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Child Healthcare: Childhood infections

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Child Healthcare addresses all the common and important clinical problems in children, including:immunisation history and examination growth and nutrition acute and chronic infections parasites skin conditions difficulties in the home and society

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Child Healthcare: Childhood infections

  1. 1. 10 Childhood infections communities where vaccines against these Objectives viral illness are routinely given. When you have completed this unit you should be able to: MEASLES • Diagnose and manage children with measles, chickenpox and mumps. • Diagnose and manage children with 10-2 What is the cause of measles? herpes stomatitis. Measles is caused by a virus. It is an acute, • Diagnose and manage children with very infectious (contagious) illness and is viral hepatitis. transmitted from person to person when the • Diagnose and manage children with measles virus is breathed, coughed or sneezed tickbite fever. into the air and then inhaled by another • Diagnose and treat children with person who becomes infected by droplet acute conjunctivitis. spread. Measles often occurs in epidemics and is an important cause of childhood death in poor, unimmunised communities.INTRODUCTION Measles is a highly infectious and serious disease.10-1 Which are the common childhoodinfections? 10-3 What are the signs and symptoms of measles?• Measles• Chickenpox Measles has an incubation period of about 10• Mumps days (the delay between infection and the start• Herpes stomatitis of the illness).• Viral hepatitis At first the child develops a fever, runny nose,• Tickbite fever conjunctivitis and cough, and is generally• Conjunctivitis unwell.Some infections, such as measles, mumps and Two days after the start of the illness, Koplikviral hepatitis, are becoming uncommon in spots appear. These are numerous small white
  2. 2. 174 CHILDHOOD INFECTIONSspots on a granular red base inside the cheeks, 10-5 What is the relationship betweenopposite the back teeth. measles and malnutrition?After a further 2 days the typical pink or red There is a close and important relationshipblotchy maculopapular (both seen and felt) between measles and malnutrition (i.e.rash appears, starting on the face and neck undernutrition).and slowly spreading down to the hands and Measles is far more severe in children whofeet. The rash therefore appears 4 days after the are malnourished, especially if they are alsochild first becomes unwell. vitamin A deficient. In addition, complicationsThe fever increases and the child becomes are more common and more serious inincreasingly ill with the onset of the rash. Over malnourished children.a few days the rash fades, the temperature Measles, especially with complications suchdrops and the child feels better. as diarrhoea, often results in failure to thrive.Skin pigmentation (brown) and peeling may Measles may lead to kwashiorkor or marasmusfollow the rash (post-measles staining). in children who are underweight at the time that they get measles. Therefore, measles may NOTE The diagnosis is usually clinical but it can be result in, or aggravate, malnutrition. confirmed by serum antibody tests.10-4 What are the complications of Measles is more severe in malnourished childrenmeasles? and may make the existing malnutrition worse.• Otitis media• Laryngotracheobronchitis with a severe 10-6 How can measles be prevented? cough and stridor (measles croup) By immunising all children with measles• Pneumonia. This may be viral (measles, vaccine. This is usually given at 9 months and herpes or adenovirus) or bacterial again at 18 months. Measles vaccine is a highly• Gastroenteritis effective and has resulted in the disappearance• Oral herpes or candidiasis (thrush) of measles in many communities. Measles,• Keratitis (infection of the cornea) with mumps and rubella vaccines (MMR) are often possible corneal ulcers due to measles or combined and given together. herpes virus NOTE Clinical measles can be prevented in an• Encephalitis (rare but serious) unimmunised child if measles vaccine is given• Reactivation of tuberculosis within 12 hours of exposure to a child with• Immunosuppression measles.Measles depresses the immune systemresulting in other infections such as herpes 10-7 What is the management of a childstomatitis and adenoviral pneumonia. HIV with measles?infection may rapidly progress to AIDS while 1. The child should be kept away fromtuberculosis is often reactivated following other children until 5 days after the rashmeasles. The Mantoux skin test may be first appears. By this time the child is nonegative despite active tuberculosis for a few longer infectious to others. Measles ismonths after measles. most infectious during the 4 days of illness before the rash appears. Measles complications may be severe and result 2. Paracetamol for fever in death. 3. Adequate oral fluids to prevent dehydration
  3. 3. CHILDHOOD INFECTIONS 1754. Vitamin A for all children with measles: mouth as multiple small ulcers. Unless there is 100 000 IU orally daily for 2 days (50 000 IU secondary infection (impetigo), the rash does daily for 2 days in children under 1 year) not leave scars.5. Look out for and treat complications The diagnosis can almost always be made by (acyclovir for herpes stomatitis and stridor; finding the typical rash. Usually the illness is antibiotics for otitis media and pneumonia). mild and is not complicated.6. Measles is a notifiable disease in South Africa. NOTERarely pneumonia or encephalitis may complicate chickenpox. NOTE Other viral infections may have a rash similar to measles: rubella (German measles), erythema infectiosum (slapped cheek disease) due to 10-10 How is a child with chickenpox parvovirus, roseola infantum (‘baby measles’) managed? due to herpes virus 6, infectious mononucleosis 1. They should not come into contact with (glandular fever) due to Epstein-Barr virus and common viral infections of the bowel, e.g other children or adults who have not had coxsackie and ECHO. chickenpox until there are no more crops of new rash and all the rash has formed scabs. 2. Paracetamol for feverCHICKENPOX 3. Try to prevent secondary bacterial infection following scratching. Baby powder often helps reduce the itching.10-8 What is the cause of chickenpox? Antibiotics may be needed for impetigo. 4. Ensure an adequate fluid intake, especiallyChickenpox is caused by the Varicella zoster if the child has a sore mouth.virus. Like measles, it is very infectious and 5. A new vaccine, recently available, is verytransmitted from person to person by droplet effective in preventing chickenpox andspread. Chickenpox is most infectious at the shingles.time that the rash starts. Following chickenpox, 6. Hyperimmune immunoglobulin should bethe same virus may remain silent (dormant) given prophylactically to high-risk childrenin the body for many years before being (leukaemia, AIDS, newborns) who arereactivated to result in shingles (acute pain and exposed to chickenpox.vesicular rash affecting only part of the body). NOTE Acyclovir is indicated for pneumoniaChildren can therefore also be infected and get or encephalitis or severe rash or inchickenpox from an adult with shingles. immunocompromised children.10-9 What are the signs and symptoms ofchickenpox? MUMPSThe incubation period of chicken pox is longat 2 to 3 weeks. The child becomes pyrexialand feels generally unwell. Within hours the 10-11 What are the clinical features ofrash appears on the face, scalp, chest, back and mumps?abdomen. Mumps is an acute illness which presents withThe rash starts as a pink macule (spot) which fever as well as swelling and tenderness of onesoon becomes a papule (palpable) and then or both parotid glands. The enlarged parotida vesicle (with clear fluid) which progresses glands lift the lower part of the ear. Chewingto a pustule (containing pus) and finally a may be painful due to the swollen glands.scab. The progression takes 1–2 days and the Sometimes the submandibular glands (belowrash, which is very itchy, appears in crops for the jaw) may be involved.about 5 days. The rash also appears in the
  4. 4. 176 CHILDHOOD INFECTIONSMumps is infectious and is caused by the salivates and often refuses to eat or drink. Thedroplet spread of mumps virus. Like chicken- child is also pyrexial and generally unwell.pox, the incubation period is 2 to 3 weeks. The The stomatitis slowly resolves by 10 days. Anparotid swelling has usually resolved by 10 days. important complication of herpes stomatitis is NOTE The virus can be cultured, and serum dehydration. antibodies and mumps DNA detected, if the Undernourished children with measles, and clinical diagnosis needs to be confirmed. children with AIDS, are at high risk of severe This is uncommon. Mumps infection may herpes stomatitis. Children may also have be asymptomatic. Painless chronic parotid enlargement unrelated to mumps is common severe stomatitis due to oral candidiasis. with AIDS. NOTE Most stomatitis in children is caused by the type I Herpes simplex virus. The type II virus is10-12 What are the complications of more common in sexually-transmitted genital infection in adults (genital herpes).mumps?Mumps usually has no complications and 10-15 What is the management of a childrecovery takes about 1 to 2 weeks. However, with herpes stomatitis?mumps may cause very painful orchitis(inflammation of the testes) in postpubertal 1. Paracetamol for pain and fevermales. Mumps may also cause a viral 2. Good mouth hygiene with Glyco Thymolmeningitis. mouthwashes 3. Ensure adequate hydration. A nasogastric10-13 What is the management of children tube may be needed if the child refuses towith mumps? drink or swallow. 4. Acyclovir in severe stomatitis, especially1. Mumps is infectious until the parotid children with HIV infection. These swelling disappears. children need hospitalisation.2. Paracetamol for fever and discomfort is usually all the treatment that is needed.3. Ensure adequate fluid intake. Children with severe herpes stomatitis should be4. Good mouth hygiene with antiseptic referred to hospital. mouthwashesMumps is becoming uncommon in many 10-16 What are fever blisters?communities as the very effective mumps The herpes simplex virus can remain hiddenvaccine is often given together with measles (dormant) and then become reactivated toand rubella vaccine (MMR). cause fever blisters on the lips. This is similar to the varicella virus in chickenpox which can live on in the body for years before becomingHERPES STOMATITIS reactivated to cause shingles. The onset of fever blisters may be started by other viral illnesses with fever or excessive exposure to sunlight.10-14 What is herpes stomatitis? Fever blisters present as a few very painfulHerpes stomatitis (or oral herpes) is an acute vesicles on the lips which soon form ulcers andinfection of the mouth cause by the herpes then scabs. They can be treated with acyclovirsimplex virus The infection is common and cream if the treatment is started as soon as theoften asymptomatic. However, some children discomfort begins. Herpes virus is present inget numerous small, shallow ulcers on the fever blisters and can be spread to others bytongue, gums and mucosa inside the cheeks. direct contact such as kissing. Therefore, adultsAs the ulcers are very painful the child with fever blisters should never kiss a child.
  5. 5. CHILDHOOD INFECTIONS 177Unlike fever blisters, which occur on the lip, 10-19 What is the clinical presentation ofpainful aphthous ulcers occur repeatedly acute viral hepatitis?on the mucosa of the mouth. The cause of Acute viral hepatitis in children is oftenaphthous ulcers is still unknown. asymptomatic or presents with loose stools and a general feeling of being unwell. Clinical hepatitis may develop with loss of appetite,ACUTE VIRAL HEPATITIS nausea and vomiting and pain over the liver. The liver is enlarged and tender. Some children have jaundice with dark urine and pale stools.10-17 What is hepatitis? Acute hepatitis is the most common cause ofHepatitis is an inflammation of the liver. jaundice in children. The clinical symptomsAlthough there are many causes of hepatitis, and signs usually resolve over 2–4 weeks.the main cause in children is viral.During the early stages of hepatitis both Acute viral hepatitis is the most common cause ofbilirubin and urobilin are present in the urine jaundice in children.when tested with reagent strips. This is a usefulway of confirming the diagnosis of hepatitis. Hepatitis A virus only causes acute hepatitis NOTE With hepatitis there is an increase in the but hepatitis B virus may also cause chronic serum concentration of the liver enzymes. The hepatitis. bilirubin concentration may also be raised. 10-20 What are the complications of acute10-18 What are the common causes of viral hepatitis?acute viral hepatitis? • Liver failure with acute viral hepatitis isThere are 2 common causes of acute viral uncommon. Liver failure presents withhepatitis in children: drowsiness and confusion or severe• Hepatitis A virus: This has a shorter vomiting. These children need urgent incubation period (15–50 days) and referral to hospital. Some of these is spread by swallowing the virus in children die. contaminated food or water. Hepatitis A • Chronic hepatitis due to the hepatitis is the most common type of hepatitis in B virus may lead to cirrhosis and liver children. cancer in adulthood. Therefore, it is• Hepatitis B virus: This has a longer important to prevent hepatitis due to the incubation period (5–150 days) and in hepatitis B virus. children is usually spread from a mother NOTE In acute liver failure there is usually to her newborn infant at or soon after hypoglycaemia, low clotting factors and raised delivery. However it may also be spread serum ammonia. Chronic (active) hepatitis is orally like hepatitis A or by an unscreened recognised by persistent raised liver enzymes. blood transfusion or traditional scratching or cutting. In adults it is spread by sexual 10-21 How can viral hepatitis be contact. prevented? NOTE Antibodies to hepatitis A or B can be used Hepatitis A: to identify each virus. Hepatitis surface antigen (HBsAg) or e antigen (HBeAg) indicate persistent • This virus is spread by the virus in stool- infection and probable viral shedding with contaminated food or water, which is hepatitis B. then eaten or drunk by someone else (the faeco-oral route). Good sanitation, clean water, hand-washing before meals and the
  6. 6. 178 CHILDHOOD INFECTIONS hygienic preparation of food are therefore and mild conjunctivitis, often followed in a important to prevent the spread of the virus. few days by a maculopapular rash which can• A very effective vaccine to prevent include the palms and soles. The headache Hepatitis A is now available. Hopefully it is the most striking symptom. With careful will be added to the routine programme of inspection of the skin and scalp, a typical red, immunisation in children. raised bite with a black centre can be found. The local lymph nodes may be enlarged.Hepatitis B: The incubation period is 10 days. Usually the• As children usually acquire this virus from bite occurs on one weekend and the illness their mother who has the virus in her stool, starts on the following weekend. Infection it is important to identify women who have commonly occurs in the country where cattle hepatitis before or during pregnancy. Their are present and carry infected ticks. infants should be given hyperimmune immunoglobulin for hepatitis B after delivery when the first dose of hepatitis B Tickbite fever presents with a severe headache. vaccine should also be given.• A very effective vaccine to prevent hepatitis NOTE Tickbite fever is caused by a Rickettsia B is available and has been included in the organism. Tickbite fever may be serious, even routine programme of immunisation in fatal, in adults who may have many organs South Africa. involved. The rash may be haemorrhagic and tender due to a vasculitis. Splenomegaly is common while a positive Weil-Felix test will10-22 What is the management of a child confirm the clinical diagnosis. However, awith acute viral hepatitis? negative test does not exclude the diagnosis.1. Allow the child to eat whatever is wanted. A high energy diet with a lot of 10-24 What is the treatment of tickbite carbohydrate is best tolerated. Keep the fever? child at home if possible. It is best to avoid exposure to ticks or use2. Good hygiene prevents other children insecticide spray on shoes, socks and trousers getting hepatitis. Hepatitis A is most when walking in the country. Immediately infectious in the days just before the onset remove any ticks found on the skin. of jaundice.3. Look out for danger signs of depressed Doxycycline 100 mg orally twice a day for 5 level of consciousness, severe vomiting, days is effective. However, it should only be and jaundice that does not clear used for severe infections in children under 7 by 4 weeks. Monitor blood glucose years of age as it may stain the teeth. concentration in severely ill children. NOTEChloromycetin can be used in children NOTE Pooled immunoglobulin should be given to under 7 years. hepatitis A contacts and hyperimmune gamma globulin to hepatitis B contacts if affordable and available. ACUTE CONJUNCTIVITISTICKBITE FEVER 10-25 What are the common causes of acute conjunctivitis?10-23 What is tickbite fever? Acute conjunctivitis is common and highly infectious. Usually it is caused by a virusIt is an acute illness caused by a bite from an (e.g. adenovirus) but it may be bacterial (e.g.infected tick. It presents with fever, headache Staphylococcus). Acute conjunctivitis may
  7. 7. CHILDHOOD INFECTIONS 179occur in outbreaks in schools. Measles, tickbite • Infectious mononucleosis (Glandularfever and tuberculosis may also cause acute fever)conjunctivitis. • Rubella (German measles)Conjunctivitis due to allergy may be recurrentor chronic, and is usually associated with otherallergies. CASE STUDY 110-26 What are the clinical features of A 6-year-old child comes home from schoolacute conjunctivitis? feeling generally unwell. She has a temperature, cough and mild conjunctivitis. When a doctorIt may involve one or both eyes. The is called 2 days later he notices Koplik spots andconjunctivae become red and swollen. With diagnoses measles. After another 2 days sheviral conjunctivitis there is a watery discharge. develops a typical measles rash. Another childWith bacterial conjunctivitis the discharge may at school had measles recently.become purulent (yellow pus) and the eyelashesstick together. Allergic conjunctivitis is very 1. What are Koplik spots?itchy. Sudden onset of pain and redness of theconjunctiva in one eye suggests a foreign body. Small white spots seen on a red, granular mucosa inside the cheeks opposite the backVery localised swelling of an eyelid is usually teeth. Only measles displays Koplik spots.due to a stye (infection of a hair follicle). Localantibiotics, removal of the eyelash and warm 2. What is the incubation period forcompresses to open the obstructed hair follicle measles?are needed. 10 days from exposure to an infected child10-27 What is the treatment of acute until the onset of feeling unwell with fever,conjunctivitis? cough and conjunctivitis. Another 2 days until the Koplik spots appear and then a further 2Topical antibiotic drops or ointment (e.g. days for the rash to start. Therefore, 14 dayschloromycetin) or povidone-iodine drops are from infection to the rash.used for a few days. If there is marked swellingof the eyelids, give intramuscular ceftriaxone 3. Describe the typical rash of measles.daily for 3 days. NOTE 1% chloromycetin eye ointment, 1% A pink or red blotchy maculopapular (both tetracycline eye ointment or 2.5% povidone- seen and felt) rash starting on the face and iodine aqueous solution are used to treat spreading down the trunk to the arms and bacterial conjunctivitis. Tetracycline and legs. Skin pigmentation and peeling may povidone-iodine can also be used to treat follow the rash. conjunctivitis due to Chlamydia. 4. How can measles be prevented?10-28 What are the less common childhoodillnesses? By immunising all children. The occasional case of measles still occurs because all childrenSome childhood illnesses have almost are not fully immunised.disappeared due to routine immunisation:• Poliomyelitis (polio) 5. What are the common complications of• Whooping cough measles?• Diphtheria Otitis media, laryngotracheobronchitis andOther infections are more common in pneumonia. Gastroenteritis and stomatitisadolescents and young adults: (herpes or fungal) are also seen.
  8. 8. 180 CHILDHOOD INFECTIONS6. What is the relationship between 3. What is the danger of herpes stomatitis?measles and malnutrition? Children may become dehydrated if theyMeasles is often more severe, and can be fatal, do not drink enough because of their sorein malnourished children. In addition, the mouth. They may need nasogastric feeds ordegree of malnutrition often becomes worse intravenous rehydration.after measles.Measles is particularly severe in children with 4. Which children often get severe herpesa deficiency of vitamin A. Therefore 200 000 stomatitis?units of vitamin A should be given orally to all Children with malnutrition or measleschildren with measles. 5. What else may cause severe stomatitis?7. Can measles cause tuberculosis or AIDS? Candidiasis (thrush) can cause severeNo. But measles suppresses the immune stomatitis.system which can result in the reactivation oftuberculosis (a child with an asymptomaticTB infection now develops clinical signs of CASE STUDY 3tuberculosis). A child with asymptomaticHIV infection can also develop clinical AIDS In an orphanage a number of childrenfollowing immunosuppression due to measles. become ill. Some have a fever and loose stools while others develop jaundice and a tender abdomen. All have loss of appetite.CASE STUDY 2 1. Why have a number of children in theA 4-year-old child develops a very painful orphanage become ill?mouth, drools saliva and refuses all feeds. Hehas a high temperature and is generally unwell They probably have acute hepatitis A, whichand very miserable. His mother had fever is often spread in crowded situations such asblisters on her lip a week before. schools or orphanages. The virus is spread from the stools of a child to be ingested by other1. What is the likely diagnosis? children (faeco-oral route). This is the most common cause of acute hepatitis in children.Herpes stomatitis. This presents with manysmall, very painful ulcers in the mouth. 2. Why are some children unwell with looseThe children are also pyrexial and generally stools but do not develop jaundice?unwell. Drooling and refusing to eat is due tothe sore mouth. Many children with acute hepatitis are asymptomatic while others become ill with2. What is the cause of this condition? loose stools but do not develop jaundice. Some become jaundiced for a few weeks. RarelyThe herpes simplex virus. This child almost children with hepatitis become severely ill andcertainly was infected from his mother’s may die of liver failure.fever blisters. During the acute phase of feverblisters, the herpes virus can be spread by 3. How are children usually infected withdirect contact such as kissing. Adults with the hepatitis B virus?fever blisters should never kiss a child. They are infected by their mother at birth. Acute hepatitis due to the hepatitis B virus may not recover after a few weeks but progress
  9. 9. CHILDHOOD INFECTIONS 181to chronic hepatitis. This can lead to cirrhosisand liver cancer in adulthood.4. How can acute hepatitis A be prevented?The spread of hepatitis A virus (and to a lesserextent, hepatitis B virus) can be reduced bywashing hands after using the toilet and beforeeating. The safe distribution of human faeces(toilets) and a clean water supply is important.A vaccine is available.5. How can acute hepatitis B be prevented?Hepatitis B can be prevented by routinelyimmunising all children with hepatitis Bvaccine. Mothers who have jaundice beforeor during pregnancy must be identified forspecial management.