Paediatrics, Childhood Infections, Febrile Seizures 2.1 Flashcards
What questions to ask to get all information regarding paediatrics?
Age (or corrected age in pre-term infants)
Weight (actual vs ideal)
Route or acceptable administration methods
Allergies or ADR’s
Family and medical histories and co-morbidities
Medications
Age classification?
Define the following terms:
A) gestational age
B) chronological age
C) postmenstrual age
D) corrected age
A)
- In completed weeks: time between the first day of the last menstraul period and day of delivery
B)
- In days, weeks, months, or years: time since birth
C)
- In weeks: gestational age plus chronological age (CGA)
D)
- In weeks or months: chronological age minus the number of weeks born before 40 weeks’ gestation (only used for children born preterm upto 3 years of age)
What is absorption from the GI tract affected by?
- Gastric acid secretion
- Bile salt formation
- Gastric emptying time
- Intestinal motility
- Bowel length and effective absorptive surface
- Microbial flora
> all these factors are reduced in neonates (full-term and premature) and all may be reduced or increased in an ill child of any age.
How is absorption affected in neonates?
Rate of oral absorption is correlated with age
- ↓ gastric acid secretion (higher gastric pH)
- ↑ gastric emptying time
Immature production of pancreatic fluid and bile salts
Differences in intestinal microbial colonisation
IM absorption
- Decreased muscle mass, erratic blood flow and painful
- Generally should NOT be used – too painful in children (reserved for emergencies or if slower absorption is desired eg Vit K at birth)
Rectal: variation in blood flow to the rectum
Percutaneous absorption
- Enhanced: thinner stratum corneum, better skin hydration, larger SA.
- Potential for systemic toxicity
True or false preterm neonates have
> increased body water content
> less body fat
> lower albumin concentration
> increased blood brain barrier permeability
True
Higher doses (per kg of body weight) of water-soluble drugs are required in younger children because a higher percentage of their body weight is water
true or false
true
Albumin and total protein concentrations are lower in neonates but approach adult levels by 10-12 months = increased pharmacological effects and adverse effects at lower concentrations
True or False
True
Phase 1 and Phase 2 metabolism in neonates ?
Phase 1 metabolism
- Activity is reduced in neonates and increases progressively during the first 6 months of life
- Adult rates of metabolism may be achieved for some medications by 2-4 weeks of age
Phase 2 metabolism
> varies significantly by substrate
- delay in maturation of enzymes required for bilirubin and paracetamol conjugation
- enzymes required for morphine conjugation are fully developed even in pre-term neonates
Summary of drug absorption in neonates
- Drug absorption may be erratic
- Larger volume of distribution may result in the need for relatively larger doses (by weight) than might be expected
- Reduced metabolism and clearance may result in longer half-lives and the need for extended dosing intervals
- TDM may be helpful (in conjunction with clinical review)
> but not effective for valprotate –> doesn’t predict hepatotoxicity in children
What are some drugs that can manifest unusual toxicity in children?
- Ceftriaxone
- Codeine
- Lindane
- Prochloperazine
- Tetracycline
- SSRIs –> suicidal ideation
- Fluoroquinolones
- Diphenoxylate
- Anesthetics, topical (eg benzocaine, mixture of lidocaine and prilocaine)
Should mix medications with breast milk/formula?
No –> may change the taste of it and child may refuse it.
- small amount of apple puree on spoon may be ok
- give favourite food after medicine if necessary to disguise taste
Excipients? What are they linked with?
What measurement should dose be prescribed in?
mg not mL
> Avoid trailing decimals and clearly indicated leading 0’s
> Eg 0.2mg NOT .2mg, 12mg NOT 12.0mg
What should HR, SBP and RR be in children aging from <1 year to 5-12 years?
What formul to use for creatinine clearance in children?
Schwartz clearance, NOT cockroft-gault (>18yo only)
What factors to consider when giving medication to children?
- Age/weight
- Appropriate dose
> when the calculated dose using mg/kg exceeds the adult dose, use the recommended adult dose instead, unless otherwise specified
> Prescribe sensible and practical doses for easy measurement and administration
- Appropriate interval
> don’t confuse total daily dose with dose/interval ‘prn’: include frequency and maximum daily dose
- Appropriate route of administration
- Formulation
- Monitoring parameters
Summary of introduction to paediatrics
Age classification
- Including pre-term infants
Pharmacokinetic changes
Absorption
- Higher gastric pH, increased gastric emptying time, increased percutaneous absorption
Distribution
- Increased body water, lower albumin (less protein binding), increased BBB permeability
Metabolism
- Reduced hepatic enzyme activity in neonates. Most drugs have longer t½ in neonates
Elimination
- Renal plasma flow and GFR gradually improve over the first year or so
Specific medications
- Gentamicin, codeine, theophylline, phenytoin, levetiracetam
Role of TDM?
Adverse effects and toxicity
- Increased risk with paracetamol, valproate, topical anaesthetics, ceftriaxone, codeine, diphenoxylate, fluoroquinolones*, prochlorperazine, SSRI’s, tetracyclines*
Dosing in children
- Mg/kg vs mg/dose vs mg/kg/day vs BSA (mg/m2)
- IBW vs actual body weight
Administration
- How to measure dose
- How to give dose:
> Change medication, change route, tablet, disperse tablet, liquid, extemporaneous, SAS, half/quarter tab, injection via oral route
- Timing of dose
- Excipients
> Can cause issues (eg benzyl alcohol, gluten, ethanol, peanut oil, propylene glycol, colouring agents, carbohydrates)
Medication errors in children
- Inconsistent presentation of dosing information
- Calculations required
- Lack of familiarity
- Unlicensed/off-label use of products
- Different strength products
> Eg paracetamol 24mg/mL, 48mg/mL, 50mg/mL, 100mg/mL
- Parents giving doses in the middle of the night (tired/poor light)
- Child getting into others medication (or other products)
- Poisons information 13 11 26
Paediatric references
- AMH CDC, KEMH, PCH and RCH information etc
Monitoring parameters in children
- Different to adults and vary with age
- do NOT
What is otitis media? When does it peak? What are the 3 different types?
Inflammation of the middle ear
Peaks between 6 months and 3 years
>Eustachian drainage tube dysfunction
1. Acute Otitis Media (OM)
- Infected effusion and inflammation
2. Otitis Media with effusion
- Effusion but not infected
3. Chronic Suppurative Otitis Media (CSOM)
- infection of the middle ear with a perforated eardrum and discharge for >6 weeks
- Can cause hearing impairment and disability
- Occasionally serious complications can occur
What type of infection if AOM? Is it self-limiting?
Commonly viral infection
> antibiotics often (inappropriately) prescribed
> can also be bacterial or mixed infection
regardless of cause is usually self limiting
> Spontaneous resolution in 80% cases in 2-3 days
> Symptoms may persist up to 8 days in some children
True or false
for AOM: pull on ear and will feel better
for otitis externa: pull on ear and will hurt more
yessir true
How to diagnose acute otitis media?
Middle ear inflammation AND middle ear effusion
> Bulging tympanic membrane
> Otorrhoea (tympanic membrane perforation and effusion) –> discharge from the ear
PAIN ALONE IS NOT SUFFICIENT FOR DIAGNOSIS OF ACUTE OTITIS MEDIA
Acute otitis media where effusion is infected, what other symptoms will there be?
- Acute onset ear pain (tugging, holding, rubbing ear)
- Fever, irritability, poor feeding
- Bulging tympanic membrane
How to manage otitis media? What medications are not used? Why antibiotics not helpful?
Adequate and regular analgesia with paracetamol +/- NSAID
> Antihistamines, decongestants and steroids are NOT beneficial for AOM
> Pain is a poor indicator of response to antibiotic
- For every 100 children treated with antibiotics, only five children will be better at 2 to 3 days due to the antibiotics
- Antibiotic therapy does not improve pain at 24 hours
- Antibiotic therapy can cause harm through allergy, adverse effects and reistance
For most children antibiotics are not required for AOM, who are the exceptions?
Infants <6months
<2 years with bilateral infection
Systemically unwell (lethargic, pale, irritable +fever)
Children with otorrhoea (perforated eardrum)
Aboriginal and Torres Strait islander (ATSI) children
Children at high risk of complications (eg immunocompromised)
For normal patients, what does shared decision making with parent or carer mean for AOM?
Return to Dr if symptoms worsen, or don’t improve in 48-72 hours - antibiotics may be required
A delayed prescription for antibiotic therapy can be provided
Rare complications of AOM (without without antibiotics)
> mastoiditis and facial palsy –> urgent referral
Harms of antibiotic therapy?
- Adverse effects of antibiotics
Diarrhoea, rash or more serious hypersensitivity reactions
- Effect on microbiome
Full consequences not fully understood Yeast infections (eg thrush) to more serious infections (eg Clostridium difficile infection)
- Antibiotic Resistance
Multidrug-resistant bacteria (known as ‘superbugs’) can be spread between people, affecting your family and the community
If antibiotics are indicated for AOM:
A) what to use?
B) if no response to 48-72 hours, what to change to
C) for children with chronic otorrhea, add what?
D) if child very unwell or not responding to therapy?
A)
Amoxicillin
> do not use lower doses
B)
Amoxicillin/clavulanate
> B-lactamase producing H influenzae of M cattarhalis
C)
Ciporofloxacin ear drops until middle ear has been free of discharge for at least 3 days
D)
Urgent clinical review/hospital referral (may require IVABs)
If allergic to pencillins, what to use in place of amoxicillin or amoxicillin + clavulanate?
A) delayed non-severe hypersensitivity to penicillins
B) immediate (non severe or severe) or delayed severe hypersensitivity to pencillins
A)
- cefuroxime for 5 days
- trimethoprim + sulfamethoxazole for 5 days
B)
- trimethoprim + sulfamethoxazole as above
What are risk factors for recurrent bacterial OM?
group child care
allergic rhinitis
adenoid disease
various structural anomalies, such as cleft palate and those associated with Down syndrome
exposure to smoke (eg cigarettes, wood fires)
socioeconomic disadvantage (eg crowded housing)
What vaccination should child have to prevent bacterial OM?
Streptococcus pneumoniae vaccination
What to do if recurrent infection of OM occurs?
Manage as for acute otitis media and consider referral to an otolaryngologist
> frequent recurrences may require myringotomy and insertion of tympanostomy tubes (grommets)
How long does effusion last after resolution of AOM? Does it go away?
Middle ear effusion can persist for weeks after resolution of AOM
- By 3 months 90% will have resolved spontaneously
- May be appropriate to watch and wait 1st 3 months
What are the clinical signs of middle ear effusion?
Grey-white fluid behind an immobile tympanic membrane without signs of inflammation
What is persistent OM with effusion (glue ear) –> how long does it last for? What is the solution?
Middle effusion for > 3 months
- Usually asymptomatic
- May have hearing loss or balance/behavioural problems
- Problem if affecting hearing and speech development
- May need ENT referral and ?grommets
- Some children (eg ATSI children (see guidelines – link in eTG) or children with risk factors for recurrent OM) are at high risk of developing chronic suppurative OM
What are the aims of management of OM with effusion?
Restore hearing (if affected)
Resolve and prevent recurrent infections
Address risk factors for recurrent OM
What is chronic suppurative otitis media (CSOM)? Symptoms?
Is an infection of the middle ear with a perforated eardrum and discharge for >6 weeks
- Non-painful, copious discharge from ear
- Can cause hearing impairment and disability
- Occasionally serious complications can occur
> Intracranial infection and acute mastoiditis
> Increased risk in Aboriginal children
What is the treatment for CSOM?
Dry aural toilet
Topical antibiotic drops
- Ciprofloxacin 0.3% ear drops – 5 drops 12hourly until the middle ear has been free of discharge for >3 days
Persistent discharge may require prolonged treatment –> ENT referral
Summary for AOM
Common presentation in primary care
- Middle ear inflammation AND middle ear effusion
Often viral infection but antibiotics often prescribed
REGARDLESS OF CAUSE IS USUALLY SELF LIMITING
Management
Adequate and regular analgesia
> For most children antibiotics are NOT required
- Shared decision making
- Review or delayed prescription at 24-48 hours
- Risk of adverse effects and increased resistance from antibiotic use
> If antibiotics required:
- Amoxicillin (or if no response or concerns re resistance amoxicillin/clavulanate)
- Penicillin allergy (cefuroxime or sulfamethoxazole/trimethoprim)
Summary for preventing and managing recurrent bacterial OM
Reduce risk factors (smoke exposure, day care)
Pneumococcal vaccination
Consideration of ENT referral and grommets
Summary for otitis media with effusion
Not infected
Persistent OM with effusion if >3mths (Glue ear)
> May present with hearing or behavioural/balance problems
> Restore hearing, resolve and prevent infections, address risk factors
> Consider ENT referral +/- grommets
Risk of chronic suppurative OM (especially in Aboriginal and Torres Strait Islander children
Summary for chronic suppurative otitis media
Infection of the middle ear with perforated eardrum and discharge for >6wks
> Can cause hearing impairment and disability
> Occasionally serious complications can occur
Treatment
> aural toilet and ciprofloxacin ear drops
What is croup?
Acute laryngotracheobronchitis
- Inflammation of upper airway, larynx and trachea
How does croup present itself?
Coryzal (URTI) prodrome
Hoarseness/husky voice
Inspiratory stridor
Barking (brassy) cough (barking seal cough!)
Variable airway obstruction due to inflammatory oedema within the subglottis
What age does croup occur in, how long does it last for?
Most common 1-3 years (6mths-6 years)
Duration 2-5 days (post-viral cough may last weeks)
What is the cause for croup?
Most commonly parainfluenza viruses
Antibiotics are not indicated
What is spasmodic croup? When and who does it occur in?
Typical croup symptoms that occur without acute viral infection
- Usually in the early hours of the morning
- Shorter course than acute laryngotracheobronchitis
- Often recurrent
- Occurs in older children
> have co-existing asthma
- Treatment is the same as for acute croup
Outline the severity of coup through the following
A) Mild airway obstruction
B) Moderate airway obstruction
C) Severe airway obstruction
D) Life-threatening airway obstruction
stridor = harsh vibrating noise when breathing
A)
Mild chest wall retractions and tachycardia, but no stridor at rest
B)
Stridor at rest, chest wall retractions, use of accessory respiratory muscles, and tachycardia
C)
Persisting stridor at rest, increasing fatigue, markedly decreased air entry and marked tachycardia
D)
Restlessness, LOC↓, hypotonia, cyanosis and pallor
Minimise distress to the child as this can worsen symptoms
Differential diagnosis for croup?
Inhaled foreign body, anaphylaxis, bacterial tracheitis, epiglottitis
What to use in croup? Why use these medications?
Good evidence to support the routine use of a single dose of corticosteroids in all children with croup
> Regardless whether mild, moderate or severe
> Reduces hospital admission and prevents re-presentation
> No evidence for use of humidifier or cough suppressants
What corticosteroid to use in mild-moderate croup?
Budesonide inhalation single dose
Dexamethasone single dose
Prednisolone single dose
What corticosteroid to use in severe croup?
Adrenaline by inhalation via nebuliser, repeated after 30 minutes if no improvement
PLUS EITHER
- budesonide by inhalation via nebuliser as a single dose
OR
- dexamethasone orally or IM/IV if vomiting as a single dose
OR
- prednisolone as a single dose
Croup summary
Acute laryngotracheobronchitis
Triggered by virus
- Antibiotics are NOT indicated
URTI sx, inspiratory stridor, barking cough
Most common 1-3 years
Treatment
- Single dose of corticosteroids in ALL children with croup
- Plus nebulised adrenaline in severe croup
Spasmodic croup – sx without viral trigger (often in asthmatics)
Influenza caused by?
Caused by influenza A and B viruses
Novel strains have potential to cause pandemics due to
> lack of immunity
> increased virulence
eg swine flu influenza A H1NI 2009
Incubation period for influenza?
1-4 days
Infection control for influenza?
Spread by droplets and contact with fomites
- Hand hygiene, patient isolation, PPE
Notify HDWA
Prevent with vaccination
How is the diagnosis of influenza done?
- Rapid PCR from throat swab
Clinical features
- Temperature >38.5 OR significant history of fever (rigors, chills, sweating) PLUS 2 or more of:
> Cough, sore throat, body aches, tiredness, SOB
Do not rule out influenza in vaccinated individual
What are the complications of influenza?
Acute bronchitis, croup, AOM, pneumonia, myocarditis, pericarditis, post-infectious encephalitis, Reyes syndrome, haematological issues
Treatment of influenza?
In healthy adults with a low risk of complications
- Tx with a neuraminidase inhibitor –> decreased duration of influenza sx by <1 day on average, when tx started within 48 hrs of sx
> Limited benefit vs the potential AE’s of antiviral tx = N &V, headaches and neuropsychiatric events
How to treat children with influenza? Which patients to treat?
Most children require NO antiviral treatment
Regardless of duration of symptoms -treat patients with
- Established complications
- Being admitted to hospital for mx influenza
- With concurrent CAP
Consider treatment for individuals at higher risk of poor outcomes from influenza, who are these individuals?
Children aged <5 years
ATSI people of any age People with heart disease, Down syndrome, obesity, chronic respiratory, neurological or other chronic conditions, immune compromise
People with heart disease, Down syndrome, obesity, chronic respiratory, neurological or other chronic conditions, immune compromise
Which drugs used in treatment of influenza? What dose to use in different age groups?
Oseltamivir or zanamivir
Oseltamivir in renal impairment?
Treatment of influenza to prevent disease transmission, any backing to this?
May reduce risk of viral shedding and disease transmission
- Hospitalised or aged-care facility residents
- Have household contacts at risk of poor outcomes
Rare side AE of oseltamivir?
- Rare reports of self-injury, delirium and abnormal behaviour (some fatal) in children taking oseltamivir
True or false
Data for use in children <1 year for the prevention of influenza are limited; consider using oseltamivir only in a pandemic.
true
The earlier treatment starts, the shorter and less severe the illness, for oseltamivir. When to start?
Start within 48 hours (ideally within 24 hours) after onset of symptoms
However, in severe illness, later treatment, eg within 4 days of onset, is of benefit.
A 15 mg/mL oseltamivir liquid can be made before each dose by asking the carer to?
Mix the contents of one 75 mg capsule in 5 mL water by stirring for about 2 minutes
Draw the correct dose volume into a syringe (discard unwanted liquid)
Mix the dose in soft food to disguise the taste before giving
Tamiflu oral liquid also available
What is common in first couple of days with oseltamivir?
Nausea and vomiting in the first couple of days is common with this medicine
- Take it with food to help reduce this
- If swallowing capsules is difficult, you can take the contents of the capsule mixed in soft food, eg yoghurt, honey
Zanamivir precuations?
Airways disease (eg asthma) – bronchospasm may occur
DPI – children may not be able to inhale sufficiently –> inadequate tissue levels
Neuropsychiatric AE’s – unclear if due to influenza or zanamivir
Counselling from neuraminidase inhibitors
Neuraminidase inhibitors decrease, but do not suppress, viral excretion
treatment
- Shortens the time you have symptoms, such as fever, headache, sore muscles, cough and sore throat.
prevention
- May get flu even if you are taking this medicine
Otherwise healthy people should treat uncomplicated influenza by resting, drinking plenty of fluids and using paracetamol for symptom relief
Neuraminidase inhibitors have no effect in treating or preventing influenza-like illness (eg Coronavirus!)
Annual influenza vaccination recommended for everyone > 6months of age. Especially who? How many doses to give?
Children 6mths -5years
ATSI
People with medical conditions that increase their risk (eg asplenia, immunosuppressed, Down syndrome, long
- 1 dose per year
- 2 doses if 6mths-9 years getting vaccine for the first time CHECK THE BRAND of vaccine is ok for use in children
How is influenza vaccination given? How long does protection last for?
Preferably IM but can be given SC
Protection is expected to last for the whole season
> Optimal protection is within the first 3–4 months after vaccination
> Deferring vaccination to the beginning of winter may result in greater immunity later in the season, but may also lead to lack of protection if the influenza season starts early
> It’s never too late to vaccinate!
> Vaccinate children who need 2 doses (1st time vaccination) early in season to ensure the 2nd dose in time for winter
CI to influenza vaccination?
Anaphylaxis after a previous dose of influenza vaccination
Anaphylaxis to any component of influenza vaccination
Precuations to influenza vaccination?
Anaphylaxis to egg
- Vaccinate in medical facility with trained staff
- Remain for 30 minutes post-dose
Guillain-Barre syndrome within 6 weeks of influenza vaccination – vaccination generally not recommended
Immunotherapy – may be at increased risk of immune AE’s
Children who need both influenza and 13vPCV
> Can have both. Possible increased risk of febrile rxns
Adverse events to influenza vaccination?
Can NOT cause influenza (not a live vaccine)
Symptoms may mimic influenza
- Injection site reactions
- Fever, malaise, myalgia
- Immediate reactions rare (anaphylaxis, hives)
Influenza summary
Caused by influenza A and B viruses
- Infection control and vaccination important
Diagnosis
- Rapid PCR and clinical features (fever, cough, sore throat, body aches, tiredness, SOB)
Complications
- Acute bronchitis, croup, AOM, pneumonia, myocarditis, pericarditis, post-infectious encephalitis, Reyes syndrome, haematological issues
Treatment
- Most children require NO antiviral treatment
- Treat children with complications, CAP or being admitted to hospital
- Consider treating those with ↑ risk of complications (<5yrs, ATSI, comorbidities)
Neuraminidase inhibitors
- Oseltamivir (disperse capsule or liquid cc) or zanamivir (DPI – precaution asthma)
- Treat for individual benefit or to prevent transmission
- Rare reports of self-injury, delirium and abnormal behaviour (some fatal) in children taking oseltamivir and possibly zanamivir (?due to influenza)
- The earlier treatment starts, the shorter and less severe the illness
Influenza vaccination
> Annual influenza vaccination recommended for everyone > 6months of age
- Especially for high-risk (eg <5yrs, ATSI, immunocompromised etc)
- 2 doses if 1st year vaccinated for 6mths -9 years
- CHECK THE BRAND is ok for use in children
- Optimal protection within 3-4 months of vaccination
CI
- Previous anaphylaxis to flu vaccine or a component of flu vaccine
- Caution - egg allergy, Guillain-Barre Syndrome, immunotherapy, 13v-PCV
AE
- Mimics flu sx but it is NOT the flu, injection site reactions, anaphylaxis is rare
What is hand,foot and mouth disease (HFMD)? Who does it affect?
Group of enteroviruses
- Most commonly caused by the Coxsackie virus
Mainly children < 10yrs
Rarely causes further complications
HFMD is not linked to the foot and mouth disease which affects animals.
What are the signs and symptoms of HFMD?
Fever, sore throat, poor appetite, lethargy, small blisters on the inside of the mouth and tongue, palms of the hands, fingers, soles of feet and nappy area (blisters should not be itchy)
- Sx last ¬7-10 days
How is HFMD spread?
Spread via droplets (cough/sneeze), blister fluid and in faeces
> Good hand hygiene
> Keep away from school etc until blisters dried
Treatment for HFMD?
None – symptom management (painful mouth)
Complications extremely rare
Definition for UTI?
Urinary tract infection (UTI) refers to a bacterial infection in the bladder (cystitis), or kidneys and ureters (pyelonephritis).
Background for UTI?
Urinary tract infections in childhood are common and can be potentially serious in the first few years of life
The diagnosis of UTI should be considered in all febrile infants and young children, and in all infants with fever without focus.
Key points for UTI?
Signs and symptoms of UTI can be non-specific in young children
Urinary dipstick is a useful screening test, but a positive urine culture with pyuria confirms the diagnosis
Oral antibiotics are appropriate for most children with UTI
> Children who are seriously unwell and most infants under 3 months usually require IV antibiotics
Symptoms of UTI?
Infants and pre-verbal children often have non-specific symptoms (including jaundice in neonates)
> Fever, vomiting, poor feeding, lethargy and irritability
Older children may present with more typical symptoms
> Dysuria, urinary frequency, lower abdominal and loin pain
Ask about previous UTI
Assessment of severity of UTI, lower and upper UTI differences? Cystitis and Pyelonephritis?
Clinical distinction between lower and upper UTI difficult, especially in younger children
- Cystitis is suggested by features such as dysuria, frequency, urgency and lower abdominal discomfort
- Pyelonephritis is suggested by systemic features such as fever, malaise, vomiting and loin tenderness
How to investigate and manage UTI?
Collect urine sample
- Dipstick and microscopy screening can guide initial management
- Check culture results after 24hrs to confirm or adjust management
Urine samples should be collected prior to starting antibiotics (unless the child is seriously unwell and requires immediate IV therapy)
Older children able to void on request can provide a midstream urine sample
For younger pre-continent children, a clean catch is often suitable. Catheter or SPA may be required for seriously unwell infants
What does urine dipstick test show for UTI?
useful screening test to guide initial management
- The presence of leucocytes and nitrites is suggestive of a UTI Results ↓reliable in neonates/young infants, esp false negatives
What does urine microscopy and culture test show for UTI?
laboratory microscopy can complement dipstick results to guide initial management
- Bacteria and leucocytes on microscopy are suggestive of UTI
- Epithelial cells suggest skin contamination and a poor sample
- A positive culture with sufficient growth and pyuria confirms UTI
- Growth of a single organism at >108 CFU/litre suggests infection
What are other investigations used for UTI?
Check renal function and consider renal ultrasound if the child is seriously unwell, or not responding to appropriate therapy after 48hrs
Consider blood culture and lumbar puncture for unwell infants less than 4 weeks old, or if sepsis or meningitis is suspected at any age
- FBC, (LFTs), UEC, CRP (all < 3mths and all systemically unwell)
Treament for UTI in children? How does length change with cystitis and pyelonephritis?
Oral antibiotics are usually appropriate
Any child who is seriously unwell, and most infants under 3 months, should be admitted for initial IV antibiotics
3-7 day course for children with cystitis
7-10 day course for children with pyelonephritis
> E.coli causes 75% of UTI’s in otherwise healthy children
> Staph saprophyticus occasionally in adolescent females
> Wider range of organisms in patients with anatomical or functional abnormalities of urinary tract
Treatment of UTI in infants?
Gentamicin > 1mth – 7.5mg/kg/dose once daily
IV aminoglycosides inactivated by IV penicillins and IV cephalosporins
> Aminoglycosides rapidly bactericidal so give 1st/flush well
Ceftriaxone
- Avoid in <1 mth
- May displace bilirubin from serum albumin
- Caution in neonates with hyperbilirubinaemia
- If < 1mth and penicillin allergic –> cefotaxime
- Do NOT give IV Ca containing products to a neonate on ceftriaxone –> potentially fatal systemic calcinosis (Not within 48 hours (even if via different lines)
- IM very painful – dilute with lidocaine
What to do if multi-drug resistant organisms for UTI ab treatment?
Assess the response to therapy within 24 to 48 hours; if the child has not improved and results of culture and susceptibility testing are unavailable:
- reconsider the diagnosis
- consider if risk of multidrug-resistant bacterium
- consider switching to intravenous therapy
If resistance to all of the above drugs is confirmed, provided the pathogen is susceptible, use?
ciprofloxacin 12.5 mg/kg up to 500 mg orally, 12-hourly for 10 days
- Liquid form not available and very bitter
- Children with Pseudomonas aeruginosa UTI’s often have urological abnormalities and may require longer tx
If child is septic and MDR G-ve suspected (eg ESBL)
- Use Meropenem 20mg/kg IV (up to 1g) q8h
Summary of UTIs
Bacterial infection in the bladder (cystitis) OR kidneys/ureters (pyelonephritis)
Common and can be potentially serious if first years of life
- Symptoms can be non-specific in young kids (fever, vomiting, poor feeding, irritable)
- Older children more specific sx (dysuria, urinary frequency, lower abdo and loin pain)
Investigations
- Urine dipstick can be a useful screening test
- Can get false negatives in in neonates/young infants
- Positive urine culture with pyuria confirms diagnosis Contamination rates of MSU, clean catch, SPA, in/out catheter
- Other investigations FBC, UEC, CRP, BC, renal ultrasound
Treatment
- Oral antibiotics are appropriate for most children
- Children <3mths and very unwell children require IVAB’s
- 3-7 day course for children with cystitis
- 7-10 day course for children with pyelonephritis
Summary of UTI treatment in infants
Birth – 3months: IV amoxicillin and gentamicin
- Separate IV administration – give gentamicin first to avoid inactivation and flush well
- Caution ceftriaxone <1 mth (Avoid with calcium containing IV fluids and displaces bilirubin from serum albumin)
Birth > 3 months
- Toxic sx: IV amoxicillin and gentamicin OR ceftriaxone (note increased dose of gentamicin used)
- Unwell but not toxic sx:
> Consider IM gentamicin or IM ceftriaxone (painful –give with lidocaine)
- Discharge home with poAB’s (also for children that appear well but apparent UTI)
- Cephalexin, cotrimoxazole, Augmentin Duo Cotrimoxazole
> Avoid in <1mth infants displace bilirubin from serum albumin (risk of kernicterus)
> Avoid in G6PDH deficiency (haemolytic anaemia)
If not responding to treatment consider
- Multi-drug resistant organisms, alternative diagnosis, step-up to IVAB’s
What are simple febrile seizures?
Infants and children have a predisposition to convulse in the presence of a fever.
Etiology and pathogenesis: unknown
Provoked seizures – they are NOT epilepsy
What type of seizures are simple febrile seizures? How long do they last for?
Brief, generalised seizures (tonic-clonic)
Occurring only once in 24 hours
Last up to 15 minutes
Associated with a fever from a source outside the CNS
How long does complicated febrile seizures last for? How often do they occur?
Seizure starts focally
Last >15 minutes
Occur more than once in 24 hours
Increased risk of developing epilepsy
Prevalence of simple febrile seizures?
- Increased risk if family hx febrile seizures
- Occur in about 3% of children 6 months – 5 years of age
- 30–50% risk of recurrent febrile seizures
- Increased risk the younger the child when first febrile seizure
> 50% risk if 1yo, 30% risk if 2yo
- Low risk of chronic epilepsy
> 1-2% if no other risk factors
- No documented risk of other adverse outcomes
> Do not cause neurological damage (BENIGN condition)
Cause of simple febrile seizure?
Temperature >38 degrees – triggers seizure
Infection
- Usually viral (esp influenza, roseola virus) Can be bacterial
Post-immunisation temperature –> febrile seizure (MMR)
Differential diagnosis of simple febrile seziures?
CNS infection (meningitis)
- Esp if <12 months old or not up to date with immunisations (esp Hib, pneumococcus)
Epilepsy, metabolic disturbance
Acute treatment for simple febrile seizures?
Standard 1st aid
Call 000 if lasts >5 minutes
Prolonged seizures
- Diazepam (IV or rectal) or
- Midazolam (IV, IM, intranasal, buccal)
How to prevent simple febrile seizures?
Rarely necessary
Diazepam (oral or rectal) at the onset of fever for children at high risk of severe or complicated seizures
Rarely phenobarbitone or valproate
Paediatric references?
