N320 Common pediatric illnesses

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