Upper respiratory tract infection in pediatrics

1. Upper respiratory tract infection in pediatrics By Amal Al dabbagh,MD

3. URTI,definition,pathophysiology& etiology URTI are those 1rly affecting the structures above the larynx, but most RI affect both upper & lower RT simultaneously or sequentially. Inflammatory infiltrates & edema of the mucosa, vascular congestion, ?mucus secretion & alteration of ciliary structure & function. Most caused by viruses& Mycoplasma except for epiglottitis.

4. Child with Respiratory Disease Historical Data: Onset & Duration. Severity & Pattern. Associated airway & systemic symptoms. PPtg & predisposing conditions. Immunization & Family history.

5. Child with respiratory disease,cont. Physical examination: Vitals; RR, pulse, etc… General; ENT ,color of lips, clubbing Local; hoarseness,stridor, use of accessory muscles, air entry, quality, adventitious sounds, cardiac examination.

6. Child with respiratory disease,cont Investigations: Imaging. Cultures. ABG.

7. Acute viral rhinitis Etiology: rhino, adeno, RSV, Coxsackie's viruses. Clinical manifestations: 6-12 attacks/ year in children < 5 years. fever, rhinorrhea, sore throat, cough similar cases in the family. Complications: AOM,pharyngitis,sinusitis, conjunctivitis, pneumonia, adenitis.

8. Acute viral rhinitis,cont Treatment: Symptomatic antipyretics. saline nasal drops/ solution. decongestants. ? Antihistamines.

10. Otitis Media Acute Otitis Media. Otitis Media with effusion

12. Acute Otitis Media Defined by the presence of fluid in the middle ear accompanied by acute signs of illness. Most prevalent in infancy. Fluid may persist for weeks to months despite Rx with antibiotics. Hearing loss with subsequent speech, language and cognitive disabilities are the most common risks. In developing countries, suppurative infections as meningitis and mastoiditis remain important complications.

13. Risk Factors for AOM Age; 6-18 months of age. Daycare. Breast feeding. Tobacco smoke. Pacifier use. Ethnicity. Family history. Genetic factors. Others…socioeconomic, sleep, season, altered host defences, underlying disease.

14. Pathogenesis of AOM Patient with antecedent event (URTI or allergy). Congestion of respiratory mucosa of the nose, nasopharynx and ET. Congestion of mucosa of ET obstructs the narrowest portion of the tube, the isthmus. Obstruction causes –ve pressure followed by accumulation of secretions produced by the mucosa of the middle ear. Viruses & bacteria that colonize the URT reach the middle ear via aspiration, reflux. Microbial growth in the middle ear secretions may result in suppuration with clinical signs of AOM. The MEE persist for wks to moths after sterilization.

15. Microbiology Bacteria: S.Pn, H.influenza, M. catarrhalis. Viruses: RSV, rhinoviruses, influenza viruses, and adenoviruses. Others as Mycoplasma pn, Chlamydia trachomatis, and C.Pneumoniae. Tuberculous OM remains a cause of severe middle ear disease.

16. Clinical Manifestations of AOM Non specific S&S: fever, irritability, excessive crying, headache, apathy, anorexia, vomiting, and diarrhea. Specific S&S: Otalgia ,ear rubbing, hearing loss, vertigo and otorrhea.

18. Diagnosis of AOM Evidence of acute history. S&S of middle ear inflammation. Presence of middle ear effusion. Otoscopy. Tympanometry. Middle ear aspiration.

20. Complications and Sequelae Mild conductive hearing loss. Intratemporal: perforation, mastoiditis, petrositis and labirynthitis. Intracranial: meningitis, epidural abscess, brain abscess, lateral sinus thrombosis, cavernous sinus thrombosis, subdural empyema, and carotid artery thrombosis.

21. Management of AOM AAP 2004 guidelines concludes observation without use of antimicrobial therapy is an option for selected children with uncomplicated AOM based on diagnostic certainty, age, illness severity, and assurance of follow up. Antibacterial therapy should be administered to any child <6months, regardless on degree of diagnostic certainty. Children 6mths-2years, antibacterial therapy when diagnosis is certain or if diagnosis is uncertain but illness is severe. Observation is an option when diagnosis is not certain and illness not severe.

22. Management of AOM, cont… For > 2yrs, antibiotics if diagnosis is certain and illness is severe. Observation is an option when diagnosis is certain and illness not severe and in patients with uncertain diagnosis. Observation is only appropriate when follow-up can be ensured and antibiotics initiated if symptoms got worse. Amoxicillin remains the drug of choice, because is effective, safe, inexpensive, and has a narrow spectrum. 40- 80 mg/kg/day divided into 2 doses for 10 days for < 2years and 5-7days for > 2years.

23. Otitis Media with Effusion (OME) Serous OM or glue ear. OME is the presence of middle ear effusion in the absence of acute signs of infection. Encompasses one of the two categories of COM. Arise after a recognized or unrecognized episode of AOM. Accompanied by conductive hearing loss. Prolonged hearing impairment during 1st years of life may affect development of speech and language.

24. Clinical Manifestations of OME Acute illness usually absent, sleep disturbance, hearing loss, vertigo. Diagnosis with pneumatic otoscopy demonstrates immobility of TM with +ve pressure, tympanometry also helpful. Hearing evaluation at time of diagnosis of OME( learning problems, language delay, hearing loss). Speech and language evaluation( OME >3mths) Natural history of OME is spontaneous resolution…days-months.

25. Management of OME Depends on +/- structural damage to TM or ME or speech, language or learning problems, and severity of hearing loss. Prompt surgical referral for structural damage to TM or ME( e.g. cholesteatoma). Surgical referral for children w OME with hearing loss independent on OME, speech or language disorder, developmental delay and uncorrectable visual impairment. Surgical referral for hearing loss> 21dB, bilateral OME > 3mths, unilateral OME > 6mths.

27. Management of OME, cont.. Watchful waiting for children without speech, language or visual problems who have hearing loss>21dB. Not using antihistamines, decongestants, or steroids in the management of OME in children.

29. Pharyngitis Principal involvement is in the throat. Uncommon below 1 year. Peak at 4-7 years & continues throughout childhood. Prominent in cases of Diphtheria, herpangina, adenovirus & Infectious mononucleosis.

30. Pharyngitis, etiology Viral: Adenovirus, enterovirus, EB virus, Herpes simplex virus. Bacterial: Gp A ? hemolytic streptococcus. Mycoplasma.

31. Pharyngitis, clinical manifestations viral vs. streptococcal pharyngitis. Fever, variable depending on etiology. Throat: erythema, exudates, ulceration, enlarged tonsils & peticheal mottling of the soft palate. Conjunctivitis, rhinitis, hoarseness , cough Cervical lymphadenopathy. Headache, abdominal pain.

32. Pharyngitis,Diagnosis Clinical. Throat culture. Rapid streptococcal detection kits.

33. Pharyngitis,differential diagnosis Infectious mononucleosis, when a membranous exudate is present. Diphtheria, especially in the underimmunized. Herpangina, with many vesiculoulcerative lesions in the anterior pillars & soft palate. Agranulocytosis, yellowish dirty white exudates covering the tonsils & post ph wall. Kawasaki disease.

34. Pharyngitis, complications Low rate with viral infection. Spectrum of illness extend from pharyngitis to tonsillitis, retropharyngeal abscess or peritonsillar abscess. In debilitated children, large chronic ulcers in the pharynx (viral or bacterial). Mesenteric adenitis ( viral or bacterial) abdominal pain with or without vomiting. Acute glomerulonephritis & Rheumatic fever, may follow streptococcal infections.

35. Pharyngitis, treatment Penicillin for 10 days in proven streptococcal pharyngitis (125-250mg Q 8 hrs) Or erythromycin if allergic to penicillin. Symptomatic Rx, warm saline gargle, steam inhalation, cool bland liquids as ginger ale. Acetaminophen for throat pain.

37. Diseases associated with acute stridor Acute laryngothracheitis. Acute laryngotracheobronchitis. Acute epiglottitis. Bacterial tracheitis. Foreign body. Uncommon Peritonsillar abscess. Retropharyngeal abscess. Diphtheria

38. Viral Croup Common respiratory illness in young children. Anglo-Saxon word Kropan; cry aloud. Hoarse voice; dry barking cough; inspiratory stridor; and variable amount of respiratory distress that develops over a brief period of time.

39. Croup Syndrome Group of diseases that varies in anatomic involvement and etiologic agents. Laryngotracheitis. Spasmodic croup. Bacterial tracheitis. Laryngotracheobronchitis. Laryngotracheobronchopneumonitis.

40. CroupAcute laryngotracheitis Disease of viral origin causing subglottic & tracheal swelling. The narrowed airway is responsible for the hallmark of clinical picture. The cricoid ring in the upper trachea which is subglottic, has a narrow diameter which renders children vulnerable to inflammation.

41. Viral Croup( Acute laryngotracheitis) Etiology: Respiratory viruses e.g. parainfluenza viruses 1,2,and 3, RSV, Influenza viruses A & B. Clinical picture: Age 6mths- 3 years, M>F, Fall & winter. Gradual onset of low grade fever,URTI, barking cough, inspiratory stridor & respiratory distress. Hoarseness & aphonia may occur.

42. Croup, diagnosis & treatment Clinically Lateral neck X-ray ( steeple sign). Fluid intake Cool mist/ hot steamy bathroom. Aerosolized adrenaline. Steroids( controversial) Endotracheal intubation. Helium-Oxygen Mixture. Antibiotics

44. Acute epiglottitis, etiology Bacterial infection of the supraglottic structures( epiglottis, aryepiglottic folds & arytenoids soft tissues) causing rapid airway obstruction. Haemophilus Influenza type B in prevaccination era. Bacteria associated with epiglottitis in the Hib vaccine era include: HiA, Str. Pn, Staph aureus, ß-hemolytic streptococci Gps A,B,C,and F

45. Acute epiglottitis, clinical picture Age usually 2- 7 years. Sudden onset. High fever. Apprehensive, sitting forward, drooling saliva, hyperextended neck & protruded chin. Stridor, dysphagia.

46. Acute epiglottitis, diagnosis & treatment Direct visualization. Blood cultures. Latex agglutination of serum or urine. Treatment is a medical emergency. Ventilatory support, intubation. IV antibiotics, 2nd or 3rd generation cephalosporin's or chloramphenicol till cultures & sensitivity are known.

47. Common features in DD of Infectious Upper Airway Obstructn

67. Questions A 12 yr old boy with 4 days of sore throat comes to your office. Afebrile with rhinorrhea, cough, and one day diarrhea associated with his sore throat. Throat is mildly erythematous a with normal appearing tonsils. The best course of action is: Swab the throat and give 10 days AB. Swab his throat and wait for results. Symptomatic Rx. AB without testing for gp A strept.

68. Question 2 A 3 yr old fussy boy , febrile with proffuse rhinorrhea. Shallow ulcers are noted on the soft palate and vesicles are noted on one palm and both soles of the feet. The etiology of this infection is Gp A strept Acranobacterium hemolyticum Coronavirus. Coxackie virus