Pediatric Infectious Diseases - Clin Med 6

What is the normal HR for an infant (0-12 months)

100-160 bpm

What is the normal HR for a child (1-11 years)

70-120 bpm

What is the normal HR for a pre-teen/teen (12 and up)

60- 100 bpm

What is the normal respiration for infants

0-6 months = 30-60 bpm

6-12 months = 24-30 bpm

What is the normal respiration for child

1-5 = 20-30

6-11 = 12-20

What is the normal respiration for pre-teen/teen

12-18 bpm

What sinuses are present at 1 year old

Maxillary and ethmoid sinuses

What sinuses are present at 5 year old

Maxillary, ethmoid, and sphenoid sinus

What sinuses are present at 12 year old

Front, ethmoid, maxillary, and sphenoid

What auscultation sounds is the following

• Partial obstruction larger airways

• Often during Inspiration

• Localized over neck

Stridor - upper airway sound

What auscultation sounds is the following

• Partial obstruction smaller airways

• Often during Expiration

• Localized to chest

Wheezing - lower airway sounds

What auscultation sounds is the following

• Increased secretions intrathoracic airways

Rhonchi, crackles, rales – lower airway sounds

What auscultation sounds is the following

• Atelectasis

• Lobar consolidation

• Mass

• Pleural effusion

Decreased, absent, or asymmetric breath sounds

What does this refer to

• Tachypnea with rate > 60 (normal = 40-60/min)

• Grunting

• Subcostal retractions

• Nasal flaring

• Cyanosis

• Lethargy

• Poor feeding

• Hypothermia

• Hypoglycemia

Neonatal Respiratory Distress

What does this refer to

• Premature Infants, < 34 weeks

• Surfactant deficiency & lung immaturity

• More common in moms with DM

• Sx immediately after birth

  • Tachypnea, grunting, retractions, and cyanosis

Respiratory distress syndrome (RDS)(Hyaline Membrane Disease)

What does this refer to

• Symptoms normally worsen in first 12-24 hours

• CXR

  • Ground glass appearance

  • Air bronchograms

  • Hypoexpansion

• ABG

  • Hypoxia and acidosis

Respiratory distress syndrome (RDS)(Hyaline Membrane Disease)

What does this refer to

Neonatal Respiratory Distress Syndrome

What does this refer to

• Treatment

  • Give Surfactant (endotracheal tube)

  • CPAP

• Prevention

  • Prevent Pre-term births

  • Corticosteroids given 24 and 34 weeks (help mature lungs)

Neonatal Respiratory Distress Syndrome

What does this refer to

• A 5-year-old girl is brought to urgent care for difficulty breathing.

• For the past few days, she has had low-grade fevers, a runny nose, and a slight cough.

• Physical exam, seal-like barking cough and audible inspiratory stridor; accessory muscle use with breathing. Lung exam was normal without any wheezes.

• She is given the appropriate treatments for this condition, and the family is informed that this is likely viral and common in children.

Croup (Laryngotracheobronchitis)

What does this refer to

• Inflammation of Upper Airways

• Usually 2nd to URI

• VIRAL (80%) –

  • MC Parainfluenza virus (75%) followed by

  • Adenovirus, rhinovirus, RSV, influenza A & B

• MC from ~6 months- 3 years

Croup (Laryngotracheobronchitis)

What does this refer to

• Abrupt onset of hard/barking cough seal-like

• Inspiratory and expiratory stridor

• Hoarseness

• Dyspnea (worse at night)

  • Fall/early winter

• Low-grade Fever

Croup (Laryngotracheobronchitis)

What does this refer to

• Steeple sign (subglottic narrowing of trachea)

• Seen on AP neck x-ray

Croup (Laryngotracheobronchitis)

What does this refer to

• Treatment

  • Dexamethasone (steroids)

  • Supplemental O2

  • Racemic epinephrine nebulizer

  • **Humidified air (NOT effective)

Croup (Laryngotracheobronchitis)

What does this refer to

• In addition to the traditional nasal cannula and masks, use of a cup is much less intimidating and the children are less likely to fight and resist a “foreign device” on their face.

• To use this method

  • Cut a hole in the bottom of the cup and pass the oxygen tubing through it.

Supplemental O2 Deliver Blow-By O2 for Croup

What does this refer to

Treatment based on severity

What does this refer to

Risk factors for recurrent Croup

What does this refer to

Differential Dx of Croup and Associated Clinical Features

What does this refer to

• A 3-year-old boy is brought to the ER with an abrupt onset of fever (40 degrees Celsius), respiratory distress, and stridor. On examination, the boy appears acutely ill. He is sitting, leaning forward with his mouth open, and drooling.

Epiglottitis

What does this refer to

• MCC= haemophilus influenza type B

• Rare - due to HiB vaccine

• Kids ~ 3 months- 6 y/o

• Males>>females

Epiglottitis

What condition can cause children to do the following

• Classic Tripod Position of the Patient

Epiglottitis

What does this refer to

• Abrupt onset high fever

• Toxic appearance (distress)

• Stridor

• Dyspnea & drooling

• Tripod appearance

• Pharyngitis & odynophagia

• **Thumb print sign on lateral neck

Epiglottitis

What is diagnostic for epiglottitis

Laryngoscopy (only in OR)

What does this refer to

• Steroids- reduce edema

• Intubation prn

• Antibiotics (2/3 gen cephalosporins)

Tx (supportive) for epiglottitis

What does this refer to

• A 6-month old infant is seen in the emergency room for wheezing. His breathing has become increasingly difficult over the past 2-3 days. He has also had a worsening cough, subjective fevers, and rhinitis. Today, his parents took him to the pediatrician’s office, where his oxygen saturation was 80% on room air. He was sent immediately from the clinic to the emergency room via ambulance, where he was given supplemental oxygen.

• Physical exam - increased work of breath with nasal flaring, grunting, and intercostal retractions. He also has bilateral wheezes.

• His parents are counseled on the possibility of further interventions if his oxygen saturation does not improve.

Bronchiolitis

What does this refer to

• Inflammation of the bronchioles - narrowing

• 2 months- 2y/o

• MCC in infants = RSV (Respiratory Syncytial Virus)

• Fever, rhinorrhea, pharyngitis, cough, wheezing, rhonchi, rales

• Dx – antigen detection assays

• Tx – supportive – oxygen, acetaminophen, IVF

Bronchiolitis

What is used to dx Bronchiolitis

Antigen detection assays

What does this refer to

• Tx = supportive – oxygen, acetaminophen, IVF

Bronchiolitis

What does this refer to

• Prevention of RSV

  • Highly contagious, respiratory droplets

  • COVID type precautions

• At risk infants - should receive immune-prophylaxis with palivizumab (Synagis) – monoclonal antibodies

• 5 doses provide 6 months of protection (duration of RSV season)

Prevention of Bronchiolitis

What does this refer to

Predictors of severity in bronchiolitis

What does this refer to

Treatment of Acute Respiratory Syncytial Virus Bronchiolitis

What does this refer to

• Viral= MCC

  • RSV, Parainfluenza types 1,2,3, Influenza A

• Bacterial= less common

  • Pre-school – S. pneumoniae and HiB (vaccination reduced incidence of both)

  • School age kids (5-18 y/o) – Atypical bacteria - M. pneumoniae and Chlamydia pneumoniae

Pediatric Pneumonia

What does this refer to

• Tachypnea & Fever

• Cough +/- sputum production

• Chest retractions - (Increases the likelihood of pneumonia dx in a febrile child with tachypnea)

• Grunting - (Increases the likelihood of pneumonia dx in a febrile child with tachypnea)

• Nasal flaring - (Increases the likelihood of pneumonia dx in a febrile child with tachypnea)

• Crepitations - (Increases the likelihood of pneumonia dx in a febrile child with tachypnea)

Pediatric Pneumonia

What does this refer to

• CXR

  • Not required to confirm CAP in kids who are well enough to be treated as outpatients

  • Recommended-- any child with suspected CAP with respiratory distress or hypoxemia

  • Recommended if no clinical improvement

    • R/O complications of CAP: Pneumothorax, parapneumonic effusions, and necrotizing pneumonia

Diagnostic testing for CAP in kids

What does this refer to

• Blood cultures:

  • Usually NOT needed in non-toxic, fully immunized kids with CAP (Clinical judgment)

• CBC w. diff

  • May be useful in more serious illness – clinical context

• Pulse Ox

  • All kids with suspected CAP and hypoxemia

  • Hypoxemia will drive decisions on site of care/other testing

Diagnostic testing for CAP in kids

What does this refer to

• Follow up CXR

  • Children who recover from CAP clinically without complications do NOT need f/u CXR

  • Consider - kids w/ no clinical improvement, symptoms progress, or show clinical deterioration within 48-72 hours of initial antibiotic therapy

  • Complicated pneumonia & worsening respiratory distress, clinically unstable, or persistent fever that does not respond to therapy within 48-72 hours

  • Recurrent pneumonia same lobe or lobar atelectasis should have f/u CXR four to six weeks after diagnosis

Diagnostic testing for CAP in Kids

What does this refer to

*hypoxemia & lethargic

When CAP requires admission

What does this refer to

• Viral= MCC - antibiotics not routinely required in preschool-aged kids with CAP

• Consider atypical bacteria in school aged children and adolescents

Pediatric CAP

What does this refer to

• Amoxicillin - 1st line

  • Alternative

  • Second or third gen cephalosporin (cefpodoxime (Vantin), cefuroxime (Ceftin), cefprozil (Cefzil))

  • Levofloxacin

  • Linezolid

Treatment for Strep Pneumoniae

What does this refer to

• Macrolides

  • Azithromycin is preferred

  • Alternatives – clarithromycin, doxycycline, levofloxacin and moxifloxacin

Treatment for Mycoplasma pneumoniae

What does this refer to

• Immunizations against S. pneumoniae, H. influenza type b, pertussis

• Annual influenza vaccination ages > 6 months

• Parents/caretakers – DTaP (Pertussis) and annual influenza

• High risk infants should receive monoclonal antibody prophylaxis for RSV

Pediatric CAP Prevention

What does this refer to

• OTC cough and cold medications NOT Recommended, especially in children < 4 y/o

• Treatment:

  • Pelargonium sidoides (geranium) extract (Umcka Coldcare)

  • Nasal saline irrigation (can you hit a moving target!)

  • Vapor rub if over age 2

  • Zinc sulfate

• Don’t use antibiotics

Viral URI

What does this refer to

• Abnormal pathophysiologic condition

  • Rise in temp

  • Tachycardia

  • Disturbance of various body functions

• Fever = > 100.4 F or 38 C – rectal most accurate

  • Usually does not indicate serious illness

  • Discomfort & seizures

  • Does not cause brain damage

  • Does help fight infection

Fever In Kids

What does this refer to

• CBC with diff

• UA and culture

• LP for CSF studies and culture

• CXR if respiratory symptoms

• Stool studies/fecal WBC if diarrhea present

Labs you order for all infants that develop a fever within the first 21 days of life

What would you do for a infant who develops a fever > 100.4 F in the fist 21 days of life

Admit

What does this refer to

• GBS (Group B strep —> S. agalalactiae (Gram + cocci with a tendency to form chains)

• E. coli

• Listeria

Etiology of a fever within the first 21 days of life

What does this refer to

• IV antibiotics

  • Ampicillin + gentamicin OR

  • Ampicillin + cefotaxime (Claforan)

  • +/- acyclovir

  • NO ceftriaxone (Rocephin) in infants < 1 month due to kernicterus risk

    • Type of brain damage that can result from high levels of bilirubin in a baby’s blood

Fever in First 21 days

What does this refer to

• Clinical Features

  • In neonates two syndromes exist for ________:

    • Early-onset (<7 days old)

    • Late-onset (7-90 days old)

• Both can manifest as bacteremia, sepsis, pneumonia, and meningitis.

• Pregnancy-related infections include:

  • Bloodstream infections (including sepsis)

  • Amnionitis

  • Urinary tract infection

  • Stillbirth

Group B strep (GBS) disease

What does this refer to

• Asymptomatic carriage in gastrointestinal and genital tracts is common. Intrapartum transmission via ascending spread from the vagina occurs

• Maternal colonization with GBS is the primary risk for early onset disease in neonates

Transmission of GBS

What does this refer to

• Screen all pregnant women who have not already had + GBS vaginal or urine

• Rectal and vaginal swab

• Treat all GBS + pregnant women intrapartum with PCN if not allergic

Preventing Neonatal GBS Infection

What does this refer to

Tx for Neonatal GBS Infection

What does this refer to

• When children contract _______ they tend to have milder symptoms than adults

• Symptoms can range from asymptomatic→ to mild URI→ to ARDS requiring assisted ventilation

• Symptoms specific to _______ include:

  • Loss of smell or taste, early on and prior to coryza

  • May also have GI symptoms

    • Nausea, vomiting, & diarrhea

COVID-19 in Pediatric PatientsSARS-CoV-2

What does this refer to

• Molecular and antigen tests both have high specificity = high specific test with + result rules IN for the disease

• Antigen tests and some molecular tests have lower sensitivity → potential for false negative results

• False negative results have implications for disease spread

  • Consider recommending isolation precautions despite negative test result when pretest probability is high

• Symptoms based approach preferred to test based for ending isolation

COVID Tests

What does this refer to

Features of COVID

What does this refer to

• Viral load decreases after symptom onset

• False negative results are more likely with antigen tests that are performed more than five days after symptom onset.

Timing of COVID Tests

What does this refer to

• Genetic-- Autosomal recessive

• ______ gene encodes for cystic fibrosis transmembrane conductance regulator (CFTR), a chloride channels of epithelial cells

• Leads to abnormal movement of salt and water across cell membranes

  • =Thick secretions impacting multiple organ systems – leading to obstruction

Cystic Fibrosis

What does this refer to

• FTT, poor growth and weight gain (ADR)

• Chronic cough, recurring pulmonary infections – bronchiectasis

• (Common cause of death in CF patients)

• Recurrent sinusitis, Nasal polyposis

Clinical manifestations of Cystic Fibrosis

What does this refer to

• S. aureus and P. aeruginosa – common cause of death

Common secondary infections of cystic fibrosis