Common Pediatric Visits

Matthew Rensberry, MD, MBA

April 28, 2021

Common Pediatric Encounters

Routine child health exam (22.9%)
Otitis media (6.6%)
Acute upper respiratory infection (4.6%)
Acute pharyngitis (3.4%)
Attention-deficit/hyperactivity disorder (3.2%)
Asthma (2.8%)
Chronic sinusitis (2.4%)
Immunization visits (2.3%)
Streptococcal sore throat (1.9%)
Allergic rhinitis (1.9%)

Routine Well-Child Health Exam

History
Physical Examination
Screening
Immunizations
Anticipatory Guidance

History

Birth history
Prior screenings
Diet
Sleep
Dental care
Medical, Surgical, Family, and Social histories

Physical Examination

Head-to-toe examination
Blood pressure
Review of growth

Blood Pressure Chart Example

Pediatric Growth Chart Example

Screening

Developmental surveillance (9, 18, and 30 mo of age)
- CDC App: Milestones
Postpartum depression screening
- Mothers of infants up to six months of age
Psychosocial
Vision
Iron Deficiency (slightly controversial)
Lead for high risk

Immunizations

Reviewed and updated as appropriate.
Typically given at:
- 2 month, 4 month, 6 month, 12 month, 15 month, and 18 month visits
- 4 yo and 6 yo visits
- Annually during influenza season
CDC App: Vaccine Schedules
AAFP/STFM App: Shots Immunizations

Anticipatory Guidance

Provide age-appropriate guidance:
- Breastfeeding
- Car seats
- Dental health
- Early introduction of highly allergenic foods (peanut-based foods and eggs), before one year
- Juice and sugar-sweetened beverages
- Physical Activity (Play time)
- Screen Time

Time to answer questions from parents or caregivers
Cessation of breastfeeding <6 mo and transition to solid foods <6 mo are associated with childhood obesity
Vitamin D 400 IU supplementation for year 1 of exclusively breastfed infants - prevent vitamin D deficiency and rickets
Car seats should remain rear facing until two years of age or until the height or weight limit for the seat is reached.
Fluoride use, limiting or avoiding juice, and weaning to a cup by 12 months of age may improve dental health.
Early introduction of highly allergenic foods decreases the likelihood that a child will develop food allergies.
Juice and sugar-sweetened beverages should be avoided <1yo and limited for 1yo+
Children participate in at least 60 minutes of active free play per day.
Screen time should be avoided, with the exception of video chatting, in children <18 mo and limited to 1 hr/d for 2 - 5 yo (AAP)

Otitis Media

Otitis media

The most common pathogens:

Non-typeable H. influenzae
S. pneumoniae
M. catarrhalis
Viruses
Group B streptococcus, gram-negative enteric bacteria, and Chlamydia trachomatis

Diagnosis

Diagnosis requires:

Acute onset of symptoms
Presence of middle ear effusion
Signs and symptoms of middle ear inflammation

Diagnosis

Diagnosis of AOM is not made due to:

Acute otitis externa
Mild bulging of the TM and recent (less than 48 hours) onset of ear pain
Intense erythema of the TM

Management

Antibiotic therapy should be considered for children 6-35 months of age with AOM (LOE B)
- First line: Amoxicillin, 80-90 mg/Kg/d, in two divided doses
- Second line (or if vomiting): Ceftriaxone (Rocephin)
Antibiotic therapy should be prescribed:
- For Bilateral AOM in 6 - 23 month old without severe signs or symptoms
- For AOM (bilateral or unilateral) in children >6 months with severe signs or symptoms

Management

Antibiotic Observation option:
- Children 6-23 mo with nonsevere unilateral AOM
- Children >24mo with nonsevere AOM (either unilateral or bilateral)
Assess pain in children diagnosed with AOM.
Tympanostomy tubes may be offered for recurrent AOM:
- 3 episodes in 6 months
- 5 episodes in 18 months

Medication Calculation Practice

John is a 12 month old male who weighs 9 Kg. You diagnose him with AOM. What are your instructions for his antibiotic medication?

(Goal dose: 80 to 90 mg/Kg/day divided twice a day)

Medication Calculation

80 mg/Kg/day divided in 2 = 80 mg * 9 Kg / 2 => 720 mg/day
- Divided twice a day: 720 mg / 2 = 360 mg/dose
90 mg/Kg/day divided in 2 = 90 mg * 9 Kg /2 => 810 mg/day
- Divided twice a day: 810 mg / 2 = 405 mg/dose

Medication Calculation

Amoxicillin availability:

125 mg / 5 mL
200 mg / 5 mL
250 mg / 5 mL
400 mg / 5 mL

You choose to order 10 days of 400 mg / 5 mL at 400 mg twice a day = 100 mL

Prognosis

AOM typically resolves without antibiotic therapy in children
Children with AOM should be re-evaluated in 3 months

Acute Upper Respiratory Infection

Characterized by:

Cough
Nasal congestion
Rhinorrhea
Sneezing
Sore throat

Management

Symptomatic treatment
Antibiotics are not recommended
- Antibiotics should not be prescribed for acute laryngitis. (LOE A)
Don't use albuterol in children with bronchiolitis

Acute Bacterial Sinusitis (AAP Guidelines)

Diagnosed in older children with an acute upper respiratory infection that persists:
- Over 10 days of nasal discharge or daytime cough
- Worsening condition after improving at first
- Severe (concomitant fever of at least 102.2˚F [39˚C] and purulent nasal discharge for >3 days)

Bacterial Sinusitis Management

Antibiotics should be prescribed in children with:
- Severe
- Worsening
- or Persistent acute bacterial sinusitis
First-line: Amoxicillin alone or in combination with clavulanate

Acute Pharyngitis

Approximately 70% of children with pharyngitis have viral infections
- Manage symptomatically
When bacterial, the most common pathogen is: Group A beta-hemolytic streptococcus

Acute Pharyngitis

Assess risk for Bacterial Pharyngitis

Table 1: Centor Criteria
Absence of cough	1
Age 3 to 14 years	1
Anterior cervical lymphadenopathy	1
Fever	1
Tonsillar erythema or exudates	1

Centor Scoring

0 to 1: No further diagnostic testing or treatment indicated
2 to 3: Perform streptococcal rapid antigen detection testing - if positive, treatment is indicated
4: Antibiotic therapy is recommended

Streptococcal pharyngitis

Penicillin should be used in patients with streptococcal pharyngitis (LOE B)

Appropriate antibiotic treatment:
- Decreases the risk of rheumatic fever
- Decreases communicability
- Alleviate symptoms (by ~1 day)
Antibiotic treatment:
- Does not prevent glomerulonephritis
- Inconsistent results in the prevention of peritonsillar abscess

Attention-Deficit/Hyperactivity Disorder (ADHD)

Most common behavioral disorder in children
Many coexisting conditions
These are At-risk individuals!

Diagnosis

Cannot be reliably diagnosed in children <4 years of age
NICHQ Vanderbilt Assessment Scales (Ages 6 to 12)

Management (Goal)

Goal of ADHD treatment:

Improve symptoms
Optimize functional performance
Remove behavioral obstacles

Management (Behavioral Therapy)

Behavioral therapy should be the primary treatment for ADHD in children <6 years of age (LOE B)
Effective behavioral therapies:
- Parent training
- Classroom management
- Peer interventions

Management (Medications)

Medications are recommended as first-line therapy for older children. (LOE B)
- Psychostimulants are most effective for the treatment of core ADHD symptoms and have generally acceptable adverse effect profiles. (LOE B)
  - Examples: methylphenidate and dextroamphetamine
- Atomoxetine, guanfacine, and clonidine, are less effective than the psychostimulants

Management (Encounters)

Monthly visits initially
Record at follow-up visits:
- Height
- Weight
- Heart rate and blood pressure
- Symptoms
- Mood
- Treatment adherence

Asthma

Acute childhood asthma is a common clinical emergency!

Asthma

Chronic inflammatory disease of the airways:
- Episodic wheezing
- Reversible airway obstruction
Acute exacerbations:
- Tachypnea
- Increased work of breathing
- Tachycardia
- Reduced oxygen saturation levels

Severity (Moderate Acute Asthma)

Oxygen saturation level: 92%-95%
Pulse: 100-125bpm (>5yo) or 120-140bpm (2-5yo)
Respiratory rate: 20-30bpm (>5yo) or 30-40bpm (2-5yo)
Some use of accessory muscles (>5yo) or some chest wall recession (2-5yo)
Talking in short phrases.

Severity (Severe Acute Asthma)

Oxygen saturation level: <92%
Pulse: >125bpm (>5 yo) or >140bpm (2- 5yo)
Respiratory rate: >30bpm (>5yo) or >40bpm (2-5yo)
Use of accessory muscles (>5yo) or obvious chest wall recession (2-5yo)
Inability to complete sentences in one breath (the child speaks 1 or 2 words)
Too breathless to feed

Triggers

Viral infection (Predominant cause, detected in 80%-85% of cases)
Exercise
Allergen exposure (inhaled or ingested)
Cold weather
Poor air quality

EBM Medication Management

Beneficial:

Beta 2 agonists (high-dose inhaled)
Corticosteroids (high-dose inhaled)
Corticosteroids (systemic)
Ipratropium bromide (inhaled)
Magnesium sulfate (intravenous)
Oxygen
Salbutamol (intravenous)

Likely to be beneficial:

Theophylline or aminophylline (intravenous)

Asthma Management

Admission Risk Factors

Risk factors for asthma admissions:

Not having or not adhering to a written crisis management plan (Asthma Action Plan)
Inappropriate preventive treatment
Poor compliance
Delay of more than 24 hours in seeking advice

Not all wheezing is asthma…

Children <5 yo with lower respiratory tract infection or foreign body aspiration can present with asthma like symptoms

Chronic Rhinosinusitis

Occurs in 1% to 5% of the U.S. population
An inflammatory disease of the paranasal sinuses

Diagnosis

Chronic rhinosinusitis has at least 2/4 cardinal symptoms for >3 mo and objective evidence:
1. Nasal obstruction (81% to 95% of patients)
2. Facial pain/pressure (70% to 85%)
3. Nasal drainage (51% to 83%)
4. Hyposmia/anosmia (61% to 69%)
Objective evidence:
- Physical examination (anterior rhinoscopy, endoscopy)
- Radiography (preferably sinus computed tomography)

Goals of Therapy

To enhancing mucociliary clearance
Improving sinus drainage/outflow
Eradicating local infection and inflammation
Improve access for topical medications

Treatment

First-line treatment is nasal saline irrigation and intranasal corticosteroid sprays
Daily low-pressure/high-volume (240mL) saline irrigations (NNT=2)
There may be a role for antibiotics in patients with evidence of an active, superimposed acute sinus infection
If medical management fails, endoscopic sinus surgery may be effective
Patients not responding to first-line medical therapy should be referred to an otolaryngologist

Nasal saline irrigations improve sinonasal symptoms in patients with chronic rhinosinusitis. (LOE A)
Intranasal corticosteroid sprays improve sinonasal symptoms in patients with chronic rhinosinusitis. (LOE A)
Short courses (<3wks) of oral corticosteroids, alone or as an adjunct to standard maintenance therapy, improve sinonasal symptoms in the short term in patients with chronic rhinosinusitis and polyps. (LOE A)
Low-pressure, high-volume (240 mL) saline irrigation may significantly reduce sinonasal symptoms in 50% of patients (number needed to treat = 2)
- Superior to nasal saline spray in reducing sinonasal symptoms (absolute risk reduction = 0.2; number needed to treat = 5)
Oral antibiotics, given for up to three weeks, may be considered as a treatment option for acute exacerbations of chronic rhinosinusitis. (LOE C)
- Abx role limited

Allergic Rhinitis

Symptoms:
- Rhinorrhea
- Sneezing
- Nasal congestion, obstruction, and pruritus

Symptom Classification

Temporal pattern
- Seasonal
- Perennial
- Episodic
Frequency
- Intermittent (>4d/wk)
- Persistent (>4wks/yr)
Severity
- Mild
- Severe

Management (Things that work)

(These Work!)

Avoid known allergens
Intranasal corticosteroids (most effective treatment)
Second-line therapies:
- Antihistamines
- Leukotriene receptor antagonists
- Nonpharmacologic therapies (nasal irrigation)

Avoid exposure to:
- Cigarette smoke
- Pets
- Known trigger allergens
Intranasal corticosteroids are the most effective treatment and should be first-line therapy for persistent symptoms affecting quality of life (LOE A)
- Decrease the influx of inflammatory cells and inhibiting the release of cytokines, thereby reducing inflammation of the nasal mucosa
- Onset of action can be <30 min; peak effect may take several hours to days, with maximum effectiveness usually noted after two to four weeks of use
Second-generation antihistamines have a better adverse effect profile and cause less sedation, with the exception of cetirizine (Zyrtec)(LOE A)
- Considered safe for children >2yo
- Onset of action is typically within 15 to 30 minutes
Nasal saline irrigation is beneficial in treating the symptoms of allergic rhinitis and may be used alone or as adjuvant therapy. (LOE B)

Management (Things that don't work)

Things we have recommended that lack evidence of effectiveness (LOE A/B):

Breastfeeding
Air filtration systems
Delayed exposure to solid foods in infancy or to pets in childhood
Mite-proof impermeable mattresses and pillow covers

Other General Stuff

General Parenting Strategies

Catch them being good
Let them help you
Establish home routines
Monitor your children
Hand out discipline in a consistent manner
Save long talks and lectures for good behavior
Show sympathy when you discipline
Be a good role model
Be a parent, not a martyr
As a parent, understand that you are also a teacher
Monitor your children's use of electronic media

Some final recommendations…

Do:
- Provide access to long-acting reversible contraception for adolescents
- Promote childhood literacy development by providing free, age-appropriate books in clinical settings
Don't:
- Don't perform computed tomography of the head for children with minor head trauma

Connect with Me

Website: anchor-dpc.com
Facebook: MatthewRensberryMD
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Twitter: @RensberryMD
Email: Dr.Rensberry@anchor-dpc.com