ACUTE RESPIRATORY infections in children

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                                                                                                                                                                                            The authors

                                                                                                                                                                                            DR JO HARRISON,
                                                                                                                                                                                            consultant respiratory physician,
                                                                                                                                                                                            department of respiratory
                                                                                                                                                                                            medicine, Royal Children’s
                                                                                                                                                                                            Hospital, Melbourne, Victoria.

ACUTE RESPIRATORY                                                                                                                                                                           ASSOCIATE PROFESSOR
                                                                                                                                                                                            JOHN MASSIE,

infections in children
                                                                                                                                                                                            consultant respiratory physician,
                                                                                                                                                                                            department of respiratory
                                                                                                                                                                                            medicine, Royal Children’s
                                                                                                                                                                                            Hospital, Melbourne, Victoria.

 Background                                                                                          Table 1: Classification of acute respiratory infections
                                                                                          Acute upper respiratory infections               Acute lower respiratory infections

ACUTE respiratory infections are a         by healthy children and result in sig-         Nasopharyngitis                                  Laryngotracheobronchitis (croup)*
major cause of morbidity and mortality     nificant numbers of medical visits and
                                                                                          Pharyngotonsillitis                              Bronchitis
worldwide. They are responsible for        hospital admissions, particularly in the
one in five deaths in children under the   preschool age group.                           Otitis media                                     Bronchiolitis
age of five years, with pneumonia the         Based on the site of infection, acute
                                                                                          Epiglottitis                                     Pneumonia
cause in 90% of these deaths.              respiratory infections may be classified
  Childhood mortality from respira-        as acute upper or acute lower respira-         Laryngotracheobronchitis (croup)*                Influenza*
tory infections in developed countries     tory infections (table 1). This article
                                                                                          Influenza*                                       Pertussis**
such as Australia is fortunately rare,     reviews the most common types of
but these diseases remain a signifi-       acute respiratory infections, their clinical   *Croup and influenza involve both upper and lower airways
cant cause of morbidity. They are the      features, diagnoses and management.            **Pertussis starts as a coryzal illness, but the main recognisable clinical feature of cough is
most common infections experienced                                   cont’d next page       lower airway in origin
 HOW TO TREAT Acute respiratory infections in children

 Epidemiology                           Active RSV           Figure 1. Infant with acute viral bronchiolitis. Note hyperinflation, prominent perihilar bronchial
                                                                                                                                                                     portation factors.
 BRONCHIOLITIS is the                                                                                                                                              • Clinical assessment.
 most common cause of                   infection does not   markings and some patchy airspace shadowing. Note: for infants with a clear clinical presentation,
                                                             a chest X-ray is not required for the diagnosis of bronchiolitis.                                        Clinical features that
 acute lower respiratory                result in lasting                                                                                                          should prompt urgent pae-
 infection in children during                                                                                                                                      diatric review of an infant
 the first year of life. It is the
                                        immunity, so                                                                                                               with suspected bronchiolitis
 most common cause of                   recurrent RSV                                                                                                              are listed in table 2. The
 admission to hospital in this                                                                                                                                     stage of illness (disease tra-
 age group, accounting for
                                        infection is                                                                                                               jectory) is an important con-
 more than 50% of all such              common.                                                                                                                    sideration in determining
 admissions in Australia. The                                                                                                                                      which patients require
 peak incidence of bronchi-                                                                                                                                        review, as babies in the early
 olitis occurs in infants aged                                                                                                                                     stages of infection are at risk
 2-6 months, with more than                                                                                                                                        of further deterioration,
 80% of cases occurring in                                                                                                                                         whereas those who have
 babies under 12 months of                                                                                                                                         been symptomatic for five
 age.                                                                                                                                                              days or more are most likely
    The most common infec-                                                                                                                                         to be improving.
 tious agent responsible for
 bronchiolitis is respiratory                                                                                                                                      Specialist management
 syncitial virus (RSV), and                                                                                                                                        Treatment of RSV infection
 the epidemiology of bron-                                                                                                                                         in hospitalised infants is
 chiolitis is mainly deter-                                                                                                                                        largely supportive and gen-
 mined by the epidemiology                                                                                                                                         erally includes supplemental
 of this viral infection. RSV                                                                                                                                      oxygen and fluid replace-
 infections are most common                                                                                                                                        ment either by nasogastric
 in winter and spring in tem-                                                                                                                                      tube or intravenously. Nasal
 perate climates, with up to                                                                                                                                       suction is often helpful, but
 75% of all cases identified                                                                                                                                       other therapies, including
 between July and September                                                                                                                                        physiotherapy, are not.
 in temperate regions of Aus-                                                                                                                                      Early introduction of con-
 tralia. In tropical and sub-                                                                                                                                      tinuous positive airway pres-
 tropical climates, epidemics                                                                                                                                      sure (CPAP) for infants with
 tend to occur in the rainy                                                                                                                                        severe respiratory distress
 season.                                                          Table 2: Clinical             Assessment and                    Parents or carers should be      often obviates the need for
    There is virtually no pro-                                   features of severe             diagnosis                         given information on how         intubation and mechanical
 tection to young infants                                           bronchiolitis               The diagnosis of bronchioli-      to recognise signs of deterio-   ventilation.
 from transplacental antibod-                                                                   tis is clinical, based on the     ration in their infant and be
 ies, or from breast milk. Fur-                               • Poor feeding (fluid intake      typical symptoms and exam-        strongly advised to bring        RSV prophylaxis
                                                                <50% of normal in the
 thermore, active RSV infec-                                                                    ination findings described        them back for reassessment       Palivizumab is a human
                                                                preceding 24 hours, poor
 tion does not result in lasting                                                                above. Although fever is          if it occurs.                    recombinant monoclonal
                                                                urine output)
 immunity, so recurrent RSV                                                                     common, the finding of a             Additional therapies such     RSV antibody that is admin-
 infection is common and can                                  • Lethargy                        high fever (temperatures          as bronchodilators, systemic     istered as a monthly injec-
 occur within the same                                        • Apnoea                          >40°C) is unusual and             and inhaled corticosteroids,     tion during the RSV season.
 season.                                                      • Respiratory rate > 70           should prompt careful con-        nebulised adrenaline or          Although it does reduce hos-
    Almost all children experi-                                 breaths per minute              sideration of alternative         antibiotics have been well       pitalisation and admission
 ence at least one RSV infec-                                                                   diagnoses.                        shown to have no role in the     rates to ICU in high-risk
 tion during the first two                                    • Nasal flaring or grunting          In hospital settings the       treatment of the infant with     groups (for example, former
 years of life, although only                                 • Severe chest wall               clinical diagnosis is usually     bronchiolitis. In some cases,    preterm infants, those with
 10% of those infected                                          recession                       confirmed by identifying          bronchodilators can exacer-      chronic lung disease or
 develop acute bronchiolitis.                                 • Cyanosis                        RSV, or another respiratory       bate ventilation/perfusion       acyanotic congenital cardiac
 Most babies with bronchi-                                                                      virus, in a respiratory           mismatch and make infants        disease), it has not been
                                                              • Oxygen saturation <92%
 olitis can be managed at                                                                       sample (usually nasopharyn-       more hypoxic. This is            shown to reduce the need
 home, with about 1%                                                                            geal aspirate). Immunofluo-       important to consider, as it     for mechanical ventilation.
 requiring admission to hos-                                 by inducing cell fusion and        rescent (IF) antibody meth-       can be tempting to treat the     Consequently, its efficacy
 pital.                                                      the formation of syncytia.         ods        allow        rapid     wheeze with bronchodila-         and cost-effectiveness have
    Factors that make hospi-                                 Ciliated epithelial cells are      identification of the virus       tors ‘in case’ the diagnosis     been challenged and it is
 tal admission more likely                                   destroyed and there is necro-      responsible and enable            is asthma.                       only available for babies in
 include young age (particu-                                 sis of the bronchiole epithe-      infants with the virus to be         Children over 12 months       the high-risk groups in their
 larly babies under three                                    lia, along with oedema of          isolated, which is important      may also have bronchiolitis      first RSV season.
 months of age), prematurity                                 the bronchiole walls and           for infection control. IF         and not respond to bron-
 (particularly gestation less                                increased secretion of mucus.      results are available within      chodilators, although by this    Prognosis
 than 32 weeks), congenital                                                                     a few hours and this method       age a trial of a bronchodila-    The prognosis for most
 cardiac disease and chronic                                 Signs and symptoms                 has excellent specificity and     tor, especially in an atopic     babies who develop acute
 lung disease. Indigenous chil-                              Bronchiolitis presents most        good sensitivity. The pres-       child or one with a family       bronchiolitis in Australia is
 dren in Australia are also                                  frequently in infants aged 3-      ence of the virus is then usu-    history of asthma, is reason-    very good and overall mor-
 more likely to require admis-                               6 months, with breathing           ally confirmed by viral cul-      able. However, we would          tality rates are very low.
 sion, with rates of hospitali-                              difficulties, cough (may be        ture, but this result is not      recommend a trial dose           Fifty per cent of previously
 sation almost eight times                                   dry/irritating or moist), poor     available for up to one           (administered through a          healthy infants with bron-
 those of non-Indigenous chil-                               feeding and fever. In very         week.                             spacer) be given first under     chiolitis will be symptom
 dren.                                                       young babies (typically those         Chest X-rays are not usu-      observation to assess            free after 14 days.
    Spread of RSV occurs via                                 under 1-2 months), the only        ally helpful for diagnosing       response.                           About 10%, however,
 large droplets transferred to                               symptom may be apnoea.             bronchiolitis (they usually                                        develop a post-bronchiolitic
 the individuals’ hands,                                     Examination         findings       demonstrate a range of find-      When to refer                    syndrome with symptoms of
 where the virus can survive                                 include:                           ings from hyperinflation,         A small number of babies         cough and wheeze that per-
 for up to one hour. The virus                               • Tachypnoea.                      atelectasis and patchy infil-     with bronchiolitis will          sist for several weeks and
 is then transferred to the                                  • Increased work of breath-        trates) (see figure 1). The       require admission to hospi-      can recur intermittently for
 eyes or nose, resulting in                                    ing (intercostal and sub-        main role is if a differential    tal. In deciding which babies    several years, usually in
 infection. RSV can also sur-                                  costal recession, tracheal       diagnosis is suspected clini-     require admission, several       association with subsequent
 vive on hard surfaces for as                                  tug and sometimes expira-        cally, for example, because       factors are taken into con-      viral infections.
 long as 30 hours. The incu-                                   tory grunting).                  of localised chest signs          sideration, including:              Most eventually recover
 bation period of RSV is                                     • Chest hyperinflation.            (pneumonia) or a heart            • Age.                           completely, so that by the
 between three and eight                                     • Widespread        crackles       murmur (cardiac disease).         • Presence of underlying         age of 13 years there is no
 days.                                                         and/or wheeze heard on                                               comorbidities such as con-     increase in wheezing
                                                               auscultation.                    GP therapy                          genital heart disease.         episodes. RSV bronchiolitis
 Pathogenesis                                                   These symptoms are usu-         Mild bronchiolitis can usu-       • Premature birth or chronic     in infancy is not a risk
 RSV invades the epithelial                                  ally preceded by an initial        ally be managed at home             lung disease.                  factor for asthma in adult-
 cells of the respiratory tract                              coryzal phase lasting for 2-3      with appropriate advice and       • Socioeconomic factors.         hood.
 and spreads from cell to cell                               days.                              reassurance to the parents.       • Geographical and trans-                        cont’d page 30

28   | Australian Doctor | 8 May 2009                                  
 HOW TO TREAT Acute respiratory infections in children

 ACUTE bronchitis is a                                                                                               tussis, whereas Streptococ-         and harsh but then loosens          ing exposure to irritants,
 common clinical syndrome in                                                                                         cus pneumoniae, non-                and becomes productive.             particularly tobacco smoke.
 children, caused by inflamma-                                                                                       typeable       Haemophilus          Children younger than five             Although prescribed fre-
 tion of the trachea, bronchi                                                                                        influenzae and Moraxella            years rarely expectorate, and       quently, antitussives and
 and bronchioles, usually in                                                                                         catarrhalis may be signifi-         sputum may be seen in vom-          expectorants are not useful.
 association with a viral respi-                                                                                     cant pathogens in preschool-        itus. Parents frequently note       There is growing concern
 ratory tract infection. Acute                                                                                       ers.                                a rattling sound in the chest.      about side effects from anti-
 bronchitis is rarely bacterial                                                                                         The cause of the cough in           Examination findings are         tussives in children under
 in otherwise healthy children.                                                                                      acute bronchitis is multifac-       frequently normal although          two years and a recent
    Symptoms of acute bronchi-                                                                                       torial but involves mucosal         the pharynx may be injected.        Cochrane review failed to
 tis usually include cough that                                                                                      injury, epithelial damage and       Auscultation typically reveals      find any benefit in any age
 produces phlegm and may be                                                                                          the release of inflammatory         clear lung fields, although         group.
 associated with retrosternal                                                                                        cytokines as well as transient      scattered crackles or wheez-           Antibiotics do not relieve
 pain during deep breathing or                                                                                       bronchial obstruction and           ing can sometimes be heard.         symptoms or improve the
 coughing. Generally the clini-                                                                                      hyper-responsiveness in a              Recurrent episodes of            natural history of acute
 cal course is self-limiting, with                                                                                   proportion of patients.             acute or chronic bronchitis         bronchitis in otherwise
 complete healing and full                                                                                                                               are unusual and should              healthy patients.
 return to function typically                                                                                        Signs and symptoms                  prompt consideration of
 seen within 10-14 days after                                                                                        Acute bronchitis usually            alternative diagnoses such as       When to refer
 symptom onset.                         Acute bronchitis                    of acute bronchitis, with                begins with symptoms simi-          asthma or suppurative lung          Children with acute bronchi-
                                                                            bacteria implicated in fewer             lar to those of the common          disease (cystic fibrosis,           tis rarely require referral to a
 Epidemiology                           usually begins                      than 10% of cases. The                   cold, such as coryza, malaise,      immunodeficiency, ciliary           paediatrician unless they
 The annual incidence of bron-          with symptoms                       organism responsible is not              chills, low-grade fever, sore       dyskinesia).                        have complicating underly-
 chitis in children in the devel-                                           usually identified in clinical           throat, and back and muscle                                             ing disease. However, per-
 oped world is 20-30%, with
                                        similar to those                    practice, but when viruses               pain. The initial watery nasal      GP therapy                          sistence of symptoms for
 an equal incidence in males            of the common                       are identified they are usu-             discharge becomes thicker           The vast majority of children       more than one month or
 and females. Acute bronchitis          cold.                               ally one of the common res-              and discoloured after several       with acute bronchitis can be        recurrence of symptoms of
 occurs most commonly in                                                    piratory viruses such as                 days and is accompanied by          managed as outpatients              productive cough should
 children younger than two                                                  influenza A or B, parain-                a cough. Purulent nasal dis-        unless their illness is compli-     prompt consideration of
 years, with a second peak seen                                             fluenza or RSV.                          charge is common with viral         cated by severe underlying          alternative diagnoses such as
 in children aged 9-15 years.                                                  Bacteria that can cause               respiratory pathogens and,          disease. Treatment is               asthma, suppurative lung
                                                                            acute bronchitis in otherwise            by itself, does not imply an        directed at symptoms and            disease or retained foreign
 Pathogenesis                                                               healthy school-age children              underlying bacterial infec-         includes analgesics and             body. These will usually
 Respiratory viruses are by                                                 include Mycoplasma pneu-                 tion.                               antipyretics, ensuring ade-         require referral to a paedia-
 far the most common cause                                                  moniae and Bordetella per-                  The cough is initially dry       quate fluid intake and avoid-       trician for confirmation.

 CROUP, also known as laryngotra-                                                                                                          parent’s knee and keeping them calm        cise limitation between episodes, refer-
 cheobronchitis, is caused by a viral              Table 3: Assessing clinical severity of a child with croup                              is very important.                         ral to a paediatric respiratory physi-
 infection of the upper airway. This                                                                                                          Corticosteroids are used to treat       cian or ENT surgeon is warranted.
                                             • Mild: barking cough, no or intermittent stridor, no chest retractions
 infection results in a classic triad of                                                                                                   upper airway obstruction by reduc-
 hoarse voice, barking cough and inspi-      • Moderate: persisting stridor at rest, some chest wall recession or tracheal                 ing airway oedema and inflammation.        Emergency management
 ratory stridor. The condition usually         tug, child easily pacified and interested in surroundings                                   They should be prescribed for all but      Systemic corticosteroids are prescribed
 affects children from six months to                                                                                                       the mildest cases of croup. Recom-         if this has not already been done. Chil-
 six years of age.                           • Severe: persisting stridor at rest, marked tracheal tug and chest wall                      mended doses are oral prednisolone         dren with more severe croup may
                                               recession, lethargic or restless, pulsus paradoxis                                          1mg/kg, or dexamethasone 0.3mg/kg          require treatment with nebulised
 Epidemiology                                                                                                                              given either orally or intramuscularly.    adrenaline (1mL 1% solution mixed
 The annual incidence of croup                                                                                                             The onset of action seems to be within     with 3mL normal saline; or 1:1000
 depends on the incidence of infection                                                                                                     1-2 hours.                                 undiluted at a dose of 0.5mL/kg to a
 with viruses that cause this condition,                                Table 4: Diagnosing croup                                             There is no effect on the cough, and    maximum of 4mL), which reduces
 but peaks occur in autumn and                                                                                                             single doses, repeated as necessary,       laryngeal inflammation, thus improv-
 spring. The peak incidence occurs in       Differential diagnosis             Key features                                                should be prescribed (rather than a        ing the child’s airway. In the circum-
 children aged 1-2 years and is about                                          Triad of barking cough, stridor, hoarse voice; six          three-day course as recommended for        stance of a child requiring adrenaline,
 60 per 1000 child-years. For reasons       Croup                                                                                          asthma). Doses are given at 24-hour        the GP should call an ambulance for
                                                                               months to six years
 that are not clear, croup is rare in                                                                                                      intervals and if more than three doses     transfer to hospital.
 babies under six months of age and                                            Toxic (high temperature), drooling, muffled voice,          are required the child should see a            Nebulised adrenaline lasts for up
 uncommon in children older than six        Epiglottitis                       no cough, may be unimmunised for H influenzae               paediatrician. Parents whose children      to two hours, but rebound worsen-
 years.                                                                        type B                                                      develop recurrent croup should be          ing of the airway narrowing can occur
                                                                                                                                           encouraged to give a dose of cortico-      and this must be borne in mind.
                                            Retropharyngeal abscess            Sore throat, fever, drooling, no cough
 Pathogenesis                                                                                                                              steroid as soon as they can predict a      Repeat doses of adrenaline should be
 Croup is due to a viral URTI that                                             Sudden onset, no fever, stridor and/or wheeze,              viral URTI will develop into croup.        given as needed. A small number of
 causes generalised mucosal inflamma-       Foreign body                       difficulty feeding/swallowing if foreign body is                                                       children with croup will require intu-
 tion and oedema of the larynx, tra-                                           oesophageal                                                 When to refer                              bation to maintain their airway.
 chea and bronchi, followed by epithe-                                                                                                     Croup can cause life-threatening               Nebulised budesonide (one
 lial necrosis and shedding. The key        *Stridor at rest indicates airway narrowing of at least 70% (ie, 30% or less residual lumen)   upper airway obstruction, and chil-        1mg/2mL nebule) can be used as an
 area of airway narrowing is the sub-                                                                                                      dren with more severe illness need to      alternative to adrenaline, although
 glottis, with airway obstruction at this   suddenly during the night. Usually this         ing looser in nature after the first few       be managed in a centre with access         its onset of action is not as rapid.
 site responsible for stridor.              is preceded by a 1-2-day history of             days.                                          to staff trained in the management of      The main role for nebulised budes-
    Laryngeal inflammation also results     non-specific symptoms of a viral                                                               paediatric airways.                        onide is for parent-initiated therapy
 in impaired vocal cord movement,           URTI, such as rhinorrhoea, sore                 Assessment and diagnosis                          All children under 12 months            in those rare circumstances when
 leading to the characteristic cough. In    throat and fever.                               Croup is a clinical diagnosis based on         should be referred for a paediatric        children have a history of frequent
 addition, fibrinous exudate can some-         Stridor may develop, which can be            the symptoms and signs described               assessment, in part so that alternative    severe episodes and access to ambu-
 times result in pseudomembrane for-        associated with difficulty breathing.           above. Although there are several clin-        diagnoses can be excluded. Older chil-     lance support is poor.
 mation, which results in further com-      In more severe cases the child may              ical scoring systems these are only            dren should also be referred if they:
 promise of the airway.                     have evidence of respiratory distress,          useful as research tools and a basic           • Have tracheal, sternal or subcostal      Prognosis
    Several viruses have been implicated    with tachypnoea, tracheal tug and               classification (table 3), provides a sim-        indrawing at rest.                       Overall most children with croup
 in causing croup, but parainfluenza        chest wall retractions. Auscultation            pler guide to assessment and manage-           • Look toxic.                              have a mild illness that can be man-
 virus types 1 and 3 are responsible        usually reveals a clear chest, although         ment.                                          • Appear dehydrated, cyanosed or           aged at home, with fewer than 5%
 for about 80% of cases. Influenza          air entry may be reduced in more                                                                 exhausted.                               requiring admission to hospital. Of
 types A and B, RSV, adenovirus and         severe cases.                                   GP therapy                                        Children with milder symptoms           those admitted, only 1-2% need intu-
 metapneumovirus are responsible for           Symptoms tend to be worse at night           Formerly a popular treatment, steam            should also be referred if their family    bation, with a mortality rate for intu-
 most of the other cases.                   and may fluctuate in severity, typically        inhalation is not useful in the man-           circumstances make home care inap-         bated children of about 0.5%. Fortu-
                                            becoming more severe if the child               agement of croup and carries the risk          propriate or there is uncertainty about    nately, complications are rare in
 Signs and symptoms                         becomes upset. Croup typically lasts            of scalds. Antibiotics also have no role       the diagnosis (see table 4).               children with croup although second-
 Croup normally starts with the typical     for 2-3 days, but the cough can persist         in the treatment of croup. However,               If patients with recurrent croup have   ary bacterial infection can occur, lead-
 barking cough, which often comes on        for up to two weeks, typically becom-           sitting the child upright on their             residual symptoms of stridor or exer-      ing to pneumonia or tracheitis.

30   | Australian Doctor | 8 May 2009                                                     
INFLUENZA is a highly infec-                                                                 Signs and symptoms                  choalveolar lavage fluid.              When to refer
tious respiratory disease                                                                    Uncomplicated influenza                Rapid results are obtained          Patients who look unwell or
caused by the influenza                                                                      results in respiratory symp-        by directly detecting viral anti-      in whom the complications
viruses. Three subtypes cause                                                                toms including dry cough, sore      gens from these samples using          described above are suspected
disease in humans — influenza                                                                throat, rhinitis and otitis         the technique of reverse-tran-         should be referred to a paedia-
A, B and C — but only the                                                                    media, accompanied by sys-          scription PCR, which provides          trician or emergency depart-
first two cause clinically sig-                                                              temic symptoms including            a sensitive assay able to differ-      ment with facilities to care for
nificant disease. Influenza                                                                  fever, myalgia, headache,           entiate influenza A and B from         children. There should be a
infections are often more                                                                    malaise, fatigue, nausea and        other viruses.                         lower threshold for referral
severe than infections caused                                                                vomiting. These symptoms are                                               among patients with complex
by other respiratory viruses                                                                 typically of acute onset but can    GP therapy                             underlying medical conditions.
and cause constitutional as                                                                  be difficult to differentiate       The main treatments for
well as respiratory symptoms.                                                                from other respiratory infec-       influenza are symptomatic, in          Influenza vaccination
                                                                                             tions such as RSV.                  particular, maintaining fluids         This is really in the domain of
Epidemiology                                                                                    Influenza usually lasts for up   and encouraging rest. Antibi-          preventive therapy. For many
Outbreaks of influenza are                                                                   to a week, although the cough       otics have no role unless sec-         years there has been a stan-
unpredictable and occur in dis-                                                              and malaise can persist for 2-3     ondary bacterial infection is          dard recommendation for chil-
tinct patterns. Pandemics                                                                    weeks in some individuals.          suspected. In recent years             dren with complex medical
occur every 30-40 years and                                                                  Influenza virus may be respon-      antiviral therapy with                 conditions to receive influenza
are due to the emergence of a                                                                sible for most of the respira-      oseltamivir (Tamiflu) and              vaccination (see The Aus-
novel virus. Pandemics typi-                                                                 tory illness discussed in this      zanamivir (Relenza) have               tralian Immunisation Hand-
cally occur outside the usual       replicates. New influenza viri-                          article — bronchiolitis, bron-      become available.                      book 9th edition).
season and spread rapidly           ons are then shed into the res-                          chitis, croup and pneumonia.           The difficulty is picking              However, otherwise healthy
throughout the world. They          piratory secretions.                                        Complications of influenza       which children have influenza          children can benefit too. A
typically have high attack rates       During this process, inflam-                          can occur in patients with pre-     as the cause for their symp-           recent report from SA high-
in all age groups and result in     matory cytokines are pro-                                existing respiratory disease,       toms.                                  lighted that there were more
high rates of mortality, even in    duced, which are responsible                             but infection can also result in       A recent Cochrane review            hospitalisations from influenza
previously healthy young            for the systemic symptoms of                             secondary bacterial pneumo-         showed that oseltamivir                in the <2-year age group than
adults.                             influenza.                                               nia, cause febrile convulsions      reduced the median duration            in those over 65, and even in
   Epidemics occur much more           The pathogenesis and viru-                            and be associated with              of illness by 26% (36 hours) in        those over 85. After three
frequently, usually every 1-3       lence of the influenza virus                             encephalopathy, transverse          healthy children with labora-          deaths from influenza in 2007
years, and are associated with      depend on host factors such                              myelitis, myocarditis and           tory-confirmed influenza.              in WA in previously healthy
lower excess mortality. They        as immunocompetence, and                                 myositis in previously healthy         There were not enough               children, routine vaccination
occur as a result of antigenic      viral factors, including anti-                           children.                           data on ‘at-risk’ children (eg         for children aged between six
drift of the viruses, a process     genic variation, ability of viral                                                            chronic respiratory or cardiac         months and five years has
that results in the emergence       shedding to take place and                               Assessment and diagnosis            causes) to make a recommen-            been recommended in that
of new strains of virus caused      restriction of the cytopathic                            The influenza virus may be          dation although there is no            state.
by mutations within the virus       effect of the virus to allow con-                        isolated from cell culture and,     reason why a similar biological           Children can be immunised
antibody binding sites.             tinued replication to take                               while this remains the gold         response would not be antici-          with influenza vaccine from
                                    place.                                                   standard and is essential for       pated. Commencement of                 six months of age. Children
Pathogenesis                           The incubation period for                             monitoring circulating strains,     therapy within 48 hours of             under nine years need two
Influenza is spread from            influenza is usually 1-4 days.                           it is too slow to be useful as a    symptom onset is required.             doses at least one month apart
person to person via respira-       Children can be infectious for                           bedside test.                       There is some evidence that            the first time they receive the
tory droplets. The virus binds      several days before their symp-                             Suitable samples include         oseltamivir may be effective           vaccine (single doses are
to respiratory epithelial cells,    toms appear and can continue                             nasopharyngeal aspirates or         for prophylaxis if a household         required in subsequent years).
which are rich in receptors,        to shed the virus for more than                          swabs, throat swabs, sputum         contact has confirmed                  The principal contraindication
and enters the cell, where it       10 days.                                                 when available, or bron-            influenza.                             is allergy to eggs.

WHOOPING cough is an acute res-            Young infants do             whooping cough are paroxysms of            which include direct testing of            pregnancy should have adult per-
piratory tract infection first described                                cough followed by an inspiratory           nasopharyngeal swabs with nucleic          tussis-containing vaccine. Women
in the 1500s. Most cases are caused        not always have              whoop and/or vomiting. These               acid amplification testing (NAAT),         already pregnant can be vaccinated
by Bordetella pertussis, with B para-      the characteristic           symptoms are usually preceded by a         culture, PCR or direct immunofluo-         immediately after delivery.
pertussis responsible for about 5%                                      catarrhal phase lasting a week or two      rescent assays. An additional finding
of cases.                                  whoop and can                that resembles the common cold,            may be of a significant lymphocytosis      Treatment
                                           present with                 with coryza and a non-productive           although this is non-specific. Serol-      Antibiotics do not alter the clinical
Epidemiology                                                            cough. The paroxysmal phase lasts          ogy (B pertussis-specific IgA) is often    course of whooping cough but elim-
Whooping cough epidemics occur             apnoea even                  for several weeks, usually reaching        insensitive in the early stages of the     inate B pertussis from the nasophar-
every 2-5 years. There are 20-40 mil-      before the cough             its peak of severity in the first two      disease and particularly unreliable        ynx, rendering patients non-infec-
lion cases of whooping cough annu-                                      weeks before gradually improving           from infants.                              tious. The most effective antibiotic is
ally worldwide, 90% of which occur
                                           is recognised.               over the next 6-12 weeks.                                                             clarithromycin 7.5mg/kg (up to a
in low-income countries and result                                         Young infants do not always have        GP management                              maximum of 500mg) twice daily for
in an estimated 200,000-300,000                                         the characteristic whoop and can           Prevention                                 seven days.
fatalities a year.                                                      present with apnoea even before the        Vaccination remains the main pre-             For patients unable to tolerate
   Whooping cough is spread by res-                                     cough is recognised. Infants with          ventive measure for control of             macrolides, trimethoprim-sulfa-
piratory droplets and is highly conta-                                  pertussis may look well between            spread of this disease. The recom-         methoxazole is an alternative antibi-
gious. After exposure to an acute                                       paroxysms, without chest signs.            mended schedule for pertussis vac-         otic, given for seven days. The dose
case, 70-100% of unvaccinated                                           Petechial and/or subconjunctival           cination is at two, four, and six          is 20mg trimethoprim with 100mg
household contacts and 50-80% of                                        haemorrages may be evidence of the         months, and four years of age.             sulfamethoxazole per dose, twice
unvaccinated school contacts will                                       severity of the coughing paroxysms.        Infants are not protected until they       daily for children under six months
become infected. Infants under 12                                       Young infants are at greatest risk of      have had three doses. An adult per-        of age. This dose should be doubled
months are at highest risk of compli-                                   complications including en-                tussis booster vaccine (Boostrix) is       for older children.
cations and death.                                                      cephalopathy, pneumonia and feed-          given to adolescents who are in               A person who has been coughing
                                                                        ing problems.                              year 10 at secondary school.               for more than 21 days is no longer
Pathogenesis                                                                                                          Adults who have not been vacci-         infectious, and antibiotic treatment
Humans are the sole reservoir for                                       Assessment and diagnosis                   nated with pertussis-containing            is not indicated.
B pertussis and B parapertussis. B                                      Pertussis can be diagnosed clinically      vaccine for more than 10 years                Antibiotics should also be given
pertussis is a Gram-negative pleo-                                      in any patient with an acute cough         have waning immunity and may               to household contacts if the house-
morphic bacillus that spreads via                                       that has lasted for two weeks or           contract pertussis and pass it on.         hold includes an infant under 24
aerosolised droplets from coughing                                      more and which does not have               More than half of infants aged             months of age or a child of any age
of infected individuals. B pertussis                                    another explanation, especially if         under one year admitted to hospi-          who is not fully vaccinated. Antibi-
attaches to and damages ciliated res-                                   there is also a history of paroxysms,      tal with pertussis have an adult           otics should also be given to a con-
piratory epithelium.                                                    whoop or post-tussive vomiting.            family member with clinical or lab-        tact who is a pregnant woman
                                                                        Contact history is also helpful.           oratory-proven pertussis.                  during the last month of her preg-
Signs and symptoms                                                         The clinical diagnosis can be con-         Although not yet funded (but            nancy.
The characteristic symptoms of                                          firmed by specific diagnostic tests,       licensed for use) adults planning a                                cont’d next page

                                                                                                                                8 May 2009 | Australian Doctor |   31
 HOW TO TREAT Acute respiratory infections in children

 from previous page                            territories also have guidelines/legisla-   tions such as apnoea, poor feeding,         cardio-respiratory monitoring, fluid     patients with underlying cardiac,
 Exclusion from school or child care           tive requirements relating to exclusion     pneumonia or encephalopathy.                support and continuous oxygen            pulmonary, neuromuscular or neu-
 Children with whooping cough must             times for unimmunised children from            Older children or adolescents (who       therapy if there is hypoxia with         rological disease are at high risk for
 be excluded from school or child care         school or childcare, so GPs are advised     will not have been vaccinated for some      coughing.                                complications of pertussis (pneu-
 until five days after they start their        to contact their local public health unit   years) may simply present with a trou-        Investigations such as nasopha-        monia, seizures, encephalopathy,
 course of antibiotics. The Australian         for information regarding their own         blesome cough and at times the dif-         ryngeal PCR or culture are per-          death).
 Immunisation Handbook recom-                  state/territory requirements.               ferential diagnosis is unclear. Pertussis   formed but antibiotics are usually         The cough may persist for three
 mends that unimmunised close con-                                                         serology (pertussis-specific IgA) can       prescribed if the clinical suspicion     months (‘the 100-day cough’) and
 tacts should be excluded from child-          When to refer                               be helpful in these circumstances.          of pertussis is high.                    recrudesce with any subsequent res-
 care for 14 days from the date of last        Infants under 12 months with pertussis                                                                                           piratory infection, although rarely
 exposure or until five days after start-      should be assessed by a paediatrician,      Specialist management                       Prognosis                                enough to warrant readmission to
 ing a course of antibiotics. States and       as they are at highest risk of complica-    Specialist management involves              Infants born prematurely and             hospital.

 PNEUMONIA can be                                                                                                 Figure 2B. The same four-year-old child after 36 hours of intravenous penicillin. He is more
                                        Figure 2A. A chest X-ray of a four-year-old child who presented
 defined as inflammation and            with high fever, lethargy and cough. On examination there was             tachypnoiec with high fever. The air entry on the right is further reduced and the percussion note is
 consolidation of the lung              reduced air entry in the right lower zone with bronchial breath           stony dull. This suggests the pneumonia has become complicated by a pleural effusion or
 parenchyma, caused by an               sounds. The chest X-ray shows opacification in the right lower            empyema. The chest X-ray now shows more extensive opacification with mediastinal shift to the
 infectious organism. Most              lobe with some air bronchograms. Note: the right heart border             left and evidence of the effusion/empyema.
 cases of pneumonia in chil-            appears clear suggesting the infection is not in the middle lobe.
 dren are community acquired
                                                                                                                                                                                                        Heart shifted
 and occur in previously                                                                                                                                                                                to the left,
 healthy children. The diagno-                                                                                                                                                                          suggesting
 sis is clinical and does not                                                                                                                                                                           large volume
 require chest X-ray confirma-                                                                                                                                                                          of pleural
 tion.                                                                                                                                                                                                  fluid.

 Pneumonia is most common
 in younger children, with an
 annual incidence of 35-40
 cases per 1000 children under                                                                                     More extensive
 five years of age, which falls                                                                                    opacification
 to seven cases per 1000 in                                                                                        which may be
                                                                                                                   the pleural
 adolescents aged 12-15 years.
                                                                                                                   space fluid or
    The age of the child is                                                                                        more extensive
 important in determining the                                                                                      pneumonia.
 likely pathogen responsible.
 In neonates, group B strepto-
 coccus and Gram-negative
 enteric bacteria are the most
 common pathogens.
    Beyond the neonatal                 because the inflammatory            may present with abdominal              Blood cultures should be        Macrolide antibiotics may be        severe cases of pneumonia or
 period, viruses are by far the         process occurs predominantly        pain, particularly if the infec-     performed in children with         used as first-line treatment in     if the child is unable to
 most commonly implicated               within the alveoli (where           tion involves the lower lobes.       more severe disease who            children over five years, as        absorb oral antibiotics (eg,
 pathogens in children during           there are few cough recep-          The pain can be quite severe         require admission to hospital,     mycoplasma          infections      due to vomiting).
 the preschool years, with              tors) in the early stages of this   and is due to referred pain          although these prove positive      become more common in this             The first-line IV antibiotic
 RSV, parainfluenza, aden-              infection. Cough then               from the diaphragmatic               in fewer than 10% of cases.        age group.                          for an uncomplicated pneu-
 ovirus,                                becomes more prominent as           pleura. Older children may              Nasopharyngeal aspirates           An essential part of the         monia should be benzylpeni-
 rhinovirus, influenza and              inflammation spreads and            also complain of chest pain.         are useful for diagnosing viral    management of pneumonia in          cillin 30mg/kg six-hourly
 cytomegalovirus all potential          debris accumulates in the air-                                           infections, particularly in        children in the community is        (60mg/kg four-hourly if infec-
 causes in this age group.              ways.                               Assessment and diagnosis             younger children who require       the provision of information        tion is severe, but referral in
    In children over five years            Respiratory rate can be          Pneumonia can be diagnosed           admission to hospital.             to the child’s family to allow      these circumstances is
 of age, S pneumoniae is the            hard to count in healthy rest-      clinically in most cases,               The presence of bacteria in     them to manage fever, pre-          advised). Chest physiotherapy
 most common cause, with M              less children, but tachypnoea       although it is extremely diffi-      these samples cannot be used       vent dehydration and identify       is not beneficial and has no
 pneumoniae and Chlamydia               is an important sign in pneu-       cult to distinguish bacterial        to make a diagnosis, as they       signs of deterioration in the       place in the management of
 pneumoniae the next most               monia, as it is associated both     from viral causes on clinical        are commonly found as com-         child’s condition.                  pneumonia in children.
 frequent causative organisms.          with severity and with              grounds. Routine chest X-ray         mensals. In children with                                                 The development of respi-
                                        increased likelihood of under-      in children with uncompli-           pneumonia complicated by           When to refer                       ratory failure may necessitate
 Pathogenesis                           lying consolidation. Chest          cated lower respiratory tract        parapneumonic effusion,            If pulse oximetry is available,     transfer to the intensive care
 S pneumoniae is carried in             recession may be an accom-          infections is not necessary. A       pleural fluid should be            a key indication that the child     unit for ventilatory support.
 the nasopharynx in about               panying clinical feature.           chest X-ray is helpful if the        obtained if possible.              is likely to require admission      Parapneumonic effusions
 50% of healthy children                   Auscultation typically           diagnosis is in doubt, or the           This should be sent for bac-    to hospital is hypoxaemia,          may      require      surgical
 without causing symptoms.              reveals crackles and/or             child does not respond to            terial antigen detection as well   that is, an oxygen saturation       drainage.
 Various factors can lead to            bronchial           breathing.      therapy as expected, or com-         as microscopy and culture.         of <92%.
 invasive disease, such as the          Localised signs increase the        plications (such as parapneu-                                              Other indications include        Prognosis
 acquisition of a new serotype          chance of the infection being       monic effusion or empyema)           GP therapy                         tachypnoea (respiratory rate        Death from pneumonia is
 or concomitant viral infection         bacterial, while generalised        are suspected. Other investi-        It is difficult to differentiate   >70 breaths/minute in infants       rare in the developing world
 such as influenza, which               signs may be more typical of        gations, including FBC and           viral, mycoplasma and bac-         less than 12 months or >50          and the vast majority of chil-
 increases the attachment of            viral or mycoplasma infec-          acute-phase reactants, are also      terial causes of pneumonia by      breaths/minute in older chil-       dren recover completely.
 the streptococcus to the respi-        tion. However, these are not        unnecessary in most cases and        clinical examination. Added        dren) as well as poor feeding       Most children with a S pneu-
 ratory epithelium.                     particularly specific or sensi-     do not help distinguish              to this is concern regarding       or evidence of dehydration,         moniae infection respond
    The organisms reach the             tive findings.                      between viral and bacterial          the increasing incidence of        apnoea or grunting, or if the       within 24 hours; failure to do
 lower respiratory tract by                The presence of wheeze sug-      pathogens.                           antibiotic resistance. Thus,       family is unable to provide         so suggests more serious
 haematogenous seeding,                 gests either a viral or, particu-      Urine testing for the pres-       young children presenting          appropriate care.                   infection or development of
 although inhalation of infec-          larly in school-age children, a     ence of antigens is another          with mild symptoms of lower           Patients should be reviewed      complications such as parap-
 tious particles may be impli-          mycoplasma infection. The           unhelpful test, as their pres-       respiratory tract infection do     regularly within the first 48       neumonic effusion/empyema.
 cated. In the alveoli, the             classic mycoplasma prodrome         ence is not specific for pneu-       not require antibiotics.           hours of illness, as failure to       Other complications can
 organisms multiply and                 is high fever and headaches         monia. However, culture of a            In more severe cases, if        improve, or deterioration,          occur, such as lung abscess
 spread from alveolus to alve-          before the cough appears, but       clean-catch sample of urine          antibiotics are prescribed,        within this time frame is an        and metastatic infections,
 olus via the pores of Kohn.            almost any presentation could       should be performed in a             amoxycillin (10-25mg/kg            indication for review by a          including osteomyelitis and
                                        also be mycoplasma. It is gen-      febrile child if the infective       eight-hourly) should be the        paediatrician.                      septic arthritis.
 Signs and symptoms                     erally stated that mycoplasma       cause is unknown, to exclude         first choice, as it is effective                                         Children with no pre-exist-
 Pneumonia frequently starts            is more common in the               the possibility of an underly-       against the most common            Specialist management               ing conditions who follow a
 with a high fever accompa-             school-age group (compared          ing UTI.                             pathogens, is well tolerated       Oxygen is provided if the           standard course with rapid
 nied by tachypnoea. Cough              with preschoolers/infants),            Serology      (IgM)      for      and cheap.                         child is hypoxic. Antibiotics       resolution of symptoms do
 is often absent initially, partic-     although this assertion is being    mycoplasma has little role in           Alternatives to amoxycillin     are given if this has not been      not need a progress chest X-
 ularly when the infection is           questioned.                         the GP setting because of the        include roxithromycin (2.5-        done previously, and may be         ray if one was taken initially.
 due to S pneumoniae. This is              Children with pneumonia          delay in receiving results.          4mg/kg            12-hourly).      administered intravenously in                        cont’d page 34

32   | Australian Doctor | 8 May 2009                                                  
 HOW TO TREAT Acute respiratory infections in children

     GP’s contribution
                                          review in four days was                                                 focal chest signs and a clini-           warrant antibiotic treatment.
                                          arranged.                                                               cally severe infection?
                                             He returned in three days,                                              No. The appropriate strat-            We are currently seeing many
                                          at which time he was still                                              egy was employed — starting              cases of pertussis in the school-
                                          febrile and coughing. On                                                with a simple antibiotic                 age population. Should we be
                                          examination his temperature                                             (amoxycillin) in this age group.         offering antibiotic treatment to          References
                                          was 38.0°C, pulse 120                                                   The development of focal signs           classmates who have been in               1. Smith SM, Schroeder K,
                                          beats/minute and respiratory                                            would warrant a chest X-ray if           close contact with a patient              Fahey T. Over-the-counter
                                          rate 40 breaths/minute. He                                              the child was not improving.             with pertussis?                           medications for acute cough
          DR GED FOLEY                                                                                                                                                                               in children and adults in
            Mosman, NSW                   was once more found to have         air. He had intercostal reces-      Atypical organisms and viral                Data on contact prophylaxis            ambulatory settings.
                                          scattered expiratory wheeze,        sions and the focal signs at the    infections may cause localised           are scarce, and defining close            Cochrane Database of
 Case study                               although now he had some            right base were more marked.        disease but I would be covering          contact can be problematic.               Systematic Reviews 2008,
 JS, 18 months, presented with            focal signs at the right mid-       He was referred to the emer-        for bacterial infection if signs         The principles as outlined in             Issue 1. Art. No.:
                                                                                                                                                                                                     CD001831. DOI:
 a history of an URTI four                zone and base, with localised       gency department.                   were localised.                          the ninth immunisation hand-              10.1002/14651858.CD0018
 weeks before, followed by an             inspiratory crackles and               JS was an inpatient for only                                              book are to protect young chil-           31.pub3.
 intermittent cough. Over the             slightly reduced air entry.         two days and was treated with       Previous studies have suggested          dren (<24 months) who have                2. Matheson NJ, Harnden A,
 preceding two days the cough                The possibility of an atypi-     oxygen and roxithromycin.           that young children with puru-           not been immunised com-                   Perera R, Sheikh A,
 had become worse and was                 cal infection was considered        Subsequent sero-logy indicated      lent rhinorrhoea, fever and a            pletely (this would include all           Symmonds-Abrahams M.
                                                                                                                                                                                                     Neuraminidase inhibitors for
 associated with fever, malaise,          and erythromycin was added.         infection with Chlamydia            chesty cough have focal areas            infants under six months, none            preventing and treating
 rapid breathing and poor                 He was also given inhaled           pneumoniae. His cough per-          of pulmonary infection that are          of whom have had three doses              influenza in children.
 appetite. There was no rele-             salbutamol via a spacing            sisted for many weeks, and six      not apparent on examination.             of DTPa).                                 Cochrane Database of
 vant past or family history.             device and second-daily review      months later he still has some      Should we be initiating antibi-             If any contacts come from              Systematic Reviews 2007,
                                                                                                                                                                                                     Issue 1. Art. No.:
    On examination, JS was                was organised.                      mild shadowing in the right         otic treatment in such children?         such a household or include a             CD002744. DOI:
 febrile with a temperature of               Initially JS improved on this    middle lobe on chest X-ray             No. This constellation of             woman in her last month of                10.1002/14651858.CD0027
 38.5°C and his respiratory rate          regimen and was more settled        (being monitored by the paedi-      features is most likely viral in         pregnancy (if she delivers, the           44.pub2.
 was 48 breaths/minute. ENT               after two days. However, at         atric team).                        origin. If the child looks sys-          baby could be at risk of per-             3. National Health and
 examination was normal. Res-             further review (seven days                                              temically well and there are no          tussis) the contact should                Medical Research Council.
                                                                                                                                                                                                     The Australian
 piratory examination revealed            after initial presentation), he     Questions for the author            pulmonary signs, there is no             receive antibiotic prophylaxis. I         Immunisation Handbook 9th
 scattered expiratory wheeze              had deteriorated again. He          Is there a case for initiating      need to start antibiotics.               would also offer prophylaxis              Edition 2008:
 and scattered crackles. JS was           was febrile with a temperature      amoxycillin treatment together         Persistent symptoms, and              (and immunisation) to contacts  
 prescribed amoxycillin and               of 37.9°C, tachypnoeic and O2       with a macrolide antibiotic         particularly tachypnoea and              who have not been immu-                   immunise/publishing.nsf/
 supportive measures and a                saturation was 94% on room          when a child presents with          chest signs, are likely to               nised.

                                 How to Treat Quiz                                                                Complete this quiz online and fill in the GP evaluation form to earn 2 CPD or PDP points. We no longer accept quizzes
                                                                                                                  by post or fax.
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                                  Acute respiratory infections in children
                                                                                                                   ONLINE ONLY
                                  — 8 May 2009                                                            for immediate feedback
 1. Jared, six months, presents with a two-                    times in most patients                                bronchiolitis, bronchitis, croup and                         contacts of those with whooping cough if the
 day history of a fever and cough, preceded                 d) Recurrent episodes of bronchitis are                  pneumonia                                                    household includes an infant under 24
 by a runny nose for a few days. On                            uncommon                                           c) Detection of the influenza virus by culture is               months of age
 examination he is tachypnoeic with chest                                                                            essential for monitoring strains but too slow to          d) Adults who received the full course of
 wall recessions and widespread crackles                    4. Which TWO statements about croup are                  be a useful bedside test                                     recommended vaccinations in childhood have
 and wheeze. Your provisional diagnosis is                  correct?                                              d) Children under nine years need two doses at                  lifelong immunity to pertussis
 bronchiolitis. Which TWO features would be                 a) Stridor at rest indicates airway narrowing of at      least one month apart the first time they
 suggestive of severe infection?                               least 30%                                             receive influenza vaccine                                 9. Which TWO statements about causes and
 a) Fluid intake <50% of normal in the                      b) Key features of severe croup include drooling                                                                   presentation of pneumonia in children are
    preceding 24 hours                                         and a toxic appearance                             7. Which TWO statements about clinical                       correct?
 b) Respiratory rate of 40 breaths per minute               c) All children under 12 months with symptoms         features and diagnosis of pertussis infection                a) Streptococcus pneumoniae is the most
 c) Lethargy                                                   of croup should be referred for a paediatric       are correct?                                                    common cause of pneumonia in preschool-
 d) Oxygen saturation of 95%                                   assessment                                         a) Whooping cough is not highly infectious, with                aged children
                                                            d) Features of severe croup may include                  only about 30% of unvaccinated household                  b) Cough is frequently the first symptom in
 2. Which TWO statements about                                  lethargy or restlessness                             contacts becoming infected after exposure                    children with pneumonia, particularly when
 bronchiolitis are correct?                                                                                       b) The characteristic paroxysmal phase of                       the infection is due to S pneumoniae
 a) Bronchiolitis is best diagnosed by chest X-ray          5. Tania, two years, presents with a hoarse              whooping cough is usually preceded by a 1-                c) Tachypnoea is associated with increased
 b) Treatment of bronchiolitis in hospitalised              voice, barking cough and stridor, which                  2-week catarrhal phase                                       severity of pneumonia and increased
    infants is largely supportive with                      came on overnight. Which TWO statements               c) Young infants with pertussis infection can                   likelihood of underlying consolidation
    supplemental oxygen and fluid replacement               about the management of croup are                        present with apnoea even before the cough is              d) Children with pneumonia may present with
 c) Bronchodilators are a useful additional                 correct?                                                 recognised                                                   abdominal pain
    therapy in infants under 12 months of age               a) Steam inhalation is useful in the                  d) Bordetella pertussis-specific IgA serology is
 d) About 10% of children develop a post-                      management of mild croup                              the gold standard test for diagnosis in the               10. Which TWO statements about diagnosing
    bronchiolitic syndrome with cough and                   b) Oral corticosteroids should be prescribed             early stages of the disease, especially in                and managing pneumonia in children are
    wheeze that can recur intermittently for                   for all but the mildest cases of croup                infants                                                   correct?
    several years                                           c) Children with more severe croup may                                                                             a) All children with a clinical diagnosis of
                                                               require nebulised adrenaline                       8. Which TWO statements about managing                          pneumonia require X-ray confirmation of the
 3. Which TWO statements about bronchitis                   d) There is no role for nebulised budesonide in       and preventing pertussis infection are                          diagnosis
 in children are correct?                                      the management of croup                            correct?                                                     b) An FBC will help to distinguish between viral
 a) Most cases of acute bronchitis are due to                                                                     a) Antibiotics will reduce the severity and risk of             and bacterial causes of pneumonia
    viruses                                                 6. Which THREE statements about influenza                complications of whooping cough                           c) If oral antibiotics are prescribed, amoxycillin is
 b) Antitussives and expectorants are useful for            in children are correct?                              b) A person with whooping cough who has been                    generally the first choice in children under five
    symptomatic relief of bronchitis in children            a) Children with influenza are not infectious            coughing for more than 21 days is no longer                  years
 c) Antibiotics will relieve symptoms of                       before their symptoms appear                          infectious                                                d) Macrolide antibiotics may be used as first-line
    bronchitis and result in shorter recovery               b) Influenza virus may be responsible for             c) Antibiotics should be given to household                     treatment in children over five years

 The RACGP now requires that a brief GP evaluation form be completed with every quiz to obtain category 2 CPD or PDP points for the 2008-10 triennium. You
 can complete this online along with the quiz at Because this is a requirement, we are no longer able to accept the quiz by post                 HOW TO TREAT Editor: Dr Wendy Morgan
 or fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online.                                       Co-ordinator: Julian McAllan
                                                                                                                                                                              Quiz: Dr Wendy Morgan

     NEXT WEEK Excessive daytime sleepiness is a common symptom in general practice.The next How to Treat focuses on the primary brain disorders that can cause excessive daytime sleepiness (especially
     narcolepsy and idiopathic hypersomnia). The authors are Dr Anup Desai, senior staff specialist, department of respiratory and sleep medicine, Prince of Wales Hospital, Randwick; consultant physician in
     private practice, Camperdown (Brain and Mind Research Institute) and Randwick; and clinical senior lecturer, faculty of medicine, University of Sydney; and Dr Ben Kwan, respiratory advanced trainee regis-
     trar, Prince of Wales Hospital, Randwick, NSW.

34     | Australian Doctor | 8 May 2009