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In general, antidiarrheal preparations are not recommended for infants or children

because they have little effect on acute diarrhea, are associated with side effects, and

direct attention away from the use of oral hydration therapy.

45,46 Drugs such as

loperamide that alter GI motility should be avoided, especially in children with high

fever, toxemia, or bloody mucoid stools, because they may worsen the clinical

course of the bacterial infection. Bismuth subsalicylate preparations, which possess

antisecretory and antimicrobial effects, have not been shown to provide clinical

benefit and are not recommended.

45 Adsorbents, such as kaolin-pectin or attapulgite,

adsorb bacterial toxins and water and lessen the symptoms of diarrhea by producing

more formed stools, but there is no evidence of effectiveness, and they are not

recommended.

45 Zinc supplementation (10–20 mg for 10–14 days) has been

recommended by the WHO for the treatment and prevention of diarrheal disease in

children in developing countries; however, its mechanism of action, best method of

administration, and efficacy in different populations are not yet well understood.

43,48

Probiotics, live microbial products containing species of Lactobacillus,

Bifidobacterium, Saccharomyces, and Streptococcus, can improve the balance of

intestinal flora and diminish the effect of enteric pathogens. These microbes are

thought to exert their beneficial effects through various mechanisms, including

producing antibacterial chemicals, competing with enteric pathogens, inhibiting the

adhesive capabilities of pathogens, altering toxins or toxin receptors, and

upregulating interleukin-mediated T-cell response.

48,49 Probiotics are most useful in

infectious gastroenteritis when used early in the course of disease. Lactobacilli are

the most well-studied species and have been the most consistently effective in

clinical trials. It appears that efficacy of the different species may depend on the

specific strain, the dose, and the timing of administration, although it is generally

accepted that dosage forms with at least 10

6

to 10

9 colony-forming units and above

are required.

45,48 The manufacture of probiotics is not regulated by the FDA;

therefore, the organism count per dose might be based on the number present at the

time of production and not at time of expiration, and the labeling might incorrectly

identify the species of organism. Probiotics are not recommended for use in

immunocompromised individuals because systemic infections after the use of these

products have been reported.

43 For J.R., a Lactobacillus preparation administered for

5 days may provide some modest clinical benefit, although the benefit is most

pronounced in rotavirus diarrhea, which has not been documented in his case.

GASTROESOPHAGEAL REFLUX

GER is a common disorder, with 50% to 67% of infants experiencing recurrent

vomiting and regurgitation during the first 4 months of life.

50 Most reflux in infants is

believed to be caused

p. 2161

p. 2162

by transient relaxations of the lower esophageal sphincter (LES). Infants might also

be predisposed to reflux because of their body positioning (e.g., slumped over in a

car seat or lying supine), their consumption of a liquid feeding that exceeds the

volume capacity of the stomach, and in premature infants, a decrease in peristaltic

activity.

51

Infants and young children might also have undiagnosed underlying

conditions that predispose them to reflux (e.g., neurologic disorders, hiatal hernia,

hypertrophic pyloric stenosis, and cow’s milk protein allergy).

52 Of cases of reflux in

infants, 80% are benign and resolve by 18 months of age,

53 and reflux in older

children resolves in a timeframe similar to that of adults. If untreated, GER can result

in esophageal strictures, GI hemorrhage, or chronic respiratory disease from the

aspiration of GI contents. Studies evaluating the relationship between GER disease

(GERD) and asthma or Helicobacter pylori have shown mixed results.

54–57

Clinical Presentation

In infants, the vomiting and regurgitation of GER occur frequently, and other

symptoms often are nonspecific (e.g., failure to thrive [FTT], recurrent pneumonia,

apnea, dysphagia, reactive airway disease, apparent life-threatening events [ALTE],

hematemesis, and anemia).

58,59 A thorough diagnostic workup is generally not

necessary in a healthy infant with functional GER presenting as recurrent vomiting.

Empiric drug therapy can be initiated after the diagnosis is made based on clinical

findings and after other causes of vomiting have been eliminated.

58 Further diagnostic

evaluations, however, are indicated for infants and children presenting with

additional symptoms of GERD (e.g., FTT, irritability, ALTE, and respiratory

difficulties).

53

Treatment

Because uncomplicated GER usually resolves spontaneously in infants, therapy

should focus on providing symptom relief and maintaining normal growth.

53 The

goals of therapy are to lessen symptoms, heal esophagitis, and prevent complications

in infants and children with pathologic GER, so that surgery can be avoided.

53

Infants

and young children with underlying neurologic problems (e.g., cerebral palsy) are

unlikely to have spontaneous resolutions of GER and frequently require aggressive

antireflux therapies and surgical intervention.

POSITIONAL AND DIETARY MEASURES

CASE 104-7

QUESTION 1: S.B., a 3-month-old, 6-kg, breastfed male infant, has a 2-week history of regurgitation after

each feeding. The pediatrician noted that S.B. had not gained weight since his last visit 1 month earlier. The

presumptive diagnosis is FTT secondary to GER, and S.B. was referred to a pediatric gastroenterologist. How

should S.B. be treated initially?

S.B. can be treated conservatively because he does not present with lifethreatening complications.

58,59 First, caregiver feedings should be observed to rule

out regurgitation caused either by overfeeding or by inappropriate feeding

techniques. Sometimes infants with milk protein allergies can have a similar clinical

presentation; therefore, a change to a soy protein formula or hypoallergenic formula

should be tried.

58

Interventions to modify an infant’s body positioning or to modify

infant feedings with milk thickeners are not proven to be effective, but are reasonable

to undertake.

60,61 Maintaining S.B. at a 60-degree angle during the day while sitting

and at a 30-degree position at night should be implemented in an effort to promote

clearance of acid from the esophagus and to minimize reflux after meals. Milk

thickeners (most commonly rice cereal in the United States) and more frequent,

smaller feedings are also worthwhile interventions, although thickened formula could

lead to increased coughing during feeding. Mild cases of GER often can be treated

successfully by dietary measures alone, as well as by propping infants in an upright

position during, and 1 hour after, feedings.

59 Although the placement of infants in a

face-down prone position during sleep can reduce reflux, the greater risk of sudden

infant death syndrome (SIDS) in infants younger than 12 months of age outweighs the

benefits of such positioning.

58 Older children and adolescents should follow the

recommended dietary guidelines (i.e., avoidance of caffeine, chocolate, and spicy

foods) for adults.

DRUG THERAPY

The efficacy of pharmacologic therapy in altering the course of uncomplicated GER

in infants has not been proved.

58

In infants or children who present with nonspecific

symptoms or complications, such as S.B., acid-suppression therapy or prokinetic

therapy is warranted even in the absence of documented esophagitis.

58 When

esophagitis is present, acid suppression is always recommended to aid in the healing

process; however, these agents alone do not rectify the causes of the GER.

58 The

various agents to treat infant GER are listed in Table 104-3.

59,62–73

Acid-Suppressant Agents

Antacids

Chronic antacid therapy is generally not recommended for the treatment of GER in

infants and young children, because infants treated with aluminum-containing antacids

can accumulate sufficient aluminum to cause osteopenia and neurotoxicity.

58,62,72

In

addition, information on other antacids in infants is limited; nevertheless, antacids

can provide short-term relief of symptoms in older children and adults.

Proton-Pump Inhibitors

Proton-pump inhibitors (PPIs) are superior to histamine-2 receptor antagonists

(H2RA) in relieving symptoms and in promoting healing of significant esophagitis

from GER in infants, young children, and adults.

58,73,74 PPIs control both basal and

meal-stimulated acid secretion, which may in part explain their superior efficacy.

The incidence of adverse effects in children from PPI is similar to that reported in

adults.

64,75 Despite concerns about the long-term use of PPI, untoward effects have not

been observed from their use for up to 11 years.

76

In children, increased metabolism

and decreased bioavailability necessitate larger milligram per kilogram doses to

maintain acid suppression than adults; thus, titration of dose to response is necessary,

particularly for treatment of esophageal erosions.

60,77 Although most clinicians dose

PPI once a day, multiple, divided daily doses can prevent acid breakthrough and

better promote healing.

73 Omeprazole, lansoprazole, and esomeprazole are available

in extended-release capsules, which can be separated, opened, and sprinkled on soft

foods. Omeprazole and esomeprazole are also available as granules for an oral

suspension. Suspension formulations for both omeprazole and lansoprazole have

been extemporaneously compounded and evaluated for stability. Esomeprazole has

also been recently approved for use in children with GERD aged 1 to 11 years and

has been studied and reviewed extensively.

74,78,79

Histamine-2 Receptor Antagonists

H2RA reduce histamine-stimulated acid secretion, but have limited effects on acid

secretion by other chemical mediators and other stimuli. In randomized, controlled

trials, H2RA in infants and children relieved symptoms and facilitated the healing of

esophageal tissue.

65,66 Tolerance to the acid-suppressant activity of H2RA for a

relatively short time (<30 days), however,

67,68 can limit their use for long-term

treatment of esophagitis. Oral liquid formulations are available for most H2RA.

Ranitidine is also available in an effervescent tablet.

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p. 2163

Table 104-3

Oral Drugs Used to Treat Gastroesophageal Reflux in Infants

58,59,62–71

Agent Mode of Action Oral Dosage

Acid-Suppressing Agents

Antacids (aluminum

or magnesium

hydroxide)

Neutralizes acid 0.5–1.0 mL/kg/dose before and after feeding

(maximum, 15 mL/dose)

Proton-Pump Inhibitors

Omeprazole Decrease acid secretion via

inhibition of gastric hydrogenpotassium adenosine

triphosphatase

5 kg–<10 kg: 5 mg daily

10 kg–≤20 kg: 10 mg daily

>20 kg: 20 mg daily

Alternate dosing: 1 mg/kg daily or twice daily

Esomeprazole 1–11 years: 10 mg daily

(>1 mg/kg/day or therapy >8 weeks has not been

evaluated)

≥12 years: 20 mg daily

Lansoprazole Infants ≥3 months: 7.5 mg twice daily or 15 mg once

daily

1–11 years: 15 mg (<30 kg)–30 mg (>30 kg) daily

≥12 years: 15 mg daily

Pantoprazole <5 years: 1.2 mg/kg/day once daily

>5 years: 20 or 40 mg once daily

H2 Receptor Antagonists

Cimetidine Blocks H2

-receptors; ↓ acid

secretion

30–40 mg/kg/day divided QID

Famotidine 1 mg/kg/day divided BID

Nizatidine 10 mg/kg/day divided BID

Ranitidine 5–10 mg/kg/day divided BID or TID

Prokinetic Agents

Bethanechol Cholinergic agent; stimulates

peristalsis ↑

↑ LES pressure; ↑ gastric

emptying; ↑ colonic motility

↑ Gastric emptying; ↑ LES

pressure; augments esophageal

clearance

0.1–0.2 mg/kg/dose QID given 30–60 minutes before

feeding and HS

Metoclopramide Dopamine antagonist 0.1–0.2 mg/kg/dose QID given 30 minutes before

feeding and HS

Erythromycin Motilin agonist stimulates

smooth muscle contraction

3 mg/kg/dose QID; maximum dose: 10 mg/kg or 250

mg

Surface-Active Agents

Sucralfate Forms paste and adheres to

damaged esophageal mucosa

40–80 mg/kg/day divided QID

BID, 2 times daily; HS, at bedtime; LES, lower esophagealsphincter; QID, 4 times daily; TID, 3 times daily.

Prokinetic Agents

Metoclopramide, a dopamine antagonist with cholinergic and serotonergic effects,

accelerates gastric emptying, increases LES pressure, enhances esophageal

clearance, and accelerates transit time in the small bowel; however, its effects on

vomiting and esophageal pH in children with GER has been equivocal.

69,70

Additionally, metoclopramide has been associated with significant CNS (i.e.,

restlessness, drowsiness, and extrapyramidal) effects, recently receiving a special

alert for a higher risk of extrapyramidal symptoms in those <1 year of age, and rare

reports of gynecomastia and galactorrhea.

59 Erythromycin increases GI motility by

increasing smooth muscle contractions through its motilin agonistic activity, and it

has been used as a prokinetic agent for GER in children, when acid suppression

therapy alone was ineffective.

80 Erythromycin-induced development of infantile

hypertrophic pyloric stenosis, arrhythmias, and potential changes in bacterial

resistance patterns, however, limit its use for GER. The cholinergic agonist,

bethanechol, reportedly reduces vomiting episodes in infants with GER

40,58,81

;

however, its role in treating GER in infants is limited because of its potential to

induce bronchospasm and to stimulate gastric acid secretion. The lack of a suitable

commercially available formulation of bethanechol for young infants necessitates its

extemporaneous compounding. Baclofen, which decreases transient LES relaxations

through its γ-aminobutyric acid agonist actions, could be a future therapeutic option

for GER, pending further study.

82 Generally, prokinetic agents only are marginally

effective in the management of GER.

Surface-Active Agents

Sucralfate was equally effective as cimetidine for use in esophagitis

83

; however, its

use for GER is more limited because of concern about the adverse effects of

aluminum-containing products in infants.

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p. 2164

CASE 104-7, QUESTION 2: Four weeks after instituting positional and dietary measures, S.B. continues to

vomit and still has not been gaining weight. On physical examination, the gastroenterologist notes bilateral

wheezes; endoscopy rules out esophagitis. What would be the next step of therapy?

The treatment of S.B. can include acid-suppression therapy. Acid-suppression

therapy in children who have complications from GER can be implemented by a

step-up approach in which treatment is initiated with an H2RA followed by a PPI if

no improvement is noted, or through a step-down approach involving a PPI followed

by an H2RA for maintenance therapy. However, initial therapy with PPI is

preferred,

58,59 and S.B. may be treated with omeprazole 5 mg daily. Granules for

suspension may be mixed in 10 mL of water and administered orally.

The effectiveness of acid suppression for managing symptoms of GER in children

is not as well documented as it is for healing esophagitis; however, acid suppression

is believed to play a useful role for symptom control, particularly for managing the

respiratory symptoms.

58 Treatment should be continued for at least 3 to 4 months,

although the optimal duration of therapy is unknown. If S.B. requires additional drug

therapy to control symptoms of GER beyond 18 months to 2 years of age, surgery

should be considered because GER is unlikely to resolve spontaneously after this

age.

84 Surgery might be considered earlier if S.B. fails medical therapy or if he

develops an esophageal stricture, apnea, or recurrent respiratory disease.

58

COMMON PEDIATRIC INFECTIONS

Acute Otitis Media

Acute otitis media (AOM) is the most common reason for antimicrobial use in

children, and is associated with expenditures of $350 per episode and, cumulatively,

almost $3 billion annually.

85 AOM is most common from the ages of 3 months to 3

years, although the highest incidence occurs between 6 and 9 months of age. Most

children will have had at least one episode by the time they reach 1 year of age.

86

Incidence is higher in the winter months, concurrent with viral upper respiratory

illnesses. Several risk factors for AOM have been identified and include age younger

than 2 years, early colonization of pathogens and onset of AOM, day-care attendance,

bottle propping, cleft palate, immune compromise, and Down syndrome. Other

factors such as smoke exposure, bottle feeding, pacifier use, and ethnicity have not

been consistently found to increase risk of AOM.

87,88

Eustachian tube dysfunction, either from intermittent causes such as upper

respiratory infections or permanent causes such as cleft palate, is the primary

condition required for the development of AOM. This results in a defect in the

eustachian tube’s ability to equilibrate middle ear pressure. Thus, nasopharyngeal

contents, including bacteria, may be aspirated into the middle ear. This process is

more likely in infants and young children who have shorter, flatter eustachian tubes.

87

Changes in pressure can also cause increased vascular permeability, resulting in an

effusion. Viral infections contribute by enhancing bacterial transfer from the

nasopharynx and adherence to the middle ear.

87

S. pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis

colonize the nasopharynx early in childhood, and thus, are the most common

pathogens causing AOM.

87 Historically, these pathogens have been implicated in

28% to 54%, 32% to 59%, and up to 63% of cases of AOM, respectively.

89 The

introduction of the pneumococcal conjugate vaccine (PCV7) reduced the overall

incidence of AOM, the recurrence of AOM, and the need for tympanostomy tube

insertion.

85–87 However, the incidence of AOM caused by non-PCV7 serotypes, H.

influenzae, and M. catarrhalis increased with the reduction in AOM cases caused by

PCV7 serotypes.

85,86,90,91 These studies were used to guide the development of a 13-

valent PCV (PCV13), which was approved and licensed to replace the PCV7 in

2010. The PCV13 vaccine includes six of the serotypes that had been shown to

produce more than 60% of non-PCV7 vaccine strain invasive infections. The PCV13

vaccine has shown increased protective effects against AOM because of the

reduction in nasopharyngeal colonization by emerging serotypes.

92,93 Overall, studies

have shown that PCV13 provides a reduction in pneumococcal disease, including

AOM, in children.

93

CASE 104-8

QUESTION 1: C.D. is a 7-month-old, 8-kg infant who during the last 36 hours has developed cough, ear pain,

and rhinorrhea, became irritable and at times inconsolable, and now has a temperature of 102.4°F (39.1°C).

Physical examination shows bulging, dark, yellow opaque tympanic membranes bilaterally. This is the first time

he has had these symptoms and has had no recent courses of antibiotics. What signs and symptoms do C.D.

exhibit, which are consistent with AOM, and how should AOM be diagnosed?

Very often, as in this patient case, otitis media is preceded by an upper respiratory

tract infection. These viral infections often will produce otitis media with effusion

(OME), which typically will cause no more than temporary mild hearing loss. If

AOM develops, more signs and symptoms will usually arise. These symptoms can

include otalgia (pain causing infants to pull on or rub the ears), fever, irritability, and

otorrhea.

89 Unfortunately, aside from otorrhea, these symptoms are nonspecific and

may be present in many children who do not have AOM. As a result, a definitive

diagnosis may not be easily obtained with symptoms alone. Diagnosis should be

confirmed on visualization of the middle ear.

In 2013, the American Academy of Pediatrics (AAP) published guidelines on the

diagnosis and management of AOM that stated that a diagnosis of AOM requires mild

bulging of the tympanic membrane and either recent onset of ear pain (<48 hours) or

intense erythema of the tympanic membrane.

89 Pneumatic otoscopy should be used to

confirm the presence of effusion. Middle ear effusion can be differentiated from

AOM in that, whereas both present with bulging tympanic membranes, in AOM, the

middle ear fluid is more often dark yellow or red.

87,89 Other diagnostic tools may be

used. Tympanometry uses sound waves to measure the compliance of the tympanic

membrane. In acoustic reflectometry, the absorption of sound waves by the tympanic

membrane provides information about the middle ear in that an effusion will cause

more sound to be reflected back than a normal ear.

87 C.D.’s fever and irritability

along with fluid in the middle ear and bulging, dark yellow tympanic membranes are

consistent with the diagnosis of AOM.

CASE 104-8, QUESTION 2: How should C.D.’s otitis media be treated?

The 2013 AAP recommendations provide for the option to observe without

treatment or to treat with antibiotics, depending on the age of the patient and

symptoms present.

89 Generally, infants 6 months of age and younger should receive

antibiotic therapy in all cases. Infants and children 6 months to 2 years of age can be

managed with observation if there is a nonsevere unilateral AOM without otorrhea.

Children 2 years of age and older can be managed with observation in bilateral or

unilateral nonsevere AOM without otorrhea. Antibiotics are warranted in all cases of

AOM with otorrhea or in AOM cases with severe symptoms (e.g., temperature

>39°C in past 48 hours).

89

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p. 2165

C.D. appears to have bilateral AOM with severe symptoms based on his fever

greater than 39°C, so antibiotic therapy is indicated. Despite pneumococcal

penicillin resistance rates, initial therapy in most children who have not received

amoxicillin in the last 30 days, would still be amoxicillin at a dose of 80 to 90

mg/kg/day.

89 Amoxicillin is effective against susceptible and intermediately resistant

pneumococcus, it is affordable and palatable, and it has a narrow spectrum of

activity.

86 Providers should prescribe amoxicillin/clavulanate in children who have

received amoxicillin in the last 30 days, have concurrent purulent conjunctivitis, or

have a history of recurrent AOM unresponsive to amoxicillin.

89 Oral cephalosporins,

including cefdinir, cefuroxime, or cefpodoxime, are options in patients with a nonType I allergy to penicillin, and macrolides such as azithromycin or clarithromycin

may be used in those with Type I allergies to penicillin.

Whichever treatment course is taken in a patient (observation or antibiotic therapy

with amoxicillin or amoxicillin/clavulanate), effectiveness is assessed for 48 to 72

hours. If the treatment is effective, the patient should defervesce, irritability should

decrease, and normal activity should resume (e.g., eating and sleeping). If the

observation is ineffective, treatment with amoxicillin or amoxicillin/clavulanate is

recommended. If amoxicillin or amoxicillin/clavulanate is ineffective for C.D.,

ceftriaxone 400 mg (50 mg/kg) intramuscularly for 1 or 3 days is an option.

CASE 104-8, QUESTION 3: How should C.D.’s otalgia be managed?

Ear pain is a common feature of AOM, and it should be addressed regardless of

the decision to use antibiotics or not. Acetaminophen 120 mg (15 mg/kg) or ibuprofen

80 mg (10 mg/kg) can provide adequate relief, and are first-line agents in the

management of otalgia.

89 Home remedies such as the application of heat or cold may

also be helpful.

89 For example, a washcloth can be soaked with very warm water,

wrung out, and placed over the ear for comfort for 15 minutes several times per day.

Acute Pharyngitis

Acute pharyngitis is most common in children 5 to 15 years of age and is rare before

3 years of age. The etiology is typically viral, but bacteria such as group A

streptococci (GAS, Streptococcus pyogenes), groups C and G streptococci,

Neisseria gonorrhoeae, Mycoplasma pneumoniae, and Chlamydia pneumoniae may

also cause pharyngitis in children.

94 The majority of attention is directed toward the

detection and management of GAS infections as, untreated, they may lead to

rheumatic fever, a complication progressing to permanent heart disease.

CASE 104-9

QUESTION 1: P.J., a 6-year-old boy weighing 23.4 kg, presents to the pediatrician’s office complaining of

fever, sore throat, and headache. His mother reports that he initially complained of sore throat about 12 hours

ago. His oral temperature this morning was 102°F. He takes no medications and has no known drug allergies.

Physical examination reveals erythematous tonsils and throat, as well as an enlarged anterior cervical lymph

node. Are P.J.’s symptoms more consistent with GAS or viral pharyngitis?

Findings suggestive of GAS tonsillopharyngitis include sudden onset of throat

pain, fever, headache, abdominal pain, nausea, vomiting, tonsillopharyngeal edema,

enlarged anterior cervical lymph nodes, soft palate petechiae, and a scarlatiniform

rash.

94 Symptoms that increase the likelihood of a viral cause include rhinorrhea,

cough, conjunctivitis, and viral rash.

94 P.J. is lacking associated symptoms that would

suggest a viral cause and has more symptoms of GAS pharyngitis, but confirmatory

testing is needed.

DIAGNOSIS

Because clinical and physical findings are not definitive for GAS pharyngitis,

confirmatory testing is important to determine the need for antibiotic therapy. A rapid

antigen detection test is recommended, and, if positive, treatment is initiated. If

negative, a throat culture should also be obtained and treatment initiated if the culture

grows GAS. Rheumatic fever can be effectively prevented if treatment is started

within 9 days from the start of the illness.

94

CASE 104-9, QUESTION 2: A rapid antigen detection test for GAS is performed for P.J. and is positive.

What treatment should be initiated at this time?

TREATMENT

Penicillins remain the agents of choice for GAS pharyngitis. Either oral penicillin,

oral amoxicillin, or intramuscular benzathine penicillin may be used. Amoxicillin

suspension is more palatable than penicillin and has the advantage of a once-daily

dosing regimen. Intramuscular penicillin is a one-time dose that is helpful in those at

risk for nonadherence. In patients with a Type I hypersensitivity to penicillins,

azithromycin, clarithromycin, or clindamycin may be used. In those with a non-Type I

allergy to penicillin, a first-generation cephalosporin may be considered.

Recommended regimens are summarized in Table 104-4.

94,95 Although there is little

reported GAS resistance to penicillin, some patients have a decreased clinical

response and may respond better to cephalosporins. This is often seen in patients

who are GAS carriers and those who may have other bacteria causing infection.

Patients are no longer contagious 24 hours after the first antibiotic dose.

95

Table 104-4

Medication Regimens for the Treatment of Streptococcal Pharyngitis and

Prevention of Rheumatic Fever

94,95

Medication Dose Duration

Amoxicillin 50 mg/kg once a day or 25 mg/kg twice a day (maximum 1 g/day) 10 days

Penicillin VK Children ≤27 kg: 250 mg 2 or 3 times a day

Children >27 kg, adolescents: 500 mg 2 or 3 times a day or 250 mg 4

times a day

10 days

Benzathine penicillin G ≤27 kg: 600,000 units IM

>27 kg: 1,200,000 units IM

Once

For Patients with Penicillin Allergy

Cephalexin 20 mg/kg (up to 500 mg) twice a day 10 days

Cefadroxil 30 mg/kg (up to 1 g) once a day 10 days

Clindamycin 7 mg/kg 3 times a day (maximum 300 mg/dose) 10 days

Azithromycin 12 mg/kg once a day (maximum 500 mg) 5 days

Clarithromycin 7.5 mg/kg twice a day (maximum 250 mg/dose) 10 days

IM, intramuscular.

p. 2165

p. 2166

Table 104-5

Medication Regimens for the Prevention of Recurrent Rheumatic Fever

95,96

Medication Dose Frequency

Benzathine penicillin G ≤27 kg: 600,000 units IM

>27 kg: 1,200,000 units IM

Every 4 weeks

Penicillin V 250 mg oral Twice a day

Sulfadiazine ≤27 kg: 0.5 g oral

>27 kg: 1 g oral

Once a day

If allergic to above agents

Erythromycin

96 250 mg oral Twice a day

IM, intramuscular.

P.J. should receive amoxicillin (400 mg/5 mL), 12.5 mL (1,000 mg) every 24

hours for 10 days. For pain relief, he may also receive as-needed doses of

acetaminophen (160 mg/5 mL), 10 mLevery 6 hours, or ibuprofen (100 mg/5 mL), 10

mL every 6 hours.

Those with a history of rheumatic fever, characterized by acute generalized

inflammation of the heart, joints, brain, or skin, should receive long-term antibiotic

prophylaxis to prevent further complications from streptococcal infections.

Recommended medications and dosing regimens are summarized in Table 104-5.

95,96

Patients with acute carditis and residual heart disease should receive treatment for 10

years or until 40 years of age, whichever is longer.

95 Patients with an episode of

carditis but without residual heart disease should receive treatment for 10 years or at

least until 21 years of age.

95 Patients who had rheumatic fever without carditis should

receive treatment for 5 years or at least until 21 years of age.

95

KEY REFERENCES AND WEBSITES

A full list of references for this chapter can be found at

http://thepoint.lww.com/AT11e. Below are the key references and websites for this

chapter, with the corresponding reference number in this chapter found in parentheses

after the reference.

Key References

American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. The diagnosis and

management of acute otitis media. Pediatrics. 2013;131:e964–e1049. (89)

Gerber MA et al. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis: a

scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki

Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on

Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and

Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. 2009;119:1541. (95)

Ishimine P. The evolving approach to the young child who has fever and no obvious source. Emerg Med Clin

North Am. 2007;25:1087. (10)

Nield LS, Kamat D. Prevention, diagnosis, and management of diaper dermatitis. Clin Pediatr (Phila). 2007;46:480.

(7)

Shulman ST et al. Clinical practice guideline for the diagnosis and management of group A Streptococcal

pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e86–e102.

doi: 10.1093/cid/cis629. (94)

Vandenplas Y et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the

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European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr

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Key Websites

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OTC sales in volume. Consumer Healthcare Products Association website.

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US Food and Drug Administration. Public Health Advisory: FDA Recommends that over-the-counter (OTC)

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http://www.fda.gov/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandproviders/ucm051137.htmUpdated August 19, 2013. Accessed June 7, 2015. (25)

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