How to Recognize Croup in Your Child

Pay close attention to your child’s next cough- it may suggest a common but serious childhood condition known as croup. Experienced pediatricians can recognize this particular cough in a crowded room; a sound often described as a “seals bark” that carries a potentially deadly omen. The medical term for this condition is laryngotracheobronchitis- a complicated word for inflammation of the upper respiratory tract, specifically the trachea and larynx.

Croup is most commonly caused by any one of several viral infections, including parainfluenza, influenza (flu), rhinovirus (common cold), adenovirus, respiratory syncitial virus (RSV), enterovirus and echovirus. In about 20% of cases, bacterial infections such as Mycoplasma pneumoniae, Corynebacterium diptheriae or staph or strep species are to blame.

The typical case of croup begins in a child under 6 years old between the fall and early winter months: The child has a history of an upper respiratory infection with fever and a cough that worsens at night.  The child's breathing becomes increasingly more labored, and a high pitched sound on inspiration known as stridor develops. This characteristic barking cough may follow:

How does this happen? When the upper airways become inflamed by an infection, swelling begins to narrow the passageway below the glottis through which air travels. As the airway narrows, our bodies attempt to compensate for poor airflow by increasing the respiratory rate (breaths per minute). The result is rapid air exchange through a narrowed airway (stridor), poor ventilation/oxygenation and respiratory distress.

It’s important that a pediatrician evaluates any child with stridor. Though many cases are self limiting and resolve in less than 48 hours, the doctor will rule out more serious conditions that present in a similar fashion, particularly epiglottitis, bacterial tracheitis and aspiration of a foreign budy. A simple oral dose of steroids (dexamethasone 0.15-0.60 mg/kg) will rectify the child’s breathing difficulties, though moderate to severe cases require inhaled (nebulized) racemic epinephrine.

• A diagnosis of epiglottitis is more likely when the child is experiencing excessive drooling and leaning over in a “sniffing position”.

• If the child is not treated, croup may lead to severe respiratory distress or become complicated with a pneumonia (known as laryngotracheobronciopneumonia)

• There are reports of repeated cases of croup, known as  spasmodic croup, that may be caused by gastroesophageal reflux disease (GERD) or extreme sensitivity to the parainfluenza virus.

• Any time your child is suffering from an upper respiratory infection, he or she is at an increased risk for developing croup

References

Croup. Dynamed Database. Updated December 27, 2013. Accessed June 2, 2014.

Petrocheilou A, Tanou K, Kalampouka E, Malakasioti G, Giannios C, Kaditis AG. Viral croup: diagnosis and treatment algorithm. Pediatr pulmonol. 2014; 49(5): 421-9.

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS)

Does a simple sore throat lead to psychological symptoms such as obsessive compulsive disorder (OCD) or Tourette syndrome?

In 1998, physicians began reporting odd encephalitis (brain inflammation)-like symptoms following an infection with Group A beta-hemolytic Streptococcus (GABHS), a bacterial infection.

Currently, PANDAS is not an ICD-9 recognized disease, and there is no recommended treatment. The suggested diagnostic criteria for PANDAS is abrupt onset (or dramatic exacerbations) of OCD or tic disorder, beginning between 3yo and the start of puberty, that occurs following an infection with GABHS. The neurologic examination would reveal hyperactivity, choreiform (snake-like) movements and/or tics.

Several studies have explored this phenomenon with conflicting results. Some authors found no correlation, while others found only elevated ASO (antibody) titers or the worsening of preexisting tic or OCD disorders. While some retrospective studies verified an association between infection and these neurological changes, a direct relationship has not been established.

Many clinicians think that PANDAS is simply a misdiagnosis of Sydenham’s chorea, a criteria for acute rheumatic fever (also caused by streptococcal infection) that is characterized by spastic and purposeless movements of the face or arms. Similarly to rheumatic fever, researchers believe that PANDAS may be due to the accidental production of antibodies that attack an area of the brain known as the basal ganglia.

•  If your child develops a sudden tic or movement disorder, or begins to display uncharacteristic psychological behavior, it is important to contact your physician. While PANDAS may be only temporary, acute rheumatic fever can lead to serious heart problems.

Reference

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS). Dynamed Database. Updated February 19, 2013, Accessed May 24, 2014.

Preterm infant mortality falling, prevalence of cerebral palsy rising

A recent study by Vincer et al published in the Journal of Pediatrics and Child Health reported on the rates of preterm infant mortality and cerebral palsy (CP) over the last 20 years. They found that the birth prevalence of CP among very preterm infants (less than 31 weeks) is on the rise, but the reasons are unclear.

CP is a permanent condition caused by damage to motor control centers in the brain before or shortly after birth, resulting in non-progressive impaired movement and permanent physical disability. The affected child typically has problems with uncontrolled spastic movements and/or impaired coordination of movement. Some cases are associated with epilepsy, poor cognition and/or difficulty with communication.

Between 1988 and 2007, very preterm infant mortality steadily declined while CP has been on the upswing. Vincer et al notes that maternal risk factors, anemia and tocolytic use have all been on the rise as well. Whether or not these represent a correlation has yet to be determined.

Reference

Vincer MJ, Allen AC, Allen VM, Baskett TF, O’Connell CM. Trends in the prevalence of cerebral palsy among very preterm infants (<31 weeks’ gestational age). Paediatr Child Health. 2014; 19(4):185-9.

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.

MERS Virus Not Considered a Major Threat to the U.S.

Middle East Respiratory Syndrome (MERS) virus has made its way into the United States after killing hundreds in the Middle East. The MERS virus, first isolated in 2012, is a coronavirus that spreads through respiratory droplets and causes a severe acute respiratory illness. Symptoms of infection include fever, cough and shortness of breath.

MERS, similar to the flu, can be quite dangerous to the elderly and those with compromised immune systems. Since it’s transmitted following close human-to-human contact, family members caring for their sick relatives can easily contract the virus. This seems to be why so many have been infected in the Middle East: Owing to poor living conditions and the lack of proper medical care, an estimated 30% of those infected have died.

Two confirmed cases have been reported in patients traveling from the Arabian Peninsula to the United States.

On May 2, MERS was confirmed in an Indiana hospital. The patient, a healthcare worker, had recently arrived from Saudi Arabia following layovers in London and Chicago. He was isolated and successfully treated. Shortly after, an Illinois resident whom had close contact with the infected patient before his hospitalization began exhibiting symptoms of infection. He tested positive for antibodies to the virus, suggesting he suffered a very mild illness before fully recovering.

On May 11, MERS was reported in an Orlando hospital. The patient, a healthcare worker, was traveling from Saudi Arabia and reported layovers in London, Boston and Atlanta. He felt unwell during the flight, so visited the Emergency Room after landing. He was successfully treated and is currently in good health.

The current strain of MERS virus is not a major threat to the United States. Still, communities of immuno-compromised citizens in close quarters are at risk. It is for this reason that hospitals and nursing homes across states like Florida are warning residents to stay aware of the warning signs.

• All viruses have the ability to mutate into a deadlier strain

• There is no evidence of sustained spreading in community settings

• If you’ve been in close contact with one of the individuals infected by MERS, call your healthcare professional and inform them promptly

• Always wear a protective mask (such as N95) when caring for a patient or relative with a cough and a fever

Reference

Middle East Respiratory Syndrome (MERS). Centers for Disease Control and Prevention. Accessed May 19, 2014. http://www.cdc.gov/coronavirus/mers/index.html