PNP Management 3 Exam #1

-Hepatitis A
-Hepatitis B
-Hepatitis C
-Hepatitis D
-Hepatitis E

-Causes primary infections in the liver
-Transmitted easily in homes and childcare centers through person-to-person contact via fecal matter found on contaminated surfaces

12 to 23 months

-Personal contact with an infected individual:
can be spread to adults easily because children <6yrs are asymptomatic
-International travel
-Food-borne outbreaks

-Older children often present with similar symptoms to adults
-Nausea
-Vomiting
-Anorexia
-Fever
-Right upper quadrant pain (dull)
-Jaundice in the icteric phase
-Hepatomegaly
-Splenic tenderness
-Adenopathy

-Children may also have darkened urine and clay-colored stools
-Infants may have diarrhea, while constipation is more common in older children

-Preicteric phase:
acute febrile illness
malaise
nausea
vomiting
digestive complaints
-Icteric phase:
jaundice
dark urine
clay-colored stools
poor weight gain

-Supportive teatment
-Hep A vaccine or immunoglobulin for post exposure prophylaxis within 14 days of exposure
-Immoglobulin can be used for kids <2 years
-Immunoglobulin can be administered in some high exposure cases or prophylactically, in conjunction with HAV vaccine for those traveling internationally

-Household contacts and sexual partners of known cases
-Oersons accidently inoculated with a contaminated needle
-Newborn infants of infected, jaundiced mothers
-People with open lesions directly exposed to body secretions of known cases
-Children in schools where more than one case is reported

-All children and employees of child care centers where a case reported
-Custodial care residents and staff in close contact with an active case
-Persons traveling to developing countries for <3 months
-Can give HAV vaccine concurrently with IG if warranted, for those traveling internationally

-Prevention includes:
good hygiene
safe drinking water
HAV vaccine for children 12 months and older
-Children 2–18 years of age who have not received the HAV vaccine may receive the vaccine
-Good hand hygiene with toileting and diaper changes are important to prevent transmission in the home and childcare center

-Highly contagious and preventable with vaccine administered during infancy
-Development of chronic HBV is determined by age of initial acute HBV infection and the rate of loss of HBcAg
-More than 90% of infants infected with HBV develop chronic infection
-Approximately 25–50% of children aged 1–5 years old who develop HBV infections will go on to develop chronic infection

-Transmitted via percutaneous or permucosal exposure, including blood, semen, vaginal secretions, cerebrospinal, and pleural fluid
-It can be transmitted via birth from an infected mother, sexual contact with an infected person, personal hygiene items such as toothbrushes or razors, and infected medical equipment

-Lack of immunization among children who have immigrated to the United States from sub-Saharan Africa and East Asia, or other areas of the world with endemic states of HBV
-IV drug users and those who engage in sexual contact with infected persons -Healthcare workers exposed to contaminated bodily fluids
-Tattooing and body piercing with infected equipment

-Children who are infected with HBV at an early age are less likely to present with symptoms
-Gradual onset of nonspecific symptoms includes fever and nausea
-Hepatomegaly
-Tenderness of the liver
-Rash
-Papular acrodermatitis in infants
-Jaundice of the skin, mucous membranes, and sclera

-Newborns who mothers are HBsAg positive
-Household contacts <12 months old who have received only one prior HBV vaccine and the second dose is not due
-Sexual contact or needle-sharing with known HBsAg positive cases, including secual assault or abuse victims
-Individuals with percutaneous or permucosal exposure to body secretions of known cases

-If a mothers HBsAg is unknown before delivery, infants should receive HBV vaccine and HBIG in 2 different sites within 12 hours of birth or 24 hours of blood exposure
-HBIG can be given within 7 days of delivery if the mother tests positive for HBsAg postpartum but its less effective
-Give HBIG and HBV vaccine up to 14 days after last exposure and repeat vaccine at 1 to 6 months for sexual partners of known cases
-In <12 months with household contacts, give HBIG and 3 doses of HBV vaccine
-Hepatitis B vaccine can be used for postexposure prophylaxis if given within 12 to 24 hours after exposure

->12 months:
interferon-alfa
->3 years:
lamivudine
->12 years:
adefovir
tenofovir
->16 years:
entecavir

-Yearly liver ultrasounds
-Liver function and a-fetoprotein concentration testing
-HAV vaccines
-HBIG and corticosteroids are not found useful for chronic Hep B

-Hepatitis C infection causes most cases of chronic hepatitis
-About half of people infected with HCV are unaware of their infection and most who become infected with HCV develop chronic hepatitis C
-The incidence of chronic pediatric liver failure increases with the duration of infection

-Transmitted via blood
-The primary source of HCV infections in children is perinatal transmission, however about half of the children who become infected in this way typically see resolution between 24 months and 7 years of age

-Injection drug use
-Men who have sex with men are also at increased risk
-Vaginal births and breastfeeding do not increase the chances of HCV transmission

-Most children with HCV do not exhibit any symptoms
-Older children may have flu-like symptoms, such as nausea or anorexia
-Exam findings may include jaundice and RUQ abdominal pain

-Children with HCV who take acetaminophen or antiretrovirals should be closely followed and their hepatic transaminases monitored
-Children diagnosed with HCV should still receive the HAV and HBV immunizations
-They may still attend daycare as usual
-Discourage alcohol consumption in adolescents and young adults with HCV infection because of the potential for further liver injury
-Education regarding not sharing razors and toothbrushes should be given as well
-Educate young adults about using condoms to prevent spreading the infection if they are sexually active

-Uncommon in children
-It involves concomitant infection with Hepatitis B, as HDV requires the Hepatitis B virus to replicate
-HDV will either be a coinfection or super infection with Hepatitis B
-HDV is transmitted through mucosal, sexual, parenteral, or percutaneous contact with infected blood
-No vaccine is currently available, however, the HBV vaccine also prevents against HDV because of the comorbidity with HBV

-Drug use
-Hemophilia
-Immigration from southern Italy, some parts of Eastern Europe, South America, Africa, and the Middle East

-It can also be found in zoonotic hosts such as swine and nonhuman primates
-It is transmitted through the fecal-oral route, most commonly via contaminated water
-Children are typically asymptomatic or mildly symptomatic
-Older adolescents and young adults are typically symptomatic
-Patients usually make a complete recovery and chronic infections are considered rare
-Mortality rate is very low but increases for pregnant females

Most cases in the United States are found in immigrants or visitors from India, the Middle East, some areas of Africa, Southeast Asia, and Mexico

-Presents similarly to other hepatitis infections, and usually within 15–60 days of infection
-Malaise
-Anorexia
-Fever
-Abdominal pain
-Arthralgia
-May be jaundiced

-HEV management includes supportive management
-There is no approved vaccine.

Good hand hygeine

-HIV enters cells to target a CD4+ T cell
-Converts RNA into DNA using the reverse transcriptase enzyme
-Integrates with the T cell DNA within the cell nucleus
-Permanent infection of the host cell

-Found in blood, CSF, pleural fluid, cervical secretions, human milk, feces, saliva, and urine
-Transmission of the virus can occur via blood, semen, cervical secretions, and human milk

-This accounts for 30% of infections
-It is associated with early and severe newborn disease
-This usually occurs by 10 weeks gestation.

-This accounts for at least 60% of infections
-It results from exposure to infected blood and cervicovaginal secretions in the birth canal or due to micro transfusions between the infected mother and infant during labor

-This accounts for approximately 15% of infections in the United States
-It occurs via breast milk

-Flu-like symptoms:
fever
rash
sore throat
muscle pain
-Failure to thrive
-Chronic or recurrent diarrhea
-Pneumonia
-Recurrent bacterial infections in older kids

-Newborn exams are usually normal
-Lymphadenopathy hepatosplenomegaly
-Oral candidiasis
-Chronic parotid swelling
-Progressive neurologic deterioration

-Suppression of viral replication to undetectable levels
-Restoring or preserving immune function
-Reduction of HIV-associated sequelae
-Minimization of drug toxicity
-Promotion of normal growth and development
-Promotion of treatment regimen adherence
-Improving quality of life

-PCP’s role is to boost adherence rates and possibly monitor for side effects from drug regimen
-Factors associated with lower adherence to treatment regimen include mental health issues, age, homelessness, inconsistent access to antiretroviral therapy, and stigma
-Factors associated with greater adherence to treatment regimen include trust and satisfaction with HIV provider

-Current treatment regimen recommendations are at least three oral antiretroviral drugs from at least two drug classes
-Generally 2 nucleoside reverse transcriptase inhibitors (NRTIs) plus either a non-nucleoside reverse transcriptase inhibitor (NNRTIs) or protease inhibitor (PI) often with low-dose ritonavir
-Management specifics are determined by the specialist

-6 week course of zidovudine (Retrovir) prophylaxis protocol for HIV-exposed newborn from birth to 6 weeks
-Ensure bloodwork is done prior to antibiotic prophylaxis
-Should be prescribed trimethoprim-sulfamethoxazole prophylactically to prevent Pneumocystis jirovecii beginning at 4–6 weeks of age through the first year of life

-Adolescents who are HIV positive should use condoms during sexual incounters
-Risk of sharing needles

-Caused by M. tuberculosis
-Transmitted by droplet contamination from coughing, sneezing, or talking
-Droplets can stay in the air for hours

-Latent TB:
the child is infected but not contagious
-Active TB:
the disease is present and contagious

-Immigration
-International adoptees or travelers from high-prevalence regions such as Asia, Africa, Latin America, and the former Soviet Union countries for 1 week or more
-Homelessness
-Alcoholism
-IV drug use

-Persons in correctional facility
-Recent TB infection within the last two years
-Immunocompromised IV drug use
-Comorbid chronic conditions such as lymphoma and diabetes, chronic renal failure, and inflammatory bowel disease

4 to 8 weeks

48 to 72 hours

-Induration (5mm or greater) in children who are:
in close contact with an individual with active or previously active TB cases
have a chest X-Ray with signs of active or previous TB
clinical findings
have immunosupprressive disorder or HIV
receiving immunosuppressive drugs

-Induration (10mm or greater) in children >4 years with any high risk factors
-Induration (15 mm or greater) in children >4 years without any risk factors
-If the skin test shows induration onset after 72 hours, it should be interpreted as positive

IGRA that includes QuantiFERON TB Gold In-Tube and T-SPOT.TB

-Immunocompetent children >5 years to confirm suspected LTBI or active disease
-A positive result indicates TB infection: a negative IGRA should not rule out infection or disease if clincial signs and symptoms suggest otherwise
-Children >5 years who received BCG vaccine
-Children >5 years who are unlikely to return for TST reading
-If the initial TST is positive in children >5 years who received BCG vaccine, in whom additional evidence is needed to improve compliance, or if nontuberculous mycobacterial disease is suspected
-Might be used with other diagnostic tests in an infant suspected of having congenital TB

-Most children ages 3–15 years with primary TB are asymptomatic
-Symptoms may present 1–6 months after the infection begins:
low-grade fever, malaise, and decreased appetite
nonproductive cough, dyspnea (in infants), night sweats, and chills
erythema nodosum, phlyctenular keratoconjunctivitis

-Extrapulmonary symptoms can be present in approximately 25% of children:
meningitis
granulomatous inflammation of the lymph nodes, middle ear, or mastoid
worsening pulmonary infection may present as recurrent cough, stridor, and wheezing

Disproportionately enlarged regional lymph nodes compared with a relatively small pleural focus

-TB aspirate from gastric aspirates, sputum, bronchial washings, pleural fluid, CSF, urine, body fluids, or biopsy
-Induce coughing for children >5 years and older with hypertonic saline
-If they are <5 years, early morning gastric aspirates, collected on 3 seprate mornings and analyzed by fluorescent staining

-Progressive pulmonary disease
-Miliary disease
-Pleural effusions
-TB meningitis

-Consult a Pediatric TB specialist if the child has a positive TST, suspected TB, or TB contact
-First-line treatment is administered orally and includes specific regimens of isoniazid, rifampin, pyrazinamide, and ethambutol
-The primary care provider should be familiar with their patient’s specific antitubercular drug regimen and see the patient monthly to monitor their response to treatment
-PCP should monitor drug adherence and for signs of hepatitis

-Primary care providers should promote strict adherence to treatment regimen to prevent drug resistance
-Educate patient and family about warning signs of hepatotoxicity while on an anti-tubercular drug regimen
-Rifampin may cause orange secretions in urine, vomiting, hepatitis, flulike symptoms, thrombocytopenia, and pruritis
-Patients on oral contraceptives will need to use a backup birth control method while on rifampin

Children with TB can be given measles and other attenuated live virus vaccines at age-appropriate times, unless they are on high-dose corticosteroids, are severely ill, or have another contraindication

-Hypotonia in infancy
-Hearing loss
-Developmental delays
-Short stature
-Small ears
-Small mouth and protruding tongue
-Clinodactyly (finger or toe turns sideways)

-If there is a positive history for an inherited disorder for which the child is at risk
-Physical findings/dysmorphic features on physical exam consistent with a known syndrome
-Known inborn errors of metabolism
-Noted developmental, growth, and/or structural anomalies

-Upslanting palpebral fissures
-Epicanthal fold
-Open mouth with protruding tongue
-Brachycephaly (head is shorter than normal in the front-to-back dimension)
-Redundant skin
-Small ear with overfolded helix
-Flat facial profile

-Review newborn screen for hypothyroidism and annual review for hypothyroidism
-Evaluate routinely for critical congenital heart disease
-Monitor growth using the Down syndrome specific growth chart
-Monitor eye exams for signs of cataracts
-Monitor hearing with routine hearing evaluations
-Monitor for neurologic complications such as seizures or moyamoya
-Monitor for signs of atlantoaxial instability

-Dwarfism
-Vaulting of the skull
-Frontal bossing
-Hydrocephalus
-Hypotonia
-The infant may have developmental delays as well
-Macrocephaly
-Bowing of legs

-Short stature
-Shortening of limbs
-Short foot and toes
-Macrocephaly
-Frontal bossing
-Depressed nasal bridge
-Characteristically short hands that have a “trident” position in extension

-Growth management using syndrome specific growth chart
-Monitor for hydrocephalus, particularly during the first two years of life when it is more likely to present
-Monitor for sleep apnea
-Follow annual hearing evaluations as middle ear dysfunction is common
-Prescribe medication dosages that are appropriate for the child’s age and size

-Educate parents/caregivers about macrocephaly and skeletal dysplasia as well as increased risk for cranio-cervical junction compression
-Advise to use rear-facing car seats
-Educate parents/caregivers about the risk of lower extremity bowing and thoracolumbar kyphosis
-Advise to avoid devices that cause curved sitting like umbrella strollers
-Advise to avoid jumpers and walkers until the child can sufficiently bear weight
-Advise to avoid living at high elevations due to restrictive pulmonary disease

-Neurodevelopmentally normal with phenotypic variability, including variable facial features
-Facial features vary and include:
long, narrow facies
downward slanting eyes
micrognathia
-Tall for their age with long extremities that are disproportionate to their trunk
altered arm-span: height ratio

-Skeletal issues such as:
pectus deformities
scoliosis
pes planus
increased joint laxity

-Aortic root dilatation
-Spontaneous pneumothorax
-Reduced pulmonary reserve
-Sleep apnea
-Recurrent hernias
-Retinal detachment

-The PNP should closely monitor growth using syndrome-specific growth charts
-Monitor for musculoskeletal deformities as well, including scoliosis, pectus deformities, joint laxity, and pes planus
-Ensure appropriate ongoing cardiac screening to evaluate for aortic dilatation, including an echocardiogram
-Beta blockers can be used for treatment
-Advise restricted involvement in contact and competitive sports
-Aerobic activities should be done in moderation

-Intellectual disability
-Hand flapping
-Spontaneous persistent social smile or fits of laughter
-Speech delay with appropriate receptive language
-Abnormal sleep

-Fascination with water
-Abnormal gait with arms held high and flexed elbows
-Hypotonic trunk with hypertonic limbs
-Microcephaly
-Seizures
-Feeding and growth problems

-Monitor for developmental delays and speech problems
-Absent or near-absent speech
-They may not ever develop expressive speech, but can understand basic commands and older children may communicate with gestures
-Monitor for seizure activity
-Monitor for scoliosis

-Hypotonia and feeding problems in infancy
-Behavioral problems: tantrums, stubborn and rigid personality, ADHD, high pain tolerance, and skin picking
-Mild intellectual disability, motor and language delays, and poor coordination
-Short stature
-Failure to thrive
-Central obesity
-Sleep apnea
-Scoliosis
-Strabismus

-High pain threshold, which creates challenges for PCP to address illness/injury in timely manner
-Children with Prader-Willi syndrome rarely vomit
-Reduced salivation leads to early increased risk for dental caries
-Hypogonadism and premature adrenarche are common

-Monitor growth using standard growth charts
-Monitor for injury due to high pain tolerance
-Monitor for failure to thrive
-Assist families with behavioral issues including:
hyperphagia
tantrums
obsessive behavior
elopement

-Intellectual disability
-Language delays
-Behavioral problems such as anxiety and aggression
-Stereopathies
-Autism spectrum disorder
-Prominent forehead
-Long, narrow face
-Prominent jaw

-High arched palate/dental crowding
-Protuberant ears
-Short stature
-Connective tissue dysplasia
-Obstructive sleep apnea
-Recurrent/chronic OM
-Seizures

-Closely monitor development
-Cognitive deficits can be moderate to severe
-Monitor for hypersensitivity to sensory stimuli
-Monitor for seizure activity as there is an increased risk for seizure (decreases in adolescence)

-Evaluate infants for congenital hip dysplasia, clubfoot, and hypotonia
-They may need orthopedic referral for connective tissue dysplasia such as scoliosis or hypermobile joints
-Evaluate for inguinal hernias as children with Fragile X are at increased risk
-Ensure annual ophthalmologic evaluation

-Periodic recurrence of pervasive sadness or other grief-related feelings throughout the lives of individuals with chronic health conditions, their family, caregivers.
-Chasm between "what is" and the view of "what should be" -> for example: If you think about families of those with dementia, that was supposed to be their golden years, and instead this is what they're dealing with.
-"Living Loss"
-NORMAL response
-Chronic sorrow and chronic stress go hand in hand

Chronic sorrow they can meet life's daily demands
-They still get up and they still go to work, they still do everything they need too.

-Parents/families of children with chronic illnesses, developmental delay
-Caregivers of spouses with dementia
-Persons experiencing infertility
-Perons/families experiencing cancer
-Transplant recipients and famlies

-Health crisis
-Expected developmental milestones
-Anniversaries
-Upcoming appointments, labs

-Forgetful
-Hypervigilance
-Poor sleeing, eating d/o
-Mood disorders, PTSD
-Worsening of chronic conditions
-Short temper, misplaced keys, and forgotten appointments

-Interpersonal: talking to others
-Emotional: crying
-Cognitive: think postive
-Action oriented: keeping busy

-Plan of care: Developed by PCP, collaboration with other providers.
-Central record or database: Pertinent medical information, updated med list, equipment, supplies
-Care Coordination: Information-sharing among the child, families and providers; referral to other healthcare professionals; collaboration with agencies.
-Family support: support groups; parent-parent groups; social work; mental health services
-Communication: Families understanding of recommendations and treatment options; encouraging families to keep pertinent info and share this info with healthcare providers as needed.

-Determine needs and stengths of family/child
-Develop necessary partnerships
-Develop plan of care
-Implement plan of care

-Allergens trigger an immunoglobulin E (IgE) response in predisposed children and there are four types of allergic reactions.

-IgE mediated: develop allergic symptoms with anaphylax being the most profound symptom
-Remeber (A) = Allergic, Anaphylaxis, Atopy

-Involves IgG, IgM antibodies. Results in inflammation, cellular dysfunction or toxicity, leading to cell destruction.
-Examples of symptoms are hemolytic anemia, thrombocytopenia, or Graves disease.
-Remember (B) = antiBodies

-Immune-complex reactions resulting from the IgG or IgM antibodies - antigen complexes that accumulate in the tissue and circulation, activating the complement cascade.
-Examples of this type of reaction are serum sickness and some vasculitic syndromes.
-Remember (C) = immune Complex

-Delayed T-cell type reaction.
-Contact allergies to nickel or topical medication are type IV reactions.
-Remember (D) = Delayed

-Can trigger sneezing, hives, wheezing, vomitting, or anaphylaxis.
-Acute reactions (less than 30 minutes) can be followed by a late phase response several hours (2 to 12 hours) after the initial response.
-This late-phase response is due to the influx of other inflammatory cells (such as basophils, eosinophils, monocytes, lymphocytes, and neutrophils) and their inflammatory mediators which are recruited to the site of the acute allergic reaction.

-Feeding peanut food to infants at 4 to 6 months.
-Making sure that vitamin D is apparopriately supplemented
-Avoiding environmental exposure to allergens to decrease allergies to children.

-Complex, chronic multifaceted respiratory disease that results in inflammation, airway hyperresponsivness, and airway remodeling, although airway remodeling is more common in children who begin to show symptoms before three years of age.
-Inflammation causes the acute bronchoconstrition we see in asthma, it also causes airway edema and mucous plug formation.
-Airway inflammation can trigger hyperresponsiveness to variety of stimuli, including allergens, exercise, cold air, and any physical, chemical or pharmacologic agents.
-Hyperresponsiveness reults in bronchospasm.

-Airflow obstruction
-Wheeze, cough
-Prolonged expiratory phase
-Diminished breath sounds
-Increased work of breathing/signs of distress: tachypnea, retractions, nasal flaring, use of accessory muscles, and agitation
-Changes in vital signs such as tachycardia, hypertension, or hypotension
-Cyanosis of lips and nail beds
-Associated findings include sinusitis, atopic dermatitis, or allergic rhinitis

-Asthma Control Test (ACT)
-Asthma Control Questionaire
-Asthma Therapy Assessment Questionnaire
-Asthma Control Score
-TRACK (for children 0-5 years)
-ACT is reliable for patients with uncontrolled asthma but NOT for those who are controlled

-Symptoms two times or less per week
-Asymptomatic and normal PEF between exacerbations
-Requires SABA 2 days/week
-Exacerbations brief (few hours or days); varying intensity
-No interference with normal activity
-NIGHTTIME SYMPTOMS: two times or less per month

-FEV greater than 80% predicted; normal FEV between exacerbations

-Symptoms more than two times per week but less than one time per day
-Requires SABA more than two days/week but no more than once per day
-Exacerbations may affect activity (minor)
-NIGHTTIME SYMPTOMS: 3 to 4 per month

-FEV greater than 80%

-Daily symptoms
-Daily use of inhaled SABA
-Some limitations
-Exacerbations affect activity 2 or more per week; may last days
-NIGHTTIME SYMPTOMS: More than one time per week but NOT nightly

-FEV greater than 60% predicted, but less than 80% predicted

-Continual symptoms
-Requires SABA several/times day
-Extremely limited physical activity
-Frequent exacerbations
-NIGHTTIME SYMPTOMS: often 7X per week

-FEV less than 60% predicted.

-Wheezing at the end of expiration or no wheezing
-No or minimal intercostal retractions along posterior axillary line
-Slight prolongation of the expiratory phase
-Normal aeration in all lung fields
-Can talk in sentences

-Wheezing throughout expiration
-Intercostal retractions
-Prolonged expiratory phase
-Decreased breath sounds at the base

-Use of accessory muscles plus lower rib and suprasternal retractions; nasal flaring
-Inspiratory and expiratory wheezing or no wheezing hear with poor air exchange
-Suprasternal retractions with abdominal breathing
-Decreased breath sounds throughout the base

-Diminished breath sounds over the entire lung field
-Tiring, inability to maintain respirations
-Severely prolong expiration if breath sounds heard
-Drowsy, confused

Older than 5 years of age.

-Pulmonary function tests (PFTs) are preferred to peak flows in the diagnosis of asthma, but peak flows are good for at home use to determine severity of an exacerbation.
-Allergy testing: skin testing preferred over teh radioallergosorbent test (RAST) as it's more sensitive
-Exhaled nitrous: this is a good way to determine airway inflammation
-Pulse oximetry: this should be done at every visit for asthma with a CBC obtained if there's a secondary infection
-Sweat test: this shoul dbe considered based on history in every child with asthma, to determine an underlying diagnosis of cystic fibrosis
-Doing spirometry during well child checks and sick visits gives PCP an excellent indication of the amount of inflammation and bronchospasm present in the airway.
-If spirometry is not an option, peak expiratory flow (PEF) can be used in children as young as 4-5 years old.

-Pulmonary function test

-Measure forced expiratory volume (FEV) and forced vital capacity (FVC).
-FEV is the amount of air expelled in one second, whereas FVC is the total among of air expelled.

-Greater than 75%: Normal
-60% to 75%: Mild Obstruction
-50% to 59%: Moderate Obstruction
-Less than 49%: Severe Obstruction

-80% to 120%: Normal
-70% to 79%: Mild Reduction
-50% to 69%: Moderate Reduction
-Less than 49%: Severe Reduction

-If spirometry is not an option, peak expiratory flow can be used in children as young as 4-5 years old.
-Green zone: More than 80% to 100% of personal best signals good control
-Yellow zone: Between 50% and 79% of personal best signals caution
-Red zone: Between 0% and 50% of personal best signals major airflow obstruction

-Measure the greatest rate of airflow during a forced exhalation
-Peak flow meter will be no use if the child is in respiratory distress or unwilling to cooperate.
-Normal predicted values vary and must be compared to the child's personal best.
-Incorporate zones into an asthma action plan.

1.Have the child stand up.
2.Make sure that the indicator is at the base of the numbered scale.
3.Ask the child to take a deep breath.
4.Have the child place the peak flow meter in the mouth with the lips sealing the mouthpiece. Tell the child not to put his or her tongue in the hole of the mouthpiece.
5.Tell the child to blow out as hard and fast as possible.
6.Record the rate, but if the child coughs, do not write down that number.
7.Repeat steps 2 through 6, two more times.
8.Record the highest of the three values.

-The maximum flow rate that is produced during forced expiration with fully inflated lungs.

-First step: First assess severity which depends on the child's age and symptomalogy and is done by utilizing the classifcation of severity tables.
-Once the child is classified as either intermittent, mild persistent, moderate persistent, or severe persistent, then treatment is determined by the stepwise approach.

-SABA prn

-Low-dose ICS
-ALTERNATIVE: Cromolyn LTRA nedocromil, or theophylline

-Low-dose ICS+ LABA, Leukotriene receptor antagonists (LTRA), or theophyline
-OR medium-dose ICS

-Medium dose ICS +LABA
-ALTERNATIVE: Medium dose ICS+ LTRA or theophyline

-High-dose ICS + LABA
-ALTERNATIVE: High dose ICS + LTRA or theophyline

-High-dose ICS + LABA + oral corticosteroids
-ALTERNATIVE: high dose ICS + LTRA or theophyline + Oral corticosteroids

-Consult with asthma specialist if step 4 care or higher is required
-Consider consultation at step 3

-SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to three treatments at 20 minute intervals as needed. Short course of oral systemic corticosteroids may be needed.

-SABA prn

-Low-dose ICS
-ALTERNATIVE: Cromolyn, LTRA, nedocromil, or theophyline

-Low dose ICS + LABA
-OR Medium-dose ICS
-ALTERNATIVE: Low-dose ICS + either LTRA, theophyline, or zileuton

-Medium-dose ICS + LABA
-ALTERNATIVE: medium-dose + either LTRA, theophyline, or ziletuton

-High-dose ICS + LABA + oral corticosteroid
-AND consider omalizumab for patients who have allergies

-High-dose ICS + LABA + oral corticosteroid
-AND consider omalizumab for patients who have allergies

-Symptoms and signs suggestive of a more serious exacerbation such as marked breathlessness, inability to speak more than short phrases, use of accessory muscles, or drowsiness should result in initial treatment while immediately consults with a clinician.
-Less severe signs and symptoms can be treated initially with assessment of response to therapy and further steps as listed below.
-If available, measure PEF—values of 50% to 79% predicted or personal best indicate the need for quick-relief medication. Depending on the response to treatment, contact with a clinician may also be indicated. Values less than 50% indicate the need for immediate medical care.

-Inhaled SABAs (Albuterol), 2 to 6 puffs every 20 minutes for 3 treatments by way of MDI with a spacer, or a single neb treatment (0.15mg/kg; minimum 1.25 to 2.5mg of 0.5% solution of albuterol in 2 to 3 mL of normal saline).

-No wheezing or dyspnea (assess tachypnea in young children)
-PEF greater than 80% predicted or personal best:
-May continue inhaled SABA every 3-4 hours for 24 to 48 hours with a 3-day course of oral corticosteroids at 1 to 2mg/kg/day in two divided doses to a maximum of 60mg/day.
-Consider short course of oral systemic corticosteroids.

-Persistenet wheezing and dyspnea (tachypnea) PEF 50% to 79% predicted or personal best:
-Add oral systemic corticosteroids
-Continued inhaled SABA
-Contact clinician urgently (this day) for further instruction.

-Marked wheezing and dyspnea. PEF less than 50% of predicted or personal best:
-Add oral systemic corticosteroid.
-Repeat inhaled SABA immediately
-If distress is severe and nonresponsive to initial treatment: Call your doctor and proceed to ED; consider calling 911

-Genetic and environalmental factors are linked to the cause of AR.
-AR is rare in children under two years as it requires a few years to develop allergic response
-It can be seasonal (hay fever), perenial (year round, indoor allergens) or episodic.

-It persists for only 4 weeks or less

-It can present for longer than 4 weeks.

1. The immediate phase response occurs 15 to 30 minutes after exposure to an allergen and is caused by mast cell mediator release.
2. In about 60% to 70% of indviduals, there is a late phase response occuring 6 to 12 hours after exposure and is due to inflammatory cells (lymphocytes, basophils, eosinophils) infiltrating the nasal mucosa.

-Decreased nasal patency/stuffiness
-Mouth breathing, snoring, nasal speech
-Bogginess of nasal mucosa
-Clear, thin, watery to seromucoid rhinorrhea

-Nasal crease, a horizontal crease across the lower third of the nose
-Itching, rubbing of the nose causing “allergic salute”
-Itching of palate, pharynx, or eyes
-Redness of conjunctivae
-Enlarged tonsils and/or adenoids: “cobblestone” pharynx or conjunctivae
-Allergic shiners

-Diagnosis based on clinical findings, history of atopy. The American Academy of Allergy recently recommended against ordering large panels of allergen testing and stressed the importance of only doing testing for specific allergens by history.
-Nasal eosinophils is a non-specific finding.
-Referrals for allergy testing if more severe. RAST not as specific as skin testing and should never be used to formulate immunotherapy.

-Avoidance strategies include controlling house dust, using dust mite-proof mattress and pillow covers, washing bed linens in hot water weekly, minimizing stuffed toys in the child’s bedroom, using vertical blinds instead of horizontal or curtains, removing carpeting from the bedroom, and using plastic or wood furniture instead of cloth or upholstered.
-Eliminate smoking from the child’s environment.
-Consider pets that are hairless.
-Reduce mold, avoid damp basements, avoid vaporizers to keep humidity less than 50%.
-Use dehumidifiers and A/C with filters.
-Eliminate milk, eggs, or wheat for infants with perennial allergic rhinitis if they seem to be making things worse.
-Eliminate cockroaches.

-Oral H1 antihistamines: Helpful in seasonal form of AR
first generation: Benadryl
second-generation: Zyrtec (the second-generation is particularly effective.)
-Topical nasal antihistamines: Azelastine (older than five years of age)
-Decongestants: limited long-term benefits (rebound rhinorrhea)

-Intranasal steroids: Reducing inflammation/obstruction (very effective)
-Dymista: Combination of azelastine and Flonase (intranasal steroid)
-Allergy immunotherapy and other treatments: Goal is to reduce immune tolerance and change response to allergens
-Montelukast: This is the only approved leukotriene modifier for use in seasonal and perennial AR. It is approved for children six months to five years at a 4 mg packet (granules) once daily. It has a moderate effect when used alone. If the patient has AR, administer the dose in the morning or evening; if the patient also has asthma, give the dose in the evening.]

-Chronic, pruritic, inflammatory skin disorder with acute and chronic skin eruptions
-In infants and younger children, there is a facial/extensor pattern that involves the face, scalp, cheeks, and extensor surfaces of the extremities
-In older children, the rash localizes to the antecubital and popliteal surfaces, head, and neck
-Referred to as the “itch that rashes”
-Food allergies are common in AD

-Pruritus/eczematous changes
-One-third begin before three months of age with dry skin
-Acute manifestations (more common in infants):
intense itching and redness
papules, vesicles, edema, serous discharge/crusts
generalized dry skin

-Chronic manifestations (in older children):
lichenification
scratch marks
generalized xerosis
-Tendency for dry skin/itching
-Worsens in winter months
-Secondary infections
-Hyperpigmentation

-Signs/Symptoms:
dry skin is first sign

-Signs/Symptoms:
itch-scratch-itch cycle starts

-Signs/Symptoms:
acute presentation: common in infants: intense itching; redness, papules, vesicles, edema; serous discharge and crusts
cheeks, forehead, scalp, extending to trunk as symmetric patches or to the extremities; lateral extensor surface of arms and legs; diaper area and groin are spared of lesion
-Prognosis:
two-thirds of cases resolve by two to three years
generalized xerosis

-Signs/Symptoms:
pruritus is severe
lesions are dry and papular with circumscribed scaly patches
involves wrists, hands, popliteal and antecubital fossa; eyebrows thin and broken off with lack of the lateral third of the eyebrow (called Hertoghe sign); some only have feet involved; may have allergic-atopic facies and white dermatographism
flexural involvement
-Prognosis:
one third continue into teenage years—tendency to be chronic

-Signs/Symptoms:
begins at puberty and can commonly continue into adulthood
often involves the flexural folds (popliteal and antecubital fossae), face, neck, upper arms and back, dorsa of hands, fingers, feet, and toes
dry skin and lichenification are prominent findings
erythematous, dry-scaling papules and plaques with fewer exudates
postinflammatory hypopigmentation or hyperpigmentation that disappears
-Prognosis:
new or recurrence of a chronic condition

-Characteristic clinical findings
-A chronic or recurring rash that is pruritic and has a characteristic distribution and appearance, together with a family or personal history of atopy, is key to the diagnosis -Immunologic testing is not needed

-Itch-scratch-itch cycle must be interrupted
-Dryness of the skin must be corrected by rehydrating the stratum corneum with lubrication as the first-line therapy to enhance skin moisturization
-The moisturizer should be safe, free of additives, and inexpensive
-The best time to place the moisturizer is after the child’s bath or shower

-Do not completely dry them off after the bath and then put on the moisturizer, trapping in the residual moisture
-If moisturization does not work, then topical corticosteroids (TCPs) are used with low-potency corticosteroids for maintenance and higher potency for exacerbations -Eliminate any known offending agents (irritants and allergic triggers) and secondary bacterial or viral infections must be treated

-Antihistamines: Sedating doses at night
-Topical corticosteroids (TCSs):
reduce inflammation and pruritus
seven classes with varying potency
ointments, gels

-Topical calcineurin inhibitors (TCIs): Second-line therapy that is useful in both acute and chronic AD.
two agents are available:
1. Tacrolimus topical (Protopic) ointment 0.03% and 0.1% strengths
2. Pimecrolimus topical (Elidel) 1% cream
they have been shown to be as effective as mid-strength TCS.
they can be combined with TCS in the treatment of children whose AD has not responded to TCS.

-Prescription emollient devices
-Topical antimicrobials/antiseptics
-Ointments, Creams, and Gels:
ointments have a higher potency than creams. Need to use low-potency on the face, groin, axilla, and any large areas.
gels penetrate well but tend to be more drying. Most children are controlled with a twice-daily application for two weeks then doing a twice-weekly application of a low-dose topical steroid for up to four months once the lesions have died down.
desonide Cream is low potency and can be used on the face, also OTC hydrocortisone cream.
triamcinolone in ointment or cream can be used for the rest of the body and comes in varying potencies.

-Skin lubrication:
aquaphor works best
bathe in lukewarm not hot water.
-Avoidance and prevention:
avoidance of triggering factors, keep fingernails short to decrease trauma to the skin when scratching

-Environmental management:
increased environmental humidity.
cool temperatures are best.
soaps, detergents, clothing: Allergen-free products such as fragrance-free laundry detergent and fabric softener. Loose-fitting clothes with fabrics that breathe such as cotton
eliminate allergenic agents, such as feather pillows, fuzzy toys, stuffed animals, and pets
house-dust mites: encase mattresses and pillows, washing bedding in hot water weekly, frequent vacuuming, removing carpets, or at least frequent cleaning are recommended.

Dietary management:
n infants, whey-protein partially hydrolyzed infant formula is not hypoallergenic and should not be given to infants who have a milk allergy. Dietary restrictions should only be done based on a history of food allergy. Food allergens in older children and adults are not common triggers.

-Secondary skin infections common
-Lichenification associated with chronic itching
-With treatment, two-thirds of children will have less severe symptoms; 20% will have complete remission

-AD is a recurrent disease that can be controlled
-Precipitating factors
need to avoid precipitating factors such as extreme temperatures or humidity, excess sweat, and/or emotional stress
new clothes—wash with mild detergent (with no dyes or perfumes) before wearing them to remove chemicals, if using harsh washing detergent—add second rinse cycle when washing clothes