Lower Respiratory Tract Lower Respiratory Tract Infections in ChildrenInfections in Children

Abdelaziz ElaminAbdelaziz Elamin

Professor of Child HealthProfessor of Child Health

University of KhartoumUniversity of Khartoum

Sudan Sudan

EpidemiologyEpidemiology

IncidenceIncidence : : 30–40 cases per 1000 children per year in the UK; 30–40 cases per 1000 children per year in the UK; a GP will see, on average, 1-2 cases per year.a GP will see, on average, 1-2 cases per year.PrevalencePrevalence : :Every year, pneumonia contributes to 750,000 –Every year, pneumonia contributes to 750,000 –1.2 million neonatal deaths worldwide: 1.2 million neonatal deaths worldwide: (60% due to S. pneumoniae/H. influenzae) (60% due to S. pneumoniae/H. influenzae) H. influenzae infection is now quite rare H. influenzae infection is now quite rare

amongst UK children due to immunization.amongst UK children due to immunization.

Definition & EtiologyDefinition & Etiology

There is no hard and fast definition of lower There is no hard and fast definition of lower respiratory tract infection (LRTI), that is respiratory tract infection (LRTI), that is universally adopted. universally adopted.

Essentially, it is inflammation of the Essentially, it is inflammation of the airways/pulmonary tissue, due to viral or airways/pulmonary tissue, due to viral or bacterial infection, below the level of the bacterial infection, below the level of the larynx.larynx.

Viral causesViral causes

Influenza A Respiratory Syncytial Virus (RSV) Respiratory Syncytial Virus (RSV) Human Metapneumovirus 4 Human Metapneumovirus 4 Varicella-Zoster Virus (VZV - Chickenpox)Varicella-Zoster Virus (VZV - Chickenpox) AdenovirusAdenovirus Para-influenza virus Para-influenza virus

Bacterial AgentsBacterial Agents

Streptococcus pneumoniaeStreptococcus pneumoniae Hemophilus InfluenzaeHemophilus Influenzae Staphylococcus aureusStaphylococcus aureus MM Klebsiella pneumoniaeKlebsiella pneumoniae Enterobacteria e.g. E. coliEnterobacteria e.g. E. coli AnaerobesAnaerobes

Atypical AgentsAtypical Agents

Mycoplasma pneumoniaeMycoplasma pneumoniae

Legionella pneumophila Legionella pneumophila

Chlamydia sp.Chlamydia sp.

Coxiella burnetii Coxiella burnetii

Clinical PictureClinical Picture

PresentationPresentation Acute febrile illness, possibly Acute febrile illness, possibly preceded by typical viral URTI.preceded by typical viral URTI.

SymptomsSymptoms : :

1.1. CoughCough

2.2. Breathlessness ( preventing feeding)Breathlessness ( preventing feeding)

3.3. Irritability Irritability

4.4. SleeplessnessSleeplessness

5.5. Chest or abdominal pain in older patientsChest or abdominal pain in older patients Audible wheezing is rare in LRTI, but can occurAudible wheezing is rare in LRTI, but can occur

Physical SignsPhysical Signs

1.1. Capillary blood oxygen saturation <95%Capillary blood oxygen saturation <95%2.2. Intercostal and supra-sternal recessionIntercostal and supra-sternal recession3.3. FlushingFlushing4.4. TachypneaTachypnea5.5. High fever over 38.5 cHigh fever over 38.5 c6.6. Nasal flaring in children under 1 yr of ageNasal flaring in children under 1 yr of age7.7. Dullness to percussion over zones of Dullness to percussion over zones of

pneumonia consolidation.pneumonia consolidation.8.8. Cyanosis in advanced cases.Cyanosis in advanced cases.

Differential DiagnosisDifferential Diagnosis

Asthma Bronchiolitis (a form of LRTI) (a form of LRTI) Inhaled foreign body Pneumothorax Cardiac dyspnoea Pneumonitis of other cause e.g. Pneumonitis of other cause e.g.

extrinsic allergic alveolitis

InvestigationsInvestigations

Chest radiography if fever and tachypnea, Chest radiography if fever and tachypnea, oxygen saturation to monitor condition. oxygen saturation to monitor condition.

In hospital considerIn hospital consider capillary or arterial capillary or arterial blood gases. blood gases.

Culture of sputumCulture of sputum or nasopharyngeal or nasopharyngeal discharge/aspirate may be used in hospital discharge/aspirate may be used in hospital but has little to add in primary care.but has little to add in primary care.

Blood culturesBlood cultures if evidence of septicemia. if evidence of septicemia. Blood urea and electrolytesBlood urea and electrolytes

ManagementManagement

Admission for children under 5 years with Admission for children under 5 years with fever and breathlessness is mandatory.fever and breathlessness is mandatory.

Older children can be managed with close Older children can be managed with close observation at home if not distressed observation at home if not distressed

Physiotherapy has no place in treatment Physiotherapy has no place in treatment of uncomplicated pneumonia in children of uncomplicated pneumonia in children without pre-existing respiratory disease.without pre-existing respiratory disease.

Essential MeasuresEssential Measures

Oxygen, Oxygen, IV fluids if unable to feed,IV fluids if unable to feed, Respiratory support in severe casesRespiratory support in severe cases Cough medicines are not indicated and Cough medicines are not indicated and

may be used if cough interferes with may be used if cough interferes with feeding or sleep. Honey with lemon may feeding or sleep. Honey with lemon may be helpful.be helpful.

Antihistamines are dangerous in young Antihistamines are dangerous in young children & should be avoided.children & should be avoided.

MedicationsMedications

Antipyretics (avoid aspirin in young children due to danger of Reye's syndrome).

Antibiotic treatment for bacterial pneumonias. Pneumonia or LRTI following URTI is likely to be

viral and will not respond to antibiotic therapy. However, it is difficult to distinguish between viral and bacterial infection and young children can deteriorate rapidly. so consider antibiotic therapy depending on presentation and the clinical judgment of the concerned child.

AntibioticsAntibiotics

Streptococcal pneumonia is treated with oral Streptococcal pneumonia is treated with oral penicillin V, or synthetic penicillin such as penicillin V, or synthetic penicillin such as amoxicillin as first line drugs. amoxicillin as first line drugs.

Recent research indicates that children with Recent research indicates that children with non-severe pneumonia on amoxicillin for 3 days non-severe pneumonia on amoxicillin for 3 days do as well as those who receive it for 5 daysdo as well as those who receive it for 5 days

If a child is genuinely allergic to penicillin, If a child is genuinely allergic to penicillin, consider using a macrolide or quinolone.consider using a macrolide or quinolone.

Cephalosporin often cross-react with penicillin.Cephalosporin often cross-react with penicillin.

Antibiotics/2Antibiotics/2

For Hemophilus influenzae cephalosporins For Hemophilus influenzae cephalosporins or Amoxicillin/Calvulenic acid combination or Amoxicillin/Calvulenic acid combination are useful.are useful.

For Staph pneumonia cloxacillin and For Staph pneumonia cloxacillin and flucloxacillin are used and in severe cases flucloxacillin are used and in severe cases parenteral vancomycin is required. parenteral vancomycin is required.

Injectable antibiotics are indicated in Injectable antibiotics are indicated in severe casessevere cases

ComplicationsComplications

Bacterial invasion of the lung tissue can Bacterial invasion of the lung tissue can cause: cause: pneumonic consolidation,pneumonic consolidation, septicemia,septicemia, empyema,empyema, lung abscess(esp. S. Aureus)lung abscess(esp. S. Aureus) pleural effusion. pleural effusion. Mycoplasma P. can cause hemolysisMycoplasma P. can cause hemolysis Rarely, respiratory failure, hypoxia and death.Rarely, respiratory failure, hypoxia and death.

PreventionPrevention

It is achieved with pneumococcal vaccine It is achieved with pneumococcal vaccine and influenza vaccine and influenza vaccine

Stop indoor smoking. Smoking at home or Stop indoor smoking. Smoking at home or school is a major risk factor. school is a major risk factor.

Zinc supplementation reduces the Zinc supplementation reduces the incidence of pneumonia by over 40% in incidence of pneumonia by over 40% in malnourished children. malnourished children.

The End