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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Bulletin 10; August 1999
Classification Clinical features

Acute Infective • Nasal stuffiness, sneezing, rhinorrhoea

Rhinitis (the Common • Fever, malaise and muscular aches in more severe infections
Cold) • 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 & Most prevalent in children between 4 to 10 years of age.

Tonsillitis • 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.

Laryngotracheo- Peak age group 1 to 2 years (6 mths to 6 yrs range).

bronchitis • Antecedent URTI symptoms
• Stridor
• Hoarseness of voice
• Barking cough
May have respiratory distress but usually not very febrile or toxic

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Bulletin 10; August 1999
Classification Clinical features
Epiglottitis
Acute Bronchitis
Acute Bronchiolitis
Pneumonia
Bulletin 10; August 1999
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
• Productive cough
• Rhonchi
• Fever
• Tachypnea ± crackles
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.
• Fever
• Cough
• Tachypnea
• Constitutional symptoms.
• Crackles
• Signs of consolidation
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Classification Common Pathogens
Acute Infective • >90% are viral (Rhinovirus,
Rhinitis (the Common adenovirus, RSV, parainfluenza,
Cold) influenza viruses)
• Occasionally bacterial agents
include: Streptococcus
pneumoniae, Hemophilus
influenzae, Moraxella catarrhalis
Pharyngitis & • Predominantly viruses
Tonsillitis • Group A b -hemolytic
streptococcus is the main bacterial
cause.
Otitis Media • Streptococcus pneumoniae,
Hemophilus influenzae,
Moraxella catarrhalis, GroupA b
-hemolytic Streptococcus
• Respiratory viruses
Acute Sinusitis • Streptococcus pneumoniae,
Hemophilus influenzae,
Moraxella catarrhalis.
• Other organisms include a -
hemolytic streptococci and
respiratory viruses.
Laryngotracheo- • Mainly viruses
bronchitis • Most commonly the parainfluenza
virus.
Epiglottitis • Hemophilus influenzae type b is
almost always the infecting agent.
• Occasionally b -hemolytic
streptococci
• Usually associated with
septicaemia
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Clinical Course
• Symptoms last 1-2 days but may
persist up to 1 –2 weeks.
• Nasal discharge may continue,
becoming mucopurulent or
purulent.
• Fever and symptoms often resolve
between 3 to 5 days from onset.
• The earache usually subsides
within 8 hours of initiation of
appropriate antibiotic therapy.
• Symptoms should improve within
7 to 10 days of therapy.
• Stridor and breathlessness usually
improve in 1 to 2 days.
• The dry cough may persist for up
to 2 weeks.
• In younger children (especially
<12 mths) mild stridor may
persist for up to 2 weeks.
• Imperative that the diagnosis be
made promptly and appropriate
therapy instituted.Mortality
related to delayed
recognition.Clinical improvement
can be seen within 4 to 6 hours
after the first dose of antibiotics.
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Classification Common Pathogens
Acute Bronchitis • Mostly viral etiology
• Mycoplasma is the most common
non-viral etiological agent
• Secondary bacterial infection may
be caused by Streptococcal
pneumoniae, Hemophilus
influenzae, Staphylococcus aureus
Acute Bronchiolitis • Respiratory syncytial virus (RSV)
predominant cause. Other viruses
eg parainfluenzae virus
occasionally responsible.
• Bacterial superinfection is
uncommon.
• The latter should be suspected if:
o Fever > 1week
o Prolonged symptoms > 1 week
o Elevated total white cell count
o And CXR showing consolidation
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
Bulletin 10; August 1999
Clinical Course
• Most episodes of bronchitis clear
within 14 days.
• Even if Mycoplasma is the
causative agent, the use of
antibiotics may not be helpful in
reducing symptoms and the
disease process may resolve
spontaneously.
• Most infants recover within a
week and 10 days
• Some may have persistent cough
for up to 3 weeks.
• 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
Acute Infective • Use of antibiotics has no significant
Rhinitis (the Common benefit and may cause side-effects.
Cold) • 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.
Pharyngitis & • Symptomatic treatment.
Tonsillitis • Penicillin if Streptococcus suspected
• This is suggested by the presence of
tender cervical lymphadenopathy in a
child > 4years old.
• If Penicillin allergic, use
Erythromycin.
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
Acute Sinusitis • Amoxycillin is 1st line antibiotic
• If allergic to penicillin, trimethoprim-
sulphamethoxazole is the drug of
choice.
• 2nd line:amoxycillin/clavulanate ,
ampicillin/salbactam, or
cephalosporin.
• Symptomatic: decongestants.
Laryngotracheo- • Antibiotics are not indicated.
bronchitis • 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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Important notes
• In very young babies who are obligate
nose breathers, nasal obstruction may
impair feeding.
• Hospitalization may be necessary if
child is unable to feed.
• Important to distinguish from Epstein-
Barr 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.
• Children under the age of 2 yrs are at
higher risk of developing recurrent
episodes, chronic otitis media and
serious septic complications.
• 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.
• Important to exclude other differentials
which are medical emergencies.
• Foreign body aspiration, epiglottis,
bacterial tracheitis, retropharyngeal
abscess.
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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.
• • Do no do lateral neck x-ray or attempt
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 • 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.
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Important notes
• This is a medical emergency.
Immediate referral to hospital.
• May need to urgently secure airway
under controlled conditions
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: Determine:
Otitis Media Epiglottitis
Sinusitis ALTB
Pharyngitis/tonsillitis Bronchitis
Rhinitis Bronchiolitis
Pneumonia

* Important to differentiate exacerbation of asthma triggered by viral infections.

Indications for Chest X-rays: Indications for hospitalization:

1. Suspected Pneumonia
2. Suspected foreign body aspiration
3. Severe lower respiratory tract infection
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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Bulletin 10; August 1999