Minor Case Study: Pediatrics

Strep Induced Sepsis

Emily BrantleyAndrews UniversityDietetic Intern

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IntroductionMT is a 16 year old black male who is 170.18 centimeters tall and weighs 67 kilograms.

He was admitted to The Florida Hospital for Children with fever, sepsis and toxic shock related

to strep throat. I chose to conduct a case study on this patient because this is the first occasion

that I have ever personally witnessed sepsis beyond a textbook or educational setting. What

was especially appealing to me in this circumstance was the fact that such a severe condition

presented itself in a previously healthy adolescent. This case study began on February 4, 2014

and ended four visits later on February 7, 2014. The focus of this study is sepsis since it is the

first major health trauma MT has ever experienced.

Social HistoryMT lives at home with his mother, father, sister and grandparents. He is in the 10th

grade at Wekiva High School where he participates in basketball. Currently, he is covered by his

parents Aetna health insurance. MT and his immediate family is Baptist. During his stay, MT’s

immediate and extended family showed their support by being present daily during his

recovery process and hospitalization.

Normal Anatomy and Physiology of Applicable body functionsStrep throat is an infection that inhabits the throat and tonsils. It is caused by the

streptococcus bacteria. There are many different strains of streptococcus that are identified in

different groupings. Group A streptococcus is the strain that is most often associated with the

infection that causes strep throat because this particular streptococcal bacteria can live in a

person’s nose and throat. Group A strep infections can range from minor superficial skin

infections and strep throat to serious and life-threatening illnesses such as toxic shock

syndrome. These severe cases may occur when the bacteria get into parts of the body where

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bacteria usually are not found, such as the blood. The presence of bacteria in the bloodstream

is known as bacteremia. Bacteremia can spread infection to other organs and even cause

symptoms such as fever, rapid heart rate and low blood pressure that may lead to sepsis. 1&2

Sepsis has traditionally been defined as an uncontrolled inflammatory response to

infection or trauma. Today, it is understood that sepsis is a systemic inflammatory response and

immunosuppressive process that prevents a sufficient response to infection or to trauma. There

is hyper-metabolic catabolism of the metabolic stress response. In more straightforward terms,

sepsis is defined as a condition in which the body has a severe reaction to bacteria or other

germs. The unpredictability of this systemic response relates in part to the health status and

age of the patient.1&2

There are many physiologic and metabolic changes that arise from sepsis. These

changes are complex and they encompass most of the body’s metabolic pathways. The earliest

principal signs of sepsis include the following:

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White blood cell count (>12,000 mm3)

Increased heart rate (>90 beats/minute)

Respirations (>20 breaths/minute)

Fever (>38 °C) or hypothermia (<36 °C).

Sepsis is associated with an increase in inflammatory proteins that decrease iron

reutilization, erythropoiesis, and hematological function. Fever and sepsis are common

causes of respiratory alkalosis. Sepsis can increase C-reactive protein, fibrinogen,

complement proteins, and other acute-phase proteins. Suggestive laboratory values can

include elevated serum lactate and serum glucose. Sepsis has been shown to create

hyperglycemia, even in patients with no previous history of diabetes mellitus.

Additionally, creatinine excretion is increased by sepsis.1&3

Past Medical HistoryMT’s hospital records indicate that he was a previously healthy teenager. There was no

record to indicate that MT had any significant past medical history. This episode of sepsis has

led to MT’s first serious hospital stay.

Present Medical Status and Treatment Theoretical discussion of the disease

Sepsis is initiated by an originating source of infection and/or trauma. As previously

mentioned, sepsis is initially a serious inflammatory response. As sepsis progresses, a shift from

an inflammatory response to an anti-inflammatory response follows resulting in an inability to

support an immune response. This eventually leads to organ dysfunction and hypo-perfusion,

or decreased blood flow through an organ. In sepsis, there is an increased rate of

gluconeogenesis that results in significant catabolism, or breakdown of skeletal muscle mass.

These metabolic irregularities result in hyperglycemia and increased serum lactate.1

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Even with tremendous advances in understanding the pathophysiology of sepsis, the

morbidity and mortality accredited to sepsis remains exceptionally high. “Increasing evidence

has linked the administration of maternal intra-partum antibiotics with the emergence of

resistant bacterial strains.”4 It is apparent that while a great deal is now understood about the

biological and molecular actions involved in sepsis, this understanding has yet to be translated

into innovative new strategies. Sepsis is now classified as one of the leading causes of death in

children with an estimated 4,400 deaths that occur annually in the United States alone.5 On the

other hand, there are more than 10 million cases of mild Group A Strep infections, such as skin

and throat infections, are diagnosed each year according to the National Institute of Allergy and

Infectious Diseases (NIAID).6

Specifically, pediatric sepsis accounts for an estimated annual health care cost of $2

billion in the United States.5 There are between 9,000 and 10,000 cases of more serious

streptococcal infections, including toxic shock syndrome and necrotizing fasciitis that occur

annually. People with immune systems weakened by diseases such as diabetes or cancer, are at

a greater risk for developing serious Group A Strep infections.6

Usual Treatment of the condition

Evidence-based medical treatment protocols have been established to address the

immediate management of sepsis. Primary treatment focuses on originally treating the source

of the infection. In a seminal study of over 1100 patients, the prearrangement of appropriate

anti-microbial coverage at least one day prior to identification of the organism was associated

with improved survival. 5

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Supporting the patient with ventilation, antibiotics, and metabolic support is also

imperative. In the first hours following clinical presentation of sepsis, the goal is to maintain

oxygenation and ventilation and achieve normal balance. In the occurrence of metabolic

acidosis related to septic shock, the work of breathing accompanying the compensatory

respiratory alkalosis can be substantial. Metabolic acidosis along with fever can contribute to a

significant portion of oxygen consumption. Early intubation and positive pressure mechanical

ventilation is considered because myocardial dysfunction – which is often present in children

with sepsis – can be enhanced by the implementation of positive pressure ventilation. In

addition to oxygen, antibiotics and large amounts of fluids are given through a vein as

treatment. 1&5

Patient’s Symptoms upon Admission Leading to Present Diagnosis

According to MT’s mother, MT had symptoms of sore throat and fever for 24- 48 hours.

She took MT to urgent care where he was treated for strep with oral penicillin. Afterward, MT

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continued to do poorly with physical declination. His oral intake remained low and MT’s fevers

did not diminish.

MT was admitted through the Emergency department with a sore throat, fever,

headache, fatigue and poor oral intake. In the Emergency department, MT had a central line

placed because he was found to have severe metabolic acidosis with lactic acidosis and

hypotension. MT was diagnosed with septic shock and transferred to the Pediatric ICU for

further monitoring.

Laboratory Findings and Interpretation

The Laboratory findings for MT from February 4th – February 7th were as follows:

Lab ValuesLab Normal Ranges Visit 1

2/4/14Visit 22/5/14

Visit 32/6/14

Visit 42/7/14

Sodium 135 to 145 milliequivalents per liter (mEq/L) 136 134 140 139Potassium 3.7 to 5.2 mEq/L 3.9 3.9 3 3.1BUN 7 to 20 mg/dL 26 23 17 18Creatinine 0.6 to 1.1 mg/dL for women 1.28 1.27 0.95 0.81Blood Glucose

70 to 100 milligrams per deciliter (mg/dL) 148 116 130 148

Albumin 3.5 to 5.4 grams per deciliter (g/dL) 1.8 1.5 2.0 2.6Temperature 96.8 to 98.6 degrees Fahrenheit (˚F) 101.9˚ 100.9˚ 99.8˚ 99.9˚

Medications

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Below is a table that explains the uses and purpose of MT’s medications along with their

food/drug interactions and side effects.

Drug Name Uses Food/Drug Interactions

Side Effects

Rocephin (Ceftriaxone)

Intravenous fluid in the cephalosporin antibiotic class of medications used to treat certain infections caused by bacteria.

Continue normal diet

Pain, tenderness, hardness, or warmth in the place where ceftriaxone was injected, headache, dizziness, sweating, flushing, diarrhea, rash, bloody, watery stools, fever, stomach cramps, bloating, nausea and vomiting, heartburn, chest pain

Clindamycin Used to treat certain types of bacterial infections, including infections of the lungs, skin, blood, and internal organs. It works by slowing or stopping the growth of bacteria. Clindamycin is in the class of medications called lincomycin antibiotics.

Continue normal diet

Nausea, vomiting, joint pain, pain when swallowing, heartburn, white patches in the mouth, blisters, rash, hives, difficulty breathing or swallowing, yellowing of the skin or eyes, decreased urination

Pepcid (Famotidine)

Used to treat ulcers, gastro-esophageal reflux disease and conditions where the stomach produces too much acid. Famotidine is in a class of medications called H2 blockers that works by decreasing the amount of acid made in the stomach.

Continue normal diet

Headache, dizziness, constipation, diarrhea, hives, skin rash, itching, swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles, or lower legs, hoarseness, difficulty breathing or swallowing

Heparin Flush Used to prevent blood clots from forming in certain medical conditions or certain medical procedures that increase the chance that clots will form; used to stop the growth of clots that have already formed in the blood vessels, but it cannot be used to decrease the size of clots that have already formed; used in small amounts to prevent blood clots from forming in catheters that are left in veins over a period of time. Heparin is in a class of medications called anticoagulants. It works by

Continue normal diet

Redness, pain, bruising, or sores at the spot where heparin was injected; hair loss, coughing up blood, vomit that is bloody or looks like coffee grounds, stool that contains bright red blood or is black and tarry, blood in urine, excessive tiredness, discomfort in the arms, shoulder, jaw, neck, or back; excessive sweating, sudden severe headache, lightheadedness or fainting, sudden loss of balance or coordination, sudden numbness or weakness of the face, arm or leg, , sudden confusion, or difficulty speaking or understanding speech; difficulty

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decreasing the clotting ability of the blood.

seeing in one or both eyes, itching and burning, especially on the bottoms of the feet; chills, fever, hives, rash, wheezing, shortness of breath, difficulty swallowing

Zofran (Ondansetron)

Used to prevent nausea and vomiting caused by chemotherapy and/or surgery. It is in a class of medications called serotonin 5-HT3 receptor antagonists. It works by blocking the action of serotonin, a natural substance that may cause nausea and vomiting.

Continue normal diet

Headache, constipation, diarrhea, drowsiness, feeling cold or chills, pain, burning, numbness, or tingling in the hand or feet, fever, pain, redness, swelling, warmth, or burning in the place of injection, rash, hives, itching, swelling of the eyes, face, lips, tongue, throat, hands, feet, ankles, or lower legs, hoarseness, difficulty breathing or swallowing, shortness of breath, blurred vision or vision loss, fast, slow or irregular heartbeat, lightheadedness, fainting

Vancomycin Used to treat colitis that may occur after antibiotic treatment. Vancomycin is in a class of medications called glycopeptide antibiotics. It works by killing bacteria in the intestines. It will not kill bacteria or treat infections in any other part of the body when taken by mouth.

Continue normal diet

upset stomach, hives, skin rash, itching, difficulty breathing or swallowing, redness of the skin above the waist, pain and muscle tightness of the chest and back, unusual bleeding or bruising, fainting, dizziness, blurred vision, ringing in the ears

Continuous Infusions:D5 - 0.45 NaCl (dextrose and sodium chloride)

Intravenously used to provide a source of hydration, carbohydrate and electrolytes, indicated for parenteral replenishment of fluid, carbohydrate calories, and sodium chloride. Contains carbohydrate in the form of dextrose which restores blood glucose levels and provides calories. Carbohydrate in the form of dextrose may aid in minimizing liver glycogen depletion and exerts a protein-sparing action.

Continue normal diet

Fever, infection at the site of injection, venous thrombosis or phlebitis extending from the site of injection, extravasation and hypervolemia.

Norepinephrine + D5W

Composed of alpha- adrenergic receptors (which increase systemic blood pressure by

Continue Normal Diet

Arrhythmias, bradycardia, peripheral ischemia, anxiety, headache, dyspnea, respiratory difficulty

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inducing arteriolar vasoconstriction) and beta- adrenergic receptors (which stimulate heart rate, myocardial contractility and coronary blood flow. Used for restoration of BP in controlling certain acute hypotensive states.

Milrinone Used for the short-term treatment of acute decompensated heart failure. In the inotropes class of medication, milrinone helps the heart contract, which allows the heart to pump blood more effectively. Milrinone also widens blood vessels. This makes it easier for the heart to move blood through arteries.

Avoid alcohol consumption.

Angina, hypotension, supraventricular arrhythmia, headache, anaphylaxis, atrial fibrillation, bronchospasm, hypokalemia, injection site reaction, liver function abnormalities, MI, rash, thrombocytopenia, torsade de pointes, tremor, ventricular fibrillation.

Dopamine Important neurotransmitter that regulates function in brain heart kidneys and gut. An immediate precursor of norepinephrine and epinephrine. Used to treat shock or symptomatic hypotension by increasing myocardial contractility and peripheral dilation. Restores and preserves blood flow to organs.

Continue Normal diet.

Aberrant conduction, anginal pain, atrial fibrillation, bradycardia, ectopic beats, hyper-/hypotension, palpitation, tachycardia, vasoconstriction, ventricular arrhythmia, anxiety, headache, nausea, vomiting, polyuria, dyspnea

Furosemide Used to reduce the swelling and fluid retention caused by various medical problems. It is also used to treat high blood pressure. It causes the kidneys to get rid of unneeded water and salt from the body into the urine.

Doctor may advise to include foods rich in potassium, magnesium, and calcium in diet, or supplement potassium.

Muscle cramps, weakness, dizziness, confusion, thirst, upset stomach, vomiting, blurred vision, headache, restlessness, constipation, sore throat, ringing in the ears, unusual bleeding or bruising, loss of hearing, severe rash with peeling skin, difficulty breathing or swallowing, excessive weight loss

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Observable Physical and Psychological Changes in Patient

During the first nutrition assessment, MT was inappropriate for an interview because he

was intubated. By the second interview, he was “in and out” of consciousness. The third

assessment was the first time MT was alert and able to verbalize how he was feeling. This was

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also the day that the physician gave the orders for MT to receive Ensure oral supplements.

Finally, on the fourth visit, MT was sitting up on his own, alert, eating soft foods and very

motivated to do whatever he could to expedite his recovery.

Treatment

MT was intubated as he underwent a number of tests as treatment for Sepsis. An Echo test

revealed MT’s heart was structurally normal with decreased left ventricular heart function.

Throughout the test, MT experienced tachycardia with varying rhythm as high as 102 beats per

minute. MT’s cardiovascular system showed concern for post-strep myocarditis with moderate

to severe decrease global ventricular systolic function but no pericardial effusion and normal

forward flow into the coronary arteries. His central nervous system was found to be normal

with no evidence of vegetation.

MT went through a procedure where a 22 gage IV was placed into his right radial vein for

the administration of IV medications and fluids. He was immediately started on intravenous

Dextrose in Normal Saline to replenish his fluids while also providing calories and energy. His

antibiotics were also administered intravenously.

When the physician believed it was medically feasible, MT was gradually tapered off of

Norepinephrine. Initially, the rate of which the Norepinephrine was decreased was too much

for MT to handle and his blood pressure began to drop drastically. The Norepinephrine was

raised and when his blood pressure returned to normal, it was decreased again at a slower rate

while his blood pressure was being carefully monitored. MT was extubated by the third

nutrition assessment and his antibiotic treatment continued until his WBC count, CO2 and

Albumin levels were back within normal limits.

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Medical Nutrition Therapy

Nutrition History

MT reported that at home, he does not follow any dietary restrictions. He consumes his

breakfast at school before his classes start. MT purchases lunch at school and brings his

afterschool snack from home to eat before basketball practice 4 times per week. Most dinners

are eaten at home around 6:30 pm and prepared by his mother. MT’s mother is also the main

purchaser of groceries in his household. Before going to bed, MT admits that he eats cookies as

an evening snack.

Analysis of Previous Diet

Below is an example of a typical eating day for MT.

Time Meal Food Item Calories (kcal)

CHO (gm)

Protein (gm)

Fat (gm)

Sodium (mg)

Calcium (mg)

Fiber (gm)

6:30 AM

Breakfast Sausage Biscuit 250 30 11 10.5 342 36 2

2.5 oz Cantaloupe 27 6.5 0 0 11 6 0.74 oz apple juice 60 14 0 0 5 10 08 oz Chocolate Milk 130 24 9 1 98 288 1

11:45 Lunch 1 slice Cheese Pizza on WW 314 31 11 12 506 177 3

1/2 cup Mashed Potatoes 90 16 3 2.5 295 9 2Green Beans 47 7 2 2 36 36 24 oz Applesauce 50 13 0 0 2 5 18 oz Chocolate Milk 130 24 9 1 98 288 1

3:00 PM Snack PBJ sandwich on white

bread 327 42 10 14 483 93 3

2 oz sunflower seeds 178 7 6 15 123 26 3Bottle of water 0 0 0 0 0 0 0

6:30 PM Dinner Baked Chicken Breast

(skin on) 191 0 29 8 385 14 0

1 cup White Rice 188 35 4 4 233 17 11/2 cup Mixed Vegetables 25 5 1 0 45 23 2

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Bottle of water 0 0 0 0 0 0 08:30 PM Snack 4 Chocolate Chips Ahoy

cookies 190 26 2 9 118 10 1

8 oz LF Milk 102 12 8 2 107 305 0

Totals for the day 2299 292.5 105 81 2887 1343 22.7

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Current prescribed diet

Upon admission, MT was intubated and placed on a NPO diet in the Pediatric intensive

care unit (ICU) where he received Dextrose intravenously. Nutritional Services received a

consult for assessment because MT was NPO for more than 5 days. MT remained intubated and

NPO for the first two nutrition assessments. By the third nutrition follow up, MT was no longer

intubated and he was advanced to a clear liquid diet. After several hours of tolerating clear

liquids, such as gelatin, popsicles, broth and juice, MT was evaluated by a team of Health Care

professionals during the Pediatric ICU rounds where the Physician’s Assistant ordered Ensure

for MT via the Dietitian’s caloric recommendation. This meant that in order to meet his

estimated calorie requirements, MT was receiving 2 Ensures, 4 times per day for a total of 8 in

24 hours. By nutrition follow up number four, MT’s diet had been advanced to a mechanically

altered, soft diet.

Objectives of dietary treatment

The major objective of MT’s dietary treatment was to slowly progress him from NPO to

solid foods. This was initiated by first introducing the newly lucid MT to clear liquids. The

treatment objective of dietary improvement then changed from mere toleration to both

toleration and nourishment as the oral supplement Ensure was ordered. The ingredients of

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Ensure and their purpose were explained to both MT and his family. After one day of oral

supplementation without any major complications, MT was then advanced to soft solid foods.

Patient’s Physical and Psychological Response to Diet

When MT was conscious enough to eat, he was started on clear liquids. These items

were the first food items that MT had consumed in days. Once he showed easiness with clear

liquids, Ensure oral supplements were ordered. MT selected vanilla as his flavor of choice with

the Ensure. Because he was receiving them so many times per day, MT quickly grew tired of

having one particular flavor so he tried both strawberry and chocolate before his diet was

advanced beyond liquids. When MT was asked about how he was complying with the Ensures,

he responded, “I am drinking them because I know I need to but I wouldn’t want to live off of

these.” MT expressed his desire to try solid foods again as soon as possible to get back to what

he considered his normal diet. He was advised to take the advancement of his diet slowly.

List nutrition-related problems with supporting evidence

During the four visits, MT’s nutrition related problem remained the same. The nutrition

diagnosis is as follows:

Inadequate Protein Energy related to inability to consume adequate protein and energy as

evidenced by energy intake from diet less than estimated needs and recovering status.

Evaluation of Present Nutritional Status

According to the diet analysis table above, MT was previously meeting his estimated

calorie needs although in some cases, not from the most nutritive of sources. Upon entry to the

hospital, MT’s lab values indicated serious dehydration. MT was admitted to the hospital at

60.6 kg. Once MT was placed on IV fluids, he weighed in at 67 kg. This means that with the

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addition of adequate fluids, MT gained approximately 6 kg (13 pounds) of body weight. 67 kg is

the weight that was used for medication dosages and for caloric requirement estimations.

Kcal/Protein Guidelines

In adolescent males, the estimated energy requirements (EERs) can be used to estimate

caloric requirements. To compensate for the great variation in growth rates for this age group,

EERs are calculated using age, sex, height, weight and physical activity level. 2

Nutritional needs are often substantially increased in sepsis due to the magnitude of the

ailment. Septic patients also have significant drains on their nutrient resources with bacterial

and viral utilization of available nutrients for their own metabolism and reproduction. Daily

energy requirements in metabolic stress may be calculated by using 25-30 calories per kilogram

of body weight. 1&2

During adolescence, protein requirements vary with degree of maturation. Sepsis is a

distressing factor that increases the protein requirements above the DRI to 1.2-2 grams per

kilogram of body weight depending on the degree of illness. Administration of excessive

amounts of protein will not decrease the characteristic net negative nitrogen balance seen in

hyper-metabolic patients.1&2

Below is a chart of how MT’s needs were clinically calculated during his hospital stay from

February 4th through February 7th.

Kcal calculations Protein calculations for adjusted body weight

Fluid requirements

EER for active 16 year old male = 2449 kcal/day

Mifflin REE = 1496 x Activity Factor 1.2-1.6 = 1794-2449 kcal/day

90 gm/day1.5 g/kg admit weight

2400-2420 ml/day or per Physician

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Need for Vitamin/Mineral Supplementation and the Patient’s Nutrition Education Process

During his recovery, MT was prescribed the oral supplement Ensure to provide energy

from carbohydrates, protein, fat, vitamins and minerals. This order was made during his

transition from clear liquids to solid foods. The components of Ensure as well as the function

and importance in the diet progression were clarified to MT and his family. The explanation

was acknowledged by MT and no type of barrier to learning was identified.

General Conditions upon Discharge and Plan for Follow-Up

MT was not cleared for discharge during the time of the case study. The conditions upon

which he would be discharged included consistent acceptance of solid foods. Hopefully, this

was a one-time experience for MT. Unquestionably he will never look at bacterial infections the

same, especially sore throats. Chances are he will be cautious when it comes to protecting

himself from bacteria in the future by giving it a more serious thought.

PrognosisReceiving multiple Ensures daily was a visual, motivating factor that encouraged MT to

succeed in developing his diet. Also, it was explained to MT that if he was unable to meet his

needs by mouth, tube feeding would be the next viable means of sustenance. MT clearly

expressed his dislike for the oral supplement Ensure. Though reluctant, he did consume them

as prescribed while he was in the hospital. Seeing how many of the supplemental beverages

were required to meet his estimated calorie needs put into perspective how closely nutrition

was correlated to his recovery. Once he was advanced to a mechanically altered, soft diet, he

also conveyed his dislike of the soft food options available in the hospital. Again, although

reluctant, he consumed the soft foods little by little so not to have to resort to the alternative

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means of feeding. With the hospital room service, MT was able to call to place a food order of

his personal food selections whenever he felt hungry.

SummaryI have learned so much valuable information from this circumstance. Prior to this case

study, I only knew sepsis to be a serious illness that was to be avoided if at all possible. I had no

idea that something as common as strep throat could evolve into a severe, and in some cases,

life threatening hyper-metabolic response. Unfortunately, sepsis cannot always be avoided.

Infections can take off so quickly, before one suspects, it can happen. Learning about the

severity of sepsis has caused me to give sore throats or any minor bacterial infection a second

thought. I will not hesitate to seek timely treatment and I will encourage others to do so as

well.

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References

1. Nelms M, Sucher KP, Lacey K, Roth SL. Nutrition Therapy and Pathophysiology, 2nd Edition. Cengage Learning, Inc: 2010.

2. Mahan LK, Escott-Stump S, Raymond JL. Krause’s Food, Nutrition and Diet Therapy, 13th Edition, Philadelphia, Pa: Elsevier; 2012

3. Koenig J, Keenan W. Group B Streptococcus and Early-Onset Sepsis in the Era of Maternal Prophylaxis. Pediatric Clinicians of North America Journal 56 (3). 2009. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2702484/ Accessed February 4, 2014.

4. El-wiher N, Cornell T, Shanley T. Management and Treatment Guidelines for Sepsis in Pediatric Patients. Open Inflammatory Journal 4(101-109). 2011. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3484681/ Accessed February 15, 2014.

5. Centers for Disease Control. Group A Streptococcal (GAS) Disease. Available At: http://www.cdc.gov/ncidod/dbmd/diseaseinfo/groupastreptococcal_g.htm Accessed February 21, 2014.

6. MedlinePlus: A service of the U.S. National Library of Medicine From the National Institutes of HealthNational Institutes of Health. Drugs and Supplements. Available at: http://www.nlm.nih.gov/medlineplus/druginformation.html Accessed February 18, 2014.

7. The National Institutes of Health Daily Med. Dextrose and Sodium Chloride injection solution. Available at: http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=6926 Accessed February 21, 2014.

8. Up to Date by Wolters Kluwer Health. Available at: http://www.uptodate.com/home Accessed February 21, 2014.

9. USDA Choose My Plate Super Tracker. Available at: https://www.supertracker.usda.gov/foodtracker.aspx Accessed February 15, 2014.

10. Orange County Public Schools. School Food Menus. Available at: https://www.ocps.net/op/food/pages/nutrition.aspx Accessed February 15, 2014.

Images1. http://www.pathologyatlas.net/news/what-helps-a-sore-throat/ 2. http://www.strepthroatdoctor.org/pictures-of-strep-throat/ 3. https://www.nrc-cnrc.gc.ca/eng/dimensions/issue7/superbug.html 4. http://www.kidsdata.org/blog/?paged=3

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