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Peds therapeutics > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Pain: physiologic markers

A

-RR, heart rate, oxygen desaturations
-behavior: grimacing, high-pitched crying

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2
Q

how to estimate eGFR in peds

A

Bedside Schwartz: crCl= (o.413 x height) / SCr

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3
Q

What are some challenges in pediatric pharmacotherapy?

A

-PK/PD differences (drug selection and dosage)
-psychosocial influence on drug therapy
-caregiver medication administration hesitance
-dosage formulation selections
-off-label medication use

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4
Q

Limitations to off-label drug usage

A

-potential for denied insurance provider coverage
-liability for adverse effects
-limited experience in specific conditions or age groups
-limited available dosage formulations

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5
Q

for water containing formulations prepared from solid ingredients USP recs:

A

a beyond- use date is no later than 14 days when stored at cold temps (2-8C)

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6
Q

reasons for non-adherence in peds

A

-apprehension regarding medication adverse effects
-caregiver inability or unavailability to administer drugs
-caregiver may be overwhelmed/confused
-inappropriate measurements of medication doses
-missed doses due to resistance from the child

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7
Q

drug absorption in peds

A

-higher gastric pH early in life (more basic environment exists)
-gastric emptying rates increase dramatically during first week of life = more delivery of intact drug compounds to the site of absorption
OVERALL: effects of reduced gastric emptying and poorly coordinated intestinal contractility = decreased rate of drug absorption

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8
Q

rectal drug delivery

A

–> have higher-amplitude pulsatile contractions (expels solid dosage forms)
-may decrease time drug is able to be absorbed (decreases bioavailability)

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9
Q

Distribution of drugs

A

-larger total body water –> more intracellular fluid
-infants have less muscle/fat then adults
inc Vd of hydrophilic drugs
dec Vd of lipophilic drugs

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10
Q

Protein binding

A

-decreased concentrations of circulating proteins
-decreased binding affinity of fetal albumin
= increased free fraction of drugs
–> risk of displacement of bilirubin from albumin binding sites (kernicterus: albumin deposits in the brain and can cause cell atrophy + neurologic damage)

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11
Q

elimination implications for drug dosing

A

-slower clearance (in drug elimination by the kidney)
-longer 1/2 life
-generally, less frequent dosing required (or longer drug intervals)

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12
Q

advantage of liquid dosage forms (solutions/suspensions)

A

dose flexibility, easy to swallow
*most commonly preferred in children

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13
Q

disadvantage & challenge of liquid dosage forms

A

-lack of controlled release mechanisms, volume required for dose, accuracy in measuring devices
challenge: not all commercially available, single concentrations VS extemporaneous compounded: various available concentrations –> at risk for medication errors

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14
Q

Pros and Cons of: chewable tablets

A

P: minimizes need for additional liquid
C: relies on ability to chew, cannot utilize with extended release medications, may not mask taste, may be difficult to control dosage

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15
Q

Pros and Cons of: minitablets

A

P: ease the need for swallowing tablets
C: limited dosage flexibility, maximum milligrams per tablet

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16
Q

Pros and Cons of: ODTs

A

P: allows for quick dissolving without need for additional liquid
C: cannot easily split (limits dose flexibility), challenge with masking taste

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17
Q

Pros and Cons of: orodispersible films

A

P: can offer dose flexibility with strip cutting mechanism
C: hard to mask tase, higher cost to packaging/manufacturing

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18
Q

Pros and Cons of: powder packets

A

P: eliminated need for crushing tablets, ready to use manufactured packets
C: may require significant volume to mix, not easily titratable

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19
Q

Pros and Cons of: sprinkle capsules/granules

A

P: can ease in the administration with food
C: limited dose flexibility

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20
Q

Enteral Formulation Consideration: Palatability

A

-primary source of non-compliance in children
-manipulation can change taste
-mix with food/drink: chocolate syrup, peanut butter, applesauce

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21
Q

risk associated with excipients: benzoyl alcohol

A

-can cause neurotoxicity and metabolic acidosis, esp concerning in neonatal population
-used as a preservative to protect from microbial contamination
ex: IV lorazepam

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22
Q

risk associated with excipients: ethanol

A

-can cause neurotoxicity
-used as solvent to dissolve/disperse particle into another
ex: dexamethasone intensol solution

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23
Q

risk associated with excipients:: polysorbates

A

-can cause liver and kidney failure; thrombocytopenia, ascites, and pulmonary deterioration observed in neonates
-used as a surfactant to increase solubility of one agent with another agent
ex: IV amiodarone

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24
Q

risk associated with excipients: propylene glycol

A

-can cause seizures, hyperosmolarity, metabolic acidosis, and neurotoxicity
-used as a solvent
ex: IV phenobarbital

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25
Q

risk associated with excipients: sorbitol

A

-can lead to osmotic diarrhea
-used as a sweetener, to mask taste/increase palpability
ex: loperamide

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26
Q

beyond use date for standard non-preserved and preserved aqueous dosage forms

A

np: 14 days in fridge
p: 35 day in fridge or temp controlled room

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27
Q

beyond use date for oral liquids that are nonaqueous

A

oral liquids: 90 days in fridge or controlled room temp
other non-aqueous: 180 days in fridge or temp controlled room

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28
Q

Compounding oral suspensions: things to avoid

A

-need to avoid formulations with extended-release products
-beware capsules that are hard coated gel caps or contain time-release beads

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29
Q

Gestational age (AG)

A

-from conceptions, “how far along in the pregnancy”
ex: 34 5/7 = from the first day of the mothers last menstrual cycle to the current date is 34 weeks + additional 5 out of next 7 days

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30
Q

Post-natal Age (PNA)

A

-chronological age, time in days/weeks/months since birthday
ex: born on March 1st (today is march 3rd) PNA = 2 days

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31
Q

Post-menstrual age (PMA)

A

-combination of GA + PNA
ex: 34 5/7 + 2 days = PMA = 35 weeks

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32
Q

*Age ranges for pediatric dosing: neonate

A

birth to 30 days
–> if pt is pre-term, PMA/corrected age up to ~44 weeks

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33
Q

*Age ranges for pediatric dosing: infant

A

30 days to 1 year

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34
Q

*Age ranges for pediatric dosing: child

A

1 year to 12 years old

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35
Q

*Age ranges for pediatric dosing: adolescent

A

12 years to 18 years old

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36
Q

*weight conversion= lbs to kg

A

1 kg = 2.2 lbs

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37
Q

*height conversion inches to cm

A

1 inch = 2.54 cm

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38
Q

Body surface area equation (BSA)

A

m^2 = sqt root (height cm * weight kg) / 3600

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39
Q

*drug monograph: dosing section

A

-recommendations stratified by age, weight etc
-take note of max mg/dose or mg/day recs
-identify the correct indication for use
-be sure you are looking at the right ROUTE

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40
Q

*drug monograph: preparations for admin (peds)

A

-provides information such as concentrations and appropriate diluents for reconstitution/dilution of parenteral medications
-provides instructions for eternal preparations

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41
Q

*drug monograph: administration

A

-contains special instructions related to administration with food and missed doses
-recommendations for food or beverages allowable for mixing
-parenteral: infusion information - such as rate of infusion

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42
Q

*drug monograph: adverse reactions

A

-adverse reactions that have been observed in clinical trails/post-marketing
-may be organized by body/organ systems
-may or may not be specific to patient age, provide % incidence

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43
Q

*drug monograph: extemporaneous compounding

A

-if applicable, provided published reference for recommendations related to compounding into oral solution/suspension from tablets or capsules

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44
Q

*drug monograph: pharmacokinetics/MOA

A

-may be necessary for answering drug information questions related to how quickly a medication works, onset of action etc
-half-life can assist with understanding dosing intervals- may be age specific if available
-bioavailability: can assist with parenteral to enteral conversions if not otherwise stated

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45
Q

*drug monograph: dosage forms

A

-available products on market
-brand names and generic strengths available
-assist in determining if commercially available oral solution/suspension is available for pediatric use
-helps to determine timed release products availability

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46
Q

what are the most common organisms that cause bacterial men in < 1 month y/os?

A

-group B strep (GBS)
-E. coli
-Listeria monocytogenes
-klebsiella species

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47
Q

what are the organisms that cause bacterial men in 1-23 month year olds?

A

*S. pneumoniae
*Neisseria meningitidis
-H. influenzae
-E. coli

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48
Q

what are the common organisms that cause bacterial mem in 2-50 year olds?

A

-N. meningitidis
-S. pneumoniae

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49
Q

what are the risk factors for developing bacterial men in neonates?

A

*pre-term birth
*maternal GBS colonization
*traumatic delivery
-low birthweight, chorioamnionitis, maternal endometritis, prolonged duration of intrauterine monitering (> 12 hrs), prolonged rupture of membranes & urinary tract. abnormalities

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50
Q

what are risk factors for developing bacterial men in children?

A

*HIV
*sickle cell anemia
*daycare attendance
*penetrating head trauma
-asplenia, primary immunodeficiency, cochlear implant, CSF leak, recent upper respiratory tract infection, exposure to a case of meningococcal or H. influenza type b memingitis, lack of immunization

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51
Q

Presentation of bacterial men in infants

A

-poor feeding
-vomiting
-fever/temp instabilities
-seizures
-irritability
-lethargy
-bulging fontanelle

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52
Q

Presentation of bacterial men. in children

A

-fever
-headache
-lethargy
-vomiting
-myalgia
-photophobia
-stiff neck
-seizure
-confusion

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53
Q

How to diagnose bacterial men

A

GOLD standard: analysis of CSF from lumbar puncture
- elevated WBC
-elevated protein
-low glucose
-+ bacterial culture

(CI to LP: increased intracranial pressure, coagulopathy, hemodynamic/respiratory instability, skin infection over LP site)

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54
Q

Empiric therapy for bacterial men: < 1 month

A

-ampicillin + AG or
-Ampicillin + cefotaxime

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55
Q

Empiric therapy for bacterial men: 1-23 months

A

-vancomycin + cefotaxime or ceftriaxone

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56
Q

Empiric therapy for bacterial men: 2-50 years

A

-vancomycin + cefotaxime or ceftriaxone

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57
Q

Ampicillin therapy dose for neonates: PNA < 7 days

A

200 to 300 mg/kg/day IV Q8-12h

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58
Q

Ampicillin therapy dose for neonates: PNA 8-28days

A

300 mg/kg/day IV divided q6-8h

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59
Q

Ampicillin therapy dose for infants and children

A

-300 to 400 mg/kg/day IV q6h
-max 12 grams/day

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60
Q

Ampicillin AEs

A

-diarrhea, N/V, rash
-generally well tolerated

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61
Q

Cefotaxime dose for bac men in neonates PNA <7 and > 2 kg

A

100-150 mg/kg/day IV Q8-12h

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62
Q

Cefotaxime dose for bac men for neonates PNA 8-28 days & > 2 kg

A

150-200 mg/kg/day IV Q6-8h

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63
Q

Cefotaxime dose for infants and children

A

225-300 mg/kg/day IV q6-8hrs
-mdd 12 grams/day

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64
Q

cefotaxime AEs

A

diarrhea, nausea, vomiting, rash, prutitis

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65
Q

Ceftriaxone for tx of bac men

A

**do NOT use in neonates due to risk of hyperbilirubinemia
-infants & children: 100mg/kg/day q12h
-adult max dose: 4,000 mg/day

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66
Q

Vancomycin dose in neonates PNA <7 & > 2 kg

A

20-30 mg/kg IV q8-12 h

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67
Q

Vancomycin dose in neonates ONA 8-28 days & > 2 kg

A

30-45 mg/kg q 6-8 h

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68
Q

vancomycin dose for infants and children

A

-60-80 mg/kg/day q 6 h (infants > 3 months - 12 y/o)
-60-70 mg/kg/day q 6-8h ( children > 12 y/o)

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69
Q

Vancomycin AUC/MIC

A

> 400 but < 600

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70
Q

Vancomycin adverse effects

A

*nephrotoxicity
-ototoxicity
-infusion related reactions

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71
Q

Dexamethasone adjunctive therapy

A

-used to decrease hearing loss in pts with H. influenza (> 6 weeks old)
*may be used as adjunctive therapy 10-20 mins before or with 1st dose of abx –> 0.15 mg/kg/dose q 6 hr for 2-4 days
(consider use for s. pneumoniae if high risk of mortality)

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72
Q

Prevention strategies of bac. men

A

-Hib vaccine
-PCV13
-meningococcal conjugate vaccine

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73
Q

Risk factors of CAP

A

*recent hx of upper respiratory tract infection
-lower socioeconomic status
-crowded living environment
-exposure to cigarette smoking

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74
Q

Comorbidities with CAP

A

*asthma
-bronchopulmonary dysplasia
-cycstic fibrosis
-sickle cell disease
-congenital heart disease

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75
Q

what are 3 routes that pathogens can enter the lungs?

A

***: inhaled aerosolized particles
-through the blood stream (less common)
-aspiration

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76
Q

Signs and Symptoms of CAP

A

*fever
*cough
-pleuritic chest pain
-purulent expectorant
-tachypnea for age ( infants > 70, children > 50)
-respiratory distress
-wheezing
-crackles or rales
-pulse ox < 90% on room air
-altered mental status

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77
Q

what is used for diagnosis of CAP?

A

gold standard = chest x-ray
-looking for consolidation - lobar or diffuse
-outpatient diagnosis w/o x-ray if signs/symptoms STRONGLY suggest CAP
-blood cultures
-sputum cultures
-viral testing
-lab tests

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78
Q

who should be hospitalized for CAP?

A

-moderate to severe CAP
-significant respiratory distress
-all infants < 3 months of age
-infants < 6 months of age with suspected bacterial CAP
-suspicion/documentation of community acquired MRSA
-concern for caretaker capabilities

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79
Q

what are some bacteria that cause CAP?

A

**strep. pneumoniae (most common)
-h. influenzae
-staph aureus
-Group A strep

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80
Q

Atypical bacteria that cause CAP:

A

(in older children)
-mycoplama pneumoniae
-chlamydophila pneumoniae
-legionella (rare)

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81
Q

Viruses that cause CAP:

A

(< 2 y/o, 80%)
*influenza virus
-respiratory syncytial virus (RSV)
-parainfluenza virus (PIV)
-adenovirus
-rhinovirus

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82
Q

*what is the best predictor of cause via identification of likely pathogen & exposure:

A

age

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83
Q

what are the suspected pathogens for CAP in groups birth - 20 days:

A

-group B strep
-gram - enteric bacteria
-listeria monocytogenes

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84
Q

what are the suspected pathogens for CAP in groups: 3 weeks to 3 months

A

*S. pneumoniae
-S. Aureus
-RSV
-PIV
-bordetella pertussis
-chlamydia trachomatis

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85
Q

what are the suspected pathogens for CAP in groups 4 months - 4 years

A

*S. pneumoniae
-H. influenzae
-M. pneumoniae
-viruses
-mycobaacterium tuberculosis

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86
Q

what are the suspected pathogens for CAP in groups: 5 yrs to 15 yrs

A

*S. pneumoniae
-H. influenzae
-M. pnuemoniae
-C. pneumoniae
-influenza A or B, adenovirus
-M. tuberculosis

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87
Q

what are treatment goals of CAP?

A

1- provide appropriate empiric antimicrobial therapies to ensure adequate coverage
2. promote antimicrobial stewardship with regard to need for therapy/narrowed therapy
3- ensure pt adherence to prescribed regimen
4- minimize adverse reactions to medications
–> symptom resolution = within 48-72 hrs of tx

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88
Q

Outpatient tx of CAP: Amoxicillin dosing

A

90 mg/kg/day TID (mad daily dose 3-4 g/day)
*must use high dose regimen
(dosage forms: various commercially available suspensions, chewable tablets, capsules, tables)

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89
Q

why do we want to use high dose of amoxicillin in outpatient tx of CAP?

A

-purpose is to overcome strep. pneumo mechanism of resistance (which is the production of penicillin binding proteins)

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90
Q

Outpatient treatment of CAP: Augmentin dose

A

-90 mg/kg/day BID or TID (max single dose 875-1000mg/dose) *must use high dose regimen
dosage forms: want to use the extended spectrum forms (helps to inc the amoxicillin component of drug w/o increasing the clavulanate)
–> food may enhance absorption and decrease GI upset, ADR = diarrhea

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91
Q

Outpatient treatment of CAP: what does the clavulanate in augmentin offer?

A

helps to cover the b-lactamase producing organisms

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92
Q

Outpatient treatment of CAP: azithromycin dosing

A

-10 mg/kg/day on day 1 (MD 500mg) then 5 mg/kg/day days 2-5 (max dose 250mg)
IV dose = PO dose
–> food may enhance absorption and decrease GI upset; terrible aftertaste

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93
Q

Outpatient tx of CAP: why is only a 5 day treatment course of azithromycin used?

A

b/c we have a long 1/2 life with a post antibiotic effect

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94
Q

Inpatient tx for CAP: Ampicillin dose for empiric, S. pneumoniae (PCN MIC <2) or H. influenzae (beta-lactamase neg)

A

200 mg/kg/day IV divided q 6 hrs

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95
Q

Inpatient tx for CAP: Ampicillin dose for Group A strep

A

200 mg/kg/day IV q 6 hrs

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96
Q

Ampicillin IV AEs

A

diarrhea, rash, eosinophilia

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97
Q

Inpatient tx of CAP: ceftriaxone dosing

A

500 mg/kg/dose IV q 24 hrs
AEs: diarrhea, rash, eosinophilia, pain at injection site (IM)

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98
Q

why is ceftriaxone recommended. in un-immunized children for CAP tx?

A

concern for H. influnzae (which is beta lactamase producing) and would then need this drug to cover those organisms

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99
Q

Antiviral therapy for CAP: Oseltamivir

A

shown “only to be effective if” initiated within 48 hrs of symptoms
–> dosage forms: capsules, commercially available suspensions 6mg/mL

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100
Q

Oseltamivir dose for infants < 1 year

A

3 mg/kg/dose BID x 5 days

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101
Q

Oseltamivir dose for < 15 kg

A

30 mg BID x 5 days

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102
Q

Oseltamivir dose for 15-23 kg

A

45 mg BID x 5 days

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103
Q

Oseltamivir dose for 23-40 kg

A

60 mg BID x 5 days

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104
Q

Oseltamivir dose for > 40 kg

A

75 mg BID x 5 days

105
Q

non-serious allergies in CAP

A

-tx recommendations are not defined, trail under medical supervision
-use of cephalosporins: cefodoxime, cefprozil or cefuroxime

106
Q

hx of anaphylaxis to penicillin in CAP tx

A

can use:
-respiratory fluoroquinolone
-linezolid
-macrolide (azithromycin)
-clindamycin
-bactrim

107
Q

Duration of therapy in CAP

A

-total 10 days of tx shown to be just as effective as 14 days
-azithromycin & oseltamivir: only 5 days
-CA-MRSA may require longer tx

108
Q

complications of CAP that may require therapy for up to 4-6 weeks or 7-10 days after resolution of symptoms

A

-parapneumonic effusions
-empyema
-lung abcess

109
Q

complications of UTI

A

-recurrent UTI
-acute kidney injury
-end-stage renal disease: HTN, dialysis, renal transplantation

110
Q

when/where is UTI more likely to occur?

A

-in general, higher rates in females and among males, higher rates in uncircumcised
-in children < 12 months who present with fever, UTI prevalence is higher

111
Q

what is the most common pathogen to cause UTI?

A

E. coli

112
Q

Risk factors for UTI

A

-younger age groups (neonates/infants)
-female sex
-uncircumcised infants
-constipation
-anatomic abnormalities
-functional abnormalities
-female sexual activity
-immunocompromised state
-diabetic mellitus
-genetic predisposition

113
Q

Infection Pathways: Retrograde ascent (most common)

A

-enters through urethera and migrates to bladder

114
Q

Infection Pathways: Nosocomial infection

A

-introduction of foreign body to UT
-more resistant pathogens

115
Q

Infection Pathways: Hematogenous route

A

-infection originates outside UT resulting in systemic infection with subsequent UT seeding
-more common in infants and immunosuppressed patients

116
Q

Infection Pathways: Fistula (rare)

A

between UT and GI/vagina

117
Q

lower UTI in bladder

A

cystitis

118
Q

lower UTI in urethera

A

urethritis

119
Q

Upper UTI: kidney

A

pyelonephritis

120
Q

Upper UTI: urine

A

bacturia (can have asymptomatic cases in older adults –> no need for treatment

121
Q

Complicated UTI

A

(warrants longer duration of tx)
-GU tract w/ structural/functional abnormalities
-catheters or a UTI that occurs due to a foreign body

122
Q

Uncomplicated UTI

A

occurs in anatomically normal UT with no prior instrumentation

123
Q

Signs and Symptoms of UTI: neonates

A

jaundice, failure to thrive, fever, difficulty feeding, irritability, vomiting and diarrhea

124
Q

Signs and Symptoms of UTI: infants and children < 2 y/o

A

-nonspecific S&S similar to those reported in neonates with the exception of jaundice
-cloudy or malodorous urine, hematuria, frequency and dysuria

125
Q

Signs and Symptoms of UTI in children > 2 y/o

A

-fever, frequency, enuresis (accidents), hematuria, abdominal pain

126
Q

number of bacteria needed for a clean catch

A

> 100,000 cfu/mL one 1 bacteria

127
Q

number of bacteria needed for cauterization

A

> 50,000 cfu/mL of 1 bacteria

128
Q

1st line tx for UTI

A

-Cephalosporins
-TMP/SMX
-b-lactam/b-lactamase inhibitor

129
Q

When to give parenteral tx for UTI

A

-acutely ill (septic) children, < 2 months, immunocompromised, unable to tolerate PO
–> continued until patient is afebrile, clinically stable (then switch to oral abx)

130
Q

when to use oral abx in UTI tx

A

-complete treatment course in patients initiated on parenteral antibiotics
-initial treatment in children who do not meet criteria for parenteral antibiotics

131
Q

what is the antibiotic duration for UTI?

A

7-14 days
Uncomplicated: 7 days
Pyelonephritis: 10-14 days

132
Q

parenteral antibiotics for UTI tx

A

-ampicillin
-cefazolin (1st gen)
-cefotaxime (3rd gen)
-ceftriaxone (3rd gen)
-ceftazidime (3rd gen)
-cefepime (4th gen)
-ciprofloxacin
-gentamicin
-tobramycin

133
Q

oral antibiotic options for UTI tx

A

-amox/clav
-cephalexin (1st gen)
-cefixime (3rd gen)
-cefpodoxime (3rd gen)
-ceftibuten (3rd gen)
-ciprofloxacin
-nitrofurantoin
-TMP/SMX

134
Q

Vedicoureteral Reflux (VUR)

A

-retrograde urinary flow from bladder into ureters and possibly renal collecting system and renal pelvis
-international reflux study committee classification *grade I-V)
-28% of infants < 6 months old with febrile urinary tract infection have VUR

135
Q

VUR risk factors

A

-febrile, UTI, parent/sibiling with VUR, prenatal hydropepnrosis (water collected around the kidney in utero)

136
Q

Complications of VUR

A

-recurrent UTI, renal scarring, hypertension

137
Q

what is the prognosis and treatment of VUR?

A

Prognosis: spontaneous resolution of vesicoureteral reflux occurs in most young patients within 4-5 years of follow up
Treatment: observation, antibiotic prophylaxis, surgery

138
Q

UTI prophylaxis candidates

A

goal = prevent irreversible damage (scarring)
–> neonates/infants being evaluated for anatomic or functional UT abnormalities
–> children with VUR
–> children with dysfunctional voiding
–> immunocompromised
–> children with recurrent UTIs despite normal anatomy/function

-prophylactic antibiotics generally continued until resolution of underlying predisposing conditions

139
Q

what were the conclusions of the randomized intervention for children with RIVUR trail

A

-antimicrobial prophylaxis decreases recurrent UTI
-increased antimicrobial resistance
-no difference in renal scarring

140
Q

what are some viral causes of AOM? (~20%)

A

-RSV
-rhinovirus
-influenza
-adenovirus

141
Q

What are the bacterial causes of AOM*? (80% of cases)

A

-step pneumoniae
-H. influenzae
-moraxella catarrhalis

142
Q

What are some infrequent causes of AOM?

A

-atypical pathogens
-group A strep
-gram - organisms, including pseudomonas
- mixed infections (viral and bacterial) = 2/3 cases

143
Q

Risk factors for developing AOM:

A

*young age, esp < 2
*day care attendance
*recent viral upper resp tract illness (37% of children with viral URTI will develop AOM)
*nasopharyngeal colonization with middle ear bacterial pathogens
*tobacco smoke exposure
*bottle- feeding
*pacificer use
*sick sibiling in household

144
Q

what are signs and symptoms of acute otitis media?

A

-middle ear effusion
-acute onset of symptoms: fever, rhinorrhea, irritability, otalagia, tugging/rubbing of the ear
–> otoscopic exam: shows tympanic membrane appears erythematous, cloudy, white, bulging

145
Q

What are signs and symptoms of otitis media x/ effusion?

A

-uninfected middle ear effusion
-without acute onset of symptoms
-can precede/follow AOM

146
Q

*acute otitis media (AOM):

A

rapid onset of signs and symptoms of inflammation in middle ear

147
Q

*severe AOM:

A

-AOM with moderate-to-severe otalgia or fever > 39C (102.2F)

148
Q

*non-severe AOM:

A

AOM with mild otalgia and temp < 39C (102.2F)

149
Q

*recurrent AOM:

A

> 3 well-documented separate AOM episodes in the past 6 months, or > 4 episodes in past 12 months with > 1 episode in past 6 months

150
Q

Otitis media with effusion (OME or serous otitis media)

A

inflammation of middle ear with liquid collected in middle ear, but no signs or symptoms of acute infection

151
Q

Chronic suppurative otitis media

A

continuing inflammation of middle ear for at least 6 weeks, leading to perforated tympanic membrane and otorrhea

152
Q

treatment goals of AOM

A

-alleviate symptoms: except middle ear effusion - may persist for weeks in up to 70% of children
-preventing recurrence
-using antibiotics judiciously
-ensuring patient adherence
-preventing adverse drug reactions

153
Q

Treatment of OAM: oral analgesics

A

APAP: 10-15mg/kg
IBU (> 6 months): 10 mg/kg

154
Q

Treatment of OAM: topical analgesics

A

-anesthetics: antipyrine, benzocaine, lidocaine
-may provide short-term pain relief

155
Q

If pt has any episode of otorreha with AOM (regardless of age)

A

give antibiotics

156
Q

If pt has unilateral or bilateral AOM w/ severe symptoms

A

give antibiotics
(otalgia > 48 hrs, temp > 39C)

157
Q

if pt has bilateral AOM w/o otorrhea & is 6 months to 2 yrs old:

A

give antibiotics

158
Q

if pt has bilateral AOM w/o otorrhea & is > 2 y/o

A

can do antibiotics or observation

159
Q

If patient has unilateral AOM w/o otorrhea (any age)

A

give antibiotics or observation

160
Q

First line tx of AOM: amoxicillin criteria

A

-has not received amoxicillin in past 30 days
-does not have concurrent purulent conjunctivitis
-is not allergic to penicillin

161
Q

First line tx of AOM: amox/clav criteria

A

-has received amoxicillin in past 30 days
-concurrent purulent conjunctivitis
-hx of recurrent AOM unresponsive to amoxicillin

162
Q

In tx of AOM: if pt has non-life threatening penicillin allergy?

A

use PO cephalosporin: cefdinir, cefuroxime, cefpodoxime

163
Q

In tx of AOM: if pt has life threatening penicillin allergy

A

use macrolide: azithromycin, clarithromycin, or clindamycin

164
Q

in tx of AOM: if pt has allergies to penicillin or adherence issues:

A

ceftriaxone 50 mg/kg IV x1

165
Q

Duration of therapy for tx of AOM

A

-severe or < 2 y/o: 10 days
-2-5 y/o with mild-moderate symptoms: 7 days
-> 6 y/o with mild-moderate symptoms: 5-7 days
*reassess if symptoms worsen or fail to improve within 48-72 hours

166
Q

Tx of AOM: failure of initial tx steps:

A

-if stated with amox –> augmentin
-if started with augmentin –> ceftriaxone
-clindamycin (for more rare/failed cases)

167
Q

definiton of recurrent AOM:

A

> 3 episodes in 6 months
4 episodes in 1 yr

168
Q

what is the treatment of recurrent AOM?

A

-tympanovstomy tubes, adenoidectomy
*prophylactic antibiotics are NOT recommended

169
Q

what vaccines can be administered to prevent AOM?

A

influenza & pneumococcal vaccine

170
Q

what is appendicitis?

A

-an acute inflammatory process involving the appendix
-blockage caused by hard mucusy stool or swelling due to a virus may occur
-the blockage causes the appendix to swell and become inflated, risking possible rupture (perforated)
- quick diagnosis is crucial due to the risk of rupture

171
Q

pathophysiology of appendicitis**

A

-luminal obstruction can cause an increase in pressure within the lumen
-the appendix continues to secrete mucosal fluid, leading to distention
-ischemia, bacterial overgrowth, and eventual perforation follow suit (can lead to ischemia and necrosis)
-w/o diagnosis and tx, the patients symptoms will worse until perforation occurs = bacterial spread throughout the cavaties of the body

172
Q

physical/clinical manifestations of appendicitis

A

-N/V
-radiating pain in RLQ
-decreased appetite
-fever
-constipation

173
Q

4 ways to diagnose acute appendicitis

A

-physical exam: low grade fever, vomiting etc
-lab evaluation: elevation of WBC count, ansolute neutrophil count (ANC), and/or C-reactive protein (CRP)
-ultrasound: if non-diagnostic, further imaging with CT or MRI is required
-CT scan: modality of choice for definitive assessment of pts (major concern is radiation exposure)

174
Q

Fluid therapy & analgesia: IV hydration

A

-fluid management is CRITICAL
-NS 0.9% or lactated ringers
-1x maintenance is normally used, but can commonly see 1.5x maintenance and. fluid boluses if the pt requires

175
Q

Fluid therapy& analgesia: mild pain

A

-Acetaminophen: not to exceed 5 doses within 24 h, MDD 75mg
-Ibuprofen: infants > 6 months

176
Q

Fluid therapy & analgesia: moderate/severe pain

A

-opioids (morphine = most common)
*rec to AVOID codeine & tramadol –> metabolism variance of CYP2D6

177
Q

what 3 bacteria most likely cause appendicitis?

A

-bacteroides fragilis
-e. coli
-pseudomonas aeruginosa

178
Q

IV antibiotics for non-perforated appendicitis

A

-cefoteratan
-cefoxitin

179
Q

IV antibiotics for perforated appendicitis

A

-ampicillin-sulbactam
-pip-tazo

180
Q

2nd gen cephalosporins for appendicitis

A

-cefotetan & cefoxitin
-gram +: slightly weaker than 1st gen
-gram -: expanded to HNPEK
-cephamycins add anaerobic activity (B. fragilis)

181
Q

extended spectrum antibiotics for appendicitis

A

gram +: streptococci, enterococci, MSSA
gram -: HNPEK, anaerobes (B. fragilis)
**pip/tazo has additional coverage of pseudomonas aerginosa and CAPES orgransims

182
Q

what is the criteria for antibiotics to be d/c in appendicitis?

A

-afebrile
-adequate PO intake/tolerating regular diet
-ambulating
-benign abdominal examination
–> ok to discharge pt home on oral antibiotics (min 5 days of IV antibiotics)

183
Q

surgical approaches for appendicitis

A

-primary treatment for appendicitis is surgery
-laparoscopic > open appendectomy
–> advantages: quicker recovery, shorter hospitalization, lower infection rate/risk

184
Q

complications with appendicitis/surgery

A

-abscess
-perforation
-sepsis
-shock
-wound infection

185
Q

what is dehydration in peds?

A

a potentially harmful reduction in the overall fluid/water in the body which occurs when intake of fluid/electrolytes is LESS THAN loss of fluid/electroyltes

186
Q

what are the causes for dehydration?

A

-fever
-GI losses (viral = most common), bacterial/parasitic, DKA, inborn errors of metabolism, intestinal obstruction/hx of surgical resection, chrons, cyctic fibrosis
-sweating/excessive heat/burns
-polyuria
-imbalance in regulation of sodium/water
–> happen more quickly in neonates and infants than children

187
Q

Mild dehydration in infants and children*

A

I: 1-5%
C: 1-3%
-decreased urine output, slightly dry buccal mucosa

188
Q

Moderate dehydration in infants and children*

A

I: 6-9%
C: 4-6%
-tachycardia, < 1ml/kg/hr urine output, dry buccal mucosa, thirsty

189
Q

Severe dehydration in infants and children*

A

I: > 10% (> 15 = shock)
C: > 6% (> 9 % = shock)
-rapid and weak pulse, very low BP, oliguria, parched buccal mucosa, very delayed skin turgor, acrocyanosis, no tear, lethargic/comatose, unable to drink

190
Q

*formula for severity of dehydration (% estimated)

A

[(pre-illness weight) - illness weight) / pre-illness weight] x 100%

191
Q

*formula for fluid deficit (L)

A

% dehydration x pre-illness weight (kg) / 100

192
Q

mild to moderate dehydration treatment

A

–> Oral rehydration therapy
Mild: 50 ml/kg over 4 hrs, reassess q 2 hrs
Moderate: 100 ml/kg over 4 hours, reassess hourly
*add 10ml/kg for each loose stool/vomiting episode

193
Q

Severe dehydration treatment

A

(shock, failure of ORT, coma/unconscious, abdominal emergency) = IV fluids
1: BOLUS Dose: 10-20ml//kg/dose of 0.9% NS or lactated ringers over 30-60 mins –> repeat up to 3 times based on S/S
2: MAINTANCE:
–> first 8 hrs: calculate and replace fluid deficit
–> next 16 hrs: calculate and provide maintenance rate

194
Q

Components of IV fluid therapy

A

-sodium: 0.9% NS (isotonic)
-dextrose: D5W
-potassium: 20 mEq/L

195
Q

*Maintenance IV fluid rate: < 10 kg

A

4 ml/kg/hr

196
Q

*Maintenance IV fluid rate: 10-20 kg

A

40 mL/hr + 2 mL/kg/hr x (weight - 10kg)

197
Q

*Maintenance IV fluid rate: > 20 kg

A

60 mL/hour + 1 mL/kg/hr x (weight - 20 kg)

198
Q

Outpatient tx of dehydration: Ondansetron

A

dose: 0.15-0.3 mg/kg/dose in pts > 6 months
-8-15 kg: 2 mg/dose once
-15-30kg: 4mg/dose once
-> 30kg: 8 mg/dose once
AEs: risk of Qtc prolongation, arrhythmias

199
Q

Outpatient tx of dehydration: Zinc

A

-can be useful in pts with nutrient deficiencies as cause for diarrhea/malnutrition
< 6 months: 10 mg/day for 10-14 days
> 6 months and children: 20mg/day for 10-14 days
(dosage forms expressed in SALT = 23% elemental)
caps: 50 & 220, tabs: 220mg

200
Q

term infant weight

A

20-30 g/day
-immediatly after brith there is contraction of the extracellular fluid and a significant diuresis occurs that is accompanied by a decrease in weight –> weight should be regained within the first to second week of life

201
Q

failure to thrive in infants

A

-inadequate growth or inability to maintain growth in early childhood
-weight for age < 5th percentile on multiple occasions

202
Q

treatment for failure to thrive

A

-breast fed babies: breastfeeding more often, lactation support, formula supp
-formula fed babies: concentrated formulas
other: avoid juice or cow milk consumption, add rice cereal to foods

203
Q

nutrition in breast milk*

A

20 Kcal/ounce
-breast feed for first 6 months of life –> lots of benefits

204
Q

vitamin D supp in infants

A
  • 400 IU/day, starting in first few days of life
205
Q

fluoride supp in infants

A

-0.5 mg/day in infants 6 months or older
*only needed for exclusively breastfed infants
–> children should not use fluorinated toothpaste until 2 y/o

206
Q

Iron supp in breastfed babies

A

full term: 1 mg/kg/day from 4-12 months
pre term: 2 g/kg/day from 1-12 months

207
Q

Iron supp in formula def babies

A

full term: fortified formula containing Fe 4-12 mg//L until 12 months
per term: additional 1 mg/kg/day to bring total daily dose to 2 mg

208
Q

when to use enteral nutrition support

A

premature neonates younger than 32-34 weeks gentation b/c the suck-swallow reflux is not fully developed
-infants too sick to breast or bottle feed
-pts who are ventilated
-ant ped pt whose needs cannot be met with oral routh

209
Q

when to use parenteral for nutrition support

A

-nutritional needs cannot be met by EN or when the GI tract is not functioning

210
Q

treatment of GER in infants

A

-use supine sleeping position
-thicken the formula

211
Q

Symptoms of GERD in infants

A

-heartburn excessive regurgitation, food refusal, abdominal pain or poor weight gain

212
Q

factors that can contribute to decreased LEF pressure in GERD

A

-tobacco smoke exposure, intake of fatty foods, certain meds, & gastric distention

213
Q

Genetics and risk factors of GERN

A

-specific locus on chromosome 12
-risk factors: neurologic impairment, obesity, esophageal atresia, chronic lung disease, and prematurity

214
Q

Signs and Symptoms of GERD in infants < 1 yr

A

-regurgitation, vomiting, arching, irritability, poor weight gain, crying
-sandifer syndrome, food refusal, failure to thrive, apparent life-threatening event

215
Q

Signs and Symptoms of GERD in children 1-5 y/o

A

-regurgitation, abdominal pain, cough
-food refusal, recurrent pneumonia, dental erosions

216
Q

signs of GERD in children > 6

A

refulx esophagitis

217
Q

initial diagnosis of GERD

A

-pH monitoring: pH less than 4 for 15-30 sec
-upper GI endoscopy

218
Q

Treatment for GERD: non-pharm

A

-lifestyle modifications and antirefulx surgery (Nissen fundoplication)

219
Q

H2RAs for GERD tx

A

-maintenaince therapy for MILD
-quick onset, cost-effective
-no need to taper
-builds tolerance
–> famotidine, nizatidone, cimetidine

220
Q

PPIs for GERD tx

A

-most potent, heals esophagitis
negs: limited liquid formualtion, ADs, cost, inc infections (c. diff) & rebound
-1st line for maintenance and erosive esophagitis
-CYP2C19 & 3A4 = BID in kids
-taper off over 4 week when therapy is complete

221
Q

surface agents in GERD tx

A

surcalfate
-coat may heal mucosa, low risk of AEs,
-adjustive to H2RA or PPI in erosive esophagitis

222
Q

hat is the duration of therapy for GERD

A

12 weeks

223
Q

Live attenuated vaccines (6)

A

-MMR
-varicella
-rotavirus
-Influenza (LAIV)
-polio (OPV)
-zoster (ZVL)

224
Q

Toxoid vaccines (2)

A

-diptheria
-tentanus

225
Q

Inactivated vaccines (4)

A

-Hep A
-influenza (IIV)
-pertisus
-Polio (IPV)

226
Q

Inactivated/recombinant vaccines (3)

A

-Hep B
-HPV
-RZV

227
Q

Conjugated/polysaccharide vaccines (3)

A

-HiB
-meningococcal
-pneumoccal

228
Q

Kinrix, Quadracel vaccines are:

A

DTap + IPV

229
Q

Pentacel vaccine is:

A

DTaP + IPV + HiB

230
Q

Pediarix vaccine is:

A

DTaP + IPV + Hep B

231
Q

Proquad vaccine is:

A

MMR + Varicella

232
Q

Twinrix vaccine is:

A

Hep A + HepB (the twins)

233
Q

MenHibrix vaccine is:

A

Hib + MENCY

234
Q

what happens is vaccine is adminsteres > 5 days before the mom dosing interval?

A

should NOT be counted, repeat when age/time approproate

235
Q

what vaccines are rec and CI in pregnancy?

A

rec: influenza IIV & TDaP, COVID-19
CI: HPV, influenza (LAIV), MMR, varicella, Zoster

236
Q

vaccine interaction: chemo/radiation

A

-vaccinate 2 weeks before or 3 months after tx

237
Q

vaccine interactions: systemic corticosteroids –> when is it OK to give?

A

-topical therapy or local injection
-physiologic maintenance therapy
-low/moderate dose systemic

238
Q

vaccine interactions: high dose corticosteroids for < 14 days

A

-can vaccinate immediately or wait ~2 weeks

239
Q

vaccine interactions: high dose corticosteroid for >/= 14 days

A

MUST wait > 1 month to vaccinate

240
Q

what vaccine are given SQ?

A

-herpes zoster
-MMRV
-meningococcal (MPSV-4)
-PPV23 & polio (also given as IM)

241
Q

CI to LAIV influenza vaccine

A

-hx of vaccine allergy
-< 2 y/o and adult > 50y/o
-pregnancy
-children 2-4 y/o with asthma or hx of wheezing
-CSF leaks/cochlear implant
-asplenia
-ASA use
-healthcare workers that work with immunocompromised pts

242
Q

PFIZER 6 month to 4 y/o vaccine series

A

dose 1: 3 mcg, maroon
dose 2: 3-8 weeks later, maroon
dose 3: 8 weeks, bivalent maroon

243
Q

PFIZER 5 y/o vaccine series

A

dose 1: 10 mcg, orange
dose 2: 3-8 weeks later, orange
booster: 2 months later, bivalent orange

244
Q

PFIZER 6-11 y/o vaccine series

A

dose 1: 10 mcg, orange
dose 2: 3-8 weeks later, orange
booster: 2 months later, bivalent orange

245
Q

PFIZER 12-17 y/o vaccine series

A

dose 1: 30 mcg, gray
dose 2: 3-8 weeks later, gray
booster: 2 months later, bivalent gray OR moderana 50 blue cap/gray label

246
Q

MODERNA 6 month- 5yrs vaccine series

A

dose 1: 25 mcg blue cap/magenta
dose 2: 4-8 weeks later, blue cap/magenta
booster: 2 months later, bivalent pink cap/yellow

247
Q

MODRNA 5 yrs vaccine series

A

dose 1: 25 mcg blue cap/magenta
dose 2: 4-8 weeks later, blue cap/magenta
booster: 2 months later, bivalent pink cap/yellow OR Pfizer bivalent orange

248
Q

MODERNA 6-11 y/o vaccine series

A

dose 1: 50 mcg, blue cap/purple
dose 2: 4-8 weeks later, blue cap/purple
booster: 2 months later, bivalent blue cap/ purple OR Pfizer bivalent orange

249
Q

MODERNA 12- 17 y/o vaccine series

A

dose 1: 100 mcg red cap/blue
dose 2: 4-8 weeks later, red cap/blue
booster: 2 months later, blue cap/gray OR pfizer bivalent gray

250
Q

when do you give HGIB with Hep B vaccine

A

-given to any neonate with mother status ? or +
< 2kg: 3 additional doses starting at 1 month
> 2 kg: 2 doses

251
Q

9-14. y/o starting date of HPV/Gardasil vaccine:

A

2 doses, 2nd one 6 months after first

252
Q

15 y/o + or immunicompromised start age of HPV/gardadil vaccine:

A

3 doses, 2nd one 1-2 after first, 3rd one 6 months after first

253
Q

MMR vaccine

A

2 doses, starting at 12 months, 2nd dose 4-6 y/o, separate by 4 weeks if pt misses start date

254
Q

International travel situation with MMR

A

-1 dose should be given at 6-12 months for infant traveling but will not count as real dose and should start series
-unvaccinated > 12 months should receive 2 doses of MMR separated by 4 weeks prior to travel

255
Q

Variecella vaccine age < 13

A

2 doses, seperated by > 3 months

256
Q

Varicella vaccine age > 13

A

2 doses, seperated > 4 weeks apart

257
Q

dose series of menveo or menactra

A

A. dose 1 given at age 11-12 - booster @ 16
B. dose 1 given at 13-15 - booster @ 16-18
C. dose 1 given at > 16 - no booster
-can give menactra and DTap at same time , > 4 weeks after PCV13

258
Q

Bexsero (men B)

A

-for ages 10-25
2 dose, 1-6 months apart

259
Q

Trumenba (men B)

A

-for ages 10-25
3 doses, 0. 1-2 months, 6 months

Peds therapeutics (2 decks)

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