Outpatient Pediatrics

Quick Pointers for Common Problems

These are general guidelines and not comprehensive.  The specific clinical situation must guide treatment of individual patients, but this is a place to start.

Anemia

• Get stool hemetest, good diet history, pica and lead exposure history, and family history of anemia.
• Treat is > 2 standard deviations below the mean for age.
• If MCV/RBC is > than 13.5 it suggests iron deficiency, if < 11.5 it suggests thalassemia trait.
• If mildly hypochromic and microcytic, confirm with CBC; treat with 4 mg/kg/d elemental Fe.
• Be careful to write out specific iron preparation and mL doses, there are many OTC strengths.  Fer-in-Sol drops have 15 mg of elemental iron per 0.6 mL dropper.
• Recheck CBC in one month; if normal treat for two more months to replete Fe stores.
• If severe anemia, get CBC, retic count, Fe, TIBC, and lead.
• Hgb electrophoresis is best done after Fe deficiency is corrected.
• Treat with Fe as above if Fe deficiency is likely.
• Recheck CBC and retics in 7-10 days, then CBC at one month as above.

Asthma

• Nebulizer treatments can be performed in clinic at any time
• First episode of mild wheezing, may send home on oral albuterol, but if returns to clinic or ER wheezing, arrange home nebulizer or MDI.
• Introduce "controllers" (steroids or cromalyn) at the appropriate stage.
• Use peak flow meters in clinic and at home to show progress.
• In a pinch, styrofoam cups can be used as  spacers.

Conjunctivitis

• Fluorocein should be used if there is any chance of herpes keratitis or abrasion.
• Erythromycin ophthalmic ointment causes less reaction and discomfort for small children.
• Check acuity if there is any question of trauma or pain.

Eczema

• Dove soap, eucerin, cetaphil or other moisturizers.
• Hydrocortisone 1% cream (OTC) TID x 1-2 weeks.
• If severe: Locoid ointment (hydrocortisone butyreate) BID x 1 week, then qd x 1 week.

Fungi/Yeast

• Lotrimin (OTC) is cheaper than Nystatin (Rx).
• For Tinea capitis, need Griseofulvin; do not need to do LFTs if treating less than one month.  Also, using Sebulex shampoo twice weekly will lessen the spread of spores.

Gingivostomatitis

• Encourage fluids
• Acetaminophen q 4 hours
• For relief of mouth pain: Diphenhydramine (Benedryl) 5 mg/kg/day divided q 6 hours, mixed with the same volume of Maalox.  Both components are OTC.

Otitis

• Cerumen Removal
• Colace may be instilled for 5-10 minutes, then use tiny swab, curette or irrigate with warm water (30cc syringe and butterfly tubing).
• Pneumatic otoscopy should be performed on all patients except newborns.
• Effusion plus symptoms (eg, fever, otalgia) merit treatment.  Amoxicillin or TMP/SMX for 10 days.  Resistance varies by area, but a general guideline is that higher dose (80 mg/kg/day divided TID) amoxicillin should be used in patients under 2 years of age, in day care or with recurrent otitis media.
• If purulent drainage is present, add cortisporin otic suspension TID.  Recheck in three weeks if perforation is present, or if patient is too young to report symptoms.

Pharyngitis

• Rare to have Group A Strep throat in patient less than 3 years old.
• Perform a strep culture is rapid strep test is negative.

Scabies

• Elimite cream for 8 hours (chin down in adults; all surfaces for infants)
• Comes in 60 gm tubes; 30 gms treats average size adult.
• Treat all family members
• Give handouts or instructions about treatment of clothing, bedding, etc.
• Antipruretics (eg, hydroxyzine) are important as pruritis may persist.

Seborrhea

• Occurs in infants less than one year of age and in pubescent adolescents.
• For scalp: twice weekly massage of mineral oil and remove after 1 minutes of using anti-seborrhea shampoo such as Subulex (OTC).
• For very inflamed area: mild steroid topically such as 1% hydrocortisone cream TID

URI

• Expect 8-10 yearly, lasting about 10 days
• Encourage use of humidifier/vaporizer
• For infants, teach about saline nose drops.
• Avoid decongestants and antihistamines for URIs (cost, questionable efficacy, side effects)

UTI

• Get a good specimen.
• Renal and bladder ultrasound.
• Stress preventative measures every visit.
• Treat parentally if pyelo is likely, then PO for ten days, then treat with prophylaxis (give q hs) until the results of VCUG with/without DMSA are back.  Nitrofurantoin has a good shelf life for prophylaxis but is not available at all pharmacies.
• VCUG can be performed as early as 3 weeks after treatment.
• Consider DMSA is pyelo is likely or if the VCUG is abnormal.
• Surveillance cultures at one month and then every 3 months for one year.
• MAG III scan is for nonreflux hydronephrosis (i.e., abnormal sonogram but normal VCUG).
• also see a discussion of outpatient management of UTIs.