Oral Revalida Review2019

PEDIATRICS
Lecturer: Kevin Merquita, MD

*NOTE: Please study the trances together with the lecture II. Common Pediatric Cases For Revalida
slide
Respiratory
I. History Taking and Physical Examination - Acute nasopharyngitis
I. General Data - Allergic rhinitis
II. II. Chief Complaint - Acute tonsillopharyngitis/Herpangina
III. History of Present Illness - Pneumonia
IV. Review of Systems - Asthma
V. Personal History - Tuberculosis
A. Gestational, Birth, Neonatal (<2 yo)
- Current condition is related to perinatal Gastrointestinal
events - Acute gastroenteritis
B. Feeding History - Functional constipation
- Nutritional disorders
C. Developmental/ Behavioral Dermatologic
D. HEADSSSS - Acute urticaria
- All adolescent patients regardless of - Molluscum contagiosum
service (ages 9-18 years old) - Scabies/Pediculosis capitis
- Problems not directly related maybe - Impetigo contagiosa
added to the discussion - Hand-Foot-Mouth Disease
VI. Past Illnesses - Atopic dermatitis
VII. Immunization History
VIII. Family History Systemic
IX. Socioeconomic History - Dengue fever
X. Environmental History - Febrile seizure
*You may start obtaining history while doing
physical examinations to save time Others
- Conjunctivitis
WHO Growth Chart - Acute otitis media
- Plot the z-scores accordingly - Nutritional disorders
- Greenline: Median
- Above or preceeding line
III. Chief Complaint: Colds
Immunization Schedule
A. Acute Nasopharyngitis
- Elicit immunization history to appropriate
anticipatory guidelines - Also known as “the common cold”
- An acute viral infection of the upper respiratory tract in
which the symptoms of rhinorrhea and nasal
obstruction are prominent
- Etiology
- More than 200 types of human rhinoviruses
- Other viral etiologies of the common cold include:
Respiratory syncytial virus, Human
metapneumovirus, Parainfluenza viruses and
Adenoviruses
- Common cold symptoms may also be caused by
influenza viruses, nonpolio enteroviruses, and
human coronaviruses
Oral Revalida Review2019

PEDIATRICS
Lecturer: Kevin Merquita, MD

- Mode of transmission - Anterior cervical

lymphadenopathy or conjunctival
- spread by 3 mechanisms: injection especially with
concomitant allergic
- Direct hand contact rhinoconjunctivitis
- Inhalation of small-particle aerosols
- Management
that are airborne from coughing, or - Generally supportive
- Maintaining adequate oral hydration
- Deposition of large-particle aerosols to thin out the secretions
- Topical nasal saline
that are expelled during a sneeze and - 0.65% NaCl nasal drops
(for children less than 3 years old) or
land on nasal or conjunctival mucosa.
spray (for older children)
- Differential diagnoses
- Nasal obstruction
- Either topical or oral
adrenergic agents may be used as
nasal decongestants in older children
and adults. Must not be given for more
than 3 days to avoid rebound
congestion
- Oxymetazoline nasal drops
or spray, 2-3 drops/sprays per nostril
BID
- Phenylephrine-containing
preparations (2-6 yr 2.5 mL, 7-12 yr 5
mL, >12 yr 10 mL; all doses to be
taken q6h)

- Rhinorrhea
- The first-generation
antihistamines may reduce rhinorrhea
by 25-30%
- Loratadine-containing
preparations (>30 kg BW 5 mL, <30 kg
BW 2.5 mL; all doses to be taken
q12h)

- Cough
- Clinical manifestations
- first-generation
- Symptoms
antihistamine may be helpful
- In infants, fever and nasal discharge
- In some patients, cough
may predominate
may be a result of concomitant virus-
- Fever is uncommon in older children
induced reactive airways disease.
and adults
- Might benefit from
- Sore or scratchy throat, followed
bronchodilator or other therapy
closely by nasal obstruction and
- American Academy of Pediatrics
rhinorrhea
recommends that nonprescription
- Cough
cough and cold products not be used
- Headache, hoarseness, irritability,
for infants and children younger
difficulty sleeping, or decreased
than 6 yr of age
appetite.
- There is no evidence that the
- Signs
common cold or persistent acute
- Increased nasal secretion (may
purulent rhinitis of less than 10 days in
indicate accumulation of
duration benefits from antibiotics.
polymorphonuclear cells)
- Swollen, erythematous nasal
turbinates
 Oral Revalida Review2019
PEDIATRICS
Lecturer: Kevin Merquita, MD
B. Allergic Rhinitis
- an inflammatory disorder of the nasal mucosa marked
by nasal congestion, rhinorrhea, and itching, often
accompanied by sneezing and conjunctival
inflammation
- Risk Factors
- Family history of atopy
- Serum immunoglobulin (Ig) E higher than 100
IU/mL before age 6 yr
- Classification
- Based on frequency and severity of symptoms and
affectation to ADL or school activities
- Clinical Manifestations
- Symptoms
- Intermittent nasal congestion, itching, sneezing,
clear rhinorrhea, and conjunctival irritation
“Allergic salute” (upward rubbing of the nose with
an open palm or extended index finger) to open up
the airways
- Nasal congestion is often more severe at night,
causing mouth breathing and snoring, interfering
with sleep, and arousing irritability
- Signs
- “Allergic gape” (continuous open-mouth
breathing), chapped lips
- “Allergic shiners” (dark circles under the eyes)
- Transverse nasal crease (Maybe hard to identify
- Conjunctival edema, itching, tearing, and
hyperemia
- Clear nasal secretions; edematous, boggy, and
bluish mucus membranes with little or no erythema
- Diagnosis
- Thorough history, including details of the patient’s
environment and diet and family history of allergic
conditions such as eczema, asthma, and AR
- Physical examination, and
- Laboratory evaluation
- Skin prick test (preferred test for the diagnosis of IgE-
mediated sensitivity)
- Serum IgE determination
- Management
- Environmental control measures play a
significant role in controlling allergic rhinitis
- In patients with mild, intermittent symptoms of
allergic rhinitis
- Rhinorrhea or sneezing
- A nonsedating, oral or topical antihistamine,
taken as needed, is often very effective
- Nasal congestion
- Intranasal steroids, antihistamine-
decongestant combination or montelukast, taken
as needed may be helpful
- Patients with moderate to severe symptoms should
be reevaluated after 2 weeks
- Pharmacologic Agents
- ANTIHISTAMINES
- Oral 2nd generation antihistamines are
generally preferred over first generation
- Cetirizine
- 6 mos and < 2 yr: 2.5 mg QD to BID
- 2-5 yr: 2.5 mg QD to a max dose of 5 mg/24
hours QD or divided BID
- > 6 yr-adult: 5-10 mg QD
- LEUKOTRIENE RECEPTOR ANTAGONISTS
(e.g. montelukast)
- For adults and children with seasonal AR and in
preschool children with persistent AR
- Montelukast
- 6 mos-5 yr: 4 mg QHS
- 6-14 yr: 5 mg QHS
 Oral Revalida Review2019

PEDIATRICS
Lecturer: Kevin Merquita, MD

- > 15 yr-adult: 10 mg QHS

- INTRANASAL CORTICOSTEROIDS
- For seasonal and persistent AR
- Fluticasone furoate nasal spray (27.5
mcg/actuation) or Mometasone (50
mcg/actuation)
- 2-11 yr: initially 1 spray per nostril QD; may be
increased to 2 sprays per nostril QD
- 12 yr-adult: initially 2 sprays per nostril QD;
maintenance: 1 spray per nostril QD
- SYSTEMIC GLUCOCORTICOIDS
- Short course oral GCs for moderate-severe AR
that are not controlled with other treatments
- Not first-line; rather, a last resort
*Usually allergen avoidance will suffice

- ARIA 2016 recommendations

- Seasonal (intermittent) allergic rhinitis
- Either a combination of intranasal
corticosteroids (INCS) with oral antihistamines
(AH) or INCS alone
- Either oral AH or oral leukotriene receptor
antagonist (LTRA)
- Persistent allergic rhinitis
- INCS alone
- ARIA 2010 recommendations
- ORAL antihistamines > Intranasal antihistamines
- Oral antihistamines > Oral LTRA GROUP A STREPTOCOCCAL PHARYNGITIS
- Epidemiology
IV. Chief Complaint: Cough - Quite common among 5-15 years old (Unlikely
for younger children, most likely viral)
- In the local settings, chronic cough is defined as
- Clinical Manifestations
cough for more than 2 weeks. - Symptoms
- Sore throat and fever
A. Acute Tonsillopharyngitis - Signs
- Refers to inflammation of the pharynx, including - Erythematous pharynx
erythema, edema, exudates, or an enanthem (ulcers, - Tonsils are enlarged and often covered
vesicles) with a white, grayish, or yellow exudate that
may be blood-tinged (May be tonislolith or
- ETIOLOGY milk curd. Ask patient to gargle before
- Most causes of sore throat are nonbacterial and confirming diagnosis)
neither require nor are alleviated by antibiotic therapy - Enlarged and tender anterior cervical lymph
nodes are frequently present
- Differential Diagnoses
- Gingivostomatitis - Management
- Caused by HSV I - Nonspecific, symptomatic therapy for viral
- Herpangina pharyngitis (antipyretic/analgesic; anesthetic
- Caused by Coxsackie A16 (most common), sprays and lozenges)
Enterovirus 71 and Coxsackie A6 - Antibiotic therapy for bacterial pharyngitis
- Adenoviral pharyngitis - Hastens clinical recovery by 12-24 hours
- May present concurrently with conjunctivitis - Primary benefit and intent: prevention of
pharyngoconjunctival fever) acute rheumatic fever (Not the treatment of
- Measles
- Intense, diffuse pharyngeal erythema and Koplik
spots (Pathognomonic enanthem)
- Infectious mononucleosis
 Oral Revalida Review2019
PEDIATRICS
Lecturer: Kevin Merquita, MD
pharyngitis)
B. Pneumonia
- Defined as inflammation of the lung parenchyma
- Mostly viral but younger children may have secondary
bacterial infection
Clinical Manifestations
- Frequently preceded by several days of symptoms
of URTI
- TACHYPNEA is the most consistent clinical
manifestation of pneumonia
• - Increased work of breathing accompanied by
intercostal, subcostal & suprasternal
retractions, nasal flaring and use of accessory
muscles is common
Diagnosis
- The presence of pneumonia may be considered even
without chest radiograph in a patient presenting with
cough and/or respiratory difficulty plus
- Tachypnea in a patient aged 3 months to 5 years,
or
- Fever at any age
- The presence of pneumonia should be determined
using a chest radiograph in a patient presenting with
- Cough and/or respiratory difficulty in the ff.
situations
- Presence of dehydration aged 3 months to 5
years
- Presence of severe malnutrition aged less than
7 years
- High grade fever and leukocytosis aged 3 to 24
months without respiratory symptoms
- At the OPD as the site-of-care
- Oxygen saturation less than or equal to 94% at
room air in the absence of any comorbid neurologic,
musculoskeletal or cardiac conditions that may
potentially affect oxygenation
- Tachypnea
- Chest wall retractions
- Fever
- Decreased breath sounds; nasal flaring; cyanosis;
crackles; or localized chest findings at any age
- For pCAP A or B being managed in an ambulatory
setting, the following may be requested at initial site-
of-care
- Oxygen saturation using pulse oximetry
(assessment of gas exchange)
- Gram stain and/or aerobic culture and sensitivity
of sputum (microbial determination of underlying
etiology)
- Chest x-ray (PA & lateral view) or chest
ultrasound (clinical suspicion of necrotizing
pneumonia, multilobar consolidation, lung
abscess, pleural effusion, pneumothorax or
pneumomediastinum)
- The following may not be requested (basis for
initiating antibiotic treatment)
- CBC
- CRP
- Procalcitonin
- pCAP B: Comorbid conditions such as asthma
exacerbation (Still treated at OPD) pCAP C: Signgs
of distress such as retractions, pCAP D: Inpending
respiratpry failure
MANAGEMENT
- pCAP A or B
- Amoxicillin (40-50 mg/kg/day; max dose of
1500mg/day, in 3 divided doses for 3-7 days; may
be given in 2 divided doses for a minimum of 5
days)
- Alternatives (known hypersensitivity to
amoxicillin or suspicion of atypical
organisms)
- Azithromycin (10 mg/kg/day QD for 3 days or
10 mg/kg/day at day 1 then 5 mg/kg/day for days
2-5, max dose of 500mg/day)
• - Clarithromycin (15 mg/kg/day; max
dose of 1000mg/day, in 2 divided
doses for 7 days)
- pCAP C
- Completed primary immunization against Hib
- Penicillin G (100,000 units/kg/day in 4
divided doses)
 Oral Revalida Review2019
PEDIATRICS
Lecturer: Kevin Merquita, MD
- Has not completed primary immunization or
immunization status unknown against Hib
- Ampicillin (100 mg/kg/day in 4 divided doses)
C. Tuberculosis
- Etiology
- Mycobacterium tuberculosis
- Non-spore-forming, nonmotile, pleomorphic, weakly
Gram-positive curved rods 1-5 μm long, typically
slender and slightly bent
- Obligate aerobes; grow best at 37-41°C (98.6-
105.8°F)
- A hallmark of all mycobacteria is acid fastness—the
capacity to form stable mycolate complexes with
arylmethane dyes (crystal violet, carbolfuchsin,
auramine, and rhodamine)
- Mycobacterium tuberculosis can produce infection
and disease in almost every tissue and organ in the
body
- Since infection usually takes place by way of the
respiratory tract, the lung is the first organ involved and
it is here that the initial major manifestations of disease
occur
*No treatment for TB exposure, close monitoring
**Isoniazid for TB Infection, quad therapy for TB Disease
Primary Disease
- Initial stage in children who inhale the tubercle bacilli
- 3 elements
- Ghon focus
- Lymphadenitis
- Lymphangitis
- Asymptomatic in up to 65% of patients
- Occasionally, the initiation of infection is marked by
several days of low-grade fever and mild cough
Progressive Primary Tuberculosis
- Initial infection fails to heal and continues to progress
over a period of months or years
Secondary (Reactivation) Tuberculosis
- Reactivation of an old, possibly subclinical infection
- Occurs in less than 10% of cases of primary infection
- More common in adolescents
- Pathology
Ghon focus - a caseous granuloma; located peripherally
in any part of the lungs, close to the pleura
- Dissemination of the bacilli from the primary
granuloma in the lungs to the hilar nodes causes a
granulomatous lymphadenitis
- Ghon complex - combination of granulomatous hilar
lymphadenitis and Ghon focus
- In both lungs and lymph nodes, the lesions of the
Ghon complex heal by fibrosis, but subsequent
calcification may occur
- Diagnosis
- A positive culture with or without a positive smear for M.
tuberculosis is the gold standard for the diagnosis
- In the absence of bacteriologic evidence, however, a
child is presumed to have active TB if three or more of the
following criteria are present:
- EPIDEMIOLOGIC - exposure to an adult/adolescent
with active TB disease
- CLINICAL - signs and symptoms suggestive of TB
- IMMUNOLOGIC - positive TST
- RADIOLOGIC - abnormal chest radiograph
suggestive of TB
- LABORATORY - laboratory findings suggestive of TB
(histological, cytological, biochemical, immunological
and/or molecular) e.g. IgRA, Gene Xpert
- Clinical Manifestations
- For patients 15 years old and above
- Presentation similar to adults
- Cough of at least 2 weeks duration with or without the
ff. symptoms
- Significant and unintentional weight loss
- Fever
- Hemoptysis
- Chest/back pains not referable to any
musculoskeletal disorders
- Easy fatigability or malaise
- Night sweats
- Shortness of breath or difficulty of breathing
Unexplained cough of any duration in
- A close contact of a known active TB case
- High-risk clinical groups
- For patients below 15 years old
- At least 3 of the following clinical criteria
- Coughing/wheezing of 2 weeks or more, especially
if unexplained
- Unexplained fever of 2 weeks or more after
common causes such as malaria or pneumonia
have been excluded
- Loss of weight/failure to gain weight/weight
faltering/loss of appetite
Failure to respond to 2 weeks of appropriate
antibiotic therapy for lower respiratory tract infection
Failure to regain previous state of health 2 weeks
after a viral infection or exanthema
- Fatigue, reduced playfulness or lethargy
- Diagnostics
- Tuberculin skin test
- Based on a delayed cellular hypersensitivity to
certain antigens of the TB organism
 Oral Revalida Review2019

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Lecturer: Kevin Merquita, MD

- A prior infection with M. tuberculosis or - Pathogenesis

tuberculoproteins from BCG vaccine result in T-cell - Hypersensitivity or
sensitization that releases lymphokines at the site of susceptibility to a variety
injection of provocative exposures
- A history of BCG vaccine is not a contraindication or triggers can lead to
for TST - Airways inflammation
- Tuberculin reaction believed to be affected by BCG - Airway
wanes after 5 years from immunization hyperresponsiveness
- Interpretation - Edema
- > 5 mm - history of close contact with a - Basement membrane
known or suspected case of TB, clinical thickening
findings suggestive of TB, CXR suggestive of - Subepithelial collagen
TB and immunosuppressed condition deposition
- > 10 mm - in the absence of the above - Smooth muscle and
factors mucous gland
*Measure only the induration, not the erythema hypertrophy
- Mucus hypersecretion
- Chest radiograph
-There are NO pathognomonic radiographic findings *Most common
in childhood TB (vs. cavitation on the upper lobe in triggers: animal dander,
adult TB) dust mites,
- Neither the presence nor absence of the primary cockroaches
disease can be determined conclusively from the
chest film alone
- The following radiographic changes may be seen
- Parenchymal involvement
- Lymphangitis
- Localized pleural effusion
- Regional lymphadenitis

- DIAGNOSIS IN CHILDREN ≥ 5 YEARS OLD

- Asthma is supposed to be diagnosed with spirometry
but since younger children may not be able to follow
instructions, the following parameters are used.
- A history of variable respiratory symptoms
- Typical symptoms are wheeze, shortness of breath,
chest tightness, recurrent cough that occurs with
exercise, intense emotions, etc
- Evidence of variable expiratory airflow limitation
- FEV1 increases by more than 12% of the predicted
value after inhaling a bronchodilator (‘bronchodilator
reversibility’)
- Average daily diurnal PEF variability is >13%
- For older children, FEV1 increases by more than 12%
of the predicted value after 4 weeks of anti-
inflammatory treatment (outside respiratory infections)
- OTHER DIAGNOSTIC CLUES
- Presence of risk factors (history of atopy, parental
asthma, and/or symptoms apart from colds)
*You may suggest baseline ophthalmologic evaluation prior - Quick resolution or convincing improvement in
to therapy symptoms and signs of asthma with administration
of a SABA
D. Asthma
 Oral Revalida Review2019

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- In children <2 y/o, asthma less likely, suspect
bronchiolitis caused by virus
- Therapeutic trial in young children
- A stool volume of greater than 10 ml/kg/day
in infants and toddlers or greater than 200 g/day
in older children
- Passing 3 or more unusually loose stools in a
24-hour period or is passing stools more
frequently than usual, with a consistency looser
than what is considered normal for that individual
- Consistency more important than frequency

- Pathophysiologic Mechanisms
- Viral is the most common

- Avoidance of trigger is important

- Treatment follows stepwise approach adjusted up or
down for good symptom control while minimizing flares
and side effects
- Reclassify their treatment by level of control of
symptoms
- If good control, regular follow up after 1-2 months,
step down if with good control for 3 months. If not, step
up, for 2-6 weeks
- If with poor control or in acute exacerbation, short
course of SABA and stepping up the current regimen

- Osmotic diarrhea
- Secretory diarrhea
- Altered gastrointestinal tract motility
- LEUKOTRIENE RECEPTOR ANTAGONIST
- Clinical Evaluation
- Montelukast
- The most common manifestations of GIT
- 4 mg/tab QDHS (6mo-5 y/o)
infection in children are diarrhea, abdominal
cramps and vomiting
- Systemic symptoms dependent on the cause
- Assess the degree of dehydration and acidosis
and provide rapid resuscitation and rehydration
with oral or IVF as required
- Obtain appropriate contact, travel or exposure
history
- Clinically determine the etiology of diarrhea for
institution of prompt antibiotic therapy, if indicated
- Always ask last meal/water source and intake,
similar symptoms in the household

- Diagnostics
- When to request for a fecalysis
- Fecalysis is not routine because virus is the
V. Chief Complaint: Loose stools most common etiology
ACUTE GASTROENTERITIS - Bloody or mucoid stools
- Denotes infections of the gastrointestinal tract - If there is an epidemic (household contacts
caused by bacterial, viral, or parasitic pathogens with similar symptoms)
- Many of these infections are foodborne illnesses - Chronic diarrhea (> 14 days)
- Diarrhea is defined as - Immunocompromised patient
 Oral Revalida Review2019
PEDIATRICS
Lecturer: Kevin Merquita, MD
- Management
- Assess level of dehydration
- Oral Rehydration Therapy
- Preferred mode of rehydration and
replacement of ongoing losses
- ORS 75 is the global standard of care
- Glucose: 75, Na: 75, Cl: 65, K: 20, Citrate:
10, Osm: 245
- Less morbidity compared to other ORS
preparation
- Enteral feeding
- No need to place in special diet
- Zinc supplementation
- Decreases severity of disease
< 6 months - 10 mg elemental Zn
> 6 months - 20 mg elemental Zn
- Probiotics
- Decreases the duration
- L. rhamnosus GG and S. boulardii
VI. Chief Complaint: Abdominal Pain
Functional Constipation
- Defined as a delay or difficulty in defecation present for
2 weeks or longer and significant enough to cause
distress to the patient
- Defined symptomatically as the infrequent passage of
hard stools, straining while passing a stool, or pain
associated with the passage of a hard stool
- Classified broadly either as functional or as secondary
to underlying conditions (anatomic abnormalities,
metabolic disorders, neurologic dysfunction, or
medication effects)
- Use Bristol stool to evaluate
- Diagnosis
- Management
- Therapy for functional constipation and encopresis
includes patient education, relief of impaction, and
softening of the stool
- Establish good bowel habits
- Educate caregivers to not punish in times of accidents to
avoid reinforcing stool retention
- Pharmacologic Agents
- For disimpaction
- Glycerin suppository - for neonates and infants less
than 2 years old
- Pediatric Fleet enema
- 2 - 5 years old: 1/2 bottle
- 5 -11 years old: 1 bottle
- Bisacodyl suppository (2–10 years old: 5 mg once
/day; >10 years old: 5–10 mg once /day)
- Sodium picosulfate (< 4 years old: 0.25 mL/kg/dose;
4-10 years old: 2.5-5 mL QDHS; > 10 years old: 5-10
mL QDHS)
- For maintenance
- Lactulose 3.3g/5 mL syrup (1.5 - 3 mL/kg/24 hours)
VII. Chief Complaint: Ear Pain
Acute Otitis Media
- Peak incidence and prevalence of OM is during the 1st 2
years of life.
- Etiology
- Streptococcus pneumoniae
- Nontypeable Haemophilus influenzae
- Moraxella catarrhalis
- Clinical Manifestations
- Variable
- Ear pain, manifested by irritability or change in
sleeping or eating habits, and occasionally, holding or
tugging at the ear
- Fever
- Diagnosis
- 2013 AAP Guidelines
- Important tp visual the middle ear
- Moderate to severe bulging of the TM or new-onset
otorrhea not caused by otitis externa
- Mild bulging of the TM and recent (<48 hr) onset of
ear pain or intense TM erythema
- A diagnosis of AOM should not be made in children
without MEE
- Loss of cone of light denotes presence of effusion
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- Retroorbital pain
- Diarrhea
- Rash (petechial: early stage of disease, Herman’s
rash: Hypopigmented patches in surrounded by
flushed skin “isles of white in sea of red” heralds the
recovery phase)
- (+) Tourniquet test: indicates capillary fragility
- Anorexia
- Nausea/vomiting
- Laboratory test
- CBC (leukopenia with or without
thrombocytopenia) and/or
- Dengue NS1 antigen test or Dengue IgM
antibody test: Not confirmatory
- Diagnosis only confirmed by viral culture or PCR,
usually diagnosed by clinical suspicion

- Dengue With Warning Signs

- Lives on or travels to dengue-endemic area with fever
lasting 2-7 days, plus any one of the ff:
- Abdominal pain or tenderness
- Persistent vomiting
- Clinical signs of fluid accumulation
- Mucosal bleeding
- Management - Lethargy, restlessness
- Important to eliminate carrier state - Liver enlargement
- Amoxicillin (drug of choice) - Decreased or no UO for 6 hours
- 80-90 mg/kg/day in 2 divided doses - Lab: hemoconcentration and/or decreasing platelet
- 10 days count
- Co-amoxyclav
- 90 mg/kg/day (based on amoxicillin content) in 2 - Severe Dengue
divided doses - Lives on or travels to dengue-endemic area with fever
- Alternatives (if with penicillin allergy) lasting 2-7 days and any of the previous clinical
- Cefdinir, cefuroxime, cefpodoxime, ceftriaxone manifestations of dengue with or without warning signs
- Analgesics, Antipyretics plus any of the ff:
- Paracetamol 10-15 mg/kg - Severe plasma leakage leading to
- Shock
VIII. Chief Complaint: Fever - Fluid accumulation with respiratory distress
A. Dengue Fever - Severe bleeding
- A benign syndrome caused by several arthropod-borne - Severe organ impairment
viruses and is characterized by - Liver: ast or alt ≥ 1000
- Biphasic fever - CNS: seizures, impaired consciousness
- Myalgia or arthralgia - Heart: myocarditis
- Rash - Kidneys: renal failure
- Leukopenia
- Lymphadenopathy - Management
- Presence of warning signs warrants admission
- Etiology - For patients with dengue without warning signs
- 4 distinct antigenic types; members of the family - Obtain a reference CBC
Flaviviridae - ORS should be given as follows based on weight
- Transmitted by mosquitoes of the Stegomyia family Body weight ORS to be given
(Aedes aegypti - principal vector; daytime biting) 3-10 kg 100 mL/kg/day
10-20 kg 75 mL/kg/day
- Dengue Without Warning Signs (Probable Dengue)
20-30 kg 50-60 mL/kg/day
- Lives on or travels to dengue-endemic area with fever
plus any two of the ff: 30-60 kg 40-50 mL/kg/day
- Headache - Paracetamol (10-15 mg/kg/dose) every 4 hours as
- Body malaise needed for fever
- Myalgia, arthralgia - Watch out for warning signs: bleeding, frequent
vomiting, abdominal pain, drowsiness, mental
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confusion or seizures, pale, cold, or clammy hands & - IV: 0.2-0.5 mg/kg/dose (IV)
feet, DOB, decreased or no UO w/in 6 hours - Rectal:
- Without warning signs (Able to hydrate orally with - 2-5 y: 0.5 mg/kg/dose
adequate urine output), maybe treated as outpatient - 6-11 y: 0.3 mg/kg/dose
basis with ORS, antipyretics with close observations - > 12 y: 0.2 mg/kg/dose
for warning signs - Lorazepam
- Intravenous: 0.a05 – 0.1 mg/kg/dose
B. Febrile Seizures - Midazolam
- Seizures that occur - Intravenous: 0.2 mg/kg/dose
- MC between the age of 6 and 60 months (5 y/o) - Antipyretics
- with a temperature of >38 -39C - Phenobarbital
- not the result of CNS infection or any metabolic - Loading dose: 15-20 mg/kg/dose via slow IV
imbalance and that occur in the absence of a history of Infusion to run for 30 minutes
prior afebrile seizures. - Maintenance dose:
- Neonate: 3-5 mkday OD- BID
- Simple Febrile Seizure - Infant: 5-6 mkday OD- BID
- Primary generalized - Child 1-5 y/o: 6 – 8 mkday OD - BID
- Usually tonic-clonic
- Lasting for a max. of 15 mins - Patient is not actively seizing
- Not recurrent within a 24-hour period - Complete history and physical examination
- No increase risk of mortality - Search for focus of infection or possible source
- No long term adverse effects of >1 simple febrile of fever
seizures - Assess risk of meningitis or Intracranial infection
- Recurrent Simple Febrile Seizures do not damage the - Stand-by: Diazepam, Midazolam, Lorazepam
brain - Antipyretics
- Antipyretics can decrease the discomfort of the
- Complex Febrile Seizure child but DO NOT REDUCE THE RISK of having
- Focal a recurrent febrile seizure.
- Lasting for > 15 mins - BZD known to reduce seizure episodes in patients
- Recurs within a 24-hour period with febrile seizures:
- 2-fold long term increase in mortality as compared to - Intermittent oral diazepam (0.33 mg/kg every 8
the general population hr during fever)
- intermittent rectal diazepam (0.5 mg/kg
- Febrile Status Epilepticus administered as a rectal suppository every 8 hr)
- Lasts > 30 mins
- Evaluation
- Pathophysiology - Lumbar Puncture
- Hyperthermia (>38.3 C) can decrease GABA-A - < 6mo: all with fever and seizure
receptor mediated inhibition to a greater extent than it - 6-12mo: defcient in HiB and PCV/ unknown
decreases excitation, which may shift the balance - Any age: ill- appearing
towards excitation and contribute to seizure - 21-ch EEG
generation. - R/o pseudo–status epilepticus
- Decrease GABA release - R/o other movement disorders
- Decrease GABA-A receptor-mediated function - Identifying the type of status epilepticus for the
underlying etiology and further therapy.
- Risk Factors For Recurrence Of Febrile Seizures - Distinguish between postictal depression and later
Major Minor stages of status epilepticus in which the clinical
Age <1 yr Family history of febrile seizures manifestations are subtle (e.g., minimal myoclonic
Duration of fever <24 hr Family history of Epilepsy jerks) or absent (electroclinical dissociation)
Fever 38-39 C Complex febrile seizure - Monitoring the therapy (paralyzed and intubated)
- Serum Na, K, Ca, Phosphorus, Magnesium and CBC
Day Care
- Neuroimaging
Male Gender
Lower Serum Sodium - Treatment
- Anti-epileptic therapy is not recommended for
- Management In The Emergency Department children with ≥ 1 simple febrile seizures
- Patient is actively seizing: - Diazepam, Lorazepam, Midazolam
- O2 supplementation - Seizure > 5mins
- Seizure > 5 mins
- Diazepam
 Oral Revalida Review2019

PEDIATRICS
Lecturer: Kevin Merquita, MD

- IV Benzodiazepines, Phenobarbital, Phenytoin or

Valproate

Other Tips
- Update immunization
- EPI (if less than 1 year old)
- PCV 13 (if not yet given)
Yearly Influenza vaccine
- Proper hygiene (hand washing, oral hygiene)
- Deworming
- Albendazole
- 12 months to 24 months: 200 mg, single dose every 6
months
- 24 months and above: 400 mg, single dose every 6
months
- Mebendazole
- 12 months and above: 500 mg, single dose every 6
months
- Nutritional counseling
- Daily physical activity of at least 1 hour per day on most
days of the week
- Limit gadget use to only 2 hours per day
- Safety and injury prevention