NR 602 Grand Rounds W2 Assignment

NR 602 Grand Rounds W2 Assignment

NR 602 Grand Rounds W2 Assignment

Introduction

Every parent worries about their child getting sick. Teaching children proper hand hygiene is vital to the prevention of many illnesses. Hand, foot and mouth (HFM) disease is a common contagious illness caused by viruses in the enterovirus family, most commonly the coxsackievirus. HFMD and herpangina occur worldwide. Outbreaks involving daycare centers, schools, summer camps, hospital wards, military installations, communities, large geographic areas, and entire countries have been reported. HFM is a self-limiting illness that typically resolves in seven to ten days, with individuals being most contagious during the first week (Puenpa, et al., 2014). Human enterovirus infection occurs after oral ingestion of virus that is shed from the gastrointestinal or upper respiratory tract of infected individuals. The infection is spread by direct contact with nasal discharge, saliva, blister fluid or stool.  The individual may be asymptomatic and still be contagious with the virus persisting for several weeks, most commonly in stool. HFM is not the same as foot and mouth disease which is found in cattle and there is no cross species infectious concern. The most common virus is the coxsakievirus A16, however it may be caused by other coxsackieviruses or enterovirus 71 (Stewart, Chu, Introcaso, Schaffer, & James, 2013). Risk factors for contracting the virus include age less than ten years old, high risk exposure location, such as a daycare or preschool, poor hand hygiene and a compromised immune system.

NR 602 Grand Rounds W2 Assignment

Clinical Assessment

HFM typically presents with one to two days of fever, sore throat, …

Nail shedding may occur weeks after the other symptoms have resolved.

Differential Diagnoses

1. Herpes Simplex 1-Nongenital herpes simplex virus type 1 (HSV-1) is a common infection that most often involves the oral mucosa or lips. The primary oral infection may range from asymptomatic to very painful, …. It occurs in children who suck their thumbs (Usatine & Tinitigan, 2010).
2. Varicella-Chickenpox is usually acquired by the inhalation of airborne respiratory droplets from an infected host. After initial inhalation of contaminated respiratory droplets, … diagnostic clue (Papadopoulos, Janniger, & Schwartz, 2017).
3. Aphthous ulcers-Aphthous ulcers can be classified into three different types: minor, major and herpetiform.^1,2Minor aphthae are generally located on labial or buccal mucosa, the soft palate and the floor of the mouth. They can be singular or multiple, and tend to be small. The pathophysiology of aphthous ulcers is poorly understood. Histologically, they contain a mononuclear infiltrate with a fibrin coating. More commonly affect young adults, and a familial tendency may exist. Smoking offers a somewhat protective effect against recurrent aphthae.² Other etiologic factors such as stress, physical or chemical trauma, food sensitivity and infection have been proposed (Akintoye & Greenberg, 2014).

Diagnostic Studies/Labs

HFM is typically diagnosed clinically.  However, cultures for virus isolation can be obtained from oral lesions, cutaneous vesicles, nasopharyngeal swabs, stool or cerebrospinal fluid. Throat swabs and vesicle fluid is the most efficient test if enterovirus 71 is suspected. A CBC is not routinely needed however it may reveal an elevated WBC and atypical lymphocytes (American Academy of Pediatrics, 2013).

 

 

NR 602 Grand Rounds W2 Assignment

Treatment and Prevention

Both the CDC and The American Academy of Pediatrics recommend that treatment options focus primarily on symptom management (American Academy of Pediatrics, 2013) (Centers for Disease Control and Prevention, 2015).

For fevers in a child under age 12: Acetaminophen 15 mg/kg orally every 4-6 hours as needed (max dose of 90 mg/kg/day). Alternatively Ibuprofen 5-10 mg/kg orally every 6-8 hours as needed (max does of 40 mg/kg/day).

Topical anesthetics may also be used. These may include: Lidocaine oropharynegeal viscous solution (2%) applied to the affected areas with a cotton tipped applicator up to three times per day as needed. In addition a solution of diphenhydramine, lidocaine, aluminum magnesium and sulcrafate may be applied to affected areas in the mouth or swished around in the mouths of older children and spit out up to four times per day in place of the lidocaine solution (Roy & Contino, 2015).

Oral hydration is important to maintain as children with painful oral lesions may restrict their oral intake.

Hand washing is essential in the prevention of HFM. It is especially important to practice proper hand hygiene before and after personal care activities. To prevent further spread of the disease, any surfaces contaminated with body fluids should be cleaned with a diluted bleach solution. The infected person should have limited contact with other individuals.

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Education

Hand hygiene is vital to prevent the further spread of the disease. Be sure to wash your hands after contact with the child, including changing diapers.

Limit exposure to other individuals, especially during the first week of the illness.

Certain foods and drinks may cause stinging in the mouth when consumed.  Avoid food and drinks that are hot, spicy, salty or acidic.  Drinks such as milk or ice water tend to be soothing. Suck on ice pops. Avoid sharing of food and drinks.

Rinse the mouth with warm water after meals.

Clean and disinfect any surfaces the child may have had contact with including toys.

Best Outcomes

Best outcomes for the patient are achieved by promoting oral hydration to prevent dehydration which is the most common complication is resulting from HFM (American Academy of Pediatrics, 2013). The child should also be monitored for neck stiffness, lethargy, or severe irritability which may indicate meningitis.

NR 602 Grand Rounds W2 Assignment

Discussion Questions

1. HFM is more common during three seasons. Which three seasons and why is more common during this time of year?
2. When is it “safe” for a child to return to daycare or school?

Bonus Question: How did the coxsackievirus get its name?

Akintoye, S. O., & Greenberg, M. S. (2014, April). Recurrent aphthous stomatitis. Dental Clinics, 58(2), 281-297. doi:http://dx.doi.org/10.1016/j.cden.2013.12.002

American Academy of Pediatrics. (2013, Sept 27). Hand-foot-and-mouth disease (HFMD)/herpangina. Retrieved from American Academy of Pediatrics: https://pediatriccare.solutions.aap.org/content.aspx?resultClick=1&gbosid=189710

Centers for Disease Control and Prevention. (2015, Aug 18). Hand, foot, and mouth disease (HFMD). Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/hand-foot-mouth/about/index.html

Papadopoulos, A. J., Janniger, C. K., & Schwartz, R. A. (2017, April 14). Chickenpox. Retrieved from Medscape: https://emedicine.medscape.com/article/1131785-overview#a1

Puenpa, J., Mauleekoonphairoj, J., Linsuwanon, P., Suwannakam, K., Chieochansin, T., Korkong, S., . . . Poovorawan, Y. (2014, June 2). Prevalence and characterization of enterovirus infections among pediatric patients with hand foot mouth disease, herpangina and influenza like illness in Thailand, 2012. Plos One, 9(6), e98888. doi:https://doi.org/10.1371/journal.pone.0098888

Roy, S., & Contino, K. (2015, Sept 15). Rapidly progressing rash in an adult. American Family Physician, 92(6), 525-526. Retrieved from https://www.aafp.org/afp/2015/0915/p525.html

Stewart, C. L., Chu, E. Y., Introcaso, C. E., Schaffer, A., & James, W. (2013, Dec). Coxsackievirus A6–Induced hand-foot-mouth disease. JAMA Dermatol, 149(12), 1419-1421. doi:10.1001/jamadermatol.2013.6777

Usatine, R. P., & Tinitigan, R. (2010, Nov 1). Nongenital herpes simplex virus. American Family Physician, 82(9), 1075-1082. Retrieved from https://www.aafp.org/afp/2010/1101/p1075.html