PNP Management 2 Exam #2

-Laryngotracheobronchitis (LTB)
-Acute, inflammatory disease of the larynx, trachea, and bronchi that typically follows an upper respiratory infection
-It is the most common reason for upper airway obstruction in children
-As a child grows, incidence decreases because their upper airway increases in diameter, and they become less susceptible to obstruction secondary to inflammation

-Very similar to croup
-Short-lived and thought to be related to an allergic reaction or viral antigen
-It is unclear whether LTB is part of the same disease spectrum
-Symptoms improve with exposure to night air

-Steeple sign: subglottic narrowing
-Slight dyspnea, tachypnea, retractions
-Mild, brassy or barky cough
-Stridor
-Low-grade to high fever, may be up to 104 °F (40 °C)
-Epiglottis appears normal
-Substernal or chest wall retractions in severe cases
-Prolonged inspiration
-Wheezing or rales if lower airway involvement

-Clinical diagnosis
-Imaging studies are not recommended

-Depends on the cause, severity, and location of the obstruction.
-Humidified Air (cold and hot)
-Corticosteroids
dexamethasone 0.6 mg/kg PO or IM
use IM if child is vomiting
-Bronchodilators
if bronchospasm is also suspected, indicated by wheezing on exam, the use of bronchodilators in the usual doses prescribed for relief of asthma may be beneficial
-Oxygen
blow-by oxygen if O2 saturation falls below 92%

-Hospitalization
children with severe respiratory distress, severe retraction, stridor at rest, or who are not improving with standard treatment should be admitted to the hospital
as obstruction increases, continuous stridor, nasal flaring, and suprasternal, infrasternal, and intercostal retractions can be seen
-Nebulized Epinephrine
nebulized epinephrine can reduce airway edema by vasoconstriction of the subglottic mucosa
it has shown benefit in the treatment of croup and should be considered for any child with significant retractions or symptoms of respiratory distress

-Occasional croupy cough
-No retractions
-No chest wall retractions

-Education of caregiver
-Corticosteroids

-Frequent croupy cough
-Audible stridor and suprasternal and sternal retractions at rest
-No agitation

-Education of caregivers
-Corticosteroids

-Frequent croupy cough
-Tachypnea
-Prominent inspiratory and occasional expiratory stridor
-Agitation and distress

-Education of caregiver
-Corticosteroids
-Nebulized epinephrine
-Blow-by oxygen

-Audible stridor at rest
-Sternal retractions
-Lethargy
-Decreased level of consciousness with dusky color

-Education of caregiver
-Corticosteroids
-Nebulized epinephrine
-Blow-by oxygen until intubation
-Intubation

Group A beta-hemolytic streptococci (GABHS)

Most common between ages 5 and 13 years

-Petechiae on soft palate and pharynx; swollen, beefy-red uvula and tonsillopharyngeal tissue
-Yellow, blood-tinged exudate
-Tender, enlarged anterior cervical lymph nodes
-Bad breath
-Scarlatiniform rash, strawberry tongue, circumoral pallor with scarlet fever

Abrupt onset without nasal symptoms
Arthralgia, myalgia, headache
Moderate-high fever, malaise
Prominent sore throat, dysphagia
Nausea, abdominal discomfort, vomiting
Late winter to early spring occurrence

-Scarlatina rash with GABHS
-The scarlatina rash is erythematous, feels like sandpaper when palpated, and has concentrations in the groin and axilla
-Linear hyperpigmented areas with tiny petechiae in the joint folds, referred to as Pastia’s lines, will also be present

-Rapid strep screen
-Send out culture if rapid strep is negative
-Sexually transmitted infection (STI) testing (history of oral to genital sex need to be cultured)
-If mononucleosis is suspected, request a complete blood count and heterophile antibody test

-First Choice: Amoxicillin 50 mg/kg/day BID for 10 days (max dose of 1000mg)
-Penicillin allergy: cephalexin 40 mg/kg/day BID for 10 days (max dose of 500mg)

-Rheumatic fever
-Post-streptococcal arthritis
-Acute glomerulonephritis
-Retropharyngeal abscesses are more common in children younger than six years of age
-If antibiotics are started within nine days of symptom onset, the risk for complications decreases

-Children may return to school or daycare once they have been on antibiotics for a full 24 hours
-They will also need to discard their old toothbrush and get a new one prior to finishing their course of antibiotics so as not to reinfect themselves

-EBV
-HSV
-CMV
-Enterovirus
-Influenza
-Parainfluenza
-HIV

-Pain
-Myalgia and arthralgia
-Fever
-Sore throat and dysphagia
-Rhinitis, cough, hoarseness, stomatitis
-Gradual onset
-Erythema of tonsils or pharynx
-Reactive cervical lymphadenopathy

No diagnostic studies are required unless strep pharyngitis is suspected

Supportive care with adequate fluid intake

Bordetella pertussis

Infants <6 months

1. Catarrhal (most contagious)
2. Paroxysmal
3. Convalescent

2 to 3 weeks

-Upper respiratory infection symptoms with mild progressive dry cough
-Low-grade fever (to 101 °F [38.3 °C])
-The cough worsens as the child progresses to the paroxysmal stage

2 to 4 weeks

-There is intense and violent coughing with five to 10 coughs with an inspiratory whoop
-The cough can lead to eye proptosis and tearing, thick mucus production, and coughing
-Cyanosis, sweating, prostration, and exhaustion after coughing
-Sleep is disturbed but fever is absent or minimal
Adolescents:
-Classic paroxysm of coughing is missing in up to a third of patients
-Clinicians should consider pertussis if there is a persistent cough beyond three weeks

3 weeks to 6 months

-Symptoms wane over a variable period that can last months
-Waning of paroxysmal coughing episodes, but a nonparoxysmal cough can last as long as six weeks with coughing paroxysm occurring when the child gets another viral infection

-Culture is the gold standard of diagnostics but must be done within two weeks of symptom onset
-The result can be negative if the child has been sick for more than two weeks, was previously vaccinated, or if antibiotics were started
-A polymerase chain reaction (PCR) provides a more rapid result, earlier treatment, and has improved sensitivity and specificity
-It’s obtained with a nasopharyngeal swab and can be done within three weeks of cough onset.

-Antibiotics should be started within six weeks of disease onset for infants and within 21 days for children and adolescents
-Treating with antibiotics will decrease the course of symptomatology as well as decrease the risk of transmission to others
-The macrolide class of drugs, including azithromycin, clarithromycin, and erythromycin, is recommended for all ages
-There is an association between the development of pyloric stenosis and erythromycin in infants younger than one month

-Newborns to 6 months: Zithromax 10 mg/kg in a single dose for five days
->6 months: Zithromax 10 mg/kg on day one, then 5 mg/kg on days two through five

-Macrolide prophylaxis is recommended for household and close contacts irrespective of pertussis immunization status
-Close contact includes household members, caregivers, health care workers, and any person who was within three to four feet of a symptomatic person, shared a closed space for one hour or more, or had direct contact with nasal, oral, or respiratory tract secretions

-The complication rate is higher in infants younger than six months of age
-One out of 100 infants die from pertussis
-Other complications include apnea, secondary pneumonia, convulsions, insomnia, sinusitis, otitis media, syncope, rib fracture, and weight loss

-Usually caused by respiratory syncytial virus (RSV)
-It is characterized by an insidious onset of URI symptoms, decreased feeding, and mild fever, with apnea as a possible presentation in the younger infant
-After one to two days of URI symptoms, wheezing and coarse crackles are heard with tachypnea
-Mild to severe chest retractions that can last as long as 12 days may also be present.

Child, anywhere from infancy to two years old, who starts with a URI followed by wheezing and mild to severe respiratory distress

-URI symptoms of cough, coryza, and rhinorrhea for one to two days prior to lower respiratory symptoms
-The gradual development of respiratory distress with persistent coughing, tachypnea, chest retractions, and wheezing
-Low to moderate fever up to 102 °F (38.9 °C); decrease in appetite
-No prodrome in some infants; instead, they have apnea as the initial symptom
-Course is the worst within 48 to 72 hours after wheezing starts; the illness peaks at around five to seven days

Auscultation of the airways sounds like someone walking on snow

-Coryza (rhinitis)
-Mild conjunctivitis
-Pharyngitis

-Tachypnea: approximately 40 to 80 breaths per minute
-Substernal and/or intercostal retractions, expiratory wheezing; fine or coarse crackles
-Varying signs of respiratory distress with possible nasal flaring, grunting, retractions, cyanosis, and prolonged expiration
-Abdominal distention: palpable liver and spleen, pushed down by hyperinflated lungs and a flattened diaphragm

-Diagnosis is made on history and physical exam alone
-A chest X-ray will not help unless you’re looking for pneumonia
-Even though the causative agent is respiratory syncytial virus (RSV) in 50–80% of bronchiolitis cases, routine virologic testing is not recommended

-No evidence supports pharmacologic therapy as effective in the management of bronchiolitis
-Supportive care remains the primary therapy and includes fever control and maintaining hydration and nutrition while keeping oxygen levels greater than or equal to 90%

-The management of rhinitis using saline drops and bulb suctioning of nares
-Indications for the use of antipyretics
-Signs of increasing respiratory distress or dehydration that call for hospitalization
-Education that infants and children with bronchiolitis may cough for two to three weeks
-Limit exposure to child or daycare centers whenever possible
-Use good handwashing techniques along with alcohol-based hand sanitizers when appropriate
-Avoid tobacco smoke exposure
-Receive an RSV prophylaxis vaccination if specific criteria are met

-Guidelines for feeding an infant with signs of mild respiratory distress:
amount of fluid needed per 24 hours
smaller, more frequent feedings
monitoring of the respiratory rate
guarding against vomiting

-Apnea
-Oxygen saturation of less than 92% on room air
-Inadequate oral intake less than 50% to 75% of the usual volume
-Restlessness or markedly decreased activity
-Parent or caregiver unable to care for the baby or child at home

-Respiratory distress signs including:
grunting
respiratory rate over 60
stridor
cyanosis
rising carbon dioxide
progressive stridor
stridor at rest

-Life-threatening illness characterized by inflammation of the epiglottis
-Caused by haemophilus influenzae type B (Hib)

-Abrupt onset of high fever, irritability, muffled voice, severe sore throat, dyspnea, dysphagia leading to drooling, and increasing respiratory distress.
-The child will be acutely ill and toxic appearing.
-Inspiratory and sometimes expiratory stridor.
-Hyperextension of the neck with older children sitting in the tripod position.
-Airway obstruction follows within two to 24 hours.

Blood cultures
do not examine the throat
A lateral neck radiograph can be obtained, but someone skilled in intubation should be at the bedside when the X-ray is taken
The diagnosis is confirmed in the OR by depressing the tongue to view the swollen cherry-red epiglottis
The absence of the thumb sign on the X-ray rules out epiglottitis

-Airway management is key
-Do not place the child in a supine position and transport immediately via emergency medical services to the hospital
-The child should be then taken directly to the operating room (OR) where they can be assessed for emergency tracheotomy
-An expert in establishing an airway needs to be present, as there is a risk of reflex laryngospasm with acute or complete airway obstruction

-Keep the child as calm as possible
-IV antibiotics (ampicillin/sulbactam, cefotaxime, ceftriaxone, or clindamycin if allergic to penicillin, with the addition of vancomycin if MRSA is the etiology)
-Oxygen and respiratory support are also needed
-As the inflammation subsides, the child can be extubated with antibiotic therapy continuing for 10 days

inflammation or edema of mucous membranes in the sinuses and may or may not be infectious

-Acute (four weeks)
-Chronic (more than 12 weeks)

1. With the onset of severe respiratory symptoms
2. Upper respiratory symptoms that persist for more than 10 days, or
3. A “double sickening” with initial improvement followed by severe symptoms such as worsening cough, fever, and headache

-Caused by bacterial invasion
-Adenoids are also believed to be a reservoir for bacterial infections that can lead to nose and nasal sinus infections

-Multifactorial illness with predisposing factors such as:
other infections
environmental irritants
allergies
anatomic problems
nasal polyps
trauma
a foreign body
GERD
cystic fibrosis
primary ciliary dyskinesia
immunodeficiencies

-Facial pain or pressure (second major criterion is needed)
-Facial congestion or fullness
-Nasal congestion or obstruction
-Hyposmia or anosmia
-Fever (acute sinusitis requires a second major criterion)
-Purulence on intranasal exam

-Headache
-Fever
-Halitosis
-Fatigue
-Dental pain
-Cough
-Ear pain, pressure, or fullness

-The diagnosis is usually made on history and physical findings that last longer than 10 to 14 days with increasing severity or without improvement
-Diagnostic studies, including imaging, are not needed for acute sinusitis
-Imaging studies should only be done if a complication might be present
-If orbital or central nervous system (CNS) extension is suspected, then a CT or MRI should be obtained

-Do not overdiagnose rhinosinusitis and refer chronic or recurrent rhinosinusitis to otolaryngology (ENT)
-Treat with antibiotics:
URI lasting longer than 10 days with purulent discharge, cough or worsening fever, high fever
-Analgesics
-Amoxicillin:
45 mg/kg/day BID
if there is more than 10% community resistance to S. pneumoniae, then bump up to 80–90 mg/kg/day BID
maximum is 1,000 mg/dose or 2,000 mg/day

-Recent antibiotic use:
amoxicillin clavulanate (Augmentin) 80–90 mg/kg/day dosing on the amoxicillin component
use a 600 mg/5 ml suspension for the liquid form to reduce intake volume
-Rocephin:
can give a one-time dose of Rocephin 50 mg/kg to children who are vomiting

-Decongestants and antihistamines: No randomized controlled trials with good evidence of effectiveness
-Topical corticosteroids: No good data in children
-Saline irrigation: Clinical guidelines do not support usage

-Orbital extension
-Inflammation
-Infection
-Central nervous system inflammation and infections

-Good allergy management
-Management of GERD
-Influenza vaccination
-Relief of nasal airway obstruction

-The average duration is seven to nine days; the peak is generally on the third day when purulent discharge may be noted
-Resolves by the 10th day
-The cause:
parainfluenza
RSV
coronavirus
human metapneumovirus

-Nasal congestion, cough, sneezing, rhinorrhea, fever, hoarseness, pharyngitis
-Gradual onset
-Prominent nasal symptoms
-Sore throat and dysphagia
-Mild cough and poor sleep
-Low-grade fever
-Nasal secretions more purulent after one to three days

-Mild injection of the conjunctiva
-Red nasal mucosa with secretions of varying colors
-Mild erythema of the throat
-Anterior cervical lymphadenopathy with freely movable nodes
-Clear lung sounds.

No diagnostic studies are needed unless strep pharyngitis is suspected, at which point a rapid antigen detection test (RADT) would be administered

Supportive care with symptomatic relief (cool mist and nasal saline with bulb suction for infants)

-Secondary bacterial infections
-Acute otitis media
-Pneumonia
-Sinusitis

-Due to the risk of overdose, unsupervised ingestions, the potential for harm, and little evidence of efficacy, the use of decongestants and cough medications is no longer recommended for children younger than six years of age
-The FDA has issued warnings not to prescribe any cold medications containing codeine or hydrocodone to patients under 18 years of age due to serious side effects, deaths, and addiction potential

-Classic symptom: unilateral, purulent, foul-smelling discharge
-Epistaxis
-Obstruction
-Mouth breathing
-Nasal mass if they are embedded in the granulation tissue or mucosa

-Jewlery beads are the most common
-Depends on location, the composition of the foreign body, the skill of the practitioner, and the cooperation of the child
-If you are not experienced in removal, or if the child is uncooperative, the foreign body might be pushed deeper into the nasal cavity
-Refer to ENT if needed

-Anterior bleeding being the most frequent
-Incidence is highest during the spring and summer

-The cause is most often benign and self-limiting, and it is typically related to mechanical trauma
-Other etiologies include:
coagulopathies
allergies
neoplasms
polyps
hemangiomas,
chronic rhinitis
upper respiratory tract infection
foreign body
topical nasal sprays
viral or bacterial infection
adolescents using recreational drugs
living in dry climates or dryness from artificial heat during winter months

-Recent nasal trauma, nose picking
-Allergies, recent URI
-Unexpected bruising or bleeding from other sites
-Frequent nosebleeds
-Tarry stools from swallowing blood
-Use of nasal sprays
-Family history of excessive bleeding or bleeding disorders

-Nares visualization:
clots
masses
foreign body
polyps
raw areas
dry nasal mucosa

-Allergy:
shiners (dark circles)
Dennie-Morgan lines (lines under lower eyelid)
adenoidal facies (open-mouthed appearance in children)
pale or boggy mucosa

-Baseline hematocrit if severe or chronic
-Coagulation studies only if history suggests a coagulopathy (CBC, PLT, PT, aPTT)
-A bleeding disorder will be characterized by epistaxis that is severe, prolonged, and recurrent
-Nonaccidental injury or coagulopathy should also be considered in children younger than two years of age with spontaneous epistaxis

-Sit upright and lean forward to avoid swallowing blood
-Do not lean their head back
-Apply direct pressure at nasal ala for 10 to 15 minutes
-Packing or topical vasoconstrictor drugs are occasionally needed
-Bedside cool mist humidifier and/or normal saline drops or spray:
if using nasal corticosteroids, make sure they are spraying laterally and not towards the nasal septum

-Apply topical antibiotic creams or ointments to the site of the septal scab for two weeks to reduce nasal colonization with S. aureus crusting and inflammation
-Silver nitrate sticks can be used to cauterize exposed vessels if bleeding persists; however, the site must be easily accessible, visible, and not bleeding briskly:
silver nitrate has a high failure rate and is associated with nasal septum atrophy
-Refer to an ear, nose, and throat (ENT) specialist if persistent
-Treat the underlying cause

-Barely audible
-Heard faintly after a period of attentive listenting

Soft but easily audible

-Moderately loud
-No thrill

-Loud
-Persistent over widespread area
-Palpable thrill

-Loud, audible with stethoscope barely on the chest
-Percordial thrill present

-Heard without stethoscope
-Rare

-True

False. Once those two things are corrected the murmur should disappear

-Do NOT cause any problems
-Usually a Grade I-III
-Inform parents that murmur may come and go and may be louder at times of fever, anxiety, pain or exercise and that activities do not need to be limited or any special precautions taken

-Usually grade I to III/VI in intensity and localized
-Changes with position (sitting to lying)
-May vary in loudness or presence from visit to visit
-May increase in loudness (intesity) with fever, anemia, exercise or anxiety.
-Musical or vibratory in quality, sometimes blowing
-Systolic in timing (except for venous hum, which is continuous), peaking in first half of systole

-Duration is short
-Best heard in LLSB or pulmonic area (except for venous hum)
-Rarley transmitted
-May disappear with Valsalva manuever, position, or gentle juglar pressure.
-Vital Signs: NORMAL
-ECG: NORMAL
-General health status: good

True

-Changes with position from sitting to lying
-Fever
-Anemia
-Exercise
-Anxiety

-Child with a syndrome
-Typically diastolic
-Any systolic murmur that has a thrill.
-Grade IV or higher and it has a harsh blowing quality

-Narrowing of small or long segment of aorta
-Severity, location, degree of obstruction determine symptoms

-Not always apparent in newborn until ductus closes
-Severe COA evident in first 6 weeks
-Tachypnea, poor feeding, cool lower extremities
-In children 3–5 years of age, especially if the coarctation is not severe, it can go unnoticed until there’s hypertension or in the upper extremities or a murmur is noticed

-Systolic and diastolic hypertension in vessels proximal to narrowing; hypotension in distal vessels
-Upper extremity hypertension; lower extremity hypotension
-Absent or weak arterial/distal arterial pulses (especially femoral)
-Bounding brachial, radial, carotid pulses
-Signs of CHF (blood backs up into the right side of the heart)
-Systolic ejection murmur, ventricular heave
-Gallop rhythm in infants with CHF

-Must take on 3 different occasions if elevated
-<13 years of age: normal blood pressure is systolic and diastolic blood pressure less than 90th percentile for age, sex, and height
-Begin taking yearly at age of 3

->90th percentile
-120/80 to 129/80

>130/80

95th to 99th percentile

>99th percentile

-More likely to occur after 10 years of age
-Related to lifestyle or obesity

-Common in children younger than the age of six years old
-Significant or severe hypertensive levels
-Caused by a problem with the renal system

-Assess whether primary or secondary
-Neonatal history of prolonged mechanical ventilation, prematurity, SGA
-Prior hospitalizations, trauma
-Diet, activity, smoke exposure
-Sleep history/sleep apnea
-Medications
-Chronic illnesses, history of UTI (indicates possible renal disease)
-Headache, chest pain, dyspnea, muscle weakness, palpitations
-Family history of MI, stroke, HTN, others

-Body habitus, overweight, metabolic syndromes
-Dysmorphic features
-Edema, pallor, flushing, or skin lesions suggesting tuberous sclerosis, SLE, neurofibromatosis
-Upper/lower extremity central pulses
-Fundi abnormalities, enlarged thyroid, abdominal mass, flank bruit, decreased visual acuity, facial palsy
-Elevated BP (3 separate occasions)

-BP measurements should be done annually on all children 3 years and older with a baseline
-If it’s elevated, we want at least two follow-up blood pressure measurements taken within one to two months of the initial reading to determine whether it was a single isolated event or if they truly have hypertension
-If the hypertension is caused by them being overweight we need to treat obesity with lifestyle changes
-We want to make changes in their diet, increase their activity level if even after that, the hypertension is persistent, you’re going to refer to nephrology

-Medication initiation is done by cardiology
-Good nutrition with a decrease in dietary fat and sodium
-Prevention of overweight with diet and aerobic excerise for at least 30 minutes daily
-Stress Management
-Avoidence of caffeine, tabacco use, and prescription or over the counter medications that can exacerbate high BP (cold medications with ephedrine or phenylephrine, steroids)
-Montioring BP if oral contraceptives are used

-Transient loss of consciousness
-Usually benign; must rule out cardiovascular causes
-Recovery is quick

-Triggering factors (exercise, pain, anxiety)
-Prior episodes of syncope/fainting
-Associated injury, tonic-clonic movements, vertigo
-Chest pain, palpitations, tachy- or bradycardia
-Family history of Sudden Cardiac Death (SCD) before age 40
-Possibility of pregnancy or use of drugs
-Exercise-induced bronchospasms
-Psychological stressors
-History of event

-Adolescents

-Usually normal
-Cardiac:
abnormal ECG
-Orthostatic syncope:
more than a 30 millimeter mercury drop in blood pressure after they stand for 5–10 minutes
-After Episode:
dizziness, pallor, a clammy feeling, exhaaustion or headache

-Good hydration
-Rest 5-10 minutes, either supine or their legs up if prodromal symptoms occur or after fainting
-Restrict child from sports participation until referral to a pediatric cardiologist is completed
-If drug therapy is used, the typical duration is 1 year, followed by weaning
-If the episodes are psychogenic or psychological in nature, we can get some cognitive behavioral therapy as well

-Decrease their caffeine and increase their sodium intake so they maintain a good blood pressure and NOT hypotensive
-If they feel a episode an coming on they can do isometric leg or arm contractions, they just contract their muscles in their arms and legs and that will help push and force blood back to their head
-Squat or lie down if they feel an episode coming on and then if they may be need to use compression socks, if they're having frequent episodes

-Pediatric cardiologist if cardiac disease suspected
-Oxygen saturation <95%
-Symptoms of CHF
-Pathologic murmur; one that is difficult to differentiate
-Other murmurs referred non-emergently
-Infants with changes in breathing, increased irritability and poor feeding, cyanosis
-Older child with dizziness, chest pain with exertion, arrhythmia, dyspnea, syncope, CHF, abnormal VS

-Hole in atrial septum
-Ostium secundum: most common; midseptum in area of foramen ovale
-Primum ASD: lower portion of septum (common in Down's Syndrome)
-Defects of sinus venosus: high in atrial septum; associated with anomalous pulmonary venous return

-Often asymptomatic
-May fatigue easily/exertional dyspnea
-Thin
-Frequent URI/pneumonia
-Symptoms may be more common in late adolescence/early adulthood

-Murmur not typical until 2-3 years
-Possible mild left anterior chest bulge
-S1 normal or split; S2 often widely split, fixed
-Grade I to III/VI, widely radiating, medium-pitched, not harsh systolic murmur at pulmonic area (due to increased blood flow across the pulmonic valve)

-Defect in ventricular septum
-Perimembranous is most common

-Murmur often not heard until 2-8 weeks of age
-Classic loud murmur associated with signs of CHF

-Small VSD:
harsh
high-pitched grade 2 to 4/5
holosystolic at left lower sternal border
other findings normal
-Large VSD:
low pitched, grade 2 to 5/6 holosystolic murmur at left lower sternal border
holosystolic (murmur that begins with the first heart sound and continues through or to the second heart sound_
signs of CHF (S3 and S4 gallop if CHF is present)
thrill along left sternal border
VSD murmur that becomes higher pitched over time indicates that the defect is becoming smaller

-Overuse of goat’s milk, cow’s milk (greater than 24 oz/day), or other milk substitutes
-Childhood obesity
-Prematurity
-Low birth weight
-Exposure to lead
-Exclusive breastfeeding beyond six months of age without iron supplementation
-Weaning to whole cow’s milk without an iron source
-Feeding problems
-Prolonged bottle use
-Adolescent females with excessive menstrual bleeding

-Irritability, restlessness, and pica with Hgb levels less than 8 g/dl
-Anorexia with Hgb less than 8 g/dl
-Developmental delays and social–emotional disturbances

-May have pallor
-Tachycardia, murmurs, congestive heart failure (CHF) signs
-Stool guaiac testing in severe anemia

-Risk factors for IDA should be assessed at each visit with universal screening for Hgb at 12 months and follow-up of abnormal results
-The minimum laboratory screening for iron deficiency is Hgb level (CBC will give more information)
-A serum ferritin level will help in assessing current iron stores (can be increased with recent inflammation)

-Microcytic
-Hypochromic RBCs (RBCs are smaller than the usual size of RBCs)
-Low or normal mean corpuscular volume (MCV)
-Low or normal RBC number
-High red cell distribution width (RDW)
-Low ferritin
-High total iron-binding capacity
-Mentzer index of greater than 13 (diagnostic test that differentiates beta-thalassemia from IDA)

-Ferrous sulfate (3–6 mg/kg/day of elemental iron) in two to three divided doses or 3 mg/kg/day in one or two divided doses (for adolescents, the max dose of elemental iron is 200 mg)
-Hgb/Hct and retic count should be reassessed in four weeks following the initiation of treatment
-Follow-up Hgb in one month should reveal a minimal improvement of 1 to 2 g/dl with the reticulocyte count increasing to greater than 3% in 48 to 96 hours
-If there’s a response to iron supplementation, it should be continued to normalize the Hgb, then continued for two to three months to replace depleted iron stores
-Labs should be rechecked six months after iron supplementation is discontinued to determine resolution of the anemia and iron stores

-If there is no response to iron supplementation when the labs are rechecked in four weeks, and there is confidence that the iron supplements are being given correctly, a more extensive lab evaluation should be completed and needs to include a CBC with differential, platelet count, RBC indices, and reticulocyte count
-A peripheral blood smear should also be obtained to assess the number and morphology of RBCs, WBCs, and platelets

-Increase iron-rich foods
-Iron supplementation for exclusively breastfed infants at four months
-Avoid whole cow’s milk until 12 months
-Goat’s milk lacks adequate iron and folic acid
-Avoid giving iron with milk
-Vitamin C enhances absorption
-Stools will be black
-Keep medication away from children

1 mg/kg/day at four months until they begin iron-fortified foods at six months

-Most common thrombocytopenic purpura of childhood and is believed to be an autoimmune response in which circulating platelets are destroyed
-Cases typically occur between one and four years of age, but most resolve within six months with or without treatment
-If symptoms last longer than 12 months, it is then classified as chronic ITP, and further evaluation should be done

-Symptoms usually appear when PLT is less than 20,000/mm3
-Acute onset of petechiae, purpura, and bleeding in an otherwise healthy child; the bruising or bleeding may be most prominent over the legs
-Recent viral illness one to four weeks before the onset
-Hemorrhage of mucous membranes, especially the gums and lips
-Nosebleeds that are severe and difficult to control
-Menorrhagia in adolescent female
-No hepatosplenomegaly or lymphadenopathy
-Rarely bone pain, pallor
-Intracranial hemorrhage is the major complication of ITP

-Low platelet count (less than 150,000/mm3) with an otherwise normal CBC
-Severe thrombocytopenia: PLT less than 20,000/mm3 common
-Normal PT and aPTT
-Megathrombocytes on peripheral smear
-Normal WBC, RBC
-Hemoglobin may decrease with severe bleeding if there is a history of significant nose or menstrual bleeding, but the MVC remains normal

-Prognosis is excellent and most cases can be managed as an outpatient
-If the PLT is greater than 20,000/mm3 and there is no hemorrhage, children can be instructed to avoid contact sports, aspirin (ASA), and NSAIDs
-In severe cases (platelets less than 20,000/mm3): a short course of corticosteroid therapy may reduce severity in the initial phases
-Intravenous immunoglobulin (IVIG) is also given to children with active severe bleeding and those who have contraindications for steroid use
-A splenectomy or immunosuppressives can be used for refractory or chronic ITP

-Represent changes in circulating leukocytes, specifically lymphocytes, and are a group of malignant diseases in which normal bone marrow elements are replaced by abnormal, poorly differentiated lymphocytes known as blast cells
-They are also the most common form of pediatric cancer

-Characterized by preponderantly undifferentiated WBCs
-Peak incidence is between two and six years of age

-Less common in children
-Has a poorer prognosis

-A history of repeated infections, fever, weight loss
-Bleeding episodes with epistaxis, petechiae, and hematomas
-Lymphadenopathy and hepatosplenomegaly
-Bone and joint pain

-CBC with differential, PLT, reticulocyte counts
-Peripheral smear may show malignant cells
-Bone marrow aspirate will show an infiltration of blast cells replacing normal bone marrow elements
-Chromosomal and genetic abnormalities are found in most children with ALL
-Thrombocytopenia and anemia are present in most cases
-WBC may be elevated, normal, or low

-PCP is critical in the coordination and facilitation of referrals and communication
-It’s also important to assist the family in coping and adaptation, as life as they know it will change
-Well-check visits must continue, are important, and should not be overlooked. Immunizations should be given as scheduled depending on the stage of treatment for the child
-The child should also be monitored for any failures of remission, late effects of treatment, or metastasis (the central nervous system and testicles as common sites)

-Solid tumors of lymphatic tissues—the malignant proliferation of T cells, B cells, or indeterminate lymphocyte cells
-Occur most frequently in the second decade of life

-Acute abdomen: abdominal pain, distention, fullness, and constipation
-Nontender lymph node enlargement
-Duration of symptoms before diagnosis is usually one month
-Compression of surrounding tissue and structures

-CBC (the CBC may be normal at diagnosis), liver function, uric acid, electrolytes
-Radiography, CT, MRI, PET

-Multidisciplinary approach
-Lymphomas are sensitive to chemotherapy

Malignancy of reticuloendothelial and lymphatic systems; involves B cells
Originates in cervical lymph node

-Painless enlargement of lymph nodes, usually in the cervical area
-Chronic cough if the trachea is compressed by a large mass
-Fever, decreased appetite, weight loss of more than 10% within six months of diagnosis; drenching night sweats

-Anemia
-Elevated or depressed leukocytes, PLTs
-ESR and CRP are elevated
-Elevated copper, ferritin
-Abnormal LFTs
-Proteinuria
-Radiography, US, CT, MRI, PET

-Treatment at a comprehensive pediatric oncology center
-Lifelong monitoring for side effects

-Vascular Nevi
vascular malformations (salmon patches, port wine stains)
hemangiomas
present at birth and do not resolve spontaneously
-Pigmented Nevi
dermal melanocytosis
cafe au lait spots
acquired melanocytic nevi
atypical nevi (potential for malignancy)
lentigines

-Presence from birth, or at age first noted (usually emerge by 2 to 3 weeks of life)
-Progession of lesion
-Familial tendencies for similar nevi, especially for history of melanoma

-Classified as superficial, deep (cavernous) or mixed
-Vascular malformations or flat vascular nevi are present at birth and grow with the childs growth
-Pigmented nevi may be present at birth or aquired during childhood
-Atypical nevi are larger than acquired nevi they have irregular poorly defined borders and have variable pigmentation

-First appears as a pale macule, a telangiectatic lesion or a bright red nodular papule
1. Proliferative Phase:
grow rapidly and form nodular compressible masses ranging in sizes from a few milimeters to a few centimeters
can cover an entire limb, resulting in asymmetric limb growth
rapidly growing lesions may ulcerate
2. Involution Phase:
occurs slowly but spontaneously
average age this begins is 12 to 24 months
starts with a grey lesion follpwed by flattening from the center outward
most skin appears normal after involution but can have residual changes

-Fungal infection of the skin or the mucous membranes
-More common in infants, obese children, adolescents, and chronically ill or immunocompromised kids
-It can also occur as a secondary infection in a persistent diaper rash or with antibiotic, steroid, or oral contraceptive use in adolescents

-Mouth:
thrush: friable, adherent white plaques on erythematous base (thrush)
cheilitis: cracked lips
angular cheilitis: fissured corners of mouth
-Intertriginous areas:
bright erythema in flexural folds of neck, axillae, groin

-Diaper areas:
moist, beefy-red macules/papules with satellite lesions
-Vulvovaginal area:
thick, cheesy, yellow discharge
erythema, edema
itching
-Nail plates:
transverse ridging
loss of cuticle

-Diagnosed on clinical examination
-KOH-treated scrapings if there’s treatment failure (you would see the hyphae)

-Thrush:
first Line: nystatin suspension PO QID
if second dose is needed: oral fluconazole 6 mg/kg/day for the first day, then 3 mg/kg/day daily for 14 days if there is resistance
for older children and adolescents: clotrimazole troche 10 mg troche 5 times a day for 14 days
-Candidal Dermatitis:
nystatin cream or miconazole applied and each diaper change until the rash is gone, plus an additional 1–2 days
add in 1% hydrocortisone to the diaper area for 1–2 days for severe inflammation
if there’s a secondary infection in addition to the candidiasis, you can do a topical bacitracin or neoporacin 4–5 times a day

-Need to use nystatin until the thrush is gone, but then once the thrush is gone, continue to use it for an additional 1–2 days
-Frequent diaper changes
-Leave that diaper area open to air as much as possible
-Can blow dry diaper area with warm air on the very low setting for 3–5 minutes at the diaper change to make sure that area is completely dry without rubbing it
-Avoid using baby wipes or they can use the baby wipes that have no scent to them or no chemicals
-Avoid using baby powder because of the risk of inhalation

-Infants: cradle cap
-Adolescents: dandruff
-Overproduction of sebum

-Infants:
flaky thick crusts of yellow, greasy scales
common on the scalp, face, behind ears, neck, trunk and diaper areas
-Adolescents:
mild flakes with some erythema and yellow greasy scales
common on scalp, face, flexural surfaces, eyebrows,, forehead, nasal bridge and intertriginous areas

-Antifungal agents:
azoles
selenium sulfide
-Anti-inflammatory agents:
topical steroids
topical calcineurin inhibitors
-Keratolytic agents (removes excess scale):
topical salicyclic acid

-Mineral oil may be applied to the scalp for 5 to 10 minutes before shampooing with a mild shampoo
-Scales can be removed with a soft brush or toothbrush
-Frequent shampooing is generally effective
-There is no medicated or prescriptive shampoos approved for children under 2 years old

-Facial dermatitis:
daily ketoconazole 2% topical preparations (cream, shampoo, gel or foam)
intermittent use of low-potency topical corticosteroids (0.05% desonide cream or lotion)
-Scalp dermatitis:
medicated shampoos (tar, salicyclic acid, ketoconazole, or selenium sulfide) 2 to 3 times a week (1 to 4 times per month for African Americans) alternated with prescription strength shampoos (ketoconazole 2.5%, selenium sulfide 2.5%)
shampoos should be left on the scalp for 5 to 10 minutes before scrubbing crusts and then rinsing
topical corticosteroids added weekly for recalcitrant dermatitis (leave in foam works the best)

-Secondary infection with bacteria or candida can occur
-Severe, generalized seborrhea is commonly found in persons infected with HIV

-Lice can affect scalp, body (uncommon) and pubic areas
-Infestation = nits (eggs) or lice
-Nits incubate for 1 week, then hatch and begin laying eggs in 2 weeks
-Direct or indirect contact
-Head lice is not a health hazard (lice does not spread diseases)

-Infestations
-Dandruff-like substance in hair
-Itching of scalp/crawling sensation

-Lice can be visualized
-Nits are small white oval cases attached to the hair shaft
-Common sites: back of head, nape of neck and behind ears
-Body lice:
excoriated macules/papules
belt line, collar, underwear areas and regional lymphadenopathy

-True
-Pubic lice infestation is considered an STD
-If you ever see pubic lice on a child, that needs to be a huge red flag for sexual abuse and you need to report that
-If it’s found in an adolescent who’s sexually active, that does not need to be reported

-No diagnostic studies
-If pubic lice is found in an adolescent who’s sexually active you need to test for gonorrhea and syphilis

-We only want to treat when we see the live lice or we see those viable nits
-Treatment failure is very common in children
-Over-the-counter permethrin, which is 1%, and permethrins, are inexpensive, but there’s a high resistance

-Permethrin: first-line treatment
-Do not use a shampoo that contains a conditioner or cream rinse prior to using a pediculicide:
the conditioner or the cream rinse in the shampoo form a barrier and the pediculicide cannot get into the hair shafts and treat, cannot get on the hair and treat and kill the head lice, or any petroleum or Vaseline products on the hair or scalp prior to using that pediculicide
-Want to keep the pediculicide off the eyes

-Apply to damp hair
-Do not put it on wet air as that dilutes the actual pediculicide
-After treatment, do not rewash the hair for one to two days following that treatment
-Most treatments are going to have to be reapplied in 7–10 days
-Pregnant women and nursing mothers should not be exposed to pediculicides
-If a mom is pregnant or they’re nursing, they should not be the one applying that pediculicide onto their child’s scalp

-Comb the damp hair for a minimum of 20–30 minutes working from the top of the scalp down in one-inch section
-Take small sections of the hair, work top-down for 20–30 minutes, paying special attention to the nape of the neck and behind the ears
-If the child has lice on the eyelashes, which can occur, you can coat the eyelashes with petroleum jelly or Vaseline two to three times a day for 8–14 days and then manually remove nits

-Launder sheets, towels, clothing, any headgear, the sheets and the towels and clothing need to put while the sheets and towels need to go in the wash on hot and need to be in the dryer on the hot cycle
-Anything that cannot be washed needs to be stored in a plastic bag for two weeks
-Vacuum
-Soak any brushes, combs, or hair accessories like breads and scratches and all the things in the pediculicide
-Check daily or weekly for lice
-Might need to reapply a second time
-Can go back to school

-Rose-colored flaking
-Common, mild self limited papulosquamous disease
-Most common in adolescents
-Caused by human herpesvirus 6 or 7

-Most are usually well
-Small percentage have a prodrome phase off mild symptoms:
malaise
pharyngitis
lymphadenopathy
headache before the onset of rash
-Those with prodromal symptoms tend to have a more florid rash

-A 2 to 5 cm solitary, ovoid, slightly erythematous lesion with a finely scaled slightly elevated border that enlarges quicly with central clearning
-Typical locations include: the trunk, upper arm, neck or thigh

-Symmetric, small mascular to papular, thin and round to oval
-The lesions have thin scales centrally with thicker scales peripherally (collarette scales surround the lesions)
-They are also pale pink more common on trunk and proximal extremities from neck to knees typically sparing the face, scalp, and distal extremities
-Usually occur 2 to 21 days after the appearance of the herald patch (key finding)
-Itching is a common in patients with secondary generalized lesions

-Rash, especially on back
-Follows dermatome skin lines with oval lesions running parallel and wrapping around the trunk horizontally

-Limb-girdle pityriasis rosea can occur with lesions involving areas that are usually spared (face, axilla and groin)
-The face and neck are freuqent areas of involvment in young children, especially African American children

Have punctate hemorrhages, erosions, or ulcerations, erythemous macules or annular plaques

-No studies needed
-If needed, a KOH preparation of a skin scraping is done to rule out tinea

-Erythromycin 250 mg PO QID for 2 weeks may hasten the resolution of the eruption
-Application of calamine lotion (or other lotions containing menthol and/or camphor or pramoxine), tepid baths with Aveeno, antihistamines, and emollients may provide relief from itching
-Topical steroids do not change the lesions or hasten recovery
-Oral steroids can exacerbate symptoms
-Minimal sun exposure ca help lsions resolve more quickly

-Benign, self limiting noncontagious disease that has three cycles (emerging, persisiting and fading)
-Spontaneous resolution in 6 to 12 weeks
-Transient pigmentary changes can occur, especially in African Americans
-Recurrence is comon

-Superficial fungal infection
-Also called oityriasis vesicolor
-Occurs predominately on the trunk
-Caused by a yeast organism, malassezia furfur
-Occurs more commonly in adolescents, immunocompromised children and in warmer seasons and humid climates
-Breast feeding infants can acquire the organism from their mother

-Associated with warm, humid weather
-Occasional mild itching may occur

-Multiple, annular, scaling, discrete macules or patches ranging from hypopigmended (salmon-colored to brown) in light-skinned individuals
-Seen on the neck, shoulders, upper back and arms, chest midline, and face (especially in children)
-Guttate or raindrop pattern

-No diagnostic studies needed
-KOH scrapings reveal short curved hyphae and circular spores (spaghetti and meatballs)
-Scrapings fluoresce yellow-orange under Wood's lamp if not cleansed recently

-Slenium sulfide 2.5% lotion or 1% shampoo (over the counter) applied in a thin layer several hand-widths beyond lesions for 30 minutes twice a week for 2 to 4 weeks followed by monthly applications for 3 months to help prevent recurrences
-Older adolescents can use ketoconazole 2% shampoo as directed earlier or for smaller areas of infection, topical imidazoles (clotrimazole, miconazole, ciclopirox or terbinafine solution) or topical azoles (ketoconazole or oxiconazole) applied BID for 2 to 4 weeks
-Resistant or severe cases in older adolescents sometimes require oral antifungal treatment with fluconazole 400 mg PO once or itrazonazole 400 mg once. Followup in 1 month

-Sun exposure makes lesions appear hypopigmented as the surrounding skin tans
-Repigmentation takes several months
-If the patient is taking oral antifungal medication, encourage exercise to induce sweating, because this may enhance concentration of medication in the skin
-Skin irritation occurs with overnight application
-Absence of flaking when skin is scraped is a sign of effective treatment

-Female mite (saroptes scabiei) that burrows into the epidermis laying eggs
-Causes intense itching, especially at night
-It’s highly, highly contagious, and comes from close contact or sharing clothing and linen
-Eggs hatch in about 3–4 days and mature into adult mites in 10–4 days, and the female mite has a lifespan about 15–30 days

-Itching worse at night and progressively gets worse
-Fitfull sleep and crankiness

-S-shaped burrows in webs of fingers (classic), sides of hands, folds of wrists and armpits
-Older children have under 10 lesions
-Children under 2:
see it on the palms, the soles of the feet, the scalp, the face behind the ears, under the axilla, and concentrated in the folds
dozens of lesions (classic)
vesiculopustular lesions
-Crusted, or Norwegian scabies presents as scaly papules or plaques and is more often found in immunocompreomised patients (more contagious)

-Do not use KOH becasue it dissolves the mites, eggs and feces
-Microscopic exam of scrapings in saline or mineral oil can reveal the mite, eggs and feces
-Burrows and fresh apules are best for specimen collection
-Burrow ink test to stain burrow

-Pharmacological treatment – scabicide in thin layer to entire body; reapply in 7 days
-First line treatment: Permethrin
apply from neck down
rinse off in 8-14 hours
can repeat in 1 week
-Simultaneous treatment of close contacts

-Wash linens, clothing that has been used in the past 48 hours; vacuum house
-Store non-washable items in sealed plastic bags for 1 week
-Rash and itching persists for up to 3 weeks following treament
-Avoid overbathing and further irritation to the skin
-Can return to school 24 hours after treatment initiation

-Meant for acute oozing, crusting or itching skin
-Can help dry the skin, decrease itching and remove crusts
-Dressings should be moderately wet but not dripping, with lukewarm water and applied for 10 to 20 minutes BID to QID over a period of 48 to 72 hours
-Alternative solutions:
saline (1 tsp salt with 1 pint of water)
burow solution (1 Domeboro (aluminum acetate, calcium acetate) with 1 pint of cool or tepid water)

-Topical medications applied following wet dressing are absorbed more efficiently
-Short term (up to 10 days) topical corticosteroids under the dressing may alleviate pruritus or burning sensations
-Care must be taken to prevent excessive steroidal absorption by focused application of steroid only to the affected areas

-Decrease water evaporation from the skin and enhance hydration and absorption of topical medications
-Plastic wrap is placed over the affected area after hydrating the skin and/or applying cream/ointment
-Should not be left on longer than 8 hours
-Ointments, oils, urea compounds and propylene glucol used alone may be considered occlusive

-Lichen simplex chronicus
-Dyshidrotic eczema
-Psoriasis

-Very common viral skin infection
-Hard to get rid of
-Spread by direct contact, by fomites, or autoinoculation by scratching

-Itching at the site
-Possible exposure

-Small, firm, pink-flesh-colored papules
-Becomes umbilicated with cheesy core/surrounding dermatitis
-Single papule to numerous, clustered papules
-Can be severe in children with eczema, HIV
-Most common sites: face, axillaw, antecubital area, trunk. popliteal fossae, crural area and extremities

-Lesions resolve over time (takes 6 months to 2 years untreated to disappear)
-Decision to treat is based on comfort, to reduce itching, minimize autoinoculation and cosmetic reasons
-Mechanical removal of central core
-Irritants (surgical tape) may cause resolution
-Topical medications may be beneficial
-Cimetidine orally if treatment fails
-Report genitally grouped lesions
-Evaluate for HIV if hundreds of lesions

-Contagious bacterial infection of superficial layers of skin
-Caused by Group A strep, S. aureus, or MRSA
-Two forms: nonbollus and bollus
-Spreads through autoinoculation via hands, towels, clothing, nasal discharge and droplets

-Most common
-Classic honey crusted crusted lesions

-Occurs sporadically and this develops on intact skin
-More common in infants and young children

-Pruritus: can spread the infection to surrounding skin from itching
-Dry nose from a runny nose in the winter and as they rub their nose the skin breaks down
-Mosquitoe bites in the summer can cause itching and skin breakdown (nonbollus)

-Lesions common on face, hands, neck, extremities, perineum
-Regional lymphadenopathy

-Begins as 1 to 2 mm erythemous papules or pustules
-Progresses to vesicles or bullae, which rupture
-Leaving moist, honey colored crusty lesions on mild mrythematous eroded skin
-Less than 2 cm in size
-Little pain, but spreads quickly

-Large, flaccid, thin-walled, superficial annular or oval pustular blisters or bullae
-Ruptures easily
-Leaves the skin thin with a varnishlike coating or scale

-No diagnostic studies needed
-Gram stain/culture if needed

-Nonbollus:
topical antibiotics for superficial or localized areas
mupirocin or retapamulin
-Bollus:
IV beta-lactamase-resistant antistaphylococcal penicillin
methicillin, oxacillin or nafcillin

-For widespread infections with constitutional symptoms and deeper skin involvement and transmission to family members, use an oral antibiotic active agent
-If it’s a beta-lactamase producing strains of Staph aureus, we can use an oral antibiotic such as Augmentin, dicloxacillin, cloxacillin, or cefalexin

-Hand hygeine imperative
-Exclude from day care or school until treated for 24 hours
-Schedule follow-up appointment in 48 to 72 hours if not improved
-Postinflammatory pigmentation changes can last weeks to months

-Ringworm
-Superficial fungal skin infection found on the non hair skin areas of the body
-Contact sports (wrestling), hot and humid climates, crowded living conditions, day care, school settings and immunosuppression increases risk
-Tinea manuum (hand)
-Tinea barbae (beard)
-Tinea faciei (face)

Contact with a person or animal with tinea is sometimes reported

-Classic Appearance: annular, oval, or circinate with one or more flat, scaling, mildly erythematous circular patches or plaques with red scaly borders
-Lesions spread peripherally and clear centrally or may be inflammtory throughout with superficial pustules
-Often prominent over hair follicles
-Multiple secondary lesions may merge into a large area several centimeters in diameter

-Do testing is treatment failure or questionable diagnosis
-KOH treated scrapings of border of lesion reveal hyphae and spores
-Wood's lamp with fluoresce most tinea corporis
-Fungal culture of the lesion

-Miconazole 2% cream, powder and lotion daily or BID
-Clotrimazole 1% cream, lotion, solution, and powder BID
-Antifungal and steroid combinations should be avoided
-Apply cream to lesions including zone of normal skin BID until clinical resolution
-Can take 1 to 4 weeks for resolution

-Tinea faciei, extensive infection, tinea corporis gladiatorum, immunosuppression, coexisting tinea infections on scalp or nails, or infection that is unresponsive to topical treatment may require systemic treatment
-Drug of choice for children over 2 years: Griseofluvin for 2 to 4 weeks
-Ultramicrosized >2 years old: 10 to 15 mg/kg in single or in 2 divided doses (max of 750 mg/day)
-Microsized: 10 to 20 mg/kg/day given daily or BID (max of 1 g/day)
-Take medication with fatty foods for better absorption
-For extended therpy, need CBC, liver and renal function after 8 weeks of initiating therpy because of risk of hepatotoxicity, nephrotoxicity, and neutropenia

-Find source of infection and treat or elimination it to prevent recurrence
-Keep skin dry following application of antifungal
-Identify and treat contacts
-Educate about communicability of lesions and length of treatment
-Exclude from daycare or school until 24 hours after treatment has begun
-Follow up in 2 weeks or sooner if lesions are not responding
-If unresponsive, diagnosis is incorrect or resistance is possible
-Culture to confirm diagnosis and change class of antifungal used

-Superficial bacterial inflammation of hair follicle
-Obstruction of the follicular orifice is the most important factor contributing to the development
-Moist environment, maceration, poor hygeine, occlusive emollients and prolonged submersion in contaminated water are risk factors

-Pruritus
-Hot tub exposure
-Irritating surface agent
-Occasional fever, malaise or lymphadenopathy

-Typically asymptomatic
-Discrete, eythematous 1 to 2 mm papules or pustules on an inflammed base centered around a hair follicle
-Involvement of face, scalp, extremities (typically thighs and upper arms) buttocks, and back
-Hot tub folloculitis: prutitic papules, pustules or deep red to purple nodules, most dense in areas covered by a swimsuit 8 to 48 hours after exposure

-Gram stain and culture are occasionally ordered
-In cases of persistent or difficult to treat folliculitis, consider the possibility of MRSA

-Topical keratolytics:
benzoyl peroxide 5% to 10% BID for 5 days, especially is chronic or recurrent
-Topical antibiotics:
erythromycin cream, gel, solution, or ointment BID for 10 to 14 days
clindamycin cream, gel, solution or ointment BID for 10 to 14 days
-Warm compress after washing with soap and water several times a day
-Follow-up treatment in 1 week
-If recurrent, look for nasal or skin carrier state

-Avoid shaving
-Hot tub folliculitis: resolves in 5 to 14 days but can recur up to 3 months after exposure

-Lack of skin hyperpigmentation
-Leaves white or light colored areas
-Congenital or acquired
-Generalized vitiligo occurs most commonly in children and is generally associated with other autoimmune disorders, most commonly hypothyroidism

-Family history of vitiligo, halo nevi, traumatic depigmentation of skin or markedly premature graying of the hair
-Onset of depigmentation (birth or more recent)
-Presence of systemic or skin diseases
-Any trauma to the skin: Koebner phenomenon is noted in about 15% of children with vitiligo

-Flat, milk white macules or papules with scalloped distinct borders of varied size
-Symmetric or asymmetric, possibly following a nerve segment
-Few to multiple, seen most commonly on face and trunk

-Mild to moderate steroids show some success
-Topical calcinerurin inhibitors (tacrolimus ointment, pimecrolimus cream) eliminate atrophy
-Refer for treatment with psoralens, which may be used in combination with UVA radiation (children less than <9 years)
-Broad spectrum sunscreens are used to decrease the tanning of normal skin
-Cover agents such as skin dyes and walnut oil

-Microcomedones
-Comedones: inflammed microcomedones
-Papules, pustules or nodules: inflammed lesions
-Begins at the onset of puberty (girls 12 to 13 years) (boys (14 to 15 years)

1. Sebaceous follicles become plugged with keratinous material
2. Colonies of anaerobic bacteria grow deep in the follicle, primarily propionibacterium acnes, but coagulase negative staphylococci and m furfur can be involved
3. Sebum is pverproduced and androgen production increases resulting in expansion of the follicle
4. Inflammation occurs and pustules form secondary to trapped P. acnes and sebum. The bacteria release chemotatctic factors that attract neutophils to ingest the bacteria and release hydrolytic enzymes

-Family history
-Stage of pubertal development and menstrual history
-Facial and hair products used, especially occlusive products or pomades
-Oral and topical prescription medication, especially oral contraceptives, andtibiotics, or steroids
-Current of previous acne treatment and results
-Sports participation
-Jobs (fast-food grill)
-Other medical conditions

-Severity of acne is determined by the quantity, type, and spread of lesions
-Lesions most commonly are found on the face, back and chest
-Noninflammatory lesions:
microcomedone
open comedone (blackhead)
closed comedone (whitehead)
-Inflammatory lesions:
occur secondary to noninflammatory lesions

1. Reduce the excess production of sebum
2. Counteract the abnormal desquamation of epithelial cells
3. Decrease the proliferation of P. acnes
4. Prevent or decrease scarring

-Choice of treatment depends on:
the extent, severity, and duration of disease
type of lesions
psychological effects the adolescent is experiencing

-Medications used in treatment of acne vary by action, route of administration and strength:
topical and systemic preparations
keratolytic or comedolytic agents
antibacterial or antibiotic effects
hormonal agents

-Retinoids:
tretinoid
tretinoid/clindamycin
tazarotene
adapalene
-Keratolytic:
azelaic acid

-0.01%-0.025% gel, 0.025%-0.01% cream, 0.1% microgel
-Causes sun sensitivity
-Pea size amount should be applied 20 minutes after washing the face
-Initially it is used every other night, advancing to every night
-Sensitivity is worse in the first 2 weeks and decreases after

-0.1% cream or gel, 0.3% gel, 0.1% with 2.5% BP gel
-Less irritation and photosenitivity
-Better efficacy

-0.05%-0.1% cream, 0.05%-0.1% gel
-Used once daily

-20% cream, 15% gel
-Antibacterial and keratolytic
-Useful in individuals with sensitive or dark skin
-Effective in treating acne rosacea

-2.5%-20% gel, 5% and 10% cream, 5%-20% lotion or wash
-Most frequently used topical preparation for acne
-Used BID depending on the severity of acne and dryness of skin
-Powerful antimicrobial with comedolytic and anti inflammatory effects
-Used in combination with topical antibiotics causes less antibiotic resistance

-Clindamycin: 1% solution, lotion, gel, pledget, foam
-Clindamycin: 1% with 5% benzoyl peroxide
-Erythromycin: 1.5% to 2% solution, 3% gel or swabs
-Erythromycin: 3% with benzoyl peroxide
-Used once or twice a day in combinations with other topical medications

-Tetracycline
-Minocycline
-Doxycycline
-Erythromycin
-Used when there is no response to topical antibiotics
-Might not see improvement for 3 to 4 weeks

-Short term usage, do not use long term (<6months)
-Dose should be tapered to a daily dose and then discontinued
-Combination use with benzoyl peroxide or retinoid with continuation of topical medication after stopping the oral antibiotics

-250-500 mg BID
-Should be taken with 8 ounces of water 1 hour before or 2 hours after eating
-Contraindictated in: pregnant, breastfeeding women, and children less than 9 years

-50-100 mg BID
-Associated with more side effects
-Taken with food, but avoid dairy since it can decrease absorption
-Side effects: blue-black discoloration in scars, photosenitivity, and hypersentivity

-50-100 mg BID
-Highest rate of photosensitivity
-Taken with food, but avoid dairy since it can decrease absorption

-250-500 mg BID
-Limited to those that cannot take tertracycline
-GI upset is common
-Vulvovaginal candidiasis is common

-Oral retinoids
-Course of 20 week
-Requires evaluation by dermatology
-Contraindicated in patients with depression and anxiety
-Teratogenic in pregnancy

-LFT's
-Serum cholesterol
-Triglycerides
-hCG
-Urinalysis for pregnancy

-Isotretinoin registry
-FDA reqires healthcare providers, female patients and pharmacists to access the website monthly after office visits and before filling their prescriptions
-Documentation regarding pregnancy, blod donation, and contraceptive counseling

-Used in females
-Antiandrogens
spironolactone
-Androgen receptor blockers
-Oral contraceptive pills

-Ethinyl estradiol/norgestimate
-Ethinyl estradiol/nonethindrone acetate/ferrous fumarate
-Ethinyl estradiol/drospirenone
-Ethinyl estradiol/drospirenone/levomefolate

-Benzoyl peroxide or topical retinoid
or
-Topical combination therapy:
benzoyl peroxide + antibiotic
benzoyl peroxide + retinoid
benzoyl peroxide + retinoid + antibiotic

-Topical combination therapy:
benzoyl peroxide + antibiotic
benzoyl peroxide + retinoid
benzoyl peroxide + retinoid + antibiotic
or
-Oral antibiotic + topical retinoid + benzoyl peroxide
or
-Oral antibiotic + topical retinoid + benzoyl peroxide + topical antibiotic

-Oral antibiotic
or
-Tropical combination therapy:
benzoyl peroxide + antibioic
benzoyl peroxide + retinoid
benzoyl peroxide + retinoid + antibiotic
or
-Oral isotretinoin

-Education is key
-Adolescents need to have realistic expectations
-Follow-up visits should occur at least every 4 to 6 weeks until control is established (when lesions are clear or only a few every 2 weeks
-Refer to dermatology for severe or nonresponsive cases
-Wash face BID with mild soaps (Doce, Neutrogena, or Aveeno)
-Avoid scrubbing, rubbing, picking, and squeezing
-Medication should be applied lightly

-Use of comedone extractor can cause scarring and should be avoided
-Hot soaks can help resolution of pustules
-All products should be labeled as noncomedogenic
-Identify and discontinue use of aggravating substances (oil-based products, pomades, hair spray, mousse and face creams)
-Identify possible aggravating factors (stress, hot humid weather, job involving frying oil)

-Limited evidence supports strong association between foods and acne, but a high glucemic index foods are associated
-Discuss psychosocial concerns and provide support
-Remind the adolescent that results can take months and adherence to treatment is essential
-Sun exposure helps clear acne for some adolescnts but may worsen it for others
-Sunscreen is recommended and caution about sun exposure should be given if a medication that increases photosensitivty is being used

-Inflammation of appendix leading to necrosis, perforation, peritonitis, abscess
-Average age 6-10 years
-Perforation more common in children <5 years

Sequence of symptoms
Pain shifting to RLQ; nausea/vomiting after pain
Anorexia in 50% of children
Stool low volume with mucus
Fever neither sensitive nor specific
Scoring system useful
Perforation leads to lessening of symptoms

-Involuntary guarding, RLQ rebound tenderness
-Maximal pain at McBurney point (down and towards the middle of right lower quadrant)
-Heel-drop jarring test
-Positive psoas and/or obturator signs
-Rovsing sign: deep pressure in the left lower quadrant and then you suddenly release it and it causes pain in the right lower quadrant
-Tenderness, possible mass with rectal exam
-There is about a 36–72 hour maximum window from the onset of pain to the rupture of a gangrenous appendix
-Bad sign: acute pain and then it’s relieved (perforated appendix)

-CBC with diff
-Amylase, lipase, liver enzyme (rule out other causes)
-UA
-Stool examination
-US: enlarged appendix
-CT: highest accuracy
-hCG to rule out pregnancy

-Score of >6 = Appendicitis
-Score of <5 = Observe
-Feature:
migration: 1
anorexia: 1
nausea/vomiting: 1
RLQ tenderness: 2
coughing/hopping/percussion pain: 2
fever: 1
leukocytosis: 1
left shift on WBC differential: 1

-Surgical consultation for appendectomy
-Open or laparoscopic appendectomy if non-perforated
-Follow-up 2-4 weeks postoperatively

-Invagination of bowel into colon, usually at ileocecal valve
-Most frequent cause of intestinal obstruction in children
-Common in children under the age of 2
-Complication of children with cystic fibrosis

-Classic triad:
intermittent colicky pain
vomiting every 5 to 30 minutes
bloody mucous stools
-History of URI common
-Lethargy common
-Fever usually late sign of infarction or gangrene
-Severe prostration possible

-Glassy-eyed, groggy between episodes as if sedated
-Sausage-like mass in RUQ with emptiness of RLQ
-Distension, tenderness of abdomen
-Grossly bloody or guaiac-positive stools
-Classic sign: red currant jelly diarrhea

-Abdominal flat-plate radiograph may appear normal
-Abdominal US very accurate
-Air contrast enema both diagnostic and treatment modality

-Emergency consultation with pediatric radiologist and pediatric surgeon to do radiologic reduction
-Rehydration/stabilization; gastric decompression
-Surgery if perforation/peritonitis
-IV antibiotics prophylaxis
-Observation after radiologic reduction (12-18 hrs)

-Most will pass through the gut without problem
-Most occur between 6 months and 3 years
-Coins and small toy objects are the most common
-Disk battery injestions are very serious

-Thoracic inlet, mid-esophagus, and lower esophageal spinchter are the most common locations of impaction
-Choking, gagging, coughing initially
-Excessive salivation, dysphagia, food refusal, emesis and pain to follow
-Stridor, wheezing, cyanosis and dyspnea may occur if its in the trachea
-Disk batteries cause severe erosion (emergency endoscopy is needed)

-Most foreign bodies reaching stomach will pass through
-If >5 cm diameter, 2 cm thickness, >10 cm long, may need to be retrieved
-Open safety pins/sharp objects should be retrieved
-Perforation occurs near sphincters, areas of angulation, malformations, areas of previous surgery
-Coins with nickel, multiple small magnets, lead, batteries may cause other problems

-Blunt objects usually pass through
-Sharp/large objects should be retrieved after sedation to relax the anal sphincter

-KUB X-Ray
-Most foreign bodies are radiopaque (can see on xray)
-No labs needed

-Suction if drooling
-Esophageal foreign body should be considered impacted
-Disk batteries and sharp objects need to be removed emergently
-Stomach and lower GI tract foreign bodies usually pass through

Hypertrophied pyloric muscle that narrows the pyloric sphincter

-Projectile vomiting at 2-3 weeks of age
-Insatiable appetite with weight loss, dehydration, and constipation

-Weight loss
-Non-billious vomiting that occurs immediately after feeding (projectile)
-Olive mass may be palpated in the epigastrium to the right midline
-Reverse peristalsis visulized across the abdomen (GI obstruction somewhere)

-Pylori myatomy: widen and cut that hypertrophied muscle out
-Fluid and electrolyte imbalance correction before surgery

-Passage of gastric contents into the esophagus from the stomach through the LES
-Most common causes:
inappropriate relaxation of the LES with failure to prevent gastric acid reflux into the esophagus prolonged esophageal clearance of the gastric refluxate and
impaired esophageal mucosal barrier function
-H. pylori is associated with GERD

-Chocking, gagging, coughing, arching, discomfort and refusal
-Sources of stress
-Family history of GERD
-Horeseness, fussiness, hiccups and apnea
-Recurrent illnesses (especially croup)
-Pattern of vomiting

-Signs of esophagitis (irritability, arching, chocking, gagging, feeding aversion)
-Failure to thrive
-Symptoms resolve around 12 to 24 months of age
-Stridor
-OSA
-Otitis media
-Sinusitus

-Rergurgitation during preschool years
-Complaints of abdominal and chest pain
-Neck contortions (arching, turning head)
-Asthma
-Sinusitus
-Laryngitis
-Tooth erosion

-Recurrent regurgitation with/without vomiting
-Heartburn or chest pain
-Hematemisis
-Dysphagia
-Respiratory disorders
-Dental erosion
-BRUE (brief, resolved, unexplained event)

-History and physical exam is usually enough to make a diagnosis
-In older children and adolescents: trial of an acid blocker (PPI) for 4 weeks

-Histamine 2 Receptor Antagonists
-Proton Pump Inhibitors
-Cytoprotective Agents

-Famotidine (Pepcid):
infants 1-3 months: 0.5 mg/kg/dose once daily for up to 8 weeks
infants >3 months to 1 year: 0.5 mg/kg/dose BID for up to 8 weeks
children and adolescents: 0.25 mg/kg/dose Q12hr (max: 20mg/dose)
-Ranitidine (Zantac):
infants >1 month, children, and adolescents <16 years: 4-8 mg/kg/day divded BID (max 300 mg)
adolescents <16 years: 150 mg BID or 300 mg once HS