ACUTE RESPIRATORY TRACT INFECTIONS IN CHILDREN: OUTPATIENT MANAGEMENT Daniel YT Goh, Lynette PC Shek, Lee Bee Wah Acute respiratory tract infections are the most common illnesses in childhood, comprising as many as 50% of all illnesses in children less than 5 years old and 30% in children aged 5 – 12 years. Multiple factors determine the frequency and nature of these illnesses. These include host factors, environmental factors and infecting agents. The common acute respiratory tract infections will be individually discussed, highlighting the diagnostic features and current management guidelines. Contents • Classification of acute respiratory tract infections • Clinical features • Common pathogens • Clinical course • Management guidelines • Issues encountered in family practice

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Classification

Clinical features

Acute Infective Rhinitis (the Common Cold)

• Nasal stuffiness, sneezing, rhinorrhoea • Fever, malaise and muscular aches in more severe infections • Purulent discharge does not necessarily indicate secondary bacterial infection as desquamated epithelial and inflammatory cells can produce it. • Sometimes a cough may be present indicating some inflammation of the larynx, trachea or bronchi.

Pharyngitis & Tonsillitis

Most prevalent in children between 4 to 10 years of age. • Sore throat • Cough, • Fever, malaise, nasal stuffiness • Pharyngeal erythema ± tonsillar redness/swelling and exudates • Cervical lymphadenopathy • Presence of nasal stuffiness and cough are more typical of viral infection although occurring in 20% of Streptococcal pharyngitis.

Otitis Media

• Earache • Fever • Red and bulging tympanic membrane, ± presence of fluid in the middle ear, ± ear discharge, ear itch. In younger children, irritability, restlessness, crying and sometimes pulling at the ear may be the only symptoms. NB: Mild peripheral injection of the eardrum can occur as a result of crying.

Acute Sinusitis

No clinical finding is diagnostic of acute sinusitis. Suggestive clinical features include: • Purulent nasal discharge • Facial pain and tenderness • Periorbital swelling • Headache/toothache • Fever Symptoms should be present for at least 7 days.

Laryngotracheobronchitis

Peak age group 1 to 2 years (6 mths to 6 yrs range). • Antecedent URTI symptoms • Stridor • Hoarseness of voice • Barking cough May have respiratory distress but usually not very febrile or toxic

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Classification

Clinical features

Epiglottitis

Uncommon in our local population. Most common between 3-4 years old. May have preceding URTI. Acute onset with rapid progression within 3-4 hours • Fever, ill, lethargic • Voice and dry muffled • Refusal to eat or drink • Drooling of saliva • May have inspiratory stridor • Cough is usually not a prominent feature

Acute Bronchitis

• • • •

Acute Bronchiolitis

Affects children < 24 mths old, mainly between 1 to 6 months of age. Usually preceded by upper respiratory tract symptoms • Fever • Cough • Respiratory distress • Wheezing and • Difficulty feeding Chest hyperinflation with subcostal retractions, fine crackles, + rhonchi. Young infants (especially premature babies) may present with apnea. Cyanosis may occur in severe cases.

Pneumonia

• • • • • •

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Productive cough Rhonchi Fever Tachypnea ± crackles

Fever Cough Tachypnea Constitutional symptoms. Crackles Signs of consolidation

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Classification

Common Pathogens

Clinical Course

Acute Infective Rhinitis (the Common Cold)

• >90% are viral (Rhinovirus, adenovirus, RSV, parainfluenza, influenza viruses) • Occasionally bacterial agents include: Streptococcus pneumoniae, Hemophilus influenzae, Moraxella catarrhalis

• Symptoms last 1-2 days but may persist up to 1 –2 weeks. • Nasal discharge may continue, becoming mucopurulent or purulent.

Pharyngitis & Tonsillitis

• Predominantly viruses • Group A b -hemolytic streptococcus is the main bacterial cause.

• Fever and symptoms often resolve between 3 to 5 days from onset.

Otitis Media

• Streptococcus pneumoniae, Hemophilus influenzae, Moraxella catarrhalis, GroupA b -hemolytic Streptococcus • Respiratory viruses

• The earache usually subsides within 8 hours of initiation of appropriate antibiotic therapy.

Acute Sinusitis

• Streptococcus pneumoniae, Hemophilus influenzae, Moraxella catarrhalis. • Other organisms include a hemolytic streptococci and respiratory viruses.

Laryngotracheobronchitis

• Mainly viruses • Most commonly the parainfluenza virus.

• Stridor and breathlessness usually improve in 1 to 2 days. • The dry cough may persist for up to 2 weeks. • In younger children (especially 1week o Prolonged symptoms > 1 week o Elevated total white cell count o And CXR showing consolidation

• Most infants recover within a week and 10 days • Some may have persistent cough for up to 3 weeks.

Pneumonia

< 2 years • Predominantly viral: • Respiratory syncytial virus • Influenzae virus • Parainfluenzae virus • Adenovirus 2 years • Viruses & bacteria: • Streptococcal pneumoniae (most common) • Mycoplasma pneumoniae (esp 5 to 15 yrs) • Hemophilus influenzae • Moraxella catarhalis • Staphylococcus aureus (usually younger and more ill) • b -hemolytic streptococci

• An elevated white cell count may be more indicative of bacterial infections(usually>15,000/mm3). Viral and Mycoplasma infections more often do not have elevated white cell counts. • Viral and Mycoplasma pneumonias may take 2 to 3 weeks to resolve. • Streptococcal pneumonia usually resolve within 7 to 10 days. • Staph. aureus frequently slower to resolve.

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Classification

Management guidelines

Important notes

Acute Infective Rhinitis (the Common Cold)

• Use of antibiotics has no significant benefit and may cause side-effects. • Presence of mucopurulent rhinitis is not an indication for antibiotic therapy. • Symptomatic treatment: paracetamol, topical vasoconstrictor nasal drops. • Antihistamines or pseudoephedrine not shown to be beneficial.

• In very young babies who are obligate nose breathers, nasal obstruction may impair feeding. • Hospitalization may be necessary if child is unable to feed.

Pharyngitis & Tonsillitis

• Symptomatic treatment. • Penicillin if Streptococcus suspected • This is suggested by the presence of tender cervical lymphadenopathy in a child > 4years old. • If Penicillin allergic, use Erythromycin.

• Important to distinguish from EpsteinBarr virus infection (Infectious Mononucleosis). • In many communities, the risk of acute glomerulonephritis and rheumatic fever is less than the risk of severe allergic reactions to penicillin. • Suppurative complications of streptococcal infections eg. Peritonsillar abscess, retropharyngeal abscess, mastoidits are very rate.

Otitis Media

• Amoxycillin is 1st line antibiotic. • In patients who are penicillin-allergic, trimethoprim-sulphasoxazole is the drug of choice. • Second line antibiotics include amoxycillin/clavulanate, ampicillin/salbactam or a cephalosporin

• Children under the age of 2 yrs are at higher risk of developing recurrent episodes, chronic otitis media and serious septic complications.

Acute Sinusitis

• Amoxycillin is 1st line antibiotic • If allergic to penicillin, trimethoprimsulphamethoxazole is the drug of choice. • 2nd line:amoxycillin/clavulanate , ampicillin/salbactam, or cephalosporin. • Symptomatic: decongestants.

• Antibiotics useful because of majority are bacterial • 2nd line antibiotic if no response by 72 hours of therapy • duration of therapy 7 to 10 days • if patient better but still symptomatic by 10 days, continuation of antibiotics for another 7 days is recommended • surgical drainage rarely needed in children.

Laryngotracheobronchitis

• • • • •

• Important to exclude other differentials which are medical emergencies. • Foreign body aspiration, epiglottis, bacterial tracheitis, retropharyngeal abscess.

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Antibiotics are not indicated. Secondary bacteria infection is rare. In severe cases a single dose of oral Dexamethasone (0.3 mg/kg) or nebulised Budesonide (2000 mcg) is useful.

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Classification

Management guidelines

Epiglottitis

• Parenteral third generation cephalosporin [100mg/kg stat] (Ceftriaxone or Cefotaxime) to be given as soon as diagnosis made. •

Acute Bronchitis

• Antibiotics not routinely recommended. • Macrolide if Mycoplasma suspected. • Cough mixtures not beneficial • Trial of bronchodilators (oral or inhaled) may be beneficial if wheezing is present.

Acute Bronchiolitis

• Antibiotics are not indicated. • Bronchodilators may be beneficial in some infants but should be driven by oxygen (in more severe cases) to prevent worsening hypoxia from V/Q mismatch. • Theophylline and steroids have not been shown to be beneficial

Pneumonia

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• Amoxycillin is the antibiotic of first choice. • Macrolides if Mycoplasma suspected. • Macrolides can also be used if Penicillin allergic • 2nd line antibiotics :Amoxycillin/clavulanate, Ampicillin/Sulbactam, Cephalosporin.

Important notes • This is a medical emergency. Immediate referral to hospital. • May need to urgently secure airway under controlled conditions • Do no do lateral neck x-ray or attempt visualization of larynx/epiglottis • Repeated episodes of ‘acute bronchitis’ may be a manifestation of asthma.

• High risk patients (for respiratory failure): • underlying congenital heart disease • immunodeficiency • immunosuppressive therapy • neuromuscular disease • These patients are likely to require hospitalization for monitoring. • Although viruses are major causes of pneumonia in infants and young children, there is no simple and rapid method to distinguish viral from bacterial infection and mixed infection is not uncommon. • Pneumonia should always be considered potentially bacterial and patient treated with antibiotics. • High risk antibiotic resistance: • Child-care-going child • Recent antibiotic use

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Issues frequently encountered in family practice 1.

How frequent is too frequent? a. URTIs account for a high proportion of clinic visits to the family practitioner. Children younger than 5 years of age experience 3 to 8 episodes of URTI per year. The frequency may be as high as once a month especially if the child is attending school, day-care or has a sibling attending school. Importantly, most these episodes are minor, short-lived and self-limiting colds or sorethroats. The child should also be symptomatically well between episodes and growing satisfactorily. b. The peak incidence for LRTIs is in the first year of life after which the incidence falls progressively throughout childhood.

2.

When are antibiotics necessary? The majority of URTIs are caused by viruses. Hence antibiotics are not usually necessary. In fact meta-analysis of randomised clinical trials have failed to demonstrate that antibiotics prevent LRTI. The issue of increasing resistant strains of bacteria is becoming an alarming problem worldwide. Specific indications for antibiotics are summarized under the management section.

3.

When do we suspect it is more than just a simple URTI? Refer flow chart.

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Acute Respiratory Tract Infections in Children: Overall Management Algorithm

Suspected Respiratory Tract Infection Presence of one or more of the following: Cough, runny-nose, sorethroat, chest pain, breathlessness, noisy breathing, fever.

Determine if infection mainly localized to Upper or Lower Respiratory Tract Presence of symptoms of chest pain, breathlessness, wheezing, stridor ± Signs crackles, rhonchi, retractions, bronchial breath sounds

NO

YES

Likely URTI

Likely LRTI*

Determine: Otitis Media Sinusitis Pharyngitis/tonsillitis Rhinitis

Determine: Epiglottitis ALTB Bronchitis Bronchiolitis Pneumonia

* Important to differentiate exacerbation of asthma triggered by viral infections. Indications for Chest X-rays: 1. Suspected Pneumonia 2. Suspected foreign body aspiration 3. Severe lower respiratory tract infection

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Indications for hospitalization: 1. Inability to feed orally with risk of dehydration 2. Difficulty in breathing with risk of respiratory failure 3. Clinical course not consistent with primary diagnosis or child not responding to appropriate therapy 4. Suspected foreign body aspiration

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