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Lower Respiratory Tract Infections in Children

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					Lower Respiratory Tract
 Infections in Children


       Abdelaziz Elamin
   Professor of Child Health
    University of Khartoum
            Sudan
              Epidemiology
Incidence :
30–40 cases per 1000 children per year in the UK;
a GP will see, on average, 1-2 cases per year.
Prevalence :
Every year, pneumonia contributes to 750,000 –
1.2 million neonatal deaths worldwide:
 (60% due to S. pneumoniae/H. influenzae)
 H. influenzae infection is now quite rare
  amongst UK children due to immunization.
          Definition & Etiology

 There  is no hard and fast definition of
  lower respiratory tract infection (LRTI), that
  is universally adopted.
 Essentially, it is inflammation of the
  airways/pulmonary tissue, due to viral or
  bacterial infection, below the level of the
  larynx.
              Viral causes

 Influenza A
 Respiratory Syncytial Virus (RSV)
 Human Metapneumovirus 4
 Varicella-Zoster Virus (VZV - Chickenpox)
 Adenovirus
 Para-influenza virus
            Bacterial Agents
   Streptococcus pneumoniae
   Hemophilus Influenzae
   Staphylococcus aureus
   M
   Klebsiella pneumoniae
   Enterobacteria e.g. E. coli
   Anaerobes
            Atypical Agents

   Mycoplasma pneumoniae

   Legionella pneumophila

   Chlamydia sp.

   Coxiella burnetii
             Clinical Picture
    Presentation Acute febrile illness, possibly
     preceded by typical viral URTI.
    Symptoms :
1.   Cough
2.   Breathlessness ( preventing feeding)
3.   Irritability
4.   Sleeplessness
5.   Chest or abdominal pain in older patients
    Audible wheezing is rare in LRTI, but can occur
             Physical Signs
1.   Capillary blood oxygen saturation <95%
2.   Intercostal and supra-sternal recession
3.   Flushing
4.   Tachypnea
5.   High fever over 38.5 c
6.   Nasal flaring in children under 1 yr of age
7.   Dullness to percussion over zones of
     pneumonia consolidation.
8.   Cyanosis in advanced cases.
      Differential Diagnosis

 Asthma
 Bronchiolitis (a form of LRTI)
 Inhaled foreign body
 Pneumothorax
 Cardiac dyspnoea
 Pneumonitis of other cause e.g. extrinsic
  allergic alveolitis
           Investigations
 Chest radiography if fever and tachypnea,
  oxygen saturation to monitor condition.
 In hospital consider capillary or arterial
  blood gases.
 Culture of sputum or nasopharyngeal
  discharge/aspirate may be used in hospital
  but has little to add in primary care.
 Blood cultures if evidence of septicemia.
 Blood urea and electrolytes
              Management
 Admission  for children under 5 years with
 fever and breathlessness is mandatory.
 Older children can be managed with close
 observation at home if not distressed
 Physiotherapy has no place in treatment
 of uncomplicated pneumonia in children
 without pre-existing respiratory disease.
       Essential Measures
 Oxygen,
 IV fluids if unable to feed,
 Respiratory support in severe cases
 Cough medicines are not indicated and
  may be used if cough interferes with
  feeding or sleep. Honey with lemon may
  be helpful.
 Antihistamines are dangerous in young
  children & should be avoided.
                  Medications
   Antipyretics (avoid aspirin in young children due to
    danger of Reye's syndrome).
   Antibiotic treatment for bacterial pneumonias.
   Pneumonia or LRTI following URTI is likely to be
    viral and will not respond to antibiotic therapy.
    However, it is difficult to distinguish between viral
    and bacterial infection and young children can
    deteriorate rapidly. so consider antibiotic therapy
    depending on presentation and the clinical judgment
    of the concerned child.
                Antibiotics
 Streptococcal pneumonia is treated with oral
  penicillin V, or synthetic penicillin such as
  amoxicillin as first line drugs.
 Recent research indicates that children with
  non-severe pneumonia on amoxicillin for 3 days
  do as well as those who receive it for 5 days
 If a child is genuinely allergic to penicillin,
  consider using a macrolide or quinolone.
 Cephalosporin often cross-react with penicillin.
             Antibiotics/2
 For  Hemophilus influenzae cephalosporins
  or Amoxicillin/Calvulenic acid combination
  are useful.
 For Staph pneumonia cloxacillin and
  flucloxacillin are used and in severe cases
  parenteral vancomycin is required.
 Injectable antibiotics are indicated in
  severe cases
                Complications
   Bacterial invasion of the lung tissue can
    cause:
       pneumonic consolidation,
       septicemia,
       empyema,
       lung abscess(esp. S. Aureus)
       pleural effusion.
       Mycoplasma P. can cause hemolysis
       Rarely, respiratory failure, hypoxia and death.
             Prevention
 Itis achieved with pneumococcal vaccine
  and influenza vaccine
 Stop indoor smoking. Smoking at home or
  school is a major risk factor.
 Zinc supplementation reduces the
  incidence of pneumonia by over 40% in
  malnourished children.
The End

				
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posted:3/4/2012
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