260 PART II: PRIMARY CARE DISORDERS
Thisvaccineshouldberepeated3to5yearslaterfor
thosewitheitherfunctionaloranatomicasplenia.Ifthe
child originally was given the 14-valent vaccine, the
23-valentvaccineshouldbegiven.Meningococcaland
inuenzavaccinesshouldalsobeadministered.Infants
and children should receive folic acid daily with the
dosedeterminedbyweight.Parentsmustbecautioned
toseekimmediatetreatmentforthechildifafeveror
othersignsofsepsisdevelopbecausethevaccinewill
not protect the child completelyfrom pneumococcal
infection,sepsis,ordeath.
2,3
Asthma
General Characteristics
Asthmaisachronicinammatorydisorderoftherespira-
torytractandisthemostcommoncauseofchronicill-
ness and hospitalization in children. Asthma causes
restrictionofairow,whichresultsfromchangessuchas
bronchoconstriction, airway edema, increase in secre-
tions,airwayhyperresponsiveness,andairwayremodeling.
Asthmaprevalenceishighestamongchildrenaged5to
17 years. The incidence during childhood is higher in
boysthaningirls,andforadultstheincidenceisgreaterin
women than in men. Wheezing may begin as early as
infancyandisoftentriggeredbyviralupperrespiratory
infections(URIs).Asthmasymptomsmaybetriggeredby
anumberof otherfactors,such asexposureto tobacco
smoke from parents and other caregivers, exposure to
inhalant allergens that may precipitate wheezing, exer-
cise, weather changes, or emotional upsets. Other risk
factors,suchasAfricanAmericanheritage,prematurity,
obesity,andlowsocioeconomic environment have been
associatedwithasthma.
Becauseasthmaisachronicdisease,thediagnosismay
becomeapparentovertimewithseveralepisodesofwheez-
ing, shortness of breath, coughing (especially nocturnal
coughing),sputumproduction,dyspnea,andcomplaintsof
chesttightness.Childrendonotoutgrowasthma,buttheir
airwaysbecomelargerandthereforetheymaynotappear
symptomatic. They may continue to have subclinical
ventilation-perfusiondecitsandmayexperience a recur-
renceduringaviralillness.
Predisposingfactorsincludegeneticandprenatalinu-
ences,includingmaternalasthma.Thereisusuallyastrong
family history for immunoglobulin E (IgE)-mediated dis-
eases or atopy, which refers to allergic diseases, such as
allergic rhinitis, atopic dermatitis, and asthma. Asthma
developmentmayalsobeginduringgestationbyfetalcon-
tactwithallergensthroughallergentransferacrossthepla-
centaorswallowingamnioticuid.Earlysignsthatachild
is predisposed to developing asthma include the allergic
triad or allergic march of atopy, indicating the progression
of allergic symptoms; early food allergies (and no breast-
feeding);atopic dermatitis (eczema);and allergic rhinitis,
all of which can lead to frequent URIs and chronic or
frequentotitismedia.
4–6
Signs, Symptoms, and Diagnosis
Increasedmucusproduction,smoothmusclespasm,and
inammationintheairwaysarecharacteristicofasthma.
Coughing, wheezing, tachycardia, tachypnea, and short-
nessofbreathcommonlyoccurduringanacuteasthmatic
episode.Coughingmaydevelopwithasmallerdegreeof
bronchospasmthanrequiredtoproduceaudiblewheezing.
Coughing,especiallyatnightandduringphysicalactivity
orexcitement,isthehallmarkofasthma.Thesesymptoms
maybebroughtonbyaviralURI,exercise,orexposureto
inhalantallergens.Somechildrencoughafterlaughteror
following other intense emotions. Some childrendo not
wheezebutratherhavecoughing or profusemucuspro-
duction,withthecoughworseningatnight.Childrenwho
seem to have had recurrent pneumonia may actually be
asthmatic;onX-raytheinltratemaybeatelectasisinthe
rightmiddlelobeorlingula.
Whenachildisbeingevaluatedforwheezingorcough,
bronchiolitis, cystic brosis (CF), aspiration of a foreign
body, gastroesophageal reux disease (GERD), and ana-
tomicdefectsoftheairwayshouldbeconsidered.Thehis-
tory should include family history; history of atopy; and
onset,duration,character,andfrequencyofcough,wheez-
ing,snoring,rhinitis,andsinusitis.Thephysicalexamina-
tionmustincludeanassessmentofthegeneralconditionof
thechild,especiallysignsofdistress.Thephysicalexamina-
tionmustalsoincludeathoroughchestevaluation,includ-
ingrespiratoryexpansion,signsofrespiratorydistress,and
auscultation for rales, rhonchi, or wheezing. Asking the
childtofoldhisorherarmsandholdthemawayfromthe
chest increases the area available to evaluate both upper
lobes.Askingthechildtopretendtoblowoutacandleor
actuallyblowonapapertoweltomakeitutterwillimprove
airwaymovement,especiallyinyoungchildren.
Althoughpulmonaryfunctiontestingisoneofthemost
important diagnostic tools, a number of diagnostic tests
are commonly utilized, depending on the severity of
symptomsandageofthechild:
• CBC
• Oxygen saturation with pulse oximetry (above 97
precent represents a healthy range; 95–97 percent
represents mildoxygen deprivation)90–95percent
represents moderate deprivation; and less than 90
percentrepresentsseveredeprivation)
• ChestX-ray
• SweattestifCFisconsidered
• Immunologicskintesting
• Completespirometrytestingfordetectingthedegree
andreversibilityofrespiratoryobstruction(thistest
shouldideallybeperformedinchildrenoldenough
tocooperate)
• Peakexpiratoryow(PEF)rate
PEF is an important and commonly used diagnostic
tool.Peakowratesareeasilymeasuredintheoutpatient
setting,mostlyinchildrenaged4yearsandolder.Itisalso
usedathometoevaluatethedegreeofbronchospasmas
abasisformanagementdecisions.PEFcanbemeasured
with portable equipment, and measurements over time
can establish norms for each child. Most importantly, it
Chapter 20: Pediatric Disorders 261
provides information that can allow the parent and the
childtotake moreresponsibilityforthemanagement of
asthma. Peak ow measuresthe expiratory rate in liters
perminute.Itrequiresthatthechildexhaleintothepeak
ow meter with maximal effort.Childrenshouldexhale
twoorthreetimes,andthebestmeasurementshouldbe
used to determine the degree of bronchospasm. Normal
measurements, in centimeters, for sex and height have
beenestablishedforchildrenandadults;thisinformation
isincluded withthe ow meter. Personal normsor per-
sonalbestcanbeestablishedovertimeforeachchild,and
valuesshouldbe within 5to10 percentofoneanother.
The PEF can be used to measure the degree of asthma
controlwiththeuseofpercentagesandeasycolorcoding
to compare the result with the child’s norm or personal
best
4–6
:
•Greenzone:80to100percent,goodcontrol
• Yellow zone: 50 to 80 percent, caution, reduced
airow
• Red zone: 0 to 50 percent, danger, major airow
obstruction
Management
Guidelines for management are recommended by the
NationalAsthmaEducationandPreventionProgram.
4
The
treatment of asthma focuses on early identication and
control of asthma, including improving quality of life;
reversingairwayobstruction;reducingwheezingandcough
exacerbations, airow obstruction and remodeling, emer-
gency and hospital care, sleep disturbances, and school
absences; and preventing death. Education of the patient
andtheparents,includinganongoingeducationplan,isa
majorcomponentofasthmacare.
Pharmacologictreatmentofsymptomsisbasedonthree
agecategories(0to4years,5to11years,and12yearsto
adult) and a step classication for severity of symptoms
(fourgeneralcategoriesclassiedintosixsubcategoriesor
stepcategories).
Table 20–1presentsamodied,generalclas-
sicationforasthmaseverityinchildren,althoughthenum-
berofeventsmayvarywithinthethreeagecategories.
The pharmacologic treatment of asthma includes
establishing theseverity of symptoms, determiningthe
stepcategory,monitoringsymptomseverity,andadjust-
ing medications (increasing or decreasing dosages in a
stepwise fashion) to maintain good asthma control.
Beginningtreatmentwithadequateormaximumdosages
to achieve control and then stepping the medication
downtothelowestlevelforoptimumcontrolisgener-
allyrecommended.Themajortreatmentplanconsistsof
combinationsofinhaledcorticosteroidsforreducingair-
wayinammationandinhaledbeta
2
-adrenergic agonists
forbronchodilatation,alongwithpatienteducationand
managementplans.Medicationchoicesforchildrenare
shown in Table 20–2,whichareusuallygivenincombi-
nationtherapies.
Combinationtherapiestypicallyincludethefollowing:
• Corticosteroids:Low,medium,andhighdosagesof
inhaledcorticosteroidsareusedforcontrolofinam-
mation. Oral systemic corticosteroids are used for
shorttreatmentcoursesandseveresymptoms.
• Beta
2
-adrenergicagonists:Inhaledshort-actingbeta
2
-
adrenergic agonists (SABA) such as albuterol, and
Table 20–1
Modied Step Categories for Classifying Asthma Control
Category Symptoms/SABA* Use Nighttime Symptoms PEF
Step 1:
Intermittent 2 times per week 2 times per month > 80%
Step 2:
Mild persistent > 2 days per week
< 1 time per day
3–4 times per month > 80%
Steps 3 and 4:
Moderate persistent Daily 3–4 times per month
> 1 time per week
Not nightly
60–80%
Steps 5 and 6:
Severe persistent Several times per day > 1 time per week
7 times per week
< 60%
*SABA: Short-acting beta
2
agonist
†PEF: Peak expiratory ow
Sources: National Heart, Lung, and Blood Institute. Expert panel report 3 (EPR3): guidelines for the diagnosis and treatment of asthma. http://www.
nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf; Sharma G, Gupta P. Asthma-Follow-up. http://emedicine.medscape.com/article/1000997-followup.
Accessed November 4, 2010.

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