eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Chicken Pox or Varicella: Follow-up

Author: Richard Lichenstein, MD, Associate Professor, Pediatric Emergency Department, University of Maryland School of Medicine
Contributor Information and Disclosures

Updated: Sep 17, 2008

Follow-up

Further Inpatient Care

• Inpatient care requires strict isolation from other patients and susceptible healthcare workers. A negative pressure room is ideal.
  

Further Outpatient Care

• Warm soaks and oatmeal or cornstarch baths may reduce itching and provide comfort.
• Topical calamine lotion may produce caking of lesions and excessive drying of the skin, causing the child to scratch.

Transfer

• Most cases of hospitalized uncomplicated varicella do not require transfer to a tertiary care pediatric facility.
• Immunocompromised children with varicella may develop significant morbidity and mortality and should be transferred to a tertiary care pediatric center.
• Similarly, patients with complications of varicella, such as pneumonia, encephalitis, or severe skin manifestations such as necrotizing fascitis, should be transferred to a tertiary pediatric facility.

Deterrence/Prevention

• For susceptible individuals (see below) passive immunization with VZIG is effective against varicella if given within 96 hours of exposure.
  • Immunocompromised children
  • Susceptible pregnant women
  • Newborns whose mothers had varicella within 5 days prior to delivery or within 48 hours after delivery
• Hospitalized premature infants of 28 weeks' gestation or fewer whose mothers have no history of varicella infection. Also, VZIG should be given to hospitalized premature infants (28 wk gestation or fewer or fewer than 1000 g) regardless of maternal history when a significant exposure has occurred.
• The new recommendations for varicella vaccine include implementation of a routine 2-dose varicella vaccination program for children, with the first dose administered at age 12-15 months and the second dose at age 4-6 years and a second dose catch-up varicella vaccination for children, adolescents, and adults who previously had received 1 dose and routine vaccination of all healthy persons aged ³ 13 years without evidence of immunity.¹
• From age 13 years to young adulthood, varicella vaccine can be given to individuals without prior infection or immunization (2 doses separated by 4-8 wk).
• There should be prenatal assessment and postpartum vaccination with varicella vaccine.
• Varicella vaccine use should be expanded for HIV-infected children with age-specific CD4⁺ T lymphocyte percentages of 15-24% and adolescents and adults with CD4⁺ T lymphocyte counts 200 cells/microL or greater.
• US middle school, high school, and college entry vaccination requirements now include varicella immunization or immunity.

Complications

• In immunocompetent children, complications are rare. Skin superinfection is manifested by impetigo, furuncles, cellulitis, and erysipelas. The most severe complication is necrotizing fascitis.
• The most common complication is scarring and may be associated with staphylococcal or streptococcal infections from scratching.
• Extracutaneous complications increase proportionately to the age of the patient.
• Neurologic complications include Reye syndrome, acute cerebellar ataxia, encephalitis, meningoencephalitis, polyradiculitis, and myelitis (including Guillain-Barré syndrome).
• Other rare complications include myocarditis, glomerulonephritis, appendicitis, pancreatitis, Henoch-Schönlein purpura, orchitis, arthritis, osteomyelitis, optic neuritis, iritis, and keratitis.
• Varicella pneumonia is a complication usually of adult varicella and occurs in 1:400 cases.
• Immunocompromised children with varicella are at high risk for developing progressive varicella with multiple organ involvement.

Prognosis

• The prognosis of uncomplicated varicella is excellent.
• The mortality rate of adult varicella pneumonia is as high as 10% in immunocompetent patients and as high as 30% in immunocompromised patients.
• Immunocompromised children with varicella have significant morbidity and mortality.
• Infection confers life-long immunity, although secondary reinfection has been reported.
• Rarely, fatalities may occur from complications.

Patient Education

• To avoid Reye syndrome, use acetaminophen for fever. Do not use aspirin.
• Drink plenty of fluids.
• Keep nails short and have child wear socks on hands at bedtime to avoid scratching.
• Use medication for itching as needed.
• Children with chickenpox should avoid nonimmune pregnant women, unimmunized young infants, and others with immunodeficiencies or who are taking prednisone long term.
• Children with chickenpox may not return to school or day care until all lesions are crusted over.
• Families should be instructed to seek medical care if any of the following occur:
  • The blisters look infected.
  • A change in the child's behavior occurs.
  • Blisters are observed in the child's eyes.
  • The child has trouble breathing.
  • The child has a severe headache or has trouble walking.
  • The fever persists after the third day, or the fever was gone and then came back.
• For excellent patient education resources, visit eMedicine's Bacterial and Viral Infections Center. Also, see eMedicine's patient education articles Chickenpox and Skin Rashes in Children.

Miscellaneous

Medicolegal Pitfalls

• Although varicella is a self-limited illness of childhood, several medical legal pitfalls should be considered.
  • Problems arise when hospitalized patients who have been exposed to varicella are not appropriately isolated from high-risk inpatients who are immunocompromised. Mortality and morbidity rates from varicella are increased in immunocompromised children.
  • Failure to recognize streptococcal or staphylococcal superinfection and the need for antibiotics is also a pitfall.

Special Concerns

• Varicella in pregnancy is of special concern because it can lead to intrauterine varicella or varicella of the newborn.
  • Intrauterine varicella during the first 20 weeks of gestation may lead to congenital anomalies including limb atrophy, neurologic and ocular abnormality, and growth retardation of the neonate.
  • Infants born at term to mothers who had onset of a varicella rash within 5 days before and 2 days after delivery may develop a fatal form of varicella (varicella neonatorum). This occurs because of the infant does not receive transplacental V-Z antibody.
  • If varicella exposure to the infant occurs after the tenth day of life, the illness is usually benign and self-limiting.

• Search for CME/CE on This Topic »

• Ellis-van Creveld Syndrome (Pediatrics: Genetics and Metabolic Disease)
• Ethical and Legal Considerations in Pediatric Surgery (Pediatrics: Surgery)
• Syndrome of Inappropriate Antidiuretic Hormone Secretion (Pediatrics: General Medicine)
• Pediatrics, Apnea (Emergency Medicine)

• Chickenpox Causes
• Bacterial and Viral Infections Center
• Chickenpox Overview
• Chickenpox Symptoms
• Chickenpox Treatment
• Skin Rashes in Children Introduction

• American Academy of Pediatrics Updates Flu Recommendations
• Guidelines Issued for Hearing Assessment in Infants, Children Beyond Neonatal Screening
• Guidelines Updated for Use of Palivizumab to Prevent RSV Infections

• Essential Resources for Pediatrics
• Pacemaker and Defibrillator Therapy in Pediatrics and Congenital Heart Disease
• Improving Pediatrics Medication Safety Part I: Research on Medication Errors and Recommendations from the Joint Commission

• Pediatrics/Neonatal Care Nursing Resource Center
• Growth and Development