Infectious Diseases

IMMUNIZATIONS

Most of the improvements in caring for children with infectious diseases have been in the area of prevention. Not only do we have clean water supplies (a leading cause of death in third world countries), but vaccines have been developed, which protect our children from the most serious infections. The following is the recommended schedule for immunizations with comments, which have arisen in various controversies. For most of these diseases, there is no cure, only prevention in the form of vaccines. These shots still represent the most effective way to prevent serious life-threatening disease in your child.

1. Hepatitis is a viral infection of the liver. There are 3 common types. Type A occurs from contaminated food and is usually mild and self-limited; Type B and C occur from blood and sexual contact and frequently result in liver failure requiring liver transplant. There are Vaccines only for A and B.

Hepatitis B vaccine (HepB). All infants should receive the first dose of hepatitis B vaccine soon after birth and before
hospital discharge. The second dose is recommended at age 1-2 months. The last dose in the vaccination series should
not be administered before age 6 months.
Hepatitis A vaccine. Hepatitis A vaccine is recommended for children and adolescents in selected states and regions,
and for certain high-risk groups; consult your local public health authority.

2. Diphtheria is a respiratory disease that produces a choking membrane in the airway. Antibiotics are effective, but usually too late. Pertussis is Whooping Cough and produces a pneumonia that is poorly responsive to antibiotics. Tetanus, or Lock Jaw, is a bacteria, which produces a poison that paralyzes muscles including those used for breathing. Antibiotics may kill the bacteria, but the poison persists.

Diphtheria and tetanus toxoids and acellular Pertussis vaccine (DTaP). The fourth dose of DTaP may be
administered as early as age 12 months, provided 6 months have elapsed since the third dose and the child is
unlikely to return at age 15-18 months. Tetanus and diphtheria toxoids (Td) is recommended at age 11-12 years
if at least 5 years have elapsed since the last dose of tetanus and diphtheria toxoid-containing vaccine. Subsequent
routine Td boosters are recommended every 10 years.

3. Hemophilus Influenza, Type B Until the late 1980’s this was the most common cause of meningitis in children and caused a deadly type of croup called epiglottis. Although treated with antibiotics, death rate is high and many survivors have mental retardation, paralysis and deafness.

Hemophilus influenza type b (Hib) conjugate vaccine These may be given alone or in a combined vaccine.

4. Measles, Mumps, Rubella Measles, or the Big Red Measles, is a very serious disease, which has no treatment. It may cause some to have a fatal encephalitis or pneumonia. All are extremely sick for 10-14 days. Mumps usually cause a painful swelling in the neck but can cause sterility in men and encephalitis. Rubella is a mild 3-day disease in all but the developing fetus. A pregnant woman who gets this disease may have a child with mental retardation, deafness, and blindness.

Measles, mumps, and rubella vaccine (MMR) The second dose of MMR is recommended routinely at age 4-6 years but
may be administered during any visit, provided at least 4 weeks have elapsed since the first dose and that both doses
are administered beginning at or after age 12 months. Those who have not previously received the second dose should
complete the schedule by the 11-12 year old visit.

5. Varicella, or Chickenpox This formerly common childhood disease has no cure. While usually mild in childhood, it requires quarantine for at least a week. In adults, it is much more serious, causing pneumonia, encephalitis and shingles.

Varicella vaccine Varicella vaccine is recommended at any visit at or after age 12 months for susceptible children,
i.e. those who lack a reliable history of chickenpox. Susceptible persons aged 13 years should receive two doses, given
at least 4 weeks apart.

6. Pneumococcal Disease This is a bacterial disease, which responds to antibiotics. However it is a major cause of life-threatening infections, such as pneumonia and meningitis.

Pneumococcal vaccine (PCV) is recommended for all children age 2-23 months.
Influenza, or the Flu Yearly epidemics cause illness in millions each year. It is especially dangerous in infants, the elderly and
those with certain conditions. There are many strains of flu. The vaccine is targeted to the strain predicted to be the most
common for each year. Influenza vaccine Influenza vaccine is recommended annually for children age =6 months with
certain risk factors (including but not limited to asthma, cardiac disease, sickle cell disease, HIV, diabetes, and
household members of persons in groups at high risk. In addition, healthy children age 6-23 months are encouraged
to receive influenza vaccine if feasible because children in this age group are at substantially increased risk for
influenza-related hospitalizations.

Immunization Risks vs. Benefits: Unfortunately, there is no free lunch. Vaccines are a form of medicine and all medicines have side effects. In every case, parents have the responsibility to compare the risk vs. the benefit. In most cases, vaccines cause no side effects, or only mild reactions such as fever or soreness at the injection site. This risk of mild reactions occurs in 1-10%, dependent on the specific vaccine. Very rarely, people experience more serious side effects, like allergic reactions. Severe reactions to vaccines occur so rarely that the risk is usually difficult to calculate, but in the range of .00001%. On the other hand, the diseases are real and occur in as many as 1 in 4 children, who are not vaccinated.

What signs of a moderate or severe reaction should I look for? After you or your child are vaccinated, look for any unusual conditions, such as a serious allergic reaction, high fever or behavior changes. Signs of a serious allergic reaction include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heart beat or dizziness, and swelling of the throat.

What should be done if someone has a reaction to a vaccine? Call a doctor. If the person is having a severe reaction take him or her to a doctor right away. After any reaction, tell your doctor what happened, the date and time it happened, and when the vaccination was given. Ask your doctor, nurse, or health department to file a Vaccine Adverse Event Reporting System (VAERS) form, or call VAERS yourself at 1-800-822-7967. In the rare event that a vaccine injures a child, he or she may be compensated through the National Vaccine Injury Compensation Program (VICP). For more information about VICP call 1-800-338-2382.

FEVER

Children run fever for a wide variety of reasons. They may have a bacterial illness, such as ear infection. Viral illnesses, such as a "cold" may cause fever. Unfortunately, the degree of fever doesn’t help distinguish between the two, nor does it help very much to determine the severity of illness. Some children may have a fever of 105 with a cold virus. Some children may have a fever of only 100 and have meningitis. Simply an increase in the child’s activity level, heavy clothing, or an increased environmental temperature may cause your child to have fever.

The length of time your child has fever and the associated symptoms are all-important in determining the severity of illness. We recommend that you contact us at anytime your child appears to be seriously ill, regardless of the degree of fever. On the other hand, try not to panic if your child has fever but otherwise is playful and feels well.

FEVER ALONE IS NOT HARMFUL AND IS EVEN HELPFUL. For many, this is a surprising statement, but needn’t be. Before the antibiotic era, treatment of all infections consisted of wrapping the child up to raise the temperature, thereby killing the germ with body heat! "Yes, doctor," you say, "But doesn’t fever cause brain damage and convulsions?" NO! It depends on the disease, not the fever. A minor illness, such as a "cold virus" may cause lots of fever (even to 105), but not brain damage. A brain infection, such as meningitis, may definitely cause both fever and brain damage...but not fever alone. A very important point! Convulsions may be caused by fever alone, but it doesn’t seem to be the degree of fever, but how rapidly the fever rose. Most cases of "febrile convulsions" occur even before you recognize that the child has fever. Furthermore, the great majority of febrile convulsions in children, while frightening enough, are not dangerous.

WHAT TO DO FOR FEVER

1. Decide if fever is present by using a thermometer under the arm for 5 minutes, in the mouth for 3 minutes, or in the rectum for at least a minute. 101 or more is traditionally accepted as fever.

2. Call or come to the doctor if there is any fever in a child less than 2 months of age, fever longer than 48 hours in an older child which you cannot explain, or in any child who appears seriously ill TO YOU.

3. Keep the febrile child comfortable. Some feel better wrapped up. Some prefer to be kept cool. Encourage lots of cool fluids. Do not force food and milk as he may vomit.

4. If the fever is 103-105, your child will feel better and less achy, if you reduce the fever.

5. Lower fever by undressing your child and bathe him for 20 minutes with a lukewarm sponge bath. Allow evaporating water to cool him, lightly dry, and dress in a light tee shirt.

6. The only medicine for fever in children is acetaminophen, not aspirin. This is found in Tylenol, Tempra, Panadol, etc.

Acetaminophen dosage for infants
Age	Dosage
0-6 months	.4 ml
6-12 months	.8 ml
12-24 months	1.2 ml
2-3 years	1.8 ml

CHILDHOOD DISEASES WITH RASHES

Pediatricians have been called general practitioners for children. Unlike some other specialists, who concentrate on a particular part of the body, we concentrate on a particular age group of growing people from birth to adulthood. We have also been compared to Veterinarians, because frequently our patients can’t or won’t talk to us. Indeed, our patients don’t even come to us voluntarily. Their parents must select and pay for our service! This requires the Pediatrician to be especially skillful at communicating through the parents the health needs and problems of their children. Frequently, parental perceptions of the child’s health problems are not the same as the pediatrician’s and they have lots of miscommunication. Parents may not understand why we can’t diagnose a problem from their telephone description of the symptoms.

A typical example is a call I recently got from a frantic parent who described a rash with fever. This is usually very distressing to the family because they are sure their child has the MEASLES! They are usually surprised when I reply, "Don’t worry. Nowadays most rashes in children these days even with fever are not serious."

It seems whenever I tell patients this; it comes as a big surprise. Parents remember measles and the other childhood illnesses, which cause rashes, as being very serious problems. Of course, their memory dates from the time they were children, and the time their parents were children. During this time, the usual childhood diseases, measles, rubella (German Measles), scarlet fever, roseola, chickenpox and fifth disease were frequently confused, and certainly in the case of measles, was a very serious illness. The only treatment for this childhood rash was isolation or quarantine. The complications that occurred included pneumonia, encephalitis, and even death in a few cases. Scarlet fever, a rash with strep throat, sometimes caused nephritis or rheumatic fever. Children either died of rheumatic fever or had crippling heart disease the rest of their lives.

Fortunately, today’s parents rarely have to be concerned with serious illnesses when their child has a rash. Twenty years ago, an effective measles vaccine was developed, and all state laws in the country require that children receive the vaccine. Therefore, pediatricians who were trained within the last ten years may never have seen a case of measles. But because the vaccine is only 95% effective, a rare child may have an illness called atypical measles, which is not serious to the child, and probably is so mild as to go unrecognized.

Just as importantly, the development of penicillin-type antibiotics 45 years ago helped to dramatically decrease the chance of rheumatic fever with a case of strep throat, or scarlet fever. As children readily see the doctor and receive penicillin for sore throats, rheumatic fever and crippling heart disease has almost become a disease of the past.

So even though the usual childhood rashes do not seem to be serious nowadays, it still may be helpful for parents to have an understanding between the differences in the various rashes. Sometimes this knowledge may be useful in just reassuring a well-meaning friend or relative that your child does not have measles!

When discussing rashes, most of the time, we are talking about five or six diseases:

1) Measles (THE BIG MEASLES)

This disease usually causes a child to be very sick. He has a rash, cough, marked runny nose, and inflamed red eyes. Usually all of these things occur when the fever is the highest. The fever usually lasts for l0 days. Pneumonia and encephalitis may be life threatening. The only treatment is directed toward making the patient comfortable until the disease goes away. Important is fever control and hydration with lots of liquid nourishment. Quarantine is necessary to control spread of the disease to un-immunized children. The only good thing to say about measles is that the measles shot has made it a rare disease.

2) Rubella (German Measles)

This disease causes a mild rash, the child to feel bad, and the child to have lymph node or lump enlargement at the back of the neck. These symptoms also are present when the fever is highest, but the fever, and indeed the whole illness, only lasts 3 days. Rubella, like the measles, has become rare since introduction of the vaccine. This illness is not dangerous to the child, but may cause deformities in unborn children. Every woman of childbearing age should know the status of her immunity to rubella. If at all possible, pregnancy should be delayed until the woman is immunized. Public health measures in this country have dramatically reduced the congenital rubella baby by requiring the MMR vaccine...Measles, Mumps, Rubella... in every 15-month-old child. Crippled congenital rubella babies, who frequently are blind, retarded, and have severe heart damage, have become rare in the last 10 years...truly one of the most remarkable accomplishments of medicine.

3) Roseola

This disease is still so common, as to occur in almost every child, between the ages of 6 months and 2 years. The child usually does not feel ill, in spite of a high fever of l03 or l04, which lasts for 3 days. The fever goes away, and the child develops a small rash. After 3 days, the rash goes away. The illness is not serious. Frequently neither the child nor the parent knows the child is ill until the rash develops.

4) Scarlet Fever

Just the mention of this disease puts fear and dread into the hearts of parents, because in the days before antibiotics, it was a crippling, killing disease. The child develops a sore throat, a fine sandpaper rash, and high fever. The Streptococcus bacteria causes this disease. Nowadays taking a throat culture and giving an antibiotic such as Penicillin can easily manage it.

5) Fifth Disease

There is an illness, which is similar to the above-mentioned diseases, but has a separate set of symptoms. Since it wasn’t one of the above-mentioned diseases, it came to be called Fifth Disease. This illness is a mild one, but is associated with low-grade fever, bright red "slapped cheeks", and a lacy red rash over the groin and legs. The child will recover without treatment, although the rash may come and go over a week or more.

6) Chickenpox

This highly contagious disease, also known as Varicella, is now receiving some long overdue attention. It has been confused in the past with smallpox, but is a different virus, altogether. It is not usually serious, but still occurs in almost every child. Because it generally is only a nuisance...causing an itchy rash of small bumps and blisters with mild fever, a vaccine has not previously been thought necessary. A single bout confers life-long immunity, although the virus may be re-activated in adults as "shingles." However, some children may become quite ill with a chickenpox pneumonia or encephalitis. Also, recent evidence has linked Reyes Syndrome to children who have Varicella and are also given aspirin. A very safe vaccine now appears to be on the horizon, which has the potential to totally prevent chickenpox. Liability lawsuits against vaccine manufacturers likely will delay the introduction of this "chickenpox shot" for the near future. Treatment of the early springtime epidemics of chickenpox consists of avoiding aspirin. Acetaminophen and tepid baths can be used for the fever. Benadryl and calamine lotion may help the itching, but time is usually the best cure; the disease is usually gone in about 5-7 days.

Other Viral Rashes

Aside from the above diseases, the most common rashes are caused by a host of unimportant viruses. These are the Coxsackie, Echoviruses and others. Usually they are accompanied by a mild fever, diarrhea, or cold symptoms. They are rarely serious and disappear after only a few days with no treatment.

Indeed there is little treatment for all of these diseases, aside from using Penicillin for scarlet fever. Most of the time, treatment is aimed toward making the child comfortable, and reassuring the parents that there is rarely a serious illness present. If you are concerned about your child’s usual childhood disease...whether rashes with fever or any other aspect of your child’s health, I urge you to talk with the expert in child health...your pediatrician. I can say to you that parents need to worry less about measles nowadays if (and this is a big "IF") they insure the child regularly receives the immunizations required by state law, visits their doctor for health maintenance exams, and COMMUNICATES with their Pediatrician!

Meningitis

THE DISEASE

Hemophilus influenza type B (HIB) is a bacterium that causes disease in children. In the United States, l in 200 children will come down with one of these illnesses caused by the bacteria.

Meningitis - a brain and spinal cord infection, caused usually in young children by HIB. This may result in mental retardation, deafness, or death in l0% of cases.

Epiglottitis - a lower throat infection, similar to croup, which may be fatal.

Other infections, such as blood infections, joint infections, pneumonia, skin infections and less commonly, other bacteria, such as meningococcus, pneumococcus, staphylococcus, and viruses can cause meningitis in children.

THE VACCINE

Development - This vaccine has been in the making for several years. It was tested on 60,000 children prior to its release for use in the spring of l985.

Safety - The risks are much lower than older vaccines such as DPT, because it is not a weakened form of the germ, but only a chemical from the germ. It is very pure, even minor reactions (fever, swelling, etc.) are rare, and no major reactions have been observed.

Our Recommendations - All children from age 24 months to age 6 years should receive the vaccine as soon as possible for protection. Those children who attend day care should receive the vaccine down to l8 months of age. The vaccine can safely be given at the same time as other immunizations. It should only be delayed in those children with fever.

ALL CHILDREN NEED HIB VACCINE AS SOON AS POSSIBLE!

Ear Infections

The ear is divided into three parts, going from the outside into the head:

The outer ear ---the ear lobe and the ear canal
The middle ear---the ear drum, middle ear space, and tiny bones that conduct sound
The inner ear---the cochlea, hearing nerves and the semi-circular canals for balance

Diseases that affect each part are called

Otitis externa ...or swimmers ear
Otitis media...the most common earaches of childhood, usually caused by plugged noses
Inner ear disease…which affects either balance or nerve deafness and is more common in adults

SWIMMER’S EAR: The term "swimmer’s ear" can be described as an inflammation of the ear canal, which is common among children who swim frequently. The symptoms that accompany this illness are (l) discharge from the ear, (2) ear pain, worsened by pulling on the ear, and (3) diminished hearing. To confirm that your child has swimmer’s ear, press gently in on the button in front of your child’s ear. If this hurts, your child probably has swimmer’s ear, and should be seen by his pediatrician for treatment. The doctor will prescribe a preparation to cure the inflammation and prevent it from spreading to the external ear.

TREATMENT: Once his pediatrician has diagnosed your child as having swimmer’s ear, the treatment should be as follows:

Keep the ears dry until the infection is cured.
During baths, cotton plugs coated with petroleum jelly will keep water out.
Administer antibiotics, usually ear drops, as prescribed by your doctor.
Give aspirin/acetaminophen for relief of pain.
Keep your child from swimming until the ear tenderness and swelling is gone.

PREVENTION: Swimmers’ Ear is really an infection of the skin of the outer ear. It occurs because water gets trapped in the ear canal. Prevention is aimed at keeping the ear canal dry.

Thoroughly dry the ear after getting it wet.
A mixture of alcohol and vinegar in equal parts dropped in the ear helps to dry the ear and to kill infection.
A hair dryer on the lowest setting blown gently into the ear may also aid drying.

OTITIS MEDIA- Middle Ear Infections: This is the most common reason a parent brings their child to the doctor. When a child has an illness that the parent cannot diagnose, they most commonly suspect an ear infection...and usually they are right! Symptoms of the older child are easy to diagnose. Usually the child has severe pain deep in the ear lasting 1-4 hours. This usually follows a cold and the child sometimes has a fever. The challenge for a parent is to guess right when the child is very young or does not complain. A temporary hearing loss is common, but difficult to detect at times. I recommend having your doctor examine children for the possibility of ear infection in the following situations:

An infant less than 6 months with unexplained fever or irritability

A child, recovering from a cold who seems to get worse
Any complaints of ear pain, even if it seems to get better
Any complaints or symptoms of decreased hearing Children with a persistent cold or nasal allergy
Drainage, or blood, from the ear canal

The following are questions that parents usually ask me, which should help you in managing your child’s ears problems:

How does infection get in the middle ear?

The space behind the eardrum is bordered on all sides by bone and is deep inside the skull. However, the eardrum must vibrate, like the head of a drum. This requires the middle ear space to be filled with air at the same pressure as room air. The only way for air to get into the middle ear space is through a tiny tube called the Eustachian Tube. This runs from the middle ear space to the mouth and nose. Whatever blocks the nose, usually a cold, also blocks this tube. When the Eustachian tube can no longer equalize air pressure, fluid and infection develop in the middle ear space instead of air. The result is hearing loss, pain, and fever. The developing child’s Eustachian Tube has some features that make children especially prone to ear infection:

It is shorter
It offers a straighter path between the nose and the middle ear space
It is not made of bone and the tube collapses more easily

How can a parent tell if a young baby has an ear infection?

Babies may be fretful. They may cry out in pain. They may pull at the ear, but without pain, this usually is part of discovering the earlobe. Red ear lobes have nothing to do with middle ear infections. A more reliable sign is persistent, thick, nasal mucous or red watery eyes. Crying when sucking the bottle, or swallowing, may represent pain caused by pressure on an inflamed eardrum. In short, almost any symptom in a very young child such as crying, fever, vomiting, diarrhea, or listlessness may represent ear infection. If persistent, any of these symptoms require examination. Unfortunately, it is not unusual for the first symptom to be pus draining from the ear canal.

What happens if an ear infection is not treated?

Antibiotics were not developed and widely used until the late 1940’s. Unfortunately, deafness due to untreated ear infections was fairly common. The following occur without treatment:

Eardrum perforation, following build up of pressure behind the eardrum occurs. While the eardrum usually heals promptly, repeated burst eardrums causes permanent scars.
Ear abscess extends into the mastoid bone, and sometimes into the brain, causing brain abscess or infection.
Deafness caused by hardening of middle ear fluid, scarring the eardrum and delicate middle ear bones, is either temporary or permanent. The infection is killed by the body’s own natural defenses, the Eustachian tube reopens and the ear and hearing return to normal in a few cases without treatment.

How is an ear infection treated?

Antibiotics, consisting of a type of penicillin, sulfa, cephalosporin, or a ‘mycin drug is used. After 7-14 days, the middle ear is sterilized and the ear infection is cured. Unfortunately, the bacteria causing the infection continue to develop resistance to the antibiotics. After a few years, the antibiotic begins to lose effectiveness and newer, more powerful, and more expensive drugs need to be developed. It is a never-ending battle, which the bacteria seem to be winning.

Anesthetic eardrops, or oral pain relievers provide temporary relief.

Antihistamines, or decongestants, may help decrease Eustachian swelling, but use is controversial.

Lancing the eardrum to safely drain off the pus may be necessary.

What is middle ear fluid?

This is nothing more than nasal mucous secreted because air can no longer enter the middle ear space. Persistence of the middle ear fluid means the eardrum can no longer vibrate and transmit sound waves to the ear nerves. This is the most common cause of temporary hearing loss in children. Management of persistent middle ear fluid consists of

Encouraging the child to open the Eustachian tube by blowing while holding the nose.
Continuing a low dose of antibiotics for several weeks in hopes of preventing a new infection in the fluid.
Using decongestants to open the nose and allow air into the middle ear space.
Using nasal steroids to help shrink the swollen tissues of the nose and Eustachian tube.
Finally, inserting plastic tubes through the eardrum to allow air into the middle ear space.

How can I prevent middle ear infection?

Early use of antihistamines and decongestants during a cold or allergy attack may keep the Eustachian tube open and prevent infection.

Controlling allergy of the nose by avoidance of pollution, dust and mold as much as possible.
Avoidance of passive tobacco smoke, which paralyzes the nose and ears defenses.
Avoidance of infection by minimizing your child’s exposure to germs.
Yes, ear infections are contagious. It has been proven that a day care environment for young children increases ear infections by increasing exposure.
Help your doctor manage the problem of middle ear fluid with medication.
Consider ear tubes in the child with continuously blocked Eustachian tubes.

Sore Throat, Strep Throat, and Tonsillitis

The throat, or pharynx, is surrounded at the back of the tongue by special tissue, lymph glands, which swell and fight infection. This lymph gland is called the tonsils. For all practical purposes, sore throat and tonsillitis mean the same thing. This is true, even after the tonsils are removed, because not all the tonsillar tissue can be removed. They are part of the throat. Several conditions cause a sore throat:

Mouth breathing causes the most common sore throat. The throat becomes extremely sore because of excess drying.
A vaporizer and salt-water gargles and sprays improve it. Opening the nose with a decongestant usually helps.
Viral infections cause most infectious sore throats. The throat may be extremely red, covered with pus and cause high fever. Without lab tests, it is impossible to distinguish from strep throat.

The bacteria, Group A Streptococcus, cause strep throat. It looks like any other sore throat, but may also have distinguishing blood spots, or petechiae, over the soft palate. A strawberry appearance to the tongue, fever, congestion, stomach pain and flu-like symptoms usually are present. This is the only sore throat which antibiotics help. However, experts do not think the illness is made much better by antibiotics. The main reason to use antibiotics is to prevent complications, primarily rheumatic fever, mentioned above, which may result from strep throat untreated for a week. Over treatment of a sore throat is the most common reason for overuse of antibiotics.