Common Illness

in Childhood - 2
Desmond
Learning Objectives

1) To u n d e r s t a n d t h e e t i o l o g y of f e br ile s e i z u r e , m e n i n g i t i s ,
acute gastroenteritis.

2) To k n o w t h e p h a r m a c o t h e r a p y r e g i m e n for febrile

seizure, meningitis, acute gastroenteritis.

 Febrile Seizure

• F e b r i l e s e i z u r e is a s e i z u r e o c c u r r i ng in 6 m o n t h s to 6 years of age
a c c o m p a n i e d with fever (abo ve 38.4 C) t h a t is n o t c a u s e d by

a) Central nervous system infection.

b) Hypoglycemia
c) Acute electrolyte imbalance.

• F e b r i l e s e i z u r e s o c c u r d u r i n g b a c t e r i a l or v i r a l i n f e c t i o n s . T h e y s o m e t i m e s
occur after certain vaccinations such as measles, m u m p s , and rubella.

• T h e r e m a y a l s o be a g e n e t i c l i n k to f e b r i l e s e i z u r e .
 Febrile Seizure

• C h i l d m a y lose co nscio usnes s or

respo nsiv en es s, s h a k e a n d m o v e l i m b s
on b o t h s i d e s of t h e body.

• B e c o m e rigid and has twitches in only a

po rtio n of the body, s u c h as a n a r m , or
a leg, or on t h e r i g h t or left s i d e only.

• M a y vomit or pass urine.

• T h e y m a y a l s o be s i c k a n d f o a m at the
m o u t h , a n d t h e i r e y e s m a y roll b a c k .
Classification of febrile seizure

M o s t ( > 9 0 % ) of f e b r i l e s e i z u r e a re s i m p l e .
Prognosis of Febrile Seizure

• P r o g n o s i s for f e b r i l e s e i z u r e s u s u a l l y h a s b e e n f o u n d to be g o o d .

• Such seizures are not associated with any detectable brain damage.
• E p i l e p s y w i l l e v e n t u a l l y d e v e l o p in o n l y a s m a l l m i n o r i t y of c h i l d r e n
who have a febrile seizures.

• A n t i e p i l e p t i c d r u g s c a n p r e v e n t r e c u r r e n t f e b r i l e s e i z u r e , t h e y do not
a l t e r t h e r i s k of s u b s e q u e n t e pi l e p s y .

• Febrile status epilepticus is c o n t i n u o u s or i n t e r m i t t e n t s e i z u r e s

t h a t last ≥ 30 m i n u t e s w i t h o u t n e u r o l o g i c r e c o v e r y b e t w e e n t h e m .
C h i l d r e n w i t h s t a t u s e p i l e p t i c u s a r e at risk of brain d a m a g e .
Management of febrile seizures

• N o t all c h i l d r e n n e e d h o s p i t a l a d m i s s i o n .

• M a i n r e a s o n s for a d m i s s i o n a re :

o To e x c l u d e i n t r a c r a n i a l p a t h o l o g y e s p e c i a l l y i n f e c t i o n .

o F e a r of r e c u r r e n t s e i z u r e s .

o To i n v e s t i g a t e a n d t r e a t t h e c a u s e of f e v e r b e s i d e s m e n i n g i t i s or
encephalitis.

o To a l l a y p a r e n t a l a n x i e t y , e s p e c i a l l y if t h e y a r e s t a y i n g far f r o m
hospital.
Management of febrile seizures

1) First aid for seizures:

- Keep patient safe and away from sharp objects

- Do n o t s t i c k a n y t h i n g in t h e i r m o u t h .

2) Control fever
- A n t i p y r e t i c : S y r u p or Rectal P a r a c e t a m o l 15 mg /kg 6 h o u r l y for
patientʼs comfort.

- Tep id s p o n g i n g w i t h t a p w a t e r a n d a v o i d e x c e s s i v e c l o t h i n g .
Management of febrile seizures

Rectal D i a z e p a m
- Diazepam: fast-acting benzodiazepines and rapidly crosses biological
m e m b r a n e s , including rectal m u c o s a and blood brain barrier.

- P a r e n t s of c h i l d r e n w i t h h i g h r i s k of r e c u r r e n t f e b r i l e s e i z u r e s i n c l u d i n g
those with febrile status ep ilep ticus should be sup p lied with Rectal
Diazepam (dose: 0.5mg /kg).
- P a r e n t s s h o u l d b e a d v i s e d on h o w to a d m i n i s t e r e d if t h e s e i z u r e s last
more than 5 minutes.

Daily a n t i c o n v u l s a n t for c h i l d r e n febrile s e i z u r e are not r e c o m m e n d e d

d u e to b e h a v i o r a l a n d s e d a t i v e s i d e e f f e c t s of a n t i c o n v u l s a n t .
Risk factors for
subsequent
epilepsy after
febrile seizure
Meningitis
M e n i n g i t i s is the i n f l a m m a t i o n
of m e n i n g e s s u r r o u n d i n g the
br a in a n d s p i n a l c o r d .

Commonly caused by:

• Viral
• Bacterial
• Fungal
 Sign and symptoms
of meningitis
- A b n o r m a l v i t a l s i g n s s u c h as tachycardia .
- Poor feeding, irritability, lethargy.
- S i g n of f u l m i n a n t s e p s i s s u c h as s h o c k ,
disseminated intravascular coagulation
(DIC), purpuric rash, coma.

- Stiff neck
- P ho to pho b ia
- Bulging of soft spot in babyʼs skull
- Seiz ures m a y be p r e s e n t in 2 0 % to 3 0 %
of c h i l d r e n w i t h b a c t e r i a l m e n i n g i t i s .
Bacterial meningitis

• Neisseria meningitidis, Streptococcus pneumoniae and

Haemophilus influenza are t h e c o m m o n c a u s e s of a c u t e
bacterial meningitis.

• Haemophilus influenza B (Hib) a c c o u n t e d for u p to 4 8 % of a ll

bacterial meningitis cases. I n t r o d u c t i o n of t h e Hib v a c c i n a t i o n
p r o g r a m led to d r a m a t i c r e d u c t i o n in t h e i n c i d e n c e of H i b
meningitis.
Investigation for suspected bacterial meningitis
Lumbar
puncture

L u m b a r p u n c t u r e is
p e r f o r m e d to o b t a i n a s m a l l
a m o u n t of cerebrospinal
f lu id ( C S F ) to d e t e r m i n e is
t h e r e a n i n f e c t i o n or o t h e r
problems.
Lumbar puncture findings

Typical CSF f i n d i n g s in bacterial

m e n i n g i t i s includes:

• High white blood cell count

• Elevated protein ( >100 mg /d L)

• Low glucos e ( < 2 .2 m m o l /L)

 Management of bacterial meningitis

A s s o o n as m e n i n g i t i s is s u s p e c t e d , do l u m b a r p u n c t u r e ( u n l e s s c o n t r a i n d i c a t i o n
e x i s t s ) a n d g i v e e m p i r i c a n t i m i c r o b i a l t h e r a p y ( a n d p o s s i b l y d e x a m e t h a s o n e ) as
s o o n as p o s s i b l e .

E m p i r i c a l a n t i b io t ics
- A t h i r d - g e n e r a t i o n c e p h a l o s p o r i n ( c e f t r i a x o n e or c e f o t a x i m e ) in c o n j u n c t i o n w i t h
v a n c o m y c i n can be given as initial antibiotic therapy

- C e f o t a xi me and c e f triaxon e have excellent activity against all Hib and

N. meningitis s t r a i n s .

Dexamethasone
• E m p i r i c a l u s e of a d j u v a n t d e x a m e t h a s o n e ( 0 . 1 5 m g / k g / d o s e , 4 t i m e s a d a y )
g i v e n b e f o r e or u p to m a x i m u m of 1 2 h o u r s a f t e r t h e f i r s t d o s e of a n t i b i o t i c s
a n d c o n t i n u e d f o r 2 to 4 d a y s .
Chemoprophylaxis

- M e n i n g i t i s is c o n t a g i o u s .
- T r a n s m i t t e d t h r o u g h a ir d r o p l e t s a n d c l o s e c o n t a c t w i t h the
infected person.

- C l o s e c o n t a c t s of all c h i l d r e n w i t h m e n i n g o c o c c a l m e n i n g i t i s
s h o u l d r e c e i v e c h e m o p r o p h y l a x i s ( C e f t r i a x o n e or c i p r o f l o x a c i n )
 Acute gastroenteritis (AGE)

• D i a r r h e a or v o m i t i n g ( o r b o t h ) of m o r e t h a n 7 d a y s d u r a t i o n –
m a y be a c c o m p a n i e d by fever, a b d o m i n a l p a i n a n d a n o r e x i a .

• Rotavirus is the m o s t c o m m o n c a u s e of a c u t e g a s t r o e n t e r i t i s
worldwide.

• Causative organisms
• B a c t e r i a : Salmonella, Campylobacter, Shigella, E.coli

• P a r a s i t e s : Giarda lamblia, Cryptosporidium

Types of Diarrhea
Signs of dehydration in a child
Rehydration in acute diarrhea
Management of AGE in children - Dehydration

1) Oral r e h ydr a tio n therapy (O R S) – s h o u l d be t h e i n i t i a l t r e a t m e n t

b e c a u s e it is as e f f e c t i v e as i n t r a v e n o u s t h e r a p y a n d r e p l a c i n g
e l e c t r o l y t e s in c h i l d r e n w i t h m i l d to m o d e r a t e h y d r a t i o n .

• D o s e : 1 0 m l / k g of O R S a f t e r e a c h l o o s e s t o o l

2) I ntraveno us therapy (0.9%NS or H artmannʼs so lution) – u s u a l l y

r e s e r v e d for u s e in c h i l d r e n w i t h s e v e r e d e h y d r a t i o n ( p r e s e n c e of s h o c k
or n e a r - s h o c k ) .

• S i g n of h e m o d y n a m i c i n s t a b i l i t y : p r o f o u n d l e t h a r g y , m a r k e d l y d e l a y e d
c a p i l l a r y re f ill a n d t a c h y c a r d i a w i t h s e v e r e o r t h o s t a t i c b l o o d p r e s s u r e
changes, represent medical emergency.
 Management of AGE in children - Diarrhea
Intraluminal agent (bulk forming,
a dso r b e nt s) :
- Diosmectite ( Sm ect a ) – has s h o w n to be
safe a n d e f f e c t i v e in r e d u c i n g s t o o l o u t p u t
a n d d u r a t i o n of d i a r r h e a .
• B i n d s s e l e c t e d b a c t e r i a l p a t h o g e n s and
rotavirus
• R e s t o r e i n t e g r i t y if d a m a g e d i n t e s t i n a l
e p i t h e l i u m , r e d u c e d s t o o l o u t p u t and
d u r a t i o n of d i a r r h e a .
- Avoid use of Smecta ® in infants and
children aged below 2 years old and
pregnant or breastfeeding - p o s s i b l e r is k of
of lea d p o i s o n i n g .
 Management of AGE in children - Diarrhea

An t i - se cr e t o r y:
Racecadotril
• Enkephalinase -inhibitor

• B y p r e v e n t i n g t h e d e g r a d a t i o n of e n d o g e n o u s
enkephalins, racecadotril reduces hypersecretion
of w a t e r a n d e l e c t r o l y t e s i n t o t h e i n t e s t i n a l
lumen.

• Significantly reduced stool output (~5 0 % )

• Well t o l e r a t e d
Management of AGE in children - Diarrhea

• Other anti dia rrho ea l a gents : K a o l i n ( s i l i c a t e s ) , L o p e r a m i d e ( a n t i -

m o t i l i t y ) a n d d i p h e n o x y l a t e ( a n t i m o t i l i t y ) a re not r e c o m m e n d e d .

• A n t i - emetics ( d i m e n h y d r i n a t e , m e t o c l o p r a m i d e ) – not
r e c o m m e n d e d , p o t e n t i a l l y h a r m f u l – m a y lea d to r e t e n t i o n of f lu id
and toxin would have eliminated through vomiting.

• Zinc c a n be g i v e n to m a l n o u r i s h e d c h i l d r e n w i t h a c u t e d i a r r h e a .
• P ro b iotics h a s b e e n s h o w n to r e d u c e d u r a t i o n of d i a r r h e a .
( e f f e c t i v e n e s s is v e r y s t r a i n a n d d o s e s p e c i f i c ) .
 Antibiotic use in AGE - Diarrhea.
• A n t i b i o t i c t h e r a p y sho uld not be given ro utinely to c h i l d r e n w i t h d i a r r h e a .
• Majority of ga stro enteritis c a s e s in c h i l d r e n a re viral in origin ( r o t a v i r u s ,
norovirus, adenovirus).

• A n t i b i o t i c a re i n d i c a t e d in f o l l o w i n g s i t u a t i o n s :
- Shigella dysentery – in c a s e s p r e s e n t i n g as b l o o d y d i a r r h e a , t h e s e s h o u l d b e
t r e a t e d w i t h a n a n t i b i o t i c e f f e c t i v e for S h i g e l l a .

- W h e n Cholera is s u s p e c t e d .
- W h e n dia rrhea is associated with a no ther acute infection s u c h as p n e u m o n i a
and urinary tract infection.

- M a y be i n d i c a t e d for Salmo nella gastro enteritis in v e r y y o u n g b a b i e s ( < 3

m o n t h s ) , i m m u n e c o m p r o m i s e d , s y s t e m i c a l l y ill.
Antibiotic use in AGE - Diarrhea
References

• P a e d i a t r i c P r o t o c o l s for M a l a y s i a n H o s p i t a l s , 4 th E d i t i o n