Pediatric Primary Care (65 page)

•  Erythromycin 40-50 mg/kg/day in 4 divided doses for 14 days OR

•  Clarithromycin 15 mg/kg/day in 2 divided doses for 7 days.

d.  Adults.

•  Azithromycin 500 mg as single daily dose on day 1, then 250 mg on days 2-5 OR

•  Erythromycin 2 g/day in 4 divided doses for 14 days OR

•  Clarithromycin 1 g/day in 2 divided doses for 7 days.

5.  Alternatively use trimethoprim-sulfamethoxazole (TMP-SMX), 8-12 mg/kg/day divided every 12 hours for 14 days, if unable to take macrolides or culture resistant to macrolides.

6.  Those with pertussis should be considered contagious until treatment with appropriate therapy for 5 days.

7.  Treat all household and close contacts including daycare and school regardless of age, immunization status, symptoms.

8.  In addition to chemoprophylaxis, for children younger than 7 years of age who are not immunized or partially immunized, follow schedule for accelerated vaccination.

9.  Reportable disease to local and state health departments.

H.  Follow up.

1.  Guidelines for parents to call healthcare provider for poor fluid intake, low urine output, change in level of consciousness, cyanosis, or respiratory distress.

2.  Close outpatient follow up by telephone to monitor and reassure family.

I.  Complications.

1.  Infants younger than 6 months of age have highest rate of hospitalization, secondary pneumonia, and seizures.

2.  Children with history of prematurity or underlying chronic heart, pulmonary, or neurologic disease are at high risk for severe disease.

3.  Apnea.

4.  Secondary infection causing viral or bacterial pneumonia or otitis media. a. Secondary bacterial pneumonia causes most pertussis-related deaths.

5.  Neurologic complications include encephalopathy and seizures.

6.  Sequelae of violent coughing including conjunctival hemorrhage, CNS hemorrhage, pneumothorax, epistaxis, petechiae.

7.  Fluid and electrolyte imbalances.

8.  Death: Infants younger than 1 year of age are at highest risk.

J.  Education.

1.  Very contagious and spread by direct or indirect contact with respiratory droplets.

2.  Good handwashing, containment of coughs/sneezes prevents spread of illness.

3.  Guidelines about adequate hydration and nutrition.

4.  Children may continue to have cough for several months.

5.  Provide adequate rest and avoid activity that triggers cough.

6.  Need for antibiotic treatment of all household and close contacts.

7.  Household and close contacts are considered contagious until completed 5 days of erythromycin therapy.

8.  Need for accelerated immunization for contacts younger than 7 years of age partially immunized/not immunized.

9.  Avoid secondhand smoke exposure.

VI. ASTHMA

A.  Etiology.

1.  Asthma is chronic inflammatory disorder of airways in which many cells and cellular elements play a role.

a.  Mast cells, eosinophils, T-lymphocytes, neutrophils.

2.  May have genetic predisposition (with critical interaction with environment).

3.  The characteristics of asthma are:

a.  Symptoms of episodic airflow obstruction that is reversible.

b.  Airway inflammation.

c.  Increased airway responsiveness to variety of stimuli.

4.  Hyperresponsiveness.

a.  Chronically inflamed airways are hyperresponsive.

b.  When exposed to “triggers,” there is bronchoconstriction and airflow limitation.

c.  Inflammation contributes to airway edema and increased mucous production.

d.  Cough and wheeze are characteristic of asthma but are also common nonspecific symptoms associated with many other clinical entities.

5.  Common triggers.

a.  Inhalant allergens: animal allergens, house dust mites, cockroach allergens, molds, outdoor allergens.

b.  Irritants: active/passive tobacco smoke exposure, indoor and outdoor air pollution, strong odors, chemical cleaning products.

c.  Viral illness.

•  URI, sinusitis, rhinitis, otitis, lower respiratory infection.

•  Viral illness is primary trigger for asthma in young children.

d.  Weather: rapid change in weather; hot, humid weather; or cold air.

e.  Exercise.

f.  Emotions or stress.

g.  Occupational exposures: farm and barn exposures, formaldehydes, paint fumes, smoke, strong odors.

h.  Aspirin sensitivity (more common in adults): includes other NSAIDs.

i.  Sulfite sensitivity: in many processed foods, dried fruit, salad bars, beer, wine.

j.  Risk factors.

•  Atopy: family history or eczema.

•  Gender: preadolescent boys are at higher risk.

•  Smoking: history of mother smoking perinatally.

•  Respiratory viral disease.

k.  Aggravating factors: smoking, gastroesophageal reflux, sinusitis.

B.  Occurrence.

1.  Most common serious chronic illness among children.

2.  Onset at any age from infancy to old age; 50-80% of children with asthma develop symptoms before 5 years of age.

C.  Clinical manifestations.

1.  Recurrent wheezing.

2.  Dry, persistent cough, nocturnal cough.

3.  Recurrent chest tightness or shortness of breath, chest pain.

4.  Sputum production.

5.  Exercise-induced cough, wheezing, shortness of breath, or chest tightness.

6.  In younger children, difficulty keeping up with peers.

7.  Atopic profile.

a.  Eczema.

b.  Seasonal or perennial allergy symptoms.

c.  Rhinitis, sneezing, itching and rubbing of nose, throat clearing.

d.  Conjunctivitis.

8.  Fatigue secondary to sleep disturbance.

9.  Poor school performance secondary to sleep disturbance.

D.  Physical findings.

1.  Upper respiratory tract.

a.  Allergic shiners, “allergic salute” (characteristic crease at bridge of nose due to chronic rhinitis).