The Child with Respiratory Dysfunction

Infectious Agents

The respiratory tract is subject to a wide variety of infective organisms. Most infections are caused by viruses, particularly respiratory syncytial virus (RSV) and the parainfluenza viruses. Other agents involved in primary or secondary invasion include group A β-hemolytic streptococci (GABHS), staphylococci, Haemophilus influenzae, Chlamydia trachomatis, Mycoplasma organisms, and pneumococci.

Age

Healthy full-term infants under age 3 months are presumed to have a lower infection rate because of the protective function of maternal antibodies. The infection rate increases from age 3 to 6 months, the period between the disappearance of maternal antibodies and the infant’s own antibody production. The viral infection rate continues to remain high during the toddler and preschool years. By the time the child reaches 5 years of age, viral respiratory tract infections are less frequent, but the incidence of Mycoplasma pneumoniae and GABHS infections increases. The amount of lymphoid tissue increases throughout middle childhood, and repeated exposure to organisms confers increasing immunity as children grow older.

Some viral agents produce a mild illness in older children but cause severe lower respiratory tract illness or croup in infants. For example, pertussis causes a relatively harmless tracheobronchitis in childhood but is a serious disease in infancy.

Size

Anatomic differences influence the response to respiratory tract infections. The diameter of the airways is smaller in young children and subject to considerable narrowing from edematous mucous membranes and increased production of secretions. (See Fig. 31-5.) In addition, the distance between structures within the tract is shorter in the young child. Therefore organisms move more rapidly down the respiratory tract for more extensive involvement. The relatively short and open eustachian tube in infants and young children allows pathogens easy access to the middle ear.

Resistance

The ability to resist invading organisms depends on several factors. Deficiencies of the immune system place the child at risk for infection. Other conditions that decrease resistance are malnutrition, anemia, fatigue, and chilling of the body. Conditions that weaken defenses of the respiratory tract and predispose a child to infection include allergies (e.g., allergic rhinitis), bronchopulmonary dysplasia (chronic lung disease), asthma, cardiac anomalies that cause pulmonary congestion, and cystic fibrosis (CF). Daycare attendance, especially if the caregivers smoke, also increases the likelihood of infection.

Seasonal Variations

The most common respiratory tract pathogens appear in epidemics during the winter and spring months, but mycoplasmal infections occur more often in autumn and early winter. Infection-related asthma (e.g., asthmatic bronchitis) occurs more frequently during cold weather. Winter and spring are typically RSV season, or the time when children are indoors in close contact and more likely to spread the disease to each other.

Assessment

Assessment of the respiratory system follows the guidelines described in Chapter 6 (for nose, mouth and throat, chest, and lungs). The assessment should include heart rate, respiratory rate, depth and rhythm, and hydration status. In addition to these, special attention is given to the observations outlined in Box 32-1, the components in Box 32-2, and assessment of the following:

Nursing Care Plan—The Child with Acute Respiratory Tract Infection

The nursing care of the child with a respiratory tract infection follows established guidelines based on the child’s and family’s individualized needs (see Nursing Care Plan).

Ease Respiratory Efforts

Many acute respiratory tract infections are mild and cause few symptoms. Although children may feel uncomfortable and have a stuffy nose and some mucosal swelling, acute respiratory distress occurs infrequently. The interventions described here are usually sufficient to relieve minor discomfort and ease respiratory efforts. However, children with croup or epiglottitis may develop sufficient swelling to obstruct the airway. These children may require hospitalization for observation and therapy.

Warm or cool mist is a common therapeutic measure for symptomatic relief of respiratory discomfort. The moisture soothes inflamed membranes and is beneficial when there is hoarseness or laryngeal involvement. Mist tents have been used in the hospital for humidifying the air and relieving discomfort but are seldom used in developed countries. The use of steam vaporizers in the home is often discouraged because of the hazards related to their use and limited evidence to support their efficacy. Shallow pans with wide surface areas for evaporation increase humidity, but parents should place them where they do not pose a safety hazard.

A time-honored method (but not evidence based) of producing steam is the shower. Running a shower of hot water into the empty bathtub or open shower stall with the bathroom door closed produces a quick source of steam. Keeping a child in this environment for 10 to 15 minutes may help ease respiratory efforts. A small child can sit on the lap of a parent or other adult. Older children can sit in the bathroom under the supervision of an adult.

Promote Rest

Children who have an acute febrile illness should be encouraged to rest and engage in quiet activities. Most children are self-limiting when febrile and increase activity as the fever subsides. Often children are more likely to stay quiet if they are allowed to lie quietly on a couch where they can watch television or participate in a quiet activity such as coloring or reading a book.

Promote Comfort

Older children are usually able to manage nasal secretions with little difficulty. Instruct parents in the correct administration of nose drops and throat gargles, if ordered. For very young infants, who normally breathe through their noses, an infant nasal aspirator or a rubber ear syringe is helpful in removing nasal secretions before feeding. This practice, in addition to instillation of saline nose drops, may clear nasal passages and promote feeding.

For older children who can tolerate decongestants, vasoconstrictive nose drops may be administered 15 to 20 minutes before feeding and at bedtime. Two drops are instilled, and, because this shrinks only the anterior mucous membranes, two more drops are instilled 5 to 10 minutes later. Phenylephrine (Neo-Synephrine) 0.25% and ephedrine 1% are frequently prescribed. Older cooperative children often prefer nasal sprays. They learn to compress the plastic container at the moment of inspiration. Spray bottles and bottles of nose drops should be used only for one child and only for one illness, since they become easily contaminated with bacteria. To avoid rebound congestion, nose drops or sprays should not be administered for more than 3 days.

Hot or cold applications sometimes provide relief for children with painful cervical adenitis. An ice bag or heating pad applied to the neck decreases the discomfort, but safety precautions must be observed to prevent burns. The ice bag or heating device must be covered, and the heating pad should not be set at high ranges.

Prevent Spread of Infection

Careful hand washing is carried out when caring for children with respiratory tract infections. Children and families should use a tissue or their hand to cover their nose and mouth when they cough or sneeze, dispose of the tissues properly, and wash their hands. Used tissues should be immediately thrown into the wastebasket, not allowed to accumulate in a pile. Children with respiratory tract infections should not share drinking cups, washcloths, or towels.

To decrease contamination with respiratory viruses, wash hands frequently and do not touch eyes or nose with hands.

Parents should try to remove affected children from contact with other children. Parents should also keep affected children out of school or daycare settings to prevent the spread of infection. Ideally, ill children should be isolated in a separate room at the first sign of illness. This may be a problem when living arrangements are crowded and the family has several children. An effort should be made to teach well children to stay away from ill children, to wash their hands frequently, and to avoid eating or drinking from the same utensils or cups.

Reduce Temperature

If the child has a significantly elevated temperature, controlling the fever is important. The parent should know how to take a child’s temperature and read the thermometer accurately. Nurses should not assume that all parents can read a thermometer; those who cannot require instruction.

If the practitioner has prescribed an antipyretic such as ibuprofen or acetaminophen (Tylenol), parents may need help administering the drug. Most parents can read the label and calculate the desired dose, but some may require careful instruction. It is important to emphasize accuracy in both the amount of drug given and the time intervals for drug administration to avoid cumulative effects. Parents should also be cautious of over-the-counter combination “cold” remedies, since these often include acetaminophen. Careful calculation of both the acetaminophen given separately and the acetaminophen in combination medications is necessary to avoid an overdose. To reduce the temperature and minimize the chances of dehydration, encourage cool liquids. (See Controlling Elevated Temperatures, Chapter 27.)

Promote Hydration

Dehydration is a potential complication when children have respiratory tract infections and are febrile or anorexic, especially when vomiting or diarrhea is present. Infants are especially prone to fluid and electrolyte deficits when they have a respiratory illness because a rapid respiratory rate that accompanies such illnesses precludes adequate fluid intake. In addition, the presence of fever increases the total body fluid turnover in infants. If the infant has nasal secretions, this further prevents adequate respiratory effort by blocking the narrow nasal passages when the infant reclines to bottle- or breast-feed and ceases the compensatory mouth breathing effort, thus causing the child to limit intake of fluids. Parents can encourage adequate fluid intake by offering small amounts of favorite fluids (clear liquids if vomiting) at frequent intervals. High-calorie liquids, such as colas, fruit juice drinks, water flavored and sweetened with corn syrup, or similar drinks, help prevent catabolism and dehydration but should be avoided if diarrhea is present. Oral rehydration solutions, such as Infalyte or Pedialyte, are beneficial for infants, and drinks such as sports drinks or those containing electrolytes are appropriate for older children. Fluids should not be forced, and children should not be awakened to take fluids unless the practitioner advises it. Forcing fluids may create the same difficulties as urging unwanted food (discussed below). Gentle persuasion with preferred beverages is usually successful. (See Chapter 28 for instructions on oral hydration.)

For infants who are breast- or bottle-feeding and who have a respiratory illness and secretions, encourage the parent to instill nasal saline drops and suction the passages with a bulb syringe before the feeding. This should alleviate some of the congestion and allow infants to nurse effectively.

To assess their child’s level of hydration (see Chapter 28), advise parents to observe the frequency of voiding and to notify the nurse or practitioner if there is insufficient voiding.

Provide Nutrition

Loss of appetite is characteristic of children with acute infections, and in most cases children can be permitted to determine their own need for food. Urging foods on anorexic children may precipitate nausea and vomiting and cause an aversion to feeding that can extend into the convalescent period and beyond. Many children show no decrease in appetite, and others respond well to foods such as gelatin, Popsicles, soup, and puddings. (See Feeding the Sick Child, Chapter 27.)

Provide Family Support and Home Care

Young children with respiratory tract infections are irritable and difficult to comfort. Therefore the family needs support, encouragement, and practical suggestions concerning comfort measures and administration of medication.

In addition to antipyretics and nose drops, the child may require antibiotic therapy. Parents of children receiving oral antibiotics need to understand the importance of administering the drug regularly and continuing it for the prescribed length of time, regardless of whether the child appears ill.

Also caution parents against giving the child any medications that are not approved by the health practitioner. Adverse effects have occurred in children who have received preparations intended for adults (e.g., some long-acting nose drops and dextromethorphan cough squares [mistaken for candy]). Caution parents about giving the child unprescribed antibiotics left over from a previous illness. Self-medication with unprescribed antibiotics can produce serious side effects, and the likelihood of adverse reactions is increased when medications are administered to children without consulting the practitioner. (See Chapter 27 for administration of medications and teaching parents.)

Clinical Manifestations

Symptoms of nasopharyngitis are more severe in infants and children than in adults. Fever is common, especially in young children. Older children have low-grade fevers, which appear early in the illness. In children 3 months to 3 years, fevers occur suddenly and are associated with irritability, restlessness, decreased appetite and fluid intake, and decreased activity. Nasal inflammation may lead to obstruction of passages, producing open-mouth breathing. Vomiting and diarrhea may also be present.

The initial symptoms in older children are dryness and irritation of nasal passages and the pharynx, followed by sneezing, chilly sensations, muscular aches, an irritating nasal discharge, and sometimes cough. Nasal inflammation may lead to obstruction. Continual wiping away of secretions causes skin irritation to nares.

The disease is self-limiting and usually resolves within 4 to 10 days without complications. Occasionally fever recurs and a child (particularly an infant) might experience otitis media (OM), usually early or after the initial phase of nasopharyngitis is past. Pneumonia is less frequent but may be observed in some infants.

Therapeutic Management

Children with nasopharyngitis are managed at home. There is no specific treatment, and effective vaccines are not available. Antipyretics are prescribed for mild fever and discomfort. (See Chapter 27 for management of fever.) Rest is recommended until the child is free of fever for at least 1 day. Decongestants may be prescribed for children over 5 years of age to shrink swollen nasal passages. The decongestants that exert their effect by vasoconstriction are usually less effective when taken orally than when applied topically as nose drops. Because these drugs affect all vascular beds, they should be given with caution to children with diabetes.

Cough suppressants containing dextromethorphan may be prescribed for a dry, hacking cough. Some preparations contain up to 22% alcohol. They should not be administered to young children continuously and must be stored securely away from children.

Recent concerns regarding serious side effects of cough and cold preparations in young children, particularly infants, and lack of convincing evidence that such medications are effective in reducing symptoms, has prompted recommendations by health experts to carefully evaluate the benefits and risks of recommending such preparations for children under 6 years of age (Ryan, Brewer, and Small, 2008).

Antihistamines are largely ineffective in treatment of nasopharyngitis. These drugs have a weak atropine-like effect that dries secretions, but they can cause drowsiness or, paradoxically, have a stimulatory effect on children. There is no support for the usefulness of expectorants, and antibiotics are usually not indicated.

Nursing Care Management

A cold is often the parents’ first introduction to an illness in their infants. Most discomfort of nasopharyngitis is related to the nasal obstruction, especially in small infants. Elevating the head of the bed or crib mattress assists with drainage of secretions; suctioning and vaporization may also provide relief. Saline nose drops and gentle suction with a bulb syringe, particularly before feeding, are useful.

Maintaining adequate fluid intake is essential during any infectious process. Although a child’s appetite for solid foods is usually diminished for several days, it is important to offer favorite fluids to prevent dehydration. Fluids can be cool or warm, depending on individual preference.

Because nasopharyngitis is spread from secretions, the best means for prevention is avoiding contact with affected persons. This goal is difficult when large numbers of people are confined in a small area for a long time, such as daycare centers and classrooms. Family members with a cold should try to “keep it to themselves” by carefully disposing of tissues and not sharing towels, glasses, or eating utensils. They should also cover the mouth and nose with tissues when coughing or sneezing; and wash hands thoroughly after nose blowing or sneezing. The most frequent carriers of infection are the human hands, which deposit viruses on doorknobs, faucets, and other everyday objects. Children should wash their hands thoroughly before putting them near their nose, mouth, or eyes.

Clinical Manifestations

GABHS infection is generally a relatively brief illness that varies in severity from subclinical (no symptoms) to severe toxicity. The onset is often abrupt and characterized by pharyngitis, headache, fever, and abdominal pain. The tonsils and pharynx may be inflamed and covered with exudate (50% to 80% of cases) (Fig. 32-1), which usually appears by the second day of illness. However, streptococcal infections should be suspected in children over the age of 2 years who have pharyngitis even if no exudate is present.

Anterior cervical lymphadenopathy (30% to 50% of cases) usually occurs early, and the nodes are often tender. Pain can be relatively mild to severe enough to make swallowing difficult. Clinical manifestations usually subside in 3 to 5 days unless complicated by sinusitis or parapharyngeal, peritonsillar, or retropharyngeal abscess. Nonsuppurative complications may appear after the onset of GABHS—acute nephritis in about 10 days and rheumatic fever in an average of 18 days.

Children who are GABHS carriers may have a positive throat culture but often experience a coincidental viral illness. Although antibiotic administration is not indicated for most GABHS carriers, some conditions require antibiotic therapy; these are published in the American Academy of Pediatrics (2009b) Red Book. Transmission to others from a carrier is reportedly minimal.

Diagnostic Evaluation

Although 80% to 90% of all cases of acute pharyngitis are viral, a throat culture should be performed to rule out GABHS. Because some children normally harbor streptococci in their throats, a positive culture is not always conclusive evidence of active disease. Most streptococcal infections are short-term illnesses, and antibody (antistreptolysin O) responses appear later than symptoms and are useful only for retrospective diagnosis.

Rapid identification of GABHS with diagnostic test kits is possible in the office or clinic setting. However, because these kits have questionable sensitivity, they are not yet considered a substitute for culture, and a confirmatory throat culture is recommended in patients who have a negative test result with a rapid diagnostic test kit (American Academy of Pediatrics, 2009b).

Therapeutic Management

If streptococcal sore throat infection is present, oral penicillin is prescribed in a dose sufficient to control the acute local manifestations and to maintain an adequate level for at least 10 days to eliminate organisms that might remain to initiate rheumatic fever symptoms. Penicillin does not prevent the development of acute glomerulonephritis in susceptible children. However, it may prevent the spread of a nephrogenic strain of GABHS to others in the family. Penicillin usually produces a prompt response within 24 hours. Some patients require retreatment if the organism is not eradicated.

Intramuscular (IM) penicillin G benzathine is also an appropriate therapy. This drug ensures adequate blood concentrations and avoids the problem of compliance, yet it is painful. Some preparations contain penicillin G procaine as well to decrease the pain. Oral erythromycin is indicated for children allergic to penicillin. Other drugs that have been used to treat GABHS pharyngitis include clarithromycin, azithromycin and clindamycin, oral cephalosporins, amoxicillin, and amoxicillin with clavulanic acid (American Academy of Pediatrics, 2009b).

Nursing Care Management

The nurse often obtains a throat swab for culture and instructs the parents about administering penicillin and analgesics as prescribed. Some children may prefer quiet activities during the acute phase of the illness, whereas others may limit activity only if the temperature is elevated. Cold or warm compresses to the neck may provide relief. In children old enough to cooperate, warm saline gargles offer some relief of throat discomfort. Pain may interfere with oral intake, and the child should not be forced to eat. Instead encourage cool liquids or ice chips, which are usually more acceptable than solids.

Special emphasis is placed on correctly administering oral medication and completing the course of antibiotic therapy. (See Administration of Medication, and Compliance, Chapter 27.) If an antibiotic injection is required, it must be administered deep into a large muscle mass (e.g., the vastus lateralis or ventrogluteal muscle). Parents need to be aware of the residual tenderness. Local applications of heat are helpful in relieving discomfort. (For other atraumatic strategies to reduce injection pain, such as application over the site of EMLA [a eutectic mix of lidocaine and prilocaine] hours before the injection or LMX4 [lidocaine 4%] 30 minutes beforehand, see Administration of Medication: Intramuscular Administration, Chapter 27.)

Pathophysiology

Several pairs of tonsils are part of a mass of lymphoid tissue encircling the nasopharynx and oropharynx, known as the Waldeyer tonsillar ring (Fig. 32-2). The palatine, or faucial, tonsils are located on either side of the oropharynx, behind and below the pillars of the fauces (opening from the mouth). A surface of the palatine tonsils is usually visible during oral examination. The palatine tonsils are those removed during tonsillectomy. The pharyngeal tonsils, also known as the adenoids, are located above the palatine tonsils on the posterior wall of the nasopharynx. Their proximity to the nares and eustachian tubes causes difficulties in instances of inflammation. The lingual tonsils are located at the base of the tongue. The tubal tonsils, found near the posterior nasopharyngeal opening of the eustachian tubes, are not part of the Waldeyer tonsillar ring.

Anatomy Review—Location of Tonsillar Masses

Etiology

Tonsillitis often occurs with pharyngitis. Because of the abundant lymphoid tissue and the frequency of URIs, tonsillitis is a common cause of illness in young children. The causative agent may be viral or bacterial.

Clinical Manifestations

The manifestations of tonsillitis are caused by inflammation. As the palatine tonsils enlarge from edema, they may meet in the midline (kissing tonsils), obstructing the passage of air or food. The child has difficulty swallowing and breathing. When enlargement of the adenoids occurs, the space behind the posterior nares may become blocked, making it difficult or impossible for air to pass from the nose to the throat. As a result, the child breathes through the mouth.

If mouth breathing is continuous, the mucous membranes of the oropharynx become dry and irritated. There may be an offensive mouth odor and impaired senses of taste and smell. Because air cannot be trapped for proper speech sounds, the voice has a nasal and muffled quality. A persistent cough is also common. Because of the proximity of the adenoids to the eustachian tubes, this passageway is frequently blocked by swollen adenoids, interfering with normal drainage and frequently resulting in OM or difficulty hearing.

Therapeutic Management

Nursing Care Management

Nursing care of the child with tonsillitis involves providing comfort and minimizing activities or interventions that precipitate bleeding. A soft to liquid diet is generally preferred. A cool-mist vaporizer keeps the mucous membranes moist during periods of mouth breathing. Warm saltwater gargles, throat lozenges, and analgesic-antipyretic drugs such as acetaminophen are useful to promote comfort. Often opioids are needed to reduce pain for the child to drink. Combination nonopioid and opioid elixirs such as acetaminophen with codeine or with hydrocodone (Lortab) relieve pain and should be given routinely every 4 hours.

If surgery is needed, the child requires the same psychologic preparation and physical care as for any procedure. (See Chapters 26 and 27.) The following discussion focuses on specific nursing care for tonsillectomy and adenoidectomy (T&A), although both procedures may not be performed.

The nurse takes a complete history, with special notation of any bleeding tendencies because the operative site is highly vascular. Baseline vital signs are important for postoperative monitoring and observation. Signs of any URI are noted and reported, and bleeding and clotting times may be obtained with the usual laboratory work requests. During physical assessment the presence of any loose teeth is noted. (See Surgical Procedures, Chapter 27.)

After the surgery, until they are fully awake, children are placed on the abdomen or side to facilitate drainage of secretions. Suctioning is performed carefully to avoid trauma to the oropharynx. When alert, children may prefer sitting up, although they should remain in bed for the remainder of the day. They are discouraged from coughing frequently, clearing their throat, blowing their nose, or any activities that could aggravate the operative site.

Some secretions, particularly dried blood from surgery, are common. Inspect all secretions and vomitus for evidence of fresh bleeding (some blood-tinged mucus is expected). Dark brown (old) blood is usually present in the emesis, as well as in the nose and between the teeth. If parents are not prepared for this, they may be frightened at a time when they need to be calm and reassuring.

The throat is very sore after surgery. An ice collar may provide relief, but many children find it bothersome and refuse to use it. Most children experience moderate pain after a T&A and need pain medication for at least the first 24 hours. Analgesics may need to be given intravenously to avoid the oral route. Because pain is continuous, analgesics should be administered at regular intervals. Local anesthetics, such as tetracaine lollipops or ice pops, and antiemetics, such as ondansetron (Zofran) may be administered postoperatively. (See Pain Management, Chapter 7.)

Food and fluid are restricted until children are fully alert with no signs of hemorrhage. Cool water, crushed ice, flavored ice pops, or diluted fruit juice is given, and fluids with a red or brown color are avoided to distinguish fresh or old blood in emesis from the ingested liquid. Straws should be avoided, since these may damage the surgical site and cause subsequent bleeding. Citrus juice may cause discomfort and is usually poorly tolerated. Milk, ice cream, or pudding is not usually offered until clear fluids are retained because milk products coat the mouth and throat, causing the child to clear the throat, which may initiate bleeding.

Children often begin soft foods, particularly gelatin, cooked fruits, sherbet, soup, and mashed potatoes, on the first or second postoperative day or as the child tolerates feeding. The pain from surgery often inhibits intake, reinforcing the need for adequate pain control.

Postoperative hemorrhage is unusual but can occur. The nurse observes the throat directly for evidence of bleeding, using a good source of light and, if necessary, carefully inserting a tongue depressor. Other signs of hemorrhage are tachycardia, pallor, frequent clearing of the throat or swallowing by a younger child, and vomiting of bright red blood. Restlessness, an indication of hemorrhage, may be difficult to differentiate from general discomfort after surgery. Decreasing blood pressure is a much later sign of shock. A cream-colored membrane is often visible on the tonsillar bed postoperatively; reassure parents this is an expected finding.

Surgery may be required to cauterize or ligate a bleeding vessel. Airway obstruction may also occur as a result of edema or accumulated secretions and is indicated by signs of respiratory distress, such as stridor, drooling, restlessness, agitation, increasing respiratory rate, and progressive cyanosis. Suction equipment and oxygen should be available after tonsillectomy.

Etiology and Pathophysiology

The herpeslike Epstein-Barr virus is the principal cause of infectious mononucleosis. It appears in both sporadic and epidemic forms, but the sporadic cases are more common. The virus is believed to be transmitted by direct contact with oral secretions, blood transfusion, or transplantation. It is mildly contagious, and the period of communicability is unknown. There is evidence that the virus is spread through sexual contact, especially when multiple partners are involved (Rimsza and Kirk, 2005). The incubation period after exposure in adolescents is estimated to be 30 to 50 days (American Academy of Pediatrics, 2009b).

Clinical Manifestations

Symptoms of infectious mononucleosis appear anywhere from 10 days to 6 weeks after exposure and may be acute or insidious. The common presenting symptoms vary greatly in type, severity, and duration. The characteristics of the disease are malaise, sore throat, and fever with generalized lymphadenopathy and splenomegaly that may persist for several months. Often the symptoms appear insidiously with fatigue, lack of energy, and sore throat. The child’s chief complaint is difficulty in maintaining the usual level of activity. This is often attributed to lack of sleep or a URI. In many instances the manifestations never arouse enough concern to bring the affected individual to medical attention. The clinical manifestations of infectious mononucleosis are usually less severe (often subclinical or unapparent) and the recovery phase is shorter in younger children than in older children and young adults. Many young children do not develop all the expected clinical and laboratory findings. Often a complication is the only or the presenting symptom.

A skin rash that involves a discrete macular eruption (most prominent over the trunk) is present in some cases and is often associated with the administration of ampicillin or amoxicillin. Other symptoms include headache, epistaxis, and a severe sore throat. The tonsils may be enlarged, reddened, and sometimes covered with a diphtheria-like membrane. In some cases airway compromise may occur with tonsillar swelling, requiring careful airway management, corticosteroids, humidified air, and intravenous (IV) hydration (Jenson, 2007). In about half the cases the spleen is enlarged. Splenic hemorrhage or rupture may occur but is usually related to trauma (Jenson, 2007). The extensive mononuclear infiltration produces symptoms related to any body tissue, and the clinical picture can resemble that of many conditions, including neurologic manifestations and cardiac involvement.

Diagnostic Evaluation

The diagnosis is established on the basis of clinical manifestations, increase in atypical leukocytes in a peripheral blood smear, and a positive heterophil agglutination test. Differential diagnosis depends on the clinical symptoms present. For example, the pharyngitis may simulate symptoms of diphtheria and streptococcal pharyngitis. Lymphadenopathy, fever, malaise, central nervous system manifestations, and skin eruptions may be similar to symptoms seen in a variety of conditions. The leukocyte count may be normal or low, but usually lymphocytic leukocytosis develops.

The heterophil antibody test determines the extent to which the patient’s serum will agglutinate sheep red blood cells. In infectious mononucleosis a titer of 1:160 is considered diagnostic, although a rising titer during the earlier stages is the best indicator. Because young children have a lower rate of heterophil antibody responses, the diagnosis may be overlooked in this group.

The spot test (Monospot) is a slide test of high specificity for the diagnosis of infectious mononucleosis. It is rapid, sensitive, inexpensive, and easy to perform, and it has the advantage that it can detect significant agglutinins at lower levels, thus permitting earlier diagnosis. Blood is usually obtained for the test by finger puncture and is placed on special paper. If the blood agglutinates, forming fragments or clumps, the test is positive for the infection.

Therapeutic Management

No specific treatment exists for infectious mononucleosis. Common symptoms are ordinarily relieved by simple remedies. A mild analgesic is usually sufficient to relieve the bothersome symptoms of headache, fever, and malaise. Bed rest is encouraged for fatigue but is not imposed for any specified time. Affected children and adolescents should regulate activities according to their own tolerance unless complicating factors are present. If the spleen is enlarged, children should avoid activities in which they might receive a blow to the abdomen or chest.

A short course of corticosteroids may assist in decreasing some of the complications (e.g., airway obstruction) of the illness. Administration of ampicillin or amoxicillin frequently precipitates a maculopapular rash in affected persons (80% of cases); therefore their use is contraindicated. Gargles; hot drinks; analgesic or anesthetic troches; or analgesics, including opioids, can relieve a sore throat. Although corticosteroids have been used to treat respiratory distress from tonsillar hypertrophy, hemolytic anemia, thrombocytopenia, and neurologic complications, the routine use of steroids is not recommended (American Academy of Pediatrics, 2009b).

Nursing Care Management

Direct nursing responsibilities toward providing comfort measures to relieve the symptoms and toward helping affected children and adolescents and their families determine appropriate activities for the stage of the disease and their interests. Airway assessment for impending obstruction during the acute phase of the illness is imperative. The adolescent with infectious mononucleosis may not be able to swallow secretions and may be in considerable pain. The child or adolescent is encouraged to increase clear fluid intake and decrease solid foods that may exacerbate the pain. In addition, the nurse should encourage the administration of age-appropriate antipyretics and encourage the affected individual to curtail activities that are strenuous until splenomegaly is resolved. Pain medications in elixir form such as acetaminophen with codeine or hydrocodone may be required during the acute phase so the adolescent can swallow liquids. Make every effort to prevent a secondary infection by counseling the adolescent to limit exposure to persons outside the family, especially during the acute phase of illness.

Clinical Manifestations

The manifestations of influenza may be subclinical, mild, moderate, or severe. In most cases the throat and nasal mucosa are dry, and there is a dry cough and a tendency toward hoarseness. A sudden onset of fever and chills is accompanied by flushed face, photophobia, myalgia, hyperesthesia, and sometimes prostration. Subglottal croup is common, especially in infants. The symptoms last 4 or 5 days. Complications include severe viral pneumonia (often hemorrhagic); encephalitis; and secondary bacterial infections, such as OM, sinusitis, or pneumonia.

Therapeutic Management

Uncomplicated influenza in children usually requires only symptomatic treatment: acetaminophen or ibuprofen for fever and sufficient fluids to maintain hydration. Amantadine hydrochloride (Symmetrel) has been effective in reducing symptoms associated with type A disease if administered within 24 to 48 hours after their onset; the symptoms associated with influenza are reportedly shortened by 24 hours but the drug does not “cure” the disease. It is ineffective against type B or C influenza or other viral diseases. It should not be given to children under 1 year of age but is recommended for unvaccinated high-risk children. Since early 2006, however, there has been an increase in influenza strains resistant to amantadine, and thus the neuraminidase inhibitors oseltamivir and zanamivir have been recommended for influenza treatment (American Academy of Pediatrics, 2009b). A small number of influenza strains are resistant to oseltamivir.

Zanamivir and rimantadine have been approved for the treatment of flu symptoms in children under 18 years of age. Both medications must also be started within 48 hours of symptom onset. Zanamivir is an inhaled medication effective for type A and B influenza. The drug is taken twice daily for 5 days and is administered by a specially designed oral inhaler (Diskhaler). Zanamivir cannot be used for children less than 7 years of age except for specific prophylaxis indications in children ages 5 years and above (US Food and Drug Administration, 2009). Zanamivir is recommended for persons ages 7 years and above who have been exposed to H1N1 in 2009. A fourth drug, oseltamivir, is a neuroaminidase inhibitor that may be administered orally for 5 days to children over 3 months (and adults) to decrease the flu symptoms. As with other antiviral drugs, this must be taken within 2 days of the onset of symptoms. It is effective for types A and B influenza (American Academy of Pediatrics, 2009b). Bronchospasm and a decline in lung function can occur when zanamivir is used in patients with underlying airway disease such as asthma or chronic obstructive pulmonary disease. Rimantadine is effective only for type A virus; this drug is taken orally in tablet or syrup twice daily for 7 days. Rimantadine cannot be used for children less than 1 year of age. Children with influenza (or other similar viruses) should not receive aspirin because of its possible link with Reye syndrome.

Nursing Care Management

Nursing care is the same as for any child with a URI, including helping the family implement measures to relieve symptoms. The greatest danger to affected children is development of a secondary infection. Prolonged fever or appearance of fever during early convalescence is a sign of secondary bacterial infection and should be reported to the practitioner for antibiotic therapy. In addition to the measures mentioned previously, nursing care of the child with influenza includes educating the parents regarding the prevention of the spread of the disease to other individuals, especially those who are at higher risk for complications, and educating the parents about the use of antiinfluenza medications. Parents are informed about the nature of antiviral drugs in regards to symptom management. Parents may also ask the practitioner to prescribe an antibiotic for the influenza, not understanding that these are ineffective against viral infections; indiscriminate use of antibiotics may lead to increased resistance to common antibiotics. The nurse should also educate parents regarding yearly influenza immunization and its effectiveness at decreasing morbidity among children.

Etiology

AOM is frequently caused by Streptococcus pneumoniae, H. influenzae, and Moraxella catarrhalis. The two viruses most likely to precipitate OM are RSV and influenza, although the adenoviruses, metapneumoviruses, and rhinoviruses also cause a significant number of URIs and OM. The etiology of the noninfectious type is unknown, although it is frequently the result of blocked eustachian tubes from the edema of URIs, allergic rhinitis, or hypertrophic adenoids. Chronic OM is frequently an extension of an acute episode.

A relationship has been observed between the incidence of OM and infant feeding methods. Infants fed breast milk have a lower incidence of OM compared with formula-fed infants. Breast-feeding may protect infants against respiratory viruses and allergy because it contains secretory immunoglobulin A, which limits the exposure of the eustachian tube and middle ear mucosa to microbial pathogens and foreign proteins. Reflux of milk up the eustachian tubes is less likely in breast-fed infants because of the semivertical positioning during breast-feeding compared with bottle-feeding.

Pathophysiology

OM is primarily a result of a dysfunctioning eustachian tube. The eustachian tube is part of a contiguous system composed of the nares, nasopharynx, eustachian tube, middle ear, and mastoid antrum and air cells. Eustachian tubes have three functions relative to the middle ear: (1) protection of the middle ear from nasopharyngeal secretions, (2) drainage of secretions produced in the middle ear into the nasopharynx, and (3) ventilation of the middle ear to equalize air pressure within the middle ear and atmospheric pressure in the external ear canal and replenishment of oxygen that has been absorbed.

Mechanical or functional obstruction of the eustachian tube causes accumulation of secretions in the middle ear. Infection or allergy can cause intrinsic obstruction. Extrinsic obstruction is usually a result of enlarged adenoids or nasopharyngeal tumors. Persistent collapse of the tube during swallowing can cause functional obstruction associated with decreased stiffness or an inefficient opening mechanism. Eustachian tube obstruction results in negative middle ear pressure and, if persistent, produces a transudative middle ear effusion. Sustained negative pressure and impaired ciliary transport within the tube inhibit drainage. When the passage is not totally obstructed, contamination of the middle ear can take place by reflux, aspiration, or insufflation during crying, sneezing, nose blowing, and swallowing when the nose is obstructed.

Several factors predispose infants and young children to development of OM (Box 32-5 and Fig. 32-3).

Clinical Manifestations

As purulent fluid accumulates in the small space of the middle ear chamber, pain results from the pressure on surrounding structures. Infants become irritable and indicate their discomfort by holding or pulling at their ears and rolling their head from side to side. Young children usually verbally complain of the pain. A temperature as high as 40° C (104° F) is common, and postauricular and cervical lymph glands may be enlarged. Rhinorrhea, vomiting, diarrhea, and signs of concurrent respiratory tract or pharyngeal infection may also be present. Loss of appetite typically occurs, and sucking or chewing tends to aggravate the pain. In children with OME, exudate accumulates and pressure increases, with the potential for tympanic membrane rupture.

As a result of rupture, there is immediate relief of pain, a gradual decrease in temperature, and the presence of purulent discharge in the external auditory canal.

Severe pain or fever is usually absent in OME, and the child may not appear ill. Instead there is a feeling of “fullness” in the ear, a popping sensation during swallowing, and a feeling of “motion” in the ear if air is present above the level of fluid. Because chronic serous OM is the most frequent cause of conductive hearing loss in young children, audiometry may reveal deficient hearing.

Diagnostic Evaluation

Careful assessment of tympanic membrane mobility with a pneumatic otoscope is essential to differentiate AOM from OME (American Academy of Pediatrics, 2004a). If an accumulation of cerumen prevents adequate visualization of the tympanic membrane, the cerumen should be removed before inspection of the membrane. A diagnosis of AOM is made if visual inspection of the tympanic membrane reveals a purulent, discolored effusion and a bulging or full, opacified, or very reddened immobile membrane. Some practitioners also consider the presence of acute onset of less than 48 hours of ear pain with the preceding criteria to be a diagnostic factor in AOM (Powers, 2007). An immobile tympanic membrane or an orange-discolored membrane indicates OME. Clinical symptoms of otitis are also helpful in making the diagnosis. In AOM, symptoms such as acute ear pain, fever, and a bulging yellow or red tympanic membrane are usually present. In OME these symptoms may be absent, and other nonspecific symptoms such as rhinitis, cough, or diarrhea are often present.

Several tests provide an assessment of mobility of the tympanic membrane. Chapter 6, under Ears, discusses pneumatic otoscopy and tympanometry. Acoustic reflectometry measures the level of sound transmitted and reflected from the middle ear to a microphone located in a probe tip placed against the ear canal opening and directed toward the tympanic membrane. The information provides a measure of canal length and presence of effusion. The greater the cancellation of transmitted sound by reflected sound, the greater the probability of middle ear effusion.

Therapeutic Management: Acute Otitis Media

Treatment for AOM is one of the most common reasons for antibiotic use in the ambulatory setting. However, recent concerns about drug-resistant S. pneumoniae and other drug-resistant strains have led infectious disease authorities to recommend careful and judicious use of antibiotics for treatment of this illness. Current literature indicates that waiting up to 72 hours for spontaneous resolution is safe and appropriate management of AOM in healthy infants over 6 months and children (American Academy of Pediatrics, 2004a; Bhetwal and McConaghy, 2007). Furthermore some reviews of the treatment of AOM reveal no clear evidence that antibiotics improve outcomes in children younger than 2 years of age with uncomplicated AOM. However, the watchful waiting approach is not recommended for children younger than 2 years who have persistent acute symptoms of fever and severe ear pain (Kershner, 2007). In addition, all cases of AOM in infants younger than 6 months of age should be treated with antibiotics because of the infant’s immature immune system and the potential for infection with bacteria other than the three most common organisms found in older infants and children with AOM.

When antibiotics are necessary, oral amoxicillin in high doses (80 to 90 mg/kg/day, divided twice daily) is the treatment of choice for initial episodes of AOM in children who have not received antibiotics within the past month (American Academy of Pediatrics, 2004a; Bhetwal and McConaghy, 2007; Pichichero and Casey, 2005). The recommendation for the duration of antibiotic therapy is 10 days for severe AOM; for children with mild to moderate disease and those who are 6 years and older, a 5- to 7-day course is adequate (American Academy of Pediatrics, 2009b).

Second-line antibiotics used to treat OM include amoxicillin-clavulanate (Augmentin); azithromycin; and cephalosporins such as cefdinir, cefuroxime, and cefpodoxime. IM ceftriaxone is used if the causative organism is a highly resistant pneumococcus or if there is noncompliance with the therapy. An important consideration with the use of single-dose IM injections is the pain involved in this therapy. One strategy to minimize pain at the injection site is to reconstitute the cephalosporin with 1% lidocaine (without epinephrine). The use of steroids, decongestants, and antihistamines to treat AOM is not recommended.

Supportive care or symptomatic treatment of AOM includes treating the fever and pain. For fever or discomfort associated with OM, analgesic-antipyretic drugs such as acetaminophen or ibuprofen (ibuprofen only if >6 months of age) may be given. Topical pain relief is recommended by external application of heat or cold, or the practitioner may prescribe topical pain relief drops such as benzocaine drops. Antibiotic ear drops have no value in treating AOM.

Children with AOM should be seen after antibiotic therapy is complete to evaluate the effectiveness of the treatment and to identify potential complications, such as effusion or hearing impairment.

Myringotomy, a surgical incision of the eardrum, may be necessary to alleviate the severe pain of AOM. A myringotomy is also performed to drain infected middle ear fluid in the presence of complications (mastoiditis, labyrinthitis, or facial paralysis) or to allow purulent middle ear fluid to drain into the ear canal for culture. A minimally invasive laser-assisted myringotomy procedure may be performed in outpatient settings. These procedures should only be performed by ear, nose, and throat (ENT) specialists.

Therapeutic Management: Recurrent Otitis Media

Therapy for recurrent AOM has included chemoprophylaxis with long-term antibiotic therapy, immunotherapy, and surgery. Children receiving long-term antibiotic therapy should be evaluated once a month to detect any evidence of effusion. Any acute infection during prophylaxis is treated with an alternate antibiotic regimen.

Tympanostomy tube placement and adenoidectomy are surgical procedures that may be done to treat recurrent OM. Tympanostomy tubes are pressure-equalizer (PE) tubes or grommets that facilitate continued drainage of fluid and allow ventilation of the middle ear. Adenoidectomy is not recommended for treatment of AOM and is performed only in children with recurrent AOM or chronic OME with postnasal obstruction, adenoiditis, or chronic sinusitis.

Therapeutic Management: Otitis Media with Effusion

In some children, residual middle ear effusions remain after episodes of AOM. Management options for OM with residual effusion include observation, antibiotics alone, or a combination of antibiotic and corticosteroid therapy. Antibiotics are not required for initial treatment of OME but may be indicated for children with persistent effusion for more than 3 months (American Academy of Pediatrics, 2004a). It has been estimated that avoiding unnecessary treatment of OME with antibiotics would save millions of courses of antibiotics each year (American Academy of Pediatrics, 2004a).

Some children have fluid that persists in the middle ear for weeks or months. OME is frequently associated with mild to moderate hearing impairment. The major goal of therapy is to establish and maintain an aerated middle ear that is free of fluid with a normal mucosa and ultimately to achieve normal hearing.

Placement of tympanostomy tubes is recommended after a total of 4 to 6 months of bilateral effusion with a bilateral hearing deficit (American Academy of Pediatrics, 2004b). This therapy allows for mechanical drainage of the fluid, which promotes healing of the membrane and prevents scar formation and loss of elasticity. The primary objective is to allow the eustachian tube a period of recovery while the surgically placed tube performs its functions. The surgery is relatively benign; however, sometimes the tubes become plugged and they often require reinsertion. Complications of repeated or long-term tube placement are tympanosclerosis, localized or diffuse atrophy of the membrane, persistent perforation, or, rarely, cholesteatoma. Myringotomy with or without insertion of PE tubes should not be performed for initial management of OME, but may be recommended for children who have recurrent episodes of OME with a long cumulative duration. A Cochrane review concluded that tympanostomy tubes had a significant effect on decreasing the incidence of AOM in the first 6 months after insertion (McDonald, Langston Hewer, and Nunez, 2008).

Tonsillectomy, either alone or with adenoidectomy, is not considered an effective treatment of OME (American Academy of Pediatrics, 2004b). According to guidelines published by the Agency for Healthcare Research and Quality,* steroids are not recommended for treatment of OME in children of any age.

Prevention

Routine immunization with the pneumococcal conjugate vaccine PCV 7 (Prevnar) has reduced the incidence of AOM in some infants and children (American Academy of Pediatrics, 2009b). In 2010 the FDA approved a new conjugate vaccine, Prevnar 13, which replaces Prevnar. The vaccine is administered as a four-dose series beginning at 2 months of age; infants and children who have started the series with Prevnar may complete the series with Prevnar 13 (Centers for Disease Control and Prevention, 2010).

Parents can reduce risk factors for AOM by breast-feeding infants for at least the first 6 months of life, avoiding propping the bottle, decreasing or discontinuing pacifier use after 6 months, and preventing exposure to tobacco smoke (American Academy of Pediatrics, 2004a).

Prognosis

Most cases of OM resolve eventually. However, hearing loss, typically conductive, is a common complication of OM. The degree of hearing loss can vary from none to severe. Although conductive hearing loss is most often associated with OM, sensorineural hearing loss may also be present, especially in severe forms of chronic or recurrent OM, because of the passage of toxic products from fluids into the cochlea through the tympanic membrane. The longer the fluid is present, the greater the sensorineural hearing loss. Children who are prone to OM should be referred to a pediatric otolaryngologist and possibly a pediatric allergist for identification and treatment of the cause of their eustachian tube dysfunction. They should also be referred to a speech and language pathologist for primary prevention counseling. In addition, the child should ideally be monitored by an audiologist to evaluate the adequacy of hearing.

Nursing Care Management

Nursing objectives for the child with AOM include (1) relieving pain, (2) facilitating drainage when possible, (3) preventing complications or recurrence, (4) educating the family in care of the child, and (5) providing emotional support to the child and family.

Analgesics are helpful to reduce severe earache. High fever, particularly in infants, should be reduced with antipyretic drugs. An advantage of using ibuprofen rather than acetaminophen is its longer duration of action (about 6 hours), especially for nighttime comfort. Ibuprofen is only indicated for those over 6 months of age. For more severe pain, the Centers for Disease Control and Prevention and American Academy of Pediatrics guidelines recommend a stronger analgesic such as codeine. The application of heat may reduce pain in some children but may aggravate discomfort in others. Local heat should be placed over the ear while the child lies on the affected side. This position also facilitates drainage of the exudate if the eardrum has ruptured or if myringotomy was performed.

If the ear is draining, the external canal may be cleaned with sterile cotton swabs or pledgets coupled with topical antibiotic treatment. If ear wicks or lightly rolled sterile gauze packs are placed in the ear after surgical treatment, they should be loose enough to allow accumulated drainage to flow out of the ear; otherwise the infection may be transferred to the mastoid process. Parents should keep these wicks dry during shampoos or baths. Occasionally drainage is so profuse that the pinna and surrounding skin become excoriated from exudate. Frequent cleansing and application of various moisture barriers (e.g., Aloe Vesta Protective Ointment, Proshield Plus Skin Protectant), zinc oxide, or petrolatum jelly (e.g., Vaseline) can prevent this.

Parents require anticipatory guidance regarding temporary hearing loss that accompanies OM. For example, they may need to speak louder, at closer proximity, and while facing the child. They are reminded that the child is not ignoring them. The child may not be able to localize where a sound is coming from because awareness and understanding of speech are reduced either unilaterally or bilaterally, depending on the degree of hearing deficit. The schoolteacher may also need to place the child closer to the front of the class if hearing has been impaired or if the teacher believes the child is not hearing all of the information being given in class. The family should also be aware of possible behavioral changes with hearing loss, including inattentiveness to or lack of awareness of environmental sounds; requests for repetition in conversation or mishearing of content; softer or louder voice than usual; poor attention span and fidgety behavior when in a group listening situation (e.g., classroom); aggressiveness and low frustration tolerance because of frequent communication breakdowns; and impaired speech and language skills. Persistent difficulty in hearing beyond the acute stage should be evaluated.

Preventing recurrence requires adequate parent education regarding antibiotic therapy. Because the symptoms of pain and fever usually subside within 24 to 48 hours, nurses must emphasize that, although the child may appear well, the infection is not completely eradicated until all the prescribed medication is taken. It is important to stress the potential complications of OM, especially hearing loss, which can be prevented with adequate treatment and follow-up care. (See Administration of Medication, and Compliance, Chapter 27.)

Tympanostomy tubes may allow water to enter the middle ear, but recommendations for earplugs are inconsistent. Research indicates that swimming without earplugs poses a slightly increased risk of infection (Goldstein, Mandel, Kurs-Lasky, et al, 2005). Moreover, lake water is contaminated, and wearing earplugs while swimming in a lake prevents total flooding of the external canal. Parents should keep bathwater and shampoo water out of the ear, if possible, since soap reduces the surface tension of water and facilitates entry through the tube. Parents should be aware of the appearance of a grommet (usually a tiny, white, plastic spool-shaped tube) so they can recognize it if it falls out. They are reassured that this is normal and requires no immediate intervention, although they should notify the practitioner.

Parents sometimes ask about preventing ear discomfort in their infants during ascent or descent of an airplane. During ascent, air in the middle ear expands, but decompression takes place through a normal eustachian tube. If the tissues are congested with a URI, the passage of air may be blocked. A nasal mucosa–shrinking spray or oral decongestant before the trip may be helpful. During descent, the air within the middle ear decreases as atmospheric pressure increases. Swallowing is the simplest and most effective method for inflating the middle ear on descent; therefore feeding or offering a pacifier to infants during descent is beneficial.

Reducing the chances of OM is possible with simple measures, such as sitting or holding an infant upright for feedings. Propping bottles is discouraged to avoid pooling of milk while the child is in the supine position and to encourage human contact during feeding. Eliminating tobacco smoke and known allergens is also recommended. Forceful nose blowing during a URI is discouraged to avoid forcing organisms to ascend through the eustachian tube. Early detection of middle ear effusion is essential in prevention of complications. Infants and preschool children should be screened for effusion, and all schoolchildren, especially those with learning disabilities, should be tested for middle ear effusion. Frequent audiologic evaluations, medical consultation, and education of parents and children are advised when middle ear effusion is detected.

Nursing Care Management

Nurses can teach parents or patients simple steps to prevent recurrent infections. Children should limit their stay in the water to less than an hour, if possible, and ears should dry completely (1 to 2 hours) before entering the water again. The ear canal can also be dried with a small tuft of cotton (not a swab). Placing a combination of white vinegar and rubbing alcohol (50:50) in both ear canals on arising, at bedtime, and at the end of each swim is effective in preventing recurrence. A 2% acetic acid solution may also be used. The solution should remain in the canal for 5 minutes. Caution children not to pick at the ears with a pencil, cotton swab, bobby pin, or other object, which can injure or infect the ear canal.

Clinical Manifestations

The onset of epiglottitis is abrupt, less often preceded by cold symptoms and more often by a sore throat. It can rapidly progress to severe respiratory distress. The child usually goes to bed asymptomatic to awaken later complaining of sore throat and pain on swallowing. The child has a fever and appears sicker than clinical findings suggest. The child insists on sitting upright and leaning forward (tripod position), with the chin thrust out, mouth open, and tongue protruding. Drooling of saliva is common because of the difficulty or pain on swallowing and excessive secretions.

The child is irritable and extremely restless and has an apprehensive and frightened expression. The voice is thick and muffled, with a froglike croaking sound on inspiration. The child is not hoarse. Suprasternal and substernal retractions may be visible. The child seldom struggles to breathe, and slow, quiet breathing provides better air exchange. The sallow color of mild hypoxia may progress to frank cyanosis if treatment is delayed. The throat is red and inflamed, and a distinctive, large, cherry red, edematous epiglottis is visible on careful throat inspection. Throat inspection should only be performed when emergency resuscitation personnel and equipment are available.

Therapeutic Management

Epiglottitis may develop suddenly, with respiratory obstruction appearing rapidly. Progressive obstruction leads to hypoxia, hypercapnia, and acidosis followed by decreased muscular tone; reduced level of consciousness; and, when obstruction becomes more or less complete, sudden death. A presumptive diagnosis of epiglottitis constitutes an emergency.

The child is best transported while sitting in a parent’s lap to reduce distress. Examination of the throat with a tongue depressor is contraindicated until experienced personnel and equipment are at hand in the event that the examination precipitates further or complete obstruction. Immediate intubation or tracheotomy may need to be performed.

When a lateral neck radiograph of the soft tissues is indicated, the same experienced personnel should accompany the child to the radiology department. For a young child who is likely to become more agitated by the procedure, it is preferable that the child not be transported but remain on the parent’s lap in the examination area during portable radiology.

Nasotracheal intubation or tracheotomy is usually considered for the child with epiglottitis with severe respiratory distress. It is recommended that the intubation or tracheotomy and any invasive procedure, such as starting an IV infusion, be performed in an area where emergency airway maintenance can be easily and quickly accomplished. Humidified oxygen is administered as necessary either via mask in older children or as blow-by in younger children to avoid further agitation. Whether or not there is an artificial airway, the child requires intensive observation by experienced personnel. The epiglottal swelling usually decreases after 24 hours of antibiotic therapy, and the epiglottis is near normal by the third day.

Children with suspected bacterial epiglottitis are given antibiotics intravenously, followed by oral administration to complete a 7- to 10-day course. The use of corticosteroids for reducing edema may be beneficial during the early hours of treatment. Most intubated children have a course of corticosteroids for 24 hours before extubation.

Nursing Care Management

Epiglottitis is a serious and frightening disease for the child, family, and health professionals. It is important to act quickly but calmly and provide support without unduly increasing anxiety. The child is allowed to remain in the position that provides the most comfort and security, and parents are reassured that everything possible is being done to obtain relief for their child.

Acute care of the child is the same as that described for the child with acute respiratory distress and artificial airways in Chapter 31. Continuous monitoring of respiratory status, including pulse oximetry (or blood gases if the patient is intubated), is part of nursing observations, and the IV infusion is maintained. (See Chapter 28.)

Therapeutic and Nursing Care Management

The disease is almost always self-limiting without long-term sequelae. Treatment is supportive with fluids and humidified air.

Therapeutic Management

The major objective in medical management of infectious LTB is maintaining an airway and providing for adequate respiratory exchange. Children with mild croup (no stridor at rest) are managed at home. Parents need to learn the signs of respiratory distress so that they can call professional help if needed. Children whose symptoms progressively get worse should receive medical attention.

Cool mist provides relief for most children, although there is no substantial evidence to its efficacy. A cool-air vaporizer can be used at home. In the hospital mist may be provided with a face mask or as blow-by. Controversy surrounds the use of mist therapy to treat croup. Studies have failed to demonstrate any improvement in subglottic edema with mist therapy (Moore and Little, 2006).

The cool-temperature therapy modalities assist by constricting edematous blood vessels. In the home environment, suggestions to provide cool air include taking the child outside to breathe in cool night air, using a cold-water vaporizer or humidifier, standing in front of the open freezer, and taking the child to a cool basement or garage. Although these are often recommended, there is no evidence to unconditionally support their use.

Nebulized epinephrine (racemic epinephrine) is now used in children with croup that is not alleviated with cool mist. The α-adrenergic effects cause mucosal vasoconstriction and subsequent decreased subglottic edema. The onset of action is rapid. Peak effect is observed in less than 2 hours. Additional doses may be administered every 20 to 30 minutes as needed. Close observation of patients receiving nebulized racemic epinephrine is critical to detect the reappearance of symptoms, monitor the response to therapy, and note any deterioration in respiratory status. There is evidence that use of l-epinephrine is just as effective as racemic epinephrine but without the side effects of tachycardia and hypertension (Roosevelt, 2007). The patient who has received racemic epinephrine for croup should be observed for 2 to 3 hours for any visible signs of respiratory distress.

The use of corticosteroids is beneficial because the antiinflammatory effects decrease subglottic edema. Oral steroids are effective in the treatment of croup. IM dexamethasone may be given to children who are unable to tolerate oral dosing. Nebulized budesonide may be administered in conjunction with IM dexamethasone. A single dose of oral corticosteroid has shown to decrease hospitalizations and the need for multiple racemic epinephrine treatments in children with mild croup (Roosevelt, 2007). The onset of action is clinically detectable as early as 6 hours after administration, with continued improvement over a period of 12 to 24 hours.

In severe cases of LTB the administration of a mixture of helium and oxygen (heliox) may reduce the work of breathing and relieve the airway obstruction. Because helium has a lower density than room air, it forms a respirable gas (with oxygen) that reduces airway turbulence. The use of heliox, however, has not proved to be more effective than standard treatments and is currently not recommended as a standard management for croup (Myers, 2006; Vorwek and Coats, 2008).

It is essential to allow children with mild croup to continue to drink beverages they like and to encourage parents to use comforting measures with their child (e.g., holding, rocking, walking, singing). If the child is unable to take oral fluids, IV fluid therapy may be indicated.

Nursing Care Management

The most important nursing function in the care of children with LTB is continuous, vigilant observation and accurate assessment of respiratory status. Cardiac, respiratory, and pulse oximetry monitoring supplement visual observations. Changes in therapy are frequently based on nurses’ observations and assessment of a child’s status, response to therapy, and tolerance of procedures. The trend away from early intubation of children with LTB emphasizes the importance of nursing observation and the ability to recognize impending respiratory failure so that intubation can be implemented without delay. Intubation equipment and bag and valve mask equipment should be readily accessible and taken with the child during transport to other areas (e.g., pediatric intensive care if intubation and further observation are required).

To conserve energy, children are given every opportunity to rest. Infants or small children find that being placed on a face mask, coughing, having laryngeal spasms, and needing IV therapy are additional sources of distress. Infants and small children prefer sitting upright, and most want to be held. Children need the security of the parent’s presence. Because crying increases respiratory distress and hypoxia, the nurse needs to assess a child’s individual tolerance for these therapies. An extremely fussy child may do better when held in the parent’s lap with cool mist directed toward the child’s face.

The rapid progression of croup, the alarming sound of the cough and stridor, and the child’s apprehensive behavior and ill appearance combine to create a frightening experience for the parents. They need reassurance regarding the child’s progress and an explanation of treatments. The family should be allowed to remain with the child as much as possible, especially when this decreases the child’s distress.

Fortunately, as the crisis subsides and the child responds to therapy, breathing becomes easier and recovery is generally prompt. Home care after discharge includes continued humidity, adequate hydration, and nourishment. Encourage parents to ask questions about home care and preparation for discharge.

Therapeutic and Nursing Care Management

Children with spasmodic croup are managed at home. Cool mist is recommended for the child’s room. Warm mist provided by steam from hot running water in a closed bathroom may be helpful. Humidification may help, but warm temperatures will not relieve the constriction. Sometimes sudden exposure to cold air relieves the spasm (as when the child is taken out into the night air to see the practitioner). Parents are usually advised to have the child sleep in humidified air until the cough has subsided to prevent subsequent episodes. Children with moderately severe symptoms may be hospitalized for observation and therapy with cool mist and racemic epinephrine, as for LTB. Patients may respond to corticosteroid therapy. The disease is usually self-limiting.

Therapeutic and Nursing Care Management

Bacterial tracheitis requires vigorous management with antipyretics and antibiotics. Many children require endotracheal intubation and mechanical ventilation; patients are closely monitored for impending respiratory failure if not intubated. Early recognition to prevent life-threatening airway obstruction is essential.

Etiology

RSV is a paramyxovirus containing a single strand of ribonucleic acid and is related to parainfluenza virus. RSV strains have two major subgroups: A (the more virulent) and B. More children develop bronchiolitis and pneumonia from RSV subgroup A infections than from subgroup B infections during major outbreaks. The disease usually begins in the fall, reaches a peak during the winter, and then decreases during the spring. In tropical regions, peaks of activity are less pronounced, and outbreaks tend to occur in rainy seasons.

Pathophysiology

RSV affects the epithelial cells of the respiratory tract. The ciliated cells swell, protrude into the lumen, and lose their cilia. RSV produces a fusion of the infected cell membrane with cell membranes of adjacent epithelial cells, thus forming a giant cell with multiple nuclei. At the cellular level this fusion results in multinucleated masses of protoplasm, or syncytia.

The bronchiolar mucosa swells, and lumina are subsequently filled with mucus and exudate. The walls of the bronchi and bronchioles are infiltrated with inflammatory cells, and peribronchiolar interstitial pneumonitis is usually present. Because luminal epithelial cells are shed into the bronchioles when they die, the lumina are frequently obstructed, particularly on expiration. The varying degrees of obstruction produced in small air passages lead to hyperinflation, obstructive emphysema resulting from partial obstruction, and patchy areas of atelectasis. Dilation of bronchial passages on inspiration allows sufficient space for intake of air, but narrowing of the passages on expiration prevents air from leaving the lungs. Thus air is trapped distal to the obstruction and causes progressive overinflation (emphysema).

Transmission

The transmission of RSV is predominantly through direct contact with respiratory secretions, mainly as a result of inoculation from hand to eye, nose, or other mucous membranes. It can also occur by direct inoculation by large-particle aerosols or by self-inoculation from contaminated fomites (Mcintosh, 2007). RSV in secretions can survive for hours on countertops, gloves, paper tissues, and cloth, and for half an hour on skin; it remains infectious when transferred from hands or objects. There is no documentation of distant spread of RSV by small-particle aerosols (airborne transmission).

Clinical Manifestations

The younger the infant, the greater the likelihood that severe lower respiratory tract disease requiring hospitalization will occur. The peak incidence for RSV is 2 to 7 months of age, but reinfection with RSV is common at all ages, with the highest rates being reported in children who attend a daycare center. The severity of RSV tends to diminish with age and repeated infections.

The illness usually begins with a URI after an incubation of about 5 to 8 days. Symptoms such as rhinorrhea and low-grade fever often appear first. OM and conjunctivitis may also be present. In time a cough may develop. If the disease progresses, it becomes a lower respiratory tract infection and manifests typical symptoms (Box 32-6). Infants may have several days of URI symptoms or no symptoms except slight lethargy, poor feeding, or irritability.

Once the lower airway is involved, classic manifestations include signs of altered air exchange, such as wheezing, retractions, crackles, dyspnea, tachypnea, and diminished breath sounds. Pneumonia may occur in conjunction with RSV bronchiolitis. Apnea is a complication of bronchiolitis and is more common in term infants less than 1 month old, in preterm infants with a postconceptual age less than 48 weeks, and in infants with a previous history of apnea (Seiden and Scarfone, 2009).

Diagnostic Evaluation

Because RSV infection may be manifested as a URI, it is often difficult to identify the specific etiologic agent by clinical criteria alone. The most difficult distinction is between RSV and asthma, since both conditions involve the lower airway and have similar symptoms.

Identification has been simplified by the development of tests done on nasal or nasopharyngeal secretions, using either rapid immunofluorescent antibody–direct fluorescent antibody staining (DFA) or enzyme-linked immunosorbent assay (ELISA) techniques for RSV antigen detection. The more traditional viral culture is becoming obsolete, since it takes several days to get a result. Other simultaneous infections may occur with RSV. The infant should be carefully evaluated for the presence of urinary tract infection, meningitis, and bacteremia; antibiotics are prescribed for a coexisting bacterial infection (Sorce, 2009).

Therapeutic Management

Uncomplicated cases of bronchiolitis are treated symptomatically with supplemental oxygen as required, adequate fluid intake, airway maintenance, and medications. Most children with bronchiolitis can be managed at home. Hospitalization is usually recommended for children with respiratory distress or those who cannot maintain adequate hydration. Other reasons for hospitalization include complicating conditions, such as underlying lung or heart disease (e.g., prematurity), or caregiver inability to provide adequate care during illness. The child who is tachypneic or apneic, has marked retractions, seems listless, or has a history of poor fluid intake should be admitted. Pneumonia and electrolyte imbalance are commonly seen in infants who are hospitalized with RSV infection.

The American Academy of Pediatrics practice parameter (2006) recommends the use of supplemental oxygen if the infant fails to maintain a consistent oxygen saturation of at least 90% after nasal suctioning and repositioning. Routine chest physiotherapy (CPT) is not recommended; infants with abundant nasal secretions benefit from periodic suctioning. Fluids by mouth may be contraindicated because of tachypnea, weakness, and fatigue. Therefore IV fluids are preferred until the acute stage of the disease has passed. Nasogastric fluids may be required if the infant is unable to tolerate oral fluids and a peripheral IV is difficult to establish.

Clinical assessments, noninvasive oxygen monitoring, and in severe cases, blood gas values guide therapy. Medical therapy for bronchiolitis is primarily supportive and aimed at decreasing airway hyperresonance and inflammation and promoting adequate fluid intake. Bronchodilators may provide short-term benefits, yet overall significant improvement in the child’s condition is not always appreciable. A short acting β-agonist bronchodilator may be given as a test dose initially; if no improvement occurs, the medication is discontinued. Approximately 50% of infants with RSV lower airway infection and obstruction respond to a short acting β-agonist. Some centers use racemic epinephrine to produce modest improvement in ventilation status. The use of 3% nebulized (hypertonic) saline is associated with an increase in mucociliary clearance in children with RSV (Sorce, 2009) and has shown to be effective in treating RSV in a few small studies (Seiden and Scarfone, 2009).

The use of systemic corticosteroids is controversial but may be used in some centers. Antibiotics are not part of the treatment of RSV unless there is a coexisting bacterial infection such as OM (American Academy of Pediatrics, 2006). Additional treatment recommendations in the American Academy of Pediatrics practice guideline (2006) are to encourage breast-feeding; avoid passive tobacco smoke exposure; and promote preventive measures, including hand washing and the administration of palivizumab (Synagis) to high-risk infants.

Ribavirin, an antiviral agent (synthetic nucleoside analog), is the only specific therapy approved for hospitalized children. However, use of this drug in infants with RSV is controversial because of concerns about the high cost, aerosol route of administration, potential toxic effects among exposed health care personnel, and conflicting results of efficacy trials (American Academy of Pediatrics, 2006; Chávez-Bueno, Mejías, Jafri, et al, 2005; Ventre and Randolph, 2007).

The only product available in the United States for prevention of RSV is palivizumab, a monoclonal antibody, which is given monthly in an IM injection. According to the American Academy of Pediatrics practice guideline (2006), candidates for palivizumab include infants born before 32 weeks of gestation who required medical therapy such as supplemental oxygen or mechanical ventilation. Infants and children younger than 2 years of age with bronchopulmonary dysplasia who have received medical therapy (supplemental oxygen, bronchodilator, diuretic, or corticosteroid therapy) for the condition within 6 months before the anticipated RSV season may benefit from palivizumab prophylaxis. Children with more severe bronchopulmonary dysplasia may benefit from palivizumab prophylaxis for two RSV seasons. Children with severe immunodeficiencies (e.g., severe combined immunodeficiency or acquired immunodeficiency syndrome) may also benefit from prophylaxis. Infants and children younger than 2 years of age with hemodynamically significant congenital heart disease benefit from five monthly IM injections of palivizumab. Prophylaxis for RSV should be initiated at the onset of the RSV season and terminated at the end of the season (November to March). Additional age and condition recommendations are outlined in the American Academy of Pediatrics practice guideline (2006). At the time of this writing, RSV prophylaxis is only available for this subset of infants; other children may be at risk for acquiring the illness but do not qualify for palivizumab prophylaxis, which costs approximately $725 per dose. In addition, some children acquire the illness despite palivizumab prophylaxis (Sorce, 2009).

A second-generation monoclonal antibody, motavizumab, is currently undergoing phase III clinical trials; this drug is reported to be more effective in the prevention of RSV than palivizumab (DeVincenzo, 2008).

Nursing Care Management

Children admitted to the hospital with suspected RSV infection may need separate rooms or rooms with other RSV-infected children. Use Contact and Standard Precautions, including hand washing, not touching the nasal mucosa or conjunctiva, and using gloves and gowns when entering the patient’s room. Other isolation procedures of potential benefit are those aimed at diminishing the number of hospital personnel, visitors, and uninfected children in contact with the child. In some cases visitors, especially children, may be screened for illness before being allowed to visit high-risk infants. Another measure is to make patient assignments so that nurses assigned to children with RSV are not caring for other patients who are considered high risk.

Infants with RSV often have copious nasal secretions, making breathing and nursing or bottle-feeding difficult. This engenders concerns that the child will lose weight or stop breast-feeding altogether. Encourage breast-feeding mothers to pump their milk and store appropriately for later use. (See Chapter 8.) Parents should learn how to instill normal saline drops into the nares and suction the mucus with a bulb syringe before feedings and before bedtime so the child may eat and rest better; unfortunately no medications appropriate for infants can help with these symptoms. To address the issue of decreased fluid intake, parents may offer small amounts of clear fluids, 5 to 10 ml at a time, with a medication syringe every 10 minutes or so. Infants may cough or vomit as the secretions settle in the stomach and make them prone to emesis of such secretions.

The nurse aims additional interventions at monitoring oxygenation with pulse oximetry, ensuring bronchodilator therapy is optimized by using a small mask for delivery (versus blow-by), monitoring IV fluids administered, monitoring fever and administering antipyretics, and providing information for the parent regarding the infant’s status. Inform the parents that the infant’s cough may persist for a few weeks.

The critically ill infant with RSV usually is placed in the pediatric intensive care unit for continuous monitoring of respiratory status, cardiac output, and maintenance of adequate systemic pressure. IV fluids, antibiotics, mechanical ventilation, and inotropes are often required in the unstable child. Parents and family members need emotional support and information regarding the child’s status during this crisis.

The unpredictability of the infant’s individual response to the disease compounds parental anxiety when they hear about children who had serious morbidity or died from RSV. However, in most cases the infant recovers quickly from the disease and resumes normal daily activities, including fluid intake. Such infants are at risk for further episodes of wheezing that may or may not involve an RSV infection. Reinfection with the virus may occur in the same season, but subsequent infections are not as severe as the first.

Clinical Manifestations

The onset may be acute or insidious, and symptoms vary from mild fever, slight cough, and malaise to high fever, severe cough, and fatigue. Early in the illness, the cough is likely to be unproductive or productive of small amounts of whitish sputum. Breath sounds may include a few wheezes or fine crackles. Radiography reveals diffuse or patchy infiltration with a peribronchial distribution.

Therapeutic and Nursing Care Management

The prognosis is generally good, although viral infections of the respiratory tract render the affected child more susceptible to secondary bacterial invasion. Treatment is usually symptomatic and includes measures to promote oxygenation and comfort, such as oxygen administration, CPT and postural drainage, antipyretics for fever management, fluid intake, and family support. Although some authorities recommend antimicrobial therapy in the hope of reducing or preventing secondary bacterial infection, it is usually reserved for children in whom the presence of such infection is demonstrated by appropriate cultures.

Clinical Manifestations

The onset may be sudden or insidious and is usually accompanied by general systemic symptoms, including fever, chills (in older children), headache, malaise, anorexia, and muscle pain (myalgia). These symptoms are followed by rhinitis; sore throat; and a dry, hacking cough. The cough, initially nonproductive, produces seromucoid sputum that later becomes mucopurulent or blood streaked. The degree of fever varies widely, from several days to 2 weeks. Dyspnea occurs infrequently.

Radiographic examination reveals evidence of pneumonia before physical signs are apparent. There may be fine crepitant crackles over various areas of the lung fields, but consolidation is usually not demonstrated. The pathologic process consists of interstitial round cell infiltration and edema of alveolar septa and varying distribution of areas of inflammation, necrosis, and ulceration of the mucosal lining of bronchi and bronchioles. Areas of consolidation and emphysema are present.

Therapeutic and Nursing Care Management

Most affected persons recover from acute illness in 7 to 10 days with symptomatic treatment, followed by a week of convalescence. Hospitalization is rarely necessary.

Etiology and Epidemiology

S. pneumoniae is the most common bacterial pathogen responsible for community-acquired pneumonia in both children and adults (Rafei and Lichenstein, 2006). Other bacteria that cause pneumonia in children are group A streptococci, S. aureus, M. catarrhalis, M. pneumoniae, and C. pneumoniae.

Beyond the neonatal period, bacterial pneumonias display distinct clinical patterns that facilitate their differentiation from other forms of pneumonia. The onset of illness is abrupt and generally follows a viral infection that disturbs the natural defense mechanisms of the upper respiratory tract. In the 3-month to 5-year age-group, S. pneumoniae, M. catarrhalis, and group A streptococci are common causes. H. influenzae type b is causing fewer infections because of the Hib vaccine. S. aureus pneumonia is also now rarely seen in infants and toddlers.

Clinical Manifestations

The child with bacterial pneumonia usually appears ill. Symptoms include fever, malaise, rapid and shallow respirations, cough, and chest pain. The older child may complain of headache, chills, abdominal pain, chest pain, or meningeal symptoms (meningism) (Box 32-9). Respiratory distress may or may not be present. In some cases the only finding is an increased respiratory rate. The pain of pneumonia may be referred to the abdomen and confused with appendicitis.

Infants and young children develop more severe symptoms than older children. Cyanosis and apnea are common, and the parent may report the infant’s activity and eating pattern was decreased for a few days. Additional clinical manifestations in infants include abrupt fever, vomiting, diarrhea, and abdominal distention (Sectish and Prober, 2007). Because pneumonia in newborns carries a high morbidity and mortality rate, suspect bacterial infection in all neonates with respiratory symptoms.

Initially, the cough is usually hacking and nonproductive, and breath sounds are diminished or heard as scattered crackles. When consolidation is present, breath sounds may be tubular in quality with no adventitious noises. As the infection resolves, coarse crackles and wheezing are heard, and the cough becomes productive with purulent sputum.

Staphylococcal pneumonia is rare but particularly progressive and must be treated aggressively. The onset is rapid, with rapid deterioration. Conjunctivitis and furuncles are signs of a probable staphylococcal infection.

Diagnostic Evaluation

The key to a preliminary diagnosis is finding pulmonary infiltrates on radiographic examination, usually revealing lobar consolidation and, in some severe cases, pleural effusion. Laboratory studies include Gram stain and culture of sputum in older children, nasopharyngeal specimens, blood cultures, and lung aspiration and biopsy. The white blood cell count may be elevated, but it may be normal for infants with staphylococcal disease. Children with streptococcal disease usually have an elevated antistreptolysin O titer. The infant or child with recurrent pneumonia should be further evaluated for CF or an immunodeficiency disease. Diagnostic evaluation should include ruling out aspiration pneumonia as a potential cause.

Therapeutic Management

Antimicrobial therapy has significantly reduced the morbidity and mortality from bacterial pneumonia. Oral amoxicillin is widely used for outpatient management of infants and children younger than 5 years of age. Patients incompletely immunized against H. influenzae should receive amoxicillin-clavulanate or a second-generation cephalosporin (cefuroxime, cefadroxil). Erythromycin is the drug of choice for older children and adolescents because of its activity against M. pneumoniae. In the hospital, medications are given parenterally for rapid action and maximum effect. IV cefuroxime, cefotaxime, and ceftriaxone are considered the primary antibacterial agents for bacterial pneumonia in the hospitalized child (Sectish and Prober, 2007). Parenteral or oral erythromycin should be added for children older than 5 years of age until M. pneumoniae is ruled out. CPT with postural drainage may be helpful in clearing secretions in some cases.

Most older children with pneumonia can be treated at home, especially if the condition is recognized and treatment initiated early. Antibiotic therapy, rest, liberal oral intake of fluid, and administration of antipyretics for fever are the principal therapeutic measures. Hospitalization is indicated when pleural effusion or empyema accompanies the disease, when compliance with therapy is estimated to be poor, in infants less than 1 month old, and when there are chronic illnesses such as congenital heart disease or bronchopulmonary dysplasia (Rafei and Lichenstein, 2006). Pneumonia in the infant or young child may also require hospitalization because the course of illness is variable and complications are more common in very young patients. In addition, IV fluid administration is frequently necessary, and oxygen may be required if the child is in respiratory distress.

Nursing Care Management

Nursing care of the child with pneumonia is primarily supportive and symptomatic but necessitates thorough respiratory assessment and administration of supplemental oxygen (as required) and antibiotics. The child’s respiratory rate and status, oxygenation, general disposition, and level of activity are frequently assessed. If the cough is disturbing, the use of antitussives, especially before rest times and meals, is often helpful. To prevent dehydration, fluids are frequently administered intravenously during the acute phase. Oral fluids, if allowed, are given cautiously to avoid aspiration and to decrease the possibility of aggravating a fatiguing cough.

Nursing care of the child with a chest tube requires close attention to respiratory status, as noted previously; the chest tube and drainage device used are monitored for proper function (i.e., drainage is not impeded, vacuum setting is correct, tubing is free of kinks, dressing covering chest tube insertion site is intact, water seal is maintained [if used], and chest tube remains in place). Movement in bed and ambulation with a chest tube are encouraged according to the child’s respiratory status, but children often require a mild analgesic such as acetaminophen.

If needed, supplemental oxygen may be administered by nasal cannula; newborns may receive oxygen via a plastic hood. Children are usually more comfortable in a semierect position but should be allowed to determine the position of comfort. Control fever by cooling the environment and administering antipyretic drugs as prescribed. Temperature is monitored regularly to detect a rise that might trigger a febrile seizure.

Monitor vital signs and oxygenation to assess the progress of the disease and to detect early signs of complications. Children with ineffectual cough or those with difficulty handling secretions, especially infants, require suctioning to maintain a patent airway. A simple bulb suction syringe is usually sufficient for clearing the nares and nasopharynx of infants, but mechanical suction should be readily available if needed. Older children can usually handle secretions without assistance. Postural drainage and CPT are generally prescribed every 4 hours or more often, depending on the child’s condition.

The hospitalized child may be apprehensive, and the treatments and tests are frightening and stress producing. It is important to involve the entire family in the care as appropriate and to encourage questions and facilitate effective communication. Reducing the child’s anxiety, apprehension, and psychologic distress leads to relaxation and decreased respiratory efforts. Easing respiratory efforts further reduces the child’s apprehension. Encouraging the presence of the caregiver provides the child with a source of comfort and support.

Etiology

TB is caused by Mycobacterium tuberculosis, an acid-fast bacillus not readily decolorized by acids after staining. Children are susceptible to the human (M. tuberculosis) and the bovine (Mycobacterium bovis) organisms. In parts of the world where TB in cattle is not controlled or milk is not pasteurized, the bovine type is a common source of infection.

Although the causative agent for TB is the tubercle bacillus, other factors influence the degree to which the organism produces an altered state in the host. These include heredity (resistance to the infection may be genetically transmitted), gender (higher rates in adolescent girls), age (lower resistance in infants, higher incidence during adolescence), stress (emotional or physical), nutritional state, and intercurrent infection (especially HIV, measles, and pertussis). Children with HIV infection have an increased incidence of TB disease, and all children with TB should be tested for HIV (Box 32-11).

Pathophysiology

The source of infection in children is usually an infected member of the household or any frequent visitor to the household, such as a baby-sitter or domestic worker. Transmission of M. tuberculosis occurs when the child inhales microdroplets (usually 1 to 5 mm in size) into the respiratory tract after someone has coughed or sneezed. Although the lung is the most frequent portal of entry in humans, the organism M. bovis can be ingested via infected milk (unpasteurized milk or fresh cheese). When the M. tuberculosis droplet is inhaled, it passes down the bronchial tree, implants in either a bronchiole or alveolus, and starts to multiply. M. bovis typically causes cervical lymphadenitis, meningitis, and intestinal TB disease and is more common in adults and children from countries where M. bovis is prevalent (American Academy of Pediatrics, 2009b).

Epithelial cells surround and encapsulate the multiplying bacilli in an attempt to wall off the invading organisms, thus forming the typical tubercle. During the inflammatory process, some bacilli leave the focal area and are carried to the regional lymph nodes that drain the area; as a result, the child develops a fever. Radiographic examinations may be positive if such tests are performed when the child is known to have been exposed. The tuberculin skin test is positive.

Extension of the primary lesion at the original site causes progressive tissue destruction as it spreads within the lung, discharges material from foci to other areas of the lungs (e.g., bronchi or pleura), or produces pneumonia. Erosion of blood vessels by the primary lesion can cause widespread dissemination of the tubercle bacillus to near and distant sites (miliary TB). Organisms deposited in the upper lung zones, bones, kidneys, and brain may find favorable environments for growth, but organs and tissue such as bone marrow, liver, and spleen appear to inhibit multiplication of the bacilli.

Extrapulmonary TB may be manifested as superior lymphadenitis, meningitis, or osteoarthritis and may appear in the middle ear and mastoid and on the skin (American Academy of Pediatrics, 2009b; Feja and Saiman, 2005). With the exception of meningitis, treatment for extrapulmonary TB may be the same drug regimen as for pulmonary TB. Renal TB is rare in children but may occur in adolescents.

For children not immunosuppressed or immunocompromised, a strong cell-mediated immune response provides specific immunity that usually limits further multiplication of the bacilli. These children remain asymptomatic, and the lesions usually heal. TB infection is manifested by a positive skin test only. In a small percentage of persons with newly acquired TB, replication of the organism continues and TB disease occurs, as evidenced by a positive chest radiograph, positive sputum culture, and signs of disease.

Clinical Manifestations

Clinical manifestations of pulmonary TB in children are extremely variable. The disease may be asymptomatic or produce a broad range of symptoms, including general responses such as fever, malaise, anorexia, and weight loss or more specific symptoms related to the site of infection (e.g., lungs, bone, brain, kidneys). Lung disease may or may not include cough (which progresses slowly over weeks to months), aching pain and tightness in the chest, and (rarely) hemoptysis.

As increasing amounts of lung tissue become involved, the respiratory rate increases, the lung on the affected side does not expand as well as the other, auscultation reveals diminished breath sounds and crackles, and there is dullness to percussion. In children (usually infants) who are unable to contain the spread of infection, the fever persists; the generalized symptoms are manifest; and the patient develops pallor, anemia, weakness, and weight loss.

Diagnostic Evaluation

Diagnosis is based on information derived from physical examination, history, reaction to a tuberculin test, organism cultures, and radiographic examinations. In addition, it must be determined if the lesion is in the active, quiescent, or healed stage.