TYPHOID IN CHILDREN

DR.M ABBAS. SUBHANI
MBBS DCH

One of the common challenges faced by the physicians (Pediatricians) is to diagnose and treat typhoid especially in children.  It has been observed that the typhoid is usually missed especially in the early stages. Why it is so? What precautions should we take not to miss it? These aspects have been discussed in the following text.

BOOKISH CLINICAL PICTURE IS RARELY OBSERVED
Fever is usually continuous but may be remittent or even intermittent (marked fluctuation).  Relative bradycardia is not usually observed in children.  Rose spots are transient and difficult to be seen in dark skinned children.  Cough is common and chest findings may be detected, misdirecting physician’s attention to respiratory tract.  Rather than constipation, diarrhea is usual presentation in children. Pain abdomen is common, in some patients it may be severe and present as acute abdominal emergency. Headache and vomiting are also common drowsiness    may occur even in absence of encephalopathy. From this discussion it is evident that there is no uniform presentation of typhoid.                  

High index of suspicion is the key to the diagnosis.  

LABORATORY TESTS MAY NOT BE MUCH HELPFUL
Leucopenia is usual but counts may be normal or even raised.  Widal titre may not rise in upto 40% culture  proved typhoid patients. In endemic zones single titre that is less than 1/160 is not conclusive of the diagnosis.   Blood culture may be negative in upto 40% patients. Bone marrow culture is more rewarding but not easily accessible, costly & declined by majority patients. Typhidot test is being widely used. It may be positive in the first week, it is good but not foolproof ( sesitivity is more than 90 % and specificity is around 80 % )  but it is costly.

APPROPRIATE USE OF DRUGS
Ampicillin, Amoxycillin, Cotrimoxazole are relatively safe and effective in the majority of children but resistance is emerging.  If resistance is in consideration, use third generation cefalosporins.  Ceftriaxone is given as injection, it can be given in BD or OD doses.Cefixime (cefspan ) is used orally. Furazolidone may also be used.(It is cheap, used orally, effective also against resistant strains. Furazolidone should be used along with Ampicillin, Amoxycillin, or Cotrimoxazole not alone. The problem is distaste in mouth, it is not be used in G6PD deficient patients.

SOME OF THE PATIENTS ARE INAPPROPRIATELY DIAGNOSED AS RESISTANT TYPHOID CASES BEFORE LABELLING THE PATIENT AS RESISTANT PLEASE MAKE IT SURE

• IT IS TYPHOID, CONFIRM IT AND EXCLUDE OTHER POSSIBILITIES
• THE PRESCRIBED DOSE IS NOT SUBTHERAPEUTIC
• THE PRESCRIBED DOSE HAS BEEN CONSUMED
• THE DRUG HAS BEEN ABSORBED NOT VOMITED
• ADEQUATE TIME HAS LAPSED

DO NOT USE Fluoroquinolones below the age of 12 years. The recent reports suggest that the benefits outweigh the risks.

USE the upper limit of permissible doses.
In some cases a short course of steroid for three days may be given.

RECOVERY IS SLOW
Despite the use of effective drugs and adequate dosage the fever may persist for 4-5 days.  Explain this to attendants at the onset of the treatment.  This increases compliance.

DRUGS NEED TO BE CONTINUED at least for 2 weeks or 10 days after the fever is controlled, preferably for three weeks.

WATCH ON COMPLICATIONS  If encephalopathy, hemorrhage or perforation is suspected refer the patient for hospitalization.

severe abdominal pain, distension, tenderness, rigidity and guarding, signs of shock (cold limbs, sweating, rapid low volume pulse and hypotension), and altered sensorium or observation of purpuric spots or spontaneous bleeding from any site are suggestive of complications.
THESE ARE / MAY BE POTENTIALLY FATAL

DIETARY MODIFICATION AND RESTRICTION IS NOT NEEDED FOR THE MAJORITY OF THE PATIENTS
Fears concerning the use of diet in typhoid are deep rooted. Compliance in this regard may be poor.  Advise the attendants not to stop the diet completely but advise the use of blend diet  in local simple understandable language.

FOLLOW UP THE PATIENT REGULARLY FOR A LONG TIME

PREVENTION – Immunization (both oral and injectable) is effective but does not replace the need of food and water sanitation and personal hygiene. Please see immunization.

Pitfalls are common and may lead to delay in diagnosis, improper diagnosis or treatment. 

Following are the common pitfalls:
Expecting a bookish clinical picture (not considering typhoid in patients presenting with atypical picture). *Too much (undue) reliance on laboratory tests. *Use of inappropriate drugs or sub-therapeutic doses. * Impatience leading to frequent change or early discontinuation of the drugs. *Undue restriction of diet