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Pediatric Grand Rounds

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costs the US $3.5 billion each year? necessitates the average ... D. Limit outside playtime during the winter months. E. Wash hands and toys. Quiz Question # 1 ... – PowerPoint PPT presentation

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Title: Pediatric Grand Rounds


1
Pediatric Grand Rounds
  • Block 3, 2007
  • Lindsay Sherrard
  • Ryan Foret
  • Joey Patrick

2
What disease?
  • costs the US 3.5 billion each year?
  • necessitates the average household to have 4-8
    medicines?
  • is the most common human illness?

3
(No Transcript)
4
Viral Upper Respiratory Infections in Kids
  • Epidemiology
  • Pathogenesis
  • Clinical Features
  • Complications
  • Treatment
  • Prevention

5
Epidemiology of the Common Cold
  • Children are the main reservoir
  • Infants average 6 per year
  • Older kids average 4-8 per year
  • Incidence declines with age except for a spike in
    adults in their 20s
  • Families with the oldest child aged 1-4 are at
    higher risk
  • Families with a child in daycare or school are at
    higher risk

6
So what causes colds?
7
Causes of Viral URIs
  • Rhinovirus over 100 subtypes, cause 10-40 of
    colds (adults)
  • Coronavirus 20 of colds (adults)
  • RSV 10 of colds (adults)
  • Influenza, parainfluenza, adenovirus cause more
    systemic symptoms
  • Enteroviruses (echovirus, coxsackievirus) usually
    cause fever without cold symptoms
  • Human metapneumovirus (HMPV)

8
Seasonal Variations
9
Seasonal Variations
  • Generally unknown why there are worldwide
    seasonal variations.
  • No change in host resistance to rhinovirus based
    on exposure to cold climate
  • Possibly due to variations in living conditions,
    schooling, and crowding

10
Seasonal Variations
  • Rhinovirus early fall, spring
  • Parainfluenza late fall
  • RSV winter
  • Influenza winter
  • Coronaviruses winter
  • Adenovirus fall, winter, spring
  • Enteroviruses summer
  • Human metapneumovirus late winter, early spring

11
Quiz Question 1
  • You are asked to talk to local child care
    providers about infection control measures. You
    advise them that the single best intervention to
    reduce the spread of common colds to other
    children in the center is to

12
Quiz Question 1
  • A. Exclude all ill children from the center.
  • B. Have all providers wear masks.
  • C. Isolate sick children from the center.
  • D. Limit outside playtime during the winter
    months.
  • E. Wash hands and toys.

13
Quiz Question 1
  • E. Wash hands and toys.

14
Transmission
15
Transmission
  • Rhinovirus? nasal secretions
  • very small amount in saliva
  • Direct hand to hand contact and contact with
    nasal mucosa or conjunctiva
  • Large particle droplets on nasal mucosa or
    conjunctiva
  • Inhalation of small particle aerosols (especially
    RSV)

16
Transmission
  • Rhinovirus can survive 2 hours on the hands
  • Rhinovirus can survive up to several days on hard
    surfaces, less on porous surfaces
  • Children tend to shed more virus and for longer
    time

17
Pathophysiology
18
Pathophysiology
  • Symptoms begin 1-2 days (or up to 7 days) after
    inoculation
  • Viral shedding begins 12 hours after inoculation,
    peaks at 48 hours, and may continue up to 3 weeks
    for rhinovirus
  • Symptoms correlate with influx of PMNs into
    mucosa and submucosa (with immune response)
  • Colored mucus is from neutrophil enzymatic
    activity but has no correlation with positive
    bacterial cultures

19
Pathophysiology
  • Bradykinins, IL-8, and other inflammatory
    mediators increase
  • Histamine levels are not elevated
  • Elevated albumin levels suggest leaky vasculature
  • Most symptoms are due to immune response, not to
    destruction of epithelial cells by viral
    replication.
  • Adenovirus and influenza-A are more cytotoxic
    than rhinovirus and coronavirus

20
Pathophysiology
  • Immune response also explains asthma
    exacerbations during viral URIs
  • Exacerbation may last up to 4 weeks
  • Unknown if inflammatory mediators are produced
    locally in the lower respiratory tract or if they
    act from a distance

21
Quiz Question 2
  • A parent is concerned that her 4-year-old son
    always has a cold. Given what you know about
    the frequency of colds and the duration of their
    symptoms, what is the minimum number of sick
    days per year that would be considered excessive
    for a typical child?

22
Quiz Question 2
  • A. 75
  • B. 100
  • C. 125
  • D. 150
  • E. 175

23
Quiz Question 2
  • D. 150
  • Having cold symptoms up to 140 days per year is
    normal for a young child.

24
Clinical Syndromes of Viral Respiratory Infections
  • Common Cold
  • Sinusitis
  • Acute otitis media
  • Otitis media with effusion
  • Pharyngitis
  • Croup
  • Bronchiolitis
  • Pneumonia

25
Common Cold
  • Nasal discharge, often colored
  • Low grade fever for the first 2-3 days
  • Sore, scratchy throat (often the first feature in
    older kids)
  • Cough
  • Irritability
  • Difficulty sleeping
  • Decreased appetite
  • Symptoms usually last 2 weeks in children (1 week
    in adults)

26
Physical Exam Findings
27
Physical exam findings
  • Inflamed, swollen nasal mucosa and pharynx
  • Middle ear effusion
  • Cervical lymphadenopathy
  • Conjunctivitis

28
Quiz Question 3
  • A 3-year-old boy is coming to see you with what
    his mother describes as probably just a cold.
    On the phone, she said that he has had a runny
    nose and now has a worsening cough. Which piece
    of this patients past medical history would
    raise the greatest concern?

29
Quiz Question 3
  • A. Asthma
  • B. Croup
  • C. Otitis media
  • D. Sinusitis
  • E. Tonsillitis

30
Quiz Question 3
  • A. Asthma

31
Case 1 DB
  • 12y BM with history of asthma presented with
    wheezing, cough and fever for one day
  • Had runny nose for two days
  • Cough associated with chest pain and vomiting x 2
  • Still coughing and wheezing after 3 albuterol
    nebs in the ER

32
Case 1 DB
  • PMH
  • asthma with one hospitalization at age 3
  • irregular heartbeat with negative work-up
  • SH Lives with mom in carpeted trailer, no
    smokers, outdoor dog, doing well in the 7th grade
  • FH asthma-dad and uncle
  • Home meds albuterol inhaler at home, uses about
    once monthly ran out of singulair and advair 2
    months ago

33
Case 1 DB
  • Vitals T 102, P 95, R 18, SaO2 95 on room air
  • PE accessory muscle use, bilateral wheezing
  • Labs WBC 9.6, Hgb 12.7, platelets 241

34
Case 1 DB
35
Case 1 DB
  • Admitted for asthma exacerbation secondary to
    viral URI
  • On HD 2, his O2 Sat dropped in the 80s and he
    required up to 5L NC
  • ABG 7.40/33/85/20 on 5L NC

36
Case 1 DB
  • Solu-medrol dose in ER
  • Prelone 1mg/kg/day
  • Resumed advair and singulair
  • Albuterol nebs, then inhaler
  • Finally improved on HD 3 and was discharged on
    HD4
  • Told to monitor his peak flow, especially when he
    gets a cold

37
Complications of the Common Cold
  • Otitis Media
  • Sinusitis
  • Pharyngitis
  • Croup
  • Epistaxis
  • Lower respiratory infection (bronchiolitis,
    pneumonia)
  • Asthma exacerbation

38
Signs a Cold may be Complicated
  • Fever gt 102
  • Fever still present after 3 days
  • Double sickening
  • Severe cough or respiratory distress
  • No improvement within 10-14 days
  • Vomiting

39
Treatment of the Common Cold (Under age 2)
  • Supportive therapy only is best
  • Hydration
  • Elevate head of bed
  • Humidifier
  • Nasal saline drops with bulb suction
  • Clearing the nose is important to prevent
    dehydration from less PO intake
  • Fever/pain control with
    -Tylenol (over age 2 months)
    -Motrin (over age 6 months)
  • Treat bronchospasm with bronchodilator

40
Quiz Question 4
  • Your parent information sheet Colds in Infants
    includes instructions on correct use of a bulb
    syringe. Normal saline, rather thans 1/8
    phenylephrine drops (Little Noses), is
    recommended because

41
Quiz Question 4
  • A. 4-month-old infants are primarily mouth
    breathers.
  • B. Phenylephrine causes rebound congestion.
  • C. Phenylephrine causes vasodilation.
  • D. Phenylephrine has been associated with
    cardiomyopathy.
  • E. Phenylephrine must be given for 72 hours to be
    effective.

42
Quiz Question 4
  • B. Phenylephrine causes rebound congestion.

43
Instructions on using a bulb syringe
  • Place the infant on his or her back. Using a
    clean nose dropper, place 1 to 2 drops of saline
    solution in each nostril. Wait two minutes.
  • Squeeze and hold the bulb syringe to remove the
    air. Gently insert the tip of the bulb syringe
    into one nostril, and release the bulb. The
    suction will draw mucus out of the nostril into
    the bulb.
  • Squeeze the mucus out of the bulb into a tissue.

44
Instructions on using a bulb syringe
  • Repeat suction process several times in each
    nostril until most mucus is removed.
  • Wash the dropper and bulb syringe in warm, soapy
    water. Rinse well, and squeeze to remove any
    water.
  • The bulb syringe can be used two to three times
    per day as needed to remove mucus. It is best to
    do this before feeding the saline and suction
    process can cause vomiting after feeding.
  • http//www.cincinnatichildrens.org/health/info/new
    born/home/suction.htm

45
Instructions on using a bulb syringe
46
Treatment of the Common Cold (Over age 2)
  • Supportive therapy only is best
  • Hydration, chicken soup
  • Elevate head of bed
  • Humidifier
  • Nasal saline spray
  • Fever/pain control with
    -Tylenol (over age 2 months)
    -Motrin (over age 6 months)
  • Treat bronchospasm with bronchodilator
  • Can consider cough/cold meds with careful dosing
    guidance

47
Why not a little….
48
Do no harm…
  • Cough and cold medicines are associated with
    fatalities in children under age two, presumably
    by accidental overdose.
  • Metabolism and clearance is unknown and probably
    varies by age and by individual.
  • The recommended dosing of these medicines has not
    been set by the FDA for children under two.

49
Do no harm…
  • Cough and cold medicines have not been shown to
    relieve symptoms in kids of any age.
  • In 2000, 5 of poison exposures reported to
    poison control were cough/cold preparations

50
Do no harm…
51
Antihistamines
  • Thought to work by anticholinergic effect
  • No difference in symptoms compared to placebo in
    randomized controlled trials
  • Benefit sedation in some kids, helps them sleep
    instead of cough
  • Adverse effects paradoxical agitation,
    respiratory depression, hallucinations, thickened
    secretions (which may exacerabate asthma)

52
Antihistamines
  • Equivocal data in adults showing less sneezing
    and nasal discharge but no decrease in total
    symptom score
  • Consider use in patients older than 12 months
    with careful dosing, realizing the only benefit
    may be sedation

53
Decongestants (systemic)
  • No studies demonstrating efficacy in children
  • Adverse effects tachycardia, palpitations,
    elevated DBP, nausea
  • In adults, shown to give a small improvement in
    total symptom score and nasal patency
  • Also shown to reduce cough symptoms in adults
    when combined with 1st generation antihistamine
  • Not indicated, except possibly in teenagers

54
Decongestants (topical)
  • Available as phenylalanine or ipratropium nasal
    spray
  • May cause rebound congestion, which is
    particularly dangerous in babies
  • Consider for older children, for 72 hours or less

55
Antitussives
  • Several randomized trials with codeine,
    dextromethorphan, and placebo show no differences
    in symptoms
  • Adverse effects abuse potential, respiratory
    depression (dextromethorphan, hydrocodone, and
    codeine), insomnia (dextromethorphan), preventing
    asthmatics from coughing up mucus

56
Antitussives
  • In adults, some studies show benefit from
    dextromethorphan, but there is no proven benefit
    for codeine in treating cough caused by the
    common cold
  • Remind parents that cough is a protective reflex

57
Expectorants
  • No studies in children show benefit
  • In adults, they may cause perception of thinner
    secretions but no proven difference in quality or
    volume of secretions

58
Antivirals
  • Intranasal interferon-alpha-2b has been studied
    in adults and looks promising, but much more
    research needs to be done

59
Zinc
  • Studies in children and adults have conflicting
    results. Some studies do show more rapid
    resolution of symptoms with frequent zinc
    lozenges or suspensions, but most studies show no
    benefit
  • Adverse effects bad taste, nausea, sore throat,
    diarrhea
  • Side effects likely outweigh possible benefits

60
Vitamin C
  • Has not been shown to reduce duration or severity
    of colds in children or adults.
  • When taken regularly, at 200mg per day or more as
    prophylaxis before cold symptoms it reduces
    duration of cold by 13 in children and by 8 in
    adults
  • Prophylactic vitamin C reduces the incidence of
    colds by 50 for those routinely doing severe
    exercise in sub-arctic conditions
  • Data not significant to recommend daily vitamin C
    supplementation for everyone

61
Echinacea
  • Randomized trial shows no benefit in treating the
    common cold
  • Adverse effect rash
  • No shown benefit for treatment or prevention in
    adult studies either
  • Data do not support using Echinacea for the
    common cold

62
Prevention
  • Handwashing
  • Virucidal agents such as iodine, phenol/alchohol
    (Lysol)
  • Avoidance of touching mucous membranes
  • Sneezing/coughing into a tissue
  • ? Exercise ? (shown to help prevent colds in one
    adult study)

63
Prevention
64
Case 2 MV
65
Case 2 MV
66
Case 2 MV
67
Case 2 MV
68
Case 2 MV
69
Case 2 MV
70
Quiz Question 5
  • Why is it unlikely that a vaccine ever will be
    developed to prevent colds?

71
Quiz Question 5
  • A. Immunity to one viral serotype does not confer
    complete protection against others.
  • B. More than 100 different viruses cause the
    common cold.
  • C. There are numerous antigenic serotypes.
  • D. A, B, and C.
  • E. B and C only.

72
Quiz Question 5
  • D. A, B, and C.

73
Take Home Points
  • Watch for atypical presentations and double
    sickening that may be signs of more serious
    illness
  • Avoid cough/cold meds in children less than 2
  • Cough/cold meds not proven to work in any age
    kids

74
Take Home Points
  • Ask parents what OTC meds they are giving to help
    avoid accidental overdose by additive medications
  • Encourage single ingredient medications to
    prevent overdose
  • Educate parents about what to expect with a
    typical cold and what treatments have been shown
    to best relieve symptoms

75
When viral URIs get admitted… Well be ready to
send them home!
76
References
  • Crowe JE. Human Metapneumovirus Infections,
    UpToDate, 2007.
  • Douglas RM et al. Vitamin C for preventing and
    treating the common cold. Cochrane Database Syst
    Rev. 2004 Oct 18(4)CD000980.
  • Friedman ND and Sexton DJ. The Common Cold in
    Adults, UpToDate, 2007.
  • Hay CM. Microbiology and Pathogenesis of
    Rhinovirus Infections, UpToDate, 2007.
  • Hay CM. Treatment and Prevention of Rhinovirus
    Infections, UpToDate, 2007.

77
References
  • Infant deaths associated with cough and cold
    medications--two states, 2005. MMWR Morb Mortal
    Wkly Rep. 2007 Jan 1256(1)1-4.
  • Kelly LF. Pediatric Cough and Cold
    Preparations, Pediatrics in Review. Vol.25
    No.4 April 2004, pp.115-123.
  • Munoz FM. Epidemiology and Clinical
    Manifestations of Rhinovirus Infections in
    Children, UpToDate, 2007.
  • Pappas DE and Hendly JO. The Common Cold in
    Children, UpToDate, 2007.
  • Simasek M and Blandino DA. Treatment of the
    Common Cold, American Family Physician. Vol.
    754.
  • Wald ER. Clinical Features, Evaluation, and
    Diagnosis of Acute Bacterial Sinusitis in
    Children, UpToDate, 2007.

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