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.)