles – number 1 Fingers Knees Differentiation between various grades First degree: minimal pain, joint stable Second degree: severe pain, minimal joint instability Third degree: severe pain and complete instability Skinner, H.B. 3rd ed. Current Diagnosis & Treatment in Orthopedics NY, NY: The McGraw-Hill Companies. Wright, 2014

Treatment of Ankle Sprains
Grade I: ice, elevation, NSAIDs, ankle brace, weight bearing may begin immediately. D/C brace in 1 month. Grade II: ice, elevation, NSAIDs, ankle brace, no weight bearing x 7 days Grade III: walking cast x 3 – 4 weeks, PT, ankle brace Skinner, H.B. 3rd ed. Current Diagnosis & Treatment in Orthopedics NY, NY: The McGraw-Hill Companies. Wright, 2014

Fractures Most common in children: Assessment Treatment
Fingers, toes, distal radius, clavicle, ankle Assessment Capillary refill Surrounding skin Sensation Treatment Stabilization, elevation, ice Casting Wright, 2014

Chondromalacia Patella
Occurs mainly in adults but can occur in adolescents Pain occurs when climbing stairs or going from a squatting position to standing Diagnosis: Consider knee films to r/o subluxation of the patella Wright, 2014

Treatment of Chondromalacia Patella
Decrease activities which require full flexion of the knee and stress on the patellofemoral joint RICE Quad muscle strengthening Physical therapy may be helpful Consider orthotics if needed NSAIDs as needed Wright, 2014

Osgood Schlatter Disease
Most common in later childhood and early adolescence Painful swelling and tenderness of the tibial tuberosity Treatment: Decrease quad loading and bending RICE treatment protocol Quad and hamstring stretching NSAID as needed Wright, 2014

Neurologic Conditions
Wright, 2014

Headache Headaches are common in childhood and adolescence
Primary headaches account for 90+% of all headaches: Migraine Tension Cluster Wright, 2014

Headache Indications for Headache Work-up Systemic symptoms
Neurologic signs and symptoms Onset Older (< 5 or > 50) Previous headache Dodick DW. Adv Stud Med. 2003;3:87-92. Wright, 2014

Treatment for Headaches
Tension: NSAID or acetaminophen Rest and heat Migraine Trigger Avoidance Triptan (rizatriptan and almotriptan approved in children) Preventative therapies, as indicated Wright, 2014 Wright, 2014

Syncope Syncope: sudden loss of consciousness with spontaneous recovery Majority of syncopal episodes in children are benign however, must consider the following Seizure activity Cardiac malformations/pathology accessed Wright, 2014

Syncope accessed Wright, 2014

Concussion Guidelines
access Wright, 2014

What Is A Concussion? A concussion is a disturbance in brain function caused by a direct or indirect force to the head Results in a variety of non-specific signs and / or symptoms and most often does not involve loss of consciousness Should be suspected in the presence of any one or more of the following: Symptoms (e.g., headache), or Physical signs (e.g., unsteadiness), or Impaired brain function (e.g. confusion) or Abnormal behavior (e.g., change in personality) Wright, 2014 accessed

Concussions Confusion and amnesia will occur immediately after event
Often accompanied by headache, dizziness, nausea and/or vomiting Symptoms following a concussion may last up to 3 months or longer Concussions are more likely to occur within 10 days of a previous concussion access Wright, 2014

Concussion Administer prior to season; administer immediately after injury. Return to play when symptoms are consistent with baseline score accessed Wright, 2014

Return to Play This tool is not used alone but provides guidance for return to play Should NOT be returned to play on day of concussion accessed Wright, 2014

Dermatologic Conditions
Wright, 2014

Abscess Definition: Most common locations
Collection of pus in the cutaneous tissue which results in a painful, erythematous, fluctuant mass Most common locations Inguinal region, neck or back, axillary region, vaginal Wright, 2014 Wright, 2014

Cutaneous Abscesses Pathogens Treatment
Methicillin sensitive staphylococcus aureus Methicillin resistant staphylococcus aureus Treatment Incision and drainage is the treatment of choice Many recommend wound culture Antibiotics may be utilized but are not as effective as I&D Warm soaks/compresses Wright, 2014

Verruca Vulgaris Common warts
Benign lesions of the epidermis caused by a virus Transmitted by touch and commonly appear at sites of trauma, on the hands, around the periungual regions from nail biting and on the plantar surfaces of the feet Wright, 2014

Verruca Vulgaris Appearance
Smooth, flesh colored papules which evolve into a dome-shaped growth with black dots on the surface Black dots are thrombosed capillaries and can be visualized with a 15 blade Wright, 2014

Verruca Vulgaris Wright, 2014

Verruca Vulgaris Treatment
OTC product: salicylic acid topical (Compound W) or similar OTC cryosurgery kit Liquid nitrogen Duct tape Cryosurgery in office Cimetidine Immunomodulatory effects at high dosages; effects varied Imiquimod Tretinoin type products Electrocautery Blunt dissection (plantar lesions) Wright, 2014

Urticaria Etiology Referred to as wheals or hives
Causes: Foods, soaps, inhaled substances 20% of the population will have at least one episode 2 types: Acute and Chronic Acute is most common - lasting days to weeks (Cause is most often identified) Chronic: Lasts more than 6 weeks (Cause is rarely identified) In children, the most common cause is food-responsible for 62% of all cases Acute means present for less than 6 weeks Chronic-5% of the time, the cause is identified. Often subjected to expensive evaluations which waste money and e=time. Wright, 2014 Wright, 2014

Urticaria Symptoms Signs Diagnosis Hives itch!!!!! Red plaques
Red lesions which vary in size from mm Blanche with palpation Diagnosis History and physical examination Wright, 2014 Wright, 2014

Urticaria Wright, 2014

Urticaria Plan Therapeutic Stop medications if possible
Stop suspected foods or drinks Cool compresses Antihistamines/H2RA Prednisone Wright, 2014 Wright, 2014

Urticaria Plan Educational Avoid causes
Educate regarding possible etiology Discuss side effects of antihistamines (sedation) Wright, 2014 Wright, 2014

Impetigo Contagious, superficial skin infection
Caused by staphylococci or streptococci Staph is the most common cause Makes entrance through small cut or abrasion Resides frequently in the nasopharynx Spread by contact More common in children, particularly on the nose, mouth, limbs Self-limiting but if untreated may last weeks to months Contagious, superficial skin infection Caused by staphylococci or streptococci Staph is the most common cause (Usually produces larger, bullous appearing lesions) Spread by contact: Most common amongst children where there is overcrowding, poor socioeconomic conditions) More common in children, particularly on the nose, mouth, limbs (usually ages 2-5) Most often introduced by scratching and often comes from patient’s own nasopharynx Self-limiting but if untreated may last weeks to months Wright, 2014 Wright, 2014

Impetigo Symptoms: Physical Examination Findings
Rash that will not go away Begins as a small area and then increases in size Yellow, crusted draining lesions Physical Examination Findings Small vesicle that erupts and becomes yellow-brown Initially, looks like an inner tube Crust appears and if removed, is bright red and inflamed Wright, 2014

Impetigo Wright, 2014

Impetigo Physical Examination Findings Diagnosis 2-8 cm in size
Diagnostic: Culture – Today, must absolutely consider MRSA Therapeutic: Mupirocin topical (Bactroban) or retapamulin topical (Altabax) 1st generation cephalopsporin vs. TMP/SMX Wright, 2014

Impetigo Educational Good handwashing and hygiene
No school/daycare for hours Wash sheets and pillowcases Monitor for serious sequelae Wright, 2014

Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin –Resistant Staphylococcus aureus Infections in Adults and Children: Executive Summary Liu, Catherine et. al. MRSA Treatment Guidelines CID 2011:52 (1 February) Wright, 2014

Treatment for Uncomplicated CA-MRSA
No significant risk factors for adverse outcomes I&D is the treatment of choice Antibiotics are not necessary Wright, 2014

Antibiotics Indicated
Abscesses associated with the following: Severe or extensive disease Rapid progression in presence of cellulitis Signs and symptoms of systemic illness Associated comorbidities or immunosuppression Extremes of age Abscess in area unable to be drained Lack of response to I&D alone Wright, 2014

Statistics/Treatment in My Community
37% of staph infection at DHMC – MRSA Nationally, approximately 31% are MRSA CA-MRSA antibiotic susceptibility 50% will be resistant to clindamycin Trimethoprim/sulfamethoxazole (Bactrim) has best coverage/sensitivity: 96-98% Important for clinicians to obtain own antibiogram for communities in which you service Wright, 2014

Treatment of CA-MRSA Obtain culture
Should consider local antibiograms in selection of antimicrobials Skin infections: Consider beta-lactam (PCN or Cephalo) in an individual with mild infection and low rates of CA-MRSA in your community (generally thought of as < 10 – 15%) Guilbeau, J.R. and Fordham, P.N. Evidence-Based management and Treatment of Outpatient Community-Associated MRSA. The Journal for Nurse Practitioners ; Vol 6(2): Wright, 2014

Treatment of CA - MRSA TMP/SMX
Tetracycline (doxycycline or minocycline) Clindamycin Linezolid When CA-MRSA and streptococcus coverage is needed: Clindamycin alone or…. TMP/SMX with amoxicillin (or similar) Wright, 2014

Rifampin No longer recommended as a single agent or for adjunctive therapy for the treatment of skin and soft tissue infections Wright, 2014

Children Simple, uncomplicated impetigo:
Mupirocin 2% topical ointment Avoid TCN or similar in children < 8 years of age Wright, 2014

Treatment and Eradication Strategies: Recurrent infections
GOOD handwashing Treatment with TMP/SMX,clinda, TCN, Linezolid Bathe with disinfectants Hibiclens, phisodex, clorox bleach Utilize topical disinfectants Purell Mupirocin – seeing resistance Wright, 2014

Carriage of CA-MRSA Treatment recommended for individuals with recurrent infection Consider ID consult before treatment Mupirocin 2% each nostril two times daily x 5 – 10 days along with daily chlorhexidine 4% bath for 5-14 days Alternative: 1 teaspoon of bleach per gallon of water (1/4 cup per ¼ tub); 15 minutes two times weekly for 3 months Oral antibiotics are not indicated for decolonization Wright, 2014

Bites and Stings Insect Sting Treatment:
Reaction to wasp or yellow-jacket sting can begin within minutes – up to 60 minutes Anaphylaxis can occur within minutes in the individual with allergy Treatment: Remove stinger, if present Oral antihistamine Ice pack and elevate Anaphylaxis history: Epi Pen with instructions Wright, 2014

Erythema Chronicum Migrans
Etiology Caused by a spirochete called Borrelia Borgdorferi Transmitted by the bite of certain ticks (deer, white-footed mouse) 1st cases were in 1975 in Lyme, Connecticut Occurs in stages and affects many systems Children more often affected than adults Wright, 2014

This is NOT a Lyme Bearing Tick
Wright, 2014

Lyme Bearing Tick Wright, 2014

Symptoms 3-21 days after bite Stage 1 Rash (present in 72-80% of cases)-slightly itchy Lasts 3-4 weeks Mild flu like symptoms (50% of time) Migratory joint pain Stage 2 Neurological and cardiac symptoms Stage 3 Arthritis, chronic neurological symptoms Make take years to get to this stage Wright, 2014

Signs Rash: Stage 1 Begins as a papule at the site of the bite Flat, blanches with pressure Expands to form a ring of central clearing No scaling Slightly tender Arthralgias: Stage 2 Asymmetric joint erythema, warmth, edema Knee is most common location Wright, 2014

Summer 2009 Wright, 2014

Erythema Migrans Wright, 2014

Signs Systemic symptoms: Stage 3 Facial palsy Meningitis Carditis Diagnosis R/O Ringworm (Tinea Corporis) Wright, 2014

Plan Diagnostic: Sed rate: normal until stage 2 Lyme Titer IGM: Appears first: 3-6 weeks after infection begins IGG: Positive in blood for 16 months High rate of false negatives early in the disease Lyme Western Blot Wright, 2014

Plan Therapeutic Amoxicillin 500mg tid x 21 days Doxycycline 100 mg 1 po bid x 21 days If in endemic area and tick is partially engorged, may treat with doxycycline 200 mg x 1 dose with food Wright, 2014

Pityriasis Rosea Etiology Common, benign skin eruption
Etiology unknown but believed to be viral Small epidemics occur at frat houses and military bases Females more frequently affected 75% occur in individuals between 10 and 35; higheset incidence: adolescents 2% have a recurrence Most common during winter months Etiology Common, benign skin eruption etiology unknown but believed to be viral small epidemics occur at frat houses and military bases females more frequently affected: 1.5/1 ratio 75% occur in individuals between 10 and 35 but has occurred as young as 4 months-78 years of age 2% have a recurrence Most common during winter months Wright, 2014 Wright, 2014

Pityriasis Rosea Symptoms Signs
Rash initially begins as a herald patch Often mistaken for ringworm 29% have a recent history of a viral infection Asymptomatic, salmon colored, slightly itchy rash Signs Prodrome of malaise, sore throat, and fever may precede Herald patch: 2-10cm oval-round lesion appears first Most common location is the trunk or proximal extremities Symptoms Rash initially begins as a herald patch Often mistaken for ringworm 29% have a recent history of a viral infection Asymptomatic, salmon colored, slightly itchy rash Signs 2-10cm oval-round lesion appears first Most common location is the trunk or proximal extremities Wright, 2014 Wright, 2014

Pityriasis Rosea Wright, 2014

Pityriasis Rosea Signs Eruptive phase
Small lesions appear over a period of 1-2 weeks Fine, wrinkled scale Symmetric Along skin lines Looks like a drooping pine tree Few lesions-hundreds Lesions are longest in horizontal dimension Signs: 1st thing that appears is a herald patch People come in thinking they have ring worm; It is a 2-10 cm oval-round lesion that appears anywhere on the body but usually the chest or back; proximal extremities Eruptive phase small lesions appear over a period of 1-2 weeks Fine, wrinkled scale: Salmon pink Along skin lines Looks like a drooping pine tree Few lesions-hundreds 7-14 days after the herald patch Lesions are on the trunk and proximal extremities Can also be on the face Wright, 2014 Wright, 2014

Pityriasis Rosea Signs (continued) 7-14 days after the herald patch
Lesions are on the trunk and proximal extremities Can also be on the face Signs: 1st thing that appears is a herald patch People come in thinking they have ring worm; It is a 2-10 cm oval-round lesion that appears anywhere on the body but usually the chest or back; proximal extremities Eruptive phase small lesions appear over a period of 1-2 weeks Fine, wrinkled scale: Salmon pink Along skin lines Looks like a drooping pine tree Few lesions-hundreds 7-14 days after the herald patch Lesions are on the trunk and proximal extremities Can also be on the face Wright, 2014 Wright, 2014

Pityriasis Rosea Diagnosis Plan History and physical examination
Diagnostic Can do a punch biopsy if etiology uncertain Pathology is often nondiagnostic Report: spongiosis and perivascular round cell infiltrate Consider an RPR to rule-out syphilis Diagnosis History and physical examination Plan Diagnostic Can do a biopsy if etiology uncertain Consider an RPR to rule-out syphilis Wright, 2014 Wright, 2014

Pityriasis Rosea Plan Therapeutic Antihistamine Topical steroids
Short course of steroids although, may not respond Sun exposure Moisturize Educational Benign condition that will resolve on own May take 3 months to completely resolve No known effects on the pregnant woman Reassurance Plan Therapeutic Antihistamine Topical steroids to control itching Short course of steroids-if itching is intense Sun exposure-hastens resolution Moisturize Educational Benign condition that will resolve on own No known effects on the pregnant woman Reassurance Call if fever, chills, worsening sx’s occur Wright, 2014 Wright, 2014

Molluscum Contagiosum
Infection caused by the pox-virus Most commonly seen on the face, trunk and axillae Self-limiting Spread by auto-inoculation Incubation period: 2-7 weeks after exposure Contagious until gone Wright, 2014

Asymptomatic lumps May have 1 - hundreds Physical Examination 2-5mm papule with an umbilicated center Flesh toned - white in color Most often around the eye in children Scaling and erythema around the periphery of the lesion is not unusual If in the genital area of a child-should consider sexual abuse Wright, 2014

Wright, 2014

Plan Diagnostic: None or KOH prep looking for inclusion bodies Therapeutic: Conservative treatment is the best for children Curettage Cryosurgery Tretinoin Salicylic Acid (Occlusal) Laser TCA Wright, 2014

Plan Educational May resolve on own in months Contagious until lesions are gone Benign Recurrence very common Wright, 2014

Scabies Etiology Contagious disease caused by a mite
Common among school children Adult mite is 1/3 mm long Front two pairs of legs bear claw-shaped suckers Wright, 2014 Wright, 2014

Scabies Etiology Infestation begins when a female mite arrives on the skin surface Within an hour, it burrows into the stratum corneum Lives for 30 days Eggs are laid at the rate of 2-3 each day Fecal pellets are deposited in the burrow behind the advancing female mite (Scybala)-feces are dark oval masses that are irritating and often responsible for itching Wright, 2014 Wright, 2014

Scabies Etiology Transmitted by direct skin contact with infested person either through clothing or bed linen Eruption generally begins within 4 – 6 weeks after initial contact Can live for days in home after leaving skin Wright, 2014 Wright, 2014

Scabies Symptoms Signs Minor itching at first which progresses
Itching is worse at night (this is characteristic of scabies) Signs Erythematous papules and vesicles Often on the hands, wrists, extensor surfaces of the elbows and knees, buttocks Burrows are often present; May see a black dot at the end of the burrow Infants: wide spread involvement Wright, 2014 Wright, 2014

Scabies Wright, 2014

Scabies Diagnosis Plan Scraping to look for mite, eggs or feces
Diagnostic: Scraping Therapeutic Permethrin 5% cream Wright, 2014 Wright, 2014

Scabies Plan Therapeutic
Sulfur (6% in petroleum or cold cream qd x 3 days) Antihistamine Educational Cut nails short Scratching spreads the mites Itching can last for weeks Treat all family members Wright, 2014 Wright, 2014

Scabies Plan Educational Wash all clothing, towels and bed linen
Do not need to wash carpeting Consider animal bathing Bag stuffed animals x 1-2 weeks Wright, 2014

Lice/Pediculosis Caused by parasites that are found on the heads of individuals – most often children Very common in 3 – 10 year old individuals 1 out of 10 children will contract while in school Lice/eggs are most commonly located on the scalp behind the ears and near the neckline at the back of the neck Wright, 2014

Treatment Treat hair with pediculicide and comb nits daily
Machine wash all in hot water cycle (130 degrees F or dry clean items Put items which can’t be cleaned into a plastic bag and seal it for two weeks Soak combs and brushes for one hour in rubbing alcohol or Lysol Vacuum the floor and furniture Wright, 2014

Prescription Lice Products
Benzyl alcohol, 5% (Ulesfia)1 Malathion, 0.5% (Ovide)2 Spinosad, 0.9% (Natroba)3 Ivermectin, 0.5% (Sklice Lotion)4 Lindane, 1%5 Age indication ≥6 mo Safety not shown <6 y ≥4 y Use w/caution in those <110 lb Dosage 4-48 oz (varies with hair length) 2-oz bottles; apply enough to wet hair and scalp Up to 120 mL (1 bottle) depending on hair length Up to 120 mL ( 4-oz tube) 1-2 oz depending on hair length and density Time of application 10 min; repeat treatment after 7 d 8–12 hrs; repeat treatment in 7-9 d if lice present 10 minutes; repeat treatment in 7 d if lice present 10 minutes; tube is intended for single use only; consult HCP prior to re-treatment 4 min; do not re-treat Prescription Lice Products The Prescribing Information for the products listed in the table above1-5 provides the following information on the use of nit combs and other components of head lice management. Ulesfia1, Natroba3, and Sklice Lotion4: The Prescribing Information for these products, under the heading “Adjunctive Measures,” recommends that the products be used in the context of an overall lice management program that includes: Wash in hot water or dry-clean all recently worn clothing, hats, used bedding, and towels; Wash personal care items such as combs, brushes, and hair clips in hot water; A fine-tooth comb or special nit comb may be used to remove dead lice and nits. Ovide2: In the Prescribing Information, Step 10 in “Information to Patients” is “Rinse hair and use a fine-toothed nit comb to remove dead lice and eggs.” Lindane5: The Prescribing Information recommends “Manual removal of nits using a comb designed for this purpose and/or individual removal with tweezers followed by close examination of the hair and scalp.” References: 1. Ulesfia Prescribing Information. Atlanta, GA: Shionogi Pharma, Ovide Prescribing Information. Hawthorne, NY: Taro Pharmaceuticals, Natroba Prescribing Information. Magnolia, TX: Pernix Therapeutics, Sklice Lotion Prescribing Information. Swiftwater, PA: Sanofi Pasteur Inc., Lindane Prescribing Information. Morton Grove, IL: Morton Grove Pharmaceuticals, 2005. References: 1. Ulesfia Prescribing Information. Atlanta, GA: Shionogi Pharma, Ovide Prescribing Information. Hawthorne, NY: Taro Pharmaceuticals, Natroba Prescribing Information. Carmel, IN, ParaPRO, Sklice Lotion Prescribing Information. Swiftwater, PA: Sanofi Pasteur Inc., Lindane Prescribing Information. Morton Grove, IL: Morton Grove Pharmaceuticals, 2005. Wright, 2014 17

Keeping Kids in School The AAP and National Association of School Nurses state: No healthy child should be allowed to miss school time because of head lice1,2 “No-nit” policies for return to school should be abandoned1,2 School-based head lice screening programs have not had a significant effect on incidence of head lice in schools and are not cost-effective2 School nurses in concert with other health-care providers should become involved in helping school districts develop evidence-based policies1 Keeping Kids in School According to the AAP and the National Association of School Nurses (NASN), students with nits only should not be excluded from school, although monitoring of the child is appropriate.1,2 In 1 study of 1729 schoolchildren screened and observed for 14 days, only 18% of those with nits alone converted to having an active infestation.3 The American School Health Association has also taken a stand against no-nit policies, noting that such policies and practices “are not effective in controlling lice outbreaks and may be disruptive to the education process.”4 School-based head lice screening programs have not had a significant effect on incidence of head lice in schools and are not considered cost-effective.2 School nurses, according to the NASN, are in a “pivotal position” to dispel myths and stigmas about pediculosis by providing education to the family, the school, and the community at large and by reassuring children that head lice are not associated with poor hygiene.1 School nurses and other health professionals are encouraged to help in the development of evidence-based policies on management of head lice infestations. References: 1. Pontius D, Teskey C. Pediculosis management in the school setting, position statement, National Association of School Nurses, PositionPapersandReports/NASNPositionStatementsFullView/tabid/462/ArticleId/ 40/Pediculosis-Management-in-the-School-Setting-Revised Accessed July 16, Frankowski BL, Bocchini JA Jr, AAP Council on School Health and Committee on Infectious Diseases. Clinical report—head lice. Pediatrics. 2010;126(2); Williams LK, Reichert A, MacKenzie WR, et al. Lice, nits, and school policy. Pediatrics. 2001;107(5): American School Health Association. School policies in the management of pediculosis (head lice). Accessed July 16, 2012. References: 1. Pontius D, Teskey C. Pediculosis management in the school setting, position statement, National Association of School Nurses, NASNPositionStatementsFullView/tabid/462/ArticleId/40/Pediculosis-Management-in-the-School-Setting-Revised Accessed July 16, Frankowski BL, et al. Pediatrics. 2010;126(2): Wright, 2014 22

Candidiasis/Tinea Infection
Infection frequently caused by Candida albicans which invades the epidermis when there is a break in the skin and there is excessive moisture and heat Candida always involves the skin folds Orally: thrush (Oral candidiasis) Treatment: Mycelex troches, Nystatin Wright, 2014

Candidiasis/Tinea Diaper: satellite lesions with well-defined beefy red rash Treatment: Nystatin cream Tinea Cruris (male inguinal region) Clotrimazole Miconazole Keep clean and dry Consider treating the tinea pedis Wright, 2014

Atopic Dermatitis Most common inflammatory skin disease if childhood
Etiology Most common inflammatory skin disease if childhood Affects 10-12% of all children Caused by an inflammation in response to an allergen, chemical or an unidentified etiology Often occurs in an individual with a family history of allergies 50% of eczematous children will develop allergic rhinitis, asthma Wright, 2014

Etiology High levels of serum IgE are common
Higher the levels of IgE-more severe the case Proliferation of T-helper 2 cells; Th-2 cells produce cytokines Cytokines cause an inflammatory response in the skin Wright, 2014

Atopic Dermatitis Signs Pruritic, erythematous dry patches
Cracking and fissuring Lichenification (Thickening of the skin) Excoriations (Caused by scratching) Diffuse borders (different than psoriasis) Wright, 2014

Diagnosis? Wright, 2014

Infants: scalp, face, and extensors Children: neck, flexor folds, feet
Common Locations Infants: scalp, face, and extensors Children: neck, flexor folds, feet Wright, 2014

Atopic Dermatitis Plan Diagnostic Therapeutic None
Lubrication: Most important part Perform multiple times daily; particularly after a bath Wright, 2014

Atopic Dermatitis Therapeutic Limit number of baths or showers
Avoid harsh soaps Antihistamines: OTC or prescription Low potency topical corticosteroids Immunomodulator (Elidel or Protopic) Avoids soaps, bath gels, bubble baths, shower gels Intralesional injections of corticosteroids Oral corticosteroids Wright, 2014

Atopic Dermatitis Educational
Explain the chronic nature of this condition Review medications and why they are utilized Avoid harsh soaps Monitor for yellow discharge-often results in impetigo Wright, 2014

Acne Vulgaris Etiology Disease involving the pilosebaceous unit
Most frequent and intense where sebaceous glands are the largest Acne begins when sebum production increases Propionibacterium acnes proliferates in the sebum P. acnes is a normal skin resident but can cause significant inflammatory lesions when trapped in skin Wright, 2014

Diagnosis? Wright, 2014

Acne Vulgaris Diagnosis Plan History and physical examination
Diagnostic: None Therapeutic Benzoyl Peroxide Topical Antibiotics Oral Antibiotics Tretinoin OCPs Isotretinoin (Accutane) Wright, 2014

Chickenpox (Varicella)
Highly contagious viral infection Varicella-zoster virus Affects most children before puberty Peak incidence is March-May Spread via airborne droplets or vesicular fluid Contagious for days before rash until lesions crust Incubation period-up to 21 days Highly contagious viral infection Affects most children before puberty Peak age: years of age Peak incidence is March-May Spread via airborne droplets or vesicular fluid Contagious for 2 days before rash until lesions crust Incubation period-up to 21 days Individuals can have a few lesions-1000 Wright, 2014 Wright, 2014

No prodrome or very mild Rash usually begins on the trunk and scalp and then spreads peripherally Moderate to intense itching Fever: Lesions erupt for 4 days No prodrome or very mild (If present, consists of a low grade temp, headache, malaise) These appear with or just before the rash Rash usually begins on the trunk and then spreads to the face Few lesions-thousands Moderate to intense itching Fever: Lesions erupt for 4 days Crust at 7 days after eruption Wright, 2014 Wright, 2014

Physical Examination Findings Lesions 2-4 mm papule (rose petal) Thin walled clear vesicle (dew drop) Vesicle becomes umbilicated within 8-12 hours Followed by crusts Lesions are in all stages – hallmark of this disease Physical Examination Findings Lesions 2-4 mm papule (rose petal) Irregular outline Thin walled clear vesicle (dew drop) then appears on the surface of the papule “Dew drops on a rose petal” Vesicle becomes umbilicated within 8-12 hours; Breaks open and then crusts Followed by crusts Lesions can be everywhere on the body including the mouth, genital area, or eyes Temp-105 or less All three phases are present at the same time Wright, 2014 Wright, 2014

Chicken Pox Wright, 2014

Plan Diagnosis: None Therapeutic: Symptomatic Treatment NO ASPIRIN Clip Nails Caladryl or Benadryl Antiviral Plan Diagnosis: None Can send a varicella culture by breaking open a lesion containing vesicular fluid Takes 72 hours-By this time, they are in full bloom Therapeutic: Symptomatic Treatment: Most important part NO ASPIRIN Clip Nails and file Aveeno baths Caladryl or Benadryl Zovirax 20mg/kg/day x 5 days Avoid scratching: Mittens, socks End of day visit if necessary Wright, 2014 Wright, 2014

Plan Education: Call immediately for worsening of symptoms Contagious until all lesions crust Caution of pregnant women and others without immunity Monitor for secondary complications Prevention: Varicella vaccine Plan Education: Call immediately for worsening of symptoms Contagious until all lesions crust If lesions begin to crust and are associated with discharge or spreading-consider impetigo Lesions do scar Caution of pregnant women and others without immunity Consider Varicella vaccine Now provided by the state Children given 1 injection after 12 months Adults: 2 injections 6-8 weeks apart Wright, 2014 Wright, 2014

Ringworm Tinea Corporis
Caused by a fungus / dermatophytes which lives on the dead layer of the outer skin Can also be transmitted to an individual from an animal Increased sweating can promote fungal growth Wright, 2014

Tinea Corporis Wright, 2014

Tinea Corporis Produces characteristic rash Treatment
Pink Scaly Round May be 3 – 5 cm in size Treatment Antifungal – topical Miconazole Clotrimazole Avoid touching as it is very contagious No contact sports x 48 hours into treatment Wright, 2014

Herpes Simplex Virus HSV 1 and 2 Spread in 3 manners
Respiratory droplets Contact with an active lesion Contact with fluid such as saliva 90% of primary infections are asymptomatic Symptoms usually occur days after contact Wright, 2014

Herpes Simplex Virus Symptoms
Tenderness, pain, paresthesia, burning, swollen glands, headache, fever, irritability, decreased appetite, drooling Wright, 2014

Herpes Simplex Virus Physical Examination Findings
Grouped vesicles on an erythematous base Gingivostomatitis: Erythematous, edematous gingiva that bleed easily with small, yellow ulcerations Yellowish-white debris develops on mucosa Halitosis Lymphadenopathy Wright, 2014

Herpes Simplex Virus Wright, 2014

Herpetic Gingivostomatitis
Wright, 2014

Herpes Simplex Virus Plan Diagnostic Viral Culture
HSV IgG & IgM serum antibodies Most accurate: HerpeSelect Therapeutic Antiviral Pain reliever Cool rinses Oragel Wright, 2014

Herpes Simplex Virus Plan Educational:
Prevent contact with infected individuals Discussion regarding asymptomatic shedding Prevent recurrences Call for worsening of symptoms (I.e. inability to drink, no urination x 8 hours) Wright, 2014

Roseola Viral infection caused by HHV6 (human herpes virus – 6)
Most common ages: 3 months – 4 years Incubation period: 5 – 15 days Fever up to 105 will precede the rash Wright, 2014 accessed

Roseola Fever - up to 3 – 5 days
The fever falls quickly – usually between day 2 - 4 Rash will first appear on the trunk and then spreads to the limbs, neck, and face Rash lasts from hours to 2 days May be associated with a febrile seizure Wright, 2014 accessed

Roseola Treatment Ibuprofen Acetaminophen Tepid baths
Cautiously with fever Wright, 2014 accessed

Fifth’s Disease (Erythema Infectiosum)
Human Parvovirus B19 Occurs in epidemics Occurs year round: Peak incidence is late winter and early spring Most common in individuals between 5-15years of age Period of communicability believed to be from exposure to outbreak of rash Incubation period: days Can cause harm to pregnant women and individuals who are immunocompromised Human Parvovirus B19 Occurs in epidemics: Usually in the spring Most common in school aged children Spread person to person: Airborne Period of communicability believed to be from exposure to outbreak of rash Incubation period: days (But may range from 4-14 days) Can cause harm to pregnant women and individuals who are immunocompromised Pregnant women: 3rd trimester fetal hydrops 1st trimester-miscarriage Wright, 2014 Wright, 2014

Low grade temp, malaise, sore throat May occur but are less common 3 distinct phases Facial redness for up to 4 days Fishnet like rash within 2 days after facial redness Fever, itching, and petecchiae Petecchiae stop abruptly at the wrists and ankles Hands and feet only Low grade temp, malaise, sore throat 3 distinct phases Facial redness for approximately 4 days: Slapped cheed appearance Fishnet like rash 2 days after facial redness: Begins on the extremities and spreads to the buttocks, trunk, Lasts 6-14 days Rash can fade and recur several times over a 2-3 week period Fever, itching, and petecchiae Petecchiae stop abruptly at the wrists and ankles May also develop mouth sores at this time May also complain of joint aches-profound in the adult. Typically the large joints-knees and hips. Lasts 2-13 months Wright, 2014 Wright, 2014

Physical Examination Findings Low grade temperature Erythematous cheeks Nontender and well-defined borders Netlike rash Erythematous lesions with peripheral white rims Rash-remits and recurs over 2 week period Petecchiae on hands and feet Physical Examination Findings: Vary depending upon the point at which you are seeing the patient Low grade temperature Erythematous cheeks: Does not involve the nasolabial creases Netlike rash Petecchiae on hands and feet: Not above the wrists and ankles May also see mouth sores, mildly erythematous pharynx, mild injection of the conjunctiva Wright, 2014 Wright, 2014

Fifth’s Disease Wright, 2014

Diagnosis/Plan Parvovirus IgM and IgG IgM=Miserable and is present in the blood from the onset up to 6 months IgG=Gone and is present beginning at day 8 of infection and lasts for a lifetime CBC-May show a decreased wbc count Diagnosis/Plan Parvovirus IgM and IgG IgM=Miserable and is present in the blood from the onset up to 6 months IgG=Gone and is present beginning at day 8 of infection and lasts for a lifetime CBC-May show a decreased wbc count And a decreased platelet count called thrombocytopenia Wright, 2014 Wright, 2014

Diagnosis/Plan Was contagious before rash appeared therefore, no isolation needed Spread via respiratory droplets Symptomatic treatment Patient education-I.e. contagion, handwashing Can cause aplastic crisis in individuals with hemolytic anemias Concern regarding: miscarriage, fetal hydrops Adults: arthralgias Diagnosis/Plan Respiratory isolation for 7 days after onset of illness is recommended by many Others believe you were most contagious before you broke out in the rash Symptomatic treatment Tylenol. No aspirin Benadryl if itchy Adequate hydration Patient education-I.e. contagion, handwashing, call for increase in symptoms Avoid pregnant individuals, those with severe illnesses Call for temp >101, decreased eating, drinking Wright, 2014 Wright, 2014

Hand, Foot, and Mouth Disease (Coxsackie Virus)
Caused by the coxsackie virus A16 and now…A6 Most common in children 2-6 day incubation period Occurs most often in late summer-early fall Symptoms Low grade fever, sore throat, and generalized malaise Last for 1-2 days and precede the skin lesions 20% of children will experience lymphadenopathy Caused by the coxsackie virus A16 Can be isolated or epidemic Most common in children 2-6 day incubation period Occurs most often in late summer-early fall Symptoms Low grade fever, sore throat, and generalized malaise Last for 1-2 days and precede the skin lesions 20% of children will experience lymphadenopathy Usually submandibular or cervical Will occasionally have diarrhea or arthralgias Wright, 2014 Wright, 2014

cdc.gov From November 7, 2011, to February 29, 2012, CDC received reports of 63 persons with signs and symptoms of HFMD or with fever and atypical rash in Alabama (38 cases), California (seven), Connecticut (one), and Nevada (17). Coxsackievirus A6 (CVA6) was detected in 25 (74%) of those 34 patients Rash and fever were more severe, and hospitalization was more common than with typical HFMD. Signs of HFMD included fever (48 patients [76%]); rash on the hands or feet, or in the mouth (42 [67%]); and rash on the arms or legs (29 [46%]), face (26 [41%]), buttocks (22 [35%]), and trunk (12 [19%]) Of 46 patients with rash variables reported, the rash typically was maculopapular; vesicles were reported in 32 (70%) patients Of the 63 patients, 51 (81%) sought care from a clinician, and 12 (19%) were hospitalized. Reasons for hospitalization varied and included dehydration and/or severe pain No deaths were reported Wright, 2014

Hand, Foot, and Mouth Disease – A6
Wright, 2014 accessed

Physical Examination Findings Oral lesions are usually the first to appear 90% will have Look like canker sores; yellow ulcers with red halos Small and not too painful Within 24 hours, lesions appear on the hands and feet 3-7 mm, red, flat, macular lesions that rapidly become pale, white and oval with a surrounding red halo Resolve within 7 days Physical Examination Findings Oral lesions are usually the first to appear (Do so in 90% of the cases) Look like canker sores (few-10 lesions) Small and not too painful Within 24 hours, lesions appear on the hands and feet (These occur in approx 66% of the patients) 3-7 mm, red, flat, macular lesions that rapidly become pale, white and oval with a surrounding red halo Can also appear on the face, buttocks, legss Resolve within 7 days No scarring Wright, 2014 Wright, 2014

Physical Examination Findings Hand/feet lesions As they evolve – may evolve to form small thick gray vesicles on a red base May feel like slivers or be itchy Physical Examination Findings Oral lesions are usually the first to appear (Do so in 90% of the cases) Look like canker sores (few-10 lesions) Small and not too painful Within 24 hours, lesions appear on the hands and feet (These occur in approx 66% of the patients) 3-7 mm, red, flat, macular lesions that rapidly become pale, white and oval with a surrounding red halo Can also appear on the face, buttocks, legss Resolve within 7 days No scarring Wright, 2014 Wright, 2014

Hand Foot and Mouth Disease
Wright, 2014

Plan Diagnostic: None Therapeutic Tylenol Warm baths Oragel or diphenhydramine/Maalox Magic mouthwash Plan Diagnostic: None Therapeutic Tylenol Warm baths Oragel or Benadryl/Maalox Educational Very contagious (2d before -2 days after eruption begins) Reassurance No scarring Wright, 2014 Wright, 2014

Plan Educational Very contagious (2d before -2 days after eruption begins) Entire illness usually lasts from 2 days – 1 week Reassurance No scarring Plan Diagnostic: None Therapeutic Tylenol Warm baths Oragel or Benadryl/Maalox Educational Very contagious (2d before -2 days after eruption begins) Reassurance No scarring Wright, 2014 Wright, 2014

Kawasaki Disease Characterized by an systemic vasculitis throughout the body Seventy five percent of patients are under five years old It is more common in boys than girls Majority of cases occur in the winter and early spring Believed to be viral in etiology and is not contagious Wright, 2014 accessed

Kawasaki Disease Diagnosis is based on clinical criteria by the American Heart Association: fever for 5 or more days (102 – 104) a polymorphous exanthem nonpurulent conjunctivitis changes in the mucosa of the lips / oral cavity redness or edema with later desquamation of the extremities at least one cervical lymph node > 1.5 cm in diameter Wright, 2014 accessed

Kawasaki Disease Coronary artery aneurysms develop in 15% to 25% of untreated children May lead to ischemic heart disease or sudden death Treatment IV immunoglobulin Aspirin Echocardiography and cardiac consult accessed Wright, 2014

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