Family Medicine 23: 5-year-old female with sore throat

User: hyunsoo Ellis

Email: [email protected]
Date: November 29, 2020 2:04AM

Learning Objectives

The student should be able to:

Examine a patient with pharyngitis, including appropriate history and physical examination, use of clinical prediction rules and
appropriate antibiotic use.
Describe the suppurative and non-suppurative complications of Group A beta-hemolytic streptococcal pharyngitis (strep throat).
Describe the health maintenance visit for a 5-year-old.
Use CDC/ACIP chart in order to determine what immunizations are required based on age of the patient.
Describe contraindications to immunizations.
Describe how to diagnose Attention Deficit Hyperactivity Disorder (ADHD).
Describe the recommendations for screening of anemia in children.
Demonstrate how to calculate BMI in a child and be able to identify a child at risk for obesity.

Knowledge

Decision Tools for Evaluation/Treatment of Strep Throat

Predictive rules have been developed that can be helpful in determining which patients should undergo a rapid strep test. The
most commonly used of these rules, the Modified Centor Criteria, has a good negative predictive value, but a relatively poor
positive predictive value. Thus it is useful in figuring out which patients likely do not have strep pharyngitis and therefore do not
need further testing. This test should not be used to make a diagnosis of strep pharyngitis in the absence of testing for strep.

Criteria: Modified Centor (also called McIsaac Score)

Give one point for each positive response:

Tonsillar exudate or erythema

Anterior cervical adenopathy
Cough absent
Fever present

Age 3 to 14 years: +1 point

Age 15 to 45 years: 0 points
Age over 45 years: -1 point

Standard practice has been to collect a rapid strep test in all children with a Modified Centor score of 2 or more. Recently, the
American College of Physicians made a new recommendation for adults saying that rapid strep testing should be reserved only for
patients with a Modified Centor score of 3 or more. This reflects the lower prevalence of strep among adults with sore throat,
compared to children.

Approach: Clinical suspicion based

Children Adults
on Modified Centor scoring

Score of 3-5 Perform Rapid Antigen Test Perform Rapid Antigen Test

Score of 2 Perform Rapid Antigen Test Symptomatic treatment without testing

... Rapid antigen test Positive Treat with antibiotics Treat with anitbiotics

Perform confirmatory strep Do not use antibiotics. Treat symptoms. No further testing
... Rapid antigen test Negative
culture, and treat if positive (unless high risk such as immunocompromised)

Symptomatic treatment
Score of 0 or 1 Symptomatic treatment without testing
without testing

Complications of GABHS Pharyngitis

Scarlet fever is associated with GABHS pharyngitis and usually presents as a punctate, erythematous, blanching, sandpaper-like

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 exanthem. The rash is found in the neck, groin, and axillae, and is accentuated in body folds and creases (Pastia's lines). The
pharynx and tonsils are erythematous and covered with exudates. The tongue may be bright red with a white coating (strawberry
tongue).

Complications of strep throat are usually divided into suppurative and non-suppurative categories. Even though rheumatic fever
and post-streptococcal glomerulonephritis are serious, they are relatively rare. Other complications include: peri-tonsillar abscess,
mastoiditis, meningitis, and bacteremia.

Vaccinations - Withholding & Contraindications

Every visit should be seen as an opportunity to update a child's vaccination record. It is one of the easiest and most cost-effective
public health measures we can take to protect children from significant infectious disease.

When to withhold vaccinations

Patients with recent exposure to infectious diseases, or patients who have a mild illness (with or without fever), should receive
their vaccines. However, if a patient has a moderate to severe illness (including high fever, otitis, diarrhea, and vomiting) then
vaccines should be postponed until they are recovering and are no longer acutely ill.

Contraindications

Allergy or sensitivity to a specific vaccine is a contraindication for only that specific vaccine. While there are no absolute
contraindications to immunizations in general, there are some conditions that have cautions or contraindications for specific
vaccines. For example, immunodeficiency (either in the patient or in a household member) such as HIV infection or chemotherapy
are contraindications for certain vaccines.

Elementary School Admission Vaccinations

In addition to an annual influenza vaccine, between four to six years of age, a child needs a booster of DTaP, IPV, MMR, and
varicella. This assumes that they have received all the previous requisite vaccines and they are otherwise healthy.

Most states require the following vaccines prior to school entrance:

Three hepatitis B
Five DTaP
Four polio
Two MMR
Two varicella

Five-Year-Old Well-Child Exam

The well-child exam for any age can be broken down into five major components:

1. history
2. physical exam including measurements and vision and hearing screenings
3. assessment of behavior and development
4. immunizations and lab screening
5. anticipatory guidance

Evaluation of a five-year-old child should be guided by the context that the child will soon be entering elementary school. This is a
time of great change, not just for the patient, but the whole family.

During the evaluation, it's important to discuss established routines, after-school care and activities, and parent-teacher
communication with the parents. With the child, it is important to discuss friends and bullying. With both the child and parents,
discussing their fears and management of disappointments is appropriate.

Additionally, an evaluation of the child's maturity must be made as the child's language skills and social readiness can impact
success in school.

Childhood Weight and Obesity

About 25% of pre-school children and over one-third of older children and adolescents in the United States are either overweight
or obese. The prevalence of overweight and obesity increases with age.

Childhood overweight and obesity are related to:

Health risks: Risk factors for heart disease, such as high cholesterol and high blood pressure, occur with increased
frequency in overweight children and adolescents compared to children with a healthy weight.
Medical conditions: Type 2 diabetes, previously considered an adult disease, has increased dramatically in children and
adolescents. Overweight and obesity are closely linked to type 2 diabetes.
Increased risk of adult obesity : Overweight adolescents have a 70% chance of becoming overweight or obese adults.
This increases to 80% if one or more parent is overweight or obese.
Increased morbidity and mortality rates: Overweight or obese adults are at risk for a number of health problems
including heart disease, type 2 diabetes, high blood pressure, and some forms of cancer.

The most immediate consequence of overweight as perceived by the children themselves is social discrimination. This is
associated with poor self-esteem and depression.

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 The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) endorse universal screening
using body mass index (BMI) and use of BMI growth curves to identify obese and overweight children and adoescents.

There are several convenient tools to help quickly calculate the BMI, such as: BMI wheels, BMI calculators either online (as above)
or as a program on a handheld device or computer, or as part of an EMR. The BMI-for-age percentile is important when calculating
BMI for children and teens.

Normal BMI changes with age in children, as opposed to adult BMI which is constant.

BMI Categories - ADULT BMI (kg/m2)

Healthy weight 18.5 - 24.9

Overweight 25 - 29.9

Obese ≥ 30

BMI Categories - CHILD BMI (kg/m2)

Healthy weight 5th to < 85th percentile for age

Overweight 85 to less than 95th percentile for age

Obese > 95th percentile for age

Anticipatory Guidance Five-Year-Old Well-Child Exam

Nutrition

Remind parents to have their children eat whole grains like brown rice and wheat bread. It's also important to limit the amount of
sugary drinks that kids have, even juice. No more than four to six ounces of juice a day is recommended.

Physical activity

Children should get 60 minutes of physical activity every day.

Limiting screen time (television, computer, and video games) to two hours a day is helpful to keep children active. It's also good
to keep TVs, games, and computers out of kids' bedrooms.

Oral health

Schedule dental appointment.

Teach child to brush teeth.

Discuss flossing, fluoride, sealants.

Sexuality education

Expect normal curiosity of genitalia and sex.

Explain good touch/bad touch and that certain body parts are private.

Injury Prevention - Five-Year-Old Well-Child Exam

Fires/burns/test smoke alarms/fire escape plan

Appropriate booster seat placed in back seat; seatbelts
Keep home and car smoke-free
Pool/tub/water safety - swimming lessons
Use bike/skating helmet
Supervise near pets, mowers, driveways, streets
Limit time in sun, use hat/sunscreen
Childproof home (matches, poisons, guns, cigarettes, cords, cleaners, medicines, knives)
Gun safety

Determining the Need for Selective Screening - Five-Year-Old Well-Child Check

Selective screening for lead toxicity at periodic visits should be done if any of the following questions is positive:

Does your child live in or regularly visit a house or child care facility built before 1950?
Does your child live in or regularly visit a house or child care facility built before 1978 that is being or has recently been
renovated or remodeled (within the last six months)?

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 Does your child have a sibling or playmate who has or did have lead poisoning?

The following children need selective screening for anemia at periodic visits:

At risk of iron deficiency because of special health needs

Low-iron diet (i.e. nonmeat diet)
Environmental factors (i.e. poverty, limited access to food)

Tuberculosis screening guidelines:

Screening for tuberculosis is based on targeted screening of high-risk children, rather than population-wide screening. A validated
risk questionnaire has been developed for use in primary care settings. The questions include:

Has a family member or contact had tuberculosis disease?

Has a family member had a positive tuberculin skin test (or Interferon Gamma Release Assay) result?
Was your child born in a high-risk country (countries other than the United States, Canada, Australia, New Zealand, or
Western and North European countries)?
Has your child traveled to a high-risk country? How much contact did your child have with the resident population?

The decision to screen should be based on a child's individual risk. Screening may involve either a tuberculin skin test or Interferon
Gamma Release Assay (IGRA), though the former is the only recommended option for children under two years. The latter test is
typically reserved for children who have received the BCG vaccine.

Diagnosing Attention Deficit Hyperactivity Disorder (ADHD)

To be diagnosed with ADHD, individuals must meet specific criteria. In children, the diagnosis of ADHD is usually not made until a
child is at least six years old. The symptoms must be more frequent or severe compared to other children the same age. In
addition, the behaviors must be present in at least two settings, such as home and school and be present for at least six months.

Clinical Skills

Patient Education Strategies

Often, as clinicians, we give our patients a lot of information. It is neither uncommon nor unreasonable for a patient to forget or
not understand a lot of it. It is our responsibility to make sure that we give patients the opportunity to ask questions as well as
help them to remember the information. Giving them handouts, having the nurse review the information with them, referring them
to outside sources, or reviewing the information in an interactive way are just a few different strategies you can use to help ensure
that patients receive and understand the information.

Management

GABHS Pharyngitis Treatment

Penicillin V (50 mg/kg in 2-3 divided doses for 10 days, or 250 mg 2-3 times a day for children less than 27 kg) is the antibiotic of
choice for strep pharyngitis due to low cost, narrow spectrum of activity, safety and effectiveness. Penicillin V is the only antibiotic
shown to reduce the rates of rheumatic fever, and is recommended as a first-line treatment for strep pharyngitis by several
organizations (AAFP: American Academy of Family Physicians, AAP: American Academy of Pediatrics, AHA: American Heart
Association, WHO: World Health Organization, and IDSA: Infectious Disease Society of America).

Penicillin G IM is an appropriate choice when the patient is otherwise unlikely to finish the entire course of oral antibiotics. An
injection can cause significant discomfort and has an increased risk of anaphylaxis although a form of injectable penicillin mixed
with benzathine/procaine (Bicillin C-R) lessens discomfort.

Amoxicillin liquid is often given to children instead of penicillin because it tastes better. However, penicillin has a narrower
spectrum of activity effective against strep and is less likely to contribute to antimicrobial antibiotic resistance. Amoxicillin dosing
is 50 mg/kg divided 2-3 times a day for 10 days. Single dose amoxicillin is not approved for children younger than 12.

First generation cephalosporins (Cephalexin and Cefadroxil) are as effective as penicillins. They also have a broader spectrum
of activity than penicillin and may contribute to antibiotic resistance. They are recommended for patients who have an allergy to
penicillin that is not an immediate-type hypersensitivity. Cephalexin dosing is 25-50 mg/kg divided 2-3 times a day for 10 days.

Macrolides (Erythromycin ethlysuccinate or Erythromycin estolate) are reserved for patients with penicillin allergy. They also
have a broader spectrum of activity than penicillin and may contribute to antibiotic resistance. Azithromycin or clarithromycin may
have fewer gastrointestinal side effects than erythromycin.

Clinical Reasoning

Differential of Pediatric Fever and Sore Throat

Most Likely Diagnoses

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 Viral Etiologies

The most common cause of pharyngitis in children and adults

Commonly presents with dysphagia, rhinitis, cough, and low-grade fever (though fever is not always
present)
Common cold
Conjunctivitis, stomatitis, and erythematous rash (viral exanthema) also can occur

Rhinovirus, coronavirus, and adenovirus are common etiologic agents, though providers rarely test
specifically for them

The second most common viral cause of pharyngitis

Like with the common cold, nearly all patients present with rhinitis and cough.

The distinguishing features of influenza, as opposed to the common cold, may be subtle but include
higher fevers (>50% with temp > 102.2 deg F), myalgia, and malaise.
Influenza
While sporadic cases occur through the year, influenza is a much more likely diagnosis during a period of
high flu activity.

Having been vaccinated against the flu does not preclude this as a diagnosis, though the symptoms may
be milder in immunized patients.

The classic presentation of infectious mononucleosis in children and young adults consists of the triad of
fever, pharyngitis, and lymphadenopathy.

Posterior cervical lymphadenopathy is common and specific for mononucleosis.

Palatal petechiae on the posterior oropharynx distinguishes infectious mononucleosis from other causes
of viral pharyngitis. However palatal petechiae can be seen in GABHS pharyngitis, so does not help in
distinguishing infectious mononucleosis from that condition.

Hepatosplenomegaly also may be present.

Mononucleosis Suspicion for this diagnosis usually occurs after a negative rapid strep or throat culture in a patient who
is ill for more than seven to 10 days.

The monospot test will not become positive until at least seven days into the illness

Common causes of infectious mononucleosis are Epstein-Barr Virus or Cytomegalovirus.

Early in the course of mononucleosis, patients may present with a maculopapular generalized rash. The
rash is faint, rapidly disappears, and is nonpruritic. Note that if patients with mononucleosis are
misdiagnosed with strep and treated with amoxicillin or ampicillin, 90% will develop a classic prolonged,
pruritic, maculopapular rash.

Bacterial
Etiologies

GABHS is the most common bacterial cause of pharyngitis.

It is important to identify because of its rare but serious complications.

Group A Beta-
hemolytic Occasionally accompanied by a diffuse, erythematous, and finely papular rash, frequently described as
Streptococcus having a "sandpaper" texture. This condition is known as scarlet fever.
pharyngitis
Patients with bacterial pharyngitis generally do not have rhinorrhea, cough, or conjunctivitis.

Palatal petechiae are 15% sensitive and 95% specific for GABHS pharyngitis.

Less Likely and More Dangerous Diagnoses

Patients with epiglottitis usually appear ill and have a high fever (> 103 F).

They have symptoms of inspiratory stridor, "hot potato" (muffled) voice, dysphagia, and drooling.

Classically patients will be seated in a "tripod" position, leaning forwards and projecting the chin.

Epiglottitis has a rapid onset and usually presents in patients between 1 and 6 years of age.
Epiglottitis
The incidence of epiglottitis has decreased significantly due to widespread immunization against
Haemophilus influenzae type B, but should be considered in children with any of these symptoms due to
its potentially lethal nature.

Patients with suspected epiglottitis should be evaluated in a hospital with a lateral neck film or CT of the
neck.

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 The initial symptoms of pertussis are nonspecific, similar to those of the "common cold," and include runny
nose, low-grade fever, and mild cough, making the diagnosis in the early stages difficult.

Sore throat is a much less common symptom of pertussis.

However, symptoms from the common cold typically peak by day three, then slowly resolve and are gone
Pertussis
by day seven to 10.

The diagnosis of pertussis is considered when the cough has worsened and has been present for at least
14 days.

When occurring in infants < 4 months, pertussis is more likely to be severe and may be fatal.

A rare but serious complication of GABHS pharyngitis.

Most common among adolescents, but can occur at other ages.

Presents with sore throat and progressively high fevers.

Peritonsillar May cause drooling and muffled ("hot potato") voice.

abscess
Trismus occurs in two-thirds of patients and may help distinguish from tonsillitis.

Exam (which may be difficult due to trismus) reveals asymmetric swelling of the affected tonsil and
deviation of the uvula away from that side.

Urgent surgical evaluation with drainage and antibiotic therapy are the mainstays of treatment.

Retropharyngeal abscess presents with fever, difficulty swallowing, neck or ear pain, muffled "hot potato"
voice, and unwillingness to move the neck. Patients typically appear ill.

Retropharyngeal Most common among young children ages 2 to 4, but can occur at other ages.
abscess The presence of a retropharyngeal abscess may have life-threatening consequences, and should be
managed emergently.

Lateral neck films or CT of the neck aid the diagnosis.

Viral croup may present with a prodrome of mild fever, and symptoms may include a sore throat.

Viral croup also causes a barking cough, inspiratory stridor, and hoarse voice.

The diagnosis of croup is made clinically.

Viral croup A Steeple sign on x-ray is suggestive, but is only present in only 50% of children with croup. The Steeple
sign is a radiographic finding on a PA or AP view of the chest. It appears as a narrowing of the trachea as it
joins to the larynx and is the result of a narrowed column of subglottic air.

Mild cases may be managed in the out-patient setting, but more severe cases may require hospitalization
for IV steroids and safe airway management.

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