Sick Baby: undifferentiated infant under 3 months

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Young infants under 3 months can be pretty scary when they get properly sick. It seems quite ‘veterinary’, and in many ways we just have to screen and treat for sepsis – and ask questions later… But there are a number of other differentials to consider.

Signs of illness may be obvious, such as when we are presented with a pale, floppy baby, or they may be more subtle – when either the caregiver or the doctor just knows that the baby is just NQR – Not Quite Right. In this episode, we consider the assessment and management of the non-specifically unwell young infant, that is, under 3 months of age, using an ABCD structure (of course).


PEMcast Outline: undifferentiated sick young infant (<3 months)

[CP] Intro, disclaimer

[RR] What’s different about neonates / young infants?
They are brand new
Physiological changes
Possibly inexperienced parents
No chance to know what is “normal” for them
They are SCARY!
However…It is easy once you have a system as we have such a low threshold for investigation and treatment.

[CP] The background history
Antenatal problems
Birth- PROM, distress, NICU
Family history
Vitamin K

[RR] History & Examination: Systematic approach

[CP] Airway & Breathing Problems

Hx:
Congenital problems?
Progressive problem, or manifests with episodes of Infection?
Ex:  Stridor, Air entry, Sats,
Ix: CXR

[RR] Circulation

Hx:
Antenatal scans don’t pick up everything
Many cardiac problems progress over first few days (duct closure)
Feeding – tiring / sweating
Weight gain less obvious (peripheral oedema does not really happen)
Ex:
Sometimes it is easy to spot cyanosis…. (smurf)
Usually it isn’t- do saturations on both arms (pre and post ductal)
Listen for murmurs and feel for a liver
Always feel for femoral pulses
Ix: ECG and CXR

[CP] Disability (and sepsis)
Hx:
Antenatal risk factors
Fever?- if any documented fever TREAT as sepsis
Ex:
Posture?
How does the baby handle? (reactive? lively on handling?)
Fontanelle
Blood sugar (DEFG)
Ix:
? Sepsis: If any concern about sepsis- full septic screen (incl urine, CXR, BC, CSF)
? Cardiac- CXR and ECG
? Metabolic- urine, full septic screen, ammonia and cortisol

[RR] Treatment
Sepsis- cefotaxime, gentamicin and amoxycillin
Cardiac- prostin to keep duct open
Metabolic- IV glucose and NBM

Differentials for the collapsed young infant:

[CP] A: (congenital airway abnormality) Allergy/anaphylaxis

[RR] B: apnea (RSV/FB), ALTE, pneumonia, pneumothorax

[CP] C: coarctation, duct-dependent pulmonary or systemic circulation, SVT

[RR] D: intracranial bleed eg Vitamin K deficiency, NB inflicted injury (NAI)
Envenomation or poisoning (DIMTOPPE mnemonic)

[CP] E: (fever – sepsis): UTI, bacteraemia, meningitis, viraemia

[RR] DEFG: Hypoglycaemia, other metabolic incl CAH (boys)

[CP] GI: Intussusception, other causes of bowel obstruction (green vomits) incl obstructed inguinal hernia

[CP] ALTE’s: a well baby that gets admitted (see previous PEMcast)
4 features (Detailed history is important)
Not a ‘near-miss SIDS
[RR] Should be taken seriously and needs paediatric follow-up
Encourage parents to go on a life support course
Many parents buy apnoea alarms (pros & cons)

[RR] Summary
Most unwell babies will be treated for sepsis pending further investigation
It is important to look for cardiac and metabolic problems
Don’t forget Non-Accidental Injury as a differential

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Just Awful

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Here’s a bit of fun… And some lessons for Pediatric Emergency Medicine, from 1971.
It’s a kid’s book, about a boy who hurts his finger at school, and has to see the school nurse.  James feels Just Awful – until after the 3-part treatment.

We learn about assessing, cleaning and dressing wounds, and gain some insights into a child’s perspective of being a patient.

Enjoy.

Just Awful on YouTube

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MeningoCoccal Disease: Pearls and Pitfalls

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A tiny, frightening little bug: Neisseria meningitidis.  The challenge for us in healthcare is to squash this little bug before it wreaks its havoc…

Join us for a discussion of ways to protect yourself, and your patients, against the nasty threat of meningococcal disease. It creeps up on you… when you least expect.


Outline: MCD PEMcast

[cp]: Intro, welcome, disclaimer

[cp]: Problematic disease because of non-specific early clinical picture, rapid progression, potentially devastating outcomes, and because relatively uncommon (therefore difficult to get useful data/research)

[CB]: Vaccination covers some serotypes (which?)

[cp]: Challenge / Holy Grail is early diagnosis (& treatment); strategies to try to achieve this are:
- public awareness (more good than harm, despite occasional parent not being reassurable) (organisations, tumbler test)
- healthcare professionals awareness
- formal guidelines & protocols eg early parenteral antibiotics via GP or peripheral setting, prior to transfer to hospital, standardised risk-management protocols eg antibiotic guidelines, ICU consultation, etc
- search for a new test / combination of tests / scoring system etc

[cp]: Clinical features (which stand out from other causes of sepsis or meningitis):
- individually lack specificity but might raise your suspicions
[RR]: – symptoms: non-blanching rash, leg pain, rapid deterioration, others
[cp]: – signs: petechiae / purpura, cold peripheries (toe-core temperature gradient used in Glasgow meningococcal sepsis score), others

[all / cp]: Protective strategies for ED docs:
- be afraid, this disease is deceptive
- a piece of hay that turns into a needle…
- documentation – descriptive, including lay terminology, to paint an accurate clinical picture
- discharge advice for parents in setting of ‘viral illness’ or fever without source
- utilise period of observation when unsure
- keep looking out for new strategies to minimize your own risk

[CB]: Comments from Chris

[all] summary, goodbye

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Meningitis: Steroids or not?

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The most important thing about treating meningitis is to give antibiotics as soon as possible.  The second most important thing is to institute appropriate supportive care.  Whether or not to give steroids as an adjunctive treatment is perhaps less clear to us…

A recent Cochrane review goes a long way to pointing us in the right direction, but still leaves a few questions open.  Join us for a quick tour of the literature and guidelines, in our quest for the truth about using steroids in meningitis.


Outline: Steroids for Meningitis PEMcast

[cp]: intro, disclaimer, rationale / theory: decrease inflammatory damage due to bacterial lysis

[cp]: Historical background: original studies were from an era when Haemophilus & Strep were common, decreased by vaccinations
?applicability to current (developed world) population of children and infectious agents

[CB]: Comments from Chris

Papers:

[RR]: Kennedy 1991 AmJDisChild – Pneumococcus

[cp]: Gupta 2004 ArchDisChild – Meningococcus

[cp]: Brouwer 2010 Cochrane review

[CB]: Peltola 2010 Pediatrics

Guidelines:

[cp] AAP (nothing recent – litigation fear??)
1990 guideline regarding steroids in meningitis
Nigrovic 2007 JAMA (Bacterial Meningitis Score)

[RR]: NICE Guideline (esp section 1.4.39 – steroids): Over 3 months age, start ASAP if within 12 hours: dexamethasone 0.15mg/kg IV, 6-hourly for 4 days
http://guidance.nice.org.uk/CG102

Review of NICE Guidance by Radcliffe, October 2011

[RR]: SIGN Guideline (esp section 6.4.2) Invasive MCD, start within 24 hours
http://www.sign.ac.uk/guidelines/fulltext/102/index.html

[cp/CB]: local guidelines (dexamethasone 0.2mg/kg IV 6-hourly)

[all] Summary, goodbye

References

Kennedy WA, Hoyt MJ, McCracken GH Jr.
The role of corticosteroid therapy in children with pneumococcal meningitis.
Am J Dis Child. 1991 Dec;145(12):1374-8.
PubMed PMID: 1669663.

Gupta S, Tuladhar AB.
Does early administration of dexamethasone improve neurological outcome in children with meningococcal meningitis?
Arch Dis Child. 2004 Jan;89(1):82-3. Review. PubMed PMID: 14709520.

Brouwer MC, McIntyre P, de Gans J, Prasad K, van de Beek D.
Corticosteroids for acute bacterial meningitis.
Cochrane Database Syst Rev. 2010 Sep 8;(9):CD004405. Review. PubMed PMID: 20824838.

Peltola H, Roine I, Fernández J, González Mata A, Zavala I, Gonzalez Ayala S,
Arbo A, Bologna R, Goyo J, López E, Miño G, Dourado de Andrade S, Sarna S,
Jauhiainen T.
Hearing impairment in childhood bacterial meningitis is little relieved by dexamethasone or glycerol.
Pediatrics. 2010 Jan;125(1):e1-8. Epub 2009 Dec 14. PubMed PMID: 20008417.

American Academy of Pediatrics Committee on Infectious Diseases:
Dexamethasone therapy for bacterial meningitis in infants and children.
Pediatrics. 1990 Jul;86(1):130-3. PubMed PMID: 2193301.

Nigrovic LE, Kuppermann N, Macias CG, Cannavino CR, Moro-Sutherland DM,
Schremmer RD, Schwab SH, Agrawal D, Mansour KM, Bennett JE, Katsogridakis YL,
Mohseni MM, Bulloch B, Steele DW, Kaplan RL, Herman MI, Bandyopadhyay S, Dayan P, Truong UT, Wang VJ, Bonsu BK, Chapman JL, Kanegaye JT, Malley R; Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics.
Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis.
JAMA. 2007 Jan 3;297(1):52-60. PubMed PMID: 17200475.

National Institute for Health and Clinical Excellence
The management of bacterial meningitis and meningococcal septicaemia in children and young people younger than 16 years in primary and secondary care
Last updated: 10 November 2011
http://guidance.nice.org.uk/CG102

Radcliffe RH.
Review of the NICE guidance on bacterial meningitis and meningococcal septicaemia.
Arch Dis Child Educ Pract Ed. 2011 Oct 27. [Epub ahead of print] PubMed PMID: 22034519.

Scottish Intercollegiate Guidelines Network
Management of Invasive Meningococcal Disease in Children and Young People
Guideline No. 102, ISBN 978 1 905813 31 5, May 2008
http://www.sign.ac.uk/guidelines/fulltext/102/index.html

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Meningitis Diagnosis and Management

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The word strikes fear into the heart of parents. You dare not mention the ‘M’ word unless you back it up with action, or a whole heap of calming reassurance…

The clinical features of meningitis are less straightforward in younger children, and CSF findings can be tricky to interpret. In this episode, our local Paediatric Infectious Diseases expert guides us through the topic with some clinical perspectives and insights.


Meningitis PEMcast: Outline

[cp]: intro / disclaimer

[cp]: clarification – meningitis (definition) vs meningococcal disease [MCD] (spectrum of meningitis, meningococcaemia, or both)

[all]: MCD prognosis depending on this spectrum, why?

[cp]: clarification meningitis vs encephalitis / meningo-encephalitis

Aetiology:

[cp]: – Non-infectious (‘aseptic’=non-bacterial): autoimmune, neoplastic, drug-induced

- Infectious

[RR]: viral – frequent offenders (Entero= Coxsackie/Echo, HSV less common)

[sf]: bacterial – frequent offenders

neonatal: maternal (Listeria,  Group B Strep) vs acquired source (E coli, Gram-negatives, eg Klebsiella, Staph aureus)

beyond neonatal period: Strep pneumoniae, Neisseria meningitidis, Haemophilus influenzae type B

[CB]: less common pathogens – mycobacterium tuberculosis, measles, mumps, fungal, cryptococcal in immunocompromised kids

Clinical features:

[RR]: History (headache, neck stiffness, photophobia, fever – or hypothermia in neonates)

[sf]: Examination findings (fever, meningeal irritation, rarely Brudzinski or Kernig signs, altered mental state, focal neurology, seizures, drowsiness, irritability)

[cp]: differential diagnoses (including alternate causes of fever, altered mental state, headache, neck stiffness) esp Viral illness / influenza, tonsillitis, infant sepsis (eg UTI), non-specific infant unwellness (metabolic, cardiac, intussusception)

Absence of meningism is not reassuring in the younger child!

Investigations:

[RR]: bedside – blood sugar, urinalysis (differentials), ECG maybe

[sf]: lab – utility of FBC, U&E, CRP, ESR?
[cp]: lab – role for procalcitonin?

[CB]: lab – blood cultures – how often do we get the bacterium on blood culture?

[CB]: Timing of LP (do the LP as soon as it’s safe to do it)

[RR]: imaging – need for CT prior to LP? (compare adults vs children)

[sf]: Lumbar Puncture: cautions / contraindications (raised ICP, focal seizure, seizure without full recovery, cardiovascular or respiratory compromise)
Lower threshold for LP if recent oral antibiotics, esp if febrile convulsion

Needle depth (CHW): 1.5 mm/kg (for under 10kg), 1mm/kg (10-40kg)

CSF findings:

[cp]: – normal (age-related)

neutrophils ‘lymphocytes’

(non-neutrophils)

protein glucose

(CSF:blood ratio)

neonate 0 < 20 < 1.0 >= 0.6
over 1 month age 0 < 5 < 0.4 >= 0.6

[sf]: – typical viral picture (not useful in acute stage – treat as bacterial)

[RR]: – typical bacterial picture

[CB]: – oddballs: fungal, TB, Mumps

Management:

[cp]: Steroids? Best given “before” antibiotics – role to be discussed in next episode

[RR]: Presumed or confirmed bacterial: IV antibiotics
- antibiotic choice – local guidelines, neonates different (amoxycillin for Listeria, gentamicin, cefotaxime – avoid ceftriaxone – biliary sludging)
- antibiotic duration (?stop at 48 hrs when all cultures negative, vs several weeks for some organisms)
- waters muddied by prior oral antibiotic treatment

[sf]: Presumed or likely Viral:
- usually will get antibiotics initially
- supportive care (caution with IV fluids)
- when to give antiviral agent? (HSV, VZV?)
- acyclovir dosing – body surface area vs simple weight-based 10mg/kg

[CB]: Exotic bugs (immunocompromised / travel / cranial or spinal neurosurgery) – get Microbiology / Infectious Diseases specialist advice!

[all]: last words, goodbye

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