UMEM Educational Pearls - By Heidi-Marie Kellock

Meningitis Prophylaxis in Children

While H1N1 and garden-variety influenza have been taking the spotlight lately, we can't forget about other disease processes.  Meningitis is still a severe, life-threatening/altering process which occurs in various social groups (e.g. military cadets, college students).

However, with more of our parents working out of the home, child care is more often the norm, and as such, you may find yourself dealing with cases of children who have been in proximity to another child or caregiver diagnosed with meningitis.  What do you do?

The causative agent will often dictate your choice of management.

Neisseria meningitidis - nursery/child care contacts should receive chemoprophylaxis and the Menactra vaccine (if they have not already received it) within 7 days of onset;  casual school or work contacts do NOT require prophylaxis

Streptococcus pneumoniae - no chemoprophylaxis or vaccination required (unless series was not continued)

Haemophilus influenzae - if only one case reported, no intervention;  if 2 or more cases within a 60-day period, Hib vaccination and chemoprophylaxis with rifampin for BOTH children and caregivers (especially if the center cares for young children who have not completed their Hib series)

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Ductal-Dependent Cardiac Lesions in the Neonate

• Often present in the first 1-2 weeks of life (children born prematurely tend to be at the upper end of the spectrum as they may have delayed closure of the ductus arteriosus)
• May present with tachypnea, sudden onset of cyanosis or pallor (often worse with crying), diaphoresis with feeds, lethargy, or failure to thrive
• Oxygen challenge - place baby on 100% 02 via NRB;  10% improvement in SpO2 (or 30mmHg increase in PaO2 on ABG) suggests a pulmonary issue;  no or minimal change suggests a congenital heart defect
• If congenital heart disease is suspected, start PGE-1 infusion at a rate of 0.05-0.1ug/kg/minute;  improvement may be drastic and is usually seen within 15 minutes
• Side effects of PGE-1 infusion include apnea, fever, hypotension, and seizures;  have your code cart and intubation equipment ready to go prior to beginning infusion

Conjunctivitis in Children:

• Usually a self-limiting process, very common in school-aged children and children in daycare or group home settings
• Crusting/swelling treated with warm compresses
• Antibiotics are not necessary outside of the neonatal period, but they do speed recovery
• Neonates with conjunctivitis - send cultures (gonococcal ophthalmia neonatorum);  all others - no cultures necessary
• Treatment with erythromycin ointment, Polytrim solution, ciprofloxacin solution (usually practicioner preference unless dealing with a recurrent/resistant case)

HOWEVER... remember to consider other common etiologies of a red eye in a child!

• Corneal abrasions
• Acute angle closure glaucoma (sickle cell patients)
• Allergic sources

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While breastfeeding is still the preferred source of infant nutrition by the AAP, a little-known fact is that breastfeeding may expose the nursing infant to environmental pollutants to which they might not normally be exposed.  If you have a mother that appears ill due to exposure to any of these agents, don't forget to have the infant examined as well for signs of intoxication.

• Breastmilk can contain approximately 20% of the maternal toxin load, which can produce more severe effects in the infant due to the vastly different dose/weight ratio
• Toxin load is usually due to the lipid solubility of agents
• Formulas are safe due to the nature of their fat sources;  cows usually have a much lower exposure rate to pollutants, and those that are ingested are much more dilute due to the volume of milk produced in comparison to a human female;  also, with non-cows'-milk formulas, the lipid components are usually plant-derived and thus also with a lower risk of exposure
• Common offending agents include:  DDT, PCBs, Dioxin, hexachlorobenzene, Halothane, carbon disulfide, nicotine, lead, methylmercury, Heptachlor, Chlordane, and tetrachloroethylene

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Infantile Spasms (West Syndrome):

• Are brief contractions of the neck, trunk, arm, and leg muscles that last 2-10 seconds
• Are NOT seizures, but 86% of children with infantile spasms go on to develop a seizure disorder before 1 year of age
• Usually occur as the child is going to sleep or waking up
• Most commonly seen between 3 and 8 months of age
• Often mistakenly diagnosed as colic
• Poor prognosis as infantile spasms usually indicate an underlying genetic, metabolic, or developmental abnormality

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Pertussis (Whooping Cough):

• Caused by B.pertussis and B.parapertussis
• Incubation period = 6 days
• Three stages:  Catarrhal (low-grade fever, rhinorrhea);  Paroxysmal (classic "whooping" cough);  Convalescent (resolution of symptoms over a ~2wk period)
• Full course of the disease = on average 6-8 weeks, although convalescent stage may last MONTHS
• Erythromycin may be effective early on, but no effect once in the paroxysmal stage
• Complications are most common in neonates and infants, and notably, the elderly
• Complications include apnea, hypoxia, pneumonia, encephalopathy, pneumothorax/pneumomediastinum (from paroxysms in the setting of severe mucus plugging)

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