Acute respiratory infections in children

1. Acute Respiratory Infections
Acute rhinitis
Otitis media
Acute pharyngitis / tonsillitis
ALTB
Acute epiglottitis
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

2. (God speaking to Prophet Muhammad (PBUH)
Indeed Allah orders justice, kindness and giving to your relatives; and
forbids immorality, bad conduct and oppression.
He advises you so that you can follow
Al Quran surah Al-Nahl 16:90

4. Acute Respiratory Infections

5. ARI – upper respiratory tract infections
 Acute rhinitis (common cold)
 Sinusitis
 Otitis media
 Pharyngitis and Tonsillitis
 ALTB - Acute laryngotracheobronchitis (croup)
 Acute Epiglottitis

6. Clinical Scenario 1

7. Case scenario
• A nine month baby presents to OPD with runny nose,
sneezing and mild cough for the last 3 days. Mother says
baby is feeding less than before.
• On examination, baby is having watery nasal discharge. He is
noticed to have a dry cough. His respiratory rate is 36 per
minute and chest indrawing is not present. His temperature
is 99 F.
• What is your diagnosis ?
• How will you classify this child in IMNCI ?

8. IMNCI – Cough or Cold

9. Acute Rhinitis (common cold)
• Caused by Rhino virus
• Air – borne droplet infection
• Self – limiting disease in 5 – 7 days
• Babies are nasal breathers, so when their nose is blocked
they have reduced feeding and excessive crying
• Nasal discharge, sneezing, blocked nose and cough are seen
• Excoriation of skin causes local irritation
• Headache and muscular pain can occur

10. Management of common cold
• Reduce the pain – Paracetamol
• Clear the nose – frequent cleaning
– normal saline nose drops
• Reduce mucosal swelling – in children > 2 years
• Antihistamines
• Vasoconstrictors
Prevention – handwashing, social distancing

11. Acute Sinusitis
• Complication of Acute Rhinitis
• Mixed viral and bacterial infection
• Nasal discharge, blocked nose, headache and facial pain are
common
• Disease may last for days to weeks
• Treatment - Antibiotics, analgesics and decongestants

12. Clinical Scenario 2

13. Case Scenario
• A 12 month old baby presents to your clinic with runny
nose, cough and fever for the last 3 days. Mother says baby
was very irritable and crying all the time. Since yesterday
baby is having an ear discharge.
• On examination, baby is having a wet nose and white fluid
discharge is visible in ear canal. His respiratory rate count is
35 per minute and chest indrawing is not present. His
temperature is 101 F.
• What is your diagnosis ?
• How will you classify this child in IMNCI ?

14. IMNCI - Assess for Ear Problem
• ASK: Does the child have Ear Problem ?
• IF YES
• ASK: Is there Ear Pain ?
• ASK: Is there Ear Discharge ? If yes, for how long ?
• Look and Feel:
 Look for pus draining from the Ear
 Look for tender swelling behind the ear ?
 Throat and Ear examination of Child needs
appropriate position and should be performed last in
the sequence of physical examination

15. IMNCI - Classify Ear Problem

16. Ear Problems in Children
• Cause of Ear Pain –
- URTI -- (runny nose, blocked Eustachian tube)
- Acute Otitis Media -- (viral or bacterial infection)
- Otitis externa, Boil in Ear
• Cause of Ear Discharge –
Acute Otitis Media with perforated tympanic membrane
Chronic Otitis Media -- (mixed bacterial infection)
• Swelling behind the Ear – Mastoiditis

17. Acute Otitis Media (ASOM)
• Very common infection in small children
• Mixed Viral and Bacterial (S. pneumoniae, H. influenza, M.
catarrhalis ) infections
• Presenting symptom is sudden, severe ear pain
• Perforation of Tympanic Membrane occurs within hours
• With perforation of TM, pain subsides and ear discharge
starts
• Recovery takes many days. Recurrences are common
• Perforation of TM may heal after adequate treatment
• Persistent or recurrent infections lead to Chronic Otitis
Media

18. Infected Middle Ear (Otitis media)

19. Acute Otitis Media

20. Chronic Otitis Media (ChSOM)
• Persistent Ear infection for more than 2 weeks
• Perforation of Tympanic Membrane not healed
• Intermittent / persistent ear discharge
• Hearing loss can occur in children
• Delayed speech development in child

21. Mastoiditis
• Mastoiditis is a complication of Chronic suppurative
otitis media (ChSOM)
• Middle ear infection extends posteriorly into the
mastoid air cells
• Pain, swelling, redness and tenderness in the mastoid
region
• Intermittent / persistent ear discharge
• In untreated cases, Meningitis and Brain abscess may
occur
• Mastoiditis is treated by IV antibiotics, drainage of pus
and Mastoidectomy in resistant cases

22. Management of Otitis media
• Antibiotics
– Amoxycillin, Co-amoxiclav, Cephradine, Clarithromycin
– Inj. Ceftriaxone for severe cases
• Reduce the pain – Paracetamol
• Clear the nose – cleaning
– normal saline nose drops
• Reduce mucosal swelling –
– Antihistamines
– Vasoconstrictors
– Normal saline nebulization

23. IMNCI - Treat Ear Problem
• Mastoiditis – Admit / Refer
• Acute Ear Infection
-- Amoxycillin (oral)
-- Paracetamol (oral)
• Chronic Ear Infection
-- Dry the Ear by wicking
-- Ciprofloxacin Ear drops

24. Clinical Scenario 3

25. Case scenario
• A four year old child presents to your clinic with fever and
reduced his food intake for the last 2 days. You ask about
runny nose, cough, vomiting, diarrhea, pain anywhere
• On examination, his respiratory rate is 30 per minute and
chest indrawing is not present. His temperature is 102 F. His
tonsillar lymph nodes are enlarged. His tonsils are red and
have whitish exudate on them.
• What is your diagnosis ?
• How will you classify this child in IMNCI ?

26. IMNCI - Classify Throat Problem

27. IMNCI - Treat Throat Problem
• Sore Throat and Not able to Drink – Admit / Refer
• Streptococcal Sore Throat
-- Amoxycillin (oral) or Amoxycillin IV in severe cases
-- Paracetamol (oral)
• Viral Sore Throat -- Paracetamol (oral)
-- safe, soothing throat remedies

28. Causes of Sore Throat in Children
• Viral Infections –
URTI -- (runny nose, pain in throat)
Viral pharyngitis -- (diffuse redness in throat)
• Bacterial Infections
– Streptococcal Tonsillitis (High Fever)
-- Diphtheria (Not able to drink)
• Throat Abscess – Rare (unable to drink)
• Allergy – seen after intake of cold water, ice-cream,
sour food

29. Bacterial Throat Infections
Streptococcal
Tonsillitis Diphtheria Viral Sore Throat

30. Diphtheria
• Caused by Corynebacterium diphtheria
• Age 2 – 15 years, can occur in adults
• Fever, sore throat
• Enlarged cervical lymph nodes with edema – bull neck
• Unilateral Thick, Greyish Exudate (pseudo-membrane) seen
on posterior pharynx
• Laryngeal diphtheria causes stridor and Respiratory
Obstruction requiring Tracheostomy
• Diphtheria toxin causes Myocarditis and Neuropathy
• Management is Anti-diphtheria serum and antibiotics
• Mortality is high

31. Streptococcal Tonsillitis
• Causative agent is Streptococcus pyogenes, which is carried
and transmitted from the throat
• Gram positive Group A beta Hemolytic Streptococci
• Common in children from 1 to 15 years of age
• Diagnosis – clinical, throat swab culture
• Recurrent attacks are common
• Can result in Rheumatic fever
• Treatment - Penicillin
• Tonsillectomy may be indicated in very frequent attacks of
Streptococcal tonsillitis or very large tonsils in children more
than five years of age

32. Clinical diagnosis of
Streptococcal Tonsillitis
 Red enlarged tonsils
 Exudate on the tonsils
 Tender, enlarged cervical lymph nodes
 Presence of 2 of 3 signs gives a clinical
diagnosis of Streptococcal tonsillitis

33. Viral Sore Throat
• Caused by Adeno virus, Corona virus, Parainfluenza
virus
• Pain in throat
• Painful swallowing
• No fever or low grade fever
• Runny nose may be present
• Diffuse redness in throat is seen
• Recovers in 3-5 days

34. IMNCI - Assess for Sore Throat
• ASK: Does the child have sore throat ?
• ASK: Is the child able to drink ?
• ASK: Does the child have fever ?
• Look and Feel:
Fever (temperature 37.5 C or above)
 Feel the front of neck for tender enlarged lymph nodes
 Look for red, enlarged tonsils
 Look for exudate on the throat
Throat and Ear examination of Child needs appropriate
position and should be performed last in the sequence
of physical examination

35. Clinical Scenario 4

36. Case scenario
• An 18 month old baby presents to emergency in the middle
of the night with difficulty in breathing for the last few
hours. Mother says baby had runny nose for the last 3 days,
but his condition has deteriorated suddenly.
• On examination, baby is having dry, hoarse, croupy cough.
His respiration is 60 per minute and chest indrawing is
present. His temperature is 100 F. A harsh inspiratory noise
(stridor) is coming from the throat. This noise is increased
when the child is agitated.
• What is your diagnosis ?
• How will you classify this child in IMNCI ?

37. IMNCI – Stridor

38. STRIDOR
• A harsh inspiratory sound produced due to
Obstruction in or around the LARYNX
• Stridor when child is agitated - (mild obstruction)
• Stridor in the calm child - (more severe obstruction)

39. Causes of Acute STRIDOR
• ALTB (Acute laryngotracheobronchitis) or Croup
• Diphtheria
• Foreign body in larynx or trachea
• Acute epiglottitis
• Allergic laryngitis
• Bacterial tracheitis

40. ALTB - Acute laryngo-tracheo-bronchitis

41. ALTB - Acute laryngo-tracheo-bronchitis
• Alternate name: Croup
• Caused by viruses (RSV, Parainfluenza 1-3)
• Acute inflammation produces narrowing of subglottic area
• May result in Respiratory Obstruction
• Occurs between 3 months and 3 years of age
• Clinical features
• Fever, Runny nose, hoarseness, cough, stridor,
• Usually presents in the middle of the night
• Throat, carefully examined, is normal
• X-ray soft tissue neck shows STEEPLE sign

42. Croup – stridor

43. STEEPLE sign

44. STEEPLE sign
• Air column of trachea on X-ray chest
Normal ALTB

45. Management of ALTB
• Keep the child calm and quiet
• Nebulised epinephrine (short-term relief)
• DEXAMETHASONE
• 0.6 mg/kg Oral, IM or IV
• Endotracheal intubation or Tracheostomy is rarely needed

46. Clinical Scenario 5

47. Case scenario
• A 5 year old unvaccinated child presents to emergency with
high grade fever, difficulty in breathing and drooling for the
last few hours. Mother says child was well before and his
condition has deteriorated suddenly.
• On examination, child has open mouth and anxious look. His
respiration is 60 per minute and chest indrawing is present.
His temperature is 103 F. A harsh inspiratory noise (stridor)
is coming from the throat. Child is unable to speak or lie
down.
• What is your diagnosis ?
• How will you classify this child in IMNCI ?

48. Acute epiglottitis

49. Acute epiglottitis
 Caused by H. influenzae type b
• Cellulitis of epiglottis
• Causes Respiratory Obstruction
• Occurs between 3 – 7 years of age
• Clinical features
• Fever, stridor, unable to speak, dysphagia, lethargy
• Usually presents acutely
• Throat examination may precipitate respiratory
obstruction
• X-ray soft tissue neck shows THUMB sign

50. Acute epiglottitis

51. Management of Acute epiglottitis
• Keep the child calm and quiet
• IV fluids
• IV antibiotics – ceftriaxone
• Oxygen inhalation
• Endotracheal intubation or Tracheostomy is usually needed

52. Causes of stridor in children

53. Prevention of
Acute Respiratory Infections
• Vaccination –
Penta (DPT, Hib, Hep B),
Pneumococcal, Measles,
Influenza, Covid 19
• Breastfeeding, Nutrition, Micronutrients
• Masks and Social Distancing
• Hand washing,
• Control of smoking, air pollution, cold air

54. Thank You