COMMON UPPER RESPIRATORY TRACT INFECTIONS IN CHILDREN

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2 ٢ COMMON UPPER RESPIRATORY TRACT INFECTIONS IN CHILDREN Dr mostafavi SN Pediatric Infectious Disease Department Isfahan University of Medical Sciences

3 Case 1 ٣ An 18 month old infant brought with high fever, coryza, and cough since 2 days ago. Examinations shows significant erythema of the pharynx. 1. what's your diagnosis? 2. what's your prescription? For: Fever Nasal obstruction Rhinorrhea Cough

4 Note ۴ Children with viral URTI can experience fever within first 3-5 days of illness. The best treatment in viral URTI is no treatment. Symptomatic therapy is the mainstay of treatment. Symptoms not be treated unless bother the child or family ( interrupting sleep, interfering with drinking, causing discomfort) use single-ingredient medications for the most bothersome symptom with proper dosing

5 Fever ۵ Acetaminophen (> 3 mo): mg/kg/dose (max 4g/d, 75mg/kg/d) q4-6h, in < 3 mo after complete evaluation Ibuprofen (> 6 mo): 10 mg/kg/dose (max 2.4g/d, 40 mg/kg/d) q6h. Taken with food. Alternative to acetaminophen in unresponsive cases. Combinational therapy not recommended Alternate therapy seldom suggested External cooling: if more rapid and greater reduction of temperature is desired. 30 min after antipyretic.

6 Rhinorrhea ۶ Ipratropium 0.06% two sprays in each nostril 3 times/d for 4 d > 5 yrs 2-4 times nosebleeds, nasal dryness, mouth dryness

7 Nasal obstruction ٧ Oral Pseudoephedrine: HR, BP, palpitations Topical oxymetazoline, xylometazoline, and phenylephrine: nosebleeds, nasal drying, rebound congestion Effective in decreasing nasal congestion and increasing nasal patency in adults Not recommended in < 6-12 yr

8 Aromatic vapors (for external rub) ٨ Menthol, camphor, eucalyptus oil Increase the perception of nasal patency, decrease cough severity Mild irritant effect in one half Not suggested in children

9 Supportive interventions ٩ (unproven effect but inexpensive and no harmful) Adequate fluid intake Warm liquids (eg, chicken soup, tea, apple juice) Suctioning the nose with bulb syringe (infants) Saline nasal drops or sprays or irrigationi Cool mist humidifiers or vaporizers( no steam or heated humidified)

10 Antihistamines ١٠ First generations (diphenhydramine, chlorpheniramine, hydroxyzine) are thought to decrease nasal congestion and secretions via anticholinergic properties( ineffective in studies) Adverse effects: sedation, paradoxic excitability, respiratory depression, and hallucinations Not recommended in < 6-12 yr

11 Antitussives ١١ Dextromethorphan, codeine Depress the cough reflex Adverse effects: respiratory and central nervous system depression Their efficacy has not been proven WHO recommends dextromethorphan for unusual severe cough

12 Expectorants and mucolytics ١٢ Expectorants ( guaifenesin) and mucolytics (acetylcysteine, bromhexine) Increase mucus production and thin respiratory secretions Not proven efficacy in children Guaifenesin relatively safe: mild GI irritation Mucolytics: bronchospasm, GI disturbance, and fever

13 Home remedies for cough ١٣ Oral hydration Warm fluids (eg, tea, chicken soup), Honey (> 1 yr): modest beneficial on nocturnal cough; reduce cough frequency; 2.5 to 5 ml as needed Cough lozenges( > 6 yr) Hard candy( > 6yr)

14 Other remedies ١۴ Zinc: modest benefit in high doses(> 75mg/d) and common side effects, not suggested Echinacea purpurea : no better than placebo Vitamin C: not reduce the duration and severity of the cold.

15 Case 2 ١۵ An 18 month old infant brought with high fever, coryza, and cough since 2 days ago. Examinations shows significant erythema of the pharynx. The parent report severe nocturnal cough in each cold. 1. what's your diagnosis? 2. what's your prescription?

16 Severe cough in cold ١۶ Childhood asthma Wheezing, prolonged expiratory time Previous severe cough in colds Nocturnal cough Personal or family history of allergy Pertussis Postnasal discharge

17 Treatment of asthma ١٧ Salbutamol inhaler, sometimes oral Ipratropium bromide Systemic glucocorticoids Inhaled glucocorticoids id Leukotriene receptor antagonist( monteleukast)

18 Case 3 ١٨ An 18 month old infant brought with high fever, coryza, stridor and barking cough since 2 days ago. Examinations shows significant erythema of the pharynx. 1. what's your diagnosis? 2. what's your prescription?

19 Croup ١٩ Laryngotracheitis : 3mo-3yr Coryza then fever, hoarseness, barking cough, stridor and sometimes respiratory distress Improve within 3-7 Spasmodic croup: 3mo- 3 yr Always at night, short duration, abrupt onset and cessation, no fever, recurrent, only mild coryza, family history of croup and allergy

20 Treatment of croup ٢٠ Dexamethasone IV/IM/PO: 0.6 mg/kg/d or nebulized budezonide or 3-d prednisolon Nebulized epinephrine in moderate to severe cases: 0.5 cc/kg of 1/1000 soloution, max 5 ml, "rebound phenomenon Mist therapy: not proven efficacy, sense of comfort to both the child and family

21 Case 4 ٢١ An 18 month old infant brought with high fever, coryza, and cough since 2 days ago. Examinations shows significant erythema of the pharynx. The child advised to receive antipyretic and supportive measures. 2 days later the child returns with fever and some purulent nasal discharge. What's your diagnosis and plan?

22 Case 5 ٢٢ An 18 month old infant brought with high fever, coryza, and cough since 2 days ago. Examinations shows significant erythema of the pharynx. The child advised to receive antipyretic and supportive measures. 4 days later the child returns with no fever and purulent nasal discharge. What's your diagnosis and plan?

23 Viral upper respiratory infection ٢٣ 1 st 1-4 days : Fever/ clear nasal discharge/ nasal obstruction/ cough/ hoarseness/ sore throat/ GI symptoms Days 4-10: Improve of previous symptoms/ start of purulent nasal and post-nasal discharge/ purulent cough Days 10-14: Complete improve

24 Important notes ٢۴ No sign of bacterial sinusitis in URTI Fever in 1 st 4-5 days Change in color and consistency of nasal discharges Continue of symptoms for less than 14 days Severe cough Purulent nasal and post nasal discharge

25 Acute bacterial sinusitis ٢۵ Persistent of nasal symptoms (discharge, obstruction)+/- cough for >14 d High fever( 39⁰C) + purulent nasal discharge for>3-4 d Acute and significant worse of a viral URTI on the 6-7 th d(increase in discharge, cough or new fever)

26 Risk factors of bacterial resistance ٢۶ 1. Attendance at day care 2. Recent receipt(90 days) of antimicrobial treatment 3. Age less than 2 years.

27 Choice of antibiotic in ABS ٢٧ 1. mild to moderate severity, no risk of resistance: Amoxicillin (45-90 mg/kg/d, BID) Amoxicillin-clavulanate (45-90 mg/kg/d, BID) 2. moderate severity, risk of resistance: Amoxicillin-clavulanate (80-90 mg/kg/d, BID) Cefuroxime (30 mg/kg/d, BID)

28 Choice of antibiotic in ABS ٢٨ 3. Allergy to penicillin: Clarithromycin (15 mg/kg/d, BID) Azithromycin (10 mg/kg/d 1 st d, 5 mg/kg/d for 4 d) Clindamycin (30 to 40 mg/kg/d, TID-QID)+ Cefixime( 8-10 mg/kg/d, BID) Levofloxacine ( mg/kg/d, BID) No cefixime, cotrimoxazole, erythromycine, penicillin, ampicillin

29 Duration of AB treatment in ABS ٢٩ At least days (7 d after freeness of signs and symptoms) Reassessment: worsening failure to improve within 72 h

30 Case 6 ٣٠ An 18 month old infant brought with high fever, coryza, and cough since 2 days ago. Examinations shows significant erythema of the pharynx. Mild erythema of left tympanic membrane. What's your diagnosis and plan?

31 Diagnosis of certain AOM ٣١ All 3: 1. Recent onset 2. Middle Ear Effusion: 1. Bulging of the TM 2. Limited or absent mobility of the TM 3. Air-fluid level behind the TM 4. Otorrhea 3. middle-ear inflammation: 1. Distinct erythema of the TM, or 2. Distinct otalgia that precludes normal activity or sleep

32 Treatment of AOM ٣٢ < 6 mo: all cases 6mo- 2 yr: Certain cases Severe e cases unresponsive to 2 d observation cases > 2 yr: certain and severe cases unresponsive to 2 d observation cases Sever cases: moderate to high otalgia, T> 39 C

33 Antibiotic treatment in AOM ٣٣ Choice: like ABS Duration: 10 days Reassess: Worsening after 24 h Failure to improve within 72 h 1-3 mo later

34 Case 7 ٣۴ An 18 month old infant brought with high fever, coryza, and cough since 2 days ago. Examinations shows significant exudative pharynxitis. What's your diagnosis and plan?

35 GAS Pharyngitis ٣۵ Suggestive : 5-15 yrs( no < 3-4 yr), acute onset, fever ( ºC), exudates, tender lymphadenopathies, palatine petechia, scarlatiniform rash Negative evidence : coryza, significant cough, diarrhea, hoarseness, enanthema, conjunctivitis, no fever, non-scarlatiniform rash Treatment: single dose benzathine penicillin G, oral penicillin for 10 days, oral amoxicillin for 10 days

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