*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 Gastrointestinal
perinatal 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
- Elicit immunization history to appropriate A. Acute Nasopharyngitis
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
 - Mode of transmission - Anterior cervical
lymphadenopathy or conjunctival
- spread by 3 mechanisms: injection especially with
- Direct hand contact concomitant allergic
rhinoconjunctivitis
- Inhalation of small-particle aerosols
- Management
that are airborne from coughing, or - Generally supportive
- Deposition of large-particle - Maintaining adequate oral hydration
to thin out the secretions
aerosols that are expelled during a - Topical nasal saline
- 0.65% NaCl nasal drops
sneeze and land on nasal or (for children less than 3 years old) or
spray (for older children)
conjunctival mucosa.
- 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
B. Allergic Rhinitis - Thorough history, including details of the patient’s
- an inflammatory disorder of the nasal mucosa marked environment and diet and family history of allergic
by nasal congestion, rhinorrhea, and itching, often conditions such as eczema, asthma, and AR
accompanied by sneezing and conjunctival - Physical examination, and
inflammation - Laboratory evaluation
- Risk Factors - Skin prick test (preferred test for the diagnosis of IgE-
- Family history of atopy mediated sensitivity)
- Serum immunoglobulin (Ig) E higher than 100 - Serum IgE determination
IU/mL before age 6 yr
- Classification - Management
- Based on frequency and severity of symptoms and - Environmental control measures play a
affectation to ADL or school activities 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

- 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
- 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
- Diagnosis in preschool children with persistent AR
- Montelukast
- 6 mos-5 yr: 4 mg QHS
- 6-14 yr: 5 mg QHS
 - > 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
IV. Chief Complaint: Cough
- In the local settings, chronic cough is defined as
cough for more than 2 weeks.
A. Acute Tonsillopharyngitis
- Refers to inflammation of the pharynx, including
erythema, edema, exudates, or an enanthem (ulcers,
vesicles)
- ETIOLOGY
- Most causes of sore throat are nonbacterial and
neither require nor are alleviated by antibiotic therapy
- Differential Diagnoses
- Gingivostomatitis
- Caused by HSV I
- Herpangina
- Caused by Coxsackie A16 (most
common), Enterovirus 71 and Coxsackie A6
- Adenoviral pharyngitis
- May present concurrently with conjunctivitis
pharyngoconjunctival fever)
- Measles
- Intense, diffuse pharyngeal erythema and
Koplik spots (Pathognomonic enanthem)
- Infectious mononucleosis
GROUP A STREPTOCOCCAL PHARYNGITIS
- Epidemiology
- Quite common among 5-15 years old (Unlikely
for younger children, most likely viral)
- Clinical Manifestations
- Symptoms
- Sore throat and fever
- Signs
- Erythematous pharynx
- Tonsils are enlarged and often covered
with a white, grayish, or yellow exudate that
may be blood-tinged (May be tonislolith or
milk curd. Ask patient to gargle before
confirming diagnosis)
- Enlarged and tender anterior cervical lymph
nodes are frequently present
- Management
- Nonspecific, symptomatic therapy for viral
pharyngitis (antipyretic/analgesic; anesthetic
sprays and lozenges)
- Antibiotic therapy for bacterial pharyngitis
- Hastens clinical recovery by 12-24 hours
- Primary benefit and intent: prevention of
acute rheumatic fever (Not the treatment of
 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)
 - 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
 - A prior infection with M. tuberculosis or - Pathogenesis
tuberculoproteins from BCG vaccine result in T-cell Hypersensitivity or susceptibility to a variety of provocative
sensitization that releases lymphokines at the site of exposures or triggers can lead to
injection Airways inflammation
- A history of BCG vaccine is not a Airway hyperresponsiveness
contraindication for TST Edema
- Tuberculin reaction believed to be affected by BCG Basement membrane thickening
wanes after 5 years from immunization Subepithelial collagen deposition
- Interpretation Smooth muscle and mucous gland hypertrophy
- > 5 mm - history of close contact with a - Mucus hypersecretion
known or suspected case of TB, clinical
findings suggestive of TB, CXR suggestive of *Most common triggers: animal dander, dust mites,
TB and immunosuppressed condition cockroaches
- > 10 mm - in the absence of the above
factors
*Measure only the induration, not the erythema

- Chest radiograph
-There are NO pathognomonic radiographic findings
in childhood TB (vs. cavitation on the upper lobe in
adult TB)
- Neither the presence nor absence of the primary
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
 - In children <2 y/o, asthma less likely, suspect
bronchiolitis caused by virus
- Therapeutic trial in young children
- 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
- LEUKOTRIENE RECEPTOR ANTAGONIST
- Montelukast
- 4 mg/tab QDHS (6mo-5 y/o)
V. Chief Complaint: Loose stools
ACUTE GASTROENTERITIS
- Denotes infections of the gastrointestinal tract
caused by bacterial, viral, or parasitic pathogens
- Many of these infections are foodborne illnesses
- Diarrhea is defined as
- 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
- Osmotic diarrhea
- Secretory diarrhea
- Altered gastrointestinal tract motility
- Clinical Evaluation
- The most common manifestations of GIT
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
most common etiology
- Bloody or mucoid stools
- If there is an epidemic (household contacts
with similar symptoms)
- Chronic diarrhea (> 14 days)
- Immunocompromised patient

- Pharmacologic Agents
- For disimpaction
- 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
- 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
 - 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- - Severe organ impairment
borne 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 30-60 kg 40-50 mL/kg/day
plus any two of the ff: - Paracetamol (10-15 mg/kg/dose) every 4 hours as
- Headache needed for fever
- Body malaise - Watch out for warning signs: bleeding, frequent
- Myalgia, arthralgia vomiting, abdominal pain, drowsiness, mental
 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 of fever
febrile 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
- Focal having 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)
Day Care - Serum Na, K, Ca, Phosphorus, Magnesium and CBC
Male Gender - Neuroimaging
Lower Serum Sodium
- Treatment
- Management In The Emergency Department - Anti-epileptic therapy is not recommended for
- Patient is actively seizing: children with ≥ 1 simple febrile seizures
- O2 supplementation - Diazepam, Lorazepam, Midazolam
- Seizure > 5 mins - Seizure > 5mins
- Diazepam
 - 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