6 year old Ella has been sent home from school as she has been itching all day. When her mum, Val, picked her up she noticed a few spots and thought she better get them checked out. You see the classical rash of chickenpox and reassure of the relatively benign nature of the illness and discourage her from holding any ‘chickenpox parties’. As you explain that it would be wise to keep her away from babies, the immunocompromised and pregnant women, Val pauses, looks up at you and says, “I’m 15 weeks pregnant!”.
Alfie, 6, is playing at local playground under Mum’s watchful eye. He goes down the slide and jumps off, landing on his hands and feet. He starts to cry and shows his Mum a syringe lying in the bark and a needlestick injury of his left hand. Mum is distraught when she brings Alfie into your department. What next?
Needlestick injuries in the community are a source of great concern for parents.
There is one reported case of seroconversion of Hepatitis B in children.
The actual chance of viral transmission is very low.
Ensure your patient is immunised!
High risk patients should be discussed with your local infectious disease team for consideration of post-exposure prophylaxis.
Educate children not to handles needles – 2/3 CANSI’s are from intentional handling!
There is a risk of transmission of Hepatitis B, Hepatits C or HIV from a community-acquired needlestick injury (CANSI). Although the risk is very low, this is a source of significant concern to parents. Several studies lasting from several months to nearly two decades in length have looked at the epidemiology of CANSIs. These studies, undertaken in Melbourne, Montreal, Birmingham and Perth broadly agree that;
~65% CANSIs occur in boys
Mean age is around 6-8 years
In two-thirds of CANSIs, the syringe or needle was intentionally handled by the child
The most common site of injury was the hand
About a quarter of wounds bled
In the Melbourne study CANSIs often occurred in public places in parks (30%), in the street (18%), in carparks (5%) and at the beach (6%). In Montreal, CANSIs occurred predominantly in the street (30%) and in parks (24%). Whilst the obvious difference is the lack of beaches in downtown Montreal, it’s also worth noting that a number of CANSIs must also occur in private residences.
So, what’s the risk?
Each of the papers described the baseline prevalence of HBV, HCV & HIV in their population, as well as the same prevalence within the IVDU community. None of the papers reviewed (total patients 416) reported any cases of seroconversion to Hep B, Hep C or HIV. There is a single case report of seroconversion to Hepatitis B after a CANSI in a child, reported in Barcelona in 1997. In 1999, Bowden et al, proposed conversion rates in the Victorian population to be around 6-30% for HepB, 0-7% for HepC and 0.4% HIV.
Although the risk is largely theoretical, factors that are considered to be high risk for acquired infection are:
known needle source user
needle user known to be infected
a deliberate assault
a large-volume injection
wide bore, hollow needle
blood in or on syringe
deep wound (vs superficial)
These children should be discussed with your local infectious diseases team for consideration of HIV post-exposure prophylaxis, after their initial management.
What is the initial management?
Wash the wound with soap and water.
Ensure the syringe/needle has been safely disposed
History of note:
Time, date and location of CANSI
Type of exposure?
What did the needle look like?
What kind of needle was it?
Is the child immunised? (specific details of each)
Were there other children around that may have an unreported CANSI?
Is this a high-risk exposure, as outlined above?
Take blood for HepB Surface antibody (HepB AbS) in a serum gel tube to store.
Not required if immunised against tetanus in last five years.
If unimmunised, for immunoglobulin and vaccine.
Otherwise, if previously immunised, for booster dose.
Hepatitis B vaccination +/- Hep B immunoglobulin
If unimmunised, give first dose of vaccine and HepB Ig within 72 hours of exposure (in different limbs!)
If immunised, check titre & give booster.
Luckily, Alfie is immunised for both Hepatitis B and Tetanus. After a thorough wash of his hand, and some relatively obliging blood tests, he’s ready for home. His Mum asks if he needs any other medicine to reduce the risk of “catching one of those viruses you mentioned.”
Post-exposure prophylaxis : Hepatits B immunoglobulin
There is a larger argument that there are risks associated with Hepatitis B immunoglobulin, including that of acquired infection, which must be weighted against the potential benefits of preventing a seroconversion when this may be highly unlikely in the first instance.
In the UK, Hep B immunoglobulin is only recommended in patients with exposure to known Hepatitis B source, although there is some leeway depending on the clinical circumstances. The Auckland District Health Board (ADHB), in NZ states “Administration of hepatitis immune globulin (HBIG) is not indicated if the child has completed a standard three-dose regimen of hepatitis B vaccination.” RCH Melbourne advises to offer HBIG to all unimmunised children with CANSI. There remains controversy in this component of management.
Hence, if the decision is made to treat, give HBIG within 72hrs.
(In Australia, Hep B Immunoglobulin is provided by the Red Cross Blood Service.)
Give the HBIG in a different limb to the Hep B booster you’ve just administered!
<30kg – give 100 iu IM injection
>30kg – give 400 iu IM injection
Post-exposure prophylaxis: HIV
The papers reviewed had no reports of viral transmission of HIV from a CANSI. All mentioned antiretroviral therapy as potential post-exposure prophylaxis for HIV exposure. There were no clear guidelines on which children should be offered HIV-PEP; the ‘high-risk’ patients identified in the list above were more likely to receive prophylaxis. In the Montreal study, of the 210 patients who presented thereafter, an offer of prophylaxis to 87 patients (41.4%) was documented, and 82 (94.3%) of these patients accepted. Prophylaxis was zidovudine and lamivudine for 28 days in 74 patients (90.2%), additionally eight patients were also prescribed a protease inhibitor (nelfinavir, indinavir or ritonavir). Papenburg and colleagues go on to describe the rates of adverse effects from these medications. Consideration of HIV:PEP should be discussed with the local infectious diseases team.
Follow up & counselling
Although the risk of seroconversion is low, it’s important not to underestimate the stress a needlestick will place on the child and family. Provide reassurance that the risk of viral transmission from a CANSI is very low. Don’t forget some written information about completing a catch-up course of immunisation. Contact your local paediatric infectious disease team; they may be happy to provide additional follow-up or counselling. That being said, always consider the prevalence of the blood-borne viruses where you work! The majority of DFTB readers are working in the Australasian, United Kingdom & North American settings; within and without these areas, the prevalence of Hep B, C & HIV can vary considerably.
It’s also worth noting that the studies mentioned probably underestimate the rate of CANSIs; not all children with a needlestick injury will tell their parents, and likewise, not all parents whose child reports a needlestick injury will present for care.
Finally, there’s clearly a huge public health component of this issue. Papenburg et al. identified that in nearly two-thirds of cases, the child actively handled the needle; it’s important to teach children to avoid any discarded syringes or needles and to tell an adult.
Celenza, A. et al. Audit of emergency department assessment and management of patients presenting with community-acquired needle stick injuries. Australian Health Review, 2011, 35, 57–62. https://www.ncbi.nlm.nih.gov/pubmed/21367332
Garc ́ıa-Algar O, Vall O. Hepatitis B virus infection from a needle stick. Pediatr Infect Dis J. 1997;16(11):1099 https://journals.lww.com/pidj/Citation/1997/11000/Hepatitis_B_Virus_Infection_From_A_Needle_Stick.27.aspx
Decle, P. Post-Exposure Prophylaxis (PEP) guidelines for children and adolescents exposed to blood-borne viruses 06/08/2011 https://www.chiva.org.uk/professionals/health/guidelines/pep/young-pep-ref.html
A 6-month-old child presents with cough and runny nose for 2 days with increased work of breathing. She is working hard with moderate subcostal recession. Once you hear the cough, it can only mean one thing….the start of bronchiolitis season.
Bronchiolitis is a common lower respiratory tract illness in children under 2 years.
The natural course of bronchiolitis lasts 7-10 days, with day 2-3 being the most severe.
Be aware of the risk factors for severe bronchiolitis.
If the clinical picture and course doesn’t ‘fit the script’, reconsider the diagnosis.
Consider a broad range of differential diagnoses in a child presenting with increased work of breathing and fever.
Be aware of the ‘overlap’ between bronchiolitis/viral-induced wheeze and asthma.
What is it?
Bronchiolitis is, as the name suggests, inflammation of the small bronchi and bronchioles. The clinical entity we know as bronchiolitis is the most common admission diagnosis in patients under 2, accounting for high morbidity in this population. More succinctly;
“A seasonal viral illness characterized by fever, nasal discharge, and dry, wheezy cough. On examination, there are fine inspiratory crackles and/or high-pitched expiratory wheeze.” – The University of Nottingham, in their 2009 Acute Breathing Difficulty Guideline.
It is most often caused by respiratory syncytial virus (50-80%), as well as parainfluenza (especially PIV3), human metapneumovirus, influenza, rhinoviruses, and adenovirus. In the words of my first general paediatric consultant:
“Bronchiolitis is a typical winter illness, which almost every child gets in their first two years of life. What matters is first, how old you are when you get it, and secondly, what kind of condition you’re in.”
What are the clinical features?
Several days of upper respiratory tract symptoms, including fever, rhinorrhoea, and coryza. These develop into a wheeze, tachypnea, increased work of breathing, moist cough, and fevers. The increased work of breathing often leads to decreased oral intake, with or without dehydration. In infants, poor feeding and apneas with or without cyanosis may be present.
Auscultation of the lungs may reveal a wheeze and transmitted upper airway sounds. A focal zone with decreased air entry or coarse crackles is more consistent with pneumonia.
It is well described that a typical course of bronchiolitis lasts 7-10 days, with night 2-3 being the most severe. In this respect, it is important to reconsider the diagnosis in any patient not ‘sticking to the script’, or deteriorating after initial improvement. A cough may last for up to four weeks.
The diagnosis is primarily clinical. Clinical features of an area of the lung with decreased air entry or consistent focal crackles warrant a chest radiograph to exclude pneumonia. A chest radiograph infrequently adds to the clinical picture and is not routine.
Some clinicians will obtain a nasopharyngeal aspirate or flocculated swab for respiratory virus PCR. There is also a rapid antigen test, which is good for ruling in, rather than ruling out, a particular virus.
Although typing of the respiratory virus causing bronchiolitis may be helpful for bed management and nursing, it is unlikely to alter management.
This point remains controversial as knowledge of the causative organism may allow some prognostication regarding illness course and prevent unnecessary antibiotic usage. It does not rule out dual respiratory tract pathology, such as secondary bacterial infection.
In particular, there is merit to obtaining swabs in patients with risk factors for severe infection, thus:
Risk Factors for Severe Infection
Age <1 yo, especially less than 6 weeks
Congenital heart disease
Chronic respiratory illness
Inborn errors of metabolism
A previous severe bronchiolitis illness requiring CPAP or PICU admission.
Around 50% of children with severe infections have none of the above risk factors.
Children at risk of severe infection and mild symptoms should be admitted and observed.
As noted earlier, the course of the illness is that night 2-3 is usually the most severe, thus any child presenting earlier will potentially worsen, sometimes quite rapidly.
How do we manage it?
Management is supportive, with rehydration and fluid maintenance whilst unable to feed and respiratory support as required. If the child is unlikely to deteriorate and does not require inpatient observation or additional support, they can often be managed in the outpatient setting. It’s essential to provide clear safety-net advice for when to return to ED as well as strongly encouraging an early GP review.
Admit for observation
Infants <6/52 and patients with the risks for severe infection above are at risk of apnoeas, so cardiorespiratory monitoring is indicated. Oxygen saturation monitoring is indicated in all children. Keep a close eye on work of breathing and hydration as these can change as the illness progresses.
What level of oxygen saturation is acceptable?
There are differing opinions regarding target oxygen saturation in patients with bronchiolitis. Most would agree on a target somewhere between ≥94% and ≥92%. But which?
Consider the oxygen-haemoglobin dissociation curve:
Conditions that push the curve to the right (higher PO2 to maintain SaO2 and curve has a steeper gradient), are decreasing pH, increasing temperature.
Thus, in a febrile, acidotic child the curve is pushed to the right, requiring a higher PO2 to maintain the same level of saturation and thus increasing the likelihood of desaturations. In these children, aiming for an SaO2 of 94% would be reasonable. Local guidelines may have differing suggestions.
Flow rates of 2l/kg/min provide a PEEP of 4-8cm, improving the functional residual capacity.
In life-threatening cases, sedation, intubation and ventilation may be necessary and should be done with PICU and senior support. In regional and rural settings, it’s important to be aware of local limitations and consider early transfer to a tertiary centre for deteriorating, high-risk patients. For the care of such patients, make early contact with your regional Paediatric Emergency Transfer Services.
Children with acute illness are susceptible to SIADH and hyponatremia. Thus, it’s important that whilst supporting the increased insensible losses and decreased intake as a result of respiratory distress we don’t over hydrate the patient. Around 2/3 maintenance for an infant not tolerating oral intake is sufficient to both hydrate and reduce the likelihood of SIADH. Most paediatric departments would use 0.9% saline and 5% dextrose.
In mild cases of bronchiolitis, small, frequent feeds may provide sufficient hydration. As respiratory distress increases, nasogastric feeds (continuous vs bolus) may be required. For a child with severe bronchiolitis, on high-flow nasal prongs or moderately dehydrated, intravenous therapy is indicated.
Antibiotics are not indicated for bronchiolitis, nor is there a benefit in the use of steroids, nebulized adrenaline, or bronchodilators. Additionally, there is no benefit in physiotherapy or macrolide antibiotics.
Although salbutamol does not alter the clinical course of bronchiolitis, in the case of a strong family history of atopic disease or asthma it would not be unreasonable to trial a course of salbutamol, particularly in the child >6 yo who is presenting with a wheeze.
It’s important to assess the child pre- and post-salbutamol for both subjective and objective clinical response. This may also have some utility in differentiating between viral bronchitis and a viral-induced wheeze. Again, this is a controversial sub-topic with evolving evidence.
Bronchiolitis has a broad range of differential diagnoses; it is important to consider these, particularly if the patient is not responding as expected to your initial management, or if there are features of the history or examination of an alternative diagnosis.
What’s the differential?
Pneumonia or other pulmonary infections, including mycoplasma and pertussis – listen for focal crackles or signs, productive cough or radiological features of pneumonia. These patients will usually have a fever, in addition to cough and tachypnoea. Consider viral, bacterial, chlamydial or mycoplasma pneumonia. This is a common alternative diagnosis for bronchiolitis.
Recurrent viral-triggered wheezing– another common alternative diagnosis, viral-triggered wheeze may present quite similarly. Features in the history that might point you towards a viral-induced wheeze, is that of an antecedent URTI which had resolved, followed by wheeze and work of breathing a few days later, with or without fever. Differentiating between RSV bronchiolitis and a viral-induced wheeze can be particularly challenging.
Meningitis – most consultants can describe a patient who presents during a “bronchiolitis epidemic” who has meningitis. Always consider this differential diagnosis. Although it’s had to find case reports in the medical literature, unfortunately, the lay press has many examples of this.
Foreign body aspiration – characterized by rapid onset and failure of initial management. May have a low-grade fever. Have a high index of suspicion.
Croup – usually stridor rather than a wheeze, and with a similar gamut of causative organisms. Laryngotracheobronchitis can present with a wheeze in a child with bronchitic disease.
Aspiration pneumonia– consider more strongly in children with poor airway protection, including spastic cerebral palsy, or in any child having seizures or convulsions.
Gastro-oesophageal reflux – up to 40-50% of infants with GORD present with wheeze or respiratory symptoms. There is also an association with chronic cough.
Asthma – an acute exacerbation is less likely to have fevers, and will often have a personal history of atopy or allergy, or a family history of asthma. It would be rare to diagnose a child under two with asthma at a first presentation to the hospital with a wheeze.
Chronic pulmonary disease – chronic neonatal lung disease or prematurity predisposes the child to respiratory infections.
A mediastinal mass – there are multiple case reports of mediastinal masses presenting with a wheeze and respiratory distress.
Tracheoesophageal fistula – late-presentation of H-type tracheoesophageal fistula may present as coughing, abdominal distension, and recurrent chest infections. Sundar’s well described 1975 case series can be found here.
Congenital heart disease and heart failure – to be considered in any neonate presenting with increased work of breathing, with or without apneas. These patients will look unwell, with a constellation of symptoms including disproportionate tachycardia, poor perfusion with or without cyanosis, weak femoral pulses & murmurs.
Vascular ring, congenital lobar emphysema or a bronchogenic cyst – may also present in neonates with a “bronchiolitis-sounding” history.
Louie, M C & Bradin, S. Foreign Body Ingestion and Aspiration Pediatrics in Review August 2009; 30:295-301.
Sheikh S, Allen E, Shell R, Hruschak J, Iram D, Castile R, McCoy K. Chronic aspiration without gastroesophageal reflux as a cause of chronicrespiratory symptoms in neurologically normal infants. Chest. 2001 Oct;120(4):1190-5. PMID: 11591559.