01
Croup vs Epiglottitis
The most heavily tested comparison in pediatric nursing — know every difference.
- Croup (LTB) | Epiglottitis
- Full name
- Laryngotracheobronchitis | Acute supraglottitis
- Age
- 6 months – 3 years | 3 – 7 years (older children)
- Cause
- Parainfluenza virus (#1) | Haemophilus influenzae type b (Hib)
- Onset
- Gradual (1–2 day URI prodrome) | Sudden / rapid (hours)
- Cough
- Barky, seal-like ("bark like a seal") | None or muffled
- Stridor
- Inspiratory stridor (subglottic) | Inspiratory stridor (worse, higher pitched)
- Fever
- Low-grade | High fever (104+ °F)
- Drooling
- Absent | Present (classic sign)
- Posture
- Prefers lying down | Tripod position (leaning forward, jaw thrust out)
- Sore throat
- Absent | Severe — child may refuse to swallow
- Treatment
- Cool mist, racemic epinephrine, dexamethasone, calm environment | Do NOT examine throat or agitate. IV antibiotics, intubation readiness, emergency airway.
- Danger
- Moderate — responds to treatment | Life-threatening — can close airway within minutes
NEVER Do This with Epiglottitis
Do NOT use a tongue blade to examine the throat. Do NOT place the child supine. Do NOT agitate the child in any way. Do NOT attempt IV access before airway is secured in an uncooperative child. Any of these can trigger complete airway obstruction. Keep the child calm in whatever position they choose.
Croup Treatment
Cool mist humidifier or taking child outside in cool night air helps relieve stridor. In the hospital: nebulized racemic epinephrine (temporary, child must be monitored for rebound 2–4 hrs), and dexamethasone (reduces edema). Both are frequently tested.
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02
RSV & Bronchiolitis
Leading cause of hospitalization in infants under 1 year.
- RSV (Respiratory Syncytial Virus) = most common cause of bronchiolitis in infants
- Peak season: October – March
- High risk: premature infants, congenital heart disease, immunocompromised
Signs and Symptoms
- URI symptoms first (runny nose, mild fever), then progresses to:
- Wheezing, tachypnea, nasal flaring, retractions
- Difficulty feeding due to respiratory effort
- SpO2 may drop below 90%
Nursing Care
- Contact precautions + standard precautions (RSV spreads via droplets and fomites)
- Bulb suction nares before feeding (can't breathe and eat simultaneously)
- Small frequent feedings or NG feeds if too tired to eat
- Humidified O2, monitor SpO2
- RSV prevention (NOT treatment): nirsevimab (Beyfortus), a long-acting monoclonal for infants, and the maternal RSV vaccine in pregnancy are now preferred; the older monthly palivizumab (Synagis) is no longer available after December 31, 2025 — verify the current CDC/AAP schedule
Key Point
There is NO specific antiviral treatment for RSV bronchiolitis — nursing care is supportive. Antibiotics are NOT indicated (it's viral). Bronchodilators are controversial and not routinely recommended for all infants.
03
Otitis Media
Most common bacterial infection in children — and the most common reason for antibiotic prescriptions in pediatrics.
- Cause: Streptococcus pneumoniae (#1), Haemophilus influenzae, Moraxella catarrhalis
- Risk factors: daycare attendance, bottle-feeding supine, pacifier use, secondhand smoke, frequent URI
Signs and Symptoms
- Ear pulling/tugging (infants who can't verbalize pain)
- Fever, irritability, crying, difficulty sleeping
- Decreased hearing
- Otoscope: red, bulging, immobile tympanic membrane
- May have purulent drainage if TM ruptured (ear pain often improves after rupture)
Treatment and Teaching
- Antibiotics: Amoxicillin first-line (unless penicillin allergy or treatment failure)
- Complete the full course — do not stop when child feels better
- Pain management: acetaminophen or ibuprofen, warm compress
- Teaching: never prop a bottle (milk pools around Eustachian tube)
- Recurrent OM: myringotomy with PE tubes (pressure equalization)
Exam Tip
When inserting an otoscope: pull the pinna up and back in children over 3 years, down and back in children under 3 (same as infants). This is frequently tested alongside the adult technique (up and back).
? Which direction do you pull the pinna when inserting an otoscope in a 2-year-old?
Down and back for children under 3 (and infants). Pull up and back for children over 3 years and adults. The difference reflects the straighter ear canal angle in younger children.
04
Pediatric Asthma
Most common chronic disease of childhood — management focuses on trigger avoidance and stepwise medication use.
Signs and Symptoms
- Wheezing (expiratory), cough (especially nocturnal), chest tightness, dyspnea
- Accessory muscle use, nasal flaring, retractions
- "Silent chest" in severe attack = no wheeze heard = airflow severely decreased = emergency
- Triggers: allergens, cold air, exercise, viral URI, smoke, stress
Medications
- Albuterol (SABA)rescue
- Short-acting beta-2 agonist. Quick relief — use during attacks. Teach to use BEFORE exercise.
- Inhaled corticosteroidscontroller
- Fluticasone, budesonide. Daily use — reduces inflammation. Rinse mouth after to prevent thrush.
- Montelukast (Singulair)controller
- Leukotriene modifier. Long-term controller — especially for exercise-induced and allergic asthma.
- Ipratropiumacute
- Anticholinergic. Acute attacks — used alongside albuterol in the ED.
Nursing Teaching
- Use spacer with MDI — improves medication delivery to lungs
- Peak flow meter: green (80–100%) = good, yellow (50–79%) = caution, red (<50%) = emergency
- Avoid known triggers. Keep bedroom free of dust/pet dander/mold.
- Carry rescue inhaler at all times
05
Cystic Fibrosis
Autosomal recessive genetic disorder causing thick, sticky mucus in lungs and GI tract. No cure — management is the focus.
Pathophysiology
- Defect in CFTR gene — affects chloride channels
- Thick mucus clogs: lungs (recurrent infections), pancreas (malabsorption), GI tract, sweat glands
- Classic: "salty baby" — mother notices salty taste when kissing infant's skin (excess NaCl in sweat)
Diagnostic Test
- Sweat chloride test — gold standard. >60 mEq/L = positive for CF
- Newborn screen (IRT — immunoreactive trypsinogen) + genetic testing
Signs and Symptoms
- Respiratory: chronic productive cough, recurrent pneumonia, barrel chest, clubbing
- GI: steatorrhea (fatty, foul-smelling, floating stools), malnutrition, failure to thrive
- Meconium ileus in newborns — first sign of CF in some infants
- Pancreatic insufficiency: cannot digest fats/proteins without enzyme supplementation
Treatment
- Chest physiotherapy (CPT) + postural drainage — loosen mucus. Do before meals (not after — vomiting risk)
- Pancreatic enzyme replacements (Creon) — taken with every meal and snack
- High-calorie, high-protein, high-fat diet (cannot absorb nutrients normally)
- Fat-soluble vitamins: A, D, E, K (cannot absorb without pancreatic enzymes)
- Bronchodilators, mucolytics (dornase alfa — DNase), antibiotics for infections
- CFTR modulators (ivacaftor/Trikafta) — newer drugs that target the gene defect
Key CF Nursing Points
CPT is done before meals, not after. Patients need extra salt in hot weather (they lose excess NaCl in sweat). Pancreatic enzymes must be taken with every meal. High-calorie intake is essential — CF patients need 120–150% of normal caloric requirements.
06
Communicable Diseases
Know the disease, transmission, isolation type, and key nursing facts.
- Chickenpox (Varicella)airborne + contact
- Negative pressure room. Rash: starts on trunk, spreads outward. Vesicles in ALL stages simultaneously. Contagious 1–2 days before rash to when all lesions crusted. Give acyclovir to immunocompromised. No aspirin (Reye syndrome).
- Measles (Rubeola)airborne
- Negative pressure room. 3 C's: Cough, Coryza, Conjunctivitis + Koplik spots (white spots on buccal mucosa — appear before rash). Rash spreads head-to-toe. Most contagious viral illness known.
- Rubella (German Measles)droplet + contact
- Mild in children. Devastating in first trimester (congenital rubella syndrome: cataracts, deafness, heart defects). MMR vaccine prevents.
- Mumpsdroplet + contact
- Parotid gland swelling (jaw swelling). Complications: orchitis (males), meningitis, hearing loss. MMR vaccine prevents.
- Pertussis (Whooping Cough)droplet
- "Whoop" = inspiratory gasp after coughing fit. Most dangerous in infants <1 year. Tdap booster important for caregivers.
- Scarlet Feverdroplet + contact
- Strep throat + "sandpaper" rash + strawberry tongue. Treat with penicillin (prevents rheumatic fever). Complete full course.
- Meningococcaldroplet
- Isolate 24h after antibiotics started. Petechial/purpuric rash + fever + stiff neck. Rash is NON-BLANCHING — press glass test. Medical emergency.
No Aspirin Rule
Aspirin is never given to children with viral illness — risk of Reye syndrome (acute liver failure + encephalopathy). Use acetaminophen or ibuprofen for fever and pain in children.
07
Frequently Asked Questions
Common student questions on this topic.
How can I tell the difference between croup and epiglottitis?
Croup = viral, gradual onset, low-grade fever, barky/seal-like cough, inspiratory stridor, child prefers lying down. Epiglottitis = bacterial (Hib), sudden onset, high fever (104+°F), drooling, dysphagia, tripod position, no cough, severe sore throat. Epiglottitis is a life-threatening airway emergency — do NOT examine the throat or agitate the child; prepare for intubation. Croup is treated with cool mist and racemic epinephrine.
What is RSV and why is it dangerous in infants?
Respiratory syncytial virus (RSV) is the leading cause of bronchiolitis and pneumonia in infants under 1 year. Spreads via droplets and fomites. Symptoms: starts as URI (runny nose, mild fever), progresses to wheezing, tachypnea, nasal flaring, retractions, difficulty feeding. Premature infants are at especially high risk. Contact precautions, supportive care (hydration, oxygen, bulb suction). No specific antiviral. Prevention has shifted to nirsevimab (Beyfortus) for infants and the maternal RSV vaccine in pregnancy; the older monthly palivizumab (Synagis) is no longer available after December 31, 2025 (verify the current CDC/AAP schedule).
Why can't children with viral illness take aspirin?
Aspirin given to children or teens with viral illness (especially influenza or chickenpox) is associated with Reye syndrome — a rare but devastating condition causing acute liver failure and encephalopathy. Always use acetaminophen or ibuprofen for fever and pain in children. The only common exception is Kawasaki disease, where aspirin is specifically indicated under provider supervision.
How is otitis media treated and what is the best prevention?
Acute otitis media is the most common reason for antibiotics in pediatrics. First-line treatment: amoxicillin (unless penicillin allergy or recent antibiotic use). Complete the full course. Pain management with acetaminophen or ibuprofen. Prevention: never prop a bottle (lying flat lets milk pool around the Eustachian tube), avoid secondhand smoke, breastfeed if possible, keep up with pneumococcal vaccinations. Recurrent OM may require myringotomy with tubes.
What are the early signs of asthma exacerbation in children?
Watch for: wheezing (especially expiratory), cough (often worse at night), chest tightness, shortness of breath. Look for accessory muscle use, retractions, and nasal flaring. A silent chest (no wheeze) in a severely sick child is an emergency — air movement is minimal. Use the peak flow meter: green (80–100% of personal best) = good; yellow (50–79%) = caution, use rescue inhaler; red (< 50%) = emergency. Always have a written asthma action plan.
How do I administer an inhaler with a spacer to a child?
(1) Shake the inhaler. (2) Attach to the spacer, then to a face mask (for younger children) or mouthpiece. (3) Press the canister to release one puff. (4) Have the child take 6–10 slow breaths through the spacer (or one slow deep breath with a 10-second hold for older children). (5) Wait 1 minute between puffs if more than one is ordered. (6) Rinse the mouth with water after inhaled corticosteroids to prevent oral thrush.
08
Quick-Reference Cheatsheet
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Common Childhood Illnesses Cheatsheet
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