. PERIODIC GENTLE NASAL SUCTION

pertussis. Spread - by droplet route. Incubation period - 7-14 days. Clinical features - 3 stages, each lasting about 2 weeks. 1. CATARRFIAL (PRE-COUGH) STAGE - Insidious onset with coryza, moderate or mild cough and slight fever. The cough which is single at first, becomes progressively grouped and paroxysmal and more intense. No signs in chest, or bronchitic signs. 2. PAROXYSMAL (SPASMODIC) STAGE - follows with repeated episodes of short staccato cough during which the child is distressed, red faced or deeply cyanosed with bulging tearfilled eyes. As the glottis relaxes after the spasm, the older child takes a respiratory whoop which is often absent in the neonate. The paroxysm may comprise a single bout of coughs with terminal whoop, or the whole paroxysm may be punctuated by whoops and cease only when the child ejects mucus and food debris by vomiting, or coughing up, or swallowing large amount of thick mucoid sputum. After the attack, the child exhausted often goes to sleep or returns to play. Exciting causes - Feeding, excitement, activity, sudden change in temperature or sometimes no obvious cause. 3. CONVALESCENT STAGE - About the 4th week, paroxysms diminish in intensity, child ceases to vomit, then to whoop, and finally to cough. Appetite returns with improvement in general nutrition. Laboratory diagnosis - (i) Absolute lymphocytosis. (ii) Isolation of B. pertussis from upper respiratory tract taken after a spasm, by cough-plate culture method or preferably nasopharyngeal swab method on Bordet-Gengou medium. (iii) Normal ESR unless pulmonary complications. Differential Diagnosis - 1. Bronchiolitis or bronchopneumonia - In whooping cough there is history of contact, gradual onset of catarrhal symptoms progressing to spasmodic phase. 2. Enlarged tracheo-bronchial lymph nodes - usually tuberculous. Paroxysmal cough but no whoop. 3. Foreign bodies in larynx or trachea - Rapid onset Endoscopic examination reveals source of trouble. 4. Tetany with upper respiratory infection. 5. Fibrocystic disease in infants - Pulmonary lesion leads to paroxysmal coughing attacks. Family history, steatorrhoea, absence of trypsin from duodenal contents, increased concentration of sodium and chloride in sweat. Complications - 1. Pulmonary - (a) Pulmonary atelectasis - Common complication during paroxysmal phase due partly to viscid mucus secretion and bronchial blockage, and partly to bronchial and peribronchial inflammation. Degree of collapse varies from small segmental areas to collapse of a whole lobe. Recovery occurs in most cases in 2-3 weeks. Persistent low-grade infection accompanying atelectasis may lead to subsequent bronchiectasis. (b) Bronchopneumonia - usually due to secondary bacterial infection and closely associated with atelectasis. (c) Hilar adenitis and activation of tubercular disease may occur. (d) Asphyxia or cerebral anoxia are the common modes of death. 2. Mechanical or pressure effects - (a) Rise in intra-abdominal pressure -Inguinal and umbilical herniae and prolapse of rectum. (b) Rise of intrathoracic pressure -Subconjunctival hemorrhage common, occasionally petechiae on face, neck and upper trunk. (e) Cerebral hemorrhage or anoxic brain damage - may lead to convulsions, hemiplegia, cranial nerve palsies, mental retardation and coma (d) Fraenal ulcer - due to laceration by lower central incisors when the tongue protrudes forcibly during spasms. (c) Pneumothorax and mediastinal emphysema - rare. Management - 1. GENERAL MEASURES - (a) Isolation in a well ventilated room (b) Feeding - Food finely divided and in small feeds. Since feeding often provokes a paroxysm of coughing followed by vomiting in infants, it may be necessary to give a second feed after vomiting has occurred. (c) Management during a spasm - The child should be lifted from the cot and held in the head down position, patting the back until the spasm is over, to avoid inhalation of secretions and vomit. 2. DRUGS - (a) Sedatives - Phenobarbitone, or syrup of chloral hydrate, or antihistamine such as promethazine elixir 10-20 mg. per dose (b) Antispasmodies - Salbutamol or terbutaline t.d.s. may reduce frequency and severity of paroxysms. (c) Antibiotics -mildly effective in early catarrhal stage for reducing paroxysms, and to check secondary infection. Tetracycline or erythromydn -Dose per day - under 1 year 1 gm , upto 3 years 1.5 gm , upto 10 years 2 gm. , in four divided doses for 10 days. Ampicillin and cephaloridine for bronchopneumonia. (d) Anticonvulsants - such as IV diazepam or IM paraladehyde for fits, subsequent protection with sodium valproate or phenobarb. 3. OXYGEN - if convulsions or persistent hypoxemia. 4. PERIODIC GENTLE NASAL SUCTION -to remove secretions. Prevention - See immunization Chapter 10. Pertussis vaccination is not recommended over G years of age because vaccine reactions are more common in older children. Risk of pertussus vaccination (brain damage) can be reduced if vaccine is not given to infants with brain injury, CNS damage, personal or immediate family history of fits, or previous reaction to vaccine. Erythromydn 40 mg/kg/day into 4 divided doses may prevent or modify whooping cough in the non-immune neonate who has been exposed to the disease. 3. MENINGITIS Definition - Meningitis is inflammation of the