Chapter 18 Notes

Variations of Pediatric Immunity

Immunity is present at birth: Cellular immunity functional
Humoral immunity develops with exposure over time
Passive immunity:
◦ Transplacental- IgG (B-cells)
◦ Breastfeeding
Hypogammaglobulinemia @ 2-6 mos. old
1-year-old: ½ IgG of an adult
7-year-old: reach adult IgG
ANATOMY AND PHYSIOLOGY OF THE IMMUNE SYSTEM
The immune system is made up of cells, tissues, and organs that work in an organized manner to
protect the body against invaders and infectious organisms (Fig. 18-1). At birth, children have an
intact, but often immature, immune system. Infants do carry maternal antibodies until
approximately 6 months of age; however, they remain at a greater risk for infection than the
general population. Germs, including bacteria and viruses, are foreign invaders, or antigens,
which the immune system recognizes and responds to by producing proteins called antibodies to
fight the antigens. Antibodies may be produced in the thousands but sometimes disappear after
they have destroyed the antigens. Memory cells are cells that recall the original antigen and bring
up the body’s defenses if it invades the body again, and this level of protection is known as
immunity.
The white blood cells (leukocytes) are part of the defense system. There are two basic types:
phagocytes (neutrophils are the most common and fight bacteria) and lymphocytes (B
lymphocytes and T lymphocytes), which seek out and destroy organisms that might cause
disease. Leukocytes are produced or stored in the lymphoid organs: lymph nodes, bone marrow,
thymus, spleen, and tonsils. The leukocytes circulate throughout the body via the blood. Antigens
are foreign substances that invade the body. When an antigen is detected, several types of cells
work together to recognize and respond to the invader. Mature B lymphocytes independently
identify foreign antigens and differentiate into anti-body-producing plasma cells (memory cells).
Once the B lymphocytes have produced antibodies, these antibodies remember the invader so if
the same antigen is presented to the immune system again, the antibodies can respond. Although
antibodies can recognize an antigen, they are not capable of destroying it without the help of
mature T cells that are antigen-specific. Antibodies can also neutralize toxins and activate a
group of proteins that assist in killing bacteria, viruses, or infected cells.
The protection offered by the immune system is called immunity. There are three types of
immunity: innate, adaptive, and passive. Innate (or natural) immunity is a general protection and
includes the physical barriers of the body, like the skin and mucous membranes. The skin is the
first line of defense in preventing diseases from entering the body. Adaptive (or active) immunity
develops as children are exposed to diseases or immunized against diseases through vaccination.
Passive immunity is acquired by the introduction of preformed antibodies into an unprotected
individual, and it lasts for a short period of time. For example, passive immunity can occur from
antibodies that pass from the mother to the fetus through the placenta or newborns that acquire
immunity through breastfeeding.
Other Congenital Immunodeficiency Disorders
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The onset of X-linked agammaglobulinemia occurs after 4 months of age, typically in males with
low or absent IgM, IgG, and IgA antibodies and B lymphocytes. Treatment of these congenital
immunodeficiency disorders is lifelong with the administration of intravenous immune globulin
(IVIG) or (IV IgG [immunoglobulins]) (Fig. 18-3).
■ Autosomal recessive congenital agammaglobulinemia: This disorder is characterized by low B
lymphocytes and Wiskott-Aldrich syndrome is an example of an X-linked immunodeficiency
syndrome occurring from genetic mutation but only occurring in males. This disorder includes
thrombocytopenia and eczema, so the symptoms include potential bloody diarrhea, cerebral
hemorrhage, and later malignancies and autoimmune syndromes. Differential diagnosis includes
leukemia and idiopathic thrombocy-topenic purpura (ITP). Survival later than adolescence is
rare without treatment, which includes antibiotic prophylaxis with trimethoprim
sulfamethoxazole (TMP-SMZ) (Bactrim or Septra) for Pneumocystis jiroveci pneumonia and
IgG replacement therapy. Splenectomy is a possibility to decrease thrombocytopenia, and stem
cell transplant can offer a cure.
Signs and Symptoms
A good way of identifying if a child has primary immunodeficiency is by using Modell’s 10
Warning Signs of Primary Immunodeficiency:

▪ Eight or more ear infections per year

▪ Two or more serious sinus infections per year

▪ Two or more months on antibiotics with little effect

▪ Two or more pneumonias within 1 year

▪ Failure of infant to gain weight or grow normally

▪ Recurrent, deep skin or organ abscesses

▪ Persistent thrush in the mouth or on the skin after 1 year of age

▪ Need for IV antibiotics to clear infections

▪ Two or more deep-seated infections

▪ Family history of primary immunodeficiency

Diagnosis
Diagnosis of congenital immunodeficiency disorders is based on symptoms of congenital
immunodeficiency disorders that begin in infancy. The actual diagnosis depends on the exact
immune components involved. Laboratory testing should include a full blood count and
immunoglobulin levels (especially IgA, IgG, and IgM). Additional tests will be ordered
depending on the suspected disorder.
Prevention
Most primary or congenital immunodeficiency disorders are genetic and not preventable, but
good prenatal care and education regarding care can decrease the associated clinical
manifestations.
Nursing Care
Nursing care for patients with congenital immunodeficiency disorders is complex, depending on
the disorder. Many of these affected children are infants, and families are devastated by the
diagnosis of these complex disorders.
The nurse obtains blood samples for laboratory tests based on the health-care provider’s order. A
complete blood count (CBC) with differential, immunoglobulin levels (IgA, IgG, IgM), T and B
lymphocyte tests, and protein electrophoresis is drawn to determine types of immunoglobulin
disorders. Additionally, pre- and postimmunization titers for routine immunizations (e.g., tetanus,
2
diphtheria, mumps, and rubella) are drawn. These titers determine if the child has enough
immunity to form a response to these immunizations. The nurse is instrumental in monitoring for
frequency of infections, lack of response to antibiotic therapies, and the development of more
severe infections, such as Pneumocystis jiroveci pneumonia. It is important to note that some live
vaccinations may be contraindicated in immune disorders.
Education/Discharge Instructions
The nurse tells the family that continued monitoring of growth and development on standardized
growth charts is done to assess for failure to thrive or weight loss patterns. Family support and
education are essential to properly care for the child. Refer families to support groups and
healthcare specialists.

Variations of Pediatric Immunity

• Children have thinner skin that can more easily become irritated and absorb
microorganisms.
• Children younger than 5 have less resistance to infectious organisms than older children and
adults because of lower levels of immunoglobulin A (IgA).
• Children younger than three have more difficulty regulating body temperature than older
children and adults because of immature endocrine (sweat) glands.
Why Are Children More Vulnerable to Infections?
Parents often ask why children are more vulnerable to infections. Not all situations are alike, so it
is important that the nurse tailor the response to the patient and family. Here is sample
information the nurse can share:
● Children have thinner skin that can more easily become irritated and absorb
microorganisms.
● Children younger than 5 have less resistance to infectious organisms than
older children and adults because of lower levels of immunoglobulin A (IgA).
● Children younger than three have more difficulty regulating body temperature
than older children and adults because of immature endocrine (sweat) glands.
Educating the family about the role of the immune system and the natural processes that help the
body maintain resistance to disease can help keep the child’s immune system healthy. Nurses can
support the child’s immune system through nursing interventions such as meticulous skin care
and measures that target the maintenance of important barriers (Fig. 18-2).

What are the antibody classes?

• IgM - the first type of antibody made by the body in response to an infection. This antibody
helps other immune system cells destroy foreign substances. An adult level is attained by 9 to
12 months of age.
• IgG - important in fighting bacterial and viral infections. An adult level is attained by 1 year of
age.
• IgA - protect the body’s surface from foreign substances. An adult level is attained by 5 years
of age.
• IgE - causes the body to react against foreign substances such as fungus spores, animal
dander, and pollen. An adult level is attained by early childhood.
The Body’s Defense
The skin is the most important physical barrier and the body’s first line of defense. It is the

3
largest organ of the body and has several major functions:
▪ Protects the deeper tissues from injury
▪ Protects the body from foreign matter invasion
▪ Regulates temperature
▪ Aids in water retention
▪ Aids in synthesis of vitamin D
▪ Initiates the sensations of touch, pain, heat, and cold
▪ Has mucous membranes that provide a protective barrier against the entry of pathogens

Mechanical and chemical barriers also help protect the child. For example, tears, urine, vaginal
secretions, and semen have a role in primary defense against infection. The mechanical action of
these fluids flowing out from the body carries out unwanted intruders that may cause disease. An
example of a chemical barrier is the acidic secretions of the stomach and digestive enzymes that
serve to neutralize organisms taken into the body through the mouth. Chemical barriers in the
gastrointestinal (GI) system can be maintained with good nutrition.
The body’s second line of defense is the immune response. The overall purpose of the immune
response is to defend the body against microorganisms, parasites, and foreign cells such as
cancer cells and transplanted cells. Key to a normal immune response is the body’s ability to
recognize foreign substances as non-self and then to mobilize defenses and attack the invaders. A
deficiency in the immune response may lead to serious illness in the pediatric patient.
Immunoglobulins
Immunoglobulins, also known as antibodies, are substances made by the body’s immune system
in response to diseases and other insults. The major types of immunoglobulins are:

▪ IgM is the first type of antibody made by the body in response to an infection. This
antibody helps other immune system cells destroy foreign substances. An adult level is
attained by 9 to 12 months of age.
▪ IgG antibodies are important in fighting bacterial and viral infections. An adult level is
attained by 1 year of age.
▪ IgA antibodies protect the body’s surface from foreign substances. An adult level is
attained by 5 years of age.
▪ IgE causes the body to react against foreign substances such as fungus spores, animal
dander, and pollen. An adult level is attained by early childhood.

HUMAN IMMUNODEFICIENCY VIRUS (HIV [AIDS])

HUMAN IMMUNODEFICIENCY VIRUS (HIV [AIDS])
The HIV virus selectively targets and destroys helper T cells (i.e., T4 or CD4), thereby
destroying cellular immunity. The child is virtually unprotected against a number of
opportunistic infections and bacterial, fungal, and viral diseases. Every system is potentially
affected because the HIV virus integrates itself into the patient’s genetic material. However, the
body’s immune response may raise CD4 (helper T cell) levels for some time, creating a latent
period that may last 10 years or more before the child becomes sick. When CD4 levels drop,
symptoms begin to appear and the change from HIV to AIDS begins. The CDC (2020) indicates
that children who become infected with the HIV virus between 13 and 25 years old survive
longer than people who become infected later in life. If a baby acquires HIV prenatally, the
latency period may be brief and the child becomes ill quickly, developing AIDS in

4
the first year of life with a poor prognosis. An estimated 40,000 people will be diagnosed with
HIV infection this year in the U.S..
From the onset of the epidemic in the late 1970s through 1994, an estimated 14,920 perinatally
HIV-infected infants were born in the U.S.. These numbers began to drop dramatically with
important research that discovered a way to prevent infections between pregnant mother and
child (treatment with AZT). Since this breakthrough, the number of HIV-infected infants has
remained steady at fewer than 200 new infant infections per year.
The decreased incidence of perinatal transmission demonstrates the importance of screening for
HIV infection in pregnancy and treating HIV-positive pregnant women with these services. It is
estimated that there are approximately 8,500 HIV-positive pregnancies in the United States each
year, but fewer than 150 new infant HIV infections—a testament to the effectiveness of U.S.
prevention efforts. Work is still ongoing to eliminate all new pediatric HIV infections in the
United States and keep children living with HIV happy and healthy.

HIV
• The HIV virus selectively targets and destroys helper T cells (i.e., T4 or CD4), thereby
destroying cellular immunity.
• The child is virtually unprotected against a number of opportunistic infections and bacterial,
fungal, and viral diseases.
• Every system is potentially affected because the HIV virus integrates itself into the patient’s
genetic material.
^^^^

Signs and symptoms

• Lymphadenopathy
• Hepatosplenomegaly and hepatitis
• Chronic diarrhea, with malabsorption
• Failure to thrive
• Oral thrush
• Skin infections
• Fevers
• Recurrent infections, including mucous membrane and skin infections
• Thrombocytopenia (see Box 18-1)
• Developmental delay and loss of milestone achievements
Signs and Symptoms
Signs of HIV in children can include any of the following:
■ Lymphadenopathy
■ Hepatosplenomegaly and hepatitis
■ Chronic diarrhea, with malabsorption
■ Failure to thrive
■ Oral thrush
■ Skin infections
■ Fevers
■ Recurrent infections, including mucous membrane and skin infections
5
■ Thrombocytopenia (see Box 18-1)
■ Developmental delay and loss of milestone achievements
Resulting conditions include:
■ Cardiomyopathy
■ Nephropathy

Pancytopenia is an issue for children with HIV that may cause thrombocytopenia (low platelet
count). Intravenous immune globulin (IVIG) is used to raise the platelet count. Another way to
raise the platelet count is to use high-dose steroids. Sometimes WBC abnormalities also occur,
including neutropenia, leukopenia, and lymphopenia. Epoetin alfa (Erythropoietin) is a newer
medication that increases RBC and WBC production in such cases.
^^^

HIV
• Diagnosis: because of passively acquired maternal antibodies in the first 18 months of life,
there are separate criteria for this age group because this may confuse the infant’s status with
regard to HIV infection.
• Children aged 13 and older, HIV antibody testing is the same as for adults
• Prevention: counsel pregnant women to follow the guidelines for mandatory HIV
testing
• Educate adolescents about HIV transmission, prevention, and testing
• Collaborative care: complex process that includes physical, psychological, and family care.
Selected medications are used for children and adolescents who are HIV positive or have AIDS
(Table 18-1).
• Education and discharge instructions: Symptomatic and supportive care of children with HIV
or AIDS is similar to that for children with immunodeficiency conditions. Palliative and
comfort care measures are essential. Proper hygiene, comfortable clothing, good nutrition,
play, rest, and social interaction are all important aspects of care for the child. The nurse
ensures good communication between the family and health-care providers to facilitate a
realistic ongoing treatment plan.
Diagnosis
Diagnostic testing for HIV infection in children is necessary whenever the virus is suspected.
Diagnosis of HIV infection in children requires a multipronged approach using appropriate
testing and clinical observation. In infants, the diagnosis can be complicated by the transmission
of maternal antibodies. The CDC developed a separate classification system for pediatric HIV or
AIDS in 1987 and then revised it in 1994 for children younger than 13 years. Because of
passively acquired maternal antibodies in the first 18 months of life, there are separate criteria for
this age group because this may confuse the infant’s status with regard to HIV infection. For
children age 13 and older, HIV antibody testing is the same as for adults, using the enzyme linked
immunosorbent assay (ELISA) test that identifies the presence of HIV antibodies. If the initial
ELISA antibody test is positive, it merits repeating, and if the repeat test is still positive, it is
necessary to add the Western blot test, which is a confirmatory indirect fluorescent antibody test.
Other tests that are now available have less accuracy. They include an oral fluid (not saliva)
antibody test that needs a confirmatory Western blot, a urine test that needs a confirmatory
6
Western blot, a rapid test that uses blood from a finger stick or oral fluid, and home testing kits.
Only one kit, Home Access HIV Test System, using a finger prick, is approved by the Food and
Drug Administration.
Prevention
The nurse should counsel pregnant women to follow the guidelines for mandatory HIV testing.
This is the most significant way to decrease vertical transmission of HIV. The American
Academy of Pediatrics Committee on Pediatric AIDS and Committee on Adolescence has noted
that approximately half of all new HIV infections in the United States occur among youth ages
13 to 24. Therefore, nurses are instrumental in educating adolescents about HIV transmission,
prevention, and testing, including details about safe sex practices and condom use.
Collaborative Care
Nursing Care
Caring for children with HIV or AIDS is a complex process that includes physical,
psychological, and family care. The pediatric nurse assesses the family’s support systems, coping
mechanisms, and overall ability to care for the HIV-infected child. Social stigma is frequently
associated with this diagnosis, and many families may feel isolated and face rejection. Because
the diagnosis and treatment for HIV cause a family crisis, it is vital for the pediatric nurse to
provide psychological support, monitor infection, manage pain, provide developmental care,
monitor nutrition and immunizations, and focus on proper medication administration. The
primary concern for early and accurate identification of children with HIV infection is beginning
treatment. The goals of treatment for children with HIV are to slow progression to AIDS,
prevent further infections, promote normal growth and development, prevent complications
including cancers, and prolong and improve quality of life. If the mother is also infected with
HIV, the nurse determines the best way to care for both patients. Priority nursing care focuses on
decreasing the potential for opportunistic infection. HIV-infected children are at risk for these
infections that a child with normal immunity would not acquire. Pneumocystis jiroveci
pneumonia is the most common opportunistic infection in children. The nurse must be ready to
manage these infections, often with prompt and vigorous antimicrobial therapy According to
current CDC (2020) HIV and Resources Guidelines, all infants born to HIV-infected mothers are
routinely started on a prophylactic antibiotic regimen for this organism. Trimethoprim
sulfamethoxazole (TMP-SMZ) (Bactrim or Septra) is the agent of choice for this treatment.
Intravenous immune globulin (IVIG) has also been used to prevent bacterial infections in young
children. In addition, the nurse teaches the family signs and symptoms of infection and
encourages them to limit the child’s exposure to large crowds of people and to those with notable
infections.
The pediatric nurse addresses infection control information for day-care providers and school
personnel about how to care for frequent diarrhea and assess for candidiasis infections. These
issues may create problems with diaper changes and keeping the genital areas free of a
superinfection. Caretakers must use gloves properly and carefully, and body secretions must be
properly disposed of in biohazardous waste containers. Universal precautions are enforced in all
public areas and are especially important during participation in contact sports, during
menstruation in girls, and for all sexually active teens.
Pain management is a significant care concern for children with HIV. Pain in children can be
multifactorial, resulting from inflammation or from systemic manifestation of AIDS such as
cardiomyopathy, drug toxicities, invasive secondary infections, and medical procedures used to
monitor and treat the HIV infection. Most HIV-infected children report pain as a factor affecting
their daily lives. Successful management of pain is based on the same principles of pain
7
management found in other illnesses. Diligence in identification of pain, goals, and strategies to
manage pain, implementation of nonpharmacological and pharmacological pain management
strategies, and ongoing pain assessments are all-important in the plan of care. Pain control is a
major factor in quality of life and hence a primary goal for the nurse.
Developmentally appropriate preparation before painful procedures has been shown to lower the
anticipation of pain, thus decreasing the pain experience. Child life specialists may assist the
nurse to prepare the child for procedures. Preparation may include diagrams, pictures, handling
equipment, meeting medical personnel, or visiting special rooms, such as recovery or the
intensive care units.
Distraction can be useful, particularly for younger children. Techniques such as blowing bubbles,
singing songs, blowing pinwheels, or reading a favorite book may turn their attention away from
the procedure. Family members can be encouraged to participate in distraction by providing a
favorite toy.
Relaxation can be effective in pain control and actually decreases pain in the child. Nurses can
teach relaxation skills to parents early in the course of HIV. A deep sense of relaxation can be
obtained through guided imagery or hypnosis. The nurse can encourage parents to use relaxation
books that will help them direct the relaxation exercise with their child. Additional
complementary and alternative therapies include massage, acupuncture, and vitamin and other
dietary supplements.
Children who are HIV-positive are adversely affected by malnutrition in the form of either weight
loss or obesity, underscoring the need for continuous assessment and attention. Failure to thrive
causes poor weight gain, often with weight lower than the 5th percentile. The child can
experience chronic diarrhea, malabsorption-induced immunodeficiency, and adverse GI effects of
many HIV treatments. Causes of chronic diarrhea include Mycobacterium avium-intracellulare,
Giardia, and Cryptosporidium. The nurse works closely with a nutritionist to develop a plan to
manage the child’s diet in interesting and vital ways.
Obesity is a common problem in children with HIV and a contributing factor to immune
dysfunction. Obesity occurs as a result of side effects from some of the medications commonly
used to treat HIV coupled with decreased physical activity. Early involvement of a nutritional
expert to provide consultation with the family is beneficial. The nutritionist can address specific
nutritional needs and provide education about healthy dietary choices. In addition, the nutritionist
can perform a nutritional assessment that includes monitoring heights and weights, evaluating
laboratory values, and screening for dietary difficulties.
Oral supplementation is recommended to proactively meet nutritional goals of underweight
children with HIV. The overall goal of oral supplementation is to prevent malnutrition. In
addition, aggressive oral care is emphasized to prevent oral lesions that may add to decreased
intake. Another way to ensure adequate nutrition is the initiation of parenteral (tube) feedings.
Knowledge about immunizations for the child with HIV is important. In the past, HIV children
did not receive live viral vaccines (e.g., MMR and varicella) because of the concern that they
could develop these infections because of their immunosuppression. Now children can receive
these vaccinations if their immunity is good, depending on their CD4 counts (T-cell counts).
Education/Discharge Instructions
Symptomatic and supportive care of children with HIV or AIDS is similar to that for children
with immunodeficiency conditions. Palliative and comfort care measures are essential. Proper
hygiene, comfortable clothing, good nutrition, play, rest, and social interaction are all important
aspects of care for the child. The nurse ensures good communication between the family and
health-care providers to facilitate a realistic ongoing treatment plan.
8
Adolescents present their own specific challenges when infected with HIV. Based on their desire
to be independent, adhering to complicated treatment regimens may be a struggle. The nurse
works closely with the adolescent to identify strategies for managing a complex medical illness
with the need to be independent and socialize with peers. Often, referral to an adolescent support
group is helpful for children in this age group.
It is critical to help the family access available resources including social services, financial aid,
spiritual support, insurance coverage, and how to access community health clinics. Often, the
acute care setting nurse who is intermittently involved in the child’s care can initiate the
coordination of ongoing care by contacting a case manager to guide the family through the
complex health-care system. Although in the past, children with HIV were commonly not told
about the diagnosis, today most patients live into adolescence and adulthood. Guidelines for
helping to tell children about their diagnosis through the American Academy of Pediatrics (AAP)
and other national AIDS or HIV foundations, such as American Foundation for Children with
AIDS and the Elizabeth Glaser Pediatric AIDS Foundation.

HIV
Diagnosis:
◦ Because of passively acquired maternal antibodies in the first 18 months of life, there are
separate criteria for this age group because this may confuse the infant’s status regarding
HIV infection.
◦ For children aged 13 and older, HIV antibody testing is the same as for adults, using the
ELISA test that identifies the presence of HIV antibodies.
Nursing Care:
◦ Early and accurate identification
◦ Psychological support
◦ Monitor for infection
◦ Manage pain
◦ Monitor nutrition
◦ Monitor immunizations
◦ Administer meds (prophylactic antibiotics are typical for infants Born to HIV infected
mothers)
Education:
◦ Symptomatic and supportive care; Palliative and comfort care measures when necessary.
◦ Follow-up care
◦ Resources
^^^^^

Allergic Reaction
ALLERGIC REACTION
Anaphylaxis
Anaphylaxis is considered a medical emergency as the most severe allergic reaction possible.
Both IgE- and non-IgE-me-diated activities cause this life-threatening event, including the
activation of mast cells, basophils, eosinophils, histamine, leukotriene, cytokines, T lymphocytes,
and neutrophils, among other cells. Most importantly, this cascade of events activates the heart,
lungs, and vasculature in a detrimental manner, including vasodilation, hypotension, and
9
resultant shock. Histamine can cause coronary artery vasospasm and shorten diastole. Histamine
stimulates bronchial smooth muscle contraction, causing bronchospasm. Increased vascular
permeability causes laryngeal edema, closing the airway down. The body reacts violently to an
antigen (foreign substance) that causes a hyperacute allergic response. Fatalities are caused by
respiratory compromise and cardiovascular collapse, with respiratory failure being more
common in pediatric mortality. Most reactions occur quickly after exposure, although food
allergies can manifest from 25 minutes after exposure to several hours later. Insect stings and
drug allergies cause the most rapid route to anaphylaxis, with an average of 5 to 20 minutes to
onset.
Signs and Symptoms
Signs and symptoms of anaphylaxis develop suddenly and require prompt recognition and
treatment:
▪ Wheezing
▪ Tachycardia
▪ Hypotension
▪ Cyanosis
▪ Alteration in level of consciousness
▪ Nasal congestion
▪ Angioedema (swelling around mouth and oropharynx)
▪ Facial edema
▪ Anxiety
▪ Hives and urticaria
▪ Nausea and vomiting
▪ Abdominal pain
▪ Laryngospasm
▪ A sense of impending doom
▪ Vascular collapse and cardiac arrest

Diagnosis
Diagnosis of anaphylaxis must involve two body systems. Minor urticaria (hives) is not
considered one system but more severe urticaria is. Skin prick testing is contraindicated if the
child is anaphylactic to a substance, as opposed to a lesser allergic reaction. It is important to
differentiate true food allergies to those caused by cell-mediated food hyper-sensitivities (e.g.,
celiac disease, malabsorption syndromes, and food-induced colitis, which have more GI
symptoms). Also, it is important to differentiate between oral allergy syndrome, in which patients
get tingling of the palate, tongue, lips, or oropharynx after ingesting certain foods, but they never
get anaphylaxis. True anaphylactic food allergies can be life-threatening with respiratory or
cardiac arrest, although some food allergies are only manifested by urticaria and pruritus.
Prevention
Prevention of anaphylactic reactions is an essential component of nursing care. Nurses should be
vigilant about checking for allergies from patients, family members, the medical record, and
allergy bracelets. Nurses should obtain excellent histories about allergic reactions and should
document them carefully and prominently for all health-care team members to see. Some
anaphylactic reactions occur upon first-time exposure, but others, including some bee stings,
occur only on the second or subsequent exposures. If there is a family history of anaphylaxis, the
nurse should counsel the patient and other health-care team members because the patient could
well develop anaphylaxis also. Emergency medicines such as epinephrine and fast-acting
10
antihistamine medications need to be available for immediate use. Patients with history of
anaphylactic reactions should wear ID jewelry detailing the reactions, should carry wallet card
identification of the anaphylactic reaction, and should carry life-saving medicine with them (or in
the case of young children, the parents, school nurses, teachers, and other health-care team
members should have access to emergency medications).
Collaborative Care
NURSING CARE
For children who have experienced an anaphylactic reaction, the nurse must provide follow-up
care to families to prevent recurrences. If the child has allergies that cannot be completely
eliminated, a follow-up referral to an allergist for desensitization treatments or a self
administration epinephrine prescription, such as an EpiPen, is warranted. It is important that
parents are taught to recognize early indicators of anaphylaxis and are confident in their ability to
act quickly on this assessment.
MEDICAL CARE
Basic life support must be initiated with support of airway, breathing, and circulation.
Administration of oxygen and initiation of an IV therapy with an isotonic crystalloid solution as
soon as possible are standard treatment. Epinephrine (Adrenalin) injection is administered IM or
IV to provide reversal of pulmonary bronchospasm and constriction of blood vessels, thereby
improving respiratory status and blood pressure. Ongoing assessment for shock is necessary and
can be treated via IV fluid bolus. Occasionally, antihistamines and corticosteroids may be added
to further control symptoms after the initial stabilization. The majority of children respond
positively to the treatment and make a full recovery.
Education/Discharge Instructions
In case of an allergic reaction, instruct the parent to administer the medication exactly as directed
and call 911 immediately. Other education/discharge instructions include:
▪ Instruct the parents to teach the child to know their triggers.
▪ Review correct administration technique for the EpiPen or EpiPen Jr (epinephrine).
▪ Teach the child to self-inject the epinephrine medication and what to do in case of an
emergency.
▪ Tell parents of children too young to self-inject and who are separated from them to
discuss the allergy and how to use an autoinjector with another responsible adult.

The pediatric nurse plays a critical role in collaboration with the family and school personnel to
create a safe environment for a child with peanut allergy to safely attend school. The nurse
assists the family in establishing a coordinated plan including the following key components:

• Educate the school staff regarding peanut allergies. Include all staff who may be supervising
this student and who may be in a position to recognize and intervene in an
emergency.
Outline an emergency plan specific for the student to include:
• Specific instructions for staff in the event of a reaction
• Two up-to-date EpiPens on hand
• Identification and elimination of exposure to the allergen
• Placement of emergency phone numbers in a designated area
• A “peanut-free” zone in the cafeteria or a peanut-free table
• Communication with parents who may provide snacks to the child, such as parents of children
11
 in the same class, sports team, or club

Allergies & Anaphylaxis

• What is the difference?
????

Allergy
• Immune mediated response resulting in an adverse physiologic event or
reaction
• Extent of allergic response: duration, rate & amt. of exposure
• Mediated by IgE antibodies
• Asthma, allergic rhinitis, atopic dermatitis, urticaria, digestive
^^^

Food Allergies
• Immunologic reaction = ingestion of food or additive
• IgE mediated response
• Occurs in 1st few years of life
• Milk, eggs, peanuts, tree nuts, fish, & shellfish
• Reaction occurs w/in minutes
• Hives, flushing, facial swelling, mouth & throat itching, runny nose, vomiting &
diarrhea
• Assess: Food hx: Rx, suspected food, quantity ingested, time – s/s
• Tx: Recognizing, verifying & avoidance
• Antihistamines
• Epinephrine = severe reactions
• [Link]
• Teaching guidelines: Table 47.1
• Food intolerance vs. allergy
^^^^

Anaphylaxis
• [Link]
• Acute IgE mediated response to an allergen
• May involve many organ systems
• May be life threatening
• Nuts, shellfish, eggs, bees, wasp stings, PCN, NSAIDS, radiopaque dyes & Latex
• Happens in 5-10 min of exposure
• Assess: LOC; ABC’s, Brief hx about allergen exposure; What meds have been given since onset
& effect of meds on S/S
• Treatment: IM Epinephrine/ diphenhydramine; bag-valve mask O2; albuterol- bronchospasms
• Teach: Prevention/Avoid; Epi pen; medic-alert bracelet; School communication
• [Link]

12
• Anaphylaxis and EpiPen
^^^^^

Anaphylaxis Cascade
• Body reacts excessively to an antigen.
• Hyperacute response of activation of mast cells, basophils, eosinophils, histamine,
leukotrienes, cytokines, T lymphocytes and neutrophils.
• Histamine
• Coronary artery vasospasm and shortened diastole.
• Stimulation of bronchial smooth muscle contraction.
• Increases vascular permeability.
^^^^

INFECTIOUS DISEASES OF CHILDHOOD

INFECTIOUS DISEASES OF CHILDHOOD
The occurrence of infectious disease in children is the result of an interaction between several
factors including the child, the environment, and the agent causing the illness. Two main models
are used to illustrate the interaction, most commonly the epidemiological triangle (Fig. 18-4). In
the epidemiological triangle, the host, environment, and agent make up the three sides of an
equilateral triangle. The host is the organism from which a parasite obtains its nourishment, the
environment is the surroundings or conditions that influence the organism, and the agent causes
the actual effect (disease). This model illustrates the codependence that these three factors have
on one another and recognizes that a change in any one of the three factors will influence the risk
or probability of a child contracting the disease. Many factors such as age, gender, physical, and
psychosocial factors play a role in the susceptibility of the host to an infectious disease. The
normal development of the child’s immune system is also a major factor in many infectious
diseases, especially during the early childhood years. The child has natural protection from
maternal antibodies for up to the first 6 months of life; therefore, any sign of infection that
occurs during this time is taken seriously and often an extensive medical work-up is initiated.
Also, children under 6 months of age who show signs of infectious disease may be ill enough to
be hospitalized because of some compromise in their maternal and natural immunity.
The final element in the triangle, the agent, contains specific information, including infectivity,
pathogenicity, and virulence, that assists the nurse in developing the appropriate plan of care.
Infectivity includes the mode of transmission, incubation period, and communicable period. The
mode of transmission is how the pathogen actually gains access to the body. With this
knowledge, the nurse can plan care to eliminate unnecessary portals of entry (e.g., multiple IV
sites) and thoroughly inspect the skin for potential breaks that allow entrance of organisms.
Knowledge about the incubation period (period of time when an organism invades the body and
develops an onset of symptoms) and the communicable period (the time that the child is able to
transmit the pathogen to others) allows the nurse to alert others that the child is infectious and to
isolate the child for a certain period.
Pathogenicity is the percentage of those children exposed to the pathogen who will eventually
develop the disease. This information is helpful to the nurse in the community when assessing
citywide outbreaks. The nurse can notify schools, community centers, churches, shopping malls,
and other public places that an outbreak exists and that it is best to avoid these areas, especially
13
 for high-risk children. Virulence is the severity of the health problems caused by the agent. The
more virulent the disease the more necessary it is to curtail its spread. For example, in winter
during an influenza outbreak, a number of schools close so they can be thoroughly cleaned and
sanitized. Pathogenicity and virulence are often key considerations in development and
implementation of public health programs.
The Chain of Infection model is also an important way to understand transmission of infection
(Fig. 18-5). This model illustrates the exact steps that must occur for transmission and
demonstrates possible ways to stop transmission of the disease.
The first link shows that pathogenic microorganisms, whether viruses, bacteria, or fungi, require
a reservoir where the pathogen can grow. Reservoirs may be human hosts, animals, and the soil.
With knowledge about the reservoir, the nurse can eliminate it to break the chain. A mosquito
abatement program to control West Nile virus is an example of an attempt to alter the chain of
infection via reservoir elimination. Public health immunization campaigns are examples of a way
to decrease the reservoir for diseases.
The next two links in the chain involve the escape of the pathogen from the reservoir into the
host. Knowledge about the routes of transmission (contact, droplet, air-borne) enables the nurse
to initiate appropriate isolation precautions. Contact transmission refers to infection that is
contagious through skin, vomit, feces, urine, mucous membranes, and wounds. Droplet
transmission implies a spread of organisms through close mucous membrane or respiratory
secretions contact, as exemplified by rhinovirus that can cause the common cold and influenza.
Airborne transmission refers to pathogens that may be suspended in the air and therefore spread
over long distances. Examples of airborne transmission include measles, tuberculosis, and
varicella.
The final link involves a susceptible host. Susceptibility of the host to infection is decreased
mainly via good general health practices such as good hygiene, nutrition, overall good health,
lack of immunity disorders, and a decrease in stress. A listing of infectious diseases and nursing
care actions is shown in Table 18-3.

BACTERIAL
• Pertussis
• Transmitted via direct contact and air
• Incubation period is 6 to 20 days; usually 7-10 days
• Isolation precautions: Droplet
• Most communicable during the catarrhal stage but can continue through the 4th week
• Complications include pneumonia, atelectasis, OM, seizures, hemorrhage, weight loss,
dehydration, rectal prolapse
• Nursing management:
• Isolation; respiratory precautions
• Monitor respiratory status and for signs of obstruction
Presentation:
Catarrhal stage:
• Symptoms of URI infection; continues for 1 to 2 weeks when hacking cough
becomes more severe
Paroxysmal stage:
• Characteristic “whooping” cough, usually at night
• Cough until thick mucus plug is dislodged; usually followed
14
 by vomiting
Convalescent stage:
• Cough gradually decreases, vomiting stops, strength returns
DISEASE:
Pertussis (Bacterial) → Whooping cough
• Causative Agent—Bordetella pertussis bacteria
• Epidemiology—This disease occurs in unimmunized or partially immunized persons, and
outbreaks of pertussis more recently have led to recommendations for older children and adults
to get re-vaccinated with booster doses of this vaccine.
• Adults and adolescents who are no longer immune provide a major reservoir for pertussis.
• It can also spread to incompletely immunized infants and children, with higher morbidity and
mortality.
• Mode of Transmission—Transmission takes place through close contact with the infected
person and aerosol droplet.
• Infection Control—The incubation period is 6–21 days. Hospitalized children should be placed
on droplet precautions until the period of communicability has passed. Testing is possible
through culture and PCR test.
SIGNS AND SYMPTOMS: → Cold Symptoms
• The initial signs and symptoms include
a mild respiratory illness but with a cough that has a classic “whooping” sound, which is a
high-pitched inspiratory sound.
• This persistent dry cough may last for months and includes coughing paroxysms and vomiting
after coughing.
NURSING CARE:
• Nursing care includes the administration of antibiotics as ordered by the health-care provider.
• Infants younger than 6 months of age and those with severe disease are hospitalized for close
observation of respiratory status.
• Nursing care also includes maintaining open airway and monitoring oxygen saturation.
COMPLICATIONS:
• Complications in infants, especially those younger than 6 months, include apnea, seizures,
severe pneumonia, and pulmonary hypertension.
• In all children, bacterial pneumonia, seizures, encephalopathy, epistaxis, and even death can
occur.

VIRAL
Rubeola (measles)
• Communicability
• Viral infection
• Direct droplet contact
• Isolation precautions: Airborne
• Incubation period 10-20 days
• Communicable 4 days before to 5 days after rash appears
• presentation
• 3-4 days before rash:
• Mild to moderate fever
• Conjunctivitis
15
 • Fatigue
• Cough, runny nose, sore throat
• Rash:
• Koplik spots 2 days before rash
• Rash begins on face and spreads down
• complications
• Otitis media
• Pneumonia
• Mastoiditis
• Myocarditis
• Encephalitis
DISEASE:
Rubeola: Measles (Viral)
• Causative Agent—Morbillivirus.
• Epidemiology—Occurs in outbreaks among unimmunized populations.
• Peak Incidence—Peaks in winter and spring.
• Mode of Transmission—The mode
of transmission happens through the respiratory tract via droplets or direct contact with
infectious secretions like blood or urine. This disease can also be transmitted via fomites. •
Infection Control—The incubation period is 8–12 days. Airborne and contact precautions are
recommended from 2 days before onset of symptoms until 5 days after appearance of the rash
(about 14 days total).
• Measles is a reportable disease.
SIGNS AND SYMPTOMS:
• Signs and symptoms include the prodromal phase lasting about 4–5 days and a moderate fever,
cough, coryza, and conjunctivitis.
• Koplik’s spots appear on the buccal mucosa 2 days before the onset of the rash (blue- white
granules on erythematous base).
• The rash stage usually lasts about 3–4 days with a rise in fever up to 105°F (40.5°C).
• The rash first appears on forehead and behind the ears and then spreads to face, trunk, and
upper and lower extremities.
• After 4–7 days rash begins to fade, and the temperature begins to drop.
• Other common symptoms can include anorexia, malaise, fatigue, and generalized
lymphadenopathy.
NURSING CARE:
• Nursing care is supportive with antipyretics, bedrest, and increased fluids. Ensure the room is
dark if photophobia occurs. Watch for complications and superinfections (otitis media and
pneumonia).
COMPLICATIONS:
• Complications include pneumonia, otitis media, mastoiditis, encephalitis, and myocarditis. •
Younger children, medically fragile children, and children with underlying immunosuppression
are at greater risk for complications.

Rubeola (measles)
• Bed rest
• Antipyretics
16
• Dim lights (photophobia
• Cool-mist humidifier
• Tepid baths
• Monitor for complicaitons
^^^^

Rubella (German Measles)

Communicability
• Direct contact
• Incubation period from 14-21 days
• Isolation precautions: Droplet
• Communicable from 7 days before rash until ~5 days after rash
Presentation
• Low-grade fever
• Sore throat
• Headache, malaise, cough
• lymphadenopathy
• Rash on face, spreads downward; lasts 2-3 days
• Other symptoms usually disappear after onset of rash
DISEASE:
Rubella (virus)/German or 3-Day Measles
• Two forms: congenital and postnatal (after birth).
• Causative Agent—Rubeola virus
• Epidemiology—Up to 39 million cases worldwide each year
• Peak Incidence—In United States, mostly at age 6 months because infants are not vaccinated
yet.
• Mode of Transmission—This disease is highly contagious. It is spread through placenta or
nasopharyngeal secretions and fomites.
• Infection Control—Incubation period: 14–21 days.
SIGNS AND SYMPTOMS:
• Signs and symptoms include a prodrome of mild fever, sore throat, arthralgia, eye pain,
• GI upset.
• Lymphadenopathy follows and is noted for the occurrence of postauricular nodes.
• Other lymph nodes, such as cervical and occipital nodes, can become inflamed.
• The rash is a fine, light-pink, maculopapular rash on the face then traveling to the chest and
entire body.
NURSING CARE:
• Supportive care is given with antipyretics.
• Isolate the child from others while disease is active, usually for up to 1 week after rash starts.
COMPLICATIONS:
• The riskiest complications occur prenatally, in the first trimester to 16th week of pregnancy,
and include mental retardation, deafness, eye disorders, cardiac defects, and stillbirth.
• Postnatal complications include arthritis, ITP, and encephalitis.

17
 Mumps
• Transmitted via direct contact and droplet (saliva)
• Incubation period is 14 to 21 days
• Isolation precautions: Droplet
• Communicable immediately before to immediately after swelling appears (either unilateral or
bilateral)
• Nursing management includes bed rest, analgesics, and fluids
Presentation:
• Painful, swollen parotid glands
• Fever
• Muscle aches
• h/a=headache
• Earache which worsens with chewing
• Fatigue
• Loss of appetite
Complications:
• Orchitis, encephalitis, meningitis, oophoritis, mastitis, deafness, myocarditis, arthritis,
hepatitis
DISEASE:
Mumps (Parotitis) (Viral)
• Causative Agent—Paramyxovirus
• Epidemiology—This disease is highly contagious.
• Peak Incidence—Late winter to early spring, higher outbreaks among college- age persons if
not vaccinated
• Mode of Transmission—The transmission of this disease spreads via droplets directly from an
infected person (saliva and respiratory secretions). Virus may be airborne through infected
droplets.
• Infection Control—The most contagious period is from 2 days before symptoms begin to 6
days after they end. Hospitalized children require droplet precautions.
SIGNS AND SYMPTOMS:
• Signs and symptoms are mild and systemic including malaise, low- grade fever, anorexia, ear
pain and headache, and pain with chewing.
• As the disease advances, bilateral or unilateral parotid gland swelling appears; swelling
generally peaks around the third day and lasts up to 6 days.
NURSING CARE:
• Nursing care is supportive and includes control of the signs and symptoms.
• Hydration and good nutrition are important care measures.
COMPLICATIONS:
• The main complication is orchitis in post-pubertal males.
• Sterility secondary to this complication is rare.
• Less common complications are oophoritis, pancreatitis, myocarditis, and deafness.

Varicella
• Transmitted by direct contact in airborne secretions of the respiratory tract of infected person
or contaminated objects
18
 • Isolation precautions: Airborne and Contact
• Most contagious 1 day before lesions appear and until 6 days after all lesions are
crusted
• Incubation period is from 2 to 3 weeks
• Prodromal stage before rash
• Low grade fever, malaise, anorexia
• Macules start on trunk, then spread to face and extremities
Nursing Care:
• Skin care
• Antipyretics
• Antihistamines
• Acyclovir if high risk
Complications:
• Pneumonia
• Bleeding problems
• Bacterial skin infection
• Encephalitis
DISEASE:
Chickenpox (Viral)
• Causative Agent—Varicella-zoster virus, a herpes virus (VZV)
• Epidemiology—Highly contagious disease
• Peak Incidence—Late winter and spring
• Mode of Transmission—Airborne, spread through contact with respiratory droplets and contact
with lesions
• Infection Control—The incubation period is from 10 to 21 days. Children are considered
contagious 1–2 days before the eruption of lesions to the time when all lesions have crusted, or
up to 7 days after appearance of the rash. The period of communicability may be prolonged in
children who are immunocompromised.
• Airborne and contact precautions are needed for hospitalized children during the period of
communicability.
• Varicella vaccination is increasingly used in childhood and adolescence, so the incidence of
varicella has decreased over time. However, it is unclear whether this vaccine provides lifelong
immunity.
• Herpes zoster (shingles) is reactivated varicella that can occur especially in older and
immunocompromised individuals; this is a result of the varicella virus remaining dormant in
nerves after the disease.
SIGNS AND SYMPTOMS:
• Malaise, fever, possible URI, symptoms are followed by a rash. The rash is described as a “tear
drop on a rose.” It begins with a macule on a red base, then progresses to a clear vesicle, and
later forms a crust. The lesions are severely pruritic, and eruptions may continue to occur for
up to 5 days.
• Generally, the rash first appears on the face and trunk but may spread anywhere on the body.
NURSING CARE:
• Nursing care is supportive with antipruritic lotions, baths, and antihistamines.
• Some children receive oral acyclovir (Zovirax), which is not curative but can slightly shorten
the disease duration and intensity.
19
• IV acyclovir is used for immunocompromised child presenting with chickenpox.
• Must be used within 24 hours of onset to be effective.
• Varicella-zoster immune globulin (VZIG) may be given within 72 hours of exposure to
immunocompromised children. VZIG provides only temporary immunity.
• Oral antihistamines, baking soda, oatmeal baths and lotions, such as Aveeno baths and
calamine lotion are given to manage the itching.
COMPLICATIONS:
• Immunocompromised children have a high risk for complications (including those on steroids
for treatment of asthma).
• The most common complications are bacterial superinfections with lesions, encephalitis,
varicella, pneumonia, and immune thrombocytopenia purpura (ITP).
• Use of aspirin-containing medications has been linked with Reye’s syndrome in children with
Varicella-zoster (chickenpox).

Erythema Infectiosum (Fifth Disease)

• Human parvovirus
• Transmitted by respiratory secretions
• Incubation period is 4 to 14 days
• Isolation precautions: Droplet
• Communicable about 1 week prior to onset of symptoms
• Prodromal phase fever, runny nose, headache
• Three-stage rash:
• Erythema on the face (“slapped cheeks”)
• Maculopapular rash progresses to trunk and extremities, spreading proximally through 1
week
• Secondary erythemic rash can appear on rest of body
• Rash subsides but can resurface if skin is irritated or traumatized
• Nursing Care: symptomatic relief, antipyretics
• Education: Keep children away from pregnant women
Fifth Disease (Erythema Infectiosum) (Viral)
This viral disease is common in childhood, caused by human parvovirus B19. Most children do
not get seriously ill with this virus, but children who are immunocompromised may become very
ill. Pregnant women who do not have antibodies and acquire this disease from a child may
unfortunately lose their babies because of hydrops fetalis (fetal death).
Signs and Symptoms
Fifth disease is known as the “slapped cheek” virus because it begins with a red rash on the face
appearing as though the child’s cheeks were slapped. The rash then spreads to the trunk and
extremities, appearing more as a macular (flat) lacy-appearing erythematous exanthema (rash).
Fever may occur and the rash, though usually gone in a week, can recur with heat exposure for
up to 4 months.
Diagnosis
Diagnosis is made through clinical appearance of the signs and symptoms in most cases but can
be accurately diagnosed with IgM Parvovirus B19 antibodies in the serum within 30 days of rash
onset.
Prevention

20
Avoid exposure to other children with fifth disease. Maintain good hand washing techniques.
Pregnant women must avoid all contact with fifth disease as it can fatally injure the fetus.
Collaborative Care
NURSING CARE
Symptomatic relief, treatment of high fever, and warnings to keep children away from pregnant
women are the main nursing care measures. The rash is not really uncomfortable. The nurse can
help in early identification of this disease because of its classic appearance. If a pregnant woman
has been exposed to this virus, she should see her obstetrics provider immediately. Because the
disease is spread by droplet through coughing and sneezing, droplet precautions should be
instituted if a child is hospitalized. This usually implies the use of masks, gloves, eyewear, and
keeping the child in a single room.
MEDICAL CARE
Use of acetaminophen (Children’s Tylenol) or ibuprofen (Children’s Advil) according to age
appropriate guidelines is useful for high fevers, sore throat, and headache that may accompany
this disease.
Education/Discharge Instructions
The nurse should instruct the patient and family to maintain safe hygiene practices and use
careful hand washing. The child should be kept away from potentially pregnant females. The
rash can last at least a week, and it has been known to recur when the patient is exposed to heat.
Do not use aspirin-containing products for these children because of the risk of Reye’s
syndrome.

Cytomegalovirus
• Member of the herpes family, which attaches to host cells and causes disease.
• High incidence among children ages 1-3 years, teenagers, and pregnant women
• Diagnosis: Urine, saliva, blood, biopsy samples, CT lungs
• Treatment: Ganciclovir (Cytovene), antiviral agent
• Nursing Care:
• Contact precautions
• Monitor for vision changes, weight loss, anorexia, nausea, vomiting, shortness of breath,
chest tightness, fever, and recurrent symptoms that can occur after the first signs of disease. •
Education:
• Careful handling of diapers; handwashing
• Inform of risks of disease and treatments
Cytomegalovirus Infections
Cytomegalovirus (CMV) is a member of the herpes family, which attaches to host cells and
causes disease. CMV is transmitted via close contact with body fluids of an infected person. This
virus may remain in a latent form within the child’s body after the initial infection, and it can
reactivate, particularly with children who have immunodeficiency situations, as occurs in HIV
and organ transplantation. The disease is not highly contagious, and transmission is easily
prevented with good hand washing. Congenital CMV is possible and is usually associated with
congenital defects such as vision or hearing damage. Children ages 1 to 3, teenagers, and
pregnant women may have a high incidence of CMV infection. Young children in day care are a
reservoir for this disease.
Signs and Symptoms
Some babies born with CMV are asymptomatic, while others experience hearing loss, a variety
21
of neurological issues, and even intrauterine growth restriction. Older children may experience
symptoms similar to infectious mononucleosis with fever, headache, rash, abdominal pain, and
even hepatitis. CMV can also cause pneumonia and self-limited GI symptoms. Children with
immune disorders can become seriously ill from CMV, including fever and pneumonia. Retinitis,
or inflammation of the retina, can cause blindness in CMV infection associated with AIDS. CMV
hepatitis may also occur in transplanted livers.
Diagnosis
Urine, saliva, blood, and biopsy samples can be used for virus isolation to make a diagnosis.
CMV pneumonia is suggested by radiograph and lung CT scan.
Prevention
CMV infection is a source of significant morbidity and mortality in immunocompromised
children. Good hand washing is the best preventive measure. Disposable gloves should be worn
when handling linen or underclothes soiled with feces or urine. CMV-negative blood should be
provided to immunocompromised children.
Collaborative Care
NURSING CARE
The most common symptom after resolution of the acute phase of the infection is fatigue, which
may be present for as long as 18 months after the primary infection. Because CMV can be
transmitted by direct contact, nursing care involves contact precautions and careful hand
hygiene. The nurse notes if the patient has any signs of immune deficiency, which could have put
them at risk of developing CMV infection. Inquire about frequent sore throats, respiratory
infections, enlarged lymph nodes, and recurrent fevers, for example. The nurse should evaluate
the patient for potential need for acetaminophen or ibuprofen for symptom control. The nurse
should monitor the patient for vision changes, weight loss, anorexia, nausea, vomiting, shortness
of breath, chest tightness, fever, and recurrent symptoms that can occur after the first signs of
disease.
MEDICAL CARE
Ganciclovir (Cytovene), an antiviral agent, is primarily used in the treatment of life-threatening
CMV in the immunocompromised population with CMV infection. Neutropenia,
thrombocytopenia, and anemia are possible adverse effects of this drug.
Education/Discharge Instructions
The nurse educates the patients and family members about the risks of this disease and of the
treatments. Teach the parent or caregiver to handle diapers or underclothing carefully, with good
hand washing to prevent the spread of CMV. Universal precautions in acute and primary care
settings will help to decrease the risk of spread to other children and women of childbearing age,
where CMV infection can cause serious fetal harm. Pregnant employees in daycare centers and
hospital nurseries should avoid caring for CMV patients. A patient with CMV will require
optometry evaluations of the optic fundus if they have HIV/AIDS.

Signs and symptoms

Of CMV
^^^

Mononucleosis
• Epstein-Barr virus (EBV) is the most common cause
• Incubation period is 30-50 DAYS!!
22
• Isolation precautions: Standard
• Spread through saliva
• Can be transmitted through the saliva for weeks
• Complication:
• Ruptured spleen
• Diagnosis: monospot test, or heterophile antibody test. A blood test confirm the presence of
Epstein-Barr virus
• Nursing Care: rest periods and sufficient fluids during normal daily
routine. • Education:
• Avoid contact sports and roughhousing because of risk of rupture of the spleen. • Use of
acetaminophen should be avoided because of the greater risk of hepatotoxicity when the liver
is enlarged.
• Alcohol should be avoided because of the risk of hepatomegaly.
DISEASE:
Infectious Mononucleosis (Viral)
• Causative Agent—Epstein-Barr virus (EBV)
• Epidemiology—Most persons become infected with EBV sometime during their life (usually
adolescence or young adulthood).
• Peak Incidence—Ages 15–17
• Mode of Transmission—This disease is transmitted via intimate contact with the saliva of an
infected individual, but it is also infectious from blood.
• Infection Control—The incubation period is 30–50 days. Infected persons may shed virus
intermittently and without symptoms throughout life.
• No isolation beyond standard precautions needed.
• There are other diseases, such as CMV, toxoplasmosis, and HIV, that can cause a mono-like
syndrome with similar symptoms.
SIGNS AND SYMPTOMS:
• Signs and symptoms include fever, severe exudative pharyngitis, and prominent cervical and
often occipital lymphadenopathy lasting from 2–3 weeks.
• Fatigue and possible hepatosplenomegaly are also seen.
• A fine maculopapular rash may occur, especially if the patient is given amoxicillin (Amoxil) or
ampicillin (Unasyn).
• In the lab, a positive monospot or heterophile test and atypical lymphocytes on a CBC/
differential are classic.
NURSING CARE:
• Steroids are considered in the case of respiratory difficulty secondary to occlusive pharyngitis
(but must be used cautiously).
• Bedrest and avoidance of strenuous activities, especially contact sports, is required (because of
risk of splenic rupture).
COMPLICATIONS:
• Respiratory compromise is secondary to the airway swelling and exudative pharyngitis, aseptic
meningitis, and encephalitis.
• Rarely, splenic rupture occurs.
• Possible mononucleosis hepatitis.
• Aseptic meningitis or encephalitis occurs.

23
• There is a possible occurrence of thrombocytopenia and agranulocytosis.

Fungal Infection
Candida Albicans
• Yeast in the mouth can overgrow and cause oral thrush in infants.
• Signs and Symptoms: white plaques on the surface of the tongue and the buccal (cheek)
membranes.
• Diagnosis: C albicans is diagnosed via a microscopic examination of the
plaques. • Treatment: Nystatin applied directly to the buccal membranes
• Education:
• Bottle fed - cleaning the bottle nipples in hot water.
• Breastfed – cleaning the nipple and monitoring for infection.
• Administer nystatin after feedings
Candida Albicans (Oral Thrush)
Most infants have natural yeast in their mouths called Candida albicans. Because of the
immature immune system in infants, the yeast in their mouths can overgrow and cause an
infection called oral thrush. This fungal infection is quite common but can be exacerbated by
steroid inhalers or antibiotics. HIV patients are also at greater risk for thrush. Signs and
Symptoms
The main symptom is white plaques on the surface of the tongue and the buccal (cheek)
membranes.
Diagnosis
C albicans is diagnosed via a microscopic examination of the plaques.
Prevention
The nurse educates parents about the prevention of oral thrush. If the infant is bottle-fed, oral
thrush can be prevented by thoroughly cleaning the bottle nipples in hot water. If the infant is
breastfed and the mother’s nipples are sore and reddened, the nurse can encourage the mother to
contact the health-care provider about possible use of an antifungal ointment on the nipples while
the infant is also treated with nystatin (Mycostatin). Pacifiers are thoroughly cleaned in hot water.
Collaborative Care
NURSING CARE
This fungal infection is painful, and the child may not eat well. Maintaining nutrition is a priority
nursing care measure for the child. Small, frequent feedings and soft and bland foods during the
infection for the older child may help ensure good nutrition. A soft toothbrush or gauze pad can
be used to clean the mouth.
In babies with thrush, the baby’s mouth should be rinsed out with water from a medicine cup
after feedings. The baby’s hands should be washed frequently with soap and water. Pacifiers and
teething rings should be boiled for 5 to 7 minutes after each use during the course of infection.
Toys that a child may chew on should be washed in hot, soapy water. Candidal diaper rash may
occur if a baby has thrush because both are candidal overgrowths. If a baby is breast-feeding, the
mother’s nipples will need to be washed carefully, and if there are any cracks in the skin, there is
risk of passing the candidal infection to the mother, especially into the breast ducts. Mothers with
nipple thrush may need to be treated simultaneously with their infected babies. Nurses need to
administer the candidal medication with a dropper for infants and with instructions to swish and
swallow the medications for older children.
MEDICAL CARE
24
Nystatin (Mycostatin) is the medication that effectively treats thrush. It is administered with a
gloved finger using a swab placed on the buccal membranes. The medication must be
administered after feedings so it will remain in contact with the fungi rather than being washed
away immediately during the feeding. Older children may be treated with troches (lozenges that
dissolve by sucking on them), pastilles, or suspensions. Adolescents may be treated with
fluconazole (Diflucan) orally for 7 to 14 days, depending on the severity.
Education/Discharge Instructions
The nurse is aware that candidiasis can be a generalized infection, especially in newborns,
causing a bright red diaper rash. It must be treated immediately to prevent it from becoming
systemic. Parents are taught that changing diapers frequently, exposing the area to air, and
applying nystatin (Mycostatin) ointment is important.

IMMUNIZATIONS
IMMUNIZATIONS
There is a direct correlation between infant immunization rates and the rates of diseases that have
become preventable by immunization. Diseases such as polio and smallpox have been essentially
eradicated in the United States. Although polio immunization is still given, smallpox
immunization is no longer required. In other parts of the developing world, however, some of
these diseases are still present. The cornerstone of infectious disease prevention in pediatrics is
an immunization program in which the child receives the necessary vaccines. Vaccines are
produced by using weakened or killed microbes, inactivated toxins, or subunits of disease causing
microbes. The goal of an immunization program is to bring about active immunity to guard
against the onset of a specific antigen. The immune system response occurs An understanding
about the different types of vaccines can assist the nurse in planning care that
maximizes the effectiveness of immunization and anticipates possible complications that can
occur. Traditional vaccines include inactivated vaccines, live attenuated vaccines (weakened),
and toxoids. Inactivated vaccines are produced when the disease-causing microbe is killed but is
still capable of inducing the human body to produce antibodies (e.g., inactivated poliovirus
vaccine). They are very safe and require little special handling. These types of vaccines stimulate
a relatively weak immune response. For this reason, repeated boosters are required. The live virus
(attenuated) vaccine is made by using a disease-causing organism that is not killed but is grown
under special conditions designed to decrease virulence (e.g., measles vaccine). Vaccines made
with live organisms require special care, such as refrigeration. Live vaccines have the potential
for mutation, allowing the organism to revert to a more virulent form. Because of the increased
risk of mutation, live vaccines are not recommended for children (or adults who have close
proximity to the child) with compromised immune systems.
A toxoid vaccine is used in an inactivated form and is effective in producing an immune response
geared toward a toxin-producing organism. The toxoid has been treated with either heat or a
chemical to weaken its toxic effect but retains its antigenicity (e.g., tetanus toxoid). More recent
vaccine development has produced subunit vaccines, polysaccharide vaccines, conjugate
vaccines, and recombinant vaccines. Subunit vaccines use only a portion of the virus or
bacterium to produce the desired immunological response without the undesirable effects that
occur with some of the other surface antigens (e.g., Bordetella pertussis vaccine included in the
acellular DPT). The subunit vaccine produces immunity to B pertussis with less risk so it may be
more safely given to infants and young children. Some bacteria possess a polysaccharide outer
capsule that protects them from recognition and phagocytosis by the immune system. Organisms
with this coating include Haemophilus influenzae type b (Hib), Streptococcus pneumoniae, and
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Neisseria meningitides, each of which may produce a very serious case of pneumonia or
meningitis in infants or young children.
Polysaccharide vaccines (Pneumovax), made from portions of the polysaccharides making up the
protective capsule of these organisms, have long been available and are effective in producing
immunity in children older than 2 years of age. At exposure, the polysaccharide capsule does not
elicit a T-cell response; the duration of immunity is variable and not lifelong. In addition, these
antigenic components are not recognized by the immune systems of children younger than 2,
who are at highest risk for serious pulmonary or neurological infection resulting from these
bacteria.
The development of conjugate vaccines has provided an option for protecting infants and young
children. The conjugate vaccine links a recognizable antigen with the “hidden” bacterial antigen,
thereby enabling the immature immune system to identify the bacteria as non-self and respond.
In this way, the infant’s T cells may identify the otherwise unrecognizable antigen, providing
both an improved primary response and conferring immunological memory. An example of a
conjugate vaccine used in children younger than 2 years of age is the Hib vaccine. Before the
advent of this vaccination, pediatric meningitis resulting from Hib infection was a common cause
of morbidity in infants.
Production of the recombinant vaccine uses genetic engineering to insert the genes for
production of the antigens desired into a low-virulent vector. The vector then can be used to
easily produce quantities of the antigen for further purification into a subunit vaccine. The only
recombinant vaccine currently used is hepatitis B virus (HBV). The HBV surface antigen is
injected into yeast cells that produce quantities of the antigen for use in vaccination against
hepatitis B.
Nursing Care
Prevention is key to preventing infectious diseases through immunizations. The Advisory
Committee on Immunization Practices develops and revises the immunization guidelines each
year. There are four primary health-care provider immunization schedules:
▪ Ages birth to 6 years
▪ Ages 7 to 18 years
▪ Combined ages birth to 18 years
▪ Catch-up schedule ages 4 months to 18 years
Specific immunization schedules are updated every year and can be found on the CDC website.
The primary nursing goal related to vaccinations for children is to ensure up-to-date
immunizations for all children based on their health status. The pediatric nurse has several roles
in the area of immunization, including addressing family concerns about vaccines. The nurse also
plays a key role in organizing and carrying out vaccination programs and distributing accurate
and timely information regarding childhood immunizations. The nurse reminds parents when the
next immunizations are due. In addition, the nurse must use the current immunization schedule
and recognize that the complicated schedule may pose some challenges for parents. Parents are
bombarded with online information about the types and safety of immunizations. The nurse must
stay abreast of current information and discuss the parents’ concerns, as well as stay actively
involved in statewide reporting of adverse effects of the vaccine.
Over the years, an increasing number of immunizations that have been marketed, especially for
children. Newborn infants now receive a hepatitis B vaccine, and many of the other vaccines are
started at 2 months of age. Many are given in a primary series to develop the child’s immunity in
their early years. Some, but not all, are followed with booster doses later in childhood,
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adolescence, and adulthood. The pediatric nurse is familiar with pediatric immunizations and
each year’s updated immunization schedule. See Table 18-5 for detailed information about
vaccination.
The primary immunizations of childhood are:
▪ Hepatitis A and B
▪ Diphtheria
▪ Tetanus
▪ Pertussis
▪ Measles (rubeola)
▪ Mumps
▪ Rubella (German measles)
▪ Haemophilus influenzae type b I Pneumococcus
▪ Polio
▪ Gardasil or Cervarix (optional)
▪ Meningitis (usually required before college or dormitory
housing)
▪ Influenza (optional)
The nurse is diligent in maintaining current knowledge about the medication’s action and
potential side effects and any contraindications to immunizations. In addition, the nurse is skilled
in the actual administration of the vaccine. Setting up immunization clinics and long-term
tracking of children who have and have not received immunizations is important as well as
accurate documentation and follow-up care.
Types of vaccines?
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Adverse Effects of Immunizations

• Adverse effects from bacterial vaccines typically occur within hours and days of the vaccine
(i.e., PPD)
• Adverse effects from live virus vaccines typically occur 2 to 4 weeks after administration and
may mimic the symptoms of the disease
• Vaccines are no longer given when the risk of side effects is greater than the risk of sequelae
from getting the disease
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Administration of Immunizations
• Review the child’s immunization status at every health encounter
• If the schedule is interrupted, do no repeat earlier doses; continue the schedule according to
previous guidelines
• Administer the greatest possible of number of immunizations at each health encounter
• Have emergency medications and equipment on standby
• Provide vaccine information sheets
• Educate parents to observe for adverse effects, when to notify provider
• Educate parents how to manage typical adverse effects
• Consider
• Dose & timing
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• Route of administration
• Contraindications and precautions
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Immunization Schedule
[Link]

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