! Upper Respiratory Tract Infection (Child) Common Cold Sore Throat, Tonsillitis

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1 RURAL FACILITY: Approval as per HMP / CCG List YES / NO! Upper Respiratory Tract Infection (Child) Common Cold Sore Throat, Tonsillitis " URTI encompasses a wide range of illnesses that have their main effect on the upper airways. The upper airways include the nose, sinuses, throat, tonsils and bronchi " The vast majority of URTIs are caused by viruses " An important exception is group A streptococcal sore throat, which although uncommon can lead to Rheumatic Fever or Acute Post Streptococcal Glomerulonephritis if untreated. These complications are serious and avoidable. They are especially common in Indigenous communities " A viral upper respiratory tract infection can be complicated by secondary bacterial infection such as otitis media or pneumonia, requiring antibiotics " Other complications include exacerbation of asthma Related Topics: # MENINGITIS 457 May present with: Watery nasal discharge, sneezing, purulent nasal discharge Sore throat, red throat and/or tonsils with or without pus Cough, wheeze Earache Enlarged tender cervical (neck) lymph nodes Fever Headache General malaise Remember the symptoms and signs of an Upper Respiratory Tract Infection may be a precursor to more serious illnesses such as meningitis Clinical Assessment: $ Obtain a full history including past episodes or complications, and any history of asthma $ Heart rate, temperature, respiratory rate $ Examine the ears, nose and throat $ Feel for lymph glands (on the occiput, around the ears, both sides of the neck) $ Listen to the chest for air entry and any added sounds (crackles or wheezes) $ Ask about and examine for any skin rash $ Check vaccination status, see IMMUNISATION PROGRAM 430 December 03 Royal Flying Doctor Service (Queensland) Page 443

2 Management: % If child: looks sick (not alert or interactive) and has fever, treat fever with Paracetamol Schedule 2 Paracetamol DTP IHW Registered Nurses and Authorised Indigenous Health Workers may proceed Form Strength Route of Administration Recommended Dosage Suspension 120 mg/5 ml Oral Child: 15 mg/kg stat. Round dose to nearest measurable quantity Management of Associated Emergency: Consult MO Duration Stat and as ordered by MO % If: child still looks sick when temperature reduced, consult MO has any rash, consult MO has cough as the main feature; consider other diagnoses: See PERTUSSIS (WHOOPING COUGH) 448 See CROUP 449 See ACUTE ASTHMA 48 has an increased respiratory rate, or any chest findings consider other diagnoses: See BRONCHIOLITIS 451 See PNEUMONIA 452 See ACUTE ASTHMA 48 has a cough productive of mucopurulent sputum, consult MO and treat as per PNEUMONIA 452 has evidence of secondary ear infection: See ACUTE OTITIS MEDIA 467 % For the child with URTI, indications for antibiotic treatment are: follicular tonsillitis with fever and local lymphadenitis existing rheumatic heart disease scarlet fever (a characteristic and striking red blanching rash and strawberry tongue due to streptococcal infection; rash usually starts after the sore throat and lasts a week) quinsy (severe infection of the tonsils causing massive enlargement) % If quinsy is present, consult MO (may need evacuation/hospitalisation for IV Penicillin and/or surgical drainage of pus) December 03 Royal Flying Doctor Service (Queensland) Page 444

3 If not allergic treat with oral Penicillin: Schedule 4 Phenoxymethylpenicillin DTP IHW/RN Authorised Indigenous Health Workers must consult MO Rural and Isolated Practice Endorsed Registered Nurses may proceed Form Strength Route of Recommended Duration Administration Dosage Suspension 125 mg/5 ml 250 mg/5 ml Oral Child: 10 mg/kg tds Round dose to nearest measurable quantity 10 days It is important patient takes the full course even if feels better earlier Provide Consumer Medicine Information if available: Should be taken on an empty stomach; ½ to 1 hour before meals Management of Associated Emergency: As for severe allergic reactions see ANAPHYLAXIS 32 If a lack of compliance is anticipated treat with IM Penicillin: Schedule 4 Penicillin Benzathine (Bicillin LA) DTP IHW/RN Authorised Indigenous Health Workers must consult MO Rural and Isolated Practice Endorsed Registered Nurses may proceed Form Strength Route of Administration Disposable syringe 1800 mg (or 2.4 million units)/4 ml Recommended Dosage IM 3 kg to under 6 kg 225 mg (0.5 ml) 6 kg to under 10 kg mg (0.75 ml) 10 kg to under 15 kg 450 mg (1 ml) 15 kg to under 20 kg 675 mg (1.5 ml) 20 kg and over and adults 900 mg (2 ml) Duration Management of Associated Emergency: As for severe allergic reactions see ANAPHYLAXIS 32 The following technique of combining Penicillin Benzathine (Bicillin LA) with 1% Lignocaine for IM injection is commonly used to increase compliance Explain to the patient why they are receiving Penicillin Benzathine (Bicillin LA) Apply EMLA cream to the injection site minute prior to injection Transfer Bicillin LA from cartridge to 3 ml syringe Heat under warm water until Bicillin LA is in liquid state Draw up 0.5 ml of 1% Lignocaine Apply 23 g needle Stat December 03 Royal Flying Doctor Service (Queensland) Page 445

4 If allergic to Penicillin, treat with Roxithromycin: Schedule 4 Roxithromycin DTP IHW/RN Authorised Indigenous Health Workers must consult MO Rural and Isolated Practice Endorsed Registered Nurses may proceed Form Strength Route of Recommended Dosage Duration Administration Dispersible tablet 50 mg As Above Child >40kg: 150 mg bd Child <40kg: 4 mg/kg bd Round dose to nearest measurable quantity As above Provide Consumer Medicine Information if available: Should be taken on an empty stomach, ½ to 1 hr before meals Management of Associated Emergency: Consult MO For the child with uncomplicated URTI, treatment is symptomatic: % Encourage rest and increase fluid intake % Treat fever with Paracetamol to make more comfortable (do not use Aspirin in children) Schedule 2 Paracetamol DTP IHW Registered Nurses and Authorised Indigenous Health Workers may proceed Form Strength Route of Administration Recommended Dosage Suspension 120 mg/5 ml Oral Child: 15 mg/kg stat. Round dose to nearest measurable quantity Management of Associated Emergency: Consult MO Duration Stat and as ordered by MO % Topical nasal decongestants can be helpful for sleeping and eating particularly in young infants; however their use should be limited to short periods of time (5 days maximum). Nose drops of Normal Saline or cool boiled water can also be helpful and are safe % Other symptomatic treatments such as steam inhalation, nebulised saline, and lemon and honey drinks may have some subjective benefit in some children If the URTI is complicated by mucopurulent nasal secretions only, and if not allergic to Penicillin, treat with Amoxycillin: Schedule 4 Amoxycillin DTP IHW/RN Authorised Indigenous Health Workers must consult MO Rural and Isolated Practice Endorsed Registered Nurses may proceed Form Strength Route of Administration Capsule 250 mg Oral 500 mg Recommended Dosage Child: 10 mg/kg tds Round dose to nearest measurable quantity Duration 7 days Suspension 125 mg/5 ml As above As above As above Management of Associated Emergency: As for severe allergic reactions see ANAPHYLAXIS 32 December 03 Royal Flying Doctor Service (Queensland) Page 446

5 If the patient is allergic to Penicillin, treat with Trimethoprim: Schedule 4 Trimethoprim DTP IHW/RN Authorised Indigenous Health Workers must consult MO Rural and Isolated Practice Endorsed Registered Nurses may proceed Form Strength Route of Administration Recommended Dosage Duration Tablet 300 mg Oral Child >12yrs: 300 mg daily Child >6yrs: 150 mg daily 7 days Management of Associated Emergency: Consult MO Follow up: & Review next day if not improving & If antibiotics have been given for sore throat, review in 2 weeks; ask about sore joints, chest pain, breathlessness and check urinalysis. Consult MO if symptoms (see RHEUMATIC FEVER 461) or if abnormal urinalysis (see ACUTE POST STREPTOCOCCAL GLOMERULONEPHRITIS 459) Referral/Consultation: & Consult MO as above or if symptoms persist despite symptomatic treatment & If recurrent tonsillitis (>6 episodes per year) MO may consider prolonged course of prophylactic penicillin or referral to ENT Specialist for consideration for tonsillectomy/ adenoidectomy December 03 Royal Flying Doctor Service (Queensland) Page 447

6 RURAL FACILITY: Approval as per HMP / CCG List YES / NO Pertussis (Whooping Cough) " Pertussis (whooping cough) is still relatively common, more so in summer " Incubation period is days " Pertussis is a particularly severe disease in infants under 12 months of age " Adults and teenagers get pertussis. Although they may not be too ill, they can easily infect a young baby in the home " Pertussis is a prolonged illness and can occasionally lead to chronic lung disease May present with: URTI symptoms Cough (typically paroxysmal ie. intermittent episodes of prolonged coughing followed by the characteristic whoop as the infant catches its breath) Vomiting (typically after an episode of cough) Cyanosis (typically during an episode of cough) Young babies usually do not have the characteristic whoop but are likely to be very distressed by coughing and vomiting. They can develop apnoea (stop breathing) and become cyanosed during a coughing bout Adults usually have a persistent troublesome cough only, without a whoop. A cough of several weeks duration, that is worse at night, in an adult is pertussis until proven otherwise Clinical Assessment: $ See URTI 443; the whoop can be characteristic but may not always be present. The child may appear undistressed in periods between paroxysms of coughing, with few clinical signs. However the overall impression is of a sick child Management: % Consult MO who may advise evacuation/hospitalisation if symptoms are significant, especially if <6 mths appropriate tests to confirm diagnosis: - serum for IgA and/or - nasopharyngeal aspirate for PCR testing and/or C & S antibiotics; Erythromycin will not shorten the length of the illness but reduces infectivity to others if given within 2 weeks of the onset of cough eligible household and child care contacts will require Erythromycin to prevent further clinical cases or pertussis. Consult Public Health Unit for advice as soon as possible Follow up: & If not evacuated/hospitalised review daily, at least initially Consultation/Referral: & Consult MO on all occasions whooping cough is suspected December 03 Royal Flying Doctor Service (Queensland) Page 448

7 RURAL FACILITY: Approval as per HMP / CCG List YES / NO Croup/Epiglottitis " Croup usually follows 3 or 4 days of a mild URTI when the infection spreads to affect the upper airways; usually mild and self limiting " Epiglottitis (cellulitis of the epiglottis) is caused by Haemophilus influenza type B infection; fatal if untreated Related Topics: # ACUTE UPPER AIRWAY OBSTRUCTION/CHOKING 27 May present with: Acute Epiglottitis Rapid onset Weak or no cough Temp >38.5 C Septicaemia Often severe stridor Drooling saliva Unable to eat or drink Doesn t talk Any age Reluctant to move neck Croup Slow onset Croupy (barking) cough Temp <38.5 C No systemic disturbance Severe stridor less common Able to swallow Will usually drink Normal voice <4 yrs More prominent at night Immediate Management: % A calm atmosphere is beneficial % If severe respiratory distress, lethargic or cyanosed, give oxygen via Hudson mask (see O 2 DELIVERY SYSTEMS 18) to maintain O 2 saturation >94%. If >94% not maintained consult MO % If not tolerated it is best to interfere with the child as little as possible Clinical Assessment: $ Obtain a full history including of onset and any preceding URTI 443 $ Limited examination. DO NOT examine mouth or throat. DO NOT lie the child flat. If epiglottitis these can cause airway spasm/complete obstruction. If this occurs and if unable to secure airway and ventilate, perform needle cricothyroidotomy (see NEEDLE CRICOTHYROIDOTOMY 30). Consult MO as soon as circumstances allow $ Look for evidence of stridor and recession with the child quiet. Of particular importance is high fever, and evidence of drooling in a sick looking child. These are suggestive of epiglottitis December 03 Royal Flying Doctor Service (Queensland) Page 449

8 Management: % Consult MO % If epiglottitis: stay with child handle the child as little as possible MO will organise evacuation by MO skilled in paediatric airway management (and IV insertion: for IV Ceftriaxone) % If croup: Symptomatic treatment as per URTI Steam is a common treatment of questionable benefit MO may advise in moderate/severe cases: - stat dose only of steroids (IM Dexamethasone 0.3 mg/kg or oral Prednisolone 1 mg/kg or nebulised Budesonide 2 mg) - nebulised Adrenaline 0.5 ml (0.5 mg)/kg of 1 in 1000 to a maximum of 5 ml (5mg) - evacuation/hospitalisation Follow up: & If child with croup is not evacuated/hospitalised, review next day and consult MO if not improving Consultation/Referral: & Consult MO on all presentations of stridor December 03 Royal Flying Doctor Service (Queensland) Page 450

9 RURAL FACILITY: Approval as per HMP / CCG List YES / NO Bronchiolitis " A viral infection of the chest affecting infants <12mths " Most commonly due to Respiratory Syncitial Virus (RSV) " More significant in young babies (<4mths) and those with previous heart or lung problems " Is often impossible to distinguish from pneumonia May present with: Cough Fever Nasal discharge (often profuse) Rapid breathing Chest wheezes and/or crackles Nasal flaring, grunting respirations and chest recession Cyanosis Apnoea Clinical Assessment: $ See PNEUMONIA 452 $ Of particular importance is a history of URTI 443 symptoms in a child that is basically well. Chest wheezes are a feature. It may be impossible to distinguish bronchiolitis from pneumonia. Generally the child isn t as sick and the fever is less of a feature $ Oxygen saturation Management: % Consult MO who will consider treating similar to: ACUTE ASTHMA 48 if wheeze is prominent PNEUMONIA 452 if fever and rapid breathing is prominent Follow up: & Patients who are not evacuated/hospitalised should be reviewed daily. Consult MO if the patient is not improving Referral/Consultation: & Consult MO on all occasions bronchiolitis is suspected December 03 Royal Flying Doctor Service (Queensland) Page 451

10 RURAL FACILITY: Approval as per HMP / CCG List YES / NO Pneumonia (Child) " A common condition, especially in Indigenous communities, and a significant cause of morbidity and mortality " The most common causative organism is Streptococcus pneumoniae; other organisms include Haemophillus influenza and Staphylococcus (very serious) " Atypical organisms such as Mycoplasma may cause less classical symptoms and signs and may be resistant to initial treatment " Children with co-existent illnesses are more at risk. Examples are bronchiolitis and chronic lung disease (eg. due to prematurity) May present with: Cough dry or with sputum Fever Rapid breathing Nasal flaring, grunting respirations and chest recession in infants Cyanosis Apnoea in infants Be aware that many children with pneumonia become dehydrated (fever and rapid breathing both cause extra fluid loss) As with any paediatric illness, be more wary in the younger child Clinical Assessment: $ As per URTI 443 $ Of particular importance is the presence of fever and rapid breathing. This combination is a reliable indicator of pneumonia in children; more reliable than stethoscope findings which are often misleading in children $ Oxygen saturation $ Ask about fluid intake and output (wet nappies, passing urine) and check hydration (tongue moist? skin elasticity) Management: % Consult MO using the flow chart on the following page as a guide December 03 Royal Flying Doctor Service (Queensland) Page 452

11 CHILD WITH FEVER AND RAPID BREATHING Less than 3 months 3 months to 1 year 1 year to 4 years Over 4 years Resps >60 and/or Recession Grunting Apnoea Cyanosis Resps <60 Resps >50 and/or Recession Grunting Apnoea Cyanosis Resps <50 Resps >40 and/or Recession Grunting Apnoea Cyanosis Resps <40 Resps >30 and/or Recession Grunting Apnoea Cyanosis Resps <30 Moderate or severe pneumonia Mild pneumonia OR Consider other diagnoses Mild Pneumonia: % MO may advise: chest X-ray if available oral Amoxycillin if not allergic; IM Procaine Penicillin if there is likely to be a lack of compliance with oral medication; Roxithromycin if allergic to Penicillin or atypical pneumonia is suspected % Encourage rest and increase oral fluids % Treat fever with regular Paracetamol to make more comfortable Schedule 2 Paracetamol DTP IHW Registered Nurses and Authorised Indigenous Health Workers may proceed Form Strength Route of Recommended Dosage Duration Administration Suspension 120 mg/5 ml Oral Child: 15 mg/kg stat. Round dose to nearest measurable quantity Stat and as ordered by MO Management of Associated Emergency: Consult MO Moderate/Severe Pneumonia: % Give oxygen via Hudson mask (see O 2 DELIVERY SYSTEMS 18) to maintain O 2 saturation >94%. If >94% not maintained consult MO % Give oral fluids as tolerated December 03 Royal Flying Doctor Service (Queensland) Page 453

12 % MO may advise: IV cannula 45. It is usual to start with Normal Saline or Hartmann s Solution; MO will advise quantities and rate antibiotics, eg. IV Penicillin if moderate or IV Ceftriaxone and Flucloxacillin if severe; if possible take blood cultures prior to commencing antibiotics evacuation/hospitalisation Follow up: & Patients with mild pneumonia who are not evacuated/hospitalised should be reviewed daily. Consult MO if the patient is not improving & See next MO clinic Referral/Consultation: & Consult MO on all occasions pneumonia is suspected & Some children with pneumonia will warrant paediatric referral December 03 Royal Flying Doctor Service (Queensland) Page 454

13 RURAL FACILITY: Approval as per HMP / CCG List YES / NO Chronic Asthma (Child) " Careful management of asthma is essential to reduce the frequency and severity of acute exacerbations " The principles of asthma management are avoidance of trigger factors and drug prevention and treatment " All patients with asthma should be assessed by a MO at least every year and have an asthma plan in their notes. By anticipating deterioration in their asthma most people can avoid a severe exacerbation " A well-controlled asthmatic has no regular wheeze or cough. Regular symptoms indicate poor control, which can be improved by appropriate modification of treatment Related Topics: # ACUTE ASTHMA 48 # UPPER RESPIRATORY TRACT INFECTION 443 Clinical Assessment: $ Obtain a full history; specifically ask about frequency of wheeze and cough; ask about cough at night and with exercise; ask which inhalers are used and how often $ Heart rate, respiratory rate, temperature $ Listen to the chest for wheezes $ Check spirometry (FEV 1 ) if available and child is old enough (usually >6yrs), see tables in ACUTE ASTHMA 48 $ Check Peak Expiratory Flow rate if child is old enough (usually >6yrs); see manufacturer s guidelines for reference ranges of various PEF meters $ Check inhaler technique. If using a spacing device, check it is being used and cared for properly. If not using a spacer, explain the advantages and encourage to do so A diagnosis of asthma can be made with confidence when a person has variable symptoms and: - Forced Expiratory Volume (FEV 1 ) increases by 15% or more after bronchodilator medication - Peak Expiratory Flow (PEF) rate increased by 20% after bronchodilator medication Management: Avoidance of Trigger Factors Many trigger factors exist and they vary between individuals Common trigger factors include animal hair, pollens, dust, cold air, exercise, viral URTI Most asthmatics (or their parents) will be able to identify which factors make their asthma worse Consider ways to reduce the child s exposure to these factors All parents of asthmatics should be encouraged to stop smoking. See SMOKING 291 December 03 Royal Flying Doctor Service (Queensland) Page 455

14 Asthma Plans Asthma plans work on the principle of stepping up and stepping down treatment according to symptoms. It should indicate when to introduce and remove treatments and when to ask for help. Parents should be encouraged to be responsible for their child s illness until they are old enough to do so themselves Asthma plans can vary from very simple (see sample below) to highly complex depending on the parent s level of understanding and motivation. Some highly motivated parents can easily manage short courses of oral steroids without the need to ask for help. Most require a little more guidance Asthma Plan For: Date: Severity Symptoms Action Normal Wheeze less than 3 times a week Salbutamol (Ventolin) inhaler when wheezy, Beclomethasone (Becotide) 2 puffs twice daily Mild exacerbation Wheeze more than 3 times a week Salbutamol (Ventolin) inhaler when wheezy, Beclomethasone (Becotide) 4 puffs twice daily Moderate exacerbation Wheeze every day Salbutamol (Ventolin) inhaler 2 puffs 4 times daily, Beclomethasone (Becotide) 4 puffs twice daily. See nurse/call doctor Review date with doctor: % A Peak Flow Meter is useful for some children over 6 years to monitor their asthma. It must be used properly and they or their parents should be able to recognise what is a normal reading for them % Spirometry is preferred for both diagnosing asthma and assessing severity and response to treatment (see tables in ACUTE ASTHMA 48) % Educate the patient or their parents about asthma and the way the treatments work. Use the terms treater or reliever for bronchodilators and preventer for inhaled Cromoglycate and steroids % The following stepped treatments can be used to treat increasingly severe asthma: Most asthmatics are at step 1 or 2 Step 1 - occasional use of short acting inhaled bronchodilator (eg. Salbutamol); if required more than once daily move to step 2 Step 2 - short acting inhaled bronchodilator as required, plus regular inhaled Cromoglycate or regular inhaled steroid (eg. Beclomethasone) if Cromoglycate ineffective Step 3 - short acting inhaled bronchodilator as required, plus regular inhaled high paediatric dose steroid Step 4 - long acting inhaled bronchodilator (eg. Salmeterol) Follow up: & The frequency of follow up is determined by the severity of the asthma. Mild asthmatics should be reviewed yearly, severe asthmatics 3 monthly Referral/Consultation: & All asthmatics should be reviewed by a MO & Severe asthmatics may require Specialist referral December 03 Royal Flying Doctor Service (Queensland) Page 456