Paediatric Infectious Diseases — GCC Nursing Guide

Childhood Exanthems (Rash Illnesses)

Disease	Pathogen	Key Features	Management	Exclusion
Measles	Paramyxovirus (Morbillivirus)	Koplik spots 2 days before rash; maculopapular rash spreads head-to-foot; 3 Cs: cough, coryza, conjunctivitis	Supportive; Vitamin A; MMR vaccination; NOTIFIABLE	5 days from rash onset
Rubella	Rubella virus (Togavirus)	Fine pink maculopapular rash; post-auricular lymphadenopathy; CRS: deafness, cataracts, cardiac defects	Supportive; MMR; avoid pregnant contacts; NOTIFIABLE	5 days from rash onset
Varicella	VZV (HHV-3)	Crops of pruritic vesicles in various stages simultaneously; starts on trunk	Aciclovir for immunocompromised/severe/neonates; VZIG for immunocompromised contacts	Until ALL vesicles crusted (~5 days)
Roseola	HHV-6 (HHV-7)	High fever 3–5 days; rash appears as fever breaks; child typically well despite high fever; febrile seizures possible	Supportive; antipyretics; reassure parents	None (generally)
Hand Foot Mouth	Coxsackievirus A16 (Enterovirus)	Vesicles on palms, soles, mouth/buccal mucosa; low-grade fever; self-limiting 7–10 days	Supportive; analgesia/antipyretics; oral hygiene	Until vesicles crust / child well
Scarlet Fever	Group A Streptococcus (GAS)	Sandpaper rash; strawberry tongue; perioral pallor; flushed cheeks; follows strep throat/tonsillitis	Penicillin V 10 days (amoxicillin alternative); NOTIFIABLE in some regions	24h after starting antibiotics

Measles — In Detail

Prodrome (2–4 days)

High fever, cough, coryza, conjunctivitis
Koplik spots: white/blue spots on buccal mucosa — pathognomonic, appear 2 days before rash

Rash

Maculopapular, starts at hairline/face, spreads head-to-foot over 3–4 days
Fades in same order, may desquamate

Complications

Pneumonia — most common cause of death
Encephalitis — 1:1000 cases
SSPE — subacute sclerosing panencephalitis, years later
Otitis media, laryngotracheitis, diarrhoea

Measles is NOTIFIABLE. Isolate immediately. Contact public health.

Varicella (Chickenpox) — In Detail

Contagious Period

2 days before rash appears until ALL vesicles are crusted
Spreads by droplet and direct contact
School exclusion until all vesicles crusted

Treatment Indications for Aciclovir

Immunocompromised children
Severe/complicated disease
Neonatal varicella (IV aciclovir)
Adolescents/adults (more severe)

VZIG (Varicella-Zoster Immunoglobulin)

Immunocompromised contacts (non-immune)
Neonates born to mothers with varicella
Premature infants (<28 weeks or <1kg)
Give within 10 days of exposure

Congenital Rubella Syndrome (CRS)

Infection in first trimester carries ~90% risk of CRS

Classic Triad

Sensorineural deafness — most common
Cataracts / glaucoma
Cardiac defects — PDA, pulmonary artery stenosis

Other Features

Microcephaly, intellectual disability
"Blueberry muffin" rash (extramedullary haematopoiesis)
Hepatosplenomegaly, thrombocytopaenia

MMR vaccination prevents CRS. Screen pregnant women for rubella immunity.

Scarlet Fever — Nursing Points

Recognition

Sandpaper texture rash — begins in groin/armpits, spreads
Pastia lines — rash in skin creases
Strawberry tongue — white then red
Circumoral pallor (perioral pallor)

Complications (rare but serious)

Rheumatic fever — 3–4 weeks after
Post-streptococcal glomerulonephritis
Invasive GAS (necrotising fasciitis, toxic shock)

Child can return to school 24 hours after starting antibiotics and is afebrile

Meningitis & Encephalitis

EMERGENCY: Petechiae/purpura in a febrile child = meningococcal septicaemia until proven otherwise. Do the GLASS TEST. Give IV/IM ceftriaxone IMMEDIATELY — do NOT wait for LP.

Bacterial Meningitis

Pathogens by Age

Age	Organisms
<3 months	GBS, E. coli, Listeria monocytogenes
3m – 5yr	N. meningitidis, S. pneumoniae
>5yr	N. meningitidis, S. pneumoniae
Vaccinated	H. influenzae near-eliminated by Hib vaccine

Clinical Features

Fever, severe headache, photophobia, phonophobia
Neck stiffness (Kernig's and Brudzinski's signs)
Bulging fontanelle in infants
Non-blanching petechiae/purpura = meningococcal
Altered consciousness, seizures

Glass Test

Press glass firmly against petechiae — non-blanching = meningococcal emergency

Management of Bacterial Meningitis

Immediate Actions (ABCDE)

High-flow oxygen, IV access x2
Blood cultures BEFORE antibiotics if no delay
IV ceftriaxone immediately (100mg/kg/day, max 4g)
If <3 months: add IV amoxicillin (Listeria cover)
IV dexamethasone 0.15mg/kg QDS x4 days — reduces deafness in >3 months

LP — Indications & Contraindications

Do LP if: no papilloedema, not shocked, no focal neurology, not coagulopathic
Delay LP if: signs of raised ICP, haemodynamic instability, GCS <13, seizures, petechiae/purpura

CSF Findings — Bacterial

Turbid/cloudy appearance
WBC: raised neutrophils (>1000/mm³)
Protein: raised (>0.45g/L)
Glucose: low (<2/3 of blood glucose)

Viral Meningitis

Pathogens

Enterovirus — most common (summer/autumn)
HSV-2 (adolescents), HSV-1 (encephalitis)
Mumps (in unvaccinated)
EBV, CMV, HIV

CSF Findings — Viral

Clear/slightly turbid
WBC: raised lymphocytes (100–1000/mm³)
Protein: slightly raised
Glucose: NORMAL (key differentiator)

Management

Supportive care; analgesia
Aciclovir IV for HSV/neonates until HSV PCR negative
Usually self-limiting in 7–10 days

Encephalitis

Features (distinguish from meningitis)

Altered level of consciousness
Behavioural/personality change
Seizures (focal or generalised)
Focal neurological deficits
Movement disorders

HSV Encephalitis

Temporal lobe involvement — MRI: temporal hyperintensity
EEG: temporal spikes
IV Aciclovir 500mg/m² TDS x21 days
HSV PCR on CSF

Autoimmune Encephalitis

Anti-NMDAR antibodies — young females, behavioural change, movement disorder, autonomic instability
Anti-VGKC antibodies (LGI1/CASPR2)
Treatment: steroids, IVIG, plasma exchange

Meningitis vs Viral Meningitis vs Encephalitis — Quick Comparison

Feature	Bacterial Meningitis	Viral Meningitis	Encephalitis
Consciousness	Often altered	Usually preserved	Always altered
Neck stiffness	Yes	Yes	Variable
Focal neurology	Rare	No	Common
Petechiae	Meningococcal	No	No
CSF glucose	Low	Normal	Normal/Low
CSF cells	Neutrophils	Lymphocytes	Lymphocytes
Empirical Rx	Ceftriaxone + Dexa	Aciclovir if HSV suspected	Aciclovir IV

Respiratory Infections

RSV Bronchiolitis

Epidemiology

Peak age: 2–6 months (rarely >1 year)
RSV responsible for 70–80% of cases
GCC peak season: November–April
Highly contagious — droplet + contact spread

Clinical Features

Coryzal prodrome 1–3 days
Subcostal/intercostal/sternal recessions
Fine end-expiratory crackles + wheeze
Nasal flaring, grunting (severe)
Feeding difficulties — early sign of deterioration

NICE Severity Indicators

Mild	Moderate	Severe
SpO₂ ≥95%, feeding >75%, mild recession, RR <50	SpO₂ 92–95%, feeding 50–75%, moderate recession, RR 50–70	SpO₂ <92%, feeding <50%, severe recession, RR >70, apnoea, cyanosis

Management (largely supportive)

Supplemental O₂ if SpO₂ <92%
High-flow nasal cannula (HFNC/Optiflow) — reduces work of breathing
NG feeding if intake <50–75% normal
CPAP/invasive ventilation for severe cases
Nasal saline for secretion clearance
Nebulised adrenaline/salbutamol — NOT routinely recommended

Palivizumab (Synagis) Prophylaxis

Monthly IM injections during RSV season
Indicated: premature <29 weeks, chronic lung disease, haemodynamically significant CHD
Available in GCC NICUs

Croup (Laryngotracheobronchitis)

Aetiology

Parainfluenza virus types 1, 2, 3 — most common
Age: 6 months–3 years peak (up to 6 years)
Autumn–winter seasonality

Clinical Features

Barking seal-like cough (pathognomonic)
Hoarse voice / dysphonia
Stridor — initially on crying, then at rest if severe
Coryzal prodrome
Steeple sign on neck X-ray (subglottic narrowing)

Severity & Management

Severity	Features	Treatment
Mild	Occasional barking cough, no stridor at rest, no recession	Single dose oral dexamethasone 0.15mg/kg; home
Moderate	Frequent barking cough, stridor at rest, mild-moderate recession, agitated	Oral/IM dexamethasone 0.15mg/kg; observe 4h
Severe	Severe stridor, marked recession, pallor/cyanosis, decreased consciousness	Dexamethasone + nebulised adrenaline 1:1000 0.5ml/kg (max 5ml); prepare for intubation

Keep child calm — agitation worsens stridor. Sit upright. Parent present. Avoid unnecessary procedures.

Epiglottitis — Critical Differential

Epiglottitis is a life-threatening emergency — do NOT examine throat / do NOT lay child down

Feature	Croup	Epiglottitis
Age	6m–3yr	2–7yr (any age)
Onset	Gradual (days)	Sudden (hours)
Cough	Barking cough	NO barking cough
Drooling	No	YES — hallmark
Posture	Normal	Tripod/sniffing
Toxicity	Not toxic	High fever, very toxic
Voice	Hoarse	Muffled ("hot potato")
Pathogen	Parainfluenza	H. influenzae type b
Management	Dexamethasone ± adrenaline	Secure airway (OT/ITU), IV cefuroxime

Whooping Cough (Pertussis)

Pathogen

Bordetella pertussis — gram-negative coccobacillus

Stages

Catarrhal (1–2 weeks): coryzal symptoms — most infectious
Paroxysmal (2–8 weeks): paroxysmal cough + inspiratory whoop; post-tussive vomiting; cyanosis
Convalescent (weeks–months): cough gradually resolves

Danger in Infants

Apnoea without classical whoop — can present as ALTE/BRUE in infants
Bradycardia, cyanotic spells, death

Management

Azithromycin 5 days (reduces infectivity, limited clinical benefit if late)
Erythromycin/clarithromycin alternative
Notification to public health; contact tracing
Prophylactic antibiotics for household contacts
Hospital admission for infants <3 months

Maternal pertussis vaccine (Tdap) from week 20 gestation protects neonates via maternal antibody transfer

Gastrointestinal & Other Infections

Gastroenteritis

Common Pathogens

Rotavirus — most common viral in under-5s; vaccine in GCC schedules
Norovirus — all ages, highly contagious, winter vomiting bug
Campylobacter — most common bacterial; poultry
Salmonella — eggs/poultry; bloody diarrhoea
E. coli O157 (EHEC) — HUS risk; avoid antibiotics

NICE Dehydration Assessment

Sign	No Dehydration	Clinical Dehydration (5–10%)	Shock (>10%)
Appearance	Normal	Altered	Mottled/pale/grey
Eyes	Normal	Sunken	Very sunken
Mucous membranes	Moist	Dry	Very dry
Skin turgor	Normal	Reduced (tenting)	Very reduced
CRT	<2s	>2s	>3s / mottled
Urine output	Normal	Reduced	Minimal/none
HR/BP	Normal	Tachycardia	Tachycardia + hypotension

Management Principles

Oral Rehydration Solution (ORS) — Dioralyte — FIRST LINE
50ml/kg over 4 hours for dehydration; frequent small sips
Continue normal diet (including breast/formula milk) as tolerated
Stopping formula milk is outdated advice — continue feeds
IV fluids (0.9% NaCl + dextrose) ONLY if: shocked, unable to tolerate ORS, severe dehydration
Nasogastric ORS if child refuses oral but not shocked
Ondansetron (off-label) may facilitate ORS in persistent vomiting

UTI in Children

NICE NG224 Guidance

Diagnosis <3 years: urine culture (dip unreliable in infants)
Diagnosis >3 years: urine dipstick — leucocytes + nitrites; confirm with MSU if atypical
Clean catch specimen preferred; suprapubic aspirate if needed

Treatment

Lower UTI: oral trimethoprim 3–5 days OR nitrofurantoin (not <3 months)
Febrile/upper UTI: co-amoxiclav or cefalexin
IV cefuroxime/gentamicin if hospitalised/toxic/vomiting
Duration: 7–10 days for upper UTI/pyelonephritis

Investigations

Investigation	Indication
Renal USS	All febrile UTI <6 months; recurrent UTI; atypical/complex UTI
DMSA scan	6 months after UTI — detect renal scarring; recurrent UTI
MCUG	USS abnormality; VUR suspected; recurrent febrile UTI

Threadworm (Enterobius vermicularis)

Presentation

Perianal itch — worse at night (females lay eggs)
Tape test: apply clear tape to perianal area at night; examine under microscope
Vulvovaginitis in girls

Treatment

Mebendazole single dose (>2 years); repeat at 2 weeks
Piperazine alternative (>3 months)
Treat ENTIRE household simultaneously

Hygiene Measures (prevent reinfection)

Short nails, nail brushing before meals
Wash hands after toilet, before eating
Change and wash underwear/bedding daily
Shower (not bath) in morning to remove eggs

Impetigo

Pathogens

Staphylococcus aureus (most common) — bullous type
Group A Streptococcus — non-bullous (crusted) type

Types

Non-bullous (70%): golden-crusted lesions around mouth/nose
Bullous (30%): fluid-filled blisters; Staph aureus toxin
Ecthyma — deeper ulcerative form

Management (NICE NG153)

Localised: topical fusidic acid 2% TDS x5 days; or topical retapamulin x5 days
Extensive/multiple lesions: oral flucloxacillin 7 days (erythromycin if penicillin allergy)
School exclusion until lesions crusted or 48h after treatment starts
No sharing of towels; good hygiene
MRSA impetigo: topical mupirocin or oral trimethoprim (sensitivities)

Interactive: Paediatric Dehydration Assessor

Child's Age

Weight (kg)

Behaviour / Responsiveness

Urine Output

Signs Present (select all that apply)

Sunken eyes Dry mucous membranes Skin tenting (poor turgor) CRT >2 seconds Tachycardia Sunken fontanelle (infants) Mottled / pale skin Hypotension / no recordable BP

Fluid Intake Status

Duration of Illness

Neonatal Infections & The Immunocompromised Child

Early Onset Neonatal Sepsis (EONS) — <72 hours

Pathogens

Group B Streptococcus (GBS) — most common; vertical transmission
E. coli — especially preterm neonates
Listeria monocytogenes — maternal foodborne

Risk Factors (NICE NG195)

Prolonged rupture of membranes >18h (PROM)
Maternal GBS colonisation (positive swab/previous GBS infant)
Maternal fever ≥38°C in labour
Chorioamnionitis
Prematurity <37 weeks
Intrapartum fetal distress

Clinical Features

Temperature instability (fever OR hypothermia)
Respiratory distress: grunting, tachypnoea, apnoea
Lethargy, poor feeding, hypotonia
Jitteriness, seizures
Mottled skin, prolonged CRT, pallor

NICE NG195 — NeoSEPS Tool

Assess risk factors + clinical features
Guides decision: observe, investigate, or treat

Treatment

IV Benzylpenicillin (or amoxicillin) + Gentamicin
Blood cultures BEFORE first dose of antibiotics
CRP at 18–24h — if <10 and well, consider stopping
LP if: septic/meningitic, not improving, or culture positive
Duration: 7 days (sepsis); 14–21 days (meningitis)

Late Onset Neonatal Sepsis (LONS) — >72 hours

Common Pathogens in NICU

CoNS (Coagulase-negative Staph — S. epidermidis) — most common
Staphylococcus aureus (including MRSA)
Gram-negatives: Klebsiella, E. coli, Pseudomonas
Candida — especially in VLBW infants on broad-spectrum antibiotics

Risk Factors

Central venous line (PICC/UVC/UAC)
Prolonged antibiotics → disrupted microbiome
Prematurity, VLBW
TPN, intubation, invasive procedures

Empirical Treatment

Vancomycin (CoNS/MRSA cover) + Gentamicin or Piperacillin-tazobactam
Add antifungal (fluconazole/liposomal amphotericin) if Candida risk
Remove/change central lines where possible
Repeat cultures at 48–72h

Congenital CMV

Features

Classic triad: petechiae, jaundice, hepatosplenomegaly
Periventricular calcifications (CT head)
Sensorineural hearing loss (SNHL) — most common
Microcephaly, seizures, chorioretinitis
SGA/IUGR

Diagnosis

CMV PCR in urine within 21 days of birth (gold standard)
CMV PCR in blood (viral load)
Dried blood spot (Guthrie card) for retrospective diagnosis

Treatment

IV Ganciclovir or oral Valganciclovir for 6 months
Indicated for: symptomatic congenital CMV with CNS involvement
Improves hearing outcomes
Monitor FBC (neutropaenia side effect)

HIV in Children

PMTCT (Prevention of Mother-to-Child Transmission)

Maternal ART throughout pregnancy — reduces MTCT to <1%
Elective LSCS if viral load >50 copies/ml at 36 weeks
Infant prophylaxis: Nevirapine (NVP) for 4–6 weeks
Formula feeding in resource-limited settings where safe water available
Breastfeeding with maternal ART — safer than mixed feeding

Diagnosis in Infants

HIV PCR (DNA/RNA) at birth, 6 weeks, 12 weeks, 18 months
HIV antibody test unreliable under 18 months (maternal antibodies)

Monitoring

CD4 count — guides ART initiation and opportunistic infection prophylaxis
Co-trimoxazole (PCP prophylaxis) from 4–6 weeks
Viral load every 3–6 months on ART

The Immunocompromised Child — Infection Surveillance

Common Causes of Immunocompromise

Primary immunodeficiency (SCID, DiGeorge, CVID)
Chemotherapy / post-transplant
HIV/AIDS
High-dose steroids (>2mg/kg/day prednisolone >14 days)
Biologics (anti-TNF, rituximab)

Key Prophylaxis

PCP — co-trimoxazole (Septrin) prophylaxis
Fungal — fluconazole or itraconazole
CMV — valganciclovir after HSCT/transplant
IVIG — for humoral immunodeficiency (hypogammaglobulinaemia)

Febrile Neutropaenia Management

Any child on chemotherapy with fever ≥38°C = EMERGENCY — treat immediately

Blood cultures (peripheral + central lines)
FBC, CRP, renal/liver function, CXR
IV piperacillin-tazobactam (Tazocin) within 1 hour
Add vancomycin if line infection/mucositis suspected
Add antifungal after 72–96h if no improvement
G-CSF (filgrastim) per protocol
Neutrophil count <0.5 = profound neutropaenia

GCC Context & Exam Preparation

GCC-Specific Epidemiology

Vaccination & Outbreak Risks

Measles outbreaks in under-vaccinated expat communities — imported cases
H. influenzae type b near-eliminated by Hib vaccine (included GCC national schedules)
Meningococcal ACWY vaccine mandated for Hajj/Umrah pilgrims — prevents serogroup A, C, W, Y meningococcal disease
Rotavirus vaccine included in GCC schedules — reduced childhood gastroenteritis burden

Imported/Endemic Diseases

Dengue fever — importation risk from South Asian countries; aedes mosquito breeding in standing water; worsening with climate; DHF/DSS risk
MERS-CoV — children usually asymptomatic or mild; camel exposure risk; healthcare workers at risk; notify infection control immediately
Malaria — imported from endemic areas; thick and thin blood film; plasmodium falciparum most dangerous
Typhoid — Salmonella typhi; returned travellers; rose spots; relative bradycardia

RSV in GCC

Peak season: November–April (cooler months)
Palivizumab available in GCC NICUs for high-risk infants
Air-conditioning and indoor gatherings increase transmission

Regulatory Bodies & Standards

Dubai — DHA (Dubai Health Authority)

DHA Paediatric Infection Guidelines
Mandatory notification of communicable diseases
School exclusion periods enforced
DHA exam: focus on meningococcal emergency, dehydration assessment

Abu Dhabi — DOH (Department of Health)

DOH Paediatric Nursing Standards
Notifiable disease reporting within 24h
Infection control bundles for NICU

Saudi Arabia — SCFHS

Saudi Commission for Health Specialties exam
MOH neonatal sepsis guidelines
Hajj-related meningococcal vaccine requirements

Qatar — QCHP

Qatar Council for Healthcare Practitioners
QCHP Paediatric Nursing Standards
Emphasis on patient safety and infection control

Exam High-Yield Topics — DHA/DOH/SCFHS/QCHP

Meningococcal Emergency

Non-blanching petechiae/purpura = meningococcal until proven otherwise
Glass test technique
First action: IV/IM ceftriaxone — do NOT wait for LP
Dexamethasone to reduce deafness (>3 months)
Contact tracing + ciprofloxacin/rifampicin prophylaxis for close contacts
Meningococcal ACWY vaccine — 2 doses schedule

NICE Dehydration / Gastroenteritis

ORS (Dioralyte) is first-line
Continue breast/formula milk — never stop
No clear fluids only (lemonade/juice — worsen osmotic diarrhoea)
IV fluid only if shocked or can't tolerate ORS
NG tube ORS is acceptable intermediate step
AVOID antidiarrhoeals / antibiotics routinely

RSV Bronchiolitis Care

SpO₂ target ≥92% (NICE: consider ≥90% in otherwise well infant)
HFNC reduces need for intubation
Salbutamol/bronchodilators NOT routinely indicated
Physiotherapy NOT routinely recommended
Infection control: cohorting, droplet + contact precautions
Palivizumab — RSV prevention, not treatment

Neonatal Sepsis Antibiotics

EONS: Benzylpenicillin + Gentamicin (IV)
If Listeria suspected: Amoxicillin + Gentamicin
LONS in NICU: Vancomycin + Gentamicin
Take blood cultures BEFORE antibiotics
Start antibiotics within 1 hour of decision
NeoSEPS tool (NICE NG195)

Varicella Management

Contagious: 2 days pre-rash to all vesicles crusted
Aciclovir: immunocompromised, neonatal VZV, severe
VZIG: immunocompromised contacts within 10 days
Pregnant women (non-immune) + VZV exposure = VZIG
School exclusion until all vesicles crusted
VZV encephalitis: IV aciclovir

Croup vs Epiglottitis

Croup: barking cough, Parainfluenza, gradual onset
Epiglottitis: drooling, very toxic, NO barking cough
Croup Rx: dexamethasone ± nebulised adrenaline
Epiglottitis: secure airway first (ENT/anaesthesia)
Do NOT examine throat in epiglottitis
Hib vaccine prevents epiglottitis

Notifiable Diseases — GCC Nursing Responsibility

Immediately Notifiable

Measles
Meningococcal disease
MERS-CoV
Diphtheria
Rabies
Viral haemorrhagic fever (Ebola, Marburg)
Cholera

Notifiable within 24–48h

Rubella / Congenital Rubella Syndrome
Pertussis (whooping cough)
Scarlet fever (in some GCC states)
Typhoid/Paratyphoid
Hepatitis A/B
Dengue fever
Malaria (imported)

Nursing Action

Identify suspected notifiable disease
Inform senior nurse / medical team
Complete notification form / electronic reporting
Initiate appropriate isolation precautions
Do NOT wait for confirmation before notifying

Infection Control — Transmission-Based Precautions

Precaution Type	Disease Examples	PPE Required	Room
Airborne	Measles, Varicella, TB, COVID-19 (aerosol)	FFP3/N95 + gloves + gown + eye protection	Negative pressure room
Droplet	RSV, Influenza, Whooping cough, Meningococcal, Rubella	Surgical mask + gloves + apron	Single room or cohort
Contact	Impetigo, MRSA, C. difficile, RSV (also droplet), scabies	Gloves + apron ± gown	Single room preferred
Standard	All patients — baseline	Gloves, apron (as clinically indicated), hand hygiene	N/A

Hand hygiene (WHO 5 Moments) remains the single most effective infection control measure. Alcohol handrub is NOT effective for Norovirus or C. difficile — soap and water required.