Ppt

1. UNIT IV
Management of common childhood disease
By: Dr. Asrat. B
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2. COMMON DISEASES OF THE CHILDREN
• Respiratory system disorders and infections (ARI)
• Gastrointestinal infections and infestations (CDD)
• Febrile illness (malaria, meningitis, measles--)
• Nutritional deficiencies
Macro-nutrients deficiency, Protein Energy
Malnutrition (PEM)
Micro-nutrients deficiency (Vit A, D, iron etc)
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3. Providing Care of the Child With Respiratory Illnesses
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4. Providing Care of the Child With Respiratory Illnesses…
• A respiratory system dysfunction is a frequent health concern for
individuals across the life span.
• Infants and young children are particularly vulnerable to
respiratory related diseases because of specific age-related
physical differences.
• Several developmental variations increase the pediatric
population’s risks for acquiring a respiratory system dysfunction.
• Small airways, fewer alveoli, and increased chest compliance
are leading factors that predispose them to respiratory
alterations. 4

5. Anatomy
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6. 6

7. Differences in Adult and Child
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8. Upper respiratory tract infections
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9. DISEASES OF RESPIRATORY SYSTEM
Acute Nasopharyngitis (Common Cold)
• Definition : Acute viral infection of upper respiratory
tract with potential involvement of nasal passages,
sinuses, Eustachian tubes, middle ears, conjunctiva,
and nasopharynx.
Etiology
 caused by number of viruses like rhinoviruses,
adenovirus, corona virus, parainfluenza and influenza
virus.
 Human rhinoviruses (HRVs) are the most frequent
cause of the common cold in both adults and children.
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10.  Influenza virus cause a a broad array of respiratory
illnesses that are responsible for significant morbidity
and mortality in children on a yearly basis.
 Influenza viruses are divided into three types: A, B,
and C.
 Influenza virus types A and B are the primary human
pathogens and cause epidemic disease.
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11. Signs and Symptoms:
Generally lasts one week; dry cough with rhinorrhea, may
persist up to 3 weeks
1. Infants
 Irritability, restlessness, fever
 sore throat
 Rhinorrhea/ Runny nose and nasal obstruction
 Occasional diarrhea
 Changes in feeding and sleep patterns
2. Older children
 Afebrile or low-grade fever, stuffy nose, watery nasal
discharge
 Sore throat, sneezing, cough, chills
 Occasional headache, malaise
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12. Differential Diagnosis
• Underlying secondary bacterial infection—sinusitis,
OM, pharyngitis, lower respiratory tract disease
• Allergic rhinitis
• Foreign body
• Substance abuse in older children and adolescents, or
overuse of medicated nasal spray
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13. • Physical Findings
 Coryza
 Inflamed, moist nasal mucosa and oropharynx
 Chest clear
• Diagnostic Tests/Findings
 Viral cultures expensive, generally unnecessary
 If suspicious of differential diagnosis, consider
additional tests such as throat culture, chest or sinus
x-rays, allergy testing
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14. Management/Treatment:
Symptomatic/supportive care
1. Analgesics for sore throat, muscle aches and fever
Aspirin shouldn’t be given
1. Relief of nasal congestion
• Nasal decongestants (xylometazoline, oxymetazoline, or
phenylephrine )
• 1st generations Antihistamine(anticholinergic effect)
 Saline nose drops with nasal bulb syringe
 Cool mist humidification
 Antihistamines and decongestants but not routinely
recommended
 Antibiotics are not indicated in viral infections
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15. Management cont….
3. If symptoms persistent beyond 7 to 10 days,
consider secondary infection
4. Maintain hydration
• Prevention
 Good hygiene and cleaning of clothes, toys, and play
areas
 Limited exposure to crowded situations
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16. Complications
• Otitis media -5-30%
• Sinusitis-5-13% children,
-0.5-2% in adolescence adults
• Exacerbation of asthma
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17. sinusitis
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Sinusitis

18. Sinusitis
• Sinusitis is a common illness of childhood & adolescence
• There are 2 types of acute sinusitis:
 Viral
 Bacterial
• 0.5–2% of viral URTI in children and adolescents are
complicated by acute bacterial sinusitis.
• The means for appropriate diagnosis and optimal
treatment of sinusitis remain controversial.
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19. Conti ….
• Both the ethmoidal and maxillary sinuses are present at
birth, but only the ethmoidal sinuses are pneumatized.
• The maxillary sinuses are not pneumatized until 4 yr of
age.
• The Sphenoidal sinuses are present by 5 yr of age,
• The Frontal sinuses begin development at age 7–8 yr and
are not completely developed until adolescence.
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20. Etiology
• Streptococcus pneumoniae (≈30%),
• Nontypable Haemophilus influenzae (≈20%),
• Moraxella catarrhalis (≈20%).
• Staphylococcus aureus, other streptococci, and
anaerobes are uncommon causes.
• H. influenzae,
• α- and β-hemolytic streptococci,
• M. catarrhalis,
• S. pneumoniae, and
• coagulase-negative staphylococci.
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commonly recovered
from children with
chronic sinus disease

21. Clinical manifestations
o Nonspecific complaints, including nasal congestion, purulent nasal
discharge (unilateral or bilateral), fever, and cough.
o Bad breath - halitosis,
o Hyposmia - a decreased sense of smell, and
o Periorbital edema.
o Complaints of headache and facial pain are rare in children.
o Erythema and swelling of the nasal mucosa with purulent nasal
discharge.
o Sinus tenderness
o Transillumination reveals an opaque sinus that transmits light
poorly.
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22. Diagnosis
• Persistent symptoms of URTI
• Nasal discharge and cough, for >10–14 days without
improvement
 Severe respiratory symptoms, including
 Temperature of at least 39°C (102°F) and
 Purulent nasal discharge for 3–4 consecutive days, are
suggestive of a complicating acute bacterial sinusitis
• Sinus aspirate culture
• Sinus transillumination
• Sinus X-ray
• CT scan
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23. Management
 It is unclear whether antimicrobial treatment of clinically
diagnosed acute bacterial sinusitis offers any substantial
benefit
• 50–60% of children with acute bacterial sinusitis recover with-
out antimicrobial therapy.
• Initial therapy with amoxicillin (45mg/kg/day) is adequate for
the majority of children with uncomplicated acute bacterial
sinusitis, continue 7 days after resolution of symptoms
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24. Conti ….
 Alternative treatments for the penicillin-allergic patient
include
 Trimethoprim-sulfamethoxazole,
 Clarithromycin , or
 Azithromycin
• Frontal sinusitis can rapidly progress to serious intracranial
complications and necessitates initiation of parenteral
ceftriaxone until substantial clinical improvement is
achieved
• Treatment is then completed with oral antibiotic therapy
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25. Complications
• Periorbital cellulitis
• Orbital cellulitis
• Intracranial complications
• Osteomyelitis of the frontal bone (Pott puffy tumor)
• Mucoceles :-which are chronic inflammatory lesions
commonly located in the frontal sinuses that can expand,
causing displacement of the eye with resultant diplopia
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26. ??????
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27. Otitis Media (OM)
• Definition: Inflammation of the middle ear.
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28. Otitis Media (OM)…..
Etiology : S. Pneumonia.(approximately40%)
:H . influenzae (25% to 30%)
: Moraxella catarrhalis (10% to 20%)
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29. Epidemiology of OM
 Ear pain and/or discharge is one of the most common
presenting symptoms to OPD in under -5 children.
 About 1/3 of children will have at least one episode of
acute otitis media by 3 years of age.
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30. Pathophysiology:
Two important factors.
Eustachian tube dysfunction
URTI
o Clinical manifestations
• Acute: otalgia/ ear pain, ear discharge, fever,
hearing loss, generalized malaise.
• Infant - irritability, diarrhea, vomiting, malaise
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31. Types based on duration of symptoms
 Acute OM: symptoms for less than 2 weeks
 Chronic OM: symptoms for more than 2 week.
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32. Diagnosis: Clinical
• Ear discharge
• Visualization of tympanic membrane: red
membrane, loss of normal light reflex.
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33. Treatment
1. Antibiotics
– Amoxicillin or
– Ampicillin
– quinolone eardrops
2. Ear wicking
3. Antipyretic; acetaminophen
Treatment of chronic OM
Dry ear wicking -Roll clean absorbent cloth or soft, strong tissue paper into a
wick.
Place the wick in the child's ear.
Instill quinolone eardrops after dry wicking three times daily for two weeks.
• Quinolone eardrops may include ciprofloxacin, norfloxacin 33

34. Clear the Ear by Dry Wicking
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35. Complication
– Mastoiditis
– Hearing loss
– Perforation of the ear drum
– Facial nerve palsy
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36. Acute pharyngitis(Tonsilitis)
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37. Acute pharyngitis(Tonsilitis)
• Definition: Acute inflammation and infection
of the throat; when tonsils are main focus of
inflammation , tonsillitis is more appropriate
term to use.
• Incidence.
Pharyngitis (tonsillitis) is most commonly seen
in preschool and school-age children.
Rarely seen in infants and toddlers.
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38. Etiology
• The most important agents causing pharyngitis
are Viruses
• Sore throat can be caused by many viruses and
bacteria.
• Mostly viral as parts of URTI:-(adenoviruses,
rhinoviruses, respiratory syncytial virus [RSV],
herpes simplex virus [HSV]).
• Group A ß-hemolytic streptococcus is the most
common and the most important bacterial
agent.
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39. signs and symptoms.
• Common symptomatology with some variability
by causative organism
• Very sore throat with painful swallowing.
• Enlarged and red tonsils often covered in pus.
• Elevated temperature.
• Leukocytosis.
• May complain of nausea and anorexia.
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40. signs and symptoms….
40

41. signs and symptoms…..
Viral pharyngitis
• hoarseness, conjunctivitis, runny nose, cough,
cold symptoms.
• Insidious onset
• Other signs of URTI
• Contact history with individuals who has
common cold
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42. Streptococcal pharyngitis(Bacterial)
• Common in those older then 2 years of age and peak 4-7
years
• Headache, abdominal Pain, vomiting, high grade fever,
sore throat.
• On physical examination: diffuse redness
• Petechiae over palates, exudates, cervical tender
lymphadenopathy.
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43. PATHOGENESIS
 Colonization of the pharynx by GABHS can result in
either asymptomatic carriage or acute infection.
 The M protein is the major virulence factor of GABHS
and facilitates resistance to phagocytosis by
polymorphnuclear neutrophils.
 Type-specific immunity develops following most
infections and provides protective immunity to
subsequent infection with that particular M serotype.
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44. Complications
most are complications of GABHS
• Peritonsillar or retropharyngeal abscess or
cellulitis
• Cervical adenitis, AOM, sinusitis, pneumonia
• Acute rheumatic fever -in untreated GABHS
pharyngitis-prevented if treatment started
within 9 days of initial complaints of sore
throat
• Glomerulonephritis-host/immune response to
infection with GABHS
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45. Differential Diagnosis
• Stomatitis
• Peritonsillar or retropharyngeal abscess,
epiglottitis
• Allergic rhinitis, postnasal drainage
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46. Diagnosis
Physical Findings
• Erythema of pharynx-GABHS
• Enlarged tonsils with exudate- both viral and
strep infections
• Erythema of nasal mucosa with coryza—more
viral sore throats
• Cervical nodes usually enlarged with possible
tenderness
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47. Diagnosis…..
Diagnostic Tests/Findings
• Rapid strep test to determine presence of GABHS
• Throat culture
• CBC—WBC may be elevated with bacterial infection
and normal or decreased with viral infections, but
not entirely reliable.
Consider other studies —dependent on history, age,
and clinical presentation
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48. Management/Treatment
Viral pharyngitis/tonsillitis - symptomatic/ supportive
care
• Saline gargles, throat lozenges
• Analgesics for fever/pain (acetaminophen, ibuprofen)
• Encourage fluids for maintaining hydration
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49. Treatment
Bacterial pharyngitis/tonsillitis/tonsilopharngitis
• Benzathine Penicillin
• Amoxicillin often substituted for penicillin because of
better taste
• Erythromycin or first generation cephalosporin for
those with penicillin allergy
• Second line therapy include macrolides, cephalosprins,
or clindamycin
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50. Croup syndrome
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51. Croup syndrome
 Is a syndrome caused by upper airway obstruction due
to infection of the larynx and trachea or noninfectious.
 It is a generic term for heterogeneous groups of
diseases (both infectious and non-infectious) causing
upper air way obstruction.
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52. Causes of Croup syndrome
 Infectious causes
 Most common and most important
 Acute laryngotracheobronchitis (viral croup)
 Acute epiglottis
 Laryngeal diphtheria(true croup)
 Spasmodic croup- Affecting tissues below the vocal cords.
 Bacterial tracheitis
 non-infectious causes
 Laryngoedema
 Hypocalcemia
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53. Acute Laryngotrachiobronchtis (viral croup)
• Affecting tissues both above and below the vocal cords.
Epidemiology
• Most common form of croup syndrome
• Viral croup mainly affects children between the ages of 3
months to 5 yr.
• Males are predominantly affected than females.
• The rate of viral croup increases in cold season.
• Fifteen percent (15%) of cases have positive family
history.
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54. Etiology
• Parainfluenza viruses account 75% of cases. It is the
commonest cause of croup
• Other viruses such as adenoviruses, respiratory synstial
viruse (RSV) and measles virus can also be involved in
few cases.
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55. Clinical manifestations
 most often occur at night and have sudden
presentation.
Barking cough/brassy cough
Stridor
Respiratory distress
Hoarseness of voice
 Characteristic TRIAD :- barking cough,
- hoarseness, and
- inspiratory stridor.
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56. Clinical manifestations…..
• The high degree of airway obstruction in children is
because of the following reasons:
 Small size of the airways
 Loosely attached mucous membrane
 Abundant mucous glands of the airways
 Frequent respiratory infections
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57. Clinical manifestations……
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58. The degree of severity can be assessed using croup score
• There are many clinical scoring systems for croup.
• The most commonly cited is the Westley clinical
scoring system which classifies cases into mild,
moderate or severe.
• An overall assessment of the patient's condition, the
degree of respiratory distress, may be an equivalent
and simpler guide to deciding what therapy is required.
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59. Westley Croup Score
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Clinical Sign Degree Score
Stridor • Not present
• When agitated/active
• At rest
• 0
• 1
• 2
Chest Wall Retractions o Not present
o Mild
o Moderate
o Severe
o 0
o 1
o 2
o 3
Air Entry • Normal
• Mildly decreased
• Severely decreased
• 0
• 1
• 2
Cyanosis o None
o With agitation/activity
o At rest
o 0
o 4
o 5
Consciousness Level • Normal
• Altered
• 0
• 5

60. Croup Score….
 Possible score 0-17 with:
 mild croup < 3
 moderate croup 3-7; most cases admitted
 severe croup > =8
if the child has any one of severe category needs
admission for tracheostomy.
Throat examination is best deferred since the risk of
inducing laryngealspasm is very high.
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61. • Mild croup is defined by a Westley croup score of <3.
• Typically, these children have a barking cough and hoarse cry, but
no stridor at rest.
• Children with mild croup may have stridor when upset or crying
(ie, agitated) and either no, or only mild, chest wall/ subcostal
retractions.
• Moderate croup is defined by a Westley croup score of 3 to 7.
• Children with moderate croup have stridor at rest, at least mild
retractions, and may have other symptoms or signs of respiratory
distress, but little or no agitation.
8/23/2022 Airway emergencies 61

62. • Severe croup is defined by a Westley croup score of ≥8.
• Children with severe croup have significant stridor at rest,
• Although stridor may decrease with worsening upper airway
obstruction and decreased air entry.
• Retractions are severe (including indrawing of the sternum) and
the child may appear anxious, agitated, or fatigued. Prompt
recognition and treatment of children with severe croup are
paramount.
8/23/2022 Airway emergencies 62

63. Diagnosis
Diagnosis is mainly clinical.
 investigation
• Radiographs of the neck may show the typical
subglottic narrowing or “steeple sign” of croup
on the posteroanterior view
• Radiographs may be helpful in distinguishing b/n
severe laryngotracheobronchitis and epiglottitis,
but airway management should always take
priority
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64. Indications for admission
Stridor at rest
Progressing stridor
Respiratory distress
Cyanosis
Depressed sensorium
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65. Differential diagnosis
• Epiglotitis
• Bacterial tracheitis
• Foreign body aspiration
• Retropharyngeal /peritonsillar abscess
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66. Treatment of croups
1. mild croup (no stridor at rest)
Outpatient treatment
• Advice care giver to increase fluid intake,
• Offering warm oral fluids (because cold often
exacerbates the problem).
• Mist therapy-steam therapy
• Avoid manipulation of the throat
• Advice come back when danger symptoms like
stridor at rest, respiratory distress appears.
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67. 2. Stridor at rest (sever form of croup)
• Intranasal oxygen- A humidified oxygen if available
can be life saving.
• Nebulized epinephrine every 2 hours /PRN
• Corticosteroids -systemic anti-inflamatory effect.
o Dexamethasone 0.6 mg/kg IM stat
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68. Response
• If there is response within the first 3 hours of the
steroid and nebulized epinephrine therapy, discharge
with advice on the danger symptoms.
• if no response with progressive respiratory distress
and increase need of epinephrine, patient should stay
inpatient for close observation.
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69. Impending respiratory failure
• High index of suspicion in children with pulse
rate greater or equal to 150/min and increasing
PCO2.
• Artificial airway is indicated (tracheostomy,
nasotracheal intubation).
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70. Case study
• Marta is a 6-month-old who is being admitted to the
pediatric unit from the emergency department with a
diagnosis of laryngotracheobronchitis (LTB), commonly
known as croup, and suspicion of respiratory syncytial
virus (RSV). She has been running a fever for the last 24
hours with a seal-like barking cough at night until she
gags. She was admitted since the health care provider
was not sure if the croup was viral or bacterial. The
infant looked pale, was irritable and lethargic. Both
parents were concerned that the infant was not acting
like her normal self. She was admitted for intravenous
fluids, diagnostic and laboratory testing, and 24-hour
observation to rule out epiglottitis or other respiratory
distress disorders.
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71. Epiglottitis
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72. Epiglottitis
Definition
• Epiglotitis is an acute inflammatory (infectious)
processes involving the epiglottis and surrounding
structures.
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73. Epiglottitis----
Epidemiology
• Children between the age of 2 - 7 years are
affected and the peak incidence occurs at
about 3-5 years of age.
• Male to female ratio is 3:2.
• There is no seasonal variation.
73

74. Etiology
• H.influenzae type b causes almost all cases of
epiglottitis.
• Rarely S. pneumoniae and, S. pyogenes can
lead to epiglotitis.
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75. Clinical manifestations
 Classically epiglottitis starts suddenly with rapid
progression to complete obstruction.
 Patients are toxic with high grade fever, tachycardia, and
restlessness, drooling of saliva and stridor.
 Tripod posturing (“sniffing dog”) : the child having
difficulty respiring sits forward supported by his or her
hands in an attempt to breathe as efficiently as possible
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76. Tripod positioning
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77. The Four D’s for the Diagnosis of Epiglottitis
 Dyspnea—including inspiratory stridor plus other
signs of respiratory distress: nasal flaring, intercostal
retractions, tachypnea, tachycardia, and cyanosis
 Drooling
 Dysphonia—difficulty in speaking
 Dysphagia—difficulty in swallowing
• Throat examination should be avoided since it
causes sudden reflex laryngeal spasm.
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78. Diagnosis
• Diagnosis is mainly clinical.
• Laboratory investigation
• blood culture positive in 80% of cases
• Total WBC count with differential count
• Lateral neck x-Ray: ‘thumb’ sign
• Laryngoscope shows cherry red epiglottis.
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79. 79

80. Management
Principles of management are:
• Admit all cases
• Routine tracheostomy/nasotracheal intubation
• Provide oxygen
• Cetriaxone 75/kg /dose IV
• Corticosteroid therapy to reduce swelling
Prevention—Haemophilus influenzae type b vaccine
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