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Childhood diseases 2. Infections

By Robert Scott-Jupp, MB BS, FRCPCH

We continue our series on childhood diseases with a look at the types of infections that can occur in children under the age of 16. This article outlines the management of a number of infections and emphasises the occasions when it is important for a pharmacist to refer the patient for a medical opinion
The first article covered gastrointestinal problems

Over the past few decades, the pattern of infectious disease in the developed world has changed enormously.1 Bacterial infections are now much less prevalent, and most infections in children are viral in origin. Fungal infections and parasitic infestations are also less common and usually minor. The burden of infectious disease on childhood mortality has similarly reduced greatly, so that infectious deaths outside the neonatal period are now a rarity. These improvements probably arise from improved living conditions and nutrition, immunisation programmes and changes in the virulence of some bacteria, rather than from the use of antibiotics.
Most viral illnesses are self-limiting and indications for antiviral medication are few. However, it is frequently difficult for doctors to rule out the possibility of a bacterial infection on clinical examination, especially in children. Consequently, antibiotics are prescribed, and the subsequent spontaneous improvement of a viral illness convinces parents that the treatment must have “worked.”
The most common type of viral illness is an upper respiratory tract infection (URTI). It is worth noting that it is considered normal for a healthy child aged between one and five years to contract a viral illness every four to eight weeks, more often in winter.2


Immunisation (vaccination) has led to the elimination of several previously endemic diseases. New vaccines are being added to the list at regular intervals, the most recent being the type C meningococcal vaccine. The current United Kingdom schedule is shown overleaf (Table 1).3,4

Table 1: UK childhood immunisation schedule 2000
2 monthsDiphtheria/tetanus/pertussis (DTP)
Haemophilus influenzae B (Hib)
Oral polio vaccine (OPV)
Meningococcal group C conjugate vaccine (MCCV)
3 monthsDTP
4 monthsDTP
12-15 monthsMeasles/mumps/rubella (MMR)
3-5 yearsDT and OPV booster
MMR booster
10-14 yearsBCG
13-18 yearsDT and OPV booster
MCCV boosters - may become routine

Common reactions after any vaccine include soreness, redness and swelling at the site of injection, mild fever, rash and irritability. Rarely, inconsolable crying and fits can occur. The mild reactions can be treated effectively with paracetamol, which is licensed for this purpose from two months of age, but more severe reactions require a medical opinion.

Vulnerable children

Certain groups of children (listed below) are particularly vulnerable to infections and, in these, antibiotics should be prescribed more readily, often in higher doses and for longer periods. The parents of these children are usually well-informed about their particular needs.

  • Children on chemotherapy for malignant conditions, who are particularly susceptible to overwhelming bacterial infection
  • Children with a range of congenital immunodeficiency syndromes, whose susceptibility to different infection types varies
  • Children with AIDS; most of these will have acquired the human immunodeficiency virus “vertically” from HIV-positive mothers
  • Children on long-term oral steroids
  • Children receiving immunosuppressants following a transplant

All the above groups are particularly prone to severe chickenpox and, if exposed, may be prescribed varicella-zoster immunoglobulin by injection, and/or oral aciclovir. Other vulnerable groups are:

  • Children with cystic fibrosis, who are susceptible to severe, damaging chest infections
  • Children with serious symptomatic congenital heart disease

Young infants Babies under one year are less susceptible to common infectious diseases than older children because they retain maternal antibodies (acquired across the placenta during pregnancy), and are, therefore, to some extent immune to any infection that their mother is immune to. However, when such babies do succumb to infections, they can often become unwell rapidly because, until they reach one year of age, their own immune systems are relatively less well-developed. Symptoms and signs are often non-specific, and it may be difficult to know what sort of illness is developing.
Any young infant who suddenly goes off his or her feeds, becomes irritable, pale or mottled, develops a fever, difficulty in breathing, or profuse diarrhoea or vomiting, should be seen by a doctor without delay.

Symptoms and signs of infectious diseases

Many conditions have their own characteristic presenting features, but some general points can be made.

Fever Most infective agents can cause pyrogens to be produced. These are released into the bloodstream and affect the body’s temperature regulation mechanism. Body temperature then rises because of a combination of increased heat production from raised metabolism and reduced heat loss. There is controversy over whether or not increased temperature is a useful biological mechanism in fighting infection.5 Some evidence has shown that some micro-organisms reproduce more slowly at higher temperatures.6 However, in practice it is often the fever that makes the child appear unwell and causes distress to both child and carer. It is difficult to refuse requests to do something to bring the temperature down. Furthermore, about one in 20 children will be prone to developing a febrile convulsion. These are brief, generalised fits with loss of consciousness that usually occur at the beginning of a febrile illness while the temperature is rising rapidly. They are benign and do not develop into epilepsy, but can be frightening and distressing. Parents are normally advised to take steps to try to avoid them by reducing the fever.2

Rashes Rashes are many and varied, and it is often difficult to match a rash to a specific infection. Many viral illnesses produce a rash (exanthem), which often will be red, blotchy and slightly raised, and most obvious on the face and trunk. It may appear a day or two after the fever when the child is improving. Some of the more easily recognised rashes are described below, but there are many others. Topical treatment for viral exanthems is not normally recommended. The only rash in an ill child which really matters, in that prompt recognition and referral may save the child’s life, is that of meningococcal septicaemia (see below).

Behavioural symptoms Any child with a fever, or who is in pain, will become irritable and bad tempered, or listless and lethargic. The child will eat and sleep poorly. It may be these symptoms, rather than the fever itself, which lead to the parent seeking advice. Even in the absence of a fever, a child with an infection may be tired, fretful or “not himself”. Such symptoms may continue for days or weeks after many acute infections. No treatment is recommended apart from adequate rest and a normal, balanced diet. Tonics, vitamins and special nutritional supplements are unnecessary unless the child has an obvious dietary deficiency.

Recognising the seriously ill child

Some parents may seek advice from a pharmacist rather than a doctor when their child is seriously ill, so it is important that pharmacists are able to recognise these illnesses. The warning signs are:

  • Unconsciousness or drowsiness that is excessive for the child’s normal pattern at that time of day
  • In babies and toddlers, floppiness and indifference to surroundings
  • In older children, confusion, delirium or disorientation with fever
  • Severe headache, and/or inability to bend the neck, with fever, suggesting meningitis
  • Symptoms that may suggest a severe infection causing septicaemic shock include skin that is cold to the touch in spite of a fever, mottled in appearance, or where there is poor circulation to the fingers and toes in a febrile child
  • A rapidly progressing dark purple, blotchy rash anywhere on the body, that does not disappear when a glass is pressed up against it, suggests meningococcal septicaemia (see below)
  • In children with breathing difficulties (croup, asthma, bronchiolitis, etc), severe recession (“tugging-in” beneath and between the ribs with each inspiration), inability to talk, distress and exhaustion

Rash with fever

Chickenpox Chickenpox is caused by a herpes virus, the varicella-zoster virus (VZV). This is the only classic childhood exanthem which is not now routinely immunised against. It remains very common. Chickenpox is highly infectious from person-to-person contact. The incubation period is relatively long, from 10 to 21 days. The fever usually precedes the rash by a day or two. The rash is quite distinctive, with crops of small, raised, red spots that develop into vesicles (blisters) of varying size, lasting three to five days. The rash occurs more on the head and trunk than on the limbs and is very variable. Mild cases may have no spots at all, while, in severe cases (especially in immunodeficient children), the child may be completely covered.
The child is infectious from two days prior to the eruption of the rash until all the spots have crusted over. Most children with chickenpox recover uneventfully, with no specific treatment. In severe cases, there can be a number of important complications:

  • Bacterial superinfection of the spots with Staphylococcus aureus- this is common and may lead to permanent skin scarring. This infection responds to topical or oral flucloxacillin
  • Chest infection, either from a primary viral pneumonitis, from the varicella virus, or a secondary bacterial infection - this can be serious and may require antiviral and/or antibiotic therapy
  • Encephalitis - this may be serious, but is often surprisingly mild and self-limiting (Some children develop a transient loss of balance and co-ordination due to involvement of the cerebellum. This is benign and requires no treatment)
  • Hepatitis
  • Arthritis
  • Chickenpox - this commonly has a non-specific suppressive effect on the immune system of otherwise healthy children, making them more susceptible to any other infection for a few weeks afterwards

Chickenpox in pregnancy may be harmful to the foetus, and is particularly dangerous if contracted just before delivery when chickenpox in the newborn, acquired from a mother who has not had chickenpox, may be fatal. If the mother is definitely immune, however, there is no risk to the baby. Any pregnant woman or newborn baby who has been in contact with, or is showing signs of, chickenpox should be referred to a doctor immediately.
In the majority of children with uncomplicated chickenpox, treatment, if any, is purely symptomatic. Antipyretics can be used for the fever, and antihistamines or topical applications for the itching. Calamine lotion, popular in years gone by, is probably ineffective but, if used, should be given as an oily, rather than a water-based, lotion to prevent drying. Aciclovir, a specific antiviral treatment, is safe and effective in children but unnecessary, and should be reserved for those with compromised immunity or severe disease.6
In children, it is not normally desirable to try to prevent infection with chickenpox because the infection is more severe in adults. It is better that children contract the disease and acquire natural immunity while young.
A vaccine has been available for some years but has not been widely used because of fears that, if given in childhood, it could wear off and lead to severe outbreaks among adults.

Shingles (Herpes zoster) After primary chickenpox infection, the varicella zoster virus may lie dormant for many years in the dorsal root nerve ganglia, adjacent to the spinal cord.The virus may then erupt at any time in the skin area supplied by that ganglion, in the form of a localised, painful, red, blistering rash known as shingles. It is less common in children than in adults. It may keep recurring, especially when immunity is suppressed. Susceptible people can contract chickenpox from people with active shingles, but it is not possible to “catch” shingles from anyone. Treatment is with topical aciclovir, which is effective if started early enough.

The following viral illnesses are similar in that they are benign and self-limiting. Precise diagnosis is difficult, but usually unnecessary. Many other viruses can cause similar symptoms and not all are listed. Treatment is generally not needed, but antipyretics can be given as required. Antibiotics are of no value unless there is an obvious secondary bacterial infection.

Measles With the success of universal immunisation this infection is now becoming rare. Many children thought to have typical measles may have one of a number of different viruses that may mimic it, eg, rubella and roseola infantum. In measles, after two or three days of fever, coryzal symptoms and misery, the typical rash emerges - a red, confluent, blotchy rash that begins at the hairline and progresses down to cover the whole body. The rash lasts three days. Complications are common and include otitis media, laryngitis, pneumonia and, rarely, a fatal, progressive encephalitis.

Rubella (German measles) This is characterised by symptoms of a cold, fever, and then, about two days later, a generalised red rash, and swelling of the lymph nodes. Its main significance is the high risk of damage to the foetus, if contracted by women in early pregnancy. For this reason, all infants are now routinely vaccinated against rubella and, therefore, the infection is now uncommon.

Erythema infectiosum (slapped cheek disease, fifth disease) This infection is caused by a parvovirus. The most characteristic feature is the prominent red rash on the face, hence the “slapped cheek” description, followed by a generalised rash. The preceding fever is variable and may be absent. As with rubella, its significance is in the potential harm to the foetus in pregnancy.

Pharmacists who encounter children who may have either rubella or erythema infectiosum, or chickenpox, should warn them about the risks of contact with pregnant women, referring to a doctor for investigation if there is concern.

Roseola infantum (exanthem subitum, sixth disease) This infection is common and affects children under five years of age. Fever and irritability are followed after three to six days by a sudden florid, red blotchy rash over the whole body lasting from a few hours to three days. It is caused by human herpes virus 6 or 7.

Hand, foot and mouth disease This benign exanthem is caused by a Coxsackie virus. A mild fever is followed three to five days later by a characteristic vesicular rash inside the mouth and on the tongue, hands and sometimes the feet. It resolves after about a week.

Scarlet fever Scarlet fever is caused by certain strains of the bacterium Streptococcus. It nearly always develops from a painful throat infection, often with swollen tonsils. Within a day of the fever, the characteristic rough, dark red rash appears over the whole body, except the area around the mouth. The tongue becomes swollen and coated with white fur. Untreated, the rash and fever last three to four days. The organism is always sensitive to penicillins, and treatment is with oral penicillin V, amoxycillin or erythromycin.
This manifestation of streptococcal infection has become much less common in recent years, perhaps because the organism itself has changed, and many cases labelled as “scarlet fever” are now more likely to be viral infections or Kawasaki disease (see below).

Meningococcal disease This serious bacterial infection still causes a significant number of deaths and permanent disability. It is crucial to recognise and treat it early. The meningococcus organism causes both septicaemia and meningitis, but it is the septicaemia that kills rapidly, and that also causes the characteristic rash. Typically, the septicaemia presents as fever and general malaise, not necessarily with symptoms of meningitis. The rash may then appear rapidly anywhere on the body. The rash is blotchy and dark purple, like bruising under the skin, and does not fade (blanch) when a glass is pressed against it.
Any unwell child presenting with a new, developing, dark purple rash should be sent immediately to hospital. First-aid treatment in primary care is intramuscular penicillin, but this should not delay transfer of the child to hospital. Household contacts of definite cases may need to be given prophylactic rifampicin. The recently introduced vaccine prevents only the C strain of meningococcus. Cases caused by the more common B strain still occur.

Kawasaki disease This uncommon but important condition mimics infectious disease, but, so far, no causal organism has been identified. A high fever lasting at least five days is accompanied by an erythematous rash, conjunctivitis, a swollen red tongue and enlarged lymph nodes. After about two weeks, there is a characteristic peeling of the skin of the palms and soles. Its importance is in the occurrence of cardiac complications (aneurysms of the coronary arteries which, rarely, can be fatal). Complications can be prevented by early recognition and specific treatment with IV immunoglobulin. Antipyretics are of limited effectiveness.7
Any child presenting with fever, rash and malaise persisting for five days or more should be referred for a medical opinion.

Rash without fever

Herpes simplex Oral cold sores develop in children just as in adults, and may develop into a generalised stomatitis. Treatment is with topical aciclovir given early.

Skin diseases Rashes caused by skin diseases, such as impetigo, scabies, molluscum contagiosum, warts and verrucae, napkin rash, fungal infections, eczema and dermatitis will be discussed in the next article in the series.

The following less common, but significant rashes, are not infections as such but may occur following any viral illness:2

Henoch-Schonlein purpura (HSP) A characteristic, dark red rash, sometimes with bruising, occurs on the lower legs and buttocks, and spreads upwards. It is immunological in origin and can lead to joint, bowel and renal complications. A medical opinion is needed. There is no specific treatment.

Immune thrombocytopenic purpura (ITP) Again immunological in origin, in ITP abnormal antibodies cause blood platelets to be consumed, leading to excessive bleeding and bruising. The rash is widespread, painless and looks like numerous small purple bruises. Hospital diagnosis and treatment are needed.

Fever with sore throat or neck swelling

The term “viral upper respiratory tract infection” is commonly used to describe a wide spectrum of childhood illnesses, and more precise diagnosis is not usually necessary. The advice and treatment given is much the same. These viruses include colds (coryza), influenza, tonsillitis, pharyngitis, etc. Treatment is symptomatic.

Bacterial tonsillitis Bacterial tonsillitus is difficult to distinguish from a viral URTI, and, in both, children present with fever and swollen red tonsils that may be pitted and covered in pus. Many doctors prescribe antibiotics in this situation, although the evidence for any benefit is marginal.8

Glandular fever (infectious mononucleosis) This is most common in older children and young adults, but can occur at any age. It is usually caused by the Epstein-Barr virus (EBV), but other organisms can cause a similar illness.
Glandular fever starts as a straightforward sore throat and fever, with swelling of the lymph nodes in the neck. Sometimes the swelling can be considerable. However, resolution is slow, and symptoms can grumble on for many weeks. There is usually excessive lethargy and fatigue, out of proportion to the apparent severity of the illness, and susceptibility to numerous other minor complaints.
Diagnosis is usually clinical, but blood tests can sometimes confirm it. Improvement is usual over three to six months (less in younger children) but a few will go on to develop “post-viral syndrome” or “chronic fatigue syndrome”. Treatment is supportive and symptomatic. Antibiotics are unhelpful, and ampicillin and amoxycillin can cause a specific rash in this condition.
Any child with sore throat, neck swelling or excessive tiredness that has gone on for more than two weeks should see a doctor.

Mumps With universal immunisation against mumps, this infection is now uncommon. It is caused by a paramyxovirus. Fever is accompanied by painful swelling of one or both parotid glands (these are salivary glands not lymph nodes), seen over and behind the angle of the jaw, and extending backwards behind the earlobe.
Symptomatic treatment only is required, and recovery is usually uneventful over a week. Complications include encephalitis, pancreatitis, and orchitis (infection of the testes in post-pubertal males that may cause infertility), which is the main justification for the immunisation programme.

Cervical lymphadenopathy Painless swelling of the lymph nodes (or glands) in the neck accompanies many viral and bacterial infections, and normally needs no particular attention. However, sometimes there is concern about the possibility of an unusual infection within the node (eg, atypical tuberculosis) or cancer. These complications are rare in children, and such swellings only need to be referred if they become very large, fail to get smaller following the acute infection, or if they become inflamed and painful.

Respiratory infections

Croup (laryngitis, laryngo-tracheo-bronchitis) Croup is a common childhood complaint which is nearly always viral, and sometimes, but not always, occurs during an URTI.
The term “croup” refers to the characteristic noise, inspiratory stridor, that can come on quite suddenly, often at night, and cause great alarm. It is accompanied by signs of respiratory distress (see above - recognising the seriously ill child), and a “barking” cough. Most children get better rapidly but sometimes hospital admission is required. Traditional treatments include inhaling steam and inhaling cold, outside air. Oral or inhaled steroids are effective in severe cases.9

Pneumonia, bronchopneumonia, lower respiratory tract infection (LRTI) These terms cover a broad spectrum of illnesses, nearly all caused by bacteria. The symptoms are:

  • Fever, often high and unresponsive to antipyretics
  • Cough, which may not produce sputum in the early stages (young children cannot spit out sputum, even with a productive cough)
  • Localised chest or abdominal pain, in lobar pneumonia
  • Respiratory distress, ie, breathlessness, rapid breathing and rib recession

The infection usually develops as a result of organisms from the upper respiratory tract finding their way into the lungs, often during a viral URTI, rather than direct person-to-person infection. The most common organisms are Haemophilus influenzae in younger children, and Streptococcus pneumoniae in older children but many others may cause a similar illness.
Diagnosis is either clinical, from characteristic chest sounds, or by a chest X-ray. It is unusual to be able to identify the organism responsible, so antibiotic treatment is empirical. Broad-spectrum penicillins, cephalosporins and macrolides are equally effective. More unwell children and those with an underlying condition (see above - vulnerable children) may require hospital admission for intravenous antibiotics. Chest physiotherapy helps clear secretions during the recovery phase.
Atypical pneumonia caused by mycoplasma organisms presents with a less acute, more chronic course, has characteristic chest signs and responds only to macrolide antibiotics.

Bronchiolitis Bronchiolitis refers to a common, specific viral LRTI that occurs only in infants under one year of age, and is highly seasonal, occurring only in the winter months. About 80 per cent of cases are caused by the respiratory syncytial virus, which is a common cause of winter colds in older children and adults.
Most infants developing bronchiolitis present with a short history of poor feeding, rapid, noisy breathing and a characteristic wheezy, chesty cough. Younger infants may be more severely ill and have periods of stopping breathing (apnoea). Any infant with these symptoms should see a doctor, but only the more severe cases need hospital admission.
Diagnosis is usually straightforward from the clinical signs. The illness runs a predictable course and resolves over five to six days. For mild cases no treatment is needed, and antibiotics are unnecessary. A specific antiviral treatment, tribavirin (ribavirin), is available in hospital for RSV bronchiolitis but is rarely indicated.

Asthma and recurrent infant wheezing Many children are wrongly diagnosed as having recurrent chest infections when they suffer from asthma, or its equivalent, in infancy. This is particularly common in those who have had bronchiolitis. The difficulty arises because asthma attacks are most often triggered by a viral URTI, causing fever and malaise, and the symptoms and signs may be similar to those of a chest infection (ie, cough, production of sputum, noisy breathing and respiratory distress). In asthma, however, the characteristic wheeze is heard.
The distinction is important because, in asthma, there is normally no bacterial infection and antibiotics are useless, while specific asthma treatment (inhaled bronchodilators or steroids) may be of great benefit. Any child with recurring chesty symptoms or wheeze should be referred to a doctor with the suggestion that this may be asthma.

Pertussis (whooping cough) Unlike the other diseases that are routinely immunised against, pertussis remains quite common. The vaccine is less effective than the others, and babies under two months - the age of the first immunisation - are particularly vulnerable. Babies often contract the infection from a partially immune older sibling who may have no more than a slight cough.
Infants may present with dramatic, spasmodic coughing fits, during which they find it impossible to breathe in, and they may go blue or vomit. Young babies may even stop breathing, and the disease can be fatal. The characteristic “whoop” is heard only in older children. Fever and malaise are generally mild, but the cough can be very troublesome and can go on for several weeks. The causative organism, Bordetella pertussis, is a bacterium sensitive to erythromycin, but unfortunately treatment is only effective if given early. Once established, no treatment has much effect.
Any baby or young child that has a spasmodic cough with vomiting should see a doctor. Babies will generally need hospital admission, but older children can be looked after at home. Any infant household contact of a child with possible pertussis symptoms should be given prophylactic erythromycin, even if completely asymptomatic.

Tuberculosis (TB) TB is still rare in the UK, except where the child or its parents come from an area where the disease is endemic. The symptoms and signs of pulmonary TB are the same as in adults (chronic cough, weight loss, night fevers) except that children may not produce sputum.
Asymptomatic primary infection in children who have had contact is common, can be recognised from chest X-ray changes and the tuberculin skin test (Heaf, Mantoux), and requires treatment. Treatment is for three to nine months with a combination of antituberculous drugs.10 Immunisation with BCG is not routine in the UK and offers only partial protection.

Abdominal infections

Gastrointestinal infections Viral and bacterial gastroenteritis were discussed in the first article in the series (PJ, July 8, p52).

Viral hepatitis Viral hepatitis is similar in children and adults. Hepatitis A is acquired by ingesting contaminated material, and after a long incubation period of 15 to 48 days, causes fever, malaise and abdominal pain, followed by diagnostic dark urine and then jaundice. It is the only common cause of jaundice outside the neonatal period. Recovery is usually complete two to three weeks after the onset of jaundice. No treatment is needed.
Hepatitis B and C in childhood are contracted only through contaminated blood products, or through mother-to-child (vertical) transmission. There may be no symptoms apparent but both forms can lead to chronic liver disease. There is no specific treatment, but there is a specific vaccine for infants at risk of hepatitis B.

Urinary tract infection (UTI) UTIs occur when otherwise harmless bacteria that colonise the skin (usually E coli) invade the urethra and become established in the bladder or kidneys. Beyond the “nappy” age, UTI is much more common in girls than boys. In older children, UTI causes typical symptoms of pain on passing urine, frequency and incontinence, while infants may have much less specific symptoms of fever, malaise and vomiting. Its significance in younger children is that it may be a sign of an underlying congenital kidney problem, hitherto undiagnosed, and further investigation in hospital is essential. To prevent progressive kidney damage, some such children are kept on a long-term, prophylactic antibiotic, such as trimethoprim.
Diagnosis of UTI requires a urine specimen, and treatment is with an antibiotic to which the organism is found to be sensitive. Symptoms of UTI at any age should prompt a medical referral.

Other localised infections

Meningitis The bacterial form of this worrying disease is more serious than the viral form, but it can be difficult to distinguish between them. In either, there may be a preceding mild URTI, followed by, in older children, a high fever, blinding headache, vomiting, drowsiness and loss of consciousness. On examination there is the characteristic reluctance to move the head, and neck stiffness (“meningism”).
The meningococcal form of bacterial meningitis may be accompanied by signs of septicaemia (see ”recognising the seriously ill child”) and the rash (see ”meningococcal disease”). In young children, however, the signs of meningism may be absent and the fever mild, and the condition is suspected just from the child’s unwell, pale, floppy, drowsy appearance. Other less serious infections can mimic meningitis.
The only way to confirm or rule out the diagnosis with certainty is by a lumbar puncture carried out in hospital. Apart from the meningococcus, causative bacteria include Streptococcus pneumoniae and Haemophilus influenzae, and a number of viruses have been implicated. Treatment is with potent intravenous antibiotics, even if the infection may be viral, until culture results are known.
Any child with fever, headache and neck stiffness, or any infant that is floppy, pale and drowsy, requires immediate hospital assessment. Oral antibiotics should never be given where meningitis is a possibility, as this may mask the diagnosis. Prophylactic rifampicin may be recommended for close household contacts.

Otitis media Otitis media, a common infection, is really a type of URTI, because the middle ear chamber is continuous with the upper respiratory tract through the Eustachian tube. This infection, therefore, frequently follows a cold.
Typical symptoms are fever, pain and misery, deafness and rubbing of the ears. There is a discharge from the ear only when the eardrum perforates, releasing the infected fluid that was under pressure in the middle ear, with considerable relief of symptoms. Diagnosis is by observing a red, bulging eardrum with an auroscope. As with sore throats, it is difficult to distinguish viral from bacterial infection, and so antibiotics active against organisms such as Haemophilus influenzae are often prescribed. Most cases would improve on symptomatic treatment with analgesics only. Many people believe that antibiotics prevent complications, such as deafness from chronic serous otitis media, but there is little evidence to support this.11

Conjunctivitis This is the commonest eye infection in children and usually follows a viral URTI. The white of the eye becomes red, sore and inflamed, and there is often a yellow discharge. Again, distinguishing bacterial and viral types can be difficult clinically, and a topical antibiotic ointment, such as chloramphenicol, is usually prescribed.

Cellulitis An invasive infection under the skin can develop anywhere in the body. It usually follows a breach in the skin, such as a cut or a blister, or spreads from a boil or spot. There is rapid onset of throbbing pain, swelling and redness that may “track” along the skin to the nearest lymph node. In the eye, it may follow conjunctivitis and cause a particularly nasty swelling (periorbital cellulitis). It is nearly always caused by the bacterium Staphylococcus aureus. Treatment is with antistaphylococcal antibiotics, such as flucloxacillin. Early cases can be treated orally, but more established infections require hospital admission and IV antibiotics.

Septic arthritis and osteomyelitis These serious bacterial infections can occur in children. A previously well child develops fever and malaise with a painful swollen bone or joint which they are reluctant to move despite the absence of any injury.
Diagnosis may be difficult, since other less serious non-infective conditions may present similarly. Hospital investigation is required, and any of a number of bacteria may be found to be responsible. Treatment is with prolonged IV antibiotics. Any child presenting with a swollen painful joint or limb for no obvious reason should be referred to a doctor.

Dr Scott-Jupp is consultant paediatrician, Salisbury District hospital, Odstock, Salisbury

Credit for Learning: 2
This article forms the basis of questions under the PJ/College of Pharmacy Practice Credit for Learning scheme


1.Davies EG, Elliman DAC, Hart CA, Nicoll A, Rudd PT. Manual of childhood infections. London: WB Saunders, 1996.
2.Valman HB. The ABC of one to seven. 3rd ed. London: BMJ publishing, 1993.
3.Salisbury DM, Begg NT, editors. Immunisation against infectious disease. London: HMSO, 1996.
4.British National Formulary. No 39. London: British Medical Association/Royal Pharmaceutical Society of Great Britain. March, 2000.
5.Hull D. Fever - the fire of life. Arch Dis Child 1989;64:1741-7.
6.Jenks PJ, Breuer J. Aciclovir in chickenpox. Arch Dis Child 1996;74:184.
7.Campbell AGM, McIntosh N, editors. Forfar and Arneil’s Textbook of paediatrics. 5th ed. London: Churchill Livingstone, 1998.
8.Fahey T, Stocks N, Thomas T. Systematic review of the treatment of upper respiratory tract infection. Arch Dis Child 1998;79:225-30.
9.Klassen TP, Tillett AJ, Gould JDM, Cates C, Jothimurugan S, et al. Effectiveness of glucocorticoids in treating croup. BMJ 1999;319:1577.
10.Medical Research Council tuberculosis and chest diseases unit. Management and outcome of chemotherapy for childhood tuberculosis. Arch Dis Child 1989;64:1004-12.
11.Del Mar CB, Glaziou PP, Hayem M. Are antibiotics indicated as initial treatment for children with acute otitis media? A meta-analysis. BMJ 1997;314:1526.

Further reading

1.Johnson G, Hill-Smith I, Ellis C. The minor illness manual. Oxford: Radcliffe Medical Press, 1997.
2.Royal College of Paediatrics and Child Health. Medicines for children. London: RCPCH publishing, 1999.

Citation: The Pharmaceutical Journal URI: 20002198

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    Pharmacy Registration Assessment Questions 3

    Pharmacy Registration Assessment Questions 3 is the third volume in a series that follows on from the previous, highly popular Pharmacy Registration Assessment Questions 2. It features more than 400 entirely new, closed book and calculation questions. It can be used in conjunction with the previous volume or on its own.

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