Infections in children

Question 1

How large is the share of under-five deaths caused by infection globally?

Answer 1

2/3

Question 2

What are some general causes of fever?

Answer 2

Infection, cancer, immunological diseases, intracranial bleeding and medications.

Question 3

What are risk factors for serious infection in children?

Answer 3

Newborn.
Immunodeficiency (e.g. cancer or hematological diseases).
Indwelling medical devices (such as urinary catheters or vascular access devices).
Chronic illness.

Question 4

How do you measure capillary refill time (CRT)? What is considered abnormal CRT?

Answer 4

Press on the skin of the sternum or a digit at the level of the heart. Apply blanching pressure for 5 seconds. Measure the time it takes for blush to return. Prolonged CRT (> 2-3 seconds) is considered abnormal.

Question 5

What should be assessed in a child with fever?

Answer 5

Vital signs (BP, pulse, RR, CRF, saturation).
General condition.
Dehydration status.
Neurological deficits.
Local signs (GI-tract, respiratory tract, lymph glands etc.).

Question 6

What are the four main features to assess when first meeting a sick child? (To determine if the child i critically ill.)

Answer 6

Responsiveness (or consciousness)
Facial expression
Color
Position

Question 7

What is the association between high fever and risk of severe infection in children younger than 3-6 months? Can severe infection be excluded in children of this age group if the child is afebrile?

Answer 7

High fever gives high risk of severe infection. Threshold for hospital admission should be low. However, the absence of fever does not exclude severe infection.

Question 8

What are factors indicative of illness severity in children?

Answer 8

Low age VS High age.
Systemically ill or not.
High (or prolonged fever) VS Low fever.
Presence of features associated with potentially severe infections such as osteomyelitis or septic arthritis.
No localized features VS Localized minor illness such as acute otitis media or upper respiratory tract infection.
Predisposition to infection (e.g. immunodeficiency) VS Normal, otherwise healthy, child.

Question 9

What lab tests should/can be taken when examining a febrile child?

Answer 9

Complete blood count (CBC). (Erythrocytes, hemoglobin, hematocrit, leukocytes, thrombocytes.)
CRP and procalcitonin.
Blood culture.
Urine sample (dipstick test and culture).
Lumbar puncture.

Question 10

What are the most common infectious agents in sepsis for children under 3 months of age and over 3 months of age?

Answer 10

< 3 months: Group B streptococci B (GBS) and E. coli.

> 3 months: Streptococcus pneumoniae and group A streptococci (GAS).

Question 11

What are symptoms of meningococcal sepsis?

Answer 11

Rash. At first pale skin, than later skin bleeding.
Poor general appearance.
Irritability.
Reduced level of consciousness (GCS < 15).
Influenza like body pain.

Question 12

What are the main differences between symptoms of meningitis in children under and over the age of 18 months?

Answer 12

Children < 18 months: High fever, irritability/fatigue, vomiting, seizures, rash and bulging fontanelle, but often no signs of neck-stiffness.

Children > 18 months: Classical symptoms. Neck-stiffness, headache, irritability, high fever, photophobia and reduced level of consciousness.

Question 13

What is the “rule of thumb” for symptoms of meningitis if the agent is meningococci. What if the agent is pneumococci?

Answer 13

Meningitis with petechia is generally due to meningococcal infection.

Meningitis without petechia is generaly due to pneumococcal infection.

Question 14

How should meningitis in children generally be managed?

Answer 14

Lumbar puncture to confirm the diagnosis.
Intravenous antibiotics. (3rd generation cephalosporine.)
Treatment of symptoms (as for sepsis), but be careful with fluids.

Question 15

True of false: 1/3 of all infections in children are respiratory tract infection.

Answer 15

False. 2/3 of all infections in children are respiratory tract infections.

Question 16

What are examples of common upper and lower respiratory tract infections (RTI) in children?

Answer 16

Upper RTI: Common cold, otitis media, pharyngitis, tonsillitis, and laryngitis.
Lower RTI: Bronchitis, bronchiolitis, and pneumonia.

Question 17

What are the most common agents in children with respiratory tract infections?

Answer 17

Viral agents, such as rhinovirus, influenza virus and RS-virus, are the most common.

Question 18

What is the first choice of antibiotics when treating children with pneumonia (and other RTI) and why? What is the second choice?

Answer 18

Penicillin is the first choice because it has a narrow spectrum and covers both pneumococci and streptococci.

The second choice is a macrolides, which cover both chlamydia and mycoplasma.

Question 19

What is the most common bacterial agent in children with tonsillitis?

Answer 19

Group A streptococci.

Question 20

What are important aspects of a child’s breathing to assess in suspected cases of RTI?

Answer 20

Respiratory rate. 
Retraction.
Nasal flaring.
Respiratory sounds, e.g. grunting.
Auscultation sounds, e.g. crackles, stridor, wheezing.

Question 21

What are chest retractions?

Answer 21

Collapse of soft tissue due to muscular effort in breathing. (Mainly the diaphragm.)

Question 22

Why do grunting occur in children with respiratory distress?

Answer 22

It is a mechanism in which the child tries to maintain lunge volume through closure of the glottis. Breathing against the closed glottis provides PEEP (positive end-expiratory pressure).

Question 23

Define tachypnea for neonates, infants, toddlers and older children.

Answer 23

Neonates: RR > 60.
Infants: RR > 50.
Toddlers: RR > 40.
Older children: RR > 30.

Question 24

What are the diagnostics when dealing with a pediatric throat infection? How should it be treated?

Answer 24

Diagnostic: Strep A test. (CRP and blood count.)
Treatment: If positive strep A test, treat with penicillin.

Question 25

What is the most common infectious agent in children with throat infection?

Answer 25

Viral agents are most common (90 %), otherwise group A streptococci.

Question 26

What are usual symptoms of mononucleosis in small children?

Answer 26

The infection is usually asymptomatic in small children.

Question 27

What are possible complications due to mononucleosis in children?

Answer 27

Airway obstruction.
ITP.
Feeding problems.
CNS-effects, incl. encephalitis.
Spleen rupture (rare).

Question 28

Why is epiglottitis so rare?

Answer 28

Epiglottitis is most commonly caused by H. influenzae type b (Hib). Vaccination against Hib is part of the vaccination program.

Question 29

What disease is characterized by a so-called barking-cough?

Answer 29

Croup. Acute laryngitis (also known as spasmoid/viral croup or “falsk krupp”).

Question 30

What are symptoms of acute bronchiolitis in children?

Answer 30

Nasal congestion. 
(Sometimes) cough and fever.
Breathing difficulties.
Feeding difficulties.
Fatigue.

Question 31

What are findings and symptoms of pneumonia in children?

Answer 31

Cough and fever.
Signs of respiratory distress such as grunting, retractions, tachypnea, and nasal flaring.
Pathological auscultation sounds are not always present.
Consolidation on chest x-ray.

Question 32

Why and how do children get osteoarticular infections?

Answer 32

Bacteria enter the bone/joint, usually through the blood stream (hematogenous). (Different blood supply in young children.)

Osteomyelitis may spread through non-ossified growth plate into the joint (causing arthritis).

Question 33

What are symptoms of osteomyelitis?

Answer 33

Painful, immobile joint(s).
Fever.
Signs of inflammation: Redness, swelling, warmth, and tenderness.

Question 34

What are common infectious agents in osteomyelitis in children?

Answer 34

S. aureus, as well as group A and B streptococci.

Question 35

What are the most common sites of osteomyelitis in neonates and children? What are common sites of septic arthritis?

Answer 35

Osteomyelitis in neonates: Femur and humerus.
Osteomyelitis in children: Metaphysis of long bones, such as femur or tibia. Pelvis and vertebra.
Septic arthritis: Knee, hip, ankle and elbow joint.

Question 36

What is the best test for diagnosing osteomyelitis?

Answer 36

MRI.

Question 37

How is osteomyelitis and septic arthritis treated?

Answer 37

Antibiotics with coverage of staphylococci. Intravenous treatment in the beginning, then treatment oral.