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Medicine Notes Paediatrics Notes

Infection And Immunity Notes

Updated Infection And Immunity Notes

Paediatrics Notes

Paediatrics

Approximately 336 pages

Paediatric notes based upon current NICE guidance, The Illustrated Textbook of Paediatrics by Lissauer and Clayden in conjunction with the Oxford Handbook of Paediatrics...

The following is a more accessible plain text extract of the PDF sample above, taken from our Paediatrics Notes. Due to the challenges of extracting text from PDFs, it will have odd formatting:

Infection and Immunity

Maybe look at the pictures of various rashes

The Febrile Child See NICE guidance

  • Most have brief, self limiting viral infections or mild localised infections (otitis media, tonsillitis)

  • Clinical Features

    • Risk factors for infection

      • Illness of family members

      • Illness in the community

      • Unimmunised

      • Recent travel abroad (malaria, typhoid)

      • Contact with animals

      • Immunodeficiency

      • Sickle cell disease, splenectomy, nephrotic syndrome increased susceptibility to encapsulated organisms (Strep. pneumoniae, Hib, salmonella)

    • How if fever identified?

      • In hospital it is measure at:

        • <4 weeks old – electic thermometer in the axilla

        • 4 weeks – 5 years electric or chemical dot thermometer in the axilla or infrared tympanic thermometer

        • Axillary temperature is 0.5oC less than body temperature

    • How old is the child?

      • Febrile infants <3 months present with non specific clinical features (SEE neonatal infection notes)

        • Often have bacterial infection

        • Viral infections are uncommon due to massive maternal immunity

        • Should have vital signs measured and recorded

          • Temp

          • HR

          • RR

      • If no source is obvious - require urgent investigation with septic screen and IV antibiotics

        • FBC, Blood culture

        • WCC

        • Acute phase reactant (CRP)

        • Urine

        • Consider (if red flags)

          • CXR,

          • Lumbar puncture,

          • Stool culture,

          • Serum electrolytes

          • Blood gas

          • Meningococcal and pneumococcal PCR on blood/CSF, PCR for viruses in CSF (HSV, enterovirus)

      • Start parenteral antibiotics if:

        • <1 month old

        • 1-3 months and unwell

        • 1-3 months with altered WCC

    • How ill is the child?

      • Measure

        • Temp

          • Fever >38 if <3 months

          • Fever >39 if 3-6 months

        • HR

        • If raised can indicate SHOCK

        • RR

        • Cap refill

      • Assess for signs of dehydration

        • Prolonged cap refill

        • Abnormal skin turgor

        • Abnormal resp rate

        • Weak pulse

    • Is there a focus for infection?

      • When there is no apparent cause of infection the differential should include the following:

Diagnosis Symptoms and Signs
Meningococcal Disease

Non blanching rash with one or more of:

  • Ill looking child

  • Lesions larger than 2mm (purpura)

  • CRT >3s

  • Neck stiffness

Meningitis

Neck stiffness

Bulging fontanelle

Decreased consciousness

Convulsive status epilepticus

(Classic signs are often absent in infants)

HSV Encephalitis

Focal neurology

Focal seizures

Decreased consciousness

Pneumonia

Tachypnoea

  • Neonate >60

  • Infant >50

  • Young child >40

Crackles

Nasal flaring

Chest indrawing

Cyanosis

Oxygen sats <95%

UTI

Vomiting

Poor feeding

Lethargy

Irritability

Abdominal pain

Frequency / dysuria

Offensive urine / haematuria

Septic Arthritis / Osteomyelitis

Swelling of a limb or joint

Not using an extremity

Non-weight bearing

Kawasaki Disease

Fever lasting longer than 5 days plus four of:

  • Bilateral conjunctival injection

  • Change in upper resp tract mucosa

  • Change in periphera extremities (oedema, erythema, desquamation)

  • Polymorphous rash

  • Cervical lymphadenopathy

Traffic Light System to Identify Serious Illness

Green Amber Red
Colour Normal Pallor Pale, mottled, ashen or blue
Activity

Responds normally

Content, smiles

Stays awake

Awakens quickly when roused

Strong normal cry

Not responding normally

Decreased activity

Prolonged stimulation required to awaken

Unresponsive

Barely rousable

Weak, high pitched or continuous cry

Breathing Normal

Nasal flaring

Tachypnoea

Desaturation (<95%) in air

Chest crackles

Grunting

Severe distress

Hydration Normal

Dry mucous membranes

Poor feeding

Reduced urine output

Capillary refill >3s

Reduced skin turgor
Other

Generally normal

No fever

Fever >5 days

Swelling of limb/joint

New lump >2cm

Non blanching rash

Fever at time of exam

Bulging fontanelle

Neck stiffness

Seizures

Focal neurology

Bile stained vomit

  • Management

    • Children with only green features and no definite diagnosis can be managed at home

      • Perform UTI, assess for symptoms and signs of pneumonia

      • Do not perform routine blood tests or XR

    • Amber features and no diagnosis

      • Urine test, FBC, Blood culture, CRP routine

      • Perform CXR IF fever >39 and WCC raised

      • Consider lumber puncture if <1 year old

    • Any Red features and no diagnosis

      • Blood culture, FBC, urine test, CRP

      • Lumbar puncture, CXR, electrolytes and blood gas as clinically deemed necessary

    • Parenteral antibiotics are given immediately to seriously unwell children

      • Third generation cephalosporin (cefotazime, ceftriaxone) if >3 months old

      • In infants;

        • Cefotaxime in septicaemia or meningitis

        • Ampicillin in listeria / Gp B strep

      • Aciclovir in HSV encephalitis

    • Anti-pyretics paracetemol or ibuprofen

      • Do NOT use damp sponge

      • Do NOT over- or underdress the child

Septicaemia

  • Bacteria may cause a focal infection or proliferate in the blood stream leading to septicaemia

  • In septicaemia the host response involves release of cytokines and activation of endothelial cells leading to septic shock

  • Commonest cause is meningococcal infection (+/- meningitis)

    • Incidence has reduced due to immunisation

  • Pneumococcus is the commonest organism causing bacteraemia (not typically septic shock)

  • In neonates are group B strep or gram negative organisms

  • Clinical spectrum produced by 4 elements:

    • Capillary leak

      • From presentation until day 2-4 vascular permeability massively increases

      • Protein enters intravascular space and urine causing severe hypovolaemia

      • Initial vasoconstriction to compensate but eventually decreased venous return and decreased cardiac output

    • Coagulopathy

      • Severe bleed tendency in meningococcaemia

      • Presents with severe thrombosis in microvasculature of the skin, often in a glove and stocking distribution, sometimes requiring amputation

    • Metabolic derangement

      • Profound acidosis occurs with severe metabolic abnormalities including hypokalaemia, hypocalcaemia, hypomagnesaemia and hypophosphataemia

    • Myocardial failure

      • Function remains impaired even after t...

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