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Care of the Vulnerable Population: Children

Care of the Vulnerable Population: Children. Dr. James Paton Royal Hospital for Sick Children Glasgow. Care of Vulnerable Population - Children. Clinical Presentations Triage and Severity Assessment Recommended treatments – Part 1 Investigations in Hospital

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Care of the Vulnerable Population: Children

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  1. Care of the Vulnerable Population: Children Dr. James Paton Royal Hospital for Sick Children Glasgow

  2. Care of Vulnerable Population - Children • Clinical Presentations • Triage and Severity Assessment • Recommended treatments – Part 1 • Investigations in Hospital • Recommended treatments – Part 2 • Ethics & Staffing during a pandemic

  3. Fleming, D M et al. Arch Dis Child 2005;90:741-746

  4. Clinical Characteristics of RSV and ‘Flu in Hospitalised Children Meury et al Eur J Pediatr 2004; 163:359-363

  5. Timing of 153 Cases of Fatal Influenza in Children - United States, 2003-2004 Season Timing of 153 Cases of Fatal Influenza in Children – US 2003-04 Bhat, N. et al. N Engl J Med 2005;353:2559-2567

  6. Timing of 153 Cases of Fatal Influenza in Children - United States, 2003-2004 Season Whose at Risk? • Impact of Age • Impact of pre-existing medical conditions

  7. 'Flu Mortality Rate According to Age Group – US 2003-04 Bhat, N. et al. N Engl J Med 2005;353:2559-2567

  8. Relative Risk of Admission in Children without High Risk Conditions Izurieta H et al. N Engl J Med 2000;342:232-239

  9. Underlying Health Status in Children with Fatal Influenza – US 2003-04 (n- 149) Bhat, N. et al. N Engl J Med 2005;353:2559-2567

  10. Triage and General Management in 1ry Care • Recognition of ‘At Risk Groups’ • Assessment of Illness Severity • Current advice and guidance on epidemiology of pandemic

  11. Severity Assessment (CURB 65) in Adults

  12. Respiratory Distress – Severity Assessment in Children Appendix 8 Thorax 2007;62: Supplement 1

  13. Severity Assessment in Children

  14. Triage & General Management in 1ry Care Thorax 2007;62:Supplement 1

  15. Specific Treatment - Anti-Viral Therapy • Amantidine / rimantidine • Neuraminidase inhibitors • Oseltamivir (Tabs & liquid) • Effective if given within 2 days of start of illness • Reduction in time to alleviation of symptoms • Reduction in complications requiring antibiotics • Note - faster drug clearance in younger children • Not licensed under 1 year - but Japanese experience suggests is safe • Zanamavir (inhaler – so children >5yrs) • Ribavirin

  16. Triage of Children in Hospital • Assessment of Illness severity • Admit to ward if: • Severe respiratory distress; Hypoxia • Severe dehydration • Altered conscious level or prolonged seizure • Signs of septicaemia • Consider HDU/ICU • Worsening hypoxia despite oxygen • Worsening respiratory failure • Apnoea or slow/irregular breathing • Encephalopathy • If no ICU Beds?

  17. Investigations for Children in Hospital • Pulse oximetry • CXR • if hypoxic or severely ill, or deteriorating; Not routinely • FBC, U & Es, LFTs, Blood Culture • Microbiology

  18. Microbiological Investigations for Children in Hospital Early Pandemic – when you want to know • Virology • NPA for Respiratory panel - ‘flu A & B; RSV, Adeno, Rhino, Paraflu 1,2,3 • Rapid influenza tests – high specificity - R/I ‘flu • Acute & Convalescent Serum • Bacteriology • Blood • Sputum Established Pandemic – when you know • Virology – not routine • Bacteriology

  19. Anti-Viral Therapy in Hospital • Neuraminidase inhibitors • Oseltamivir (Tabs & liquid) • If severely ill with symptoms for <6 days • Child <1year with severe infection with informed consent

  20. Antibioticsfor Children in Hospital • Secondary bacterial infections are common • Pneumonia • Otitis media

  21. Pneumococcal Pneumonia in Previously Healthy Children O’Brien et al. Clin Infect Dis 2000;30:784-9

  22. Bacterial Co-infections in 24 Children with Fatal Influenza Bhat, N. et al. N Engl J Med 2005;353:2559-2567

  23. Activation-associated Cell Death of Bone Marrow GRC during LCMV infection Navarini, Alexander A. et al. (2006) Proc. Natl. Acad. Sci. USA 2006; 103: 15535-15539 Early phase of infection largely controlled by innate resistance via granulocytes. Virus-induced suppression of antibacterial resistance and immunity by IFN 1 production was caused by apoptosis of bone marrow granulocytes and impaired granulocyte emigration. Granulocytopenia was not complete but became functionally limiting during super-infection when large numbers of granulocytes were rapidly required to control infection

  24. Antibiotics for Children in Hospital • Children at risk of complications • Children with disease severe enough to be admitted Treat prophylactically with antibiotic to cover • Staph aureus • Str pneumoniae • H influenzae = Co-amoxiclav; Or clarithromycin, cefuroxime if pen. allergic

  25. Will There be Sufficient Staff?

  26. Professional Duty – Family or Patient First? Ehrenstein et al BMC Public Health 2006;6:311

  27. The Next Influenza Pandemic: Will be Ready to Care for Our Children? “The severity of the 2003-2004 'flu season will pale in comparison with that of the next pandemic” Woods and Abramson J Pediatr 2005;147:147-155

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