A Lone Zebra in a Herd of Horses Common Findings in Pediatric Primary Care Patricia A Farmer DNP APRNCNP Pediatric Practitioners of Oklahoma Claremore OK Objectives At the completion of the presentation ID: 763327
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A Lone Zebra in a Herd of Horses Common Findings in Pediatric Primary Care Patricia A Farmer, DNP, APRN-CNP Pediatric Practitioners of Oklahoma Claremore, OK
Objectives At the completion of the presentation, the participant shall be able to: Identify at least five common diagnosis treated in pediatric primary care, including supportive care and medications . Identify at least two less common but "cannot afford to miss" diagnosis treated in pediatric primary care, including emergent care and/or medication management . Identify at least two references/sources for treatment of common pediatric diagnosis Discuss three elements of preparation for common pediatric office emergencies, including medication and equipment.
Select Immunization Update General statements:Children under 5 are the most susceptible to vaccine preventable illnesses Though extremely rare, there can be serious complications from vaccines. The risk of complications from the preventable illness is greater Meningialcoccal Flu (“Possible Side,” 2017
TDaP Given as a one time dose at 11 yrs of agePregnant women should receive between 27 – 36 weeks of pregnancy with EACH pregnancy (CDC, ACOG and ACNM) Family members who will spend increased time with the infant All adults once, if not previously received (“Diphtheria, Tetanus,” 2016)
Meningococcal Disease 11 – 12 yr old should receive a meningococcoal conjugate vaccine ( Menveo or Menactra ) with booster at 16 yrs old16 – 23 yr old may receive serogroup B vaccine ( Bexero & Trumenba ) 2 doses 6 mos apart (came out as 3 dose series) (“Meningococcal,” 2017)
Human Papillomavirus (HPV) Cancer of cervix, vagina, vulva, penis, anus and back of throat 30,700 cancers in men and women annually in the USA Genital warts (HPV for Clinicians," 2017)
HPV (cont.) Ages: Kids: 11 – 12 yrs of ageWomen: through 26 yrs of age Men: through 21 yrs of age Transgender: through 26 yrs of age Immunocompromised: through 26 yrs of age CDC, 2017
HPV (cont.) Dosing2 doses 6 mos apart if started before 15 yrs of age 3 doses if started 15 – 26 yrs of age or immunocompromised (CDC, 2017)
Acute Otitis Media “Moderate to severe bulging of tympanic membrane (TM) or new onset of otorrhea not due to acute otitis externa accompanied by acute signs of illness and signs or symptoms of middle ear inflammation” (symptoms include <48 hours of ear pain or intense erythema of the TM) Most common 6 – 18 mos during winter months ( Lieberthal et al., 2013)
AOM Treatment First line therapy w/o PCN allergy<2 yrs old, TM perforation and hx of recurrent AOM: Amoxicillin or Amoxicillin- clavulanate for 10 days > 2yrs old, intact TM and w/o recurrent AOM: Amoxicillin or Amxocillin-clavulanate for 5-7 days All doses are 90 mg/kg twice daily Suggestion: use amoxicillin 400mg/5 ml ( Lieberthal et al., 2013)
AOM Treatment (cont.) Second-line therapy with delayed PCN reaction:Cefdinir : 14 m/kg/day in 1-2 doses (max 600mg/day) cefpodoxime ( Vantin d/c): 10mg/kg (max 400 mg/day)cefuroxime ( Ceftin ): 30 mg/kg/day 2 doses (max 1 g/day) Ceftriaxone ( Rocephin ): 50 mg/kg IM once daily for 3 doses (one dose may be all that is needed if improved w/in 48 hrs of 1 st dose) ( Lieberthal et al., 2013)
AOM Treatment (cont.) Second-line therapy with Type 1 PCN reaction:Azithromycin is acceptable 10 mg/kg Day #1 and 5 mg/kg Day #2 – Day #5, once daily ( Lieberthal et al., 2013)
Mastoiditis Usually a complication of AOM Usually requires hospitalization (Wald, 2017)
Atopic Dermatitis (eczema) Chronic, pruritic, inflammatory skin condition that gets better or worse but doesn’t resolve easilyPruritus is hallmarkMoisturize, Moisturize and Moisturize more Topical steroids Dampened cotton wraps or clothing under dry clothing can help (Weston & Howe, 2017)
Atopic Dermatitis (eczema) Caution with steroids to face and skin folds, consider Eucrisa Low potency steroid: desonide 0.05% ointment Medium – high potency: triamcinolone 0.1% cream or ointment High potency: triamcinolone 0.5% cream or ointmentClacineurin inhibitors: > 2 yrs of age (Weston & Howe, 2017)
Strep Throat Acute onset, fever, H/A, abdominal pain, N/V, plus possible scarlatiniform rash, tonsillopharyngeal erythema, exudate, and tender anterior cervical lymph nodes” (Wald, 2017) Recommendation NOT to test if viral symptoms are present (Wald, 2017)
Commonalities of HFMD and Herpangina Multiple enterovirus serotypes, commonly Coxsackievirus A serotypes Oral-fecal transmission Dx made clinically Virus can be shed for weeks or months Presents with mouth or throat pain or refusal to eat (Romero, 2017 )
Herpangina Benign illness with fever and painful papulo-vesiculo-ulcerative oral enanthem High fever, 102 - 104 Rare complications DD: HSV – clusters of vesicular lesions that are friable and bleed easily (Romero, 2017)
HFMD Oral enanthem and a macular, maculopapular or vesicular rash of hands and feetFever usually below 101DD: HSV – lesions are usually unilateral and HFMD usually bilateral Recent case study: Knox, 2 yrs old (Romero, 2017)
Molluscum Contagiosum Common childhood conditionPoxvirus Self-limited chronic localized skin infection Flesh colored papules with umbilicated centers Spread by direct skin-to-skin contact, including autoinoculationCan be associated with immunodeficiency (Isaacs, 2017)
Molluscum Cantagiosum (cont.)Consider sexual abuse if involve genitalia of children Most treatments are off label and limited success No restriction for daycare, school or sports Peds ophthalmology if eye is involved (Isaacs, 2017)
Croup Pediatric illness of larynx and tracheaUsually viralConcerning for children 6 mos – 3 yrs Rarely occurs after age 6 yrs Late fall and winter monthsWarm moist air vs dry cold air Woods, 2017
Croup (cont.) Mild: no stridor at rest, barking cough, hoarse cry and 0 to mild retractionsModerate : stridor at rest, mild retractions, little or no agitation; dexamethasone (0.6 mg/kg, max 10 mg, PO, IV, IM Nebulized budesonide (2 mg/2 ml) x1 Severe : should be seen in ED (Woods, 2017)
Aspiration of Foreign Body Case study: 8 mo old initially dx with Croup No response to oral steroids Hospitalized after approx. 1 wk Initial bronch negative Repeat bronch positive
Epiglottitis (supraglottitis) Less common with HIB vaccine Acute respiratory distress, sitting up, sniffing position Woods, 2017
Respiratory Syncytial Virus (RSV) Acute lower respiratory infectionInfection usually by age 2 yrs Supportive care is mainstay of treatment No routine bronchodilators or steroids (Barr & Graham, 2017)
Fever in Newborn 0 – 60 days 100.4 F rectal temp or higher Evaluate at nearest ED able to handle a critically ill newborn NO fever reducers Full septic work-up Antibiotics pending results
Measles Highly contagious Fever, malaise, cough, coryza and conjunctivitis, followed by exanthem Exanthem: arises 2-4 days after fever; red maculopapular on face/head and spreads downward; blanches early on; resolves in 5-6 days Reportable illness ( Gans & Maldonado, 2017)
Fun Case Study Harry8 yrs old
Fun Case - Harry
Bubbles: She has heard enough.
Miss Max: Headed Down the Trail Thank you for your time.
References Barr, F. E., & Graham, B. S. (2017). In M. S. Edwards & G. B. Mallory (Eds.), Respiratory syncytial virus infection: Treatment. Retrieved September 30, 2017, from UpToDate Web site: https://www.uptodate.com/contents/ respiratory-syncytial-virus-infection-treatment Diphtheria, Tetanus, and Pertussis Vaccination: Information for healthcare professionals . (2016, November 22). Retrieved September 30, 2017, from CDC Web site: https://www.cdc.gov/vaccines/ vpd / dtap - tdap -td/hcp/index.html
References Gans, H., & Maldonado, Y. (2017). In M. S. Hirsch & S. L. Kaplan (Eds.), Measles: Clinical manifestations, diagnosis, treatment and prevention . Retrieved September 30, 2017, from UpToDate Web site: https://www.uptodate.com/contents/ measles HPV for clinicians. (2017, August 23). Retrieved September 30, 2017, from CDC Web site: https://www.cdc.gov/ hpv /hcp/ index.html Isaacs, S. N. (2017). In M. S. Hirsch, M. L. Levy, & T. Rosen (Eds.), Molluscum contagiosum . Retrieved September 30, 2017, from UpToDate Web site: https://www.uptodate.com/contents/ molluscum-contagiosum
References Lieberthal, A. S., Carroll, A. E., Chonmaitree, T., Ganiats , T. G., Hoberman , A., Jackson, M. A., Joffe, M. D., ... Tunkel, D. E. (2013). The diagnosis and management of acute otitis media. Pediatrics, 3 (3), 131. Meningococcal Vaccination: Information for healthcare professionals . (2017, May 19). Retrieved September 30, 2017, from CDC Web site: https://www.cdc.gov/vaccines/ vpd / mening /hcp/ index.html Possible side-effects from vaccines . (2017, March 10). Retrieved September 30, 2017, from CDC Web site: https://www.cdc.gov/vaccines/ vac -gen/side-effects.htm
References Romero, J. R. (2017). In M. S. Edwards & J. E. Drutz (Eds.), Hand, foot, and mouth disease and herpangina . Retrieved September 30, 2017, from UpToDate Web site: https://www.uptodate.com/contents/hand-foot-and-mouth-disease-and herpangina Wald, E. R. (2017). In M. S. Edwards & A. H. Messner (Eds.), Acute mastoiditis in children: Clinical features and diagnosis . Retrieved September 30, 2017, from UpToDate Web site: https://www.uptodate.com/contents/acute-mastoiditis-in-children
References Wald, E. R. (2017). In M. S. Edwards & A. H. Messner (Eds.), Group A streptococcal tonsillopharyngitis in children and adolescents . Retrieved September 30, 2017, from UpToDate Web site: https://www.uptodate.com/contents/group-a-streptococcal-tonsillopharyngitis-in-children and adolescents Weston , W. L., & Howe, W. (2017). In R. P. Dellavalle , M. L. Levy, & J. Fowler (Eds.), Treatment of atopic dermatitis (eczema) . Retrieved September 30, 2017, from UpToDate Web site: https://www.uptodate.com/contents/ treatmnt -of-atopic-dermatitis-eczema
References Woods, C. R. (2017). In M. S. Edwards, G. C. Isaacson, & G. R. Fleisher (Eds.), Epiglottitis (supraglottitis): Clinical features and diagnosis . Retrieved September 30, 2017, from UpToDate Web site: https://uptodate.com/contents/epiglottitis- supraglottitis Woods, C. R. (2017). In S. L. Kaplan & A. H. Messner (Eds.), Croup: Approach to management . Retrieved September 30, 2017, from UpToDate Web site: https://www.uptodate.com/contents/croup