Ebook Manual of ambulatory pediatrics (6th edition): Part 2

(BQ) Part 2 book Manual of ambulatory pediatrics presents the following contents: Management of common pediatric problems (allergic response to hymenoptera, allergic rhinitis and conjunctivitis, anorexia nervosa, aphthous stomatitis,...), drug index (altabax ointment, amoxicillin and clavulanate potassium, budesonide inhalation suspension,...).

P A R T I I

Management

of Common

Pediatric Problems

Elizabeth S Dunn and Sherri B St Pierre

Part II covers common pediatric health problems within the scope of

practice for nurse practitioners and others responsible for the delivery

of primary health care The most common management problems are

included and are developed according to the SOAP format, an outline

form that includes subjective data, objective data, assessment, and plan

The subjective data include the information with which the child or

parent presents or the provider expects to elicit in a history of the

present-ing illness

The objective data include the information that would be obtained

from the physical examination of the child and from laboratory tests

In the assessment, the differential diagnoses for each management

problem are listed and include relevant information to assist the provider

in making an accurate diagnosis The plan consists of various treatment

modalities used in managing the case, as well as specific pharmaceutical

and symptomatic treatment

Additionally, for each protocol, there is an extensive education

sec-tion that includes pertinent informasec-tion for parents as well as helpful

sug-gestions for the health care provider It incorporates physical care,

psychosocial issues, medication information, and general information

about the presenting problem

The etiology, incidence, communicability, and incubation period

have been included for each protocol when applicable Similarly,

compli-cations and indicompli-cations for follow-up, consultation or referral are a part of

every protocol Where applicable, resources for both the health care

provider and patient/family have been included at the end of the protocol

Before initiating a treatment plan for any management problem,

sev-eral factors must be recognized and assessed First, a high anxiety level may

interfere with the parent’s or child’s ability to hear and remember the

rec-ommended plan; the provider should recognize this anxiety and deal with

it Second, the ability to follow through with recommendations should be

assessed; for example, a parent already stressed by the daily care of several

small children may find the additional tasks involved in coping with a sick

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201

child overwhelming Third, given that compliance is enhanced by knowledge, it isessential to evaluate the parent’s or child’s understanding of the disease and the treat-ment The provider must be aware of potential barriers to compliance, such as ethnic

or religious customs or restrictions, and address them as necessary Fourth, regardingpharmaceuticals, it is necessary to ascertain whether the family can afford the pre-scribed medication, how they intend to measure the dosage, whether they understandthe route of administration, whether they can give it at proper intervals, and whetherthey know the importance of continuing the medication for the duration prescribed.Protocols are included for some of the most common childhood problems.Changes and additions may need to be noted, because specific practices and geo-graphic locations may necessitate minor revisions For most effective use, eachprotocol should be carefully reviewed by the health care team and amended, if nec-essary, for their particular health center Once reviewed and amended by the nursepractitioner and collaborating physician, they can be used as guidelines for practice

as required for nurses practicing in an expanded role

Indications for use and dosages for drugs are from current literature However,because medicine is a constantly changing science, recommendations for manage-ment and standards for use of drugs are subject to frequent change For this reason,current recommendations should be reviewed on a regular basis

Health care providers must be cautious and vigilant in their diagnosis and intheir prescribing of antimicrobials in this era of ever-increasing antibiotic resis-tance It is incumbent on us to use antibiotics carefully and judiciously to avoid per-petuating or contributing to the current trend It is also our responsibility to be aware

of the resistant strains in our communities before prescribing for children.Anorexia and bulimia have been included in this section Although these are notnecessarily problems that should be managed solely in the primary health care set-ting, the health care provider is responsible for the diagnosis, referral, and coordina-tion of care for these contemporary issues Such cases are presented with pertinentbackground information, presenting signs and symptoms, indicators for diagnosis,broad guidelines for management, and referral sources The health care provider maychoose to keep a list of local resources pertaining to each of these protocols

E.S.D.

An inflammatory eruption involving the pilosebaceous follicles characterized bycomedones (open and closed), pustules, or cysts It is a chronic disorder, has a var-ied presentation, and is often resistant to treatment

I Etiology

A Pilosebaceous follicle activity is stimulated by increased androgen

lev-els during puberty Desquamation of the follicular wall occurs, creating

a number of cells that, combined with sebum, result in a plug, ing the lumen of the follicle Corynebacterium acne enzymes hydrolyzethese trapped sebaceous lipids, causing distention and rupture of thesebaceous ducts

obstruct-Acne 203

B An inflammatory reaction occurs in the dermis with the release of the

keratin, bacteria, and sebum

II Incidence

A Affects approximately 80% of adolescents in varying degrees.

B Generally disappears by the early 20s in males, somewhat later in

females

C Severe disease affects males 10 times more frequently than females III Subjective data

A Vary according to the degree of severity; complaints include:

1 “Bumps,” blackheads, whiteheads, pimples, cysts, scarring

2 Pain on application of pressure

3 Premenstrual flare

B Location: Face, chest, back, buttocks

C Pertinent subjective data to obtain

1 Does patient see acne as a problem and want treatment for it?

2 Does acne flare with stress or emotional upheaval?

3 Does acne flare premenstrually?

4 Do seasonal changes affect acne (e.g., improve in summer or

worsen with high humidity)?

5 Does acne worsen in response to certain foods? What are these

types of food?

6 What treatment has been used in the past?

7 What was the response to previous treatment?

8 Has female patient been on birth control pills?

9 Are there any associated endocrine factors?

a Does patient have regular menstrual periods?

b Does patient complain of hirsutism?

10 Does patient use cosmetics or creams on skin? Determine type—

oil-based or water-based

11 Is patient exposed to heavy grease and oil?

D Note: Often the patient will not complain of any symptoms because of

embarrassment It is the responsibility of the nurse practitioner to raisethe issue

IV Objective data

A Inspect the entire body Lesions may be found on the face, earlobes,

scalp, chest, back, buttocks; they generally recur in the same areas

B Lesions

1 Mild acne

a Closed comedones (whiteheads)

b Open comedones (blackheads)

3 Severe, inflammatory acne

a Comedones—open and closed

b Erythematous papules

c Pustules

d Cysts

C Scarring may be present in any stage.

D Hair is often very oily.

V Assessment

A Diagnosis is easily made by the appearance of the different lesions

present on the skin

B Assess degree of involvement—both physical and emotional—to

deter-mine the best therapeutic plan

VI Plan

A Mild acne

1 Topical bacteriostatic: Benzoyl peroxide products are potent

antimicrobial agents as well as exfoliant, sebostatic, andcomedolytic agent

a Use one of the following:

(1) Desquam-X (clear aqueous gel) (2) Benzagel (clear alcohol gel) (3) PanOxyl (clear alcohol gel) (4) Benzac W (2.5% aqueous base gel)

b Begin with 5% used once daily (With fair or sensitive skin, use

every other day and increase frequency accordingly.)

c Follow-up telephone call in 2 weeks If no sensitivity,

gradu-ally increase application to twice daily

or add

2 Topical antibiotic

a T-Stat pads, bid

b Cleocin T lotion, gel, or solution, bid

use to once daily if no irritation develops

c Combined retinoid-bacteriostatic therapy (1) Apply retinoid cream or gel at bedtime (2) Apply benzoyl peroxide preparation in AM

(3) With Retin-A, do not apply simultaneously; will

inacti-vate both chemicals

(4) Differin gel or cream has a lower incidence of irritation

than Retin-A gel and is compatible with concurrent cation of benzoyl peroxide

appli-4 Recheck in the office in 1 month Continue regimen if condition

responds to treatment If there is no response to treatment and nosensitivity to the medication:

a Increase strength of benzoyl peroxide preparations to 10% used

once daily Increase frequency to twice daily after 2 weeks if nosensitivity

b Increase strength of Retin-A to 0.05% cream or 0.025% gel

used once daily Increase frequency to twice daily after 2 weeks

if no sensitivity Use cream base for dry skin, gel base foroily skin

c During early treatment, an increase in inflammatory lesions is

common Improvement may take as long as 2 months

5 Further follow-up should be individualized according to the

patient’s needs and the degree of response to therapy

4 BenzaClin Topical gel, twice a day

5 Hot soaks to pustules 5 to 6 times a day

6 Tetracycline 250 mg qid or 500 mg bid, over age 12

or alternatelyErythromycin 1 gm/d

7 Recheck in 5 weeks

a With no improvement and no local irritation:

(1) Increase tetracycline to 1.5 g/d for 2 weeks, then 2 g/d for

2 weeks

(2) Increase strength of keratolytic gel to 10% or increase

Retin-A to 0.1% cream or change to 0.025% gel

b With marked improvement, decrease tetracycline to 250 mg

(1) Decrease tetracycline to 250 mg qid or discontinue if

already decreased to bid

(2) Continue with topical medication.

9 Continue individualized follow-up:

a Every 4 to 8 weeks while on tetracycline

b Every 3 to 6 months while on topical medication

10 Note: If patient is an adolescent female on the birth control pill or

seeking oral contraception order, Ortho Tri-Cyclen #28

a It has minimal intrinsic androgenicity.

b Studies have shown clinically significant improvement in total

acne lesions and inflammatory lesions

C Severe or inflammatory acne

1 Topical medication as above

2 Hot soaks to inflamed lesions 5 to 6 times a day

1 Limit refills on tetracycline to ensure follow-up visits.

2 Tetracycline is generally drug of choice It is inexpensive, has few

side effects, and is well-tolerated for long-term administration Theusual precautions for young children or possibility of pregnancyshould be followed

3 Antibiotic therapy may take 6 to 8 weeks for any noticeable

improvement to occur

4 Sulfur can be comedogenic.

5 Keratolytic gels penetrate better than creams or solutions.

6 When discussing acne, do not hesitate to touch the area so child

does not feel he or she is “dirty.” Tell child that blackheads are notdirt but oxidized melanin

7 Psychological scarring may occur.

8 Appropriate therapy should be instituted if patient perceives acne

as a problem

9 “Prom Pills”—Emergency clearing of inflammatory acne for a

prom, wedding, or other major event: Prednisone, 20 mg everymorning for 7 days

10 Do not use BenzaClin gel in conjunction with erythromycin VII Education

A Acne is chronic It cannot be cured, but it can be controlled Acne flare

ups occur in cycles, both hormonal and seasonal

B Explain etiology (for psychological support).

C When local treatment is instituted, acne may appear worse before it

improves Expect 6–8 weeks before treatment is effective

D For mild and moderate acne, the aim is to dry and desquamate the skin.

Expect some dryness, peeling, and faint erythema of the skin

E Topical medication

1 If marked erythema and pruritus develop in response to topical

medication, discontinue use temporarily and then resume with lessfrequent application

2 Apply 20 to 30 minutes after gentle washing.

3 Apply lightly to affected area Do not rub in vigorously.

4 Expect a feeling of warmth and slight stinging with application.

F Hygiene

1 Avoid abrasive agents (e.g., over-the-counter scrubs).

2 Shampoo frequently; no special shampoo is necessary.

3 Change pillowcase daily.

4 Do not pick or squeeze lesions; this will retard healing and cause

scarring

5 Use face cloth and hot water for soaks Try to soak for 10 to

20 minutes 5 to 6 times a day

6 Wash face gently three times daily with mild soap; excess

scrub-bing can exacerbate acne

7 Facials may exacerbate acne.

8 Use only water-based cosmetics.

a Oil-free is not necessarily water-based.

b Use loose powder and blush.

9 Acne medications can be applied under cosmetics and sunscreens.

10 Avoid oily sunscreens Sundown and PreSun are generally

acceptable

G Avoid foods that seem to make acne worse.

H Overexposure to sunlight can exacerbate acne, alone or in combination

with topical medications Topical medications can be used under screens It may, however, be necessary to discontinue these medications

sun-in the summer

I Mild sun exposure often dramatically improves acne.

J High humidity and heavy sweating exacerbate acne, as does exposure

to heavy oils and grease

K Tetracycline

1 While on medication, restrict exposure to sunlight.

2 Do not take if there is any question of pregnancy.

3 Take 1 hour before or 2 hours after a meal.

4 If unable to take four times a day because of schedule, take 500 mg

every 12 hours Nurse practitioner should acknowledge that itmay be a problem for an adolescent to have an empty stomach

4 times a day

5 Patient must take the full dose for at least 1 month for effective

treatment

6 Moniliasis may occur in females.

L Discuss preparations available over the counter Explain to adolescent

(and parent, if applicable) that it is more cost-effective to follow thetreatment regimen than to try all the latest acne products for the dra-matic cures that advertisements promise

M.Birth control pill may need to be changed to one that does not contain

norgestrel, norethindrone, or norethindrone acetate

N T-Stat should be applied with the disposable applicator pads Drying

and peeling can be controlled by reducing the frequency of application

O BenzaClin gel may bleach hair or fabric.

P Inflammatory acne can result in scarring and/or pigment changes.

Treatment will prevent or minimize these changes

VIII Follow-up

A Acne is chronic Treatment should be continued until the process subsides

spontaneously but may be interrupted or discontinued during summermonths when temporary remission may occur because of sun exposure

B Return visits need to be individualized according to the severity of the

acne and the emotional needs of the adolescent Once control has beenachieved, however, the frequency of follow-up can be decreased Thepatient may need to remain on a 250- to 500-mg daily maintenancedose of tetracycline for several months, in which case 6- to 12-weekreturn visits should continue If patient is on topical medications alone,after acne is controlled, the frequency of application can be adjusted bythe patient, and telephone follow-up may be sufficient

A Moderate acne: Consult for treatment if no improvement noted after

treat-ment with tetracycline for 2 months before continuing treattreat-ment plan

B Severe or inflammatory acne: Consult for treatment Refer if no

improvement noted after treatment with tetracycline for 1 month Itmay require more aggressive therapy, such as treatment with Accutane

C Severe or resistant acne in a woman if accompanied by hirsutism,

irreg-ular menses, or other signs of virilism

A D H D

A neurodevelopment disorder, attention deficit hyperactivity disorder (ADHD) sents as a persistent pattern of inattention, hyperactivity, and impulsivity that ismore frequent and severe than is typically observed in people at a comparable level

pre-of development (Diagnostic and Statistical Manual pre-of Mental Disorders IV]) There is strong evidence of a genetic component

[DSM-Inattention, hyperactivity, and impulsivity—the core symptoms—must beobserved before the age of 7 years and have been present for at least 6 months Impair-ment of social, academic or occupational functioning must be evident in more thanone setting ADHD is diagnosed clinically since no objective tests exist to confirmthe diagnosis

EnvironmentalCNS Insults

II Incidence

A 4%–12% of school children in US according to DSM-IV Males are at

an increased risk

B It frequently co-exists with other conditions For example, Oppositional

Defiant Disorder is present in 35%, conduct disorder in 26%, anxietydisorder in 26%, and depressive disorder in 18%

C Up to 80% continue symptomatic into adolescence and up to 60% into

1 In constant motion—squirms, fidgets, cannot sit still

2 Talks too much

3 Cannot play quietly

4 Continually “flits” from one activity to another

C Impulsivity

1 Interrupts conversations and games

2 Cannot wait for turn

3 Answers before question completed

4 Acts without thinking—e.g., runs into street

D Parents have difficulty with discipline or managing behaviors

E Poor time management.

F Room, desk, belongings in a state of chaos.

IV Objective

A DSM-IV Criteria for ADHD

1 Inattention: Six or more of the following symptoms of inattention

have been present for at least 6 months to a point that is disruptiveand inappropriate for developmental level:

a Does not give close attention to details or makes careless

mis-takes in schoolwork, work, or other activities

b Often has trouble keeping attention on tasks or play activities

c Often does not seem to listen when spoken to directly

d Often does not follow instructions and fails to finish

school-work, chores or duties in the workplace (not due to tional behavior or failure to understand instructions)

e Often has trouble organizing activities

f Often avoids, dislikes, or doesn’t want to do things that take a

lot of mental effort for a long period of time (such as work or homework)

school-g Often loses things needed for tasks and activities (e.school-g., toys,

school assignments, pencils, books, or tools)

h Is often easily distracted

i Is often forgetful in daily activities

2 Hyperactivity-impulsivity: Six or more of the following

symp-toms of hyperactivity-impulsivity have been present for at least

6 months to an extent that is disruptive and inappropriate fordevelopmental level:

Hyperactivity

a Often fidgets with hands or feet or squirms in seat.

b Often gets up from seat when remaining in seat is expected.

c Often runs about or climbs when and where it is not

appropri-ate (adolescents or adults may feel very restless)

d Often has trouble playing or enjoying leisure activities

quietly

e Is often “on the go” or often acts as if “driven by a motor.”

f Often talks excessively.

Impulsivity

a Often blurts out answers before questions have been finished

b Often has trouble waiting one’s turn

c Often interrupts or intrudes on others (e.g., butts into

conversa-tions or games)

d Some symptoms that cause impairment were present prior to

7 years of age

e Some impairment from the symptoms is present in two or more

settings (e.g., at school/work and at home)

f There must be clear evidence of significant impairment in

social, school, or work functioning

g The symptoms do not happen only during the course of a

per-vasive developmental disorder, schizophrenia, or other chotic disorder The symptoms are not better accounted for byanother mental disorder (e.g., mood disorder, anxiety disorder,dissociative disorder, or a personality disorder)

psy-V Assessment

A Diagnosis:

Assessment is based on the above criteria which is obtained by tion and evaluation of Connors questionnaires from parents and teachers

observa-or by the Vanderbilt rating scale (see Appendix O, p 572)

There is no single diagnostic test The diagnosis involves mation from several sources and should be made following DSM-IVcriteria

infor-1 ADHD, Combined Type: If both criteria from infor-1 and 2 have been

met for the past 6 months (Six or more symptoms of inattentionand six or more symptoms of hyperactivity have been present.)

2 ADHD, Inattentive Type: If criterion from 1 has been met for the

past 6 months (Six or more symptoms of inattention have beenpresent.)

3 ADHD, Hyperactive-Impulsive Type: If criterion 2 has been met

for the past 6 months (Six or more symptoms of hyperactivity/impulsivity have been present.)

B Rule Out Co-morbid Conditions

1 Oppositional defiant disorder: Loses temper easily, defiant, hostile,

and intentionally annoying; estimated prevalence 35%

2 Anxiety: Fear, worry, panic; estimated prevalence 25%

3 Depressive disorder: Estimated prevalence 18%

4 Conduct Disorder: Estimated prevalence 25%

5 Learning disorders

VI Treatment

A Treatment is multifaceted and is predominantly pharmacotherapy

with behavioral interventions, parent training, and school vention Dosage of medication should be started low and titratedupward Seventy percent of children respond to the first stimulantprescribed Approximately half who respond poorly will respond tosecond drug prescribed

of other racemic methylphenidate HCL drugs

c Metadate CD: 10-, 20-, 30-, 40-, 50-, or 60-mg extended

release capsules

(1) 8-hour duration (2) Can be sprinkled (3) Onset of action 1.5 hours after dosing.

2 Intermediate Release Stimulants

a Adderall: 5-, 7.5-, 10-, 12.5-, 15-, 20-, or 30-mg tablets (1) First dose on awakening

(2) If needed, give 1 or 2 more doses at 4- to 6-hour intervals (3) Maximum dose usually 40 mg/d in 2 or 3 divided doses

b Adderall XR: 5-, 10-, 15-, 20-, 25-, or 30-mg extended-release

capsules

(1) Give once daily in AM

(2) May be sprinkled (3) Maximum dose 30 mg/d

c Dexedrine: 5-mg tablets (1) Give in AM

(2) Repeat dose every 4–6 hours prn (3) Maximum dose: 40 mg in 2 or 3 divided doses (4) May switch to Dexedrine Spansules once titrated

d Dexedrine Spansules: 5-, 10-, 15-mg sustained-release capsules (1) Used for once daily dosing once Dexedrine titrated (2) Maximum dose 40 mg/d

3 Methylphenidate patch (Daytrana): 10-, 15-, 20-, and 30-mg

trans-dermal patch

a Slow release

b Useful when child resistant to oral medication

c Apply daily to alternating hip 2 hours prior to desired effect.

d Remove after 9 hours May remove earlier if shorter duration

of effect desired or late day side effects

e Titrate at one-week intervals.

C Non-stimulant

1 Atomoxetine

a Start with 0.5 mg/d for 3–5 days.

b Titrate up to 1.2–1.4 mg/kg/d

c Use if intolerable side effects with stimulants, treatment failure,

or if parents object to stimulant medication

d Follow-up on 4–6 weeks.

e Contraindicated with monoamine oxidase inhibitors (MAOIs).

f Concurrent use with albuterol, other beta-agonists, and

over-the-counter (OTC) cough and cold preparations with ephedrine may cause increases in blood pressure and heartrate

pseudo-D Monitor academic progress.

1 Maintain contact with school personnel.

E Monitor social relationships.

F Monitor height, weight, blood pressure, and pulse on a regular basis.

G Behavioral Therapy

1 Use in conjunction with medication.

2 Positive reinforcement

3 Time out

4 Withdraw rewards or privileges for unwanted behavior.

5 Set reasonable goals.

H Document baseline severity with parents and teachers.

VI Education

A Return for height, weight, blood pressure and pulse monitoring as

scheduled

B Safety issues

1 Child is apt to be a “risk taker.”

2 Impulsivity and inattention can increase incidence of accidents.

3 Adolescents with ADHD are more prone to motor vehicle accidents.

C Medication: It may take several trials to adjust the correct medication

and dosage

D Atomoxetine

1 May take 3–6 weeks for effect

2 Use if parents object to stimulants

3 Consider use when sleep disturbance and/or significant early

morning hyperactivity are problematic

E Stimulant medication side effects

F Administer medication with or after a meal.

G Beads from sprinkled capsules should not be chewed.

H Without treatment, child at-risk for

1 Disorganization in school work

2 Poor self-esteem

3 Risky behavior

4 Poor peer relationships

5 Increased incidence of depression, anxiety, and/or substance abuse.

I Reassure parents that it is not “their fault.”

J Maintain firm, consistent limits: Present a “united front.”

K Reward positive behaviors.

L Adhere to a daily routine Advise child prior to change in routine M.Provide quiet place with minimal distractions for homework.

N Behavioral therapy assists child in learning about responsibility and

control over his or her behavior

O Anticipate problem settings: Make a plan, review rules, and establish

R Time outs for infractions should be limited in length.

S ADHD generally continues into adulthood.

T Recognize that a child with ADHD creates stress for parents.

U Maintain open communication with schools Discuss implementation of

accommodations with teacher and administration Daily behavior chartsare effective as well

V Additional services can be obtained, if appropriate, through

1 IDEA (Individuals with Disabilities Education Improvement Act)

2 Section 504 (Rehabilitation Act of 1973)

3 ADA (Americans with Disabilities Act of 1990)

4 ESEA-NCLB 2001 (the Elementary and Secondary Education Act)

5 However, in itself, ADHD is not considered a learning disability W.Treatment for ADHD is long-term and will require ongoing communi-

cation and planning with child’s doctor, teacher, and others involvedwith the child

VII Follow-up

A Telephone call every one to two weeks to check on medication response.

B Recheck in office monthly until medication is adjusted and satisfactory

progress is seen

C Further follow-up visits according to need based on school and social

progress and expected outcomes

D Parent will need to come to office every month to get prescription for

medication

VIII Consultation/referral

A Children with cardiovascular abnormalities

B Children under 7 years of age

C Children with co-morbid conditions

Resources/Suggested Readings

B OOKS

American Academy of Pediatrics (2004) ADHD: A complete and authoritative guide Elk

Grove Village, IL: Author

Ashley, S (2005) ADD and ADHD answer book Naperville, IL: Sourcebooks, Inc Barkley, R A (2000) Information and guidance for parents in the management of children with ADHD Taking Charge of ADHD: The Complete Authoritative Guide for Parents.

New York: Guilford Publications

Gordon, M (1991) Jumpin’ Johnny get back to work! A child’s guide to ADHD/Hyperactivity Ages 5–10 DeWitt, NY: GSI Publications.

Hallowell, E., & Ratey, J (2005) Delivered from distraction: Getting the most out of life with attention deficit disorder New York: Random House Publishing Group.

Reif, S F (2005) How to reach and teach children with ADD/ADHD: Practical techniques, strategies, and interventions Hoboken: NJ: John Wiley & Sons.

W EBSITES

National Institute of Mental Health Telephone: 301-443-4513 Website: http://www.nimh.nih.gov

National Attention Deficit Disorder Association Telephone: 847-ADHD-377 Website:http://www.add.org

Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) Telephone:800-233-4050 Website: http://www.chadd.org

A local or systemic reaction to the sting of an insect, generally a bee, wasp, orhornet

I Etiology

A Hypersensitivity is an IgE-mediated response Generally an initial

exposure is followed by re-exposure, and the re-challenge elicits thereaction

B Hymenoptera

1 Bee family: Bees and honey bees

2 Wasp family: Yellow jackets, wasps, and hornets

3 Ant family: Fire ants of southeastern United States (attack en masse)

II Incidence

A 90% of children experience a normal reaction of less than 2 inches in

diameter and less than 24 hours in duration

B 10% of children will have a large local reaction greater than 2 inches in

diameter and lasting up to 7 days

C Anaphylaxis occurs in 0.4% to 0.8% of the general population.

D Approximately 50 deaths from stings occur in the United States

every year The sting of a bee, wasp, or yellow jacket is more apt toproduce severe, immediate hypersensitivity reactions than any otherinsect

III Subjective data

A History of bite or sting

B Local reaction

1 Swelling and redness at site of sting

2 Intense local pain

C Systemic reaction; may be a combination of the following:

1 Anxiety, initially

2 Nausea

3 Itching

4 Sneezing, coughing

5 Hives or frank angioedema, with various parts of skin swollen

6 Swelling of lips and throat

IV Objective data

A Local reaction

1 Local wheal and flare reaction with central punctum

2 Edema around sting site

3 Normal reaction

a Swelling less than 2 inches in diameter

b Duration less than 24 hours

4 Large local reaction

a Edema more than 2 inches in diameter

A Hymenoptera sting by history (honey bee, if the stinger is left intact)

B Differential diagnosis of anaphylaxis

1 Vasopressor syncope: Self-limited, no pulmonary involvement,

rarely occurs when child is prone, blood pressure and pulse do notdrop, child rouses after breathing amyl nitrite

2 Cardiac failure

3 Anxiety attack

4 Penicillin allergy

5 Obstruction in laryngotracheobronchial tree

6 Aspiration of foreign body

VI Plan

A Normal local reaction

1 Remove stinger by scraping off The protruding end contains the

venom sac, and pinching or using forceps will cause more venom

to be pumped into the wound

2 Topical application of ice

3 Benadryl, 1 mg/kg, up to 50 mg

4 Calamine lotion

B Large local reaction or multiple stings

1 Local measures as above

2 Prednisone, 1 mg/kg/d for 5 days may be helpful

C Systemic reaction

1 Apply tourniquet proximal to sting on an extremity.

2 Remove stinger; shave off stinger of honey bee (has reverse

serrations)

3 Administer epinephrine 1:1000, 0.01 mL/kg SC (maximum

0.3 mL); rub Repeat in 15 to 30 minutes (see Table 2-1)

4 Benadryl, 1 mg/kg, up to 50 mg

a Antihistamines should be used as an adjunct to epinephrine to

block the effects of histamine on the receptor sites

b Antihistamines do not prevent bronchoconstriction; their greatest

benefit is in blocking reaction of mucous membrane and skin

5 Transport patient immediately to emergency room.

6 Refer patient to allergist for testing and possible immunotherapy.

7 Order EpiPen, and instruct patient or parent in its use.

a EpiPen for patients 30 kg and over

b EpiPen Jr for patients 15 kg and over

c Use trainer pen for instruction

8 Order rapid-acting antihistamine: Zyrtec (syrup 1 mg/mL, chewables

5 mg and 10 mg, tablets 5 mg and 10 mg)

a 0.25 mg/kg: less than 2 years of age

b 2.5–5 mg: 2–6 years of age

c 5–10 mg: More than 6 years of age VII Education

A Do not wear perfumes, hair spray, aftershave, and so forth when outside.

B Wear neutral colors; flowery prints are apt to attract bees.

C Do not walk barefoot outside Yellow jackets, the most aggressive

hymenoptera, nest in the ground

D Avoid flower beds, playgrounds, picnic areas, and trash or garbage

disposal areas

E No insect repellent is available that repels stinging insects.

F Do not run or engage in physical activity after a sting.

G The honey bee stinger has reverse serrations and leaves its stinger in the

skin with the venom sac attached to it The venom sac continues to ejectvenom and will empty out completely if compressed Do not squeeze it;instead, scrape or shave the stinger off

H Wasps and yellow jackets retain their stingers and may sting repeatedly.

I 70% of deaths due to hymenoptera are caused by airway edema or

respiratory compromise

T A B L E 2 – 1 Epinephrine 1:1000 Dosage Table

J 85% of children who go into anaphylactic shock do so within the first

15 to 30 minutes of exposure

K Anaphylaxis has occurred as late as 6 hours following exposure, but

this is highly unusual

L Steroids do not help against the initial insult but will help against a

delayed recurrence after the initial treatment

M.Skin testing for allergy may yield a false-negative result if done too

soon after treatment for a sting; wait 3 to 4 weeks after a sting beforedoing such testing

N Immunotherapy reduces risk of life-threatening complications from

60% to less than 5%

O EpiPen spring-loaded syringe contains epinephrine in a premeasured

dose EpiPen delivers 0.30 mg (in patients >30 kg) and EpiPen Jr.delivers 0.15 mg (in patients >15 kg) of epinephrine

P Administer EpiPen into anterolateral aspect of thigh—through clothing

if necessary

Q Parents should notify school, day care, camp, and other caretakers of

reaction and have EpiPen available for child at all times

R Child should wear a MEDIC ALERT bracelet.

VIII Follow-up

A Contact after discharge from hospital to ensure that parent or child has

made appointment with allergist for testing

IX Complications

A Anaphylaxis following rechallenge

B Delayed systemic reaction

X Consultation/referral

A Refer any patient who has had an immediate systemic reaction to allergist.

B Consult with allergist on any patient who has had a large local reaction.

AL L E R G I C RH I N I T I S A N D CO N J U N C T I V I T I S

An allergic response resulting in inflammation of the mucous membrane It is acterized by chronic, thin, watery nasal discharge with or without concurrent con-junctival discharge, inflammation, and pruritus

char-I Etiology

A IgE-mediated immunologic reaction to common inhaled allergens

(pol-lens, molds, dust, animal dander) The mediators cause increased meability of the mucosa and produce vasodilation, mucosal edema,mucous secretions, stimulation of the itch receptors, and a reduction inthe sneezing threshold

per-B Seasonal allergic rhinitis is generally caused by non-flowering,

wind-pollinated plants, and fungal spores

Allergens vary seasonally and by geographic distribution andcommonly include tree pollens in the early spring, grasses in late spring

and early summer, and weeds primarily in the fall However, in manyareas, various weeds pollinate from spring through fall.

C Perennial allergic rhinitis is caused by allergens that are present year

round such as animal dander, dust, cockroaches, and molds

D Food allergens are not a common cause of allergic rhinitis.

II Incidence

A Allergic rhinitis is the most common atopic disease and the most

com-mon chronic disease in children

B Usually seen after 3 to 4 years of age but can develop at any age

C Affects approximately 10% of the population

D 80% to 90% percent of children with asthma have concomitant allergic

rhinitis

III Subjective data

A Nasal stuffiness: Varies from mild to chronic obstruction

B Rhinorrhea: Bilateral, thin, watery discharge

C Paroxysms of sneezing

D Itching of nose, eyes, palate, pharynx

E Conjunctival discharge and inflammation

K Persistent, nonproductive cough

L Pertinent subjective data to obtain

1 History of associated allergic symptoms: Asthma, urticaria,

con-tact dermatitis, eczema, food or drug allergies

2 Family history of allergy

3 Does child always seem to have a cold, or does it occur at specific

times of the year (perennial versus seasonal)?

4 Are symptoms worse in any particular season?

5 Do parents or child notice that symptoms are worse after exposure

to specific allergens, such as animals, wool, feathers, or going intoattic or cellar?

6 Are symptoms worse when child is indoors or outside?

7 What do parents or child think causes symptoms?

8 Can child clear nose by blowing?

9 What makes child feel better?

10 How much do symptoms bother child and family?

IV Objective data

A Allergic shiners: Bluish cast under eyes

B Allergic crease: Transverse nasal crease at junction of lower and middle

thirds of nose

C Clear mucoid nasal discharge

D Pale edematous nasal mucosa

E Nasal turbinates swollen and may appear bluish

1 Differentiate between the following:

a Seasonal allergic rhinitis occurs seasonally as a result of

expo-sure to airborne pollens: generally tree pollens in late winterand early spring, grass pollens in spring and early summer, andweeds in late summer and early fall

b Perennial allergic rhinitis occurs all year but is usually worse in

winter due to increased exposure to house dusts from heatingsystems, pets, wool clothing, and other allergens

2 Classify as:

a Mild: No sleep interruption, no interference with activities, no

troublesome symptoms

b Moderate–severe: Involves sleep interruption and/or

impair-ment of daily activities, troublesome symptoms

c Intermittent: Symptoms less than 4 days/week or duration

under 4 weeks

d Persistent: Symptoms over 4 days/week or duration more than

4 weeks

B Differential diagnosis

1 Infectious rhinitis or recurrent colds: Nasal discharge watery to

thick yellow, low-grade fever, symptoms develop after exposure

to cold virus, 5 to 7 days duration

2 Foreign body: Unilateral purulent nasal discharge with foul odor

3 Vasomotor rhinitis: Symptoms precipitated by exposure to

temper-ature changes or specific irritants (smoke, air pollutants, strongperfume, chemicals); symptoms appear suddenly and disappearsuddenly

4 Rhinitis medicamentosus: History of chronic use of nose drops

5 Acute or chronic sinusitis: Nasal mucosa is usually inflamed and

edematous; discharge is generally mucopurulent; may have grade fever

low-6 Cystic fibrosis: Consult if nasal polyps are present.

VI Plan: Involve child in treatment plan as much as developmental level

allows

A Pharmacologic therapy

1 Antihistamines relieve rhinorrhea, sneezing, and itching.

2 Decongestants improve nasal congestion.

3 Intranasal steroids suppress the entire inflammatory process in the

nose but do little for relief of ocular symptoms or systemic manifestations

4 Optimal results may be obtained with a combination of nasal

cro-molyn or steroids and an antihistamine or decongestant

5 Antihistamines for seasonal rhinitis

a Ages 6 to 12 years (1) Benadryl, 5 mg/kg/d in four divided doses (>10 kg,

symptoms

6 Decongestant-antihistamine combination

a Pseudoephedrine (Actifed, Sudafed): 2–6 years, 5 mL qid;

6–12 years, 10 mL qid

b Rondec: 2–6 years, 1.25 mL every 4–6 hours, max 7.5 mL/d

6 –12 years: 2.5 mL every 4–6 hours, max 15 mL/dMore than 12 years: 5 mL every 4–6 hours, max 30 mL/d

7 Intranasal corticosteroids: Believed by many experts to be the

most effective pharmacologic therapy for allergic rhinitis

a Vancenase AQ: 1–2 sprays each nostril once daily for children

over 6 years of ageor

b Nasacort AQ: 2 sprays in each nostril once daily for children

over 12 years of age, 1 spray each nostril once daily for dren ages 6 to 12 years

chil-or

c Rhinocort Aerosol: 1–2 sprays each nostril q 12 hours for

chil-dren over 6 years of age May increase to 2 sprays each nostrilonce daily Over 12 years, maximum 4 sprays each nostrilonce daily

or

d Flonase, one spray in each nostril once daily for children over

4 years of age; may increase to 2 sprays once daily

8 Ophthalmic preparations:

a Patanol ophthalmic: 1 gtt in each eye twice daily at 6- to 8-hour

intervals for children over 3 years of age; indicated for all signsand symptoms, including itching, erythema, lid edema, andtearing

or

b Alocril ophthalmic: 1 to 2 drops in each eye, every 12 hours for

children over 3 years of ageor

c Alomide ophthalmic: 1 to 2 drops in each eye, qid for up to

3 months, for children over 2 years of ageor

d Optivar ophthalmic: 1 drop in each eye, bid for children more

than 3 years of age

B Avoidance: Identify and avoid offending allergens (see Environmental

Control for the Atopic Child, p 291)

1 Seasonal allergic rhinitis: Ragweed, trees, grasses, molds

2 Perennial: House dust, feathers, animal dander, wool clothing or

rugs, mold

3 Environmental stimuli: Cold air, paint fumes, smoke, perfumes

C Desensitization: Referral, indicated if

1 symptoms are severe and cannot be controlled with symptomatic

therapy

2 recurrent serous otitis occurs with resultant hearing loss.

3 symptoms become progressively worse or asthma develops.

4 allergen avoidance is impossible.

VII Education

A Advise parents that this is a chronic problem, although symptoms may

sometimes decrease with age and then disappear Exacerbation ofsymptoms may occur, particularly as child approaches puberty

B Discuss indications for hyposensitization.

1 Inability to suppress symptoms with conservative treatment

2 Inability to avoid allergens

3 Severe symptoms affecting child’s normal lifestyle (school, sleep,

play)

4 30% to 50% of children with allergic rhinitis who are not treated

develop asthma

5 Desensitization is a lifelong process.

C Discuss specific allergen control (see Environmental Control for the

Atopic Child, p 291)

D Advise child and parents of possible hearing loss due to serous otitis.

E Notify school of child with hearing loss.

F Inadequate symptom control may contribute to learning impairment.

G Side effects of antihistamines.

1 Sedation (often resolves with continued use); nightmares

2 Excitation, nervousness, tachycardia, palpitations, irritability

3 Dryness of mouth

4 Constipation

H Antihistamines relieve nasal congestion, itching, sneezing, and

rhinor-rhea Continuous therapy is more efficacious than sporadic use

I Topical anti-allergic ophthalmics also have a positive effect on nasal

symptoms by draining into inferior nasal turbinates

J Intranasal corticosteroids

1 Reduces nasal stuffiness, discharge, and sneezing

2 Maximum benefit achieved in 1 week

K Child should not wear soft contact lenses when using ophthalmic drops.

L Ophthalmic preparations may cause transient stinging or burning M.Child with allergic rhinitis is more prone to upper respiratory and ear

infections

N Child cannot clear nose by blowing it.

O Child may not be able to chew with his or her mouth closed.

P Epistaxis may be a problem because of nose picking and rubbing

Con-trol nosebleed by compressing lower third of nose (external pressureover Kiesselbach’s triangle) between fingers for 10 minutes

VIII Follow-up

A Return visit or telephone follow-up in 2 weeks for reevaluation Contact

sooner if adverse reaction to medication occurs

B If no response to medication, increase dosage to control symptoms.

Reevaluate in 2 weeks Change type of antihistamine if indicated

C If symptoms under control, continue medication until suspected allergen

no longer a threat Medication may then be used as needed to controlsymptoms

D Return visit at any time that child or parent feels symptoms are worse

or medication has ceased to control symptoms

A Anorexia nervosa is generally hypothesized to be due to reactivation at

puberty of the separation-individuation issue: the adolescent’s attempt

to maintain or initiate a sense of autonomy and separateness from themother

B Starvation gives the adolescent a sense of identity and control over

what is happening to one’s body

II Incidence

A Affects approximately 5% of women ages 15–30.

B 90% to 95% of anorexics are female, with the peak onset occurring at

ages 14 and 18 years

C Most cases are from middle to upper socioeconomic families but can be

of any race, gender, age, or social stratum Patients are commonlymembers of the same family

D Generally seen in perfectionists or “model children” with poor

self-images They are high achievers academically and are frequentlyengaged in strenuous physical activity, such as varsity sports or vigor-ous exercise programs Parents are often overprotective, controlling,and demanding Children feel unable to live up to parental expectationsdespite strict adherence to these expectations

E In terms of body weight, 80% of anorexics respond to therapy, although

other psychosocial problems may be prolonged Amenorrhea persists in13% to 50% even after weight returns to normal or is stabilized at 85%

I Dry skin and hair

J Headaches (“hunger headaches”)

K Fainting or dizziness

L Anorexia

M.Pertinent subjective data to obtain

1 Preoccupation with food and dieting

a History of dieting

b Denial of hunger

c Patient finds food revolting but may spend time preparing

gourmet meals for others

d History of food rituals

2 Morbid fear of gaining weight

3 Weight history: Highest and lowest weights achieved

4 Vomiting after meals

5 Low self-esteem, poor body-image; patient complains of being fat,

when in reality, one is not

6 Dietary history

7 Menstrual history

8 Perceived body image

9 History of impulsive behaviors: Stealing, self-mutilation

10 History of suicide gestures

11 Excessive exercising

12 Laxatives, diuretics, or other medications used to control weight

13 Recent family or social stress

14 History of unpleasant sexual encounter; patient may be using

star-vation to try to halt development of secondary sex characteristics

15 History of sexual activity; condition may be unconscious attempt

to abort a pregnancy

16 History of drug or alcohol abuse

N Note: Anorexia nervosa may be identified in its early stages by a

con-scientious health care provider eliciting a history during a routine healthmaintenance visit Any combination of the above should create a highindex of suspicion

IV Objective data

A Weight loss: More than 15% below ideal body weight (IBW) or in

prepubertal patients, failure to gain height and weight

B Emaciation: Patient appears gaunt, skeletal.

C Bradycardia

D Orthostatic hypotension

E Hypothermia

F Skin: Dry and flaky, lanugo hair, loss of subcutaneous fat, jaundice

G Hair loss: Scalp and genital area

H Extremities: Edema, cyanosis, mottling, cold; slow capillary refill in

hands and feet

I Compulsive mannerisms (e.g., handwashing)

J Apathy, listlessness

K Loss of muscle mass

L Occasionally, scratches on palate from self-induced vomiting M.Laboratory findings

1 Usually normal until later stages of malnutrition

c Low sedimentation rate

d Low fibrinogen levels

e Low serum lactic dehydrogenase estrogens

f Low T3

g Electrolyte imbalance if vomiting: MG, Ca, Phos

h BUN (1) High with dehydration (2) Low with low protein intake

i Cholesterol levels often dramatically elevated in starvation

states

j LFT may be mildly elevated.

k Blood glucose: Low or low normal

4 Cranial MRI to rule out hypothalamic tumor if neurologic

symp-toms present and in all males (cerebral atrophy often seen) It willdemonstrate decreased gray and white matter volumes

5 CT scan demonstrates enlarged intracranial CSF spaces in the

acute phase

6 ECG for all patients who are purging or are bradycardic

V Assessment

A Diagnosis is made by evaluation of the subjective and objective data.

Primary among these are the adolescent’s intense or morbid fear ofbeing fat, a poor or distorted body image, and weight 15% or morebelow IBW (weight at which normal menstruation is restored in amenarchal female and weight at which normal sexual and physicaldevelopment is restored in a premenarchal female.)

1 Identify types of anorexia

a Restrictive type: Adolescent restricts calories and engages in

vigorous activity

b Binge-eating, purging type: Use of laxatives, enemas, diuretics,

and self-induced vomiting are considered purging

B Differential diagnosis

1 Inflammatory bowel disease

2 Endocrine disorders

3 Psychiatric illnesses (e.g., schizophrenia or depressive disorder)

4 Pregnancy (starving to abort pregnancy)

VI Plan

A Outpatient treatment

1 Refer to psychotherapist.

2 Refer to nutritionist.

3 Weekly visit to check weight and urine (water loading will be

detected by specific gravity)

4 Refer family for counseling or parents group.

5 Restrict physical activity Helps maintain weight by decreasing

energy expenditure and can motivate sports-minded teenager to eatproperly to resume activity

6 Daily structure should include three meals a day.

7 Clearly identify parameters for admission:

a Weight less than 85% of ideal body weight or acute weight loss

with food refusal

b Dehydration

c Electrolyte imbalance

d EKG abnormalities

e Severe bradycardia (40 bpm or less), hypotension (less than

80/50 mm Hg), hypothermia, orthostatic changes

f Failure to make progress as an outpatient in 4 weeks (less than

0.5 k a week weight gain)

g Refusal to eat

h Suicidal ideation

i Severe depression

B Hospitalization indicated with severe malnutrition or for failure to

make progress as an outpatient over a 4-week trial; treatment includesthe following:

a selective serotonin reuptake inhibitors (SSRIs)

b Avoid tricyclic antidepressants (TCAs), monoamine oxidase

inhibitors (MAOIs), bupropion

VII Education

A This is a chronic condition and may require medical management and

counseling for as long as 2 to 3 years

B A consistent approach by all caretakers and family is necessary.

C Aversion to food decreases as self-image improves.

D Emphasis should be on weight gain, not eating.

E Recommended weight gain is about 3 lb/wk Too rapid weight gain

may cause adolescent to begin dieting again as it reinforces perceptions

of being ineffective, powerless, and worthless

F Weekly weights preferable to daily weights.

G Adolescent may drink copious amounts of water or conceal weights on

body prior to weigh-in

H Bathroom use may need to be monitored for prevention of self-induced

vomiting after meals

I Laxative use may continue if not closely monitored.

J Anorexics who are cured generally stabilize at 85% to 90% of normal weight.

K Television use should be monitored Cultural influences such as

tele-vision promote a preoccupation with food In addition, teletele-vision andfashion magazines are dedicated to a “thin is in” image—an ideal figurethat few can hope to achieve

L Hospitalization should not be perceived as a punishment, but rather as an

adjunct or intensification of treatment It is increasingly difficult withsome insurance plans to secure inpatient hospitalization for treatment ofanorexia In spite of established and accepted criteria developed for eachpatient, in many instances, patients have not been accepted for intensi-fied treatment unless overtly suicidal (and that does not include the “not-so-subtle signs” consisting of laxative and appetite suppressant abuse)

M.Acknowledge that the adolescent feels fat, and avoid stating that he or

she looks thin because that can be perceived as a compliment

N Clearly identify threats to health: Cold hands and feet, amenorrhea,

syncope represent physiologic reaction to starvation, much like an animal in hibernation

O Explain that unless the anorexic is dehydrated, most laboratory values

(except for cholesterol, which is almost always elevated) will be withinnormal limits

VIII Follow-up

A Schedule on an individualized basis Many patients need to be seen on

a weekly basis and sometimes biweekly, until stabilized It is an ing problem, and the child may need to be followed for years

ongo-B Contact patient or family following all referrals to ascertain that

appointments have been made and kept, and to provide support

Resources

National Association of Anorexia Nervosa and Associated Disorders, Inc (ANAD) MailingAddress: Box 7, Highland Park, IL 60035 Toll-free hotline: 847-831-3438 Website:http://www.anad.org

The Massachusetts Eating Disorder Association (MEDA) Telephone: 617-558-1881 Website:http://www.medainc.org E-mail: masseating@aol.com

National Eating Disorders Association Telephone: 800-931-2237 Website: http://www.NationalEatingDisorders.org

The Academy for Eating Disorders Telephone: 703-556-9222 Website: http://www.aedweb.orgThe American Anorexia Bulimia Association Address: 165 W 46th St., Suite 1108, NewYork, NY, 10036 Telephone: 212-575-6200 Website: http://www.aabainc.org

List Local Referral Sources

B Emotional and physical factors often precede eruptions and have been

implicated in the etiology, but no definite proof is available

C Certain foods, especially chocolate, nuts, and fruits, can precipitate

lesions, as can trauma from biting or dental procedures

D Herpes simplex is not the cause.

II Incidence

A Most commonly seen between the ages of 10 and 40.

B Estimated prevalence is about 20% of the general population.

III Subjective data

A History of tingling or burning sensation preceding eruption for up to

24 hours

B Complaint of canker sores or recurrent painful oral lesions

C Pertinent subjective data to obtain: Lesions occur after a specific

3 Oval, shallow erosions

4 Light yellow or gray

5 Clearly defined erythematous border

B Distribution: Buccal or labial mucosa, lateral tongue, palate, pharynx

C Rarely, extremely large or numerous lesions

D Rarely any systemic symptoms or adenopathy

V Assessment

A Diagnosis is made by the characteristic appearance of the lesion, its

recurrent nature, and the absence of systemic symptoms

B Differential diagnosis

1 Herpes simplex: Lesions are on the skin, most commonly at the

mucocutaneous junction

2 Herpangina: Elevated temperature, sore throat, vesicular

erup-tions on an erythematous base on the anterior pillars; no lesions

on gingival or buccal mucosa

3 Acute herpetic gingivostomatitis: Vesicles, erosions, maceration

over entire buccal mucosa; marked erythema and edema of gingiva,submandibular adenopathy

VI Plan: Objective of treatment is to control pain, to shorten duration of

lesions and to abort new lesions

A Kenalog in Orabase: Applied to lesion qid

B Topical anesthetics for pain

2 Benadryl elixir

a Apply directly to lesion

b May be mixed with kaopectate

or

3 Xylocaine Viscous solution

a Apply directly to lesion or

b For children 5 to 12: 3

⁄4to 1 tsp every 4 hours Over 12 years ofage, 1 tbsp (15 mL or 300 mg) swished around mouth every 4hours (dosage is 4.5 mg/kg)

or

4 Ora-Jel (20% benzocaine), prn

C Tetracycline compresses (250 mg/30 mL water): 4 to 6 times a day for

5 to 7 days, for children over 8 years of age

D Toothpaste swish: Brush teeth and swish the toothpaste around in the

mouth after meals and at bedtime

E Oral hygiene: Rinse mouth gently with warm water.

VII Education

A With recurrent lesions, use Kenalog in Orabase as soon as tingling or

burning is felt This may be useful in aborting aphthae or shorteningduration of ulcers

B Topical anesthetics

1 Dry lesion before using topical anesthetic.

2 Apply to lesion only; do not use on surrounding skin or mucous

membrane

3 Topical anesthetics provide pain relief for about 1 hour; do not

overuse Do not eat within 1 hour after using

4 Do not use more than 120 mL (approximately 8 tbsp of Xylocaine

Viscous) in 24 hours for children over 12 years Maximum 40 mLfor children ages 5 to 12 years

C Tetracycline compresses abort lesions, shorten healing, and prevent

secondary infection

1 Dissolve 250 mg tetracycline in 30 mL water Apply for 20 to

30 minutes using gauze pledgets

2 Do not eat or drink for 1/2 hour following treatment.

D Identify triggering factor if possible; avoid specific foods or drugs felt

to be precipitating factors

E Use soft toothbrush if trauma seems to precipitate lesions.

F Encourage liquids.

G A bland diet is helpful; avoid salty or acidic foods.

H Recurrences are common.

I Lesions heal in 1 to 2 weeks.

J Lesions are not the same as cold sores.

VIII Follow-up

A Telephone follow-up in 24 hours if child is not taking liquids well

B Routine follow-up visit not indicated

IX Complications: Dehydration in a small child with several lesions

Asthma 231

X Consultation/referral

A Infants

B Any signs or symptoms of dehydration

C Child with very large or many lesions, or with concurrent skin, ocular,

or genital lesions

A disease of the lungs characterized by reversible or partially reversible airwayobstruction, airway inflammation, and airway hyper-responsiveness The usualmanifestations are wheezing, cough, and dyspnea, although any of the three can bethe sole presenting complaint It is the most common chronic disease and the mostserious atopic disease in children

I Etiology

A Hyper-reactivity and inflammation of the tracheobronchial tree to

chemical mediators

B Allergens

1 Environmental inhalants, such as dust, molds, animal dander, pollens

2 Food allergens, such as nuts, fish, cow’s milk, egg whites, and

chocolate provoke asthma in about 10% of children with asthma

3 Anaphylactic reaction

C Upper and lower viral respiratory tract infections

1 Viral infections are more common in younger children, particularly

those in day care, who may easily have more than 12 infections a year

2 In the younger age group, viral infections are the primary cause of

asthma attacks

D Exertion: Exercise-induced asthma

E Rapid temperature changes, cold air, humidity

F Air pollutants: Smog, smoke, paint fumes, aerosols

G Emotional upsets: Fear, anxiety, anger

H Gastroesophageal reflux

II Incidence

A Prevalence of asthma has been increasing Asthma is the leading cause

of chronic illness in children

B Asthma affects about 5% of children under 18 years of age and

dis-proportionately affects poor and minority children

III Subjective data

A Onset may be abrupt or insidious.

B Generally preceded by several days of nasal symptoms (sneezing,

rhinorrhea)

C Allergic salute or rubbing tip of nose upward with palm of hand

D Dry, hacking cough

E Tightness of chest

F Wheezing

G Dyspnea

H Anxiety, restlessness

I Rapid heart rate

J Pertinent subjective data to obtain

1 History of upper respiratory tract infections, particularly in infants

2 History of allergic rhinitis or atopic dermatitis

3 Family history of atopic disease (e.g., allergic rhinitis, bronchial

asthma)

4 History of inciting factors that may have initiated current attack

5 Review of environment (e.g., pets, heating system)

6 History of bronchospasm occurring after vigorous exercise

7 History of recurrent pneumonia or bronchitis

8 Cough, especially at night

K Clues to diagnosis in nonacute phase

1 Symptoms

a Cough: Exercise-induced asthma may be manifested as a

cough with no wheezing

b Episodic wheezing: Acute wheezing may indicate aspiration of

a foreign body

c Shortness of breath

d Tightness of chest

e Excessive mucus production

2 Pattern of seemingly isolated symptoms

a Episodic or continuous with acute exacerbations

b Seasonal, perennial, or perennial with seasonal exacerbations

c Frequency of symptoms

d Timing: After exercise, consider exercise-induced asthma;

during night, consider gastroesophageal reflux

3 Factors precipitating symptoms: Exposure to common triggers

(i.e., allergens, viral infections, exertion, pollutants, emotionalupheavals, cold air)

L History: Absence of symptoms that would indicate other chronic

diseases (e.g., cystic fibrosis, cardiac disease)

1 Wheezing associated with feeding

2 Failure to thrive

3 Sudden onset of cough or choking

4 Digital clubbing

IV Objective data

A Prolonged expiratory phase; exhales with difficulty

B Bilateral inspiratory wheezing; sometimes expiratory wheezing as well,

which reflects exacerbation of the process Patient with severe tory distress may not have enough air exchange to generate wheezing

respira-C High-pitched rhonchi

D Rales; sibilant or sonorous throughout lung fields

E Cough, especially at night

F In infants, inspiratory and expiratory wheezing with tracheal rales

G Hyperresonance to percussion

H Tachypnea

I Evidence of hyperinflation; child sits upright with shoulders hunched

forward to use accessory muscles of respiration

J Fever, if concurrent infection

K History or signs of atopic disease; rhinitis, flexural eczema

L In infants, intercostal and suprasternal retractions M.Flaring of alae nasi

N Altered mental status; indicates impaired gas exchange

O Examination may be negative in a child with mild or moderate asthma

who presents between episodes, except for signs of allergic rhinitis (seeprotocol, p 218)

P Examination may be negative for clinical features suggesting other

dis-eases: Failure to thrive, digital clubbing, cardiac murmur, unilateral signs

Q Laboratory findings and diagnostic procedures

1 In mild or moderate acute attacks, laboratory studies are not

gener-ally indicated; diagnosis is genergener-ally clinical, depending on historyand physical examination

2 X-ray studies are not generally indicated except to rule out a

for-eign body or infectious process

3 For recurrent episodes or mild asthma, skin testing and cytology

may provide valuable data

4 Oxygen saturation testing is useful in an acute episode.

5 Pulmonary function tests (PFT)

a Spirometry: A 10% improvement in the forced expiratory

vol-ume in 1 second, or a 25% increase in the mean forced tory flow at 25% or 75% of vital capacity after inhaling abronchodilator indicates reversible airway obstruction Simplespirometry can be done in the primary care provider’s office

expira-b Bronchial challenge tests: Refer to pulmonologist for testing

and evaluation

6 A complete blood count is generally not indicated for diagnosis,

but if it is done, eosinophilia might indicate allergies Blood gasesshould be analyzed with a severe episode

V Assessment

A Acute asthma attack: Diagnosis clinical, dependent on history and

physical examination (see Appendix M, p 551)

B Asthma

1 Diagnosis is generally made by history of symptoms and pattern of

occurrence, physical examination, and if indicated, PFT

2 Severity can then be classified clinically or with PFT.

a Intermittent asthma (0–4 years) (1) Symptoms that occur twice a week or more, with no

nighttime awakenings

(2) No significant lifestyle disruptions

b Intermittent asthma (5–11 years of age) (1) Symptoms that occur twice a week or less, with nighttime

awakenings 2 or fewer times per month

(2) No significant lifestyle disruptions

c Mild persistent asthma (0–4 years) (1) Daytime symptoms that occur two or more days per week

but not daily, nighttime symptoms that occur one to twotimes per month

(2) Minor disruption of lifestyle

d Mild persistent asthma (5–11 years) (1) Symptoms that occur more than 2 times per week but not

daily and nighttime awakenings 3–4 times per month

(2) Minor disruption of lifestyle

e Moderate persistent asthma (0–4 years) (1) Daily symptoms, symptoms that occur at night three to

four times per month

f Moderate persistent asthma (5–11 years) (1) Daily symptoms with nighttime awakenings more than

1 time per week but not nightly

g Severe persistent asthma (0–4 years) (1) Continual daytime symptoms, nighttime symptoms more

than one time per week

(2) Low-grade coughing and wheezing almost constantly

h Severe persistent asthma (5–11 years) (1) Symptoms throughout the day and often have nightly

nighttime awakenings

(2) Extremely limited activity

C Differential diagnosis

1 Bronchitis: Elevated temperature, poor response to epinephrine,

negative family or patient history of atopy

2 Foreign body in trachea or bronchi: especially common in young

children with negative history of atopy and unilateral wheezing.Confirm with bronchoscopy if history, physical examination, andx-ray studies are inconclusive

3 Bronchiolitis: Most common in infants under 6 months, although it

can occur in children up to 2 years of age Temperature is variable;infant presents with paroxysmal cough, dyspnea, tachypnea, shal-low respirations, marked hyperresonance, and markedly dimin-ished breath sounds A challenge with epinephrine usually doesnot cause improvement Strongly suspect asthma if child has a second episode of bronchiolitis

4 Pertussis: Rule out by history of exposure; nasopharyngeal

cul-tures in children under 11 years or within 2 weeks of onset ofsymptoms, or serology in patients over 11 years with an illness ofmore than 2 weeks duration

5 Cystic fibrosis: Rule out by previous history and, if indicated, by

history and physical examination and sweat test

6 Laryngotracheobronchitis: Usually seen in children under 3 years;

characterized by insidious onset, with history of upper respiratorytract infection; harsh, barking cough with severe inspiratory stridor;slightly elevated temperature

7 Bronchopneumonia: Dyspnea, tachypnea; rales or crackles may be

present; expiratory wheezes generally not present; in advanced,consolidative phase, decreased breath sounds

VI Plan

A Acute severe attack: Immediate treatment

1 Albuterol (nebulized), 5 mg/mL

a Dosage: 0.10 to 0.15 mg/kg (up to 2.5 mg)

b Frequency: Every 20 minutes, up to three doses

c Observe at least 1 hour.

d Refer stat if no response.

2 Oxygen as needed for O2sat less than or equal to 92%

3 Poor response: Refer to emergency room.

4 Stable with good response after 1 hour of observation, normal

respiratory rate, PEFR more than 70% to 90% baseline with noretractions or dyspnea

a Discharge home.

b Continue albuterol every 3 to 4 hours for 24 hours.

c Continue routine medications.

d Call stat if symptoms recur.

5 Incomplete response after first nebulizer treatment

a Repeat nebulized albuterol.

b Monitor heart and respiratory rate.

c Consult with physician.

d Consider nebulized ipratropium Less than 20 kg: 250 mcg/dose

every 20 minutes for 3 doses; more than 20 kg: 500 mcg/doseevery 30 minutes for 3 doses

6 If improved after repeat nebulizer treatment, may go home with

medications after 1 hour of observation

a Prednisone or Orapred 1 to 2 mg/kg/d in three divided doses

for 3–5 days

b Dose need not be tapered.

c Recheck again in 48 to 72 hours.

d Initiate inhaled corticosteroids at that time.

7 If diminished consciousness or unable to generate PEFR

a Administer epinephrine hydrochloride 1:1000 SC,

0.01 mg/kg (up to 0.3 mg), every 15 to 20 minutes for up

to three doses

b Auscultate chest and heart after each dose Do not repeat if

pulse is over 180 beats/min

c Refer stat to emergency room for probable status

asthmaticus

B With viral respiratory infection: Bronchodilator treatment every 4 to

6 hours up to 24 hours and then reevaluate; repeat for no more thanonce every 6 weeks because the increased need for bronchodilator treat-ment may necessitate the need to increase or initiate long-term therapy

Patients are encouraged to begin use of bronchodilator at first sign ofcold due to trigger effect of most upper respiratory infections (URI) onasthma Patient should come in for evaluation.

C Exercise-induced asthma

1 Inhaled beta-agonist, two puffs before exercise; repeat in 2 hours

as needed if exercise sustained

2 Alternative: Inhaled cromolyn sodium, two inhalations before

exercise; lasts about 1 to 2 hours

3 If control not achieved, use inhaled beta-2 agonist, two

inhala-tions, and inhaled cromolyn sodium, two inhalations 5 to 10 utes after albuterol inhalation or salmeterol Warming up beforeexercise may help to reduce bronchospasm

min-D Long-term treatment (see Appendix N, p 558)

1 Goal of treatment is to control chronic symptoms, maintain normal

activity levels, maintain normal or near-normal pulmonary tion, and prevent acute episodes

func-2 Frequency of exacerbations can be diminished by continuous

therapy

3 Side effects of prescribed drugs diminish with long-term

administration

a Intermittent asthma (1) Infants and children 0–11 years (a) No daily medication needed; inhaled beta-agonist as

needed for wheezing

(b) Reevaluate if a beta-2 agonist is needed on a daily

basis This usually indicates need for additionaltherapy

b Mild persistent asthma (1) Infants and children younger than 4 years (a) Low-dose inhaled corticosteroid (with nebulizer or

metered-dose inhaler with a holding chamber with orwithout face mask or dry-powder inhaler)

(b) Alternative treatment: Cromolyn (nebulizer with

holding chamber) or leukotriene receptor agonist

(c) Consider consultation (2) Children older than 4 years (a) Preferred treatment: Low-dose inhaled cortico-

steroids

(b) Alternative treatment: Cromolyn, leukotriene

mod-ifier, nedocromil, or sustained-release theophylline

(Note: These are not necessarily in order of preference.)

(c) Consider consultation

c Moderate persistent asthma (1) Infants and children younger than 4 years (a) Preferred treatments: Low-dose inhaled cortico-

steroids and long-acting inhaled beta-2 agonists

or medium-dose inhaled corticosteroids

(b) Alternative treatment: Low-dose inhaled

cortico-steroids or leukotriene receptor antagonist

(c) For patients with recurring severe exacerbations:

Preferred treatment, medium-dose inhaled steroids and long-acting beta-2 agonists; alternativetreatment, medium-dose inhaled corticosteroids andleukotriene receptor agonist

cortico-(2) Children older than 4 years (a) Preferred treatment: Low- to medium-dose inhaled

corticosteroids and long-acting inhaled beta-2 agonists

(b) Alternative treatment: Increase inhaled corticosteroids

within medium-dose range or low- to medium-doseinhaled corticosteroids and either leukotriene modi-

fier or theophylline (Note: These are not necessarily

listed in order of preference.)

(c) For patients with severe exacerbations: Preferred

treatment, increase inhaled corticosteroids withinmedium-dose range and add long-acting inhaledbeta-2 agonists; alternative treatment, increaseinhaled corticosteroids within medium-dose rangeand add either leukotriene modifier or theophylline

d Severe persistent asthma: Referral to asthma specialist (1) Preferred treatment: High-dose inhaled corticosteroids

and long-acting inhaled beta-2 agonists and if needed,corticosteroid tablets or syrup long-term (2 mg/kg/d,generally not to exceed 60 mg/d)

(2) Make repeated attempts to reduce system

cortico-steroids and maintain control with high-dose inhaled corticosteroids

E Peak flow monitoring program with moderate or severe asthma

F Environmental control (see p 291) VII Medications (See charts in Appendix N, p 558, for dosages for long-term

control medications and comparative daily dosages for inhaled teroids.)

corticos-A Beta-2 agonists: Albuterol (Proventil, Ventolin), metaproterenol (Alupent)

1 Metered-dose inhaler: 2 to 4 inhalations every 4 to 6 hours

depending on preparation

2 Dry-powder inhaler: One capsule every 4 to 6 hours

3 Nebulizer solution: Albuterol, 0.10 to 0.15 mg/kg every 4 to 6 hours,

up to 2.5 mg

B Cromolyn sodium (Intal)

1 Metered-dose inhaler: Adult, 2 to 4 inhalations, tid–qid; pediatric,

1 to 2 inhalations tid–qid

2 Dry-powder inhaler: One capsule, bid–tid

3 Nebulizer solution: One ampule, tid–qid

C Theophylline

1 Less desirable as dosage based on serum level; should achieve

serum concentration of 10 to 20 mcg/mL

2 Begin with low-dose and increase at 3- to 4-day intervals,

depend-ing on clinical response and serum concentration

3 Children’s dosage: 5–9 years, 20–24 mg/kg/d; 9–12 years,

D Corticosteroids (see comparative daily doses in Appendix N, p 558)

1 Metered-dose inhaler (beclomethasone [Beclovent, Vanceril]):

2 inhalations 4 times a day, or 4 inhalations every 12 hours

2 Oral (liquid [Pediapred] or tablets [prednisone]): 1 to 2 mg/kg/d

(maximum: 60 mg/d for 3 to 10 days)

a 1 year: 10 mg bid for 5 to 7 days

b 1 to 3 years: 20 mg bid for 5 to 7 days

c 3 to 13 years: 30 mg bid for 5 to 7 days

d Over 13 years: 40 mg bid for 5 to 7 days

E Epinephrine hydrochloride 1:1000; 0.01 mg/kg subQ; maximum of

three doses at spaced intervals

A Do not give antihistamines during an acute attack; they dry up respiratory

secretions and may produce mucous plugs

B Try to keep child calm during acute attack: Anxiety can increase

bronchospasm

C Postural drainage: Lie on bed with head hanging over the side.

D Side effects of medications

1 Epinephrine: Tremor, tachycardia, anxiety, sweating

2 Theophylline: Irritation, nausea, vomiting, diarrhea, headache,

palpitations, restlessness, insomnia

3 Albuterol: Palpitations, tachycardia, tremor, nausea, dizziness,

headache, insomnia, drying or irritation of oropharynx

4 Cromolyn sodium: Cough, wheezing, nasal congestion, dizziness,

headache, nausea, rash, urticaria

E Theophylline

1 Metabolism varies among individuals and may be decreased by

drugs such as cimetidine (Tagamet), ciprofloxacin (Cipro), andcorticosteroids, causing an increase in serum concentrations

2 Smoking may increase theophylline metabolism and decrease its

effectiveness

F Cromolyn sodium

1 Prevents and reduces inflammation.

2 Prevents allergen- or exercise-induced bronchoconstriction.

3 Action comparable to that of theophylline or inhaled

corticosteroids

4 No bronchodilating activity; useful only for prophylaxis and does

not work for acute attacks

G Albuterol

1 Produces bronchodilation with less cardiac stimulation than older

sympathomimetics

2 Provides the most rapid relief of acute asthma symptoms with

fewest adverse side effects

3 Improvement should be noted within 15 minutes of use.

4 Do not exceed recommended dosage; action may last up to

6 hours

H Tablets are less expensive than liquids or chewables.

I Metered-dose inhalers

1 Shake inhaler

2 Breathe out, expelling as much air from lungs as possible.

3 Place mouthpiece in mouth, holding inhaler upright.

4 While breathing deeply, depress top of metal canister, then remove

from mouth

5 Hold breath as long as possible.

6 If two inhalations are prescribed, wait several minutes and repeat

steps 1 to 5

7 Clean plastic case and cap in warm water after each use.

J Aerosol-holding chambers (Aerochamber)

1 Consider using Inspirease or Aerochamber with metered-dose

inhaler

2 Improves delivery for children who cannot inhale all medication in

one breath and provides more efficient delivery to the lungs

3 Eliminates need to synchronize actuation and inhalation.

4 Clean chamber periodically with soap and water.

K Dry-powder inhaler

1 Drug products designed to dispense powders for inhalation DPI

contains active ingredient(s) alone or with a suitable excipient(s)

A DPI product may discharge up to several hundred metereddoses of drug substance(s) Current designs include pre-meteredand device-metered DPIs, both of which can be driven by patientinspiration alone or with power-assistance of some type

L Peak flow meter

1 Used to detect airflow obstruction before child is symptomatic

2 PEFR will have decreased by 25% or more before wheezing can

be detected by auscultation

3 PEFR should be measured each morning before taking medication.

4 Monitoring before and after medication in the morning and at

bed-time yields the best information

5 Healthy children generally have a PEFR 90% or above predicted

value

6 Measurements below 80% of predicted value suggest obstruction

that requires treatment; measurements 50% or lower herald asevere attack

M.Avoid offending allergens.

N Environmental control (see p 291)

O Encourage child to participate in all activities that he or she is capable

of doing

P There is no cure for asthma, but child should be symptom-free with

proper medication (see Appendix M, Stepwise Approach, p 551)

Q Without adequate treatment to control asthma, life-threatening pulmonary

complications may develop

R Parents or health care provider should maintain working relationship

with school personnel

1 Ensure that school nurse has information on child’s medications,

including side effects Request that nurse share this informationwith teachers

2 Identify allergen and irritant exposures in the classroom (e.g.,

ani-mals, carpeting, chalk dust, plants)

3 Periodic hearing impairment is common in allergic child

Sug-gest periodic audiometric evaluations and preferential seating ifindicated

S Give patient or parent written instructions for plan of care Include

medications, use of peak flow meter, graphs, indications for returning

to office, use of metered-dose inhaler, and Aerochamber

1 One-Minute Asthma by Thomas F Plaut, M.D is a highly-rated,

excellent educational tool

2 Helpful to give individual informational sheets, which you can

develop

IX Follow-up

A Call immediately if:

1 Breathing difficulty worsens.

2 Skin or lips turn blue.

3 Restlessness or sleeplessness occurs.

4 Cough or wheezing persists, or chest pain or fever develops.

5 Presence of side effects from medication (e.g., nausea, vomiting,

irritability, palpitations)

B Measure theophylline level 2 to 3 days after initiating oral therapy and

every 2 to 3 months while on medication

C Return visit indicated for medication adjustment if asthma is not

well-controlled

D Routine follow-up every 6 months

E When asthma is stable or under control, measure PEFR in office.