Running Head: PEDIATRIC PROBLEMS

Pediatric Problems
Tara Phelan
Ocean Lakes High School

PEDIATRIC PROBLEMS

2
Executive Summary

I completed mentorship in August 2014 under the supervision of Dr. Michele

Wadsworth. Dr. Wadsworth is a pediatrician at Premier Pediatrics on First Colonial Road
in Virginia Beach, Virginia. Premier Pediatric is one of seventeen CHKD pediatric
practices in the region. As a pediatrician, Dr. Wadsworth sees patients from infancy up
until age 21. It is her job to prevent, detect, manage, and treat injuries and diseases of all
of her patients. I had the opportunity to follow Dr. Wadsworth to all her patient
appointments during my mentorship experience. For a well child visits, Dr. Wadsworth
measured and evaluated the growth and development of a child through height, weight,
and body mass index curves. During sick child visits, she took the subjective information
given by the patient as well as results of a physical examination and any lab work or xrays completed to create a treatment plan for the illness or infection. I also had the
opportunity to work with the nurses and the front desk during my mentorship.
To become a pediatrician like Dr. Wadsworth, an undergraduate degree is needed
first. Undergraduate programs in pre-medicine are offered at many universities and
colleges and can be completed in conjunction with a major in a specific field such as
biology or chemistry. Next, a medical degree must be achieved through medical school.
The Medical College Admission Test as well as transcripts and letters of recommendation
are needed for acceptance into a four-year med school. After graduating from med school,
a residency must be completed. Residencies are paid hands-on experiences with trained
pediatricians that may take between 3 and 10 years to complete. In addition, the United
States Medical Licensing Examination must be passed in order to practice medicine in
the United States. Dr. Wadsworth received her medical education at Eastern Virginia

PEDIATRIC PROBLEMS
Medical School followed by a residency at the CHKD Hospital. She currently holds
board certification with the American Board of Pediatrics and in Pediatric Emergency
Medicine.
During my mentorship, I observed and learned about my three case studies:
infectious mononucleosis, hand foot mouth, and strep throat. The Epstein Barr virus
causes infectious mononucleosis and patients usually exhibit symptoms of a sore throat,
fatigue and fever. As for hand foot mouth, it is caused by the coxsackievirus and creates
painful red oral and skin lesions. Strep throat is causes by streptococcus bacteria, which
creates swollen tonsils with red bumps within the mouth.

PEDIATRIC PROBLEMS

4
Infectious Mononucleosis

The Epstein Barr virus (EBV), a member of the herpes virus family, is one of the
most common human viruses. Since it is a virus, it can not multiply by itself, but must
infect a host cell in order to reproduce1. The bodys immune system fights off the virus,
explaining why patients with an Epstein Barr virus infection typically do not become
very ill.
The Epstein Barr virus is transmitted from patient to patient through saliva. This
can be in the form of kissing, a cough or sneeze, sharing a cup, or sharing utensils2. The
majority of Americans will be infected with the Epstein Barr virus at some point within
their life. The virus is a life long, latent infection with over 90% of US adults being
infected3. Once a patient has received the Epstein Barr virus, the virus exists in saliva for
6 months and then is sporadically released for rest of life4. It is immunosuppression, or
the inactivation of a specific antibody, that allows for the reactivation of latent EBV
intermittently throughout life. Since seemingly healthy people can spread the disease at
any point within their life, the disease prevention is impractical and almost impossible1.
In addition, no special precautions or isolation procedures are taken for a person with the
Epstein Barr virus since the majority of people already have the virus in their saliva1.
Research shows a link between the Epstein Barr virus and rare cancers like
Burkitt's lymphoma, Hodgkin lymphoma, and nasopharyngeal carcinoma, as well
as multiple sclerosis5. However, in young children, they are less likely to exhibit the
typical complications and symptoms6.
Infectious mononucleosis, simply known as mono, is the leading manifestation of
the Epstein Barr virus. A person may be infected with the Epstein Barr virus, but not

PEDIATRIC PROBLEMS

notice any signs or symptoms of infectious mononucleosis for up to four to six weeks1.
However, when these symptoms begin, the most commonly exhibited symptoms of
patients with mono include fever, rash, fatigue, malaise, sore throat, swollen lymph
nodes, and loss of appetite3. In some cases, the spleen or liver may become enlarged as
well. Splenic enlargement may cause the upper left part of the stomach to experience
discomfort or tenderness4. In severe cases, the spleen may rupture, causing sharp pain in
the upper left abdomen and may require surgery2. Symptoms of mono usually last two to
four weeks, with gradual recovery of energy lasting a few weeks to months4.
Infectious mononucleosis is spread through the transmission of the Epstein Barr
virus. As stated earlier, the virus spreads through saliva. Since kissing is one of the ways
saliva transmits infectious mononucleosis, it is sometimes referred to as the kissing
disease. Other ways the disease can be spread include blood transfusions, organ
transplantations, as well as sexual intercourse3. The incubation period for the disease is
estimated to be approximately 30 to 50 days3. This time period is said to be shorter, 14 to
20 days, if the infection is acquired through transfusion6.
Infectious mononucleosis is most common in teens and young adults in their
twenties. The teenage years are when kissing begins, making the transmission of the
disease through this method very common. In addition, young adults also tend to be the
age group that shares drinks most often. Cups, bottles, and glasses all retain a persons
saliva, and drinking after someone who has the infection can spread it.
Infectious mononucleosis can be diagnosed by a blood test. A blood sample is
drawn from a vein in the patients arm and then tested to detect antibodies of the Epstein
Barr virus, confirming if a patient has mono. There are multiple blood tests that can be

PEDIATRIC PROBLEMS

preformed to test for mono, one of which being the monospot test. Although it has the
capability of detecting the infection, it typically will not be able to diagnose the disease
within the first week of symptoms beginning2. Other blood tests may be used to calculate
the number of white blood cells. While an elevated white blood cell count does not
necessarily imply the patient has mononucleosis, it is a good indicator. It acts as an
indicator because white blood cells are responsible for making antibodies and fighting off
infections1. They are in higher quantity when the body is faced with the task of fighting
off a virus, such as Epstein Barr.
Another test a doctor could choose to use for diagnosing a patient with
mononucleosis is the heterophile antibody test. This test correctly identifies 85% of
infectious mononucleosis in children and adults during the second week of infection3.
Heterophile antibodies are not specific to just patients infected with Epstein Barr, but
when combined with symptoms of mononucleosis, test results are helpful in diagnosing a
patient5. In addition the specific antibodies present within an Epstein Barr infection help
to indicate if there is no infection, an acute infection, a recent infection, or a past
infection3. VCA IgG stands for viral capsid antigen and a positive result indicates a high
likelihood for an Epstein Barr Infection where as a positive VCA IgM result means there
is a high chance the infection is in its early stages5. EA-D stands for D early antigen and
EBNA stands for Epstein Barr nuclear antigen, which plays a role in identifying if it was
a past Epstein Bar virus infection5. EBNA antibodies cultivate six to eight weeks after the
initial infection and exist for life7.
As far as treatment for mononucleosis stands, there is no one specific treatment
since no antiviral drugs or vaccines are available1. Rest and symptomatic treatments are

PEDIATRIC PROBLEMS

the best for getting over a case of mononucleosis. Drinking water and fruit juice, using
over the counter pain relievers, and getting plenty of sleep can help a patient cope with
the symptoms of mono2. Some doctors may also put a patient on corticosteroids for no
more than two weeks to help them get over the infection.
In some cases, other infections can be present in combination with the Epstein
Barr infection. The most common include a streptococcal infection, more commonly
known as strep throat, a sinus infection, or tonsillitis2. In these circumstances, antibiotics
can be given to treat these accompanying infections. Ampicillin and amoxicillin should
not be prescribed however, as they cause nonallergic morbilliform rashes in a high
percentage of patients with an active Epstein Barr infection3. The reaction is caused by a
hypersensitivity to the antibiotic in the presence of an Epstein Barr infection, although the
exact interaction between the antibiotic and virus is not fully understood.
Symptoms of mononucleosis should improve within two to four weeks, with
some lasting up to a possible four months. If symptoms persist for over six months, the
Epstein Barr infection causing the infectious mononucleosis is said to be chronic1. A
chronic infection, however, is quite rare. Infectious mononucleosis has a few possible
complications. These include a ruptured spleen, trouble breathing caused by a swollen
throat and, rarely, jaundice, skin rashes, pancreatitis, seizures, and encephalitis5.
While suffering from infectious mononucleosis, contact sports should not be
played within the 3 weeks following the onset of the symptoms3. This is due to splenic
fragility and a possibility for splenic rupture. After three weeks, the patient should return
to see the doctor. If the patient's symptoms have improved and the presence of
splenomegaly, an enlarged spleen, has decreased the patient can return to sports.

PEDIATRIC PROBLEMS

Determining the presence of splenomegaly can be done by the doctor applying pressure
to the abdomen area or by imaging modalities such as ultrasonography or computerized
tomography3.
During my mentorship experience at Premier Pediatrics, I got to see a patient with
Dr. Wadsworth who was infected with mononucleosis. Patient A was a 16 year old
Caucasian female. She was in the office to get the results from her lab work, which
included a heterophile antibody test. Two weeks prior, the patient had seen another doctor
within the practice. At that time she was extremely sleepy, had a low grade fever, and a
red, swollen throat. The patient had also been experiencing intense stomach pain, causing
her to double over for the previous week or two. The doctor at the time had felt her
stomach and could tell her spleen was enlarged. The doctor instructed the patient to stop
playing field hockey and not to participate in any other forms of physical activity for the
time being. The doctor also sent the patient to get blood work done to confirm the
diagnosis of infectious mononucleosis. The patient stated that she had a friend on her
field hockey team who had been diagnosed with mono about a month prior. She couldnt
remember an exact instance that she shared her teammates water bottle, but she thinks
that is likely where she acquired the infection.
When the patient saw Dr. Wadsworth, she explained that she felt like she had
more energy and was getting back to a more regular sleep pattern. Her mother said that
she could see an improvement in the patients daily energy level. The patient now had no
fever and the redness in her throat had decreased. The patient also said her stomach pain
had subsided and was not causing her problems anymore. Dr. Wadsworth then examined
the patients abdomen. She pressed against the upper left abdomen, where the spleen is

PEDIATRIC PROBLEMS

located, to see if the splenomegaly was still present. Dr. Wadsworth stated that she could
not feel any signs that the spleen was still enlarged. In addition, Dr. Wadsworth discussed
the patients test results. The patient was negative for the antibodies of a Epstein Barr
infection VCA IgG, VCA IgM, and EA(D). She was positive for EBNA. Dr. Wadsworth
was unclear as to why the VCA IgG came back negative because it was clear the patient
was infected with mononucleosis. Dr. Wadsworth did keep in mind that false negative
results occur in 10-15% of patients. With that, the results then indicated that the patient
either had a recent or past infection.
After going over the patients current symptoms and test results, Dr. Wadsworth
felt confident in clearing the patient to return to sports. The symptoms had begun three to
four weeks prior and spleen enlargement had greatly decreased. Dr. Wadsworth did
caution the patient to stop activity if symptoms were to reappear when she began physical
activity again.
Overall, patient A exhibited the classic case of mononucleosis. Her spleen
enlargement, throat pain, fever, and fatigue are all common symptoms of patients with
mononucleosis. Standard procedure was taken to have her stop physical activity and take
time to rest. When her symptoms improved she was finally cleared to resume regular
activity and monitor her symptoms.
Like other patients with a history of infectious mononucleosis, Patient A will have
the Epstein Barr infection living in her body for life, normally in a dormant state.
Periodically, the virus may become active again, but it is highly unlikely the symptoms of
mono will reoccur and the patient will become ill again. If symptoms do occur, it is likely
that the cause of another medical condition and the patient should see a doctor to

PEDIATRIC PROBLEMS
determine the specific cause of the symptoms. Typically, only people with weakened
immune systems will experience the symptoms of infectious mononucleosis caused by
the Epstein Barr virus again.

10

PEDIATRIC PROBLEMS

11
References

1. The Patient Education Institute [Internet]. Coralville (IA): The Patient Education
Institue, Inc; c 1995-2010. Epstein-barr virus/mono: reference summary; 2010 Dec 19
[cited 2014 Oct 5]; [about 4 pages]. Available from:
http://www.nlm.nih.gov/medlineplus/tutorials/epsteinbarrvirusmono/id 299104.pdf
2. Mayo Clinic Staff [Internet]. Rochester (MN): Mayo Foundation for Medical
Education and Research; c 1998-2015. Diseases and conditions: mononucleosis; 2012
[cited 2014 Oct 5]; [about 5 screens]. Available from:
http://www.mayoclinic.org/diseases-conditions/mononucleosis/basics/definition/CON20021164?p=1
3. American Academy of Pediatrics. Red book: 2012 report of the committee on
infectious diseases. Elk Grove Village (IL): American Academy of Pediatrics; 2012.
4. Kliegman, R. M., Stanton, B. M. D., St. Geme, J., Schor, N. F., & Behrman, R.E.
Nelson textbook of pediatrics 19th edition. Philadelphia (PA): El Sevier; 2011.
5.American Association for Clinical Chemistry [Internet]. Washington (DC): American
Association for Clinical Chemistry; c 2001-2015. Epstein-barr virus antibodies; 2013
[cited 2014 Oct 5]; [about 3 screens]. Available from:
http://labtestsonline.org/understanding/analytes/ebv/tab/test
6. Zitelli, B.J., & Davis, H.W. Atlas of pediatric physical diagnosis. St. Louis: Mosby;
2002.
7.Cafasso, Jacquelyn [Internet]. San Francisco (CA): Healthline Networks, Inc.; c 20052014. Epstein-barr virus (ebv) test; 2012. [cited 2014 Oct 5]; [about 7 screens]. Available
from:

PEDIATRIC PROBLEMS
http://www.healthline.com/health/epstein-barr-virus-test#Overview1

12

PEDIATRIC PROBLEMS

13
Hand Foot Mouth

The coxsackievirus is a member of the enterovirus family that lives within the
human digestive tract1. Coxsackie viruses are viruses within the RNA, or one stranded
ribonucleic acid, of the body. The coxsackievirus can cause a multitude of different
infections. Hand foot mouth is an infection where red blisters occur in within the mouth,
on the soles of the feet, and on the hands. Coxsackievirus can also cause herpangina, an
infection with the presence of blisters and ulcers on the tonsils and back part of the roof
of the mouth. Another coxsackievirus A24 infection includes hemorrhagic conjunctivitis,
which includes eye discomfort, light sensitivity, and blurred vision1. More serious
infections the coxsackievirus can cause include viral meningitis, an infection of the
membranes surrounding the brain and spinal cord, encephalitis, a brain infection, and
myocarditis, a heart muscle infection1. These infections may require hospitalization
depending on the severity of the patients case.
Coxsackie viruses are also very contagious and can be spread through unwashed
hands, contaminated feces, sneezing, or coughing. In addition, people who are infected
with the virus are most contagious within the first week the infection begins. There is
currently no vaccine to prevent the coxsackievirus. The one thing that can be done to
prevent an infection is to frequently wash hands thoroughly with soap and water. Also,
eating foods containing probiotics can help support a healthy immune system.
In addition, the coxsackievirus is most common in children ages 5 and under.
Children are more likely to contract coxsackievirus because they have not yet built up
immunity to the virus. Childcare centers and schools therefore are huge places for the
infection to be transmitted. It is recommended that toys be cleaned frequently because the

PEDIATRIC PROBLEMS

14

virus can live on an object for days. Also, if a child has been diagnosed with a
coxsackievirus infection, they should be kept out of school or day care in order to avoid
spreading the infection. If a child has a simple coxsackievirus infection they can recover
within a few days without needing treatments. They should drink plenty of fluids, rest,
and relax and should be feeling better within a few days. However if symptoms such as
fever, poor appetite, vomiting, diarrhea, difficulty breathing, sores on the skin, severe
sore throat, severe headache, or other alarming symptoms arise, the patient should seek
medical attention1. In these cases, medicines can be prescribed by a doctor for
symptomatic treatment, however a medicine does not exist to treat the coxsackievirus.
One of the most common diseases the coxsackievirus can cause is hand foot
mouth. Its leading cause is the coxsackievirus strain A162. A few other strands can cause
hand foot mouth, such as coxsackievirus A6 and enterovirus 71, but coxsackievirus A16
causes the majority of the cases. Symptoms may include a fever, malaise, sore throat,
oral lesions, and skin lesions. The lesions are typically mildly painful and appear as
yellow ulcers surrounded by red halos2. The lesions are more likely found on the hands
than on the feet. Lesions on the hands and feet are usually tender and range from 3 to 7
mm in diameter2. They frequently occur on the palms of the hands and soles of the feet.
90% of patients also experience lesions in the mouth3. When just oral lesions are present,
it initially looks similar to herpes gingivostomatitis. Coxsackievirus oral lesions are much
less painful than herpes lesions however. The lesions in the mouth make it very
uncomfortable for the patient to eat or drink. It is therefore very important to drink lots of
fluids, as it is easy to become dehydrated. The buttock may also have lesions, but this is

PEDIATRIC PROBLEMS

15

less common. It is also likely that a skin rash will appear with hand foot mouth. This rash
will develop over the first day or two.
Hand foot mouth is very contagious and has an incubation period of
approximately 2-6 days3. Symptoms typically last for 2 days to 1 week for a patient, a
time frame similar to that of the incubation period. Hand foot mouth can occur at any
time throughout the year, but is more common in the summer through the early fall3. This
is typical, as summer is the main time for fever and rash illnesses, while winter is more
likely to have common cold like illnesses. In tropical environments, it is more likely for
hand foot mouth to be prevalent at all times during the calendar year.
The hand foot mouth infection is also more common in small children than adults.
Kids tend to have weaker immune systems than adults and are therefore more susceptible
to diseases. In addition, the disease easily spreads between children as they touch infected
toys and dont cover their mouth or nose when sneezing or coughing. In adults who get
the virus for hand foot mouth, they may show no signs or symptoms of the disease but
will still be contagious4. In this way, parents may transmit the infection to their children
without knowing.
Hand foot mouth is also worse in patients with pre-existing skin conditions such
as eczema2. Eczema, also known as atopic dermatitis, is a medical condition in which a
patient experiences an intense skin itch and a rash develops. Typically the skin is
reddened and becomes scaly. Continued scratching of the itch leads to oozing. Eventually,
a thick layer of reddened skin covers the oozing and the itching begins again. This is
sometimes referred to as the itch-ooze cycle. The onset of hand foot mouth may be
confused with a flare up of eczema. The oozing from scratching the epidermis, or outer

PEDIATRIC PROBLEMS

16

layer of the skin, may resemble the liquid that comes out of the blisters common with
hand foot mouth. The ooze of hand foot mouth however is contagious and if touched by
other people can spread the disease. The ooze of eczema poses no harm to the touch of
other people. In addition, eczema is more common in infancy and many people grow out
of it during their youth years and into adulthood. Since it is more common at younger
ages, it plays a large impact on hand foot mouth patients who also tend to be of the
younger age bracket.
Complications of hand foot mouth that may arise include dehydration and
secondary infection5. Dehydration is typical as the sores in the mouth and throat may
make swallowing difficult. Drinking plenty of fluids can help prevent this. In addition,
there is a risk that the blisters and sores on the skin could become infected. If pain,
redness or swelling accompany large discharges of pus from the skin it is likely an
infection is present and medical attention should be obtained5. Antibiotic creams or
tablets can be prescribed to heal any skin infection. Another possible complication that
has been reported is the loss of a fingernail or toenail. Within four weeks of having hand
foot mouth, nail loss may occur, but no medical treatment is needed to induce the nail to
grow back4. Medical researchers are still investigating the cause of nail loss.
More serious and rare complications include viral meningitis and encephalitis5.
Viral meningitis is less severe than bacterial meningitis and does not pose a serious health
threat. Symptoms of viral meningitis include high temperature, drowsiness, headache,
stiffness in the neck, and light sensitivity5. There is no treatment for viral meningitis other
than symptomatic relief with painkillers. Recovery typically lasts two weeks.
Encephalitis, infection to brain tissue, is the most serious complication. It is only possible

PEDIATRIC PROBLEMS

17

however, when the virus is caused by the enterovirus 71. Symptoms are similar to that of
the flu and may also include lethargy, jerking, weakness or paralysis of the limbs, or
sensitivity to light5. Hospitalization is needed to treat encephalitis. Thus far, cases of hand
foot mouth that have developed into encephalitis have only occurred in countries located
in Southeast Asia such as China and Taiwan.
Hand foot mouth occurs all over the world. In countries with temperate climates
the majority of the cases are seen in the spring until fall. The first case of hand foot mouth
was reported in New Zealand in 1957. Since 1997, large outbreaks of hand foot mouth
have been reported in countries in Southeast Asia such as Taiwan in 1998 and China in
20106. The outbreaks were primarily caused by the enterovirus 71 and affected mostly
children4. The effect on children is a common trait of hand foot mouth since kids lack
immunity to the virus.
Since the end of 2011, there have been an increasing number of hand foot mouth
cases in the United States. Over this past summer of 2014, there was an increase in the
number of reported cases in multiple states. Emergency rooms in Richmond, Virginia saw
up to 5 cases a night of the disease. Pittsburgh, Pennsylvania and states in the Midwest
also reported a spike in the number of patients with hand foot mouth disease.
During my mentorship at Premier Pediatrics, I got to see a pretty severe case of
hand foot mouth. This was during the summer of 2014 when cases of the infection were
common. Patient B was a 3-year-old caucasian female. Her mother had brought her into
the office after having red blisters on her hands and feet for the past two days. The
mother originally thought a burn from touching a hot pan had caused the initial blister.
The mother had not watched her daughter touch the pan, but thought it could have

PEDIATRIC PROBLEMS

18

occurred in the kitchen while her back was turned. The one blister then multiplied and
turned into a multitude of blisters. They continually worsened, causing discomfort to the
patient. The mother also thought it could have been a flare up of the patients eczema, as
the patient had suffered with severe eczema since infancy. The mother applied the
creams for eczema, but they were not helpful in improving the blisters or pain. The
mother found that putting socks on the patients hands and feet helped to calm the
itchiness and burning sensations. The socks however, limited the patients mobility. The
blisters also hurt when water touched them, so the patient hadnt bathed in a day. In
addition, the mother reported that the patient did not desire to eat or drink anything since
the blisters appeared.
When Dr. Wadsworth examined the patient, she saw the red blisters on the hands
and feet. The patient was also covered with red spots on the stomach, cheeks, and legs. In
addition, the patient also had a severe diaper rash. Dr. Wadsworth diagnosed the patient
with hand foot mouth based on the red halos she observed around the yellow blisters. The
halo is a defining characteristic of hand foot mouth. Dr. Wadsworth also stated that since
the patient has eczema, it explains the severity of her hand foot mouth infection. As
treatment, Dr. Wadsworth prescribed Augmentin, an antibiotic, to get rid of the bacterial
infection of the diaper rash. The blisters would likely clear up within a few days as the
virus ran its course. Since hand foot mouth is very contagious, Dr. Wadsworth also
cautioned the mother to make sure her other children did not share drinks with the
infected patient or touch any ooze that seeps from the blisters. The mother was instructed
to wash the patients bed sheets to get rid of any fluid that had drained from the patients
blisters. Also, careful washing of the patients toys was highly advised. If the other

PEDIATRIC PROBLEMS

19

children in the family were to exhibit similar symptoms to Patient B, they were to come
back into the office. Since Patient B was only 3 years old and did not attend a daycare,
no restrictions were needed on that.
The particular case of hand foot mouth patient B exhibited was one of the worst
the nurses and Dr. Wadsworth had seen before. It therefore was an instructive example to
witness. The clear halo around the blister was blatantly clear to even my untrained eye, as
in a less severe case it may have been more difficult to identify.
Hand foot mouth is also an interesting topic as the increase of outbreaks in recent
years, may lead to an investigation into a new vaccine to fight against the virus. Vaccines
can work to fight off both viruses and bacteria, so the creation of a new vaccine is a
possibility. It will be interesting to track this in the future.

PEDIATRIC PROBLEMS

20
References

1.Green, N. A. Kids Health [Internet]. Nemours Foundation; c1995-2014. Infections:

coxsackievirus infections; 2014 [cited 2014 Nov 6]; [about 5p.]. Available from:
http://kidshealth.org/parent/infections/bacterial_viral/coxsackie.html#
2.Kliegman, R. M., Stanton, B. M. D., St. Geme, J., Schor, N. F., & Behrman, R.E.Nelson
textbook of pediatrics. 19th ed. Philadelphia, PA: El Sevier; 2011
3.Zitelli, B. J., & Davis, H. W. Atlas of pediatric physical diagnosis. 14th ed.
Philadelphia, PA: Mosby, Inc; 2002.
4.Centers for Disease Control and Protection. Hand, foot, and mouth disease(HFMD).
[report on the internet]. Atlanta (GA): CDC; 2013 [cited 2014 Nov 6]. Available from:
http://www.cdc.gov/hand-foot-mouth/
5. NHS Wales [Internet]. National Health Service Wales. Hand, foot and mouth disease;
2014 [cited 2015 Jan 2]; [about 10 screens]. Available from:
http://www.nhsdirect.wales.nhs.uk/encyclopaedia/h/article/hand,footandmouthdisease/#to
p
6. Emerging Disease Surveillance and Response. Hand, foot and mouth disease
information sheet.[report on the internet]. Western Pacific Regional Office: World Health
Organization; 2012 [cited 2014 Nov 6]. Available from:
http://www.wpro.who.int/emerging_diseases/hfmd.information.sheet/en/

PEDIATRIC PROBLEMS

21
Strep Throat

The streptococcus bacterium causes streptococcal infections. Streptococci are

then broken up into alpha-hemolytic and beta-hemolytic. Alpha-hemolytic bacteria cause
an incomplete lysis of red blood cells and therefore form a greenish zone of discoloration
around the colony in a blood agar plate. A blood agar plate is a growth medium
containing mammalian blood used to diagnose infection based on hemolytic activity.
Beta-hemolytic bacteria cause complete lysis of red blood cells and therefore form a clear
zone around the colony1.
Alpha-hemolytic streptococci include Streptococcus pneumonia and Viridans
Streptococci. Streptococcus pneumonia can cause illnesses such as pneumonia, ear
infections, sinus infections, meningitis, and bacteremia. The bacterium spreads through
coughing, sneezing, and direct contact with someone infected. Symptoms depend on the
exact infection but may include fever, cough, chest pain, confusion, sensitivity to light,
pain, chills, sleeplessness, and irritability2. Severe cases may lead to hearing loss, brain
damage, or death. The bacteria are more common in developing countries as well as in
the winter and early spring. In addition, individuals over the age or 65 or under 2 years
old are at a higher risk to contract the bacteria. Those with weak immune systems, those
who smoke, or those with asthma are also more likely to get the disease. In order to
prevent from pneumococcal disease, the 23-valent pneumococcal polysaccharide vaccine
(PPSV23) for adults or the 13-valent pneumococcal conjugate vaccine (PCV13) for
children up to age 19 can be administered2.
The other alpha-hemolytic streptococcus is Viridans Streptococci. These bacteria
are found in the oral cavity, upper airway, and gastrointestinal and genitourinary tracts.

PEDIATRIC PROBLEMS

22

Although the Viridans Streptococci bacterium doesnt usually produce disease, if it gets
in the bloodstream it can cause dental caries, infective endocarditis, and other disorders in
immunosuppressed individuals3. Penicillin is typically used as the antibiotic to treat
endocarditis due to Viridans Streptococci.
The beta-hemolytic bacteria is broken up into Group A and Group B Streptococci.
Group A strep is commonly found on the surface of the skin and inside the throat4.
Usually, it causes infection in adults and children. Group B strep typically causes no
harm, living naturally in the digestive system and a womans vagina4. It only infects
newborn babies and usually creates a serious infection.
Group A strep can cause both mild infections and more serious infections. Mild
infections do not pose a serious threat to a persons health. Strep throat, impetigo,
cellulitis, a middle ear infection, and sinusitis are all examples of mild group A strep
infections4. More serious infections are called invasive, as they penetrate deeper into the
bodys organs and tissues posing a greater threat to a persons health. Examples of
invasive infections include pneumonia, necrotizing fasciitis, or streptococcal toxic shock
syndrome. About 9,000-11,500 cases of invasive group A strep occur in the United States
each year, of which 1,000-1,800 result in deaths annually5.
Group A Streptococcus is spread through direct contact with mucus or saliva of an
infected individual. A person is considered contagious until they have been on antibiotics
for 24 hours. However, finishing the complete course of antibiotics is very important, so
that complications such as rheumatic fever do not arise. It is also possible for a person to
be contagious but exhibit no signs or symptoms of Group A Strep infection.

PEDIATRIC PROBLEMS

23

Diagnosis for Strep A can be done be taking a swab of the affected tissue or saliva
and testing it for bacteria. A blood test could also be done to test for the production of
certain antibodies to fight off a Strep A infection. Minor Strep A infections are very
common, but more so in those with weakened immune systems. Minor Strep A infections
will need little treatment. Anti-inflammatory drugs such as ibuprofen can help reduce
fever or pain and antibiotics can be prescribed in some cases. For more serious cases,
treatment will include 7-10 days of antibiotics such as penicillin and clindamycin and
admission to the hospital (pneumonia does not always require a hospital stay)5. Blood
transfusions may be needed to neutralize toxins or surgery may be needed to repair
damaged tissue. These invasive Strep A infections may result in death.
As for Strep B infections, people develop immunity at a young age. Infections are
therefore usually only in newborn babies because they have yet to develop their
immunity to Step B. Step B infections are sometimes caused by a pregnant mother having
Strep B bacteria in her vagina. The bacteria can infect the baby through amniotic fluid.
Infected amniotic fluid is said to affect 1 in every 2,000 births4.
Symptoms of a Strep B usually begin within the first 12 hours of birth and include
poor feeding, grunting while breathing, irritability, unusually high or low temperature,
and unusually fast or slow breathing or heart rate4. When Strep B symptoms begin a few
months after birth, it is known as late-onset group B strep infection. There is no known
reason as to the delay of symptoms but known risk factors include premature birth, being
born a multiple (twins, triplets, etc.) or having a mother with history of Strep B infection.
Treatment for strep B infections is done on a preventative approach. Since
newborns have weak immune systems, bacteria can spread rapidly through their body.

PEDIATRIC PROBLEMS

24

Therefore, healthcare professionals try to identify high-risk babies and give antibiotic
injections to the mother during labor. Antibiotics can also be given intravenously to the
baby just after birth. Certain factors that may play a role in the need for antibiotic
injections include if the mother has already had a child with a strep B infection, strep B is
found in the mothers urine tests, strep B is found on vaginal or rectal swabs, the mother
has a high temperature during labor, or labor is premature4. In these cases, antibiotics are
given to the mother prior to delivery or to the baby right after birth.
A group B strep infection in adults causes bloodstream infections, skin and soft
tissue infections, or bone and joint infections6. The cause of infection in adults is
unknown. Blood or spinal fluid samples can be used to diagnose group B Strep
infections. It can be treated with penicillin or other antibiotics and may need surgery to
repair soft tissue or bone infections. The average age of non-pregnant adults with cases of
group B strep is 60 years old6. In addition the rate of serious infection increases with age.
During my mentorship, I saw 4 cases of group A Strep infections, all of which
were patients with strep throat. Strep throat symptoms include throat pain, difficulty
swallowing, red and swollen tonsils, white patches or streaks of pus, tiny red spots on the
soft or hard plate of the mouth, swollen lymph glands in the neck, fever, headache, rash,
and stomachache7. Strep is also most common in children ages 5 to 15 as well as during
the late fall or early spring.
Testing for strep can be done with a rapid strep test, also know as rapid antigen
detection test. A rapid strep test uses a cotton swab to get a sample of the fluids in the
back of the throat done to see if group A Strep bacteria is present8. The test gives results
in a matter of minutes; however, it is not always accurate. A rapid strep test may come

PEDIATRIC PROBLEMS

25

back negative even if the patient does have strep. For that reason, a throat culture is also
preformed. With the swab that is done for the rapid strep throat, the sample is put onto a
culture plate that allows bacteria to grow in the lab. Chemical tests are done to determine
the specific infection. If no bacteria is grows, then the test is negative and the patient does
not have strep throat.
If a person is diagnosed with strep throat, they are prescribed antibiotics to take
for 10 days. Penicillin and Amoxicillin are the two most commonly prescribed for
treatment8. Within 48 hours of beginning the antibiotic, the patient should begin to feel
better. They are also no longer contagious after 24 hours of being on the medicine.
Drinking liquids, gargling salt water, and cool-mist vaporizers or humidifiers may also
help reduce the pain and discomfort of a sore throat. Also, staying home from work,
school, or day care is crucial to not spreading the disease. After 24 hours of antibiotics, a
person can then resume normal activity. In addition, replacement of an individuals tooth
brush after no longer being contagious is important so that they do not get the infection
again after the antibiotics are completed.
Untreated strep throat may cause complications. Rheumatic fever, an
inflammatory disease that may affect the heart, joints, skin, or brain, could develop 14-28
days after strep throat if no treatment is received8. Treatment of strep with antibiotics
makes it so rheumatic fever does not occur. Another possible, yet rare, complication is
post-streptococcal glomerulonephritis. It develops 1-2 weeks after an untreated strep
infection and causes the blood vessels in the filtering units of the kidneys to become
inflamed and less able to filter urine8.

PEDIATRIC PROBLEMS

26

During my mentorship experience at Premier Pediatrics, I first saw a 3-year-old

female with strep throat. She came in with her mom who had just been diagnosed with
strep throat the day prior. The patient was also complaining of a sore throat and said she
felt very tired. Her mom stated that the patient had a very low appetite and had a fever
that started during the middle of the night. Dr. Wadsworth then examined the patients
throat. The back of the patients throat was red and had bumps. Dr. Wadsworth then
allowed me to look at the throat before conducting a swab for the rapid strep test. The
sample was tested and came back positive. Dr. Wadsworth then explained the antibiotic to
the patient and her mother. The mother, however, asked if there was an alternative
treatment method because the patient hated the taste of the amoxicillin. The mother was
concerned the patient would refuse to take the antibiotic as needed. Dr. Wadsworth
suggested a bicillin shot. The shot is injected into a large muscle, in this case the thigh,
and it is a long acting penicillin antibiotic. Over the course of a few days, the drug would
slowly be released from the injection site. It is more painful than most shots, explaining
why it is not the first treatment option offered although it is just as effective. The patient
chose the bicillin shot as treatment and received 600,000 units, which was determined
based on her weight.
The following day, the little girls three brothers came into the office all
experiencing similar symptoms. The youngest brother had a very red throat covered in
bumps and was said to be sharing drinks with his sister, likely where he got the infection.
His rapid strep test came back positive. The middle-aged brother had some redness in the
back of his throat, but his strep test came back negative. Dr. Wadsworth was surprised,
but said it was likely the Polymerase Chain Reaction (PCR) culture would come back

PEDIATRIC PROBLEMS

27

positive from the lab. The following day Dr. Wadsworth informed me that the PCR did
indeed come back positive. She also said the rapid strep test will come back negative and
the PCR will come back positive 10% of the time. Finally the oldest brother had slightly
enlarged tonsils, but no redness or pain in his throat. His rapid strep test came back
positive. All three boys were prescribed a 10-day course of amoxicillin to treat their cases
of strep throat. Dr. Wadsworth also recommended getting new toothbrushes for all the
children to prevent getting the infection again after the antibiotics were complete.
The example of strep throat I saw during my mentorship clearly demonstrates the
contagious nature of the streptococcal bacteria. It also reveals the ease and importance of
treating the infection immediately in order to reduce the risk of other complications that
could arise if the infection goes untreated.

PEDIATRIC PROBLEMS

28
References

1.Buxton, Rebecca. American Society for Microbiology [Internet]. Salt Lake City (UT):
American Society for Microbiology; c2014. Blood Agar Plates and Hemolysis Protocols;
2005 [modified 2013 July 22; cited 2014 Nov 30]; [about 19 paragraphs]. Available from:
http://www.microbelibrary.org/component/resource/laboratory-test/2885-blood-agarplates-and-hemolysis-protocols
2. Centers for Disease Control and Prevention [Internet]. Atlanta (GA): Centers for
Disease Control and Prevention; c2014. Pneumococcal Disease; 2013 May 8 [modified
2014 Aug 5; cited 2014 Nov 30]; [about 2 screens]. Available from
http://wwwnc.cdc.gov/travel/diseases/pneumococcal-disease-streptococcus-pneumoniae
3.Han X, Kamana M, Rolston, K. Viridans Streptococci Isolated by Culture from Blood
of Cancer Patients: Clinical and Microbiological Analysis of 50 Cases. Journal of Clinical
Microbiology. 2006;44:160-165.
4. NHS [Internet]. United Kingdom; NHS Choices; c2013. Streptococcal Infections; 2013
March 21 [cited 2014 Nov 30]; [about 31 paragraphs]. Available from:
http://www.nhs.uk/conditions/streptococcal-infections/pages/introduction.aspx
5.New York State Department of Health. New York State [Internet]. (NY): New York
State; c2014. Streptococcal Infections (invasive group A strep, GAS); 2011 Nov [cited
2014 Nov 30]; [about 10 paragraphs]. Available from:
https://www.health.ny.gov/diseasesfga/communicable/streptococcal/group_a/fact_sheet.ht
m

PEDIATRIC PROBLEMS

29

6.Centers for Disease Control and Prevention [Internet]. Atlanta (GA): Centers for
Disease Control and Prevention; c2014. Group B Strep Infection in Adults; 2014 June 1
[cited 2014 Nov 30]. Available from: http://www.cdc.gov/groupbstrep/about/adults.html
7. National Institute of Allergy and Infectious Diseases [Internet]. Atlanta (GA): US
Centers for Disease Control and Prevention; c2014. Strep Throat; 2014 Sep 24 [cited
2014 Nov 30]; [about 9 paragraphs]. Available from:
http://www.niaid.nih.gov/topics/strepThroat/Pages/default.aspx
8. Medline Plus [Internet]. Bethesda (MD); U.S. National Library of Medicine; c2014.
Strep throat; 2014 Nov 7 [cited 2014 Nov 30]; [about 24 paragraphs]. Available from:
http://www.nlm.nih.gov/medlineplus/ency/article/000639.htm

PEDIATRIC PROBLEMS

30
Reflection

My mentorship experience at Premier Pediatrics was a huge learning experience. I

thoroughly enjoyed my experience at my mentorship site and learning about the field of
pediatrics. A few considerations about my mentorship experience include the limited
number of patients I was able to see since the office was just opening and there was not a
huge patient clientele built up yet. I was also not able to see patients similar to my age or
that I previously knew. The other drawback of my experience was that it did not involve
hands on activity. Without a medical degree, I was limited to the amount of things I was
able to complete myself. However I was able to learn a ton from watching and observing.
Overall, I absolutely loved my mentorship experience. The entire staff at Premier was
extremely welcoming and kind, making my experience really enjoyable. Dr. Wadsworth
was extremely knowledgeable and able to answer any and all questions I had about
patients we had seen throughout the day. She also allowed me the opportunity to get a
feeling for all the aspects of the office including nursing, the front desk, and billing. This
was one of my favorite parts about my experience because it allowed me to see different
career possibilities within the pediatric field. The office was also brand new, so I got to
see all the planning and details that go into opening a new business and running a
practice. Another positive of the office being new was that two of the nurses were brand
new as well, so as they were being trained and taught, I could listen in. This was
extremely interesting because everything was explained in detail to them from vaccines
to the computer system to different tasks the doctors could ask them to do such as an ear
flush or setting up a nebulizer treatment. I also loved my experience because I got to see
kids everyday. The kids all have such fun personalities and make the office a happier

PEDIATRIC PROBLEMS

31

place. My experience really assured me that I would love to enter the field of pediatrics
and have the ability to work with kids.
My mentorship had a huge impact on my future. I began my mentorship thinking
that I wanted to be a doctor. I knew that I loved working with kids, so I though pediatrics
would be perfect for me. After my mentorship experience, I realized that only half of my
initial thoughts were true. I absolutely love pediatrics because I find working with kids to
be so enjoyable. I love their unique personalities and watching them grow and develop.
However, I realized that I no longer want to become a pediatrician, but would prefer a job
as a nurse. Some of my favorite times spent at Premier were working with the nurses. I
loved the personal interactions the nurses had with the patients. I also was extremely
intrigued by vaccines, which is a huge part of the nurses job. Finally, I could see myself
enjoying charting the information the nurse gathers (height, weight, vision, etc.) more
than the information of the doctor (diagnosis, treatment, etc.). Overall, my mentorship
experience was an amazing learning experience and opened my eyes to my dream career
as a pediatric nurse.
My mentorship was definitely a highlight of my academy experience. Despite the
extensive time and effort that went into the project, I really enjoyed it. I loved my
mentorship experience, and it certainly expanded my horizons. I am extremely lucky to
have experience in a job field that I intend to enter. This is something not many students
have the opportunity to do and I think it is tremendously helpful in assuring the path I
want to take in college to set me up for my career. I was also able to learn so much about
the field of pediatrics from talking to the nurses and the rest of the staff about their
different jobs and educational requirements. Additionally, I found the research for my

PEDIATRIC PROBLEMS

32

case studies extremely interesting. I was intrigued by the different infections and the
viruses that cause them. I also feel that writing the case studies will help in the future, as
college essays may model a similar structure and need extensive research to be completed
on a topic. On the whole, my senior project helped me grow as a student and prepare me
for a future in the medical field.