Etiology

Helminths (parasitic worms) & protozoa

US: giardiasis & pinworms. Giardia is making a come back in the US, especially in daycare centers. Some worms can survive a while out side of the body, you catch it by touching something that’s contaminated. Most common infection in the US.

Source: oral/fecal route. Kids like to play with other kids, like to put things in their mouth, spend time at daycare with care providers that change a lot of diapers.

Nsg: Identify organism, treat infections, prevent reinfection & spread

Usually, whole family needs tx

Giardia lamblia , & other family members=protozoa /c flagella

Increased incidence 2nd daycares (17-50% of cases)

Transmission: oral-fecal, contaminated water (pools /c diapers, mountain lakes & streams), food, animals (esp. puppies), splash pads

Can get them in public swimming pools from swimming diapers, then the water gets in to peoples’ mouths. Mountain streams can have it. Any animals can carry giardia. And undercooked food can have it. Giardia is seen under a microscope. Can’t see it by yourself.

Vomiting, diarrhea, anorexia, FTT , abdominal cramps /c intermittent loose stools & constipation, may have sulfur-tasting belches and ↑ flatulence. Stools-malodorous, watery, pale, greasy, floaters. Recurrent. Abdomen is really bloated, really bad smelling poop, unique smell.

Dx : Stools (x3-4) over several weeks, stays in small intestine so you must have repeated stool specimens in order to get a positive.

Tx : metronidazole (Flagyl) and tinidazole (Tindamax)

SE: Flagyl - Metallic taste in the mouth. Don't drink alcohol!

Teach parents, hand washing, hand washing, hand washing! Don’t swim if you have diarrhea. Take a shower before you swim in a pool. Make sure your food is cooked properly. Wipe things down in daycare. Shouldn’t bathe one kid in the same bathtub as another with giardia.

Enterobius vernicularis, found in temperate (mild temperatured) climates, spread in crowded environment (daycare), oral-fecal route.

You get it from other kids, sandboxes, dogs, cats, daycares. Again, they like to put things in their mouth, not good at hygiene.

S/S: ↑anal itching>>scratching>>eggs under nails>>finger to mouth>>you get the picture, might see bed wetting. #1 sign of pinworms is itching their bottom.

Dx: Tape-test - Before the child goes to bed, get a piece of Scotch tape and place it over their anus. After the night, take the piece of tape to the doctor for diagnosis.

Tx: Mebendazole (Vermox), repeat dose 2 wks. Wash all bedclothes in hot water and family members should be treated for worms as well.

Chelation therapy: Anytime a medicine is given to bind with a poison to be excreted. Usually by NG tube lavage with indicated antidote.

Common bc of lack of parental education about dosing; it tastes good for kids.

2-4 hours after ingestion: nausea, vomiting, and sweating

24-36 hours after ingestion: Improvement in condition

36-7 days or longer: hepatic stage, liver toxicity, possibly liver failure - right upper quadrant pain, coagulation problems, jaundice.

Final stage: death or recovery

Treatment: acetylcysteine (Mucomyst). Tastes terrible. Given through NG tube lavage. Must sit them up 90 degrees during lavage.

90% poisonings at home--PREVENTION IS KEY.

Kids like to put things in their mouth AND they like to imitate. If they see Mom or Dad take medicine, they want to take medicine too.

1 st-Call poison control center-1-800-222-1222

Assessment--treat child first, not poison

Time & speed are major factor in good outcomes

Common agents: acetaminophen, aspirin, iron, hydrocarbons, corrosives and lead

#1 symptoms with aspirin poisoning is ringing in the ears. Can be neurotoxic, can have seizures, have a low grade temp, hyperventilation, respiratory alkalosis, n/v, lethargy or excitability. Chronic aspirin will cause bleeding problems. Antidote is activated charcoal. For a 30 lb child, the toxic amount would be 12 adult aspirin and 48 baby aspirin.

Common bc pregnant women usually have iron pills easily accessible

Initial period: vomiting, diarrhea, bloody emesis and stools

Latency period: Improvement

Systemic toxicity period: metabolic acidosis, hyperglycemia, bleeding, fever, shock death

Hepatic injury period: seizures or coma

Treatment: Deferoxamide mesylate (Desferal) lavage through NG tube

Gastric decontamination: forced emesis and gastric lavage no longer, recommended for routine poisoning

Activated charcoal: Used for pts in the ER who've OD'd. Very thick. Can cause aspiration, obstruction of the bowel. Administer in Styrofoam cup with a lid on it. Mix it with something. Most children will not drink, must be lavaged.

Carthartics: Stimulate the bowel into immediate diarrhea to flush the GI system.

Common concern is dehydration!

Specific treatments that counteract the poison. Tylenol: N-acetycysteine (Mucomyst). Opioid OD: Naloxone (Narcan)

Lead paint(<1980,esp <1950’s) & gasoline (no longer), contaminated soil & dust, paint chips, dishes. Lead dust particles can be inhaled.

Young children less than 6 years absorb 50% of lead exposed to (adults 10%). Can affect any body system, mostly neuro, renal, & heme. Tastes sweet. Lead is toxic to the young child’s brain.

↓ Iron & Vit D/Calcium=↑ Lead absorption

Low dose exposure: ADHD-like s/s - easily distracted, impulsive, hyperactive, hearing impaired, mild intellectual disability

High dose exposure: Cognitive impairment, blindness, paralysis, seizures, death

Other symptoms: Renal impairment and anemia.

Routine screening for all children btwn the ages of 1-2 and again btwn the ages of 3-6. There is treatment available, very important to diagnose so it can be treated. Will cause significant neuro impairment if left untreated.

Treatment: Low levels - high vit D and calcium diet

High levels: 1) Succimer (Chemet) - Oral agent, TID for 5 days, BID 14 days

SE: n/v, diarrhea, anorexia, increased liver function tests, neutropenia.

Hydration is essential for excretion through the kidneys

2) Calicum disodium edetate EDTA - IV or IM (mix w/ procaine if IM). Used if BLL greater tan 45 mcg/dl. Monitor: kidneys, BUN, creatinine, CBC. Give 5 days in a row, typically hospitalized. Also excreted in urine.

Wet clean to remove lead dust

Good nutrition to decrease absorption (calcium and iron w/ meals)

Follow up BLL after poisoning, BLL over 20 requires clinical management

Hazard removal to limit exposure, might even have to move

Lead encephalopathy: Permanent, irreversible brain damage and cog impairment.

Even w/ low to moderate exposure may have learning/behavioral problems.

Intentional physical abuse or neglect, emotional abuse, or sexual abuse of children by adults. Can take on different forms and have varying levels.

#1 message is is you suspect child abuse, you’re obligated by law as a nurse to report that to the police so they can investigate. Not the hospital’s job to prove child abuse, but you must report suspected/actual neglect/abuse.

Intentional physical abuse: punching, beating, kicking, biting, burning, shaking, or harming (ex.: shaken baby syndrome). ¾ of child abuse injuries to head, face, mouth, & neck

Child neglect— failure to provide basics. Physical-deprivation of food, clothing, shelter, supervision, medical care, education. Not providing the necessities to a child like food, water, a place to live.

Emotional neglect- Failure to provide love, affection, attention, nurturance and fostering maladaptive behavior.

Emotional abuse or omission- deliberate destruction of child’s self-esteem, rejecting, terrorizing, ignoring, corrupting, verbally assaulting>>cause/could cause serious behavioral, cognitive, emotional, or mental d/o

Sexual abuse of children by adults: fondling, intercourse, incest, rape , sodomy, exhibitionism, commercial exploitation

Emotional abuse almost always present with other types maltreatment

Violence between parents also occurs

These kids are often the “runaways”>>exposed to even more violence and abuse when away from home.

Nursing considerations:

All socioeconomic levels could be victim or abuser, abuser may gain trust of victim before abuse (esp. sexual)

Review p. 979, Box 33-3 “Clinical Manifestations of Potential Child Maltreatment”

Abused children often behave differently from peers

Children will seldom reveal parents are abuser because do not want to lose what security and love they do have.

Children will take responsibility for what has happened & feel guilty

HEADS UP—

PARENTS--who shows little concern, & no understanding of child’s feelings, are very critical of child, and act as if the assault on the child is an assault on them.

CHILD—underattached or overattached to parent

Parental: Not directly related to the child, lack of education, substance abuse, stress, hx of abuse as a child, young single parents, large number of children

Child: Disability, mental impairment, any child that adds stress (like colic), unwanted temperament, unwanted pregnancy, fussy, less independent

Environmental: Poverty, lack of access to medical care, health insurance, and adequate child care, unemployed, overcrowded house, stressful environment, residential instability (moving a lot), military background (drill sergeant parents), high income families w/ nannies, butlers, caretakers, etc.

Interview: quiet neutral location.

Non-leading questions to prevent planting memories. Ask child “can you tell me what happened”, chronological, nonsexual>sexual questions

Video record or chart subjective answers verbatim

Drawings & anatomically correct dolls my help child communicate

Munchausen Syndrome by Proxy (MSBP):

Child parent, usually mother, fabricates or induces child’s illness to gain attention

Often has some medical training/knowledge

Usually dramatic illness /c multiple medical visits/test/procedures

Must involve Child Protective Team>>multidisciplinary effort>>Legal action

Remember abusers generally were abused /c low self-esteem, lack support system,

Typically the mother has some kind of medical training or knowledge. Suspect it anytime the parent tells a story that doesn’t quite match up with what is observed. Frequent medical visits.

Warning signs: Munchausens

unexplained, prolonged, recurrent, or extremely rare illness

discrepancies between clinical findings & hx

illness unresponsive to tx

s/s occuring only in parent’s presence

parents knowledge of illness, tx, procedures

parent very interest interacting with health team members

parent very attentive toward child (refuses to leave hospital)

Family members with similar s/s

RSV, GABHS, Staph, HIB, Chlamydia, mycoplasm, pneumococci, pertussis

Children more vulnerable bc immature immunity (esp.3-6m/o), increased exposure, anatomical differences of a young child. Other risk factors: Poor hygiene around toilet training years, seasonal variations- cold/flu, allergies.

Etiology: 1000’s viruses, some rhinoviruses, adenovirus, influenza, parainfluenza,

S/S:

↓Age>↑Severity bc they breath through their nose and they can’t blow their nose when they’re sick.

Fever common, (3m-3y often sudden), irritable, restless, anorexia, malaise

Nasal obstruction>mouth-breathing

Congestion, coughing, vomiting & diarrhea

4-10d

Rest, ↑fluids, & fever management when appropriate, bedside vaporizer

Decongestants & antihistamines (for sleep aid, not congestion) for infants>6m/o

Cough suppressant for only for DRY, HACKY cough (rare in children), NOT for congested cough

No antibiotics - they won't work bc it's a virus

Hand washing

Flush away the tissues

Hydration

Use vaporizer to thin secretions

No cough suppressants, need to cough secretions up. Use only for dry, hacking cough so they can sleep

Can use a nasal aspirator, but throw them away after the illness

Call the doctor when: the cold doesn’t get better after 10 days, a fever that lasts over 24 hours or is higher than 101, not having as many wet diapers or not urinating as much (dehydration), any wheezing, tachypnea, nasal flaring, retractions, grunting, or stridor bring them to the doctor.

Most common dx in primary care

Boys>girls

<In winter months

Typically, pain will happen after the membrane ruptures. Drainage, swollen lymph nodes, high fever (104 common), anorexia, don’t like to eat or drink the bottle (sucking aggravates pain), irritability, and pulling of the ears or hitting of the head.

Children younger than 2 are high risk. Then it returns around age 5.

Risk factors: Any child who has a cold, allergies, attends daycare, exposed to second hand smoke, cleft palate, down syndrome, bottle propped babies.

Dx: Based on clinical s/s through pneumatic otoscopy and tympanometry (measures TM mobility and patency)

Tx: Supportive care: manage fever and pain

80% of children younger than have spontaneous resolution with not antibiotics.

Antibiotics used: High dose amoxicillin (augmentin ES) - gives horrible diarrhea

A cephalosporin or Bactrim.

None work 100% anymore bc of overuse and increased resistance.

Children who get multiple ear infections usually get bilateral myringotomy tubes. They relieve the pressure and allow the ear to drain so fluid doesn’t fester in the ear and cause other ear infections. They’ll fall out on their own. With the tubes, they can put antibiotics in ear drop form.

Untreated ear infections cause hearing loss.

Droplet precautions: Mask w/ goggles or face shield and gown required.

Caused by a certain strain of strep throat virus (GABHS).

S/s: Rash called a sand paper rash that’s itchy, appears all over the body, during first 1-2 days the tongue is swollen and white. After the first couple days, the white stuff comes off tongue is red (strawberry tongue), swollen glands, high fever, facial rash.

Strep throat is GABHS infection of upper airway.

S/s: sore throat, swollen glands, fever, abdominal pain, headache.

Treatment: Oral penicillin for 10 days.

Teaching: MUST treat sore throat bc it can lead to glomerulonephritis and rheumatic fever (inflammation of the heart, can affect joints and brain, has long lasting effects), take all antibiotics as directed, do not return to school until on antibiotics for 24 hours.

Can be viral or bacterial

Inflammation causes edema

Mouth breathers are more susceptible

Exudate, pus, food or other particles stuck in tonsils

Treatment: pain relief, rest, antibiotics if indicated, cool mist vaporizer, soft or liquid diet, warm salt water gargles, tonsillectomy

Children who get them: any child who has sleep apnea, repeated tonsillitis (more than 3 times a year), persistent foul smelling breath or bad taste in their mouth.

Children who shouldn’t get them out: Any child w/ bleeding disorder, cleft palate.

Nursing interventions:

• Monitor for swelling and bleeding
• HOB elevated
• Pain management ATC w/ Tylenol
• Monitor for continuous swallowing - a sign of hemorrhage

Teaching:

• Avoid coughing, clearing throat, blowing nose, straws
• Hydration: no red or brown fluids - could look like blood or hide hemorrhage. Drink cool, clear fluids
• Avoid milk products - acts like a film over tonsils that they want to clear out
• Don't want them crying - soothe them by picking them up
• Don't blow their nose, drink through straws, cough, clear throat. Don't want to loosen clots in the throat.

Caused by Epstein-Barr virus

Transmitted by saliva

Incubation period 10-50 days

S/s: Fever, sore throat, enlarged nodes, liver, spleen, increase in atypical lymphocytes, macular rash, palantine tonsils petechiae

Usually 7-10 days of acute symptoms. Fatigue then takes effect for weeks or months.

Dx: Blood test called Monospot

Tx: Rest, no contact sports if spleen enlarged

Swelling and edema in the airway

Risk for resp distress

Usually affects children from 3 months to 3 years

Usually viral

See more in fall and winter months

Severe enough will cause resp obstruction and hypoxia

Typically, kids have a cold beforehand

Slow onset, barking cough, "crowing" sounds, inspiratory stridor, worse at night, slight temp (102), restlessness, retractions (if resp distress).

Mild croup: manage at home

Vigilant observation and assessment for resp distress: retractions, restlessness/anxiety, nasal flaring, tachycardia, tachypnea.

Have intubation equipment nearby in the hospital

Keep calm, don’t let cry, reassure

Sit up

Treatment:

Racemic epinephrine: causes vasoconstriction - inhaled right into lungs

Steroids – inhaled or IV

Fluids

Swelling of the epiglottis. Can also result in airway obstruction. Signs of resp distress. Have drooling and inspiratory stridor.

Medical emergency that comes on quickly and the children go down quickly. Usually caused by bacteria (need antibiotics).

Never examine the throat of the child with a tongue blade, might cause the airway to close off.

3 clinical observations that are associated with epiglottitis: 1. drooling 2. agitated/anxious 3. absence of spontaneous cough. Typically presents with child sitting up in tripod position, prefer to sit upright.

Treatments are first to sit them up and decrease anxiety. Meds are racemic epinephrine.

A chronic inflammatory disorder of the airways that results in intermittent obstruction

Obstruction is caused by inflammation and airway hyper-responsiveness

Who is at risk: Young children, children exposed to cig smoke, children with allergies or airway hypersensitivity, hx of asthma in the family.

Smoking, reflux, allergies, exercise, resp infections, temp changes, cold air, stress, emotions, strong odors, medications, food additives, pollutants, gastric reflux.

ASTHMA:

Adrenergics

Steroids - will not abort your asthma attack. Albuterol will open airway so steroids can get inside

Theophylline - given IV to pts who don't respond to normal therapy

Hydration (IV)

Mask O2

Anticholinergics - Quick acting agents used for brochodilating

When the child is well: take a deep breath and blow as hard and fast into the meter as you can. It's the standard to compare to when having an attack. Gives a good indicator of how asthma is affecting oxygenation.

Come to hospital when breathing 50% of the normal AFTER albuterol treatment.

Respiratory assessment

Check ABGs, SaO2, CBC and xray results

High Fowlers position

Oxygen therapy as ordered

Initiate and maintain IV access

Be calm

Treat infections

Medications: Use spacer w/ steroids bc of candidiasis. Gargle after to rinse out of the mouth.

Life threatening airway obstruction unresponsive to usual treatment. Emergency.

Symptoms: Does not respond to usual tx, usually in ICU, distended neck veins, cardiac and resp arrest.

TX: administer humidified oxygen

Assist with intubation

Medications

IV access