Sinusitis – In BriefPediatr. Rev. 2006;27;395-

397Allison Taylor and Henry M.

Adam

Update on Allergic RhinitsPediatr. Rev. 2005;26;284-

289Todd A. Mahr and Ketan

Sheth

All Slides from PIR

Pediatric Cough and Cold PreparationsPediatr. Rev. 2004;25;115-123Leslee F. Kelly

SinusitisPediatr. Rev. 2001;22;111-117David Nash and Ellen Wald

A parent is concerned that her 4-year-old son “always has a cold.” Given what you know about thefrequency of colds and the duration of their symptoms, what is the minimum number of “sick days” peryear that would be considered excessive for a typical child?

A. 75.B. 100.C. 125.D. 140.E. 175.

D - 150

The average number of colds per year generally is quoted as being 3 to 10. If each cold lasts the usual 10 to 14 days, this translates to up to 140 days of cold symptoms per year.

Sinusitits: Rhinosinusitis (RS) is the term

currently used because the inflammation is believed to begin in the nasal epithelium (rhinitis).

It is estimated that of the average six to eight upper respiratory tract infections (URIs) per year experienced by school-age children, 5% to 10% will be complicated by RS.

PIR

It also is estimated that 6% to 13% ofchildren will have had one case of RS

bythe age of 3 years. RS also is classifiedby the duration of days of persistentsymptoms. Acute rhinosinusitis (ARS)refers to symptoms that last longer

than 10 days but fewer than 30.

PIR

The maxillary and ethmoidsinuses are fully formed and clinicallysignificant from birth. The sphenoidsinuses begin to develop at age 3

years and are fully formed by age 7 to 8

years. The frontal sinuses are the last to

develop and are not fully formed untilthe early teenage years.

ARS is defined as unabated upper respiratory tract symptoms lasting longer than 10 days or as worsening of symptoms by 7 to 10 days of illness.

It is important to distinguish a single prolonged illness from consecutive URIs.

The symptoms of ARS include nasal discharge, cough (typically day and night), and halitosis.

When fever precedes the URI symptoms, the illness is more likely to be viral.

Older children and adolescents may present

with symptoms more typical of adultdisease: headaches, facial pain and

pressure, maxillary dental pain, pharyngitis,

and frequent throat clearing.

If purulent nasal discharge is seen draining from the middle meatus, a diagnosis of ARS can be fairly certain.

This finding may be recognized by lookingthrough the otoscope while gently pushing up on the nares, a technique not easily done, especially with younger children.

Ethmoid sinusitis may be accompanied by periorbital edema. In older children and adolescents, gentle pressure on the maxillary and frontal sinuses may elicit pain or discomfort

Allergic rhinitis is best characterized by:

A. Cold air-induced rhinorrhea.B. Fever.C. Nasal pruritus.D. Nocturnal cough.E. Unilateral nasal discharge.

C. Nasal pruritus.

In 1998, the Joint Task Force on Practice Parameters in Allergy,

Asthma, and Immunology defined rhinitis as "inflammation of the membrane lining the nose, characterized by nasal congestion,

rhinorrhea, sneezing, itching of the nose and/or postnasal drainage."

You are asked to talk to local child care providers about infection control measures. You advise them thatthe single best intervention to reduce the spread of “common colds” to other children in the center is to:

A. Exclude all ill children from the center.B. Have all providers wear masks.C. Isolate sick children within the center.D. Limit outside playtime during the winter months.E. Wash hands and toys.

E. Wash hands and toys.

Spread of virus can be prevented through specific infection control techniques, namely, those that decrease hand contamination with virus. This can be accomplished simply by correct handwashing of both caregiver’s and children’s hands.

Of the following conditions, the one most commonly coexisting with allergic rhinitis is:

A. Asthma.B. Chronic sinusitis.C. Immunodeficiency.D. Otitis media with effusion.E. Sleep apnea.

A. Asthma.

Some studies have found that nearly one third of children who have AR also have asthma.

As physicians try to limit antibiotic use in children who have colds, parent education takes on an increasingly important role. Common colds are caused by viruses. The most common viral causes are:

A. Adenoviruses.B. Coronaviruses.C. Influenza viruses.D. Reoviruses.E. Rhinoviruses.

E – Rhinovirus (at least 100 serotypes)

RhinovirusesCoronavirusesRespiratory syncytial virusParainfluenza virusesAdenovirusesNonpolio enterovirusesInfluenza virusesReoviruses

Your parent information sheet “Colds in Infants” includes instructions on correct use of a bulb syringe. Normal saline, rather than 1/8% phenylephrine drops, is recommended because:

A. 4-month-old infants are primarily mouth breathers.

B. Phenylephrine causes rebound congestion.C. Phenylephrine causes vasodilation.D. Phenylephrine has been associated with

cardiomyopathy.E. Phenylephrine must be given for 72 hours to be

effective.

B. Phenylephrine causes rebound congestion.

Topical nasal decongestants can cause significant rebound congestion, which is especially dangerous in infants 6 months of age and younger, who are extremely dependent on nasal airflow for respiration.

Allergen AvoidanceAllergy avoidance is the first recommendation for thepatient who has AR.

Although it may be easy to recommend avoiding pets or pollen, such avoidance is extremely difficult for many patients.

A more realistic goal is to decrease allergen exposure as much as possible, keeping in mind that many patients are allergic to multiple allergens.

Strategies include -staying inside during high pollen times (5 AM to 10 AM), -keeping air-conditioning on during spring and fall pollen seasons,-avoiding drying clothes outside during high pollen times.

To avoid molds, strategies include -Decreasing humidity in the home, using a dehumidifier-Keeping obvious areas of mold clean with a bleach solution.

Allergic RhinitisThe ideal solution for pets is to remove

them from the home, although this often is not feasible or easy to accomplish.

An alternative is to remove pets from thebedroom at night and during the day. Reservoirs for pet dander and allergen also

should be avoided, such as pillows and heavy upholstered furniture.

A 3-year-old boy is coming to see you with what his mother describes as “probably just a cold.” On the phone, she said that he has had a runny nose and now has a worsening cough. Which piece of this patient’s past medical history would raise the greatest concern?

A. Asthma.B. Croup.C. Otitis media.D. Sinusitis.E. Tonsillitis.

A. Asthma.

First-generation antihistamines should be used cautiously in children who have asthma because they thicken secretions and can make them harder to clear.

Allergen avoidance, when possible, is the best way to control allergic rhinitis. Of the following, the most

effective intervention in reducing the symptom burden of allergic rhinitis is to:

A. Increase home humidity.B. Keep air-conditioning on during pollen

seasons.C. Prevent all exposure to pets in the first

postnatal year.D. Restrict outside play to early morning hours.E. Spray pillows and comforters to eliminate

dust mites.

B. Keep air-conditioning on during pollen seasons.

Strategies include staying inside during high pollen times (5 AM to 10 AM), keeping air-conditioning on during spring and fall pollen seasons, and avoiding drying clothes outside during high pollen times.

Why is it unlikely that a vaccine ever will be developed to prevent colds?

A. Immunity to one viral serotype does not confer complete protection against others.

B. More than 100 different viruses cause the common cold.

C. There are numerous antigenic serotypes.D. A, B, and C.E. B and C only.

D. A, B, and C.

It is unlikely that a vaccine ever will be developed to prevent the common cold completely because of the numerous different antigenic

serotypes as well as antigenic variation among many of the respiratory viruses. Immunity to one serotype offers little protection against others.

A 6-year-old girl presents in the early spring with a 2-week history of paroxysmal sneezing associated with itching of her nose and eyes. She had similar symptoms last year that lasted for 2 months before abating. You diagnose seasonal allergic rhinitis and review appropriate avoidance measures. Of the following, the most effective control of her nasal symptoms would be achieved by proper use of an:

A. Intranasal corticosteroid.B. Intranasal decongestant.C. Oral first-generation antihistamine.D. Oral leukotriene receptor antagonist.E. Oral second-generation antihistamine.

A. Intranasal corticosteroid.

Pharmacologic options for treating AR include antihistamines (oral and intranasal), oral leukotriene receptor antagonists (LTRA), and intranasal corticosteroids (INS). Treatment guidelines for AR support the use of INS as first-line therapy. INS are

approved for use in patients as young as 2 years of age.

In considering empiric antibiotic therapy for a 17-year-old boy in whom you suspect acute sinusitis, you

should prescribe:

A. Amoxicillin 40 to 50 mg/kg per day.B. Cefotaxime 300 mg/kg per day.C. Cefuroxime axetil.D. Erythromycin succinate.E. Sulfamethoxazole-trimethoprim.

A. Amoxicillin 40 to 50 mg/kg per day.

If the patient’s symptoms persist after 3 days of therapy, you should prescribe a course of:

A. Amoxicillin 40 to 50 mg/kg per day.B. Cefotaxime 300 mg/kg per day.C. Cefuroxime axetil.D. Erythromycin succinate.E. Sulfamethoxazole-trimethoprim.

C. Cefuroxime axetil.

ALLERGIC RHINITIS SX

Patients who have AR may experience a variety of signs and symptoms. Parents usually

report mouth breathing, snoring, or a nasal voice in affected children. Other symptoms typically include paroxysmal sneezing, nasal itching,

sniffing, snorting, nose blowing, congestion or postnasal drainage, and occasionally coughing. Additional symptoms include itchiness of the eyes, throat, and palate.

Acute bacterial sinusitis is best distinguished from a viral upper respiratory tract infection by:

A. Cough.B. Duration of symptoms for greater

than 10 days.C. Facial pain and headache.D. Presence of fever for 1 to 2 days.E. Purulent nasal drainage.

B. Duration of symptoms for greater than 10 days.

A diagnosis of acute bacterial sinusitis should be based on:

A. A precise clinical history regarding quality and duration of symptoms.

B. Bacterial culture from the nasopharynx.C. Computed tomography of the paranasal

sinuses.D. Physical examination of the nose and

pharynx.E. Plain film radiographs of the paranasal

sinuses.

A. A precise clinical history regarding quality and duration of symptoms.

The average number of colds per yeargenerally is quoted as being 3 to 10. If each

cold lasts the usual 10 to 14 days, this translates to up to 140 days of cold

symptoms per year.

Table 1. Signs and Symptoms ofthe Common Cold● Nasal discharge● Nasal congestion/obstruction● Scratchy/sore throat● Malaise● Postnasal drip● Headache● Cough● Sneezing● Decreased appetite● Low-grade fever (102.2°F [<39°C])● Myalgias● Irritability● Decreased sleep● Conjunctivitis● Mild pharyngitis● Watery eyes● Fatigue● Hoarseness

The term “common cold” is understood to mean that the cause is viral.

Cough and cold medicines contain pharmacologically active ingredients that alone or in combination are intended to relieve some or all of a patient’s symptoms.

Management of the common cold is intended to provide temporary relief of symptoms until the cold completes its natural history.

If there are complications of the common cold, treatment is directed at the specific complication.

For infants and young children, relieving nasal obstruction is one of the most important goals because this symptom can impair drinking, and dehydration can result.

Relieving cough often is an important goal of the family and frequently the reason for seeking care.

Many children and parents lose sleep because thecough keeps them up at night.

More than 800 cough/cold preparations are availablein the United States.

A Journal of the AmericanMedical Association review of clinical trials on over-the-counter cold medications from 1950 to 1991:

Concluded that no good evidence has demonstrated the effectiveness of over-the-counter cold medications inpreschool-age children, but certain medicines and combinations of medicines have been shown to reduce cold symptoms in adolescents and adults.

AntihistaminesThese drugs block H1 receptors on nasal vasculature andcompete with histamine for receptor sites. First generation antihistamines:diphenhydramine, hydroxyzine, chlorpheniramine, brompheniramine, and clemastine,

cross the blood-brain barrier and affect the central nervous system (CNS).

Promethazine is a phenothiazine type of antihistamine that usually is combined with a cough suppressant.

Have anticholinergic properties. Because histamineis not an inflammatory mediator in the commoncold, the effects of the antihistamines are believed to becaused by the anticholinergic drying action on mucousmembranes.

Table 4. Adverse Effects ofAntihistamines● Sedation● Paradoxic excitability● Dizziness● Respiratory depression● Hallucinations● Tachycardia● Heart block● Arrhythmia● Dry mouth● Blurred vision● Urinary retention

First-generation antihistaminesshould be used cautiously in childrenwho have asthma because they thicken secretions and canmake them harder to clear.

Cochrane Database of Systematic Reviews

“In general, antihistamines alone in older children and adults do not offer clinically significant benefits. In small children, there is no evidence that they have any benefit other than inducing sleepiness.”

The second-generation antihistamines include terfenadine, astemizole, loratadine, and cetirizine.

Because these do not cross theblood-brain barrier to any great extent,they cause fewer CNS effects. They donot possess anticholinergic propertiesand have little drying effect. For this

reason, they are not as effective as thefirst-generation antihistamines for thenasal symptoms of the common cold.

DecongestantsCommon decongestants include

pseudoephedrine, phenylephrine, and oxymetazoline.

Decongestants are sympathomimetic agents that decrease nasal congestion by causing vasoconstriction. They improve patency by reducing blood volume and swelling in the

nasal mucosa and paranasal sinuses.

Topical nasal decongestants can cause significantrebound congestion, which is especially dangerousin infants 6 months of age and younger, who are extremely dependent on nasal airflow for respiration.

If used, they should be administered sparingly for no more than 72 hours.

Continued use of topical decongestants can cause rhinitis medicamentosa, a chronic inflammatory rhinitis.

In one study, infants younger than 12 months of agewho had infection with respiratory syncytial virus weretreated with 1/8% phenylephrine or normal saline nasaldrops. There was no change in clinical respiratory scores

Table 5. Adverse Effects of DecongestantsSystemic

● Tachycardia● Irritability● Agitation● Sleeplessness● Hypertension● Anorexia● Headache● Nausea● Vomiting● Palpitations● Dysrhythmias● Seizures● Dystonic reactions

Topical● Drying of nasal membranes● Nosebleeds● Rebound nasal congestion

Antitussives

Cough may be the most frustrating and concerning cold symptom to parents. It typically keeps the child up at night, and parents and siblings lose sleep as well.

It is importantto explain to parents that a cough

is a beneficial protective airway reflex.Coughing clears excessive secretions

to maintain airway patency.

narcotic and nonnarcotic cough medicines

Narcotic cough medicines typically contain codeine or hydrocodone, which act on the medullary coughcenter in the brainstem.

Narcotic medicines do not suppress cough completely, even in adults, and have serious adverse effects, especially in overdose. These include respiratory depression, which can lead to apnea, nausea, vomiting, constipation, dizziness, and palpitations.

Nonnarcotic cough medicines

Dextromethorphan

a narcotic analog

In adults, it suppresses cough as effectively as codeine, but it still

can cause respiratory depression in overdose.

Randomized, placebo controlled, blinded trials have not discovered any difference between the medicine and placebo in terms of symptom relief for small children, except that they are more likely to fall asleep within 2 hours than those receiving placebo or no medication.

In many cases, this sleepiness is considered a benefit in a child who is exhausted from lack of sleep due to the cold.

In older children and adults, there may be some overall beneficial effect of decreased nasal symptoms.

Nonpharmacologic Therapies

These therapies are primarily supportive and include humidified air, bulb suctioning, saline nasal drops, positioning with the head elevated, and increased fluid intake.

Such therapies are safer and less expensive than medications. It generally is agreed in the literature that such supportive therapies should form the mainstay of treatment for children who have common colds.

Saline nasal drops can be used before the nose is suctioned, but parents need specific instructions to do this correctly. The suction bulb should be aimed back in the direction of the nasal passage. Suctioning should be performed sparingly at times most likely to be helpful, such as prior to feedings and sleep. If suctioned too frequently, nasal trauma can cause swelling of the nasal mucosa, leading to greater congestion.

Another “therapy” is education.

Over the Counter but No Longer under the Radar —Pediatric Cough and Cold Medications

n engl j med 357;23 www.nejm.org december 6, 2007

Consumers purchase about 95 million packages of such medication for use in children each year.

Since 1985, all six randomized, placebo-controlled studies of the use of cough and cold preparationsin children under 12 years of age have not shown any meaningful differences between the activedrugs and placebo.

Poison-control centers have reported more than750,000 calls of concern related to cough and cold

products since January 2000

Centers for Disease Control and Prevention identified more than 1500 emergency room visitsin 2004 and 2005 for children under 2 years of age who had been given cough or cold products.

A review by the Food and Drug Administration (FDA) identified 123 deaths related to the use of such products in children under six during the past several decades.

After the meeting, the major manufacturers of these products announced that they disagreed with the committee and would continue to market these preparations for children between 2 and 5 years of age.

Although the FDA does not need to follow the recommendations of its advisory committees, we believe that it should immediately ask companies to remove these products from store shelves and begin legal proceedings to require them to do so.

Legislation to expedite the FDA’s oversight of the marketing and advertising of over-the-counter has been proposed.

Decongestants Decongestants can help to relieve symptoms of

a runny nose or stuffy nose. They include ingredients like phenylephrine and pseudoephedrine. Phenylpropanolamine (PPA) was a decongestant that was removed from the market in 2000, and should be avoided. Although often helpful, decongestants can make some children hyperactive or irritable.

Sudafed - Children's Nasal Decongestant Chewables

Cough Suppressants If your child's cough is interfering with sleep or his daily

activities, then as long as he isn't having any trouble breathing, he may benefit from a cough suppressant, such as dextromethorphan (DM). Codeine and hydrocodone are ingredients in prescription cold medicines and may cause drowsiness. Since coughs are often caused by post-nasal drip, you should usually use a decongestant with a cough syrup (see below).

Delsym Extended-Release Suspension 12 Hour Cough Relief

Robitussin DM

Triaminic Long Acting Cough (blue)

http://www.pediacare.com/childrens_long_acting_cough

Effects of Dextromethorphan – Recreational Use

When consumed in small recreational amounts, DXM is often noted to have a psychedelic effect related to the combination of alcohol, marijuana, and opiates. With a greater dose users may experience intense euphoria, vivid imagination, and closed-eye hallucinations. With an even greater dose, intense changes in consciousness have been noticed, along with out-of-body experiences or even psychosis. Many people find such large doses to be extremely unpleasant and do not want to repeat them.

Antihistamines While effective for a runny nose that is caused by

allergies, it is the side effects of the antihistamines that can make them useful in treating colds, including drowsiness and a dry mouth and nose. They include ingredients such as diphenhydramine, brompheniramine, chlorpheniramine, and carbinoxaimine, and are usually found in allergy and 'night time' cold medicines.

Dimetapp - Children's Cold & Allergy Liquid

Benadryl Allergy Relief

Triaminic Night Time Cold & Cough Syrup (purple)

Night Time Triaminic Thin Strips Cold & Cough

PediaCare NightRest Cough & Cold for Children

Dimetapp - Children's Nighttime Flu Syrup

Cough and Cold Medicines Since most colds are accompanied by a runny nose, post-nasal drip and a cough,

'Cough and Cold' Medicines are usually the most helpful, since they usually include a decongestant and a cough suppressant. Unless they are noted to be non-drowsy, they may also contain an antihistamine.

Dimetapp - Children's Cold & Cough Elixir

Dimetapp - Children's Decongestant Plus Cough Infant Drops (non-drowsy)

Little Colds Decongestant Plus Cough (non-drowsy)

PediaCare Decongestant & Cough Drops for Infants (non-drowsy)

Robitussin CF Alcohol-Free Cough Syrup (non-drowsy)

Triaminic Day Time Cold & Cough (non-drowsy)

Triaminic Softchews Cough and Runny Nose

Vicks NyQuil - Children's Cold, Cough Relief

Vicks Pediatric 44M, Cough & Cold Relief

http://fdb.rxlist.com/drugs/drug-144973-Nariz+Oral.aspx?drugid=144973&drugname=Nariz+Oral&source=0