Reference Work Entry

Encyclopedia of Public Health

pp 774-779

Infectious Diseases in Pediatrics

  • Monika KornAffiliated withFriedrich-Ebert-Krankenhaus GmbH

Synonyms

Infectious diseases in childhood; Childrens' diseases; Childhood diseases

Definition

Due to their frequency in childhood, infectious diseases play an important role in pediatrics. They are divided into infections that exclusively or predominantly appear in children, or at particular stages of childhood (e. g. newborns or babies), and those which occur both in children and adults. The severity of an infectious disease can vary considerably at different phases of life.

Basic Characteristics

Special Features in Pediatrics

Children are not simply little adults. Even though they are targets of the same pathogens as adults, the consequences of an infection for children can be quite different. As the body surface is relatively greater in children, as is the percentage of water, clearly when replacement is required there is a relatively higher need for fluids and electrolytes per kilogram body weight. The younger a child is, the more it is endangered by fluid loss due to feverish infections or diarrhea.

At the time of birth, the immune system is still immature; thus infectious diseases in newborns and young babies can have severe or even deadly consequences. Pathogens can be transmitted intrauterinally, leading to congenital infections. On the other hand, directly after birth, children are protected against several – predominantly viral – infections by maternal antibodies, which they received intrauterinally. This so-called nest protection lasts for a couple of months.

As to the treatment of infectious diseases, again differences between children and adults are to be found. Besides the special features regarding body fluid balance, the treatment of infectious diseases in children can present specific problems, e. g. antibiotics can have developmental side-effects (like discoloration of teeth due to tetracyclines or damage to connective tissue and cartilage due to gyrase inhibitors) and several drugs are not licensed for children, due to a lack of evidence-based experience or for other reasons.

Even the transmission of infectious diseases has special pediatric features. Children often attend communal services (day-nurseries, kindergartens) or spend long hours in large groups (for example in school or sports clubs). Their play and social behavior is characterized by close contact. Especially in younger children, there often is a common use of toys and other objects, like hygienic articles, dinner‐services and drinking vessels; meals are frequently eaten together, sweets are often shared by biting off or licking. Due to these special environmental and behavioral conditions, the risk of transmission of infectious diseases is considerably increased. The close contact enables the spread of those organisms which need direct contact for their transmission, like lice (primarily head lice) and scabies. Early childhood is thus a time of exposure to highly contagious infectious diseases. A further aspect which has to be considered is the lack of, or at least an insufficient, knowledge of hygiene in children which puts them at high risk of the fecal-orally transmitted diseases.

The liability to infectious diseases is increased by insufficient nutrition. This factor is particularly significant in developing countries.

In infectious diseases, children often develop fever, and in younger children, febrile seizures frequently appear. An inflammation of the bones (osteomyelitits ) has to be taken very seriously in childhood as damage to the epiphysis can impair bone length growth. Due to their mode of transmission, sexually transmitted diseases (STD) do not play a significant role in the field of pediatrics, however, on the one hand, some of the STDs can be transmitted to the child during pregnancy or birth, and, on the other hand, due to promiscuity and child prostitution, these social diseases do occur in children. Also, sexual abuse has to be taken into consideration.

Classic Childhood Diseases

Diseases, said to be classic childhood diseases, fulfill typical conditions: they are highly contagious (without preventive measure they appear in more than 90% of all children up to the age of five), and they usually leave a lifelong immunity.

Most of the pathogens are viruses. Since there are only restricted possibilities concerning the treatment of viral infections, active vaccination (vaccination, active) plays a significant role in the prevention of childhood diseases. Vaccination programs concentrate on the first 18 months of life with boosters – or indication vaccinations – being given later in life. Consistent execution of the recommended vaccinations is still important.

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Figure 1

Membraneous tonsillitis in infectious mononucleosis; photo kindly provided by Prof. Wilhelm Kirch, Dresden

The term “childhood diseases” sounds harmless and children's diseases are overcome without consequences in a high percentage of cases, but complications are possible and, at times, the diseases can be anything but harmless. For example serious infections are found in immunodeficient children; furthermore, childhood disease occurring later in life (in teenagers or adults) can run much more severe courses. As an example of the perilous nature of a childhood disease one has just to look at the history of measles. In the 16th century, the virus was brought to America by the Spanish conquistadores. As the natives did not have any means of defense (antibodies) against the disease, an outbreak of measles occurred leading to a great number of deaths. Besides measles, whooping cough, mumps, rubella, chicken pox, poliomyelitis and diphtheria belong to the classic childhood diseases. Other infections, which are commonly found in children, are erythema infectiosum, exanthem subitum, infectious mononucleosis (Fig. 1) and scarlet fever (Fig. 2). Tetanus is a transmissible disease, which can occur at any stage of life; the infection can be prevented by active and – if necessary – passive vaccination, even in babies.

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Figure 2

Early development of raspberry tongue in a 7-year-old boy with scarlet fever (2nd day of disease) (Lentze et al. 2002)

Congenital and Neonatal Infections

In congenital infections, the pathogens have been transmitted to the unborn child via the placenta . In general, infections of the fetus only occur when the mother has no antibodies against the disease. As sensitivity to the different germs varies during pregnancy, the time of infection significantly determines the extent of the damage suffered by the unborn child. The important congenital infections are toxoplasmosis, rubella (congenital rubella syndrome (CRS)), erythema infectiosum (congenital erythema infectiosum), cytomegaly (CMV) (congenital cytomegaly (CMV)), varicella (congenital varicella) and syphilis (congenital syphilis). If a newborn baby is suspected of having a congenital infection, a TORCH serology can be performed. Malaria can also be transmitted during pregnancy; but this problem quite exclusively concerns non-immune pregnant women who undertake a journey to tropical or subtropical regions. Since the 1980s, congenital HIV-infection and AIDS have gained in significance. Further congenital infections, which have to be mentioned, are hepatitis B infection and congenital listeriosis. Directly before or during birth, the child can be infected with germs from the mother's genital tract. Thus, infections with Listeria (congenital listeriosis), herpes‐simplex viruses (congenital herpes‐simplex infection), gonorrhea (congenital gonorrhea), syphilis (congenital syphilis), Chlamydia trachomatis ( Chlamydia trachomatis infection) or Ureaplasma urealyticum ( Ureaplasma urealyticum infection) can occur. Infections in newborns develop if amniotic infection syndrome or a premature rupture of the amnion is present. Ascending pathogens get into the amniotic fluid and are swallowed by the baby. They are resorbed in the intestinal tract and spread via the blood vessels. Often, the symptoms of a neonatal infection are non-specific (reduced muscle tonus, changed skin color, instability of body temperature) and require great experience on the observer's behalf. The most common pathogens in the first three days of life are Group B streptococci (GBS), E. coli and Klebsiellae. Listeria monocytogenes also play a certain role in neonatal infections. As the infecting pathogen is generally initially unknown, a fixed regimen of a combined antibiotic therapy is prescribed.

Respiratory Tract Infections

Respiratory tract infections are the most frequent infections at all stages of life (see sysnopsis), but there are some special features relevant to childhood. During the first 10 years of life, on average, every child falls sick with 3–8 respiratory tract infections every year, without an underlying increased liability to infections. Transmission takes place by droplets or direct contact with contagious secretions. Apart from time spent in communal services (kindergartens, schools), passive smoking is a risk factor of respiratory tract infections. Due to special anatomic features, babies can suck (drink) and breathe simultaneously. As they usually nearly exclusively breathe through their noses, a simple cold with impairment of nasal breathing causes considerable discomfort. An impaired ventilation of the auditory tube (eustachian tube), which connects the pharynx with the middle ear, leads to otitis media (an inflammation of the middle ear). Otitis media is most frequently seen in younger children due to their relatively large adenoids. Chronic effusion in the tympanic cavity can impair hearing and impede language development. In cases of recurring inflammations of the middle ear surgical interventions may be necessary, e. g. the removal of the adenoids (adenotomy), an incision of the eardrum (paracentesis) or the insertion of eartubes into the tympanic membrane. The airways of a child are narrower than those of adults. In children, a swelling of the mucous membranes leads to an impairment of breathing more readily than in adults. This is due to the differences in the relative circular areas of the windpipe and bronchi (\( A = \pi \times r^{2} \)). The narrowness of the airway system plays an important role in spasmodic croup, which is a typical disease in younger children, as well as in bronchitis and bronchiolitis. The latter is frequently caused by respiratory-syncytial-virus (RSV) infection. Epiglottitis, which was feared in earlier times, nowadays seldomly occurs due to active HIB vaccination (HIB vaccination, active). As for pneumonia , in general, the germs are the same in children as in adults, but some pathogens predominantly occur in particular age-groups. Chlamydia , for example, causes pneumonia in newborns, only plays a minor role in younger children, and again becomes more frequent in schoolchildren. In comparison with the incidence in adulthood, tuberculosis is quite rare in children.

Infectious Diseases of the Gastrointestinal Tract/Enteritis

Usually, infections of the gastrointestinal tract are fecal-orally transmitted diseases, with pathogens being swallowed in food, contaminated drinking water or after finger-to-mouth direct contact with the source of infection. The responsible germs are the same in children and adults but, due to the special features of children's anatomy and physiology, social associations and social behaviors, infectious enteritis is much more frequent and often takes a more serious course in childhood than in adulthood. As for babies and small children, enteritis due to rotavirus (rotavirus infection) or Norwalk virus infection have to be mentioned as well as infection with Clostridium botulinum which is particularly dangerous in babies. To prevent rotavirus infection, an active rotavirus vaccination (rotavirus vaccination , active) is available.

Urinary Tract Infections

Urinary tract infections are a common disease in childhood. In newborns, the infection is most frequently caused by a hematogenic spread (via blood vessels); in later age groups, infections usually ascend from the lower urinary tract. The severity of disease depends on whether infections concern the bladder (cystitis) or affect the kidneys (pyelonephritis). The appearance of urinary tract infections or of relapses is facilitated by anatomical abnormalities and functional disorders. The younger a child is the less specific are the symptoms. During the first months of life, urinary tract infections often present as a septic disease. Up to the eighth year of life, general symptoms of illness predominate, e. g. loss of appetite, stomach ache and an increased body temperature. Older children primarily report local symptoms, like frequent micturition (polyuria), dysuria or burning micturition. During urinary tract infections, a child, who is usually dry, may suffer nocturnal enuresis (bed-wetting). More than 80% of urinary tract infections are caused by Escherichia coli . Proteus mirabilis , Klebsiella pneumoniae and enterococci each are responsible for 3–5% of the infections. Diagnosis is made by the detection of an elevated amount of pathogens in the urine (>\( 10^{5} \) germs/µl in midstream urine). In younger children, urine usually has to be collected in plastic bags with an adhesive paper on one end; thus contamination is an easy possibility. Therapy depends on the severity of the infection and the sensitivity of the pathogens. In general, trimethoprim , aminopenicillins and cephalosporines are used. To avoid urinary tract infections, intestinal pathogens should be prevented from reaching the opening of the urethra. Particularly in girls, one has to pay attention to the correct cleansing of the anogenital region: it has to be wiped from the front to back and rubbing should be avoided. It is important to teach children this technique during their toilet training. In cases of known anatomical abnormalities, functional disorders or other risks of recurrent urinary tract infections, an antibiotic relapse prophylaxis may be necessary; usually, trimethoprim, cephalosporines or nitrofurantoin are prescribed.

Encephalitis/Meningitis

An inflammation of the brain tissue (encephalitis) can be caused by a number of pathogens. While most infections can appear in all age groups, encephalitis due to congenital herpes simplex infection and congenital toxoplasmosis are more prevelant in newborns. Up to 65–80% of the bacterial inflammations of the membranes that envelop the brain (meningitis) occur in childhood, especially during the first two years of life. In newborns, meningitis is treated with a combination of a 3rd generation cephalosporine (cefotaxime) and a broad-spectrum penicillin; for later age groups, ceftriaxone monotherapy is prescribed.

Septic Courses of Diseases

sepsis is a systemic inflammatory reaction, which can lead to shock and organ failure with a possible lethal outcome. It is not very common in childhood; but one has to be prepared for sepsis in pediatric oncology and intensive care medicine. A feared septic disease in pediatrics is Waterhouse–Friderichsen syndrome (Fig. 3).

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Figure 3

Waterhouse–Friderichsen syndrome in meningococcal sepsis. a Skin bleedings. b Intravital livor mortes. Photographs kindly provided by Prof. Wilhelm Kirch, Dresden

Cross-References

Antibodies

Body Fluid Household

Bronchiolitis

Chicken Pox

Chlamydia trachomatis Infection

Congenital Cytomegaly (CMV)

Congenital Erythema infectiosum

Congenital Gonorrhea

Congenital Herpes simplex Infection

Congenital Listeriosis

Congenital Rubella Syndrome (CRS)

Congenital Syphilis

Congenital Varicella

Cytomegaly (CMV)

Diphtheria

Encephalitis

Epiglottitis

Erythema Infectiosum

Erythema subitum

Febrile Seizures

Fever

Food-Safety and Fecal-Orally Transmitted Infectious Diseases

HIB-Vaccination, Active

HIV-Infection and AIDS

Immunization, Active

Immunization, Passive

Infection with Clostridium botulinum

Infectious Mononucleosis

Lice

Measles

Meningitis

Midstream Urine

Mumps

Nest Protection

Norwalk Virus Infection

Poliomyelitis

Respiratory-Syncytial-Virus (RSV) Infection

Rotavirus Vaccination, Active

Rubella

Scabies

Scarlet Fever

Sepsis

Sexually Transmitted Diseases

Spasmodic Croup

Tetanus

TORCH Serology

Toxoplasmosis

Tuberculosis

Ureaplasma urealyticum Infection

Vaccination, Active

Waterhouse–Friederichsen Syndrome

Water Quality and Waterborne Infectious Diseases

Whooping Cough

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