Approach to a child with acute respiratory infections

2. An infection of any part of respiratory tract
anywhere from nose to alveoli, with a wide range
of combination of symptoms and signs lasting
less than 30 days (15 days for otitis media)

3.  National Family Health Survey (NFHS) studies reported an
overall ARI prevalence of 6.5%, 19.0% and 5.8% among under-
five children in the preceding two weeks before the survey in
three surveys at three time-periods over last two decade

4.  India is predicted to have over 700 million episodes of ARI and over 52 million
episodes of pneumonia every year.
 The Central Bureau of Health Intelligence of the MoHFW reported ARI mortality
ranging from 3200 to 6900 each year, giving a mortality rate of 0.32 to 0.61 deaths
per l00,000 population.
 The WHO / UNICEF estimated an ARI case fatality rate of 0.93%
 In India: 10-50 children die per 10,000 episodes of ARI
• Joseph L Mathew, Ashok K Patwari, et al; Acute Respiratory Infection and Pneumonia in India: A Systematic
Review of Literature for Advocacy and Action: UNICEF-PHFI Series on Newborn and Child Health, India ; Indian
Pediatrics, Volume 48__March 17, 2011: 191-218

5.  Low level of literacy,
 Suboptimal breast feeding,
 Malnutrition,
 Unsatisfactory level of immunization coverage,
 Cooking fuel used other than liquefied petroleum gas
• WHO (1995), The Management of acute respiratory infections in children, Practical
guidelines for out patient care, WHO, Geneva

6.  Acute Upper Respiratory Tract Infections (AURTI)
 Common cold,
 Epiglottitis,
 Laryngotracheobronchitis
 Otitis media, etc.
 Acute Lower Respiratory Tract Infections(ALRTI)
 Bronchitis,
 Bronchiolitis,
 Pneumonia, etc,

7.  8 episodes / year is avg in children
 Etiologies: Rhinoviruses (30-35%), Corona viruses(10%), Misc (20%)
 Clinical: Sore throat, running nose, nasal congestion, myalgia,
fatigue. Seasonal variations
 Transmission: Direct contact, droplet, fomites
 Incubation period 12-72 hrs
 Diagnosis: R/o serious infections like Strep throat, adenovirus and
diphtheria
 Treatment: Symptomatic
COMMON COLD

8.  Life threatening infection of epiglottis
 Peak age 1 to 6 years
 Cause: Hemophilus infleunza type B
 Concomitant bacteremia, pneumonia, otitis media, arthritis or other invasive
infection by HiB may be present
 Clinical:
 High fever, sore throat, dyspnea, rapidly progressive respiratory obstruction.
Patient becomes toxic, difficult swallowing and labored breathing.
 Drooling and hyperextended neck.
 Tripod position while sitting, cyanosis, coma and death
 Stridor – late finding
 OE: Cherry red appearance of epiglottis, Thumb sign on lateral neck X ray
ACUTE
EPIGLOTTITIS

9. ACUTE
EPIGLOTTITIS

10. Treatment:
 Admit in ICU
 Fluid and electrolyte support
 IV Ampicillin 100 mg/kg/d in div doses
OR
IV Ceftrioxazone 100 mg /kg/d in div doses
 Prophylaxis:
 Rifampicin – to close contacts
ACUTE
EPIGLOTTITIS

11.  Etiology: Influenza, parainfluenza and RSV
 Common age: 6 mo to 6 yrs
 Clinical:
 Rhinorrhea, mild cough, fever, barking cough,
hoarseness of voice, nasal congestion
 Symptoms worsen at night and on lying
 Spontaneous resolution in a week
 Diagnosis: Clinical. Steeple Sign on X Ray Treatment:
 Symptomatic
 Humidified air
 Nebulized racemic epinephrine
 Corticosteroids
ACUTE
LARYNGOTRACHEOBRONCHITIS
(CROUP)

12.  Etiology: Most often respiratory syncytial virus (RSV)
 Common age: 6 mo to 2 yrs
 Clinical:
 Coryza, vomiting, irritability, wheeze, feeding difficulty, episodes of apnea
 Physical Signs
 Tachypnoea, flaring of alae nasi, cyanosis or pallor, use of accessory muscles f respiration,
expiratory wheeze, grunting, hyper resonant percussion note, Liver and spleen may be
palpable
 Diagnosis:
 X Ray Chest: Hyperinflation of chest, increased bronchovesicular markings
 Pulse oximetry: to assess hypoxia
 Nasopharyngeal swabs – for RSV culture or antibody titers
BRONCHIOLITIS

13. Complications:
 Pneumonia
 Pneumothorax
 Dehydration
 Respiratory acidosis
 Heart failure
 Prolonged apneic spells leading to death
BRONCHIOLITIS

14. Treatment:
 Supportive
 Prop up 30 to 400
 Limit oral feeds / Parenteral fluids to avoid dehydration
 Correct acidosis and electrolyte imbalance
 Nebulized racemic adrenaline
 Mechanical ventilation
BRONCHIOLITIS

15. Inflammation of lung parenchyma and consolidation of
alveolar spaces
Etiology:
 In developed world: Mostly viral, low mortality
 In developing world: Bacteria and PCP in 65%, Common cause of
death
PNEUMONIAS

16.  CBC: WBC > 15 000
 Blood C/s : positive in 25% cases
 Sputum: Gram’s stain, AFB
 Pleural fluid: exam if present
 ASO titers – for Strep
 Tuberculin skin test
 Viral titers, cultures/antigen tests
PNEUMONIAS - LABS

17.  Bacterial
 Poorly demarcated opacities with
air bronchogram
 Lobar or segmental opacification
 Specific:
 Staphylococcal: areas of
breakdown
 Klebsiella: Cavitation, median
fissure effusion
 Tuberculosis: Pleural effusion,
mediastinal glands
PNEUMONIAS
- RADIOLOGY
 Viral
 Perihilar streaking
 Interstitial changes
 Air trapping

18.  Bacterial
 Poorly demarcated opacities with
air bronchogram
 Lobar or segmental opacification
 Specific:
 Staphylococcal: areas of
breakdown
 Klebsiella: Cavitation, median
fissure effusion
 Tuberculosis: Pleural effusion,
mediastinal glands
PNEUMONIAS
- RADIOLOGY

19.  Empyema
 Lung abscess
 Pnumothorax
 Pleural effusion
 Delayed resolution
 Respiratory failure
 Metastatic septic lesions
 Meningitis
 Otitis media
 Sinusitis
 septicemia
PNEUMONIAS -
COMPLICATIONS

20. Source: WHO and MCEE provisional estimates 2015

21.  Antibiotics:
 Amoxicillin, co – amoxiclav, cefaclor, macrolides
 For Severe pneumonia:
 IV Co-amoxiclav, Cefotaxime of Cefuroxime
 Special categories
 As per the suspected organism sensitivity
 Oxygen
 Hydration
 Temp control
 Hydration
 Chest drain – if empyema +
PNEUMONIAS -
TREATMENT

22.  ARI Case Management : 84% reduction in mortality
 ARI control program was started in India during 1990.
 ARI strategy an integral to the Child Survival and Safe Motherhood (CSSM)
program in 1992; continued into the RCH Phase I project in 1997.
 Maternal education and Referral are integral part of the programme
 Under this program, cotrimoxazole tablets are made available at health
facilities above the level of sub-centers
 F-IMNCI focuses on appropriate inpatient management of birth asphyxia,
sepsis and low birth weight among neonates and pneumonia, diarrhea,
malaria, meningitis, and severe malnutrition in children.

23. Physical examination
 Count the breaths in one minute
Breathing count depends on the age of the child
Count respiratory rate for a minute
Age of the Child Fast Breathing
< 2 mo 60 breaths / min
2 mo to 12 mo 50 breaths / min
12 mo to 5 years 40 breaths / min

24. Breathing
OUT is
difficult due to
narrowing of
the air
passages
Wheeze
Occurs when
the effort
required to
breath in, is
much greater
than normal
Chest
indrawing
Occurs due to
narrowing of
trachea,
larynx or
epiglottis
Stridor
Sign of hypoxia
Cyanosis
Underlying
Risk factor
Malnutrition

25. WHO protocol comprises 4 steps:
1. Case finding & Assessment
2. Case Classification
3. Institution of appropriate therapy
4. Follow-up of cases

26. STEP 1
Ask
- How old is the child?
- Is the child coughing or having difficulty of breathing?
- For how long?
Age of the Child H/o. Danger Signs
Age 2 months to 5
years
• Is the child able to drink?
Age less than 2 months • Has the child stopped feeding?
• For how long?
• Has the child had convulsions?
• Has the child had fever?

27. Look; Listen; and Feel
1. Count the breaths in one minute
2. Look for the chest indrawing
3. Look and listen the stridor
4. Look and listen the wheeze
5. See if the child is abnormally sleepy or difficult to wake
up
6. Feel for fever or low body temperature
7. Look for severe malnutrition
8. Look for cyanosis
STEP 1

28. STEP 2:
Purpose:
- To make decision about severity of disease
- Choose line of action or treatment
It is done on the basis of danger signs and respiratory rate

29. Child age 2–59 months
with cough and/or
difficult breathing
Cough and cold:
no pneumonia
Home care advice
Fast breathing and/or
chest indrawing:
pneumonia
Oral amoxicillin and
home care advice
General danger signs:
†severe pneumonia
or very severe disease
First dose antibiotic
and referral to facility
for injectable antibiotic
/ supportive therapy
† Not able to drink, persistent vomiting, convulsions, lethargic or unconscious, stridor in a calm child or severe
malnutrition.

30. STEP 3:
Antibiotic Dose
Frequency
Age < 7 days Age 7 days to 2 mo
Inj. Ampicillin
AND
50 mg/kg/dose 12 hourly 8 hourly
Inj.Gentamycin 2.5 mg/kg/dose 12 hourly 8 hourly

31. Antibiotic Dose Interval Mode
A Inj. Ampicillin 50 mg/kg/dose 6 hourly IM
B If condition improves, then for next 3 days
Ampiciline/Amoxicilline
If no improvement for next 48 hrs –
Change antibiotic
50 mg/kg/dose 6 hourly/
8 hourly
Oral
C Provide symptomatic treatment for fever and wheezing, if present
D Monitor fluid and food intake
E Advise mother on home management on discharge.
STEP 3:

32. Age / Weight
Pediatric Tablet
Sulfamethaoxazole 100 mg &
Trimethoprim 20 mg
Pediatric Syrup
Each spoon (5 ml) contain
Sulfamethaoxazole 200 mg &
Trimethoprim 40 mg
< 2 months (wt: 3-5 kg) One tablet BD Half spoon BD
2 – 12 months (wt:6-9 kg) Two tab BD One spoon BD
1-5 yrs (wt: 10-19 kg) Three tab BD One and half spoon BD
STEP 3:

33. STEP 4:
Mother should
– Keep the baby warm
– Continue breast feeding and feeding the child
– To increase feeding after recovery
– To clear the nose if it interferes with feeding
– Proper dose of antibiotic for 5 days
– Cough can be relieved by home made decoctions
– To bring back the child after 2 days for
reassessment – to watch for danger signs

34. Feeding children with adequate amounts of nutritious food5
Breastfeeding infants exclusively1
Avoiding respiratory irritation by indoor air pollution2
Avoid the use of dried cow dung as fuel for indoor fires.3
Immunization of all children with the routine EPI Vaccines4
Avoid contact with patients who have ARIs.6

35. 3. HiB vaccine
2. Pneumococcal vaccine
1. Measles vaccine
4. Influenza Vaccine

36.  The specific goals for 2025 are to:
 Reduce mortality from pneumonia in children < 5 yrs to < 3 per 1000 live
births
 Reduce mortality from diarrhea in children < 5 yrs to < 1 per 1000 live births
 Reduce incidence of severe pneumonia & severe diarrhea by 75% in children <
5 yrs of age compared to 2010 levels
 90% full dose coverage of each relevant vaccine (with 80% coverage in every
district)
 90% access to appropriate pneumonia and diarrhea case management
 At least 50% coverage of exclusive breast feeding during first 6 months
 Virtual elimination of pediatric HIV

37.  The specific goals for 2030 are to:
 Universal access to basic drinking-water in health care facilities and homes
 Universal access to adequate sanitation in health care facilities by 2030 and in
homes by 2040
 Universal access to handwashing facilities (water and soap) in health care
facilities and homes
 Universal access to clean and safe energy technologies in health care facilities
and homes
• Ending Preventable Child Deaths from Pneumonia and Diarrhea By 2025, The Integrated Global Action
Plan For Pneumonia And Diarrhea. WHO, UNICEF - 2013

38. Dr.C.S.N.Vittal