Lecture 4

Question 1

what is a fever

Answer 1

 temperature > 38.0C (100.4F)
 axillary, tympanic and “temporal artery” temperatures are never reliable in comparison to oral, rectal and bladder (Foley) temperatures
 Neonate/infant temperatures- gold standard is rectal temp
 hypothalmamic set point rises - set point can be influenced by infection, malignancy, collagen vascular disease, drugs
 heat is conserved (vascular redistribution, shivering, etc.) - you often see flushing because the capillaries are expanding to blow off the heat

Question 2

fever “spikes”

Answer 2

o fever comes in “spikes” every 4-6 hours
 set point changes, patient feels they are too cold and conserves heat
 temperature rises to fever
 set point resets, and patient feels they are too warm, then dispels heat
 temperature returns to normal

Question 3

fever in neonates

Answer 3

o neonates are unable to mount a temperature as well as older infants due to their body surface area to body mass ratio
 often hypothermic (<36.0C) instead of febrile when ill
 they are not good at mounting temperatures
 they are much more likely to get hold than to get hot – they have a hard time generating heat

Question 4

treatment of fever

Answer 4

 reassurance to address parental fever “phobia”
• rarely causes harm – if you are a neurologically normal person, the chances of your body producing enough heat to fry your own brain is highly unlikely
• body’s natural reaction to infection
• in normal people, temperature needs to reach > 41.7C (107F) to cause harm
• febrile seizures are common and usually harmless

 antipyretics for comfort
• acetaminophen (watch for toxicity)
• ibuprofen (>6 months of age)
• aspirin (>18 years of age))

 non-medical support (baths, cool cloths, clothing)

 maintenance of hydration (greater insensible losses)

Question 5

common infectious categories

Answer 5

o Bacterial
 Generally considered higher risk with a few exceptions
 Treated with antibiotics targeted toward most common organisms

o Viral
 Most common causes of infection
 Rarely have antiviral treatments available
• Exceptions: Influenza (oseltamivir) and HSV (acyclovir)

o Fungal
 Usually localized infections in healthy children
• Exception: Disseminated disease in NICU babies and immunocompromixed patients

Question 6

Serious bacterial infections in 0-29d neonates

Answer 6

o Infants under 90 days of age are at increased risk of serious bacterial infections (SBI)
 Often divided into 0-30d, 30-60d, 60-90d

o Up 10-15 % of infants in this age group will have an SBI
 10% urinary tract infections/pyelonephritis
 2% bacteremia
 1% meningitis

o All infants 0-29d require evaluations of all three locations
 Urinalysis and urine culture
 CBC, +/- inflammatory markers (PCT, CRP) and blood culture
 Lumbar puncture and CSF culture

o Infants are treated empirically with antibiotics while awaiting cultures (Ampicillin, gentamicin, cefotaxime)

o Babies that have a fever of 100.4 need to go to the emergency room where they will have blood, urine, and CSF drawn – they will then get abx empirically while waiting for the results

Question 7

Serious bacterial infections in 30-59d neonates

Answer 7

o Under 30 days is highest risk for SBI

o Infants 30-59d – slightly lower risk of having SBI
 Can depend on institutional guidelines
 Minimum urine and blood evaluation
 Based on those results and clinical presentation, consider LP

o In general, all of these kids will get blood and urine, its just a question of whether or not the spinal tap will be done (if the kid looks sick, you do the tap. If they don’t look sick, its clinical judgment to do the tap or not)

o Infants 60-90d
 Again, can depend
 Minimum urine evaluation
 Consider blood evaluation (10% of pyelo will have bacteremia)
 Based on above and clinical presentation, consider LP

o If you are under 90 days with fever, you will get a cath specimen and can then decide if you will do blood and spinal tap

Question 8

important bacterial infections

Answer 8

o	Urine infections
o	Acute otitis media
o	Sinusitis
o	(Pneumonia)
o	Pharyngitis
o	Gastroenteritis
o	Lymphadenitis
o	Cellulitis, etc.
o	Bacteremia (blood stream)
o	Meningitis

Question 9

UTI in infants

Answer 9

o Most common bacterial infection in infants

o Infants have shorter urethras – both boys and girls. Most UTIs come from GI pathogens

o Diapers allow easy contamination of urinary system
 Primarily stool pathogens in this age group

o	Boys (particularly uncircumcised) have higher incidence <3mos
	Even higher than girls at this age

o Girls surpass boys >3mos (urethras stay short)

o Bacteria normally enter bladder but exit with voiding

Question 10

UTI risk factors

Answer 10

 Urologic abnormalities (hypospadias, vesicoureteral reflux)
 Neurologic abnormalities (tethered cord, spina bifida, neurogenic bladder)
 Poor hygiene (front to back!)
 Sexual activity
 Behavioral dysfunctional voiding – the kids afraid to use the bathroom at school – if youre holding your bladder you may be at risk for UTI
 Constipation – if there is enough poop in the lower abdominal space, may affect the ability of the bladder to void

Question 11

UTI sxs

Answer 11

	Fever
	Dysuria
	Poor feeding
	Foul-smelling urine
	Vomiting, sometimes diarrhea
	Abdominal pain
	Flank/back pain

Question 12

UTI labs

Answer 12

o Collection methods
 Adhesive bag
 Straight catheter
 Suprapubic bladder aspiration

o Urinalysis
 Suggests infection, does not diagnose it
 WBCs, RBCs, nitrites, leukesterase

o Urine culture
 Gold standard
 Looking for single organism with sensitivites

o DIAGNOSIS=
 PYURIA/BACTERIURIA AND >50K COLONIES OF A SINGLE ORGANISM

Question 13

UTI protocol

Answer 13

o Pyelo and UTI are considered synonymous under 2 months of age

o Multiple UTIs in childhood can cause renal scarring and hypertension

o	Early UTI can suggest a GU abnormality 
	Vesicoureteral reflux
	Posterior urethral valves
	Single/horseshoe kidney
	Duplex collecting system

o Under 2 mos of age
 Renal ultrasound
 Consider voiding cystourethrogram

o 2 mos to 2 years
 Free pass for first UTI, then ultrasound
 VCUG if ultrasound abnormal or recurrent UTIs

Question 14

Acute otitis media

Answer 14

o Infection of the middle ear

o Symptoms
 Ear pain
 Conductive hearing loss
 Sometimes fever

o Can start with URI and progress to ear infection – common theme that it starts with a cold

o Bacterial pathogens
 Streptococcus pneumoniae
 Haemophilus influenzae
 Moraxella catarrhalis

o Any time that a normal body fluid stays static for too long, its an issue

o If you can see the bones of the middle ear, then theres no pus between you and the middle ear

o If the tympanic membrane is swollen or infected, you won’t be able to see the cone of light

Question 15

otitis media treatment

Answer 15

 Watchful waiting (could be viral)
 Pain control
 1st line- Amoxicillin (covers all the pneumos)
 2nd line- Augmentin (Amoxicillin/Clavulanic Acid)
 3rd line- Ceftriaxone IM

Question 16

otitis media complications

Answer 16

 Frequent/persistent infections
• Tympanocentesis
• Myringotomy tube placement
 Hearing loss

Question 17

bacterial sinusitis

Answer 17

o Inflammation of paranasal sinuses

o Symptoms
 Severe nasal discharge
 Persistent respiratory symptoms (>2wks)
• Cough, headache, facial pressure, tooth pain, halitosis

o Usually a clinical diagnosis

o Sinus XR or CT can help

o Treatment
 Watchful waiting – you cant just watch and wait everyone, there are very bad complications, so you need to use clinical judgement
 Amoxicillin

o Complications
 Orbital cellulitis
 Brain abscess

Question 18

bacterial conjunctivitis

Answer 18

o Usually unilateral

o Symptoms/Signs
 Conjunctival injection
 Purulent drainage

o Pathogens
 Staph aureus
 Strep pneumo
 H. flu Moraxella

o Clinical Pearl: H. flu can cause concurrent AOM and conjunctivitis

o Complication
 Periorbital cellulitis

Question 19

periorbital/orbital cellulitis

Answer 19

o Periorbital – outside in kind of problem – usually starts as pimple on eyelid, bug bite, etc.
 Can start as conjunctivitis, bug bite
 Staph, strep pyogenes

o Orbital – in to out – swimming in nasty lake
 Spreads from sinus outwards
 Polymicrobial, staph, strep, more gram negatives and anaerobes

Question 20

bacterial pharyngitis

Answer 20

o Symptoms
 Sore throat
 Difficulty swallowing
 Poor feeding in younger infants

o Primary bacterial pathogen is Group A Strep aka Streptococcus pyogenes

o	Complications
	Cervical lymphadenitis
	Peritonsillar abscess
	Rheumatic fever 
	Acute post-streptococcal glomerulonephritis

Question 21

S. pyogenes

Answer 21

o	Classic symptoms
	Fever
	Pharyngitis
•	Palatal petichiae
•	Tonsillar exudate
•	Strawberry tongue
	Tender cervical lymphadenopathy
	Headache
	Abdominal pain +/- vomiting
	Rash – scarlatina which is a sandpaper like rash
	Absence of cough

o Testing
 Rapid antigen test
 Culture

o Treatment
 Penicillin/Amoxicillin

Question 22

bacterial gastroenteritis

Answer 22

o More commonly viral, but bacterial pathogens do exist

o Food-borne = S. aureus, B. cereus

o Fecal-oral = Campylobacter, E. coli (0157H7), Shigella, Salmonella

o Symptoms
 Vomiting/diarrhea
 Fever
 Blood or mucus in stool

o Treatment
 Rarely treated, tends to resolve without antibiotics
 Antibiotics must be used cautiously, many strains can cause Hemolyic Uremic Syndrome

Question 23

lymphadenitis

Answer 23

o Infection of lymph node, usually following upper respiratory infection

o Symptoms
 Fever
 Large, red, hot tender node

o Most commonly affects cervical nodes

o Common pathogens: Staph aureus, strep pyogenes, gram negatives

o Rarer pathogens: Bartonella henselae (cat scratch disease), tuberculosis

o Might need to address: Kawasaki Disease, cancer

o If you have fever and a big node that is NOT red, hot, and tender, consider the above dxs

Question 24

cellulitis

Answer 24

o an acute, diffuse, spreading, edematous, suppurative inflammation of the subcutaneous tissues, which may be associated with abscess formation
o ill-defined borders
o sometimes start with skin trauma or superficial infection
o Staphylococcus aureus (MSSA, MRSA)
o Streptococcus pyogenes (Group A strep)
o watch closely for necrotizing fasciitis

Question 25

things that look like/could be cellulitis

Answer 25

o folliculitis  small follicle-associated papules & pustules o furuncle  boil including hair follicle o carbuncle  multiseptate abscesses including several hair follicles  involves subcutaneous tissue o may progress to skin abscess o Parents often assume spider bite ``` o Impetigo  Small bumps become vesicular/cloudy  “honey crusting” is classic  Strep pyogenes and Staph aureus  Start by treating topically  Can require oral antibiotics ```

Question 26

bacteremia

Answer 26

o Younger infants are at increased risk due to immature immune systems ``` o Neonates/Infants  E. coli  Group B streptococcus  Staph aureus  Klebsiella  Listeria ``` o Older infants/children  E. coli  Staph aureus  Strep pneumoniae

Question 27

bacterial meningitis evaluation with lumbar puncture

Answer 27

 Gram stain and culture  Cell count  Protein  Glucose

Question 28

bacterial meningitis early and late complications

Answer 28

``` o Early complications  Brain abscess  Subdural empyema  Seizures  SIADH  Sensorineural deafness ``` o Late complications  Developmental delay  Hydrocephalus  Epilepsy

Question 29

important viral infections

Answer 29

``` o Upper respiratory infections +/- pharyngitis o (Bronchiolitis) o (Croup) o Conjunctivitis o Gastroenteritis o Hand-Foot-Mouth o Roseola o Warts o Molluscum contagiosum o Meningitis/Encephalitis o Herpes o Influenza o Epstein-Barr Virus ```

Question 30

upper respiratory infection

Answer 30

o Epidemiology  children under six typically have 6-8 colds per year, with an average symptom duration of 14 days  a child may have cold symptoms up to half of all days between September and April and still have a normal frequency & duration of colds  most contagious in first 2-4 days. Hand washing and alcohol gels are the most effective means of preventing transmission o Clinical symptoms  fever for up to 3 days  cough, nasal & pharyngeal symptoms for up to 7-21 days  color of nasal mucus not significant indicator of severity of disease

Question 31

URI viral infections and similar presentations

Answer 31

``` o Viral infections  rhinoviruses (10-40%)  coronaviruses (~20%)  RSV (respiratory syncytial virus) (~10%)  influenza  parainfluenza  enteroviruses (echovirus and coxsackievirus)  Adenovirus ``` o similar presentations  vasomotor rhinitis  allergic rhinitis

Question 32

URI tx

Answer 32

o Treatment does little to alter natural course of viral URIs o Symptomatic care  fluids (to prevent dehydration)  antipyretics (no ibuprofen under 6 months, no aspirin under 18 years)  nasal bulb suction or wash  review symptoms of complications to be monitored • 5-15% of children with colds develop otitis media (viral or bacterial) • bacterial conjunctivitis, sinusitis, pneumonia • asthma exacerbation • dehydration o medications – decongestants, expectorants, cough suppressants  no definitive proof of efficacy  FDA advisory panel recommended against use in age under 6 years  in children over 12 months, antihistamines may provide slight benefit  AAP policy statement against dextromethorphan, codeine o zinc, vitamin C and echinacea have limited data regarding efficacy in children; honey (>1year) can help cough

Question 33

viral conjunctivities

Answer 33

o Usually bilateral o Symptoms/signs  Conjunctival injection  Can be very crusty, sometimes mildly purulent  Often accompanies URI symptoms o Pathogens  All the same as URI o Not to be confused with  Allergic conjunctivitis (itchier)  Dacryostenosis – the tube that drains the eye becomes obstructed and you get crusty stuff – the conjunctiva is actually still clear, not red

Question 34

viral gastroenteritis

Answer 34

o Extremely common and contagious o Most children will have AGE at least once by 2yo o Rotavirus, enterovirus, norovirus, adenovirus, sapovirus ``` o Symptoms  Vomiting  Diarrhea  Fever  Decreased urine ``` o Anti-diarrheal medications can prolong illness o Children more sensitive to dehydration o Can increase risk of UTI

Question 35

hand-foot-mouth

Answer 35

o Enteroviral infection, most commonly Coxsackie A o Symptoms  low grade fever  malaise  pharyngitis o “hand, foot, mouth” and sometimes diaper area  oral and pharyngeal ulcers  peeling macules on palms and soles o oral aversion may lead to dehydration

Question 36

roseola

Answer 36

o Human herpes virus 6 or 7 o Symptoms  Fever alone, often high, for 3-5 days  Followed by eruption of full body rash after fever gone

Question 37

warts

Answer 37

o Benign intradermal lesions caused by HPV o Can be very hard to teach o Skin-colored papules ``` o Treatment  salicylic acid – don’t use in infants because they can OD  duct tape  tretinoin cream  liquid nitrogen  canthradin  imiquimod (podophyllin) ```

Question 38

molluscum contagiosum

Answer 38

``` -UMBILICATED o caused by a pox virus o induces epidermis to proliferate o umbilicated, skin colored papule o chronic course of proliferation and gradual resolution ```

Question 39

viral encephalitis/meningitis

Answer 39

o Infection of brain itself or its surrounding fluid o Generally less severe than bacterial infection in the same space ``` o Symptoms/Signs  Fever  Lethargy  Headache  Neck stiffness  Irritability  Vomiting  Bulging fontanelle ``` o Most common: Enterovirus o Most serious: HSV o Symptoms are the same between viral and bacterial

Question 40

Herpes simplex virus

Answer 40

-in general, herpes in kids is VERY serious o Neonatal infection  Can be passed vertically at birth  Highest risk is moms infected for the first time (up to 50%)  Lower risk if mom has recurrence of old disease  More likely to be disseminated or involve central nervous system the younger the infant o Testing done by surface culture and PCR of blood/CSF o Three categories  Skin-Eye-Mouth  Disseminated (bloodstream, liver)  CNS (meningitis, encephalitis)

Question 41

HSV meningoencephalitis

Answer 41

o Rarer outside of neonatal period ``` o Symptoms  Headache  Fever  Lethargy  Change in behavior  Seizures (temporal lobe) ``` o Work-up  CSF studies, includes HSV PCR vs. culture  MRI  EEG o Treatment  IV acyclovir for 21 days

Question 42

HSV sem

Answer 42

o Person-to-person transmission by direct contact o Incubation 2-14 days o Primary infection is most severe – whole mouth ends up having sores o Followed by dormant stage with incorporation of virus into neuron cell bodies o Recurrence with sensory nerve sx  Pain, tingling, numbness, hyperesthesia before the vesicles appear

Question 43

HSV labialis

Answer 43

o Recurrent cold sores o Often preceded by tingling o Acyclovir can shorten the course

Question 44

HSV gingivostomatitis

Answer 44

o Often a child’s primary HSV infection ``` o Symptoms  Fever  Perioral and oral lesions  Drooling  Dehydration  Can spread to rest of skin ``` o Can be very painful and require inpatient admission for hydration and acyclovir to shorten course

Question 45

Herpetic whitlow

Answer 45

o Primary or recurrent HSV on the finger o Symptoms  Pain->swelling->erythema and vesicles o Can arise after autoinoculation due to gingivostomatitis o Often misdiagnosed as cellulitis (bacterial)

Question 46

Eczema herpeticum

Answer 46

-HSV on top of eczema o Eczema causes weakening of the skin barrier o HSV vesicles spread rapidly and diffusely o Complication: herpes keratitis (into the eye – dendritic lesions)

Question 47

influenza

Answer 47

o Seasonal January-April o Highest risk patients: Infants and patients with asthma or immunodeficiency ``` o Symptoms  Fever  URI, conjunctivitis  Cough  Body aches  Vomiting/diarrhea ``` o Treatment  Oseltamivir = mediocre, upset stomach, use only in severe cases or hospitalized patients o Kids do die of flu!!

Question 48

epstein-barr virus

Answer 48

o Aka Mono, The Great Mimicker ``` o Symptoms/Signs  Fever  Sore throat  Lymphadenopathy  Fatigue  Splenomegaly (risk of spleen rupture)  Infants- asymptomatic ``` o Monospot tests for heterophile antibody  Good rapid test for teens/adults  Usually takes >1 wk to become positive  Children (<10ish) don’t necessarily make heterophile antibodies • KNOW THIS – kids don’t necessarily make it so you can do the monospot but if its negative, that doesn’t actually definitively mean its negative  -> high false negative rate o Can do antibody (IgM and IgG) testing o Treatment: supportive, steroids if airway concerns

Question 49

other common infections

Answer 49

o Diaper candidiasis o Tinea o Scabies o Lice

Question 50

diaper candidiasis

Answer 50

o VERY common skin infection o Caused by candida albicans o Red with irregular borders and satellite lesions  Big red area and little dots outside ``` o Treatment  Air  Barrier cream  Nystatin/Clotrimazole  (Avoid powders in infants) – because kids can inhale these and cause lung complications ```

Question 51

tinea

Answer 51

``` o Capitis o Corporis (ringworm) o Cruris (jock itch) o Pedis (athlete’s foot) o All can be treated topically except capitis – scalp doesn’t respond well to topical so you have to use oral ```

Question 52

tinea versicolor

Answer 52

o More common in teens and young adults o Light or dark patches, sometimes scaly o Pathogen: Malasezzia sp. o Treated topically  Miconazole, clotrimazole, selenium

Question 53

scabies

Answer 53

o Female mite (Sarcoptes scabiei) burrows into skin and lays eggs o Burrows are linear o Typically in intertriginous areas  Finger webs, waist line, bra line o Very itchy and very contagious o Treatment: permethrin for all o In kids, the scabies don’t necessarily follow the interdigitous pattern, its mostly dispersed

Question 54

lice

Answer 54

o Louse (grey bug) lays eggs (nits) that attach to hairs o Very itchy and very contagious o Tends to be close to the scalp, towards back of head o Treatment  Permethrin shampoo for all  Mayonnaise/vaseline method