1. common infections of childhood
Jen Avegno, MD
LSU – New Orleans Emergency Medicine
Resident Conference 2010

2. 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)

3. rule #2. most kids don’t get THAT sick.
this lecture is about
NOT

4. objectives
Review high-yield, commonly encountered, infections of childhood
Discuss pathophysiology, common organisms, presentations, management and treatment of each
See LOTS of pictures of my children

5. 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 and a normal exam for age.

6. fever < 3 mo

7. 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

8. 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

9. 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 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

10. what constitutes a fever?
NO REAL EVIDENCE to support the hard-and-fast cutoff of (38°C) – evidence suggests that oral temps 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

11. 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!

12. common infectious pathogens in the neonate
AGE
BACTERIAL
VIRAL
OTHER
0-28 days
Group B Strep
Listeria
E. Coli
C. trachomatis
N. gonorrhoeae
Herpes simplex
Varicella
Enterovirus
RSV
Flu
Bundling
environment
1-3 months
H. flu
S. pneumo
N. meningiditis
E. coli
flu

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

14. 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!!

15. management of neonatal fever

16. standard management
again, ABCs … consider intubation for respiratory distress, hypoxia, altered MS
fluid resuscitation: 20 ml/kg IV/IO fluids to total of 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?

17. major guidelines for fever < 90 days
PHILADELPHIA
ROCHESTER
BOSTON
AGE
29-60 d
<60 d
28-89 d
TEMP
>38.1
>37.9
EXAM
well, no focus
LAB VALUES (low-risk)
WBC <15
Band<0.2
UA < 10 wbc
CSF < 8 wbc
neg CXR
WBC 5-15
band <1500
UA <10 wbc
WBC <20
CSF <10 wbc
HIGH-RISK dispo
admit, IV Abx
LOW-RISK dispo
home, no Abx
home, empiric Abx
How good is it??
sens/spec
PPV/NPV
98%/42%
14%/99.7%
92%/50%
12%/98.9%
NPV 94.6%
** these rules miss very few kids with SBI **

18. watch out for … cancer toxic shock
autoimmune and/or congenital disorders (cardiac, pulmonary)

19. 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 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 She looks droopy, but interacts well with her parents.

20. fever 3-36 months

21. 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

22. 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

23. treating a fever WHY do we treat a fever? HOW 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

24. 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!!

25. common infectious pathogens in the young child
AGE
BACTERIAL
VIRAL
OTHER
3-36 months
S. pneumo
N. meningiditis
E. coli
Varicella
Enterovirus
RSV
Flu
Mono
Roseola
Adenovirus
Norwalk
Coxsackie
Leukemia
Lumphoma
Neuroblastoma
Wilms’ tumor

26. history length of illness localized symptoms?
headache – neck pain – sore throat – 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

27. 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

28. algorithm for pediatric fever

29. 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

30. 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

31. watch out for … CANCER autoimmune disease: JRA, Kawasaki’s
brain tumors

32. case #3
Mom brings in a 6 year-old boy with “pink eye.” She got a call from school today that the child’s right eye was red and draining yellow gunk, and that she needed to pick him up. The boy is afebrile and non toxic, with no recent illnesses or PMH. Immunizations are up to date. He has mildly injected right conjunctiva with some seropurulent drainage from the eye, as well as mild nasal mucoid rhinorrhea. What now?

33. conjunctivitis

34. not just the dreaded pink eye!
conjunctivitis = “inflammation of bulbar & palpebral conjunctiva caused by various viral, bacterial, mechanical, allergic & toxic agents”
most frequent pediatric eye complaint in the ED

35. common infectious pathogens in the young child
viral: adeno, coxsackie, entero, rhino, flu
**MOST COMMON**
bacterial:
S. pneumo
H. flu
S. aureus
M. catarrhalis
N. gonorrhoeae (yuck)
less common: other Gram negatives (Pseudomonas)

36. history & physical
viral – generally itchy, red, irritated with watery or purulent discharge, preauricular LAN
associated with other URI sc
may start in one eye & spread to other
may last longer than bacterial
bacterial – “pinkeye,” redness, FB sensation, lid swelling, drainage, “eye boogers”
usually no photophobia or vision impairment
allergic – very itchy, usually bilateral

37. what type?

38. what type?

39. what type?

40. how do you tell them apart?
FINDING
BACTERIAL
VIRAL
Bilateral at onset
50-74%
35%
Conjunctival discharge
mucopurulent
watery
Preauricular adenopathy
late
early
Concurrent OM
20-73%
10%

41. management & treatment
viral – artificial tears, cool compresses, antihistamine drops if necessary
bacterial – warm compresses & topical Abx:
sulfa, floxin (ok in kids!), erythromycin, neomycin
ointment vs. drops??
ointment – soothing, prolonged contact with conjunctiva
drops – do not blur vision, ?easier to get in?
tx for 7 days

42. “Doctor, when can they go back to school???? (desperation)”
no established guidelines for ED management/care of conjunctivitis (darn.)
bacterial conjunctivitis – most common standard is return to school 24 hours after beginning Abx treatment
viral conjunctivitis – ??
If you don’t think it’s pinkeye … SAY SO & DOCUMENT for parents!

43. watch out for
ophthalmia neonatorum – conjunctivitis within 1st month of life
within 1st 2 weeks – gram stain & culture of drainage
N. gonorrhoeae – usually from birth canal, within 1st 1-7 days of life – must carefully evaluate for disseminated GC
tx = Rocephin
Chlamydia – usually sx between 5-19 days old
tx = topical Erythromycin
chemical – from ointment given at birth; dx of exclusion
HSV & VZV can affect the eyes and lead to scarring, dry eye

44. case #4
Mom brings in a 15-month old girl who woke up last night screaming and with fever to 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.

45. otitis media

46. 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

47. 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

48. pathophysiology When the eustachian tube becomes obstructed …
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
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
CHILD

49. common pathogens in otitis media
S. Pneumoniae
H. flu –higher % in OME
M. catarrhalis
S. aureus
S. pyogenes
gram-negative bacteria
VIRUSES:

50. 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

51. a normal TM pars flaccida malleus pars tensa umbo
eustachian tube opening
light reflex

52. signs/symptoms What does the TM look like? bulging erythematous
hemorrhagic
normal

53. 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!

54. diagnosis
AAP/AAFP guidelines state that the following should be present to dx AOM:
Recent, usually abrupt onset of s/s
Presence of middle ear effusion
(bulging, limited TM mobility, air-fluid level, otorrhea)
S/s of middle ear inflammation
(erythema or otalgia)

55. 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 mg/kg/day
If treatment failure by hours – reconsider dx or change ABx

56. OTITIS MEDIA - treatment
Temp <39.1 or severe otalgia or BOTH
Initial Tx
Clinical failure after hrs with initial tx NO
Amox mg/kg/day
PCN all: cefdinir, cefuroxime, cefpodoxime, azith, clarith
Augmentin 90 mg/kg/day (of amox)
PCN all: Rocephin (3 day tx), clinda
YES
PCN all: Rocephin (1-time or 3 day tx)
Rocephin (3 days)
PCN all: clinda + tympanocentesis

57. 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

58. watch out for
otitis externa
mastoiditis

59. case #5
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.

60. pharyngitis

61. 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

62. common infectious pathogens
BACTERIAL:
Strep
Group A
Groups C & G
mixed anaerobic (“Vincent’s angina”)
N. gonorrhoeae
C. diphtheriae
Arcanobacterium haemolyticum; Yersinia; tularemia
atypicals

63. 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!

64. weird looking throats herpangina HSV stomatitis diphtheria
Vincent’s angina
diphtheria

65. 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

66. 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
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

67. 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

68. 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.

69. 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 hours after onset of symptoms (may be longer)

70. case #6
Two worried parents rush their 1 year old baby to the ER at 2 am because of “breathing problems” and fever. She was a normal healthy infant until she woke up at midnight with a high fever, breathing fast, and wheezing. There is no prior history of asthma and no sick contacts. The baby is febrile to 101.3, breathing 40 times a minute with some retractions and audible wheezes but has a vigorous cry.

71. rsv & croup: common respiratory diseases

72. rsv worldwide phenomenon, usually winter – spring
transmitted through secretions
may manifest as
bronchiolitis – may result in bronchial obstruction
pneumonia – severe inflammation in alveoli & interstitial tissue – greatest in kids < 1 yr
greatest % of hospitalizations for respiratory reasons in infants (2-5% of those hospitalized will need intubation)
increased risk in preemies, congenital conditions, boys, lower socioeconomics

73. croup most likely (75%) caused by parainfluenza virus
peak incidence 3 mo – 3 years
MCC infectious airway obstruction in kids (subglottic … at narrowest diameter)

74. history & physical - RSV
3-5 day incubation period, followed by:
cough
WHEEZE
prolonged expiratory phase
apnea (up to 20% infants with RSV)
may have RAPID decompensation (kids have less pulmonary reserve)
CXR may be normal, show lobar pneumonia or peribronchial inflammation

75. history & physical - croup
steeple sign
1-4 day incubation period
barking, “seal-like” cough with “whistling” (stridor) on inspiration, sneezing, nausea/vomiting, fever, hoarseness
often worse at night … then gets better when the kid is taken outside to drive to ER …
90% of cases are mild! (whew)

76. management - RSV treatment is largely SUPPORTIVE supplemental oxygen
secretion management
admitted kids – consider ribavirin, NO, heliox
high-risk kids get preventative antibody/immunoglobulin
nebulized B-agonists – short-term improvement in oxygenation, unclear if there is a real benefit (same for racemic epi)
NO significant benefit for steroids

77. management - croup Westley croup score SIGN/SX 1 2 3 4 5 Retractions1 2 3 4 5
Retractions
None
Mild
Moderate
Severe
Stridor
With agitation
At rest
Cyanosis
LOC
Normal
Disoriented
Air entry
Decreased
Markedly decreased
≤2 = mild croup
3-7 = moderate
≥8 = severe croup

78. treatment - croup
about 6% kids with croup are hospitalized, only 1% of these are intubated
moderate – severe croup despite tmt usually means admission
mist inhalers, steam showers
nebulized racemic epi?
short-lived benefit; sx may recur within 2 hours
may give q1 hr – but >1 dose often means admission
steroids
IM or po dexamethasone (0.6 mg/kg) may decrease need for hospitalization and/or return visits

79. watch out for aspirated FBs underlying lung pathology (CF)
other causes of pneumonia/bronchitis

80. 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 …

81. THANK YOU!