1. Upper Respiratory
Infections
Khaled Saad Zaghloul
MD Pediatrics

2.  The most common cause ofThe most common cause of cough inin
children is represented by airwayschildren is represented by airways
respiratory infection,respiratory infection, mostly concerning the
upper airway and of viral origin (URTI).
 A healthy child is expected to present with
3.8–8 infective episodes per year, vs. the
average of two episodes for an adult .
Monto AS. Epidemiol Rev 1994: 16: 351–73Monto AS. Epidemiol Rev 1994: 16: 351–73..
Leder et al. Aust N Z J Public Health 2003: 27:399–404Leder et al. Aust N Z J Public Health 2003: 27:399–404..

3. Cough associated with a single
infective episode may last from days
to weeks, with an average of 1–3
weeks , and it has been demonstrated
that 10% of children will be expected
to be still coughing after 4 weeks from
the beginning of the infection.
Hay & Wilson . Br J Gen Pract 2002: 52: 401–9.
Hay et al. Fam Pract 2003:20: 696–705.

4. The infections may occurThe infections may occur ‘‘back to back’’
and give the impression of a chronicand give the impression of a chronic
persistent cough. However, these childrenpersistent cough. However, these children
should experience short breaks in theirshould experience short breaks in their
symptoms in between infections.symptoms in between infections.

5. UPPER RESPIRATORY TRACT
IFECTIONS
 Common cold
 Pharyngitis
 Sinusitis
 Ear infections

6. The common cold
 Short, mild and usually self-limiting illness.
 Children may have up to12 colds per year.
 200 types of viruses, the most common is
rhinovirus ( 40% ).

7. Clinical features of common cold:
 Rhinorrhea, sore throat,cough,fever and
malaise lasting up to 7 days and often
lingering mucopurlant nasal discharge.
 In infants cold may manifest as irritability,
snuffles and difficulty with feeding.
 Infants under 3 months of a age are
susceptible to LRTI.

8. Treatment of common cold
Echinacea, humidified air, nasal decongestants,
vitamin C and zinc have reported some
positive results but there insufficient data to
recommend any of these for treatment.
Hems and Henderson, Respiratory disorders. Forfar and
Arneil' Textbook of Pediatrcs, 715,2008

9. Acute sore throat

10. Pharyngitis
 Bacterial infectionBacterial infection
 Viral infection
 Streptococcus pyogenes – most serious type
 Scarlet fever
 Rheumatic fever
 Glomerulonephritis

11. Streptococcus pyogenesStreptococcus pyogenes
Group A is virulent
Streptolysins - toxin (hemolysins)
Erythrogenic – toxin
Toxins can act as superantigens
Over stimulate T cells
Tumor necrosis factor

12. ƄƄ Bacterial infection:Bacterial infection:
Group A beta-hemolytic Streptococcus
• Most common and important
• Commonly presents in children aged 5–6
• Fever, dry sore throat, cervical adenopathy,
dysphagia, and odynophagia
• The tonsils and pharyngeal mucosa are
erythematous and may be covered with
purulent exudate
• The tongue may also become red ("strawberry
tongue")
• Sequelae: acute rheumatic fever and
poststreptococcal glomerulonephritis

13. The surface antigens of group A streptococcus serve as
virulence factors.
Fig. 21.5 Cutaway view of group A streptococcus.

15. Streptococcus infection causing inflammation of the throat
and tonsils.

16. Treatment of acute phryngitis
 Penicillin V 250 mg/dose for children and
500mg/dose for adolescents and adults.
 Amoxicillin; 750 mg once daily for10 days or
50 mg/kg/day for 6 days divided bid.
 A single IM injection of benzathine penicillin
(600,000U for children < 27 kg; 1,2 million U
for larger children and adults.
 Erythromycin 40 mg/kg in divided doses for
10 days.

17. Azithromycin offers convenience of once-
daily administration and shorter length of
therapy.
Cephalosporins appear to be as, good as or
better than penicillin, perhaps because these
drugs are more effective in eradicating
streptococcal carriage. Evidence is not
sufficient to recommend shorter courses of
cephalosporins for routine therapy at this time
Pappas and Henley: Nelson textbook of pediatrics, 2007Pappas and Henley: Nelson textbook of pediatrics, 2007

18. Candida

19. Coxsackie virus:
•Herpangina
ulcerative vesicles over the tonsils, posterior
pharynx, and palate
• Commonly occurs in children under the age of 16
• Generalized symptoms of headache, high fever,
anorexia, and odynophagia

20. EBVEBV
 DiagnosisDiagnosis
By Clinical presentation
CBC with differential (atypical lymphocytes –T
lymphocytes)
Detection of heterophil antibodies (Monospot test)
IgM titers

21. EBV petechiae

22. Herpes Simplex Virus-1Herpes Simplex Virus-1

23. Herpes labialis
• Recurrent infection
• HSV-1
• vesicle at lip or
mucocutaneous junction

24. Acute herpes gingivostomatitis
Colour Atlas of
Infectious Disease,

26. Inflamed pharynx and tonsils marked by a grayish
pseudomembrane formed by the bacteria are characteristic
signs of diphtheria.

28. Sinuses
 Sinuses are moist air spaces within the bones of
the face around the nose
 Human have 4 pairs of sinuses
 The ethmoid and the maxillary sinuses form in the
third to fourth gestational month
 The sphenoid sinuses are generally pneumatized
by 5 years of age
 the frontal sinuses appear at age 7 to 8 years but
are not completely developed until late
adolescence.

29. Sinuses

30. Sinusitis

31. Microbial etiologyMicrobial etiology
 Viruses are the most frequent cause ofViruses are the most frequent cause of
rhinosinusitisrhinosinusitis
 viruses are known to predispose toviruses are known to predispose to
subsequent bacterial infection via suchsubsequent bacterial infection via such
mechanisms as viral-induced impairmentmechanisms as viral-induced impairment
of the mucociliary apparatus.of the mucociliary apparatus.

32. Microbial etiology

33. Bacterial causes of sinusitis
OrganismOrganism %%
S. pneumoniaeS. pneumoniae 30%30%
H. Influenzae (nontypableH. Influenzae (nontypable(( 20%20%
M. catarrhalisM. catarrhalis 2%2%
50% of H. Influenzae and 100% M. catarrhalis are B-
lactamase positive

34. Sign and symptoms
 In pediatric patients, most URIs last 5-7 days.
By 10 days, the URI almost always improves.
Most rhinoviral infections improve within 7-10
days so the complaint of persistent or worsening
symptoms may indicate a developing bacterial
sinusitis.
Pediatric patients may complain of a daytime
cough and persistent nasal discharge.
Complaints of facial pain and headache are rare in
children.

35. The clinical diagnosis of Bacterial sinusitis is
based solely on history.
Persistent of symptoms of URI , including
nasal discharge and cough, for >10-14 days,
or temp 39 C and purulent discharge for 3-4
days

36. Chronic sinusitisChronic sinusitis
 CoughCough
Nasal discharge or nasal congestion lasting
more than 90 days

37. Physical examination
- Facial tenderness to palpation is present
- Nasal mucosa is inflammation, redness and
swelling
- Purulent secretions in the middle meatus
(highly predictive of maxillary sinusitis)
- Complete opacification of sinus on
transillumination is present..

38. Antibiotics for siuusitisAntibiotics for siuusitis
 Risk factors:
1. antibiotics treatment in the preceding1-3 mo,
2. day care attendance, age ≤2 yr )
3. resistant bacterial species
4. failure to respond to initial amoxicillin within
72 hr

39.  Frontal sinusitis can rapidly progress toFrontal sinusitis can rapidly progress to
intracranial complication -parenteralintracranial complication -parenteral
ceftriaxone until improvement then oraluntil improvement then oral
antibiotic therapy.antibiotic therapy.
The use of decongestants, antihistamines,
mucolytics and intranasal steroids have not
adequately studied in children

40. POST-NASAL DRIP SYNDROMEPOST-NASAL DRIP SYNDROME
The leading cause of PND, is allergic rhinitis or,The leading cause of PND, is allergic rhinitis or,
more appropriately, chronic rhinosinusitis. Inmore appropriately, chronic rhinosinusitis. In
Hong Kong, the prevalence of allergic rhinitisHong Kong, the prevalence of allergic rhinitis
in children between 6 and 7 years old is 33%,in children between 6 and 7 years old is 33%,
and this figure increases to 52% in childrenand this figure increases to 52% in children
between 13 and 14 years oldbetween 13 and 14 years old..
Bousquet et al. J Allergy Clin Immunol 2001; 108:S147-334Bousquet et al. J Allergy Clin Immunol 2001; 108:S147-334..
Lau & Karlberg . J Paediatr Child Health 1998; 34:47-52Lau & Karlberg . J Paediatr Child Health 1998; 34:47-52..
Leung et al.Eur Resp J 1997; 10:354-60Leung et al.Eur Resp J 1997; 10:354-60..

41. The pathogenesis of PND induced cough isThe pathogenesis of PND induced cough is
probably due to the inflammatory nature of theprobably due to the inflammatory nature of the
nasal secretion and/or direct mechanicalnasal secretion and/or direct mechanical
stimulation of the cough receptors bystimulation of the cough receptors by
secretions dripping from the nostrils down intosecretions dripping from the nostrils down into
the hypopharynx. Microaspiration of thethe hypopharynx. Microaspiration of the
secretions and nasobronchial reflex have alsosecretions and nasobronchial reflex have also
been suggestedbeen suggested..
Bush A. Paediatric problems of cough. Pulm Pharmacol Ther 2002;15:309-15Bush A. Paediatric problems of cough. Pulm Pharmacol Ther 2002;15:309-15..
Lack G. Pediatric allergic rhinitis and comorbid disorders. J Allergy Clin Immunol 2001; 108:S9-15Lack G. Pediatric allergic rhinitis and comorbid disorders. J Allergy Clin Immunol 2001; 108:S9-15..

42. Acute Otitis MediaAcute Otitis Media

43. . Otitis media is one of the most common
diagnosis made by pediatricians
 30-60% of children have had at least one
putative episode of AOM by age one.
 10-20% have had three or more.
 80% have had at least one episode by age
3 years.

44. Approximately 80-90% will have had
at least one episode of either AOM or
asymptomatic middle ear effusion in
the first year of life.

45. Eustachian Tube
Connects middle ear and nasopharynx
Lumen shaped like two cones with apex
directed toward middle
Mucosa has mucous producing cells and
ciliated cellscells

46. Eustachian tube
 Adults
 ant 2/3- cartilaginousant 2/3- cartilaginous
post 1/3- bonypost 1/3- bony
 45 degree angle45 degree angle
 isthmus 1-2 mmisthmus 1-2 mm
 nasopharyngeal orificenasopharyngeal orifice
8-9 mm8-9 mm
 Children
 longer bony portion
 10 degree angle
 isthmus larger
 nasopharyngeal orifice
4-5 mm in infants

47. Eustachian tube
Usually closed
Opens during swallowing, yawning, and
sneezing
Opening involves cartilaginous portion
Tensor veli palatini responsible for active tubal
opening
No constrictor function

48. Eustachian tube function
Protection from nasopharyngeal sound and
secretions
clearance of middle ear secretions
ventilation (pressure regulation) of middle
ear

50. Bacteria can migrate along the eustachian tube from
the upper respiratory tract, and a buildup of mucus
and fluids can cause inflammation and effusion.
Fig. 21.2 An infected middle ear.

51. Risk factors for AOM
Age
 Male genderMale gender
Exposure to group day care
Exposure to environmental smoke or other
respiratory irritants and allergens that interfere
with Eustachian tube function.
Lack of breast feeding.
Supine feeding position.

52. Risk factors for AOM
 URIURI
 Winter season
 Siblings in household
Immunodeficiency
 AllergiesAllergies
 Craniofacial abnormalitiesCraniofacial abnormalities
 Down syndromeDown syndrome
 PacifierPacifier

55. NEVER bottle-feed an infant on it’s back
like this!

58. Large tonsils can obstruct the
Eustachian tubes

59. How we are challengedHow we are challenged….….
**Clinical History is a poor predictorClinical History is a poor predictor……
**A clear view isn’t always easyA clear view isn’t always easy……
**Examining a crying child can be toughExamining a crying child can be tough!!

60.  Otalgia usually is associated withusually is associated with
inflammation of the external orinflammation of the external or
middle ear, but it may represent painmiddle ear, but it may represent pain
referred from involvement of thereferred from involvement of the
teeth, temporomandibular joint, orteeth, temporomandibular joint, or
pharynx.pharynx.

61. In young infantsIn young infants,,
-- pulling or rubbing the ear along withpulling or rubbing the ear along with
-- general irritability or poor sleep, especiallygeneral irritability or poor sleep, especially
--when associated withwhen associated with fever, may be the only, may be the only
signs of ear pain.signs of ear pain.
Ear pulling alone is not diagnostic of ear
pathology.

62. Three important keys to improving diagnostic
accuracy for AOM centre around the
following:
 diligent cleaning of ear cerumen for better
visualisation of the tympanic membrane.
 use of nickel–cadmium or lithium
rechargeable batteries.
 and the use of original equipment full-length
speculums.

64. Normal EarNormal Ear

65. Acute Otitis MediaAcute Otitis Media

66. Acute Otitis MediaAcute Otitis Media

67. Middle ear effusion
(MEE)
YesYes YesYes
Diagnostic Criteria: OME andDiagnostic Criteria: OME and
AOMAOMAt least two of:
1. Abnormal color of tympanic
membrane (TM): white, yellow,
amber, blue
2. Opacification not due to
scarring
3. Decreased or absent motility
Bubbles or air-
fluid interfaces
Adapted from Hoberman A, et al. Pediatr Ann. 2000;29:609-620.
Otitis media with
effusion (OME)
No acuteNo acute
inflammationinflammation
AcuteAcute
inflammationinflammation
At least one of:
1. Distinct fullness or bulging of the
TM
2. Marked redness of the TM
3. New onset of ear pain
Acute otitis media
(AOM)
YesYes
Acute purulent
otorrhea not due
to otitis externa
YesYes
OrOr

68. S. pneumoniae*
50%
M. catarrhalis
15%
Other
5%
H. influenzae*
30%
Predominant AOM Pathogens
Barnett ED, et al. Pediatr Clin North Am 1995;42:509–517.
Jacobs MR. Pediatr Infect Dis J 1996;15:940–943.

69. Clinical GuidelinesClinical Guidelines
AMERICAN ACADEMY OF PEDIATRICS
AMERICAN ACADEMY OF FAMILY
PHYSICIANS
Subcommittee on Management of Acute Otitis Media
CLINICAL PRACTICE GUIDELINE
Diagnosis and Management of
Acute Otitis Media

70. AOM OutcomeAOM Outcome InitialInitial
AntibacteriaAntibacteria
l Therapyl Therapy
InitialInitial
ObservatioObservatio
nn
PP
Incidence of mastoiditis orIncidence of mastoiditis or
suppurative complicationssuppurative complications
0.59%0.59% 0.17%0.17% NSNS
Persistent MEE at 4–6 weeksPersistent MEE at 4–6 weeks 45%45% 48%48% NSNS
Persistent MEE at 3 monthsPersistent MEE at 3 months 21%21% 26%26% NSNS
Antibacterial agent–inducedAntibacterial agent–induced
diarrhea or vomitingdiarrhea or vomiting
16%16% —— ——
Antibacterial agent–inducedAntibacterial agent–induced
skin rashskin rash
2%2% —— ——
Is antibiotic therapy of AOM necessary?
Source: AAP/AAFP Clinical Practice Guideline on AOM, March 2004

71. AOM OutcomeAOM Outcome InitialInitial
AntibacteriaAntibacteria
l Therapyl Therapy
InitialInitial
ObservatioObservatio
nn
PP
Symptomatic relief at 24Symptomatic relief at 24
hourshours
60%60% 59%59% NSNS
Symptomatic relief at 2–3Symptomatic relief at 2–3
daysdays
91%91% 87%87% NSNS
Symptomatic relief at 4–7Symptomatic relief at 4–7
daysdays
79%79% 71%71% NSNS
Clinical resolution at 7–14Clinical resolution at 7–14
daysdays
82%82% 72%72% NSNS
Pain duration, mean daysPain duration, mean days 2.82.8 3.33.3 NSNS
Crying duration, mean daysCrying duration, mean days 0.50.5 1.41.4 .>.>0000
11
Analgesic use, mean dosesAnalgesic use, mean doses 2.32.3 4.14.1 ..004004
Fever duration, medianFever duration, median
daysdays
2.02.0 3.03.0 ..004004
Is antibiotic therapy of AOM necessary?

72. AOM spontaneous resolution rateAOM spontaneous resolution rate
varies by pathogenvaries by pathogen
OrganismOrganism SpontaneousSpontaneous
bacteriologicbacteriologic
clearance rateclearance rate
S. pneumoniaeS. pneumoniae 19%19%
H. influenzaeH. influenzae 48%48%
M. catarrhalisM. catarrhalis 75%75%
Howie VM. Clin Infect Dis 1992;14:S209-10; Klein JO. PIDJ 1993;12:973-5

73. 2004AAP/AAFP Clinical Practice
Guideline on AOM
 Released March 2004
 Evidence-based clinical practice guideline:
 3461 articles initially identified; 760 reviewed
 Extensively peer-reviewed
 Scope: diagnosis and management of uncomplicated
AOM in children aged 2 m to 12 y
 Excludes children with:
 underlying conditions that predispose to AOM
 children with recurrence of AOM within 30 days of AOM
or underlying chronic OME

74. 2004AAP/AAFP Clinical Practice
Guideline on AOM: Conclusions II
1. To diagnose acute otitis media the clinician should confirm a history of
acute onset, identify signs of middle–ear effusion, and evaluate for the
presence of signs and symptoms of middle-ear inflammation
(Recommendation).
2. The management of AOM should include an assessment of pain. If pain is
present, the clinician should recommend treatment to reduce pain (Strong
Recommendation).
3A. Observation without use of antibacterial agents in a child with
uncomplicated AOM is an option for selected children based on diagnostic
certainty, age, illness severity, and assurance of follow-up (Option).
3B. If a decision is made to treat with an antibacterial agent, the clinician
should prescribe amoxicillin for most children. (Recommendation). When
amoxicillin is used, the dose should be 80–90 mg/kg/day (Option).

75. 2004AAP/AAFP Clinical Practice Guideline on
AOM: Conclusions II
4. If the patient fails to respond to the initial management option within
48–72 hours, the clinician must reassess the patient to confirm AOM
and exclude other causes of illness. If AOM is confirmed in the
patient initially managed with observation, the clinician should begin
antibacterial therapy. If the patient was initially managed with an
antibacterial agent(s), the clinician should change the antibacterial
agent(s) (Recommendation).
5. Clinicians should encourage the prevention of AOM through
reduction of risk factors (Recommendation).
6. There is insufficient evidence to make a recommendation regarding
the use of Complementary and Alternative Medicine (CAM) for AOM
(No Recommendation).
The recommendations in this guideline do not indicate an exclusive
course of treatment or serve as a standard of medical care.
Variations, taking into account individual circumstances, may be
appropriate.

76. Criteria for initial antibacterial therapy vs. observation:
2004 AAP/AAFP AOM Guidelines
AgeAge Certain DiagnosisCertain Diagnosis Uncertain DiagnosisUncertain Diagnosis
>>66momo Antibacterial therapyAntibacterial therapy Antibacterial therapyAntibacterial therapy
66mo–2 ymo–2 y Antibacterial therapyAntibacterial therapy Antibacterial therapy ifAntibacterial therapy if
severe illness; observationsevere illness; observation
option* if non-severe illnessoption* if non-severe illness
<=<=22yy Antibacterial therapy ifAntibacterial therapy if
severe illness;severe illness;
observation option* ifobservation option* if
non-severe illnessnon-severe illness
Observation optionObservation option**
*Observation is an appropriate option only when follow-up can be ensured
and antibacterial agents started if symptoms persist or worsen.
Non-severe illness is mild otalgia and fever >39o
C in the past 24 hours. A
certain diagnosis of acute otitis media meets all 3 criteria: 1) rapid onset, 2)
signs of middle-ear effusion, and 3) signs and symptoms of middle-ear
inflammation.

77. Amoxicillin: first line therapy for AOM
 Recommended as the first line drug of choice by:Recommended as the first line drug of choice by:
 CDC DRSP Working GroupCDC DRSP Working Group Pediatr Infect Dis JPediatr Infect Dis J 1999;18:1-91999;18:1-9
 AAP/AAFP Subcommittee on AOM, March 2004AAP/AAFP Subcommittee on AOM, March 2004
 Active againstActive against S. pneumoniaeS. pneumoniae::
 Recommended dose now isRecommended dose now is 90 mg/kg/day90 mg/kg/day divided BID:divided BID:
achieves adequate MEF levels to kill pen-I and many pen-Rachieves adequate MEF levels to kill pen-I and many pen-R
pneumococcipneumococci
 At this dose, superior to all other oral antibiotics against pen-At this dose, superior to all other oral antibiotics against pen-
NS pneumococci in vitroNS pneumococci in vitro
 NotNot effective against β-lactamase producingeffective against β-lactamase producing H.H.
influenzaeinfluenzae oror M. catarrhalisM. catarrhalis (but these are more(but these are more
likely to resolve spontaneously)likely to resolve spontaneously)
 Decades of experience: safe, effective, inexpensive,Decades of experience: safe, effective, inexpensive,
narrow-spectrum; tastes goodnarrow-spectrum; tastes good

78.  AOM is commonly over diagnosed. Thus, if
clinicians are going to continue to overuse
antibiotics—because of parental pressure or
the lack of diagnostic accuracy—it is better
to limit the mistake to less expensive drugs
with a narrower spectrum.

79. Antibiotic therapy: at time of diagnosis
2004 AAP/AAFP AOM Guidelines
Temperature <39Temperature <39oo
CC
and/or Severe Otalgiaand/or Severe Otalgia
At Diagnosis for Patients Being TreatedAt Diagnosis for Patients Being Treated
Initially With Antibacterial AgentsInitially With Antibacterial Agents
RecommendedRecommended Alternative forAlternative for
Penicillin AllergyPenicillin Allergy
NoNo Amoxicillin 80–90Amoxicillin 80–90
mg/kg/daymg/kg/day
Non-Type I: cefdinir,Non-Type I: cefdinir,
cefuroxime,cefuroxime,
cefpodoximecefpodoxime
Type I: azithromycin,Type I: azithromycin,
clarithromycinclarithromycin
YesYes Amoxicillin-Amoxicillin-
clavulanate (90clavulanate (90
mg/kg/day ofmg/kg/day of
amoxicillin withamoxicillin with
6.4 mg/kg/day of6.4 mg/kg/day of
clavulanateclavulanate
Ceftriaxone—1 or 3Ceftriaxone—1 or 3
daysdays

80. Antibiotic therapy: clinical failures, 48-72 hr
2004 AAP/AAFP AOM Guidelines
Temperature <39Temperature <39oo
CC
and/or Severe Otalgiaand/or Severe Otalgia
Clinically Defined Treatment Failure at 48–Clinically Defined Treatment Failure at 48–
72 Hours After Initial Management With72 Hours After Initial Management With
Antibacterial AgentsAntibacterial Agents
RecommendedRecommended Alternative forAlternative for
Penicillin AllergyPenicillin Allergy
NoNo AmoxicillinAmoxicillin
-clavulanate (90-clavulanate (90
mg/kg/day ofmg/kg/day of
amoxicillin, withamoxicillin, with
6.4 mg/kg/day of6.4 mg/kg/day of
clavulanateclavulanate))
Non-Type I:Non-Type I:
ceftriaxone—3 daysceftriaxone—3 days
Type I: clindamycinType I: clindamycin
YesYes Ceftriaxone— 3Ceftriaxone— 3
daysdays
Tympanocentesis;Tympanocentesis;
clindamycinclindamycin

81. Drugs chosen for second-line treatment should be
effective against B lactamase- producing strains of H.
influenzae and M. catarrhalis
and against susceptible and most nonsusceptible
strains of S. pneumoniae. Only 3 drugs have been
shown clearly to meet that requirement: amoxicillin-
clavulanate, cefuroxime axetil, and intramuscular
ceftriaxone.
Kersshner J E,Otitis Media In:Nelson Textbook of Pediatrics, 2641,
2007

82. Cefdinir was not available when the above
recommendations were made. However, clinical
Practice and efficacy with cefdinir suggest that it
deserves consideration as a second line agent as well,
with antibacterial spectrums similar to those
of cefuroxime axetil, and good rates of compliance' as
the medicationis quite palatable.
Kersshner J E,Otitis Media In:Nelson Textbook of Pediatrics, 2641,Kersshner J E,Otitis Media In:Nelson Textbook of Pediatrics, 2641,
20072007

83. Conjunctivitis–otitis syndrome:
ß lactamase- producing H influenzae
tends to be the predominant organism, causing
both conjunctivitis and AOM.
High-dose amoxicillin–clavulanate (90
mg/kg/day), cefdinir or cefpodoxime would be
preferred choices.
Block S L. Arch Dis Child 2006;91:959–961.

84. Ambulatory pneumonia (‘‘walking
pneumonia’’ AND O M
As atypical pathogens (Chlamydia
pneumoni , Mycoplasma pneumoniae) are
such a common cause of milder pneumonias
in children ≥ 2 years of age, macrolides such
as azithromycin or clarithromycin are
preferred.
Block S L. Arch Dis Child 2006;91:959–961.

85. ImpetigoImpetigo

86. Impetigo or skin infection and AOM:
Typically, impetigo and skin infections are caused by
Staphylococcus aureus and only rarely by Streptococcus
pyogenes. Staphylococcus aureus in the
produces b lactamase, rendering amoxicillin useless.
Clinicians would be wiser to initiate treatment with a b
lactamase-stable antibiotic, such as amoxicillin-clavulanate,
cefdinir or even cefuroxime,
which possess activity against both methicillin-susceptible
Staphylococcus aureus and typical otopathogens.
Block S L. Arch Dis Child 2006;91:959–961.

87. Impetigo or skin infection and AOM:
Patients whose skin infection does
not respond in 24–28 h would then
additionally receive either clindamycin
or trimethoprim-sulfamethoxale
for presumptive methicillin-resistant
Staphylococcus aureus.
Block S L. Arch Dis Child 2006;91:959–961.

88. Aspirin
Non-narcotic, anti-inflammatory; antiplatelet
Antipyretic, nonsteroidal agent.
Used in the treatment of pain, inflammation and
fever by inhibition of prostaglandin synthesis.
Dose:-
10-15 mg/kg/dose q 4-6 hr

89. Aspirin
Cautions: contraindicated in children below 16yr
with chickenpox or flu-like symptom due to
risk of Reye syndrome. Distintinue if hearing
loss or tinnitus occurs.
Adverse events: Bleeding from gums or GIT,
gastric ulcers, bronchospasm in asthmatics,
hearing loss or tinnitus.

90. Acetaminophen
Mechanism of action
Inhibits the synthesis of prostaglandins in the centralInhibits the synthesis of prostaglandins in the central
nervous system and peripherally blocks pain impulsenervous system and peripherally blocks pain impulse
generation.generation.
Acetaminophen produces antipyresis from inhibition ofAcetaminophen produces antipyresis from inhibition of
the hypothalamic heat regulating centre.the hypothalamic heat regulating centre.
Dosage:Dosage:
10-15 mg/kg every 4 to 6 hours P.O.10-15 mg/kg every 4 to 6 hours P.O.

91. Acetaminophen, 10-15mg/kg orally every4hr,
is not associated with significant adverse
effects; however, prolonged use may produce
renal injury, and massive overdose may
produce hepatic failure

92. Ibuprofen
Nonsteroidal anti-inflammatory agent thatNonsteroidal anti-inflammatory agent that
inhibits prostaglandin synthesis and used toinhibits prostaglandin synthesis and used to
treat pain fever and rheumatoid arthritistreat pain fever and rheumatoid arthritis..
DoseDose: -: -
Children: 5 -10 mg/kg/dose q6-8hrChildren: 5 -10 mg/kg/dose q6-8hr
Juvenile rheumatoid arthritisJuvenile rheumatoid arthritis::
30-50mg/kg/24 hr in 4 divided doses30-50mg/kg/24 hr in 4 divided doses

93. Ibuprofen
Adverse eventsAdverse events::
Abdominal pain, heartburn, nausea, GITAbdominal pain, heartburn, nausea, GIT
bleeding and perforation, fluid retention,bleeding and perforation, fluid retention,
edema, hypertension, tachycardia, acute renaledema, hypertension, tachycardia, acute renal
failurefailure..

94. Nimesulid
Nimesulide has a disadvantage of long duration of action andNimesulide has a disadvantage of long duration of action and
hence ideally should be repeated 12 hourly. Its therapeutichence ideally should be repeated 12 hourly. Its therapeutic
dose is small (5 mg/kg/day) as compared to paracetamol (60dose is small (5 mg/kg/day) as compared to paracetamol (60
mg/kg/day) and has small therapeutic window. These factsmg/kg/day) and has small therapeutic window. These facts
result in easy overdosing by negligence or ignorance, leadingresult in easy overdosing by negligence or ignorance, leading
to adverse effectsto adverse effects..
nimesulide may cause lowering of body temperature to evennimesulide may cause lowering of body temperature to even
subnormal levels that can be harmfulsubnormal levels that can be harmful..
It has been found to have serious side effects, Maternal ingestionIt has been found to have serious side effects, Maternal ingestion
of nimesulide has been shown to result in end-stage renalof nimesulide has been shown to result in end-stage renal
failure in a neonate(9failure in a neonate(9))

95. Diclofenac Sodium
Diclofenac, a nonselective nonsteroidal anti-
inflammatory drug, exerts analgesic action
both in the peripheral tissues and in the central
nervous system by inhibiting cyclooxygenase
enzymes COX-1/2 .
Diclofenac inhibits prostaglandin synthesis

96. What Can Be DoneWhat Can Be Done??
 Options for reducing
rates of severe otitis
media:
 Additional hygiene
practices
 Immunisation
 Antibiotics