COMMON INFECTIONS OF CHILDHOOD

Jen Avegno, MDLSU – New Orleans Emergency Medicine

rule #1: kids get sick.

2006 National Hospital Ambulatory Medical Care Survey showed: most common ED diagnosis for

kids <1 = upper respiratory infection kids 2-12 = otitis media/ear disorders

In all, fever is the most common chief complaint of kids presenting to the ED (about 20-30% all peds visits)

rule #2. most kids don’t get THAT sick.

this lecture is about

NOT

objectives

Review pediatric fever guidelines Discuss some common infections in childhood See LOTS of pictures of cute kids!

case # 1

Mom brings in a 3-week-old baby girl with a fever for 4 hours. The child was a normal vaginal delivery with no complications and has been feeding and growing well at home. This morning, she began to “spit up” her bottle and had several loose stools. She has been somewhat sleepy but does respond to her parents. Physical exam reveals a child in no distress with a rectal temperature of 100.8 and a normal exam for age.

fever < 3 mo

the dreaded neonatal fever

what is the risk of serious bacterial illness (SBI) in kids less than 3 months with fever? SBI = UTI, bacteremia, meningitis, osteo, pneumonia,

gastroenteritis, cellulitis, septic arthritis risk is about 6-10% in these kids, with those younger than

1 month having the highest chance of SBI kids under 3 months may present looking like “viral

syndrome” but still have SBI … in one study, kids less than 60 days with temp>38: 22% had RSV 7% with RSV also had concomitant SBI

why do neonates get fever?

immature immune system exposure to pathogens during delivery (esp. GBS) cannot mount immune response to prevent

localized infection from disseminating

what does temperature really mean? what IS a fever?

fever = “a pyrogen-mediated rise in body temperature above normal range”

what is a NORMAL temp? the magical 98.6 was set as “normal” by a German guy in

the 19th century using a 22cm long mercury glass thermometer … we now think that his instruments may have been OFF by 1.5-2 degrees!!

normal temps can vary by age in kids from 99.5 (neonates) to 98 (older kids)

temps are influenced by age, sex, race, time of day, activity level, ambient temp, site of measurement, type of device

what constitutes a fever?

NO REAL EVIDENCE to support the hard-and-fast cutoff of 100.4 (38°C) – evidence suggests that oral temps 37.2-37.8 may be considered febrile depending on situation

BEST SITE to measure temperature … the hypothalamic artery. (yeah, right)

take-home point: fever is an ARBITRARY number – base your workup on overall clinical impression, not a particular cutoff

what about people without thermometers?

oh, yeah, the “mom hands” … don’t blow them off! 60% of parents use their hands instead of a thermometer

to assess fever is this method accurate? studies show:

74-90% sensitive 76-86% specific 85-94% NPV

the exact number or method doesn’t matter … BELIEVING the parents is!

common infectious pathogens in the neonate

AGE BACTERIAL VIRAL OTHER

0-28 days Group B StrepListeriaE. ColiC. trachomatisN. gonorrhoeae

Herpes simplexVaricellaEnterovirusRSVFlu

Bundlingenvironment

1-3 months H. fluS. pneumoN. meningiditisE. coli

VaricellaEnterovirusRSVflu

Bundlingenvironment

history

length of illness localized symptoms? pertinent PMH, birth hx of both mom & baby sick contacts vaccination status any meds/ABx

physical exam findings

VITAL SIGNS (yes, ALL of them!!) ABCs – respiratory/airway distress? signs of shock?

tachycardia? for infants less than 1 year, HR should increase 10 beats

for every 1°C TAKE THOSE CLOTHES OFF!! just remember … in non-immunocompetent kids

(neonates) … fever may be the ONLY presenting sign of SBI – do not be reassured by a “normal” exam!!

management of neonatal fever

standard management

again, ABCs … consider intubation for respiratory distress, hypoxia, altered MS

fluid resuscitation: 20 ml/kg IV/IO fluids to total of 60-100 ml/kg (if hypovolemia persists)

cultures prior to Abx, if possible sterilization of CSF can occur as quickly as 15 min – 2 hrs

after receiving Abx, so watch results! BROAD SPECTRUM TREATMENT:

Ampicillin + (Gentamycin or Cefotaxime) – avoid Rocephin in kids <28 days

Vanc? Acyclovir?

major guidelines for fever < 90 days

PHILADELPHIA ROCHESTER BOSTON

AGE 29-60 d <60 d 28-89 d

TEMP >38.1 >37.9 >37.9

EXAM well, no focus well, no focus well, no focus

LAB VALUES (low-risk)

WBC <15Band<0.2UA < 10 wbcCSF < 8 wbcneg CXR

WBC 5-15band <1500UA <10 wbc

WBC <20

UA <10 wbcCSF <10 wbcneg CXR

HIGH-RISK dispo admit, IV Abx admit, IV Abx admit, IV Abx

LOW-RISK dispo home, no Abx home, no Abx home, empiric Abx

How good is it??sens/specPPV/NPV

98%/42%14%/99.7%

92%/50%12%/98.9%

NPV 94.6%

** these rules miss very few kids with SBI **

watch out for …

cancer toxic shock autoimmune and/or congenital disorders (cardiac,

pulmonary)

case # 2

Dad comes to the ED with little Maria, age 2, and reports that she has had a fever for the last 2 days (up to 103.4 at home). The parents have tried Tylenol and Motrin to no avail. Maria has not eaten much but is still drinking water and juice. She had a “runny nose” a few days ago, but is not sneezing, coughing, or vomiting. In the ED, Maria has a temperature of 102.8. She looks droopy, but interacts well with her parents.

fever 3-36 months

only slightly less scary … fever between 3-36 months

fever is the most common complaint in this age group!!

unlike neonates, of young children who present with viral illness (RSV, croup, bronchiolitis etc) and fever (>39), less than 0.5% will also be bacteremic

the well-appearing febrile child 3-36 months

concern here is for OCCULT BACTEREMIA before HiB and Prevnar, the rate of occult bacteremia in

the non-focal febrile child was 5% currently … it is less than 1% with other pathogens more

prevalent N. meningiditis urinary pathogens

treating a fever

WHY do we treat a fever? feel better/decrease anxiety lower morbidity/mortality prevent febrile seizures

HOW do we treat a fever? ambient temp control light clothing/bedding fluids sponge bath warm feet/potatoes or onions in socks (REALLY!) antipyretics

how do you give Tylenol & Motrin?

Acetaminophen 15 mg/kg every 4-6 hours Ibuprofen 10 mg/kg every 6 hours alternate??

evidence shows some minor benefits in reducing fever faster and lasting longer BUT …

potential for dosage/scheduling errors; synergistic renal toxicity; difficult to understand and comply

detailed information/handout at appropriate reading level on administration of antipyretics should be given to caregivers!!

common infectious pathogens in the young child

AGE BACTERIAL VIRAL OTHER

3-36 months S. pneumoN. meningiditisE. coli

VaricellaEnterovirusRSVFluMonoRoseolaAdenovirusNorwalkCoxsackie

LeukemiaLumphomaNeuroblastomaWilms’ tumor

history length of illness localized symptoms?

headache – neck pain – sore throat – pulling @ ears – cough (describe!!) – wheeze – vomiting – RASH – mental status

use of antipyretics (**defervesence after use does NOT exclude bacteremia!)

sick contacts po intake/output vaccination status any meds/ABx

physical exam findings

VITAL SIGNS (yes, ALL of them!!)

ABCs – respiratory/airway distress? signs of shock? tachycardia? capillary refill is an easy and

reliable indicator of perfusion TAKE THOSE CLOTHES OFF!!

thorough search for focal findings

algorithm for pediatric fever

notes on the workup

most guidelines argue for getting the WBC first, then CXR if WBC > 20k … but who does this?

study showed that rate of pneumococcal bacteremia increased to 0.5% with WBC 10-15k; 3.5% with WBC 15-20k; 18% with WBC>20k ANC >10k (include all immature forms) increases risk of

bacteremia by 10-fold over those with ANC<10k

management & treatment the post-immunization world has resulted in much

lower rates of bacteremia for this age group: where bacteremia rates in febrile kids >1.5%, the most

cost-effective strategy is a WBC, blood CX, and empiric Abx (Rocephin)

when rates <0.5%, clinical judgment alone for treatment & management is most useful to select out high-risk groups

kids 3-6 mo are still relatively non-immunocompetent … recommendations are for all kids in this age group with temp >39 to have WBC & BCx; treat all WBC > 15k with empiric ABx

watch out for …

CANCER autoimmune disease: JRA, Kawasaki’s brain tumors

case #3

Mom brings in a 15-month old girl who woke up last night screaming and with fever to 101.2. She has not eaten much today but is drinking liquids with normal urine output. All of her immunizations are up to date and she is otherwise healthy. On exam, you note a mildly ill appearing, non-toxic child who responds well to mom. The left TM is red and bulging with loss of landmarks.

otitis media

epidemiology

Most commonly diagnosed disease in kids <15 By age 3 – estimated that more than 80% of kids

have had one episode; 40% have had >3 Risk factors:

Male Smoking Day care Family history Anatomic abnormalities Winter Bottle feeding

definitions ACUTE: s/s of acute infxn WITH effusion

aka “acute suppurative” or “prurulent” OM OME: effusion WITHOUT s/s of acute infxn

aka “serous,” “mucoid,” “secretory,” “nonsuppurative” CHRONIC: chronic ear discharge from perforated

membrane RECURRENT: >3 episodes in 6 mo or >4 episodes

in 1 year

pathophysiology

It’s all about the tube – functions of the eustachian tube: Ventilates middle ear for pressure

equilibration Drains middle ear Protects ear from NP secretions Only open when

yawning/chewing/swallowing

CHILD

When the eustachian tube becomes obstructed …

Middle ear ventilation Negative middle ear cavity pressure causes fluid to move into middle ear (transudate)and combine with NP secretions & bacteria

common pathogens in otitis media

•S. Pneumoniae •H. flu –higher % in OME•M. catarrhalis•S. aureus•S. pyogenes•gram-negative bacteria•VIRUSES:

history

“Pulling at ears” Cough Vomiting & diarrhea Decreased po intake Fever – may be present in only ¼ of cases, with less

than 10% having temp >40 URI sx

a normal TMpars flaccida

umbo

malleus

light reflex

pars tensa

eustachian tube opening

signs/symptoms

What does the TM look like?

normal

bulging

erythematoushemorrhagic

more pictures

Middle ear effusions

other indicators of AOM:

lack of TM mobility *** (MOST RELIABLE SIGN)cloudy, retracted, dull TM

1/3 of cases may NOT have symptoms!

diagnosis

AAP/AAFP guidelines state that the following should be present to dx AOM:

1. Recent, usually abrupt onset of s/s2. Presence of middle ear effusion

(bulging, limited TM mobility, air-fluid level, otorrhea)

3. S/s of middle ear inflammation (erythema or otalgia)

treatment AAP guidelines on management of AOM in

kids: Dx by hx of acute onset + signs of effusion + signs of

middle ear inflammation Assess for pain – if present, treat Limited role for observation in select patients > 2

years (must have “a ready means of communication with clinician”)

If treat with ABx – start with amox 80-90 mg/kg/day

If treatment failure by 48-72 hours – reconsider dx or change ABx

OTITIS MEDIA - treatment

Temp <39.1 or severe otalgia or BOTH

Initial Tx Clinical failure after 48-72 hrs with initial tx

NO Amox 80-90 mg/kg/dayPCN all: cefdinir, cefuroxime, cefpodoxime, azith, clarith

Augmentin 90 mg/kg/day (of amox)PCN all: Rocephin (3 day tx), clinda

YES Augmentin 90 mg/kg/day (of amox)PCN all: Rocephin (1-time or 3 day tx)

Rocephin (3 days)PCN all: clinda + tympanocentesis

treatment Important points:

“treatment failure” = lack of clinical improvement and/or persistent signs of AOM

Bactrim & macrolides often considered 2nd line, but resistance rates approach 30-40%

Courses are generally 10 days in patients < 2 yrs , perf TM, and recurrent OM, recommended in patients <6 years

NO INDICATION for antihistamines, decongestants, steroids, or tubes in single episode AOM

Auralgan may be useful for pain relief Tx of OME (either alone or following episode of OM) is

controversial – ABx? Antihistamines? Tubes for patients with OME for 4-6 months, failed tmt, and

hearing loss

watch out for

otitis externa mastoiditis

case #4

Parents bring an 8 year old boy to the ED with fever of 102.3, and complaints of headache and abdominal pain. He was otherwise healthy until this morning, and his shots are all up to date. The patient is febrile and tachycardic to 120 with normal blood pressure. He is ill-appearing but non-toxic, speaks normally, and is not drooling. His oropharynx is red with bilateral white exudates and tender, palpable cervical lymphadenopathy.

pharyngitis

acute pharyngitis

dx of tonsillitis/acute pharyngitis is made more than 7 million times/year

MCC is viral in kids MCC bacterial pharyngitis is GABHS (15-30%)

kids 5-15 y/o predominantly Group C & G Strep are likely much more common than

typically thought & may be missed by routine testing about 1 in 4 kids with acute sore throat has serologically

confirmed GABHS MC in winter when respiratory viruses predominate

common infectious pathogens

BACTERIAL: Strep

Group A Groups C & G

mixed anaerobic (“Vincent’s angina”) N. gonorrhoeae C. diphtheriae Arcanobacterium haemolyticum; Yersinia; tularemia atypicals

common infectious pathogens

VIRAL: rhino, corona, adeno, paraflu, flu, CMV; HSV 1 & 2 – oral gingivostomatitis Coxsackie – aka herpangina – fever & painful, white-gray

papulovesicular lesions/ulcers in posterior OP EBV - **mono**

severe pharyngitis with GENERALIZED LAD (posterior cervical), hepatosplenomegaly, periorbital edema, palatal petechiae

Amoxil rash!! HIV** may be most common presenting sx!

weird looking throats

herpanginaHSV stomatitis

Vincent’s angina

diphtheria

history & physical

sick contacts – common in both bacterial & viral causes

how to differentiate viral vs. bacterial sore throat?BACTERIAL (GABHS) VIRAL

Sudden onset More gradual

+ fever +/- fever

headache conjunctivitis

N/V/abd pain diarrhea

Tender anterior LAD Cough, hoarseness, coryza

Patchy discrete exudates myalgias

Scarlatiniform rash

the Centor criteria

single throat swab & culture is 90-95% sensitive; rapid kits are 90-99%

Modified Centor criteria for dx of GABHS in kids: tonsillar exudates tender anterior cervical LAD or lymphadenitis absence of cough hx of fever age < 15 add 1 point

SCORE RISK OF GABHS

MGT

0 1-2.5% No testing or Abx

1 5-10%

2 11-17% Culture; Abx for + results

3 28-35%

4-5 51-53% Tx without test

management & treatment

most common viral causes are self-limited and resolve with supportive tx

GABHS is generally self-limited and resolves without tx … but … why do we treat with Abx? symptom relief; decrease spread; shorten duration of

illness (16 hrs) prevent complications (1 in 1000)

suppurative – bacteremia, endocarditis, mastoiditis, meningitis, OM, PTA, RPA, pneumonia

nonsuppurative – PSGN, RF

treatment

Abx options: Pen V K po or Pen G IM Amox PCN allergy – Keflex, Azithromycin (resistance rates near

10% thanks to us!) supportive measures – antipyretics, warm salt

water gargles, cool soothing fluids, etc.

watch out for

mono retropharyngeal abscess peritonsillar abscess (older adolescents) epiglottitis (more common in adults now) scarlet fever – caused by pyrogenic exotoxin-

producing form of GABHS in non-immune individuals outbreaks are cyclical rash 24-48 hours after onset of symptoms (may be longer)

summary

kids will be kids and get SICK fortunately, most of the time they are not TOO SICK

(let us all say a prayer of thanks to the guy(s) who invented vaccines)

when you hear hoofbeats … it’s OK to consider a zebra, as long as the herd of horses doesn’t trample you while you’re thinking …

THANK YOU!