CCS Pediatric Cases: Common Presentations & Age-Specific Approaches

Pediatric CCS Cases: Age-Specific Approach

Pediatric CCS cases test your ability to recognize age-appropriate presentations, apply different diagnostic thresholds based on age, and manage common childhood emergencies (fever, bronchiolitis, croup). The key principle: fever evaluation and treatment differ dramatically by age. A neonate with fever is sepsis until proven otherwise. A 3-year-old with fever and URI symptoms is almost always viral. This guide walks you through the age-stratified approach examiners expect.

Neonatal Fever (<28 Days): Sepsis Workup

Critical principle: ALL neonates with fever = presumed sepsis. Full workup and empiric antibiotics are mandatory.

Risk Factors for Neonatal Sepsis

• Maternal: GBS colonization (GBS+), chorioamnionitis, prolonged rupture of membranes (PROM >18 hours), maternal fever during labor

• Neonatal: Prematurity (<35 weeks), low birth weight (<1500 g), male sex, low Apgar score

• Presentation: Fever (rare in neonates—many present with hypothermia instead), lethargy, poor feeding, irritability, jaundice, vomiting, diarrhea

Diagnostic Workup (Mandatory)

1. Blood culture × 2 (from different sites if possible)

2. CBC with differential: Absolute neutrophil count <5,000 or >21,000 concerning

3. Lumbar puncture (LP): ALWAYS in neonates with fever/sepsis suspicion

◦ CSF culture, Gram stain, protein (normally 45-100 mg/dL), glucose (normally 40-80% of serum)

◦ Opening pressure, cell count

◦ Elevated protein + normal/low glucose = bacterial meningitis

4. Urinalysis + urine culture (via catheterization or suprapubic aspiration—NOT bag specimen)

5. CXR (if respiratory symptoms)

6. Lactate, procalcitonin (elevated = concerning for sepsis)

Empiric Antibiotics (Start Immediately)

Do NOT wait for cultures:

• Ampicillin 50 mg/kg IV/IM q12h (covers GBS, Listeria)

• PLUS Gentamicin 7.5 mg/kg IV/IM q12h (covers gram-negatives, E. coli)

• OR Cephalosporin (cefotaxime 50 mg/kg q8h) instead of ampicillin in some centers (ceftriaxone NOT used in neonates due to biliary sludge risk)

Duration: Continue empiric coverage pending cultures (≥48-72 hours minimum); switch to organism-specific therapy once identified

Herpes Simplex Virus (HSV) Consideration

• If maternal history of HSV or vesicles on exam: Add acyclovir 20 mg/kg IV q8h

• CNS involvement (seizures, altered mental status, vesicles) = acyclovir mandatory

> Study Tip: The StudyCCS question bank includes 5+ neonatal fever/sepsis cases showing the complete workup and the exact moment when you must get LP and start empiric antibiotics. You'll practice recognizing subtle signs of neonatal sepsis (poor feeding, lethargy) and the aggressive evaluation this age group demands.

Pediatric Fever (1-36 Months): Age-Stratified Approach

This is where age changes everything. A 12-month-old with fever and no source is at risk for occult bacteremia—very different from a 4-year-old with the same presentation.

Fever Without Source: Age-Based Risk

1-3 months:

• Risk of occult UTI: 5-10%

• Risk of occult bacteremia: 5-15%

• Meningitis risk if meningismus present

• Workup: UA + urine culture, blood culture, CXR, consider LP

• Management: Admit, IV antibiotics (ampicillin + gentamicin ± cefotaxime for meningitis coverage)

3-36 months (Focal vs Non-Focal):

Non-focal fever (no localizing signs, no meningismus):

• Age 3-6 mo: Higher risk bacteremia; UA + culture, blood culture, consider CXR

• Age 6-12 mo: Risk decreases; UA + culture; blood culture if high fever (>39°C) + WBC >15,000

• Age 12-36 mo: Lowest risk; UA + culture; blood culture only if high fever + high WBC

Focal fever (ear infection, UTI, pneumonia):

• Treat the source; lower bacteremia risk

• Imaging/cultures guided by suspected source

Evaluation Tools: UTI Workup by Age

Urinalysis findings concerning for UTI:

• Pyuria (>5 WBC/hpf or LE positive)

• Nitrites (gram-negative organisms)

• Bacteria on Gram stain

Urine collection:

• <12 months: Straight catheter (clean-catch unreliable)

• >12 months: Mid-stream clean-catch acceptable

• Avoid bag specimens (high false-positive rate)

If UA suggests UTI: Send urine culture; start empiric antibiotics pending culture

• 1st-line: Amoxicillin-clavulanate 25 mg/kg/day divided BID

• Alternative: Cephalexin, trimethoprim-sulfamethoxazole

Common Pediatric Presentations

Bronchiolitis (Ages 2 Months - 2 Years)

Most common viral lower respiratory infection in infants

Etiology: Respiratory syncytial virus (RSV) >90%, parainfluenza, influenza, rhinovirus

Clinical presentation:

• Preceded by URI symptoms (rhinorrhea, congestion)

• Progresses to cough, tachypnea, retractions (intercostal, subcostal), grunting

• Wheezing or crackles on auscultation

• Hypoxia if severe (SpO₂ <92%)

• Peak symptoms POD 3-5 of illness

Diagnosis:

• Clinical (URI symptoms + lower respiratory signs)

• CXR: Hyperinflation, atelectasis, bronchial wall thickening (not needed routinely)

• RSV rapid antigen test (optional, doesn't change management)

• Oximetry: Baseline SpO₂

Management (Supportive Care):

• Oxygen: If SpO₂ <92% at rest or with activity; nasal cannula

• Hydration: IV fluids if unable to tolerate oral (respiratory distress, secretions)

• Suctioning: Frequent suctioning of secretions (every 1-2 hours)

• NO routine antibiotics (viral, not bacterial)

• NO routine corticosteroids (minimal benefit in uncomplicated bronchiolitis)

• Ribavirin: Rare, for severely immunocompromised (high cost, teratogenic)

Admission criteria:

• SpO₂ <92% on room air

• Severe retractions, respiratory distress (RR >70)

• Apnea spells

• Age <3 months OR prematurity

• Inadequate support at home

Discharge: Once stable on room air, tolerating feeds, adequate follow-up

Croup (Laryngotracheobronchitis) — Ages 6 Months - 3 Years

Classic viral upper airway infection

Etiology: Parainfluenza virus type 1 (most common), RSV, influenza

Clinical presentation:

• Barking/seal-like cough ("croupy cough")

• Stridor (biphasic or inspiratory)

• Hoarseness

• Often preceded by mild URI symptoms

• Worse at night

• Low-grade fever

Severity classification:

• Mild: No stridor at rest, normal voice

• Moderate: Stridor at rest, chest retractions, anxious

• Severe: Stridor at rest, severe retractions, drooling, altered mental status

Diagnosis: Clinical (no routine testing needed; avoid upsetting child with unnecessary exams)

Management:

Mild croup (majority):

• Dexamethasone 0.6 mg/kg (max 10 mg) single dose PO/IM (reduces symptoms in 12-24 hours)

• Cool mist/humidity (empiric, though evidence mixed)

• Discharge with dexamethasone

Moderate croup:

• Dexamethasone 0.6 mg/kg PO/IM

• Consider IM epinephrine only if stridor worsens

• Can often manage as outpatient with close follow-up

Severe croup:

• Racemic epinephrine 0.05 mL/kg (max 0.5 mL) nebulized (onset 10 minutes, effects 1-2 hours)

• Dexamethasone 0.6 mg/kg

• Budesonide 0.15 mg/kg nebulized (longer-acting alternative; onset slower but 4-6 hour effect)

• Oxygen if SpO₂ <92%

• ICU admission for potential airway compromise

• Have intubation equipment ready (Heliox [helium-oxygen] mixture if available)

Admission criteria:

• Severe stridor, respiratory distress

• Altered mental status

• No response to epinephrine + dexamethasone within 30-60 min

• Age <6 months (rarer but more severe)

> Practice Alert: Croup is a common CCS pediatric case. The StudyCCS question bank includes cases showing the progression from mild to moderate to severe—and the exact moment when epinephrine becomes necessary. You'll practice dexamethasone dosing and recognizing when a child needs hospitalization.

Febrile Seizures (6 Months - 5 Years)

Most common seizure type in children

Definition: Seizure occurring during fever (usually >38.5°C) in the absence of intracranial infection or previous afebrile seizures

Risk factors: Family history, younger age at first febrile seizure, high fever

Clinical presentation:

• Seizure during high fever (most commonly during fever spike, not early in illness)

• Typically generalized tonic-clonic (90%), <5 minutes duration

• Post-ictal confusion

• No focal neurologic signs

Simple vs Complex:

• Simple febrile seizure (90% of cases): Single, generalized, <15 min

• Complex febrile seizure: Multiple seizures in 24h, focal features, >15 min

Diagnosis (Must Rule Out Meningitis):

• History and physical exam

• Lumbar puncture: STRONGLY consider LP in children <12 months OR if signs of meningitis (neck stiffness, altered mental status, petechiae)

• LP less critical if >12 months, no meningeal signs, well-appearing, reliable follow-up

• EEG: NOT routinely indicated

Management:

• Acute: Position supine, protect airway, remove constrictive clothing

• If seizure ongoing >5 min:

◦ IV lorazepam 0.05 mg/kg (max 4 mg) OR

◦ Rectal diazepam 0.5 mg/kg (if no IV access)

• Once afebrile: Typically need no further seizure medications (not epilepsy)

• Treat underlying fever: Ibuprofen or acetaminophen

Prophylaxis:

• Continuous phenobarbital/phenytoin: NOT recommended (side effects outweigh benefits, seizure recurrence rate not dramatically reduced)

• Intermittent lorazepam during febrile illnesses: May be considered if high recurrence risk or parental anxiety

Prognosis:

• ~30% recurrence rate with first febrile seizure

• Most children outgrow febrile seizures by age 5

• Febrile seizures do NOT cause epilepsy or brain damage

Discharge:

• Education: Seizure precautions, fever management

• Prescription for rectal diazepam if high-risk recurrence

• Follow-up with PCP; neurology referral only if atypical features or concern for epilepsy

Pediatric Asthma Exacerbation

High-risk CCS presentation

Differs from adults in management nuances:

Triggers: URI, exercise, allergens, cold air, emotional stress

Severity assessment:

• Mild: Dyspnea with play, normal speech, no retractions

• Moderate: Dyspnea at rest, short phrases, mild retractions

• Severe: Speech in words only, marked retractions, accessory muscle use, peak flow <50% predicted

Management:

• Albuterol: 0.1 mg/kg (max 5 mg) nebulized q20-30min (continuous in severe)

• Ipratropium: 0.25 mg q4-6h (synergistic with albuterol in children)

• Corticosteroids: Prednisone/methylprednisolone 1-2 mg/kg (max 60 mg) × 5-7 days

• Magnesium sulfate: 25-40 mg/kg IV (max 2 g) over 20 min if severe/not responding

• Oxygen: Target SpO₂ ≥94%

Discharge: Home albuterol inhaler + spacer, ICS inhaler, asthma action plan, family education

Kawasaki Disease (Ages 6 Months - 5 Years)

Rare but don't-miss diagnosis

Etiology: Unknown, self-limited vasculitis of medium vessels

Clinical presentation:

• Prolonged fever (≥5 days) unresponsive to antibiotics

• Bilateral conjunctival injection (non-exudative)

• Oral changes: Red, cracked lips; strawberry tongue

• Rash (polymorphous, spares face)

• Hand/foot swelling, erythema, desquamation

• Cervical lymphadenopathy (usually unilateral, >1.5 cm)

• Irritability, often ill-appearing

Diagnosis: Clinical (no test)—must meet ≥4 of 6 principal features for diagnosis

Urgency: Untreated → coronary artery aneurysms in 25% (leading cause of acquired heart disease in children)

Management:

• IVIG: 2 g/kg IV × 1 dose (within 10 days of fever onset for optimal benefit)

• Aspirin: High-dose (80-100 mg/kg/day in 4 divided doses) × 2-3 weeks, then low-dose 3-5 mg/kg/day × 6-8 weeks (antiplatelet)

• Echocardiography: Baseline and 2-4 weeks to assess for coronary involvement

• Pediatric/Cardiology consultation: STAT

• Most improve dramatically after IVIG (fever resolves within 24-48 hours)

Don't-miss: Asymmetric Kawasaki (incomplete features) → still requires IVIG if high suspicion

Intussusception (Ages 6 Months - 3 Years)

Classic presentation: Episodic severe abdominal pain + bloody stools

Pathophysiology: Telescoping of bowel (usually ileocolic), most common surgical abdomen in this age group

Clinical:

• Episodic severe crying/abdominal pain (clasping abdomen)

• Intermittent periods of lethargy/play

• "Currant jelly" stools (bloody mucoid)

• Palpable mass (sausage-like) in right upper quadrant

• Vomiting (often bilious if obstruction complete)

Diagnosis:

• Abdominal ultrasound: Gold standard (target sign, doughnut sign on longitudinal view)

• Plain films: Nonspecific

Management:

• Air or hydrostatic enema: Therapeutic in 60-90% if no perforation

• Success confirmed by opacification of terminal ileum

• Surgery: If failed enema, perforation, or recurrent intussusception (>2 episodes)

• IV fluids, NGT decompression initially

• Antibiotics only if perforation (cephalosporin + gentamicin)

Pyloric Stenosis (Ages 3-12 Weeks)

Classic: Projectile vomiting + desire to feed immediately after

Presentation:

• Progressive projectile vomiting 1-3 weeks after birth

• Hungry after vomiting ("hungry vomiter")

• Dehydration, weight loss

• Visible peristaltic waves

• Palpable "olive" in epigastrium (rigid pylorus)

• Hypochloremic, hypokalemic metabolic alkalosis (from loss of gastric acid)

Diagnosis:

• Ultrasound: Pyloric muscle thickness >3 mm, channel >14 mm

• Upper GI (barium): Rarely needed

Management:

• Fluid resuscitation: IVF (LR or normal saline), replace electrolytes

• Correct alkalosis: 0.9% saline (NaCl)-containing fluids

• Surgical: Pyloromyotomy (definitive; typically after fluid correction)

• Pre-op: NGT, NPO

Pediatric Vital Signs & Developmental Milestones (Reference)

Vital Sign Ranges by Age

Developmental Milestones (Key Screening Points)

• 2 mo: Smiles responsively, fixes gaze

• 4 mo: Rolls prone → supine, babbles

• 6 mo: Sits with support, transfers toys

• 9 mo: Crawls, waves bye-bye, pincer grasp

• 12 mo: Stands with support, single words, separation anxiety

• 18 mo: Walks independently, 10+ words, points to body parts

• 2 years: Runs, 2-word phrases, follows 2-step commands

> Study Tip: The StudyCCS question bank includes pediatric developmental screening cases showing how to quickly assess if a child is meeting milestones and when further evaluation is needed.

Don't-Miss Pediatric Diagnoses

When a child presents with fever or respiratory symptoms:

• Meningitis/Bacterial infection: Neck stiffness, altered mental status, petechae, high fever; LP mandatory

• Epiglottitis: Stridor, drooling, tripoding, dysphagia (now rare due to Hib vaccine); airway emergency

• Anaphylaxis: Urticaria, angioedema, wheezing, hypotension; give IM epinephrine 0.01 mg/kg

• Type 1 diabetes: Polyuria, polydipsia, DKA; check glucose, venous pH

• Appendicitis: RLQ pain, vomiting, fever; ultrasound/CT

• Testicular torsion: Acute scrotal pain; doppler ultrasound, STAT urology

Complete Order Set: Fever in Different Ages

Neonate (0-28 Days) with Fever

• Blood culture × 2

• CBC with differential, lactate

• Lumbar puncture (CSF culture, Gram stain, protein, glucose)

• Urinalysis + urine culture (straight cath)

• CXR

• Empiric IV antibiotics (ampicillin + gentamicin ± cefotaxime)

• Consider HSV PCR/acyclovir if risk factors

Infant (1-3 Months) Fever Without Source

• Blood culture

• CBC, CMP

• Urinalysis + urine culture (straight cath)

• CXR

• LP (strongly consider if <3 months or signs of meningitis)

• IV/IM antibiotics if admitted (ceftriaxone 50 mg/kg q8h ± vancomycin)

Toddler (1-3 Years) with Fever

• UA + urine culture (if UTI suspected)

• Blood culture (if high fever >39°C + WBC >15,000 + no focal source)

• CBC if appears ill

• CXR (if respiratory symptoms)

• Treat localizing source if present

2-Minute Screen

Pediatric cases in 120 seconds:

1. Neonatal fever: Full sepsis workup (blood culture, LP, UA + culture); empiric ampicillin + gentamicin

2. Infant fever 1-3 mo: Consider LA bacteremia; UA + culture, blood culture, LP

3. Bronchiolitis: 2 mo-2 yr with URI + lower respiratory signs; supportive care (O₂, hydration, suctioning); NO antibiotics

4. Croup: Barking cough + stridor; mild = dexamethasone; moderate/severe = +/- epinephrine

5. Febrile seizure: Seizure during fever; rule out meningitis with LP if <12 mo or meningeal signs; benign prognosis; no prophylactic seizure meds

6. Kawasaki: Prolonged fever + 4/6 features; IVIG + aspirin; cardiology consult urgent

7. Intussusception: Episodic pain + bloody stools; ultrasound diagnostic; air/hydrostatic enema therapeutic

8. Pyloric stenosis: 3-12 weeks, projectile vomiting, hungry after; ultrasound diagnostic; surgical pyloromyotomy

Related Articles

• CCS Sepsis in Children: Recognition & Empiric Therapy

• CCS Asthma Exacerbation: Severity Assessment to Discharge

• CCS Meningitis: Bacterial vs Viral Approach

• CCS Dehydration: Assessment & Rehydration Strategies

Ready to practice? The StudyCCS question bank includes 10+ pediatric cases across all ages—from neonatal sepsis requiring full workup and empiric antibiotics to febrile seizures, bronchiolitis, and Kawasaki disease. Each case walks you through age-specific evaluation strategies, vital sign interpretation, and when to escalate to specialist consultation. Real-time scoring highlights your decision-making on empiric therapy timing and diagnostic urgency. Try a case today.