The child dysfunctions with Respiratory Dysfunctions

Infections of the Lower Airways

Considered the "reactive" portion of the lower respiratory tract Includes bronchi and bronchioles Cartilaginous support is not fully developed until adolescence Constriction of airways

Manifestations of LTB

Inspiratory stridor Suprasternal retractions Barking or seal-like cough Increasing respiratory distress and hypoxia Can progress to respiratory acidosis, respiratory failure, and death

Respiratory Manifestations of CF

Present in almost all CF patients, but the onset and extent vary Viscous secretions are difficult to expectorate and obstruct bronchi and bronchioles Cause atelectasis and hyperinflation Stagnant mucus leads to destruction of lung tissue Stagnant mucus provides a favorable environment for bacteria growth

Treatment Goals for CF

Prevent or minimize pulmonary complications Adequate nutrition for growth Assist the child in adapting to a chronic illness

influenza diagnosis

DIAGNOSIS: is confirmed by analyzing nasopharyngeal secretions for viral culture or rapid detection testing. Influenza A and B can be rapidly detected by direct fluorescent antibody and indirect immunofluorescent antibody staining.

Nursing Interventions for Respiratory Infections

Ease the respiratory effort Manage fever Promote rest and comfort Control infection Promote hydration and nutrition Provide family support and teaching

Asthma Interventions

Exercise Evaluate for EIB Chest physical therapy (CPT) Breathing exercises Hyposensitization

Aspiration Pneumonia

Risk for a child with feeding difficulties Prevention of aspiration Feeding techniques and positioning Avoid aspiration risks Oily nose drops Solvents Talcum powder

E-cigarettes

A 2014 study showed wide ranging nicotine levels in e-cigarettes and substantial variability between listed and actual nicotine levels in these products. In 2009, the FDA conducted lab tests and found detectable levels of toxic cancer-causing chemicals, including an ingredient used in antifreeze, in two leading brands of e-cigarettes and 18 various cartridges. A 2014 study found that e-cigarettes with a higher voltage level have higher amounts of formaldehyde, a carcinogen. It is urgent for FDA to begin its regulatory oversight of e-cigarettes, which would require ingredient disclosure to FDA, warning labels and youth access restrictions

Acute Spasmodic Laryngitis

Also known as spasmodic croup or midnight croup Recurrent paroxysmal attacks Occurs chiefly at night Inflammation is mild or absent Therapeutic management Children with spasmodic croup are managed at home. Cool mist is recommended for the child's room. Warm mist provided by steam from hot running water in a closed bathroom may be helpful. Humidification may help, but warm temperatures will not relieve the constriction. Sometimes sudden exposure to cold air relieves the spasm (as when the child is taken out into the night air to see the practitioner). Parents are usually advised to have the child sleep in humidified air until the cough has subsided to prevent subsequent episodes. Children with moderately severe symptoms may be hospitalized for observation and therapy with cool mist and racemic epinephrine, as for LTB. Patients may respond to corticosteroid therapy. The disease is usually self-limiting.

Bronchitis

Also known as tracheobronchitis Definitions Causative agents Clinical manifestations Bronchitis (sometimes referred to as tracheobronchitis) is an inflammation of the large airways (trachea and bronchi) that is frequently associated with a URI. Viral agents are the primary cause of the disease, although M. pneumoniae is a common cause in children older than 6 years of age. The condition is characterized by a dry, hacking, and nonproductive cough that is worse at night and becomes productive in 2 or 3 days. Bronchitis is a mild, self-limiting disease that requires only symptomatic treatment, including analgesics, antipyretics, and humidity. Cough suppressants may be useful to allow rest, especially at night, but can interfere with clearance of secretions. Most patients recover uneventfully in 5 to 10 days. Adolescents with chronic bronchitis (>3 months) should be screened for tobacco or marijuana use. Chronic bronchitis can be associated with underlying conditions such as CF and bronchiectasis.

Goals of Asthma Management

Avoid exacerbation Avoid allergens Relieve asthmatic episodes promptly Relieve bronchospasm Monitor function with a peak flow meter Self-management of inhalers, devices, and activity regulation Support child, adolescent, and family

Standards of Care

CPR Pediatric advanced life support (PALS)

Respiratory Management of CF

CPT Bronchodilator medication Forced expiration Aggressive treatment of pulmonary infections Home IV antibiotic therapy Aerosolized antibiotics Pneumothorax Hemoptysis Nasal polyps Steroids or nonsteroidal anti-inflammatory drugs (NSAIDs) Transplantation

Acute Asthma Care

Calm nursing presence Monitor with pulse oximetry Allow older children to sit up if they are more comfortable in that position Allow parents to remain with children

Pneumonia

Causative organism varies greatly by age category The most useful classification is etiologic agent Viral Bacterial Mycoplasmal Aspiration of foreign substances

Pertussis (Whooping Cough)

Caused by Bordetella pertussis In the United States, it occurs most often in children who have not been immunized Highest incidence is in spring and summer Highly contagious Risk to young infants Effectiveness of vaccine (booster)

Croup Syndromes

Characterized by hoarseness, barking cough, inspiratory stridor, and varying degrees of respiratory distress Croup syndromes affect the larynx, trachea, and bronchi Epiglottitis, laryngitis, laryngotracheobronchitis (LTB), tracheitis

Infectious Mononucleosis

Characterized by increased mononuclear elements of the blood; general symptoms of an infectious process Common among adolescents Principal cause is Epstein-Barr virus Self-limiting; no specific treatment

Pathophysiology of CF

Characterized by several clinical features Increased viscosity of mucous gland secretions Responsible for many of the clinical manifestations Elevation of sweat electrolytes Increase in several organic and enzymatic constituents of saliva Abnormalities in the autonomic nervous system Increase in sodium and chloride in saliva and sweat

Further Respiratory Progression

Chronic hypoxemia causes contraction and hypertrophy of muscle fibers in pulmonary arteries and arterioles Pulmonary hypertension Cor pulmonale Pneumothorax Hemoptysis

Asthma

Chronic inflammatory disorder of the airways Recurring episodic symptoms Wheezing Breathlessness Chest tightness Cough (especially at night) Limited air flow or obstruction that reverses spontaneously or with treatment Bronchial hyperresponsiveness

Family Support for the Child with CF

Coping with the emotional needs of the child and family Child requires treatments multiple times each day Frequent hospitalizations Implications of genetic transmission of disease

Bronchiolitis and RSV

Definitions Respiratory syncytial virus (RSV) Pathophysiology Diagnostics Therapeutic management Prevention of RSV: prophylaxis Nursing considerations Diagnostic Evaluation Because RSV infection may be manifested as a URI, it is often difficult to identify the specific etiologic agent by clinical criteria alone. The most difficult distinction is between RSV and asthma, since both conditions involve the lower airway and have similar symptoms. Identification has been simplified by the development of tests done on nasopharyngeal secretions, using either rapid immunofluorescent antibody-direct fluorescent antibody staining or enzyme-linked immunosorbent assay techniques for RSV antigen detection. The more traditional viral culture is becoming obsolete, since it takes several days to get a result. Other simultaneous viral or bacterial infections may occur with RSV. The infant should be carefully evaluated for the presence of urinary tract infection, meningitis, and bacteremia; antibiotics are prescribed only for a coexisting bacterial infection. Therapeutic Management Uncomplicated cases of bronchiolitis are treated symptomatically with supplemental oxygen as required, adequate fluid intake, airway maintenance, and medications. Most children with bronchiolitis can be managed at home. Hospitalization is usually recommended for children with respiratory distress or those who cannot maintain adequate hydration. Other reasons for hospitalization include complicating conditions, such as underlying lung or heart disease (e.g., prematurity), or caregiver inability to provide adequate care during illness. The child who is tachypneic or apneic, has marked retractions, seems listless, or has a history of poor fluid intake should be admitted. Pneumonia and electrolyte imbalance are commonly seen in infants who are hospitalized with RSV infection. The American Academy of Pediatrics practice parameter (2006) recommends the use of supplemental oxygen if the infant fails to maintain a consistent oxygen saturation of at least 90% after nasal suctioning and repositioning. Routine chest physiotherapy (CPT) is not recommended (Roque Figuls, Gine-Garriga, Granados Rugeles, et al, 2012); infants with abundant nasal secretions benefit from periodic nasopharyngeal or nasal suctioning. Fluids by mouth may be contraindicated because of tachypnea, weakness, and fatigue. Therefore, IV fluids are preferred until the acute stage of the disease has passed. Nasogastric fluids may be required if the infant is unable to tolerate oral fluids and a peripheral IV is difficult to establish. Clinical assessments, noninvasive oxygen monitoring, and, in severe cases, blood gas values guide therapy. Medical therapy for bronchiolitis is primarily supportive and aimed at decreasing airway hyperresonance and inflammation, and promoting adequate fluid intake. Bronchodilators are not recommended and are rarely beneficial. A short-acting β-agonist bronchodilator may be given as a test dose initially in case reactive airway disease is present; if no improvement occurs, the medication is discontinued. Approximately 50% of infants with RSV lower airway infection and obstruction respond to a short acting β-agonist. Some centers use racemic epinephrine to produce modest improvement in ventilation status. The use of 3% nebulized (hypertonic) saline is associated with an increase in mucociliary clearance in children with RSV (Sorce, 2009) and has shown to be effective in treating RSV in a few small studies (Seiden and Scarfone, 2009). The use of systemic corticosteroids is controversial but may be used in some centers. Some studies have reported prolonged viral shedding with corticosteroid use. Antibiotics are not part of the treatment of RSV unless there is a coexisting bacterial infection such as OM or pneumonia (American Academy of Pediatrics, 2006). Additional treatment recommendations in the American Academy of Pediatrics practice guideline (2006) are to encourage breastfeeding, avoid passive tobacco smoke exposure, and promote preventive measures, including hand washing and the administration of palivizumab (Synagis) to high-risk infants. Ribavirin, an inhaled antiviral agent (synthetic nucleoside analog), is the only specific therapy approved for hospitalized children. However, use of this drug in infants with RSV is controversial because of concerns about the high cost, aerosol route of administration, potential toxic effects among exposed health care personnel, and conflicting results of efficacy trials (American Academy of Pediatrics, 2006; Chávez-Bueno, Mejías, Jafri, et al, 2005; Ventre and Randolph, 2007). The only product available in the United States for prevention of RSV is palivizumab, a humanized mouse monoclonal antibody, that is given once every 30 days (15 mg/kg) between November and March. It is usually given as an IM injection but may also be given IV. Candidates for this drug include: • Infants born before 32 weeks' gestation • Infants and children younger than 2 years of age with bronchopulmonary dysplasia who have received medical therapy (supplemental oxygen, bronchodilator, diuretic, or corticosteroid therapy) for the condition within 6 months before the anticipated RSV season Additionally, infants born 32 to less than 35 weeks' gestation may receive it: • If less than 3 months before the onset of or during the RSV season • If at least one of the two risk factors is present (attends day care, at least one other child younger than age 5 in the household) • If under 3 months of age The cost of the antibody is approximately $1200 per dose. In addition, some children acquire the illness despite palivizumab prophylaxis. Nursing Care Management Children admitted to the hospital with suspected RSV infection may need separate rooms or rooms with other RSV-infected children. Use Droplet, Contact, and Standard Precautions, including hand washing, not touching the nasal mucosa or conjunctiva, and using gloves, gowns, and masks when entering the patient's room. Other isolation procedures of potential benefit are those aimed at diminishing the number of hospital personnel, visitors, and uninfected children in contact with the child. In some cases, visitors, especially children, may be screened for illness before being allowed to visit high-risk infants. Another measure is to make patient assignments so that nurses assigned to children with RSV are not caring for other patients who are considered high risk. Infants with RSV infection often have copious nasal secretions, making breathing and nursing or bottle-feeding difficult. This engenders concerns that the child will lose weight or stop breastfeeding altogether. Encourage breastfeeding mothers to pump their milk and store appropriately for later use. (See Chapter 7.) Parents should learn how to instill normal saline drops into the nares and suction the mucus with a bulb syringe before feedings and before bedtime so the child may eat and rest better; unfortunately no medications appropriate for infants can help with these symptoms. To address the issue of decreased fluid intake, parents may offer small amounts of fluids, 5 to 10 ml at a time, with a medication syringe every 10 minutes or so. Infants may cough or vomit as the secretions settle in the stomach and make them prone to emesis of such secretions. The nurse aims additional interventions at monitoring oxygenation with pulse oximetry, ensuring any bronchodilator therapy is optimized by using a small mask for delivery (versus blow-by), monitoring IV fluids or NG fluids administered, monitoring fever and administering antipyretics, and providing information for the parent regarding the infant's status. Inform the parents that the infant's cough may persist for a few weeks. The critically ill infant with RSV usually is placed in the pediatric intensive care unit for continuous monitoring of respiratory status, cardiac output, and maintenance of adequate systemic pressure. IV fluids, antibiotics, mechanical ventilation, and inotropes may be required if the child is unstable. Parents and family members need emotional support and information regarding the child's status during this crisis. The unpredictability of the infant's individual response to the disease compounds parental anxiety. However, in most cases the infant recovers quickly from the disease and resumes normal daily activities, including fluid intake. Such infants are at risk for further episodes of wheezing that may or may not involve an RSV infection. Reinfection with the virus may occur in the same season, but subsequent infections are not as severe as the first. Families are educated to avoid exposure to secondhand smoke and about the importance of hand hygiene, especially with high-risk infants who are at risk for exposure to respiratory infections from other family members or contacts.

Prognosis of CF

Estimated life expectancy for a child born with CF in 2008 was 37.4 years CF continues to be a progressive, incurable disease Organ transplantation has increased the survival rate Heart-lung and bilateral lung transplantation Liver and pancreas transplantation Maximize health potential Nutrition Prevention and early aggressive treatment of infection Pulmonary hygiene

Cystic Fibrosis (CF)

Exocrine gland dysfunction that produces multisystem involvement Most common lethal genetic illness among Caucasian children Autosomal recessive trait Child inherits a defective gene from both parents, with an overall incidence of 1:4 Approximately 3% of the U.S. Caucasian population are symptom-free carriers

Clinical Manifestations of pharyngitis

GABHS infection is generally a relatively brief illness that varies in severity from subclinical (no symptoms) to severe toxicity. The onset is often abrupt and characterized by pharyngitis, headache, fever, and abdominal pain. The tonsils and pharynx may be inflamed and covered with exudate (50% to 80% of cases) which usually appears by the second day of illness. However, streptococcal infections should be suspected in children over the age of 2 years who have pharyngitis even if no exudate is present Anterior cervical lymphadenopathy (30% to 50% of cases) usually occurs early, and the nodes are often tender. Pain can be relatively mild to severe enough to make swallowing difficult. Clinical manifestations usually subside in 3 to 5 days unless complicated by sinusitis or parapharyngeal, peritonsillar, or retropharyngeal abscess. Nonsuppurative complications may appear after the onset of GABHS—acute nephritis in about 10 days and rheumatic fever in an average of 18 days. Children who are GABHS carriers may have a positive throat culture but often experience a coincidental viral illness. Although antibiotic administration is not indicated for most GABHS carriers, some conditions require antibiotic therapy

Pharyngitis: What does it Cause

GABHS infection of the upper airway (strep throat) is not in itself a serious disease, BUT: affected children are at risk for serious sequelae: acute rheumatic fever, which is an inflammatory disease of the heart, joints, and central nervous system. There can be permanent damage from sequelae like Acute rheumatic fever. GABHS: May cause skin manifestations like Impetigo and pyoderma. Scarlet Fever may also occur: W/ Manifestation like pharyngitis, and rashes. Scarlet fever may also occur as a result of a strain of group A streptococcus. The clinical manifestations of scarlet fever include pharyngitis and a characteristic erythematous sandpaper-like rash; otherwise scarlet fever shares the same clinical manifestations as those mentioned for GABHS, and treatment and sequelae are the same. Severe scarlet fever is rarely seen in the United States.

Respiratory Progression

Gradual progression follows chronic infection Bronchial epithelium is destroyed Infection spreads to peribronchial tissues, weakening the bronchial walls Peribronchial fibrosis Decreased exchange of O2 and CO2

Therapeutic Management of Bacterial Tracheitis

Humidified oxygen Antipyretics Antibiotics May require intubation Bacterial tracheitis, an infection of the imucosa and soft tissues of the upper trachea, is a distinct entity with features of both croup and epiglottits. The disease occurs typically at a mean age between 5 and 7 years and may cause severe airway obstruction. It is believed to be a complication of LTB, and although Staphylococcus aureus is the most frequent organism responsible, M. catarrhalis, S. pneumoniae, S. pyogenes, and H. influenzae have also been implicated. Anteroposterior or lateral neck x-rays show narrowing (Steeple sign), and infiltrates may be seen. An endoscopy may be performed in the operating room (OR) or intensive care unit (ICU) for diagnosis and to obtain cultures of the secretions. Many of the manifestations of bacterial tracheitis are similar to those of LTB but are unresponsive to LTB therapy. There is a history of previous URI with croupy cough, stridor unaffected by position, toxicity, absence of drooling, respiratory distress, and high fever. A prominent manifestation is the production of thick, purulent tracheal secretions. Respiratory difficulties are secondary to these copious secretions. Children with this condition may develop a life-threatening upper airway obstruction, respiratory failure, acute respiratory distress syndrome (ARDS), and multiple organ dysfunction (Hopkins, Lahiri, Salerno, et al, 2006; Shargorodsky, Whittenmore, and Lee, 2010). Therapeutic and Nursing Care Management Bacterial tracheitis requires vigorous management with antipyretics, fluid status, and antibiotics (10-day course). A trial of inhaled bronchodilators may be performed but is generally not beneficial. Many children require endotracheal intubation and mechanical ventilation; patients are closely monitored for impending respiratory failure if not intubated. Early recognition to prevent life-threatening airway obstruction is essential.

Bacterial Tracheitis

Infection of the mucosa of the upper trachea Distinct entity with features of croup and epiglottitis Clinical manifestations are similar to those of LTB Affects children younger than age 3 years May be a complication of LTB Thick, purulent secretions result in respiratory distress

Influenza

Influenza (the "flu") is caused by three of the orthomyxoviruses, which are antigenically distinct: types A and B, which cause epidemic disease (and are included in the vaccine), and type C, which causes milder illness and is not included in the vaccine. The viruses undergo significant changes from time to time. Major changes that occur at intervals of usually 5 to 10 years are called antigenic shift; minor variations within the same subtypes, antigenic drift, occur almost annually. Consequently, antigenic drift can alter the virus sufficiently to result in susceptibility of individuals to a type for which they were previously immunized or infected. The disease is spread from one individual to another by direct contact (large-droplet infection) or by articles recently contaminated by nasopharyngeal secretions. There is no predilection for a specific age-group, but attack rates are highest in young children who have not had previous contact with a strain. It is frequently most severe in infants and older adults. During epidemics, infection among school-age children is believed to be a major source of transmission in a community. Influenza is more common during the winter months. The disease has a 1- to 4-day incubation period, and affected persons are most infectious for 24 hours before and after the onset of symptoms. The virus has a peculiar affinity for epithelial cells of the respiratory tract mucosa, where it destroys ciliated epithelium with metaplastic hyperplasia of the tracheal and bronchial epithelium with associated edema. The alveoli may also become distended with a hyaline-like material. The viruses can be isolated from nasopharyngeal secretions early after the onset of infection, and serologic tests identify the type by complement fixation or the subgroups by hemagglutination inhibition. Outbreaks in the community can last many weeks. H1N1 (swine flu) is a subtype of influenza type A. In 2009, a pandemic of H1N1 caused significant morbidity and mortality, particularly in Mexico and the United States, and it was declared at an end in August 2010. The signs and symptoms of H1N1 flu are the same as those mentioned below for influenza. A pandemic is defined by the World Health Organization (WHO) as the spread of a new disease to which the population has little or no immunity and that spreads rapidly from human to human. The H1N1 vaccine has been included in the seasonal influenza vaccination since the 2011-2012 season. Occasionally influenza type A disease can be caused by a virus that had a swine or avian origin. Any influenza virus that is novel in nature is reportable to the Centers for Disease Control and Prevention.

Drug Therapy for Asthma

Long-term control medications Preventive Quick relief medications Rescue Metered-dose inhaler (MDI) Corticosteroids Cromolyn sodium Albuterol, metaproterenol, terbutaline Long-term bronchodilators (salmeterol [Serevent]) Theophylline (monitor serum levels) Leukotriene modifiers Others

Therapeutic management Tonsilitis

Medical Treatment: Because the illness is self-limiting, treatment of viral pharyngitis is symptomatic. Throat cultures positive for GABHS infection require antibiotic treatment. It is important to differentiate between viral and streptococcal infection in febrile, exudative tonsillitis. Because the majority of infections are of viral origin, early rapid tests can eliminate unnecessary antibiotic administration. Surgical Treatment: Tonsilectomy: may be indicated for massive hypertrophy that results in difficulty breathing or eating. Absolute indications are peritonsillar abcess, airway obstruction, tonsillitis resulting in febrile seizures, and tonsils requiring tissue pathology. Adenoidectomy: recommended for children who have hypertrophied adenoids that obstruct nasal breathing; additional indications for adenoidectomy include recurrent adenoiditis and sinusitis, OM with effusion, airway obstruction and subsequent sleep-disordered breathing, and recurrent rhinorrhea Contraindications to either tonsillectomy or adenoidectomy are (1) cleft palate, since both tonsils help minimize escape of air during speech; (2) acute infections at the time of surgery because the locally inflamed tissues increase the risk of bleeding; and (3) uncontrolled systemic diseases or blood dyscrasias. Surgical Treatment Surgical treatment of chronic tonsillitis is controversial. Except in documented cases of recurrent, frequent streptococcal infection or a history of development of a peritonsillar abscess, tonsillectomy is not indicated in the child who has recurrent pharyngitis. Tonsillectomy (surgical removal of the palatine tonsils). Adenoidectomy (the surgical removal of the adenoids. lists the following criteria for consideration of tonsillectomy: at least seven episodes in the previous year, at least five episodes in each of the previous 2 years, or at least three episodes in each of the previous 3 years. They clarify that one episode of tonsillitis is a sore throat plus at least one of the following: temperature greater than 100.9° F (38.3° C), cervical adenopathy (>2 cm or tender nodes), exudate on the tonsils, or positive culture for GABHS. For some children the effectiveness of tonsillectomy or adenoidectomy is modest and may not justify the risk of surgery. In practice, most primary care providers rely on individualized decision making and do not subscribe to an absolute set of eligibility criteria for these surgical procedures. Generally, removal of the tonsils should not occur until after 3 or 4 years of age because of the problem of excessive blood loss in young children and the possibility of regrowth or hypertrophy of lymphoid tissue. The tubal and lingual tonsils often enlarge to compensate for the lost lymphoid tissue, resulting in continued pharyngeal and eustachian tube obstruction.

Endocrine Management of CF

Monitor blood glucose levels Diet Exercise Regular eye examinations

Foreign Body Aspiration

More common in children 1 to 3 years of age Diagnosis is based on the history and physical signs May result in life-threatening airway obstruction Nursing assessment must recognize the signs of foreign body aspiration Prevention

Acute Laryngitis

More common in older children and adolescents Usually caused by a virus Chief complaint is hoarseness Generally self-limiting and without long-term sequelae Treatment is symptomatic

Diagnostics Pharyngitis

Most cases it is Acute pharyngitis which is viral (But should Rule out GABHS) Rule Out GABHS by: 1) Throat Culture and/or 2) rapid antigen testing (Obtained by vigorous swabbing of tonsils and the posterior Pharynx There are Rapid identifiers like Diagnostic test kits but they aren't always accurate so to confirm its not GABHS you need to do a throat culture. (especially if kit says negative but there are signs of infection) Because some children normally harbor streptococci in their throats, a positive culture or antigen test is not always conclusive evidence of active disease. Most streptococcal infections are short-term illnesses, and antibody (antistreptolysin O) responses appear later than symptoms and are useful only for retrospective diagnosis.

LTB

Most common croup syndrome Generally affects children younger than 5 years of age Organisms: RSV, parainfluenza A and B viruses

Influenza management

Nursing Care Management Nursing care is the same as for any child with a URI, including helping the family implement measures to relieve symptoms. The greatest danger to affected children is development of a secondary infection. Prolonged fever or appearance of fever during early convalescence is a sign of secondary bacterial infection and should be reported to the practitioner for antibiotic therapy. In addition to the measures mentioned previously, nursing care of the child with influenza includes educating the parents regarding the prevention of the spread of the disease to other individuals, especially those who are at higher risk for complications, and educating the parents about the use of antiviral medications. Many institutions have developed protocols to allow nurses to screen patients for eligibility to receive the influenza vaccine. The protocol then functions as an order to administer it to those who are eligible.

Nursing considerations Pharyngitis

Obtains a throat swab for culture and Instructs the parents about administering the antibiotic and analgesics as prescribed. Some children may prefer quiet activities during the acute phase of the illness, whereas others may limit activity only if the temperature is elevated. Cold or warm compresses to the neck may provide relief. In children old enough to cooperate, warm saline gargles offer some relief of throat discomfort. Pain may interfere with oral intake, and the child should not be forced to eat. Instead, encourage cool liquids or ice chips, which are usually more acceptable than solids. Special emphasis is placed on correctly administering oral medication and completing the course of antibiotic therapy. If an antibiotic injection is required, it must be administered deep into a large muscle mass (e.g., the vastus lateralis or ventrogluteal muscle). Parents need to be aware of the residual tenderness. Local applications of heat are helpful in relieving discomfort (For other atraumatic strategies to reduce injection pain, such as application over the site of EMLA [a eutectic mix of lidocaine and prilocaine].

Otitis Media (OM)

Otitis media (OM) is the presence of fluid in the middle ear along with acute signs of illness and symptoms of middle ear inflammation. It is one of the most prevalent illnesses of early childhood. Its incidence is highest in the winter months. Many cases of bacterial OM are preceded by a viral respiratory tract infection. The two viruses most likely to precipitate OM are RSV and influenza. Most episodes of acute otitis media (AOM) occur in the first 24 months of life, but the incidence decreases with age, except for a small increase at age 5 or 6 years when children enter school. OM occurs infrequently in children older than 7 years of age. Children who have siblings or parents with a history of chronic OM have a higher incidence of OM. Out-of-home day care is a significant risk factor for OM. Children living in households with many members are more likely to have OM than those living with fewer persons. Passive smoking increases the risk of persistent middle ear effusion by enhancing attachment of the pathogens that cause otitis to the respiratory epithelium in the middle ear space, prolonging the inflammatory response and impeding drainage through the eustachian tube. Family socioeconomic status and extent of exposure to other children are the two most important identifiable risk factors for the occurrence of OM. A relationship has been observed between the incidence of OM and infant feeding methods. Infants fed breast milk have a lower incidence of OM compared with formula-fed infants. Breastfeeding may protect infants against respiratory viruses and allergy because it contains secretory immunoglobulin A, which limits the exposure of the eustachian tube and middle ear mucosa to microbial pathogens and foreign proteins. Reflux of milk up the eustachian tubes is less likely in breastfed infants because of the semivertical positioning during breastfeeding compared with bottle-feeding. Breastfeeding should be encouraged for at least 6 months (Lieberthal, Carroll, Chonmaitree, et al, 2013). OM has been defined in a variety of ways. The standard terminology is given in Box 28-4, and AOM and OM with effusion (OME) guidelines have been published (Lieberthal, Carroll, Chonmaitree, et al, 2013). AOM is frequently caused by Streptococcus pneumoniae, H. influenzae, and Moraxella catarrhalis. The two viruses most likely to precipitate OM are RSV and influenza, although the adenoviruses, human metapneumoviruses, and picornaviruses (rhinovirus and enterovirus) also cause a significant number of URIs and OM. The etiology of the noninfectious type is unknown, although it is frequently the result of blocked eustachian tubes from the edema of URIs, allergic rhinitis, or hypertrophic adenoids. Chronic OM is frequently an extension of an acute episode. Pathophysiology OM is primarily a result of a dysfunctioning eustachian tube. The eustachian tube is part of a contiguous system composed of the nares, nasopharynx, eustachian tube, middle ear, and mastoid antrum and air cells. Eustachian tubes have three functions relative to the middle ear: protection of the middle ear from nasopharyngeal secretions, drainage of secretions produced in the middle ear into the nasopharynx, and ventilation of the middle ear to equalize air pressure within the middle ear and atmospheric pressure in the external ear canal and replenishment of oxygen that has been absorbed. Mechanical or functional obstruction of the eustachian tube causes accumulation of secretions in the middle ear. Infection or allergy can cause intrinsic obstruction. Extrinsic obstruction is usually a result of enlarged adenoids or nasopharyngeal tumors. Persistent collapse of the tube during swallowing can cause functional obstruction associated with decreased stiffness or an inefficient opening mechanism. Eustachian tube obstruction results in negative middle ear pressure and, if persistent, produces a transudative middle ear effusion. Sustained negative pressure and impaired ciliary transport within the tube inhibit drainage. When the passage is not totally obstructed, contamination of the middle ear can take place by reflux, aspiration, or insufflation during crying, sneezing, nose blowing, and swallowing when the nose is obstructed. Several factors predispose infants and young children to development of OM Diagnostic Evaluation Careful assessment of tympanic membrane mobility with a pneumatic otoscope is essential to differentiate AOM from OME. If an accumulation of cerumen prevents adequate visualization of the tympanic membrane, the cerumen should be removed before inspection of the membrane. A diagnosis of AOM is made with moderate to severe bulging of the tympanic membrane, acute onset of ear drainage not due to acute otitis externa, onset of less than 48 hours of ear pain, and intense erythema of the tympanic membrane. An immobile tympanic membrane or an orange-colored membrane indicates OME. In OME these symptoms may be absent, and other nonspecific symptoms such as rhinitis, cough, or diarrhea are often present. Several tests provide an assessment of mobility of the tympanic membrane. Chapter 4 discusses pneumatic otoscopy and tympanometry. Acoustic reflectometry measures the level of sound transmitted and reflected from the middle ear to a microphone located in a probe tip placed against the ear canal opening and directed toward the tympanic membrane. The information provides a measure of canal length and presence of effusion. The greater the cancellation of transmitted sound by reflected sound, the greater the probability of middle ear effusion. Therapeutic Management: Acute Otitis Media Treatment for AOM is one of the most common reasons for antibiotic use in the ambulatory setting. However, recent concerns about drug-resistant S. pneumoniae and other drug-resistant strains have led infectious disease authorities to recommend careful and judicious use of antibiotics for treatment of this illness. Current recommendations regarding antibiotic administration to children with AOM are as follows (Lieberthal, Carroll, Chonmaitree, et al, 2013): • Prescribe antibiotics to children 6 months old and older with severe signs or symptoms of AOM (moderate or severe otalgia for at least 48 hours or temperature ≥102.2° F [39° C]). • Prescribe antibiotics for bilateral AOM in children younger than 24 months without severe signs or symptoms (moderate or severe otalgia for at least 48 hours or temperature <102.2° F [39° C]). • Either prescribe antibiotics or offer observation with close follow-up (based on joint decision making with parent or caregiver) for unilateral AOM in children 6 months to 23 months of age without severe signs or symptoms (moderate or severe otalgia for at least 48 hours or temperature <102.2° F [39° C]); if child does not improve within 48 to 72 hours, begin antibiotic therapy. • Either prescribe antibiotics or offer observation with close follow-up (based on joint decision making with parent or caregiver) for unilateral or bilateral AOM in children 24 months old or older without severe signs and symptoms (moderate or severe otalgia for at least 48 hours or temperature <102.2° F [39° C]). The latest American Academy of Pediatrics recommendations also place emphasis on assessment and management of pain in children with AOM. For fever or discomfort associated with OM, analgesic-antipyretic drugs such as acetaminophen or ibuprofen may be given. The health care practitioner may prescribe topical pain relief drops such as benzocaine or lidocaine. A narcotic analgesic with codeine may be required for children with severe pain, but side effects are common and the child should be closely monitored for GI upset, constipation, respiratory depression, and altered mental status (Lieberthal, Carroll, Chonmaitree, et al, 2013). The watchful waiting approach is not recommended for children younger than 24 months who have persistent acute symptoms of fever and severe ear pain. In addition, all cases of AOM in infants younger than 6 months of age should be treated with antibiotics because of the infant's immature immune system and the potential for infection with bacteria other than the three most common organisms found in older infants and children with AOM. When antibiotics are necessary, oral amoxicillin in high doses (80 to 90 mg/kg/day, divided twice daily) is the treatment of choice for initial episodes of AOM in children who have not received antibiotics within the past month (Lieberthal, Carroll, Chonmaitree, et al, 2013). The recommendation for the duration of antibiotic therapy is 10 days for severe AOM; for children with mild to moderate disease and those who are 6 years and older, a 5- to 7-day course is adequate (Lieberthal, Carroll, Chonmaitree, et al, 2013). Second-line antibiotics used to treat OM include amoxicillin-clavulanate (Augmentin) (which is recommended if conjunctivitis is also present); azithromycin; and cephalosporins such as cefdinir, cefuroxime, and cefpodoxime. IM ceftriaxone is used if the causative organism is a highly resistant pneumococcus or if there is noncompliance with the therapy. An important consideration with the use of single-dose IM injections is the pain involved in this therapy. One strategy to minimize pain at the injection site is to reconstitute the cephalosporin with 1% lidocaine (without epinephrine). A topical anesthetic cream such as EMLA or LMX4 can be applied to the site beforehand to reduce pain. The use of steroids, decongestants, and antihistamines to treat AOM is not recommended. Supportive care or symptomatic treatment of AOM includes treating the fever and pain. For fever or discomfort associated with OM, analgesic-antipyretic drugs such as acetaminophen or ibuprofen (ibuprofen only if over 6 months of age) may be given. Topical pain relief is recommended by external application of heat or cold, or the practitioner may prescribe topical pain relief drops such as benzocaine drops. Antibiotic ear drops have no value in treating AOM. Decongestants and antihistamines are not recommended for children with ear infections. Children with AOM should be seen after antibiotic therapy is complete to evaluate the effectiveness of the treatment and to identify potential complications, such as effusion or hearing impairment. Myringotomy, a surgical incision of the eardrum, may be necessary to alleviate the severe pain of AOM. A myringotomy is also performed to drain infected middle ear fluid in the presence of complications (e.g., mastoiditis, labyrinthitis, or facial paralysis) or to allow purulent middle ear fluid to drain into the ear canal for culture. A minimally invasive laser-assisted myringotomy procedure may be performed in outpatient settings. These procedures should only be performed by ear, nose, and throat (ENT) specialists. Therapeutic Management: Recurrent Otitis Media Therapy for recurrent AOM has included chemoprophylaxis with long-term antibiotic therapy, immunotherapy, and surgery. Chemoprophylaxis is no longer recommended because of the cost of therapy, potential adverse effects of therapy (e.g., allergic reaction, GI upset), and possible contribution to bacterial resistance (Lieberthal, Carroll, Chonmaitree, et al, 2013). Tympanostomy tube placement may be indicated with chronic OM (three episodes in 6 months or four episodes in 1 year, with one episode during the preceding 6 months) (Lieberthal, Carroll, Chonmaitree, et al, 2013). Tympanostomy tubes are pressure equalization devices (grommets) that facilitate drainage and ventilation of the middle ear. Therapeutic Management: Otitis Media with Effusion In some children, residual middle ear effusions remain after episodes of AOM. Management options for OM with residual effusion include observation, antibiotics alone, or a combination of antibiotic and corticosteroid therapy. Antibiotics are not required for initial treatment of OME but may be indicated for children with persistent effusion for more than 3 months (American Academy of Pediatrics, 2004a). It has been estimated that avoiding unnecessary treatment of OME with antibiotics would save millions of courses of antibiotics each year (American Academy of Pediatrics, 2004a). Hearing testing should be considered in children who have OME for 3 months or more. Some children have fluid that persists in the middle ear for weeks or months. OME is frequently associated with mild to moderate hearing impairment. The major goal of therapy is to establish and maintain an aerated middle ear that is free of fluid with a normal mucosa and ultimately to achieve normal hearing. Placement of tympanostomy tubes is recommended after a total of 4 to 6 months of bilateral effusion with a bilateral hearing deficit (American Academy of Pediatrics, 2004b). This therapy allows for mechanical drainage of the fluid, which promotes healing of the membrane and prevents scar formation and loss of elasticity. The primary objective is to allow the eustachian tube a period of recovery while the surgically placed tube performs its functions. The surgery is relatively benign; however, sometimes the tubes become plugged, and they often require reinsertion. Complications of repeated or long-term tube placement are tympanosclerosis, localized or diffuse atrophy of the membrane, persistent perforation, or, rarely, cholesteatoma. Myringotomy with or without insertion of PE tubes should not be performed for initial management of OME but may be recommended for children who have recurrent episodes of OME with a long cumulative duration. A Cochrane review concluded that tympanostomy tubes had a significant effect on decreasing the incidence of AOM in the first 6 months after insertion (McDonald, Langston Hewer, and Nunez, 2008). Tonsillectomy, either alone or with adenoidectomy, is not considered an effective treatment of OME (American Academy of Pediatrics, 2004b). According to guidelines published by the Agency for Healthcare Research and Quality,* steroids are not recommended for treatment of OME in children of any age. Prevention Routine immunization with the pneumococcal conjugate vaccine PCV 7 (Prevnar) has reduced the incidence of AOM in some infants and children (Lieberthal, Carroll, Chonmaitree, et al, 2013). In 2010 the FDA approved a new conjugate vaccine, Prevnar 13, that replaces Prevnar. The vaccine is administered as a four-dose series beginning at 2 months of age; infants and children who have started the series with Prevnar may complete the series with Prevnar 13 (Centers for Disease Control and Prevention, 2010). Influenza vaccination to children over 6 months is also important. Parents are encouraged to reduce risk factors for AOM by breastfeeding infants for at least the first 6 months of life, avoiding propping the formula bottle, decreasing or discontinuing pacifier use after 6 months, and preventing exposure to tobacco smoke (American Academy of Pediatrics, 2004a; Lieberthal, Carroll, Chonmaitree, et al, 2013). Xylitol or birch sugar, either in chewing gum or lozenge form, may be beneficial in the prevention of recurrent AOM in children over the age of 2 years when used three to five times a day (Lieberthal, Carroll, Chonmaitree, et al, 2013). Nursing Care Management Nursing objectives for the child with AOM include relieving pain, facilitating drainage when possible, preventing complications or recurrence, educating the family in care of the child, and providing support to the child and family. Analgesics are helpful to reduce severe earache as well as control fever (ibuprofen and acetaminophen). Ibuprofen has a longer duration of action (about 6 hours) and is especially beneficial for nighttime comfort. The application of heat over the ear while the child lies on the affected side may reduce pain in some children but may aggravate discomfort in others. This position also facilitates drainage of the exudate if the eardrum has ruptured or if myringotomy was performed. If the ear is draining, the external canal may be cleaned with sterile cotton swabs or pledgets coupled with topical antibiotic treatment. If ear wicks or lightly rolled sterile gauze packs are placed in the ear after surgical treatment, they should be loose enough to allow accumulated drainage to flow out of the ear; otherwise the infection may be transferred to the mastoid process. Parents should keep these wicks dry during shampoos or baths. Occasionally drainage is so profuse that the pinna and surrounding skin become excoriated from exudate. Frequent cleansing and application of various moisture barriers (e.g., Proshield Plus Skin Protectant), zinc oxide-based products, or petrolatum jelly (e.g., Vaseline) can prevent or treat this. Preventing recurrence requires adequate parent education regarding antibiotic therapy. Because the symptoms of pain and fever usually subside within 24 to 48 hours, nurses must emphasize that although the child may appear well, the infection is not completely eradicated until all the prescribed medication is taken. It is important to stress the potential complications of OM, especially hearing loss, which can be prevented with adequate treatment and follow-up care. (See Administration of Medication, and Compliance, Chapter 23.) Tympanostomy tubes may allow water to enter the middle ear, but recommendations for earplugs are inconsistent. Research indicates that swimming without earplugs poses a slightly increased risk of infection. Moreover, lake water is contaminated, and wearing earplugs while swimming in a lake prevents total flooding of the external canal. Parents should keep bathwater and shampoo water out of the ear, if possible, since soap reduces the surface tension of water and facilitates entry through the tube. Parents should be aware of the appearance of a tympanostomy tube (usually a tiny, white, plastic spool-shaped tube) so they can recognize it if it falls out. They are reassured that this is normal and requires no immediate intervention, although they should notify the practitioner. Parents sometimes ask about preventing ear discomfort in their infants during ascent or descent of an airplane. During ascent, air in the middle ear expands, but decompression takes place through a normal eustachian tube. If the tissues are congested with a URI, the passage of air may be blocked. A nasal mucosa-shrinking spray or oral decongestant before the trip may be helpful. During descent, the air within the middle ear decreases as atmospheric pressure increases. Swallowing is the simplest and most effective method for inflating the middle ear on descent; therefore, feeding the child or offering a pacifier to infants during descent is beneficial. Reducing the chances of OM is possible with simple measures, such as sitting or holding an infant upright for feedings. Propping bottles is discouraged to avoid pooling of milk while the child is in the supine position and to encourage human contact during feeding. Eliminating tobacco smoke and known allergens is also recommended. Forceful nose blowing during a URI is discouraged to avoid forcing organisms to ascend through the eustachian tube. Early detection of middle ear effusion is essential in prevention of complications. Infants and preschool children should be screened for effusion, and all schoolchildren, especially those with learning disabilities, should be tested for middle ear effusion. Frequent audiologic evaluations, medical consultation, and education of parents and children are advised when middle ear effusion is detected.

Clinical Manifestations of CF

Pancreatic enzyme deficiency Progressive chronic obstructive pulmonary disease (COPD) associated with infection Sweat gland dysfunction Failure to thrive Increased weight loss despite increased appetite Gradual respiratory deterioration

Cardiopulmonary Resuscitation (CPR)

Pediatric cardiac arrest frequently represents the terminal event following respiratory failure or progressive shock Pediatric cardiac arrest rarely results from sudden cardiac collapse, as in adult populations

How Serious is Pertussis

Pertussis is the most severe in the first 6 months of life and in preterm or unimmunized infants. Almost all deaths and over 80 percent of hospitalizations associated with pertussis have been in infants less than 3 months of age

Influenza prevention

Prevention The influenza vaccine is now recommended annually for children 6 months to 18 years (completed). Influenza vaccine (inactivated influenza vaccine [IIV]) may be given to any healthy children aged 6 months and older. The vaccine may be given simultaneously with other vaccines but at a separate site. IIV is administered yearly because different strains of influenza are used each year in the manufacture of the vaccine. It is safe and effective provided the antigens in the vaccine correlate with the circulating influenza viruses, but they are contraindicated in patients who have a hypersensitivity or anaphylactic reaction to eggs. Two doses are needed at least 28 days apart to all children 6 months to 9 years in their first or second vaccination seasons to adequately protect them against influenza. The live attenuated influenza vaccine (LAIV) is an acceptable alternative to the IM vaccine (IIV) for ages 2 to 49 years. It is a live vaccine administered via nasal spray. Several groups are excluded from receiving it: children with a chronic heart or lung disease (asthma or reactive airways disease), diabetes, or kidney failure; children who are immunocompromised or receiving immunosuppressants; children younger than 5 years of age with a history of recurrent wheezing; children receiving aspirin; patients who are pregnant; children who have a severe allergy to chicken eggs or who are allergic to any of the nasal spray vaccine components; and children with a history of Guillain-Barré Syndrome after a previous dose. An intradermal preparation of influenza vaccination has been available since 2012 for people aged 18 to 64. It provides the same immune response as the IIV, but there are frequent reports of injection site reactions after administration.

Infectious Pathogens

Pseudomonas aeruginosa Burkholderia cepacia Staphylococcus aureus Haemophilus influenzae Escherichia coli Klebsiella pneumoniae

Diagnostic Evaluation of CF

Quantitative sweat chloride test Chest x-ray Pulmonary function tests (PFTs) Stool fat and/or enzyme analysis Barium enema

Synagis (Palivizumab)

RSV prophylaxis for high risk infants and toddlers 15mg/kg IM every month for 5 doses /season Criteria < 29 weeks gestation , CLD of prematurity . Significant congenital heart disease, airway anomalies or neuromuscular dz with impaired airway clearance Severely immunocompromised

GI Management in CF

Replacement of pancreatic enzymes High-protein, high-calorie diet, as much as 150% of the recommended daily allowance (RDA) Treat constipation Reduction of rectal prolapse Salt supplementation Treat gastroesophageal reflux Place the patient in the upright position after meals

Status Asthmaticus

Respiratory distress continues despite vigorous therapeutic measures Emergency treatment is epinephrine 0.01 mL/kg subcutaneously (maximum dose, 0.3 mL) Concurrent infection in some cases Therapeutic intervention

Passive Smoking

Secondhand smoke is especially harmful to young children. Secondhand smoke is responsible for between 150,000 and 300,000 lower respiratory tract infections in infants and children under 18 months of age, resulting in between 7,500 and 15,000 hospitalizations each year. It also causes 430 sudden infant death syndrome (SIDS) deaths in the U.S. annually. Secondhand smoke exposure may cause buildup of fluid in the middle ear, resulting in 790,000 doctor's office visits per year, as well as more than 202,000 asthma flare-ups among children each year.7 More than 24 million, or about 37 percent of children in the U.S. have been exposed to secondhand smoke. (American Lung Association)

Tonsillitis Pathophysiology and etiology

Several pairs of tonsils are part of a mass of lymphoid tissue encircling the nasopharynx and oropharynx, known as the Waldeyer tonsillar ring. The palatine, or faucial, tonsils are located on either side of the oropharynx, behind and below the pillars of the fauces (opening from the mouth). A surface of the palatine tonsils is usually visible during oral examination. The palatine tonsils are those removed during tonsillectomy. The pharyngeal tonsils, also known as the adenoids, are located above the palatine tonsils on the posterior wall of the nasopharynx. Their proximity to the nares and eustachian tubes causes difficulties in instances of inflammation. The lingual tonsils are located at the base of the tongue. The tubal tonsils, found near the posterior nasopharyngeal opening of the eustachian tubes, are not part of the Waldeyer tonsillar ring. Tonsillitis often occurs with pharyngitis. Because of the abundant lymphoid tissue and the frequency of URIs, tonsillitis is a common cause of illness in young children. The causative agent may be viral or bacterial.

Inhalation Injury: Smoke and Carbon Monoxide

Severity depends on the nature of the substance, environment, and duration of contact Heat injury Chemical injury Systemic injury Therapeutic management Nursing considerations

Therapeutic Management Pharyngitis

Streptococcal sore throat infection: oral penicillin is prescribed in a dose sufficient to control the acute local manifestations and to maintain an adequate level for at least 10 days to eliminate organisms that might remain to initiate rheumatic fever symptoms. Penicillin does not prevent the development of acute glomerulonephritis in susceptible children. BUT: it may prevent the spread of a nephrogenic strain of GABHS to others in the family. Penicillin usually produces a prompt response within 24 hours. Some patients require retreatment if the organism is not eradicated. Amoxicillin given once a day for 10 days is just as effective as penicillin If allergic to penicillin, Give Erythromycin. Alternatives are: Penicillin G Benzathine, Clarithromycin, azithromycin, clindamycin, oral cephalosporin and amoxicillin. Intramuscular (IM) penicillin G benzathine is also an appropriate therapy. This drug ensures adequate blood concentrations and avoids the problem of compliance, yet it is painful. Some preparations contain penicillin G procaine as well to decrease the pain. Oral erythromycin is indicated for children who are allergic to penicillin. Other drugs that have been used to treat GABHS pharyngitis include erythromycin, clarithromycin, azithromycin, clindamycin, oral cephalosporins, and amoxicillin with clavulanic acid.

Influenza Clinical Manifestations

The manifestations of influenza may be subclinical, mild, moderate, or severe. In most cases the throat and nasal mucosa are dry, and there is a dry cough and a tendency toward hoarseness. A sudden onset of fever and chills is accompanied by flushed face, photophobia, myalgia, hyperesthesia, and sometimes prostration. Subglottal croup is common, especially in infants. The symptoms last 4 or 5 days. Complications include severe viral pneumonia (often hemorrhagic); febrile seizures, encephalitis, encephalopathy; and secondary bacterial infections, such as myocarditis, OM, sinusitis, or pneumonia.

Clinical manifestations Tonsillitis

The manifestations of tonsillitis are caused by inflammation. As the palatine tonsils enlarge from edema, they may meet in the midline (kissing tonsils), obstructing the passage of air or food. The child has difficulty swallowing and breathing. When enlargement of the adenoids occurs, the space behind the posterior nares may become blocked, making it difficult or impossible for air to pass from the nose to the throat. As a result, the child breathes through the mouth. Chronic enlargement of the tonsils and adenoids may result in obstruction of breathing during sleep. Because air cannot be trapped for proper speech sounds, the voice has a nasal and muffled quality. A persistent cough is also common. Because of the proximity of the adenoids to the eustachian tubes, this passageway is frequently blocked by swollen adenoids, interfering with normal drainage and frequently resulting in OM or difficulty hearing. If mouth breathing is continuous, the mucous membranes of the oropharynx become dry and irritated. There may be an offensive mouth odor and impaired senses of taste and smell.

therapeutic management Influenza

Therapeutic Management Uncomplicated influenza in children usually requires only symptomatic treatment: acetaminophen or ibuprofen for fever and sufficient fluids to maintain hydration. Amantadine hydrochloride (Symmetrel) has been effective in reducing symptoms associated with type A disease if administered within 24 to 48 hours after their onset; the symptoms associated with influenza are reportedly shortened by 24 hours, but the drug does not "cure" the disease. It is ineffective against type B or C influenza or other viral diseases. It should not be given to children under 1 year of age but is recommended for unvaccinated high-risk children. Since early 2006, however, there has been an increase in influenza strains resistant to amantadine, and thus the neuraminidase inhibitors oseltamivir and zanamivir have been recommended for influenza treatment. A small number of influenza strains are resistant to oseltamivir. Rimantadine can be used for patients over 1 year of age but is only effective against type A virus. It is taken orally for 7 days. Zanamivir can be used to treat patients aged 7 and older or as prophylaxis for patients aged 5 and older. It is an inhaled medication effective for types A and B influenza. The drug is taken twice daily for 5 days and is administered by a specially designed oral inhaler (Diskhaler); bronchospasm may occur in children with an underlying airway disease. A fourth drug, oseltamivir, is a neuroaminidase inhibitor that may be administered orally for 5 days to children over 1 year (and adults) to decrease the flu symptoms. As with other antiviral drugs, this must be taken within 2 days of the onset of symptoms. It is effective for types A and B influenza. Bronchospasm and a decline in lung function can occur when zanamivir is used in patients with underlying airway disease such as asthma or chronic obstructive pulmonary disease. Children should not receive aspirin because of its possible link with Reye syndrome.

Gastrointestinal (GI) Tract

Thick secretions block ducts, leading to cystic dilation, degeneration, and diffuse fibrosis Prevents pancreatic enzymes from reaching the duodenum Impaired digestion and absorption of fat, or steatorrhea, occurs Impaired digestion and absorption of protein, or azotorrhea, develops Endocrine function of the pancreas is initially unchanged Eventually, pancreatic fibrosis occurs; may result in diabetes mellitus Focal biliary obstruction results in multilobular biliary cirrhosis Impaired salivation

Etiology of Cardiac Arrest

Varies with age and the underlying chronic medical conditions Out-of-hospital causes include trauma, sudden infant death syndrome (SIDS), poisoning, choking, severe asthma attacks, and drowning In-hospital causes are typically due to an underlying condition

Clinical Manifestations of Respiratory Infections

Vary with age Generalized signs and symptoms and local manifestations differ in young children 1) Fever 2) Anorexia, vomiting, diarrhea, abdominal pain 3) Cough, sore throat, nasal blockage or discharge 4) Respiratory sounds

Presentation of CF

Wheezing respiration; dry, nonproductive cough Generalized obstructive emphysema Patchy atelectasis Cyanosis Clubbing of fingers and toes Repeated bouts of bronchitis and pneumonia Meconium ileus Earliest postnatal manifestation of CF Prolapse of the rectum Distal intestinal obstruction syndrome Excretion of undigested food in stool Stool is bulky, frothy, and foul smelling Wasting of tissues Delayed puberty in females Sterility in males Parents report that children taste "salty" Dehydration Hyponatremic or hypochloremic alkalosis Hypoalbuminemia

Nursing considerations Tonsillitis

providing comfort and minimizing activities or interventions that precipitate bleeding. A soft to liquid diet is generally preferred. A cool-mist vaporizer keeps the mucous membranes moist during periods of mouth breathing. Warm saltwater gargles, warm fluids, throat lozenges, and analgesic-antipyretic drugs such as acetaminophen are useful to promote comfort. Often opioids are needed to reduce pain for the child to drink. Combination nonopioid and opioid elixirs such as hydrocodone (Lortab) relieve pain. Analgesics should be given routinely every 4 hours while symptoms persist. If surgery is needed, the child requires the same psychologic preparation and physical care as for any procedure. (See Chapter 23.) The following discussion focuses on specific nursing care for tonsillectomy and adenoidectomy (T&A), although both procedures may not be performed. The nurse takes a complete history, with special notation of any bleeding tendencies because the operative site is highly vascular. Baseline vital signs are important for postoperative monitoring and observation. Signs of any URI are noted and reported, and bleeding and clotting times may be obtained with the usual laboratory work requests. During physical assessment the presence of any loose teeth is noted. (See Surgical Procedures, Chapter 23.) After the surgery, until they are fully awake, children are positioned to facilitate drainage of secretions. Suctioning is performed carefully to avoid trauma to the oropharynx. When alert, children may prefer sitting up, although they should remain in bed for the remainder of the day. They are discouraged from coughing frequently, clearing their throat, blowing their nose, or any activities that could aggravate the operative site. Some secretions, particularly dried blood from surgery, are common. Inspect all secretions and vomitus for evidence of fresh bleeding (some blood-tinged mucus is expected). Dark brown (old) blood is usually present in the emesis, as well as in the nose and between the teeth. If parents are not prepared for this, they may be frightened at a time when they need to be calm and reassuring. The throat is very sore after surgery. An ice collar may provide relief, but many children find it bothersome and refuse to use it. Most children experience moderate pain after a T&A and need pain medication at regular intervals for at least the first 24 to 48 hours. Analgesics may need to be given intravenously to avoid the oral route, however liquid analgesics may be given as tolerated. Local anesthetics, such as tetracaine lollipops or ice pops, and antiemetics, such as ondansetron (Zofran), may be administered postoperatively