Welcome back class!
Last week we reviewed the more common viral infections that infiltrate our homes and annihilate our plans for days to weeks at a time. As I mentioned, viral infections do NOT require antibiotics; however, there are many bacterial infections that do.
It can be difficult to detect which illnesses are caused by viruses and which are caused by bacteria, even for physicians. But by taking a history, asking the right questions, examining the child and ordering certain tests, we can usually crack the case. It is important to identify whether a virus or bacteria is causing the illness because the treatments differ. If you or your child are diagnosed with a bacterial infection, antibiotics will likely be prescribed. Some doctors use the “watch-and-wait” approach – you may be given an antibiotic but may be asked to hold off on starting the medicine. If you start getting better on your own, then you won’t start the medicine. If you start getting worse, that may be a sign that you do indeed need the antibiotics.
Sometimes, a viral illness will weaken the immune system, allowing bacteria to overgrow and cause a secondary infection. Typically, bacterial infections are more severe and fevers persist over several days instead of improving gradually.
Usually bacterial illnesses come from a focal source such as ears, chest or urine, as opposed to some viral illnesses, which have vague, generalized symptoms such as fever, fatigue and achiness.
Bacteria are usually spread via close contact, aerosolized particles such as sneezing or coughing. As such, handwashing is the best way to prevent spreading them, along with covering your cough or sneeze in your elbow. Sneezing into your hands doesn’t make much sense since you’ll then go and use the phone or the computer, or your kids will then go play with blocks or video games. Commonly shared items can harbor pathogens which can then go on to infect others. The incubation period is the time it takes from when the infection is contracted to the time you start experiencing symptoms. This can sometimes be up to two weeks long.
Here are the key characteristics of the more common childhood bacterial infections, as well as how to prevent them and how we treat them.
Otitis media – Literally translates to “inflamed or infected middle ear.” Tugging at the ear is the classic sign of an infected child. Fever, irritability, loss of appetite, temporary loss of hearing can accompany the ear pain. Usually the illness begins with an upper respiratory virus which can inflame the membranes of the upper airway and Eustachian tubes and weaken the body’s defenses against bacterial pathogens. Fluid can accumulate in the middle ear and is responsible for increased pressure on the eardrum, which usually causes the pain. An ear exam is usually the only test necessary for a doc to diagnose OM.
Treatment typically includes antibiotics and medicines to reduce fever and pain. Decongestants and antihistamines have NOT been found to reduce symptoms or the duration of illness. In addition, they can have serious side effects in young children. If you remember nothing else from this article, please do NOT give young children aspirin or products that contain aspirin. There is a risk of Reye’s syndrome (http://www.reyessyndrome.org/what.html), which can be fatal. This link shows you which prescription and over-the-counter medications contain aspirin (http://www.reyessyndrome.org/aspirinlists.html).
Occasionally, anatomical variations can make a child more susceptible to ear infections. Children’s ear canals are horizontal – as we age and our skulls change shape, our ear canals begin to slant downward, allowing easier drainage. For this reason, children with recurrent infections may be referred to an ENT specialist for T-tubes or tympanostomy tubes. These plastic tubes are inserted through the eardrum to create an outlet for drainage of fluid and prevention of recurrent infection.
Strep throat – Although there are many viruses and bacteria that cause sore throats, Group A Streptococcus is the most common in children. GAS seems to occur most often in the peak of winter. Symptoms include fever, sore throat/difficulty swallowing, swollen glands, possibly white patches in the throat, inflamed uvula and red sores or spots in the mouth. Usually a cough and runny nose are NOT associated with strep throat.
In addition to the history and physical exam, your doc will usually take a culture of the throat using a long Q-tip. Most can run a rapid strep test in the office to identify strep right away. The culture will also be sent out to a lab to identify which antibiotics are the most effective for your child’s strain of bacteria. Again, treatment usually includes antibiotics, hydration and medications to alleviate symptoms. Children with any kind of sore throat should be monitored for dehydration due to pain or inability to swallow. Signs of dehydration include dry lips and tongue and lack of urinary output.
Pneumonia – Any illness that causes difficulty breathing can be very frightening. And there are MANY causes of difficulty breathing, including non-bacterial infections such as croup and bronchiolitis which are caused by viruses. Asthma, bronchitis and allergies can also cause symptoms similar to those of bacterial pneumonia. Cough, congestion, vomiting, fast or noisy breathing, decreased appetite and even chest pain can be present in cases of pneumonia. Again, physicians ask a lot of questions for a reason – the answers give us clues to figuring out what type of illness is causing your child’s symptoms. The doctor will examine the entire respiratory tract including mouth, ears, nose and chest to put the pieces of the puzzle together.
An x-ray may be warranted along with cultures of any sputum the child can bring up. If the child is toxic appearing, the physician may refer a child with pneumonia to the hospital for urgent treatment with antibiotics and medications that will help decongest and open the airways.
Urinary Tract Infection – If the child has a fever but does not have an obvious source of infection, we will usually check a urine sample. Untreated, UTIs can cause damage to the kidneys, so it is important to identify and treat them early. As its name suggests, a UTI can occur anywhere in the urinary system – kidneys, ureters, bladder or urethra.
UTIs are more common in young girls because of key anatomical differences in their urinary tracts – girls have shorter urethras than boys. Girls also tend to wipe from back to front, which can bring bacteria from the lower GI tract up towards the ordinarily – sterile urinary tract. It is important to instruct girls to wipe from front to back to avoid complicated infections of the urinary tract. Because of their superior plumbing, boys don’t usually get UTIs. Their long urethras allow better elimination of bacteria that may line the urinary tract. Any young boy with a UTI should be evaluated by a physician as there may be other abnormalities of the urinary tract that is predisposing him to infection.
UTIs can be largely asymptomatic except for fevers in young children. Older kids will complain of pain with urination, foul-smelling or dark urine or even possibly flank or lower abdominal pain. Again, a physical exam will be done in conjunction with urine testing (usually done right in the office). Treatment includes antibiotics, aggressive hydration to flush the system, pain and fever reducers. Preventive measures include proper hygiene and hand-washing.
Meningitis – For me, one of the scariest things in medicine is a child with a stiff neck and fever. Again, meningitis – inflammation of the brain and spinal cord covering – can be caused by viruses or bacteria. But bacterial meningitis can be rapidly fatal and even those who do survive often will suffer long-term complications. Infants will present with vague symptoms such as poor feeding, irritability, vomiting, and possibly bulging soft spots. Older children may complain of headache, stiff neck, vomiting, confusion, or sensitivity to light. Seizures and personality changes are possible, as is a purplish, spotted rash.
Emergent medical evaluation is warranted for any child with such symptoms. Along with a physical exam, blood cultures and lumbar puncture are likely to be performed. An LP will take fluid from the spinal canal and test it for bacteria, protein, sugar and other cellular components that can help differentiate viral from bacterial meningitis. A CT scan of the brain may be done prior to the LP to help determine if it’s safe to do a lumbar puncture. As always, there may be other conditions causing the child’s symptoms, so a CT will help determine which tests are safest and most likely to provide answers.
Even if the physician is not sure whether the meningitis is caused by virus or bacteria (and may not know for 24-48 hours), she will almost always start the child on IV antibiotics and observe the child in the hospital where quick treatment can be delivered. Waiting is usually not an option, because if the tests confirm bacterial meningitis, it may be too late to cure.
Of note, bacterial meningitis is a potentially fatal illness that is easily spread in military bases, boarding schools and college dorms due to living in close proximity. Therefore the meningitis vaccine is highly recommended for any student who will be living in one of these settings.
Remember that the classic presentations I describe here might not apply to infants under one year of age. If there are any signs of illness in young infants, seek medical attention quickly.
Sometimes subtle symptoms such as fever can be the only sign of a developing infection such as pneumonia or UTI.
One final note – believe it or not, childhood vaccines for pneumonia and influenza do not only protect against pneumonia and influenza. If your child is less likely to have one of those infections, they are also less likely to develop some of these secondary infections.
Now, we’ll be having a pop quiz…
Which medication should you never give to young children?
Alexis Hugelmeyer, D.O. is the wife of Michael, mother of Isabella, 5, and Lance, 2, and a family physician whose passion is hands-on manipulation for treatment and healing of any and every type of medical problem. She is administrative director of medical education and internship director at Peconic Bay Medical Center and also a private practitioner in Riverhead. A graduate of Villanova University and New York College of Osteopathic Medicine, she lives in Baiting Hollow.
Look for Dr. Mom every Saturday on Riverheadlocal.com
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