Introduction Acute respiratory infections (ARI) are a major cause of morbidity and mortality in young children world wide.

They account for nearly 3.9 million deaths every year globally. On an average a child has 5 to 8 attacks of ARI annually. ARI accounts for 30-40% of the hospital visits by children in office practice.
Classification

ARI is classified based on the site of infection as Acute Upper Respiratory Infections (AURI) and Acute Lower Respiratory Infections (ALRI). AURI includes nasopharyngitis, pharyngotonsillitis and otitis. ALRI includes epiglottitis, laryngitis, laryngo tracheitis Bronchitis, Bronchiolitis and pneumonia Acute Upper Respiratory Infections Infections of the upper respiratory tract are very common in childhood. They constitute a major sector of the illness in Pediatric Office practice. Though mostly self limiting, they are a leading cause of morbidity like deafness and learning handicaps.
Note:

Beware of serious conditions like measles, mumps and diphtheria which may begin as nasopharyngitis. Blood stained nasal discharge especially unilateral, may indicate conditions like diphtheria or foreign body (old) and hence needs ENT evaluation. Sinusitis, serous otitis media or acute lower respiratory infections are common complications following nasopharyngitis. Clinically viral pharyngotonsillitis is indistinguishable from bacterial pharyngotonsillitis.

Acute Upper Respiratory Infections (AURI) Site Common Organisms Pattern Recognition NasoVIRAL: (commonest) *Seasonal (winter) *outbreaks Pharyngitis Rhinovirus, in community *Prodrome: (Common Adenovirus, Fever sneezing, rhinorrhea, cold) Coronavirus Coxsackie lacrimation, nasal obstruction virus Influenza virus * Worsening of above symptoms BACTERIAL: * Increasing fever and Gp. A.. Hemolyticconstitutional symptoms streptococci *Purulent nasal discharge Mycoplasma *Poor activity and appetite coryne bacteria H. Influenza

Therapy Self limiting Paracetamol 50 mg/kg in 3-4 div doses Normal saline nasal drops/spray 3-4 times a day. In infants, ten minutes before feeding. Penicillins (Amoxycillin 50mg /kg/d in 3-4 divided doses for 5 days) OR Macrolides

Strep. Pneumonia

Pharyngo Tonsillitis

VIRAL: (commonest) Rhinovirus, Adenovirus, Coronavirus Coxsackie virus Influenza virus BACTERIAL: Gp. A.. Hemolytic Streptococci Mycoplasma coryne bacterium Diphtheria

*Seasonal (winter) *Prodrome: Fever, cough, sore throat rhinitis *Throat: exam: Pharynx inflammed,exudates on the lymphoid follicles on hard palate and tonsils,cervical adenopathy, lymphocytosis *Over crowding *Prodrome: Headache vomiting, abdominal pain, fever > 40C,poor appetite & activity *Throat exam: Tonsils enlarged,anterior pillar flushing, anterior cervical adenopathy, petichiae over the soft palate. *Neutrophilic leuco-cytosis. (Throat swab culture and sensitivity is warranted)

(Erythromycin 50 mg /kg/d in 3-4 divided doses for 5 days) Warm liquid diet Saline gargle Paracetamol 50 mg /kg/d 3-4 divided doses to reduce pain Steam inhalation Penicillins (Penicillin V 50 mg /kg/d 3-divided doses for 5 days) before food or Macrolides Erythromycin 50 mg/kg/d 3-4 divided doses x 5 days

Note:

Rhinitis, hoarseness of voice and cough rarely occurs in bacterial and presence of 2 out of these indicates viral origin. Examination of the throat using tongue depressor is mandatory in all cases presenting with soreness of throat (exception acute epiglottitis). Presence of membranous exudate over the tonsils indicates conditions like diphtheria, herpangina, infectious mononucleosis, and agranulocytosis and warrants investigation (CBC, throat swab).

Beware of complications like otitis media, chronic pharyngeal ulcers, peritonsillar abscess following attack of pharyngotonsillitis. Rheumatic fever and acute post streptococcal glomerular nephritis are Immunological complications of Gp A hemolytic streptococcal pharyngotonsillitis and hence whenever suspected, treatment with penicillin V for 10 days (Primary chemoprophylaxis for rheumatic fever) is mandatory.

Otitis Media: It is a common pediatric ailment. Frequent respiratory infections often leads to otitis media. The other predisposing factors include bottle feeding, recurrent tonsillitis, anatomical and physiological anomalies like cleft palate and cranio facial defects. Hearing defects,perforation and middle ear problems are common complications occurring due to lack of timely administration of medications.

Acute Upper Respiratory Infections

Otitis Media Site Common Organisms Bacterial: Streptococcus pneumoniae H. Influenza Moraxella catarrhalis Streptococcus Group A Staphylococcus

Otitis Media

Pattern recognition :

Signs Tender Swelling behind the ear

Classification

Treatment Give first dose of IV antibiotic Give paracetamol for pain relief Refer urgently to ENT Surgeon. Give Amoxycillin for 10 days or Cotrimoxazole 8 mg/kg of TM in 2 div doses Give paracetamol for relief of pain Dry ear by wicking Follow up after 5 days Dry the ear by wicking* Send an ear swab for culture and sensitivity Give antibiotics as per sensitivity pattern for 10 days ENT evaluation No additional treatment.

Mastoiditis

Pus is seen draining from the Earn and discharge is reported for < 14 days OR Ear pain Pus is seen draining from the Earn and discharge is reported for < 14 days No ear pain and no pus seen draining from the ear
Note:

Acute Ear Infection(ASOM) Chronic ear infection (CSOM) No ear infection

High pitched, incessant cry and tugging at the ears following an attack of upper respiratory infection indicates acute ear infection in neonates and infants. Otoscopic examination should routinely be done for all children presenting with an acute upper respiratory infection in Pediatric office practice. A bulging, opacified, discoloured ear drum through which the land marks are poorly visualized, with decreased mobility of the drum, defines acute otitis media The patient should be reevaluated within 30 days of starting therapy to determine the persistence of middle ear infection. Persistence of middle ear effusion for more than 8 weeks (glue ear) with an immobile tympanic membrane indicates chronic otitis media, requiring ENT surgeon consultation and intervention. Otorrhea > 14 days with tympanic membrane perforation or cholesteatoma, is a sequelae to ASOM and the patient should be referred to otorhinolaryngologist for evaluation and management. Children with recurrent otitis media or chronic otitis media require audiological evaluation.

Common Queries in the treatment of AURI Role of antihistaminic decongestant combinations in AURI There is lack of data on the efficacy, safety, and toxic potentials of such combinations. According to American Academy of Pediatrics Committee on Drugs rational therapeutics should not include such combinations.

Decongestant therapy in AURI There are topical and oral decongestants. Topical decongestants are generally preferred to oral decongestants.Normal saline nasal spray is the nasal (topical) decongestant preferred. Other nasal decongestants like oxymetazoline and xylometazoline are not preferred in pediatric office practice as they are notorious to cause rebound congestion and they also destroy the natural mucociliary mechanics. Oral decongestants like pseudoephedrine and phenyl propanolamine are less preferred in view of their systemic side effects like restlessness, sleep disturbance,agitation, tachycardia, headache and hypertension. Besides phenyl propanolamine is a powerful anorexiant. They are never

used in children under 6 months of age. However, they may be helpful in some older children with troublesome rhinorrhea. Role of antiinflammatory drugs in AURI Paracetamol is the analgesic and antipyretic of choice in AURI. There is no role for nonsteroidal antiinflammatory drugs in the management of pain in AURI. The popular practice of Asprin/Disprin throat gargle is strongly condemned. NSAIDS can precipitate bronchospasm in Atopic individuals.

Role of anti-histaminics in AURI Antihistaminics are ideally preferred in the management of allergic rhinitis which manifests as sneezing, nasal discharge, itching, conjunctival itching and lacrimation. There is no role for antihistamines in viral coryza. Promethazine and diphenhydramine are the anti-histaminics preferred in Pediatric office practice. Antihistamines should be avoided when ALRI is also coexisting as they dry up the secretions and may cause segmental atelectasis in the lungs. Acute Lower Respiratory Infections Acute upper respiratory infections (AURI) occur more commonly and are usually self limiting, while ALRI contributes to increased mortality. These include epiglottitis, laryngitis, laryngotracheitis, bronchitis, bronchiolitis and pneumonia. Pneumonia is the leading cause of death among ARI. Incidence of pneumonia is 3-4% in developed countries and ranges from 10-20% in the developing countries. Although it is mandatory to know the clinical features and management of individual types of Acute Lower Respiratory infections, pneumonia being the major killer. WHO, has provided guidelines to detect varying severity of ALRI having in mind pneumonia as the most important of the ALRI. Pediatric pneumonia:Pneumonia is infla-mmation of the lung parenchyma. Pediatric pneumonia has several causative agents. Pneumonia is a common illness in-children and is of two types. a) Community acquired pneumonia :they may have a "typical" or atypical presentation. Causes of Community acquired pneumonia: a. Mycoplasma pneumoniae (atypical) b.Streptococcus pneumoniae c.H.Influenza d. Chlamydia pneumoniae e.Staph Aureus f. Nocardia Spp g.Viruses Influenza CMV

RSV Measles Varicella-Zoster virus h. Fungi Histoplasma Coccidioidomycosis Blastomyces i. Mycobacterium tuberculosis j. Chlamydia psittaci b) Hospital acquired pneumonia (Nosocomial infection) :It tends to be more severe as the defence mechanisms of the host is usually compromised in these patients. The etiological agents in hospital acquired pneumonias are different from that in community acquired pneumonia. These include enteric gram negative Bacilli including Pseudomonas aeruginosa besides staph-aureus and anaerobes. Mode of infection: a) aspiration from oropharynx b) entry of the infected aerosol c) hematogenous spread d) direct inoculation Pattern Recognition: Pneumonia is included as one of the diseases in the integrated management of childhood illness and its pattern recognition and management is based on the WHO guidelines. The sick child should be classified into one of the following categories as per the guidelines: (Refer Table-1) 1. very severe disease 2. severe pneumonia 3. pneumonia 4. no pneumonia (cough or cold) AURI
Age 1.Very Severe Pneumonia Signs Treatment

Infants < 2 months 2 months to 5 years

Signs (as in 2 & 3 plus) Stopped feeding well Convulsions Abnormally sleepy or Difficult to wake Stridor or Fever or low body temperature

Hospitalise, ** Investigate Give first dose of antibiotic Keep infant warm Hospitalise (ICU set up) Administer parenteral

Not able to drink Convulsions Abnormally sleepy or Difficult to wake Severe malnutrition

antibiotic* Treat fever Treat wheeze

2. Severe Pneumonia

Infants <2 months Chest indrawing or Fast breathing (60 min or more)

(if recurrent wheezer treat for wheezing)

Hospitalise ** Investigate Keep infant warm Give first dose of parenteral antibiotic Hospitalise ** Investigate Give first dose of parenteral antibiotic* Treat fever with Paracetamol Treat wheeze ** Investigate Advise mother to give home care Give an antibiotic * Treat fever, if present Treat wheezing if present Advise mother to return within 2 days for reassurance or earlier if the child is getting worse.

2 months to 5 years
3. Pneumonia

Chest indrawing

2 months to 5 years

No chest indrawing Fast breathing ( 50/min or more if child is 2 to 12 month;40/ min or more If child 1 to 5 years).

4. No pneumonia (AURI) :

The above physical signs are absent. The mother must be advised to feed and keep the infants warm. Older children should be assessed for AURI. The mother should be taught to recognize signs of deterioration, and to return if there is a problem.

Diagnosis: The diagnosis of pneumonia in infants and children can be readily established by the patients history, physical examination and chest roentgenogram, but the microbial etiology of pneumonia is difficult to determine. Chest roentgenogram does not always distinguish viral from bacterial pneumonia. Blood cultures may be positive only in 5-10% of the cases. Rapid bacterial antigen detection is test in serum, urine and pleural fluid may be positive in as many as 25% but is not specific for the bacterial etiology of pneumonia.

Guidelines for hospitalization in a patient presenting with pneumonia a. Associated conditions (diabetes mellitus, neoplasm, immunosuppression, heart or kidney

involvement) b. If the suspected cause is staph aureus, gram negative or anaerobes c. Severe leukopenia (< 500 wbc/ml) d. Inability to take oral medications or failure of outpatient management e. Tachypnea Tachycardia Hypotension (<90 mm of Hg systolic) Hypoxemia (PaO2 < 60 mm of Hg) f. Altered mental status g. Associated suppurative conditions like septic arthritis, meningitis, empyema. Treatment:The decision to give antimicrobial therapy is most often based on the physicians assessment of the probability of bacterial infection. This decision and the choice of antibiotic therapy is based on the clinical findings (severity of illness), the most likely organism for the patients age, immunological competence of the host, and epidemiological factors. (Refer Table - 2) Duration of therapy:A total duration of 7-10 days therapy is recommended for treating uncomplicated pneumonia. Those with complications like pleural effusion, or empyema require 2 to 4 weeks of therapy. Nosocomial or hospital acquired pneumonia:Nosocomial viral respiratory infections are common in winter and are caused by RSV or influenza viruses. Hospital acquired bacterial pneumonias commonly occur in children who are intubated and are receiving mechanical ventilation. Fever, change in the character of the sputum and newer pulmonary infiltrates on the chest roentgenogram suggest possible pneumonia in such patients. The bacterial etiologic agents are those that colonise the orotracheal airway. Initially antibiotic therapy is directed against the organisms colonising the host and the known nosocomial pathogens within the ICU. In general an aminoglycoside is included in the initial antibiotic regimen, since gram negative organisms commonly colonise in this setting. If MRSA is endemic within the unit, vancomycin is used. Pneumonia in the immuno compromised host:Patients who are immunocompromised as in those with HIV infection or on chemotherapy for leukemia or those who develop neutropenia, are susceptible to gram negative bacterial infections.A combination of an aminoglycoside (gentamicin, amikacin) and an extended spectrum of - lactiam, such as mezlocillin, piperacillin or ceftazidime is appropriate. Addition of antistaphylococcal agent is to be considered if the child has an indwelling central line and thus is prone to G+ bacteremia. Infection with pneumocystis carinii is suspected in these individuals who present with cough, fever, exertions/dyspnea hypoxia and diffuse alveolar infiltrates. Parenteral co-trimoxazole (20 mg/kg of

TMP) is the drug of choice. Amphotericin B is indicated for children with suspected or proven fungal pneumonia. S.pneumoniae and H.influenza are predominant pathogens in children with AIDS. Cefuroxime is an appropriate choice for initial therapy.

Other conditions: Pleural fluid:A diagnostic thoracocentesis, is indicated initially for cultures and other microbiologic tests, cell count and chemical tests (protein, glucose, pH). Therapeutic drainage is indicated in empyema. Supportive care:

Maintenance of adequate oxygenation Hydration Acid-base balance Respiratory failure necessitates intubation and mechanical ventilation Symptomatic therapy with antipyretics and nebulization with salbutamol.

Tuberculin test: The possibility of Tuberculosis should always be considered in a child with pneumonia. Mantoux test is indicated if the child does not respond to initial antibiotic therapy as expected or if there is a history of possible exposure to a person with tuberculosis. Second chest Roentgenogram: If a normal child with pneumonia responds promptly to antibiotic therapy, is clinically well and has normal physical findings at follow-up, another chest roentgenogram at 6 weeks is optional. However, if child continues to be symptomatic, has signs of pneumonia or if foreign body aspiration or congenital malformation is suspected chest x-ray has to be repeated.
Conclusion:

Pediatric pneumonia remains an important public health problem in children globally. Much of this could be reduced by recognizing the disease early and by instituting early antibiotic therapy.