Pediatric emergency medicine trisk 2347 2347
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develops lethargy or will not take adequate amounts of fluids. Clinicians can
choose to offer empiric antibiotics (e.g., ceftriaxone) for children being
considered for outpatient care. A follow-up evaluation by telephone or a revisit
to the child’s regular provider or the ED should be scheduled for the next day.
HIV-infected children with severe immunosuppression (CD4% <15%) should
receive antiviral prophylaxis within 48 hours of exposure to a patient with
influenza.
PEP: Providers may be asked by families about PEP after children are
exposed to HIV via contact with blood or other body fluids, after contact with
discarded needles in a nonhealthcare setting, or after sexual assault. The risk
after specific exposures is reviewed in Table 94.23 . It is important for families
to realize that risk of drug-associated adverse events, estimated to cause
treatment cessation in over one-third of HIV-infected patients, is substantially
higher than the risk of transmission. PEP is not recommended for needlesticks
from discarded needles, nor is it suggested that needles are sent for testing for
HIV. Consultation with a local HIV specialist is recommended prior to the PEM
provider initiating prophylaxis.
Syphilis, Congenital
Congenital syphilis has an incidence of 23 per 100,000 live births in the United
States. The incidence has more than doubled since 2012. Risk factors for a child
being born with congenital syphilis include birth in Southern states and birth to
African-American mothers. Clinical findings early in congenital syphilis can
range from very profound (stillbirth) to initially asymptomatic. The rate and the
severity of infection correlate with the staging in the mother. Women with
untreated early syphilis are estimated to have a 40% rate of spontaneous
abortion. The rate of transmission to the fetus is very high in maternal secondary
syphilis but decreases for mothers with latent or tertiary syphilis. The most
common symptoms and the diagnostic criteria for congenital syphilis are
summarized in
e-Table 94.31 . Other findings include diffuse bilateral
pneumonia (pneumonia alba), chorioretinitis, nephritis, and testicular masses.
Late findings of congenital syphilis include dental changes (Hutchinson teeth—
small hypoplastic teeth with enamel anomalies; mulberry molars—
maldevelopment of the cusps), other bony changes (frontal bossing, prominent
mandible, shortened maxilla, saddle nose, saber shins), swelling of the
sternoclavicular joint (Higouménakis sign), sensorineural hearing loss, and
interstitial keratitis. Any infant whose mother has inadequately treated syphilis,
