What are 3 possible non-infectious causes of acute diarrhea?
1) Lactose intolerance
2) Drug-induced (eg. antibiotics)
3) Dietary changes in infants
~30-40% of gastroenteritis are caused by ___________
viruses
What is the most common virus to cause diarrhea in infants <2y.o?
Rotavirus
What is the most common virus to cause diarrhea in school aged children?
Norwalk
What are 2 other infectious causes of acute diarrhea?
Bacteria
Parasites
Describe 5 sign/symptoms of acute viral diarrhea in children
1) Watery diarrhea X 3-6 days
2) +/- vomiting
3) +/- fever
4) +/- URT symptoms
5) DEHYDRATION
What are 8 important questions to ask the caregiver of a child with acute diarrhea?
1) Onset? - refer if prolonged
2) Fever? Vomiting? - may indicate infection
3) Urine output? - assess dehydration
4) Feeding history? - dietary change?
5) Behaviour? - active?
6) Illness in other family members?
7) Travel history?
8) On antibiotics?
What are 2 signs of MILD dehydration (<5% fluid deficit) in children?
1) mildly increased thirst
2) Mild decrease in urine output
(Fontanelle is NORMAL)
What are 5 signs of moderate/severe dehydration in children/infant?
1) Increased thirst
2) Absent tears when crying
3) Sunken fontanelle
4) decreased peripheral perfusion (severe)
5) decreased or absent urine output
What are 4 goals of therapy for management of diarrhea?
1) Determine cause if possible
2) If infectious, prevent spread to others
3) Reduce symptoms and re-establish "normal" BMs
4) PREVENT DEHYDRATION
Why can't plain water be used to rehydrate?
Would dilute serum and result in HYPONATREMIA
How should oral dehydration solutions be given for children for mild dehydration? (how much/dose/frequency)?
Give throughout day, q1-4h as tolerated
Aim for 50ml/kg over 4-6 hours
follow product instructions but be aware of unrealistic guidelines
if vomiting, give small amounts q30-60min
For toddlers and older children with acute diarrhea, when should they return to solid foods?
If no vomiting, start feeding solids after 6-8 hours
How should dehydration be managed in young infants (<6month) who are breastfed?
Keep breastfeeding, shorten duration and amount per feed (eg only 10min/feed)
How should dehydration be managed in young infants (<6month) who are on formula?
Hold formula for 5-6 hours
Use ORS instead q30-60min as tolerated
aim for 50ml/kg over 5-6 hrs
return to formula once diarrhea is better, and use ORS q24h
watch for symptoms/signs of dehydration
What type of diet is best for children with acute diarrhea? What should be avoided?
Diet rich in wheat/CHO is best
no evidence for BRAT diet
Avoid cow's milk, juice, fruit (b/c of sugar content)
How long should caregiver expect stools to normalize after acute diarrhea?
7 days to fully normalize
Children younger than ______ should not use loperamide for acute diarrhea due to what major risk?
3y.o
Risk of TOXIC MEGACOLON
(= dilation/hypertrophy of colon)
What are 3 other ADRs of loperamide in children <12y.o?
1) Lethargy
2) Respiratory depression
3) Necrotising enterocolitis (<2y.o)
In children <3y.o, loperamide was shown to decrease duration of diarrhea by how long?
<1 day
What other OTC product has a risk of causing toxic megacolon?
Bismuth subsalicylate (Pepto bismol)
If infectious diarrhea, bismuth subsalicylate may increase what?
retention of bacterial endotoxins
What 4 situations should child with acute diarrhea be referred to MD?
1) <3-4 months old
2) Bloody stools
3) vomiting >4 hours
4) Signs of moderate/severe dehydration
What are the 3 microbs in probiotics?
1) Lactobacilli
2) Bifidobacteria
3) Saccharomyces
In what 3 ways do probiotics modify the GI flora?
lower GI pH
enhance GI barrier function
role in immunomodulation
For prevention of ANTIBIOTIC-induced diarrrhea in children, what 2 strains of probiotics were shown to be most effective?
1) Lactobacillus rhamnosus GG (LGG)
2) Saccharomyces boulardii
What strain of probiotic was shown most effective for treating acute INFECTIOUS diarrhea?
Lactobacillus rhamonsus GG (LGG)
What virus-induced diarrhea was LGG shown most effective for? Duration of diarrhea was reduced by how long?
Rotavirus
reduced by 16-30 hrs (best if started within 48hrs of diarrhea)
Why might LGG be unnecessary for treatment of rotavirus diarrhea?
There is a vaccine for rotavirus (administered at 2 and 4 months)
What is the most common form of dermatitis in infants?
Diaper rash
What age group is diaper rash most common in? Why?
6 -12 months olds
changed less frequently then a newborn
more movement and friction
changes in diet
How long does a diaper rash typically last?
1-10 days
What are 2 infectious causes of diaper rash?
1) Yeast (Candida)
2) Bacterial (Strep, staph)
What does diaper rash caused by yeast look like?
Satellite lesion
What are 7 ways to PREVENT diaper rash?
1) Barrier creams (zinc oxide)
2) Petrolatum jelly
3) Cornstach (not in yeast), or Talcum powder
4) Mineral oil to clean sticky stool
5) Avoid perfumed lotions, scented wipes
6) Change diapers frequently, clean with water/mild soap, pat then air dry, don'
What are the best treatment for non-infectious cause of diaper rash?
Barrier creams, Vaselin
lessen friction against irritated skin
What can be used for inflammatory lesions but should be avoid in yeast lesions?
Corticosteroid creams/oinment (eg. hydrocortisone)
apply sparingly
What can be used to treat yeast-induced diaper rash?
Anti fungals
clotrimazole
nystatin cream
What is colic?
Excessive crying
self-limited, intermittent, unexplained
How much crying is considered colic in healthy baby?
>3 hours/day
>3 days/week
When does colic usually onset, how long might it persist?
onset after 2-4 weeks
30% might persist until 4 months
What is the MOST LIKELY cause of colic?
GI related etiology:
lactose intolerance
intolerance to proteins in mom's diet (eg cow's milk)
If colic approaching 4 months, what disease might be considered?
GERD
What are 5 management strategies for parents of infant with colic?
1) Parent reassurance - self-limting, no long term sequelae, nobody's fault
2) Keep a diary
3) Relief and support
4) Regular schedule and routine
5) **DIET change in MOM (avoid diary, green veggies)
What are 3 nonpharm measures for colic?
1) Rocking, music, patting, car, burping
2) Check bottle nipple; feed baby more upright
3) If formula fed, switch formulas
What is a pharmacological measure for colic that is SAFE?
Simethicone (Ovol)
0.25-0.5ml drops with meals
but no proven efficacy
What pharm measure for colic might be effective but has safety concerns?
Antispasmodices
dicyclomine (Bentyl)
What are 2 safety concerns with antispasmodics, therefore should not be recommended?
seizures
apnea
What is the recommendation for probiotics for treatment of colic?
Insuffiicent evidence to recommend for or against
What is the problem with gripe water?
has alcohol,
effect is likely to sedate infant
complications of ___ include otitis, sinusitus, meningitis, sepsis, febrile seizure and dehydration
URI/common cold
What are some appropriate interventions for URI/common cold?
humidity, nasal toilette/gtts, PO fluids, analgesics, antipyretic, rest, culture, ABX for bacerial URI - usually if sick > 10-14 days
What disease is a middle ear infection/bacterial
otitis media
frequent URI's, short narrow eustacian tube, immature mucosal lining and immune system can lead to:
otitis media
what does pain, fever, anorexia, ear tugging, irritability, red/bulging TM, decreased light reflex, + tragal tenderness
acute otitis media
what is the tympanic membrane like in otitis media?
red bulging
how will you relieve a ruptured TM?
drainage, NSAIDS, antibiotic ear drops, oral abx
what does a dull grey TM, light reflex, fluid filled TM, and serous, think sterile effusion indicate?
chronic otitis media
Interventions for otitis media?
NO bottle propping, oral ABX, analgesics, local heat/gtts (Auralgan),
What is inflammation of the lymphoid tissue located in the pharyngeal cavity which filters and protects against pathogen entry?
tonsilitis
A pt comes in with swollen uvula, white spots on red swollen tonsils, throat redness, and a grey furry tongue. What is this?
Bacterial tonsilitis
Pt presents with red swollen tonsils and throat redness. No pus. What is the cause and what can be done at home?
Viral tonsilitis. Monitor at home, gargle with salt water
Nursing concernes post-op tonsilectomy (3)
Airway, Bleeding, Comfort, prevent nausea/vomiting
tonsilectomy pre-op assmnt
clotting time
tonsilectomy post op assess for
bleeding, frequent swallowing, nausea
tonsilectomy post op- prevent bleeding
no hard objects, tongue blades, no gargling, no straws
best position post op tonsilectomy
side lying/prone
Infection/inflammation of larynx, trachea, bronchi
laryngotracheobronchitis/croup
is laryngotracheobronchitis/croup - viral or bacterial?
viral
age range affected by laryngotracheobronchitis/croup
6m-3y
hoarsness, barky cough, stridor, rales, ronchi and fever are characteristic of?
laryngotracheobronchitis/croup
interventions for mild s/s of laryngotracheobronchitis/croup
hot steam/shower, NSAIDS
medication given for laryngotracheobronchitis/croup
oral/systemic corticosteroids - Decadron/Prednisolone/Pediapred
What are indications for croup admission?
Severe distress
Unusual symptoms (hypoxia, hyperpyrexia)
Dehydration
Persistent stridor despite therapy
Persistence of tachycardia, tachypnea
Complex PMHx (premature, cardiac, respiratory)
What five features are assessed in the croup score?
Stridor
Retractions
Air Entry
Cyanosis
LOC
How do steroids help in croup?
Reduce symptoms, need for aerosolized epinephrine, readmission to ED
Shorter hospital stays
Faster improvement in hospitalized pts
Decreased incidence of intubation
Higher doses (>0.3mg/kg) more effective than lower
Benefit in mild, moderate and severe
If a child with croup is given epinephrine, why must that child be monitored (2hr) afterward?
Temporizing
May see rebound effect of epinephrine if not given steroids
In choking children, who should receive back blow/chest thrusts and who should receive Heimlich maneuveur?
<1yo: 5 back blows and 5 chest thrusts (hold head below chest)
>1yo: subdiaphragmatic thrusts
What are the stages of pertussis?
Catarrhal Stage (1-2wk): URTI and cough
Paroxysmal Stage (2-4wk): Severe paroxysms of staccato cough, may have apnea if <6mo
Convalescent Stage (6-10wk): symptoms begin to wane
Nasal Cannula
Disposable plastic tube w/ 2 prongs
Delivers O2 concentrations of 24-40% at flow rate of 1-6L/min
Safe, easy to apply, well-tolerated
Child can eat, talk, ambulate
Used by infants & older children
Assess patency of nares & make sure that they fit properly
Pediatric Face Mask
Covers child's nose & mouth
Not tolerated well
Provides up to 60% FIO2
Complications of Oxygen Therapy
Combustion
No flammable materials, smoking, sparking toys near oxygen
Cotton gown & well-grounded electric devices only
Oxygen toxicity
Can result from high concentrations of oxygen, long duration, lung disease
Signs & symptoms: nonproductive cough, subst
Suctioning
Oral, nasal, endotracheal (ETS)
Complications of Suctioning
Hypoxia
Stop
Limit suction attempt to <10-15sec
Limit suction to 2-3 attempts
Allow child 30-60sec to recover btwn sessions
Hyperoxygenate child before & after suctioning pass
Acute Tonsillitis
Occurs when tonsils become inflamed & reddened
Small patches of yellow-ish pus may be visible
Can block nose & throat (interfere w/ normal breathing, nasal & sinus drainage, sleeping, swallowing, speaking)
Can disrupt normal functioning of eustachian tube
Tonsils
Masses of lymph-type tissue found in pharyngeal area
Filter pathogenic organisms (viral/bacterial) to protect respiratory & GI tracts
Contribute to antibody formation
Highly vascular
Normally enlarged until about age 8 yr
Palatine Tonsils
Located on both sides of oropharynx
Removed during tonsillectomy
Pharyngeal Tonsils
AKA adenoids
Removed during adenoidectomy
Risk Factors for Tonsillitis
Exposure to bacterial or viral agent
Immature immune system
Symptoms of Tonsillitis
Sore throat w/ difficulty swallowing
Hx of otitis media & hearing difficulties
Signs of Tonsillitits
Mouth odor
Mouth breathing
Snoring
Nasally voice
Fever
Tonsil inflammation
Lab Tests for Tonsillitis
Throat culture (group A beta-hemolytic streptococci)
Preop CBC (anemia, infection)
Nursing Care for Tonsillitis
Viral tonsillitis: rest, cool fluids, warm salt-water gargles
Bacterial tonsillitis: antibiotics
Pharmacologic Tx for Tonsillitis
1. Antipyretics: decrease fever
acetaminophen (Tylenol)
2. Antibiotics: full course
amoxicillin (Amoxil)
3. Analgesics: pain control, prevent overdose
acetaminophen (Tylenol)
Surgical Tx for Tonsillitis
Tonsillectomy
Pre-Tonsillectomy Nursing Care
Warm salt-water gargles, throat lozenges
Monitor hydration & fluid intake until NPO
Post-Tonsillectomy Nursing Care
Position: side to faciliate drainage; elevate HOB when fully awake
Assessment: check for bleeding (frequent swallowing, clearing throat, restlessness, bright red emesis, tachycardia, pallor), check VS & airway, monitor breathing
Comfort: ice collar & anal
Post-Tonsillectomy Discharge Teaching
No sharp things in mouth
Administer pain meds
Encourage fluid intake & diet advancement to soft diet
No spicy foods or hard, sharp foods
Limit strenuous activity & physical play
No swimming for 2wks
Full recovery w/in 10days-2wks
Complications of Tonsillectomy
Hemorrhage
Observe throat frequently & thoroughly
Assess for signs of bleeding, hypotension (late sign of shock)
Chronic Infection
Pose threat to other parts of body
May develop rheumatic fever or kidney infection
Infectious Agents of Common Respiratory Illnesses
GABHS, RSV, Haemophilus influenzae, S. pneumoniae, M. pneumoniae
Risk Factors for Common Respiratory Illnesses
Age
Infants (3-6mo) have decreased maternal antibodies
Viral infections common in toddlers & preschoolers
GABHS & M. pneumoniae infection rates increase in >5year olds
Anatomy
Short, narrow airway easily obstructed w/ mucus & edema
Short resp tract allows
Nasopharyngitis
Common cold
Self-limiting virus
Persists for 7-10days
Sx: Nasal inflammation, rhinorrhea, cough, dry throat, sneezing, nasally voice, fever, decreased appetite, irritability
Pharyngitis
Strep throat
Caused by GAHBS
Sx: Inflamed throat w/ exudate, pain w/ swallowing, headache, fever, abdominal pain, cervical lymphadenopathy, truncal/axillary/perineal rash
Allergic Rhinitis
Seasonal reaction to allergens
Most often in fall or spring
Sx: Watery rhinorrhea, nasal congestion, itchiness of nose/eyes/pharynx, itchy water eyes, nasally voice, dry scratchy throat, snoring, poor sleep & poor performance in school, fatigue
Croup Syndromes
Bacterial epiglottitis, acute laryngitis, acute laryngotracheobronchitis, acute spasmodic laryngitis
Nursing Care for Acute & Infectious Respiratory Illnesses
Monitor for respiratory distress
Have emergency equip available
Don't attempt tongue depressor use or throat culture (if epiglottitis-Suspect)
Use oxygen & high humidity
Use postural drainage & CPT
Maintain hydration
Maintain upright position
Tx for Acute & Infectious Respiratory Illnesses
1. Epinephrine: for vasoconstriction of submucose; to decrease edema
Via nebulizer
Observe for 3h after administration; may feel increased HR
2. Corticosteroids: to decrease inflammation
Via nebulizer or IV route
Rinse mouth
dexamethasone (Decadron)
budes
Discharge Teaching for Acute & Infectious Respiratory Illnesses
Cool-air vaporizer for humidity
Rest during febrile illness
Encourage fluid intake
Limit use of nose drops or sprays for 3days to prevent rebound congestion
Decrease spread of infection
Complications of Acute & Infectious Respiratory Illnesses
Airway Obstruction
May result from respiratory infection or foreign body aspiration
Position properly
Perform suctioning PRN
Don't examine throat or use tongue blade if epiglottitis
Administer meds
CPT
Deep breathe, use splint, expectorate sputum
Viral Croup (laryngotracheobronchitis)
a viral infection resulting in edema of the subglottic space
affects younger children (3m-5y)
fall and winter
caused by parainfluenza virus
Viral Croup S/S
prodome of URI, followed by a barking cough and stridor
Mild: stridor w/ agitation only
Moderate: stridor at rest
Severe: stridor at rest w/ retractions, air hunger & cyanosis
Viral Croup DX
Imaging: AP and lateral soft tissue neck x-ray
subglottic narrowing with a normal epiglottis
"steeple sign
Viral Croup TX
Mild: supportive with oral hydration and minimal handling
Moderate: O2 (>90), racemic epinephrine, dexamethasone (0.6mg/kgIM) or (0.15mg/kgPO) x 1dose, observe for 3hrs if all resolve = d/c home
Severe: ET intubation, extubation should be accomplished wit
What should you do if a child presents with drooling and history of a sore throat?
Do not touch the patient and call for help. Prepare for teach
Caregivers of a child with RSV should avoid...
Caring for other high-risk children to prevent spread
What type of humidifier is recommended for children?
Cool mist
What is important for parents to know if they use a humidifier
They must follow the manufacturer recommendations for cleaning it routinely
Peak age for foreign body aspiration is...
Children less than 3 years and is a leading cause of death in children less than age 1
Signs of foreign body aspiration (FBA)
Sudden onset coughing and gagging, may wheeze
Stridor, cyanosis, inability to speak or cry or swallow