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Pediatric Grand Rounds

Pediatric Grand Rounds. Block 3, 2007 Lindsay Sherrard Ryan Foret Joey Patrick. What disease?. costs the US $3.5 billion each year? necessitates the average household to have 4-8 medicines? is the most common human illness?. Viral Upper Respiratory Infections in Kids. Epidemiology

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Pediatric Grand Rounds

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  1. Pediatric Grand Rounds Block 3, 2007 Lindsay Sherrard Ryan Foret Joey Patrick

  2. What disease? • costs the US $3.5 billion each year? • necessitates the average household to have 4-8 medicines? • is the most common human illness?

  3. Viral Upper Respiratory Infections in Kids • Epidemiology • Pathogenesis • Clinical Features • Complications • Treatment • Prevention

  4. Epidemiology of the Common Cold • Children are the main reservoir • Infants: average 6 per year • Older kids: average 4-8 per year • Incidence declines with age except for a spike in adults in their 20s • Families with the oldest child aged 1-4 are at higher risk • Families with a child in daycare or school are at higher risk

  5. So what causes colds?

  6. Causes of Viral URIs • Rhinovirus: over 100 subtypes, cause 10-40% of colds (adults) • Coronavirus: 20% of colds (adults) • RSV: 10% of colds (adults) • Influenza, parainfluenza, adenovirus cause more systemic symptoms • Enteroviruses (echovirus, coxsackievirus) usually cause fever without cold symptoms • Human metapneumovirus (HMPV)

  7. Seasonal Variations

  8. Seasonal Variations • Generally unknown why there are worldwide seasonal variations. • No change in host resistance to rhinovirus based on exposure to cold climate • Possibly due to variations in living conditions, schooling, and crowding

  9. Seasonal Variations • Rhinovirus: early fall, spring • Parainfluenza: late fall • RSV: winter • Influenza: winter • Coronaviruses: winter • Adenovirus: fall, winter, spring • Enteroviruses: summer • Human metapneumovirus: late winter, early spring

  10. Quiz Question # 1 • You are asked to talk to local child care providers about infection control measures. You advise them that the single best intervention to reduce the spread of “common colds” to other children in the center is to:

  11. Quiz Question # 1 • A. Exclude all ill children from the center. • B. Have all providers wear masks. • C. Isolate sick children from the center. • D. Limit outside playtime during the winter months. • E. Wash hands and toys.

  12. Quiz Question # 1 • E. Wash hands and toys.

  13. Transmission

  14. Transmission • Rhinovirus→ nasal secretions • very small amount in saliva • Direct hand to hand contact and contact with nasal mucosa or conjunctiva • Large particle droplets on nasal mucosa or conjunctiva • Inhalation of small particle aerosols (especially RSV)

  15. Transmission • Rhinovirus can survive 2 hours on the hands • Rhinovirus can survive up to several days on hard surfaces, less on porous surfaces • Children tend to shed more virus and for longer time

  16. Pathophysiology

  17. Pathophysiology • Symptoms begin 1-2 days (or up to 7 days) after inoculation • Viral shedding begins 12 hours after inoculation, peaks at 48 hours, and may continue up to 3 weeks for rhinovirus • Symptoms correlate with influx of PMNs into mucosa and submucosa (with immune response) • Colored mucus is from neutrophil enzymatic activity but has no correlation with positive bacterial cultures

  18. Pathophysiology • Bradykinins, IL-8, and other inflammatory mediators increase • Histamine levels are not elevated • Elevated albumin levels suggest leaky vasculature • Most symptoms are due to immune response, not to destruction of epithelial cells by viral replication. • Adenovirus and influenza-A are more cytotoxic than rhinovirus and coronavirus

  19. Pathophysiology • Immune response also explains asthma exacerbations during viral URIs • Exacerbation may last up to 4 weeks • Unknown if inflammatory mediators are produced locally in the lower respiratory tract or if they act from a distance

  20. Quiz Question # 2 • A parent is concerned that her 4-year-old son “always has a cold.” Given what you know about the frequency of colds and the duration of their symptoms, what is the minimum number of “sick days” per year that would be considered excessive for a typical child?

  21. Quiz Question # 2 • A. 75 • B. 100 • C. 125 • D. 150 • E. 175

  22. Quiz Question # 2 • D. 150 • Having cold symptoms up to 140 days per year is normal for a young child.

  23. Clinical Syndromes of Viral Respiratory Infections • Common Cold • Sinusitis • Acute otitis media • Otitis media with effusion • Pharyngitis • Croup • Bronchiolitis • Pneumonia

  24. Common Cold • Nasal discharge, often colored • Low grade fever for the first 2-3 days • Sore, scratchy throat (often the first feature in older kids) • Cough • Irritability • Difficulty sleeping • Decreased appetite • Symptoms usually last 2 weeks in children (1 week in adults)

  25. Physical Exam Findings

  26. Physical exam findings • Inflamed, swollen nasal mucosa and pharynx • Middle ear effusion • Cervical lymphadenopathy • Conjunctivitis

  27. Quiz Question # 3 • A 3-year-old boy is coming to see you with what his mother describes as “probably just a cold.” On the phone, she said that he has had a runny nose and now has a worsening cough. Which piece of this patient’s past medical history would raise the greatest concern?

  28. Quiz Question # 3 • A. Asthma • B. Croup • C. Otitis media • D. Sinusitis • E. Tonsillitis

  29. Quiz Question # 3 • A. Asthma

  30. Case 1: DB • 12y BM with history of asthma presented with wheezing, cough and fever for one day • Had runny nose for two days • Cough associated with chest pain and vomiting x 2 • Still coughing and wheezing after 3 albuterol nebs in the ER

  31. Case 1: DB • PMH: • asthma with one hospitalization at age 3 • irregular heartbeat with negative work-up • SH: Lives with mom in carpeted trailer, no smokers, outdoor dog, doing well in the 7th grade • FH: asthma-dad and uncle • Home meds: albuterol inhaler at home, uses about once monthly; ran out of singulair and advair 2 months ago

  32. Case 1: DB • Vitals: T 102, P 95, R 18, SaO2 95 on room air • PE: accessory muscle use, bilateral wheezing • Labs: WBC 9.6, Hgb 12.7, platelets 241

  33. Case 1: DB

  34. Case 1: DB • Admitted for asthma exacerbation secondary to viral URI • On HD #2, his O2 Sat dropped in the 80s and he required up to 5L NC • ABG: 7.40/33/85/20 on 5L NC

  35. Case 1: DB • Solu-medrol dose in ER • Prelone 1mg/kg/day • Resumed advair and singulair • Albuterol nebs, then inhaler • Finally improved on HD #3 and was discharged on HD#4 • Told to monitor his peak flow, especially when he gets a cold

  36. Complications of the Common Cold • Otitis Media • Sinusitis • Pharyngitis • Croup • Epistaxis • Lower respiratory infection (bronchiolitis, pneumonia) • Asthma exacerbation

  37. Signs a Cold may be Complicated • Fever > 102 • Fever still present after 3 days • “Double sickening” • Severe cough or respiratory distress • No improvement within 10-14 days • Vomiting

  38. Treatment of the Common Cold (Under age 2) • Supportive therapy only is best • Hydration • Elevate head of bed • Humidifier • Nasal saline drops with bulb suction • Clearing the nose is important to prevent dehydration from less PO intake • Fever/pain control with: -Tylenol (over age 2 months) -Motrin (over age 6 months) • Treat bronchospasm with bronchodilator

  39. Quiz Question # 4 • Your parent information sheet “Colds in Infants” includes instructions on correct use of a bulb syringe. Normal saline, rather thans 1/8% phenylephrine drops (“Little Noses”), is recommended because:

  40. Quiz Question # 4 • A. 4-month-old infants are primarily mouth breathers. • B. Phenylephrine causes rebound congestion. • C. Phenylephrine causes vasodilation. • D. Phenylephrine has been associated with cardiomyopathy. • E. Phenylephrine must be given for 72 hours to be effective.

  41. Quiz Question # 4 • B. Phenylephrine causes rebound congestion.

  42. Instructions on using a bulb syringe • Place the infant on his or her back. Using a clean nose dropper, place 1 to 2 drops of saline solution in each nostril. Wait two minutes. • Squeeze and hold the bulb syringe to remove the air. Gently insert the tip of the bulb syringe into one nostril, and release the bulb. The suction will draw mucus out of the nostril into the bulb. • Squeeze the mucus out of the bulb into a tissue.

  43. Instructions on using a bulb syringe • Repeat suction process several times in each nostril until most mucus is removed. • Wash the dropper and bulb syringe in warm, soapy water. Rinse well, and squeeze to remove any water. • The bulb syringe can be used two to three times per day as needed to remove mucus. It is best to do this before feeding; the saline and suction process can cause vomiting after feeding. • http://www.cincinnatichildrens.org/health/info/newborn/home/suction.htm

  44. Instructions on using a bulb syringe

  45. Treatment of the Common Cold (Over age 2) • Supportive therapy only is best • Hydration, chicken soup • Elevate head of bed • Humidifier • Nasal saline spray • Fever/pain control with: -Tylenol (over age 2 months) -Motrin (over age 6 months) • Treat bronchospasm with bronchodilator • Can consider cough/cold meds with careful dosing guidance

  46. Why not a little….

  47. Do no harm… • Cough and cold medicines are associated with fatalities in children under age two, presumably by accidental overdose. • Metabolism and clearance is unknown and probably varies by age and by individual. • The recommended dosing of these medicines has not been set by the FDA for children under two.

  48. Do no harm… • Cough and cold medicines have not been shown to relieve symptoms in kids of any age. • In 2000, 5% of poison exposures reported to poison control were cough/cold preparations

  49. Do no harm…

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