Module 4 NSG 520 eBook

Nodular involvement and bony overgrowth in Juvenile idiopathic arthritis

Butterfly rash seen in Systemic Lupus Erythematosus

Erythema Marginatum- nonpruritic macular rash that is one of the major criteria for diagnosis of rheumatic fever.

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If you have access to tympanometry in your practice, this is a good way to assess pressure in the ear drum and it can help distinguish things going on in the EAC and middle ear. This is also a billable procedure and takes only a couple of minutes. It can be tricky to get done on children however as the child should remain still for optimal results.

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Subconjunctival hemorrhages from vaginal birth- in most cases just monitor &amp; it goes away.

Exophthalmos- bulging of the eye.&#160; from hyperthyroid, neoplastic disease, pseudo-tumor, &amp; genetic diseases. Always requires referral to ophthalmology &amp; investigation of underlying cause- TSH, T4?

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Subconjunctival hemorrhages from coughing. This child had pertussis and broke various blood vessels from harsh paroxysmal coughing. Treat the cough but this too will go away &amp; needs monitoring.&#160;

Strabismus: a defect in ocular alignment Commonly called "lazy eye"

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A top of what?What in the world is atopic?&#160;

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ESSENTIAL Atopic Dermatitis Non-Pharmacological Therapy •&nbsp;Skin lubrication •&nbsp;Emolliate with a moisturizer. Lubricants maintain the skin's hydration, and emollients are the treatment of choice for dry skin. •&nbsp;An ointment-based emollient (e.g., Vaseline, petrolatum jelly, Crisco, vegetable oil, whipped petrolatum, Aquaphor) can be applied just before getting out of the bath water or just after getting out of the bath while still damp. If the child does not like the greasy feel of an ointment, other topical creams (e.g., Vanicream, CeraVe, Cetaphil) can be used. This is also a good time to apply TCPs, because absorption of the agent is more effective if the skin is hydrated. •&nbsp;Emollients can be applied three or four times a day as needed, such as fragrance-free Eucerin cream, Crisco (plain, not butter flavored), Aveeno, Moisturel, Neutrogena, Dermasil, Curel, or petroleum jelly (an occlusive agent). If a child is sensitive to fragrances, scented creams, such as Nivea and Vaseline Intensive Care, should be avoided. TriCeram is a moisturizer that repairs the stratum corneum barrier function. Like CeraVe, it is a ceramide-dominant, lipid-based emollient. Urea-containing products, such as Aquacare cream or lotion and Ureacin Crème, soften and moisturize dry skin. Stinging is a side effect when using urea-containing products on fissured or flaring skin. •&nbsp;For some children with AD (xerotic individuals), frequent bathing may exacerbate their pruritus and thus aggravate their skin problems. Bathing must be limited in these patients and emollients used. If a child experiences stinging when bathing during acute exacerbations, adding 1 cup of table salt into the bath may reduce the stinging sensation. •&nbsp;Avoidance of triggering factors •&nbsp;Avoid common irritating substances, including toiletries, wool, and harsh chemicals. •&nbsp;Keep fingernails short to decrease additional skin trauma from scratching. •&nbsp;Consider stopping the use of fabric softeners and using a sensitive-skin detergent (e.g., All Free Clear). •&nbsp;Evaluate for possible food triggers and if history is positive, testing is not needed (<a href="https://jigsaw.vitalsource.com/books/9780323243384/epub/OPS/xhtml/chp00025_s2.xhtml#bib57">Schneider et al, 2013</a>;&nbsp;<a href="https://jigsaw.vitalsource.com/books/9780323243384/epub/OPS/xhtml/chp00025_s2.xhtml#bib60">Sicherer et al, 2012</a>). The clinician should&nbsp;not&nbsp;do an extensive battery of allergy tests and then make recommendations for food elimination based on those tests, without history of food sensitivity.

Bullous myringitis- large blister on the ear drum. Very painful and usually requires antibiotic treatment with same line as other otitis media infections- Amoxicillin first.

<a href="https://youtu.be/mXhXHiT4R8o">SEE eyes and ears video here</a>

Cholesteotoma (above) - a small growth in middle ear secondary to congenital cause or repeated ear infections. Needs immediate referral due to risk of hearing loss. Note the white lesion.

Otitis externa (swimmers' ear)- antibiotic drops. Fluoroquinolone first line due to risk of most cases being pseudomonas. 

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Allergic Rhinitis and Asthma Inhaled Corticosteroids 

<a href="https://youtu.be/ygmX1S4mzTs">Atopic disorders</a> <a href="https://youtu.be/ygmX1S4mzTs"> #2 Video</a>

Evoked otoacoustic emission&nbsp;(EOAE) testing is the method of hearing screening used for universal newborn screening. The normal-hearing ear has the ability to emit detectable sounds called&nbsp;spontaneous otoacoustic emissions.&nbsp;The normal ear also emits these sounds when given a stimulus (EOAE) and provides evidence that the outer hair cells of the cochlea are functioning appropriately and hearing is likely to be intact. EOAE is efficient, highly sensitive, and easy to perform in a quiet, cooperative child, which makes it conducive for use in newborns. However, the EOAE does not quantify hearing deficit and may not identify auditory nerve dysfunction; ambient room noise and an uncooperative child may interfere with the test and provide unreliable results. The EOAE and ABR technologies result in highly acceptable levels of hearing sensitivity and specificity at relatively low cost (Burns et al., 2017).

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Part 4: Rhematologic and Immunodeficiency Disorders

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What is "Rheumatic? Rheumatic diseases refer to immune-mediated disorders affecting the musculoskeletal system, soft tissues, autoimmune diseases, and some connective tissue disorders.

Juvenile Idiopathic Arthritis (JIA) and Systemic Lupus Erythematosus (SLE) are rheumatic disorders that can occur in childhood. They are connective tissue disorders marked by inflammatory changes in connective tissues throughout the body. The exact cause of these collagen diseases is not completely understood; however, an autoimmune basis is postulated as a key factor in rheumatic disease.

Acute rheumatic fever (ARF) is a nonsuppurative complication following a Lancefield GAS pharyngeal infection that results in an autoimmune inflammatory process involving the joints (polyarthritis), heart (rheumatic heart disease), CNS (Sydenham chorea), and subcutaneous tissue (subcutaneous nodules and erythema marginatum).

Fibromyalgia&nbsp;is the term used to describe a chronic, idiopathic pain syndrome characterized by widespread, diffuse, nonarticular musculoskeletal pain and fatigue with multiple trigger points that are discrete painful sites. It is considered a subset of musculoskeletal pain syndromes.&nbsp;

Eye, Ear, Atopic, Rheumatologic, and Immunodeficiency Disorders

The most important early component of eczema is Stopping the itch-scratch-cycle!!!!!!&#160;

Less itch means less scratch meaning better skin integrity meaning less chance for infection!

40-50% of children with eczema/atopic dermatitis have food or other environmental allergies. If you have a young child with uncontrolled atopic dermatitis consider RAST allergy testing or referral for skin allergy testing if over age 3 years.

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The wheels in our minds go round and round, round and round, round and round

The wheels in our minds go round and round, all through crazy learning town!

Refractive errors (fancy way of saying they need glasses)

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Bulging otitis media (Antibiotic treatment necessary), Recheck 2 weeks.

TM perforation. If from injury- refer to ENT immediately. If from infection treat with antibiotic drops and PO and refer that week. Educate on no EAC exposure to fluid.

Cerumen- scoop or use irrigation to remove if TM visibility is needed immediately.

Effusion or any fluid levels/bubbles in middle ear must be monitored but if no infection is present then no antibiotics are indicated. Fluid present for 12 weeks requires referral to ENT given risk for hearing loss and speech development.

Atopic dermatitis Topical steroid potency- start low go slow

<a href="https://youtu.be/0yjDfn5_ekM">See atopic disorders</a> <a href="https://youtu.be/0yjDfn5_ekM">video #1</a>

Common Atopic Disorders of Childhood: # 1 Asthma

Criteria •&nbsp;Two major or one major and two minor manifestations&nbsp;plus&nbsp;evidence of a preceding GAS infection •&nbsp;Two minor manifestations&nbsp;plus&nbsp;evidence of a preceding GAS infection<a href="https://jigsaw.vitalsource.com/books/9780323243384/epub/OPS/xhtml/chp00025_s1.xhtml#fn0025">§</a> •&nbsp;Other major manifestations or evidence of GAS infection not required •&nbsp;Do not require any other criteria to be diagnosed as having rheumatic heart disease and/or aortic valve disease Major Manifestations •&nbsp;Carditis •&nbsp;Polyarthritis •&nbsp;Chorea •&nbsp;Erythema marginatum •&nbsp;Subcutaneous nodules Minor Manifestations •&nbsp;Clinical fever, polyarthralgia •&nbsp;Laboratory elevated acute phase reactants (ESR or leukocyte count)

Diagnostics •&nbsp;Elevated acute-phase reactants (ESR, white blood cells [WBCs], CRP) •&nbsp;Leukocytosis •&nbsp;Prolonged PR interval on ECG Elevated ASO titer?

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Vasculitis Diseases (described as autoimmune)

Pediatric vasculitis is a complex group of disorders that are characterized by inflammation in the blood vessel (Burns et al. 2017).

Two most common vasculitis diseases of childhood:

•&nbsp;Bilateral conjunctival injection •&nbsp;Changes of the lips and oral cavity •&nbsp;Cervical lymphadenopathy •&nbsp;Polymorphous exanthema •&nbsp;Changes in the peripheral extremities (swelling of the hands or feet) or perineal area

Physical Examination •&nbsp;Skin rash: Starts as a pinkish maculopapular rash and progresses from red to purple to brown palpable purpura •&nbsp;Arthritis •&nbsp;Warmth, swelling, and erythema over the joints •&nbsp;Periarthritis is common and involves the knees and ankles •&nbsp;Diffuse abdominal pain on palpation •&nbsp;Edema of the scrotum, eyes, or hands

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