The document discusses acute respiratory infections (ARIs), which encompass a range of conditions affecting the respiratory tract in children, leading to significant morbidity and mortality, particularly pneumonia. It highlights the role of various causative agents, risk factors, and the importance of preventive measures such as vaccination and improved healthcare practices. Treatment guidelines for pneumonia are provided, emphasizing the use of antibiotics and monitoring strategies to manage cases effectively.

1. DEPT OF PAEDIATRICS
ARI control
program

2. • It causes the inflammation of the respiratory tract anywhere from nose to alveoli.
• Depending on the site of infection it is classified into:
1. Acute Upper respiratory infections ( AURI) include common cold,Pharygitits and otitis
media.
2. Acute Lower respiratory infections (ALRI) include
Epiglottitis ,Laryngitis,Laryngotracheitis ,Bronchitis,Bronchiolitis and Pneumonia.
• CF: Running nose,cold,cough,Fever, sore throat,difficult breathing and ear infections.
INTRODUCTION

3. • 4 million deaths per year worldwide.
• 30-50% of hospital visits and 20-40 % of hospital admissions.
• About 90% of the ARI Deaths are due to Pneumonia and it is usually bacterial in origin
• Incidence:3-4% in developed countries and 20-30% in developing countries .
• kills more children than AIDS,Malaria & Measles combined.
• In India,13% of inpatient deaths in paediatric wards area due to ARI.
• PNEUMONIA was responsible for 18% of all ‘under 5 years’ deaths in India. Leading cause of
mortality
INTRODUCTION

4. • Streptococcus pneumoniae is the major cause of illness and death in children and adults.
• Haemophilus influenzae type B: 3 million cases of severe pneumonia & meningitis;3,86,000
deaths/yr in children under 5 years.
• Staph
CAUSATIVES
AGENT AGE GROUP CHARACTERISTIC CF
BORDETELLA PERTUSIS INFANTS AND YOUNG CHILDREN PAROXYSMAL COUGH
HEMOPHILUS INFLUENZAE( type B) CHILDREN ACUTE EPIGLOTTITIS
STREPTOCOCCI ALL AGES
Lobar/Broncho/Multilobar
Pneumonia,Pharyngitis,Tonsilllitis.
CORYNEBACTERIUM DIPTHERIAE CHILDREN
Nasal/Pharyngeal/tonsillar
membranous exudate + or - severe
toxemia

5. • Viruses like Adenovirus:-
Endemic types(1,2,5)-young children-LRTI
Epidemic types(3,4,5)-older children & young adults-febrile pharyngitis
• Measles-young children-variable respiratory illness with characteristic rash.
• Influenza B- school children-fever,aching,malaise,occasional primary pneumonia
• Parainfluenza:- 1&2-young children-Croup- re infection-mild upper respiratory
3- infants-Bronchiolitis & Pneumonia.
• Respiratory syncytial virus-Infants& young children-severe bronchiolitis and pneumonia.
• Rhino virus and corona virus - common cold.
CAUSATIVES

6. • HOST FACTORS: CFR- Developing ountries- Young infants,Malnourished and LBW.
Developed countries -rare fatality.
• RISK FACTORS: 1)Overcrowding, poor nutrition,indoor smoke pollution, LBW in developing
countries.
2)Influenza epidemics
3)Maternal cigarette smoking-RTI in first year of life.
FACTORS AFFECTING THE
INFECTIONS

7. • Improving primary medical care services, development of better methods for
early detection, early treatment and prevention is the best strategy to control
ARI.
• Mortality rate can be decreased effectively by treating Pneumonia.
• Education of the mother.
• Immunisation as per schedule.
• Exclusive breast feeding.
ARI CONTROL

8. • History taking:
1. Age of the child
2. Onset of cough
3. Ability to drink( 2months-5 years)
4. Feeding
5. Fever
6. Illness like measles
7. Excessively drowsy or difficult to wake
8. Convulsions
9. Difficulty in breathing.
CLINICAL ASSESSMENT

9. • ONE MINUTE BREATH COUNT: Fast breathing or not depends on the age of the child.
PHYSICAL EXAMINATION
60 breaths/min or more <2months of age
50 breaths /min or more 2-12 months
40 breaths /min or more 12 months upto 5 years

10. UPPER RESPIRATORY TRACT INVOLVEMENT:
• Croup,acute epiglottis,Ludwig angina
• Retro pharyngeal abscess
• Foreign body aspiration
• Diphtheria
• Laryngospasm.
CAUSES OF FAST BREATHING

11. LOWER RESPIRATORY TRACT INVOLVEMENT:
• Pneumonia
• Bronchiolitis
• Asthma
• Pleural effusion,Empyema & Hemothorax.
• Pneumothorax
• Atelectasis
• Hypersensitivity Pneumonitis.
CAUSES OF FAST BREATHING

12. NON PULMONARY CAUSES:
• CHF due to Heart disease or severe
anemia.
• CNS infections, cerebral
edema,Tumor,spinal cord injury, Guillian
Barre syndrome.
• Metabolic acidosis due to renal
failure,DKA,Renal tubular
acidosis,shock,lactic acidosis.
• Psychogenic
hyperventilation,anxiety,panic attacks.

13. • CHEST INDRAWING
• STRIDOR
• WHEEZE
• SLEEPING AND WAKING UP
• FEVER
• CYANOSIS
• SEVERE MALNUTRITION
PHYSICAL EXAMINATION

15. NO PNEUMONIA:
• Only cough or cold
• No chest Indrawing and no fast breathing
• If coughing for more than 30 days, refer for assessment.
PNEUMONIA:
• Fast breathing is present but no chest indrawing.
• Home care with antibiotics
• Re assessment after 2 days.
CLASSIFICATION OF ILLNESS

16. SEVERE PNEUMONIA:
• Chest indrawing present.
• If recurrent wheeze present,treat wheeze directly.
• Urgently to hospital and immediate antibiotic is given.
VERY SEVERE PNEUMONIA:
• Presence of Danger signs: Decreased feeding,Stridor when calm, Convulsions, Abnormal
sleeping or difficult to awake, Wheezing, Fever or low body temperature, cyanosis, difficulty
in feeding, altered sensorium,
• Immediately to the hospital, maintain temperature, start antibiotic.
CLASSIFICATION OF ILLNESS

17. FOR PNEUMONIA( fast breathing and no chest retractions):
• Oral AMOXICILLIN- atleast 40 mg /kg/dose twice daily [ 80mg/kg/day] for five days
FOR SEVERE PNEUMONIA:
• Oral AMOXICILLIN- at least 40 mg /kg/dose twice daily for five days.
• AMPICILLIN: 50mg/kg or Benzyl penicillin: 50000 units per kg IM or IV every 6 hours for at
least five days.
• GENTAMYCIN: 7.5mg/kg IM or IV once a day for atleast five days.
• CEFTRIAXONE can be used in children who failed on first line treatment.
TREATMENT

18. • In SEVERE pneumonia, if condition improves with First line treatment, then:
• If there is no improvement,then:
• AMPICILLIN CHLORAMPHENICOL .
• CHLORAMPHENICOL. CLOXACILLIN(25 mg/kg/dose 6hrly) + GENTAMYCIN (2.5mg/kg/
dose 8th Hrly)
TREATMENT
PROCAINE
PENICILLIN
50000IU/kg/dose 6th Hrly/ IM
AMPICILLIN 50mg/kg/dose 6th Hrly/ oral
CHLORAMPHENICOL 25mg/kg/dose 6th Hrly/ oral

19. In VERY SEVERE DISEASE, availability of Oxygen and intensive monitoring is necessary.
• DOC:- CHLORAMPHENICOL IM
• Given for 10 days
• After 48 hrs, switch to CLOXACILLIN OR GENTAMYCIN.
TREATMENT

20. • In, young infants, upon confirmation:
TREATMENT
ANTIBIOTIC DOSE AGE < 7 days AGE 7days-2months
IM BENZYL
PENICILLIN
50000IU/kg/dose 12hourly 6hourly
IM AMPICILLIN 50mg/kg/dose 12hourly 8 hourly
IM GENTAMYCIN 2.5mg/kg/dose 12 hourly 8 hourly

21. • New classification is simplified into 2 categories:
1. Pneumonia: Pneumonia with fast breathing and/or chest indrawing,which require
home therapy with oral Amoxicillin.
2. Severe Pneumonia: Pneumonia with any general danger signs.,which requires referral
and injectable therapy.
• Dosages for treatment in health facilities:
1. 2months-12months (4-10kg)
2. 12months-3years(10-14kg)
3. 3years - 5years. (14-19kg)
REVISED WHO CRITERIA

22. • RECOMMENDATION 1:
• Children with fast breathing pneumonia with no chest indrawing or general
danger signs should be treated with oral AMOXICILLIN: at east 40mg/kg/dose
twice daily for 5 days.
• Same treatment for 3 days in areas with low HIV prevalence.
• Who fail on first line treatment should have the option for referral to a facility where
there is second line treatment available.
• Kabra eat al: ambulatory—>Amoxicillin more effective than cotrimoxazole.
Hospitalised—>Penicillin more effective than cotrimoxazole.
• Haider eat al: 3 day course of antibiotics=five day course in fast breathing pneumonia.
RECOMMENDATIONS

23. • RECOMMENDATION 2:
• Children age. 2-59 months with chest indrawing pneumonia should be
treated with oral amoxicillin: at least 40mg/kg/dose twice daily for five
days.
• Addo-Yobo at al:Oral amoxicillin is as effective as injectable penicillin in
treatment of chest indrawing pneumonia in children in low resource settings.
• PIVOT TRIAL (2007): oral Amoxicillin is equally effective for pneumonia of
various severities in high resource setting.
• Hazier eat al: (NO SHOTS STUDY):It is safe to treat chest indrawing
pneumonia at home with oral amoxicillin.
• Home therapy with oral amoxicillin is effective in a range of settings.
• Amoxicillin is more effective when given in high doses than 45mg/kg/day.

25. • RECOMMENDATION 3:
• Children aged 2-59 months with severe pneumonia should be treated
with parenteral ampicillin(or penicillin) & gentamicin as a first line
treatment.
A. Ampicillin:50mg/kg or benzyl penicillin:50000units/kg/IM/IV
every 6 hours for at least 5 days
B. Gentamicin:7.5mg/kg I’m/I’ve once a day for at least 5 days
C. CEFTRIAXONE should be used as a second line drug in severe
pneumonia having failed on first line treatment.

26. • RECOMMENDATION 4:
• Ampicillin(or penicillin when ampicillin is not available) plus gentamicin
or ceftriaxone ae recommended as a first line antibiotic regimen for HIV
infected and exposed infants & for children < 5 yrs of age with chest
indrawing pneumonia or severe pneumonia.
• CEFTRIAXONE alone can be used as a second line drug.

27. • RECOMMENDATION 5:
A. Empiric Cotrimoxazole treatment for suspected Pneumocystis jirovecii
pneumonia (PCP) is recommended as an additional treatment for HIV
infected & exposed infants aged 2 months up to 1 year with severe or
very severe pneumonia.
B. Empirical Cotrimoxazole treatment for Pneumocysis jirovecii
pnemonia(PCP) is not recommended for HIV infected and exposed
children over 1 year of age with chest indrawing or severe pneumonia.

28. 1. Oral amoxicillin can e used to treat both fast breathing and chest indrawing pneumonia.
2. Pneumonia classification and management are simplified to two categories instead of
three.
3. Access to antibiotic treatment closer to home is increased.
4. The need for referrals to higher level facilities is decreased.
5. The probability of hospitalisation and thus the risk of nosocomial&injection borne diseases
is reduced.
6. The probability of anti microbial resistance is diminished due to better adherence t the
simplified treatment.
7. Training of health workers is simplified.
Implications for implememtation

30. MEASLES VACCINE:
• Pneumonia is the most common cause of death worldwide associated with measles.
• Live attenuated vaccine
• Freeze dried product
• Subcutaneously or Intra muscularly.
• At 9 months.
IMMUNISATION

31. HAEMOPHILUS INFLUENZAE TYPE B (Hib) vaccine:
• Haemophilus INFLUENZAE type B is an important cause of pneumonia and meningitis
among children.
• As combined preparation with DPT and Poliomyelitis.
• At 6,10 and 14 weeks of age.
• Booster dose can be given after 12 months.
• Single dose enough if missed primary immunisation.
IMMUNISATION

32. PNEUMOCOCCAL PNEUMONIA VACCINE:-
A. PPV23: Polysaccharide non conjugate vaccine
• Contains 23 capsular antigens against 23 serotypes.
• After 2 years of age
• Single IM dose
B. PCV: PCV10 and PCV13 are available.
IMMUNISATION

33. Thank you.