Pediatric Primary Care (60 page)

American Academy of Pediatrics.
2009 red book: report of the Committee on Infectious Diseases.
28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

Choby B. Diagnosis and treatment of streptococcal pharyngitis.
Am Family Physician.
2009;79(5):383-390.

Clark M, Krol D.
PACT module: protecting all children's teeth, oral health initiate.
Elk Grove Village, IL: American Academy of Pediatrics; 2009.

Dulin M. Management of cervical lymphadenopathy in children.
Am Family Physician.
2008;78(9):1097-1098.

Ebell M. Epstein-Barr virus infectious mononucleosis.
Am Family Physician.
2004;70(7):1279-1287.

Feder HM. Periodic fever, aphthous stomatitis, pharyngitis, adenitis: a clinical review of a new syndrome.
Clin Opin Pediatr.
2000;12:233-236.

Florin T, Zaoutis T, Zaoutis L. Beyond cat scratch disease: widening spectrum of Bartonella henslae infection.
Pediatrics.
2008;121:e1413-e1425.

Hayden G, Hendley J. An up-to-date approach to pharyngitis in children.
Resp Dis Pediatr J.
2001;3:125-131.

Heims S. Foreign bodies in the ear, nose and throat.
Am Family Physician.
2007;76(8):1185-1189.

Leung A, Robson L. Childhood cervical lymphadenopathy.
JPed Health Care.
2004;18:3-7.

Mahr T, Sheth K. Update on allergic rhinitis.
Pediatrics in Rev.
2005;26:284-289.

Margileth M. Recent advances in the diagnosis and treatment of cat scratch disease.
Current Infectious Dis Rep.
2000;2(2):141-146.

Ownby DR, et al. Exposure to dogs and cats in the first year of life and risk of allergic sensitization at 6 to 7 years of age.
JAMA.
2002;288:963-972.

Platts-Mills TAE. Allergen avoidance in the treatment of asthma and rhinitis.
N Engl J Med.
2003;349:207-208.

Sinus and Allergy Health Partnership. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis.
Otolaryngol Head Neck Surgery J.
2003;130(suppl):1-44.

Welch M.
Guide to your child's allergies and asthma.
Elk Grove Village, IL: American Academy of Pediatrics; 2010.

CHAPTER 24

Respiratory Disorders

Marti Michel

I.  CROUP

A.  Etiology.

1.  Acute upper airway obstruction in children, most often caused by viral infection.

a.  Most common form of viral croup is laryngotracheitis resulting from inflammation and edema of larynx, subglottic area.

•  Causative agents include parainfluenza 1, 2, 3 (parainfluenza 1 and 3 most common), influenza A and B, respiratory syncytial virus (RSV), adenovirus, measles.

b.  Spasmodic croup is similar to viral croup but is not associated with fever and symptoms, lasts only hours, not days.

•  Onset typically occurs during night in a child who has been well.

•  May represent allergic reaction to viral antigen.

c.  Laryngotracheobronchitis (LTB) and laryngotracheobronchopneumonia (LTBP) involve upper airway; also affect lower airway, specifically bronchi.

•  Same viral agents are common to LTB and LTBP.

•  Bacterial superinfection occurs more commonly in this croup variant; includes
Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae, Haemophilus influenzae, Corynebacterium diphtheria.

i.   Agents are infrequent causes but tend to cause more severe illness.

B.  Occurrence.

1.  Viral croup occurs at 6 months to 5 years of age, with peak in second year of life.

2.  Affects boys more than girls.

3.  Occurs in late fall, early winter; correlates with the activity of viral agents causing the syndrome.

4.  Symptoms typically last 3-7 days.

C.  Clinical manifestations.

1.  Gradual onset with rhinorrhea, sore throat, mild fever.

2.  Disease has wide spectrum from very mild illness to severe illness.

3.  Harsh, “seal-like” barking cough.

4.  Hoarseness.

5.  Inspiratory stridor.

6.  Increasing obstruction.

a.  Tachycardia, tachypnea–usually not > 50 breaths/min.

b.  Suprasternal, supraclavicular, substernal, and intercostal retractions.

c.  Paradoxical abdominal and chest wall movement.

d.  Progressive restlessness and anxiety correlates with hypoxemia.

D.  Physical findings.

1.  Normal or mildly elevated temperature.

2.  Mild erythema and edema of nasal mucosa.

3.  Inspiratory stridor.

4.  Hoarseness.

5.  Harsh, barky cough.

6.  Nontoxic appearing.

7.  On auscultation, normal breath sounds except transmission of stridor.

8.  With increased obstruction: wheezing, prolonged expiration, decreased breath sounds.

E.  Diagnostic tests.

1.  Diagnosis made on basis of history and clinical presentation.

2.  Imaging is not usually necessary in the ambulatory setting; posteroanterior neck X-ray.

a.  Classic “steeple sign”: narrowed air column consistent with narrowing of subglottic space.

b.  Lateral view is useful in ruling out epiglottitis, retropharyngeal abscess, or radiopaque foreign body.

3.  If indicated, WBC normal or low with polymorphonucleotides (PMNs).

4.  Clinical croup score can classify severity of illness and aid in decision making regarding hospitalization.

F.  Differential diagnosis.

1.  Epiglottitis: toxic appearing, drooling, high fever, acute onset, age range typically 3-7 years.

2.  Laryngeal foreign body: history, age, abrupt onset, lack of preceding respiratory symptoms.

3.  Diphtheria: characteristic thin, gray membrane extends from tonsil to associated soft/hard palate.

4.  Retropharyngeal or peritonsillar abscess: severe throat pain, refusal to swallow or speak, fever to 105°F (40.6°C).

5.  Bacterial tracheitis: affects children of any age, acute onset with respiratory stridor, high fever, and copious and purulent secretions.

G.  Treatment.

1.  Most children have mild airway obstruction that resolves without specific treatment.

2.  Supportive care at home includes making the child comfortable, avoiding fatigue and anxiety; encourage fluids and antipyretics for fever.

3.  Cool mist vaporizer may be used.

4.  Nebulized epinephrine has been beneficial for children with more severe croup in the emergency department or hospital setting.

5.  Corticosteroids.

a.  Systemic or nebulized corticosteroids are mainstay of both outpatient and inpatient treatment.

b.  Decrease edema of laryngeal mucosa.

c.  Single dose 0.6 mg dexamethasone given orally or IM or 2 mg dose of nebulized budesonide.

d.  Clinical improvement in 6-12 hours.

e.  Efficacy did not vary according to route of administration

f.  Facilitates clinical improvement, decreases hospitalizations and fewer follow-up visits.

6.  Criteria for hospitalization: