Pediatric Primary Care (62 page)

1.  Cystic fibrosis: sweat test is gold standard for diagnosis.

2.  Pneumonia: viral URI symptoms and coryza with low-grade fever; bacterial pneumonia; abrupt onset with high fever;
Mycobacterium pneumoniae
(insidious onset and nontoxic appearance).

3.  Asthma: pattern of symptoms, absence of fever, inspiratory wheezing, prolonged expiratory phase.

4.  Foreign body aspiration: typically in toddler; may be detected on X-ray or by bronchoscopy.

5.  Aspiration: swallowing study to determine silent or free aspiration.

6.  Chlamydial infection: manifests from 3 to 19 weeks of age, afebrile, repetitive, staccato cough with tachypnea; wheezing is rare; cervical lymphadenopathy.

7.  Immunodeficiency: systemic illness following vaccination with live virus; severe, life-threatening illness with viral infection.

8.  Congenital heart disease: accompanied by heart murmur, signs of CHF, poor feeding, poor growth.

9.  Gastroesophageal reflux.

G.  Treatment.

1.  Treatment is supportive, maintaining adequate hydration, oxygenation; monitor closely for increasing respiratory distress.

a.  Management of nasal congestion and rhinitis.

b.  Use of antipyretics.

c.  Guidelines for feeding and urine output.

d.  Recognition of signs of increasing respiratory distress.

e.  Patients have a worsening of clinical symptoms with peak at day 3-4 of illness.

f.  Bronchodilators are not routinely recommended.

g.  Consider a monitored trial of bronchodilator and continue only if a clinical response is documented.

2.  Criteria for hospitalization.

a.  Age (younger more likely).

b.  Tachypnea/hypoxemia.

c.  Hydration management.

H.  Follow up.

1.  Most infants improve within 4-6 days.

a.  Guidelines for parents to call healthcare provider: increased respiratory distress, poor fluid intake, or low urine output.

b.  Close outpatient follow-up by telephone or visit may be indicated.

I.  Complications.

1.  Acute complications.

a.  Respiratory failure, apnea: rarely secondary bacterial infection.

b.  Spontaneous pneumothorax due to air trapping, airway narrowing.

c.  Worsening of chronic lung disease.

d.  Mortality 1-5% with higher rates in high-risk groups.

2.  Long-term complications.

a.  Recurrent episodes of wheezing.

b.  Infants have airway hyperreactivity and impaired pulmonary function for up to 10 years after RSV infection.

J.  Education.

1.  Avoid secondhand smoke exposure.

2.  Prevention.

a.  For high-risk populations passive immunity (monoclonal antibody technology) through monthly administration of palivizumab (Synagis) from October/November through April. Check current guidelines for recommended number of doses.

b.  Good handwashing, avoidance of ill contacts during bronchiolitis season.

3.  Post-illness.

a.  Reinfection common; having RSV offers no immunity to subsequent infections.

b.  May have period of prolonged wheezing after infection.

c.  Recurrent wheezing is common, especially with URIs.

d.  Cough and other signs resolve gradually over 1-2 weeks.

III. INFLUENZA

A.  Etiology.

1.  Influenza is a highly contagious respiratory illness caused by influenza viruses.

a.  Influenza viruses are orthomyxoviruses.

b.  Type A and B are primary pathogens, responsible for community outbreaks.

c.  Influenza A viruses are subcategorized based on surface (H) and neuraminidase (N).

•  Subtypes include H1N1, H1N2, and H3N2.

2.  Influenza is spread by large-particle respiratory droplet.

a.  Close contact with person with influenza.

b Direct contact with articles contaminated with nasopharyngeal secretions.

c.  Virus is shed 1 day prior to developing symptoms.

•  Children may shed virus several days prior to developing symptoms and can remain infectious more than 10 days.

•  Immunocompromised persons may shed virus for weeks to months.

d.  Incubation period is 1-4 days with average of 2 days after exposure.

B.  Occurrence.

1.  Peak of flu season can occur from December through March.

2.  About 1% of children require hospitalization annually.

3.  Influenza can cause URI, croup, bronchiolitis, pneumonia.

C.  Clinical manifestations.

1.  Abrupt onset of fever with rigors, chills.

2.  Pharyngitis.

3.  Cough.

4.  Diffuse myalgia.

5.  Extreme fatigue, headache, and generalized malaise.

6.  Gastrointestinal symptoms: abdominal pain, nausea, vomiting.

7.  Conjunctivitis.

8.  With severe disease: irritability, change in mental status.

9.  Symptoms progressively worsen over 12-24 hours.

10.  May present with nonspecific signs of febrile illness, limited respiratory symptoms.

D.  Physical findings.

1.  High fever.

2.  Tachycardia, tachypnea.

3.  Nonproductive cough.

4.  If lower respiratory tract infected, physical findings consistent with pneumonia or bronchiolitis.

E.  Diagnostic tests.

1.  Identification of virus or viral antigen in nasopharyngeal secretions.

a.  Specimens should be obtained within 72 hours of illness, due to decrease in viral shedding after that time.

b.  Specimen obtained by swab, nasal aspirate, or wash.

c.  Viral culture.

d.  Rapid diagnostic tests via fluorescent antibody staining, enzyme-linked immunoassay, or optical immunoassay.

•  Rapid tests are more sensitive on pediatric specimens than adult specimens.

•  Some tests detect both influenza A and B; some detect only one strain.

e.  Reverse transcriptase-polymerase chain reaction (RT-PCR).

2.  Diagnosis of specific flu-related complications.

3.  Chest X-ray normal or areas of atelectasis.