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Pediatrics- Well Baby Care 06-01-10- HENNY

** Designed for the care of children who are receiving competent parenting
- Have no manifestations of any important health problems
- And are growing and developing in a satisfactory fashion

Goals of Well Child Care

** To inform and support parents
- To gain the knowledge and skills required to understand and manage the various stages of their child’s
development

** Reassure parents of normal development and growth

- Health surveillance
- Clinical assessment that their child is developing normally
- Ensure any health/developmental concerns and refer appropriately

** Promote positive parenting skills and attachment

** Identify special needs children. Provide or facilitate access to other health or community services where
possible

** Provide a strong foundation for ongoing healthy development (nutrition, exercise)

Well Visit Schedules

1- Pre-natal visit
2- Newborn
3- 2-4 days
4- By 1 month
5- 2months
6- 4 months
7- 6 months
8- 9 months
9- 12 months
10- 15 months
11- 18 months
12- 24 months
13- Yearly until 21

Note: In Jamaica the MOH recommends a minimum of 10 well child visits over the first 2 years of life

Prenatal Visit
** For the prenatal visit the following persons should attend:
- First time parent
- High risk mothers
- Those who request a conference

** The discussion usually involves the following topics including:

- Pertinent medical history
- What to expect at delivery
- Feeding methods and breast-feeding promotion

Newborn Visit
** Full clinical examination including:
- Anthropometry
- Systemic examination

** Hepatitis B vaccine and IG to positive mothers

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** General discussion:
- Development
- Feeding
- Bowel movements
- Skin care
- Safety

** The visit provides an opportunity to discuss parental concerns

** Contact numbers for emergency purposes

Development
** Typical children follow a trajectory of increasing physical size and increasing complexity of function
- The child triples his/her birth weight within the first year

Gross Motor (Large Muscle Groups)

** In the first 2 years children develop their motor skills in a cephalocaudal direction
- Lift their heads with good control at 3 months
- Sit independently at 6 months
- Crawl at 9 months
- Walk at 1 year
- Run by 18 months

Fine Motor
- Follows slow-moving objects
- Looks and responds to faces
- Grasping skills

** The grasp begins as a raking motion involving the ulnar aspect of the hand at age 3-4 months.
- The thumb is added to this motion at age 5 months
- The thumb opposes the fingers for picking up objects by age 7 months
- Neat pincer grasp emerges at about age 9 months
- Children should not have a significant hand preference before 1 year of age and typically develop
handedness between 18 and 30 months

Language
- Cries, makes some response to sound

Social Development
- Recognizes familiar voices
- Calms to high-pitched, soft voice; quiets to gentle touch

Primitive Reflexes
- Root, suck, moro, grasp

Feeding
** Provide advice for breastfeeding

** If the mother is using formula they should use one that is:
- Iron fortified
- Offer as much as your baby will take
- Feed whenever your baby signals
- Do not warm bottles in the microwave oven

** Pacifiers are generally unnecessary. Do not give honey during the baby’s first year
- Do not use recreational drugs or cigarettes
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Bowel Movements
1- Meconium- sticky, tarry black stools
- Are the earliest stools of an infant
- Unlike later feces, Meconium is composed of materials ingested during the time the fetus spends in the
uterus
- Contains intestinal epithelial cells, mucus, amniotic fluid, bile and water
- Meconium is almost sterile unlike later feces
- Viscous and sticky like tar and has no odor
- Should be completely passed by the end of the first few days of post-partum life
- Note: Hirschsprung’s disease presents as a failure to pass Meconium

2- Breast milk stools- are usually yellow, seedy, runny and have a musty odor
- Breastfed babies may have frequent bowel movements
- May have a movement after every feed
3- Formula fed stools- are pastier than those of breastfed babies. Sometimes have firmer or less frequent
stools
- If hard, pebble-like stools or significant pain with stooling or absence of stool in five days contact a
doctor for advice

Skin Care
** Newborn babies’ skin often will peel or flake. This is a natural process and is a part of the newborn’s
adjustment to life in the open air
- No special lotions or oils are needed

** Preventing/Managing Diaper Rash

- Clean thoroughly but gently after each bowel movement
- Use a dabbing motion rather than rubbing
- Clean a girl’s diaper area with motion from front to back
- If using commercial wipes, invert the container between use
- Pat bottom dry and then allow to air dry
- Make sure the diaper area is dry before covering with a barrier cream

** Caring for the Umbilical Cord

- Use a Q-tip moistened with rubbing alcohol at least once daily or whenever soiled

** Clean and bathe the infant daily

Toys and Stimulation

** For babies less than 3 months old, the most stimulating object is the caregiver.
- Baby will stare at patterns of black and white or sharply contrasting colors
- Play music

Discharge
** If discharge is considered before 48 hrs it should be limited to infants who are of singleton birth between 38
and 42 weeks gestation
- These neonates should be of birth weight appropriate for gestational age

1- The antepartum, intrapartum and postpartum courses for mother and infant are uncomplicated

2- Vaginal delivery

3- The infant’s vital signs are documented as being with normal ranges and stable for the last 12 hrs
preceding discharge
- Respiratory rate below 60 breaths/min
- Heart rate of 100-160 beats/min
- Axillary temperature of 36.5 deg C – 37.4 deg C
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4- The infant has urinated and passed at least 1 stool spontaneously

5- The infant has completed at least two successful feedings with documentation that the infant is able to
co-ordinate sucking, swallowing and breathing while feeding

6- Physical examination reveals no abnormalities that require continued hospitalization

7- The clinical significance of jaundice, if present before discharge, has been determined

8- Maternal and infant blood test results are available and have been reviewed, including:
- Maternal syphilis and hepatitis B surface antigen status
- Cord or infant blood-type and direct Coomb’s test results
- Screening tests performed (eg HIV)

** The infant should be scheduled for a follow up visit with a physician if being discharged before 48 hrs. The
purpose of the follow-up visit is to:
- Weight the infant and assess the general health, hydration and degree of jaundice
- Review feeding pattern and technique including observation of breastfeeding
- Assess quality of mother-infant interaction
- Reinforce maternal or family education in infant care
- Review the outstanding results of lab tests performed prior to discharge
- Verify the plan for health care maintenance including well-baby visits, immunizations, etc

By 1- Month Visit
- Ensure that the family is adjusting to the new addition
- Feeding routines established
- Sleeping routine established
- Identify the at risk mother

Gross Motor:
- Developing better head control
- Able to lift head off the bed when lying on stomach

Fine Motor:
- Still has automatic grasp reflex when objects touch his or her hand

Language:
- May be developing different cries for pain, hunger and fatigue

Social:
- Watches and quiets when others speak to infant
- Opens and closes mouth as others speak

Colds
** If a cold develops:
- Elevate the head of the crib
- Run a cool-mist vaporizer
- Use an infant bulb syringe to gently suction mucus from the nose. Normal saline drops also help to
loosen the mucus
- Seek medical attention if the baby has a rectal temperature of 100.4 F (38C) or higher or is coughing
frequently, or refusing to eat

2-Month Visit
** Full clinical examination and developmental milestones
- Immunization
- DPT
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- Polio
- Hib
- Hep
- Rotavirus
- Prevnar- vaccine against pneumoccal bacteria (streptococcus pneumoniae)
- Health promotion (nutrition, sleep, stimulation)

Gross Motor:
- Holds head in midline and lifts chest off the table

Fine Motor
- No longer clenches fist tightly

Speech:
- Coos

Social
- Reaches for familiar people or objects and anticipates feeding

4-Month Visit

Gross Motor:
- Rolls over
- Supports on wrists and shifts weight

Fine motor
- Reaches with arms in unison, brings hands to the midline

Speech:
- Laughs, orients to voice

Social:
- Enjoys looking around

Sleep:
- Wide variation in night sleep patterns
- Some infant sleep 8 or more hours, others 4-6 some wake every 3hrs

Nutrition:
- Breastfed and formula fed infants do not need solid foods until 6 months

** Signs of readiness for solid food include trying to sit up and showing interest in watching others eat

** The first goal of eating solid foods is simply to learn the new skill. The best time to feed the baby solids is
often in the mid-morning
- Start with rice cereal once a day
- One or two tablespoons
- Allow one new food every week
- After cereals, add single fruits and vegetables that have been pureed
- Gradually increase solid food meals to 2-3 times daily over the next few months
- If the baby dislikes the taste of a food the first time it is offered, you can try again later
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6-Month Visit
Gross Motor:
- Sits unsupported
- Puts feet in mouth when lying supine

Fine Motor
- Unilateral reach
- Using raking grasp
- Transfers objects

Speech
- Babbles
- Lateral orientation to bell

Social:
- Recognizes that someone is a stranger

Nutrition
- Begin using a cup for water
- Juice is not necessary. If given limit to no more than 4 oz per day
- Add rice cereal, pureed fruits and vegetables

Sleep:
- Encourage the use of transitional object
- Sleep routine
- Discourage 3 hourly feedings

Toys:
- put in, take out toys
- Noisy toys
- Stacking toys
Teeth
- The first teeth can appear at any time from about 4-12 months
- Baby may become irritable
- Offer your baby something to chew on
- Occasionally teething gels or acetaminophen may be soothing
- Keep the teeth clean by wiping daily with a cloth, gauze or toothbrush

9-Month Visit
Gross Development:
- Pivots when sitting, crawls well, pulls to stand, crusies

Fine Development:
- Uses immature pincer grasp
- Probes with forefinger
- Holds bottle, throws object

Speech
- “Mama” Dada indiscriminately, waves bye-bye, gestures, understands NO

Social
- Starts exploring environment
- Plays gesture games

Note: Wait until your child is 12 months old to introduce whole cow’s milk
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1-Year Visit
** Immunization: MMR and varicella

Gross Motor:
- Walks alone

Fine Motor:
- Uses mature pincer, can make crayon marks

Speech:
- Uses 2 words other than mama/dada, follows one step commands with gestures

Social:
Imitates actions, comes when called, co-operates with dressing

15-Month Visit
** Immunization- Hib booster

Gross Motor-
- Creeps upstairs, walks backwards independently

Fine Motor
- Scribbles in imitation, builds tower of 2 in imitation

Speech
- Uses 4-6 words
- Follows 1 step command without gesture

Social
- Uses cup and spoon

18-Month Visit
** Boosters: DPT and polio

Gross Motor:
- Runs, throws object from standing without falling

Fine Motor
- Scribbles spontaneously, build tower of 3, scribbles spontaneously

Speech
- Two word phrases, understands 2 step commands

Social
- Mimics parents

2-Year Visit
Developmental Milestones
Clinical examination

Toilet Training
** Many children train themselves with little encouragement by 3 years. To become toilet trained children
require the following skills:
i- Motor Skills- stand, sit and walk unaided
ii- Verbal skills- to express needs
iii- Social skills- uncomfortable when messy
iv- Sensory skills- retain a full bladder/rectum
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Teeth
- Before the emergence of teeth, clean the oral cavity with a soft washcloth and water
- No toothpaste under the age of two, the mechanical action of brushing with a soft toothbrush is
sufficient
- Supervise brushing of teeth up to age 8-10
- Use a pea sized amount of toothpaste
- Floss children’s teeth
- 6 monthly visits to dentist
- First dental visit at age 2 years

Adolescent Issues

Home
- Household composition
- Family dynamics and relationships
- Living and sleeping arrangements
- Guns in the home

Education
- School attendance
- School performance
- Goals for the future

Activities
- Friends with same and opposite sex
- Dating
- Recreational activities

Drugs
Sexuality
- Sexual feelings towards same or opposite sex
- Partners, use of contraception, history of STD’s abortions

Suicide/Depression
- Feelings about self
- Suicidal thoughts
- Sleep disturbances

Physical Exam
- Anthropometry
- Dentition/gums
- Skin
- Thyroid
- Spine
- Breasts
- External genitalia
- Pelvic
- Immunization: HPV, Menningococcal
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Immunization- GOODEN 14-11-10

Immunization- is a method of preventing disease by administering vaccines

** There are two wars in which vaccines confer immunity:
i- Active immunization- is the process by which the immune system is stimulated to produce
memory for a particular disease after inoculation with the organism or part of the organism
- EX: Tetanus toxoid, diptheria toxin
- Live attenuated vaccines induce active immunity
- Immunity is usually lifelong with live vaccines
- BUT boosters are required for killed vaccines

ii- Passive immunization- is achieved by direct administration of preformed antibodies or

specific immune globulins
- Given to a patient who is immunocompromised
- Or in the case of post-exposure prophylaxis where there would be insufficient time to build up
natural immunity

Vaccination- is the main method of producing effective immunity for a number of communicable diseases

Vaccine Info:
- Names of vaccines
- Dose and Route of administration
- Storage/cold chain
- Side effects
- Contraindications MINISTRY OF HEALTH - JAMAICA
- Mandatory vaccines (Ministry of Health)
IMMUNIZATION SCHEDULE FOR CHILDREN
- Other vaccines
Vaccines are listed under the routinely recommended ages. Shaded bars indicate range of acceptable ages for vaccination

AGE
VACCINE BIRTH 6 WEEKS 3 MONTHS 6 MONTHS 12 MONTHS 18 MONTHS 4-6 YEARS

BCG
BCG BCG

Polio
OPV / IPV OPV / IPV OPV / IPV OPV / IPV OPV / IPV OPV /IPV

Diphtheria
Pertussis, DPT / DT DPT / DT
Tetanus (DPT)
Or Diphtheria
Tetanus (DT)

DPT/HepB/Hib DPT/HepB/Hib DPT/HepB/Hib DPT/HepB/Hib

Measles
Mumps
Rubella MMR MMR
(MMR)

Sponsored by PAHO/WHO
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Immunization Goals- Jamaica

- Vaccination of all children 0-11 months with BCG, DPT/HBV/HIB, MMR, Polio
- Full immunization of all children less than 7 years before school entry (Public Health Law)
- Immunization of antenatal clients to prevent neonatal tetanus

Immunization Schedule- Jamaica

Vaccine Age
BCG At birth
DPT/Hib/HBV & OPV 6 weeks, 3 months, 6 months
DPT & OPV 18 months and 3-6 years
MMR 12 months, 18 months and females of reproductive
age
DT Pregnancy

BCG
** Bacille Calmette-Guerin vaccine (BCG) consists of live attenuated Mycobacterium bovis
- Given to prevent tuberculosis

Dose: 0.05 mL intradermally in right deltoid area

Storage Temp- 2.8 deg C
Age: from birth to 6 weeks

** Sensitizes the vaccinated individual for 5-50 years

- Stimulates both B and T-cell immune responses

Side Effects:
- Fever and swelling at the injection site
- Local ulceration/abscesses and regional lymph node enlargement
- Lupus vulgaris- are painful cutaneous tuberculosis skin lesions with nodular appearance
- Most often on the face around nose, eyelids, lips, cheeks and ears
- BCG adenitis- is the inflammation of local lymph nodes

Contraindications:
- Pregnant women
- Immunocompromised individuals- because it has caused disseminated or fatal infections

** BCG reduces the risk of tuberculous meningitis and disseminated TB in pediatric populations by 50-100%
- When given in the first month of life

DPT
DPT= Diptheria, whole cell pertussis, tetanus
DTaP- Diptheria, tetanus, acellular pertussis
- Killed vaccine
- Storage at 2-8 deg C

Dose- 0.5 mL intramuscular

Site:
- < 2 years = anterolateral thigh
- > 2 years = deltoid

** Given at 2, 4 and 6 months

- Booster at 18 months and 4 years

** Children > 7years use dT vaccine

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Contraindications:
- Previous anaphylaxis to this vaccine or any of its components
- Guillain Barre Syndrome within 6 weeks of previous dose
- Unstable or evolving neurological condition is contraindicated for the pertussis component

Side Effects:
- Fever, redness and swelling at the injection site
- Fever > 40 deg C
- Persistent inconsolable crying lasting more than 3 hours
- Hypotensive, hyporesponsive episode
- Seizures
- Side effects can occur within 48 hrs of vaccinations

Pertussis
** Bordatella pertussis is a highly communicable pathogen that causes whooping cough.
- After incubation period of about 2 weeks, the catarrhal stage develops with mild coughing and
sneezing
- During the paroxysmal stage the cough develops its explosive character and the characteristic whoop
on inhalation
- This leads to rapid exhaustion and may be associated with vomiting, cyanosis and convulsions
- Major complications occur mostly in infants
- Every infant should receive 3 injections of pertussis vaccine during the first year of life followed by a
booster series for a total of 5 doses
- Note: Prophylactic administration of erythromycin for 5 days may also benefit unimmunized infants
or heavily exposed adults

** Pertussis causes seizures, pneumonia, encephalopathy and death

- Increasing cases in adolescents and adults with mild disease with transmission to newborns and infants
with serious illness
- DPT vaccine used in Jamaica
- DTaP vaccine is used in USA and other developed countries

** Adverse effects of the DTP include:

- Local and febrile reactions
- Anaphylaxis 2/100,000
- Seizures within 48 hrs
- Collapse/shock like state
- Fever >40.5 deg C
- Prolonged crying

** The DTaP (acellular vaccine) has an improved safety profile with decreased risk of side effects
- Crying, high fever, seizure <1%
- Shock, seizure, coma <0.003%

** Contraindications to DTP or DTaP include:

- Immediate anaphylactic reaction
- Encephalopathy within 7 days
- Individuals with progressive neurologic disorders until their neurologic status is clarified and stabilized
- EX: infantile spasms, uncontrolled epilepsy, progressive encephalopathy

** Precautions to DTaP vaccination include:

- High fever (>40.5 degC)
- Persistent inconsolable crying
- Seizures within 3 days of a previous dose
- Guillain Barre Syndrome less than 6 weeks after a previous tetanus like vaccine
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Diptheria
** Diptheria is an acute infection of the upper respiratory tract or skin caused by toxin-producing
Corynebacterium diptheriae
- Corynebacteria are gram-positive bacilli
- Diptheria toxin kills susceptible cells by irreversible inhibition of protein synthesis

** The toxin is absorbed into the mucus membranes and causes destruction of epithelium and a superficial
inflammatory response
- The necrotic epithelium becomes embedded in exuding fibrin and red and white blood cells
- This forms a grayish pseudomembrane over the tonsils, pharynx or larynx
- Any attempt to remove the membrane exposes and tears the capillaries resulting in bleeding
- The diptheria bacilli within the membrane continue to produce toxin, which is absorbed and may result
in toxic injury to heart muscle, liver, kidneys and adrenals
- The toxin also produces neuritis resulting in paralysis of the soft palate, eye muscles or extremities

Note: Death may occur as a result of respiratory obstruction or toxemia and circulatory collapse

** Diptheria can affect the immunized, partially immunized and un-immunized persons
- Waning immunity in adolescents and adults

Polio
** Poliovirus infection is subclinical in 90-95% of cases. It causes non-specific febrile illness in about 5% of
cases and aseptic meningitis
- Paralytic disease 1-3%
- 1992 was the last indigenous case from CAREC member country
- Epidemic polio in Hispaniola
- Mutation from polio Type I virus in Sabin OPV
- Mutation through serial passage of vaccine-virus in non-immunized persons
- Happened before in Egypt and China

** The initial symptoms are fever, myalgia, sore throat and headache for 2-6 days
- Mild cases resolve completely
- In only 1-2% of these children does high fever, severe myalgia and anxiety portend progression to loss
of reflexes and subsequent flaccid paralysis
- Sensation remains intact
- However hyperaesthesia of the skin overlying paralyzed muscles is common and pathogonomic
- Paralysis is usually asymmetrical
- Proximal limb muscles are more often involved than distal
- Bulbar involvement affects swallowing, speech and cardio respiratory function
- Bladder distention and marked constipation usually accompanies lower limb paralysis

Note: Aseptic meningitis due to poliovirus is indistinguishable from that due to other viruses
- Paralytic disease in the USA is usually due to non-polio enteroviruses
- Polio may resemble Guillain-Barre syndrome, polyneuritis, tick paralysis

Treatment: Supportive
- Bed rest, fever and pain control
- No intramuscular injections should be given in the acute phase

** In the USA there has been no wild-type polio for more than 20 years
- 1 in 2.4 million risk of vaccine associated polio with the use of OPV
- BUT the OPV is more effective in developing herd immunity than the IPV

OPV- live attenuated vaccine

Dose- 2 drops
Storage- in freezer at <) deg C
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IPV- inactivated polio vaccine (killed virus)

- Store at 2-8 deg C
- Dose- 0.5 mL IM

Schedule: 2, 4, 6 months with a booster at 18 months and 4 years

Contraindications:
- Previous anaphylaxis to this vaccine or its components
- OPV should not be given to those who are immunosuppressed

Side Effects:
- Fever, redness and swelling at injection site
- Loose stools
- Vaccine associated polio- rarely with OPV only

Adverse Effects: Allergic reaction

MMR
** Live attenuated vaccine stored at 2-8 deg C
Dose- 0.5 mL subcutaneous in the anterolateral thigh

Contraindications:
- Previous anaphylaxis to this vaccine or to neomycin, which is one of its components
- Severe immunodeficiency
- Precaution if there is egg allergy

Side Effects:
- Develop 7-12 days after immunization
- Fever, redness and swelling at the site
- Transient rash
- Encephalitis (rarely)
- Transient thrombocytopenia

Measles
** The attack rate in susceptible individuals is extremely high. Spread is via respiratory droplets
- High fever and lethargy
- Sneezing, eyelid edema, tearing, cough, photophobia, coryza (acute rhinitis)
- Koplik spots are white, macular lesions on the buccal mucosa usually opposite the lower molars
- Discrete maculopapular rash begins when the respiratory symptoms are maximal
- The rash spreads quickly over the face and trunk and coalesce to a bright red
- Lymphopenia is a characteristic finding
- Vaccination prevents the disease in susceptible exposed individuals if given within 72 hrs

Note: The MMR vaccine is contraindicated in pregnant women and women intending to become pregnant in
the next 28 days
- Also contraindicated in immunocompromised persons
- EXCEPT those with asymptomatic HIV with age specific CD4 lymphocyte counts
- Also contraindicated in children receiving high dose corticosteroid therapy (>2mg.kg/day or 20mg/day
total, for longer than 14 days

Measles Vaccines: Precautions & Contraindications

- Urticaria, anaphylaxis (neomycin + gelatin)
- Thrombocytopenia- 1 per 25,000
- Increased risk of seizures
- Suppresses tuberculin skin test reactivity
- Contraindicated in the immunodeficient and those on high dose steroids
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- Give MMTR to HIV/AIDS patients because they have a high risk of mortality if they contract wild type
measles

Rubella
** Aerosolized respiratory secretions transmit rubella
- Patients are infectious 5 days before until 5 days after the rash
- Congenital rubella usually follows maternal infection in the first trimester

** Young children may only have a rash. Older patients have a non-specific prodrome of low-grade fever,
ocular pain, sore throat and myalgia
- Post auricular and suboccipital adenopathy is characteristic
- The rash consists of erythematosus discrete maculopapules beginning on the face
- Rash spreads quickly to the trunk and extremities

** Congenital infection has more serious consequences. The main manifestations are:
i- Growth Retardation- between 50-85% of infants are small at birth
ii- Cardiac anomalies- pulmonary artery stenosis, patent ductus arteriosus, ventricular septal defect
iii- Ocular anomalies- cataracts, micropthalmia, glaucoma, retinitis
iv- Deafness- sensorineural in >50%
v- Cerebral disorders- chronic encephalitis, retardation
vi- Hematological disorders- thrombocytopenia, dermal nests of extramedullary hematopoiesis,
lymphopenia
vii- Others- hepatitis, osteomyelitis, immune disorders, malabsorption, diabetes

Note: Congenital infection is associated with low platelet counts, abnormal LFTs, hemolytic anemia and very
high rubella IgM antibody titers

Note: Congenital rubella must be differentiated from congenital CMV infection, toxoplasmosis and syphilis

** A pregnant woman possibly exposed to rubella should be tested immediately

- If seropositive she is immune
- If she is seronegative, a second specimen should be drawn in 3 weeks
- Seroconversion in the first trimester suggests high fetal risk and such women require counseling
regarding therapeutic abortion
- When pregnancy termination is not an option some recommend intramuscular administration of 20 ml of
immune globulin within 72 hrs after exposure to prevent infection

Note: The prognosis of rubella is excellent in all children and adults

- BUT poor in congenitally infected infants
- In these infants the defects tend to be irreversible or progressive

** The following conditions are under surveillance in Jamaica

- Acute Flaccid Paralysis
- Fever + rash (measles/rubella/dengue)
- Congenital Rubella Syndrome
- Invasive bacterial diseases
- Adverse reactions
- Needle stick injuries

Rotavirus
** Rotavirus accounts for 45% of severe diarrhea in infants and children worldwide
- Oral tetravalent rotavirus vaccine (RRV-TV) was recommended
- July 1999 was associated with increased risk of intussusception

** The new Human Bovine Reassortant Pentavalent Rotavirus Vaccine (HBRP)

- Safe, immunogenic and efficacious
- No increased risk of fever, irritability, vomiting or serious adverse events
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- Minimal replication of vaccine virus in GIT and low incidence of viral shedding in stool
- NO increased risk of intussusception
- Prevents 88% of all rotavirus disease
- Oral vaccine given in 3 doses
- Live attenuated vaccine

Storage at 0 deg C
Dosage: oral route (2 mls)
- Rotarix- give 2 doses (6 weeks to 6 months)
- Rotateq- give 3 doses- from 6 weeks to 8 months

Side Effects:
- Diarrhea and vomiting
- Irritability
- Nasopharyngitis
- Bronchiolitis
- RARE: intussusception

Contraindications:
- Previous anaphylaxis to this vaccine or any of its components
- Precaution in immunocompromised host or children with chronic GI illnesses
- Infants transfused with blood products or immunoglobulins within 6 weeks

Influenza
** Symptomatic infections of influenza are common in children because they lack immunologic experience
with influenza viruses
- Infection rates in children are greater than in adults
- Epidemics occur in the fall and winter
- Three main types of influenza viruses (A/H1N1, A/H3N2, B) cause most human epidemics
- Spread of influenza occurs via airborne respiratory secretions.
- Incubation periods is 2-7 days
- Attack rates of 10-40% in healthy children
- Hospitalization rates of 1%
- Pneumonia, croup, bronchiolitis- 0.20-0.25%

** Increased morbidity and mortality with:

- Sickle cell anemia
- Asthma
- Neonates with neoplasms, diabetes, chronic renal disease, heart disease with L-R shunts

** The inactivated influenza vaccine has 3 virus strains (Type A-2, B-1)
** The following persons should receive an influenza vaccine:
- Asthma
- Chronic lung disease
- Cardiac disease
- Immunosuppression
- HIV
- Sickle cell anemia
- Chronic renal disease
- Long term aspirin use
- Diabetes
- Late pregnancy
- Health care personnel
- Persons less than 6 months

** Administer vaccine annually, 1-2 months before influenza season

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** There are 2 types of influenza vaccine: injection or nasal spray

- Stored at 2-8 deg C
- Flu shot- killed vaccine given from age 6 months and older
- Flu nasal spray- live attenuated- recommended from 2 years onward

Contraindications:
- Allergy to egg or neomycin
- Prior history of Guillan Barre Syndrome

Adverse Effects
- Local reactions
- Mild fever
- Guillain Barre syndrome
- Anaphylaxis- due to allergy to egg or chicken protein

H. influenzae B
** 40% of cases occur in children younger than 6 months who are too young to have completed a primary
immunization series

** Eradicated in developed countries due to Hib vaccine implementation

** In KSA high morbidity associated with 26% ampicillin resistance
- Hib vaccine is implemented in Jamaica

** Hib may cause the following:

1- Meningitis- infants usually present with fever, irritability, lethargy, poor feeding with or without
vomiting and a high pitched cry
2- Bacteremia/Septicemia
3- Epiglottitis (supraglottic croup)- evidence of dysphagia, characterized by a refusal to eat or swallow
saliva and drooling.
- This finding along with a high fever in a toxic child should strongly suggest the diagnosis and lead to
prompt intubation
- The above signs are significant even without the classic cherry-red epiglottis on direct examination
- Note: Stridor is a late sign

4- Septic arthritis- Hib is a common cause of septic arthritis in unimmunized children younger than 4
years
- Child is febrile and refuses to move the involved joint and limb
- Examination reveals swelling, warmth, redness, tenderness on palpation and severe pain when
movement is attempted

5- Periorbital and facial cellulitis

6- Pneumonia
7- Sinusitis
8- Otitis media

** Four separate carbohydrate protein conjugate Hib vaccines are currently available
- HibTITER
- PedvaxHIB
- ActHIB
- ProHIBIT

** Killed vaccine stored at 2-8 deg C

** Vaccine dose is 0.5mL given IM in the anterolateral thigh

Contraindications: Should not be given to anyone who has had a severe allergic reaction to a prior vaccine
dose
- Should not be given to infants before 6 weeks of age
17

** Given at 2, 4, 6 months and a booster at 15 months

Side Effects: Local pain, redness and swelling in 25% of cases
- Systemic reactions such as fever and irritability are rare

Treatment- All patients with bacteremic Hib disease require hospitalization for treatment
- Use third generation cephalosporins to treat (cefotaxime or ceftriaxone)
- Meropenem is an alternate choice

Note: In addition to antibiotics children with Hib meningitis should be given dexamethasone immediately after
diagnosis
- The steroid continued for 4 days may reduce the incidence of hearing loss in children with Hib
meningitis
- Dosage: 0.6 mg/kg/day in 4 divided doses for 4 days

Streptococcus Pneumoniae
** Streptococcus pneumoniae is the most common cause of invasive bacterial infection in children
- Vaccine is given as a 0.5 mL IM dose
- 2, 4, 6 and 15 months (booster) for 7 valent
- Booster at 4 years for the 23 valent
- Killed vaccine
- 23 valent polysaccharide vaccine or 7 valent protein conjugate vaccine
- Storage at 2-8 deg C
- Especially important for patients with sickle cell disease

Contraindications: Individuals who suffered a severe allergic reaction such as anaphylaxis after a previous
vaccine dose
- Vaccination should be deferred during moderate or severe acute illness, with or without fever
- History of invasive pneumococcal disease is not a contraindication to vaccination

Adverse Effects: Fever, induration and tenderness at the injection site

- When given simultaneously with DTaP, no increase in febrile seizures has been seen

** Streptococcus pneumoniae is responsible for:

- Pneumonia
- Septicemia
- Meningitis
- Pleural empyema
- Arthritis
- Otitis media

Note: Pneumonia is the most common cause of death in the developing world
- S. pneumoniae accounts for 70% of pneumonias and 25% all cause mortality in developing counties
- Worldwide increase in drug-resistance

** Conjugate Pneumococcal Vaccine (Prevnar)

- Heptavalent conjugate pneumococcal vaccine licensed for 7-23 months
- Two doses for 24-59 months if high risk for pneumococcal disease
- EX: functional or anatomic asplenia, HIV, sickle cell anemia, nephrotic syndrome

** Serotypes covered in the conjugate pneumococcal vaccine

- 6B, 14, 19F, 23F, 18C, 4, 9V

** Serotypes causing disease in developed counties

- 6B, 14, 8*, 5*, 1*, 19F, 9V, 23F, 18C, 15B*, 7F*
18

** Prevalent serotypes in Jamaica:

- 23, 4*, 6, 19*, 10*, 15*, 1*, 9, 11*, 14, 18, 21*, 33*

*Indicates serotype absent from vaccine

** Polysaccharide Pneumococcal Vaccine (23PS)- Single dose of 23PS given to ALL children 24-59 months
old regardless of risk of pneumococcal illnesses
- In Jamaica given to sicklers, functional or anatomic asplenia or other immunodeficiency

Meningococcus
** Meningococcal vaccination is a tetravalent meningococcal polysaccharide-protein conjugate
- Currently recommended for routine use in young adolescents (11-12 years), those entering high school
and college freshmen living in dorms

** Vaccination is also recommended for the following groups:

1- College freshmen living in dormitories
2- Persons living in or traveling to countries with endemic meningococcal disease
3- Persons with complement deficiencies
4- Functional or anatomic asplenia
5- Military recruits
6- Microbiologists working with N. meningitides

** Infections with Neisseria meningitides can cause significant mortality and morbidity
- Meningococcal disease has a case fatality rate of 10-14% even when treated
- 19% of survivors are left with serious disabilities
- Ex: neurologic deficits, loss of limbs or limb function, hearing loss

** Meningococcus can cause meningitis, meningococcemia or both

- Purpura, DIC, coma, death within hours
- Arthritis, myocarditis, pericarditis, pneumonia, endopthalmitis

** Vaccine covers A, C, Y, W-135 as a quadrivalent vaccine >2 years

- No vaccine for group B disease
- Vaccinate for more than 2 years if high risk group
- Vaccine given as a single IM dose of 0.5 mL

Contraindications: Anyone with a severe allergic reaction to any component of the vaccine
- This includes allergy to diptheria toxoid and rubber latex
- Contraindicated in persons with prior history of Guillain Barre Syndrome
- Can be given to immunosuppressed individuals

Adverse Effects: Local reactions of redness, swelling and induration

- More severe systemic reactions include fever, headache, malaise, chills, arthralgia, anorexia

** Close contacts of a patient with invasive meningococcal disease should receive antimicrobial prophylaxis
to prevent spread of disease
- Ideally within 24 hrs of exposure

** Close contacts are defined as:

- Household members
- Day care center contacts
- Anyone in contact with infected persons secretions
- Kissing, mouth to mouth resuscitation, endotracheal intubation

** Rifampin or ceftriaxone are used for chemoprophylaxis in children

19

Varicella
** Live, attenuated varicella vaccine used as routine immunization of children 12 months and older
- Storage 2-8 deg C
- Dose- 0.5 mL subcutaneous in the deltoid
- Given at 12 months with a booster given a minimum of 1 month after first dose
- Note: The booster can be given at any time after the first dose
** Varicella is responsible for:
- Chicken pox
- Bacterial super infection
- Thrombocytopenia
- Arthritis
- Hepatitis
- Cerebellar ataxia
- Encephalopathy
- Meningitis
- Glomerulonephritis

Varicella- consists of mild systemic symptoms followed by groups of red macules

- Macules becomes small vesicles with surrounding erythema
- Form pustules, become crusted and then scab over
- The rash appears mainly on the trunk and face
- Lesions can occur in the scalp, nose, mouth, conjunctiva, and vagina
- If varicella occurs in the first few months of life, it is often mild due to persisting maternal antibody
- Once crusting begins the patient is no longer contagious

** Similar rashes include those of:

i- Coxsackievirus Infection- fewer lesions, lack of crusting
ii- Impetigo- fewer lesions, smaller area, no classic vesicles, positive Gram stain, peripheral lesions
iii- Papular urticaria- insect bite history, non-vesicular rash
iv- Scabies- burrows, no typical vesicles, failure to resolve
v- Herpes zoster- eruption usually involves a single dermatome usually truncal or cranial. The rash
does not cross the midline

Complications:
** Secondary bacterial infection with staphylococci or group A streptococci is most common
- Protracted vomiting or a change in sensorium suggests Reye syndrome or encephalitis
- Reye syndrome would be seen in patients who were using salicylates
- Encephalitis usually involves cerebellitis with ataxia

** Varicella pneumonia usually affects immunocompromised children

- Especially those with leukemia or lymphoma
- Those receiving high doses of corticosteroids or chemotherapeutics
- Cough, dyspnea, tachypnea, rales and cyanosis occur several days after onset of rash

** Neonates born to mothers who develop varicella from 5 days before to 2 days after delivery are at high risk
for severe or fatal disease
- These neonates should be given varicella-zoster immune globulin

** Varicella during the first 20 weeks of pregnancy may cause congenital infections
- Associated with cicatricial skin lesions, limb anomalies and cortical atrophy

Note: Unusual complications of varicella include optic neuritis, myocarditis, transverse myelitis, Orchitis,
arthritis

Dosage: Two doses of VAR vaccine are recommended for immunization of all healthy children aged 12 months
and older
- Also for adolescents and adults without evidence of immunity
20

- VAR can be given simultaneously with MMR at separate sites

** Vaccine is 85-90% effective in preventing varicella. Seroconversion in >95%

- Immunity for 11-20 years
- Mild reactions in 5-35%- pain, redness, swelling, rash, low grade fever
- Mild varicella-like syndrome in 1-5%

Contraindications: Severe allergic reaction after a previous vaccine dose or to a vaccine component
- VAR and MMRV are live-virus vaccines therefore they are contraindicated in children with cellular
immunodeficiencies
- EX: leukemia, lymphoma, congenital T-cell abnormalities
- EXCEPTION: Can be given to HIV-infected children who are not severely immunosuppressed
- Contraindicated in children receiving immunosuppressive therapy including high-dose steroids
- Should not be given to pregnant women BUT can be given to children living with pregnant women in
their household

Adverse Effects: Minor injection site reactions

- May develop a varicelliform rash outside of the injection site
- Herpes zoster infection has occurred in recipients of VAR in immunocompetent and
immunocompromised persons within 25-722 days after immunization

Yellow Fever Vaccine

** Flavivirus, causing febrile illness with hepatitis and hemorrhagic fever
- Tropical areas of South America and Africa

** Indicated for children as young as 6 months traveling to endemic areas or to countries that require it for
entry
- Otherwise immunization should be delayed until 9 months or older

** Yellow fever vaccine is a live attenuated vaccine made from 17D yellow fever attenuated virus strain
grown in chick embryos
- Protects for 10 years
- Given as a single subcutaneous injection of 0.5 mL

Contraindications:
- Infants younger than 6 months due to increased susceptibility to vaccine associated encephalitis
- Anaphylactic egg allergy
- Immunocompromised individuals
- Persons with a history of thymus disease

Adverse Reactions: Mild usually low grade fever, mild headache and myalgia
- Serious adverse reaction syndrome is vaccine associated viscerotropic disease, consists of severe
multiple organ system failure and death within 1-2 weeks post vaccination

Cholera Vaccine
** New oral vaccines are highly effective against Vibrio cholerae
- Does not prevent unapparent infection or introduction of organism into the country
- Do not give vaccine to close contacts
- Vaccine cannot control spread of cholera

** Given as 2 doses one week apart. Has an 85% vaccine efficacy against V. cholerae in the first 6 months
- Greater than 50% cross protection against enterotoxigenic E. coli diarrhea
21

Hepatitis A
** Accounts for symptomatic hepatitis in 30% of children
- Symptomatic in most older children and adults with jaundice in 70%
- Prolonged, relapsing for > six months
- Fulminant hepatitis, underlying liver disease
- Fecal-oral transmission

** Most hepatitis A infections occur in individuals without known risk factors for the disease
- More than 50% of all infections are thought to occur in children
- Children are more likely than adults to be asymptomatic while infected
- Therefore they are often the mechanism by which hepatitis A is spread through households and
communities

** Vaccine is recommended for the following:

1- Travelers to countries with high rates of hepatitis A
2- Children with chronic hepatitis B or Hepatitis C
3- Children with clotting factor disorders
4- Adolescent/adult males who have sex with men
5- Occupational exposure to hepatitis A
6- Illegal drug users

** Two inactivated hepatitis A vaccines

- Havrix and Vaqta

** Given IM at 1 year and then 6-12 months later

- Immunogeniticy- 88-95%
- Efficacy 94-100% and protects for 8 years
- The vaccines are interchangeable
- Mild pain and induration at injection site

Hepatitis B
** Hepatitis B vaccine is a recombinant DNA vaccine
- Stored at 2-8 deg C

** Given at 2, 4 and 6 months

- Minimum dosing interval between the first dose and second dose is 4 weeks
- Minimum dosing interval between the second and third dose is 8 weeks
- There should be at least 16 weeks between the first and third doses

Contraindications:
- Previous anaphylaxis to this vaccine or any of its components
- Including a serious allergy to yeast
- Pregnancy is NOT a contraindication to vaccination

Side Effects:
- Fever, redness and swelling at the injection site
22

Human Papilloma Virus

** Approximately 70% of cervical cancers are caused by the high cancer risk types 16 and 18
- Over 90% of genital warts are caused by the low cancer risk types 6 and 11

** The quadrivalent HPV vaccine types 6, 11, 16 and 18 was licensed for use in females aged 9-26 years for
the prevention of the following:
- HPV-related cervical cancer
- Cervical cancer precursors
- Vaginal and Vulval cancer precursors
- Anogenital warts

** Killed vaccine stored at 2-8 deg C

** Used in females aged 9-49 to prevent infection with the 4 most common serotypes responsible for cervical
cancer and genital warts
- 3 doses of 0.5 mL each given intramuscularly
- Second dose given 2 months after first dose
- 3rd dose given 6 months after first dose

Contraindications:
- Previous anaphylaxis to the vaccine
- History of anaphylaxis to yeast
- Pregnancy

Side Effects:
- Fever, redness and swelling at the injection site
- Myalgia, dizziness and headaches
- Post marketing reports of syncope have been reported after vaccination so vaccine recipients should be
observed for 15 mins after vaccination

Cold Chain
** To ensure the efficacy of the vaccines, certain guidelines that govern storage, handling and transport of the
vaccines must be adhered to

** Diluent and vaccine must be collected from the airport as soon as they arrive
- Transported at the correct temperature from one storage site to another
- Stored at the correct temperature at the central, parish and health center levels
- Transported at the correct temperature to outreach sites
- Kept cold during immunization sessions
23

THE INFANT OR CHILD WITH FEVER

A mother brings a 10-month-old male infant to casualty, with a complaint that he has been having fever
for the past 5 days. The fever is intermittent and worse at night. She used a thermometer at home and the
highest temperature recorded was 39.8 0 C. She tried sponging the infant with cold water, but he began
shivering. His appetite has been decreased and he is irritable.
a) How would you determine if this child has fever? What factors affect body temperature?

** The core temperature of the deep tissues of the body remains constant (within +/- 1 deg F)
- Except when a person develops a febrile illness

** The skin temperature however rises and falls with the temperature of the surroundings

Note: The average normal core temperature is usually between 98- 98.6 deg F when measured orally and about
1 deg F higher when measured rectally

** Balancing heat production against heat loss controls body temperature.

Heat Production
- Basal rate of metabolism of all the cells in the body
- Extra rate of metabolism caused by muscle activity (includes muscles contractions caused by
shivering)
- Extra metabolism caused by the effect of thyroxine on the cells (testosterone and growth hormone)
- Extra metabolism caused by the effect on epinephrine, norepinephrine and sympathetic stimulation on
the cells.
- Extra metabolism caused by increased chemical activity in the cells, especially when the cell
temperature increases
- Extra metabolism needed for digestion, absorption and storage of food (thermogenic effect of food)

Note: Therefore most of the heat produced in the body is generate in the deep organs
- Especially the liver, brain, and heart and skeletal muscles during exercise
- The heat is transferred from the deeper tissues to the skin and then is lost to the air

** The skin and subcutaneous tissues (fat) act as a heat insulator

- Fat only conducts heats 1/3 as readily as other tissues
- Therefore the insulation beneath the skin is an effective means of maintaining normal internal core
temperature

** Blood vessels are distributed beneath the skin. A high rate of skin flow causes heat to be conducted from the
core of the body to the skin
- Therefore by controlling blood flow within plexuses beneath the skin through vasoconstriction and
vasodilation it can act as an effective mechanism for heat transfer from the body core to the skin

- The vasoconstriction is controlled mostly by the sympathetic nervous system om response to changes
in body core temperature and changes in environmental temperature

** The clothes a person is wearing can affect body temperature. This is because clothing entraps air next to the
skin and decreases the flow of convection air currents
- Therefore the rate of heat loss from the body by conduction and convection decreases

** Stimulation of the anterior hypothalamus (preoptic area) by excess heat causes sweating
- The nerve impulses from this area that cause sweating are transmitted in the autonomic pathways to the
spinal cor
- Then through sympathetic outflow to the skin everywhere in the body
24

- Sweat is produced from sweat glands and evaporation of the sweat removes heat from the body

** Body temperature is regulated by nervous feedback mechanism. Most of these mechanism functions
through temperature regulating centers in the hypothalamus
- Cold and hot receptors are found throughout out the body and these help to elicit the reflex regulation
responses

** To determine if a child has a fever begin with the history. Elicit from parents information duration of fever,
how the temperature was taken, maximum height of fever documented at home
- All associated symptoms
- Chronic medical conditions and any medications taken
- Fluid intake and urine output
- Exposures and travel

** Document temperature, heart rate, respiratory rate and blood pressure as well as oxygen saturation
Change in general appearance (eg, toxic, lethargic)
Head - Bulging or sunken fontanelle in young children
Eyes - Discharge, pupil size
Ears - Signs of ear infection (loss of light reflect, bulging, red and immobile tympanic membrane)
Nose - Discharge
Mouth - Dry mucus membrane or lesions
Throat - Erythema, exudates, lesions
Neck - Meningeal irritation or adenopathy
Heart - Murmur, rubs, tachycardia, bradycardia
Lungs - Abnormal lung sounds, such as wheezing, rhonchi, or rales
Abdomen - Rigidity, guarding, abnormal bowel sounds
Genitals - Rash, discharge
Neurologic status - Not consolable, lethargic
Extremities - Signs of osteomyelitis, cellulitis, septic arthritis (pseudoparalysis)
Skin - Rash (especially petechial rash), cellulitis, abscess, omphalitis
** Perform a complete physical examination including a neurologic exam. Pay attention to the child’s degree
of toxicity and hydration status

b) What methods are used to measure body temperature?

** Temperature in pediatric patients can be measured in a variety of ways:

a) Rectal- using a mercury or digital thermometer
b) Oral- using a mercury or digital thermometer
c) Axillary- mercury, digital or liquid crystal strip
d) Forehead- liquid crystal strip
e) Tympanic- this type is quick and requires little patient cooperation
- Shown to be less accurate in infants younger than 3 months
- Subject to false readings if the instrument is not positioned properly or the external ear canal is occluded
by wax

c) How does the body produce fever? (Be prepared to explain this process to parents and colleagues.)
** Fever is defined as a body temperature above the usual range of normal.
- Can be caused by abnormalities of the brain itself or by toxic substances that affect the temperature-
regulating centers
** Fever occurs when there is a rise in the hypothalamic set point in response to endogenously produced
Pyrogens
 25

** Causes of fever include:

- Infections
- Malignancies
- Autoimmune diseases
- Metabolic diseases
- Chronic inflammatory conditions
- Medications- including immunizations
- CNS abnormalities
- Exposure to excessive environmental heat

** Many proteins, breakdown products of proteins, lipopolysaccharide toxins released from bacterial cell
membranes, can cause the set point of the hypothalamic thermostat to rise
- Substances that cause this effect are called Pyrogens
- When the set point of the hypothalamic temperature regulating center becomes higher than normal, all
the mechanisms for raising the body temperature

d) What other causes of elevated body temperature exists and how do they differ from true fever?
** Other causes of elevated body temperature include dehydration
- Over-bundled with clothes in a relatively warm environment

** True fever is defined as an increase in body temperature due to an elevation of the thermal set point in the
anterior hypothalamus secondary to the release of Pyrogens

** With hyperthermic conditions other than true fever, the hypothalamic set point is not adjusted
- Therefore a fever occurs when the body sets the core temperature to a higher temperature, through the
action of the anterior hypothalamus
- However hyperthermia occurs when the body temperature is raised without the consent of heat control
centers

** Non-febrile hyperthermia occurs when heat gain exceeds heat loss such as with:
- Inadequate heat dissipation
- Exercise
- Drugs- amphetamines, cocaine, SSRIs
- Environmental Causes

Note: In addition giving anti-pyretics can reduce true fever. These drugs have no benefit in the treatment of
hyperthermia
** Hot, dry skin is a typical sign of hyperthermia. Fever by contrast usually produces cool, damp skin
.
e) How do you classify fever?

Fever classification
Temperature in rectum,
Temperature in mouth Temperature under the arm
vagina, or ear
(oral temp.) (axillary temp.)
(core temp.)
Grade °C °F °C °F °C °F
low grade 38-39 100.0-102.2 37.2-38.2 99-100.8 36.8-37.8 98.4-100.2
moderate 39-40 102.2-104.0 38.2-39.2 100.8-102.6 37.8-38.8 100.2-102
high-grade 40-41.1 104.0-106.0 39.2-40.3 102.6-104.6 38.8-39.9 102-104
hyperpyrexia >41.1 >106.0 >40.3 >104.6 >39.9 >104
26

** Fever can also be classified according to whether it is continuous or intermittent

i- Continuous Fever- Temperature remains above normal throughout the day and does not fluctuate
more than 1 deg C in 24 hrs
- Ex: typhoid fever

ii- Intermittent Fever- Elevated temperature is present only for some hours of the day and becomes
normal for remaining hours
- Ex: malaria

iii- Remittent Fever- Temperature remains above normal throughout the day and fluctuates more than 1
deg C in 24 hrs
- EX: infective endocarditis

Different types of fever - Usually fever is differentiated with its mode of onset and character as:

Acute - Sudden onset of temperature and has a short course

Chronic - Slow, progressive and recurrent in nature; some people, even after recovering from typhoid, function
as carriers and suffer from it periodically.

Recurrent - Fever recurring often due to improper treatment.

Continuous fever - The temperature is continuous and variation is not more than 1°C and never touches normal
in a whole day.

Remittent - The temperature variation is more than 2°C and never touches the normal level in a whole day.

Intermittent - The fever is on and off and is only for a few hours and for the remaining period, the temperature
will be normal. Also, intermittent fever has been further classified as.

Quatidian - which occurs daily

Tertian - which occurs on alternate days, for example - malaria fever

Quartan - when there is a gap of two days between two episodes

Contagious - The fever spreads easily from one to another, through droplet infection or by means of contacts, for
example, influenza, typhoid, chickenpox, smallpox, measles, dengue, mumps, plague, tuberculosis, jaundice and
diphtheria

Non-contagious - The fever does not spread from one to another, for example, fever due to connective tissues,
heart problems, malignancy, trauma, fear, metabolic disorder like gout, milk fever, etc.

f) What information do you need to determine this infant’s problem? Explain why the information
would be necessary

** Previous reading of temperature by the caregiver.

- How long has the body temperature been elevated
- Is the temperature elevation constant or intermittent
- Activity level of child
- Presence of ill contacts in the household
- Associated symptoms such as rigor
27

Rigor is an episode of shivering or shaking followed by excessive sweating that follows a rapid increase in
body temperature
- Changes in appetite or behavior

Social History
- The environment the child lives in
- Who is the primary caregiver
- Contact with recent immigrants or persons who have traveled
- Exposure to homelessness and poverty

Information regarding immunizations

g) What other historical data would you elicit if the boy was less than one month old and older than 3
years old?

** If the child was less than a month old history from the mother is needed regarding the pregnancy and
delivery as well as the early neonatal life of the febrile neonate
- Typically infections that occur in the first week of life are secondary to vertical transmission
- Infections after the first week are usually community acquired

** Maternal history of STIs, maternal group B streptococcus status and prophylaxis

- Mode of delivery
- Prolonged rupture of membranes
- History of maternal fever

** The following factors are risk factors for serious bacterial infection in the neonate
- Birth weight of less than 2500 grams
- Rupture of membranes before the onset of labor
- Septic or traumatic delivery
- Fetal hypoxia
- Maternal peripartum infection
- Galactosemia

Information about the neonates nursery course should be noted, including the age at which the patient was
discharged from the nursery
- If circumcision was done or not
- Use of peripartum or antepartum antibiotics
- Diet and if formula fed hygiene surrounding bottle preparation
- Sleep histories

Note: Decreased oral intake or an acute change in sleep patterns may be clues to infection

Immunization history for the older child

h) What features in the examination would you elicit to rule out meningitis? How do the features
change with age?
Meningism is the triad of:
- Nuchal rigidity
- Photophobia
- Headache

** The main clinical signs that indicate meningism are

1- Nuchal Rigidity- the inability to flex the head forward due to rigidity of the neck muscles
2- Kernig’s sign
3- Brudzinski’s Signs- appearance of involuntary lifting of the legs in meningeal irritation when lifting a
patient’s head
28

** Signs of meningeal irritation. Inflammation or irritation of the meninges can lead to increased resistance to
passive flexion of the neck and the extended leg
- The corresponding signs are neck stiffness (nuchal rigidity) and Kernig’s sign

Kernig’s sign is positive when attempts to extend the knee are resisted by spasm, which is detected in the
hamstrings, and the other leg may flex at the hip and knee
Note: Kernig’s sign is not present in local causes of neck stiffness
- EX: cervical spine disease or raised intracranial pressure

** The most common causative organism varies with age:

i- Neonates- E. coli and Group B streptococcus
ii- Infants 30-60days- Group B streptococcus
iii- Infants > 2 months- S. pneumoniae and N. meningitides
iv- Pre-school child- H. influenzae
v- Older child and adult- N. meningitides, S. pneumoniae

** For bacterial meningitis, the younger the child, the less likely he/she is to exhibit the classic symptoms of
fever, headache and meningeal signs

** Children younger than 3 months have very non-specific symptoms including: hypothermia or hyperthermia,
change in sleeping or eating habits, irritability or lethargy, vomiting, high-pitched cry or seizures

** After age 3 months the child may display symptoms associated with bacterial meningitis:
- Fever, vomiting, irritability lethargy or any change in behavior

Note: Fontanelle bulging, diastasis of the sutures and nuchal rigidity point in meningitis in young infants but are
usually late findings

** After age 2-3 years children may complain of headache, stiff neck and photophobia

i) What are the common causes of fever in children less than one month old, 3-36 months old, older
than 3 years old?

Viral and bacterial infection

Medications
Drugs/Toxins
Heat illnesses

j) What groups of children are considered high risk when they have fever?

** Febrile infants 28 days or younger have a high likelihood of serious disease including sepsis
- Children with incomplete immunizations or immunizations not up to date for age
- Immunocompromised children
- History of abuse and neglect
- History of chronic illness- cancer, diabetes

** Children younger than 3 months with a temperature of 38 deg C or higher

- Children aged 3-6 months with a temperature of 39 deg C or higher

k) What investigations would you do? Do investigations vary with age? Explain why?

** A full sepsis evaluation is recommended in all febrile neonates. This includes:

- CBC count
- Blood culture
- Urinalysis
29

- Urine Culture
- CSF analysis and culture- CSF should be assessed for CBC count and differential, glucose level, protein
level, gram stain and routine culture
- Stool culture- if diarrhea is present

** A chest radiograph should be considered for neonates with signs of respiratory illness
- Coryza, cough, tachypnea, rales, rhonchi, nasal flaring or wheezing

** Lumbar puncture should be performed on the following children unless contraindicated

- Infants younger than 1 month
- All infants aged 1-3 months who appear unwell
- Infants aged 1-3 months with WBC less than 5 x 10 9 or > 15 x 10 9

** The approach to fever in a febrile infant

l) What complications may occur with fever?

- Febrile seizures
- Dehydration
- Shock
- Death

m) What is the aetiology of fever in children?

- Bacterial or viral infection

- Gastroenteritis
- Otitis media
- Meningitis
- Childhood immunizations
- Overdressing in warm clothes

- Infections
- Malignancies
- Autoimmune diseases
- Metabolic diseases
- Chronic inflammatory conditions
- Medications- including immunizations
- CNS abnormalities
- Exposure to excessive environmental heat

n) How is fever treated?

Antipyretics
Encourage hydration
Rest
o) How often is a doctor likely to encounter this problem? What type of patient is likely to be seen with this
problem?

http://emedicine.medscape.com/article/1609019-overview (READ)

http://emedicine.medscape.com/article/800286-followup

http://www.nice.org.uk/nicemedia/pdf/CG47Guidance.pdf
30

A 1-year-old boy was brought to casualty because he had the sudden occurrence of
stiffness and then jerking of his body, associated with upturning of his eyes and frothing
at the mouth. This occurred about 15 minutes ago. Mom noted that he felt quite hot to
touch, and she has been unable to communicate with him.

a) What information would you need to obtain from his caregiver to determine the cause
of his seizures? Explain your reasons.

- The type of seizure and its duration, if seizures had occurred before
- History of fever, duration of fever and potential exposures to illness
- Presence of ill contacts
- History of recent travel or contact with travelers
- History of the cause of fever (viral illnesses, gastroenteritis)
- Recent antibiotic use- because partially treated meningitis should be considered
- History of seizures, neurologic problems, developmental delay or other potential
causes of seizures (trauma, ingestion of toxins)
- Family history of seizures

b) What features in the examination would help you to identify the cause of his
problem?
** Search for the underlying cause of the fever
- Physical examination to find otitis media, pharyngitis or other signs of viral infection
- Serial evaluations of the patient’s neurologic status
- Check for meningeal signs
- Check for signs of trauma or toxic ingestion

c) How would you investigate?

Investigations for source of fever: CBC, blood culture, and lumbar puncture
- CT scan should be considered in patients with complex febrile seizures

d) How do you classify febrile seizures? Explain

1- Simple Febrile Seizures- generalized and last for <15 mins and do not recur within
24 hrs
2- Complex Febrile Seizures- are prolonged, recur more than once in 24 hrs or are
focal

e) What are the risk factors for recurrence of febrile seizures? What is the risk of
recurrence?
** One third of all children with a first febrile seizure experience recurrent seizures. Risk
factors for recurrent febrile seizures include:
- Young age at time of first febrile seizure
- Relatively low fever at time of first seizure
- Family history of a febrile seizure in a first degree relative
- Brief duration between fever onset and initial seizure
- Multiple initial febrile seizures during same episode
31

** Patients with all 4 risk factors have a grater than 70% chance of recurrence. Patients with
no risk factors have less than a 20% chance of recurrence

** Risk factors for developing febrile seizures include:

- Family history
- High temperature
- Parental report of developmental delay
- Neonatal discharge at an age greater than 28 days (suggests perinatal illness)
- Daycare attendance

f) How are febrile seizures treated?

ABCs!
- Airway management
- High flow oxygen
- Anticonvulsants- benzodiazepines, phenytoin, Phenobarbital
- Antipyretics

g) What is the cause of febrile seizures?

**Often caused by viral illnesses
- Febrile seizures also tend to occur in families

h) How would you counsel this child’s parents?

** Children with febrile seizures have a slightly higher incidence of epilepsy compared with
the general population (2% vs 1%)
** Risk factors for epilepsy later in life include complex febrile seizure, family history of
epilepsy or neurologic abnormality and developmental delay

** Counsel about the link between family history and febrile seizures. The risk of a sibling
developing febrile seizure is 10% and almost 50% if the parent has had febrile seizures as
well

** Parental anxiety and fear that their child may die or will develop brain damage should be
addressed with reassurance and education
** Risk of mortality associated with a simple febrile seizure is not increased
- Seizures that are complex occurred before the age of 1 year or were triggered by a
temperature <39 deg C were associated with a 2X increased mortality rate during the first 2
years after seizure occurrence

i) How often is a doctor likely to encounter this problem? What type of patient is
likely to be seen with this problem?

** Tend to occur in all races. Slight male predominance. By definition febrile seizures occur
in children aged 3 months to 5 years
32

Arterial Blood Gases

** Blood test used to determine the:
- pH of the blood
- Partial pressure of carbon dioxide and oxygen
- Bicarbonate level

Analyte Range Explanation

pH 7.35-7.45 <7.35 = acidotic >7.45 = alkalemic
PaO2 80-100 mmHg A low O2 indicates that the patient is not respiring
properly and is hypoxemic. PaO2 <60mmHg the
patient should be given supplemental oxygen
PaO2 <26 mmHg the patient is at risk of death
PaCO2 35-45 mmHg A high PaCo2 (respiratory acidosis) and indicates
underventilation
A low PaCO2 (respiratory alkalosis) suggests
hyper or over ventilation
HCO3- 22-26 mmol/L The HCO3- ion indicates whether a metabolic
problem is present. Low HCO3 indicates metabolic
acidosis
High HCO3 indicates metabolic alkalosis
Base Excess -3 to +3 mmol/L Base excess is used for the assessment of the
metabolic component of acid-base disorders
A negative base excess indicates the patient has
metabolic acidosis
A positive base excess suggests that the patient has
metabolic alkalosis (primary or secondary to
respiratory acidosis)

Oxygen
Saturation

** Oxygen saturation is a measure of the amount of oxygen dissolved in a medium.

Measures the percentage of hemoglobin binding sites in the bloodstream occupied by
oxygen.
- An oxygen saturation of under 90% indicates some degree of hypoxemia

Ph = 7.29- acidosis
PCO2- 42.3 Normal
PO2- 147.3 Over 100%- measure of ventilation
HCO3- 20.5- slight metabolic acidosis
Base Excess- positive 6.8- - metabolic alkalosis?
O2 Sat- 98%
33

Growth & Development- DR. PIERRE 12-01-10

Growth
- Formation of tissues
- Enlargement of head, trunk and limbs
- Progressive increase in strength and ability to control muscle groups

Development:
- Acquisition of functional skills
- Development of social relatedness, thought and language
- Emergence of personality

** Growth and development are dependent on several factors including:

- Heredity
- Biologic
- Social
- Psychological

Characteristics of Growth
** Growth is a series of changes, not just adding on:
i- Specialization
ii- Alteration of shape
iii- Adding Material
iv- Subtracting Material- eg thymus grows and then eventually regresses at a certain
age
v- Substitution- cartilage precedes the final bony substrate

** Differential growth of different tissues of the body

Growth Phases

1) Fetal Phase- growth that occurs within the womb

- The fetal phase is the fastest period of growth
- Accounts for 30% of eventual height

- Determinants of growth during the fetal phase include:

A. Placental Integrity- any cause of placental insufficiency will affect fetal growth
- Therefore placental integrity plays a large role in growth during the fetal phase

B. Maternal Size-
C. Growth Factors- insulin as a hormone plays a major role in the fetal phase of
growth
- Other growth factors include: IGF-2, human placental lactogen
34

2) Infantile Phase- growth from 0- 12 months

- Another period of rapid growth
- Accounts for 15% of eventual height
- Second fastest growth period
- Determinants include:
- Normal health and nutrition
- Thyroid hormone stimulation- at this period thyroid hormone is the most important
hormonal determinant of growth

Note: Inadequate weight gain during this period is known as failure to thrive

3) Childhood Phase- growth from 1 year to 10 years

- Accounts for 40% of final height
- Tends to be slow and prolonged
- Slow but steady prolonged period of growth
- The main determinant during this time is growth hormone secreted by the pituitary
- GH acts to produce insulin-like growth factor 1 (IGF-1) at the epiphyses

4) Pubertal Phase- accounts for 15% of final height

- Sex hormones (testosterone and estradiol) play a role during this phase.
- These hormones contribute to the epiphyseal growth plates
- Once the fusion occurs growth stops
- Growth spurts occur during this time period
- Females- growth spurts happen in the second phase of puberty
- Males- growth spurts happen in the third phase of puberty

Failure to Thrive
** Failure to thrive is used to describe infants and young children whose weight curve has
fallen off by two major percentiles from a previously established rate of growth
- Therefore the term describes suboptimal weight gain in infants and toddlers

** Mild failure to thrive involves a fall across two centile lines

- Severe failure to thrive is a fall across three centile lines

Note: It may be difficult to differentiate the infant who is failing to thrive from a normal
BUT small/thin baby
- Normal but short infants have no symptoms, are alert, responsive and happy and
their associated development is satisfactory

** Wasting- is the acute loss of weight or failure to gain weight at the expected rate that
produces a condition of reduced weight for height

** Stunting- is the reduction in height for age that is seen with more chronic malnutrition
35

** The causes of failure to thrive are classified as organic and non-organic

- Non-organic failure to thrive is usually associated with a broad spectrum of
psychosocial and environmental deprivation

** There are 5 broad causes of failure to thrive:

1) Inadequate Intake - which may be due to either organic or non-organic causes
I. Inadequate availability of food (non-organic cause)
- Feeding problems- insufficient breast milk or poor technique, incorrect preparation of
formula
- Insufficient or unsuitable food offered
- Lack of regular feeding times
- Low socioeconomic status

II. Psychosocial Deprivation (non-organic cause)

- Poor maternal-infant interaction
- Maternal depression
- Poor maternal education

III. Neglect/Child Abuse (non-organic cause)

IV. Impaired Suck/Swallow (organic cause)

- Oro-motor dysfunction, neurological disorder (cerebral palsy eg)
- Cleft palate

V. Chronic illness leading to anorexia (organic cause)

- Crohn’s disease, chronic renal failure, cystic fibrosis, liver disease

2) Inadequate Retention- vomiting, severe gastro-esophageal reflux

3) Malabsorption- Celiac disease, cystic fibrosis, cow’s milk protein intolerance

- Short gut syndrome
- Post-necrotising enterocolitis

4) Failure to Utilize Nutrients

- Chromosomal disorders- eg Down’s syndrome
- Intrauterine growth restriction
- Extreme prematurity
- Congenital infection
- Metabolic disorders- eg congenital hypothyroidism, storage disorders, amino and
organic acid disorders

5) Increased Requirements
- Thyrotoxicosis - Chronic infection- HIV
- Cystic fibrosis - Congenital heart disease
- Malignancy - Chronic renal failure
36

** The history should focus on:

1. A detailed dietary history
2. Feeding- details of exactly what happens at mealtimes
3. Activity Level- of the child along with associated symptoms such as vomiting,
cough, lethargy
4. Prematurity/IUGR- at birth or any other significant medical problems
5. The growth of other family members and any illnesses in the family
6. Child’s development
7. Psychosocial problems in the home

Growth Assessment
** Requires the following: Equipment, Technique, Growth charts, Interpretation

** Measuring head circumference (occipito-frontal circumference)

- Measures brain growth
- Maximum circumference around the supra-orbital ridges and occipital protuberance
- Take 3 measurements and then use the largest of the 3 measurements

Percentile Concept
** Children of the same age will have different values for a particular parameter

Growth Monitoring
** Consists of measuring, recording and interpreting an individuals growth over a period
of time
- Particularly important during periods of rapid growth
- Ex: neonatal period, infancy and childhood
- Commonly employed with young children in the first 5 years of life
- Intended to promote and sustain good health by detecting early growth failure

Note: Trends over time are more important than a single measurement
- Illness tends to restrict growth over an acute period
- Chronic low growth may be nutritionally related

Fetal Phase- Abnormal Growth

1) Intrauterine Growth Retardation- the baby is born full term but the baby is small and
appears malnourished
- May be due to severe maternal hypertension, poorly controlled diabetes, vascular
disorders (vasculitides), maternal smoking
- Note: Any condition that affects the vascularity of the placenta can lead to IUGR
- Maternal diabetes may cause IUGR because diabetes affects the vasculature of the
placenta along with his other effects on vessels in the body

** The IUGR infant has reduced glucose stores in the form of glycogen and body fat

2) Prematurity
37

3) Large for Gestational Age- Infants of poorly controlled diabetic mellitus because the
high concentration of glucose in mother is transferred across the placenta
- Therefore the fetal pancreas undergoes hyperplasia and increases the production of
insulin in the fetus
- Insulin is a growth hormone of fetal life and the fetus becomes larger
4) Familial- genetics

Infant/Child Phase- Abnormal Growth

- Genetics and syndromes
- Familial
- Constitutional growth delay- is a
diagnosis of exclusion, therefore
must rule out all other conditions
- Children with CGD is the most
common cause of short stature and
pubertal delay
- Global delay in development that
affects every organ system
- Severe IUGR and prematurity-
may never completely catch up
- Chronic infection and illness
- Endocrinopathies
- Psychosocial

Development
** Process of acquisition of functional skills

Functional Areas
1) Gross Motor 4) Cognition
2) Fine Motor/Vision 5) Personal/Social/Adaptive
3) Language/Speech/Hearing

Key Principles
** Consistency in pattern of children’s developmental progress.
- Motor development is a continuous process and occurs in an orderly fashion
- Motor development proceeds in a cephalocaudal direction
- Begins with control of neck muscles, then trunk muscles, followed by proximal and
distal limbs
- After this is achieved the child can then pull to stand

** They can lift their heads with good control at 3 months, sit independently at 6 months,
crawl at 9 months, walk at 1 year and run by 18 months.
- The child learning to walk has a wide-based gait
- Walks with legs closer together, a heel-toe gait develops, and the arms swing
symmetrically by 18-24 months
- The sequence of development is the same in all children, BUT the rate of
development varies between children
- The rate of development varies with children even among siblings

Note: The rate of attainment of milestones in one area may not parallel that in another
- Certain primitive reflexes must regress before corresponding voluntary movements
can be attained
38

Primitive Reflexes
** Normal newborns have reflexes that facilitate survival (rooting + sucking) and sensory
abilities that allow them to recognize their mother within a few weeks of birth

** The retina is well developed at birth BUT visual acuity is poor (20/400) because of a
relatively immobile lens
- Acuity improves rapidly over the first 6 months
- Fixation and tracking becomes well developed by 2 months

** The resting tone of a normal term newborn should exhibit:

i- Flexion of the upper and lower extremities
ii- Symmetrical spontaneous movements

Note: Extension of the extremities should result in spontaneous recoil to the flexed position

** Primitive Reflexes include:

1) Moro (Startle) Reflex- Hold the infant supine while supporting the head
- Allow the head to drop 1-2 cm suddenly
- Arms abduct at the shoulder and extend at the elbow with spreading of the fingers
- Followed by adduction with flexion
- Reflex develops by 28 weeks gestation and disappears by 3 months (age)

2) Sucking Reflex- in response to a nipple or finger in the mouth.

3) Rooting Reflex- Head turns to the side of a facial stimulus
- Stroke the side of the cheek and the infant turns in the direction of the stimulus

4) Grasp Reflex- palmar grasp with the placement of a finger in the neonate’s palm.
Disappears by age 4 months
5) Placing & Stepping
6) Asymmetric Tonic Neck Reflex- Forcibly turn the infant’s head to one side, the arm
and leg on that side will extend while the opposite arm and leg flex (fencing
position)

Postural Reactions
- Help maintain orientation of the body in space
- These righting reactions- up to 12 months
- Protective equilibrium response at 4-6 months
- Parachute reactions- at 8-9 months

Parachute Reaction- When an infant is held in ventral suspension and is tilted abruptly
forward towards the floor the response is a protective abduction of arms, extension of
elbows and wrists and spreading of fingers
- In normal infants the response is symmetrical
- Asymmetry of the response is seen in infants with hemiparesis and an early sign of
cerebral palsy
39

Gross Motor
Head Control 2-3 months
Roll over 4-5 months
Sit unsupported 6 months
Crawl/creep 7-8 months
Pull to stand 9-10 months
Cruise 10-11 months
Walk 12 months
Run, kick 18 months
Hop 20 months
Up and down stairs 24 months
Ride tricycle 36 months (3 years)

Note: Infants roll over from front to back initially and then from back to front later on

Fine Motor
Fix & Follow 6 weeks
Hand regard 3-4 months
Reaches 4 months
Transfers 6 months
Pincer grasp 9 months
Scribbles 14 months
Hand skills 18+ months

** Mature pincer grasp- holding objects between the thumb and forefinger
- Most young children have symmetrical movements
- Children should not have a significant hand preference (handedness) before 18
months
- If a child shows a preference for a hand before 18 months, they should be investigated
because there may be weakness on one side.

Personal Social
Social smile 6 weeks
Stranger anxiety 7 months
Plays peek a boo 7-9 months
Waves bye-bye 10 months
Drinks from cup 12 months
Holds spoon 15-18 months
Interactive play 3-4 years
Dresses self 5 years
40

Language
Cooing 2 months
Turns to sound 4 + months
Babbles 6 months
Non-specific dada/mama 8 months
Specific words 12 months
Follows 1-step command 14 months
Shows parts of body 16 months
2- word sentences 24 months
Intelligible speech 36 months

Note: Child turns to sounds at 4 months BUT at 6 months there is a definitive turn to source
of sound

Cognitive
Concept of object permanence 7-9 months
Concept of time 24+ months
Can perform mental operations 6-11 years
Capacity for abstract thought > 11 years
Object Permanence- is the understanding that objects continue to exist even when they
cannot be seen, heard or touched

Important Limit Ages

No social smile 8 weeks- check vision and hearing
No eye contact 3 months
Not reaching for objects 5 months
Not sitting unsupported 9 months
Not walking unaided 18 months
No single words with meaning 18 months
No two or three word sentences 30 months
Not responding to simple commands 24 months
Speech unintelligible 36 months
** At 6-11 years problems related to learning disabilities etc are discovered when the child
attends school

Developmental Delay
** Failure to achieve developmental milestones at the expected age
** Delay may be global or specific to one area of development
** Child health surveillance important to be able to track trend

Patterns of Abnormal Development

** Plateau pattern- may have had a severe insult at a point in time that plateaus the growth
- Ex: Severe meningitis- with the resultant sequelae of impaired posture and tone

** Regression Pattern- seen in metabolic disorders, HIV, lead poisoning etc.

41

Evaluation of Development
History:
- Family history
- Perinatal issues
- Acquired infections
- Seizures
- Poor feeding or growth
- Toxin exposure
- Psychosocial issues

Examination: growth parameters

- Dysmorphysism
- Neurocutaenous lesions
- Abnormal neuromuscular examination
- Vision, hearing

Investigations:
- Vision and hearing assessment
- Chromosome studies
- Metabolic studies
- Neuroimaging

Developmental Tests- Denver II (screening test)

Appropriate Referral
42

Nutrition- 15/01/10- PROF. THAME

Nutritional Needs of the Infant

** The infant should be ideally breastfed for the first 6 months of life
- Breast milk has ALL the nutrients needed for this time
- Breast fed babies should not be fed water
- The foremilk contains water and this satisfies the thirst of the baby
- As the baby continues sucking the rest of the milk following the foremilk becomes
thicker and contains the majority of the nutrients needed

** Physiological changes occur in the gut that allows digestion of milk initially and
eventually transitions to complex foods at 1 year
- Changes occur from mainly a sucking action to a chewing action
- Other physical changes that allow a transition from breastfeeding to solid foods are
head control, sitting up
- Developmental changes that facilitate eating solid foods include recognition of the
spoon, interest in other persons eating

** The nutrient requirements of children are influenced by:

i- Growth rate
ii- Body composition
iii- Composition of new growth

Note: These factors vary with age

Growth
** Babies normally lose weight in the first few days after birth.
- They lose weight, hit a plateau and then begin increasing their weight
- The initial weight loss after birth is because during this time 70-80% of their weight
is water
- Approximately 10% of their birth weight should be lost initially
- If more than 10% is lost, investigations should be done

Note: Breast-fed babies lose more weight than bottle fed infants
- Within the first 10-14 days the infant regains its birth weight

Growth Rates
** In utero between 18 and 34 weeks the fetus increases its weight by 34g per day
- In neonatal life the infant increases its weight by 20-30g per day

** Growth rates per day in the first year of life is greatest and exceeds any other time in the
life cycle
- Growth slows after 12 months and the appetite decreases as well
- Between 2-6 years of life the growth rate is slow and the appetite is poor
 43

** Growth rates are higher in early infancy than at any other time, including the adolescent
growth spurt

** Nutrient requirements depend on body composition

- In a full term neonate the brain accounts for 10% of body weight and for 44% of
total energy needs
- Therefore in the young infant, total basal energy expenditure and the energy
requirement of the brain are relatively high

** Growth charts are used to monitor growth. Most children track along a centile curve
- However crossing two centile lines is a red flag

** Because of the high nutrient requirements for growth and the body composition, the
young infant is especially vulnerable to undernutrition
- Slowed physical growth is an early and prominent sign of undernutrition in the
young infant

Energy Cost
** Infants need more than twice as much energy/kg as adults
- Infants need 93-120 Kcal/kg/day
- Adults only need 40 kcal/kg/day

Note: ¼ of their requirements is needed for growth

** The parent is responsible for:

- What the child is offered to eat
- Where the child eats
- When the food is presented

** Parents should be aware of child-sized portions. Giving too much food at once will
overwhelm the child and may discourage eating

** Parents should create a routine for meals, this will encourage a child to eat

Basic Four-Food Plan

1. Milk- 2-3 cups per day, more than this will replace other foods in the diet and lead to
deficiencies
- Solid food eventually replaces milk
- If the milk intake after age 1 year is more than 3 cups it will replace the food/nutrients
that the child also needs for growth/development
- From ages 1-10 years about 800 mg of calcium is needed per day
- Calcium can be obtained from a variety of sources but dairy products are the best
- Print Slide #20 -24

2. Fruits & Vegetables- 4 servings per day.

- One tbs per year of age or ¼ of the adult serving = child portion
 44

3. Breads + Cereals- 4 servings per day

- Child’s serving = 1/3 to ¼ adult portion
- Adult serving = 1 slice of bread, 5 crackers or ½ cup of rice or cereal

4. Meats. Fish, Poultry- 2 servings per day

- Adult serving is 2-3 ozs per meal

** Discourage the use of bottles for the following reasons:

1- Lack of proper bottle hygiene can lead to the development of gastroenteritis
2- Bottle caries- especially if the bottles are given as soothers in the night

Rule of Thumb: Portion Sizes

- Child’s serving should be ¼ to 1/3 adult portion size or 1 tbs per year of age
- 16 ozs of milk plus 1 oz of meat/meat substitute provides enough protein for children
up to age 3 years

** Look at the distribution of choices among food groups. Children may be picky in spurts.
- Therefore an isolated day or 2 of unbalanced eating is alright
- As long as the overall trend over the past 2 weeks is balanced
- Expect a nutritionally adequate diet on a weekly average not daily

** A daily food plan is interpreted as the average of intake for several days up to a week

** Calories vary from day to day. A child between one and 3 years should have:
- 40 calories per inch of height OR 1000-1300 calories per day

Note: When a breastfed infant is first being offered food that is not the breast it should be
initially given by a caregiver who is not nursing the infant
- If the nursing mother attempts to offer another type of food, the infant will smell the
breast milk and refuse the food being offered

Iron
** Children 1-3 years need 15 mg iron per day. Iron deficiency anemia continues to be a
problem up to 2 years
** IDA may be the result of two common nutritional errors:
1- Over consumption of milk- more than 16-24 oz per day
- Resultant low intake of iron containing foods

2- Poor Snack Selection

** Animal sources of iron are better absorbed.

- Therefore eating meat together with vegetable iron improves the absorption of the
vegetable iron
- Limit liver consumption to twice a month to control vitamin A intake
45

Nutritional Outcome
** Nutrition influences mental performance. The brain accounts for 20% of basal energy
expenditure
- Iron and other micronutrients are cofactors for normal metabolism
- Iron deficient children show lower attention span and lower cognitive function
- Because the brain continues to grow up to 18 months after birth, nutritional deficits
in this period may be detrimental to the developing brain

Note: Children who have suffered malnutrition may have deficit BUT their stimulation and
environment may counter this insult

** Children’s diet influence dentition. Tooth formation requires:

- Vitamins A, C, D, K
- Minerals- calcium + phosphorous

** The adherence of carbohydrates to the tooth’s surface is the biggest dietary factor that
promotes tooth decay
- Bacteria in the mouth ferments the carbohydrate
- This leads to the production of acid which breaks down the enamel and causes dental
caries

** Foods that protect against dental caries are:

- Cheese, raw vegetables and hard bread

Childhood Obesity
** Worldwide 11% are overweight and 14% are at risk. Most likely cause is low physical
activity as opposed to caloric intake

** The probability of obesity persisting into adulthood has been estimated to increase from
20% at 4 years to 80% at adolescence

** Obesity is associated with cardiovascular and endocrine abnormalities (dyslipidemia,

insulin resistance, type II diabetes)
- Orthopedic problems, pulmonary complications, mental health problems
- Hypertension, artherosclerotic disease

** BMI is the standard measure of obesity in adults. Its use in children provides a consistent
measure across age groups

**Obesity is defined as a BMI at or above the 95th percentile for age and gender

** The at risk for being over weight are those above the 85th percentile but below the 95th
percentile for age and gender

Note: This definition is for children between 2-20 years

46

Note: For children younger than 2 years, weight for length greater than the 95th percentile
indicates overweight

Prevention Strategy
1- Encourage the child to eat slowly
2- Allow children to stop eating when they are full
3- Teach children to enjoy the social aspect of eating
4- Select low fat snacks
5- Serve appropriate portions for age
6- Do not tie self worth to eating or weight
7- Avoid overrestricting children’s energy intake during periods of growth
8- Encourage daily physical activity for the whole family

Treatment Strategies
** Therapy should be based on risk factors:
- Age
- Severity of obesity
- Comorbidites
- Family history and support

** For all children with uncomplicated obesity, the primary goal is to achieve healthy
eating and activity patterns
- Not necessarily to achieve ideal body weight

** For children with a secondary complication, improvement of the complication is an

important goal

** For the at risk child (BMI >85th and < 95th percentile for age and gender) without
complications the goal should be maintenance of baseline weight
- Therefore portion sizes should be cut and exercise encouraged
- Maintain a stable weight or slow rates of weight gain
- This allows the child to grow into his or her height
- Therefore allows the height to catch up with the weight

** If secondary complications are present, weight loss is recommended

- However excessive acute weight loss should be avoided because this may contribute
to nutrient deficiencies and linear growth stunting
- Severe restrictions may also lead to eating disorders

Print slide #46 important

** Management of the obese child must address 4 important areas

1- Medical
2- Psychosocial
3- Nutritional
4- Physical activity- should be appropriate to the child’s weight
47

TUTORIAL #2- THE CHILD WITH A RASH

Case 1

A 3-year-old presents with a 1-week history of a pruritic skin rash “all over” but
primarily involving his legs and arms. Mother says some are beginning to look “like
sores”. The pruritus is worst at nights. He is otherwise well with no constitutional
symptoms.

Infectious Causes
- Varicella- absence of systemic symptoms
- Scabies- typical burrows, propensity for hands and soles. Presence of excoriated
papules and pustules and a history of severe itching at night suggest infestation with
the human body louse
- Fungal infections
- Pityriasis rosea- Papulosquamous eruptions, typically the generalized eruption is
preceded for up to 30 days by a solitary, larger scaling plaque with central clearing

Non-infectious Causes
- Atopic eczema- childhood eczema (flexural eczema) usually found in the antecubital
and popliteal fossae, the neck, wrists and sometimes hands or feet
- Urticaria/allergic reactions
- Contact dermatitis
- Insect bites/Papular urticaria- history of being bitted by insects. Characterized by
grouped erythematosus papules surrounded by a urticarial flare
- Distributed over the shoulders, upper arms and buttocks
- Usually no other family members are affected
- Psoriasis- erythematosus papules covered by thick white scales

Comment on the possible differential diagnoses?

On examination there is a papular rash on his forearms and legs with excoriation of
some papules but no crusting. There are many superficial scratch marks in the
surrounding area.

Where else would you like to examine to aid in making a definitive diagnosis? Please give
reasons.
- Examination of hands and soles for signs of burrows
- Linear burrows about the wrists, ankles, finger-webs, areolas, anterior axillary folds,
genitalia

On further history his brother has had a similar rash for the past 3 days.

What is the most likely diagnosis?

Scabies
48

Discuss the further management of this patient.

** Identification of the female mite or her eggs/feces is necessary to confirm the diagnosis
- Scrape an unscratched papule or burrow with a blade and examine microscopically in
immersion oil to confirm

** Permethrin 5% is the treatment of choice for scabies. Applied as a single overnight

application
- Treatment of ill contacts
- Wash clothes and bedding with hot water

Case 2

An 8-month-old female infant presents with a history of a “fine rash” on her chest and
back for 2 weeks and her skin “seems dry”.

What are the possible causes of this rash?

She had no significant history of pruritus and is otherwise well. She had a similar rash
at age 3 months, which resolved spontaneously.
On examination there are patches of fine papules involving her neck, chest and back.
There is mild desquamation involving her eyebrows and scalp.

What is the most likely diagnosis for this patient?

Non-Pruritic Rash- Differential Diagnosis

- Roseola infantum
- Adenovirus infection
- Coxsacki virus
- Exanthematous viral illnesses

Discuss the further management of this child.

49

WELL BABY CARE ISSUES

Divide the class into five groups and each group take one case scenario to explore

Case scenario 1
A mother brings her 6-week-old infant for immunization; counsel her on the benefits of
immunizations in general and on the side effects of the vaccines you are about to administer.

- As a infant grows eventually he loses the protection of maternal antibodies that has
been passed along via birth and breastfeeding
- Immunization helps to continue their initial protection
- Exposing the child to weakened versions or dead cells of agents that cause illnesses
with significant morbidity and mortality in children will prevent them from getting
these illnesses
- Immunization is a proven tool for controlling and eradicating
- Childhood immunization helps the immune system to build up resistance to disease

BCG: Side Effects

- Redness and pain at the site of injection
- Eventually a wheal will arise and later on a scar may be left behind
- Do not puncture or disrupt the wheal
- Keep out of sunlight for the first few days
- After bathing the child, pat the arm dry instead of rubbing
- May feel enlarged lymph nodes

DPT
- Redness, pain and swelling at the site of injection
- Irritability and fever

** The pertussis component can cause:

- Seizures
- Persistent inconsolable crying that lasts more than 3 hours
- Hypotensive-hyporesponsive episodes

OPV
- Loose stools
- Rarely can cause vaccine-associated polio
- Ensure proper hand washing before and after changing diapers because the live virus
will be shed in the stool for up to 6-8 weeks after receiving the vaccine

Note: For all vaccines, anaphylaxis is a possible side effect

50

Case scenario 2
A mother brings her 8-month infant who is presently cruising, for a well child visit; what
anticipatory guidance would you give her about injury prevention in the home?

- Cover electrical sockets

- Run cords behind furniture
- Ensure that curtain cords/blind cords are not dangling
- Remove all household toxins/poisons from low cupboards
- Ensure all medications are in a locked, high cabinet
- Pad sharp edges of countertops and tables
- Remove hanging tablecloths
- Turn pot handles inwards
- Keep matches out of reach
- Place safety gates at the tops and bottoms of stairs and to prevent them from entering
the kitchen
- Keep bathroom doors closed and toilet lids down
- Ensure pool areas are covered or gated
- Do not allow buckets/containers to stand uncovered if they contain water

Crib Safety:
- Remove stuffed toys etc from the crib because they can step on it and attempt to
climb out
- Remove hanging mobiles from reach
- Remove hanging curtain cords

Case scenario 3
A mother brings her 18-month-old toddler for a routine well baby visit; counsel her on
toilet training.

** Toilet training involves the ability to both to inhibit a normal reflex release action and
then relax the inhibition of the involved muscles

** Toilet training depends on both physiologic and psychological readiness.

- Toilet training is recommended to begin at age 2 years

** The child must develop certain skills in order to be successful at toilet training:
i- Motor Skills- to stand, sit, and walk unaided
ii- Verbal Skills- to express needs
iii- Social skills- to be uncomfortable when messy
iv- Sensory Skills- to retain a full bladder/rectum. Therefore the child should display
evidence of dry periods. This suggests a cognitive skill which allows them to hold
in their urine
51

** When toilet training, parents should take the following approach:

1- Teach the children the appropriate vocabulary for elimination
- Ex: pee-pee, potty, messy

2- Allow the child to become comfortable with the potty before starting.
Allow the child to play with it and sit on it with their clothes on

3- Encourage cleanliness and dryness by changing children frequently.

Parents should ask their children whether they need to be changed using
the appropriate vocabulary

4- Explain the connection between dry pants and going to the potty

5- Help children understand the physiologic signals for using the toilet.

6- Routinely place the child on the potty at set intervals. Also place the child
on the potty after naps and after meals.

** Encourage children with rewards and positive approval. Do not punish them for accidents,
simply change the clothes quickly.

Case scenario 4
A mother brings her 6-year-old male child who is still wetting his bed at night. What key
information do you need to elicit from the history and examination and how would you
manage this child?

Enuresis is defined as involuntary or intentional urination in children whose age and

development suggest achievement of bladder control
- Voiding into the bed or clothing at least twice a week for at least 3 consecutive
months

** Urinary continence is achieved earlier in girls than in boys

- Therefore diagnosis of enuresis if for girls over the age of 5 years and boys over the
age of 6 years

** Diurnal enuresis- is wetting that occurs in the day

**Nocturnal enuresis (Sleep Enuresis)- refers to involuntary urination that occurs during
the night
- Primary Enuresis- is defined as a child that has never achieved sustained dryness
- Secondary Enuresis- is defined when urinary incontinence recurs after 3-6 months
of dryness
52

Causes of Enuresis
** Primary nocturnal enuresis is rarely related to an organic cause. The following are some
of the causes:
1. Faulty Toilet Training-
2. Maturational Delay- the development of the inhibitory reflex of voiding may be
delated in some children
- This may contribute to enuresis until the age of 5 years
- Unlikely that maturational delay persists as a cause of enuresis beyond this age

3. Small Bladder Capacity- some children with enuresis have smaller bladder
capacities
4. Sleep Disorder/Impaired Arousal- may have diminished arousal during sleep
5. Allergens- the ingestion of caffeine containing beverages may exacerbate nocturnal
enuresis
6. Nocturnal polyuria/Relative vasopressin deficiency- Non-enuretic children have a
diurnal variation in vasopressin secretion
- This rhythm is disrupted in some children with enuresis, resulting in nocturnal
polyuria

7. Dysfunctional Bladder Contraction- contractile disturbances of the bladder

affecting normal voiding\

** Secondary nocturnal enuresis usually results from an organic problem

- UTI - Medication- diuretics, theophylline
- Diabetes mellitus - Neurogenic bladder- in association
- Diabetes insipidus with cerebral palsy, sacral
- Nocturnal seizures agenesis, myelomeningocoele
- Genitourinary anomalies- ectopic - Psychological Causes- abuse,
ureter parental separation, school
- Sickle cell anemia problems, emotional stress
Note: When primary enuresis is both nocturnal and diurnal, some of the above causes of
secondary enuresis should be considered

** The information that should be elicited in the history should include:

1. Is the enuresis primary or secondary
2. Is the enuresis diurnal, nocturnal or both
3. How old was the child when he was toilet trained
4. How old was the child when he achieved daytime and night time dryness
5. How often does the child urinate and defecate during the average day
6. Is the child’s urinary stream forceful or dribbling
7. Presence of post-void or pre-void dribbling
8. Symptoms: polydipsia, polyuria, dysuria, urgency, frequency, problems with stooling
9. Does the child seem to delay using the toilet
10. Does the child wear diapers at any point in the day or night
11. Does the child assume any unusual or distinct postures to avoid being incontinent
12. Is there a family history of enuresis
53

Note: Enuresis has a familial basis. As many as 77% of children are enuretic if both parents
were similarly affected

** Pattern of growth should be plotted. Blood pressure should be measured

- Abdomen assessed for evidence of organomegaly, bladder size and fecal impaction
- Practitioners should determine whether children can start and stop micturition
- Dribbling in girls may indicate ectopic ureter

** The neuromuscular integrity of the lower extremities should be evaluated.

- Lower limb reflexes and sensation
- Perineal sensation

** Urinalysis including specific gravity should be done.

- Studies such as urine culture and blood glucose are more often indicated in cases of
secondary enuresis

Management
** Management is dependent on the history and diagnosis of the patient in terms of primary
or secondary enuresis.
- Need to rule out underlying organic causes

** Family counseling- issues related to psychosocial stress should be explored

- Families should be advised not to punish the enuretic child
- Children should be encouraged to take responsibility by removing the soiled bedding
and helping with the laundry
- Reward for dry nights with star charts or other means of incentive charting

** Conditioning Therapy- involves the use of an alarm that is triggered when children void
during the night
- Children are awakened by the sounding of the alarm and further urination is inhibited
- Eventually bladder distention is associated with inhibition of the urge to urinate

** Other methods that can be used are:

1) Day time bladder training- keeping the urine in as long as possible in the day time
which helps to strengthen the muscles
2) Restrict fluids before bedtime
3) Take child to the bathroom before bed (double void)
4) No punishment for wetting the bed
5) Address issues of self esteem
6) Medication- including tricyclic antidepressants and desmopressin
- TCAs, especially Imipramine have been successful in treating nocturnal enuresis
- May be due to the drug’s effect on sleep and arousal and its anticholinergic properties
- Desmopressin (DDAVP) is an analog of vasopressin
54

Note: The management of secondary enuresis should focus on the treatment of the causal
disorder

Case scenario 5
A mother brings in her 2-year-old because she thinks the child is a picky eater and is small
for her age. What key information do you need to elicit from the history and examination
and how would you manage this child?

** Nutritional Assessment- including dietary recall

** Weaning process- when the transition to soft solids, family pot etc occurred
** Use objective standards to determine if the child is small for age- therefore use growth
charts etc
- To determine if there was an acute or chronic illness in the past contributing to the
current size one needs to see the trend

** Other information in the history needed include:

- Past history of acute illnesses
- Evidence of immunocompromise
- Antenatal history of HIV
- Signs of oral thrush, recurrent OM, recurrent pneumonia

** Evidence of nutritional deficiencies on examination

- Hair signs, skin changes etc
- Evidence of anemia or other vitamin deficiencies

** Assess the family history

** Management depends on whether the child is well but is simply a picky eater OR if the
child is undernourished by objective standards

Strategies
- Tell parents that they should not allow the child to substitute a snack for a meal
- Different food groups- teach the parents that the child can get starch from alternate
areas eg bread vs rice
- Find good foods that the child wants to eat and allow them to eat it
- Disguise foods
- MVT to supplement
- High energy drinks to support decreased caloric intake
55

PNEUMONIA
Pneumonia- defined as infection of the lung parenchyma
** The incidence of pneumonia is highest in infancy and remains relatively high in
childhood
- Incidence is low in adults and increases again in old age
- Caused by a variety of viruses and bacteria
- Note: In half of cases no causative pathogen is identified
- Viruses are the most common cause in younger children and bacteria are commoner
in older children

** The pathogens that cause pneumonia vary according to the child’s age:

1. Newborn- organisms from the mother’s genital tract

- Group B streptococcus, gram-negative enterococci

2. Infants + Young Children- Respiratory viruses are common especially respiratory

syncytial virus
- Bacterial infections such as streptococcus pneumoniae, hemophilus influenzae,
Bordatella pertussis, Chlamydia trachomatis
- Staph aureus is an infrequent but serious cause

3. Children over 5 Years- Mycoplasma pneumoniae, streptococcus pneumoniae and

Chlamydia pneumoniae are the main causes

Note: Mycobacterium tuberculosis should be considered at all ages

Note: From age 1 month to 4 months, viruses are the most common pathogens

** In temperate climates, pneumonia is more common in cold months due to enhanced

person-to-person droplet spread of pathogens due to crowding
- Also due to decreased host resistance due to impaired mucociliary clearance from
dry indoor air

Other risk factors include:

1. Lower socioeconomic levels- children exposed to cigarette or wood stove smoke have a
higher incidence
2. Boys have a higher incidence as compared to girls
3. Adolescents that smoke or drink alcohol are at a higher risk because of impaired
mucociliary clearance and increased risk of aspiration
4. Children with underlying medical disorders- sickle cell, cystic fibrosis, asthma,
gastroesophageal reflux, congenital heart disease, immunodeficiency syndromes
5. Children with neuromuscular disease or seizure disorder are at risk for aspiration
pneumonia
56

Pathogenesis
** Pneumonia usually follows an upper respiratory tract infection
- Organisms that cause LRTIs usually are transmitted by droplet spread directly from
close contacts or indirectly by contaminated fomites

** After initial colonization of the nasopharynx, organisms may be inhaled

- This leads to a pulmonary focus of infection
- Less commonly bacteremia may result from the initial upper airway colonization and
leads to seeding of the lung parenchyma

** The normal pulmonary host defense system consists of multiple mechanical barriers:
- Saliva
- Nasal hair
- Mucociliary apparatus
- Epiglottis
- Cough reflex

** Humoral immunity including the secretory immunoglobulin (IgA) and serum IgG
defends against pneumonia
- Phagocytic cells (neutrophils, alveolar macrophages) also play a role in defense

Etiology
Age 1month - 4 months
Respiratory syncytial virus (RSV) has the highest attack rate in the first 6 months
- Present with symptoms of bronchiolitis usually
- Pneumonia with focal infiltrates and absence of wheezing can be seen
- Parainfluenza virus can cause similar LRTI in young infants

Chlamydia trachomatis causes a distinctive respiratory tract illness usually at 6 weeks of

age
- Due to vertical transmission
- Present with tachypnea
- Radiographs show interstitial infiltrates
- BUT children are afebrile and do not appear ill

Pneumococcal pneumonia is the most common pyogenic lung infection throughout

childhood

Few months- pre-school age

** Viruses- especially RSV and para influenza

** The major bacterial pathogen is the pneumococci

57

Clinical Features
** Fever and difficulty breathing are the commonest presenting symptoms
- Usually preceded by an URTI
- Other symptoms include: cough, lethargy, poor feeding, “unwell” appearance
- Localized chest, abdominal or neck pain is a feature of pleural irritation and
suggests bacterial infection

** The history should focus on the:

- Duration of illness
- Respiratory symptoms- quality of cough, wheezing, difficulty breathing
- Extra respiratory symptoms- fever, headache, sore throat, myalgias, lethargy
- Previous episodes of respiratory illness
- Ill contacts
- Recent antibiotic therapy
- Chronic illnesses

** The physical examination should focus on the respiratory system

- Tachypnea
- Retractions- intercostal, subcostal, suprasternal
- Wheezing
- Nasal flaring
- Grunting

Note: Tachypnea is the most sensitive and specific sign of pneumonia

- Found twice as frequently in children who have evidence of pneumonia on chest
radiography than for those with no such findings
- > 50 breaths/min at 2-12 months of age
- > 40 breaths/min at 1 to 5 years
- > 20 breaths/min for those older than 5 years
- Subtracting 10 if the child is febrile

** In addition to tachypnea findings of increased work of breathing and decreased oxygen

saturation (< 95%) are also predictive of LRTI

** Auscultator findings of pneumonia include:

- Dullness to percussion
- Decreased breath sounds
- Bronchial breath sounds

** The overall severity of illness in children with lung findings of pneumonia should be
assessed.
58

** Those that are ill-appearing, dehydrated or in respiratory distress require rapid and
aggressive management including:
- Blood cultures
- Chemistry profiles
- CBC
- Chest Radiography
- Administration of IV fluids, oxygen and antibiotics

Note: Outpatient management is sufficient for most children diagnosed with pneumonia in
primary care practice

Management
** Classic bacterial pneumonia, usually caused by pneumococci has:
- Abrupt onset- often following an URTI
- Fever
- Mild respiratory distress
- Cough that may be productive
- Focal findings on examination
- Chest pain + no wheezing
- Extra respiratory symptoms

** Children with atypical pneumonia (Mycoplasma or C. pneumoniae) are usually

- School age or older
- Present with constitutional symptoms of myalgias, fever, malaise, headache
- Gradual development of dry cough
- Chest radiograph shows bilateral patchy infiltrates

** Children with viral LRTIs generally present with upper respiratory infection symptoms
- They are usually not febrile or toxic
- Wheezing is common

** Therefore the choice of antibiotic is dependent on the cause of the pneumonia

- Note: In 50% of cases there is infection by BOTH viral and bacterial agents
- The choice is also determined by the child’s age, severity of illness and appearance
on chest X-ray
- Newborns- broad spectrum IV antibiotics
- Older infants- oral amoxicillin or augmentin
- Children > 5years- amoxicillin or an oral macrolide (erythromycin)
- Macrolides are used in older children because of the potential that their infection
being caused by M. pneumoniae or C. pneumoniae

Note: Children with an abrupt onset of symptoms, ill appearance, high temperature or focal
pulmonary findings on examination should be treated with a beta-lactam because this
indicates higher probability of bacterial infection
59

** Hospitalization may be recommended in the following types of patients:

1. Infants- between 3 weeks and 3 months are usually admitted
- Especially if they have fever, hypoxia, respiratory distress or dehydration

2. Older infants, children + adolescents- that present with signs of ongoing respiratory
distress should be admitted
3. Children- with chronic illnesses
4. Children who worsen clinically despite appropriate outpatient therapy

Complications
** Major suppurative complications of pneumonia include:
1. Parapneumonic effusion- type of pleural effusion that develop in association with
bacterial pneumonia
- May be simple and sterile
- Can develop as purulent effusions with resultant empyema
- Ill appearance, febrile, tachypnea, chest pain and splinting

2. Lung abscess- diagnosed based on chest imaging that shows a thick-walled cavity
with an air-fluid level in a child with symptoms of pneumonia
A. Lung abscesses usually develop following an aspiration event
B. May be related to a seizure or underlying neuromuscular disorder
C. Mouth organism such as streptococcus, anaerobes, staph aureus, gram
negative rods are usually involved
D. Tuberculosis should be considered

3. Necrotizing pneumonia- rare complication of bacterial pneumonia in which

liquefaction and necrosis of lung tissue is caused by toxins of highly virulent
organisms

Recurrent Pneumonia- is defined as more than one radiographically confirmed episode in a

year
OR more than 3 episodes in a lifetime

Differential Diagnosis- for recurrent pneumonia includes:

1. Anatomic Lesions- vascular rings, cysts, pulmonary sequestration
2. Respiratory Tract Disorders- cystic fibrosis, GE reflux, aspiration
3. Immunologic Disorders- HIV infection, chronic granulomatous disease,
hypogammaglobulinemia
60

Table III (Article)- Community Acquired Pneumonia: Clues to Causes

1. Age, season of year
2. Fever
3. Extra respiratory symptoms- headache, conjunctivitis, rash, myalgias, lethargy, sore
throat, anorexia, vomiting, diarrhea
4. Nature of cough, congestion, chest pain, difficulty breathing, chocking
5. Underlying disorders
6. Risk of foreign body aspiration
7. Possible TB exposure- contact with prisoners, homeless, individuals from endemic
TB areas, persons with chronic cough, weight loss and fever
8. Ill contacts/child care attendance
9. Microbial agents in the community
10. Travel history
11. Immunization status
12. Animal exposures/insect bites
13. Previous episodes of LRTI and reactive airway disease
61

Pneumonia
Defn: An inflammation or infection for the lungs

Pathology
** Lobar pneumonia has 4 stages:
1. Congestion- lasts 24 hrs and is characterized by vascular engorgement with fluid
and neutrophils in the alveoli
2. Red hepatization- involves fibrin deposition in the alveolar spaces and
extravascation of red blood cells
3. Grey hepatization- is characterized by contracting fibrinous plugs containing
degraded cells in the alveolar spaces
4. Resolution- begins after 1 week and involves digestion and macrophage-mediated
phagocytosis of fibrinous material

** Interstitial Pneumonia- the walls of the alveoli and interstitial septae are involved
1. The alveolar space is spared
2. Interstitial cellular infiltrate is present that mainly includes lymphocytes,
macrophages, plasma cells

Management Neonates
** Bacterial pneumonia in the first day of life may be impossible to distinguish from:
1. Hyaline membrane disease
2. Transient tachypnea of the newborn

** Therefore respiratory distress in newborns generally should be treated as bacterial

pneumonia until proven otherwise
When associated with chorioamnionitis it is caused most commonly by E. coli or group B
streptococci

Note: Neonates may develop bacterial pneumonia transnatally in the absence of maternal
chorioamnionitis
In these cases the causative organism is likely to be group B streptococcus
62

The Febrile Child

Normal Body Temperature = 37 deg C or 98. 6 deg F

Fever- is defined as an increase in internal body temperature by at least 1-2 deg over what is
considered normal body temperature
- Therefore a fever can be defined as an elevation of body temperature to at least 100.4 deg F
** Most febrile children have a brief, self-limiting viral infection
** Factors that need to be considered are:
1. Past medical history
2. Ill contacts
3. If a specific illness is prevalent in the community
4. Immunization status
5. Recent travel abroad
6. Contact with animals
7. Predisposition to infection- chronic illnesses

How would you determine if this child has fever? What factors affect body
temperature?
** To determine if a child has a fever begin with the history. Elicit from the parents
information regarding duration of fever, how the temperature was taken, maximum height of
fever documented at home
1. Associated symptoms- activity level of the child, appetite changes, rigor
2. Nature of the fever
3. Any chronic medical conditions
4. Any medications taken
5. Medication allergies
6. Fluid intake
7. Urine output
8. Exposures and travel
9. Immunization information

Rigor- is an episode of shivering or shaking followed by excessive sweating that follows a

rapid increase in body temperature

** Measure temperature, heart rate, respiratory rate, blood pressure and oxygen saturation
** Perform a complete physical exam, including a neurologic exam
Note especially the child’s degree of toxicity and hydration status

** Changes in general appearance that may contribute to an ill or toxic appearance include:
a) Head- bulging or sunken fontanelles in young children
b) Eyes- discharge, pupil size
c) Ears- signs of ear infection
Loss of light reflex, bulging, red and immobile tympanic membrane

d) Nose- nasal discharge

e) Mouth- dry mucus membranes or lesions, excessive drooling
63

f) Throat- erythema, exudates, lesions,

g) Neck- signs of meningeal irritation or adenopathy
h) Heart- murmur, rubs, tachycardia, bradycardia
i) Lungs- abnormal lung sounds
j) Abdomen- rigidity, guarding, abnormal bowel sounds
k) Genitals- rash, discharge, urinary changes
l) Neurologic status- lethargic, non-consolable
m) Extremities- signs of osteomyelitis, cellulitis, septic arthritis

** Factors affecting body temperature include: physiological causes and non-physiological

causes

Physiological Causes
a) Endocrinopathies- hyperthyroidism
b) Diurnal variations- lower temperatures in the early morning and higher
temperatures in the evening/late afternoon
c) Ovulation
d) Factors which increase the metabolic rate
e) Exposure to excessive environmental heat
f) Exercise

Non-Physiological Causes
a) Clothing- increased amounts of clothing can raise temperature
b) Drugs- steroids, cocaine, anesthetics (malignant hyperthermia in susceptible
individuals), atropine, overdose of salicylates
c) Infections- viral, bacterial, parasitic etc
d) Ectodermal dysplasia- congenital absence of sweat glands
e) Malignancies
f) Metabolic diseases
g) Autoimmune diseases- SLE, Kawasaki disease
h) Chronic inflammatory conditions
i) CNS abnormalities

What methods are used to measure body temperature?

** Temperature in pediatric patients can be measured in a variety of ways:

a) Rectal- using a mercury or digital thermometer- measures core temperature and
should be left in place for 3 mins
b) Oral- using a mercury or digital thermometer
c) Axillary- mercury, digital or liquid crystal strip
d) Forehead- liquid crystal strip
e) Tympanic- this type is quick and requires little patient cooperation
- Shown to be less accurate in infants younger than 3 months
- Subject to false readings if the instrument is not positioned properly or the external
ear canal is occluded by wax
64

How does the body produce fever?

** Fever is can be caused by abnormalities of the brain itself or by toxic substances that
affect the temperature regulating centers
Therefore fever occurs when there is a rise in the hypothalamic set point in response
to endogenously produced Pyrogens

** Proteins, breakdown products of proteins and lipopolysaccharide toxins released from

bacterial cell membranes along with other exogenous Pyrogens stimulate the body’s
immune system
- As a result macrophages and white blood cells are activated
- They produce cytokines such as IL-1, IL-6, TNF
- These cytokines stimulate the production of endogenous Pyrogens
- The result is that prostaglandins (PG-E2) are produced that reset the
hypothalamus
- This re-setting activates physiological and behavioral changes to release heat from
the body

What other causes of elevated body temperature exists and how do they differ from
true fever?
** Other causes of elevated body temperature include dehydration
- Over-bundled with clothes in a relatively warm environment

** True fever is defined as an increase in body temperature due to an elevation of the

thermal set point in the anterior hypothalamus secondary to the release of Pyrogens

** With hyperthermic conditions other than true fever, the hypothalamic set point is not
adjusted
- Therefore a fever occurs when the body sets the core temperature to a higher
temperature, through the action of the anterior hypothalamus
- However hyperthermia occurs when the body temperature is raised without the
consent of heat control centers

** Non-febrile hyperthermia occurs when heat gain exceeds heat loss such as with:
- Inadequate heat dissipation
- Exercise
- Drugs- amphetamines, cocaine, SSRIs
- Environmental Causes
- Conditions that result in increased metabolic activity

Note: In addition giving anti-pyretics can reduce true fever. These drugs have no benefit in
the treatment of hyperthermia
** Hot, dry skin is a typical sign of hyperthermia. Fever by contrast usually produces cool,
damp skin
 65

p) How do you classify fever?

Fever classification
Temperature in
rectum, Temperature in mouth Temperature under the arm
vagina, or ear (oral temp.) (axillary temp.)
(core temp.)
Grade °C °F °C °F °C °F
low grade 38-39 100.0-102.2 37.2-38.2 99-100.8 36.8-37.8 98.4-100.2
moderate 39-40 102.2-104.0 38.2-39.2 100.8-102.6 37.8-38.8 100.2-102
high-grade 40-41.1 104.0-106.0 39.2-40.3 102.6-104.6 38.8-39.9 102-104
hyperpyrexi
>41.1 >106.0 >40.3 >104.6 >39.9 >104
a

Low grade fever = viral origin

High grade fever = severe bacterial illness, septicemia, salicylate toxicity, inflammatory
disease, malignancy

** Fever can also be classified according to whether it is continuous or intermittent

iv- Continuous Fever- Temperature remains above normal throughout the day and
does not fluctuate more than 1 deg C in 24 hrs
- Ex: typhoid fever

v- Intermittent Fever- Elevated temperature is present only for some hours of the day
and becomes normal for remaining hours
- Ex: malaria

vi- Remittent Fever- Temperature remains above normal throughout the day and
fluctuates more than 1 deg C in 24 hrs
- EX: infective endocarditis

vii- Hectic Fever- persistent elevations of temperature but with wide variations
throughout the day
- Also known as a spiking fever
- Ex: abscesses, Pel-Ebstein fever (cyclical fever associated with Hodgkin’s
lymphoma)

Defn: Fever of Unknown Origin- Fever that lasts for more than 7 days which has been
adequately investigated and no cause can be found

What information do you need to determine this infant’s problem?

** Information needed is related to the differential diagnosis of fever in infants
66

Upper respiratory tract infection

- Sneezing
- Nasal discharge
- Problems swallowing
- Enlarged lymph nodes

Lower respiratory tract infection

- wheezing
- cough
- Chest pain
- Shortness of breath
- Signs of respiratory distress

Otitis Media
- Signs of ear boxing
- Irritability

Pharyngitis
- Drooling
- Refusing food

Viral Exanthem (Skin rashes)

- Parvovirus- fever + rash (erythematosus macular rash on cheeks) “slapped cheek
appearance
- Measles Rash- begins at the hairline and moves to face and arms
- Varicella- usually starts on the trunk and moves outwards
- Coxsackie Rash- hand + foot + mouth- abrasions/ulcers in the oral cavity, vesicular
rash on fingers and toes
- Roseola Infantum- rash follows a high fever. Begins on the face and spreads
downwards

Urinary Tract Infection

- Vomiting
- Malodorous urine
- Changes in urine color
- Signs of pain/crying during micturition
- Presence of blood in the urine

Features of sepsis

Diarrheal Disease
- Viral diarrhea tends to be watery and non-bloody
- Blood + mucus in the stool along with high fever is suggestive of dystentery
(bacterial infection)
67

Kawasaki Disease
- Enters the differential for a fever that lasts longer than five days
- Initially known as mucocutaneous lymph node syndrome
- 80% of patients are younger than 5 years

** The diagnostic criteria are fever for more than 5 days and at least 4 of the following
features:
1. Bilateral, painless, non-exudative conjunctivitis

2. Lip or oral cavity changes- lip cracking/fissuring, redness, strawberry tongue (red
tongue + prominent papillae),, inflammation of the oral mucosa

3. Cervical lymphadenopathy- more than 1.5 cm in diameter and usually unilateral

4. Polymorphous exanthema- skin eruption involving the trunk and extremities

- Rash usually appears within 5 days of the fever
- Papular or maculopapular rash
- Vesicles/bullae are not seen

5. Extremity changes- redness of palmar surfaces, swelling of the dorsum of hands/feet,

desquamation of skin over these areas

** The potential for cardiovascular complications is the most serious aspect of Kawasaki
disease. Complications during the acute illness include:
- Myocarditis
- Pericarditis
- Valvular heart disease (mitral or aortic regurgitation)
- Coronary arteritis

** Coronary artery lesions range from mild transient dilation to large aneurysms
- Aneurysms rarely form before day 10 of illness
- Untreated patients have a 15-25% risk of developing coronary aneurysms

** Those at greatest risk of aneurysm are:

- Males
- Young children <6 months
- Those not treated with IVIG

** Early treatment using IVIG is required before the 10th day of the illness
- Therapy is effective in decreasing the incidence of coronary artery dilation and
aneurysm formation

Note: The differential diagnosis of a fever lasting more than 5 days includes:
- Unusual viruses- eg EBV
- Bacterial focus of infection
- Inflammatory diseases
68

- Malignancy
- Kawasaki Disease

What other historical data would you elicit if the boy was less than one month old and
older than 3 years?

Child less than a month old

** A history from the mother is needed regarding the pregnancy and delivery
- Typically infections that occur in the first month of life are secondary to vertical
transmission
- Infections after the first month are usually community acquired

** Maternal history of the following infections are needed (TORCHS)

- Toxoplasmosis
- Rubella
- Cytomegalovirus
- Hepatitis B/C, Herpes, HIV
- Syphilis
- Maternal group B streptococcus status and prophylaxis

** In addition the mother should be asked if she had symptoms of high fever, skin rash, or
joint pain at any time during pregnancy
- UTI during pregnancy
- Vaginal discharges during pregnancy
- If she received HIV treatment or prophylaxis before delivery

** Information regarding the nature of the delivery:

- Mode of delivery
- Prolonged rupture of membranes
- Rupture of membranes before the onset of labor
- Septic or traumatic delivery

Chorioamnionitis - is an inflammation of the fetal membranes (amnion + chorion) due to

bacterial infection
- Results from bacteria ascending into the uterus from the vagina
- Most often associated with prolonged labor
- Uterine tenderness
- Foul odor
- Fetal distress

** Information about the neonates nursery course should be noted, including the age at which
the patient was discharged from the nursery
- If circumcision was done or not
- Use of peripartum or antepartum antibiotics
- Diet and if formula fed, hygiene surrounding bottle preparation
- Sleep histories
69

Note: Decreased oral intake or an acute change in sleep patterns may be clues to infection

** For a child older than 3 years, an immunization history is important

What features in the examination would you elicit to rule out meningitis? How do the
features change with age?
Meningism is the triad of:
- Nuchal rigidity
- Photophobia
- Headache

** The main clinical signs that indicate meningism are

4- Nuchal Rigidity- the inability to flex the head forward due to rigidity of the neck
muscles
5- Kernig’s sign
6- Brudzinski’s Signs- appearance of involuntary lifting of the legs in meningeal
irritation when lifting a patient’s head

** Signs of meningeal irritation. Inflammation or irritation of the meninges can lead to

increased resistance to passive flexion of the neck and the extended leg
- The corresponding signs are neck stiffness (nuchal rigidity) and Kernig’s sign

Kernig’s sign is positive when attempts to extend the knee are resisted by spasm, which is
detected in the hamstrings, and the other leg may flex at the hip and knee
Note: Kernig’s sign is not present in local causes of neck stiffness
- EX: cervical spine disease or raised intracranial pressure

** The most common causative organism varies with age:

vi- Neonates- E. coli and Group B streptococcus
vii- Infants 30-60days- Group B streptococcus
viii- Infants > 2 months- S. pneumoniae and N. meningitides
ix- Pre-school child- H. influenzae
x- Older child and adult- N. meningitides, S. pneumoniae, atypical organisms
(mycoplasma)

** For bacterial meningitis, the younger the child, the less likely he/she is to exhibit the
classic symptoms of fever, headache and meningeal signs

** Children younger than 3 months have very non-specific symptoms including:

hypothermia or hyperthermia, change in sleeping or eating habits, irritability or lethargy,
vomiting, high-pitched cry or seizures
- Irritability especially when being held
- Fever, vomiting, anorexia, lethargy
- Petechial rash- meningococcal infection
70

** After age 3 months the child may display symptoms associated with bacterial meningitis:
- Fever, vomiting, irritability lethargy or any change in behavior

Note: Fontanelle bulging, diastasis of the sutures and nuchal rigidity point in meningitis in
young infants but are usually late findings

** After age 2-3 years children may complain of headache, stiff neck and photophobia

What are the common causes of fever in children less than one month old, 3-36 months,
older than 3 years?
< 1 month
- Serious bacterial infections
- Vertical transmission of infection

>3 years
- Viral infection

What groups of children are considered high risk when they have a fever?
- Neonates up to 2 months- some persons extend the definition to include children 3
months and younger
- Children with incomplete immunizations or immunizations not up to date for age
- Immunocompromised children
- Children with indwelling catheters, lines or shunts
- History of chronic illness- sickle cell, cancer, diabetes
- Children with a stoma- meningomyelocele
- Steroid therapy or chemotherapy
- Malnourished children

Note: Children with congenital heart disease are not necessarily higher risk or more prone to
infection in general BUT they are susceptible to developing specific conditions such as
infective endocarditis

What investigations would you do? Do investigations vary with age?

A fever in a child younger than one month is an indication for a full sepsis screen
** A full sepsis evaluation is recommended in all febrile neonates. This includes:
- CBC count
- Blood culture
- Urinalysis
- Urine Culture
- CSF analysis and culture- CSF should be assessed for CBC count and differential,
glucose level, protein level, gram stain and routine culture
- Stool culture- if diarrhea is present

** A chest radiograph should be considered for neonates with signs of respiratory illness
- Coryza, cough, tachypnea, rales, rhonchi, nasal flaring or wheezing
71

** Lumbar puncture should be performed on the following children unless contraindicated

- Infants younger than 1 month
- All infants aged 1-3 months who appear unwell
- Infants aged 1-3 months with WBC less than 5 x 10 9 or > 15 x 10 9

** A child under 18 months that is moderately ill, one should have a high index of suspicion
- Therefore an LP is often performed even in the absence of meningeal signs

** The approach to fever in a febrile infant depends on the clinical findings after examination

q) What complications may occur with fever?

- Febrile seizures
- Dehydration
- Brain damage secondary to hyperpyrexia

How is fever treated?

** Use of antipyretics:
i- NSAIDs- have a longer duration of action but should not be used until gastritis is
ruled out, especially if a child is not eating
ii- Acetaminophen- side effects are liver toxicity after overdose

Note: Anti-pyretics do not prevent febrile convulsions

- Because the convulsions tend to be the initial manifestation of the illness
- Also because the convulsions usually follow a rapid rise and therefore the fever could
not have been anticipated

** No evidence that tepid sponging works. Sponge the child from head to toe with room
temperature water
- But do not allow the child to shiver

** Do not use rubbing alcohol because the fumes may be toxic

- Also only causes cutaneous vasoconstriction
- Therefore the skin only feels cool to touch temporarily

** Do not bundle children with fever and do not immerse in ice water
72

Skin Rashes
** Rashes are assessed in terms of appearance:
i- Macular- flat
ii- Papular- raised
iii- Squamous- scaly
iv- Vesicular- fluid filled
v- Bullous- large and fluid filled

** The extent of the rash is also determined. Rashes may be described as generalized or
localized
- Note the location of the rash as well

** In addition, rashes that are associated with fever can be differentiated from those that are
not.
- Rashes seen in febrile children are called exanthems
- Exanthems may be associated with enanthems (lesions in the oral cavity)

** Papulosquamous eruptions are raised, scaly lesions.

- They are often localized to certain parts of the body
- But the site varies according to the age of the child
- The rashes are frequently pruritis BUT the children are usually afebrile

** Two of the most common causes of papulosquamous eruptions in children are:

- Atopic dermatitis
- Scabies

** Atopic dermatitis affects about 3-5% of children. Males and females are affected with
equal frequency
- The itching associated with atopic dermatitis and other pruritic rashes is worse at
night
- Symptoms are often worse during the winter months

Clinical Presentation- Papulosquamous Rashes

** Papulosquamous eruptions consists of erythematosus, raised, scaly lesions that may
involve the face, trunk or extremities
- The lesions are highly pruritic
- Scratching may lead to excoriation or secondary infection
- Sometimes multiple family members are affected
- Chronicity may lead to thickening or lichenification of involved skin
73

Pathophysiology- Atopic Dermatitis

- Attributed to immune dysfunction
- Characterized by IgE overproduction and diminished cell-mediated immunity
- Non-IgE immune factors, particularly T-helper cells and cytokines IL-4 + IL-5 also
play a role
- Disturbances in fatty acid metabolism, especially deficiencies in omega-6 fatty acid
are noted in some infants
- The result is inflammatory hyperactivity of the skin and other sites (lungs, nasal
tissues)

Pathophysiology- Scabies
- Inflammatory response is triggered by an infestation with a mite Sarcoptes scabiei
- Adult female burrows under the skin and lays her eggs
- After 2 weeks the eggs become adults
- With time, usually 10-30 days after infestation, signs and symptoms become apparent

** The reaction relates to the development of cellular or humoral immunity to the mite,
feces or eggs
- In infants the rashes may develop in areas away from the site of infestation as a sign
of an allergic reaction to foreign material

** Scabies may resemble atopic or seborrheic dermatitis in infants and young children
- The lesions may be papules, pustules or vesicles
- The characteristic burrow is usually about 1 cm long
- Lesions are most often noted on the skin of the hands and feet
- Including the palms and soles in infants and young children
- Intertriginous areas- intraglueal region, groin and finger webs are commonly
infected
- Scratching and secondary infection may alter the appearance of the rash

Note: Reddish-brown nodules may be characteristic of chronic infection

- These nodules may be an immune reaction to the dead mite

Differential Diagnosis
** The major conditions that are associated with papulosquamous eruptions in children are:
- Atopic dermatitis - Psoriasis
- Seborrheic dermatitis - Papular urticaria
- Allergic contact dermatitis - Flea bites
- Scabies - Fungal infections of the skin
- Xerosis - Infantile acropustulosis dermatosis
- Lichen planus
74

Note: Eczema is a general term used to denote a papulosquamous eruption.

** The two most common eczematous conditions seen in children are:
1. Atopic eczema (dermatitis)- is a disorder of infancy and childhood

- 60% of affected individuals become symptomatic with a pruritic rash during the
first year of life
- 85% develop symptoms during the first 5 years
- The area of involvement changes with age
- Infancy/childhood- the face and extensor surfaces are involved. The diaper area is
often spared
- Adolescence- the flexor surfaces show the changes of chronic inflammation with
lichenification and accentuation of the flexor folds
- Clinically- erythema and a pruritic papular eruption are apparent
- Scratching and rubbing leads to excoriation, weeping and eventually lichenification
- Changes in coloring (hypo/hyperpigmentation) may also occur
- Note: Hypopigmented areas known as pityriasis alba are noted on the face
- Xeroderma (dry skin) is a frequent co-existing condition
- Lesions around the mucosa include:
- Dennie-Morgan infraorbital fold- under the eye
- Cheilitis- around the mouth (inflammation)

Note: Symptoms of other allergic conditions, such as rhinorrhea, wheezing, food-related

allergies may occur
- A positive family history is usually elicited

2. Seborrheic dermatitis - develops during the first 3 months of life

- Characterized by scaliness, especially of the scalp
- Scalp eruptions are referred to as cradle cap
- Prefers intertriginous areas (folds of the diaper region, area behind the ears)
- Intertriginous areas- areas of apposed skin surfaces
- Scaly eruptions may involve the eyebrows and around the nose
- The reddish or pinkish rash may have a greasy quality

Note: The use of baby oil often exacerbates the condition

- Secondary infection may occur with candida in the intertriginous areas or with
Pityrosporum in the scalp
- Seborrheic dermatitis is less pruritic than atopic dermatitis

Note: The intertriginous involvement and the onset shortly after birth also differentiate
these two types of dermatitis
75

Contact Dermatitis
- Occur when individuals come into physical contact with an irritant or a specific
allergen
- Diaper dermatitis and Rhus dermatitis (poison ivy/oak) are two common types of
contact dermatitis
- Hands and exposed areas are frequently affected
- The rash is papulosquamous, oozing and may become lichenified

** There are two types of contact dermatitis:

Primary Irritant- develops within a few hours, reaches a peak severity at 24 hrs then
disappears
- Diaper dermatitis is the most common form of primary irritant contact dermatitis
- Caused by prolonged contact of the skin with urine and feces
- The excreta contains irritating chemicals such as urea and intestinal enzymes
- Erythema and scaling of the skin in the perineal area
- 80% of cases that last more than 3 days, the affected area becomes colonized by C.
albicans.

Allergic eczematous- has a delayed onset of 18 hrs, peaks at 48-72 hrs

- May last as long as 2-3 weeks even if exposure to the allergen is discontinued
- Has features of delayed type (T-lymphocyte mediated) hypersensitivity

Xerosis (Xeroderma)
- Dry skin
- Frequently fund in patients prone to atopic dermatitis
- May be seen in other individuals under drying conditions
- EX: low humidity, frequent bathing with drying soaps
- Skin may be scaly and pruritic
- Scratching may result in excoriations
- Note: A papular eruption is usually absent

Lichen Planus
- Papulosquamous eruption
- Polygonal, brownish-pink, scaly lesions are located on the flexor surfaces

Psoriasis
- Papulosquamous eruption with more plaque-like features
- Older children- face and scalp affected
- Infants- eruptions usually occur in the diaper area
- May becomes secondarily infected by Candida
- Only mildly itchy
76

Papular Urticaria
- Found in children between the ages of 3 years and 10 years
- Characterized by grouped erythematosus papules surrounded by a urticarial flare
- Papules are distributed over the shoulders, upper arms and buttocks
- Lesions represent delayed hypersensitivity reactions to stinging/biting insects
- Usually a reaction to flea bites
- Other insects: mosquitoes, lice, scabies, bird + grass mites
- Usually no other family members are affected
- Treatment: Remove the offending insect
- Use topical corticosteroids and oral antihistamines to treat

Note: Papular urticaria is characterized by crops of symmetrically distributed pruritic

papules
- May occur on any body part
- BUT tend to be grouped on exposed areas, especially the extensor surfaces of the
extremities

Fungal Infections
- Tinea corporis + tinea pedis
- May appear as papulosquamous eruptions
- Papules may be grouped in a circle with a central clearing of the scaliness

Infantile acropustulosis
- Very pruritic papules and vesicles on the sides of the hands and feet
- Lesions become scaly and hyperpigmented
- Evidence of secondary infection
- Found mainly in African-American and Native American children under age 3
years

Rash History
- How long has the child had the rash?
- What did the rash first look like when it appeared
- Are other family members affected
- Have any medications been used to treat the rash
- +/- pruritis
- Associated symptoms- wheezing, rhinorrhea
- Does the child have a history of contact between the affected skin and any irritating
substance
- Has the child been febrile

Note: The presence of rash in other family members suggests:

- Contagious condition such as scabies
- Familial disorder- atopic dermatitis or psoriasis
- An onset in the first few weeks of life is consistent with seborrheic dermatitis
77

Examination
- Nature of the eruption and distribution
- Examine entire body
- Especially intragluteal region + web spaces between fingers and toes

Management
** Topical steroids used to treat various PS eruptions and minimize inflammation
- Triamcinolone 0.1%, hydrocortisone cream- used for atopic and seborrheic dermatitis
- Systemic steroids- may be needed for more severe exacerbations
- Psoriasis- does not usually respond to hydrocortisone 1% alone nad may require a
combination tar-hydrocortisone preparation

** Management of atopic dermatitis involves the reduction of dryness and irritation

- Avoid the use of drying soaps
- Apply moisturizers after bathing

** Antibiotics are indicated if secondary infection is present

- Staph aureus is the most common pathogen involved
- Topical antibiotics (muciprocin, bacitracin) may be used in localized secondary
infections

Maculopapular Rashes
** Maculopapular rashes can involve the face, trunk or extremities
- The rash is usually erythematosus and the lesions are flat or slightly raised
- Occasionally lesions in the mouth (enanthems) are seen
- Most children are febrile

** The pathophysiology of the rash is variable. In some case the rash is the reaction of the
body to infection or the presence of a toxin
- Exposure to an infectious agent through droplet contamination or fecal-oral
contamination
- The agent replicates usually in the reticuloendothelial system
- Lymphadenopathy is common

Note: Maculopapular rashes are associated with several diseases:

- Measles, rubella, erythema infectiosum, roseola, enterovirus-caused diseases,
Kawasaki syndrome, scarlet fever
78

Viral Exanthems

Type of Lesion (Primary Lesions) Infection

Macular/papular/maculopapular
Macules- red/pink discrete flat areas that
blanch on pressure. Any circumscribed color
change in skin that is flat
Papules- solid, raised hemispherical lesions,
less than 1 cm that blanch on pressure
Purpuric/Petechial
Non-blanching red/purple spots
Vesicular
Circumscribed, elevated lesion <1cm in
diameter and containing clear serous fluid
Pustular/Bullous
Bulla- circumscribed elevated lesion >1cm in
diameter, containing clear serous fluid
Pustule- a vesicle containing a purulent
exudate
Desquamation
Dry and flaky loss of surface epidermis
Rubella- macular only, measles,
HHV6/7, enterovirus
Uncommon: scarlet fever, Kawasaki
Disease
Non-infectious- drug rashes
Meningococcal, enterovirus,
thrombocytopenia
Chickenpox, shingles, herpes simplex,
hand foot and mouth disease
Impetigo, scalded skin syndrome
Post scarlet fever, Kawasaki disease

Exanthem- is a widespread rash that is usually accompanied by systemic symptoms (fever,

malaise, headache)
- Usually caused by an infectious agent (eg virus)
- Represents either a reaction to a toxin produced by the organism, damage to the skin
by the organism, or an immune response

** Childhood exanthems are common and are usually associated with the following viral
skin infections

Erythema infectiosum (Fifth disease)

- Caused by human parvovirus B19
- Most commonly seen in children aged 5-15 years during the spring
- Spread is through respiratory secretions
- Non-specific mild flu-like illness may occur during the initial viremia at 7-10 days
- Characterized by a sudden onset of the rash
- The characteristic rash occurring 10-17 days represents an immune response
- The patient is viremic and contagious prior to but not after the onset of the rash

** Presents with fever and rash. The rash begins as raised, fiery red maculopapular lesions
on the cheeks
- The lesions coalesce to give the slapped cheek appearance
- Lesions are warm, non-tender and sometimes pruritic
- Found scattered on the forehead, chin, postauricular areas
- BUT not on the circumoral regions
79

- Within 1-2 days similar lesions appear on the proximal extensor surfaces of the
extremities
- Spread distally in a symmetrical fashion
- Palms and soles are usually spared
- Trunk, neck and buttocks are commonly involved

** The rash fades in several days to several weeks

- BUT frequently reappears in response to local irritation, heat (bathing), sunlight,
stress

** Mild systemic symptoms may occur in up to 50% of children

- Low grade fever, mild malaise, sore throat and coryza
- Symptoms appear for 2-3 days and followed by a week-long asymptomatic phase
before the rash appears

Note: Although most children are only mildly ill, children with underlying hematologic
disorders may experience aplastic crises

Measles
- High fever and lethargy
- Rash is preceded by symptoms such as sneezing, eyelid edema, tearing, copious
coryza, photophobia and eventually harsh cough
- Koplik spots appear on the buccal mucosa
- Forschhermier spots- are pinpoint, rose-colored, petechial spots on the soft palate
- Discrete maculopapular rash begins when the respiratory symptoms are maximal
- Rash spreads quickly over the face and trunk and coalesces to a bright red
- As it involves the extremities it fades from the face
- Disappears completely within 6 days
- The fever peaks when the rash appears and usually falls 2-3 days afterwards

Note: The conjunctivitis associated with measles is purulent, which distinguishes it from
Kawasaki syndrome
- Measles rash usually begins on the head, especially behind the ears and around the
edges of the scalp
- Spreads over the rest of the body
- Initially the lesions are discrete papules that coalesce and become pruritic
- Associated with lymphadenopathy, especially in the posterior cervical region

Rubella
- Older children have a non-specific prodrome of low grade fever, ocular pain, sore
throat + myalgia
- Post-auricular and suboccipital adenopathy is characteristic
- Rash consists of erythematosus, discrete maculopapules beginning on the face
- Rash consists of fine macules and papules that start on the face and progress causally
- Rash spreads quickly to trunk and extremities
- Disappears in 4 days
80

Roseola Infantum
** Benign illness caused by human herpesviruses 6 or 7
Virus is shed in the saliva
- Characterized by an abrupt onset of fever
- May reach as high as 40.6 deg C
- May last up to 8 days (average 4 days) in an otherwise mildly ill child
- Fever then ceases abruptly (defervescence) and a characteristic rash appears
- Rash consists of fine pink macules and papules on the neck and trunk
- Usually occurs in children aged 6 months to 3 years (90% of case occur before the
second year)

** Rash begins on the trunk and spreads to the face, neck and extremities
- Rose pink macules or maculopapules 2-3 mm in diameter
- Non-pruritic, tend to coalesce and disappear in 1-2 days without pigmentation or
desquamation

** Infants may appear sickest during the prodromal phase, when the fever is very high
- Therefore may need tests to rule out sepsis

Note: In children who receive antibiotics or other medication at the beginning of the fever,
the rash may be attributed incorrectly to drug allergy

Enteroviruses
- Most common cause of exanthems in the summer months
- 68 types of enteroviruses are recognized
- Previously they were classified as coxsackievirus, echovirus or poliovirus

** The rashes associated with enterovirus infections are highly

Scarlet Fever
- Bacterially transmitted illness that can produce a maculopapular eruption
- The rash and illness are due to an exotoxin produced by group A beta-hemolytic
streptococcus
- Usually seen in young children with pharyngitis
- Incubation period is 2-5 days
- Symptoms of fever (103 deg F), headache, vomiting, malaise and sore throat appear
suddenly
- Tonsils are covered with a white exudate and palatal petechiae are seen
- Edema of the papillae make them appear prominent
- The face is flushed EXCEPT around the mouth (circumoral pallor)
- A discrete facial rash is absent
- The fine rash is concentrated on the trunk and intensified in the flexor folds
- Pastia’s Lines- bright red lines noted in the antecubital fossa
- As the scarlet fever rash resolves, desquamation begins in 4-5 days
81

EBV
- Associated with rash in young children
- Eruption is morbilliform (measles-like)
- Lesions may be erythematosus or copper-colored

** Associated symptoms with EBV rash include:

- Fever, upper respiratory symptoms
- Lymphadenopathy
- Hepatosplenomegaly
- Facial and peripheral edema- including unilateral periorbital edema

Coxsackie Virus (Enterovirus)

Hand-foot-mouth disease caused by the coxsackieviruses
- Vesicles or red papules are found on the tongue, oral mucosa, hands and feet
- Often appear near the nails and on the heels
- Associated fever, sore throat and malaise are mild

Varicella
- Mild systemic symptoms followed by crops of red macules that rapidly become
small vesicles with surrounding erythema
- Vesicles eventually form pustules and become crusted and then scab over
- Rash appears mainly on the trunk and face
- Lesions can occur in the scalp, mouse, nose, conjunctiva and vagina
- Severity of systemic symptoms parallels the skin involvement
- Intense pruritis
-

Physical Examination
** The focus of the physical examination is to help define the characteristics of the eruption
- Location, extent + degree of coalescence

** The presence of any associated physical findings

- Fever, lymphadenopathy
- Enanthem, desquamation
- Rhinorrhea
- Conjunctivitis
- Organomegaly
- CNS symptoms

Laboratory Tests
** Serologic testing is most valuable for defining a community outbreak of a specific
disease
- Ex: measles

** Viral cultures are usually not obtained unless aseptic meningitis is diagnosed
82

** Neutropenia and lymphocytosis characterize many viral illnesses. Therefore they are not
helpful in differentiating between causal agents
- Lymphocytosis- with characteristically atypical lymphocytes distinguishes EBV
infection

** Scarlet fever is characterized by leukocytosis

- Throat culture reveals the presence of group A-beta hemolytic streptococci

** Kawasaki syndrome is associated with a few laboratory abnormalities- elevated

- Elevated platelet count
- Erythrocyte sedimentation rate
- C-reactive protein
- Alpha anti-trypsin
- IgE
- Hypoalbuminemia- with prolonged fever
83

Vesicular Exanthems
** Varicella is the most common vesicular exanthem seen in childhood

** Vesicular exanthems are lesions that are raised and fluid-filled

- Lesions may be pruritic
- Other symptoms that may accompany these rashes include: fever, upper respiratory
symptoms, + decreased appetite
- Find history of affected contacts
- Lesions may appear on mucus membranes

** Vesicles and bullae arise from a cleavage at various levels of the skin either within:
i- Intraepidermal- within the epidermis
ii- Subepidermal- at the epidermal-dermal junction

** Specific changes occur in the epidermis depending on the etiology of the vesicular
exanthem:
1- Ballooning Degeneration- varicella, herpes simplex, herpes zoster
2- Spongiosis- intracellular edema as seen in dyshidrotic eczema

Differential Diagnosis
** Parasites such as Sarcoptes scabiei can cause an intensely pruritic vesicular eruption in
combination with papules and linear burrows

** Fungal pathogens that cause vesicopustular lesions that appear on the feet include:
- Trichophyton rubrum
- Epidermophyton floccosum

** A delayed hypersensitivity reaction secondary to contact with poison ivy/oak causes the
classic linear vesicular lesions of Rhus dermatitis

** The differential diagnosis of acute vesicular exanthems also can be organized according to
the distribution of the lesions.
- Distinctive locations as well as specific patterns are important
- Presence or absence of fever (temperature >101 deg F)
- Historic information- such as known exposure to varicella prior to eruption, contact
with poison ivy/oak
- Presence of a specific prodrome
- Pain on swallowing often occurs with coxsackie virus infection

Note: A past history of similar lesions lessens the likelihood of acute primary infection
- Suggests a chronic condition such as dyshidrotic eczema
84

Physical Examination
** Take vital signs to verify +/- fever
** Examine the oropharynx for vesicular/ulcerative lesions on the tongue, gingival, buccal
mucosa, anterior tonsillar pillars + posterior pharynx

** Examine the lips for evidence of vesicular lesions that may occur with a primary or
recurrent herpes simplex infection

** Determine if the vesicles are grouped in a particular dermatomal distribution as with

zoster (shingles)
- More generally distributed and in various stages of development as in varicella
- Linear distribution may suggest contact with poison ivy or poison oak

Laboratory Tests
** Definitive confirmation of scabies can be made by microscopic examination of skin
scrapings from suspicious lesions
- Presence of the adult mite or ova, larva or feces is diagnostic

** A Tzanck smear shows multi-nucleated giant cells that contain intranuclear viral
inclusions may be useful in making a preliminary diagnosis of a herpesvirus

Treatment
** Conditions are usually self-limited and require only supportive therapy

1- Topical Agents- used in children with intense pruritis or multiple lesions.

- Ex: calamine lotion, oatmeal soaks etc
- Topical products that are potentially sensitizing should not be used
- Ex: diphenhydramine

2- Antipyretics- (acetaminophen, ibuprofen) used to treat children with fever in

varicella
- Also for symptomatic relief of pain associated with coxsackie virus mouth lesions

3- Oral antihistamines- used in varicella or scabies for the pruritis

4- Steroids- should only be used after one is sure that the lesions are NOT secondary to
varicella or HSV
5- Oral acyclovir- should be considered for generalized eruptions or in
immunocompromised patients
85

Preventive Strategies in the Management of Illness: A Pediatric Perspective

Primary Prevention: To preserve health by removing the precipitating cause or

determinants of ill health
- To decrease the incidence of disease and injury
- Reduction of the number of new cases of a disease, disorder or condition

Secondary Prevention- To detect and correct illness as early as possible

- To decrease the prevalence of disease and disability
- To screen before disease is manifested by symptoms or signs
- Reduces the prevalence of disease and other illness by shortening their duration or
diminishing their impact through early selection

Tertiary Prevention- Rehabilitation

- Reduces impairment and disabilities to minimize the suffering caused by existing
disease
Note: The primary preventive medicine has changed the causes of death of children over the
last century

Therapeutic Alliance- requires an understanding and appreciation of the individual context

of each child and his/her family
- Allows greater opportunity for primary prevention and early detection of disease
between health supervision visits

Major Childhood Illnesses

Newborn Child
- Prematurity - Poisoning
- Jaundice - Accidents + injuries
- Respiratory distress - Infections
- Congenital anomalies - Nutritional problems
- Infection
Adolescent
Infant - Accidents + injuries
- Diarrheal illnesses - STI/HIV
- Respiratory infections - Teenage pregnancy
- Nutritional problems - Depression/suicide
- Injuries - Substance abuse

Overview of Prevention Principles

- Provide safe environment
- Enhance immunity
- Promote a healthy lifestyle
- Maintain good nutrition
- Have well-born children
- Provide healthcare prudently
86

1) Provide safe environment

- Appropriate waste and sewage disposal
- Control of vectors- mosquitoes, dengue fever, malaria
- Food hygiene- pasteurization/food poisoning
- Provision of safe water
- Appropriate housing- to prevent overcrowding

2) Enhance immunity- through immunization

3) Promote healthy lifestyle

- Education + counseling about diet to prevent obesity
- Accidental poisoning prevention
- Avoiding passive smoking
- Dental care- brushing, flossing, fluoridation, preventing baby bottle decay
- Injury prevention- seat belt legislation, child safety seats, pool fence, remove guns,
ammunition in secure location
- Prevention of key adolescent issues- STI/HIV, teenage pregnancy,
depression/suicide, substance abuse
- Psychological immaturity of teens
- Peer pressure
- Voluntary testing and treatment of STIs

4) Maintain good nutrition- breastfeeding

- Appropriate complementary feeds
- Prevent nutritional deficiencies
- Prevent obesity

5) Have well born children- appropriate antenatal care

- Avoid exposure of developing fetus to toxins
- Screening- antenatal screening (HIV/HBV, ultrasound)
- Newborn screening- sickle cell disease, thyroid disease

6) Provide anticipatory healthcare-

- History
- Regular physical examinations
- Dental care
- Screen for abuse
- Anthropometry including BMI
- Developmental assessment
- School performance
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Key Successes
a) Immunization- protects children against several severe life threatening diseases
- Has eradicated certain diseases
- Has made other diseases extremely rare
b) Breastfeeding initiative
c) Use of oral rehydration solutions- prevent dehydration
d) Fluoridation- decrease in tooth decay
e) Seatbelt legislation
f) Antiretroviral prophylaxis

** The MOH in Jamaica recommends a minimum of 10 well child visits over the first two
years of life
- At well child visits malnutrition or obesity is detected at an early stage
- Allows action to be taken early

** The 5 effective areas of primary prevention are:

- Nutrition
- Immunization
- Dental care- first visit to the dentist for examination by 12-18 months of age
- Accident prevention
- Prevention of emotional and developmental problems

Dental Care
- Before eruption of teeth clean oral cavity with soft washcloth and water
- No toothpaste under the age of two
- Supervise brushing of teeth up to age 8-10 years

Accidents/Prevention
** Accidents are the second leading cause of death in the 1-4 year age group
- Leading cause of death in the 5-9 year age group
- Among adolescents 10-19 years it was the second leading cause of discharges from
public hospitals and the leading cause of death in government hospitals

** In Jamaica 2-4 year old children were at greatest risk of poisonings

- kerosene, bleach, drugs, pesticides
- Most deaths were from kerosene and pesticides

** The focus of accident prevention varies with age and developmental stage
1- Transport- occupants/pedestrians
2- Home- falls/lacerations, blunt injuries, burns, drowning, poisonings
88

Emotional & Behavioral Problems

Sleeping Problems
- Night awakening/ Nightmares
- Persistently sleeping in parents’ bed
- Bed Wetting Treatment- educate parents, incentive charting, no punitive measures,
restricting fluids prior to bedtime, voiding exercises

Feeding Problems: Picky eater, Refusing solids, Refusing to sit at table for meals, Obesity

Toilet Training
- 18 months before neurological maturity
- Motor skills- to stand, sit and walk unaided
- Verbal skills- to express needs
- Social skills- to be uncomfortable when messy
- Sensory skills- to retain a full bladder/rectum

** Make the potty the child’s choice

- Allow practice runs, never force
- Praise successful attempts
- Accept accidents, change the clothes quickly and encourage for next attempt

Discipline
- Never use discipline in a child less - Physical punishment teaches
than a year aggression
- Appropriate discipline measures - The more often it is used the less
- Define acceptable behavior effective it becomes
- Be consistent - Time outs and curtailing of
- Foster open communication within privileges
the family

Temper Tantrums
** Normally they are demands for attention or signs of frustration, anger or protest
- In between tantrums the child’s disposition and mood are normal
** Problematic- when there are more than 5 per day or they worsen beyond 5 years old
- If there is destruction of property
- The child harms himself or others
- There is a persistent negative mood or behavior between tantrums

** Teach the child acceptable ways to express anger and frustration

- Important for parents to remain calm, praise positive behavior, ignore some tantrums,
time outs, hold child

Sexual behavior
- Children are naturally curious about their body
- Teach proper names for body parts
- Masturbation is normal
89

Meningitis
** Meningitis occurs when there is inflammation of the meninges covering the brain
- Confirmed by finding inflammatory cells in the CSF
- Viral infections are the most common cause of meningitis and most are self-
resolving
- Other causes of meningitis include: malignancy, autoimmune diseases, bacteria,
fungi

Neonatal Disease
** Group B Streptococcus is the most common neonatal meningitis pathogen
- Sporadic cases related to Listeria monocytogenes and gram-negative agents (E. coli)
continue to be important
- The maternal genital tract is usually the source of the pathogen for both early and
late onset disease
- Late onset disease is often associated with CNS infection

Note: The few cases of GBS disease occurring after 3 months of age are generally seen in
infants who were born preterm

Neonatal Gram-negative Meningitis

** E. coli is the most commonly isolated pathogen of this type of meningitis
- Usually acquired from the maternal genital tract
- Prematurity, maternal intrapartum infection and prolonged rupture of membranes are
predisposing factors

** Neonates may be more vulnerable to CNS infection due to:

- Less efficient defense mechanisms
- Deficient transfer of antibodies from mother to baby in ther preterm infant of less
than 32 weeks gestation
- Increased ability of bacteria to penetrate the blood-brain barrier

Neonatal Herpes Simplex Virus (HSV) Infection

** HSC in the newborn can present as isolated skin or mucus membrane lesions,
encephalitis or a disseminated process
- 75% of cases are caused by HSV-2

** The majority of time transmission occurs when an infant is delivered vaginally through an
infected birth canal
Note: Ascending infection can occur despite intact amniotic membranes
- Occasionally horizontal transmission from a caregiver/health care worker occurs
from a non-genital source
- Usually related to virus transfer from mouth or hands

Note: The incubation period is 2 days to 2 weeks

- Most infants who develop HSV CNS infections are 2-3 weeks of age
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Neonatal Listeria Meningitis

** Maternal infection relates to a food-borne source
- Unpasteurized milk, soft cheeses, undercooked poultry, unwashed raw vegetables
- Maternal infection can precipitate abortion, preterm delivery or early-onset infection

** A septic appearance in the neonate is typical in cases of early onset

- Characteristic papular truncal rash can be identified

Common Non-Neonatal Bacterial Pathogens

** Streptococcus pneumoniae (Pneumococcus) has emerged as the leading pathogen causing
bacterial meningitis in infants and young children
- Occurs primarily through nasopharyngeal colonization with subsequent bacteremia
and seeding of the choroid plexus

** Neisseria meningitides- is the predominant bacterial agent of meningitis in young adults

** An increased risk of colonization is noted with:
- Crowding
- Exposure to active + passive smoking
- Pneumococcal carriage
- Concomitant upper respiratory tract infection

** Other conditions that predispose to meningococcal infection include:

- Anatomic or functional asplenia
- Terminal complement deficiency
- Lab exposure
- Travel to epidemic or hyperendemic regions

Viral & Non-infectious Pathogens

Aseptic Meningitis- is a syndrome of meningeal inflammation in which common bacterial
pathogens have not been identified
- Caused by a variety of infectious and non-infectious agents
- The most common agent is viral
- The most common viral agent in the pediatric population are the enteroviruses

** Most children are not severely ill and often present with a non-specific febrile illness
- Meningeal signs may be present

** The fecal-oral route transmits enteroviruses. Cases of meningitis are most commonly in
children younger than 1 year of age

** In young neonates who have symptoms and signs consistent with sepsis, a history to elicit
maternal symptoms should be done
- Maternal enteroviral infection may precede neonatal infection in up to 70% of
neonates diagnosed as having enteroviral disease within the first 10 days after birth
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** Cause of non-infectious aseptic meningitis include those that are

- drug-induced- NSAIDs (ibuprofen), IVIG, trimethorprim-sulfate
- Related to vasculitis- SLE, Kawasaki disease

Mycobacterium Tuberculosis
** Pediatric meningitis caused by M. tuberculosis tends to be a complication of primary
infection in the child 5 years or younger
- Primary infection occurs after droplet inhalation
- Followed by dissemination from the lung to the lymphatics and to the bloodstream

Clinical Manifestations of Meningitis

** Infants younger than 1 month of age who have viral or bacterial meningitis can present
with a constellation of constitutional, non-specific signs:
- Fever
- Hypothermia
- Lethargy
- Irritability
- Poor feeding

Note: Signs/symptoms of increased intracranial pressure and meningeal inflammation

such as vomiting, apnea and seizures can also occur

** Infants older than 1 month of age and young children can also present with the same non-
specific constitutional symptoms
- Fever, lethargy, irritability

** Signs and symptoms due to meningeal inflammation and increased ICP including mental
status changes, vomiting and seizures, continue to predominate

** Older children and adolescents often experience:

- Headache
- Photophobia
- Neck stiffness
- Anorexia + nausea

History
** 20-25% of children with pneumococcal meningitis have a predisposing risk factor
1- Mechanical Risk Factors- CNS trauma, cochlear implants, CSF leak
2- Medical Risk Factors- HIV infection, asplenia, chronic renal disease
- Recent infections such as otitis media, sinusitis, mastoiditis can predispose a child to
bacterial meningitis

** For infants, a birth history, maternal GBS colonization status and treatment and maternal
history of STI should be elicited
- Enquire about immunization
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Examination
** Meningismus is suggestive of meningeal irritation. However this is usually not present in
the young infant
Note: In young infants paradoxical irritability is the usual sign of meningeal irritation
- The infant with meningitis does not want to be handled and prefers to remain
motionless

** In the older child, signs of meningeal irritation should be elicited

1- Kernig Sign- patient lies supine and the thigh is flexed at right angle to the trunk. If
knee extension from this position elicits pain, the Kernig sign is positive
2- Brudzinski Sign- patient lies supine and flexes the neck
- Positive sign occurs if the patient also reflexively flexes the lower extremities
(knees)

** Papilledma can be present with Lyme meningitis

- Cranial 3, 4 and 6 palsies are possible with bacterial and Lyme meningitis

** Joint involvement can present in GBS or meningococcal infection

** Skin involvements include:

i- Petechiae + purpura- meningococcal or pneumococcal disease
ii- Exanthems- typical for enteroviruses
iii- Vesicles- in the infant 6 weeks or younger suggest the diagnosis of HSV infection

** Contraindications for lumbar puncture include:

- Focal neurologic deficits
- Signs of increased ICP
- Uncorrected coagulopathy
- Cardiopulmonary compromise

Bacterial Meningitis is characterized by CSF pleocytosis with a predominance of

polymorphonuclear leucocytes
- Glucose concentration is usually less than one-half of the measured serum value
- Protein concentration is greater than 1.0 g/dL

Note: CSF culture is the gold standard for diagnosing bacterial meningitis

** Viral meningitis is characterized by a lower cell count (WBC 0.05-0.5 x10 9)

- Glucose and protein concentrations are frequently normal
- Protein value can be slightly elevated
- Gram stain is universally negative

Prognosis
- 5-10% of children with bacterial meningitis die
- Among the survivors, the risk of neurologic sequelae is highest in children who have
pneumococcal meningitis
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** The most common sequelae are:

- Intellectual deficits
- Hydrocephalus
- Spasticity
- Blindness and severe hearing loss

** Anaerobic meningitis in children generally occurs as a complication of chronic otitis

media with mastoiditis, chronic sinusitis, recent craniotomy, and abdominal trauma
94

Cough, Cold, SOB

** A cough is a protective reflex to ensure airway patency
- Cough is one of the most common presenting symptoms in pediatrics
- Common in all age groups
- Involves the respiratory, cardiovascular and GI systems

Historical Information

Cough
- Type- barking, whooping, productive, non-productive
- Frequency
- Timing- diurnal variation
- Effects on patient, parents, other- does it affect sleep, causes vomiting, pain,
hemoptysis
- Duration- persistent, chronic, recurrent

Cold
- Define what the patient means by “cold”- mucus, noise when the child breathes
- Color, odor, +/- blood

SOB
- Description
- Duration

Other Related Symptoms

- Wheeze, stridor
- Cyanosis
- Chest pain
- Vomiting, choking (foreign body)
- Fever, night sweats
- Loss of appetite, decreased activity
- CVS symptoms, GI symptoms, CNS symptoms
- Review of systems: GU, MS, Skin

Past Medical History

- How many previous episodes of symptoms
- How did the previous episodes resolve
- Asthama, allergic rhinitis or other allergic disorder
- Sickle cell disease, cardiac disease, neurologic impairment, GE reflux
- Other immunocompromised states
- Family history- of asthma, sickle cell disease, immunodeficiency, atopy
95
96

Pathophysiology
** Coughing is a reflex initiated through irritation of one of the multiple cough receptors.
** These receptors are found in the:
- Nose
- Paranasal sinuses
- Ear canal
- Posterior pharynx
- Larynx
- Trachea
- Bronchi
- Pleura
- Stomach
- Pericardium
- Diaphragm

Note: Receptors are not found in the lung parenchyma or the alveoli
- Therefore pneumonia may no produce a cough
- Receptors can be found both inside and outside of the respiratory tract

** Stimulation of any of these receptors by a chemical, mechanical, thermal or inflammatory

irritant can initiate the cough reflex

** The receptors send the cough message along the vagal and laryngeal nerves to the upper
brainstem
- In the brain the cough center in the medulla receives the message and coordinates the
cough mechanism

Note: The cough center can be voluntarily stimulated or suppressed

- Therefore cough is under both voluntary and involuntary control

** The cough can be broken down into three phases:

1) Glottis opens with an inspiratory gasp
2) Glottis closes with forceful contraction of the chest wall, diaphragm + abdominal
muscles
3) Glottis opens again with the release of airway pressure in an expiratory phase

Note: This process expels mucus or irritants from the airways, clearing the passages for
normal airflow

Note: Coughing during sleep is pathological

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Respiratory Disorders: Classification

Acute:- Cough that persists for 2 weeks or less

- Infections
- Non-infectious causes- foreign bodies, asthma

Sub-acute/Chronic- defined as a cough that lasts for more than 2-4 weeks
- Infections
- Non infectious- allergic rhinitis/sinusitis/asthma

Note: Chronic cough ALWAYS begins acutely

Respiratory Infections
** Respiratory infections can be classified anatomically:
- Upper respiratory infections
- Lower respiratory infections

Etiology
- Viral, Bacterial, Mycobacterial, Mycoplasma and Chlamydia, Fungal

Acute Upper Respiratory Infections

Viral:
- Common cold (rhinopharyngitis)
- Otitis media
- Tonsillitits
- Laryngotracheobronchitis (LTB)- viral croup

Bacterial:
- Otitis media
- Tonsillitis
- Sinusitis
- Epiglottitis
- Bacterial tracheitis

Acute Lower Respiratory Infections

Viral:
- Bronchiolitis
- Bronchopneumonia

Bacterial:
- Pneumonia
- Lung abscess
- Empyema
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Chronic Respiratory

Upper Respiratory Tract:

1- Viral
2- Bacterial
3- Non-infectious- chronic suppurative otitis media, chronic sinusitis

Lower Respiratory Tract:

- Viral- HIV-related Lymphocytic Interstitial Pneumonia
- Bacterial- tuberculosis
- Protozoan- pneumocystis carinii pneumonia
- Non-infectious- bronchiectasis, cystic fibrosis, ciliary disorders
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Differential Diagnosis- Cough

** The age of the child can influence the diagnostic possibilities. Congenital anomalies are
most likely to present in the first few months of life include:
i- Tracheoesophageal fistula

ii- Laryngeal cleft- condition that results from the failure of posterior
cricoid fusion
- May have stridor
- Have severe aspiration resulting in recurrent/chronic pneumonia and failure to thrive

i- Vocal cord paralysis

ii- Tracheobronchomalacia- exists when the cartilaginous framework of the
airway is inadequate to maintain airway patency
iii- Congenital heart disease- can produce a cough from heart failure and
pulmonary edema
iv- Congenital mediastinal tumors- can cause coughing if the tumor presses
on the bronchial tree

** The duration of the cough can also help to determine its possible cause. Most acute
coughs are infectious in nature
- Upper respiratory tract infections initiate an acute cough through stimulation of the
cough receptors in the nose and posterior pharynx
- If nasal congestion and cough persist, a diagnosis of allergic rhinitis or sinusitis
should be considered
- Serous otitis media can cause a persistent cough
- Children with pneumonia may present with either an acute or chronic cough

** The presence of a night time cough is also significant. Pathologic coughs caused by the
following are morel likely to occur at night :
- Sinusitis with post-nasal drip
- Gastroesophageal reflux
- Asthma

** The character of the cough is also important. Some conditions produce a very specific
type of cough
i- Barking Cough- consistent with laryngeal edema and croup
ii- Inspiratory Whoop- is characteristic of pertussis or parapertussis
iii- Honking Cough- psychogenic coughing

** Common viral agents that produce a chronic cough in children include:

i- Adenovirus + RSV- in infants
ii- Influenza + parainfluenzae- affect children of all ages

Note: Bordatella pertussis, mycoplasma and Chlamydia also cause a chronic cough
** The most common cause of chronic cough is reactive airway disease (asthma)
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Common Cold

Young Infants

Laryngomalacia
** Laryngomalacia is a benign congenital disorder in which cartilaginous support for the
supraglottic structures is underdeveloped
- It is the most common cause of persistent stridor in infants
- Usually seen in the first 6 weeks of life

** Stridor tends to be worsened in:

- Supine position
- Increased activity
- Upper respiratory infections
- Feeding

** The condition usually improves with age and resolves by age 2 years

Common Cold
** Combinations of runny nose, nasal congestion, sore throat, tearing, cough, and sneezing
characterize the common cold syndrome.
- Low grade fever may be present
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** Changes in respiratory epithelium, local obstruction and altered local immunity are
sometimes the precursors of more severe illnesses such as: otitis media, pneumonia and
sinusitis

** During and following a cold the bacterial flora change and bacteria are found in
normally sterile areas of the upper airway

** The common cold is frequent in the age group 3-10 years.

- School age children
- Daycare
- School age siblings

** Symptoms last up to 10-14 days. Symptoms tend to improve around day 7

- Self limited
- Purulent discharge
- Halithosis

** Causes of the common cold include:

i- Rhinovirus- 100 serotypes
ii- Coronavirus
iii- Adenovirus
iv- Echovirus
v- Coxsackievirus

Symptoms
** The patient usually experiences a sudden onset of clear or mucoid rhinorrhea, nasal
congestion, sneezing and sore throat
- Cough and fever may develop and tend to be mild
- Runny eyes +/- mucus
- Not short of breath BUT parents may describe mouth breathing or noisy breathing as
SOB

Note: Common cold symptoms are non-specific and they tend to occur in other illnesses

** The nose, throat and tympanic membranes may appear red and inflamed
- Nasal secretions tend to become thicker and more purulent after day 2 of infection
due to shedding of epithelial cells and influx of neutrophils
- The discoloration should not be assumed to be a sign of bacterial rhinosinusitis
unless it persists beyond 10-14 days
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Allergic Disease
** Allergic disease can manifest in many ways:
- Asthma
- Atopic dermatitis
- Allergic rhinitis
- Allergic conjunctivitis
- Urticaria - is the clinical rash produced by vasodilation and edema of the skin as a
result of an allergic condition.
- Angioedema- is the extension of the urticarial process deeper into the dermis of the
skin
- Producing circumscribed swelling
- Anaphylaxis
- Food allergies- vomiting and diarrhea

** Children with allergic disease frequently present with persistent, clear rhinorrhea,
sneezing, postnasal drip or injected pruritic conjunctiva

** Skin manifestations include dry, scaling, erythematosus rashes, wheals or subcutaneous

swelling
- A recurrent cough or wheezing on chest examination is further evidence of allergic
disease

Allergic Rhinitis
** Allergic rhinitis is caused mainly by an antigen-antibody reaction involving IgE
- Antigen specific IgE is produced by the B-lymphocytes of allergic patients on
exposure to a particular antigen

** The IgE attaches to mast cells in the conjunctiva and mucus membranes of the
respiratory tract
- On re-exposure the antigen reacts with this specific IgE on the mast cells, releasing
vasoactive mediators
- EX: histamine, leukotrienes, kinins, prostaglandins
- These mediators produce vasodilation and edema
- Stimulates neural reflexes to produce mucus hypersecretion and sneezing

** Allergic rhinitis may contribute to the development of rhinosinusitis and asthma

exacerbations
- The duration and pattern of symptoms are seasonal and related to triggers/allergens

** Symptoms include:
- Nasal congestion
- Frequent sneezing
- Rubbing of the nose
- Clear rhinorrhea
- History of mouth breathing + snoring at nights
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** On physical examination of the nasal turbinates are swollen and may red or pink
- Allergic salute- a transverse crease across the nose due to repeated rubbing of the
nose
- Allergic shiners (Panda eyes)- dark circles under the eyes due to venous stasis
- Dennie-Morgan lines
- Adenoidal facies- the mouth gains a high arched palate from chronic mouth
breathing
- Discolored conjunctive, eyelids + lips
- Cobblestone pattern- at back of throat
- Associated asthma, eczema, allergic conjunctivitis
- Family history of atopy

Note: Need to differentiate the allergic rhinitis child from a child with recurrent common
colds
- No fever or constitutional symptoms with allergy
- Unlike allergic rhinitis, infectious etiologies of rhinitis result in inflammatory nasal
mucosa and possible fever

Rhinosinusitis
** The term rhinosinusitis has replaced sinusitis because it acknowledges that the nasal and
sinus mucosa are involved in similar and concurrent inflammatory processes

** Sinusitis is characterized as acute if it has lasted less than 4 weeks

- Sub acute - 4-8 weeks
- Chronic - lasted longer than 8 weeks

Recurrent Sinusitis- is defined as 3 or more episodes of acute sinusitis per year

Note: Rhinitis typically precedes sinusitis

- Sinusitis without rhinitis is rare

** Not all of the paranasal sinuses exist from birth. The degree of pneumatization of
different sinuses vary from one individual to another
- The maxillary sinus pneumatizes first beginning between birth and 12 months of age
- The ethmoid sinuses are rudimentary at birth and do not reach adult size until 24
months of age
- Frontal + sphenoid sinuses develop after the ethmoids and do not complete opening
until late adolescence

Acute Bacterial Rhinosinusitis

** Acute bacterial rhinosinusitis is a bacterial infection of the paranasal sinuses that lasts
less than 30 days
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** The most common bacterial pathogens associated with ABRS are:

i- Streptococcus pneumoniae
ii- Hemophilus influenzae
iii- Moraxella catarrhalis

Note: Chronic sinusitis may be the result of the above pathogens as well as organisms such
as Pseudomonas aeruginosa and other anaerobes
- Fungi - may also be a factor in chronic infection

** Acute rhinosinusitis usually presents as a cold that lasts longer than usual
- Usually a cold that does not improve by 10-14 days or worsens after 5-7 days
- The maxillary and ethmoid sinuses are most commonly involved

** Nasal discharge may be thin or thick, clear or mucoid

- Cough can be wither wet or dry
- Must be present in the day time and may worsen at night
- Malodorous breath
- Facial pain and headache may be present
- Occasional painless morning time eye swelling (periorbital swelling)
- Pain above or behind the eye
- Tenderness over sinuses
- Discoloration of eyelids
- Fever if present is mild
- Headache, facial pain, swelling + tenderness
- Nasal congestion
- Post-nasal drainage
- Ear pressure or fullness

** Acute bacterial rhinosinusitis is almost always preceded by a viral URTI

- Viral URTI may cause sinus mucosal injury and swelling
- Results in osteomeatal obstruction, loss of ciliary activity and mucus hypersecretion

** Complications of ABRS occur when infection spreads to adjacent structures

- EX: overlying tissues, eye, brain
- Orbital complications are the most common, arising from the ethmoid sinuses
- Intracranial extension can lead to meningitis, epidural, subdural and brain abscesses

Sub acute/Chronic Sinusitis

** Symptoms of sinusitis that last for more than 30 days and less than 8 weeks without
improvement

Note: Chronic rhinosinusitis is diagnosed when the child has NOT cleared the infection in
the expected time but has not developed acute complications
- BUT recurrent rhinosinusitis occurs when episodes of ABRS clear with antibiotic
therapy but recur with each or most upper respiratory infections
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Symptoms:
- Nasal obstruction/congestion
- Cough- day + night
- Sore throat because of mouth breathing
- Nasal discharge less prominent

** Patients with chronic sinusitis may have a much more subtle presentation, often with
nasal congestion as the main symptom
- Persistent post-nasal discharge
- Slight headache and fatigue because the congestion interferes with restful sleep

** Important factors that may lead to chronic sinusitis are:

i- Allergies
ii- Anatomic variations- septal deviation, polyp, foreign body
iii- Disorders in host immunity- cystic fibrosis, ciliary dyskinesia, immunodeficiency
iv- Mucosal inflammation leading to obstruction- most commonly caused by allergic
rhinitis
v- Gastroesophageal reflux
vi- Samter’s Triad or Triad Asthma- NSAID drug allergy, nasal polyposis + asthma

Note: Sinus CT is often used to confirm a diagnosis of chronic sinusitis

- MRI may be useful for defining soft-tissue involvement in the event of extension of
sinusitis into adjacent tissues

Note: Topical decongestants may improve sinus drainage but may cause additional problems
with rebound nasal congestion if used longer than 3-5 days

** If a patient responds favorably to the initial 3-5 days of therapy but only partially responds
to a 10-14 day course of antibiotics, a new type should be used because of potential bacterial
resistance
- Use of beta-lactams, cephalosporins, macrolides, or quinolones
106

Infections of the Ear

1. Otitis Externa- inflammation of the skin lining the ear canal and surrounding soft
tissue
- Infections due to Staphylococcus aureus or Pseudomonas aeruginosa are the most
common
- Symptoms include pain and itching in the ear
- Movement of the pinna or tragus causes pain
- The ear canal is typically grossly swollen

2. Otitis Media- infection of the middle ear

- Infection associated with middle ear effusion (collection of fluid in the middle ear
space) or with otorrhea
- Otorrhea is a discharge from the ear through a perforation in the tympanic
membrane

3. Mastoiditis- is in inflammation of the mastoid bone

Otitis Media
- 20% of children <4 years will have one per year
- 85% of children will have one by age 3 years
- 50% of children will have 2 or more

** Otitis media can be classified into the following four categories:

vi- Acute OM- (Acute suppurative/purulent OM) is the sudden onset of
inflammation of the middle ear
- Often accompanied by fever and ear pain

vii- OM with effusion- is the presence of middle ear fluid after antimicrobial
treatment
- Resolution of acute inflammatory signs has occurred
- BUT there is a persistence of a more serous, non-purulent effusion
- Usually resolves within 3-4 weeks

viii- Recurrent acute OM- defined as frequent episodes of acute OM with

complete clearing between each case
- Also defined as 3 episodes of acute OM requiring antibiotic treatment within a 6
month period

ix- Chronic OM with effusion- (serous OM, secretory OM or non-suppurative

OM)- is a chronic condition characterized by persistence of fluid in the
middle ear for 3 months or longer
- The tympanic membrane is retracted or concave with impaired mobility and shows
no signs of acute inflammation
- Affected children may be asymptomatic
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Note: To distinguish acute otitis media from otitis media externa, signs of inflammation of
the tympanic membrane and symptoms of acute infection must be present

** Otospecific findings for AOM are a:

- Bulging TM
- Impaired visibility of the ossicular landmarks
- Yellow or white color
- Opacification of the eardrum
- Squamous exudate or bullae on the eardrum

** Tympanic membrane findings by otoscopy

Color
i- Cloudy opacified tympanic membrane- PPV 80%
ii- Red tympanic membrane
- Multiple causes including crying and other viral illnesses

Position
i- TM bulging- PPV 89%
- First occurs n the posterior-superior quadrant
- TM most compliant in posterior-superior quadrant

ii- Loss of landmarks-

iii- Light reflex may be absent from bulging TM

** The highest peak of OM occurs between 6 and 36 months of age.

** Risk factors include:
- Familial predisposition
- Presence of siblings in the household
- Low socioeconomic status
- Altered host defenses
- Environmental factors- daycare attendance + passive smoke exposure
- Underlying conditions- cleft palate, other craniofacial anomalies

Mobility
i- TM immobile by pneumatic otoscopy- PPV 78%
ii- Tympanometry:
- Normal tympanogram suggests no AOM
- Middle ear effusion

Clinical Presentation
** Children with acute OM have a history of fever and ear pain

Associated Symptoms: URI, cough, diarrhea

- Decreased appetite, waking at night or irritability in infants
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Diagnosis- Otitis Media

1. Ear Pain (otalgia)- 40-60%
- Predicts <50% of OM
- Predicts 80% of OM in the presence of URTI
- Only 12% of children pulling ear have OM
- Other causes of otalgia include: URTI, cerumen impaction, sterile effusion

2. Rhinitis- 90%
3. Cough- 78%

4. Constitutional Symptoms- (60-80%)- poor appetite, irritability

5. Low grade fever (22-69%)- temp under 101 F <24 hrs
6. Difficulty sleeping in infants- 35-50%

7. Ear Drainage (5%)-

- Liquefied cerumen from fever or
- Pus from perforated tympanic membrane

8. Unilateral hearing loss

9. URI- incidence of OM after 5 days of URI = 40%

Pathophysiology
** The causative organisms for otitis media are
- Streptococcus pneumoniae- 30-50%
- Hemophilus influenza
- Moraxella catarrhalis

** Less common cause include: group A streptococcus, Staphylococcus aureus, alpha-

hemolytic streptococcus, pseudomonas aeruginosa

** Respiratory viruses such as RSV, adenovirus, rhinovirus, parainflunza and influenza A

also play a role

** Eustachian tube dysfunction occurs primarily for two reasons:

i- Abnormal patency
ii- Obstruction

** Functional obstruction occurs commonly in infants and young children because the tube is
less cartilaginous than in adults
- The tensor veli palatini muscle is also les efficient in younger age groups

** Intrinsic mechanical obstruction of the Eustachian tube occurs as the result of

inflammation secondary to a URI or allergy in patients beyond 5 years of age
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Differential Diagnosis
** The most common cause of otalgia (ear pain) is acute OM
** Other causes include
- mastoiditis
- Otitis externa
- Referred pain from the oropharynx, teeth, adenoids or posterior auricular lymph
nodes
- Foreign body- in the ear canal can produce symptoms similar to OM

** To diagnose OM, the tympanic membrane must be visualized.

- Evaluate the position, color, degree of translucency and mobility of the TM

** In acute OM the TM is full or bulging, hyperemic, opaque and has limited or no mobility
- The light reflex is usually distorted or absent

** In persistent or chronic OM, signs of inflammation are usually absent and the TM may be
retracted with limited or no mobility

Laboratory Tests
** Tympanocentesis is the most definitive method of verifying the presence of middle ear
fluid and of recovering the organism responsible for infection

Management
** Oral antibiotics are the first line treatment of acute OM
- Amoxicillin is the first-line drug of choice
- Active against S. pneumoniae and H. influenzae
- Bactrim can be used in penicillin allergic individuals
- Augmentin may be used in cases of resistant organisms
- Course of treatment is 10-14 days

** Frequent bouts of OM require a further search for respiratory allergies, sinusitis,

immunologic deficiencies and anatomic abnormalities (submucosal cleft palate,
nasopharyngeal tumor)

** Complications associated with OM are divided into two categories:

A. Extracranial:
- Tympanic membrane perforation - Mastoiditis
- Conductive and sensorineural - Facial nerve paralysis
hearing loss - Osteomyelitis of the temporal bone

B. Intracranial complications:
- Meningitis - Brain abscess
- Extradural or subdural abscesses - Hydrocephalus
- Lateral venous sinus thrombosis
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Predisposing Factors

1. Bacterial Colonization- Nasopharyngeal colonization with Strep pneumoniae, H.

influenzae or Moraxella catarrhalis increases the risk of otitis media

2. Viral Upper Respiratory Infections- increase the colonization of the nasopharynx

with otitis pathogens
- Viral infections also impair Eustachian tube function by causing both adenoidal
swelling and edema of the tube
- Factors that increase the frequency of viral respiratory infections such as:
- Child care attendance, smoke exposure, absence of breast feeding
- Promote colonization with otitis pathogens and predispose to otitis media

3. Smoke Exposure- Passive smoking increases the risk of persistent middle ear
effusion by enhancing colonization and prolonging the inflammatory response

4. Eustachian Tube Dysfunction- infants born with craniofacial disorders are often
affected by AOM and OME
- EX: Down syndrome, cleft palate
- When the tube is obstructed, a vacuum develops in the middle ear
- This pulls down nasopharyngeal secretions and pathogens into the middle ear

5. Impaired Host Immune Defenses-

6. Bottle feeding- breastfeeding reduces the incidence of acute respiratory infections,

provides IgA antibodies that reduce colonization with otitis pathogens
7. Genetic Susceptibility
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PHARYNGO-TONSILLITIS
** Over 90% of cases of sore throat and fever in children are due to viral infections

Sore Throat
Sore Throat- is a painful inflammation of the pharynx, tonsils or surrounding areas

** Sore throats are common in children 5-8 years of age

- Uncommon in children under 1 year

** The organisms that cause bacterial and viral pharyngitis are present in the saliva and
nasal secretions
- Spread from child to child in school is the common mode of transmission

** Most children with sore throat present with sudden onset of pain and fever
- Fever tends to be higher in younger children
- Throat/tonsils are red and the breath may be malodorous
- Headache, nausea, vomiting and abdominal pain may occurs
- Appetite may be decreased
- Activity level may decrease

** In children with the common cold- rhinorrhea and post-nasal discharge are present
- Cervical nodes may be enlarged and are usually not tender
- A pharyngeal or Tonsillar exudate is not typical

**BUT children with streptococcal pharyngitis usually have:

- High fever
- Pharyngeal + Tonsillar exudate
- Tender cervical lymph nodes

Pathophysiology
** Bacterial and viral organisms produce sore throat by causing inflammation in the ring of
posterior pharyngeal lymphoid tissues (tonsils, adenoids, surrounding lymphoid tissue)
- This ring of tissue (Waldeyer’s ring) drains the oral and pharyngeal cavity

** Viral sore throats may be acquired by inhalation or self-inoculation from the nasal
mucosa or conjunctiva
- The local respiratory epithelium becomes infected with the virus and inflammation
occurs

** Group A streptococcus and other bacterial organisms directly invade the mucus
membranes
112

Viral Infection
** Viral infections are the most common cause of sore throat in children
- Most often associated with a URI caused by a rhinovirus

Adenovirus- leads to exudative pharyngitis, frequently in children less than 3 years old
- Pharyngoconjunctival fever is characterized by a high fever, conjunctivitis and
exudative tonsillitis

Coxsackie virus + echovirus (enteroviruses)- are the usual cause of herpangina

- Vesicles + ulcers are found on the attention Tonsillar pillars and soft palate
- May also be found on the pharynx or posterior buccal mucosa
- Children may have a high fever, irritability and refuse to eat or drink

HSV- may lead to pharyngotonsillitis BUT this can be distinguished from the enteroviral
infections because HSV almost always involves the anterior portion of the mouth and lips
- AND is associated with a gingivitis (herpes gingivostomatitis)
- High fever and refusal to eat or drink because of the painful lesions

EBV- may cause exudative pharyngotonsillitis either alone

- OR as part of the infectious mononucleosis syndrome (fever, malaise,
lymphadenopathy, hepatosplenomegaly)

Bacterial Infection
** Group A beta-hemolytic streptococcus is the most common cause of bacterial sore throat
in children over 3 years of age
- The pharynx is typically very red and sometimes edematous
- Tonsils are red, enlarged and covered with exudate
- Symptoms: dysphagia, fever, vomiting, headache, malaise, abdominal pain
- Swollen anterior cervical lymphadenopathy and petechiae on the soft palate and uvula
are usually seen

Note: The occurrence of a scarlatiniform rash, strawberry tongue and Pastia’s lines
indicates scarlet fever
Note: Rheumatic fever and glomerulonephritis are non-suppurative complications of group A
streptococcal infection

** Suppurative complications are peritonsillar abscess or cellulitis and cervical

lymphadenitis
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Other Causes of Sore Throat

1. Candida albicans- in infants/children who are immunocompromised or taking
antibiotics
- Present with whitish plaques on the labial or buccal mucosa that do not wipe off
easily

2. Retropharyngeal abscess- usually occurs in children <4 years

- Fever, refusal to swallow, drooling ,stridor and meningismus in toxic appearing
children are suggestive

3. Epiglottitis- may present as sore throat

- 2-7 years of age
- Present with signs of toxicity, stridor, difficulty swallowing and drooling

4. Allergic Rhinitis- with post-nasal drip

5. Kawasaki Disease- persistent sore throat may be a symptom of Kawasaki

Croup Syndrome
** Croup describes acute inflammatory disease of the larynx. Includes the following:
1. Viral croup (LTB)
2. Epiglottitis
3. Bacterial tracheitis

Viral Croup
- Generally affects younger children in the fall and early winter months
- Most often caused by parainfluenza virus
- Other organisms causing croup include: RSV, influenza, rubeola virus, adenovirus,
mycoplasma pneumoniae (above 5-6 years)
- Viral croup most commonly occurs between 3 months and 3 years
- Inflammation of the entire airway is present
- BUT edema formation in the supraglottic space accounts for the main signs of upper
airway obstruction

** Prodrome of upper respiratory tract symptoms followed by a barking cough and stridor
- Fever usually absent or low-grade
- As obstruction worsens, stridor occurs at rest
- Note: the presence of cough and the absence of drooling favor the diagnosis of viral
croup over epiglottitis

Epiglottitis
- Incidence has decreased with the introduction of the Hib vaccine
- Sudden onset of fever, dysphagia, drooling, muffled voice, inspiratory retractions,
cyanosis and stridor
114

Bacterial Tracheitis
- Also known as pseudomembranous croup is a severe life-threatening form of
laryngotracheobronchitis
- Organisms most commonly isolated is Staph aureus
- Occurs after localized mucosal invasion of bacteria in patients with primary viral
croup
- Resulting in inflammatory edema, purulent secretions and pseudo membranes

Bronchiolitis
- The most common serious acute respiratory illness in infants and young children
- Characteristically occurs in children < 2 years
- Approximately 80% of all cases occur in the first year of life
- Age of highest incidence is between 2 to 6 months
- Typical Presentation: acute onset of tachypnea, cough, expiratory wheezing after 1-
2 days of rhinorrhea
- Respiratory syncytial virus (RSV) is the most common viral cause of acute
bronchiolitis
- Next most common cause are the parainfluenza viruses

** The usual course of RSV bronchiolitis is 1-2 days of fever, rhinorrhea and cough
- Followed by wheezing, tachypnea, and respiratory distress
- Breathing pattern is shallow with rapid respirations
- Nasal flaring, cyanosis, retractions and rales may be present
- Prolongation of the expiratory phase and wheezing may be present depending on the
severity of illness

Risk Factors:
- Age
- Prematurity
- Chronic lung disease

Wheezing & Asthma

** Shortness of breath is usually associated with disorders of the lower respiratory tract:
- Pneumonia
- Bronchiolitis
- Asthma

** May occur with disorders of the larynx and trachea

- Laryngotracheobronchitis
- Epiglottitis

** Recurrent wheezing is a frequent symptom of obstructive airway disease in children.

May be caused by:
- Intrinsic or extrinsic compression of the airway
- Bronchospasm
- Inflammation or defective clearance of secretions
115

Note: Reactive airway disease (asthma) is the most common cause of wheezing in
childhood

** Wheezing in children under 1 year of age is most commonly due to:

- Bronchiolitis
- Infectious disease caused by RSV
- Pneumonia
- Asthma

** Less common cause include:

- Congenital structural anomalies
- Gastroesophageal reflux and aspiration
- Cardiac failure, cystic fibrosis and foreign bodies

** Infants may present with apnea, inspiratory and expiratory wheezing, fever and
respiratory distress
Note: Infants with recurrent bronchiolitis may have reactive airway disease

** In older children, asthma is the most common cause of persistent or recurrent wheezing

** Asthma is a lung disease with the following characteristics:

1. Increased airway responsiveness to a variety of stimuli
2. Reversible airway obstruction
3. Inflammation of the airways

Clinical Presentation
** Children with asthma may present with acute symptoms of cough and shortness of
breath
- Wheezing may be audible
- Some children may have a cough, which may be nocturnal or recurrent as a
predominant symptom
- Some patients have symptoms (cough, wheezing) that are precipitated or exacerbated
by exercise

Pathophysiology
** Asthma is a chronic inflammatory disorder of the airways. The immunohistopathologic
features of asthma include:
1. Denudation of the airway epithelium
2. Collagen deposition beneath the basement membrane
3. Edema
4. Mast cell activation
5. Inflammatory cell infiltration
116

** These changes lead to:

- Airway hyperresponsiveness
- Airflow limitation
- Respiratory symptoms
- Disease chronicity

** The limitation to the flow of air includes:

- Acute bronchoconstriction
- Airway edema
- Mucus plug formation
- Airway wall remodeling

Note: Atopy is the genetic predisposition to the development of IgE=mediated response to

common aeroallergens
- Atopy is the strongest predisposing factor for developing asthma

** The physiologic changes involved in asthma occur in two phases:

1. An immediate response to the offending agent causes edema and bronchial smooth
muscle constriction
- Leads to narrowing of the airway and plugging it with secretions
- Air is trapped behind the narrowed airways, resulting in altered gas exchange,
increased respiratory rate, decreased tidal volume and increased work of breathing

2. The late response, occurs 4-8 hours after initial symptoms

- Primarily involves infiltration of the airways with inflammatory cells
- The end pathway in the disease process is obstruction to airflow

Causes of Wheezing other than Asthma

- Bronchiolitis - Recurrent aspiration - Chronic infections-
- Congestive cardiac - Worms TB, PCP,
failure - Congenital disorders- bronchiectasis
- Tracheomalacia webs, cysts, vascular - Tumors,
- Bronchomalacia rings, lung disorders lymphadenopathy
- BPD - Immune deficiencies - Cystic fibrosis
- Bronchopneumonia - Vocal cord paralysis - Ciliary disorders
- Foreign body

Uncommon & Rare Causes of Cough, Cold + SOB

- TB - Congenital malformations of
- Immune deficiencies airways, lung and heart
- Cystic fibrosis - Ciliary disorders
- Bronchiectasis - Sarcoidosis
- Tumors - Pulmonary hemosiderosis
117

Malnutrition Tutorial- 21-01-10- DR. TAYLOR BRYAN

Malnutrition- is the insufficient, excessive or imbalanced consumption of nutrients

Primary Malnutrition- insufficient or unbalanced consumption of nutrients that is not

related to an underlying pathophysiologic problem

Secondary Malnutrition- intake is adequate, however there is an underlying

pathophysiologic problem which leads to undernutrition

Classification Systems

Gomez Classification

Gomez Classification- The child’s weight is compared to that of a normal child (50th
percentile) of the same age
- Useful for population screening and public health evaluations

- 90- 110%- Normal

- 75- 89%- Grade I- mild malnutrition

- 60-74%- Grade II moderate malnutrition

- < 60%- Grade III- severe malnutrition

Note: Gomez system uses weight for age and therefore does not consider the height of the
child

Wellcome System
Weight for Age (Gomez) With Edema Without Edema
60-80% kwashiorkor undernutrition
< 60% marasmic-kwashiorkor marasmus

Waterlow Classification:

Chronic malnutrition results in stunting. Malnutrition also affects the child's body
proportions eventually resulting in body wastage.

percent weight for height = ((weight of patient) / (weight of a normal child of the same
height)) * 100percent height for age = ((height of patient) / (height of a normal child of the
same age)) * 100
118

Weight for Height Height for Age (stunting)

(wasting)
Normal > 90 > 95
Mild 80 - 90 90 - 95
Moderate 70 - 80 85 - 90
Severe < 70 < 85

** For a malnourished child, a detailed dietary history is necessary

- Breastfeeding- how long
- Transition to formula, soft diet, solid foods
- How the formula was mixed
- Age of weaning
- Amount of juice, water given
- 24 hr recall
- Food replacement

Examination

Affect:
- Apathy Mouth
- Irritability - Angular chelosis- due to vitamin
B12 deficiency
Hair Changes - Oral thrush
- Alopecia - Ulcers
- Hair loss - Glossitis
- Forest sign - Loss of papillae
- Flag sign - Bleeding gums
- Pluckability - Loss of teeth

Eyes: Body:
- Sunken eyes - Dry, flaky skin
- Jaundiced sclera - Flaky paint dermatosis
- Pale mucus membranes - Crazy pavement dermatosis
- White spots in the eyes due to - Pretibial edema
Vitamin A deficiency - Palpable pitting edema
- Wrinkling of the cornea - Rickettsia rosary- most common
- Dry eyes on the lower 4-6 ribs
- Angular palpebritis - Hepatomegaly- due to fatty liver
- Keratus cornea infiltration
- Periorbital edema
119

Dehydration vs Malnutrition

** Features of dehydration include:

i- Crying without tears
ii- No saliva- due to atrophy of tear ducts and salivary glands
iii- Decreased skin turgor- due to loss of subcutaneous tissue

** Therefore to determine the difference between dehydration and malnutrition, or to

determine dehydration in a malnourished child other standards should be assessed:
1- Urine output
2- Compromised circulatory volume- pulse volume + capillary refill

Note: Malnourished children are usually totally potassium-depleted with an increase in

intracellular sodium
- WHO solution + sucrose has decreased sodium and more potassium

Phases of Recovery

1- Resuscitation Phase- stabilize the child at the cellular lavel, so that normal cellular
responses can take place
- Assess issues of hypovolemia
- Underlying infections
- Edema

2- Rapid Catch-up Growth Phase- increase calorie density of feed. Reaching the
appropriate weight for height is the target at this time

3- Home

** There are 4 criteria for the end of the maintenance phase:

i- Infections treated
ii- Return of affect
iii- Return of appetite
iv- Resolution of edema

NOTE: See NUTRITION notes from REID and TAYLOR-BRYAN

120

Dehydration
** A number of pathophysiologic conditions alter fluid requirements. Conditions that
increase a patients metabolic rate will also increase their fluid requirement
- EX: fever

** Other hypermetabolic conditions include: thyrotoxicosis, salicylate poisoning

Pathophysiology and Dehydration

** Dehydration is one of the most common pathophysiologic alterations in fluid balance
encountered in pediatrics
- Most children have a deficit of both water and electrolytes

** Dehydration can occur as a result of:

1. Diminished intake
2. Excessive losses through the GI tract- diarrhea, vomiting
3. Excessive losses from the kidney or skin- polyuria due to osmotic diuresis
4. Combination of the above factors

** Children are at increased risk for episodes of dehydration for a number of reasons
- Young children have 3-4 x the body surface area per unit body weight compared with
adults
- Therefore they have relatively higher fluid needs
- As a result it is much easier for children to become dehydrated in the face of
decreased intake or increased losses that accompany common childhood illnesses

** In addition children/infants are dependent on caregivers and therefore are unable to

increase their own fluid intake in response to thirst independently

** Dehydration is classified as:

A. Isotonic/isonatremic- is the most common type of dehydration. Net loss of
isotonic fluid containing both sodium and potassium
- Sodium is lost to the environment AND some shifts to the intracellular fluid to
balance the loss of potassium
- There is no net loss of fluid from the ICF
- Therefore the total water deficit comes primarily from the ECF

B. Hypotonic/hyponatremic- Net solute loss exceeds that of water

- May be the reslt of excessive sodium wasting in the stool or urine
- The ECF osmolarity is reduced and fluid shifts from the ECF to the ICF
- As a result the ECF volume is compromised to a greater degree than in isotonic
dehydration
- Results in more severe signs of dehydration
121

C. Hypertonic/hypernatremic- occurs when net loss of water exceeds that of solute

los
- Seen in clinical conditions where there is a rapid loss of hypotonic fluid in stools,
vomitus or urine
- This rapid loss is accompanied by failure of adequate water intake due to anorexia or
vomiting
- There is a shift of fluid from the ICF to the ECF to attain osmotic balance
- Therefore the ECF volume is spared at the expense of the ICF and signs of
dehydration may be delayed
- BUT the fluid loss from the ICF results in intracellular dehydration
- Therefore in the brain there is a decrease in brain size
- As the brain shrinks, the bridging veins within the skull may stretch and result in
subdural hemorrhage

History
** The history should focus on the cause of the dehydration
- Type and amount of oral intake
- Duration, quality and frequency of the vomitus and/or diarrhea
- Presence of blood in the stool
- Presence or absence of a fever
- Frequency of urination
- How much did the child weigh on the last visit to the physician

** The most accurate way to assess the degree of dehydration is to compare current weight
to a recent pre-illness weight
- In acute dehydration the loss of weight is mainly due to fluid loss
Clinical Signs Mild Dehydration Moderate Severe Dehydration
Dehydration
Loss of body weight 5% 10% 15%
(infant/young child)
Loss of body weight 3% 6% 9%
(older child/adult)
Skin turgor Normal to slightly Decreased Markedly decreased
reduced (tenting)
Skin color + Pale or normal Ashen, cool Mottled, cool
temperature
Dry mucus +/- + ++
membranes
Absent tears +/- + ++
Sunken eyeballs +/- + ++
Increased pulse +/- + ++ (may be thready)
Blood pressure Normal normal Reduced (in late
shock)
Urine output Normal or reduced oliguria Oliguria/anuria
BUN Normal Normal or mild Usually >30mg/dL
increase
122

** The management of the dehydrated child involves consideration of three components:

1- Normal maintenance fluid and electrolyte requirement
2- Fluid and electrolyte deficit incurred during the present illness
3- Ongoing fluid and electrolyte losses- most commonly ongoing losses result
from continued vomiting and diarrhea

** Oral rehydration therapy is preferred for children with mild dehydration and most
children with moderate dehydration

** Parenteral fluid therapy should be used in children with severe dehydration, when oral
therapy has failed
- Also in children in shock or impending shock
- Anatomic defect such as pyloric stenosis or ileus

Vomiting

Vomiting- is defined as the forceful ejection of the stomach contents though the mouth
- Mechanism involves a series of neurologically co-ordinated events under the control
of the CNS

Regurgitation- is the effortless bringing up of one or two mouthfuls of food without distress
or discomfort
- Freqeunt symptom of gastroesophageal reflux

Rumination- is a form of autostimulation. Voluntary induction of regurgitation

- Occurs in infants with developmental retardation
- Or with a distrurbed mother-infant relationship
123

Breastfeeding
Exclusive Breastfeeding- Feeding infants with breast milk only for the first 6 months of life
- Giving no other food or drink
- After which appropriate and adequate complementary foods should be introduced
gradually
- Breastfeeding should be continued up to and beyond two years of age

Ten Steps to Successful Breastfeeding

Step 1:
- Have a written policy that is routinely communicated to all health care steps

Step 2:
- Train all health care staff in skills necessary to implement this policy

Step 3:
- Inform all pregnancy women about the benefits and management of breastfeeding

Step 4:
- Help mothers initiate breastfeeding within half-hour of birth
- Give mother the baby to hold skin-to-skin immediately after birth and for at least one
hour if possible

Step 5:
- Show mothers how to breastfeed and how to maintain lactation even if they are
separated from their infants

Step 6:
- Give newborn infants no food or drink unless medically indicated

Step 7:
- Practice rooming-in allow mothers and infants to remain together 24 hours a day

Step 8:
- Encourage breastfeeding on demand
- Whenever the baby wants for as long as the baby who is well attached wants
- Waking the baby if he sleeps too long
- That is giving at least 6-8 feeds in 24 hours to a large baby or 10-12 feeeds to small or
jaundiced babies in 24 hrs

Step 9:
- Give no artificial teats or pacifiers (soothers) to breast-feeding infants

Step 10:
- Foster the establishment of breast-feeding support gropus and refer mothers to them
on discharge from the hospital or clinic
124

HIV Mothers are advised to utilized only to exclusive breastfeed

- This has the lowest incidence of passage of HIV to the infant
- The highest incidence occurs with mother who mixed feed
- The formula tends to irritate the stomach, allowing the antigens in breast milk easier
entry into the blood stream

Benefits of Breastfeeding
- Provides optimal nutrition
- Reduces incidence and severity of infections
- Protects against food allergies and eczema
- Increased cognitive, visual development
- Promotes bonding

Immune Functions of Milk

- Ig- specific, antigen binding
- Lactoferrin- deprives baceria of iron
- Bifidus Factor- supports lactobacillus bifidus
- Oligosaccharides- block antigens binding to mucosa in the genitourinary tract
- Nucleotides- promote maturation of gut

Nutrient Content
Foremilk- the milk released at the beginning of a feed is watery, low in fat and high in
carbohydrates RELATIVE to the creamier hindmilk released as the feed progresses

** The nutrient content is relatively independent of maternal diet except for fluid intake
- Carbohydrates- lactose, oligosaccharides
- Fat- Tgs, fat soluble vitamins
- Protein- casein 30%, whey 70%, immune proteins
- Minerals

** Compared with cow’s milk, breast milk has a lower renal solute load as welll as:
- Higher carbohydrates
- Lower protein
- Higher whey %
- Lower Fe
- Lower Fe
- Lower Ca
- Lower PO4

Breast Anatomy
- Alveoli are small sacs made of milk-secreting cells
- Prolactin makes the cells produce milk
- Muscle cells contract and are acted on by oxytocin

Note: The difference between small and large breasts is fat content.
- The internal duct structure is the same
125

Prolactin
- Prolactin is secreted after the feed to produce milk for the next feed
- Baby sucking stimulates the release of prolactin in the blood
- More prolactin is secreted at night
- Suppresses ovulation
- Most prolactin is in the blood 30 mins after the feeding and produces milk for the
next feeed

Oxytocin Reflex
- Oxytocin works before or during feed to make milk flow
- Oxytocin reflex can be stimulated before actual sucking by thinking lovingly of baby,
sounds of baby, sight of baby
- The reflex can be hindered by worry, stress, pain, doubt

Note: The presence of milk in the breast ie a breast full of milk acts as an inhibitor and stops
the secretion of further milk

Baby Reflexes
1. Rooting- when something touches the lips, the baby opens mouth and puts tongue
down and forward
2. Sucking- When something touches the palate the baby sucks
3. Swallowing Reflex- as the mouth fills with milk, the baby swallows

Good Attachment
- Taken much areola and underlying tissue into the mouth
- Stretched the breast tissue to form a teat and the nipple forms about 1/3 of the teat
- Therefore the baby is suckling from the breast NOT solely the nipple
- Tongue cupped round nipple
- More areola is above the top than below the bottom lip
- The baby’s mouth is wide open
- Lower lip turns outwards
- Baby’s chin touches the breast

Cradle Hold- Same arm, supports while drinking from the same breast
Cross Cradle Hold- especially useful for young infants who have not figured out how to
breastfeed yet
Football Hold- works well have large breasted mothers and those that need to avoid the baby
being on their abdomen
Australian Hold- recommended when a mother has too much milk or the flow of milk is too
fats
- Because one is reclined backwards or lying down, gravity will help your milk come
out slower
- Therefore less chance of baby gagging on excess milk
126

Milk Expression
i- Engorgement
ii- Very full breasts
iii- Ensuring that the baby gets enough (prematurity)
iv- Need for measurement of milk
v- Sick mother
vi- Separation
vii- Return to work