Growth sequelae \200 \200 \200 Direct effects on epiphyseal plates. Growth hormone de \201 ciency from hypothalamic/pitui tary damage. Muscle damage and avascular necrosis of bone. CNS sequelae \200 \200 \200 Somnolence and tiredness. Hypothalamic and pituitary damage. Intellectual effects: memory. Radiation myelitis. Eyes: commonly reduced numeracy and short-term \200 cataracts, retinal damage. Other organ system sequelae Gonads: infertility/hypogonadism. \200\230Second \200\231 primary malignancies Risk of 4 \200\2236% of occurrence within rad iotherapy \201 eld. Common second malignancies include solid tumors occurring in the \201 eld of radiotherapy, as well as non-melanoma skin cancers. Epithelial tumors predomina te. Late effects of chemotherapy Sequelae depend on age at the time of exposure, drugs and dose s (see b p.678). Well recognized long-term toxicities include: \200 \200 \200 Cardiotoxicity following anthracyclines. Nephrotoxicity following platinum drugs and alkyla ting agents. Pulmonary \201 brosis following bleomycin. 18_McClure_18.indd 688 11/14/2012 3:51:04 PM PRINCIPLES OF FOLLOW-UP 689 \200 \200 Impaired fertility following alkylating agents. Ototoxicity following antibiotics. Second m alignancies related to chemotherapy include and myelodysplastic syndrome associated with to poisomerase II inhibitors and alkylating agents. s leukemia Fertility \200 This is affected by gonadotoxic chemotherapy and by radiotherapy \201 elds that impinge o n the gonads. The younger the patient when treated, the better the prognosis for future fer tility. More spermatic recovery is seen after chemotherapy than radiotherapy. Risk of gonad otrophin de \201 ciency greatest for radiotherapy directed towards suprasellar and nasopha ryngeal tumors, but fertility may be preserved with aid of pulsatile gonadotrophin-releasin g hormone (GnRH) therapy. Quality of survival It is understood that the long-term effects of treatment go beyond the purely physical consequences of treatment and this is an evolving area of clinical research . Cancer survivors (and their family members) are at increased risk of impaired psychosocia l wellbeing. Risk is not clearly as- sociated with a speci \201 c cancer type or treatment and is likely to be multi- factorial in origin. Survivors are also at increased risk for n eeding special education and, as they enter adulthood, unemployment or underemploy- ment. 18_McClure_18.indd 689 11/14/2012 3:51:05 PM CHAPTER 18 Oncology 690 Palliative care Around 30% of children with cancer will die, mostly from progressive di- se ase. Death from complications of treatment is more likely to be swift, with limited opportu nity for preparation. Palliative care is the active total care of patients whose disease is no longer curable. It needs to embrace physical, emotional, social, and spiritual needs of children and their fami- lies. Chemotherapy, radiotherapy, and surgery may still be used f or pallia- tion and control of symptoms. Breaking bad news It is extremely important to be honest with an open approach, avoiding fa lse hope. What to tell the child is always dif \201 cult; many families tend to be over-pr otective. This risks loss of their child \200\231s trust when the truth can no longer be hi dden. Organization of care There are few pediatricians specializing in palliative care: \200 Location: prefer a hospice and a minority the acute hospital ward. A multiprofessional appr oach is required and will vary according to needs and organization of local healthcare. The Association for Children with Life threatening or Terminal Conditions (ACT; www.act.org.uk ) has played a central role in the development of pediatric palliative care as a specialty in the UK. Bereavement support should be considered part of the role of the palliative care team and may be provided by various disciplines within the team, depending on local arrang ements. most children die at home, through family preference; some Symptom control Anticipated symptoms will depend on the diagnosis. Symptom control measures may be pharmacological or non-pharmacological. Aim to cor- rect the underlying cause, e.g. constipation, infection. Good communica- tion and consideration of psychosocial and spirit ual factors will contribute to good control. Pain \200 Oral route is effective for most, until the terminal phase, when SC infusion, often in comb ination with anti-emetics, sedatives, and anticonvulsants may be preferred. The transdermal route is used for some agents. Different agents suit different types of pain, e.g. in \202 ammatory and neuropathic pain, muscle spasm, and raised ICP. Combining different agent s is more effective than escalating dose of one. 18_McClure_18.indd 690 11/14/2012 3:51:05 PM PALLIATIVE CARE 691 World Health Organization (WHO) three step analgesic ladder (see b pp.890, 1018). \200 \200 \200 Step 1: Step 2: Step 3: +/ \200\223 adjuvants. non-opioid +/ \200\223 adjuvants (e.g. paracetamol, NSAID); weak opioid (e.g. codeine) + no n-opioid +/ \200\223 adjuvants; strong opioid (e.g. morphine, fentanyl) + non-opioid Adjuvants are additional drugs used in pain management. They include: \200 analgesics that relieve pain in speci \201 c circumstances, such as gabapentin for neuropa thic pain, anti-spasmodics (hyoscine, glycopyrronium), muscle relaxants (diazepam), cortico steroids, bisphosphonates; drugs to control adverse analgesic effects, e.g. laxatives, anti emetics. Other symptoms \200 Nausea , vomiting: domperidone, cyclizine (particularly for raised intracranial pressure), methotrimeprazine, haloperidol, ondansetron, metaclopramide. Convulsions, cerebral irritati on: Spinal cord compression: bowel management. Terminal restlessness: Dyspnoea opioids, ben zodiazepines, oxygen, steroids. Excess secretions: hyoscine, glycopyrronium. diazepam, meth otrimeprazine, amitriptyline. Anxiety, depression: anticipate by prescribing laxatives when starting opioids; Constipation: select least constipating opioids (e.g. fentanyl); may nee d high enemas. Bowel obstruction: antispasmodics, stool softeners, rectal preparations to r educe impaction, octreotide to reduce secretions and vomiting. Sweating, from advanced dise ase fever or drugs: cimetidine, NSAIDs. Pruritus: cimetidine if due to disease, antihistami ne if opiate induced (anemia, hemorrhage, bruising): transfuse (blood Hematological +/ \200 \223 platelets) only for symptomatic improvement and for quality of life; topical tranexami c acid or adrenaline for troublesome mucosal bleeding. \200 diazepam, midazolam. dexamethasone, radiotherapy, bladder and \200 midazolam. : non-pharmacological measures (position, play therapy, fan), \200 \200 \200 \200 18_McClure_18.indd 691 11/14/2012 3:51:05 PM This page intentionally left blank 693 Chapter 19 Infectious diseases Introduction 694 The child with fever 696 Fever: examination and assessment 698 Fever: mana gement (green features) 700 Fever: management (red or amber features) 701 Prolonged fever o f unknown cause 702 Common infections characterized by rash 704 Exanthem 1: measles 706 Exa nthem 2: group A streptococcus 707 Exanthem 3: rubella 708 Exanthem 4: enteroviruses 708 Ex anthem 5: parvovirus 709 Exanthem 6: human herpes virus 6 709 Rash: chickenpox and zoster 7 10 Rash: infectious mononucleosis 711 Lyme disease 712 Mumps 713 Bacteraemia and shock 714 Kawasaki disease 716 Skin and soft tissues 718 Meningitis 720 Mycobacteria 722 Tropical inf ections 723 Immunode \201 ciency disorders 724 Human immunode \201 ciency virus 726 Immun izations 728 19_McClure_19.indd 693 11/14/2012 3:51:52 PM CHAPTER 19 Infectious diseases 694 Introduction Infection and infectious disease form a large part of clinical practice in pae - diatrics and child health. The following list shows the core areas that one should be fam iliar with. \200 The child with fever ( \200 Common infections characterized by rash ( \200 Bacteraemia and shock: (b p.70), and b p.714. Mycobacterial infections: b p.722. Sys temic infections: glomerulonephritis (b pp.374 \200\223375), and b p.707. Skin and soft tis sues: Nervous system infection ( Upper and lower respiratory tract infections: for the comm on cold, pharyngitis, bronchitis, bronchiolitis, pertussis, pneumonia, pleural effusion, an d empyema (b pp.282 \200\223293). Cardiovascular system: and myocarditis (b pp.242 \200\223 248). GI system: (b pp.338 \200\223342, 723). GU system: Musculoskeletal: arthritis (b pp.7 38 \200\223741). The eye see also b Chapter 6 for infections in the fetus and Special hosts : newborn (b pp.180 \200\223183); b Chapter 18 for infections in children with malignancy a nd transplantation (b pp.682 \200\223683); and b pp.724 \200\223727. Immunizations Tropical diseases b pp.696 \200\223702). b p.704). see also b Chapter 5 for sepsis and shock see also b Chapter 9 for TB (b p.294), and see also b Chapter 11 for post-streptococcal \200 \200 see b pp. 718, 826 \200\223828. b p.720). see also b Chapter 9 see also b Chapters 8 and 5 for endocarditis see also b Chapter 10 for gastroenteritis and viral hepatitis \200 see also b Chapter 11 for UTI (b p.356). see b Chapter 20 for osteomyelitis and infective \200 (b pp.146, 914 \200\223915). \200 (b p.728). (b pp.723, 1026). 19_McClure_19.indd 694 11/14/2012 3:51:52 PM INTRODUCTION 695 19_McClure_19.indd 695 11/14/2012 3:51:52 PM CHAPTER 19 Infectious diseases 696 The child with fever In children aged 4wks to 5yrs body temperature should be measured usin g any one of: \200 \200 \200 Fever in babies (cid:1)6mths is rare. Fever >=38.5 C re quires further investigation. Electronic thermometer in the axilla. Chemical dot thermometer in the axilla. Infrared tymp anic thermometer. Differential diagnosis The majority of children with fever have a self-limiting viral infec tion that resolves without any problem. However, in the very young it is particular- ly imp ortant to consider the possibility of an underlying serious infection. When there is no app arent cause of infection, the differential diagnosis of fever includes the following. \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 b p.714). Bacteraemia (see Respiratory tract infection (see Meningitis and encephalitis (see b p.356) . UTI (see b pp.704 \200\223710). Viral infection (see b p.740). Osteomyelitis (see Bacteri al gastroenteritis (see b p.242). Endocarditis (see Rheumatic fever (see b p.723). Malaria (see Tuberculosis (see Post-vaccination fever. b pp.282 \200\223293). b pp.78 \200\22379, 720). b pp.302, 339). b p.244). b pp.294, 722). Box 19.1 highlights the signs and symptoms of disease that requires spe- ci \201 c medical treatment (see also b pp.698 \200\223702). 19_McClure_19.indd 696 11/14/2012 3:51:52 PM THE CHILD WITH FEVER 697 Box 19.1 Features of illness needing speci \201 c treatment Sepsis including meningococcal sepsis (b p.714) Non-blanching rash (purpuric or petechial l esions is suggestive of menin- gococcal sepsis) increased HR, respiration rate (RR) for age and capillary re \201 ll time (cid:2)2s, Meningitis including meningococcal meningitis (b pp.714, 720) \200 purpuric or petechial lesions is suggestive of Non-blanching rash: meningococcal disease Neck stiffness may not be present in very young B ulging fontanelle may or may not be present Depressed level of consciousness is a worrying sign Seizures \200 \200 \200 Herpes simplex encephalitis (b p.79) \200 \200 \200 Pneumonia (b p.290) \200 \200 \200 \200 Urinary tract infection (b p.356) \200 Focal neurology may or may not be present Focal or generalized seizures Depressed level of consciousness Tachypnoea, nasal \202 aring, and chest recession Chest crackles on auscultation Pulse ox imeter oxygen desaturation May be silent and only detected on CXR Vomiting, poor feeding, with or without abdominal pain or tenderness Lethargy or irritabili ty Urinary frequency or dysuria Haematuria \200 \200 Septic arthritis or osteomyelitis (b pp.738 \200\223741) \200 \200 Kawasa ki disease (b p.716) Fever lasting longer than 5 days and at least 4 of the following: \200 \200 Swelling of limb of joint Not using an extremity, non-weight bearing Bilateral conjunctival injection Change in upper respiratory tract mucous membranes with in jected pharynx, dry cracked lips, or strawberry tongue Change in peripheries with oedema, e rythema, or desquamation Polymorphous rash Cervical lymphadenopathy \200 \200 19_McClure_19.indd 697 11/14/2012 3:51:52 PM CHAPTER 19 Infectious diseases 698 Fever: examination and assessment When assessing a child with a fever a thorough history an d examination are required. In the UK the National Institute for Health and Clinical Excell ence (NICE) has provided a clinical guideline on \200\230Feverish illness in children \200 \231 (see M www.nice.org.uk/CG047 for updates). The following sec- tion is adapted from thi s guideline. The key priorities are: \200 History: a fever in their child. Check for ill contacts, immunization history. Measurements : rate, and capillary re \201 ll time are measured as this will determine the order of you r priorities (see b Chapter 4, b p.36). Signs and symptoms: symptoms and signs indicating s erious illness. consider very seriously parent \200\231s concerns and perception of make sure that temperature, heart rate, respiratory assess the child for the presence or absence of Boxes 19.2 \200\22319.4 summarize the NICE guidelines on features of an illness that are at low-risk of indicating serious illness (green), to intermediate- risk (amber), to high-ris k (red). Box 19.2 Features ( \200\230green \200\231) indicating low risk of serious illness \200 \200 Color: Activity: \200 \200 \200 \200 Breathing: Hydration: Other: \200 \200 normal color of skin, lips, and tongue responds normally is content and smiles stays awake or awakens quickly if roused strong nor mal cry \200 \200 normal normal generally normal no fever at time of examination 19_McClure_19.indd 698 11/14/2012 3:51:52 PM FEVER: EXAMINATION AND ASSESSMENT 699 Box 19.3 Features ( \200\230amber \200\231) indicating intermediate risk of serious illness \200 \200 Color: Activity: \200 \200 Breathing: \200 \200 pallor reported by parent or carer not responding normally and decreased activity prolonged stimulation required to awaken chi ld nasal \202 aring tachypnoea (>50breaths/min in 6 \200\22312-mth-olds; >40breaths/min in > 1yr-old) desaturation in air ( chest crackles \211 95% in air) \200 Hydration: \200 \200 \200 \200 Other: \200 \200 \200 \200 dry mucous membranes poor feeding reduced urine output capillary re \201 ll time >3s (cid:2)5 days fever swelling of limb or joint non-weight bearing or not using an extremity a new lump >2c m Box 19.4 Features ( \200\230red \200\231) indicating high risk of serious illness \200 \200 Color: Activity: \200 \200 Breathing: Hydration: Other: \200 \200 \200 \200 \200 \200 pale, mottled, ashen, or blue unresponsive, appears ill, and barely rousable weak high-pitched or continuous cry \200 \200 grunting, severe distress reduced skin turgor non-blanching rash fever at time of examination bulging fontanelle neck stiffness seizures or focal neurology bile-stained vomiting 19_McClure_19.indd 699 11/14/2012 3:51:52 PM CHAPTER 19 Infectious diseases 700 Fever: management (green features) Children with solely green features do not need to be ad mitted to hospital. However, other criteria for admission may include additional factors: \200 \200 \200 \200 social and family circumstances; parental anxiety, instinct, or concerns; child \200\231s c ontact with serious illness; child \200\231s recent travel abroad to tropical or subtropica l areas, or travel to any high-risk areas of endemic infectious disease. If a child is discharged home, then the parents should be given clear instructions about wh at to look for and when to call for medical help (Box 19.5). Box 19.5 Advice to parents of a child with fever managed at home Urgent problems Check on your child, even during the night: \200 Offer your child regular drinks: if breastfeeding, continue with breast feeds. Seek medical advice if child stops drinking Look for signs of dehydration, e.g. dry mouth, no tears, su nken fontanelle. Seek medical advice if present Look for a non-blanching rash. Use a glass tumbler and press it \201 rmly against any rash \200\224if the spots can be seen through the glass and they do not fade, this is a non-blanching rash. Seek immediate medical advice if present Do If your child has a convulsion \200 not sponge your child with water seek medical advice Other advice \200 Keep your child off school or nursery. This is necessary whilst there is fever; notify them If the fever is present for >5 days If you are not happy with your child \200\231s health, or if you have concerns, or if your child gets worse seek medical advice \200 seek medical advice 19_McClure_19.indd 700 11/14/2012 3:51:52 PM FEVER: MANAGEMENT (RED OR AMBER FEATURES) 701 Fever: management (red or amber features) Children with red/amber features need admission. Those with red fea- tures have life-threatening illness and need urgent treatment. \200 In hypoxic children or those in shock, follow the emergency care outlined in b Chapter 5 (b pp.54, 56, 90). If there is no apparent source of infection, despite fever, then the inves tigations should include the following: culture, FBC, CRP, electrolytes; \200 \200 test for UTI; \200 Blood \200\224 Urine \200\224 lumbar puncture \200\224 there are no contraindications (see b p.720); consider if high white blood cell count. CXR \200\224 consider if the clinical assessment dictates and Antibiotics Immediate treatment Maximum dose third-generation cephalosporins (cefotaxime or ceftriax- o ne) should be given to children with fever and: \200 \200 signs of shock or coma signs of meningococcal disease Consider giving high dose IV aciclovir if suspect herpes simplex encepha- litis or dissemin ated neonatal disease. Consider giving IV corticosteroid if con \201 rmed bacterial meningitis (but not in infants younger than 3mths Treatment for suspected bacterial infection Give third-generation cephalosporin if any of t he following are sus- pected \200 \200 \200 \200 \200 Neisseria meningitidis Streptococcus pneumoniae Escherichia coli Staphylococcus aureus Haem ophilus in \202 uenzae type b Special cases Consider choice of antibiotics or route of administration carefully in the fo llowing instances: \200 Child <3mths: \200 Child with decreased level of consciousness: \200 Signi \201 cant rates of antibiotic resistance: add antibiotic against listeria (e.g. ampicillin) give parenteral antibiotics. follow local guidelines Antipyretics Fever should be treated if the child is unwell with it: \200 \200 \200 Do not use tepid sponging. Do not over- or underdress the child. Only use paracetamol or ib uprofen if the child is distressed with fever. 19_McClure_19.indd 701 11/14/2012 3:51:53 PM