Pediatric Primary Care (64 page)

8.  Foreign body aspiration: typically in toddler, unilateral physical findings, X-ray or by bronchoscopy.

G.  Treatment.

1.  Treatment is supportive.

2.  Cough suppressants should be avoided in children with productive cough.

3.  Rest as needed.

4.  Avoidance of environmental irritants.

5.  Empiric trial of bronchodilator therapy.

6.  Acetaminophen for chest pain, fever.

7.  Antibiotic therapy may be considered if bacterial infection is strongly suspected (prolonged symptoms, patient's age, high fever).

8.  Humidification of air promotes comfort.

9.  Chest physiotherapy may be indicated if productive cough, coarse crackles on exam.

H.  Follow up.

1.  If cough for 2 weeks or worsens, fever, or signs of respiratory distress: contact healthcare provider.

I.  Complications.

1.  In healthy children, bronchitis is not a serious illness.

2.  In chronically ill children, may develop concurrent otitis, sinusitis, pneumonia.

J.  Education.

1.  Avoid large daycare settings for young children to minimize frequency of viral infection.

2.  Avoid secondhand smoke exposure.

3.  Bronchitis is usually caused by viral infection; antibiotics are not effective.

4.  Acute bronchitis is a benign, self-limited illness usually lasting 2 weeks.

5.  Should consult with healthcare providers before administering cough suppressants.

6.  If child has signs of respiratory distress, contact healthcare provider.

7.  If cough does not resolve within 2 weeks or worsens or fever recurs, contact healthcare provider.

V.  PERTUSSIS

A.  Etiology.

1.  Pertussis: highly contagious, vaccine-preventable bacterial infection caused by
Bordetella pertussis
, less commonly by
B. parapertussis
(Gramnegative coccobacillus).

2.  Transmission: airborne, occurs by contact with respiratory droplets of infected person or by indirect contact with contaminated surfaces.

3.  Disease is endemic in United States, with all 50 states reporting cases annually.

4.  Most cases in United States occur between June and October.

B.  Occurrence.

1.  Pertussis causes disease in every age group.

a.  Significantly impacts nonimmunized or partially immunized young children; can cause severe disease. Highest mortality in infants younger than 6 months of age.

2.  Incubation period is 7-10 days with a range of 5-21 days.

3.  Persons with pertussis are considered infectious from 7 days after exposure to 3 weeks after person enters paroxysmal stage.

a.  Pertussis is most contagious from catarrhal stage until 2 weeks after onset of cough without appropriate therapy.

C.  Clinical manifestations.

1.  Pertussis is lengthy disease lasting 6-10 weeks, divided into 3 stages.

a.  Catarrhal stage lasts 1-2 weeks, may not be recognized in infants younger than 3 months.

•  Characterized by URI symptoms such as rhinorrhea, sneezing, mild cough, low-grade fever.

b.  The paroxysmal stage lasts 2-4 weeks or longer.

•  Characterized by paroxysmal cough/bouts of rapid cough, sudden coughing.

•  Have color change, bulging eyes, tearing, tongue protrusion.

•  May be triggered by feeding, crying, excitement, activity.

•  May have multiple episodes each hour during peak but appear well between episodes.

•  May have characteristic whoop during forceful inspiration.

•  Post-tussive vomiting, exhaustion are common following episode.

•  Infants younger than 3 months of age have apnea, choking, gasping.

c.  Convalescent stage lasts 1-2 weeks, but cough can persist for several months. During this stage, cough and post-tussive vomiting decrease.

D.  Physical findings.

1.  Cough.

a.  Catarrhal stage: mild.

b.  Paroxysmal cough: associated with cyanosis, lacrimation, exhaustion, post-tussive vomiting.

c.  Subconjunctival hemorrhages and petechiae on head and neck.

2.  Breath sounds are normal, unless significant atelectasis or pneumonia.

E.  Diagnostic tests.

1.  Consider in cases of prolonged cough with history of post-tussive vomiting, whoop, paroxysmal cough.

2.  Culture is “gold standard” for laboratory diagnosis.

a.  Most likely to be positive during catarrhal stage to peak of paroxysmal stage.

b.  Use calcium alginate or Dacron swab of posterior nasopharynx for 15-30 seconds or by nasal wash and plate on specialized media, incubate for 7 days.

3.  Rapid testing by nasal wash for direct fluorescent antibody (DFA) or polymerase chain reaction (PCR).

a.  Do not use calcium alginate swabs for PCR as it is inhibitory to PCR.

4.  Serology.

a.  Enzyme immunoassay detects antibody to B pertussis in acute and convalescent samples: not helpful during acute illness and difficult to interpret in immunized persons.

5.  CBC: leukocytosis with lymphocytosis in catarrhal and early paroxysmal stages.

a.  Present in infants and young children but not in adolescents.

F.  Differential diagnosis.

1.  Adenoviral infection: presence of fever distinguishes from pertussis.

2.  
Mycoplasma
infection: causes prolonged cough but fever, systemic symptoms, crackles on auscultation help differentiate from pertussis.

3.  
B. parapertussis
infection: less severe illness.

4.  In infancy, consider chlamydia, cytomegalovirus (CMV).

G.  Treatment.

1.  Most children beyond infancy can be managed at home.

2.  Macrolides are treatment of choice for infected persons and close contacts.

3.  Azithromycin, erythromycin, or clarithromycin are first-line agents for treatment and prophylaxis.

a.  Do not use in young infants because of association with infantile hypertrophic pyloric stenosis (IFPS).

4.  Dosing.

a.  Less than 30 days of age:

•  Azithromycin 10 mg/kg/day as single daily dose for 5 days.

•  All infants younger than 30 days of age who receive macrolides should be monitored for IFPH during and for 1 month following completion of course.

b.  1-5 months of age.

•  Azithromycin 10 mg/kg/day as single daily dose for 5 days OR

•  Erythromycin 40-50 mg/kg/day in 4 divided doses for 14 days OR

•  Clarithromycin 15 mg/kg/day in 2 divided doses for 7 days.

c.  Infants 6 months of age or older and children.

•  Azithromycin 10 mg/kg/day as single daily dose on day 1 (maximum dose 500 mg), then 5 mg/kg/day (maximum dose 250 mg) on days 2-5 OR