Transcript Peds Grand Rounds

Pediatric Grand Rounds
Block 3, 2007
Lindsay Sherrard
Ryan Foret
Joey Patrick
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?
Viral Upper Respiratory
Infections in Kids
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Epidemiology
Pathogenesis
Clinical Features
Complications
Treatment
Prevention
Epidemiology of
the Common Cold
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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
So what causes colds?
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)
Seasonal Variations
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
Seasonal Variations
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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
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:
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.
Quiz Question # 1
• E. Wash hands and toys.
Transmission
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)
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
Pathophysiology
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
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
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
Quiz Question # 2
• A parent is concerned that her 4year-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?
Quiz Question # 2
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A. 75
B. 100
C. 125
D. 150
E. 175
Quiz Question # 2
• D. 150
• Having cold symptoms up to 140
days per year is normal for a young
child.
Clinical Syndromes of Viral
Respiratory Infections
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Common Cold
Sinusitis
Acute otitis media
Otitis media with effusion
Pharyngitis
Croup
Bronchiolitis
Pneumonia
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)
Physical Exam Findings
Physical exam findings
• Inflamed, swollen nasal mucosa
and pharynx
• Middle ear effusion
• Cervical lymphadenopathy
• Conjunctivitis
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 patient’s past medical history
would raise the greatest concern?
Quiz Question # 3
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A. Asthma
B. Croup
C. Otitis media
D. Sinusitis
E. Tonsillitis
Quiz Question # 3
• A. Asthma
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
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
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
Case 1: DB
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
Case 1: DB
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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 HD#4
• Told to monitor his peak flow,
especially when he gets a cold
Complications of the
Common Cold
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Otitis Media
Sinusitis
Pharyngitis
Croup
Epistaxis
Lower respiratory infection
(bronchiolitis, pneumonia)
• Asthma exacerbation
Signs a Cold may be
Complicated
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Fever > 102
Fever still present after 3 days
“Double sickening”
Severe cough or respiratory
distress
• No improvement within 10-14 days
• Vomiting
Treatment of the Common
Cold (Under age 2)
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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
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:
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.
Quiz Question # 4
• B. Phenylephrine causes rebound
congestion.
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.
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/newborn/ho
me/suction.htm
Instructions on using a
bulb syringe
Treatment of the Common
Cold (Over age 2)
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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
Why not a little….
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.
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
Do no harm…
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)
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
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
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
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
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
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
Antivirals
• Intranasal interferon-alpha-2b has
been studied in adults and looks
promising, but much more research
needs to be done
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
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 subarctic conditions
• Data not significant to recommend daily
vitamin C supplementation for everyone
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
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)
Prevention
Case 2: MV
Case 2: MV
Case 2: MV
Case 2: MV
Case 2: MV
Case 2: MV
Quiz Question # 5
• Why is it unlikely that a vaccine
ever will be developed to prevent
colds?
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.
Quiz Question # 5
• D. A, B, and C.
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
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
When viral URIs get admitted…
We’ll be ready to send them home!
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.
References
• “Infant deaths associated with cough and cold
medications--two states, 2005.” MMWR Morb
Mortal Wkly Rep. 2007 Jan 12;56(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.
75:4.
• Wald ER. “Clinical Features, Evaluation, and
Diagnosis of Acute Bacterial Sinusitis in Children,”
UpToDate, 2007.