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KIDS ARE NOT LITTLE ADULTS

EXAMINING A BABY

PEDIATRICS CAN BE DAUNTING

So we are here to give you some pearls of practice

PEARL #1: LEARN HOW TO EXAMINE A

CHILD
General Principles
HEENT
Cardiac
Respiratory
Abdominal Exam
Skin
Neuro
Musculoskeletal

GENERAL PRINCIPLES
Stop, Look, and Listen
Sit down
Make it a game
Save the worse for last
Dont ask and dont lie
Engage parents

No shots, I
promise!
Can I look in
your ears?

HEENT

Head:
Anterior fontanelle
Assess upright
while calm
Closes ~ 9-18 mo

Eyes
Infants head fall

Ears

Oropharynx

HEENT

CARDIAC/RESPIRATORY
Quiet
Murmurs
Pulses
Respiratory rate
How long should you count?
Periodic breathing
How can you get a good respiratory assessment?
Younger patients
Older patients

ABDOMINAL EXAM

Distraction

Let a parent do it

Lift up legs to relax abdominal muscles

Umbilical hernia
Should be easily reducible
Can be normal up to 5 years of age

Liver edge what is normal?

Neonate : 3.5 cm below right costal margin
School age : up to 2 cm below right costal margin

Spleen size
More likely to feel spleen tip in newborns
1-2 cm below costal margin

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NEURO - TODDLER
Coordination grab for object in
multiple directions
Assess tone/head lag/suck
Gait walk to mom or dad
Walk to parent

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SKIN

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MUSCULOSKELETAL
Assess in the most comfortable position
Abducted and externally rotated hip
concern for septic hip
Arm hanging straight down at side and not
using Nursemaids elbow

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PEARL #2: LITTLE PEOPLE DONT HAVE

LITTLE VITAL SIGNS
Respiratory
Rate
(breaths/min)
Heart
Rate
(rate/min)
Temperature:
36-38C
Definition
of Hypotension
by
Systolic
Blood Pressure and Age

Age
Age

Age
Infant
Newborn
to 3 months
Term neonates (0 to 28 days)
Toddler

Awake Rate
Rate
85 to

Sleeping Rate

Systolic Blood Pressure

20530 to 60
80 to 160
<60 mm Hg
24 to 40

3 months to 2 years

100 to 190

75 to 160

2 to 10 years

60 to 140

60 to 90

Preschooler
Infants
(1 to 12 months)

School-age child
Children 1 to 10 years (5th BP
>
10 years
percentile)
Adolescent
Children >10 years

22 tomm
34 Hg
<70

60 to

18 to 30
<70 mm Hg + (age in years x 2)
100
50 to 90
mm
Hg16
12 to
<90 mm Hg

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PEARL #3: IMMUNIZATIONS REALLY DO

WORK

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WHAT DO YOU DO IN A CHILD WITH A

FEVER?

Age < 28 days:

CBC & Blood culture
UA & Urine culture
LP with CSF studies and culture
Ampicillin and Cefotaxime

Age 28 days- 3 months:

CBC & Blood culture
UA & Urine culture
If they look sick, not eating well, very sleepy, etc, consider LP
If labs look peachy, can follow up with pediatrician and not admit
If you admit, think really hard about the LP before starting
antibiotics

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WHAT DO YOU DO IN A CHILD WITH A

FEVER?

Age > 3 months:

Ear infection
Pharyngitis
Pneumonia
UTI
Sinusitis
Cellulitis

If unimmunized:
If they look good, look for sources of
fever on exam
If they dont look good, treat them like
a little baby
Consider infections such as measles
and pertussis that immunizations
cover for

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PEARL #4: KNOW HOW TO MANAGE

OUCHIES

Look for sources of pain

Mild Pain
Tylenol 15mg/kg q4 (PO/IV/PR)
Ibuprofen 10mg/kg q6

Moderate Pain
Oxycodone
Toradol (IV/IM)

Severe Pain
Fentanyl IV or IN
Morphine 0.1mg/kg

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PEARL #5: WHEN ALL ELSE FAILS, SUCK

OUT SOME SNOT

Respiratory illnesses are the most common

illnesses in children

Common cold

Croup

Bronchiolitis

Asthma

Pneumonia

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CROUP

Parainfluenza virus is the most

common cause

Inflammation of small airways

with increased secretions,
subglottic and tracheal swelling

Characterized by barking cough

on days 2-3

Fever

Inspiratory Stridor

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CROUP: THE EVIDENCE

Steroids: strongly recommended that a single dose be

administered for mild, moderate or severe croup
Decreased return visits to ED as compared with placebo
Patients receiving dexamethasone verses prednisolone
demonstrated a statistically significant decreased likelihood of
return to ED

Nebulized Epinephrine: clinically and statistically significant

reduction of symptoms of croup 30 min post treatment
Recommend for moderate-severe croup

Humidified air: no demonstrable effect in the acute setting

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BRONCHIOLITIS

#1 cause of hospitalization
for US infants < 12 months

Self limited viral disease

Inflammation and
obstruction of the lower
respiratory tracts

Typically worse days 3-5

Characterized by cough,
respiratory distress,
increased secretions, wet
wheezes

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BRONCHIOLITIS: THE EVIDENCE

HR/RR monitors: Use only when suspect an increased

rate of apnea/bradycardia (premies, <3mo, chronic
disease)
Several studies have reported more severe progression of
disease with lower initial SpO2

Oxygen: start when sats consistently <91%, wean when

>94%

SABA: recommend trial when FH of atopy, allergy, asthma

Racemic Epi: better short term improvement in pulmonary

physiology compared with albuterol or placebo

Suctioning: improves delivery of inhalational meds and

patients symptoms

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BRONCHIOLITIS
THINGS WITHOUT GREAT EVIDENCE

Scheduled SABA: No improvements in

hospitalization rates or LOS

Hypertonic Saline Nebs: studies have not been

homogeneous enough to validate therapy, may
induce bronchospasm

Corticosteroids: no difference in hospital

admission, LOS, symptomatic benefit

CXR, RSV PCR ($403), viral PCR ($686)

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BRONCHIOLITIS: ADMISSION CRITERIA

Depends on your clinical judgment

Respiratory distress, apnea, RR >70

Requiring supplemental O2

Requiring frequent suctioning with BBG or NP Cath

Unable to maintain po feeds for adequate hydration

Social concerns

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ASTHMA

Disease of the lower

respiratory tract
characterized by:
Cough
Wheezing
Mucous production
Increased work of
breathing

Reversal of
symptoms by a
bronchodilator

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ASTHMA: THE EVIDENCE

Oxygen: start when sats consistently <91%, wean

when >94%

SABA: every 10-20 min x 3 treatments

Levalbuterol has demonstrated comparable efficacy for
treatment of acute exacerbations in the ED
Reduction in HR, BP, and tremors has not been
demonstrated at equivalent doses but is less so with
MDI vs neb
Delivery: no sig difference reported for nebs vs MDI in
regards to recovery of asthma sx, repeat visits, or
hospital admission

Atrovent: adding up to 2 doses decreases rate of

admission from ED to floor

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ASTHMA
THE EVIDENCE

Steroids: speed resolution of airflow obstruction, rate of

relapse, and may reduce hospitalization
Dosages in excess of 1mg/kg have been associated with adverse
behavioral effects with no further improvement in lung function
No improvement shown for IV form vs oral
Insufficient evidence for inhaled steroids during exacerbation
Dexamethasone: 0.6mg/kg x 1-2 doses

Magnesium Sulfate: decreases hospitalization, improves lung

function
indicated in moderate to severe exacerbations
SE: hypotension, hypotonia

IM Epinephrine: 0.01mg/kg, try if you think they are too tight

to even get the albuterol in

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PNEUMONIA

Viruses

S. pneumoniae

Group A Strep

MRSA

H. flu

Mycoplasma

Chlamydia trachomatis

Chlamydia pneumoniae

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PNEUMONIA: THE EVIDENCE

Blood Culture: indicated when admitting to hospital,
un-immunized, not improving on outpatient therapy
Rapid Flu: strong evidence to perform if high clinical
suspicion
CXR: Not routinely indicated if pt is well appearing
and being discharged
If hypoxemia or being admitted, obtain PA and lat views
CBC, ESR, CRP not routinely indicated and can not
be used as sole determinants to distinguish
between viral vs bacterial causes of CAP

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PNEUMONIA: TREATMENT

Antimicrobial therapy not indicated for

preschool children with CAP

Amoxicillin 45mg/kg BID: previously healthy,

immunized

Ampicillin: 1st line if admitted, immunized

Ceftriaxone: not fully immunized, complicated

pneumonia

Clinda/Vanc + -lactam: concern for S. aureus

Azithromycin + -lactam: concern for atypicals

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PNEUMONIA: WHEN TO ADMIT

Respiratory Distress and SpO2 <90%
Infants < 6 months of age
Suspected pathogen with increased
virulence (MRSA)
Sustained HR, RR
Fever does not indicate a need for
admission

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QUESTIONS?

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