Of all the chief complaints you'll see as a primary care FNP, three pediatric ones dominate: ear pain, sore throat, and fever. The FNP boards mirrors that distribution. Master these three workups and you'll handle a significant portion of pediatric questions.
Pediatric primary care is pattern recognition. The patterns repeat. Learn them once, recognize them always.
Acute Otitis Media
When to treat vs. observe
The AAP recommends observation OR antibiotics depending on age, severity, and certainty:
- <6 months: treat all confirmed AOM.
- 6–24 months with bilateral AOM or severe symptoms: treat.
- 6–24 months, unilateral, non-severe: may observe with follow-up.
- ≥24 months, non-severe: may observe with follow-up.
Severe = moderate-severe otalgia, otalgia >48 hours, fever ≥39°C/102.2°F.
First-line treatment
Amoxicillin 80–90 mg/kg/day in 2 divided doses x 10 days (5–7 days if older than 6 years).
When to escalate
Amoxicillin-clavulanate if:
- Recent amoxicillin use (last 30 days)
- Concurrent purulent conjunctivitis (suspect H. flu)
- Recurrent AOM not responsive to amoxicillin
Penicillin allergic: cefdinir, cefpodoxime, or azithromycin.
Diagnostic criteria
Moderate to severe bulging of TM, OR new otorrhea not due to otitis externa, OR mild bulging with recent otalgia or marked erythema. Don't diagnose AOM from a red TM alone — kids cry, ears get red.
Clinical Pearl: Otitis media with effusion is fluid in the middle ear WITHOUT signs of acute infection. Do NOT antibiotic. Watchful waiting, refer to ENT if persistent >3 months.
Strep Pharyngitis
Use the Centor or McIsaac criteria
- Fever >38°C
- Tonsillar exudates
- Tender anterior cervical lymphadenopathy
- Absence of cough
- Age modifier (McIsaac): 3–14 years = +1, ≥45 = -1
Higher score = test or empirically treat. The IDSA recommends rapid strep testing for any patient with clinical suspicion. Don't treat without confirmation in most cases.
Treatment
- Penicillin V or amoxicillin x 10 days (first-line)
- Cephalexin if mild penicillin allergy
- Azithromycin or clindamycin if anaphylactic penicillin allergy
Why treat?
To prevent rheumatic fever, not just to shorten symptoms. Glomerulonephritis prevention is not consistently improved with treatment.
What about mono?
Mono mimics strep but with prolonged fatigue, posterior cervical lymphadenopathy, splenomegaly. Get a monospot and CBC. Strep + amoxicillin in mono = morbilliform rash. Don't be fooled.
Fever Without a Source
Approach by age
0–28 days with fever ≥38°C: Full sepsis workup (CBC, BMP, blood cx, urine cx, CSF), admit, empiric antibiotics. No exceptions.
29–90 days with fever: Risk stratification. Use Rochester or Step-by-Step criteria. Many will require workup; well-appearing infants may be managed outpatient with close follow-up.
3–36 months with fever: Assess appearance. Well-appearing with no source — observe, encourage hydration, return precautions. Always check UA in girls <2, all uncircumcised boys <2, circumcised boys <6 months. Consider blood culture if very young or appearance changes.
>3 years: Treat the source you find. Otherwise observe.
Red flags requiring workup
- Toxic appearance
- Petechial or purpuric rash (think meningococcemia)
- Severe headache, neck stiffness, photophobia
- Persistent vomiting
- Lethargy or irritability disproportionate to fever
- Bulging fontanelle in infants
- Refusal to bear weight (consider septic joint)
Other High-Yield Pediatric Conditions
- Bronchiolitis (RSV most common): wheezing, retractions, age <2. Supportive care only. No antibiotics, no steroids, no albuterol routinely.
- Croup: barky seal-like cough, low-grade fever, age 6 months to 6 years. Mild = humidified air, dexamethasone single dose. Stridor at rest = racemic epinephrine.
- Hand-foot-mouth (coxsackie): vesicles on hands, feet, mouth. Supportive only.
- Roseola (HHV-6): high fever 3–5 days, then rash appears as fever resolves.
- Fifth disease (parvovirus B19): slapped-cheek rash, then lacy body rash.
- Pertussis: paroxysmal cough, whoop, post-tussive emesis. Azithromycin. Treat household contacts.
Vital Signs by Age
Memorize approximate ranges:
- Newborn: HR 100–160, RR 30–60
- 1 year: HR 90–140, RR 24–40
- 5 years: HR 70–120, RR 18–30
- 10 years: HR 60–110, RR 16–25
- Adolescent: HR 60–100, RR 12–20
BP norms: roughly 90 + (2 × age in years) systolic.
The Strategy
For every pediatric question, get the age and the chief complaint first. Build your differential from there. The exam rewards systematic. Drill these three workups and pediatric questions become some of your most reliable points.