This document provides an overview of lower respiratory tract infections (LRTI) in children. It covers the epidemiology, pathophysiology, clinical presentation, diagnosis, and management. The most common causes of LRTI in children are viral infections like respiratory syncytial virus (RSV) and bacterial infections such as Streptococcus pneumoniae. Clinical features vary by age but may include fever, cough, tachypnea, grunting, and hypoxia. Diagnosis is usually based on symptoms and physical exam. Most children can be treated as outpatients with supportive care and antibiotics when indicated. Severe cases requiring hospital admission include those with hypoxia, respiratory distress, or comorbidities. Complications are rare but may include

1. Dr.Osama Felemban MBBS DCH CABP AFSA CPPF
Consultant Pediatric Pulmonology
Clinical Assistant Professor
Pediatric Department
King Abdulaziz University Hospital
Faculty of Medicine
KAU

2. 1. Over view
2. Epidemiology
3. Pathophysiology
4. Clinical Presentation
5. Clinical Approach
6. Differential diagnosis
7. Investigations
8. Management
9. Complication & prognosis
10. Prevention
11. Take Home massages
12. References

3. 1- Over view
 LRTI : infection below the level of larynx
 Larynogotracheobronchitis
Bronchitis
 Bronchiolitis
 Pneumonia

4. 2- Epidemiology
 The estimated incidence of LRTI is 30 per 1,000 children
per year in the UK.
 Boys affected > than girls, (children born between 24-28
weeks compared to born at term.)
 Haemophilus influenzae infection is uncomon because of
immunization.

5. 3 - Pathophysiology
 Essentially, it is inflammation of the airways/pulmonary
tissue, due to viral or bacterial infection, below the level
of the larynx.
 Gastro-oesophageal reflux may cause a chemical
pneumonitis.
 Smoke and chemical inhalation may cause pulmonary
inflammation

9. Etiology
 Viral infections : e.g
 Influenza A
 Respiratory syncytial virus (RSV)
 Human metapneumovirus (hMPV)
 Varicella-zoster virus (VZV)
 Chickenpox

10.  Bacterial infection :
 Streptococcus pneumoniae (the majority of bacterial
pneumonias)
 H. influenzae
 Staphylococcus aureus
 Klebsiella pneumoniae
 Enterobacteria - eg, Escherichia coli
 Anaerobes

11.  Atypical organisms
 Mycoplasma pneumoniae
 Legionella pneumophila,
 Chlamydophila pneumoniae
 Secondary bacterial infection
 relatively common following viral upper respiratory tract infection (URTI)
or LRTI.

12. 4 - Clinical Presentation
 typical viral URTI
 Fever
 Bacterial pneumonia :++ in children (persistent or repetitive
fever > 38.5°C) with chest recession and a raised resp.rate
 Audible wheezing is not seen very often in LRTI (common
with more diffuse infections ; M. pneumoniae and
bronchiolitis).
 Stridor or croup suggests URTI, epiglottitis or foreign body
inhalation.

13. 5 – Clinical Approach
 History :symptoms of LRTI is variable with age
 Newborn and neonates present with:
 Grunting
 Poor feeding
 Irritability or lethargy
 Tachypnoea ±
 Fever (±Hypothermia)
 Cyanosis (in severe infection)
 Cough (±)
In this age group beware:
 Particularly of streptococcal sepsis and pneumonia in the first 24 hours
of life
 Chlamydial pneumonia, which may be accompanied by chlamydial
conjunctivitis (presents in the second or third week)

14. History
 Infants present with:
 Cough (the most common symptom after the first four weeks)
 Tachypneic (according to severity)
 Grunting
 Chest indrawing
 Feeding difficulties
 Irritability and poor sleep
 Breathing, which may be described as 'wheezy' (but usually upper
airway noise)
 History of preceding URTI (very common)
 Atypical and viral infections (especially pneumonia) may have
only low-grade fever or no fever

15.  Toddlers/pre-school children:
 Preceding URTI is common
 Cough is the most common symptom
 Fever occurs most noticeably with bacterial organisms
 Pain (chest and abdominal)
 Vomiting with coughing is common (post-tussive vomiting)
 Lower lobe pneumonias can cause abdominal pain

16.  Older children:
 There will be additional symptoms to those above
 More expressive and articulate children will report a wider
range of symptoms
 Constitutional symptoms may be variable described
 Atypical organisms are more likely in older children

17. Physical Examination
 General points:
 Examination can be difficult in young children
(particularly auscultation)
 A careful routine of observation is essential to identify
respiratory distress
 Pulse oximetry can be very useful in evaluation.
 High fever over 38.5°C may occur often

18.  signs of respiratory distress:
 Cyanosis in severe cases
 Grunting
 Nasal flaring. In children aged under 12 months this can
be a useful indicator of pneumonia
 Marked tachypnoea
 Chest indrawing (intercostal and suprasternal recession)
 Other signs ;subcostal recession, abdominal 'see-saw'
breathing and tripod positioning
 Reduced oxygen saturation (less than 95%)

19.  Observation:
 In good light, with the chest and abdomen uncovered, is essential
 Count respirations and note the respiratory rate (RR)
 Newborn 30-60/minute
 Infant 20-30/minute
 Toddler 20-30/minute
 Child 15- 20/ minute
 Observe the infant's feeding (to uncover decompensation during
feeding)
 Observe the chest movements (for example, looking for splinting of
the diaphragm)

20.  Auscultation:
 Examine with warm hands and a stethoscope
 Take the opportunity to examine a quiet sleeping child
 Upper respiratory noises can be identified by listening at
the nose and chest
 Crepitations in the chest may indicate pneumonia, +
when accompanied by fever

21.  Percussion:
 Identifies consolidation
 Consolidation is a later and less common finding than
the crepitation of a pneumonia
 Later in older children there may be dullness to
percussion over zones of pneumonic consolidation
 Bronchial breathing and signs of effusion occur late in
children and localization of consolidation can be difficult
to diagnose

22. 6 - Differential diagnosis
 Asthma
 Inhaled foreign body
 Pneumothorax
 Cardiac dyspnoea
 Pneumonitis from other causes:
 Extrinsic allergic alveolitis
 Smoke inhalation
 Gastro-oesophageal reflux

23. 7 - Investigations
 CBC:
 White cell count is often elevated.
 Microbiological studies:
 Blood cultures are seldom positive in pneumonia (fewer
than 10% are bacteraemic in pneumococcal disease).
 Sputum culture
 Imaging:
 Chest radiography (CXR) is not routinely indicated in
outpatient management.
 CXR cannot differentiate reliably between bacterial and
viral infections.

24.  Other tests:
 Tuberculin skin testing if tuberculosis is
suspected.
 Cold agglutinins when mycoplasmal infection
is suspected (50% sensitive and specific).
 ESR , CRP
 Diagnostic procedures:
 Drainage and culture of pleural effusions may
relieve symptoms and identify the infection.

25. 8 - Management
 Most children with lower respiratory tract infection
(LRTI) and pneumonia can be treated as outpatients,
with oral antibiotics.
 Older children can be managed with close observation
at home if they are not distressed or significantly
dyspnoeic and parents can cope with the illness.
 Viral bronchitis and croup do not require antibiotics
and mild cases can be treated at home

26.  Admission of severe LRTI :
 Oxygen saturation <92%
 Respiratory rate >70 breaths/minute (≥50 breaths/minute in an older
child)
 Significant tachycardia for level of fever
 Prolonged central capillary refill time >2 seconds
 Difficulty in breathing as shown by intermittent apnea, grunting and
not feeding

27. Presence of comorbidity :
 congenital heart disease,
 chronic lung disease of prematurity,
 chronic respiratory conditions such as
- cystic fibrosis,
- bronchiectasis or
- immune deficiency

28. Admission should also be considered for:
 All children under the age of 6 months
 Children in whom treatment with antibiotics has failed (most
children improve after 48 hours of oral, outpatient antibiotics)
 Patients with troublesome pleuritic pain

29.  Be sure to offer the patient and parents general support,
explanation and reassurance.
 Respiratory support as required, including oxygen
 Pulse oximetry to guide management
 Severe respiratory distress with ↓level of consciousness
and failure to maintain oxygenation indicates a need for
intubation

30. Medications
 Antipyretics
(avoid aspirin due to the danger of Reye's syndrome).
 Antibiotic treatment

31. 9 - Complication & prognosis
 Complete resolution after treatment should be expected in
the vast majority of cases.
 Bacterial invasion of the lung tissue can cause pneumonic
consolidation, septicemia, empyema, lung abscess
(especially S. aureus) and pleural effusion.
 Respiratory failure, hypoxia and death are rare unless
there is previous lung disease or the patient is
immunocompromised.

32. 10 - Prevention
 Prevention of pneumococcal pneumonia and influenza by
vaccination, for high-risk individuals with pre-existing
heart or lung disease.
 Smoking in the home is a major risk factor for all
childhood respiratory infection.

33. 11 - Take Home massages
 Understanding the pathophysiology of LRTI
 Conducting proper History
 Performing careful physical Examination
 Comprehension the Impact of the disease on the family
 Close follow up after discharge
 Avoidance of bad Habit : Smoking

34. 12 - References
 Guidelines for the management of community acquired pneumonia in children;
British Thoracic Society (2011)
 Pediatric Essntial Nelsom 2011
 van Woensel JB, van Aalderen WM, Kimpen JL; Viral lower respiratory tract
infection in infants and young children. BMJ. 2003 Jul 5;327(7405):36-40.
 Michelow IC, Olsen K, Lozano J, et al; Epidemiology and clinical
characteristics of community-acquired pneumonia in hospitalized children.
Pediatrics. 2004 Apr;113(4):701-7.
 Krilov LR; Respiratory syncytial virus disease: update on treatment and
prevention. Expert Rev Anti Infect Ther. 2011 Jan;9(1):27-32.
 Feverish illness in children - Assessment and initial management in children
younger than 5 years; NICE Guideline (May 2013)
 Mahabee-Gittens EM, Grupp-Phelan J, Brody AS, et al; Identifying children
with pneumonia in the emergency department. Clin Pediatr (Phila). 2005
Jun;44(5):427-35.
 Haider BA, Saeed MA, Bhutta ZA; Short-course versus long-course antibiotic
therapy for non-severe Cochrane Database Syst Rev. 2008 Apr
16;(2):CD005976.