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

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

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 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

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 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 **

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? 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

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. pneumo N. meningiditis E. coli Varicella Enterovirus RSV Flu Mono Roseola Adenovirus Norwalk Coxsackie Leukemia Lumphoma Neuroblastoma Wilms’ 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 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?

conjunctivitis

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

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)

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

what type?

what type?

what type?

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%

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

“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!

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

case #4 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 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

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 TM pars flaccida malleus pars tensa umbo eustachian tube opening light reflex

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

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: 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)

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/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

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 #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.

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 herpangina HSV stomatitis diphtheria 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 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)

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.

rsv & croup: common respiratory diseases

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

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

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

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)

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

management - croup Westley croup score SIGN/SX 1 2 3 4 5 Retractions 1 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

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

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

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!