Common Problems in Infants and Toddlers (teething, colic and fever)

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Common Problems in Infants and Toddlers(teething,
colic and fever)

• PHM 456
• Angela Trope MSc
• The Hospital for Sick Children

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Common Problems in Infants and Toddlers

• PJ 271 2003
• Survey to determine the extent and use of OTCs in
  children
• and to examine how OTCs are handled at home.
• Study population lt 12y old
• N 424 questionnaires completed by
  parents/caregivers (61 RR)
• Acetaminophen and cough/cold remedies- most
  frequently purchased
• 16 of purchases were from non-pharmacy outlets
• Storage at home 50 respondents were sure that
  medicines were safely stored

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Common Problems in Infants and Toddlers

• 30 requested medicines with no sugar
• Dosing info most followed instructions on
  container insert own knowledge/friends. 17
  used a health care professional ? tended to be
  parents of younger children (median 4 vs 6yr)
  i.e. parents learn from experience
• Most used a medicine spoon
• Frequency of dosing was generally appropriate
• DisposalMost respondents saved medicines for
  future use

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Role of the pharmacist

• Provide advice wrt choice of medicine,
• brand vs generic
• Dosing and administration/measuring device
• Safe storage
• Ensure the safe and effective use of medications
  in children

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Teething You are asked by a mother to
recommend something for infant whom she thinks is
teething. She says that her baby is feeling
miserable, is drooling a lot and has diarrhea.

• Teething occurs from about 6-36 months of age
• (refers to the process by which teeth move from
  their site of development
• within the jaws to their final functional
  position in the mouth)
• 20 primary (baby) teeth come in by about 3 years
  of age
• The first permanent teeth come in at 6-7 years of
  age. Children lose primary teeth until about 12
  years of age

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Teething Signs and SymptomsBeliefs versus
Academic Publications

• Many symptoms have been attributed to teething in
  infancy
• Biting
• Drooling
• Gum rubbing
• Irritability
• Sucking
• Change in appetite
• Changes in sleep patterns
• Cough
• Rash on face / in diaper area
• Diarrhea
• Fever

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Teething Fever and Diarrhea

• There is no good evidence to support an
  association between teething and fever or
  diarrhea
• cultural beliefs in an association between
  teething and diarrhea /loose stools may exist
• Dont ignore diarrhea
• mild increase in temperature (lt102?F) may be seen
  on the day of a tooth eruption
• Other causes of high or prolonged fevers must be
  ruled out

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Teething Pharmacists Dialogue

• General aspects of dental hygiene for
  infants/toddlers (lt 4yr)
• Avoid going to bed with bottle of milk, formula
  or juice
• Children lt 6 years old use less than a pea-sized
  amount of fluoridated toothpaste
• lt2- 3years old use a non fluoridated toothpaste
  as it is difficult for young children to avoid
  swallowing.

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Teething Pharmacists dialogueManagement

• ? Acetaminophen not more than 65mg/kg/day
• Topical agents
• Local anaesthetic agents- AVOID

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Infantile Colic Unexplained infant
irritabilityYou are asked by a parent to
recommend a remedy for her 2 month old colicky
baby. You note that the baby is sleeping
peacefully and looks well nourished.

• Excessive crying in healthy, thriving infants
• The infants may be inconsolable, may draw up
  their legs, pass gas and have difficulty stooling
• Crying typically occurs at the same time each day
  e.g evenings
• Onset first weeks of life up to 4-5 months
• Incidence highly variable

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Infantile Colic Etiology remains unclear

• ? Painful gut contractions secondary to excess
  gas, cows milk allergy or lactose intolerance
• ? Behavioural problem difficult temperament and
  parent - infant interaction may be less than
  optimal
• ? Extreme end of normal crying

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Infantile Colic Pharmacists DialogueManagement

• Reassure caregiver/parent
• Colic is not a disease
• It is self limiting
• Formula switching caution is required!
• Trial new feed for one week
• Do not discourage breast feeding
• Avoid over stimulation of infant

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Infantile Colic Pharmacists DialogueManagement

• Medications
• Simethicone, surface active agent
• Not beneficial
• Dicyclomine, anticholinergic agent
• Beneficial but not recommended because of serious
  side effects
• See CPS monograph

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FeverIt is midwinter and you are working the
evening shift. You received a phone call from a
mother who lives in Alliston. Shes very
concernedbecause her baby has a fever and she
cannot take her to the local hospital because
the area is snowed in. The mother says that she
has some ASA in the house and thinks that there
may be some adult Tylenol in the car.
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Fever General principles

• Febrile illness ?10-20 of pediatric visits to
  Emerg Depts
• Fever is a symptom not a disease
• physical sign or symptom that often accompanies
  an illness
• Fever rectal temperature gt38C (100.4F)
• mouth/armpit or ear gt37.8 C/ gt 37.5 C
  respectively
• Use rectal or axillary temperatures in children
  lt5years
• Most fevers in children are due to viral
  infections
• Need to carefully assess fever in children lt3
  years without a focus for infection in order to
  rule out serious bacterial infection

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Fever General principlesConsider physical signs
and symptoms

• How sick does the infant/child look
• Is it difficult to wake the infant/child
• Is the child delirious/confused
• LOC poor or absent eye contact or failure of a
  child to
• recognize parents or interact with objects in the
  environment
• Is the infant/child inconsolable
• Does the infants/childs skin colour look
  pale/grey
• Are there small purple spots on the skin

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Fever with no source of infection in children
lt 3yrDifferent age groups have been assigned
different risk categoriesBabies lt 3months are
most vulnerable!!

• All febrile babies/neonates lt1 month must be
  hospitalized to rule out serious bacterial
  infection e.g sepsis, meningitis or UTI
• Febrile infants 1-3 months must be seen by a
  physician ? assign risk ?? treat accordingly
• Infants/toddlers 3-36 months
• If temperature gt39C, ? investigated
• If temperature is lt39C, may manage at home.
  Reevaluate if temperature
• persists for 2-3 days

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Fever AntipyreticsMust give clear instructions
in order to avoid misadventures in dosing

• Acetaminophen
• 10-15mg/kg po q4-6 prn
• (max 65mg/kg/day)
• Measuring device
• Availability drops,syrup,
• chew tablets, tablets/caplets

• Ibuprofen
• lt 6mos 5mg/kg po q8h prn
• gt 6mos
• Tlt 39C 5mg/kg po q6-8h prn
• T ? 39C 10mg/kg po q6-8h prn
• But 10mg/kg is optimal
• suspension, tablets, drops,
• tablets/caplets

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Fever AntipyreticsMust give clear instructions
in order to avoid misadventures in dosing

• Alternating doses
• no evidence to support this strategy
• potential for confusion/dosing errors
• Interventions
• Avoid insufficient dose e.g. for acetaminophenlt
  10mg/kg/dose or dosing intervals gt6h
• Avoid prn dosing, if necessary, BUT limit
  duration
• Use ibuprofen when fever unresponsive to maximal
  doses of acetaminophen. Ibuprofen has a longer
  duration of action
• ?Taste

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Resources

• Canadian Society of Paediatrics
• American Academy of Pediatrics
• Canadian Dental Association