THE COMMON INFECTIOUS

DISEASES IN CHILDREN

Sumadiono
Pediatric Department Faculty of Medicine Gadjah Mada University
 Malaria
5% Measles
7%
Other
Diarrhea
32%
19%
Approximately 70%
of all childhood Malnutrition
deaths are asociated 54%
With one or more of
These conditions

Acute Respiratory
Perinatal Infections (ARI)
18% Sick child flv
19%
 Depleted stores

Immunological changes
Body stores

Subclinical infections

Infections

Death

Decreasing Nutrient Intake

Impact of Decreasing Intake on Immunity and Infection

Infectious Pediatric
Pneumonia
Quiz Question

What is the most sensitive and specific sign of

pneumonia in children?
A. Difficulty breathing
B. Fever
C. Tachypnea
D. Tachycardia
Quiz Question

If available, a chest x-ray should be done for

children with possible pneumonia:
A. When a diagnosis is made
B. When a history of tachypnea is present
C. When antibiotics are started
D. When complications are suspected
Quiz Question

Which of the following immunization

effectively reduce pneumonia mortality in
children?
A. Haemophilus influenzae b Vaccine
B. Pneumococcal Conjugate Vaccine
C. Measles Vaccine
D. All of the above
What is Pneumonia?

Pneumonia: an acute infection of the

pulmonary parenchyma

The term Lower Respiratory Tract Infection

(LRTI) may include pneumonia, bronchiolitis
and/or bronchitis
EPIDEMIOLOGY AND
PATHOPHYSIOLOGY
Epidemiology

Pneumonia kills more children under the

age of five than any other illness in every
region of the world.
It is estimated that of the 9 million child
deaths in 2007, 20% (1.8 million) were due to
pneumonia
Approximately 98% of children who die of
pneumonia are in developing countries.
Basic Pathophysiology

Most cases of pneumonia are caused by the

aspiration of infective particles into the lower
respiratory tract.
Organisms that colonize a childs upper
airway can cause pneumonia.
Pneumonia can be caused by person to
person transmission via airborne droplets.
 Pneumonia - Common Pathogens
Age Group Common Pathogens (in Order of Frequency)
Newborn Group B Streptococci
Gram-negative bacilli
Listeria monocytogenes
Herpes Simplex
Cytomegalovirus
Rubella
1-3 months Chlamydia trachomatis
Respiratory Syncytial virus
Other respiratory viruses
3-12 months Respiratory Syncytial virus
Other respiratory viruses
Streptococcus pneumoniae
Haemophilus influenzae
Chlamydia trachomatis
Mycoplasma pneumoniae
From: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition.
American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.
 Pneumonia - Common Pathogens
Age Group Common Pathogens (in Order of Frequency)
2-5 years Respiratory Viruses
Streptococcus pneumoniae
Haemophilus influenzae
Mycoplasma pneumoniae
Chlamydia pneumoniae
5-18 years Mycoplasma pneumoniae
Streptococcus pneumoniae
Chlamydia pneumoniae
Haemophilus influenzae
Influenza viruses A and B
Adenoviruses
Other respiratory viruses

From: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition.
American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.
Pneumonia History
Fundamentals
Age
Presence of cough, difficulty breathing,
shortness of breath, chest pain
Fever
Recent upper respiratory tract infections
Associated symptoms (e.g.. headache,
lethargy, pharyngitis, nausea, vomiting,
diarrhea, abdominal pain, rash)
Duration of symptoms
Recognition of Signs of
Pneumonia
Tachypnea is the most sensitive and specific
sign of pneumonia

Tachypnea had a Sensitivity of 61% and 79%

and Specificity of 79% and 65% for
pneumonia in malnourished and well-
nourished Gambian children respectively
WHO Definition of Tachypnea

Age Respiratory Indication of

Rate severe
(breaths/min) infection
(breaths/min)
< 2 months > 60 >70
2 to 12 months > 50
12 months to 5 > 40 >50
years
Greater than 5 > 20
years
 Other signs of pneumonia -
Indrawing

out---breathing---in
Lower chest wall indrawing: with inspiration,
the lower chest wall moves in

From: Integrated Management of Childhood Illness. Chapter Three: Cough or difficulty breathing. World Health Organization. 2000
https://apps.who.int/chd/publications/referral_care/chap3/chap31.htm. Accessed February 2, 2012
 Other signs of pneumonia -
Nasal Flare

Nasal flaring: with inspiration, the side of the

nostrils flares outwards

From: Integrated Management of Childhood Illness. Chapter Three: Cough or difficulty breathing. World Health Organization. 2000
https://apps.who.int/chd/publications/referral_care/chap3/chap31.htm. Accessed February 2, 2012
 Diagnosis in Community
Setting
SIGNS Classify AS Treatment

Tachypnea Severe Pneumonia Refer urgently to hospital for

Lower chest wall injectable antibiotics and oxygen
indrawing if needed
Stridor in a calm child Give first dose of appropriate
antibiotic
Tachypnea Non-Severe Prescribe appropriate antibiotic
Pneumonia Advise caregiver of other
supportive measure and when to
return for a follow-up visit
Normal respiratory rate Other respiratory Advise caregiver on other
illness supportive measures and when to
return if symptoms persist or
worsen

From: Pneumonia The Forgotten Killer of Children. Geneva: World Health Organization (WHO)/United Nations Childrens Fund (UNICEF), 2006.
 Pneumonia Severity
Assessment
Mild Severe
Infants Temperature <38.5 C Temperature >38.5 C
RR < 50 breaths/min RR > 70 breaths/min
Mild recession Moderate to severe recession
Taking full feeds Nasal Flaring
Cyanosis
Intermittent Apnea
Grunting Respirations
Not feeding
Older Children Temperature <38.5 C Temperature >38.5 C
RR < 50 breaths/min RR > 50 breaths/min
Mild breathlessness Severe difficulty in breathing
No vomiting Nasal Flaring
Cyanosis
Grunting Respirations
Signs of dehydration
From: Pneumonia The Forgotten Killer of Children. Geneva: World Health Organization (WHO)/United Nations Childrens Fund (UNICEF), 2006.
Indications for Admission -
IMCI
All Children with Very Severe Pneumonia
need admission
Very Severe Pneumonia includes any of:
Cough or difficult breathing plus at least one of the following:
Central cyanosis
Inability to breastfeed or drink, or vomiting everything
Convulsions, lethargy or unconsciousness
Severe respiratory distress (e.g. head nodding)
Some or all of the other signs of pneumonia (tachypnea,
grunting, nasal flare, indrawing, changes in auscultation)
Indications for Admission
Age Group Indications for Admission to Hospital
Infants Oxygen Saturation <= 92%, cyanosis
RR > 70 breaths /min
Difficulty in breathing
Intermittent apnea, grunting
Not feeding
Family not able to provide appropriate observation or
supervision
Older Children Oxygen Saturation <= 92%, cyanosis
RR > 50 breaths /min
Difficulty in breathing
Grunting
Signs of Dehydration
Family not able to provide appropriate observation or
supervision

From: British Thoracic Society (BTS) of Standards of Care Committee.

BTS Guidelines for the Management of Community Acquired Pneumonia in Childhood. Thorax. 2002;57: i1-i24.
In-Patient Management

Consideration must be given to the provision of

adequate hydration, oxygenation, nutrition,
antipyretics and pain control.
Monitoring should include:
Respiratory rate
Work of breathing
Temperature
Heart rate
Oxygen saturation (if available)
Findings on auscultation.
Right Upper Lobe Pneumonia
Right Middle Lobe Pneumonia
Laboratory Investigations
Routine blood work is not required in children
with uncomplicated lower respiratory tract
infections who will be treated as outpatients
Tests to consider if available:
CBC, particularly WBC
Electrolytes, particularly Sodium
Consider blood cultures, sputum cultures
HIV and TB testing as appropriate
Treatment IV Antibiotics

Common medications for treating pneumonia:

Penicillins: Amoxicillin, Ampicillin, Benzyl
Penicillin
2nd generation Cephalosporins: Cefuroxime
3rd generation Cephalosporins: Cefotaxime
Dose according to childs weight
Treatment IMCI Guidelines

Antibiotic therapy
Chloramphenicol (25 mg/kg IM or IV every 8 hours)
until the child has improved. Then continue orally 3 x/
day for a total course of 10 days.
If chloramphenicol is not available, give
benzylpenicillin (50 000 units/kg IM or IV every 6
hours) and gentamicin (7.5 mg/kg IM once a day) for 10
days.
Treatment IMCI Guidelines

If the child does not improve within 48 hours,

Switch to gentamicin (7.5 mg/kg IM once a day)
and cloxacillin (50 mg/kg IM or IV every 6 hours),
for staphylococcal pneumonia.
When the child improves, continue cloxacillin (or
dicloxacillin) orally 4 times a day for a total course
of 3 weeks.
 Supportive Treatment IMCI
Guidelines
Oxygen therapy

If fever (=>39oC) causing distress, give paracetamol

If wheeze is present, give a rapid-acting broncho-

dilator

Gentle suction any thick secretions in the throat, which

the child cannot clear.
 Supportive Treatment IMCI
Guidelines
Ensure that the child receives daily maintenance fluids for the
child's age - avoid overhydration.
Encourage breastfeeding and oral fluids.
If the child cannot drink, insert a NG tube and give maintenance
fluids in frequent small amounts.
If the child is taking fluids adequately by mouth, do not use a NG tube as
it increases the risk of aspiration pneumonia.
If oxygen is given by nasopharyngeal catheter at the same time as NG
fluids, pass both tubes through the same nostril.
Encourage the child to eat as soon as food can be taken.
Key Points

Pneumonia is an acute infection of the

pulmonary parenchyma
Pneumonia kills more children under the age of
five than any other illness.
A diagnosis of pneumonia should be considered
in all children with tachypnea and difficulty
breathing.
Common first-line antibiotics include amoxicillin
and co-trimoxazole .
 Varicella

Etiology
Varicella-zoster (VZV) is a herpesvirus

Humans are the only source of infection

Incubation 14-21 days

 Epidemiology

Person to person
Direct contact and respiratory secretions

Ages: 5- 9 years

Contagious:
- 2 days before the rash appears
- until 5 days after new lesions stop erupting
Chickenpox: Rash Appearance
(in various stages)
Rash and Complication

Rash: Face, scalp, trunk, spreads centrifugally

Macules papules vesicles pustules crusts

Complications:
encephalitis, pneumonia, superceded
Staphylococcal infection, disseminated disease
in immunocompromised
Treatment

Acyclovir, vidarabine, famvir, foscarnet

Acyclovir is the drug of choice for children
Acetominophen may be used to control fever

Immunization
Varicella
ROSEOLA
Roseola
Etiology :

Human herpesvirus 6 (HHV6)

Human herpesvirus 7 (HHV7) may also play a role
Roseola
Age: 6 months - 2 years
Symptoms
Irritability, runny nose, malaise, high fever
Most kids will be alert and playful

Rash appearance
Pale rose-pink flat spots with a white halo over
neck and trunk, extremities spared
lasts for 1-2 days
Incubation period: 5-15 days
Roseola: Rash Appearance
Roseola

Diagnosis
Clinical
History very important
Can check blood test

Treatment
Supportive care
 Hand, Foot and Mouth Disease
Enterovirus family
Coxsackie virus A16 infection MCC

>> Young children

Direct contact with respiratory secretions

or feces from an infected individual

Incubation period: 4 6 days

Communicable period
from the onset of oral ulcers to weeks following
resolution of the illness
Hand Foot Mouth Disease

Prodrome
Fever, sore throat,
decreased appetite for solids

Rash appearance
Oral ulcers first
2 days later, vesicles appear
on hands and feet
Hand, Foot and Mouth Disease:
Rash Appearance
Hand Foot Mouth

Exam shows ulcers or blisters in the pharynx,

lips and or tongue
Fevers, loss of appetite, headache
Supportive treatment. Control fever, good
hydration
Has a benign course
MEASLES

Unwell child
Incubation 7-14 days
Fever, conjunctival suffusion, coryza
Maculopapular rash starting on face and
progressing to whole body
Kopliks spots are pathognomonic
Complications: Otitis media, pneumonia,
hepatitis, myocarditis, encephalomyelitis, SSPE
MEASLES
Measles: Rash Appearance on
Face and Trunk/Body
Measles: Kopliks Spots on Oral
Mucosa
 Rubella (German Measles)
Mild febrile viral illness
Children usually present few or no clinical
symptoms
Rash appearance
Pink maculopapular rash
Starts on face then spreads downward and peripherally
lasts 2-5 days (3-day measles)
Transmitted via contact with infected
nasopharyngeal secretions
Incubation period: 16-18 days
Communicable period: 5 days before to 5-7 days
after rash onset
Infection can be detrimental to a developing fetus
Rubella: Rash Appearance and
Cataracts in Congenital Rubella
Syndrome

*Centers of Disease Control and Prevention

Methicillin-Resistant
Staphylococcus Aureus (MRSA)
Type of Staph infection that is resistant to
commonly used antibiotics
Commonly misdiagnosed as a spider bite
Symptoms may include redness, warmth, swelling,
pus, skin tenderness, pimples, boils, or blisters
MRSA-infected skin lesions (sores) can change from
skin or surface irritations to abscesses or serious skin
infections
If left untreated, MRSA can infect blood and bones
Manifestations of
MRSA Infections
Often mistaken for
spider bites
Only way to confirm
is through a wound
culture
Treating MRSA infections

Many MRSA infections can be treated by

draining the abscess or boil and may not require
antibiotics
Only healthcare providers should drain sores
Always keep draining sores covered to prevent
others from getting sick
Exclusion is dependent on age and where lesion
is
Vigorous hand washing
Surface disinfection
If wound is visible, it must be covered
Judgment call!
 Hepatitis A Virus (HAV)
Viral infection of the liver
Usually spread person to person through fecal
contamination and ingestion (occasionally by
infected food-handlers, shellfish, blood, etc.)

Infection in childcare centers is a major source for HAV

spread in the community

Most children are not symptomatic

Outbreaks are detected when adult caretakers become ill
(fever, jaundice, nausea, loss of appetite)
A vaccine is available and licensed for children over the age
of 2
 Hepatitis B Virus (HBV)

Transmission in child care may occur through

direct blood exposure (injuries, scratches that
break the skin

Toothbrushes should not be shared

Known HBV carriers may attend

Unless abnormal behavior, injury, severe skin
problems, or bleeding disorder
Other children already vaccinated
HIV/AIDS

Risk of transmission in childcare is minimal

In general HIV-infected children can attend school /
HIV infected adults can work
Biting, scratching, generalized skin condition, or
bleeding problems should be considered
individually
Not all infections are recognized
Handle ALL blood and blood-containing body
fluids and wounds with gloves
Immunosuppressed individuals require special
protection from measles or chicken pox
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