Angel Solomon, MS PA C June 2011

Transcription

1 Angel Solomon, MS PA C June 2011

2 Infant & Childhood Development Gross Motor 3 month head control 4 month roll over 6 month sit independently 9 month crawl 12 month walk 18 month climbs stairs, run 24 month kick ball

3 Infant & Childhood Development Language 2 month coos 6 month babbles 12 month mama, dada 18 month 4 20 words 24 month combining words, 50% comprehensible

4 Infant & Childhood Development Language cont 3 year 75% comprehensible 4 year 100% comprehensible Age 7 or 8 speech, language, articulations close to adult

5 Infant & Childhood Development Social/Fine motor 3 month laugh 6 month reaches, feeds self 9 month indicates wants, pincer grasp 12 month imitates, follow 1 step commands

6 Infant & Childhood Development Social/Fine motor cont 18 month scribbles, feeds self w/spoon, potty training, stacks 3 4 blocks 24 month follow 2 step commands, wash/dry hands 3 yr dresses with supervision

7 Newborn & Infant Growth Newborns may lose up to 10% of their birth weight in the first week of life Most regain birth weight in about 10 days First 6 months: gain about 1oz/day At 6 months: weigh 2x birth weight At 12 months: weigh 3x birth weight, height 1.5x birth length

8 Childhood Growth After 2 years of age: 2 3 kg and 5 7cm/year Average 30 month child weighs 30 pounds and is 30 inches tall Average 4 year old weighs 40 pounds and is 40 inches tall Weight LOSS in a child is always suspicious

9 HEENT URI Acute Otitis Media Chonic Otitis Media Otitis Externa Epiglottitis Croup Strabismus Amblyopia Allergic Rhinitis Oral candidiasis ENT Foreign Bodies

10 VIRAL URI Common in any age group; especially infants and toddlers Lasts 7 10 days MCC: Rhinovirus Symptoms: Runny nose, nasal congestion, coryza, sneezing, mild conjunctivitis, sore throat, hoarseness, cough. Fever often presents for first 2 3days Tx: Cough and cold medications. No antibiotics!!!

11 OTITIS MEDIA Acute Otitis Media Suppurative infection of the middle ear cavity Most prevalent in children between 6 and 24 mo Bacterial Streptococcus Pneumoniae (most common) Haemophilus influenza Moraxella Catarrhalis Viral Respiratory Syncytial Virus Rhinovirus Influenza virus

12 Otitis Media Risk Factors Day Care Attendance Formula Fed Infants (feeding position) Second hand cigarette smoke Presentation & Diagnosis Often follows an upper respiratory tract infection(uri) by 1 7 days Usually presents with fever, poor feeding, pain and/or irritability, vomiting, ear pulling TM : bulging, red, landmarks not visualized, immobile (Pneumatic Otoscopy with evaluation of movement of TM) Antibiotics DOC: Amoxicillin 40mg/kg/d OR 80 90mg/kg/d If antibiotic use or tx failure on Day 3: High dose amox, high dose amoxicillin/clavulanate, cefuroxime axetil or ceftriaxone

13 Chronic Otitis Media Definintion recurring or persistent infection or inflammation for several months Risk Factors multiple ear infections, allergies, trauma, swelling of the adenoids Sx hearing loss, otorrhea, pressure, ear ache PE: infxn, air fluid levels. discharge, perforation Tx: Abx, Surgery (Myringotomy/Repair/Adenoids) Complications: Mastoiditis, Deafness

14 OTITIS EXTERNA Inflammation of the skin in the outer ear canal Commonly caused by water trapped in the canal from swimming in lakes or pools Pathogens: Staphylococcus aureus Pseudomonas aeruginosa Symptoms: Pain, purulent discharge, pain elicited with traction on pinna or tragus Treatment: Antibiotic/Corticosteroid drops

15 Epiglottitis / Viral Croup Epiglottitis: Most common pathogen is H. influenza RAPID onset of sore throat, muffled voice, high fever, and drooling Thumbprint sign on lateral neck X ray Assume a critical airway and DO NOT examine the oropharynx unless able to intubate STAT Viral Croup Laryngotracheobronchitis Most common cause of stridor in children Peak ages : 6 months to 3 years. Fall/Winter Barking cough, URI symptoms, hoarseness, fever, inspiratory stridor Pathogen: parainfluenza virus common Diagnosis: H & P, season helpful (Fall/Winter) <50% steeple sign on ant neck X ray Treatment: Hydration, Humidity! Steroids if severe

16 STRABISMUS Definition: Misalignment of the visual axes of the eyes; results from imbalance in eye muscle movements Affects 4 5% of the US population Infants may not develop coordinated eye movements until 3 5 months of age Eye may deviate inward(esotropia), outward (exotropia), upward (hypertropia) or downward (hypotropia) Treatment: Glasses, occlusion, surgery

17 Courtesy of Dean John Bonsall, MD, FACS

18 AMBLYOPIA Definition: decreases or loss of vision in one or both eyes in the absence of ocular or CNS pathology Initiated by any condition that results in abnormal/unequal visual input between the critical period of birth to 8 9 years of age (ie. Congenital cataracts, strabismus) Treatment is essential within the critical period; otherwise loss may be permanent

19 ALLERGIC RHINITIS Inflammation of nasal and sinus packages associated with sneezing, runny nose, congestion, itchy eyes Affects 20 30% of all kids and up to 75% of kids with asthma Know this triad: asthma/allergy/eczema!!!!! Physical exam pearls: Allergic shiners, Allergic salute Treatment: Removal of offending agents, oral/topical (spray) medications Note: Check nasal mucosa for polyps! In kids, polyps are suggestive of cystic fibrosis and should be investigated further

20 Oral Candidiasis Etiology: Candida Albicans Signs: adherent creamy plaques on buccal, gingival and lingual mucosa Tx: Nystatin RF: Inhaled steroids, Abx, immune system disorder

21 ENT FOREIGN BODIES Commonly seen: Buttons, beads, marbles, nuts, toy parts, Bugs too Ear: Ear pain, drainage, hearing loss Nose: Unilateral purulent rhinitis, persistent sinusitis, blocked nasal passage on exam Removal: Do not blindly probe! If visible, forceps, curette, Foley (inflated past foreign body), etc Restraint is essential to prevent further injury

22 Lungs Bronchiolitis Pneumonia Viral Bacterial Atypical Pertussis Hyaline Membrane Disease Cystic Fibrosis Foreign bodies

23 BRONCHIOLITIS The most common lower respiratory illness in infants and young children less than 2 years old. Pathogen: Respiratory Syncytial Virus(RSV) in 50 90% of cases Symptoms: Cough, mild fever, tachypnea, and wheezing. Thick nasal congestion Diagnosis: RSV antigen nasal wash. CXR Hyperinflation WBC Increases lymphocytes Treatment: Controversial Nebulized albuterol commonly used Oral steroids if sx severe Ribavirin has been used in hospitalized cases Synagis now used to prevent RSV in preemies

24 PNEUMONIA VIRAL Common in all age groups; follows URI Etiology: MCC of pneumonia in children. RSV (MC), parainfluenza, & influenza viruses Symptoms: URI precedes onset of cough Wheezing, grunting, nasal flaring common Labs: WBC may be low, normal, or slightly elevated. A high WBC makes viral etiology unlikely Imaging: CXR may show perihilar streaking, increased interstitial markings, peribronchial cuffing Treatment: It is rarely possible to reliably differentiate viral from bacterial pneumonia based upon history, exam, labs or radiographs Therefore it is common for appropriate concomitant antibiotic coverage to be used for viral pneumonia in children

25 PNEUMONIA BACTERIAL Inflammation of the lung classified according to the infecting organism and site Occurs in all age groups, but more commonly in children < 2 years old Common pathogens: S. pneumoniae, Group A strep Group B strep (neonates) Symptoms: URI precedes abrupt onset of fever, chills,sob, anorexia, cough, dyspnea N/V, abdominal/chest/shoulder pain typical, malaise

26 Signs: Pneumonia Bacterial tachypnea: reliable sign of pneumonia in kids! Cough, grunting, nasal flaring, Exam usually shows decreased breath sounds, rales, dullness to percussion, but can be normal Wheezing unusual in bacterial pneumonia unless pt has baseline reactive airway disease Labs: WBC >15,000 or greater Blood cultures positive in 10 15% of cases Imaging: Lobar consolidation, patchy infiltrates common May see effusions Atelectasis vs infiltrate often hard to tell Treatment: Neonates: IV ampicillin/gentamycin Others: penicillin. Amoxicillin, 2nd or 3rd generation cephalosporin

27 PNEUMONIA ATYPICAL Chlamydia pneumonia Occurs between 2 weeks to 6 months of age. Peak incidence (>90%) by 8 weeks Most common cause of pneumonia in children under 6 months of age (25 45% of cases) Pathogen: C. trachomatis (maternal STD) URI prodrome; nearly 100% afebrile Staccato cough, tachypnea, rales, conjunctivitis Dx: Nasal wash, eosinophilia common Tx: Erythromycin. Hospitalization for those with paroxysmal cough, apnea, resp distress

28 Pneumonia Atypical Mycoplasma pneumonia: Common over the age of 5 years, esp teens Pathogen: Mycoplasma pneumonia Long incubation: 2 3 weeks Symptoms: Gradual onset, Dry cough, progressing to productive. Fever,HA, malaise, Signs: Rales, bullous myringitis CXR: Middle and lower lobe infiltrates Tx: Macrolides usually shorten course and may lessen severity of symptoms

29 PERTUSSIS Whooping Cough Infants/toddlers; un /partially immunized Pathogen: Bordetella pertussis Spread by teens/adults who are no longer immune Sx: 3 stages Cattarhal: URI (1 2 weeks) Paroxysmal: Staccato cough and whoop on inspiration(1 2 weeks) Convalescent: Dry cough (1 2 weeks) Dx: Hx, characteristic paroxysmal cough Tx: Erythromycin

30 Hyaline Membrane Disease Cause: Deficiency of surfactant S&S: increased RR, cyanosis, expiratory grunting Dx: CXR shows hypoexpansion, B/L atelectasis Tx: Oxygen, early intubation, ventilation Surfactant replacement

31 CYSTIC FIBROSIS Most common severe inherited disease in the Caucasian population 1:2500 Resp symptoms: chronic cough or sinusitis, recurrent pneumonia, nasal polyps, clubbing GI symptoms: meconium ileus (20%), pancreatic insufficiency (85%), failure to thrive Dx: Sweat chloride is the gold standard >60meq/L is abnormal. Genetic testing Tx: ATB, pancreatic enzymes, bronchodilators, postural drainage. Mean survival age is increasing!

32 RESPIRATORY FOREIGN BODIES Throat: Stridor, choking, cyanosis. (Can also occur if foreign body is in esophagus) Ball valve effect may cause hyperinflation Heimlech if suspected upper airway FB and respiratory distress Rigid bronchoscopy if in lower airway.