Pediatric Food Poisoning

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Background

Food-borne illnesses are diverse in etiology, and food poisoning can follow ingestion of infectious organisms or noninfectious substances. Food-borne diseases (FBDs) constitute a serious public health problem in the United States. FBDs encompass classic toxin-mediated food poisoning, such as botulism; gastroenteritis that follows ingestion of preformed Staphylococcus aureus toxin; ingestion of chemicals in foods; and bacterial (see the image below), parasitic, and viral infections. Many FBDs are zoonoses, which implies that the infectious agent has a primary animal reservoir and that humans are affected incidentally.



View Image

Escherichia coli on Gram stain. Gram-negative bacilli.

See 5 Cases of Food Poisoning: Can You Identify the Pathogen?, a Critical Images slideshow, to help identify various pathogens and symptoms related to foodborne disease.

Pathophysiology

Although the GI tract is the primary target, autonomic nervous system disturbances and CNS impairment are prominent manifestations in chemical-related, plant-related, and seafood-related poisonings and in botulism. The severity of dehydration can vary depending on the pathogen.

Typically, FBDs in which severe vomiting (eg, staphylococcal-toxin gastroenteritis) and small bowel diarrhea occur, typified by Vibrio cholerae infection, can cause life-threatening dehydration. Other organs involved include the liver in hepatitis A, muscles in trichinosis, lymph nodes in toxoplasmosis, and, importantly, the kidneys in hemolytic-uremic syndrome (HUS), which follows enterohemorrhagic Escherichia coli -induced diarrhea.

See the image below.



View Image

Escherichia coli on Gram stain. Gram-negative bacilli.

Epidemiology

Frequency

United States

The US Centers for Disease Control and Prevention (CDC) estimates 1 in 6 Americans (48 million people) are affected by foodborne illness annually. The estimates suggest 128,000 people are hospitalized and 3,000 die.[1] The 31 known pathogens account for an estimated 9.4 million annual cases, 55,961 hospitalizations, and 1,351 deaths. Unspecified agents account for 38.4 million cases, 71,878 hospitalizations, and 1,686 deaths.[2]

The most common pathogens are as follows:[1]

The most common pathogens responsible for hospitalizations are as follows:[1]

The CDC recognized the following outbreaks and sources in 2012:[1]

International

International statistics are probably impossible to compute, but the obvious relevance of worldwide FBDs is the risk to travelers in the very mobile American and world population and the estimated 2 million deaths in children alone.[3, 4, 5]

Mortality/Morbidity

The epidemiologic relevance of FBD is that outbreaks can involve an immense number of individuals and have the potential to overwhelm local health care services. Death can occur in a small proportion of affected patients; therefore, practitioners must take responsibility for reporting suspected FBDs and participate in investigations by the agency (eg, by saving food or vomitus samples).

Race

No specific racial predilection is noted, except that invasive Salmonella infections are more prevalent in individuals with hemoglobinopathies, which, in turn, are more common among people of African and Mediterranean descent.

Sex

No sex predilection is known for any food-borne illness; however, Listeria infection is often severe and life threatening in pregnant women.

Age

The CDC found that 5 bacterial enteric pathogens (Campylobacter, E coli 0157 , Salmonella, Shigella, and Y enterocolitica) caused 291,162 illnesses annually in children younger than 5 years.[6] This resulted in 102,746 doctor visits, 7,830 hospitalizations, and 64 deaths. Rates of illness remain higher in children.

History

Because few food-borne illnesses present with their own pathognomonic clinical picture, and because laboratory tests are of limited value in acute food poisoning, a systematic interrogation of patients and their families is the best way to deduce the etiology. Immediately following initiation of supportive treatment, the practitioner should obtain a history in the areas described below. This allows the list of possible agents to be narrowed, which helps dictate treatment and laboratory investigation.

A statement of the etiology and a brief description of the illness are included with each of the 4 incubation periods (ie, intervals between suspected food and onset of illness) to help relate this important historical clue to the specific infective agent.

Short incubation (ie, within 1 d, usually < 16 h)

See the list below:

Intermediate incubation (1-3 d)

See the list below:

Long incubation (3-5 d)

See the list below:

Food sources

See the list below:

Other sources

See the list below:

Physical

Symptoms and signs of food poisoning include the following:

Causes

See the list below:

Laboratory Studies

Stool culture is an expensive test with a very low yield and is indicated particularly if patients with food poisoning have bloody diarrhea, severe abdominal pain, or are immunocompromised. When the likely pathogen is a Campylobacter, Yersinia, or Vibrio species, or if Shigalike toxin-producing E coli (eg, E coli O157:H7) is suspected, the laboratory should be notified because special media or incubation conditions (high or low temperature) are required.

Stool examination for parasites is indicated for GI tract illnesses that appear to have occurred after a long incubation period. Certain travel history, such as travel to tropical countries, camping, and drinking well or stream water should prompt consideration of parasitic food-borne illness.

Blood cultures are performed for bacteremic food-borne diseases (FBDs).

Serum electrolyte levels, BUN levels, creatinine levels, CBC count, and urinalysis are performed to assess hydration, renal function, and presence of hemolytic-uremic syndrome (HUS). Evidence of hemolysis and thrombocytopenia are present in patients with HUS.

Toxin testing, serotyping, and molecular techniques are available only from large commercial and public health laboratories. They are generally ordered only as part of an epidemiologic investigation.

Testing of food or vomitus for toxins may be offered by a poison control center or the local health authorities.

Medical Care

The mainstay of medical treatment in food poisoning is fluid and electrolyte replenishment. Guidelines for the diagnosis and management of food-borne illnesses have been established by the American Medical Association, American Nurses Association-American Nurses Foundation, the Centers for Disease Control and Prevention, Center for Food Safety and Applied Nutrition, the US Food and Drug Administration (FDA), Food Safety and Inspection Service, and US Department of Agriculture.[11]

The treating physician should be careful not to assign blame for the cause of food poisoning, for example, a particular restaurant or gathering, since the information available is almost always circumstantial until health or law enforcement officials have completed an investigation.

Bioterrorism or negligence of hygiene may be suspected but difficult to prove by the physician.

Immediate specific antibiotic therapy is not indicated in most food-borne illnesses; therefore, the physician should not be concerned about medicolegal pitfalls regarding failure to prescribe an antibiotic. In fact, in enterohemorrhagic E coli (EHEC) infection that may lead to hemolytic-uremic syndrome (HUS), antibiotics are contraindicated.[12]

Most food-borne diseases (FBDs) are not amenable to specific antidotes or antimicrobial therapy, but the few exceptions are mentioned below.

Short incubation

See the list below:

Intermediate incubation

See the list below:

Long incubation

See the list below:

Very long incubation

See the list below:

Consultations

Consultation with an infectious disease specialist may be beneficial in complicated or unusual cases.

For chemical or mushroom poisonings, consult with a poison control center for advice on specific antidotes and for help with identifying the implicated mushrooms.

For suspected point-source outbreaks of staphylococcal toxins or infective pathogens, call the local health department. Staff members usually have information regarding the species or strain involved and its antibiotic susceptibility.

Diet

As with other pediatric gastroenteritides, dietary restrictions are no longer are the standard of care, and the child is allowed solid foods as desired to maintain nutritional status.

Medication Summary

See Medical Care for treatment of food poisoning.

Inpatient & Outpatient Medications

See Medical Care for treatment of food poisoning.

Deterrence/Prevention

Prevention of food-borne diseases (FBDs) occurs on 2 levels.

Patient Education

See the list below:

Author

Sunil K Sood, MBBS, , MD, Professor of Clinical Pediatrics, Department of Pediatrics, Albert Einstein College of Medicine; Chief, Pediatric Infectious Diseases, Firm Director, Pediatric Unit, Schneider Children's Hospital at North Shore, North Shore University Hospital

Disclosure: Nothing to disclose.

Specialty Editors

Mary L Windle, PharmD, Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Larry I Lutwick, MD, FACP, Editor-in-Chief, ID Cases; Moderator, Program for Monitoring Emerging Diseases; Adjunct Professor of Medicine, State University of New York Downstate College of Medicine

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD, Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Disclosure: Nothing to disclose.

Acknowledgements

Rosemary Johann-Liang, MD Medical Officer, Infectious Diseases and Pediatrics, Division of Special Pathogens and Immunological Drug Products, Center for Drug Evaluation and Research, Food and Drug Administration

Rosemary Johann-Liang, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

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Escherichia coli on Gram stain. Gram-negative bacilli.

Escherichia coli on Gram stain. Gram-negative bacilli.

Escherichia coli on Gram stain. Gram-negative bacilli.