Editing Pediatric Nursing (section)

== Common childhood illnesses ==

=== Otitis media ===

Presents with ear pain, ear tugging in preverbal children, fever, irritability, and a bulging, erythematous, immobile tympanic membrane. Feeding an infant '''flat on the back with a propped bottle''' and exposure to tobacco smoke are modifiable risk factors. Many cases are managed with observation and analgesia; antibiotics are prescribed for younger infants, severe symptoms, or bilateral disease. Teach caregivers to complete the entire antibiotic course. After myringotomy with tympanostomy tube placement, teach that '''drainage for a few days is expected''' and that tubes usually extrude spontaneously in 6 to 12 months.

=== Croup (laryngotracheobronchitis) ===

Viral, usually in children 6 months to 3 years, gradual onset, often worse at night. Findings are a '''barking or seal-like cough, inspiratory stridor, and hoarseness''' with low-grade fever. Radiography, if obtained, shows the '''steeple sign'''. Management is '''corticosteroids (dexamethasone)''' for nearly all cases and '''nebulized epinephrine''' for stridor at rest, with humidified air and hydration. Keep the child calm, because crying worsens obstruction. Home advice includes cool night air or a cool-mist humidifier.

=== Epiglottitis ===

A true airway emergency, now uncommon because of '''Haemophilus influenzae'''  type b vaccination. Onset is abrupt with high fever and a toxic appearance. Remember the '''four Ds: drooling, dysphagia, dysphonia, and distress''', plus the '''tripod position''' with the chin thrust forward, absence of a cough, and muffled voice.

'''Application note.''' '''Do not inspect the throat, do not obtain a throat culture, and do not place anything in the mouth''', including a tongue blade, because laryngospasm and complete obstruction can result. Keep the child upright in the caregiver's lap, keep the child calm, give nothing by mouth, administer oxygen if tolerated, and notify the provider immediately while emergency airway equipment and personnel are assembled.

=== Bronchiolitis and respiratory syncytial virus ===

Most common in infants under 2 years. Begins with rhinorrhea and progresses to wheezing, tachypnea, retractions, and poor feeding. '''Apnea may be the presenting sign in young infants and in former preterm infants.''' Management is supportive: nasal suctioning before feeds, hydration, oxygen, and monitoring. '''Contact plus droplet precautions''' are required. Palivizumab or an equivalent monoclonal antibody may be given as prophylaxis to high-risk infants; it is prophylaxis, not treatment.

=== Asthma ===

Chronic airway inflammation with reversible obstruction. Teach the distinction between '''rescue''' medication (short-acting beta-2 agonist such as albuterol) and '''controller''' medication (inhaled corticosteroid taken daily even when well). Teach spacer use with a mask for younger children, rinsing the mouth after inhaled corticosteroids to prevent oral candidiasis, and peak flow zones (green 80 to 100 percent of personal best, yellow 50 to 79 percent, red below 50 percent). A '''quiet chest with absent wheezing in a child in distress signals severe obstruction and is worse, not better'''.

=== Gastroenteritis and dehydration ===

Dehydration is graded by weight loss and clinical signs. Early findings include decreased urine output, dry mucous membranes, and absence of tears. Later findings are sunken eyes and fontanel, poor skin turgor, tachycardia, and lethargy. '''Weight change is the most accurate measure of fluid loss in children.'''

* '''Oral rehydration solution is first-line for mild to moderate dehydration''', given in small frequent volumes. Plain water, juice, soda, and sports drinks are inappropriate because of inadequate or unbalanced electrolyte content.
* Severe dehydration or shock is treated with a '''20 mL/kg bolus of isotonic crystalloid''' (0.9 percent sodium chloride or lactated Ringer's), which may be repeated with reassessment after each bolus.
* Rotavirus vaccine has substantially reduced severe infantile gastroenteritis.
* Contact precautions apply; alcohol-based hand rub is not reliable against norovirus or ''Clostridioides difficile'', so use soap and water.

=== Pyloric stenosis ===

Typically presents at '''3 to 6 weeks of age''' with '''projectile, non-bilious vomiting''' immediately after feeding, in an infant who is '''hungry again right afterward'''. A firm, olive-shaped mass may be palpable in the right upper quadrant, and visible peristaltic waves may cross the abdomen. Loss of gastric contents produces '''hypochloremic, hypokalemic metabolic alkalosis'''. Treatment is pyloromyotomy after fluid and electrolyte correction.

=== Intussusception ===

Telescoping of bowel, most often between 3 months and 3 years. Sudden, severe, '''colicky abdominal pain with the knees drawn to the chest''', alternating with pain-free intervals; vomiting; a '''sausage-shaped right-sided abdominal mass'''; and the late finding of '''"currant jelly" stools''' containing blood and mucus. Treated with air or hydrostatic contrast enema, with surgery if that fails. '''The passage of a normal brown stool may indicate spontaneous reduction and must be reported immediately, because it changes the plan of care.'''

=== Kawasaki disease ===

An acute vasculitis of young children. Classic criteria are '''fever lasting 5 or more days''' plus at least four of: '''bilateral non-exudative conjunctivitis; oral changes including strawberry tongue and cracked lips; polymorphous rash; extremity changes with erythema and edema of the hands and feet followed by periungual peeling; and unilateral cervical lymphadenopathy'''. The child is characteristically extremely irritable.

'''Application note.''' The danger is '''coronary artery aneurysm'''. Treatment is '''intravenous immunoglobulin plus aspirin''', and echocardiography is obtained at baseline and in follow-up. Kawasaki disease is one of the few pediatric indications for aspirin. Because IVIG contains live-virus antibodies, '''live vaccines such as measles-mumps-rubella and varicella must be deferred for about 11 months''' after high-dose IVIG.

=== Febrile seizures ===

Usually occur between 6 months and 5 years with a rapid rise in temperature. Simple febrile seizures are generalized, last under 15 minutes, and do not recur within 24 hours. Nursing care is protective: '''turn the child to the side, do not restrain, do not put anything in the mouth''', protect the head, note the time and characteristics, and stay with the child. Antipyretics treat comfort; they have not been shown to prevent recurrence.

=== Bacterial meningitis ===

Findings include fever, headache, photophobia, nuchal rigidity, and altered consciousness. In infants the presentation is nonspecific: poor feeding, high-pitched cry, irritability that worsens when held, a '''bulging fontanel''', and hypothermia or fever. '''Droplet precautions are initiated on suspicion and continued for 24 hours after effective antibiotic therapy begins.''' Position the child with the head of the bed slightly elevated, keep the room quiet and dim, and monitor for increased intracranial pressure and for seizures.

=== Other frequently tested conditions ===

* '''Sickle cell disease:''' vaso-occlusive crisis is managed with hydration, oxygen, warmth, and scheduled analgesia including opioids. '''Cold, dehydration, infection, stress, and high altitude precipitate crises.''' Never apply cold to a painful area. Splenic sequestration presents with a rapidly enlarging spleen and shock and is an emergency.
* '''Cystic fibrosis:''' thick secretions affect lungs, pancreas, and reproductive tract. Findings include meconium ileus in the newborn, steatorrhea, failure to thrive despite a large appetite, and a positive '''sweat chloride''' test. Give '''pancreatic enzymes with every meal and snack''', a high-calorie, high-protein diet, and airway clearance therapy.
* '''Type 1 diabetes mellitus:''' teach carbohydrate counting, rotation of injection sites, sick-day rules, and hypoglycemia treatment with 15 grams of fast-acting carbohydrate. Adolescents may omit insulin for weight control or peer reasons; assess for this.
* '''Nephrotic syndrome''' presents with '''massive proteinuria, hypoalbuminemia, and generalized edema with periorbital swelling worst in the morning'''; corticosteroids are the mainstay. '''Acute post-streptococcal glomerulonephritis''' presents 1 to 3 weeks after a streptococcal infection with '''tea-colored or smoky urine, hypertension, mild edema, and only modest proteinuria'''.
* '''Reye syndrome:''' acute encephalopathy with fatty liver change linked to salicylate use during viral illness. Therefore '''aspirin is avoided in children with viral illness such as influenza or varicella''' unless specifically indicated as in Kawasaki disease.
* '''Congenital heart disease:''' signs of heart failure in infants include '''poor feeding, diaphoresis while feeding, tachypnea, tachycardia, and poor weight gain'''. In tetralogy of Fallot, a hypercyanotic "tet" spell is managed by placing the infant in the '''knee-chest position''' and giving oxygen while calming the child.