jen avegno, md lsu – new orleans emergency medicine
TRANSCRIPT
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COMMON INFECTIONS OF CHILDHOOD
Jen Avegno, MDLSU – New Orleans Emergency Medicine
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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)
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rule #2. most kids don’t get THAT sick.
this lecture is about
NOT
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objectives
Review pediatric fever guidelines Discuss some common infections in childhood See LOTS of pictures of cute kids!
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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.
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fever < 3 mo
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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
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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
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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
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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
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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!
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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
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history
length of illness localized symptoms? pertinent PMH, birth hx of both mom & baby sick contacts vaccination status any meds/ABx
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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!!
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management of neonatal fever
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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?
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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 **
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watch out for …
cancer toxic shock autoimmune and/or congenital disorders (cardiac,
pulmonary)
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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.
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fever 3-36 months
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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
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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
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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
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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!!
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common infectious pathogens in the young child
AGE BACTERIAL VIRAL OTHER
3-36 months S. pneumoN. meningiditisE. coli
VaricellaEnterovirusRSVFluMonoRoseolaAdenovirusNorwalkCoxsackie
LeukemiaLumphomaNeuroblastomaWilms’ tumor
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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
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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
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algorithm for pediatric fever
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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
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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
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watch out for …
CANCER autoimmune disease: JRA, Kawasaki’s brain tumors
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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.
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otitis media
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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
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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
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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
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common pathogens in otitis media
•S. Pneumoniae •H. flu –higher % in OME•M. catarrhalis•S. aureus•S. pyogenes•gram-negative bacteria•VIRUSES:
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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
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a normal TMpars flaccida
umbo
malleus
light reflex
pars tensa
eustachian tube opening
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signs/symptoms
What does the TM look like?
normal
bulging
erythematoushemorrhagic
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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!
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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)
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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
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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
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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
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watch out for
otitis externa mastoiditis
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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.
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pharyngitis
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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
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common infectious pathogens
BACTERIAL: Strep
Group A Groups C & G
mixed anaerobic (“Vincent’s angina”) N. gonorrhoeae C. diphtheriae Arcanobacterium haemolyticum; Yersinia; tularemia atypicals
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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!
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weird looking throats
herpanginaHSV stomatitis
Vincent’s angina
diphtheria
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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
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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
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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
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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.
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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)
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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 …
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THANK YOU!