Paediatric Infectious Disease

1. Paediatric Infectious Disease Ben Ryan Final Year Medical Student

2. Contents • Childhood Immunisations • General Management of Childhood Infections • Meningitis • Causes, Diagnosis, Management, Complications • Meningococcal Disease • Febrile Convulsions • Gastroenteritis • Public Health England – Notifiable Diseases

3. Childhood Immunisations Schedule • http://www.nhs.uk/Tools/Pages/NHSvaccinationplanner.aspx

6. Childhood Immunisations Schedule • 2 months – 3 injections and 1 solution • DTTPHibHepB (6 in one), Men B, PCV, Oral Rotavirus • 3 months – 1 injection and 1 solution • DTTPHibHepB (6 in one), Oral Rotavirus • 4 months – 3 injections • DTTPHibHepB, Men B, PCV • 12-13 months – 4 injections • HibMenC, MMR, PCV, Men B

7. Childhood Immunisations Schedule 2 • 2-8 years old – annual flu vaccine • 3 years and 4 months (40 months) - 2 injections • DTPP (4 in 1), MMR • 14 years – 2 injections • Men ACWY and DTP

8. Other things to be aware of • BCG – TB vaccine for those considered at risk of catching TB. Not given to those over the age of 35. • Born in areas of UK where TB is high • Have a parent/grandparent born in a country where TB is high • Effective at preventing TB meningitis, but not as good against pulmonary TB • Vaccine have additives in • Enhancers, stabilisers, preservatives • https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/448789/8584-what-to-expect-after-vaccination-2015-2P-A5-02-web.pdf

9. “What to expect after vaccinations” PIL • Baby may cry for a little while, but normally settles shortly • Most babies don’t have any other reaction • Reactions at the site of injection • Swelling, redness or a hard lump – usually only lasts 2-3 days and no treatment needed • Fevers • Paracetamol given after 2 month and 4 month vaccinations • MMR • Can cause fever, rashes and swollen glands. Not infectious.

10. Other vaccination info • Check allergies first! • Allergies to vaccinations are rare – nurse/doctor giving vaccination will know how to treat • Some contain pork gelatin, eggs, human albumin, formaldehyde and antibiotics • Vaccinations do not affect when they can swim. • Atopy does not affect vaccinations • Vaccinations can’t be given during illness with fever • Vaccinations are given at same age for premature babies

11. Management of Feverish Children

12. Measurement of Temperature • <4 weeks • Use an axilla thermometer • Fever detected by parents/carers should be considered valid

13. Traffic Light System – Assessing Risk of Serious Illness • Thorough assessment to include the following • Colour (of skin, lips or tongue) • Activity • Respiratory • Circulation and Hydration • Other • Each area should be assessed as green, amber or red • Any criteria in red = high risk • Criteria in amber but not in red = intermediate • All green = low risk

14. Colour • Green • Normal colour • Amber • Pallor reported by carer • Red • Pale/mottled/blue

15. Activity • Green • Normal response to social cues • Stays awake or awakens quickly • Not crying, or strong normal cry • Amber • Not responding normally to social cues • Wakens only with prolonged stimulation • Decreased activity • Red • No response to social cues • Appears ill to a healthcare professional • Does not wake, or stay awake for long • Weak, high-pitched or continuous cry

16. Respiratory • Amber • Nasal Flaring • Slightly raised RR • Oxygen sats <95% in air • Crackles in the Chest • Red • Grunting • Markedly raised RR (>60) • Moderate or severe chest indrawing/recessions

17. Circulation and Hydration • Green • Normal skin and eyes • Moist mucous membranes • Amber • Tachycardia • Slow CRT • Dry mucous membranes • Poor feeding in infants • Reduced urine output • Reduced Skin Turgor

18. Others • Amber • Aged 3-6 months with temp >39 • Fever for 5 or more days • Rigors • Swelling of a limb or joint • Non weight-bearing limb • Red • Age <3 months with a temp >38 • Non-blanching rash • Bulging fontanelle • Neck Stiffness • Status epilepticus • Focal neurological signs • Focal seizures

19. Assessment of Risk • Green • Generally cared for at home • Amber • Should be assessed but urgency depends on clinical judgement • Red • Urgently assessed within 2 hours – ?PAU • Life-threatening • 999 • A-E Approach • ALWAYS safety net and give advice

20. Specific Illnesses causing Fever • Pneumonia • UTI • Septic Arthritis/osteomyelitis • Kawasaki Disease • Meningococcal Disease • Bacterial Meningitis • Herpes Simplex Encephalitis

21. Pneumonia • Consider if fever plus any of the following: • Tachypnoea • Crackles in chest • Nasal Flaring • Chest indrawing/recessions • Cyanosis • Oxygen sats <95% on room air

22. UTI • Consider UTI in any child younger than 3 months with fever • Consider UTI if fever, older than 3 months, and any of the following: • Vomiting • Poor Feeding • Lethargy • Irritability • Abdominal Pain or Tenderness • Urinary Frequency or Dysuria • Big topic, will cover elsewhere

23. Septic Arthritis/Osteomyelitis • Consider in children with fever and any of the following: • Swelling of a limb or joint • Not using an extremity • Non-weight bearing

24. Kawasaki Disease • Consider if fever for more than 5 days and who have at least 4 of the following features: • Bilateral conjunctival infection • Change in mucous membranes on upper respiratory tract (strawberry tongue, dry cracked lips, inflamed pharynx) • Changes in extremities (oedema, erythema or skin peeling) • Polymorphous rash (red, blotchy) • Cervical lymphadenopathy

25. Kawasaki Disease – CRASH and Burn • C – conjunctivitis • R – rash • A – adenopathy • S – Strawberry Tongue • H – Hands swelling or erythema (or anywhere else on extremities) • Burn – 5 days of fever

26. Kawasaki Disease • No specific test – clinical diagnosis • Management • High dose aspirin – only time this is given in kids, can cause ‘Reye’s Syndrome’ • IV immunoglobulins • Echocardiogram – Kawasaki disease can cause coronary artery aneurysms

27. Meningococcal Disease and Meningitis

28. Definitions • Meningitis is a condition caused by inflammation of the meninges • Causes can be infective and non-infective (certain cancers, autoimmune disorders) • Bacterial meningitis is a life-threatening condition that affects all ages, but is most common in babies and children • Neisseria meningitidiscan result in bacterial meningitis, or meningococcal septicaemia. Other bacteria can also cause meningitis • Meningococcal septicaemia is when a N. meningitidisinfection is in the bloodstream.

29. Causes – Meningitis • Bacterial causes: • 3 months and older - Neisseria meningitidis, streptococcus pneumoniae and Haemophillus influenza type b • Neonates – streptococcus agalctiae, E coli, Streptococcus pneumoniae, Listeria monocytogenes • More common in winter season • Other causes • Viral causes are most common cause. Most are self-limiting. • Herpes Simplex (also typically causes encephalitis) – important as can cause death and severe neurological impairment. High dose acyclovir. • Tuberculosis

30. Diagnosis – When to suspect bacterial meningitis • Meningism (positive in meningitis and intra-cranial bleeds): • Photophobia • Stiff neck, Back rigidity • Nuchal rigidity – can’t forward flex neck • Kernig’s sign – flex thigh and knee at 90 degrees, extend knee – positive if knee extension painful • Brudzinki’s signs – lie patient supine, lift patient’s head – positive if involuntary lifting of legs • Headache • Non-blanching rash • Fever/vomiting/nausea/lethargy/irritable/ill appearance/headache • Altered Mental State • Unconsciousness • Bulging Fontanelle • Seizures

31. Diagnosis of bacterial meningitis • As always, A to E approach as could be life-threatening • Full history and examination • Full set of observations • Bloods • FBC, CRP, U&E, blood glucose, blood gas, lactate • PCR for N meningitidis • Blood cultures • Lumbar Puncture • Diagnostic test. • Contra-indications – signs of raised ICP, shock, infection at site. Do not need to perform a CT first. • Happy to go through interpretation of lumbar puncture if needed

32. Management of Bacterial Meningitis • A to E approach • IV ceftriaxone • Can give before diagnosis if needed. Do not delay. • Likely to be long course, at least 10 days. Might be changed by sensitivities. • Dexamethasone used in many cases for 4 days • Monitor for complications: • Hypoglycaemia, hypokalaemia, hypocalcaemia, hypomagnesia • Anaemia, coagulopathy • Acidosis • Treat raised ICP if needed

33. Complications of Bacterial Meningitis • Hearing loss (33%) • Seizures (12.6%) • Motor deficit (11.6%) • Cognitive Impairment (9%) • Hydrocephalus (7%) • Visual disturbance (6.3%) • Death • Disseminated Intravascular Coagulation (although this appears to be more connected to meningococcal septicaemia)

34. Quick note on meningococcal septicaemia • Meningococcal septicaemia without bacterial meningitis does not seem to cause as many of the neurological signs/symptoms, particularly meningism

35. Meningococcal Disease • Infectious caused by Neisseria meningitidis • Different serotypes (including A, B, C, W135, X and Y) • Vaccinations against • Consider if fever and non-blanching rash, especially if: • Ill-looking • Lesions larger than 2mm in diameter • Slow CRT • Neck Stiffness

36. SEPSIS 6BUFALO (or Give 3, Take 3) • Blood Cultures • Urine Output (?Catheterise) • Fluid Challenge – 0.9% sodium chloride solution • Can’t get an IV line in? You can go IO - intraosseous • Antibiotics (broad spectrum) • Lactate • Oxygen (high-flow)

37. Septic screen for neonates and young infants (less than 3 months old) • If less than 3 months old, fever is a bad sign • Other signs too: increase in PEWS, reduced movements, jaundice • Sepsis screen (many vary from trust to trust, or depending clinical picture: • Full blood count • Blood Culture • Urinalysis • Urine Culture • Lumbar Puncture CSF studies • CSF culture

38. Febrile Convulsions What to know when going into an OSCE – advice to parents

39. First – Clarifying Seizure Definitions • Distribution of seizure in brain: • Generalised – affect both sides of brain (and all over the body). • Focal (partial) – affects just one part of the brain (so focal neurological symptoms/signs during seizure) • Secondary generalised – Starts as focal seizure, then becomes generalised • Affect on consciousness: • Simple – Aware and alert, will usually know what is happening and will remember the seizure afterwards • Complex – consciousness affected. May be confused or unaware of what they are doing. (Generalised seizures are almost always ‘complex’ so simple/complex are normally only used to describe focal seizures)

40. More definitions • Findings/features during seizure • Tonic – Muscles become stiff, may fall over, may injure themselves – more likely to hurt back of head • Atonic (drop attacks) – muscles become floppy, falling, may injure themselves – more likely to hurt front of head/face • Clonic (might be the same as myoclonic?)– muscle jerking • Tonic-clonic is a common type of seizure – generalised stiffness (tonic), followed by an episode of muscle jerks (clonic) • Absence seizures (may look a bit like daydreaming) – unconscious for a short period of time, may look blank and stare, eyelids might flutter, not aware of what they’re doing.

41. What is it? • A fit or seizure that can happen if a child has a fever of more than 38 • Usually harmless • Usually last more than 5 minutes • Likely become stiff (tonic), twitch (clonic), then lose consciousness • May be sleepy or tired afterwards

42. Presentation • Affects children typically between the ages of 6 months and 5 years • High temperature (more than 38) at time of seizure • Tonic and/or clonic, symmetrical, generalised seizure lasting <5 minutes • No signs of CNS infection, focal neurological signs or a previous history of epilepsy

43. Investigations • Full history • What happened • How long it lasted • Recovery • May consider an EEG • If possible meningitis, may consider an LP

44. Algorithm • Neck stiffness present • Admit to acute paediatric facility • Treat as meningitis • Complex febrile seizure (high risk of meningitis) • admit, consider LP • Younger than 18 months, or prior treatment with Abx • Admit, identify source of fever, regular anti-pyretics • If older than 18 months with no previous Abx • Attempt to identify and treat cause of fever. Discharge after parents informed, advise to contact GP, regular anti-pyretics, safety netting, and once parents are happy

45. Short-term Management • Recovery position – teach parents recovery position • Don’t put anything into mouth during seizure • Take them to hospital/dial 999 if: • First fit • Longer than 5 minutes (although some sources say 15?) • Feel unwell otherwise • Breathing difficulties

46. Management of seizure (medical) • If seizure lasts more than 5 minutes • Give rectal diazepam or one dose of buccal midazolam • Can repeat after 5 minutes • Call 999 if 10 minutes after first dose: • Seizure has not stopped • Ongoing twitches • Another seizure has begun before child regains consciousness • Measure Blood glucose if child can not be roused

47. Long-term Management • Paracetamol can lower temperatures (however should be given with the intent to make child more comfortable, not to simply reduce likelihood convulsion) • Recurrence rate about 30% • Recurrence is more likely if they are younger than 18 months with their first seizure • NOT THE SAME AS EPILEPSY – parents will be worried about that • Low risk of getting epilepsy – similar to background population. More likely if abnormal development, complex febrile seizures

48. Lumbar Punctures

49. MCQ City

50. MCQ 1 • A 4 year old male, weight 16kg, presents to the Emergency Department with a 2 day history of feeling generally unwell. Today, he has developed a headache and a rash. His mother reports that his After further questioning you find out that his neck feels stiff and he struggles to look at the light. The rash is red and purpuric in nature and does not change colour when pressure is applied. • Observations: HR 155, BP 90/60mmHg, Temp 39.0, RR 40, CRT > 3 seconds, Oxygen Sats 94% • Which of the following would not be part of your initial management? • A - 80mL 0.9% sodium chloride IV Stat • B – Lumbar Puncture • C – Blood Cultures • D – IV Ceftriaxone • E – High-flow Oxygen