Ear Infection in Children

Ear infections are one of the most common disease processes seen by pediatricians. It is estimated that up to 85% of children suffer from at least one episode of ear infection before the age of 3.

The typical age range during which ear infections are seen is from 6 to 15 months old. Symptoms range from mild pain to hearing loss and brain abscess. There are three areas that become infected in the ear, and to understand this requires some knowledge of the anatomy:

The external or outer ear is where otitis externa (OE), also known as swimmer's ear, occurs. This is  is the only infection that causes pain with manipulation of the ear. The outer ear will usually be red and tender the the touch. The most common cause of this is a bacteria called pseudomonas, which thrives in wet conditions. The treatement for this, therefore, is over the counter ear drops that dry out the ear canal and make the area uninhabitable for the bacteria.

The middle ear is behind the eardrum or tympanic membrane. It is the space that houses the ear ossicles, the bones which transmit sound from the eardrum to the cochlea of the inner ear. This area is connected to the back of the nose (pharynx) via a hollow tube known as the eustachian tube.  An infection of this space is known as otitis media (OM). There are different types of OM, depending on the length of time it has persisted and whether or not fluid (effusion) is present.

Acute otitis media (AOM) typically occurs in <2 years old, usually caused by viruses such as RSV, cytomegalovirus (CMV) and Haemophilus influenzae (Hflu) but can also be due to bacteria. Mucosal congestion caused by the upper respiratory infection (URI) is aspirated up into the middle ear where inflammation occurs.
Treatment: If younger than 2 years old, an antibiotic such as amoxicillin will be prescribed. If older than 2 years old, doctors may choose to wait 48 hours to see if symptoms improve on their own before deciding to add an antibiotic. This is because studies have shown spontaneous resolution (without treatment) in up to 80% of this age group in 2-14 days.

Otitis media with effusion (OME) occurs when bacteria gets into the middle ear and fills it with pus. In growing children less than 7, the eustachian tube is often short and less vertical, so pus cannot drain properly and begins to back up. This growing pocket of fluid causes a large amount of pressure and pain to the child. The doctor will use a pneumatic otoscope to blow a burst of air at this ear drum. Normally the ear drum will move but in the case of OME, no movement occurs. Tympanometry may also be used to determine this. Long term OME (>3 episodes in 6 months or >4 episdoes in 12 months) may lead to hearing and language problems, so treatment is often indicated.
Treatment: myringotomy (hole is cut into the ear drum) with tympanostomy tube insertion is surgically performed. This allows fluid to freely drain out of the ear instead of backing up. It also alows antibiotic drops to be placed in the ear, which move through the tube and into the middle ear space to treat bacterial infections. Parents are instructed to apply the drops for 10 days whenever they see pus draining from the ears, which allows them to treat infections at home.

Reference

American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics Subcommittee on Otitis Media with Effusion. Otitis media with effusion. Pediatrics 2004; 113(5): 1412-29.

What is Hirschsprung Disease?

Hirschsprung disease, also known as toxic megacolon, is a life threatening intestinal obstruction seen in children.

When a fetus is developing in the womb, each type of cell must successfully migrate to where it belongs and, once there, perform their assigned duties. In this case, the cells, neuroblasts, do not make it to their destination in the distal intestine or they arrive but forget to do their job.

The condition is relatively rare, only occurring in 1 in every 5,000 live births. It is four times more common in males, and the risk is increased in Down syndrome or if a family history is present.

One of the most telltale signs that an infant is suffering from Hirschsprung Disease is the failure of an infant to pass his or her first bowel movement, known as meconeum, within the first 24 hours of life. Other signs include abdominal distention, bilious (yellow bile) vomiting, jaundice and feeding intolerance.

Over 80% of cases occur in infants, but occasionally the condition is seen in older children. In these cases, the child may show signs of chronic constipation, abdominal distention, failure to thrive, fever, diarrhea, vomiting, explosive stools and/or overflow incontinence. These children typically have intermittent problems with having a proper bowel movement, often on laxatives to ease their pain.

The pediatrician will do a physical examination when he or she suspects intestinal obstruction, looking for abdominal distention and a tight anal sphincter. An abdominal x-ray will typically show a dilated section of bowel preceding the area of obstruction. If enterocolitis is ruled out, a contrast enema will be performed, though this test is only 70% sensitive (83% specific). The disease is confirmed by a pathologist following a suction rectal biopsy performed by a surgeon.

If the child is over 12 months old, this condition is very unlikely. Other conditions that may mimic this condition include functional constipation, medication side effects, lead poisoning, sepsis, intussusception, meconeum ileus, meckel diverticulum, hypothyroidism and intestinal malrotation, atresia or stenosis.

Studies have shown that these infants, especially if preterm, also have an increased risk for other congenital abnormalities, such as heart problems, so a doctor may decide to do a thorough workup.

The immediate treatment for Hirschsprung Disease is to “decompress” the bowel obstruction using a nasogastric tube, antibiotics and IV fluids. Once the child is stable, a surgeon will fix the abnormality by removing the affected area of bowel (Pull-through procedure). If the surgery is successful and infection (enterocolitis) is avoided, the prognosis is excellent (<1% mortality) and the child will live a normal life.

Reference

Hirschsprung Disease. DynaMed Database Accessed May 23, 2014, Updated January 24, 2013.

An Update on Cat Scratch Fever

Cat Scratch Disease, also known as Cat Scratch Fever, is found in more locations than just a Ted Nugent album. This disease, first isolated in 1992, is caused by a bacteria called Bartonella henselae and affects roughly 6.6 in every 100,000 children in the United States. It's mostly benign (harmless), and in some cases goes unnoticed. Every now and then, though, a mother may see this in her child and become concerned:

The bacteria is transmitted to cats, typically kittens, by fleas. When a child is scratched by the cat, or in some cases pets the cat and then rubs his or her eye, the bacteria enters their bloodstream.

In 2-3 weeks, the child will develop lymphadenopathy, or the enlargement of the lymph nodes. The most common location of the lymphadenopathy is in the neck (33% of cases), followed by the axilla (underarm, 27%) and inguinal (groin, 18%). The child will also develop the characteristic fever and may complain of a sore throat.

In children with weak immune systems (immunocompromised), the disease may become disseminated (spread throughout the body) and cause infection of the bone (osteomyelitis), brain (encephalitis, resulting in seizures) and eye (oculoglandular conjunctivitis). In children with heart valve problems, this disease may cause endocarditis (infection of heart valve). For this reason, the CDC recommends that these children and adults avoid playing with cats or kittens, especially those with fleas.

Since the disease goes away on its own, a doctor will only need to prescribe pain medication for the painful lymph nodes. There is limited evidence that antibiotics are helpful in treating Cat Scratch Fever, so put on an old record and let Ted do all of the work.

• Cases in adults are not uncommon. 80% of patients with cat-scratch disease are < 21 years old

• Cases of dogs, monkeys, porcupine quills and thorns have been reported

• The disease is not contagious. There are no reports of person-to-person transmission

• Laboratory diagnosis is difficult, since the organism can be difficult to see. Currently, polymerase chain reaction (PCR) or Warthin-Starry Stain is used

• Differential diagnosis of chronic lymphadenopathy includes L. venereum, mycobacteria, tularemia, brucellosis. mononucleosis, syphilis, toxoplasmosis, systemic fungal infections, sarcoidosis, lymphoma, connective tissue disease and kawasaki disease

Reference

Cat Scratch Disease. In DynaMed [database online]. EBSCO Information Services. 

Updated 2012 Oct 25. Accessed May 10, 2014.

SIRS: The End of a Deadly Disease Spectrum

When an infant or child falls very ill, one of the most feared complications is systemic inflammatory response syndrome (SIRS). 

SIRS is a deadly ending to a spectrum of bloodstream infection which begins when a bacteria or virus enters the bloodstream (bacteremia). In most cases, young bodies can successfully fight off the organism before it causes any serious problems. Unfortunately, this is not always the case. Sometimes, the immune system goes a bit too far and decides to put all of its cards on the table. It releases everything it has, including white blood cells, pro-inflammatory molecules and blood-clotting proteins. This most often leads to the loss of fluids in our blood vessels and the collapse of our circulatory system. Inside the body, the organs (heart, lungs, kidneys, brain) lose vital oxygen and nutrients and begin to shut down. Outside the body, doctors notice signs of shock, which include fever and changes in breathing, heart rate, mental status, blood pressure and temperature regulation. If caught very early, doctors can typically keep the patient alive. In many cases, however, nothing the physician does will save the patient from the downward spiral.

The inci­dence of SIRS is highest in infants (5.16 per 1000), occurring in 20% of low birthweight neonates and resulting in death in over 10% of cases. Studies show that 37% of infections leading to SIRS arise from the respiratory tract, while 25% are primary bloodstream infections (BSIs). 

The management of SIRS is performed in a neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU). Doctors will culture the blood and monitor vital organs while ensuring the body is receiving adequate oxygen. A broad spectrum antibiotic (fights many different infections) is started until a culture comes back from the lab showing what specific organism is causing all the trouble. The antibiotic is then switched to one specifically formulated to kill that bug. One of the most frightening scenarios for a physician is when the culture comes back showing a bacteria that is resistant to all the drugs we have available. This is becoming the case with some gram negative bacteria (Klebsiella and E. coli) that release something called endotoxin and are resistant to our last line of antibiotic defense against them, carbapenems.

Scientists and physicians continue to conduct studies in order to discover ways to prevent SIRS from occurring. Though many different types of treatments have been attempted, the most effective of them continues to be early detection with  prompt antibiotic administration and fluid resuscitation.

• Occasionally, other conditions can trigger SIRS (trauma, ARDS, neoplasm, burn injury, pancreatitis)
• In order to reduce your child's risk, always ensure they are up to date on their vaccinations and be sure to keep them away from undercooked meat, especially beef and chicken.

References

Principles and Practice of Pediatric Infectious Diseases. Judith A. Guzman-Cottrill, Beth Cheesebrough, Simon Nadel, and Brahm Goldstein. Part II, Section A, 11: The Systemic Inflammatory Response Syndrome (SIRS), Sepsis, and Septic Shock. Pg 97-104.