This document discusses the approach to assessing and treating upper respiratory tract infections (URTIs) in children. It begins by introducing URTIs as a common problem, then describes the anatomy of the respiratory tract. It outlines symptoms of URTIs and the approach to taking a history and examining the patient. It discusses common causes of URTIs like the common cold, allergic rhinitis, sinusitis, pharyngitis, and more severe conditions like croup, epiglottitis and diphtheria. For each condition, it covers symptoms, diagnosis, treatment and prevention.

2. Health is
Our Concern

3. Approach to child with URTI
Dr. Raheel Ahmed Shaikh
FCPS Pediatrics
Children Hospital, Chandka Medical College Larkana

4. Introduction
▸ Respiratory tract infection are common problem all age groups.
▸ Upper respiratory infections consist of almost 40-50% of all OPD
cases.
Reference:
Incidence of infectious diseases in pakistan URL available: https://www.who.int/workforcealliance/knowledge/resources/MLHWCountryCaseStudies_annex9_Pakistan.pdf. Accessed on 18 jan,2022

5. THE RESPIRATORY SYSTEM
▸ The upper respiratory tract:
▹ Nasal cavity, sinuses, pharynx, and larynx
▹ Infections are fairly common.
▹ Usually nothing more than an irritation
▸ The lower respiratory tract:
▹ Lungs and bronchi
▹ Infections are more dangerous.
▹ Can be very difficult to treat

6. Symptoms
▸ Fever
▸ Coryza
▸ Cough
▸ Breathlessness
▸ Stridor/Wheze
▸ Chest Pain
▸ Cynosis
▸ Convulsion
▸ Lethargic
▸ Dec intake/ refuse to feed

7. Approach
▸ History
▹ Age
▹ Symptoms
▹ Duration
▹ Aggravating/relieving factors
▹ Diurnal variation
▹ Other system involvement
▸ Physical Examination
▹ General: A, Cy, Cl, signs of
allergy
▹ ENT Examination
▹ Respiratory Examination
▸ Investigations
▹ X-ray: chest, soft tissue neck,
sinus
▹ ABG
▹ Microbiology
▹ Airway visualization
▹ CT/MRI

8. PATHOGENS OF THE RESPIRATORY SYSTEM

9. CommonCold
▸ Naso-pharyngitis = Common
cold.
▸ Essentially Viral infection of the
nose & throat.
▸ Characterized by rhinorrhea
and nasal obstruction.
▸ Etiology
RHV, RSV, MPV, coronavirus,
adenovirus.
▸ Assessment (S &S):
1. Younger child
▹ Fever, sneezing, irritability, vomiting
2. Older child
▹ Dryness & irritation of nose & throat,
sneezing, cough & muscular aches.
▸ Usually no need of
investigations.
PCR/ serology
▸ Complications of
nasopharyngitis:
▹ Otitis media
▹ Lower respiratory tract infection
▹ Older child may develop sinusitis
▹ Acute exacerbation of asthma

10. CommonCold
▸ Treatment: symptomatic
▹ Adequate hydration (warm
fluids)
▹ Antimicrobial agents>>no
▹ Cough: Honey (5-10ml in >1
year), 1st generation histamine
▹ Fever: NSAID (Acetaminophen)
▹ Nasal obstruction: topical
adregenic agents, saline nasal
drops and irrigation
▹ Rhinorrhea: 1st generation
histamine, ipratopium bromide
▹ Antivairal: Ribavirin for RSV
(immunocompromised),
neuroamidease inhibitor
(oseltamivir, zanamavir) for
influenza virus
▸ Prophylactic antibiotics DO
NOT
▹ Shorten duration
▹ Prevent sinusitis/OM/Pneumonia
▹ Reduce Symptoms

11. CommonCold
▸ Prevention:
▹ Hand wash
▹ Avoid touching nose, mouth, eye
▹ Alcohol sanitizer usage
▹ Avoid crowded area
▹ Zinc can reduce sympyoms
▹ No role of vit C, vit D

12. AllergicRhinitis
▸ 20% population
▸ Ch: by nasal congestion, itching,
sneezing, and discharge
▸ Hx
▹ Seasonality
▹ Hx of atopy
▹ Exposure to parental smoking,
pets, nuts, dust mite, carpets
bedding
▸ Examination
▹ Mouth breathing
▹ Postnasal drip
▹ Cough
▹ Nose rubbing
▹ Suborbital venous congestion
▹ Watery red eyes
▸ Investigation
▹ Skin prick test for specific
antigens
▹ S. Ig E measurement
▸ Tx
▹ Allergen avoidance
▹ Symptomic: Antihistamines,
montelukast, intanasal
steroids.

13. Sinusitis
▸ Inflammation of the sinuses
and nasal passages, upper
respiratory tract infection,
▸ the most common three
causative agents are
▹ Streptococcus
pneumoniae(~30%),
▹ Haemophilus influenzae
(~30%) and
▹ Moraxella catarrhalis (~10%)

14. ▸ Types:
▹ Acute : symptoms >10 days <1month
▹ Subacute: 1-3 month
▹ Chronic: >3month (90days)
▸ Predisposing factors
▹ Viral infections, School age sibling, Allergic rhinitis, Expose to
tobacco smoke, Immunodeficiency
▹ CF, PCD, GERD, Cleft palate

15. Sinusitis
▸ S&S
▹ Nasal congestion, prulent nasal discharge(>3 days), fever and
cough(>10 days)
▹ Sinus tenderness,
▹ transillumination test reveals opaque.
▸ Diagnosis
▹ History,
▹ Sinus aspiration culture
▹ Sinus plain films/ct scan
▹ Rigid nasal endoscopy

17. Sinusitis
▸ Treatment
▹ Antibiotics
▹ Amoxycillin/ cefuroxime/ co-amoxiclav/
Macrolide
▸ If severe/ failure to 1st line
▹ Iv Ceftriaxone/Cefotaxime or
oral Cefpodoxime
▸ Complications:
▹ periorbital cellulitis,
▹ epidural abscess,
▹ osteomyelitis,
▹ mucocele

19. Pharyngitis
▸ Pharyngitis: = Sore throat including tonsils.
- Uncommon in children under 1 yr. The peak
incidence occurring between 4 & 7 yrs of age.
- Causative organism:
- viruses or
- bacterial : group A beta-hemolytic streptococcus,
Group C&G streptococcus, Mycoplasma,
Chlamydia,
- Part of other disease: Kawasaki disease

21. Pharyngitis
Assessment (S &S) of pharyngitis:
1. Younger child
Fever, anorexia, general malaise, & dysphagea
2. Older child
Fever (40 c), anorexia, Headache abdominal pain,
vomiting, & dysphagea, Sore throat, cervical
adenopathy,

22. Management of Pharyngitis
▸ A throat culture:
- Antibiotic medicine is needed if streptococcus found to be the causative organism.
- Oral amoxicillin for 10 days. Or Benzathine pencillin G IM once.
- No special treatment if caused by a virus.
- Do not smoke around this child.
- . Introduce soft foods or warm soups.
- Give this child 6 to 8 glasses of liquids like water and fruit juices each day.
- Run a cool mist humidifier in the child's room.
- If this child is 8 years or older, have him gargle with a mixture of 1 teaspoon salt in 1
cup warm water.

24. Tonsillitis
▸ Tonsillitis is a viral or bacterial infection in the throat
that causes inflammation of the tonsils.
▸ In the first six months of life tonsils provide a useful
defense against infections.
▸ Tonsillitis is one of the most common ailments in pre-school children, but it can
also occur at any age.
▸ Children are most often affected from around the age of three or four, when
they start nursery or school and come into contact with many new infections.
▸ A child may have tonsillitis if he/she has a sore throat, a fever and is off food.

26. Advice and treatment:
▸ Encourage bed rest.
▸ Introduce soft liquid diet according to the child's preferences.
▸ Provide cool mist atmosphere to keep the mucous membranes moist
during periods of mouth breathing.
▸ Warm saline gargles & paracetamol are useful to promote comfort.
▸ If antibiotics are prescribed, counsel the child's parents regarding
the necessity of completing the treatment period
▸ The controversy of tonsillectomy:
▸ Surgical removal of chronic tonsillitis (tonsillectomy) is controversial.
Generally, tonsils should not removed before 3 or 4 yrs of age.

28. Stridor
▸ Stridor is a harsh, high
pitched respiratory sound
▸ usually inspiratory but can
be biphasic
▸ is produced by turbulent
airflow;
▸ it is not a diagnosis but a
sign of upper airway
obstruction

29. Viral croup/ laryngotreacheobronchitis
▸ the most common form of acute upper respiratory
obstruction
▸ Mucosal inflamation affecting anywhere from nose to lower
airway
▸ The term laryngotracheobronchitis refers to viral infection of
the glottic and subglottic regions.
▸ Common organisms; parainfluenza virus75%, influenza
virus, RSV
▸ Age 6m to 6y.
▸ family members might have mild respiratory illnesses

30. Viral croup/ laryngotreacheobronchitis
▸ characteristic barking cough, hoarseness, and
inspiratory stridor.
▸ child may prefer to sit up in bed or be held upright
▸ Physical examination can reveal a hoarse voice,
coryza, normal to moderately inflamed pharynx, and a
slightly increased respiratory rate
▸ Hypoxia and low oxygen saturation are seen only when
complete airway obstruction is imminent.
▸ The child who is hypoxic, cyanotic, pale, or obtunded
needs immediate airway management

32. Viral croup
Diagnosis
Mild croup is characterized by:
■ fever
■ a hoarse voice
■ a barking or hacking cough
■ stridor that is heard only when the child is
agitated.
Severe croup is characterized additionally
by:
■ stridor even when the child is at rest
■ rapid breathing and lower chest indrawing
■ cyanosis or oxygen saturation ≤ 90%.
Treatment
Mild croup can be managed at home with
supportive care, including encouraging oral fluids,
breastfeeding or feeding, as appropriate.
A child with severe croup should be
admitted to hospital.
Steroid treatment: Give one dose of oral
dexamethasone (0.6 mg/kg), If available, use
nebulized budesonide at 2 mg
Adrenaline: give the child nebulized adrenaline (2 ml of
1:1000solution). If this is effective, repeat as often as
every hour
Intubation and/or tracheostomy
Oxygen, Antibiotic treatment (not effective),
Supportive care, Monitoring

33. Epiglottitis (Supraglottitis)
▸ Life threatening condition
▸ Inflammation of epiglottis and septicemia due to H.
influenza type b infection.
▸ Age 1-6y
▸ Rare after Hib immunization
▸ condition is characterized by an acute rapidly
progressive and potentially fulminating course of
high fever, sore throat, dyspnea, and rapidly
progressing respiratory obstruction

34. Epiglottitis (Supraglottitis)
Clinical features
▸ the otherwise healthy child suddenly develops a sore
throat and fever
▸ Within a matter of hours, the patient appears toxic,
swallowing is difficult, and breathing is labored.
▸ Other: Drooling, neck hyperextended, tripod position,
stidor
▸ A brief period of air hunger with restlessness may be
followed by rapidly increasing cyanosis and coma
▸ cherry red, swollen epiglottis by laryngoscopy

37. Epiglottitis
Diagnosis
■ sore throat with difficulty in speaking
■ difficulty in breathing
■ soft stridor
■ fever
■ drooling of saliva
■ difficulty in swallowing or inability to drink
Treatment
directed to relieving the airway
obstruction and eradicating the infectious
agent.
> Keep the child calm, and provide humidified
oxygen, with close monitoring.
> Avoid examining the throat if the signs are
typical, to avoid precipitating obstruction.
>Give IV antibiotics when the airway is safe:
ceftriaxone at 80 mg/kg once daily for 5 days
>Call for help and secure the airway, Elective
intubation is the best treatment if there is
severe obstruction but may be very difficult

38. Indications for rifampin prophylaxis
▸ for all household members include
▹ a child within the home who is younger than 4 yr of age and
incompletely immunized,
▹ younger than 12 mo of age and has not completed the primary
vaccination series,
▹ or immunocompromised.
▸ Dose: (20 mg/kg orally once a day for 4 days;
maximum dose: 600 mg)

39. DIPHTHERIA
▸ Classic diphtheria
(Corynebacterium diphtheriae):
slow onset, then marked toxicity
▸ Arcanobacterium hemolyticum
(formerly Cornyebacterium
hemolyticum)
▸ exudative pharyngitis in
adolescents and young adults with
diffuse, sometimes pruritic
maculopapular rash on trunk and
extremities

40. Microbiology: A Clinical Approach © Garland Science
…DIPHTHERIA
© Visuals Unlimited
Corynebacterium diphtheriae

41. Diphtheria
Diagnosis
Carefully examine the child’s nose and
throat and look for a grey, adherent
membrane.
Great care is needed when
examining the throat, as the examination
may precipitate complete obstruction
of the airway.
A child with pharyngeal
diphtheria may have an obviously swollen
neck, termed a ‘bull neck’.
Treatment
Antitoxin
Give 40 000 U diphtheria antitoxin (IM
or IV) immediately.
Antibiotics: IM injection
of procaine benzylpenicillin at 50 mg/kg
(maximum, 1.2 g) daily for 10 days.
Intubation and/or tracheostomy
Avoid Oxygen until incipitating obstruction,
Supportive care, Monitoring,
Public health measures: vaccine, Prophylaxis
Complications
Myocarditis and paralysis may occur 2–7
weeks after the onset of illness.

42. Diphtheria
PROPHYLAXIS:
▸ Asymptomatic case contacts:
▹ All house hold contacts or those who come in contact with
secretions
▹ Macrolide for 7 days or I/M penicillin single dose
▹ Age appropriate vaccination
▸ Asymptomatic carriers: Macrolide for 7 days

43. Laryngomalacia
▸ most common congenital laryngeal anomaly
▸ most common cause of stridor in infants and
children.
▸ 60% of congenital laryngeal anomalies e stridor are
due to laryngomalacia
▸ Stridor is inspiratory, low-pitched, and exacerbated by
any exertion: crying, agitation, or feeding
▸ Symptoms usually appear within the 1st 2 wk of life
and increase in severity for up to 6 mo, although
gradual improvement can begin at any time.
▸ 15-60% of infants with laryngomalacia have
synchronous airway anomalies

44. ▸ DIAGNOSIS
▹ primarily based on symptoms
▹ confirmed by flexible laryngoscopy
▹ complete bronchoscopy for moderate to severe obstruction.
▸ TREATMENT
▹ Expectant observation- resolve spontaneously
▹ surgical intervention via supraglattoplasty
▹ For progressive respiratory distress, cyanosis, or failure to
thrive.