Acute Respiratory infections in Children

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Common Queries in the treatment of AURI
Role of antihistaminic decongestant combinations in AURI
There is lack of data on the efficacy, safety, and toxic potentials of such combinations. According to American Academy of Pediatrics Committee on Drugs rational therapeutics should not include such combinations.



Decongestant therapy in AURI
There are topical and oral decongestants. Topical decongestants are generally preferred to oral decongestants.
Normal saline nasal spray is the nasal (topical) decongestant preferred. Other nasal decongestants like oxymetazoline and xylometazoline are not preferred in pediatric office practice as they are notorious to cause rebound congestion and they also destroy the natural mucociliary mechanics. Oral decongestants like pseudoephedrine and phenyl propanolamine are less preferred in view of their systemic side effects like restlessness, sleep disturbance,agitation, tachycardia, headache and hypertension. Besides phenyl propanolamine is a powerful anorexiant. They are never used in children under 6 months of age. However, they may be helpful in some older children with troublesome rhinorrhea.

Role of antiinflammatory drugs in AURI
Paracetamol is the analgesic and antipyretic of choice in AURI. There is no role for nonsteroidal antiinflammatory drugs in the management of pain in AURI. The popular practice of Asprin/Disprin throat gargle is strongly condemned. NSAIDS can precipitate bronchospasm in Atopic individuals.



Role of anti-histaminics in AURI
Antihistaminics are ideally preferred in the management of allergic rhinitis which manifests as sneezing, nasal discharge, itching, conjunctival itching and lacrimation. There is no role for antihistamines
in viral coryza. Promethazine and diphenhydramine are the anti-histaminics preferred in Pediatric office practice. Antihistamines should be avoided when ALRI is also coexisting as they dry up the secretions and may cause segmental atelectasis in the lungs.

Acute Lower Respiratory Infections
Acute upper respiratory infections (AURI) occur more commonly and are usually self limiting, while ALRI contributes to increased mortality. These include epiglottitis, laryngitis, laryngotracheitis, bronchitis, bronchiolitis and pneumonia. Pneumonia is the leading cause of death among ARI. Incidence of pneumonia is 3-4% in developed countries and ranges from 10-20% in the developing countries. Although it is mandatory to know the clinical features and management of individual types of Acute Lower Respiratory infections, pneumonia being the major killer. WHO, has provided guidelines to detect varying severity of ALRI having in mind pneumonia as the most important of the ALRI.

Pediatric pneumonia: Pneumonia is infla-mmation of the lung parenchyma. Pediatric pneumonia has several causative agents. Pneumonia is a common illness in-children and is of two types.
a) Community acquired pneumonia : they may have a "typical" or atypical presentation.
Causes of Community acquired pneumonia:
a. Mycoplasma pneumoniae (atypical)
b.Streptococcus pneumoniae
c.H.Influenza
d. Chlamydia pneumoniae
e.Staph Aureus
f. Nocardia Spp
g.Viruses Influenza
CMV
RSV
Measles
Varicella-Zoster virus
h. Fungi Histoplasma
Coccidioidomycosis
Blastomyces
i. Mycobacterium tuberculosis
j. Chlamydia psittaci

b) Hospital acquired pneumonia (Nosocomial infection) : It tends to be more severe as the defence mechanisms of the host is usually compromised in these patients. The etiological agents in hospital acquired pneumonias are different from that in community acquired pneumonia. These include enteric gram negative Bacilli including Pseudomonas aeruginosa besides staph-aureus and anaerobes.

Mode of infection:
a) aspiration from oropharynx
b) entry of the infected aerosol
c) hematogenous spread
d) direct inoculation

Pattern Recognition:
Pneumonia is included as one of the diseases in the integrated management of childhood illness and its pattern recognition and management is based on the WHO guidelines.
The sick child should be classified into one of the following categories as per the guidelines: (Refer Table-1)
1. very severe disease
2. severe pneumonia
3. pneumonia
4. no pneumonia (cough or cold) AURI

Age Signs Treatment
1.Very Severe Pneumonia



Infants < 2 months


Signs (as in 2 & 3 plus) Stopped feeding well Convulsions Abnormally sleepy or Difficult to wake Stridor or Fever or low body temperature Hospitalise,
** Investigate
Give first dose of antibiotic Keep infant warm
2 months to 5 years Not able to drink Convulsions Abnormally sleepy or Difficult to wake Severe malnutrition Hospitalise (ICU set up)
Administer parenteral
antibiotic*
Treat fever
Treat wheeze
2. Severe Pneumonia    
Infants <2 months


(if recurrent wheezer
treat for wheezing)
Chest indrawing or Fast breathing (60 min or more) Hospitalise
** Investigate
Keep infant warm Give first dose of parenteral
antibiotic
2 months to 5 years Chest indrawing Hospitalise
** Investigate Give first dose of parenteral
antibiotic* Treat fever with Paracetamol
Treat wheeze
3. Pneumonia    
2 months to 5 years No chest indrawing Fast breathing ( 50/min or more if child is 2 to 12 month;40/ min or more If child 1 to 5 years). ** Investigate Advise mother to give home care
Give an antibiotic
* Treat fever, if present
Treat wheezing if present
Advise mother to return within 2 days for reassurance or earlier if the child is getting worse.
4. No pneumonia (AURI) :    
The above physical signs are absent. The mother must be advised to feed and keep the infants warm. Older children should be assessed for AURI. The mother should be taught to recognize signs of deterioration, and to return if there is a problem.    

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tinaannjohn 

good info

dinesh-RML 

good material. references should be given.

palakkmc 

good site

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