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CPU-Net MEDICAL ALERT
Jul-Aug 2005
A Bi-Monthly Bulletin Published by the Child Protection Unit Network Vol. 3 Issue 4
-Net colleague: September 2 :
Deadline for submission of abstract Thanks for participating in the survey. This is the second part of CPU-Net Medical Alert Vol. 3 to the San Diego Conference Issue 4 on Pediatric Vulvovaginitis. This gives a synopsis on treatment including a practical handout for patients with nonspecific vaginitis in English and Filipino. The first part which was November 7 - 8 :
sent to you with the survey deals with the etiology and methods of evaluation of vaginal CPU-Net Annual Conference discharge in children. CPU-NET RESEARCH & PUBLICATION TEAM November 16 -18:
ISPCAN Asian Regional Conference Second of two parts Singapore PEDIATRIC VULVOVAGINITIS: EVALUATION & TREATMENT

Treatment
clinical response can be achieved with a course of oral penicillin, In most pediatric cases, vulvovaginitis does not have a specific cephalosporin, or erythromycin. Amoxicillin 40 mg/kg/day or cause. In those cases, treatment should focus on improving erythromycin 30-50 mg/kg/day for 10 days usually offers hygiene and providing appropriate vulvar care. Figures 1 & 2 are adequate therapeutic coverage for the common pathogens that parent/patient education handouts for vulvovaginitis and include cause vulvovaginitis. instructions on perineal hygiene. If a specific overgrowth of bacteria is noted, antibiotic therapy Small amounts of a bland nonmedicated ointment may be used should be directed toward the particular pathogen. If a diagnosis to protect the vulvar skin. If a child is suspected to be in an itch- of pinworm is made, therapy should be instituted using scratch cycle from pruritus secondary to chronic discharge and mebendazole 100 mg orally in a single dose and repeated in 1 inflammation, sitz baths should be recommended. Sitz baths week. In these cases, it is advised to treat the entire family to consist of having the child sit in lukewarm water to soothe the prevent reinfection. inflamed vulva. It is best to minimize the use of soap on the vulva and wash with a white washcloth or fingers. Occasionally, a low- If symptoms fail to resolve after 2 courses of broad-spectrum dose topical steroid (hydrocortisone 1% or 2.5%) may help antibiotic therapy, then an examination under anesthesia to rule relieve itching and inflammation if unresponsive to conservative out a foreign body or referral to a specialist should be considered. Sexual y transmitted infections (STIs) though not common should be ruled out and appropriate interventions are If symptoms do not resolve with hygiene methods, broad- done. The implications of STIs and the corresponding treatment spectrum antibiotics should be initiated ONLY AFTER are presented in tables 2, 3 and 4. APPROPRIATE CULTURES HAVE BEEN DONE. Adequate

TABLE 2. IMPLICATIONS OF COMMONLY ENCOUNTERED STIS FOR THE DIAGNOSIS AND REPORTING OF SEXUAL ABUSE OF INFANTS AND PREPUBERTAL CHILDREN
Suggested Action Syphilis* Diagnostic Diagnostic Report C trachomatis infection* T vaginalis infection Highly suspicious C acuminata infection* (anogenital warts) Herpes simplex (genital location) Bacterial vaginosis Medical follow-up * If not perinatally acquired and rare nonsexual vertical transmission is excluded. Although the culture technique is the "gold standard," current studies are investigating the use of nucleic acid–amplification tests as an alternative diagnostic method in To the agency mandated in the community to receive reports of suspected sexual abuse. If not acquired perinatally or by transfusion. Unless there is a clear history of autoinoculation. N.B. The presence alone of T. vaginalis, C. acuminata and Herpes simplex are NOT diagnostic NOR CONCLUSIVE of child sexual abuse. Further investigation is warranted to find out if abuse happened. CPU-Net Phone: (632) 404-3954 Fax: (632) 404-3955 Mobile Hotline: 0917-8900445 E-mail: [email protected] URL: www.childprotection.org.ph
CPU-Net MEDICAL ALERT (2nd part) Jul - Aug 2005 Volume 3, Issue 4 Page 2
FIGURE 1. PARENT/PATIENT EDUCATION HANDOUT FOR VULVOVAGINITIS (ENGLISH). VULVAR CARE FOR VULVOVAGINITIS
Your child has a minor bacterial infection, which may cause vaginal discharge, itching, redness, and pain. Typically the bacteria come from the respiratory tract or from the rectum. It is therefore important to encourage and assist your daughter with appropriate vulvar hygiene. These instructions for vulvar care will help prevent further occurrences. [ Ensure that your child takes the medication as prescribed by her doctor: [ Use 100% white cotton underwear and wash this in gentle detergent that has no perfumes or dyes. Encourage your child to change underwear daily. [ Use toilet paper with no perfumes or dyes. Do not use talcum powder or other chemicals that may irritate her. Avoid bubble baths. [ If your child has some discomfort, have her do sitz baths, where she may sit in a tub of lukewarm water to soothe the inflamed vulva. Do this for 10 minutes daily for 7 days. [ Use lactic acid (e.g. Lactacyd, pH care, etc.) or a bar of gentle soap with no perfumes or deodorants. Avoid using soap on the vulva. Wash the vulva well with clean water. [ Keep your child's bottom as clean and dry as possible. [ Review instructions to wash and wipe from front to back after using the bathroom. [ Review frequent hand washing with your daughter. [ Have your daughter urinate with her legs apart.
FIGURE 2. PARENT/PATIENT EDUCATION HANDOUT FOR VULVOVAGINITIS (FILIPINO).
WASTONG PAGLILINIS NG ARI NG BATA
Ang inyong anak ay may impeksyon sa ari na maaring magkaroon ng sipon, pangangati, pamumula at pananakit. Kalimitan ito ay dahil sa mga bacteria na sanhi ng ubo't sipon o galing sa kanyang puwet. Importante na maging malinis ang ari ng inyong anak. Ang sumusunod ay upang maiwasan ang pag-ulit ng ganitong impeksyon. [ Siguraduhing inumin ang gamot na iniresita ng inyong doctor: [ Magpalit ng panty araw-araw. Gumamit lamang ng "cotton" na panty. Bawal ang masisikip na shorts at pantalon at nylon na panty. Bawal din maglagay ng pulbos at iba pang mga kemikal sa bandang ari ng bata. [ Magbabad o magtampisaw sa isang batya na may maligamgam na tubig ng 10 minuto araw-araw. Bigyan ng laruan para magtagal ng 10 minuto. Gawin ito ng isang linggo. [ Gumamit ng "lactic acid solution" (hal. Lactacyd, pH care, etc.) imbes na sabon para linisin ang bandang ari at puwet at mag-banlaw. Ugaliing maghugas ng tubig tuwing matapos umihi at dumumi. Maaring gumawa ng sariling lactic acid solution sa bahay: magdagdag lamang ng isang kutsaritang suka sa isang litro ng malinis na tubig at gamitin ito ng pang-linis. [ Tuwing maghuhugas pagkatapos ng bawat pagihi o pagdumi, siguraduhing palikod (papunta sa bandang puwet) ang pagpunas, at hindi paharap. Ito'y para maiwasan ang pagiwan ng dumi sa bandang harapan ng bata na maaring maging sanhi ng "discharge" o parang nana galing sa ari. [ Maghugas ng kamay pagkatapos gumamit ng palikuran. [ Paihiin ang iyong anak ng nakabuka ang kanyang hita upang walang maiwan na ihi sa kanyang ari.

CPU-Net Phone: (632) 404-3954 Fax: (632) 404-3955 Mobile Hotline: 0917-8900445 E-mail: [email protected] URL: www.childprotection.org.ph
CPU-Net MEDICAL ALERT (2nd part) Jul - Aug 2005 Volume 3, Issue 4 Page 3


TABLE 3. RECOMMENDED TREATMENT REGIMENS FOR THE MOST COMMON VAGINITIS IN CHILDREN & ADOLESCENTS
PATIENT CANDIDIASIS
BACTERIAL
VAGINOSIS
Children <45 kg Topical azole preparation 5 mg/kg/dose TID for 7 days 5 mg/kg/dose TID for 7 days (Clotrimazole cream !% BID or (maximum 1 gram per day) PO (maximum 2 grams per day) TID for 14-28 days OR Ketoconazole cream 2% BID for 14-28 days) Adolescents and children >45 kg Topical azole preparation as Metronidazole 500 mg orally Metronidazole 400 mg oral y twice daily x 7 days Fluconazole 150 mg orally in a Metronidazole gel 0.75%, one single dose applicator (5g) intravaginally once a day for 5days
TABLE 4. GONOCOCCAL INFECTION TREATMENT FOR CHILDREN & ADOLESCENTS
Disease Prepubertal
children
lb (<45kg)
Patients weight >100 lbs (>45 kg) & who are
>8year old
Uncomplicated vulvovaginitis, Ceftriaxone 125mg IM in single dose Ceftriaxone 125mg IM in single dose cervicitis, urethritis, proctitis, or OR
Spectinomycin 40mg/kg (maximum 2g) IM, single PLUS
dose
Azithromycin (maximum 1 g) orally in single dose Doxycyline (100mg oral y twice a day for 7 days) Azithromycin 20mg/kg (maximum 1 g) orally in
single dose
OR
Erythromycin 50 mg/kg per day (maximum 2
g/day) oral y in 4 divided doses in 14 days
Disseminated gonococcal Ceftriaxone 50mg/kg per day (max. 2g/day) IV or Ceftriaxone 1g IV or IM once a day for 7 days infection (e.g., arthritis- IM once a day for 7 days dermatitis syndrome) Cefotaxime 1 g IV every 8 hours for 7 days Azithromycin or erythromycin Azithromycin 1 g orally in single dose
OR
Doxycyline 100mg orally twice a day for 7 days

In addition to the recommended treatment of gonococcal infection therapy for Chlamydia trachomatis is recommended on the presumption that the patient
has concomitant infection. Routine presumptive treatment is not recommended because many entities have similar clinical presentations. Perineal hygiene
and hot sitz bath is essential part of supportive treatment. Vaginal douche is not recommended since this can cause infection to upper tract.

Clinical Pearls
1.
Most cases of vulvovaginitis are nonspecific, with cultures demonstrating normal urogenital flora and no other identifiable etiology. Vulvovaginal candidiasis is very rare in children unless the child is immunocompromised or on antibiotics. Foreign bodies are rare and are often associated with foul-smelling bloody discharge. Hygiene is critical in the management of vulvovaginitis (see patient handouts, Fig 1 & 2). Chronic vulvovaginitis unresponsive to therapy warrants a referral to a specialist. STIs though uncommon have specific implications that warrant intervention and specific treatment.
References:
5. Ingram D, et al, Risk assessment for gonococcal and chlamydial 1. Kumetz LM et al. Common Pediatric Vulvar Disorders: infections in young children undergoing evaluation for sexual abuse. Vulvovaginitis, Lichen Sclerosus, and Labial Agglutination. Available Pediatrics 107(5) May 2001. at Medscape from WebMD. Available August 8, 2005 at 6. Burnstein G, Murray P, Diagnosis and management of sexually transmitted pathogens among adolescent. Pediatrics in Review, 2. Kellogg N; American Academy of Pediatrics Committee on Child March 2003; 24(3) 75-81 Abuse and Neglect. The evaluation of sexual abuse in children. 7. Burnstein G, Murray P, Diagnosis and management of sexually Pediatrics. 2005 Aug;116(2):506-12. transmitted disease among adolescent. Pediatrics in Review, April 3. Mitchell H, ABC of sexually transmitted infections vaginal discharge- 2003; 24(4) 119-126 causes, diagnosis and treatment. BMJ May 2004, 328: 1306-1308 8. National Guidelines in management of suspected sexually infection 4. Robinson A, Watkeys, J et al, Sexually transmitted organism in in children and young people. sexually abused children. Arch Dis Child 1998; 79: 356-358 9. American Academy of Pediatrics, Red Book. 2003 CPU-Net Phone: (632) 404-3954 Fax: (632) 404-3955 Mobile Hotline: 0917-8900445 E-mail: [email protected] URL: www.childprotection.org.ph

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