DISORDERS OF SKIN IN CHILDREN

1. BACTERIAL INFECTION
2. FUNGAL INFECTIONS
3. VIRAL INFECTIONS
4. TYPES OF SKIN INFECTION

1.BACTERIAL INFECTIONS :

1. Impetigo

2. Cellulitis

3. Folliculitis

4. Boils

5. Carbuncles.

6. Staphylococcal scaled skin syndrome

1.Impetigo:  It is contagious and can spread to all the members of the family and also leads
to re-infection of children. These lesions open and become crusty and have honey color
which is typical of impetigo .

 The lesions are often grouped and have a red base.

 Impetigo is a superficial infection of the skin, caused by bacteria.

Definition:

Impetigo is most common in children, but adults may also have it due to poor hygiene and
warm temperatures.

Common bacterias that are found on skin normally causes impetigo:

The most common causative organisms are-

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ETIOLOGY :

1. Group A β hemolytic Streptococcus

2. Staphylococcus Aureus. When bacteria enters an open area in the skin, infection occur.

Clinical features:

 Impetigo starts as a small vesicle or fluid filled lesion.

 Child may also presents with swollen lymph nodes.
 The lesions may all look different, with different sizes and shapes.
 The lesion then ruptures and fluid drains leaving areas that are covered with honey
colored crusts.
 Impetigo usually occurs on face, neck, arms and limbs. But the lesions can be
observed on any part of the body.

Diagnostic evaluation:

 Diagnosed based on complete history

 Culture of lesion can be done to confirm the diagnosis and the type f bacteria.
 The lesions of impetigo are unique and are clearly diagnosable.
  Physical examination

Treatment:

1. For child with many lesions oral antibiotics are given

2. If child has only few lesions, topical antibiotics are applied directly on the affected area.

3. Bath the child daily with an antibacterial soap to help decrease the chance of spreading the
infection.

Specific treatment is given based on –

1. Child’s age, overall health and medical history.

2. Extent of condition.

3. Child’s tolerance to specific medications.

Management:

 Avoid sharing of garments, towels and other house hold items to prevent the
spreading of infection.
 Keep the child’s finger nails short to decrease the chances of scratching and
spreading the infection.
 Proper hand washing technique by everyone in the house hold is very important to
help diagnosis the chance of spreading the infection.

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2.CELLULITIS :

 Cellulitis is a deep bacterial infection of the skin.

 It may happen in normal skin, but it usually occurs after some types of trauma causing
an opening in the skin This opening can lead to infection.
 The infection usually involves the face, arms and legs.

Etiology :

The most common bacterial cause of Cellulitis include the following-

1. Group A B – Hemolytic streptococcus
2. Streptococcus pneumoniae
3. Staphylococcus aureus.

Clinical features :

 Red streaks
 Feeling weak
 Chills
 Headache
 Fever
 Blisters
 Bruising
 Pain
 Warm skin
 Tenderness
 Swelling of the skin

Manifestations of cellulitis :

If the child has diabetes or weakened immune system.

 If the skin appears black

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  If the affected area has- 1. Numbness 2. Tingling  Fever  Very large area of red
inflamed skin

Diagnostic evaluation:

 Diagnosis is usually based on medical history and physical examination of the child. 
 Blood and skin samples may be taken to confirm the diagnosis and the type of
bacteria that is present.

Complications :

 Glomerulonephritis
 Septic arthritis
 Meningitis

Management:

Elevate the effected part and reduce activity of that part.

Surgical intervention:

 Warm, wet dressings on infection site.

 Oral or iv antibiotics.

3.FOLLICULITIS :

Folliculitis is the inflammation of hair follicles due to an infection, injury or irritation.It is

characterized by tender, swollen areas that form around the follicles, often on the neck,
breast, buttocks and face.

Boils: Boils are usually located I the waist area, groins, buttocks and under the arm. Boils are
pus filled lesions that are painful and usually firm.

Carbuncles: These are usually found in the back of the neck or thigh. Carbuncles are clusters
of boils.

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Clinical features :

The following are the most common symptoms of folluculitis, boils and carbuncles. However
each child may experience symptoms differently.

Symptoms of folliculits-

a) Pus in the hair follicle

b) Irritated red follicles

c) Damaged hair.

Symptoms of boils-

a) Pus in the centre of boil

b) Whitish, bloody discharge from the boil

3)Symptoms of carbuncles may include- a) Pus in the centre of the boil b) Whitish, bloody
discharge from the boils c) Fever d) Fatigue.

Diagnostic evaluation:

-Thorough medical history and physical examination.

- Culture of wound

Management  :

Specific treatment-

1. Topical antibiotics

2. For carbuncles and boils, a warm compress to promote drainage of lesion

3. Oral and IV antibiotics

4. Possible removal of boils and carbuncles.

4.STAPHYLOCOCCAL SCALED SKIN SYNDROME:

This can be life threatening. This mostly affects infants, young children and individuals with
depressed immune response or renal insufficiency. It is characterized by peeling of skin.
Staphylococcal scaled syndrome is an infective response occurred due to staphylococcus.

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Clinical features :

This disease usually begins with fever and redness of skin. This blister ruptures very easily
leavening an area of moist skin .Then a fluid filled blister may form.

Other symptoms includes-

 Crusted infection site

 Blstering ,Red, painful areas around infection site
 Top layer of skin slips off with rubbing or gentle pressure (Nikolsky’s Sign).
 After the top layer has peeled off- 1. Fever 2. Chills 3. Weakness 4. Fluid loss.
 Older children most common have lesions on their arms, legs and trunk.
 In newborns this infection is often observed in diaper area and around the umbilical
cord.

Diagnostic evaluation :

 Medical history
 Physical examination
 Blood tests .
 Biopsy and skin culture

Management :

Treatment includes the following-

Treatment usually requires hospitalization, often in the burn unit of hospital.

1. Antibiotics ( oral, IV ) against staphylococcus

2. IV fluids to prevent dehydration

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2.TYPES OF FUNGAL SKIN INFECTIONS:

1. Candidiasis (Yeast Infection)

2. Tinea infections (Ring Worm)
3. Athlets foot
4. Joch itch
5. Scalp ringworm (Tinea Captis)
6. Nail ringworm (Tinea ungium)
7. Body ringworm (Tinea Corpis)

1.CANDIDIASIS (YEAST INFECTION):

Candidiasis, sometimes called moniliasis, is an infection caused by yeast on the skin

and or mucus membranes . It causes infection when the skin is damaged or when conditions
are warm and humid or when there is depressed system. Although yeast is normally a
harmless inhabitant of the digestive system and vaginal area. Antibiotics can also cause yeast
to grow.

 Location Symptoms/ signs Skin folds or navel:

 Rash ,Patches and Pimples

 Itching or burning Vagina
 White or yellow discharge from vagina
 Itching Redness in the external area of vagina
 Burning Penis, Redness on the underside of the penis scaling on the inner side of the
penis
 Painful rash on the underside of the penis Mouth (thrush)
 White patches on tongue and inside cheeks
 Pain Corners of mouth Cracks and or tiny cuts on the corner of the mouth
 Nail beds Swelling ,Pain
 Pus White or yellow nail that separates from the nail bed.

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Diagnosis:

 Prompt medical history

 Physical examination of child’s skin scraping
 Culture of scrapped part

Management:

 Treated highly with medicate ointments.

 Severe infection in an immune compromised child may be treated with oral anti yeast
medication.
 Oral thrush is treated with medicated mouth wash.
 Yeast infections of vagina and anus are treated with suppositories.

2.TINEA INFECTION (RING WORM):  

Ring worm is characterized by ring shaped, red, scaly patches with clear centers. Different
fungi depending on their location causes ring worm.

There is an increased risk of contracting ringworm in child-

1. Who is malnourished

2. Has poor hygiene

3. Lives in warm climate

4. Has contact with other children or pets with ring worm infection

5. Immunocomprimised due to disease or medication.

3.ATHLETE’S FOOT ( TINEA PEDIS/ FOOT RING WORM): This common condition
mostly affects teen and adult males. It less frequency affects children before puberty.

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Causes include:

1. Sweating

2. Not drying feet well after swimming or batching

3. Wearing tight socks and shoes

4. Warm weather conditions

Symptoms:

 Blisters over the foot

 Itchy rash on the skin
 Scaling of the feet
 Whitening of the skin between the toes

4.JOCK ITCH (TINEA CRURIS/ GROIN RINGWORM):

This condition is also more common in males and occurs more often during warm conditions.
It is very rare in females.

Symptoms:

1. Red, ring like patches in the groin area.

2. Itching in the groin area.
3. Pain in the groin area.
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5.SCALP RING WORM(TIENA CAPITIS):
Scalp ringworm is highly contagious especially among children. It occurs mainly in children
between the ages 2-10 years. It occurs very rarely in adults

Symptoms-

1. Red, scaly rash on the scalp

2. Itching of the scalp

3. Hair loss on the scalp

4. Rash elsewhere on the body.

6.NAIL WORM (TINEA UNGIUM) :

It is an infection of the finger or toe nail, characterized by a thickened and deformed

nail. This condition is more often affects the toe nails than the finger nails. Tinea ungium
occurs more often in adolescents and adults rather than young children.

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Symptoms-

1. Thickening of the ends of the nails.

2. Yellow color of the nails.

7.BODY RINGWORM (TINEA CORPORIS):

This skin infection is characterized by the ring like rash anywhere on the body or the
face. It occurs in all ages but is seen more frequently in children. It is more common in
warmer climates.

Symptoms-

1. Red, circular lesion with raised edges.

2. The middle of the lesion may become less red as the lesion grows.

3. Itching at the affected area.

Diagnostic evaluation:

 Medical history
 Physical examination
 Lesions of the ringworm are unique and allow for a diagnosis simply based on basis
of physical examination.
 Culture of skin is also advisable

Management:

 Oral anti fungal medications

 Topical anti fungal ointments.
 Use of antifungal shampoos to eliminate fungus.

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TINEA VERSICOLOR:

Tinea versicolor is a common skin infection characterized by light or dark patches on the
skin.It occurs mostly in adolescents and early adulthood. Patches are more often found on the
chest and prevent the skin from tanning evenly.

Etiology:

Caused by fungi pityrosporum orbiculate

Clinical features:

 White, pink patches mostly noticeable in summer

 Patches worsen in heat.
 Rash does not usually occurs on face
 The rash usually occurs on the trunk
 Infection only on the top layers of their skin

Diagnostic evaluation:

 Medical history
 Physical examination
 Skin scraping can be taken for culture.
 UV light is used to visualize the patches more clearly.

Management:

 Topical creams or oral antifungal medications may be prescribed.

 To be effective, shampoo treatment is effective and may required for several nights.
 Shampoo is left on the skin overnight and washed off in the morning.
 Medicated antimicrobial dandruff shampoo on the skin as prescribed by doctor.

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3.VIRAL SKIN INFECTIONS :

Introduction: Many viral infections in childhood are called “viral exanthemas”. Exanthema is
another name for a rash or skin eruption. This type of rash is mainly caused by virus. It may
also be caused by medications, especially antibiotics.

Common childhood viral exanthemas are-

1. Measles or Rubeola

2. Rubella

3. Varicella (chickenpox)

4. Roseola.

Three main groups of viruses that causes majority of skin infections are-

1. Human Papilloma Virus

2. Herpes Simplex Virus

3. Poxvirus.

 Immunizations has decreased the number of cases of measles, mumps, rubella and
chickenpox.

 COMMON SKIN INFECTIONS IN RELATION TO CHILDREN-

1. WARTS

2. MOLLUSCUM CONTAGIOSUM

3. RUBELLA

4. RUBEOLA

5. CHICKENPOX 

1.WARTS :

Warts are non-cancerous skin growths caused by Papilloma virus. Warts can spread to other
parts of the body and to other person . Warts are not painful, except when located on the feet.Most
warts go away, without treatment, over an extended period.

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There are many different types of warts, due to many different papilloma virus types.

 Common types of warts-

1. Common warts: grows around nails and back of hands. Usually have rough surface,
grayish yellow or brown in color.

2. Foot warts- Located on the soles of feet (plantar warts) with black dots( clotted blood
vessels that once fed them). Clusters of plantar warts are called mosaic. These warts are
painful Small, smooth

3.Flat warts- growth that grow in group up to 100 at a time. Most often appear on child’s
face.

4.Genital warts- Grow on the genitals, are occasionally sexually transmitted. These are soft
and do not have a rough surface like other common warts.

5. Filliform Warts- These are small, long, narrow growth that usually appear on eyelids,
face or neck.

Management-

 Application of salicylic and lactic acid (which soften the infected area).
 Freezing with liquid nitrogen.
 Laser surgery.
 Electrodessication (using an electrical current to destroy the wart).

2.MOLLUSCUM CONTAGIOSUM :

Mollusucm contagiosum is a viral disease of the skin that causes small pink or skin colored
bumps on the child’s skin. It is not harmful and usually does not have any other symptoms.
The virus is inside the bumps and is mildly contagious. These bumps are usually clear and
extend on period of time.

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It is most common in children and adolescents, although it can affect adults.

Etiology: Malluscum contagiosum is a viral disease caused by virus called the poxvirus.

Clinical features :

 They are not harmful but may cause some cosmetic concern for child if they appear
on the face of other visible areas.
 The lesion usually occur in groups or clusters.
 The number of lesion a child has is usually between 2 to 20.
 Eventually the bumps tend to have a small sunken centre.
 Bumps are small and are usually pink or skin colored.

Diagnostic evaluation :

 Molluscum contagiosum is usually diagnosed based on medical history and physical

examination of the child
 The lesions are unique and usually are diagnosed on the basis of physical
examination. Additional test are not routinely required.

Management:

 Use of topical medications.

 Removal of the lesions

3.RUBELLA (GERMAN MEASLES) :

Rubella is a viral illness that results in a viral exanthema. It spreads form one child to other
through direct contact with discharge from the nose and throat. Infants and children who
develop the disease usually have mild rash and side effects.

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Etiology :

 Caused by virus- RUBVIRUS.

 It can spread from a pregnant mother to the unborn child, or form secretions from
infected person.
 It is most prevalent in late winter and early spring

Clinical features:

Common symptoms are-

 Rash eruption
 14-21 days for child to develop signs and symptoms.
 A low grade fever and diarrhea.
 Begins with a period of not feeling well
 Rash begins on face and then spreads down to the rams and legs.
 Rash then appears as pink area of small, raised lesions
 Older children and adolescents may develop some soreness and inflammation in their
joints. Lymph nodes in the neck may also become enlarged
 Rash usually fades by 3rd to 5th day.

Diagnosis :

 Physical examination
 Based on medical history

Management:

 Increased fluid intake

 Assure that all the child’s conatct have been properly immunized.
 Children who are born with rubella are consiudered contagious for the first year of life
 Children should not attend school up to seven days after onset of rash.
 Rubella is preventable by proper immunization with the rubella vaccine.

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4.RUBEOLA (MEASLES): Rubeola also called measles. It is viral illness that results in a
viral exanthema.

Etiology:

 The virus that causes measles, is classified as Morbillivirus belonging to

paramyxoviridae family.
 Sometimes it spreads through air-borne droplets from an infected child.
 It spreads form one child to another direct contact with discharge form the nose and
throat of infected child.
 Rubeola has a distinct rash that helps in the diagnosis.

Clinical features:

 Hacking cough
 Redness and irritation of the eyes
 Fever
 Small red spots with white centers (KOPLICKS’S SPOTS) appear on the inside of the
cheek
 Rash- deep , red flat rash that starts on the face and spreads down to the trunk, arms,
legs and feet.
 After three to seven days , the rash will begin to clear leaving brown discoloration and
skin peeling. The rash starts as small distinct lesions, which then combines as one big
rash.

Serious complications-

 Inflammation of brain.
 Croup
 Pneumonia
 Ear infections

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Diagnostic evaluation:

 Rubeola is usually diagnosed based on complete medical history and physical

examination.
 Lesions are unique and allows for diagnosis.

Management:

 Increased fluid intake

 WHO recommended two doses of vit-A for all children to prevent eye damage and
blindness
 Acentaminophen for fever.

Prevention:

 Children should not attend school or daycare for four days after the rash is positive.
 Assure that all child’s contacts have been properly immunized.

5.CHICKENPOX :

Chickenpox is a highly infectious disease caused by Varicella- Zoster Virus (VZV), a form of
herpes virus. Transmission occurs from person- person by direct contact or through the air
buy coughing and sneezing.

Clinical features:

 Fatigue and irritability

 Itchy rash on the trunk, face, scalp, armpits, upper arms, legs and inside the mouth.
 Fever

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  Cough or running nose.
 Muscle or joint pain
 Decreased appetite
 Feeling ill

Diagnostic evaluation :

 Physical examination
 Complete medical history

Management :

 Acetaminophen for fever

 Antibiotics for treating any bacterial infections
 Calamine lotion ( to relieve itching)
 Antiviral drugs
 Bed rest
 Cut children’s fingernails' short.
 Do not let children scratch the blisters which could lead to secondary bacterial
infections. Cool baths( to relieve itching)
 Increased fluid intake

Complications-

 Secondary bacterial infections

 Death
 Reye’s syndrome (a serious condition that affects all major systems or organs)
 Myelitis
 Cerebellar ataxia
 Encephalitis
 Pneumonia

Immunity from chicken pox :

Once infections can give them immunity for the rest of their lives.

OTHER PARASITIC SKIN INFECTIONS :

SCABIES :

Introduction :

Scabies is an infestation of mites characterized by small red bumps and intense itching. This
highly contagious infection often sp[reads from person to person while they are sleeping
together in the same bed or have close personal personal contact. Parities are small worms
that or insects that make a deep burrow on skin to live there or lay their eggs.

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 The itching is caused by the mites burrowing into the skin where they lay eggs that
hatch a few days later Scabies occurs mostly in children and young adults. Scabies can affect
of all ages.

Clinical features

 Itching, usually severe

 Scaly or crusty skin.
 Rash with small pimples or red bumps

Diagnosis and management:

 Diagnosis of scabies , the skin and skin creases are examined by the physician
 A sample of skin obtained by scrapping the skin may be examined under a
microscope to confirm the presence of mites.

Management:

1. Application of prescribed creams and lotions (lindane solution)

2. Oral antihistamines medications

3. Topical ointments

4. Wash all the cloths and bed sheets in hot water and dry in hot dryer.

5. Itching may continue for several weeks.

Other disorders- diaper rash  :

Rash in the diaper region are common during early infancy. It is more common in artificially
fed infants, especially those in whom it is changed infrequently.

 Involves buttocks, scrotal sacs, Mons pubis or inner side of thigh.

 These are contact dermatitis secondary to detergents.
 Skin appears red like parchment which becomes infected giving rise to pustular
erosions.

Management:

 Antimicrobial cream or lotions.

 Cool wet compress on rash region.
 Wash with mild soap.
 Plastic diapers should not be used.
 Single layer porous diapers should be used.

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DISORDER OF EYE :

CONJUNCTIVITIS:

 Definition: Inflammation of conjunctiva.

Etiology:

 Viral

• Bacterial

• Allergic

• Foreign body/chemicals

Clinical manifestations:

Bacterial conjunctivitis:

•Purulent discharge

•Crusing of eye lids

•Inflammed conjunctiva

•Swollen lids

Viral conjunctivitis :

 Swollen lids
 Inflammed conjunctiva
 Serous ( watery discharge)
 Occurs with URI

Allergic conjunctivitis :

 Swollen lids
 Inflammed conjunctiva

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 Watery to thick, stringy discharge
 Itching

Conjunctivitis caused by foreign body:

• Tearing

• Pain

• Inflammed conjunctiva

• Usually only one eye is affected

Chemical conjunctivitis:

• Mild eyelid edema

• Sterile, non purulent eye discharge (fuloria & krieter, 2002)

Management:

• Treat the cause.

• Viral conjunctivitis: self limiting

• Treatment is limited to removal of accumulated secretions

• Bacterial conjunctivitis: topical antibacterial agents eg. Polysporin, sodium sulfacetamide,

trimethoprim and polymyxin.

 Fluroquinolones: approved for children > 1year old

• Best antimicrobial agent available ( Lichenstein , rinchart , 2003)

 Eye drops may be used in day time and ointment at bedtime ( ointment remains in eye for
longer time)

Nursing care:

• Keep eye clean

• Administer ophthalmic medications

• Remove accumulated secretions by wiping from inner to outer canthus

• Prevention of infection to other family members

• Child should refrain from rubbing the eye

• Teach hand washing technique

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KERATOMALACIA:
Keratomalacia is an eye disorder that involves drying and clouding of cornea due to vitamin
A deficiency.

Causes :
• Decreased vitamin A intake
• Poor metabolism ( eg. in case of celiac syndrome and ulcerative colitis)
• Insufficient conversion, storage , absorption and transport of vitamin A
• Infants and children who are allergic to milk are at high risk
Role of vitamin A : Vitamin A is required to maintain epithelia of cornea and conjunctiva.
Pathophysiology:
Presice mechanism is not known Lack of vitamin A Atrophic changes in normal mucosal
surface Loss of goblet cells Replacement of normal epithelium by inappropriate keratinized
squamous epithelium

• In addition substantia propria of cornea breaks down and liquefies Keratomalacia Cornea
becomes totally opaque Blindness
Clinical manifestations:
• Highly perforated and soft cornea
• Changes in vision
• Wrinkling and cloudiness in cornea
• Corneal ulcers
• Decreased night vision
• Photophobia
• Corneal scar
• Dryness of ocular glands like lachrymal glands, cornea and conjunctiva

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• Formation of bitots spots
Diagnosis:
• History
• Physical Examination
• Eye examination
• External appearance
• Visual acquity
• Eye movements
• Visual field
• Slit lamp examination of conjunctiva and cornea
• Blood studies (beta carotene and vitamin A levels)
Treatment :
• Vitamin A Supplementation
• Mild to moderate deficiency : 10,000mcg of fat soluble vit A x 10 days
• Severe cases : 50,000mcg of fat soluble vit A for several weeks
• A single dose of 1lakh mcg vit A will prevent vit A deficiency in children for about 6
months
• Treatment of secondary cause if any
Dietary sources:
• Fish liver oil
• Butter, egg
• Green leafy vegetables , Cod liver oil, Carrot , Pumkin
• Milk and milk products .

CONGENITAL/ DEVELOPMENTAL GLAUCOMA :

• Congenital glaucoma are a group of diverse disorders in which abnormal high intraocular
pressure results due to developmental abnormalities of angle of anterior chamber obstructing
the drainage of aqueous humur.

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Types:

Primary developmental/ congenital glaucoma.

• Developmental glaucoma with associated congenital ocular anomalies

• Developmental glaucoma with associated systemic abnormalities

Primary developmental/ congenital glaucoma: Refers to abnormally high intraocular

pressure which results due to developmental anomaly of the angle of anterior camber not
associated with any other systemic anomaly.

Depending on age of onset developmental glaucomas are termed as:

1. Newborn glaucoma /true congenital glaucoma : IOP is raised during intrauterine life .
Child is born with ocular enlargement and Accounts for 40% cases

 2. Infantile glaucoma: Labelled when disease manifests before child’s third birthday.
Accounts for 55% of cases

3. Juvenile glaucoma: When disease occurs after 3 years of age but before adulthood. Also
known as Juvenile Primary Open Angle Glaucoma ( JPOAG). About 35% patients with
JPOAG are myopes and Has strong autosomal dominant inheritance. Genetic anomaly on
long arm of chromosome 21.

 Pathogenesis:

Maldevelopment of neural crest derived cells of trabeculum including the iridotrabecular

junction ( trabeculodysgenesis)

• Impaired aqueous outflow

• Increased intra ocular pressure

• Trabeculodysgenesis: absence of angle recess with iris having flat/ cocave insertion into
surface of trabeculum

Clinical Manifestations:

• Lacrimation

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• Photophobia

• Blepherospasm

• Corneal edema

• Corneal enlargement

• Tears and breaks in descement’s membrane(Haab’s strial)

• Sclera becomes thin & appears blue due to underlying uveal tissue

Assessment:

Measurement of intraocular pressure, Measurement of corneal diameter

• Slit lamp examination

• Ophthalmoscopy

• Gonioscopic examination : (to evaluate the internal drainage system of the eye, also
referred to as the anterior chamber angle. The "angle" is where the cornea and the iris meet. )

 Treatment :

• Medications are not very effective so treatment is primarily surgical

• IOP must be lowered by hyperosmotic agents, acetazolamide and beta- blockers, till surgery
is taken up

Surgery:

Inscisional angle surgery:

1. Internal approach –goniotomy.

2. External approach – trabeculectomy.

• Goniotomy: Incision is made in the angle approximately midway between the root of iris
and Schwalbe’s ring.

Trabeculectomy: Useful when corneal clouding prevents visualization of angle or in case

goniotomy has failed.

• Vertical scleral incision is made after making a conjunctival flap and partial thickness skin
flap.

• Break is created in the inner wall of schlemm’s canal

• Combined trabeculectomy and trabeculotomy

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Cataract:

Congenital/ Developmental Cataract:

• A cataract is a clouding of the lens in the eye which leads to a decrease in vision .

• Cataract may be present at birth (congenital) or it may develop later ( developmental)

Pathogenesis:

• Lens is formed in layers

• Central nucleus being the earliest formation around which concentric zones are laid down

• This process continues till late adolescence

• Developmental cataract has a tendency to affect the particular zone which was being formed
• As time goes on the opacity is deeply buried in the lens

 Causes:

• Cause is unknown

• Possible factors include

• Maternal and infantile malnutrition

• Maternal infections by viruses eg. Rubella

• Deficient oxygenation owing to placental hemorrhages

• Hypocalcemia and storage disorders

Types:

• Punctate cataract

• Zonular cataract

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• Fusiform cataract

• Coronary cataract

Assessment:

• Assessment of vision

• Occular status

• Intraocular pressure

• Fundus examination to rule out associated diseases like retinoblastoma

• B scan Ultrasonography – to assess posterior segment of eye –to rule out retinal detachment
• A scan ultrasonography – to compare axial length of two eyes

• Assessment of density of cataract.

Treatment:

• Not indicated unless vision is impaired

• Central cataract

• Good vision through clear cortex

• Mydriasis if required.

• Monitor distant and near vision.

• Look for progression of cataract until puberty

• If opacity is large and dense – cataract surgery • Intraocular lens may be implanted after
surgery

• Lamellar cataract – surgery not advisable until child is 1-2 years old

• Pediatric cataracts are soft and can be aspirated through incisions that are 1-1.5mm in size at
the limbus

Childhood blindness:

Childhood blindness:

• Important public health problem in developing countries Prevalence • In India 0.8 /1000
children • Currently 270,000 blind children in India.

28
Causes:

• Vitamin A deficiency

• Measles

• Conjunctivitis

• Ophthalmia neonatorum

• Injuries

• Congenital cataract

• Retinopathy

• Glaucoma in childhood

Vision 2020:

• Right to sight initiative in India .

AIM:

• To eliminate avoidable causes of childhood blindness by the year 2020

Activities:

• Detection of eye disorders -At the time of primary immunization , At school entry

• Periodic checkup every 3 years for normal children and every year for those with defects

Preventable childhood blindness should be taken care through effective measures :

• Prevention of xerophthalmia.

• Preventions and early treatment of trachoma by active intervention.

• Refractive errors to be corrected at primary eye care centers.

• Childhood glaucoma to be corrected promptly.

29
• Harmful/ traditional practices need to be avoided.

• Prevention of retinopathy of prematurity by proper screening and monitoring.

Curable childhood blindness:

• Retinopathy of prematurity, corneal opacity and other causes to be taken care by experts at
secondary and tertiary level eye care services.

Nursing care:

• Disturbed sensory perception (visual) related to altered sensory perception secondary to

altered status of sense organs.

• Anxiety related to changes in health status ( alteration in vision) and unmet needs.

 • Risk for injury related to falls secondary to impaired vision

• Deficient knowledge regarding disease condition, prognosis, treatment and discharge needs
related to lack of exposure.

ENT DISORDERS IN CHILDREN:

EAR DISORDER:

ACUTE OTITIS MEDIA:

Otitis media is a common early childhood morbidity that refers to viral or bacterial infection
of the ‘middle ear cleft’. Anatomic features that predispose a young child to ear infections
include a shorter more horizontal and compliant Eustachian tube and bacterial carriage in the
adenoids.

Risk factors:

 Cigarette smoke
 Overcrowding
 Bottle feeding
 Use of pacifier
 Cleft palate
 Immune dysfunction
 Gastroesophageal reflux.

Etiology:

The most common causative organism are streptococcus pneumonie, hemophillus influenza
and moraxella catarrhalis in 75% cases.

30
Less common pathogens include S. pyogens, S.aureus and pseudomonas aeruginosa; viruses
may be the sole pathogen in 15% of cases.

Clinical features:

The condition is characterized by rapid onset of symptoms such as otalgia or ear tugging,
fever, crying and irritability.

Older children may report impaired hearing.

Diagnosis:

 History of upper respiratory tract infection is common.

 Otoscopy reveals a red and bulging tympanic membrane or perforation of the
tympanic membrane with otorrhea .
 The diagnosis is considered in the presence of the following criteria: Rapid onset of
symptoms, signs of middle ear effusion and signs and symptoms of middle ear
inflammation.

Treatment:

 Antimicrobial therapy is recommended in all patients except a few who may qualify
for a trial of observation. Amoxicillin is the first choice of therapy. Higher doses (80-
90mg/kg/day) are considered where streptococcal resistance is endemic.
 Coamoxiclav , cefaclor, cefuroxime and newer generation cephalosporins are useful
second –line drugs.
 Adjuvant treatment with oral and topical decongestant agents is not necessary.
 Antihistaminic agents , which contribute little to resolution of otitis media.

CHRONIC OTITIS MEDIA:

Chronic otitis media is defined as chronic inflammation of the middle ear space and mastoid
air cells. It may result in perforation of the tympanic membrane, tympanosclerosis, retraction
pocket in the tympanic membrane, ossicular damage or cholesteatoma leading to ear
discharge and/or hearing loss. Chronic supportive otitis media is diagnosed in the presence of
an ear discharge persisting for longer than 6 weeks.

Risk factors:

 Recurrent infections through a perforated tympanic membrane

 Ascending infection from nasopharynx through Eustachian tube
 Colonization of middle ear by bacteria.

Management :

 Medical therapy chiefly consists of topical antibiotics and aural toilet.

 Parents are instructed to avoid water exposure.
 Topical quinolones are effective and safe.

31
  Systematic antibiotics
 Otolaryngology referral is necessary to rule out cholesteotoma.
 Surgery is indicated in cases that do not respond to conservative treatment, and
involves repair of the tympanic membrane perforation with or without
mastoidectomy.

Complications of otitis media:

 Hearing loss
 Acute coalescent mastoiditis
 Labyrinthine fistula
 Facial nerve paralysis
 Meningitis
 Brain abscess
 Thrombosis of the sigmoid or transverse sinus.

HEARING LOSS:

Hearing loss in children may be congenital or acquired. Based on pathology, hearing loss is
categorized as conductive, sensorineural or mixed. Early detection of hearing loss in children
interferes with development of speech, language and cognitive skills.

Conductive hearing loss:

Any pathology that interferes with the conduction of sound through the ear canal, tympanic
membrane or middle ear ossicles may cause conductive hearing loss. Hearing loss is usually
acquired and mild to moderate in severity.

Common causes include otitis media with effusion, tympanic membrane perforation,
tympanosclerosis and cholesteatoma.

Less commonly, conductive hearing loss is congenital, associated with congenital ossicular
fixation or discontinuity and atresia of the ear canal.

Sensorineural hearing loss:

This is caused by pathology in the cochlea, auditory nerve or central auditory pathway.
Congenital and acquired hearing loss is equally prevalent.

 The most common cause of sensorineural hearing loss is meningitis.

Other causes are:

- Prematurity
- Hyperbilirubinemia
- Perinatal hypoxia
- Acquired immunodeficiency syndrome
- Head trauma

32
 - Medications( aminoglycosides, loop diuretics)
 The chief etiology of congenital hearing loss is intrauterine infections(e.g.
TORCH,syphilis).
 Over 65 genes are associated with inherited hearing loss.

Screening for hearing loss:

 Significant hearing loss is present in 1-3 per 1000 newborns, particularly in babies
requiring neonatal intensive care. Hearing loss has significant implications for
development of speech, language and cognitive skills.
 Indian Academy of Pediatrics recommend universal screening for hearing loss in
newborn period.
 Hearing screening and intervention programme is the ‘1-2-3’guideline. This
reccoemnds screening all newborns for 1 months, 2months and 3 months of age.
 Screening for older children includes otoscopy with attention to middle ear pathology.
 Doubtful cases require referral for audiologic evaluation.

Management of hearing loss:

 For mild and moderate loss option of treatment includes tympanostomy tube for otitis
media with effusion, tympanoplasty tube for tympanic membrane perforation
mastoidectomy and tympanoplasty for cholesteatoma canaloplasty for canal atresia.
 Conventional hearing aid, bone conduction hearing aid or middle ear implant are
considered in patiens with conductive hearing loss, if the pathology cannot be
surgically corrected.
 Unilateral and bilateral hearing aid usage is advised for mild to moderate
sensorineural hearing loss.
 Pediatric Cochlear implantation: It directly stimulates the residual cochlear nerve cells
in the spiral ganglion. The US FDA approves cochlear implanataion in adults with
bilateral severe to profound sensorineural hearing loss. Evaluation before surgery
includes computed tomography and MRI to assess anatomic anomalies and confirm
the presence of cochlear nerve.

DISEASES OF NOSE:

Viral rhinitis(common cold)

It is the most frequent cause of nasal obstruction and rhinorrhea in children, occurring up
to 6-8 times a year, usually due to infection with rhinovirus, influenza or adenovirus.
Symptoms include malaise, low to moderate grade fever, nasal congestion and rhinorrhea,
with or without sore throat.

- Antipyretics, saline nasal drops, oral degongestants and antihistamines provide

symptomatic relief.

33
 - Annual influenza vaccination reduces the incidence of severe cases. Less than 5%
affected children develop superimposed bacterial rhinosinusitis and suppurative otitis
media.

Allergic Rhinitis:

 The condition is due to an IgE-mediated reaction to specific allergens, commonly

inhaled house dust mite, pollen and spores. Coexisting atopic dermatitis and
asthma are common.
 Presentation is with sneezing, ithching, nasal obstruction and clear rhinorrhea that
are seasonal or perennial with intermittent exacerbations.
 Examination shows pale nasal mucosa, hypertrophied nasal turbinates and thin
mucoid rhinorrhea with or without conjuctival ithching and redness.
 Diagnosis:
-supportive tests such as eosinophillia on nasal smear
-skin tests for common allergens and increased serum total or allergen-specific
IgE are not essential.

Management:

 Comprises of allergen avoidance.

 Topical corticosteroid sprays provide symptomatic relief.
 Topical decongestants are discouraged due to the risk of rebound congestion and
rhinitis medcamentosa

Acute bacterial rhinosinusitis:

It is termed acute, if symptoms are for less than 12 weeks.

It usually follows viral rhinitis, but may develop and recurrently in the presence of
predisposing factors such as allergic rhinitis, adenoid inflammation and hypertrophy, cystic
fibrosis, immunodeficiency, ciliary dyskinesia, daycare attendance, exposure to tobacco
smoke and gastroesophagyeal reflux.

Viral infections cause mucosal edema and ciliary hypoactivity causing obstruction of sinus
ostia and stasis of secretions.

Clinical features:

Persistent fever , facial pain or heaviness, ansal obstruction or purulent discharge, cough,
dental pain and ear acheor fullness beyond 7-10 days of URTI.

While a proportion of cases resolve spontaneously, therapy with orala antibiotics

(amoxicillin, coamoxiclav for 10-14 days) is preferred.

Longer courses and/or second line antibiotics may be indicated based on organism sensitivity
and nature of illness.

34
Measures such as oral or topical degongestants, mucolytics ana nasal saline provide early
symptomatic relief.

Patiens with complications may require parenteral antibiotics with or without endoscopic
sinus surgery and abscess drainage.

CHRONIC BACTERIAL RHINOSINUSITIS:

 When symptoms of rhinosinusitis persist for >12 weeks, infection with S.aureus ,
anaerobes and even fungi should be considered apart from usual bacterial pathogens
 Nasal obstruction, purulent discharge , chronic cough, facial heaviness, dental pain,
malaise and headache are common features.
 Young children may be just irritable.

Management:

 Chronic bacterial rhinosinusitis is treated with a broad spectrum

antibiotic( coamoxiclav, broad spectrum cephalosporin or floroquinolone) for 3-6
weeks.
 Oral decongestants and topical corticosteroid sprays ( e.g. mometasone or fluticasone)
hasten symptomatic patency of sinus ostia.
 Nasal steroid sprays are safe and do not impact facial or body growth.
 Saline irrigation decreases mucosal edema and improve mucocilliary clearance of the
nose and paranasal sinuses.
 Managing underlying gastro-esophageal reflux with proton pump inhibitors may defer
the need for surgery.

CHONAL ATRESIA:

This term refers to congenital failure of the nasal cavities to open into the nasopharynx.
Unilateral or bilateral chonal atresia or stenosis is hypothesized to be caused by complete or
partial persistence of buccopharyngeal membrane(separating oral cavity from pharynx) or
nasobuccal membrane( separating nose from oral cavity) or abnormal neural crest cell
migration.

As infants are obligate nasal breathers, patients with bilateral choanal atresia present
immediately after birth with respiratory distress and intermittent cyanosis, precipitated by
suckling that improves when the child cries.

Bilateral atresia can be associated with CHARGE syndrome.

Pateins present with persistent unilateral nasal discharge or blockage, typically when the
opposite nasal passage is blocked due to rhinitis or adenoid hypertrophy.

The diagnosis of choanal atresia is considered when a 6F feeding catheter cannot be passed
through the nose into the nasopharynx at birth. Flexible nasal endoscopy and CT confirm the
diagnosis.

35
 Management:

EPISTAXIS:

Bleeding from the nose is frequent in children and usually follows injury to the anterior
portion of the nasl septum in liitle’s area, the location of kiesselbach arterial plexus.

Bleeding follws local trauma, especially by nose picking during hot summer days, when
reduced ambient humidity causes crusting in the anterior nasal cavity.

Examination reveals prominent vessels that bleed promptly when touched with a cotton
tipped probe or a dried clot over little’s area.

Avoidance of nose picking, use of lubricating ointment and pinching the nose to stop the
bleeding are taught to the child and parents. Refractory cases require chemical or
elctro cauterization.

SORE THROAT:

Viral pharyngitis: it is common and cuased by rhinovirus, influenza or parainfluenzavirus,

adenovirus or coxsackie virus.

Patients present with fever, sore throat, dysphagia, rhinorrhea, nasal obstruction, cough and
bodyache.

Examination shows non exudative erythma of pharynx and tonsils and tender cervical
lymphadenopathy.

Supportive treatment with analgesics, saline gargles and saline nasal drops is sufficient.
Antibiotics are required in cases of secondary bacterial infection.

Acute bacterial pharyngotonsillitis:

It is usually caused by group A β- hemolytic streptococci. Less common pathogens include

non-group A streptococci, S. aureus, H. influenza, M..catarrhalis, diphtheria,
gonococci, Chlamydia and mycoplasma spp.

Pharyngitis presents with fever, throat pain, odynophagia and occasionally, headache,
abdominal pain, nausea and vomiting.

Sevre cases show purulent exudation with or without membrane formation on tonsils cervical
lymphadenopathy.

A rapid strep test helps distinguish viral from streptococcal pharyngotonsillitis; negative results
should be confirmed by throat culture. If strongly suspected , therapy against streptococcus
should begin without awaiting microbial confirmation.

36
Initial therapy is with penicillin or a first generation cephalosporin for 10 days.

Coamoxiclav, clindamycin or erythromycin and metronidazole are considered in refractory

cases.
Complications:
-peritonsillar, parapharyngeal or retropharyngeal abscesses
-scarlet fever
-Acute rheumatic fever
-Poststreptococcal glomerulonephritis.

TONSILLECTOMY:

Indications for tonsilloadenoid resection include adenotonsillar hypertrophy causing

obstructive sleep apnea, speech defects, craniofacial growth abnormality, dysphagia, failure
to thrive or cor pulmonale. Other indications for tonsillectomy are recuurent acute tonsillitis,
associated with valvar heart disease or recurrent febrile seizures, recurrent peritonsillar
abscess, infectious mononucleosis with severely obstructing tonsils refractory to medical
management, and suspected tonsillar neoplasia.

Acute laryngobronchitis (croup) is a viral upper respiratory tract infection that affects
children, 6 months to 3 years of age. Patients present with biphasic stridor, barking cough and
low grade fever after an episode of common cold

Symptoms may evolve over several days. Chest X-ray reveals characteristics
narrowing of the subglottic region, known as the ‘steeple’ sign. Most cases of croup are mild
and resolve in 1-2 days with conservative management , including reassurance, cool mist and
oral hydration. Nebulized epinephrine (1:1000, in doses of 0.1-0.5 ml/kg, to a maximum of 5
ml) provides symptomatic relief.

A dose of dexamethasone(0.3-0.6 mg/kg, intramuscular) reduces severity, if given within the

first 24 hours.

Inhaled budesonide(1mg twice a day for two days) also shows satisfactory results.
Antibiotics against staphylococcus and H.influenza are indicated, if the child fails to improve
and/or purulent secretions are present.

Acute epiglottitis (supraglottitis):

It is due to infection with H.influenza type B, is less common but a more severe illness than
croup. The incidence has declined following improving immunization against haemophilus.
Patients , usually 3-6 years of age, present with acute sore throat, high fever, muffled voice,
inspiratory stridor, marked dysphagia and drooling.

37
Unlike croup, cough is usually absent. The patient looks toxic and prefers to sit in a leaning
forward,’tripod’ position that helps them breathe better.

 Lateral neck X-ray reveals a characteristics thickening of the epiglottis.

 Rapid airway management is crucial and includes intubation by skilled personnel or
rigid bronchoscopy followed by tracheotomy.
 In atypical presentations, skilled physician might try flexible endoscopy, which shows
significant edema and erythema of the supraglottic structures compromising the airway.
 IV , cefotaxime or ceftriaxone are administered for 7 days.

COMMON COMMUNICABLE DISEASES IN CHILDREN:

COMMUNICABLE DISEASE:

“Transmitted from one person to another person or from a reservoir to a susceptible host.”
E.g.: Tuberculosis etc.

Diseases that are “catching”, diseases that are caused by germs or pathogens. Examples of
pathogens include: viruses, bacteria, p parasitic worms and fungi.

Communicable Period: Time period require for transmission of infectious agent from
reservoir to a susceptible host.

Controlled by:

 Improvement of personal hygiene

 Improvement of social hygiene
 Awareness about health
 Awareness about disease

Types of Communicable Disease Depending upon source:

1. 1.Respiratory Infections: E.g.: Tuberculosis etc

2. 1.Intestinal Infections: E.g.: Hepatitis etc
3. 1.Arthropod Borne Infections: E.g.: Plague etc
4. 1.Surface Infections: E.g.: Leprosy etc
5. 1.Sexually Transmitted Disease: E.g.: AIDS etc

Modes of Transmission:

• Direct Contact: Exposure to infected body fluids such as blood or saliva.

• Vectors/Reservoirs: Germs are spread by an animal or insect, usually through a bite.

38
• Food and Water: Food and water can become contaminated with germs and people can get
sick when they eat or drink them.

• Airborne: Germs are spread through the air, for example when someone coughs or sneezes.

• Indirect contact: Pathogens remain on surfaces that were in contact with an

CHICKEN POX:

Chicken pox is a common disease caused by the varicella zoster virus (VZV) which is a
member of the herpes virus family. Usually occurs during childhood (normally 5-9) , but you
can get it at any time in your life.

Clinical features:

Chicken Pox (Varicella-Zoster virus) Signs and Symptoms Initial infection begins with sudden
onset of fever that coincides with a rash on the surface of the skin.1,2 The bumps are initially
vesicular (fluid-filled) for 3-4 days and then form pustules (pus-filled lesions) and scab or crust over.

As the illness progresses, the skin lesions often appear with several stages of maturity at the
same time, e.g., raised bumps, vesicles, and scabs. The skin lesions tend to be more numerous on
covered, rather than exposed, areas of the body.

Other Symptoms:

• Small fever, body aches and loss of appetite.

• Within 1or 2 day, the rash appears, begins as red spots which then form blisters and spreads
to the rest of the body.

• Incubation Period Usually 14 to 16 days; occasionally as early as 10 days or as late as 21 days.

Period of Communicability Patients are most contagious from 1 to 2 days before onset of rash
until all lesions are crusted (usually about 5 days).
 Treatment Child’s parents should contact his/her pediatrician for instructions . Children with
chicken pox should NOT be given salicylates (aspirin or medications containing aspirin) because
administration of such medications increases the risk of Reye (continued on next page) 9
Syndrome. The physician may prescribe antiviral medication.

Prevention:
• There are no actual cures for it ,but you can get a vaccine shot to help prevent it.
• Baths with uncooked oatmeal, baking soda, or cornstarch can help relieve itching.
• Tylenol is used for fever or pain relief. (Aspirin should be avoided.)
• Antiviral drugs such as Acyclovir may be prescribed.
• You can put Calamine lotion on the pocks to help stop the itching.
 Per the Advisory Committee on Immunization Practice (ACIP), two doses of varicella
vaccine are recommended for children. The first dose should be given between 12 and 15

39
 months of age. The other dose should be given between the ages of 4 and 6 years, before the
child enters kindergarten or first grade.
 Susceptible individuals who are exposed to chicken pox can receive varicella vaccine as post-
exposure prophylaxis, provided there are no contraindications for its use. When administered
within 3 to 5 days following exposure to chicken pox, the vaccine can prevent or modify the
disease. In exposed individuals who cannot receive the varicella vaccine, VariZIG, IGIV or
acyclovir can be considered to prevent illness.
 Children who have not been immunized for chicken pox should receive the vaccine within 3
to 5 days of exposure OR be excluded from child care or school from the 10th to the 21st day
following exposure to the last person with chicken pox at the affected school.

DIPHTHERIA:

It is caused by bacteria Corynebacterium diphtheriae.

Symptoms:

 Sore throat
 Low fever
 Swollen neck glands
 Airway obstruction and breathing difficulty
 Shock.

Modes of Transmission:

• Solely among humans, spread by droplets

• Secretions, direct contact, Poor nutrition

• Low vaccine coverage among infants & children.

Prevention:

• Sanitary: Reduce carrier rate by use of vaccine.

• Immunological: A vaccine (DPT) prepared from an alkaline formaldehyde inactivated toxin (i.e.
toxoid) is required. Passive immunization with antitoxin can be used for patients.

• Chemotherapeutic: Penicillin, erythromycin or gentamicin are drugs of choice.

FILARIASIS:

Filariasis Infection caused by 3 closely related Nematodes-

• “Wuchereria bancrofti”

• “Brugia malayi”

• “Brugia timori”

Symptoms:

40
  Filarial fever,
 Lymphangitis,
 Lymphadenitis,
 Elephantiasis of genitals/legs/arm
 Filarial arthritis, Chyluria.

Mode of transmission: Transmitted by the bite of infected mosquito responsible for considerable
sufferings.

PREVENTION

• Treating the infection by Cooling the leg, drying, exersice.

• Treatment and prevention of Lymphoedema.

• Drugs effective against filarial parasites-

1. Diethyl Carbamazine citrate (DEC)

2.Ivermectin

3.Albendazole

4.Coumarins compound

HIV/AIDS:

According to WHO ”Pediatric AIDS is suspected in a child presenting with at least 2major
signs associated with 2 minor signs in the absence of known causes of immune-suppression
such as cancer, malnutrition or other recognized etiologies”.

AIDS is caused by a retrovirus namely human immunodeficiency virus or Lymphadenopathy

associated virus(LAV) or human T lymphotropic virus III .

MODE OF TRANSMISSION:

The transmission of HIV occurs by two ways-

1. Horizontal
- Sexual intercourse
- Needle stick injury
- Contaminated blood and blood products
2. Vertical
- In utero (30-35%)
- During delivery (60-65%)
- Breast feeding(1-3%)

WHO CLINICAL STAGING OF HIV IN CHILDREN:

CLINICAL STAGE 1:

41
  Asymptomatic
 Persistent generalized lymphadenopathy

CLINICAL STAGE 2:

 Unexplained persistent hepatospleenomegaly

 Papular pruritic eruptions
 Extensive wart virus infection
 Fungal nail infection
 Recurrent oral ulceration
 Herpes zoster
 Recurrent or chronic upper respiratory infections

CLINICAL STAGE 3:

 Unexplained moderate malnutrition

 Unexplained persistent diarrhea
 Unexplained persistent fever
 Pulmonary TB
 Lymph node TB
 Persistent oral candidiasis
 Severe recurrent pneumonia
 Chronic HIV associated with lung disease
 Unexplained anemia.

CLINICAL STAGE 4:

 Unexplained wasting or severe malnutrition not responding to standard therapy.

 Recurrent severe bacterial infections
 Chronic simplex herpes simplex infection
 Extra pulmonary TB
 Kaposi’s sarcoma
 HIV encephalopathy
 Cytomegalovirus infection symptomatic HIV associated nephropathy or HIV
associated Cardiomyopathy.

CLINICAL COURSE OF VERTICALLY ACQUIRED HIV INFECTION:

A. Rapidly progressive form: symptoms occurs within 3-4 months pneumocystis carnii
pneumonia is the presenting illness in 40%
B. Slow progressive form: These children may present as late as 8 years of life and the
presenting feature is lymphocytic interstitial pneumonia in most children.

DIAGNOSTIC EVALUATION:

42
Laboratory diagnosis is necessary to determine if HIV infection has occurred and also to
detect immunodeficiency , particularly the reduction of circulating T helper cells.

 The Enzyme Linked Immunosorbent Essay (ELISA) is used for screening

 Western Blot test is used for confirmation.
 In recent years investigators have demonstrated the utility of highly accurate blood
tests in diagnosing HIV infection in Children 6 months of age and younger.
 A technique called Polymerase Chain Reaction (PCR) can detect minute quantities of
the virus in an infant’s blood.

MEDICAL MANAGEMNT:

Aggressive anti retroviral therapy(ART) is indicated when the child demonstrates signs of
immunosuppression or HIV associated symptoms.

There are 2 categories of antiretroviral viral drugs- non reverse transcriptase

inhibitors(NRTIs) and non nucleoside Reverse Transcriptase Inhibitors(NNRTIs).

NRTIs NNRTIs
Stavudine (d4t) or Nevrapine (NVP)or
Zidovudine (AZT) Efavirenz (EFV)
Lamivudine (3TC)  If age< 3 years or weight
< 10kgs-Nevrapine
 If > 3 years or weight >
10 kg – Nevrapine or
efavirenz

 Along with antiretroviral therapy , Pneumocystis pneumonia prophylaxis should be

given to infants in whom infection is detected on the basis of positive viral test.
 Use of intravenous immunoglobulin(IV Ig) in infected children who have had two or
more serious bacterial infections within 1year.
 Antifungal drugs such as Nystatin, ketoconazole, fluconazol and clotrimazole may be
given in cases of persistent or recurrent oral candidiasis.

POLIOMYELITIS:

Poliomyelitis is a highly infectious disease caused by three serotypes of poliovirus.

Symptoms: febrile illness, aseptic meningitis, paralytic disease, and death.

Modes of Transmission:

• Oral-oral infection: - direct droplet infection.

• Faeco-oral infection: – Food-borne (ingestion) – Hand to mouth infection.

43
 Prevention:

General prevention:

• Health promotion through environmental sanitation.

• Health education (modes of spread, protective value of vaccination). Active immunization:

– Salk vaccine (intramuscular polio trivalent killed vaccine).

 Sabin vaccine (oral polio trivalent live attenuated vaccine).

MALARIA:

It is caused by four Plasmodium species.

•P. falciparum

•P. vivax

•P. malariae

•P. ovale

Symptoms:

 Chills
 Fever
 Internal fever
 Body ache.
Mode of transmission: It is transmitted by female anopheles mosquito, sporozoites injected
with saliva & enter circulation then infected person.

Life cycle of malaria parasite:

 sporozoites invade salivary glands.

 fusion of gametes in gut.
 gametocytes infective for mosquito.
 merozoites invade RBCs.
 exoerythrocytic schizogony.
 invade liver cells.
 sporozoites injected during mosquito feeding.

Prevention:

• Use a spray containing permethrin on clothing.

• Apply insect repellents regularly in cream, spray or gel form that contain
diethyltoluamide (DEET).

44
 • Use coils and mats impregnated with insecticide in closed rooms to repel the
mosquitoes. • Malaria prophylaxis are taken.
• Anti-malarial drugs are used such as chloroquine.

MEASELES:

It is caused by agent- RNA virus (Paramyxo virus family, genus Morbillivirus ).

Symptoms:

 Diarrhea
 Pneumonia
 Convulsions
 SSPE (sub acute sclerosing panencephalitis).

• Modes of transmission: Transmitted by Droplet infection 4 days before and 4 days after
rash.

PREVENTION:

• Live attenuated measles virus (Edmonston-zagreb strain) Propagated on human diploid cell.
(0.5 ml of vaccine)

• Measles vaccine has to be given at 9 months.

• If Measles vaccine is given a 3 months gap is advisable to give MMR vaccine.

• The vaccine should be reconstituted with the diluent supplied (Sterile water for injection)
using a sterile Auto disabled syringe with needle.

• After reconstitution the vaccine should be used immediately.

• If the vaccine is not used immediately then it should be stored in the dark at 2° - 8°C for no
longer than 8 hours.

TETANUS:

A Neurological disease characterised by increased muscle tone & spasms Caused by

CLOSTRIDIUM TETANI.

• It is found worldwide in soil, in inanimate environment, in animal faeces & occasionally

human faeces.

Symptoms:

45
  Muscle rigidity
 Dysphagia
 Rigidity
 Spasm
 Trismus
 hyperpyrexia.

• Mode of transmission: Infection is acquired by contamination of wounds with tetanus

spores.

Prevention:

• Goal is to eliminate the source of toxin, neutralize the unbound toxin & prevent muscle
spasm & providing support - support

• Admit in a quiet room in ICU

• Continuous careful observation & cardiopulmonary monitoring.

• Minimize stimulation.

• Protect airway.

•Preparations: combined vaccine : DPT. Monovalent vaccine : plain / formol toxoid tetanus
vaccine.

RABIES :

• Rabies is a viral disease that causes acute encephalitis in warm blooded animals, it can be
transmitted to humans from other species.

• The rabies virus infects the CNS, cause disease in brain & death.

• Symptoms:

• Partial paralysis
• Anxiety
• Insomnia
• Confusion
• Agitation
• abnormal behavior
• terror

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 • hallucinations
• progressing to delirium.

• Modes of transmission: Rabies may also spread through exposure to infected domestic
animals, groundhogs, bears, raccoons and other wild carnivorans. Small rodents such
as squirrels hamsters,  guinea pigs, gerbils, chipmunks rats and mice.

 Prevention:

• Vaccinating dogs, cats, rabbits, and ferrets against rabies.

• Keeping pets under supervision.

• Not handling wild animals or strays.

• Contacting an animal control officer upon observing a wild animal or a stray, especially if
the animal is acting strangely.

• If bitten by an animal, washing the wound with soap and water for 10 to 15 minutes and
contacting a healthcare provider to determine if post-exposure prophylaxis is required.

Management of wounds and drainages:

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