Pediatric conditions encompass a wide range of disorders affecting children from infancy through adolescence. Children are not simply small adults; they have unique physiology, developmental considerations, age-specific disease patterns, and medication dosing requirements. This article provides comprehensive coverage of major pediatric conditions.
Common Childhood Illnesses
Acute Otitis Media (Ear Infection)
| Parameter | Detail |
|---|---|
| Definition | Acute infection of the middle ear with rapid onset of signs/symptoms of middle ear inflammation and middle ear effusion |
| Peak age | 6-24 months (most common); second peak 4-6 years |
| Pathophysiology | Eustachian tube dysfunction (short, horizontal, immature in children) -> negative middle ear pressure -> fluid accumulation -> bacterial superinfection |
| Common pathogens | S. pneumoniae (most common), H. influenzae (non-typeable), M. catarrhalis, Group A Strep, viruses (RSV, influenza, rhinovirus) |
| Risk factors | Daycare attendance, bottle feeding (vs breastfeeding), pacifier use, smoke exposure, immunodeficiency, craniofacial abnormalities (cleft palate, Down syndrome), family history |
AOM Diagnosis (AAP Guidelines)
| Criteria | Finding |
|---|---|
| Acute onset | Rapid onset of symptoms (ear pain, fever, irritability, pulling at ears) |
| Middle ear effusion | Bulging tympanic membrane, decreased mobility on pneumatic otoscopy, otorrhea |
| Inflammation | Erythematous TM or otalgia |
AOM Treatment
| Age | Severity | Treatment |
|---|---|---|
| <6 months | Any | Amoxicillin 80-90 mg/kg/day x10 days |
| 6-24 months | Non-severe (unilateral, mild symptoms, <39C) | Amoxicillin or observation (watchful waiting with safety net) |
| 6-24 months | Severe (bilateral, severe pain, fever >39C) | Amoxicillin 80-90 mg/kg/day x10 days |
| >=24 months | Non-severe | Observation (watchful waiting) or amoxicillin x5-7 days |
| >=24 months | Severe | Amoxicillin x10 days |
| Treatment failure (48-72 hours) | – | Amoxicillin-clavulanate (high-dose) |
| Penicillin allergy | – | Cefdinir, cefuroxime, ceftriaxone (IM), clindamycin |
| Prevention | – | Pneumococcal conjugate vaccine (PCV15, PCV20), influenza vaccine, avoid smoke exposure, breastfeeding, limit pacifier use |
Respiratory Syncytial Virus (RSV)
| Parameter | Detail |
|---|---|
| Definition | Single-stranded RNA virus (Paramyxoviridae, Pneumovirus genus) causing respiratory tract infections, most significant in infants |
| Seasonality | Fall-winter (November-March in Northern hemisphere) |
| Transmission | Respiratory droplets, fomites; survives on surfaces for hours |
| Incubation | 4-6 days |
| Clinical presentation | Mild URI (rhinitis, cough) to severe bronchiolitis/pneumonia; apnea (especially in infants <2 months, preterm) |
RSV Severity and Risk Factors
| Severity | Features | Management |
|---|---|---|
| Mild | URI symptoms, mild cough, no respiratory distress | Supportive care (hydration, suctioning) |
| Moderate | Lower respiratory tract involvement (bronchiolitis: tachypnea, wheezing, crackles, retractions, nasal flaring), SpO2 90-94% | Supportive care, nasal suctioning, oxygen if SpO2 <90%, trial of nebulized hypertonic saline (3%), consider HHFNC |
| Severe | Respiratory distress, SpO2 <90%, apnea, poor feeding, lethargy, dehydration | Hospitalization, oxygen, HHFNC or CPAP, IV fluids, mechanical ventilation (if failing) |
RSV Risk Factors for Severe Disease
| Risk Factor | Relative Risk |
|---|---|
| Prematurity (<37 weeks) | 2-3x |
| Chronic lung disease (BPD) | 3-5x |
| Congenital heart disease (hemodynamically significant) | 3-4x |
| Immunodeficiency | 2-3x |
| Age <12 weeks at start of RSV season | 2x |
| Daycare attendance | 1.5x |
| Smoke exposure | 1.5-2x |
RSV Prevention and Treatment
| Intervention | Details |
|---|---|
| Supportive care | Mainstay: nasal suctioning, fever control, adequate hydration, no routine bronchodilators, no steroids, no antibiotics (unless secondary infection) |
| Palivizumab (Synagis) | Monoclonal antibody (monthly IM during RSV season) for high-risk infants (preterm <29 weeks, BPD, CHD) |
| Nirsevimab (Beyfortus) | Single-dose monoclonal antibody for all infants entering first RSV season (new AAP recommendation) |
| RSV vaccine (maternal) | RSVpreF (Abrysvo) vaccine given at 32-36 weeks gestation to protect infant through first 6 months |
| RSV vaccine (older adults) | RSVPreF3 (Arexvy) or RSVpreF (Abrysvo) for >=60 years |
Croup (Laryngotracheobronchitis)
| Parameter | Detail |
|---|---|
| Definition | Viral infection of the upper airway (larynx, trachea, bronchi) causing subglottic edema and characteristic barking cough |
| Peak age | 6 months - 3 years |
| Common pathogens | Parainfluenza virus (types 1, 2, 3 - most common), RSV, influenza, adenovirus, rhinovirus, metapneumovirus |
| Incubation | 2-6 days |
| Classic presentation | Barking seal-like cough, inspiratory stridor, hoarseness, worse at night, preceded by URI symptoms 1-2 days; low-grade fever |
Croup Severity and Treatment
| Severity | Features | Management |
|---|---|---|
| Mild | Barking cough only when agitated, no stridor at rest, no respiratory distress | Outpatient: single dose dexamethasone 0.6 mg/kg (max 10 mg) PO/IM/IV; supportive care (cool mist, hydration, calm child) |
| Moderate | Barking cough, stridor at rest, mild-moderate retractions, no cyanosis | Dexamethasone as above; nebulized epinephrine (racemic 2.25% 0.5 mL or L-epinephrine 1:1000, 5 mL) if moderate distress; observe 2-4 hours after epinephrine |
| Severe | Stridor at rest, severe retractions, cyanosis, lethargy, poor air entry, altered mental status | Dexamethasone + nebulized epinephrine (may repeat); Heliox; ICU admission; intubation if impending respiratory failure |
Hand-Foot-and-Mouth Disease (HFMD)
| Parameter | Detail |
|---|---|
| Definition | Common viral exanthem caused by enteroviruses, characterized by fever, vesicular enanthem (mouth) and exanthem (hands, feet) |
| Peak age | <5 years (most common); children and adults can be affected |
| Most common pathogens | Coxsackievirus A16 (most common, mild); Enterovirus A71 (EV-A71, more severe, CNS complications) |
| Incubation | 3-7 days |
| Transmission | Fecal-oral, respiratory droplets, contact with vesicle fluid; highly contagious |
| Seasonality | Summer and early fall |
| Clinical features | Fever (1-2 days), sore throat, malaise; oral vesicles/ulcers (tongue, buccal mucosa, palate, ~5-10 lesions); cutaneous vesicles (palms, soles, buttocks, ~3-50 lesions, 3-7 mm, greyish, elliptical); rash may be papular/vesicular on knees, elbows, trunk |
HFMD Complications
| Complication | Pathogen | Features | Management |
|---|---|---|---|
| Dehydration | Any | Painful oral ulcers -> poor intake | Oral hydration (cold liquids, popsicles); analgesic mouth rinses (lidocaine/diphenhydramine/Maalox); IV fluids if severe |
| Viral meningitis/encephalitis | EV-A71 (most common), CVA16 (rare) | Fever, headache, myoclonus, ataxia, cranial nerve palsies, altered mental status, neurogenic pulmonary edema (EV-A71) | Supportive care; ICU monitoring; parenteral hydration/analgesia; no specific antiviral |
| Cardiopulmonary failure | EV-A71 | Tachycardia, hypertension, pulmonary edema, cardiogenic shock | ICU, inotropes, ventilation, IVIG (may be beneficial) |
| Onychomadesis | Any | Nail shedding 1-2 months after infection | Self-limited; no treatment needed |
| HFMD treatment | – | Supportive (fever control, hydration, pain management); no specific antiviral; isolation until lesions resolve |
Immunization Schedule Summary (CDC 2024)
| Age | Vaccines |
|---|---|
| Birth | HepB |
| 1-2 months | HepB |
| 2 months | RV, DTaP, IPV, Hib, PCV20 (or Prevnar 20/PCV15) |
| 4 months | RV, DTaP, IPV, Hib, PCV20 |
| 6 months | DTaP, IPV, Hib, PCV20, COVID-19, influenza (annual starting at 6 months) |
| 12-15 months | MMR, VAR, PCV20 (booster if PCV13 received), Hib (booster), HepA (dose 1) |
| 15-18 months | DTaP (booster) |
| 18-24 months | HepA (dose 2) |
| 4-6 years | DTaP, IPV, MMR, VAR |
| 11-12 years | Tdap, HPV (2-3 doses), MenACWY |
| 16 years | MenACWY (booster), MenB (shared decision) |
Congenital Disorders
Common Congenital Anomalies
| Condition | Incidence | Etiology | Key Features | Management |
|---|---|---|---|---|
| Cleft lip and palate | 1:700 | Multifactorial (genetic + environmental), syndromic (Van der Woude, Stickler, Pierre Robin sequence) | Cleft lip (unilateral/bilateral), cleft palate (submucous, soft, hard, complete) | Surgical repair: lip at 3-6 months, palate at 9-18 months; multidisciplinary team (ENT, speech, orthodontics, genetics) |
| Congenital heart disease | 1:100 | Multifactorial, genetic (Down syndrome - AV canal, Turner - coarctation, DiGeorge - conotruncal), environmental (rubella, maternal diabetes, alcohol) | VSD (most common, 30%), ASD, PDA, tetralogy of Fallot, transposition of great arteries, coarctation, HLHS, single ventricle | Medical management (PGE for ductal-dependent lesions), surgical repair/correction, cardiac catheterization, heart transplant (HLHS, failed palliation) |
| Neural tube defects (NTD) | 1:1,000 (declined with folic acid fortification) | Multifactorial (folic acid deficiency, genetic, environmental, medications - valproate) | Spina bifida (meningocele, myelomeningocele most common), anencephaly, encephalocele | Prenatal folic acid (0.4 mg daily all women; 4 mg if prior NTD); prenatal surgical repair (MOMS trial); postnatal closure, CSF shunt for hydrocephalus, multidisciplinary care |
| Down syndrome (Trisomy 21) | 1:700 (increases with maternal age) | Non-disjunction (95%), translocation (4%), mosaicism (1%) | Intellectual disability, hypotonia, flat facies, epicanthal folds, single palmar crease, CHD (AV canal, VSD), duodenal atresia, Hirschsprung, hearing loss, hypothyroidism, Alzheimer risk | Multidisciplinary: cardiology, audiology, ophthalmology, endocrinology, developmental pediatrics; treat hypothyroidism, screen for celiac, CHD repair |
Newborn Screening (Commonly Screened Conditions in US)
| Condition | Test | Onset if Untreated | Treatment |
|---|---|---|---|
| Phenylketonuria (PKU) | Guthrie test (heel stick) | Progressive intellectual disability by 3-6 months | Phenylalanine-restricted diet (lifelong) |
| Congenital hypothyroidism | TSH, T4 | Irreversible intellectual disability by 3-6 months | Levothyroxine (start immediately) |
| Cystic fibrosis | IRT, DNA analysis | Failure to thrive, recurrent respiratory infections | CFTR modulators, pancreatic enzymes, airway clearance |
| Sickle cell disease | Hemoglobin electrophoresis | Vaso-occlusive crises, stroke risk, infection risk | Hydroxyurea, vaccination, penicillin prophylaxis |
| Medium-chain acyl-CoA dehydrogenase (MCAD) deficiency | Tandem mass spectrometry | Hypoglycemia, metabolic acidosis, sudden death | Avoid prolonged fasting, L-carnitine, sick day management |
| Congenital adrenal hyperplasia (CAH) | 17-OHP by heel stick | Salt-wasting crisis (life-threatening), virilization | Hydrocortisone, fludrocortisone, salt supplementation |
Growth Disorders
Normal Growth Parameters
| Parameter | Normal Variation | Abnormal Threshold | Evaluation |
|---|---|---|---|
| Height velocity (1-3 years) | 5-8 cm/year | <5 cm/year (<2nd percentile) | Bone age, growth chart review, endocrine workup (IGF-1, IGFBP-3, TSH, celiac screen) |
| Height velocity (3-10 years) | 5-6 cm/year (pre-pubertal) | <4.5 cm/year | Same as above |
| Height velocity (10-14 years, puberty) | 8-14 cm/year (peak) | <6 cm/year (delayed puberty) | Pubertal staging, bone age, GnRH/LH/FSH, sex steroids |
| Weight gain | Follows growth curve percentile | Crossing 2+ percentiles downward | Medical history, dietary assessment, endocrine/metabolic workup |
| Head circumference | Follows curve | Crossing 2+ percentiles upward or downward | Neuroimaging (if indicated), developmental assessment |
Short Stature Etiologies
| Category | Cause | Key Features |
|---|---|---|
| Normal variant | Familial short stature | Normal growth velocity, bone age = chronologic age, parents short |
| Constitutional delay of growth and puberty | Delayed bone age, delayed puberty, family history of late bloomers, eventually normal adult height | |
| Endocrine | Growth hormone deficiency | Slow growth velocity, delayed bone age, low IGF-1/IGFBP-3, low GH on stimulation testing; may have midline defects, hypoglycemia |
| Endocrine | Hypothyroidism | Growth deceleration, delayed bone age, elevated TSH, low T4; other hypothyroid symptoms |
| Endocrine | Cushing syndrome | Growth failure, weight gain, moon facies, striae, elevated cortisol |
| Genetic | Turner syndrome (45,X) | Short stature, webbed neck, broad chest, low hairline, gonadal dysgenesis; consider in all girls with unexplained short stature |
| Genetic | Noonan syndrome | Short stature, webbed neck, CHD (pulmonic stenosis), pectus deformity, intellectual disability |
| Skeletal dysplasia | Achondroplasia | Rhizomelic shortening (proximal limbs), macrocephaly, frontal bossing, trident hands; most common skeletal dysplasia |
| Chronic disease | Celiac disease | Malabsorption, abdominal pain, short stature, anemia, positive tTG |
| Chronic disease | IBD | Growth failure may precede GI symptoms; poor nutrition, inflammation |
| Chronic disease | CKD | Growth failure due to metabolic acidosis, anemia, malnutrition; improve with treatment |
| Psychosocial | Psychosocial dwarfism (deprivation) | Growth failure, delayed bone age, abnormal social interactions, improve with change in environment |
Growth Hormone Therapy Indications
| Indication | FDA Approval | Expected Height Gain |
|---|---|---|
| Growth hormone deficiency | Yes | Variable (depends on degree of deficiency and age at diagnosis) |
| Turner syndrome | Yes | 5-8 cm |
| Chronic kidney disease | Yes | 4-6 cm |
| Noonan syndrome | Yes | 3-5 cm |
| Small for gestational age (SGA) without catch-up by age 2-4 | Yes | 5-7 cm |
| Prader-Willi syndrome | Yes | Improved body composition |
| Idiopathic short stature (height SDS < -2.25) | Yes (controversial, high cost, modest benefit) | 3-5 cm |
Childhood Cancers
| Type | Peak Age | Frequency | Key Features | 5-Year Survival |
|---|---|---|---|---|
| ALL (Acute Lymphoblastic Leukemia) | 2-5 years | 25% of childhood cancers (most common) | B-cell (85%) > T-cell; pallor, fatigue, bruising, fever, bone pain, hepatosplenomegaly; WBC >50K is high-risk | >90% (best outcomes in developed world) |
| Brain tumors | Variable | 20% | Most common solid tumor; astrocytoma/pilocytic astrocytoma (most common, good prognosis), medulloblastoma (posterior fossa, peak 3-8), ependymoma, brainstem glioma | 75-85% (varies by type) |
| Neuroblastoma | <5 years (median 18 months) | 8% | Abdominal mass (adrenal), proptosis (periorbital metastases), opsoclonus-myoclonus; MYCN amplification is poor prognostic | 50-80% (age-dependent; infants >90%) |
| Wilms tumor (nephroblastoma) | 3-4 years | 5% | Abdominal mass, hematuria, hypertension; associated with WAGR, Beckwith-Wiedemann, Denys-Drash syndromes | >90% |
| Hodgkin lymphoma | 15-19 years (bimodal also: 25-30) | 5% | Painless lymphadenopathy (cervical, supraclavicular), B symptoms; nodular sclerosis most common; good prognosis | >95% |
| Non-Hodgkin lymphoma | 7-11 years | 6% | Burkitt (most common), DLBCL, lymphoblastic, anaplastic large cell; abdominal, mediastinal, nodal | 80-90% |
| Osteosarcoma | 10-20 years (growth spurt) | 3% | Long bone metaphysis (distal femur, proximal tibia), pain, swelling, Codman triangle, sunburst appearance | 60-70% |
| Ewing sarcoma | 10-15 years | 2% | Diaphysis (femur, pelvis, chest wall), t(11;22) EWSR1-FLI1; primitive neuroectodermal tumor | 70-80% |
| Rhabdomyosarcoma | 2-6 years, 15-19 | 3% | Most common soft tissue sarcoma; head/neck, genitourinary, extremities; PAX3/PAX7-FOXO1 fusion | 70% |
| Retinoblastoma | <2 years | 2% | Leukocoria (cat’s eye reflex), strabismus; RB1 gene; hereditary (40%, bilateral, early) vs sporadic (60%, unilateral) | >95% |
| Germ cell tumors | Variable | 3% | Sacrococcygeal (infants), ovarian, testicular, mediastinal; increased AFP, beta-hCG | >90% |
Common Oncologic Emergencies in Children
| Emergency | Common in | Presentation | Management |
|---|---|---|---|
| Tumor lysis syndrome (TLS) | ALL, Burkitt lymphoma | Hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia, AKI, cardiac arrhythmias | Rasburicase, aggressive IV hydration, allopurinol, management of electrolytes, dialysis if needed |
| Superior vena cava syndrome (SVCS) | ALL, NHL, mediastinal masses | Facial/neck edema, stridor, dyspnea, headache, jugular venous distension; anesthesia risk (airway compromise) | Corticosteroids, radiation (low dose); avoid biopsy under general anesthesia |
| Febrile neutropenia | Any chemo | Fever (single >38.3C or sustained >38C x1 hour) in neutropenic patient (ANC <500) | Broad-spectrum IV antibiotics (cefepime, piperacillin-tazobactam), growth factors (G-CSF) if prolonged |
| Spinal cord compression | Neuroblastoma, sarcomas, lymphoma | Back pain, limb weakness, bowel/bladder dysfunction, sensory level | Corticosteroids, emergent radiation or neurosurgical decompression |
Attention-Deficit/Hyperactivity Disorder (ADHD)
| Parameter | Detail |
|---|---|
| Definition | Neurodevelopmental disorder characterized by persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development |
| Prevalence | 5-10% of children (most common neurodevelopmental disorder); M:F 3:1 in children |
| Age of onset | Symptoms before age 12 (required per DSM-5) |
| Pathophysiology | Dysregulation of dopamine and norepinephrine in prefrontal cortex, executive function networks, frontostriatal circuitry; strong genetic component (heritability 70-80%) |
ADHD Subtypes (DSM-5)
| Subtype | Predominant Symptoms | Frequency |
|---|---|---|
| Predominantly inattentive | Inattention (>=6 of 9 symptoms): careless mistakes, difficulty sustaining attention, not listening, not following through, disorganized, avoids sustained mental effort, loses things, easily distracted, forgetful | 20-30% |
| Predominantly hyperactive-impulsive | Hyperactivity-impulsivity (>=6 of 9 symptoms): fidgets, leaves seat, runs/climbs inappropriately, unable to play quietly, on the go, talks excessively, blurts answers, difficulty waiting turn, interrupts | 10-15% |
| Combined | Both inattention and hyperactivity-impulsivity criteria met | 50-75% (most common) |
ADHD Treatment
| Intervention | Examples | Notes |
|---|---|---|
| Behavioral therapy (preschool, mild) | Parent training in behavior management, classroom management, organizational skills training | First-line for preschool (age 4-5); recommended as adjunct for all ages |
| Stimulants (first-line pharmacotherapy) | Methylphenidate (Ritalin, Concerta, Daytrana, Metadate) - short and long-acting; Amphetamine (Adderall, Vyvanse, Dexedrine, Evekeo) | Highly effective (70-80% response); monitor appetite, sleep, growth, BP, HR; no increased risk of tics or future substance abuse when treated |
| Non-stimulants (second-line) | Atomoxetine (SNRI), guanfacine ER (alpha-2 agonist), clonidine ER (alpha-2 agonist) | For poor response/intolerance to stimulants, comorbid anxiety/tics; slower onset of action; effective for symptom control |
| School interventions | 504 Plan, IEP, preferential seating, extended time, reduced workload, breaks | Legal rights under IDEA and ADA |
| Comorbidity management | Treat coexisting conditions (anxiety, depression, ODD, learning disabilities) | 60-80% of children with ADHD have at least one comorbid condition |
Pediatric Asthma
Refer to the Respiratory Diseases article for comprehensive asthma information.
Key Pediatric Considerations
| Aspect | Children | Adults |
|---|---|---|
| Diagnosis | Clinical (wheezing, cough, dyspnea, chest tightness) + family history + therapeutic trial; spirometry from age 5-6 | Spirometry + bronchodilator reversibility |
| Triggers | URI (most common), allergens, exercise, cold air, emotions, tobacco smoke | Allergens, exercise, cold air, NSAIDs, beta-blockers, occupational, less viral |
| Differential | Viral-induced wheezing, bronchiolitis, foreign body (sudden onset, unilateral), GERD, cystic fibrosis, croup, vocal cord dysfunction, tracheomalacia, congenital anomalies, aspiration | COPD, CHF, vocal cord dysfunction, PE, hypersensitivity pneumonitis, chronic cough from ACEi, GERD |
| Medication dosing | Weight-based (mg/kg) | Standard dosing |
| Inhaler device | Metered dose inhaler (MDI) + spacer (preferred for all ages) or nebulizer for young children | MDI, DPI (preferred for coordination issues) |
| Growth monitoring | Monitor height/weight during treatment (ICS may cause growth deceleration, usually minimal and not progressive) | Not applicable |
| Transition to adult care | Begin transition at age 12-14; complete transfer at 18-21 | – |
| Acute severity classification (NAEPP EPR-3) | Mild: normal mental status, slight tachypnea, wheeze end-expiratory; Moderate: agitation, tachypnea, wheeze throughout, retractions; Severe: agitation, marked tachypnea, severe retractions, air entry poor, cyanosis; Impending respiratory failure: lethargic/drowsy, silent chest, no respiratory drive, bradycardia | Similar but with risk stratification (PEFR) |
Factors Predicting Persistent Asthma in Wheezing Children (API - Asthma Predictive Index)
| Major Criteria | Minor Criteria |
|---|---|
| Parental MD diagnosis of asthma | MD diagnosis of allergic rhinitis |
| MD diagnosis of atopic dermatitis | Wheezing unrelated to URI |
| Aeroallergen sensitization | Eosinophilia >=4% |
Interpretation: 1 major OR 2 minor criteria = positive API (predicts asthma persistence at school age).