WEBVTT 00:00:06.059 --> 00:00:09.800 Welcome to the bed. We'll go ahead and give you 00:00:09.800 --> 00:00:12.580 the story. This is all going to happen super 00:00:12.580 --> 00:00:46.909 fast. Welcome to the emergency room. Welcome 00:00:46.909 --> 00:00:49.469 back to The Deep Dive. Today we are tackling 00:00:49.469 --> 00:00:51.890 a topic that I think a lot of people, I mean 00:00:51.890 --> 00:00:54.929 even seasoned clinicians, tend to underestimate 00:00:54.929 --> 00:00:57.850 a little bit. It's so easy to dismiss it as, 00:00:58.030 --> 00:01:00.640 you know, just sniffling kids and a bit of pink 00:01:00.640 --> 00:01:02.520 eye. Right, the bread and butter stuff. Exactly. 00:01:02.899 --> 00:01:05.500 But when you are actually standing there in a 00:01:05.500 --> 00:01:07.980 pediatric clinic or maybe you're a nursing student 00:01:07.980 --> 00:01:11.459 staring at a crying toddler who is just clawing 00:01:11.459 --> 00:01:14.400 at their ear, you realize this is a beast of 00:01:14.400 --> 00:01:17.519 a topic. It is. So today, we are diving into 00:01:17.519 --> 00:01:20.760 the pediatric sensory system. Specifically, we 00:01:20.760 --> 00:01:22.780 are breaking down what our sources say about 00:01:22.780 --> 00:01:24.939 sensory perception and disorders of the eyes 00:01:24.939 --> 00:01:27.400 and ears. And it is a massive topic. You're totally 00:01:27.400 --> 00:01:30.079 right, the underestim - factor is real. I think 00:01:30.079 --> 00:01:32.439 people think, okay, eyes and ears, antibiotics 00:01:32.439 --> 00:01:34.939 and glasses, done. Yeah, probing solved. But 00:01:34.939 --> 00:01:37.480 when you actually dig into the source material, 00:01:37.859 --> 00:01:39.620 you know, the textbook chapter, the lecture slides, 00:01:39.760 --> 00:01:42.299 the drug guides, you realize we aren't just talking 00:01:42.299 --> 00:01:45.480 about treating an infection. We are talking about 00:01:45.480 --> 00:01:48.060 protecting the actual architecture of a developing 00:01:48.060 --> 00:01:50.290 brain. That is the angle that really grabbed 00:01:50.290 --> 00:01:52.370 me when I was prepping for this. That we aren't 00:01:52.370 --> 00:01:55.609 just mechanics fixing a broken part. We are safeguarding 00:01:55.609 --> 00:01:58.469 how a child learns to exist in the world. So 00:01:58.469 --> 00:02:00.409 for our listeners, whether you are that nursing 00:02:00.409 --> 00:02:03.510 student who is terrified of the boards or a clinician 00:02:03.510 --> 00:02:06.090 wanting to sharpen your assessment skills, that 00:02:06.090 --> 00:02:08.969 is our mission today. We are taking this mountain 00:02:08.969 --> 00:02:11.349 of material and stripping it down to the Pareto 00:02:11.349 --> 00:02:15.270 8020. The vital few. That 20 % of the material 00:02:15.270 --> 00:02:18.340 that answers 80 % of the exam questions and and 00:02:18.340 --> 00:02:22.280 critically keeps these kids safe from permanent 00:02:22.280 --> 00:02:24.379 developmental harm. Exactly. We have a lot to 00:02:24.379 --> 00:02:26.120 get through. We've got the textbook chapter, 00:02:26.439 --> 00:02:28.560 lecture notes, the drug guides. We're going to 00:02:28.560 --> 00:02:32.060 map this out logically. First, the master 80 00:02:32.060 --> 00:02:35.000 -20 map, the anatomy patterns that basically 00:02:35.000 --> 00:02:38.280 dictate destiny. Then a deep dive into the ear 00:02:38.280 --> 00:02:40.939 complex, the whole soup to nuts of otitis media. 00:02:41.360 --> 00:02:43.620 After that, the eye complex infections trauma. 00:02:45.219 --> 00:02:47.219 the silent killers of vision. And finally, we 00:02:47.219 --> 00:02:48.699 will synthesize it all with the developmental, 00:02:48.699 --> 00:02:51.280 so what? Sounds like a plan. And I just want 00:02:51.280 --> 00:02:53.039 to emphasize that point about development again. 00:02:53.500 --> 00:02:57.080 In adults, sensory issues are often, they're 00:02:57.080 --> 00:02:58.960 an annoyance. Right, a huge annoyance, but you 00:02:58.960 --> 00:03:01.379 get through it. But in children, they can be 00:03:01.379 --> 00:03:03.400 a developmental emergency. It's a completely 00:03:03.400 --> 00:03:05.240 different ballgame. OK, let's start right there 00:03:05.240 --> 00:03:08.099 then. Section A, the master 80 -20 map. You mentioned 00:03:08.099 --> 00:03:11.300 anatomy is destiny. When I look at the statistics 00:03:11.300 --> 00:03:14.969 in these documents, the sheer volume of ear infections 00:03:14.969 --> 00:03:19.330 in children compared to adults is. It's just 00:03:19.330 --> 00:03:21.770 staggering. It's not even close. Not even close. 00:03:21.870 --> 00:03:25.110 So why is that? What is the structural flaw in 00:03:25.110 --> 00:03:27.330 a child's head? Well, it's not so much a flaw 00:03:27.330 --> 00:03:30.129 as it is a work in progress. It really all comes 00:03:30.129 --> 00:03:32.770 down to the horizontal tube concept. This is 00:03:32.770 --> 00:03:35.189 the absolute cornerstone of pediatric sensory 00:03:35.189 --> 00:03:37.830 anatomy. If you look at the figures in the source 00:03:37.830 --> 00:03:40.210 material, they do a great job comparing the adult 00:03:40.210 --> 00:03:42.990 Eustachian tube to the child's. I'm looking at 00:03:42.990 --> 00:03:45.189 one now. The adult one looks like a nice, steep 00:03:45.189 --> 00:03:47.830 slide. The child's looks, well, it's functionally 00:03:47.830 --> 00:03:51.090 flat. Exactly. In an adult, The eustachian tube 00:03:51.090 --> 00:03:54.330 angles downward at about, what, 45 degrees? Gravity 00:03:54.330 --> 00:03:57.110 is your best friend here. It helps drain any 00:03:57.110 --> 00:03:59.069 fluid from the middle ear right down into the 00:03:59.069 --> 00:04:02.449 throat. But in an infant or a young child, that 00:04:02.449 --> 00:04:05.129 tube is shorter. It is wider, or critically, 00:04:05.629 --> 00:04:07.770 it is positioned almost horizontally, maybe 10 00:04:07.770 --> 00:04:10.610 degrees. It's a nearly straight line from the 00:04:10.610 --> 00:04:12.889 nasopharynx to the middle ear. So instead of 00:04:12.889 --> 00:04:15.689 a slide for drainage, you've got a hallway. A 00:04:15.689 --> 00:04:18.470 hallway that is, yeah, extremely prone to flooding. 00:04:19.310 --> 00:04:21.470 And there is a nuance here that the text mentions, 00:04:21.529 --> 00:04:23.470 but often gets kind of glossed over in lectures, 00:04:23.870 --> 00:04:26.709 the muscle function. Oh, interesting. In adults, 00:04:27.329 --> 00:04:31.649 the tensor veli palatini muscle actively opens 00:04:31.649 --> 00:04:33.939 that tube when you yawn. That's what gives you 00:04:33.939 --> 00:04:35.819 that pop on an airplane. Right. It equalizes 00:04:35.819 --> 00:04:38.480 the pressure. It equalizes the pressure. In infants 00:04:38.480 --> 00:04:40.699 though, that muscle is functionally immature. 00:04:41.019 --> 00:04:44.199 It's floppy. Floppy. So not only is the tube 00:04:44.199 --> 00:04:46.939 flat, meaning gravity can't help drain the fluid, 00:04:47.459 --> 00:04:49.720 but the mechanism to manually open the door and 00:04:49.720 --> 00:04:52.620 let air in is also incompetent. It just doesn't 00:04:52.620 --> 00:04:54.420 work right yet. So you have a tube that won't 00:04:54.420 --> 00:04:57.139 drain and a door that won't open. Precisely. 00:04:57.379 --> 00:04:59.939 And that creates the absolute perfect storm for 00:04:59.939 --> 00:05:03.250 negative pressure. When that tube stays closed, 00:05:04.089 --> 00:05:05.870 the air that's already inside the middle ear 00:05:05.870 --> 00:05:09.370 gets absorbed by the mucosa. That creates a vacuum. 00:05:09.990 --> 00:05:12.930 And what does the vacuum do? It sucks fluid right 00:05:12.930 --> 00:05:14.589 out of the surrounding tissue and into that middle 00:05:14.589 --> 00:05:17.689 ear space. That is how you get fluid accumulation 00:05:17.689 --> 00:05:20.189 without even having an active infection yet. 00:05:20.810 --> 00:05:23.790 It is purely a physics problem caused by that 00:05:23.790 --> 00:05:26.240 flat anatomy. And then on top of that, you add 00:05:26.240 --> 00:05:28.879 the fact that kids are basically germ factories. 00:05:29.180 --> 00:05:30.740 Right. I mean, their nesopharynx, the back of 00:05:30.740 --> 00:05:33.740 the throat, is just teeming with bacteria and 00:05:33.740 --> 00:05:36.079 viruses because kids are constantly putting things 00:05:36.079 --> 00:05:38.439 in their mouths and getting colds. Because that 00:05:38.439 --> 00:05:40.860 tube is so short and horizontal, it acts like 00:05:40.860 --> 00:05:43.339 a superhighway for pathogens. Bacteria don't 00:05:43.339 --> 00:05:45.439 have to climb a hill. They just walk right across 00:05:45.439 --> 00:05:47.720 the hall from the throat to the ear. This explains 00:05:47.720 --> 00:05:51.139 so clearly why the recent upper respiratory infection 00:05:51.139 --> 00:05:54.220 is such a massive risk factor on every exam question 00:05:54.220 --> 00:05:56.660 about this. It is the number one precursor. You 00:05:56.660 --> 00:05:59.519 get a cold, the adenoids swell up, which by the 00:05:59.519 --> 00:06:02.180 way blocks the tube even more, and then the bacteria 00:06:02.180 --> 00:06:05.000 just migrate. It's almost a mechanical inevitability 00:06:05.000 --> 00:06:07.220 in some kids. Okay, so that's the ear anatomy 00:06:07.220 --> 00:06:09.600 pattern. The horizontal tube is the villain. 00:06:10.150 --> 00:06:13.949 What about the eyes? Is there a similar structural 00:06:13.949 --> 00:06:17.170 destiny going on there? With the eyes, it's less 00:06:17.170 --> 00:06:19.110 about plumbing and more about the neurological 00:06:19.110 --> 00:06:22.389 trajectory. The key concept here is really use 00:06:22.389 --> 00:06:25.170 it or lose it. The sources all emphasize that 00:06:25.170 --> 00:06:27.670 visual acuity is not fully developed at birth. 00:06:28.170 --> 00:06:30.529 Not even close. I was actually surprised by the 00:06:30.529 --> 00:06:32.810 numbers in the text. It says babies are essentially 00:06:32.810 --> 00:06:35.750 legally blind at birth. They are. A newborn's 00:06:35.750 --> 00:06:38.180 visual acuity is around 2 ,400. They can see 00:06:38.180 --> 00:06:40.600 shapes. They can see high contrast, which is 00:06:40.600 --> 00:06:42.279 why those black and white mobile toys are so 00:06:42.279 --> 00:06:45.360 popular. Right. But they cannot see detail. The 00:06:45.360 --> 00:06:47.639 brain hasn't learned how to process a sharp image 00:06:47.639 --> 00:06:49.899 yet. So the hardware is there, but the software 00:06:49.899 --> 00:06:52.000 is still downloading. That's a fantastic way 00:06:52.000 --> 00:06:54.360 to put it. And that download process takes time. 00:06:54.720 --> 00:06:56.839 We expect them to reach 20, 20 vision by about 00:06:56.839 --> 00:07:00.459 each five to seven. But. And this is the critical, 00:07:00.639 --> 00:07:04.000 but that software installation only happens if 00:07:04.000 --> 00:07:06.519 the brain receives clear, focused images from 00:07:06.519 --> 00:07:09.199 both eyes during those critical first few years. 00:07:09.680 --> 00:07:11.519 This is leading us straight to the concept of 00:07:11.519 --> 00:07:14.860 amblyopia, right? Lazy eye. Correct. Amblyopia, 00:07:15.120 --> 00:07:17.259 or lazy eye, is the consequence of interrupting 00:07:17.259 --> 00:07:20.740 that download. If anything blocks or blurs vision, 00:07:20.980 --> 00:07:23.660 a cataract, a droopy eyelid, or the eyes being 00:07:23.660 --> 00:07:27.519 crossed, strabismus. Before age seven, The brain 00:07:27.519 --> 00:07:29.860 literally stops trying to process the image from 00:07:29.860 --> 00:07:32.079 that eye. It just gives up on it. It's a matter 00:07:32.079 --> 00:07:34.319 of ruthless efficiency. If the brain is getting 00:07:34.319 --> 00:07:36.500 a blurry image from one eye and a clear image 00:07:36.500 --> 00:07:39.319 from the other, it views the blurry one as noise, 00:07:39.720 --> 00:07:42.600 as static. So it just tunes it out. It suppresses 00:07:42.600 --> 00:07:44.560 the neural pathway. It effectively hits the mute 00:07:44.560 --> 00:07:46.680 button on that eye to avoid double vision. And 00:07:46.680 --> 00:07:49.160 the scary part, which the texts really emphasize, 00:07:49.360 --> 00:07:51.519 is that you can't just unmute it later in life. 00:07:51.720 --> 00:07:54.319 Exactly. In an adult, if you patch an eye for 00:07:54.319 --> 00:07:56.180 a week, you take the patch off and you see fine. 00:07:56.660 --> 00:07:59.379 In a child under seven, if you block clear vision 00:07:59.379 --> 00:08:01.399 for a significant amount of time, the neural 00:08:01.399 --> 00:08:04.199 connections literally atrophy. You can cause 00:08:04.199 --> 00:08:06.040 permanent blindness in that eye because the brain 00:08:06.040 --> 00:08:09.180 development just halts. Wow. That really raises 00:08:09.180 --> 00:08:11.160 the stakes for those early vision screenings. 00:08:11.379 --> 00:08:12.899 We aren't just checking if they need glasses. 00:08:13.040 --> 00:08:14.639 We are checking if their brain is still connected 00:08:14.639 --> 00:08:17.300 to their eye. That is the 80 -20 takeaway for 00:08:17.300 --> 00:08:20.000 eyes. Vision is a developmental race against 00:08:20.000 --> 00:08:23.240 time. If we don't fix the structural issues by 00:08:23.240 --> 00:08:26.259 school age, that window closes. Maybe not completely, 00:08:26.379 --> 00:08:28.560 but it gets a lot harder. All right. Let's move 00:08:28.560 --> 00:08:31.879 into our section B, the system by system lecture. 00:08:32.259 --> 00:08:34.759 We are going to start with the ear complex. This 00:08:34.759 --> 00:08:36.559 feels like the bread and butter of pediatric 00:08:36.559 --> 00:08:39.480 nursing, but the terminology can feel like that 00:08:39.480 --> 00:08:42.940 alphabet soup. We have A -O -M -O -M -E -O -E. 00:08:42.980 --> 00:08:45.220 It is alphabet soup. Yeah. but you absolutely 00:08:45.220 --> 00:08:49.159 have to know the flavors. The exam and your clinical 00:08:49.159 --> 00:08:53.019 triage in real life relies entirely on distinguishing 00:08:53.019 --> 00:08:55.919 the angry ear from the full ear, from the swimmer's 00:08:55.919 --> 00:08:58.200 ear. I love that framework. OK, let's break those 00:08:58.200 --> 00:09:02.600 down. The angry ear, that's AOM, acute otitis 00:09:02.600 --> 00:09:05.679 media. Right. AOM is the acute infection. This 00:09:05.679 --> 00:09:07.659 is what parents mean when they say, my kid has 00:09:07.659 --> 00:09:10.919 an ear infection. Pathologically, you have fluid 00:09:10.919 --> 00:09:13.379 in the middle ear, that space behind the eardrum, 00:09:13.960 --> 00:09:16.580 that is actively infected with bacteria or a 00:09:16.580 --> 00:09:20.049 virus. The key identifiers here are rapidity 00:09:20.049 --> 00:09:22.509 and pain. It comes on fast. So tell me what this 00:09:22.509 --> 00:09:24.350 kid looks like. I'm in the clinic waiting room, 00:09:24.429 --> 00:09:26.610 what am I seeing? You see a miserable child, 00:09:27.909 --> 00:09:29.990 just inconsolable. Might have had a cold for 00:09:29.990 --> 00:09:32.509 a few days, a little runny nose, and then suddenly 00:09:32.509 --> 00:09:35.029 they're spiking a fever. They're crying, they're 00:09:35.029 --> 00:09:37.570 irritable. If they're an infant, a pre -verbal 00:09:37.570 --> 00:09:39.470 kid, they might be rolling their head from side 00:09:39.470 --> 00:09:41.750 to side or pulling at their ears. And critically, 00:09:41.870 --> 00:09:43.940 they might refuse to lie down. This is a big 00:09:43.940 --> 00:09:45.820 one. Because lying down increases the pressure. 00:09:46.279 --> 00:09:49.159 Exactly. When they lie flat, vascular engorgement 00:09:49.159 --> 00:09:51.399 and the fluid shifts increase the pressure in 00:09:51.399 --> 00:09:54.059 that tight middle ear space. It hurts more. So 00:09:54.059 --> 00:09:56.679 they want to be held upright on mom's or dad's 00:09:56.679 --> 00:09:59.220 shoulder. Now, I grabbed the otoscope. What am 00:09:59.220 --> 00:10:01.539 I looking for inside? What's the classic sign? 00:10:01.720 --> 00:10:03.840 You are looking for what I call the angry donut. 00:10:04.419 --> 00:10:08.230 A normal eardrum, a tympanic membrane is pearly 00:10:08.230 --> 00:10:10.409 gray, it's translucent, you can kind of see through 00:10:10.409 --> 00:10:13.110 it, and it's concave, so it curves inward slightly. 00:10:13.750 --> 00:10:16.649 In AOM, it is bulging. It looks like it's about 00:10:16.649 --> 00:10:18.710 to burst out towards you because of all the pus 00:10:18.710 --> 00:10:21.149 pressure behind it. It's bright red, it's opaque, 00:10:21.230 --> 00:10:23.169 so you can't see through it, and you can't see 00:10:23.169 --> 00:10:25.429 the normal landmarks like the handle of the malleus 00:10:25.429 --> 00:10:30.190 bone. They're gone. Okay. Bulging. Red. Painful. 00:10:30.549 --> 00:10:34.149 Fever. That's A -O -M. Now let's contrast that 00:10:34.149 --> 00:10:37.129 with O -M -E, otitis media with effusion. You 00:10:37.129 --> 00:10:39.230 called this the full ear. Right, so think of 00:10:39.230 --> 00:10:41.529 O -M -E as a plumbing clog but without the fire. 00:10:42.269 --> 00:10:44.230 There is fluid in the middle ear, just like an 00:10:44.230 --> 00:10:46.370 A -O -M, but it is not infected, it's sterile. 00:10:46.629 --> 00:10:49.370 It's usually serous fluid, so thin, watery, or 00:10:49.370 --> 00:10:51.649 maybe a bit mucus -like. So does it hurt? Is 00:10:51.649 --> 00:10:54.740 the kid still miserable? Usually no. And that's 00:10:54.740 --> 00:10:56.679 the tricky differentiator, especially for parents. 00:10:57.139 --> 00:10:59.200 The child isn't screaming. They aren't febrile. 00:10:59.460 --> 00:11:01.659 They might complain of a popping sensation or 00:11:01.659 --> 00:11:03.840 a feeling of fullness, you know, like being underwater. 00:11:03.960 --> 00:11:06.480 But they're eating, they're sleeping mostly okay. 00:11:06.679 --> 00:11:08.879 It's much more subtle. And visually, what does 00:11:08.879 --> 00:11:10.980 the eardrum look like then? The eardrum won't 00:11:10.980 --> 00:11:14.559 be bulging and red. It will look dull. grayish. 00:11:14.720 --> 00:11:17.700 It might even look retracted, sucked back because 00:11:17.700 --> 00:11:19.419 of that negative pressure vacuum we talked about 00:11:19.419 --> 00:11:22.320 earlier. And often, if you look closely, you 00:11:22.320 --> 00:11:25.899 can see a fluid level line or little air bubbles 00:11:25.899 --> 00:11:28.360 behind the eardrum. It literally looks like a 00:11:28.360 --> 00:11:30.759 little fish tank in there. Bubbles and dullness 00:11:30.759 --> 00:11:33.200 versus bulging and redness. That is the exam 00:11:33.200 --> 00:11:35.700 differentiator. 100%. If you can see bubbles, 00:11:35.899 --> 00:11:38.460 it's OME. If it's bulging and you can't see anything, 00:11:38.659 --> 00:11:42.059 it's AOM. And then the third one, OE, otitis 00:11:42.059 --> 00:11:45.320 externa. The swimmer's ear. This one is completely 00:11:45.320 --> 00:11:47.100 different because it's not behind the eardrum 00:11:47.100 --> 00:11:50.100 at all. It is an infection of the skin of the 00:11:50.100 --> 00:11:52.919 ear canal itself, the outer ear. Okay. It's usually 00:11:52.919 --> 00:11:55.120 caused by water getting trapped in there after 00:11:55.120 --> 00:11:58.500 swimming, which changes the pH and allows bacteria 00:11:58.500 --> 00:12:01.059 like Pseudomonas or even fungi to grow. And the 00:12:01.059 --> 00:12:03.779 test for this is all physical, right? Yes, the 00:12:03.779 --> 00:12:06.980 tragus test. This is your go -to. If you wiggle 00:12:06.980 --> 00:12:10.759 the earlobe, the pinna, Or you push on that little 00:12:10.759 --> 00:12:12.240 flap of cartilage in front of the ear canal, 00:12:12.379 --> 00:12:14.679 the tragus, and the child jumps through the ceiling. 00:12:15.100 --> 00:12:18.000 That is otitis externa. Why is that differentiation 00:12:18.000 --> 00:12:20.019 so important? Because a child with a middle ear 00:12:20.019 --> 00:12:22.740 infection, like AOM, usually won't care if you 00:12:22.740 --> 00:12:25.059 wiggle their earlobe. The infection is deep inside, 00:12:25.320 --> 00:12:29.039 protected behind the drum. But for OE, the skin 00:12:29.039 --> 00:12:32.080 of the canal is so exquisitely inflamed that 00:12:32.080 --> 00:12:34.240 any movement is excruciating. So if you touch 00:12:34.240 --> 00:12:36.750 the ear and they scream, think external. That 00:12:36.750 --> 00:12:39.750 is such a crucial need to know. So simple, but 00:12:39.750 --> 00:12:42.009 so effective. Okay, let's talk about management. 00:12:42.129 --> 00:12:43.750 We have to address the elephant in the room, 00:12:44.090 --> 00:12:46.769 antibiotics. The source material is very clear 00:12:46.769 --> 00:12:48.990 about the wait and see approach for AOM. Or watchful 00:12:48.990 --> 00:12:51.090 waiting, yeah. Right. But I'll be honest, if 00:12:51.090 --> 00:12:53.269 I'm a parent and my two -year -old has been screaming 00:12:53.269 --> 00:12:55.710 for six hours straight, and you tell me to wait 00:12:55.710 --> 00:12:58.389 and see... I am not going to be a happy camper. 00:12:58.610 --> 00:13:01.429 No. I want the pink stuff. I want the amoxicillin. 00:13:01.750 --> 00:13:04.549 Now, it is an incredibly difficult conversation 00:13:04.549 --> 00:13:07.370 to have. It's one of the hardest parts of pediatric 00:13:07.370 --> 00:13:10.529 primary care. You are essentially telling a parent, 00:13:11.110 --> 00:13:13.570 I see your child is in pain. I know there's an 00:13:13.570 --> 00:13:16.509 infection and I am going to choose not to attack 00:13:16.509 --> 00:13:19.750 it with drugs yet. It feels completely counterintuitive. 00:13:20.110 --> 00:13:22.269 Why are the sources and the American Academy 00:13:22.269 --> 00:13:25.309 of Pediatrics so adamant about this? Is the risk 00:13:25.309 --> 00:13:27.529 of the drug really higher than the risk of the 00:13:27.529 --> 00:13:29.590 infection? That's the critical question, isn't 00:13:29.590 --> 00:13:32.250 it? Yeah. And the data suggests that for a huge 00:13:32.250 --> 00:13:34.549 percentage of these kids, specifically those 00:13:34.549 --> 00:13:37.809 over six months old with uncomplicated non -severe 00:13:37.809 --> 00:13:41.129 AOM, the body clears the infection on its own 00:13:41.129 --> 00:13:43.570 within 72 hours at pretty much the same rate 00:13:43.570 --> 00:13:45.950 as it would with antibiotics. Really? Yeah. Many 00:13:45.950 --> 00:13:47.370 of these are viral to begin with, or they're 00:13:47.370 --> 00:13:49.529 just self -limiting bacterial infections. that 00:13:49.529 --> 00:13:51.409 a healthy immune system can handle. So the drug 00:13:51.409 --> 00:13:53.909 isn't actually speeding up the cure in many cases. 00:13:54.169 --> 00:13:57.649 In many, many cases, no. But the side effects 00:13:57.649 --> 00:14:01.470 of the drug are guaranteed. Diarrhea, rash, potential 00:14:01.470 --> 00:14:04.610 allergic reactions, and the big global threat 00:14:04.610 --> 00:14:07.789 antibiotic resistance. If we prescribe Amoxicillin 00:14:07.789 --> 00:14:11.110 for every single red ear, we burn through our 00:14:11.110 --> 00:14:14.129 first line of defense. We create superbugs. But 00:14:14.129 --> 00:14:16.450 there's a safety net here. Right. We aren't just 00:14:16.450 --> 00:14:18.070 sending them into the wilderness and saying good 00:14:18.070 --> 00:14:21.299 luck. No, absolutely not. And that's the SNAPP 00:14:21.299 --> 00:14:23.320 protocol that's mentioned in the slides, the 00:14:23.320 --> 00:14:25.500 safety net antibiotic prescription. Okay, tell 00:14:25.500 --> 00:14:27.740 me about that. You give the parent the physical 00:14:27.740 --> 00:14:29.539 prescription paper or send it to the pharmacy, 00:14:29.620 --> 00:14:32.580 but you say, don't fill this until Friday. Give 00:14:32.580 --> 00:14:35.559 the pain medicine, use a warm compress. If he 00:14:35.559 --> 00:14:37.519 isn't significantly better by Friday morning, 00:14:38.019 --> 00:14:40.639 then you fill it. It puts the power back in the 00:14:40.639 --> 00:14:43.080 parent's hands while still adhering to good antibiotic 00:14:43.080 --> 00:14:45.179 stewardship. That makes a lot of sense, but there 00:14:45.179 --> 00:14:47.320 are exceptions. Who gets the drugs immediately? 00:14:47.539 --> 00:14:49.700 No questions asked. Babies under six months. 00:14:50.220 --> 00:14:52.840 We don't gamble there. Their immune systems are 00:14:52.840 --> 00:14:55.279 too immature, and the risk of sepsis is higher. 00:14:55.720 --> 00:14:58.539 Also, any child of any age with severe symptoms, 00:14:58.799 --> 00:15:03.179 so a high fever over 39 Celsius or 102 .2 Fahrenheit, 00:15:03.639 --> 00:15:06.820 severe pain, or a bilateral infection in a young 00:15:06.820 --> 00:15:09.500 child, they get treated immediately. No waiting. 00:15:09.840 --> 00:15:12.480 OK, now what about the kid who has chronic fluid? 00:15:13.200 --> 00:15:15.600 The OME that just will not go away. We see this 00:15:15.600 --> 00:15:20.490 term PE tubes all the time. Pressure equalizing 00:15:20.490 --> 00:15:23.429 tubes. If a child has OME, that non -infected 00:15:23.429 --> 00:15:25.330 fluid that lasts for more than three months, 00:15:25.710 --> 00:15:28.309 or if we document any hearing loss associated 00:15:28.309 --> 00:15:30.470 with it, we start considering tubes. I think 00:15:30.470 --> 00:15:32.309 there is a misconception out there that these 00:15:32.309 --> 00:15:33.870 tubes are just drains, like you're putting a 00:15:33.870 --> 00:15:35.889 faucet in the ear to let the gunk out. It is 00:15:35.889 --> 00:15:37.950 a common thought. But actually, they are primarily 00:15:37.950 --> 00:15:40.450 pressure equalizers. That's what the PE stands 00:15:40.450 --> 00:15:42.750 for. One of that horizontal floppy eustachian 00:15:42.750 --> 00:15:45.730 tube that isn't working. The PE tube acts as 00:15:45.730 --> 00:15:47.950 an artificial eustachian tube. It's a tiny little 00:15:47.950 --> 00:15:50.059 grommet that's sits in the eardrum and allows 00:15:50.059 --> 00:15:52.120 air to flow into the middle ear from the outside. 00:15:52.419 --> 00:15:54.639 By equalizing the pressure, it prevents that 00:15:54.639 --> 00:15:56.799 vacuum effect that sucks the fluid into the first 00:15:56.799 --> 00:15:59.379 place. It ventilates the ear. That makes so much 00:15:59.379 --> 00:16:01.960 more sense. It's not draining fluid out, it's 00:16:01.960 --> 00:16:05.379 letting air in. Exactly. It stops the fluid from 00:16:05.379 --> 00:16:07.620 ever accumulating. And what do we tell parents 00:16:07.620 --> 00:16:10.659 about these? Because they are tiny pieces of 00:16:10.659 --> 00:16:12.779 plastic in their kid's head. It can be a little 00:16:12.779 --> 00:16:16.039 scary. The biggest teaching points are, one, 00:16:16.159 --> 00:16:18.529 they fall out on their own. usually in six to 00:16:18.529 --> 00:16:21.269 twelve months as the eardrum heals. Pairs shouldn't 00:16:21.269 --> 00:16:23.289 be alarmed if they find a tiny little school 00:16:23.289 --> 00:16:26.750 in the earwax one day. Okay. And two, water precautions. 00:16:27.889 --> 00:16:30.889 The source material is a bit nuanced here, and 00:16:30.889 --> 00:16:33.509 surgeons differ, but the general consensus is 00:16:33.509 --> 00:16:36.149 if swimming in dirty water, like a lake or a 00:16:36.149 --> 00:16:38.730 non -chlorinated pond, they should wear earplugs. 00:16:39.029 --> 00:16:41.009 We don't want lake bacteria getting a direct 00:16:41.009 --> 00:16:43.190 route into the middle ear. What about bath water? 00:16:43.899 --> 00:16:45.940 Bathwater and chlorinated pools are usually considered 00:16:45.940 --> 00:16:48.100 fine without plugs, but parents should always 00:16:48.100 --> 00:16:50.379 follow the specific instructions from their ENT 00:16:50.379 --> 00:16:52.320 surgeon. Okay, that covers the medical side. 00:16:52.659 --> 00:16:54.460 But I really want to pivot to the developmental 00:16:54.460 --> 00:16:56.240 impact because you mentioned this earlier and 00:16:56.240 --> 00:16:59.100 it's so important. Why do we care so much about 00:16:59.100 --> 00:17:02.320 OME, that fluid, if it doesn't even hurt? We 00:17:02.320 --> 00:17:04.920 care because of hearing. That's the whole ball 00:17:04.920 --> 00:17:07.700 game. Fluid in the middle ear muffles sound. 00:17:08.119 --> 00:17:10.599 It causes a conductive hearing loss. It's like 00:17:10.599 --> 00:17:12.700 listening to the world while wearing heavy earmuffs 00:17:12.700 --> 00:17:14.880 or with your head underwater. And if you are 00:17:14.880 --> 00:17:16.740 a 30 -year -old, that's really annoying for a 00:17:16.740 --> 00:17:19.539 few weeks. Right. But if you are 18 months to 00:17:19.539 --> 00:17:23.279 3 years old, you are in the prime critical window 00:17:23.279 --> 00:17:26.059 for speech acquisition. You are learning how 00:17:26.059 --> 00:17:28.339 to articulate those high -frequency consonant 00:17:28.339 --> 00:17:32.420 sounds. The T's and S's and K's. If you can't 00:17:32.420 --> 00:17:34.759 hear them clearly because of the fluid, you won't 00:17:34.759 --> 00:17:36.920 learn to speak them clearly. So the red flag 00:17:36.920 --> 00:17:40.099 here is a speech delay. A huge red flag. If you 00:17:40.099 --> 00:17:42.420 have a toddler who has a history of frequent 00:17:42.420 --> 00:17:45.019 ear infections, or you suspect chronic fluid, 00:17:45.299 --> 00:17:47.859 and they aren't talking, or their speech is unintelligible 00:17:47.859 --> 00:17:50.539 to strangers, or maybe they even stop babbling, 00:17:50.779 --> 00:17:53.480 you need a hearing test immediately. It's not 00:17:53.480 --> 00:17:56.039 just, oh, he's a late bloomer. It might not be. 00:17:56.160 --> 00:17:58.539 It might be he literally cannot hear the data 00:17:58.539 --> 00:18:01.119 he needs to learn. Wow. That connects it all 00:18:01.119 --> 00:18:03.900 perfectly. The anatomy causes the fluid. The 00:18:03.900 --> 00:18:06.380 fluid causes the hearing loss. The hearing loss 00:18:06.380 --> 00:18:08.859 causes the developmental delay. And that is the 00:18:08.859 --> 00:18:12.380 80 -20. You diagnose the delay to find the fluid 00:18:12.380 --> 00:18:15.259 to fix the ear to save the development. It's 00:18:15.259 --> 00:18:18.460 a chain reaction. Okay. Moving on to topic two. 00:18:19.400 --> 00:18:22.779 Conjunctivitis. Pink eye. The bane of every daycare 00:18:22.779 --> 00:18:25.200 center's existence. It is highly contagious and 00:18:25.200 --> 00:18:27.900 incredibly common. But for the exam and for your 00:18:27.900 --> 00:18:30.680 clinical triage, it is all about the discharge. 00:18:30.880 --> 00:18:32.799 You have to become a connoisseur of eye gunk. 00:18:33.079 --> 00:18:36.059 Gross, but absolutely necessary. Okay, let's 00:18:36.059 --> 00:18:37.920 play the differential diagnosis game. I'll describe 00:18:37.920 --> 00:18:40.180 the eye. You tell me the type. Let's do it. Okay, 00:18:40.480 --> 00:18:42.500 scenario one. A four -year -old wakes up and 00:18:42.500 --> 00:18:44.759 his eyes are completely glued shut. There is 00:18:44.759 --> 00:18:47.440 dry, crusty, yellow stuff all over the lashes. 00:18:47.579 --> 00:18:49.319 When you wipe it away, there's more thick white 00:18:49.319 --> 00:18:52.119 or yellow pus coming out. One eye started yesterday 00:18:52.119 --> 00:18:54.779 and now both have it. That is classic bacterial 00:18:54.779 --> 00:18:58.079 conjunctivitis. The key words are purulent, meaning 00:18:58.079 --> 00:19:01.380 pus, glued shut, or crusted in the morning, and 00:19:01.380 --> 00:19:03.559 that typical unilateral to bilateral spread. 00:19:03.779 --> 00:19:05.660 And the treatment is straightforward. Pretty 00:19:05.660 --> 00:19:08.119 much antibiotic drops or ointment. And strict 00:19:08.119 --> 00:19:11.259 hygiene warm compresses to gently clear the crusts. 00:19:11.259 --> 00:19:15.220 Lots of hand washing. OK. Scenario two. A seven 00:19:15.220 --> 00:19:18.380 -year -old has red eyes, but they are super watery, 00:19:18.640 --> 00:19:20.660 like tears are just streaming down their face. 00:19:20.980 --> 00:19:23.059 They also have a runny nose and maybe some swollen 00:19:23.059 --> 00:19:25.599 glands you can feel in their neck lymphadenopathy. 00:19:25.759 --> 00:19:28.680 That's your viral conjunctivitis. The key words 00:19:28.680 --> 00:19:31.740 are watery discharge and the association with 00:19:31.740 --> 00:19:35.359 a cold or an upper respiratory infection. Those 00:19:35.359 --> 00:19:37.640 swollen lymph nodes are also a classic viral 00:19:37.640 --> 00:19:40.500 sign, specifically the pre -auricular nodes right 00:19:40.500 --> 00:19:42.619 in front of the ear. And the treatment for that. 00:19:43.149 --> 00:19:46.450 Symptomatic relief only. Cool or warm, compresses, 00:19:46.470 --> 00:19:48.710 whatever feels better. No antibiotics, they won't 00:19:48.710 --> 00:19:50.869 touch a virus, just has to run its course, which 00:19:50.869 --> 00:19:53.789 can be, you know, seven to 14 days. But it's 00:19:53.789 --> 00:19:55.849 highly, highly contagious. They need to be kept 00:19:55.849 --> 00:19:58.210 home from school until the drainage stops. Got 00:19:58.210 --> 00:20:00.609 it. Scenario three. A 10 -year -old comes in 00:20:00.609 --> 00:20:02.509 rubbing their eyes like crazy. They are red, 00:20:02.630 --> 00:20:05.369 they're puffy, and watery. He says they itch 00:20:05.369 --> 00:20:07.869 really, really bad, and it's both eyes at the 00:20:07.869 --> 00:20:10.490 same time. That is allergic conjunctivitis. The 00:20:10.490 --> 00:20:13.160 number one key word is itching. Intense itching 00:20:13.160 --> 00:20:16.039 or poritis. Bacterial and viral might burn or 00:20:16.039 --> 00:20:18.599 feel gritty, but that intense, can't -stop -rubbing 00:20:18.599 --> 00:20:21.460 -it itch is almost always allergy. Anything else? 00:20:21.660 --> 00:20:23.599 Yeah, often you'll see cobblestoning of the inner 00:20:23.599 --> 00:20:26.359 eyelid if you ever did. And it's usually bilateral 00:20:26.359 --> 00:20:29.019 from the start. Treatment there is antihistamines 00:20:29.019 --> 00:20:32.200 oral or drops and avoiding the allergen if you 00:20:32.200 --> 00:20:35.380 can. Now there is a can't miss safety point here 00:20:35.380 --> 00:20:37.299 regarding medication. I saw a big warning in 00:20:37.299 --> 00:20:40.400 the notes about steroids. Yes. This is a massive 00:20:40.400 --> 00:20:43.809 exam prep and a huge clinical safety issue. Do 00:20:43.809 --> 00:20:46.710 not use corticosteroids in the eye unless you 00:20:46.710 --> 00:20:49.190 are an ophthalmologist. Why is that? I mean, 00:20:49.369 --> 00:20:50.890 steroids reduce inflammation, right? Seems like 00:20:50.890 --> 00:20:53.329 it would help. They do. But they also suppress 00:20:53.329 --> 00:20:55.930 the local immune response. And if that child 00:20:55.930 --> 00:20:58.829 actually has a herpes simplex viral infection 00:20:58.829 --> 00:21:00.990 in their eye, which can look a lot like regular 00:21:00.990 --> 00:21:03.849 viral conjunctivitis at first, and you give them 00:21:03.849 --> 00:21:06.490 steroids, you are pouring gasoline on a fire. 00:21:06.670 --> 00:21:09.430 Wow. It can cause the virus to just explode, 00:21:09.869 --> 00:21:12.250 leading to corneal scarring and permanent blindness. 00:21:13.059 --> 00:21:15.740 So simple antibiotic drops or antihistamines 00:21:15.740 --> 00:21:18.380 are fine for primary care. But you stay away 00:21:18.380 --> 00:21:20.319 from the steroids unless you're absolutely sure 00:21:20.319 --> 00:21:22.839 what you're treating. That is terrifying and 00:21:22.839 --> 00:21:25.799 a great exam point. OK, practical nursing skill 00:21:25.799 --> 00:21:29.400 time. Administering eye drops to a toddler. Have 00:21:29.400 --> 00:21:31.099 you ever tried to do this? It's like wrestling 00:21:31.099 --> 00:21:33.359 an alligator. It is. And the natural instinct 00:21:33.359 --> 00:21:36.519 is to try to pry their eyelids open while they're 00:21:36.519 --> 00:21:38.980 screaming. But you risk poking them in the eye 00:21:38.980 --> 00:21:41.400 and you traumatize everyone involved. It doesn't 00:21:41.400 --> 00:21:43.950 work. So what's the trick? What do the sources 00:21:43.950 --> 00:21:46.549 recommend? The sources suggest a very clever 00:21:46.549 --> 00:21:48.890 physics -based technique. You have the child 00:21:48.890 --> 00:21:51.910 lying down flat. If they are fighting and squeezing 00:21:51.910 --> 00:21:53.890 their eye shut, that's fine. Let them keep them 00:21:53.890 --> 00:21:56.930 closed. OK. You then place the prescribed drop 00:21:56.930 --> 00:21:59.970 in the inner corner of the closed eye, the nasal 00:21:59.970 --> 00:22:03.210 campus, right in that little well. So just right 00:22:03.210 --> 00:22:05.009 on the skin there. Right in that little pocket 00:22:05.009 --> 00:22:07.029 at the corner of the eye. Then when the child 00:22:07.029 --> 00:22:09.349 eventually opens their eye, even for a split 00:22:09.349 --> 00:22:11.960 second to check if you're still there, gravity 00:22:11.960 --> 00:22:15.240 pulls the drop right into the conjunctival sac. 00:22:15.559 --> 00:22:18.380 It's so much less traumatic, it helps build trust, 00:22:18.480 --> 00:22:20.339 and it actually gets the medication where it 00:22:20.339 --> 00:22:22.920 needs to go. That is a pro tip. I love that. 00:22:23.180 --> 00:22:25.700 Okay, let's move to topic three, visual development 00:22:25.700 --> 00:22:27.640 and structural disorders. We touched on this 00:22:27.640 --> 00:22:30.019 in the anatomy section, the idea that the brain 00:22:30.019 --> 00:22:33.220 will literally turn off a bad eye. Let's dig 00:22:33.220 --> 00:22:36.079 into strabismus. Strabismus is just the medical 00:22:36.079 --> 00:22:38.839 term for misalignment of the eyes. So one eye 00:22:38.839 --> 00:22:41.079 looks straight ahead while the other turns in. 00:22:41.079 --> 00:22:43.839 That's esotropia, or it turns out that's exotropia. 00:22:43.880 --> 00:22:45.880 And this is normal for newborns for a little 00:22:45.880 --> 00:22:47.740 while, right? For the very first few months up 00:22:47.740 --> 00:22:50.640 to about three or four months old, intermittent 00:22:50.640 --> 00:22:53.039 crossing is pretty common. The ocular muscles 00:22:53.039 --> 00:22:56.059 are just weak and uncoordinated. But the text 00:22:56.059 --> 00:22:59.859 is clear. If it persists past four months or 00:22:59.859 --> 00:23:02.519 if it is a constant fixed deviation at any age, 00:23:03.000 --> 00:23:05.380 it needs a referral. So how do we test for this 00:23:05.380 --> 00:23:07.599 in the clinic? I see the corneal light reflex 00:23:07.599 --> 00:23:09.400 mentioned everywhere. This is the Hirschberg 00:23:09.400 --> 00:23:12.539 test. It's so simple and so effective. You shine 00:23:12.539 --> 00:23:14.319 a pen light at the bridge of the child's nose 00:23:14.319 --> 00:23:16.480 from a little distance. You then look at the 00:23:16.480 --> 00:23:18.200 reflection of that light in their pupils. And 00:23:18.200 --> 00:23:20.059 what are you looking for? It should be in the 00:23:20.059 --> 00:23:22.240 exact same spot on both eyes, like at 12 o 'clock 00:23:22.240 --> 00:23:24.759 on both pupils or 2 o 'clock on both pupils. 00:23:25.039 --> 00:23:29.200 Symmetrical. And if it's asymmetrical? If the 00:23:29.200 --> 00:23:31.460 reflection is in the center of one pupil and 00:23:31.460 --> 00:23:33.420 maybe on the edge of the pupil on the other eye, 00:23:33.720 --> 00:23:36.299 that other eye is misaligned. That's a positive 00:23:36.299 --> 00:23:38.809 Hirschberg test. That's strabismus. And then 00:23:38.809 --> 00:23:42.150 there is the cover test. This detects the lazy 00:23:42.150 --> 00:23:45.109 component, the amblyopia. It confirms the strabismus. 00:23:45.589 --> 00:23:48.250 This is the next step. You have the child focus 00:23:48.250 --> 00:23:51.089 on an object. You cover their good eye, the one 00:23:51.089 --> 00:23:52.970 that's looking straight at you. Then you watch 00:23:52.970 --> 00:23:54.930 the other eye, the bad eye. And what will it 00:23:54.930 --> 00:23:58.109 do? If that bad eye suddenly moves to pick up 00:23:58.109 --> 00:24:00.809 fixation and focus on you when the good eye is 00:24:00.809 --> 00:24:03.509 covered, that means it was drifting before. It 00:24:03.509 --> 00:24:06.130 confirms the misalignment. So we have the diagnosis. 00:24:06.430 --> 00:24:08.630 Now we have to treat it to prevent amblyopia, 00:24:08.950 --> 00:24:11.130 and the main treatment is patching. But this 00:24:11.130 --> 00:24:13.450 is the part that always confuses students. Which 00:24:13.450 --> 00:24:15.769 eye do we patch? This is a classic exam question. 00:24:16.230 --> 00:24:19.650 You patch the healthy eye, the good eye, the 00:24:19.650 --> 00:24:21.650 one that sees well. That feels so mean. You are 00:24:21.650 --> 00:24:24.089 taking away their clear vision. It does feel 00:24:24.089 --> 00:24:27.130 mean, and parents hate it. But you have to think 00:24:27.130 --> 00:24:29.049 of it like strength training. If you have a weak 00:24:29.049 --> 00:24:31.089 left arm and a strong right arm and you want 00:24:31.089 --> 00:24:33.329 to strengthen the left one, you have to stop 00:24:33.329 --> 00:24:35.190 using the right one. OK, that's a good analogy. 00:24:35.349 --> 00:24:37.650 If you don't patch the good eye, the brain will 00:24:37.650 --> 00:24:40.029 just continue to rely on it and ignore the weak 00:24:40.029 --> 00:24:42.269 one. You have to force the issue. You have to 00:24:42.269 --> 00:24:45.549 make the brain use that lazy eye's neural pathway. 00:24:45.910 --> 00:24:49.450 And the text mentions compliance is a huge issue, 00:24:49.490 --> 00:24:52.150 I can imagine. Incredibly hard. Imagine you were 00:24:52.150 --> 00:24:54.769 three years old and someone covers your good 00:24:54.769 --> 00:24:58.190 eye. Now you can't see well. You feel vulnerable, 00:24:58.589 --> 00:25:00.710 clumsy. You're going to rip that patch right 00:25:00.710 --> 00:25:03.650 off. So what's the nursing role there? A lot 00:25:03.650 --> 00:25:05.869 of parent education on the psychology of it. 00:25:06.089 --> 00:25:08.710 Use pirate patches. Create reward charts. Let 00:25:08.710 --> 00:25:11.170 them decorate their patches. Or do the patching 00:25:11.170 --> 00:25:13.309 during high value screen time because they're 00:25:13.309 --> 00:25:15.670 motivated to focus and might forget it's on. 00:25:15.970 --> 00:25:17.950 And how long do they typically have to do it 00:25:17.950 --> 00:25:20.609 for? It varies, but usually it's for two to six 00:25:20.609 --> 00:25:22.869 hours a day. It doesn't necessarily have to be 00:25:22.869 --> 00:25:25.359 24 -7, which makes it a bit more manageable for 00:25:25.359 --> 00:25:28.460 families. Now, there is one visual finding that 00:25:28.460 --> 00:25:31.539 is an absolute drop everything emergency. We 00:25:31.539 --> 00:25:34.480 have to talk about leukocoria. Yes. This is a 00:25:34.480 --> 00:25:37.339 can't mess red flag. When you shine that light 00:25:37.339 --> 00:25:39.380 for the red reflex, you know, like when you get 00:25:39.380 --> 00:25:42.119 red eye in a photograph, that's normal. You should 00:25:42.119 --> 00:25:44.000 see a reddish orange reflection from the retina. 00:25:44.039 --> 00:25:46.039 And if you don't, if you see something else, 00:25:46.099 --> 00:25:48.900 if you see white, a white pupil or what's sometimes 00:25:48.900 --> 00:25:51.599 called a cat's eye reflex, that is leukocoria. 00:25:51.799 --> 00:25:53.599 And what does that mean? What's the differential 00:25:53.599 --> 00:25:55.519 for that? It means something is blocking the 00:25:55.519 --> 00:25:57.740 light from hitting the retina or the light is 00:25:57.740 --> 00:26:01.859 reflecting off a mass. In kids, the two big terrifying 00:26:01.859 --> 00:26:06.160 fears are a congenital cataract or retinoblastoma. 00:26:06.819 --> 00:26:09.359 Retinoblastoma is a cancer. Yes, a malignant 00:26:09.359 --> 00:26:12.099 tumor of the retina. It is life threatening if 00:26:12.099 --> 00:26:14.819 it metastasizes to the optic nerve and the brain. 00:26:15.339 --> 00:26:18.720 A cataract while not cancer, is a vision emergency 00:26:18.720 --> 00:26:20.940 because it's completely blocking the light and 00:26:20.940 --> 00:26:23.900 will cause profound irreversible amblyopia if 00:26:23.900 --> 00:26:26.619 not removed. So the bottom line is white pupil 00:26:26.619 --> 00:26:29.160 immediate referral to ophthalmology. Do not pass 00:26:29.160 --> 00:26:32.299 go. Do not wait. It's an emergency. Got it. White 00:26:32.299 --> 00:26:35.359 is bad. Red is good. Now let's quickly touch 00:26:35.359 --> 00:26:38.640 on retinopathy of prematurity or ROP. This is 00:26:38.640 --> 00:26:41.119 a very specific condition for the NICU population. 00:26:41.339 --> 00:26:44.160 Correct. When a baby is born very premature, 00:26:44.539 --> 00:26:46.740 Their retinal blood vessels aren't finished growing 00:26:46.740 --> 00:26:49.099 yet. They are fragile. If we have to give them 00:26:49.099 --> 00:26:51.779 high concentrations of oxygen to survive, or 00:26:51.779 --> 00:26:53.759 if their oxygen levels are unstable swinging 00:26:53.759 --> 00:26:56.059 up and down, it can cause those delicate vessels 00:26:56.059 --> 00:26:58.720 to grow wildly and then spasm. And that leads 00:26:58.720 --> 00:27:01.299 to scarring. Yes, it creates scar tissue that 00:27:01.299 --> 00:27:03.380 can pull on the retina. In the worst cases, it 00:27:03.380 --> 00:27:05.900 causes a retinal detachment and blindness. This 00:27:05.900 --> 00:27:08.400 is actually why Stevie Wonder is blind. It was 00:27:08.400 --> 00:27:10.819 R .O .P. from the 1950s before we understood 00:27:10.819 --> 00:27:14.079 oxygen toxicity. So oxygen is a drug. Oxygen 00:27:14.079 --> 00:27:16.539 is absolutely a drug with a narrow therapeutic 00:27:16.539 --> 00:27:19.180 window and significant toxicity. The exam point 00:27:19.180 --> 00:27:22.000 here is knowing the risk factors, very low birth 00:27:22.000 --> 00:27:24.339 weight, early gestational age, and the duration 00:27:24.339 --> 00:27:26.660 and concentration of supplemental oxygen. We 00:27:26.660 --> 00:27:29.319 have to titrate oxygen so, so carefully in preemies. 00:27:29.579 --> 00:27:31.559 Okay, let's slide into our last topic in this 00:27:31.559 --> 00:27:34.880 section. Topic four, eye trauma, the ouch section. 00:27:35.220 --> 00:27:37.180 Kids are clumsy, they play with sticks, things 00:27:37.180 --> 00:27:40.309 happen. Trauma is surprisingly common. And the 00:27:40.309 --> 00:27:42.630 interventions are very specific and very testable. 00:27:42.769 --> 00:27:44.730 Let's do the need -to -know for the big ones. 00:27:45.170 --> 00:27:48.309 A simple foreign body, sand or dirt in the eye. 00:27:48.730 --> 00:27:51.970 First rule, do not rub. Rubbing is like taking 00:27:51.970 --> 00:27:55.049 sandpaper to the cornea. You irrigate with saline. 00:27:55.549 --> 00:27:58.730 You can try to avert the eyelid, flip it up like 00:27:58.730 --> 00:28:00.809 a hood if you can, to see if you can sweep it 00:28:00.809 --> 00:28:03.690 out with a moist cotton swab. Okay. What about 00:28:03.690 --> 00:28:05.789 a chemical injury, like a kid gets into the cleaning 00:28:05.789 --> 00:28:07.950 supplies? Irrigate, irrigate, irrigate. That's 00:28:07.950 --> 00:28:10.480 the only answer. copious amounts of water or 00:28:10.480 --> 00:28:12.940 saline immediately. Don't wait to get to the 00:28:12.940 --> 00:28:16.019 ER to start flushing. Time is vision. You flush 00:28:16.019 --> 00:28:18.740 for at least 15 -20 minutes holding the eye open. 00:28:19.059 --> 00:28:21.900 And the big one. A penetrating injury. The kid 00:28:21.900 --> 00:28:24.259 who was running with a pencil and fell. The pencil 00:28:24.259 --> 00:28:26.579 is now sticking out of the eye. Never remove 00:28:26.579 --> 00:28:29.240 the object. That is the golden rule. All caps, 00:28:29.500 --> 00:28:31.779 bold, underlined. If you pull it out, you might 00:28:31.779 --> 00:28:34.000 pull the contents of the eye out with it. The 00:28:34.000 --> 00:28:37.440 vitreous humor. Or you could cause a massive 00:28:38.279 --> 00:28:40.140 uncontrollable bleed. So what do you do instead? 00:28:40.319 --> 00:28:42.680 You can't just leave it. You stabilize the object, 00:28:43.180 --> 00:28:44.900 you build a little fort around it with gauze 00:28:44.900 --> 00:28:47.839 rolls, or you take a paper cup, cut out the bottom 00:28:47.839 --> 00:28:50.500 and place it over the eye and tape the cup down 00:28:50.500 --> 00:28:52.140 to the face so the object doesn't get bumped 00:28:52.140 --> 00:28:54.759 or moved. And here's the other critical piece 00:28:54.759 --> 00:28:56.859 I saw in the notes, which is so easy to forget. 00:28:57.140 --> 00:28:59.839 You cover both eyes, even the uninjured one. 00:29:00.099 --> 00:29:03.480 Yes. This is counterintuitive, but absolutely 00:29:03.480 --> 00:29:06.930 vital. Why both? If only one is hurt. It's because 00:29:06.930 --> 00:29:09.549 of consensual movement. Our eyes are wired to 00:29:09.549 --> 00:29:11.730 move together. If the child looks around the 00:29:11.730 --> 00:29:13.910 room with their good eye to see mom or the nurse, 00:29:14.450 --> 00:29:17.009 the injured eye will move, too, in sync. And 00:29:17.009 --> 00:29:19.450 that movement could cause more damage. Way more 00:29:19.450 --> 00:29:21.589 damage if there's a foreign object lodged inside. 00:29:22.450 --> 00:29:24.490 By covering both eyes, you stop them from looking 00:29:24.490 --> 00:29:26.950 around. It keeps the injured eye as still as 00:29:26.950 --> 00:29:29.940 possible. That is such a critical nursing intervention, 00:29:30.119 --> 00:29:32.000 but it totally changes the care plan. You've 00:29:32.000 --> 00:29:33.940 just blinded them temporarily. You have to talk 00:29:33.940 --> 00:29:36.480 to them constantly. Exactly. You become their 00:29:36.480 --> 00:29:39.119 eyes. You have to narrate everything. I am holding 00:29:39.119 --> 00:29:41.500 your hand now. We are moving the bed to the left. 00:29:42.200 --> 00:29:44.779 It requires a really high level of communication 00:29:44.779 --> 00:29:47.079 and reassurance. All right. We have covered the 00:29:47.079 --> 00:29:49.140 systems. Now I want to bring it all back to the 00:29:49.140 --> 00:29:52.259 so what. Specifically regarding development, 00:29:52.480 --> 00:29:55.380 we talked about hearing loss, and speech delay. 00:29:56.039 --> 00:29:59.099 What about vision loss? What are the developmental 00:29:59.099 --> 00:30:02.079 red flags we should be looking for there? Vision 00:30:02.079 --> 00:30:04.319 is how an infant learns about their environment 00:30:04.319 --> 00:30:07.220 before they can crawl or walk. If they can't 00:30:07.220 --> 00:30:09.799 see, they are isolated. They can't see the smile 00:30:09.799 --> 00:30:11.799 on their mother's face, so they don't learn to 00:30:11.799 --> 00:30:15.099 smile back socially. It impacts bonding. So what 00:30:15.099 --> 00:30:17.480 are the specific red flags an exam might ask 00:30:17.480 --> 00:30:20.809 for, the concrete behaviors? In an infant. Does 00:30:20.809 --> 00:30:22.910 not fix and follow an object with their eyes 00:30:22.910 --> 00:30:25.369 by three or four months. Does not make eye contact. 00:30:25.509 --> 00:30:28.910 Has a dull vacant stare. Or, and this is a subtle 00:30:28.910 --> 00:30:31.430 one, does not imitate facial expressions like 00:30:31.430 --> 00:30:33.250 sticking out their tongue. And for a toddler 00:30:33.250 --> 00:30:34.809 who can move around? That's when you see them 00:30:34.809 --> 00:30:36.869 rubbing their eyes constantly, squinting a lot, 00:30:36.910 --> 00:30:39.190 bumping into objects. Or a big one is holding 00:30:39.190 --> 00:30:41.509 books or tablets inches from their face to see 00:30:41.509 --> 00:30:43.869 them. And how does this manifest socially or 00:30:43.869 --> 00:30:46.150 behaviorally? It can look like a behavior problem. 00:30:46.269 --> 00:30:48.890 This is the synthesis piece that's so important. 00:30:49.529 --> 00:30:51.809 A child who is labeled as clumsy or aggressive 00:30:51.809 --> 00:30:54.349 or withdrawn might just be terrified because 00:30:54.349 --> 00:30:56.849 they can't see who is coming at them. They might 00:30:56.849 --> 00:30:59.450 self -stimulate like rocking or poking their 00:30:59.450 --> 00:31:02.130 eyes because they aren't getting external visual 00:31:02.130 --> 00:31:03.849 stimulation, so they're trying to create their 00:31:03.849 --> 00:31:06.970 own. So what's a key nursing intervention for 00:31:06.970 --> 00:31:09.769 a visually impaired child who's hospitalized? 00:31:10.609 --> 00:31:14.470 Promote independence, but provide a safe, predictable 00:31:14.470 --> 00:31:16.819 environment. You always announce yourself when 00:31:16.819 --> 00:31:19.000 you enter the room. Don't just touch them. That's 00:31:19.000 --> 00:31:21.559 terrifying. You describe the room layout. Your 00:31:21.559 --> 00:31:24.059 chair is to your left. And for eating, you use 00:31:24.059 --> 00:31:26.980 the clock method. The clock method is a classic 00:31:26.980 --> 00:31:29.980 NCLEX question. It is because it's so practical. 00:31:30.200 --> 00:31:31.960 Your peas are at three o 'clock on your plate. 00:31:32.019 --> 00:31:34.180 Your chicken is at six o 'clock. It allows the 00:31:34.180 --> 00:31:36.160 child to feed themselves. It preserves their 00:31:36.160 --> 00:31:38.619 dignity and fosters independence, which is the 00:31:38.619 --> 00:31:41.619 ultimate goal of pediatric nursing. OK, we are 00:31:41.619 --> 00:31:45.059 entering the final stretch, section C. The crosslinking 00:31:45.059 --> 00:31:48.039 and synthesis. We have thrown a ton of information 00:31:48.039 --> 00:31:51.640 out there. Let's recap the red flag differentiators 00:31:51.640 --> 00:31:54.880 that will help our listeners on an exam or in 00:31:54.880 --> 00:31:57.559 triage. Let's simplify it. Let's boil it down 00:31:57.559 --> 00:31:59.859 into three main categories of differentiation. 00:32:00.420 --> 00:32:02.480 If you remember nothing else from this deep dive, 00:32:02.759 --> 00:32:05.099 remember these three distinct patterns. Go for 00:32:05.099 --> 00:32:08.440 it. One, pain differentiation. It's all about 00:32:08.440 --> 00:32:10.759 the location and type of pain. Okay. If it hurts 00:32:10.759 --> 00:32:13.200 when you touch the outside of the ear, The tragus 00:32:13.200 --> 00:32:16.779 or the pinna is otitis externa, full stop. If 00:32:16.779 --> 00:32:19.000 it hurts deep inside, it disrupts their sleep 00:32:19.000 --> 00:32:21.000 and they are pulling at the ear, that's your 00:32:21.000 --> 00:32:22.680 acute otitis media. And if it doesn't really 00:32:22.680 --> 00:32:25.480 hurt but feels full or is popping, that's otitis 00:32:25.480 --> 00:32:27.559 media with effusion. Perfect. What's number two? 00:32:27.680 --> 00:32:30.039 Two. Discharge differentiation. This is for the 00:32:30.039 --> 00:32:32.829 eyes. Got it. Pus or thick purulent discharge 00:32:32.829 --> 00:32:35.970 equals bacterial conjunctivitis, watery discharge 00:32:35.970 --> 00:32:38.549 plus intense itching equals allergic conjunctivitis, 00:32:39.089 --> 00:32:40.950 and watery discharge plus a cold and swollen 00:32:40.950 --> 00:32:43.710 lymph nodes equals viral conjunctivitis. Clear 00:32:43.710 --> 00:32:48.230 and simple. And the third. Three. Reflex differentiation. 00:32:48.509 --> 00:32:51.170 This is for the vision screening. An asymmetrical 00:32:51.170 --> 00:32:53.589 corneal light reflex, where the light is centered 00:32:53.589 --> 00:32:56.230 in one pupil and off -center in the other, equals 00:32:56.230 --> 00:33:00.349 strabismus. And a white reflex, leukocoria, equals 00:33:00.349 --> 00:33:03.170 a potential cataract or retinoblastoma, which 00:33:03.170 --> 00:33:05.490 is an emergency. That is the cheat sheet right 00:33:05.490 --> 00:33:08.750 there. That is the Pareto 8020 of pediatric sensory 00:33:08.750 --> 00:33:11.390 assessment. And one final safe practice consensus 00:33:11.390 --> 00:33:14.069 point, just a hammer at home, regarding antibiotics 00:33:14.069 --> 00:33:16.950 for ears. If sources seem to disagree, always 00:33:16.950 --> 00:33:19.430 stick to the AAP guideline. Watchful waiting 00:33:19.430 --> 00:33:21.609 is safe and preferred for healthy kids over six 00:33:21.609 --> 00:33:24.980 months with mild to moderate AOM. but under six 00:33:24.980 --> 00:33:27.500 months or severe symptoms always get treated. 00:33:27.940 --> 00:33:29.099 Perfect. You know, one thing I want to add before 00:33:29.099 --> 00:33:31.880 we close, we talked about the anatomy being destiny, 00:33:32.279 --> 00:33:34.420 that horizontal tube, but we can influence that 00:33:34.420 --> 00:33:36.839 destiny with prevention. The sources highlight 00:33:36.839 --> 00:33:39.099 three really key things parents can do. Okay, 00:33:39.119 --> 00:33:41.539 let's hear them. First, breastfeeding. The sources 00:33:41.539 --> 00:33:44.019 are clear on this. It confers maternal antibodies, 00:33:44.400 --> 00:33:46.500 and the sucking mechanism at the breast is better 00:33:46.500 --> 00:33:49.019 for eustachian tube function than a bottle. Makes 00:33:49.019 --> 00:33:53.660 sense. Second, no smoking. This is huge. Secondhand 00:33:53.660 --> 00:33:56.859 smoke paralyzes the cilia in the eustachian tube. 00:33:57.420 --> 00:33:58.980 Those little hairs are supposed to sweep fluid 00:33:58.980 --> 00:34:01.420 out. If they're paralyzed, the fluid just sits 00:34:01.420 --> 00:34:04.519 there and infection breeds. Passive smoke is 00:34:04.519 --> 00:34:06.779 a massive risk factor for recurrent ear infections. 00:34:06.839 --> 00:34:10.360 And the third? Feeding position. Never, ever 00:34:10.360 --> 00:34:12.699 prop a bottle and let a baby drink lying flat 00:34:12.699 --> 00:34:15.639 on their back. The milk or formula can pool in 00:34:15.639 --> 00:34:18.159 the nasopharynx and flow right up that horizontal 00:34:18.159 --> 00:34:20.699 highway into the ear. It's basically a direct 00:34:20.699 --> 00:34:22.840 injection of sugar water into the middle ear. 00:34:23.079 --> 00:34:25.320 Which bacteria love. Which bacteria absolutely 00:34:25.320 --> 00:34:28.019 love. Feed them upright. Those are three massive 00:34:28.019 --> 00:34:30.079 parent education points that can prevent the 00:34:30.079 --> 00:34:32.440 whole problem before it even starts. Alright, 00:34:32.559 --> 00:34:34.780 this has been an incredibly comprehensive deep 00:34:34.780 --> 00:34:37.579 dive. We have unpacked the anatomy, the infections, 00:34:37.920 --> 00:34:40.320 the critical visual development, and the trauma. 00:34:40.380 --> 00:34:42.420 We have definitely covered a lot of ground. As 00:34:42.420 --> 00:34:44.309 we sign off, I just want to leave our listeners 00:34:44.309 --> 00:34:46.730 with a thought. We spend so much time in nursing 00:34:46.730 --> 00:34:49.750 school memorizing the drugs, the amoxicillin, 00:34:49.809 --> 00:34:51.769 the drops, the dosage calculations, and those 00:34:51.769 --> 00:34:53.230 are important, of course. Oh, there they are. 00:34:53.469 --> 00:34:56.889 But in pediatrics, the medical fix is often the 00:34:56.889 --> 00:34:59.750 easy part. The hard part is understanding the 00:34:59.750 --> 00:35:02.489 why behind the development. Why does this matter 00:35:02.489 --> 00:35:05.789 to this kid at this age? Absolutely. The provocative 00:35:05.789 --> 00:35:09.530 thought I'd leave you with is this. A child's 00:35:09.530 --> 00:35:12.199 sensory system. is their interface with humanity. 00:35:12.719 --> 00:35:14.599 It's how they connect, it's how they learn, it's 00:35:14.599 --> 00:35:17.059 how they love. If that interface is broken, if 00:35:17.059 --> 00:35:20.159 they have cloudy vision or muffled hearing, they 00:35:20.159 --> 00:35:23.380 aren't just sick. They're isolated. They are 00:35:23.380 --> 00:35:27.059 lonely. They are confused. A behavioral outburst 00:35:27.059 --> 00:35:29.840 in a classroom might not be ADHD. It might be 00:35:29.840 --> 00:35:32.179 a kid who hasn't heard a clear sentence in six 00:35:32.179 --> 00:35:34.260 months because of chronic fluid in their ears. 00:35:34.519 --> 00:35:36.940 So when you're assessing that kid, look deeper. 00:35:37.179 --> 00:35:39.219 Don't just look at the eardrum. Look at the child 00:35:39.219 --> 00:35:41.420 behind the eardrum. Exactly. That's the art of 00:35:41.420 --> 00:35:43.420 pediatric nursing. Keep your eyes open and your 00:35:43.420 --> 00:35:45.679 ears to the ground. Thanks for listening to the 00:35:45.679 --> 00:35:47.539 Deep Dive. We'll see you next time. Take care.