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Care of the Vulnerable Population: Children. Dr. James Paton Royal Hospital for Sick Children Glasgow. Care of Vulnerable Population - Children. Clinical Presentations Triage and Severity Assessment Recommended treatments – Part 1 Investigations in Hospital - PowerPoint PPT Presentation
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Hot Topic Meeting by:
Royal College of Physicians of Edinburgh & The Scottish Executive Health Department
Pandemic Flu
Planning Scotland’s Health Response
5th June 2007
Queen Mother Conference Centre
June – 2007 2
Care of the Vulnerable Care of the Vulnerable Population: ChildrenPopulation: Children
Dr. James Paton Royal Hospital for Sick Children
Glasgow
June – 2007 3
Care of Vulnerable Population - Care of Vulnerable Population - ChildrenChildren
• Clinical Presentations
• Triage and Severity Assessment
• Recommended treatments – Part 1
• Investigations in Hospital
• Recommended treatments – Part 2
• Ethics & Staffing during a pandemic
June – 2007 4
June – 2007 5
Fleming, D M et al. Arch Dis Child 2005;90:741-746
June – 2007 6
Clinical Characteristics of RSV and Clinical Characteristics of RSV and ‘Flu in Hospitalised Children‘Flu in Hospitalised Children
Meury et al Eur J Pediatr 2004; 163:359-363
June – 2007 7
Bhat, N. et al. N Engl J Med 2005;353:2559-2567
Timing of 153 Cases of Fatal Influenza in Timing of 153 Cases of Fatal Influenza in Children – US 2003-04Children – US 2003-04
June – 2007 8
Whose at Risk?Whose at Risk?• Impact of Age
• Impact of pre-existing medical conditions
June – 2007 9
'Flu Mortality Rate According to Age 'Flu Mortality Rate According to Age Group – US 2003-04Group – US 2003-04
Bhat, N. et al. N Engl J Med 2005;353:2559-2567
June – 2007 10
Izurieta H et al. N Engl J Med 2000;342:232-239
Relative Risk of Admission in Children without Relative Risk of Admission in Children without High Risk ConditionsHigh Risk Conditions
June – 2007 11
Bhat, N. et al. N Engl J
Med 2005;353:2559-2567
Underlying Health Status in Children with Fatal Underlying Health Status in Children with Fatal Influenza – US 2003-04 (n- 149)Influenza – US 2003-04 (n- 149)
June – 2007 12
Triage and General Management in 1ry Triage and General Management in 1ry CareCare
• Recognition of ‘At Risk Groups’• Assessment of Illness Severity• Current advice and guidance on
epidemiology of pandemic
June – 2007 13
Severity Assessment (CURB 65) in Adults
Item Measure ScoreConfusion Mental test score ≤8 Urea >7mmol/l
Respiratory Distress
Respiratory Rate ≥30/min
Blood Pressure
SBP <90mmHg or DBP ≤60mmHg
Age - >65yr Age ≥65yr
June – 2007 14
Respiratory Distress – Severity Assessment in Children
Mild Severe
Infants Temp >38.5 ⁰CMild Respiratory Distress Taking Full Feed
Temp >38.5 ⁰CSevere Respiratory DistressCyanosisGrunting / ApnoeaNot feeding
Children Temp >38.5 ⁰CMild Respiratory DistressNo vomiting
Temp >38.5 ⁰CSevere respiratory DistressCyanosisGruntingSigns of dehydration
Appendix 8 Thorax 2007;62: Supplement 1
June – 2007 15
Severity Assessment in Children
Item Measure ScoreTemperature >38.5⁰CConfusion Complicated or prolonged seizure;
Altered conscious levelUrea Dehydration - Older Children
Respiratory Distress
↑Rate, Recession, Nasal Flaring, Cyanosis, Grunting, ApnoeaNot feeding
Blood Pressure
Signs of Shock – extreme pallor, hypotension, floppy infant
Age - >65yr Age <1yr
June – 2007 16
See CHP(Nurse or Doctor if Child <7yrs)
Cough, fever and/or 'flu-like symptoms
Temp >38.5 deg C
Age <1yr or Child atRisk of Complications
Refer to GP
Yes
Yes
Treat at home withantipyretics and fluids
No
Antipyreticsand fluids
Symptoms <2 daysNo No
Triage & General Management in 1ry CareTriage & General Management in 1ry Care
Thorax 2007;62:Supplement 1
June – 2007 17
Specific Treatment - Anti-Viral TherapySpecific Treatment - Anti-Viral Therapy• Amantidine / rimantidine
• Neuraminidase inhibitors– Oseltamivir (Tabs & liquid)
• Effective if given within 2 days of start of illness• Reduction in time to alleviation of symptoms• Reduction in complications requiring antibiotics• Note - faster drug clearance in younger children• Not licensed under 1 year - but Japanese experience
suggests is safe– Zanamavir (inhaler – so children >5yrs)
• Ribavirin
June – 2007 18
See CHP(Nurse or Doctor if Child <7yrs)
Cough, fever and/or 'flu-like symptoms
Temp >38.5 deg C
Age <1yr or Child atRisk of Complications
Refer to GP
Yes
Yes
Treat at home withantipyretics and fluids
No
Antipyreticsand fluids
Symptoms <2 daysNo No
Chronic Disease?
or Breathing Difficulties Severe earache Vomiting > 24hrs Drowsiness
Is the Child Severely Ill?
Oseltamivir,antipyretics and fluids
Antipyreticsand fluids
Symptoms <2 daysNo
Oseltamivir,antipyretics and
fluids
Age<1yr?
If deterioratesAntipyretics,
fluids & (antibiotics)
NoNo
Yes
Yes
Yes
Yes Yes
Refer for Hospital AdmissionYes
June – 2007 19
Triage of Children in HospitalTriage of Children in Hospital• Assessment of Illness severity• Admit to ward if:
– Severe respiratory distress; Hypoxia– Severe dehydration– Altered conscious level or prolonged seizure– Signs of septicaemia
• Consider HDU/ICU– Worsening hypoxia despite oxygen– Worsening respiratory failure– Apnoea or slow/irregular breathing– Encephalopathy
• If no ICU Beds?
June – 2007 20
Investigations for Children in HospitalInvestigations for Children in Hospital
• Pulse oximetry• CXR
– if hypoxic or severely ill, or deteriorating; Not routinely
• FBC, U & Es, LFTs, Blood Culture • Microbiology
June – 2007 21
Microbiological Investigations Microbiological Investigations for Children in Hospitalfor Children in Hospital
Early Pandemic – when you want to know– Virology
• NPA for Respiratory panel - ‘flu A & B; RSV, Adeno, Rhino, Paraflu 1,2,3
• Rapid influenza tests – high specificity - R/I ‘flu• Acute & Convalescent Serum
– Bacteriology• Blood • Sputum
Established Pandemic – when you know– Virology – not routine– Bacteriology
June – 2007 22
Anti-Viral Therapy in HospitalAnti-Viral Therapy in Hospital• Neuraminidase inhibitors
– Oseltamivir (Tabs & liquid)
– If severely ill with symptoms for <6 days– Child <1year with severe infection with informed
consent
June – 2007 23
AntibioticsAntibiotics for Children in Hospitalfor Children in Hospital
• Secondary bacterial infections are common– Pneumonia– Otitis media
June – 2007 24
O’Brien et al. Clin Infect
Dis 2000;30:784-9
Pneumococcal Pneumonia in Previously Pneumococcal Pneumonia in Previously Healthy ChildrenHealthy Children
June – 2007 25
Bhat, N. et al. N Engl J
Med 2005;353:2559-2567
Bacterial Co-infections in 24 Children Bacterial Co-infections in 24 Children with Fatal Influenzawith Fatal Influenza
June – 2007 26
Navarini, Alexander A. et al. (2006) Proc. Natl. Acad. Sci. USA 2006; 103: 15535-15539
Activation-associated Cell Death of Bone Marrow GRC Activation-associated Cell Death of Bone Marrow GRC during LCMV infectionduring LCMV infection
Early phase of infection largely controlled by innate resistance via granulocytes.Virus-induced suppression of antibacterial resistance and immunity by IFN 1 production was caused by apoptosis of bone marrow granulocytes and impaired granulocyte emigration. Granulocytopenia was not complete but became functionally limiting during super-infection when large numbers of granulocytes were rapidly required to control infection
Early phase of infection largely controlled by innate resistance via granulocytes.Virus-induced suppression of antibacterial resistance and immunity by IFN 1 production was caused by apoptosis of bone marrow granulocytes and impaired granulocyte emigration. Granulocytopenia was not complete but became functionally limiting during super-infection when large numbers of granulocytes were rapidly required to control infection
June – 2007 27
Antibiotics for Children in HospitalAntibiotics for Children in Hospital• Children at risk of complications• Children with disease severe enough to be admitted
Treat prophylactically with antibiotic to cover • Staph aureus • Str pneumoniae• H influenzae
= Co-amoxiclav; Or clarithromycin, cefuroxime if pen. allergic
June – 2007 28
Will There be Sufficient Staff?
June – 2007 29
PhysiciansY D/K N
It would be ethical for HCP to abandon their workplace during a pandemic to protect themselves and their families
24% 11% 64%
HCP should be allowed to decide whether they report to work during a pandemic
25% 8% 67%
HCP without children should primarily care for influenza patients during a pandemic
16% 12% 72%
Professional Duty – Family or Patient First?
Ehrenstein et al BMC Public Health 2006;6:311
June – 2007 30
June – 2007 31
The Next Influenza Pandemic: Will be Ready to Care for Our Children?
“The severity of the 2003-2004 'flu season will pale in comparison with that of the next pandemic”
Woods and AbramsonJ Pediatr 2005;147:147-155
Hot Topic Meeting by:
Royal College of Physicians of Edinburgh & The Scottish Executive Health Department
Pandemic Flu
Planning Scotland’s Health Response
5th June 2007
Queen Mother Conference Centre
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