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These are illnesses which can result in death if they are not correctly managed. Every effort must be made to prevent them, recognise them early and treat them correctly. Many serious illnesses which are rarely seen in children in developed countries, are still major problems in poor communities with overcrowding.
Important serious illnesses include:
Some serious illnesses, such as pneumonia and typhoid, are discussed in other units.
Acute rheumatic fever is the most common cause of acquired heart disease in children, especially in poor, overcrowded communities. It is a complication of pharyngitis (a throat infection) caused by Streptococcus bacteria. An unusual immune response by the body to this bacterial infection damages the joints, heart and other tissues of the body. The exact mechanism whereby this happens is still not fully understood. Acute rheumatic fever is usually seen in children aged 5 to 15 years.
Rheumatic fever is the most common cause of acquired heart disease in children in developing countries.
Acute rheumatic fever develops 2–3 weeks after a Streptococcal pharyngitis. The classical features of acute rheumatic fever are:
Children with acute rheumatic fever do not necessarily develop all the classical signs. The rash, subcutaneous nodules and chorea are less common signs of acute rheumatic fever.
Carditis is an inflammation of the heart. The heart muscle, valves and pericardium are involved. The signs of carditis are:
By documenting a Streptococcal infection plus 2 major or 1 major and 2 minor criteria.
The major criteria are:
The minor criteria are:
Always suspect acute rheumatic fever in an unwell child older than 3 years who presents with fever, tachycardia and shortness of breath or painful joints.
Strict clinical criteria are used to diagnose acute rheumatic fever.
It is difficult to know if an acute sore throat is due to a virus or Streptococcus. Therefore, antibiotics should be given to all children under 15 years who have a fever and sore throat (pharyngitis) without the signs of a common cold, i.e. blocked nose and nasal discharge. Oral penicillin, amoxycillin or erythromycin for 5 days are needed. However, it is also important that antibiotics are not given to all children with a viral upper respiratory tract infections such as the common cold or influenza.
With the more frequent use of antibiotics, acute rheumatic fever has become uncommon in wealthy countries.
Repeated attacks of acute rheumatic fever can be prevented in children, who have previously suffered one or more attacks, by giving benzathine penicillin (Bicillin LA) 1.2 million units intramuscularly every 4 weeks (600 000 units if the child weighs less than 30 kg). This must be continued until adulthood when it should be reviewed. As the injections are painful, the child and family must understand that it is most important to prevent ongoing heart damage. The mother should keep a card which records the monthly injections. Careful follow up is essential.
Acute rheumatic fever should resolve in 4 weeks. Some children recover completely while others are left with permanent damage to their hearts. Acute rheumatic fever tends to recur and the risk of permanent heart damage (rheumatic heart disease) increases with each acute attack. Every effort must therefore be made to prevent repeat attacks.
One or more attacks of acute rheumatic fever can cause permanent damage to one or more heart valves. This is called chronic rheumatic heart disease. Leaking of the mitral valve (mitral incompetence) or narrowing of the mitral valve (mitral stenosis) are the most common permanent valve defects. Damage to a valve or damage to the heart muscle can cause heart failure.
Every effort must be made to prevent repeated attacks of acute rheumatic fever.
These children are often underweight and have delayed developmental milestones due to their heart disease. Their schooling may be interrupted. On examination they have signs of leaking (incompetent) or narrowed (stenotic) heart valves. They may also have signs of heart failure.
These children are at great risk of developing infective endocarditis after dental procedures (bacteria enter the blood stream and then stick to the heart values where they cause infection and damage). The dentist should give a dose of prophylactic antibiotic before the procedure.
Children with chronic rheumatic heart disease must be managed by a special cardiac clinic team. It is very important that they do not have any further attacks of rheumatic fever. Most children can be managed with drugs to control heart failure but some will require cardiac surgery.
There are many causes of heart failure, including acute rheumatic fever, chronic rheumatic heart disease, congenital heart disease and severe anaemia.
It is an acute inflammation of the kidney which follows a few weeks after an infection with Streptococcus. The infection is usually of the skin (i.e. impetigo) but may follow a throat infection (therefore often called acute post-streptococcal glomerulonephritis). The inflammation of the kidney is the result of an unusual response to the infection by the body’s immune system. Antibodies produced against the Streptococcus damage the kidney. This is similar to the immune response which results in acute rheumatic fever. Again, the reason for this unusual response is not fully understood.
The severity of signs varies widely. In many children the condition is asymptomatic and would only be diagnosed by testing the urine for blood and protein, or by measuring the blood pressure.
Acute glomerulonephritis usually presents with dark urine, reduced urine output and oedema.
Most children present with oedema and visible haematuria. However, hypertension can occur with no oedema and with haematuria only detected on reagent strips.
Children usually recover completely. By 2 weeks the urine output increases and the oedema and hypertension disappear. The urine may remain dark (due to blood) for up to 6 weeks but blood may be detected on reagent strips for a few months.
It is very important to look for signs of complications.
Respiratory distress due to pulmonary oedema should be managed with oxygen, furosemide 1 mg/kg intravenously, sitting the patient up and referring to hospital urgently.
Most cases occur in children over the age of 2 years in poor communities where Streptococcal infections, especially of the skin are common. It is important that skin infections are treated promptly with local antiseptics (e.g. Savlon). Scabies, which is often complicated by impetigo, should be treated. Oral penicillin should be given for 5 days if there is extensive impetigo. The more frequent use of antibiotics in developed countries has resulted in a fall in the number of children with acute glomerulonephritis (and acute rheumatic fever). However, this is not a reason to give antibiotics to every child with a few patches of impetigo that can be treated locally.
Septicaemia is an acute serious illness caused by bacterial infection of the blood. This is often a complication of local infection, such as pneumonia or pyelonephritis. Septicaemia may in turn result in the spread of infection to other sites, such as meningitis and osteitis.
Septicaemia may be caused by either Gram positive bacteria (such as Staphylococcus or Streptococcus) or Gram negative bacteria (such as E. coli or Klebsiella).
Children with septicaemia are seriously ill, often without an obvious site of infection.
Shock is the failure of normal peripheral circulation with a fall in blood pressure. The heart rate increases and urine output falls. The skin temperature may be low with shock and the hands and feet often feel cold. The oxygen saturation may also fall. Most importantly, the capillary filling time is prolonged to over 3 seconds.
This is estimated by compressing the skin for a few seconds over the hands, feet or chest, with your finger, to produce blanching (a pale area). When the pressure of the finger is removed, the time it takes for the pink colour to return is measured. This is called the capillary filling time. A normal capillary filling time is 3 seconds or less.
With finding a positive blood culture. Always take a blood culture before starting treatment.
The white cell count may be high at first and later fall. The platelet count may also fall and the blood clotting factors may be low.
A blood culture is needed to confirm the clinical diagnosis of septicaemia.
The fist choice of antibiotics is either:
The aim of treatment is to correct the blood pressure and improve the peripheral perfusion. A fast intravenous infusion must be started immediately with 20 ml/kg of normal saline or Ringer’s lactate. If the signs of shock are not corrected, repeat the bolus of intravenous fluid. This will usually correct the shock. Always give oxygen. Urgent transfer to hospital is needed. Start treating shock before moving the patient.
Shock must be treated before the patient is moved to hospital.
This is a serious illness caused by septicaemia due to Meningococcus (i.e. Neisseria meningitidis). Meningococcus is transmitted from person to person by droplet spread (coughing and sneezing). It often causes asymptomatic colonisation of the upper respiratory tract only. However, some people get a septicaemia, meningitis or both. Meningococcal infection is more common in overcrowded conditions where epidemics may occur.
The patient presents with the signs of septicaemia. However, a rash also develops. This starts as small red spots on the skin and conjunctivae which rapidly become purpuric (larger pink or purple spots). The spots do not blanch when pressed. The rash becomes very dark and may become necrotic (ulcerate). Gangrene of the skin may occur. Without early treatment the mortality is high. It is very important to look for a rash in all children who are thought to have septicaemia.
Always look carefully for a rash if a child has a diagnosis of possible septicaemia.
Many children with meningococcal septicaemia will also have meningococcal meningitis. Most will rapidly develop shock.
Similarly to other types of septicaemia. The choice of antibiotic is benzyl penicillin or ceftriaxone intravenously. Start antibiotics immediately as the clinical condition deteriorates rapidly without treatment.
Do not do a lumber puncture as this is very dangerous due to brain swelling and will not alter the choice of initial treatment. Treat shock and move the patient to hospital urgently.
Meningococcal infection is a notifiable disease in South Africa.
All those in contact with the patient, including the health staff, should take rifampicin 10 mg/kg twice a day for 2 days (5 mg/kg in infants less than 1 month) or ceftriaxone 125 mg intramuscularly once. This will treat and prevent colonisation of the upper respiratory tract. All contacts should be closely observed for signs of illness.
A short-lived vaccine against meningococcus can be used to help end epidemics. Overcrowding in schools, army camps and crèches should be avoided.
It is a serious infection of the meninges (the membranes covering the brain). Meningitis may be due to a viral or bacterial infection. Bacterial meningitis is usually far more dangerous. Causes of bacterial meningitis include both Gram positive and Gram negative bacteria. The most common causes are Pneumococcus (Streptococcus pneumoniae), Haemophilus (Haemophilus influenzae) and Meningococcus (Neisseria meningitidis).
Bacteria usually reach the meninges via the blood stream. Rarely, infection is by direct spread, e.g. from mastoiditis. Tuberculosis also causes bacterial meningitis. Fungal meningitis may be seen in children with AIDS.
The signs of meningitis and septicaemia are very similar. Both must be suspected in any child who is seriously ill or unconscious or who has a high fever without an obvious cause.
Headache, fever and vomiting suggest meningitis.
By obtaining a sample of cerebrospinal fluid (CSF) by lumbar puncture. CSF should be sent to the laboratory for chemistry, microscopic examination for cells and bacteria, and for culture. As many children with meningitis also have septicaemia, the bacterial cause can often also be identified on a blood culture.
No. Therefore, all cases of clinical meningitis must initially be managed as if they are bacterial meningitis until the cause of the meningitis is identified. However, children with viral meningitis are often not as severely ill as children with bacterial meningitis. Only the findings on the lumbar puncture enable one to tell whether the infection is viral or bacterial.
Children with viral meningitis usually improve rapidly after a lumbar puncture and have fewer complications. The management is supportive and antibiotics can be stopped once the results of the lumbar puncture exclude bacterial meningitis. Tuberculous meningitis also has a similar presentation and must be distinguished on lumbar puncture and other investigations.
It is not possible to distinguish between viral and bacterial meningitis on clinical examination alone.
The most important step is to start antibiotics as soon as possible. If a lumbar puncture cannot be done immediately, it is better to start antibiotics before transferring the child to hospital for investigation and further treatment. The sooner the treatment is started the better is the clinical outcome.
Antibiotics must be started as soon as possible if a clinical diagnosis of bacterial meningitis is made.
The introduction of immunisation against Haemophilus influenzae into the routine schedule at 6, 10 and 14 weeks after birth has prevented most cases of haemophilus meningitis. The promise of new vaccines against Pneumococcus and Meningococcus will hopefully also prevent these causes of meningitis.
All those in contact with a patient with meningococcal meningitis or septicaemia should be given rifampicin or ceftriaxone prophylaxis.
About 25% of children with bacterial meningitis will die and about 25% of the survivors will have permanent brain damage such as:
Pyelonephritis is a bacterial infection of the kidney and the most serious form of urinary tract infection. If not diagnosed and treated early, repeated attacks of pyelonephritis can lead to permanent kidney damage resulting in hypertension and renal failure.
E. coli (Escherichia coli) is usually the bacteria causing a urinary tract infection. Most commonly the infection is mild and only affects the bladder (cystitis). Less commonly, the infection spreads up the ureters to affect the kidney (pyelonephritis). Pyelonephritis may be secondary to a renal tract abnormality that causes an obstruction to the normal flow of urine. This increases the chance that infection will spread to one or both kidneys.
Often the symptoms are non-specific and, therefore, the diagnosis is frequently missed. Fever, dysuria (pain or discomfort when passing urine), frequency (passing frequent small amounts of urine) and abdominal or back pain are common presenting complaints. A high fever and vomiting suggests pyelonephritis rather than a mild form of urinary tract infection.
It is very important to get a clean specimen of urine. A midstream urine or clean catch sample (urine collected after the child has already started passing urine), a sample collected by passing a catheter into the bladder under aseptic methods or a suprapubic aspiration (best done with ultrasonography) are by far the best methods. Using a urine bag is very inaccurate and is should be avoided if possible.
Leukocytes, nitrites and protein, and sometimes blood, are typical findings when the urine is tested with a reagent strip. It is probably not a urinary tract infection if the reagent strip test on a sample of freshly passed urine is completely normal, i.e. negative for protein, nitrite, blood and leucocyte esterase.
Pus cells are usually present on a spun deposit of urine.
The only accurate way to confirm a urinary tract infection is a positive culture when the urine has been collected correctly. More than 100 000 bacteria/ml on a clean catch urine, more than 1 000 bacteria/ml on a catheter specimen or any bacteria on a suprapubic sample is abnormal.
It is very important to make an accurate diagnosis and not simply send a urine bag sample to the laboratory. A normal urine bag result will exclude a urinary tract infection but a positive result may simply be due to skin or stool contamination. A confirmed diagnosis is also important because it indicates that a series of management steps is required. Treating a presumed urinary tract infection without confirming the diagnosis is bad practice.
It is important to collect a clean specimen of urine to make an accurate diagnosis before starting treatment.
Diabetes is due to inadequate amounts of insulin being produced by the pancreas. As a result, the body cannot remove glucose from the blood leading to a very high blood glucose concentration. Diabetes, if not well controlled, may result in severe complications and even death. Therefore, it is important to diagnose diabetes as soon as possible.
The diagnosis of diabetes must be suspected if a very high blood glucose concentration is found, using reagent strips. All children with suspected diabetes must be referred urgently to hospital. An intravenous infusion with normal saline must be started before transferring a child with diabetic coma. Later the clinical diagnosis of diabetes must be confirmed with a glucose tolerance test. Children with diabetes usually need daily injections of insulin for life to control their diabetes.
Diabetes usually presents with tiredness, weight loss and polyuria.
Convulsions (fits) present with a sudden onset of abnormal movements and an altered level of consciousness due to abnormal brain activity. Convulsions have many different causes and may present in a wide variety of ways. Important causes are:
All children with convulsions must be urgently transferred to hospital for investigation, to establish the cause, and start correct management.
Before moving a child with convulsions, make sure the airway is open and give oxygen. Always measure the blood glucose concentration with a reagent strip and correct any hypoglycaemia. Cool the child if the temperature is very high.
Always look very carefully for the cause and treat this if possible. If a fit last longer than 5 minutes it can be usually be stopped with one of the following:
Any convulsion lasting longer than 5 minutes should be stopped.
These are generalised convulsions caused by a high temperature. Often there is an obvious cause of the fever, e.g. upper respiratory tract infection. The child is usually between 6 months and 5 years old and there may be a family history of febrile convulsions. Some children have febrile convulsions whenever they have a viral infection with a high fever. Usually the convulsion does not last longer than 15 minutes and there are no other abnormal neurological signs after the child recovers from the convulsion.
Management is to lower the fever and reassure the parents. Given paracetamol (Panado) when the child is ill to keep the temperature normal. Do not use aspirin. Children usually outgrow febrile convulsions. Oral anticonvulsants are usually not used to prevent febrile convulsions.
Children with epilepsy have repeated generalised convulsions. There is usually no obvious cause, and they are well between convulsions. The diagnosis is usually based on the history. Epilepsy often starts at puberty and can be controlled (prevented) with oral anticonvulsants. All children with epilepsy should be referred to a neurological clinic for assessment and initial management. Long-term management can be supervised from a primary care clinic.
Malignancies (‘cancers’) are not common in children. However, it is important to know the warning symptoms and signs of childhood malignancy as many childhood malignancies are curable if they are diagnosed and treated early.
Malignancy in children often has a good prognosis if diagnosed and treated early.
Children presenting with any of these warning (danger) symptoms or signs must be urgently referred for an expert opinion.
A 5-year-old child presents with a fever and a one-week history of pain and swelling of the knees and elbows. Over the past few days the pain has moved from joint to joint. On examination the child is unwell with arthritis of both knees. The heart rate is noted to be 110 beats per minute. A soft murmur is heard when her heart is examined. The heart appears enlarged on a chest X-ray. On questioning the mother says the child had a sore throat a few weeks back.
Acute rheumatic fever. The child has 2 major criteria (polyarthritis and carditis) and one minor criteria (fever). There is also a history of a sore throat.
A rash (erythema marginatum), subcutaneous nodules and chorea. Only 2 major criteria are needed to make the diagnosis of acute rheumatic fever.
A streptococcal infection.
A heart murmur, tachycardia and enlarged heart.
The child should be referred to hospital. With bed rest, antibiotics (oral amoxycillin for 10 days or a single dose of intramuscular benzathine penicillin) and aspirin the acute rheumatic fever usually recovers within 4 weeks. It is important to look for signs of heart failure.
It may result in chronic rheumatic heart disease with damaged heart valves. Rheumatic fever is the most common cause of acquired heart disease in poor, overcrowded communities.
With 4 weekly intramuscular injections of benzathine penicillin.
A 3-year-old child has had a swollen face and dark urine for the past 24 hours. There are numerous areas of impetigo on his legs. The mother says he is very short of breath when he lies down.
The dark urine is probably due to the presence of blood. Haematuria can be confirmed with reagent strips. His swollen face is due to fluid overload as a result of decreased urine production.
The streptococcal skin infection (impetigo). This is an unusual immune response to Streptococcus where antibodies damage the kidney.
By preventing or treating impetigo. Usually, local treatment is adequate. An oral antibiotic should be given with widespread impetigo.
Due to fluid overload. The most serious complications of acute glomerulonephritis are:
Reduced fluid intake, a low salt diet and furosemide. These children should be managed in hospital.
A severely ill child is brought to the clinic. He has a high temperature without an obvious cause. His heart rate is fast, blood pressure low and hands feel cold. The capillary filling time over the chest is 8 seconds. The nurse notices that he has a fine rash which reminds her of purpura. The child is fully conscious with no neck stiffness.
The child has the clinical signs of septicaemia.
The low blood pressure, fast pulse and cold hands, in spite of a fever, indicate that the child is shocked. This is often seen in patients with septicaemia.
It is abnormally long, as the pink colour should return to a blanched (pale compressed area) area of skin within 3 seconds. The long capillary filling time confirms that the child is shocked.
A fine pink or purpuric rash strongly suggests that the septicaemia is due to Meningococcus. This is an extremely serious condition.
By finding a positive blood culture.
There are no signs of meningitis. However, meningitis is very common with meningococcal septicaemia.
Take a blood culture and start a fast intravenous infusion with normal saline or Ringer’s lactate. Immediately start antibiotics. Benzyl penicillin or ampicillin plus gentamicin or amikacin would be the antibiotic combination of choice. Do not perform a lumbar puncture. The child should be moved to hospital as soon as possible.