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JACK KASEL, DHA, MS, PA-C, DFAAPA
Pediatric Pearls
DisclosuresNONE
Overview of Presentation
INTRODUCTION PEDIATRICS IN THE FAMILY MEDICINE
SETTING
YOUR PATIENT IS NOT ONLY
PATIENT
FIVE MOST COMMON
COMPLAINTS
EVALUATION AND TREATMENT
APPROACHES
Introduction Pediatrics in family medicine involves well care but this will not be the focus of this presentation
My background in the care of pediatric patients
Look for opportunities to expand your clinical experience with pediatric patients
Approach will be on the evaluation, diagnosis and treatment for five common pediatric complaints
Impact of Covid-19
Pediatrics in the Family Medicine Setting
Your Patient is not the Only Patient
Parents typically provide the important history you need to provide care for your pediatric patient
Parents have expectations that may not be clearly identified without effective communication by the NP or PA
Observing the interaction between parent and child will provide needed insight at times depending on the patient complaint
Five Most Common
Complaints
Concern about respiratory symptoms
Rashes and other dermatologic concerns
Fevers
Injuries
GI complaints such as pain, diarrhea, constipation
Respiratory Symptoms
EVALUATION LIKELY DIAGNOSES TREATMENTS
Respiratory Symptoms: Evaluation
When did the symptoms begin and what were exposures?
Is there a fever and what has been the range?
Is there cough, rhinorrhea, sore throat, ear pain?
Any signs of respiratory distress: nasal flaring, retractions, grunting, rapid breathing, skin changes
What medications have been given and effect on symptoms
Current patient vital signs Testing: labs, imaging results if indicated
Possible Respiratory-
related Diagnoses
Viral URI Otitis Media Viral or bacterial pharyngitis Bronchiolitis Pneumonia Asthma exacerbation Croup Sinusitis Allergic rhinitis
Pediatric Covid-19
Considerations
One study showed children more typically acquire Covid infection from other family members versus being the source of infection
Another study 79% of cases were from adult household contacts
In US about 2% of confirmed cases in patients less than 18
Key consideration is to identify any symptoms that may require hospitalization for supportive treatment such as respiratory distress and dehydration
Rashes and other dermatologic complaints
EVALUATION LIKELY DIAGNOSES TREATMENTS
Rashes: Evaluation
Location and start of the rash or
lesion?
Color and location of the
rash?Any crusting or
blisters?
Has the rash been present in the
past?
Any fever or other symptoms with or
preceding the rash?
Any new medications,
supplements, or allergens?
Any other contacts have
similar symptoms?
Any treatments you have used
and the response?
Possible Diagnoses
Recommend selection of a dermatology reference to build your knowledge base regarding rashes (high risk)
Contact or atopic dermatitis Impetigo Tinea or candidiasis Viral exanthems, scarlatina Folliculitis Diaper rash
Pediatric Dermatology Reference
Atopic Dermatitis
Pruritic dermatitis that may present of face and extensor surface for young children then flexural surfaces on older
Acute versus chronic presentation Triggers may include excessive bathing, certain clothing Consider irritant or allergic dermatitis in acute
presentations
Chronic condition that may or may not resolve over time Treatments: cool compress, topical steroids
(hydrocortisone, fluocinonide 0.05%)- use up to 5 days only , avoid face
Use of emollients after bathing is recommended
Possible secondary infection will require an antibiotic
Contact Dermatitis
Pruritic papulovesicular lesions at site of contact with irritant
Good history regarding exposures needed Avoid further contact with identified allergen Fluorinated steroid treatment for 10 days Antihistamine to control itching Extent of rash may indicate need for oral
steroid for 10 to 14 days and taper
Tinea Location of infection determines whether topical or oral medication is used Lesions typically have raised margins with
erythema and scale, scalp may show hair loss Diagnose with Wood lamp (Microsporum vs
Trichophyton) or KOH preparation of scraping Treat tinea corporis with a topical antifungal
until clear then continue for another week Tinea capitis treatment: micronized griseofulvin
20mg/kg/day for 8 weeks Erythrasma caused by bacterial infection: use
erythromycin
Diaper Rash Preventative care for diaper rash Distinguish between bacterial versus yeast
infection Oral antibiotics for pyoderma Initial treatment with 1% hydrocortisone If rash persists then add topical antifungal
Fevers
EVALUATION LIKELY DIAGNOSES TREATMENTS
Fevers: Evaluation
What is the temperature
and method?
What medications have been
used?
Any recent immunizations?
How has child been eating
and drinking?
Is the child alert and responsive?
What other symptoms are
present?Is your child in
pain?Any exposure to others with same
symptoms?
Possible Diagnoses
Age of child is key: full work up indicated in some cases
Viral URI Otitis media Streptococcal infections Pneumonia UTI Other
Injuries Evaluation Considerations
Injuries: Evaluation
What is the injury? Was there a head injury? Any loss of consciousness? How is the child doing now? Is there a burn injury? Animal bite? Laceration?
Injuries: Considerations
Evaluation of head injury should include complete neurological exam
Use of head CT if intracranial bleed concern Appropriate use of x-rays for suspected fractures Details regarding animal bite to determine rabies status Laceration repair Appropriate burn treatment and follow-up Child abuse considerations
GI Complaints
EVALUATION LIKELY DIAGNOSES TREATMENTS
GI Complaints:
Evaluation
Nausea, vomiting, diarrhea, fever, pain? Length of symptoms Spoiled food or toxic ingestion? Others with same symptoms? Bowel movements? Medications? Hydration status, appetite, activity?
Abdominal Pain
Acute versus chronic Obstruction, appendicitis, malrotation, injury GERD Lactose intolerance Emotional Indicated labs and imaging GI referral
Acute Diarrhea
Typically viral (rotavirus, enterovirus, adenovirus, Norwalk)
About 20% are bacterial (Shigella, Salmonella, E.coli, Campylobacter, Yersinia)
Discontinue lactose based formulas and electrolyte fluids
Monitor for dehydration Advance diet as tolerated
GERD Reflux of stomach contents into esophagus due to relaxation of the lower esophageal sphincter
Evaluate symptoms around meals or feedings Is child hungry? Weight normal? Use of OTC reflux medications GI referral to confirm in more severe cases
(anemia, hypochloremia, failure to thrive)
Constipation What is stool pattern and daily diet? Check T4 and TSH if hypothyroidism is a
concern Typical cause is low fiber and high carb and
dairy diet Rashes or fissures may result in avoidance First treatment is diet modification Only use stool softeners and stimulants when
diet fails
GI Complaints: Other causes
Lactose intolerance Emotional Dietary
Five Most Common
Complaints
Concern about respiratory symptoms
Rashes and other dermatologic concerns
Fevers
Injuries
GI complaints such as pain, diarrhea, constipation
Thanks for your attention!
References
Posfay-Barbe KM, Wagner N, Gauthey M, et al. COVID-19 in Children and the dynamics of infection in families. Published online July 2020. Pediatrics. doi:10.1542/peds.2020-1576
Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention. JAMA
Livingston E, Bucher K. Coronavirus Disease 2019 (COVID-19) in Italy. JAMA
Su L, Ma X, Yu H, et al. The different clinical characteristics of corona virus disease cases between children and their families in China –the character of children with COVID-19. Emerging Microbes and Infection 2020; 9(1): 707-13.
https://pediatrics.aappublications.org/content/early/2020/07/08/peds.2020-1576#T1
References (cont.)
CDC COVID-19 Response Team. Coronavirus Disease 2019 in Children — United States, February 12–April 2, 2020. MMWR Morbidity and Mortality Weekly Report. ePub: 6 April 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6914e4external icon .
Tagarro A, Epalza C, Santos M, et al. Screening and Severity of Coronavirus Disease 2019 (COVID-19) in Children in Madrid, Spain. JAMA Pediatr
Up to Date Hurwitz Clinical Pediatric Dermatology, 5th Edition
http://dx.doi.org/10.15585/mmwr.mm6914e4
Pediatric PearlsDisclosuresOverview of PresentationIntroductionPediatrics in the Family Medicine SettingYour Patient is not the Only PatientFive Most Common ComplaintsRespiratory SymptomsRespiratory Symptoms: EvaluationPossible Respiratory-related Diagnoses Pediatric Covid-19 ConsiderationsRashes and other dermatologic complaintsRashes: EvaluationPossible DiagnosesPediatric Dermatology ReferenceAtopic DermatitisContact DermatitisTineaDiaper RashFeversFevers: EvaluationPossible DiagnosesInjuriesInjuries: EvaluationInjuries: ConsiderationsGI ComplaintsGI Complaints: EvaluationAbdominal PainAcute DiarrheaGERDConstipationGI Complaints: Other causesFive Most Common ComplaintsThanks for your attention!ReferencesReferences (cont.)
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