infections

September 20 2022

Pneumonia in Children – Symptoms, Diagnosis, Treatment

PME-Admin article, medical children, infections, pediatric, pediatrics, pneumonia

Pneumonia in Children – Symptoms, Diagnosis, and Treatment
Santa J. Bartholomew M.D.

Pneumonia is a form of lung inflammation that can cause serious respiratory illness, and can be especially life-threatening in children. Symptoms of pneumonia range from mild to severe, and the condition can be fatal in some cases. Early diagnosis and treatment of pneumonia is essential for easy recovery. In this blog post, we will discuss the symptoms, diagnosis, and treatment of pneumonia in children.

Symptoms and Diagnosis of Pneumonia

The main symptoms of pneumonia in children include:

Coughing up mucus
Rapid breathing or difficulty breathing
Chest pain when coughing or breathing
Fatigue or exercise intolerance
Fever, excessive sweating, or chills
Loss of appetite
Nausea, vomiting, or diarrhea
Bluish tint to lips or nails

How to Treat Pneumonia in Children

Treatment for pneumonia in children usually involves antibiotics and rest. In severe cases, hospitalization may be necessary. With early diagnosis and treatment, most children recover from pneumonia without any complications.

Pneumonia Prevention

To prevent pneumonia in children, it is important to practice good hygiene habits such as washing hands frequently and avoiding close contact with people who are sick. It is also important to make sure your child is up-to-date on their vaccinations, as some types of pneumonia can be prevented with vaccination. If your child is showing signs or symptoms of pneumonia, it is important to call a doctor right away. Early diagnosis and treatment are essential for a child’s recovery from pneumonia.

Final Thoughts on Pneumonia in Children

Pneumonia is a serious respiratory illness that can cause severe symptoms in children. Early diagnosis is paramount.

Studies have shown that children…

Pneumonia Prevention

Final Thoughts on Pneumonia in Children

Pneumonia is a serious respiratory illness that can cause severe symptoms in children. Early diagnosis is paramount.

Resources

Symptoms: https://www.mayoclinic.org/diseases-conditions/pneumonia/symptoms-causes/syc-20354204
Diagnosis: https://www.childrenscolorado.org/conditions-and-advice/conditions-and-symptoms/conditions/pneumonia/
Additional Information: https://my.clevelandclinic.org/health/diseases/4471-pneumonia

Disclaimer: This web site provides general information about pediatric health and related subjects. The information and other content provided on this website or in any linked materials are not intended and should not be considered, or used as a substitute for, medical advice, diagnosis or treatment. Never disregard professional medical advice or delay in seeking it because of something that you have read on this website or in any linked materials.

September 13 2022

Monkeypox and the Impact of Pediatric Infections

PME-Admin article, medical children, infections, monkeypox, pediatric, pediatrics

Monkeypox and the Impact of Pediatric Infections — Santa J. Bartholomew M.D.

Monkeypox and the Impact of Pediatric Infections

Monkeypox is a rare viral disease that is similar to human smallpox. Prior to 2021, the last outbreak of monkeypox in the United States occurred in 2003, when there were 47 confirmed and probable cases. However, the majority of these cases were imported from Africa, where the disease is more common.

The first known outbreak of monkeypox occurred in 1958 in the Democratic Republic of Congo. This outbreak was confined to monkeys, while the first documented human case of Monkeypox was not discovered until 1970.

Since then, there have been sporadic outbreaks of the disease in Africa. The largest outbreak of monkeypox occurred in 1996-1997 in the Congo Basin region. During that outbreak, more than 500 people were infected and 37 people died.

Studies have shown that children under the age of five are three times more likely to die from monkeypox than adults.

What is Monkeypox?

Monkeypox is caused by a virus from the Orthopoxvirus genus. This family of viruses includes variola virus, which causes smallpox, and vaccinia virus, which is used in the smallpox vaccine. There are two different strains of monkeypox virus: West African monkeypox and Central African monkeypox. Central African monkeypox is more severe and has a higher fatality rate.

How Does Monkeypox Spread?

Monkeypox can be spread through contact with an infected animal, such as a monkey, rat, or squirrel. It can also be spread through contact with infected material from these animals, such as their blood or skin. The disease can also spread from person to person through close contact with an infected individual, such as touching or kissing them.

How Does Monkeypox Impact Children?

Children are particularly susceptible to monkeypox infections. In fact, studies have shown that children under the age of five are three times more likely to die from monkeypox than adults. Monkeypox can be deadly in some cases, but with prompt medical treatment, patients have a good chance of recovery.

Recent Pediatric Monkeypox Infections and the Impact on Children

There have been several outbreaks of monkeypox in Africa over the past few years. Children have been adversely affected by these outbreaks. During a 9-month period in 2020, for example, 42% of those affected by the virus were children.

What is concerning is that the case fatality ratio during this period for children under 5 years of age was 4.2%, which was a 0.8% increase from those over the age of five.

In the United States, there have been 22,630 reported cases as of the publication of this article. California (4,300) and New York (3,679) exhibited the highest number of cases, with Florida (2,282), Texas (2,017), and Georgia (1,607) rounding out the top five states.

Children under 15 years of age were largely not impacted by the recent infections. The largest demographic impacted by Monkeypox in the US has statistically been men aged 31-35 years of age.

Conclusion

Although it is rare, monkeypox can be a serious illness, especially in young children. The best way to protect yourself from this disease is to avoid contact with animals that may be carrying the virus. Wash your hands thoroughly if you come into contact with an infected animal. If you think you may have been exposed to monkeypox, please seek medical attention immediately.

Resources:

Nigeria Outbreak: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7694534/
US Cases: https://www.cdc.gov/poxvirus/monkeypox/response/2022/us-map.html
Case Fatality Ratio: https://www.who.int/emergencies/disease-outbreak-news/item/monkeypox-democratic-republic-of-the-congo
2003 US Outbreak: https://www.cdc.gov/poxvirus/monkeypox/outbreak/us-outbreaks.html
1958 and 1970 Outbreaks: https://www.cdc.gov/poxvirus/monkeypox/about/index.html#:~:text=The%20first%20human%20case%20of,central%20and%20western%20African%20countries.
Children Affected US: https://www.cdc.gov/poxvirus/monkeypox/response/2022/demographics.html

April 5 2022

Acute Rheumatic Fever

PME-Admin article, medical acute rheumatic fever, ARF, children, Group A Strep, infants, infections, pediatrics

Acute Rheumatic Fever (ARF) — Santa J. Bartholomew M.D.

The incidence of ARF is 8-51/100,000 people worldwide. It most commonly affects children ages 5-15 years after having a Group A Streptococcal infection (Strep throat). Overcrowding and poverty are directly proportional to the incidence of ARF as strep can sweep through a community and untreated can lead to acute rheumatic fever. The incidence of untreated Group A strep leading to Acute Rheumatic Fever is approximately 3% and recurrence is 50% in children who have had ARF. Timely treatment of strep throat can prevent acute rheumatic fever and is the most effective way to prevent all rheumatic heart disease (RHD).

PATHOPHYSIOLOGY

Group A Strep (GAS) is also known as streptococcus pyogenes is a gram-positive bacterium with more than 100 different serotypes but only serotype B causes disease. A protein on the outside of the cell called Protein M helps the bacterium cling to the skin of the host (typically a child) and cause illness. This protein causes a large inflammatory response and the clinical symptoms that the children experience. The immune response causes the child’s body to make proteins that can attack the muscle of the heart. This usually occurs 10 days to 5 weeks after the Group A strep pharyngitis.

The immune response causes the child’s body to make proteins that can attack the muscle of the heart.

CLINICAL DIAGNOSIS

GAS pharyngitis (strep throat) rarely affects children younger than 3 years old. Typically, children experience a sore throat, fever and headache. Some children may have nausea, vomiting and abdominal pain. On physical examination the physician may find exudate in the throat and on the tonsils but not always, redness or erythema. There are often swollen lymph nodes in the neck and sometimes petechiae on the soft portion of the palate. The uvula at the back of throat may be red and swollen. There maybe a fine red, sandpaper like rash over the child’s skin. It is also helpful to know if the child was near another recently diagnosed with strep throat.

Evidence of GAS infection can be obtained by drawing blood for titers in the blood to group A strep, in the acute setting throat swabs can help make the diagnosis of strep throat and thus quick treatment initiated avoiding ARF.

DIAGNOSIS OF ARF

Acute rheumatic fever is diagnosed using modified Jones criteria that were fist published in 1944 and have undergone multiple revisions through the years the last time in 2015 and are still used today.

The initial diagnosis of ARF is positive if there are 2 major criteria or 1 major and 2 minor criteria present along with evidence of persistent streptococcal infection. Further the presence of Sydenham Chorea is by itself enough to diagnose acute rheumatic fever. Sydenham chorea is a movement disorder in which the child has purposeless involuntary movements that disappear when the child is asleep. Face and hands are mostly involved and can only be suppressed very briefly. Children have deterioration in their handwriting, they can have slurred speech and emotional lability.

The Modified Jones Criteria (2015)

LR Populations

Major Criteria	Minor Criteria
Carditis-Clinical and/or subclinical	Polyarthalgia
Arthritis Polyarthritis only	Fever (≥ 38.5ºC)
Chorea	ESR ≥ 60 mm/h and/or CRP ≥ 3.0 mg/dL
Subcutaneous nodules	Prolonged PR interval after accounting for age variability
Erythema marginatum

Moderate Risk to HR Polulations

Major Criteria	Minor Criteria
Carditis-Clinical and/or subclinical	Monocarthralgia
Arthritis Monoarthritis or polyarthritis Polyarthralgia	Fever (≥ 38ºC)
Chorea	ESR ≥ 30 mm/h and/or CRP ≥ 3.0 mg/dL
Subcutaneous nodules	Prolonged PR interval after accounting for age variability
Erythema marginatum

CRP, C-reactive protein: ESR, erythrocyte sedimentation rate. For all patient populations with evidence of preceding Group A streptococcal infection. Diagnosis of initial ARF: 2 major manifestations or 1 major plus 2 minor manifestations.

TREATMENT

Primary treatment

prevention of the primary streptococcal infection to avoid ARF completely with the use of oral penicillin or IM doses of penicillin G, or like antibiotics. Prevention of repeated GAS infections is the most efficient way to prevent progression of ARF to rheumatic fever.

Secondary treatment

supportive and is not based on robust clinical trials, the mainstay is anti-inflammatory agents that will help with joint and cardiac inflammation but to date there is little evidence that these change outcome.

ARTHRITIS
- Ambulatory restriction for arthritis for 6 weeks
- High dose aspirin for typically 1-4 weeks
- On occasion corticosteroids are used for persistent inflammation
ACUTE CARDITIS
- Restricted activity for 4-6 weeks
- Aspirin
- Prednisone and/or Immunoglobulin in severe cases
- Treatment of heart failure associated with carditis
- Surgical procedures for valve problems associated with severe RHD.
SYDENHAM CHOREA
- Usually resolves spontaneously in 4-5 weeks
- Dopamine antagonists have been used with some success.
- Carbamazepine and Valproate have been used for prolonged movement problems.

ARF and RHD continue to be a major health problem in the United States and around the world. The most common clinical features of ARF are arthritis, chorea and carditis. ARF can be controlled by a combination of prevention, prompt recognition and treatment of Strep infections and improving access to health care.

December 5 2021

Late Group B Strep Disease

PME-Admin article, medical children, group b strep, infections, pediatrics, strep

Late Group Strep B Disease — Santa J. Bartholomew M.D.

Group B Strep (GBS) is a huge burden of disease in developed countries. It is divided into three categories: early GBS, Late GBS (7-89 days post birth) and very late GBS (> 90 days post birth). Early onset rates have fallen in the last 20 years due in great part to screening and treatment of mothers prior to delivery and as written about in another blog early onset GBS is caused by passage through the birth canal. This is an organism that lives in the vagina without causing disease in the mother.

Late onset GBS rate have remained steady for the last 25 years: 0.4/1000 live births despite changes in care of mother making it clear that acquisition of disease is not via delivery through the birth canal but acquired after birth of infant. Late onset GBS disease is as severe as that suffered by younger infants causing 27% of all meningitis in this age group as well as severe sepsis without meningitis. The mortality rate of meningitis in late onset GBS ca be as high as 10% with 35% of survivors having severe neurologic sequelae. In addition to sepsis and meningitis, however, GBS has been the cause of bone infections in infants (osteomyelitis) as well as joint infections, cellulitis, urine infections, brain infarction (stroke), and subdural collections in infants.

Late onset GBS is acquired by the infant from the mother or other colonized household members through routine care and touching but this is not typically a disease acquired passing through the birth canal. The infant can also become colonized going through the birth canal by swallowing vaginal secretions that result in bacterial adherence in the respiratory and GI tract mucous membranes that can later cause bacterial invasion causing pneumonias and sepsis much later in infancy. As many as 50% of infants of mothers colonized with GBS can become colonized with the same organism as the mother.

Late onset GBS is acquired by the infant from the mother or other colonized household members through routine care and touching.

Although it is not acquired through the birth canal it is most seen in in pre-term infants born <28 weeks of gestation. Other risk facts for late onset group B strep include young maternal age, HIV exposure, ethnicity (being more common in black children). There is also emerging data that breast milk may also expose infant to GBS in colonized mothers however it is believed that the benefits of breast feeding overall outweigh the risk of acquiring late GBS infection.

CLINICAL PRESENTATION

Temperature: fever, low or unstable temperature
Eating habits: feeds poorly, refuses to eat, not waking to feed, vomiting
Sleeping habits: sleeping too much, difficulty being aroused
Breathing: fast, slow, or difficult breathing
Sounds: high pitch cry, shrill moaning, whimpering, inconsolable, constant grunting
Behavior: marked irritability, reacting as if skin is tender, listless, floppy, not moving an arm or leg, blank stare, body stiffening, uncontrollable jerking
Skin Appearance: blue, gray or pale skin, blotchy or red skin, tense or bulging fontanelle, infection at the base of umbilical cord or head punctures from internal fetal monitor. Sometimes jaundice.

HOW TO DIAGNOSE

It is imperative that late onset GBS be considered in any infant that presents with signs of infection in the first three moths of life. High index of suspicion and empiric treatment are invaluable in prognosis.

Blood culture
Urine culture
CBC with differential
Lumbar puncture
Chest x-ray
If there is concern about joint swelling than radiographs of joints or MRI may be indicated.
If there is a twin, that infant should be evaluated.

TREATMENT

ANTIBIOTICS

Recognition and management of shock
Careful management of body salts
Management of breathing if child has oxygenation issues or is not awake and alert including placement of breathing tube and ventilator management.
Treatment of seizures
Treatment of anemia

All of these secondary treatments are aimed at preventing secondary brain injury while the antibiotics kill the organism.

DURATION OF THERAPY DIFFERS

Bacteremia without a focus – 10 days
Meningitis – 14 days is sufficient for uncomplicated meningitis; complicated central nervous system (CNS) infections require longer treatment
Cellulitis-adenitis – 10 to 14 days
Septic arthritis – 14 to 21 days
Osteomyelitis – 21 to 28 days
Urinary tract infection – 10 days

PROGNOSIS

Fatality is 1-3% for late onset disease, considerably higher in preterm infants up to 8%.

Meningitis in particular has substantial morbidity including:

Seizures
Permanent neurologic disability
Cerebral palsy
Greatly impaired cognitive development.

November 15 2021

Early Group B Strep Infections in Children

PME-Admin article, medical children, group b strep, infections, pediatrics, strep

Early Strep B Infections in Children — Santa J. Bartholomew M.D.

Group B Strep (GBS) is an organism that lives in the bowels and genitals of adults. In women group B strep lives in the vagina and does not cause illness in these women but as the infant comes through the birth canal, they can become infected causing great harm to the infant. Because of the catastrophic consequences to the infant, pregnant women are routinely checked for GBS and treated before the infant is born. Group B strep infections in infants come in two categories: early onset and late onset. It is only early onset that is transmitted via birth. There are many serotypes of this bacteria but only 6 cause significant disease.

Neonatal or early onset GBS is acquired in utero via “silent” intraamniotic infection or via early rupture of membranes as well as passage through the vagina. When mothers are tested the higher quantities of bacteria in the vagina the greater risk of transmission to the infant. GBS infections are 0.5 per 1000 births with higher rates in black infants.

Despite many prevention policies enacted early onset GBS has not been eradicated in the USA. Late onset GBS disease has seen no decrease since the 1990’s and this is NOT prevented by treating the mother before birth.

Because of the catastrophic consequences to the infant, pregnant women are routinely checked for GBS and treated before the infant is born.

Incidence of early- and late-onset neonatal invasive group B streptococcal disease: Active Bacterial Core surveillance areas (1990 to 2018).

Early and Late Onset Neonatal Group B Strep

RISK FACTORS FOR BABIES GETTING GBS

Colonized mother: transmission to the baby is 1 in 2 (50%)
Prior delivery of a baby with GBS disease
Delivery of a baby < 37 weeks gestation
Rupture of membranes more than 18 hours
Preterm labor with rupture of membranes
Chorioamnionitis
Fever in mom during labor

These risk factors have been incorporated into a prevention guideline to minimize risk to the newborn. This can be found at CDC website: ”Prevention of perinatal group B streptococcal disease.” These are imperative to follow as they dramatically decrease the risk of infection in the neonate.

Diagnosis of early-onset GBS disease in infants presents in fist week of life. It is crucial to review pregnancy and labor and delivery history as this can avoid catastrophic disease in the newborn.

GBS can manifest as Generalized Sepsis: temperature instability, poor perfusion, lethargy, respiratory symptoms like grunting and fast breathing, shock.
These babies can also have Persistent Pulmonary Hypertension in which blood does not flow easily to the lungs and can be quickly fatal disease.
Pneumonia accounts for 10% of GBS disease in newborns and usually include CXR findings of alveolar disease, as well as low oxygen levels and signs of distress like fast breathing, gruntiong noises, periods of apnea.
Meningitis Occurs in 5-10% of infants and presents as irritability, lethargy, poor feeding, vomiting, may or may not have respiratory symptoms.

When a baby is identified at high risk, there are two acceptable approaches to care listed below.

Approach to evaluating neonates born ≥35 weeks gestation who are at risk for group B strep infection:

“Enhanced observation” approach to evaluating neonates born ≥35 weeks gestation who are at risk for group B streptococcal infection:

TREATMENT

In any infant who shows symptoms, an evaluation should be initiated immediately and should include:

Blood cultures
CBC with differential
Lumbar puncture if there is clinical suspicion for sepsis
CXR
Urine culture

Treatment should be started with intravenous Ampicillin and Gentamicin.

PROGNOSIS

Approximately 3% die of infants infected with GBS. Among the infants that survive the risk of dying remains elevated in the first decade of life as much as 3 times higher than uninfected infants. There is even higher mortality in infants that are preterm, weigh less than 2500 grams, present in shock, have apnea, seizures or low white count or platelets at presentation.

Even in the survivors they are at serious risk for cerebral palsy, seizures, neurologic disabilities, and blindness. Infants who have meningitis have the highest risk of disability, as high as 22-25%.

The key to good outcome is prenatal testing of mothers and treatment of mothers before birth. If this is not possible then high index of suspicion and observation +/- treatment in the neonate is paramount for good neonatal outcome.

infections

Pneumonia in Children – Symptoms, Diagnosis, Treatment

Pneumonia in Children – Symptoms, Diagnosis, and TreatmentSanta J. Bartholomew M.D.

Symptoms and Diagnosis of Pneumonia

How to Treat Pneumonia in Children

Pneumonia Prevention

Final Thoughts on Pneumonia in Children

Pneumonia Prevention

Final Thoughts on Pneumonia in Children

Resources

Monkeypox and the Impact of Pediatric Infections

Monkeypox and the Impact of Pediatric Infections

What is Monkeypox?

How Does Monkeypox Spread?

How Does Monkeypox Impact Children?

Recent Pediatric Monkeypox Infections and the Impact on Children

Conclusion

Acute Rheumatic Fever

PATHOPHYSIOLOGY

CLINICAL DIAGNOSIS

DIAGNOSIS OF ARF

The Modified Jones Criteria (2015)

LR Populations

Moderate Risk to HR Polulations

TREATMENT

Primary treatment

Secondary treatment

Late Group B Strep Disease

CLINICAL PRESENTATION

HOW TO DIAGNOSE

TREATMENT

DURATION OF THERAPY DIFFERS

PROGNOSIS

Early Group B Strep Infections in Children

RISK FACTORS FOR BABIES GETTING GBS

TREATMENT

PROGNOSIS

Pneumonia in Children – Symptoms, Diagnosis, and Treatment
Santa J. Bartholomew M.D.