Diphtheria in Children
Comprehensive Nursing Management Guide
Introduction
Diphtheria is a serious bacterial infection caused by Corynebacterium diphtheriae, primarily affecting the mucous membranes of the nose and throat. This comprehensive guide focuses on diphtheria management in pediatric populations, providing essential knowledge for nursing students to effectively identify, diagnose, and manage this communicable disease in both hospital and home settings.
Despite vaccination programs, diphtheria remains a significant public health concern in many parts of the world. Understanding proper nursing management is crucial for preventing complications and controlling outbreaks.
Table of Contents
Pathophysiology of Diphtheria
Causative Agent
Diphtheria is caused by the bacterium Corynebacterium diphtheriae, a gram-positive, non-spore-forming bacillus. The severity of diphtheria depends on whether the strain is toxigenic or non-toxigenic.
Corynebacterium diphtheriae Structure
Cytoplasm
Club-shaped Bacillus with Metachromatic Granules
Disease Mechanism
Toxin Production and Action
The hallmark of diphtheria pathogenesis is the production of diphtheria toxin by toxigenic strains infected with a lysogenic β-phage carrying the tox gene. This toxin consists of:
- Fragment A: Inhibits protein synthesis in host cells
- Fragment B: Binds to cell receptors and facilitates entry of fragment A
The toxin primarily affects the heart, kidneys, and nervous system by inhibiting cellular protein synthesis, leading to cell death and tissue damage.
Local and Systemic Effects
- Organism attaches to respiratory epithelium
- Local inflammatory response occurs
- Formation of pseudomembrane (characteristic gray-white membrane)
- Toxin enters bloodstream
- Systemic spread to heart, kidneys, and nervous system
- Organ damage and potential failure
Key Pathophysiological Points
- The classic pseudomembrane in diphtheria consists of fibrin, leukocytes, epithelial cells, and bacteria
- Toxin-mediated inhibition of protein synthesis leads to myocarditis, neuritis, and nephropathy
- Airway obstruction can occur from pseudomembrane extension
- Systemic toxicity can lead to multi-organ failure
Epidemiology
Global Distribution
Diphtheria was once a major cause of childhood mortality worldwide. Today, it remains endemic in regions with low immunization coverage, particularly in parts of Asia, Africa, South America, and Eastern Europe.
| Region | Current Status | Risk Factors |
|---|---|---|
| Developed Countries | Rare cases; sporadic outbreaks | Incomplete vaccination, waning immunity, international travel |
| Developing Countries | Endemic in some regions | Low immunization rates, overcrowding, poor healthcare access |
| Conflict Zones | Outbreaks in refugee camps and conflict areas | Disrupted healthcare systems, population displacement |
Transmission
Diphtheria primarily spreads through:
- Respiratory droplets from coughing or sneezing
- Direct contact with respiratory secretions
- Contact with discharge from skin lesions (cutaneous diphtheria)
- Fomites (contaminated objects)
The incubation period typically ranges from 2-5 days, though it can extend to 10 days.
At-Risk Populations
- Unimmunized children: Highest risk group, especially in endemic areas
- Partially immunized individuals: Inadequate protection against the disease
- Adults with waning immunity: Protection decreases over time without boosters
- Immunocompromised patients: Reduced ability to mount immune response
- Individuals in overcrowded conditions: Increased transmission risk
Epidemiological Concerns
While diphtheria is well-controlled in countries with high vaccination rates, vaccine hesitancy and disruptions to immunization programs pose a risk for resurgence. Nurses must remain vigilant for cases, especially in travelers from endemic regions and in undervaccinated communities.
Clinical Manifestations
Types of Diphtheria
Respiratory Diphtheria
Most common and severe form
- Affects nasal passages, pharynx, tonsils, and larynx
- Characterized by pseudomembrane formation
- Can cause airway obstruction
Cutaneous Diphtheria
Skin infection form
- Presents as non-healing ulcers
- More common in tropical regions
- Usually less toxigenic but still contagious
Other Sites
Less common manifestations
- Conjunctival diphtheria
- Vaginal or vulvar diphtheria
- External auditory canal diphtheria
Clinical Presentations in Children
Progression of Diphtheria Symptoms in Children
Day 1-2
Mild sore throat, low-grade fever, malaise
Day 2-3
Formation of pseudomembrane, increasing pain
Day 3-5
Neck swelling, respiratory difficulties, systemic symptoms
Week 1-3
Complications: myocarditis, neuritis if untreated
Classic Symptoms
- Sore throat with difficulty swallowing
- Low-grade fever (usually below 38.5°C/101.3°F)
- Malaise and fatigue
- Grayish-white pseudomembrane on tonsils, pharynx, or larynx
- Distinct sweet-putrid odor
- Cervical lymphadenopathy (“bull neck” appearance)
- Voice changes, hoarseness, or barking cough in laryngeal cases
Complications
- Airway obstruction: From pseudomembrane extension
- Myocarditis: Usually appears 1-2 weeks after onset
- Peripheral neuropathy: Typically 3-7 weeks after onset
- Cranial nerve palsies: Affecting eye, throat muscles
- Renal dysfunction: Proteinuria and acute kidney injury
Special Considerations in Pediatric Patients
Children with diphtheria may present unique challenges:
- Smaller airways increase risk of obstruction
- Faster deterioration compared to adults
- Higher risk of cardiac complications
- May have atypical presentations, especially in partially immunized children
- Infants may present with nasal discharge as primary symptom
Mnemonic: “DIPHTHERIA” Signs & Symptoms
- D – Difficulty swallowing
- I – Inflammation of throat
- P – Pseudomembrane formation
- H – Hoarseness or voice changes
- T – Temperature elevation (mild fever)
- H – “Hemorrhagic” toxicity (systemic effects)
- E – Edema of the neck (“bull neck”)
- R – Respiratory distress
- I – Increasing heart rate
- A – Airway obstruction (late stage)
Diagnosis and Assessment
Diagnostic Approaches
Clinical Diagnosis
Clinical diagnosis is based on the characteristic features of diphtheria, including:
- Presence of adherent pseudomembrane on pharynx/tonsils
- Low-grade fever with disproportionate toxicity
- Cervical lymphadenopathy
- History of incomplete vaccination
- Possible exposure to a confirmed case
Laboratory Confirmation
Laboratory confirmation is essential for definitive diagnosis:
- Culture from throat or pseudomembrane swab
- Gram stain showing gram-positive bacilli with metachromatic granules
- PCR testing for toxin gene
- Toxigenicity testing (Elek test)
- Serology for anti-diphtheria antibodies
Important Note on Sample Collection
Specimens should be collected before antimicrobial therapy whenever possible. For suspected diphtheria cases, swabs should be taken from:
- Beneath the pseudomembrane (if present)
- Both nasopharynx and oropharynx
- Any skin lesions for cutaneous diphtheria
Transport specimens in appropriate media and notify the laboratory of suspected diphtheria as special culture techniques may be required.
Nursing Assessment
| Assessment Component | Key Findings in Diphtheria | Nursing Implications |
|---|---|---|
| Respiratory Assessment |
|
Monitor respiratory rate, effort, and oxygen saturation frequently. Be prepared for possible airway intervention. |
| Cardiovascular Assessment |
|
Continuous cardiac monitoring for early detection of myocarditis. Assess for signs of shock. |
| Neurological Assessment |
|
Perform regular neurological checks. Assess for swallowing difficulties and risk of aspiration. |
| Hydration Status |
|
Monitor intake and output. Assess need for IV fluids. Watch for renal complications. |
Differential Diagnosis
Several conditions can mimic diphtheria and should be considered during diagnosis:
Streptococcal Pharyngitis
- Higher fever
- Exudative tonsillitis
- No true pseudomembrane
- More localized symptoms
Infectious Mononucleosis
- Prominent lymphadenopathy
- Tonsillar exudates
- Splenomegaly
- Atypical lymphocytosis
Epiglottitis
- Rapid onset
- Higher fever
- Drooling
- Toxic appearance
Mnemonic: “DETECT” Diphtheria Diagnosis
- D – Dysphagia and difficulty breathing need assessment
- E – Examine thoroughly for pseudomembrane
- T – Take proper specimens for culture
- E – Evaluate vaccination history
- C – Check for complications early
- T – Toxin effects require monitoring
Nursing Management in Hospital
Immediate Management
Priority Nursing Interventions
Diphtheria requires rapid interventions to prevent life-threatening complications:
- Implement strict isolation protocols immediately upon suspicion
- Assess and maintain airway patency
- Administer antitoxin after sensitivity testing (if available)
- Initiate appropriate antibiotic therapy
- Monitor for complications, especially cardiac and neurological
Respiratory Management
- Position patient to optimize airway patency
- Administer oxygen as needed
- Prepare for possible intubation or tracheostomy
- Suction carefully to avoid dislodging pseudomembrane
- Perform regular respiratory assessments
Medication Administration
- Antitoxin: Administer diphtheria antitoxin (DAT) as soon as possible after sensitivity testing
- Antibiotics: Administer prescribed antibiotics (penicillin or erythromycin)
- Cardiac medications: As needed for myocarditis
- Other supportive medications: Antipyretics, analgesics as appropriate
Ongoing Nursing Care
| Nursing Care Domain | Interventions | Rationale |
|---|---|---|
| Infection Control |
|
Prevents transmission to healthcare workers and other patients. Diphtheria remains contagious until antibiotics have cleared the organism. |
| Cardiac Monitoring |
|
Myocarditis is a common complication, often appearing 1-2 weeks after symptom onset. Early detection can improve outcomes. |
| Nutritional Support |
|
Dysphagia is common in diphtheria. Adequate nutrition supports recovery. Neurological complications may affect swallowing. |
| Neurological Assessment |
|
Neurological complications can occur weeks after initial infection. Early detection allows for appropriate intervention. |
| Psychological Support |
|
Isolation and invasive procedures can be traumatic for children. Adequate support improves cooperation and reduces stress. |
Documentation and Monitoring
Critical Parameters to Document
- Vital signs trends, particularly respiratory rate and heart rate/rhythm
- Oxygen saturation levels
- Appearance and extent of pseudomembrane
- Neurological assessment findings
- Fluid balance
- Medication administration and response
- Isolation compliance
Warning Signs Requiring Immediate Attention
- Increasing respiratory distress
- Arrhythmias or ECG changes
- Hypotension
- New onset of neurological symptoms
- Decreased urine output
- Extension of pseudomembrane
Mnemonic: “DIPHTHERITIC” Care
- D – Droplet precautions for infection control
- I – Isolation until cultures are negative
- P – Position to maintain airway patency
- H – Heart monitoring for myocarditis
- T – Toxin neutralization with antitoxin
- H – Hydration and nutritional support
- E – ECG monitoring daily
- R – Respiratory assessment frequently
- I – Interventions for complications
- T – Therapy with appropriate antibiotics
- I – Intake and output monitoring
- C – Cranial nerve assessment
Nursing Management at Home
Post-Hospital Discharge Care
After hospital discharge, pediatric patients with diphtheria require continued monitoring and care. Nurses play a crucial role in educating families and providing home care instructions.
Home Care Instructions
- Complete the full course of prescribed antibiotics
- Monitor for signs of complications, particularly cardiac and neurological
- Ensure adequate rest during recovery period
- Maintain good nutrition and hydration
- Follow isolation recommendations until cleared by healthcare provider
- Keep follow-up appointments for cardiac evaluation
Warning Signs to Report
- Difficulty breathing or swallowing
- Chest pain or palpitations
- Unusual fatigue or weakness
- Numbness or tingling in extremities
- Vision changes or difficulty focusing
- Trouble walking or coordination problems
- Return of fever or sore throat
Convalescent Care
Recovery Timeline After Diphtheria
Week 1-2
- Continue antibiotics
- Rest and limited activity
- Monitor for cardiac issues
Week 2-4
- Gradual increase in activity
- Cardiac follow-up
- Watch for neurological symptoms
Week 4-8
- Neurological assessment
- Return to school (if cleared)
- Continue follow-up
Week 8+
- Final cardiac clearance
- Resolution of neurological symptoms
- Review vaccination status
Activity Recommendations
- Limit physical activity, especially during weeks 1-2 after discharge
- Gradually increase activity as tolerated and as advised by healthcare provider
- Avoid competitive sports until cleared by cardiologist (usually 6-8 weeks)
- Schedule rest periods throughout the day
- Return to school only when cleared by healthcare provider and no longer infectious
Nutritional Support
- Provide soft, easily swallowed foods if dysphagia persists
- Ensure adequate protein intake to support healing
- Maintain good hydration (6-8 glasses of fluid daily)
- Small, frequent meals if appetite is poor
- Monitor weight weekly and report significant changes
Family Education
Key Educational Topics
Effective family education is critical for successful home management of diphtheria recovery. Nurses should ensure families understand:
- The disease process and expected recovery timeline
- Importance of completing all medications as prescribed
- How to recognize complications requiring medical attention
- Importance of follow-up appointments
- Infection control measures to prevent transmission
- Importance of vaccination for all family members
Medication Management
- Teach proper administration of prescribed antibiotics
- Emphasize the importance of completing the full course
- Explain potential side effects and when to report them
- Create a medication schedule or chart
- Discuss potential drug interactions
Home Infection Control
- Separate personal items (towels, utensils, etc.)
- Proper hand hygiene for all family members
- Disinfection of frequently touched surfaces
- Management of laundry and waste
- Visitor restrictions as advised
Important Reminders for Parents
- Diphtheria can cause delayed complications, even weeks after apparent recovery
- Children should avoid strenuous activities until cleared by their physician
- Close contacts should be evaluated and possibly treated with antibiotics
- Keep a log of symptoms, medications, and concerns to share at follow-up appointments
- Have emergency contact information readily available
Prevention Strategies
Vaccination
Vaccination is the cornerstone of diphtheria prevention. The diphtheria toxoid is typically administered as part of combination vaccines.
| Vaccine Type | Age Group | Schedule | Notes |
|---|---|---|---|
| DTaP (Diphtheria, Tetanus, acellular Pertussis) | Infants and children under 7 years | 2, 4, 6, 15-18 months, 4-6 years | Primary series for children |
| Tdap (Tetanus, diphtheria, acellular pertussis) | Adolescents and adults | 11-12 years, then every 10 years | Booster dose with reduced diphtheria toxoid |
| Td (Tetanus, diphtheria) | Adults | Every 10 years after initial Tdap | Maintenance boosters |
| DT (Diphtheria, Tetanus) | Children under 7 years | As per DTaP schedule | For children who cannot receive pertussis component |
Nursing Role in Vaccination
- Educate families about the importance of diphtheria vaccination
- Address vaccine hesitancy with evidence-based information
- Maintain accurate immunization records
- Identify and reach out to undervaccinated populations
- Administer vaccines according to recommended schedules
- Monitor for and report adverse reactions
Health Education
Community Education
- Raise awareness about diphtheria and its prevention
- Conduct educational sessions in schools and community centers
- Distribute informational materials in multiple languages
- Use social media and other platforms to disseminate accurate information
- Engage community leaders in promoting vaccination
Individual Education
- Educate about respiratory hygiene practices
- Teach proper hand washing techniques
- Explain importance of avoiding close contact with infected individuals
- Clarify misconceptions about vaccines
- Provide information on when to seek medical care
Special Populations
Prevention Strategies for Vulnerable Groups
Immunocompromised Children
- Ensure “cocoon” vaccination of all contacts
- Extra vigilance with respiratory hygiene
- Early medical attention for exposures
- Individualized vaccination planning
Refugee and Migrant Children
- Screening upon entry
- Catch-up vaccination programs
- Culturally appropriate education
- Coordination with relief agencies
Unvaccinated Communities
- Targeted outreach programs
- Culturally sensitive education
- Mobile vaccination clinics
- Community leader engagement
Preventive Measures for Healthcare Workers
- Maintain up-to-date diphtheria vaccination (Tdap/Td boosters)
- Use appropriate personal protective equipment when caring for suspected cases
- Practice strict hand hygiene and infection control measures
- Understand and follow isolation protocols
- Report exposures promptly for possible prophylaxis
- Participate in surveillance and reporting systems
Mnemonic: “PREVENT” Diphtheria
- P – Promote vaccination for all ages
- R – Respiratory hygiene education
- E – Encourage booster doses
- V – Vigilant surveillance systems
- E – Early identification of cases
- N – Notify authorities of suspected cases
- T – Targeted education for vulnerable groups
Control Measures
Case Management
Prompt and appropriate management of diphtheria cases is essential for controlling transmission and preventing outbreaks.
Isolation Protocols
- Isolate suspected cases immediately
- Implement droplet precautions
- Continue isolation until:
- 14 days after antibiotic treatment initiation, OR
- Two negative cultures taken 24 hours apart
- Limit patient movement and transport
- Dedicated equipment and proper disinfection
Treatment for Control
- Antitoxin: Neutralizes circulating toxin (doesn’t affect toxin already bound to tissues)
-
Antibiotics: Eradicates the organism, stops toxin production, and limits transmission
- Penicillin G: 100,000-150,000 units/kg/day for children
- Erythromycin: 40-50 mg/kg/day for 14 days
- Supportive care: Maintains physiological function during recovery
Nursing Care for Control
Nurses play a pivotal role in diphtheria control through:
- Strict adherence to isolation and infection control procedures
- Proper collection of diagnostic specimens
- Timely and accurate administration of antitoxin and antibiotics
- Monitoring for treatment response and complications
- Documentation of case details for epidemiological investigation
- Patient and family education about preventing transmission
Contact Management
| Contact Type | Assessment | Interventions |
|---|---|---|
| Household Contacts |
|
|
| Close Contacts (School, Daycare) |
|
|
| Healthcare Workers |
|
|
Common Prophylactic Regimens
- Erythromycin: 40-50 mg/kg/day (max 2g/day) in 4 divided doses for 7-10 days
-
Penicillin G benzathine (IM):
- Children <30kg: 600,000 units as a single dose
- Children/Adults ≥30kg: 1.2 million units as a single dose
- Alternative (penicillin allergy): Azithromycin 12 mg/kg (max 500mg) once daily for 5 days
Outbreak Management
Surveillance and Reporting
- Immediate reporting of suspected cases to public health authorities
- Active case finding in affected communities
- Enhanced surveillance in healthcare facilities
- Monitoring of contacts for secondary cases
- Laboratory confirmation of cases
Mass Vaccination Campaigns
- Identify target population based on outbreak characteristics
- Rapid deployment of vaccination teams
- Focus on undervaccinated groups
- Coordinate with schools, community centers, and religious institutions
- Monitor vaccine coverage and effectiveness
Nursing Role in Outbreak Control
Clinical Role
- Case identification
- Specimen collection
- Patient isolation
- Treatment administration
- Contact tracing support
Public Health Role
- Mass vaccination campaigns
- Community education
- Surveillance activities
- Risk communication
- Resource distribution
Administrative Role
- Data collection and reporting
- Protocol development
- Staff education
- Resource management
- Interdisciplinary coordination
Mnemonic: “CONTROL” Diphtheria Outbreaks
- C – Case identification and isolation
- O – Obtain specimens for laboratory confirmation
- N – Notify public health authorities immediately
- T – Trace and manage contacts
- R – Review vaccination status of population
- O – Organize mass vaccination if needed
- L – Launch public education campaigns
Helpful Mnemonics
Mnemonics can be valuable tools for nursing students to remember key aspects of diphtheria identification, management, and prevention.
Clinical Features: “DIPHTHERIA”
- D – Difficulty swallowing
- I – Inflammation of throat
- P – Pseudomembrane formation
- H – Hoarseness or voice changes
- T – Temperature elevation (mild fever)
- H – “Hemorrhagic” toxicity (systemic effects)
- E – Edema of the neck (“bull neck”)
- R – Respiratory distress
- I – Increasing heart rate
- A – Airway obstruction (late stage)
Complications: “TOXIC”
- T – Throat obstruction (respiratory compromise)
- O – Organ damage (kidneys, liver)
- X – Xyloid process pain (myocarditis)
- I – Impaired nerve function (neuropathy)
- C – Cardiac conduction abnormalities
Nursing Priorities: “MEMBRANE”
- M – Monitor respiratory status continuously
- E – Evaluate cardiac function
- M – Maintain isolation precautions
- B – Balanced hydration and nutrition
- R – Rapid administration of antitoxin and antibiotics
- A – Airway management preparation
- N – Neurological assessment
- E – Education for patient and family
Prevention: “VACCINATE”
- V – Verify immunization history
- A – Administer age-appropriate vaccines
- C – Community education campaigns
- C – Check for contraindications
- I – Implement booster schedules
- N – Note adverse reactions
- A – Address vaccine hesitancy
- T – Track coverage rates
- E – Ensure herd immunity
Diagnostic Approach: “DETECT”
- D – Dysphagia and difficulty breathing need assessment
- E – Examine thoroughly for pseudomembrane
- T – Take proper specimens for culture
- E – Evaluate vaccination history
- C – Check for complications early
- T – Toxin effects require monitoring
References
- World Health Organization. (2018). Diphtheria vaccine: WHO position paper – August 2017. Weekly Epidemiological Record, 93(31), 417-435. https://www.who.int/publications/i/item/who-wer9331
- Centers for Disease Control and Prevention. (2021). Diphtheria. In Epidemiology and Prevention of Vaccine-Preventable Diseases (14th ed.). Public Health Foundation. https://www.cdc.gov/vaccines/pubs/pinkbook/dip.html
- American Academy of Pediatrics. (2021). Diphtheria. In Red Book: 2021-2024 Report of the Committee on Infectious Diseases (32nd ed., pp. 319-323). American Academy of Pediatrics.
- Hadfield, T. L., McEvoy, P., Polotsky, Y., Tzinserling, V. A., & Yakovlev, A. A. (2000). The pathology of diphtheria. The Journal of Infectious Diseases, 181(Suppl 1), S116-S120. https://doi.org/10.1086/315551
- Sharma, N. C., Efstratiou, A., Mokrousov, I., Mutreja, A., Das, B., & Ramamurthy, T. (2019). Diphtheria. Nature Reviews Disease Primers, 5(1), 81. https://doi.org/10.1038/s41572-019-0131-y
- Wagner, K. S., White, J. M., Lucenko, I., Mercer, D., Crowcroft, N. S., Neal, S., & Efstratiou, A. (2012). Diphtheria in the postepidemic period, Europe, 2000-2009. Emerging Infectious Diseases, 18(2), 217-225. https://doi.org/10.3201/eid1802.110987
- Heymann, D. L. (Ed.). (2015). Control of Communicable Diseases Manual (20th ed.). American Public Health Association.
- Meade, B. D., & Bollen, W. A. (1994). Recommendations for use of the polymerase chain reaction in the diagnosis of Bordetella pertussis infections. Journal of Medical Microbiology, 41(1), 51-55. https://doi.org/10.1099/00222615-41-1-51
- Tiwari, T., & Wharton, M. (2018). Diphtheria toxoid. In S. A. Plotkin, W. A. Orenstein, P. A. Offit, & K. M. Edwards (Eds.), Plotkin’s Vaccines (7th ed., pp. 261-275). Elsevier.
- World Health Organization. (2017). Operational protocol for clinical management of Diphtheria. Bangladesh, Cox’s Bazar. https://www.who.int/health-cluster/resources/publications/WHO-operational-protocols-diphtheria.pdf