Child Healthcare addresses all the common and important clinical problems in children, including:immunisation history and examination growth and nutrition acute and chronic infections parasites skin conditions difficulties in the home and society.

1. 13
Serious illnesses
• Acute rheumatic fever
Objectives • Acute glomerulonephritis
• Septicaemia, especially meningococcal
When you have completed this unit you septicaemia
should be able to: • Meningitis
• Diagnose and manage acute • Pyelonephritis
rheumatic fever.
Some serious illnesses, such as pneumonia and
• Diagnose and manage acute
typhoid, are discussed in other units.
glomerulonephritis.
• Diagnose and manage septicemia and
meningitis.
• Diagnose and manage pyleonephritis. ACUTE RHEUMATIC FEVER
• Diagnose and refer children with
diabetes or epilepsy.
• List the warning signs of childhood 13-2 What is acute rheumatic fever?
cancer. Acute rheumatic fever is the most common
cause of acquired heart disease in children,
especially in poor, overcrowded communities.
INTRODUCTION It is a complication of pharyngitis (a throat
infection) caused by Streptococcus bacteria.
An unusual immune response by the body
13-1 What serious bacterial infections are to this bacterial infection damages the joints,
seen in children? heart and other tissues of the body. The exact
These are illnesses which can result in death if mechanism whereby this happens is still not
they are not correctly managed. Every effort fully understood. Acute rheumatic fever is
must be made to prevent them, recognise them usually seen in children aged 5 to 15 years.
early and treat them correctly. Many serious NOTE Many strains of Group A beta haemolytic
illnesses which are rarely seen in children in Streptococcus can cause rheumatic fever which is
developed countries, are still major problems in a multisystem disease affecting the heart, joints,
poor communities with overcrowding. skin and brain. Recent studies suggest that skin
infections (impetigo) may also cause rheumatic
Important serious illnesses include: fever.

2. 212 SERIOUS ILLNESSES
• A rubbing noise (friction rub) heard
Rheumatic fever is the most common cause of
on auscultation, which indicates an
acquired heart disease in children in developing
inflammation of the pericardium
countries. (pericarditis)
13-3 What are the clinical features of acute 13-5 How is the clinical diagnosis of acute
rheumatic fever? rheumatic fever made?
Acute rheumatic fever develops 2–3 weeks By documenting a Streptococcal infection plus
after a Streptococcal pharyngitis. The classical 2 major or 1 major and 2 minor criteria.
features of acute rheumatic fever are:
The major criteria are:
• Fever
• Flitting polyarthritis
• A ‘flitting’ polyarthritis. Pain, redness and
• Carditis
swelling (arthritis) of a number of joints
• Erythema marginatum
(polyarthritis) where the arthritis moves
• Nodules
within days from joint to joint (flitting).
• Chorea
Usually the large joints (elbows, knees) are
involved. The minor criteria are:
• Carditis
• Fever
• Eythema marginatum. A short-lived
• Arthralgia (joint pain only) without
erythematous (pink) rash which forms
arthritis
irregular patterns on the trunk.
• Blood tests indicating inflammation, i.e.
• Subcutaneous nodules. Small, non tender
raised erythrocyte sedimentation rate
lumps under the skin over the elbows,
(ESR), raised C reactive protein (CRP) or a
knuckles, wrists, knees and spine.
leucocytosis (raised white cell count)
• Chorea. Usually seen in girls who become
• An abnormal electrocardiogram (ECG)
clumsy and very emotional with unusual
especially a prolonged PR interval (do not
jerky movements. Their handwriting
use this minor criteria if carditis is used as
deteriorates and they have difficulty
a major criteria)
doing up buttons due to the abnormal
movements. Chorea may only appear NOTE These are the modified Duckett-Jones
months after the throat infection. criteria. A Streptcoccal infection is documented
by a positive throat culture or a raised
Children with acute rheumatic fever do not antistreptolysin O titre. A blood culture is useful
necessarily develop all the classical signs. The to exclude bacterial endocarditis which should be
rash, subcutaneous nodules and chorea are less considered in any child with fever and a murmur.
common signs of acute rheumatic fever. Two minor criteria are needed to diagnose
acute rheumatic fever in a child with establised
rheumatic heart disease.
13-4 What are the signs of carditis?
Always suspect acute rheumatic fever in an
Carditis is an inflammation of the heart. The
unwell child older than 3 years who presents
heart muscle, valves and pericardium are
with fever, tachycardia and shortness of breath
involved. The signs of carditis are:
or painful joints.
• A heart murmur due to inflammation or
damage to one or more heart valves
Strict clinical criteria are used to diagnose acute
• Tachycardia, especially when resting or
asleep. Signs of heart failure may develop rheumatic fever.
(e.g. shortness of breath).
• An enlarged heart seen on chest X-ray

3. SERIOUS ILLNESSES 213
13-6 How is acute rheumatic fever treated? which records the monthly injections. Careful
follow up is essential.
1. Bed rest until all signs of acute rheumatic
fever have disappeared and the resting
heart rate is normal. All children with 13-9 What are the possible outcomes of
acute rheumatic fever should be admitted acute rheumatic fever?
to hospital if possible Acute rheumatic fever should resolve in 4
2. Amoxycillin 10 mg/kg 6 hourly orally for weeks. Some children recover completely
10 days or a single dose of benzathine while others are left with permanent damage
penicillin 1.2 million units intramuscularly. to their hearts. Acute rheumatic fever tends to
3. Aspirin for symptomatic relief of fever and recur and the risk of permanent heart damage
joint pain. Acute rheumatic fever is one (rheumatic heart disease) increases with each
of the very few indication for aspirin in acute attack. Every effort must therefore be
children. made to prevent repeat attacks.
4. Observe closely for signs of heart failure.
One or more attacks of acute rheumatic fever
can cause permanent damage to one or more
13-7 How can the first attack of acute
heart valves. This is called chronic rheumatic
rheumatic fever be prevented?
heart disease. Leaking of the mitral valve
It is difficult to know if an acute sore throat (mitral incompetence) or narrowing of the
is due to a virus or Streptococcus. Therefore, mitral valve (mitral stenosis) are the most
antibiotics should be given to all children common permanent valve defects. Damage
under 15 years who have a fever and sore to a valve or damage to the heart muscle can
throat (pharyngitis) without the signs of a cause heart failure.
common cold, i.e. blocked nose and nasal
discharge. Oral penicillin, amoxycillin
Every effort must be made to prevent repeated
or erythromycin for 5 days are needed.
However, it is also important that antibiotics attacks of acute rheumatic fever.
are not given to all children with a viral
upper respiratory tract infections such as the 13-10 What are the features of chronic
common cold or influenza. rheumatic heart disease?
With the more frequent use of antibiotics, These children are often underweight and
acute rheumatic fever has become uncommon have delayed developmental milestones due
in wealthy countries. to their heart disease. Their schooling may
be interrupted. On examination they have
13-8 How can repeated attacks of acute signs of leaking (incompetent) or narrowed
rheumatic fever be prevented? (stenotic) heart valves. They may also have
signs of heart failure.
Repeated attacks of acute rheumatic fever can
be prevented in children, who have previously These children are at great risk of developing
suffered one or more attacks, by giving infective endocarditis after dental procedures
benzathine penicillin (Bicillin LA) 1.2 million (bacteria enter the blood stream and then stick
units intramuscularly every 4 weeks (600 000 to the heart values where they cause infection
units if the child weighs less than 30 kg). This and damage). The dentist should give a dose of
must be continued until adulthood when prophylactic antibiotic before the procedure.
it should be reviewed. As the injections are NOTE A large single oral dose of amoxycillin or
painful, the child and family must understand clindamycin an hour before dental extraction
that it is most important to prevent ongoing reduces the risk of bacterial endocarditis on
heart damage. The mother should keep a card damaged valves.

4. 214 SERIOUS ILLNESSES
Children with chronic rheumatic heart disease and complement to form immune complexes
must be managed by a special cardiac clinic which are deposited in, and damage, the
team. It is very important that they do not glomeruli.
have any further attacks of rheumatic fever.
Most children can be managed with drugs 13-13 What are the presenting signs of
to control heart failure but some will require acute glomerulonephritis?
cardiac surgery. • Haematuria and proteinuria. There may
be obvious blood in the urine seen with
13-11 What are the clinical symptoms and the naked eye (dark urine). Marked
signs of heart failure? haematuria looks like dilute Coca Cola.
• Tiredness with exhaustion after only a little The red cells can also be seen under the
exercise microscope. Haematuria and proteinuria
• Shortness of breath and wheezing, can be detected with reagent strips.
especially when lying flat • Decreased urine volume (oliguria).
• Swelling of the ankles due to oedema In severe cases there may be no urine
• An enlarged liver produced (anuria).
• Oedema of the face (especially in the
There are many causes of heart failure, morning) and feet (especially in the
including acute rheumatic fever, chronic evenings)
rheumatic heart disease, congenital heart • Hypertension
disease and severe anaemia.
The severity of signs varies widely. In many
children the condition is asymptomatic and
ACUTE would only be diagnosed by testing the urine
for blood and protein, or by measuring the
GLOMERULONEPHRITIS blood pressure.
13-12 What is acute glomerulonephritis? Acute glomerulonephritis usually presents with
dark urine, reduced urine output and oedema.
It is an acute inflammation of the kidney
which follows a few weeks after an infection
NOTEOedema plus marked proteinuria without
with Streptococcus. The infection is usually haematuria suggests nephrotic syndrome.
of the skin (i.e. impetigo) but may follow a
throat infection (therefore often called acute
13-14 What is the clinical course of acute
post-streptococcal glomerulonephritis). The
glomerulonephritis?
inflammation of the kidney is the result of an
unusual response to the infection by the body’s Most children present with oedema and visible
immune system. Antibodies produced against haematuria. However, hypertension can occur
the Streptococcus damage the kidney. This is with no oedema and with haematuria only
similar to the immune response which results detected on reagent strips.
in acute rheumatic fever. Again, the reason for
Children usually recover completely. By 2
this unusual response is not fully understood.
weeks the urine output increases and the
NOTE Damage to the glomeruli of both kidneys oedema and hypertension disappear. The urine
results in blood and protein leaking into the urine may remain dark (due to blood) for up to 6
and a decrease in urine production. Retained weeks but blood may be detected on reagent
fluid causes oedema and fluid overload. Although
strips for a few months.
there are many causes of glomerulonephritis,
acute glomerulonephritis is usually post- It is very important to look for signs of
streptococcal. Proteins from specific strains of complications.
Group A Streptococcus combine with antibodies

5. SERIOUS ILLNESSES 215
13-15 What are the complications of acute 13-17 How can acute glomerulonephritis
glomerulonephritis? be prevented?
• Hypertensive encephalopathy which Most cases occur in children over the age of 2
usually presents with headaches, vomiting, years in poor communities where Streptococcal
drowsiness and convulsions. This may be infections, especially of the skin are common.
the first sign of acute glomerulonephritis. It is important that skin infections are treated
• Pulmonary oedema and heart failure due to promptly with local antiseptics (e.g. Savlon).
fluid overload. This presents with breathing Scabies, which is often complicated by
difficulties, especially when lying down. impetigo, should be treated. Oral penicillin
• Acute renal failure with raised serum urea should be given for 5 days if there is extensive
and creatinine impetigo. The more frequent use of antibiotics
in developed countries has resulted in a
13-16 What is the management of a child fall in the number of children with acute
with acute glomerulonephritis? glomerulonephritis (and acute rheumatic
fever). However, this is not a reason to give
1. Refer the child to hospital if possible. antibiotics to every child with a few patches of
2. Oral phenoxymethyl penicillin (penicillin impetigo that can be treated locally.
V) 12.5 mg/kg 6 hourly or oral amoxycillin
for 10 days to treat the Streptococcal
infection.
3. Restrict the daily fluid intake to 20 ml/kg
SEPTICAEMIA
plus the volume of the previous day’s urine
output. It is important to keep a careful 13-18 What is septicaemia?
check on the fluid intake and output.
4. Weigh daily to assess fluid status. Septicaemia is an acute serious illness caused
5. Low sodium and low protein diet until the by bacterial infection of the blood. This is
urine output increases (diuresis). Bread, often a complication of local infection, such
jam, rice, fruit and vegetables with no as pneumonia or pyelonephritis. Septicaemia
added salt is a practical diet. may in turn result in the spread of infection to
6. Furosemide (Lasix) 1 mg/kg orally to help other sites, such as meningitis and osteitis.
increase urine output Septicaemia may be caused by either Gram
7. Observe the blood pressure every 6 hours. positive bacteria (such as Staphylococcus or
8. Check serum urea, creatinine and Streptococcus) or Gram negative bacteria
electrolytes to monitor any renal failure. (such as E. coli or Klebsiella).
NOTE Severe hypertension can be treated as an
NOTE Gram described the method of staining
emergency with nifedipine (Adalat) bacteria blue and then dividing them into those
0.25 mg/kg sublingually (under the tongue). bacteria that retained the stain (Gram positive)
Convulsions can be stopped with rectal diazepam. and those that lost the stain (Gram negative)
Respiratory distress due to pulmonary oedema when exposed to other chemicals. Gram positive
should be managed with oxygen, furosemide 1 bacteria usually live on the skin and in the upper
respiratory tract while Gram negative bacteria
mg/kg intravenously, sitting the patient up and
normally live in the bowel. Rarely fungi can also
referring to hospital urgently. cause septicaemia.
NOTE Serum C3 complement is classically
markedly reduced. The chest X-ray often shows 13-19 What are the clinical features of
an enlarged heart plus features of pulmonary septicaemia?
oedema due to fluid retention. Serum
Streptococcal antibodies are usually raised. • There may be a local source of infection.
• At first the child may feel generally
unwell but not have any specific signs. It

6. 216 SERIOUS ILLNESSES
is, therefore, often difficult to make an
A blood culture is needed to confirm the clinical
early clinical diagnosis of septicaemia. As
diagnosis of septaecaemia.
the septicaemia becomes worse the child
appears seriously ill.
• Fever is almost always present. NOTE The C reactive protein (CRP) level may
initially be normal but rises after a few hours.
• The patient may become shocked (septic
shock).
• Shock leads to failure of many organs such 13-23 What is the management of
as the kidney and lungs. septicaemia?
1. Start antibiotics immediately. Do not wait
Children with septicaemia are seriously ill, often for the result of the blood culture.
2. Treat shock if it is present.
without an obvious site of infection.
3. Transfer the patient urgently to hospital.
Give oxygen during transport.
13-20 What is shock? 4. Look for an underlying cause and monitor
Shock is the failure of normal peripheral for complications such as organ failure.
circulation with a fall in blood pressure. The fist choice of antibiotics is either:
The heart rate increases and urine output
• Benzyl penicillin 50 000 units/kg every
falls. The skin temperature may be low with
6 hours intravenously (or ampicillin 50
shock and the hands and feet often feel cold.
mg/kg every 6 hours intravenously) plus
The oxygen saturation may also fall. Most
gentamicin 7.5 mg/kg daily (or amikacin
importantly, the capillary filling time is
20 mg/kg daily), given slowly intravenously
prolonged to over 3 seconds.
over 5 minutes.
NOTE In early shock the blood pressure may still • Ceftriaxone 80 mg/kg daily intramuscularly
be normal (compensated shock) although the or by slow intravenous injection. This is
peripheral perfusion is poor. Later the blood
very useful in a primary care facility before
pressure falls (uncompensated shock).
the child is transferred to hospital.
13-21 How is the capillary filling time
13-24 What is the treatment of shock?
measured?
The aim of treatment is to correct the
This is estimated by compressing the skin for
blood pressure and improve the peripheral
a few seconds over the hands, feet or chest,
perfusion. A fast intravenous infusion must
with your finger, to produce blanching (a
be started immediately with 20 ml/kg of
pale area). When the pressure of the finger is
normal saline or Ringer’s lactate. If the signs
removed, the time it takes for the pink colour to
of shock are not corrected, repeat the bolus of
return is measured. This is called the capillary
intravenous fluid. This will usually correct the
filling time. A normal capillary filling time is
shock. Always give oxygen. Urgent transfer to
3 seconds or less.
hospital is needed. Start treating shock before
moving the patient.
13-22 How is the clinical diagnosis of
septicaemia confirmed?
Shock must be treated before the patient is
With finding a positive blood culture. Always
moved to hospital.
take a blood culture before starting treatment.
The white cell count may be high at first and
13-25 What is meningococcal septicaemia?
later fall. The platelet count may also fall and
the blood clotting factors may be low. This is a serious illness caused by septicaemia
due to Meningococcus (i.e. Neisseria

7. SERIOUS ILLNESSES 217
meningitidis). Meningococcus is transmitted 13-28 How is meningococcal infection
from person to person by droplet spread prevented?
(coughing and sneezing). It often causes
All those in contact with the patient, including
asymptomatic colonisation of the upper
the health staff, should take rifampicin 10
respiratory tract only. However, some people
mg/kg twice a day for 2 days (5 mg/kg in
get a septicaemia, meningitis or both.
infants less than 1 month) or ceftriaxone 125
Meningococcal infection is more common
mg intramuscularly once. This will treat and
in overcrowded conditions where epidemics
prevent colonisation of the upper respiratory
may occur.
tract. All contacts should be closely observed
for signs of illness.
13-26 What is the typical presentation of
meningococcal septicaemia? A short-lived vaccine against meningococcus
can be used to help end epidemics. Over-
The patient presents with the signs of crowding in schools, army camps and crèches
septicaemia. However, a rash also develops. should be avoided.
This starts as small red spots on the skin and
conjunctivae which rapidly become purpuric
(larger pink or purple spots). The spots do
not blanch when pressed. The rash becomes
MENINGITIS
very dark and may become necrotic (ulcerate).
Gangrene of the skin may occur. Without 13-29 What is meningitis?
early treatment the mortality is high. It is very
important to look for a rash in all children It is a serious infection of the meninges (the
who are thought to have septicaemia. membranes covering the brain). Meningitis
may be due to a viral or bacterial infection.
Bacterial meningitis is usually far more
Always look carefully for a rash if a child has a dangerous. Causes of bacterial meningitis
diagnosis of possible septicaemia. include both Gram positive and Gram negative
bacteria. The most common causes are
Many children with meningococcal Pneumococcus (Streptococcus pneumoniae),
septicaemia will also have meningococcal Haemophilus (Haemophilus influenzae) and
meningitis. Most will rapidly develop shock. Meningococcus (Neisseria meningitidis).
Bacteria usually reach the meninges via the
13-27 How is meningococcal septicaemia blood stream. Rarely, infection is by direct
managed? spread, e.g. from mastoiditis. Tuberculosis also
Similarly to other types of septicaemia. The causes bacterial meningitis. Fungal meningitis
choice of antibiotic is benzyl penicillin or may be seen in children with AIDS.
ceftriaxone intravenously. Start antibiotics
immediately as the clinical condition 13-30 What are the symptoms and signs of
deteriorates rapidly without treatment. meningitis?
Do not do a lumber puncture as this is very • Feeling generally unwell with fever. Most
dangerous due to brain swelling and will not children with meningitis rapidly appear
alter the choice of initial treatment. Treat shock seriously ill.
and move the patient to hospital urgently. • A severe headache, vomiting and
photophobia (avoids bright light)
Meningococcal infection is a notifiable disease
• Irritability, drowsiness, loss of
in South Africa.
consciousness and convulsions
• Young infants may present with poor
feeding, lethargy and apnoea.

8. 218 SERIOUS ILLNESSES
• Neck stiffness. It is painful if the patient and antibiotics can be stopped once the results
tries to flex his/her neck so that the chin of the lumbar puncture exclude bacterial
touches the chest. It is also painful and meningitis. Tuberculous meningitis also has a
difficult if the examiner tries to flex the similar presentation and must be distinguished
patient’s neck. Neck stiffness may be absent on lumbar puncture and other investigations.
in young children with meningitis.
• Infants may have a full (bulging)
fontanelle.
It is not possible to distinguish between viral and
bacterial meningitis on clinical examination alone.
The signs of meningitis and septicaemia are
very similar. Both must be suspected in any NOTEIn viral meningitis most cells in the CSF are
child who is seriously ill or unconscious or lymphocytes, the CSF glucose is normal and the
who has a high fever without an obvious cause. Gram stain and culture are negative for bacteria.
Headache, fever and vomiting suggest meningitis. 13-33 What is the correct management of
bacterial meningitis?
13-31 How is the clinical diagnosis of The most important step is to start antibiotics
meningitis confirmed? as soon as possible. If a lumbar puncture
cannot be done immediately, it is better to
By obtaining a sample of cerebrospinal fluid start antibiotics before transferring the child
(CSF) by lumbar puncture. CSF should be sent to hospital for investigation and further
to the laboratory for chemistry, microscopic treatment. The sooner the treatment is started
examination for cells and bacteria, and for the better is the clinical outcome.
culture. As many children with meningitis also
have septicaemia, the bacterial cause can often 1. The first choice of antibiotic is ceftriaxone
also be identified on a blood culture. 100 mg/kg intravenously immediately and
then repeatedly daily. In older children the
NOTE Do not do a lumbar puncture if there
second choice is benzyl penicillin 100 000
is reduced level of consciousness, focal
units/kg 6 hourly plus chloramphenicol
neurological signs or features of meningococcal
meningitis. With bacterial meningitis the CSF 25 mg/kg 6 hourly intravenously (or
protein is raised (normal 0.15–0.4 g/l) and the intramuscularly if an intravenous line
glucose is low (normal 2–4 mmol/l) with many cannot be started). In neonates the second
polymorphonuclear cells. Bacteria may be seen choice is ampicillin and gentamicin.
on a stained spun deposit or may be cultured. 2. Convulsions should be stopped.
3. Paracetamol and tepid sponging can be
13-32 Is it easy to tell clinically whether used to lower the temperature.
meningitis in a child is due to a bacterial or 4. Always look for signs of shock and exclude
viral infection? hypoglycaemia.
5. The patient must be transferred urgently to
No. Therefore, all cases of clinical meningitis
hospital.
must initially be managed as if they are
bacterial meningitis until the cause of the
meningitis is identified. However, children with Antibiotics must be started as soon as possible if a
viral meningitis are often not as severely ill as clinical diagnosis of bacterial meningitis is made.
children with bacterial meningitis. Only the
findings on the lumbar puncture enable one to
13-34 Can meningitis be prevented?
tell whether the infection is viral or bacterial.
The introduction of immunisation against
Children with viral meningitis usually improve
Haemophilus influenzae into the routine
rapidly after a lumbar puncture and have fewer
schedule at 6, 10 and 14 weeks after birth
complications. The management is supportive

9. SERIOUS ILLNESSES 219
has prevented most cases of haemophilus 13-37 What are the clinical features of a
meningitis. The promise of new vaccines urinary tract infection?
against Pneumococcus and Meningococcus
Often the symptoms are non-specific and,
will hopefully also prevent these causes of
therefore, the diagnosis is frequently missed.
meningitis.
Fever, dysuria (pain or discomfort when
All those in contact with a patient with passing urine), frequency (passing frequent
meningococcal meningitis or septicaemia small amounts of urine) and abdominal
should be given rifampicin or ceftriaxone or back pain are common presenting
prophylaxis. complaints. A high fever and vomiting
suggests pyelonephritis rather than a mild
13-35 What are the complications of form of urinary tract infection.
meningitis?
13-38 How is the clinical diagnosis of a
About 25% of children with bacterial
urinary tract infection confirmed?
meningitis will die and about 25% of the
survivors will have permanent brain damage It is very important to get a clean specimen of
such as: urine. A midstream urine or clean catch sample
(urine collected after the child has already
• Cerebral palsy
started passing urine), a sample collected
• Intellectual impairment
by passing a catheter into the bladder under
• Nerve deafness
aseptic methods or a suprapubic aspiration
• Hydrocephalus
(best done with ultrasonography) are by far
• Epilepsy
the best methods. Using a urine bag is very
inaccurate and is should be avoided if possible.
PYELONEPHRITIS Leukocytes, nitrites and protein, and
sometimes blood, are typical findings when
the urine is tested with a reagent strip. It is
13-36 What is pyelonephritis? probably not a urinary tract infection if the
reagent strip test on a sample of freshly passed
Pyelonephritis is a bacterial infection of the
urine is completely normal, i.e. negative for
kidney and the most serious form of urinary
protein, nitrite, blood and leucocyte esterase.
tract infection. If not diagnosed and treated
early, repeated attacks of pyelonephritis can Pus cells are usually present on a spun deposit
lead to permanent kidney damage resulting in of urine.
hypertension and renal failure.
The only accurate way to confirm a urinary
E. coli (Escherichia coli) is usually the bacteria tract infection is a positive culture when the
causing a urinary tract infection. Most urine has been collected correctly. More than
commonly the infection is mild and only 100 000 bacteria/ml on a clean catch urine,
affects the bladder (cystitis). Less commonly, more than 1 000 bacteria/ml on a catheter
the infection spreads up the ureters to affect specimen or any bacteria on a suprapubic
the kidney (pyelonephritis). Pyelonephritis sample is abnormal.
may be secondary to a renal tract abnormality
It is very important to make an accurate
that causes an obstruction to the normal
diagnosis and not simply send a urine bag
flow of urine. This increases the chance that
sample to the laboratory. A normal urine bag
infection will spread to one or both kidneys.
result will exclude a urinary tract infection but
NOTE Vesico-ureteric reflux, hydronephrosis and a positive result may simply be due to skin or
posterior urethra valves increase the chances that stool contamination. A confirmed diagnosis is
a urinary tract infection will result in pyelonephritis. also important because it indicates that a series

10. 220 SERIOUS ILLNESSES
of management steps is required. Treating the blood leading to a very high blood glucose
a presumed urinary tract infection without concentration. Diabetes, if not well controlled,
confirming the diagnosis is bad practice. may result in severe complications and even
death. Therefore, it is important to diagnose
diabetes as soon as possible.
It is important to collect a clean specimen of
urine to make an accurate diagnosis before
13-42 What are the presenting symptoms
starting treatment. and signs of diabetes?
• Passing frequent, large amounts of urine
13-39 How should a urinary tract infection
(polyuria). The child may start to bed-wet
be managed?
again after being dry for months or years.
1. Once the urine sample has been collected, • Drinking a lot of water
a course of antibiotics must be started, • Weight loss and tiredness
usually oral nalidixic acid 10 mg/kg 6 • Collapse (shock), dehydration, loss of
hourly for 7 days in children older than 3 consciousness (diabetic coma) and fast
months. breathing (due to metabolic acidosis). This
2. In younger infants and any child with is a life-threatening emergency.
a clinical diagnosis of pyelonephritis,
The diagnosis of diabetes must be suspected if a
intravenous cefuroxime or intramuscular
very high blood glucose concentration is found,
ceftriaxone is indicated.
using reagent strips. All children with suspected
3. All children with a proven urinary
diabetes must be referred urgently to hospital.
tract infection must be referred for
An intravenous infusion with normal saline
investigation. Usually an ultrasound
must be started before transferring a child with
examination is done. Other special
diabetic coma. Later the clinical diagnosis of
investigations may also be needed.
diabetes must be confirmed with a glucose
tolerance test. Children with diabetes usually
need daily injections of insulin for life to control
OTHER BACTERIAL their diabetes.
INFECTIONS
Diabetes usually presents with tiredness, weight
loss and polyuria.
13-40 What serious bacterial infections are
less common?
• Osteitis (bacterial infection of bone) CONVULSIONS
• Septic arthritis (bacterial infection of a
joint)
• Mastoiditis (bacterial infection of the 13-43 What are convulsions?
mastoid bone behind the ear) Convulsions (fits) present with a sudden onset
of abnormal movements and an altered level of
consciousness due to abnormal brain activity.
DIABETES Convulsions have many different causes
and may present in a wide variety of ways.
Important causes are:
13-41 What is diabetes?
• Epilepsy
Diabetes is due to inadequate amounts of • High fever
insulin being produced by the pancreas. As a • Meningitis
result, the body cannot remove glucose from

11. SERIOUS ILLNESSES 221
• Hypoglycaemia abnormal neurological signs after the child
• Cerebral cysticercosis (brain cysts caused recovers from the convulsion.
by the pig tapeworm)
Management is to lower the fever and reassure
All children with convulsions must be urgently the parents. Given paracetamol (Panado) when
transferred to hospital for investigation, the child is ill to keep the temperature normal.
to establish the cause, and start correct Do not use aspirin. Children usually outgrow
management. febrile convulsions. Oral anticonvulsants are
usually not used to prevent febrile convulsions.
Before moving a child with convulsions,
make sure the airway is open and give NOTE If the child is over 18 months, has a typical
oxygen. Always measure the blood glucose repeat febrile convulsion and there are no
concentration with a reagent strip and correct meningeal signs, a lumbar puncture is not needed.
any hypoglycaemia. Cool the child if the
temperature is very high. 13-46 What is epilepsy?
Children with epilepsy have repeated
13-44 How are convulsions stopped? generalised convulsions. There is usually no
Always look very carefully for the cause and obvious cause, and they are well between
treat this if possible. If a fit last longer than 5 convulsions. The diagnosis is usually based
minutes it can be usually be stopped with one on the history. Epilepsy often starts at puberty
of the following: and can be controlled (prevented) with oral
anticonvulsants. All children with epilepsy
• A single dose of rectal diazepam (Valium) should be referred to a neurological clinic for
0.5 mg/kg. Intravenous diazepam may assessment and initial management. Long-
cause apnoea unless given very slowly. term management can be supervised from a
• Phenobarbitone 15 mg/kg intravenously or primary care clinic.
intramuscularly. This is safe.
• Phenytoin 15 mg/kg by slow intravenous
injection can also be used. Never give CANCER
phenytoin intramuscularly, as it damages
the tissues locally.
NOTE Lorazepam 0.1 mg/kg intravenously is 13-47 Are malignancies common in
very effective at stopping a convulsion. Buccal children?
midazolam 0.1 to 0.2 mg/kg is also effective.
Malignancies (‘cancers’) are not common
in children. However, it is important to
Any convulsion lasting longer than 5 minutes know the warning symptoms and signs of
should be stopped. childhood malignancy as many childhood
malignancies are curable if they are
diagnosed and treated early.
13-45 What are febrile convulsions?
These are generalised convulsions caused by
a high temperature. Often there is an obvious
Malignancy in children often has a good
cause of the fever, e.g. upper respiratory tract prognosis if diagnosed and treated early.
infection. The child is usually between 6
months and 5 years old and there may be a 13-48 What malignancies occur in children?
family history of febrile convulsions. Some
• Leukaemia
children have febrile convulsions whenever
• Lymphoma
they have a viral infection with a high fever.
• Brain cancer
Usually the convulsion does not last longer
• Kidney cancer (Wilm’s tumour)
than 15 minutes and there are no other

12. 222 SERIOUS ILLNESSES
NOTE Less common malignancies in children 2. What are the other major criteria?
include liver and bone cancer, retinoblastoma
(eye), rhabdomyosarcoma (muscle) and germ A rash (erythema marginatum), subcutaneous
cell tumours. nodules and chorea. Only 2 major criteria
are needed to make the diagnosis of acute
13-49 What are the warning signs of rheumatic fever.
malignancy in children?
3. What is the likely cause of the sore throat?
1. Pallor and bleeding
2. Aching bones or joints, especially waking A streptococcal infection.
the child at night; backache
3. Unexplained weight loss, fever or fatigue 4. Which signs suggests that this child has
4. Persistent, unexplained lymphadenopathy carditis?
5. Abdominal masses
A heart murmur, tachycardia and enlarged
6. Lumps in the neck, testes or limbs
heart.
7. Eye changes: white pupil, sudden squint or
loss of vision, bulging eyeball
8. Neurological symptoms or signs: 5. What is the management of acute
headaches, early morning vomiting, rheumatic fever?
unsteady gait, cranial palsies, change in The child should be referred to hospital.
behaviour With bed rest, antibiotics (oral amoxycillin
Children presenting with any of these warning for 10 days or a single dose of intramuscular
(danger) symptoms or signs must be urgently benzythine penicillin) and aspirin the acute
referred for an expert opinion. rheumatic fever usually recovers within 4
weeks. It is important to look for signs of heart
failure.
CASE STUDY 1
6. What is the danger of repeated attacks of
acute rheumatic fever?
A 5-year-old child presents with a fever and
a one-week history of pain and swelling of It may result in chronic rheumatic heart disease
the knees and elbows. Over the past few days with damaged heart valves. Rheumatic fever
the pain has moved from joint to joint. On is the most common cause of acquired heart
examination the child is unwell with arthritis disease in poor, overcrowded communities.
of both knees. The heart rate is noted to be
110 beats per minute. A soft murmur is heard 7. How can repeated attacks of acute
when her heart is examined. The heart appears rheumatic fever be prevented?
enlarged on a chest X-ray. On questioning the
mother says the child had a sore throat a few With 4 weekly intramuscular injections of
weeks back. benzathine penicillin.
1. What is your clinical diagnosis?
CASE STUDY 2
Acute rheumatic fever. The child has 2 major
criteria (polyarthritis and carditis) and one A 3-year-old child has had a swollen face and
minor criteria (fever). There is also a history of dark urine for the past 24 hours. There are
a sore throat. numerous areas of impetigo on his legs. The
mother says he is very short of breath when he
lies down.

13. SERIOUS ILLNESSES 223
1. What is the probable diagnosis? that he has a fine rash which reminds her of
purpura. The child is fully conscious with no
Acute glomerulonephritis.
neck stiffness.
2. Why does he have dark urine and a
1. What is the likely diagnosis?
swollen face.
The child has the clinical signs of septicaemia.
The dark urine is probably due to the presence
of blood. Haematuria can be confirmed with
reagent strips. His swollen face is due to 2. Why is the blood pressure low?
fluid overload as a result of decreased urine The low blood pressure, fast pulse and cold
production. hands, in spite of a fever, indicate that the child
is shocked. This is often seen in patients with
3. What is the cause of this condition? septicaemia.
The streptococcal skin infection (impetigo).
This is an unusual immune response to 3. What does a capillary filling time of 8
Streptococcus where antibodies damage the seconds mean?
kidney. It is abnormally long, as the pink colour should
return to a blanched (pale compressed area)
4. How is this condition prevented? area of skin within 3 seconds. The long capillary
filling time confirms that the child is shocked.
By preventing or treating impetigo. Usually,
local treatment is adequate. An oral antibiotic
should be given with widespread impetigo. 4. Why is there a rash?
A fine pink or purpuric rash strongly suggests
5. Why is this child short of breath? that the septicaemia is due to Meningococcus.
This is an extremely serious condition.
Due to fluid overload. The most serious
complications of acute glomerulonephritis are:
5. How is the diagnosis of septicaemia
• Severe hypertension resulting in confirmed?
encephalopathy
• Pulmonary oedema and cardiac failure due By finding a positive blood culture.
to fluid overload
• Acute renal failure 6. Do you think the child has meningitis?
There are no signs of meningitis.
6. What is the management of the fluid However, meningitis is very common with
overload? meningococcal septicaemia.
Reduced fluid intake, a low salt diet and
furosemide. These children should be 7. What is the correct management of
managed in hospital. septicaemia with shock?
Take a blood culture and start a fast
intravenous infusion with normal saline or
CASE STUDY 3 Ringer’s lactate. Immediately start antibiotics.
Benzyl penicillin or ampicillin plus gentamicin
A severely ill child is brought to the clinic. He or amikacin would be the antibiotic
has a high temperature without an obvious combination of choice. Do not perform a
cause. His heart rate is fast, blood pressure low lumbar puncture. The child should be moved
and hands feel cold. The capillary filling time to hospital as soon as possible.
over the chest is 8 seconds. The nurse notices