RESPIRATORY TRACT INFECTIONS (RTIs)

EPIDEMIOLOGY:

More than half of the world’s annual new childhood pneumonia cases are concentrated in just five countries where 44% of the world’s children aged less than 5 years live: India (43 million), China (21 million) and Pakistan (10 million) and in Bangladesh, Indonesia and Nigeria (6 million each).⁽¹⁾

Even more striking is the fact that, according to the official estimates from WHO for the year 2000, two-thirds of all these deaths are concentrated in just 10 countries:⁽²⁾ India (408 000 deaths), Nigeria (204 000), the Democratic Republic of the Congo (126 000), Ethiopia (112 000), Pakistan (91 000), Afghanistan (87 000), China (74 000), Bangladesh (50 000), Angola (47 000) and Niger.

The Reviews of Infectious Disease monograph summarizes⁽³⁾ the findings of the Bureau of Science and Technology in Development (BOSTID) epidemiologic studies in 12 developing countries (including Pakistan) between 1983 and 1988:

• Upper Respiratory Infections (URI) incidence rate: Overall 6-8 episodes / year; children experienced URI symptoms on the average for 22-40% of a calendar year; but 5-20% of children had no episodes at all.
• Lower Respiratory Infections (LRI) incidence rate: 0.2- 4 episodes / year; children spent 0.3- 14% of the time with LRI symptoms.
• The case fatality ratio (CFR) of LRI was 3-16% (30 + times greater than in developed countries); the highest being in infants and girls.

PATHOPHYSIOLOGY:

URIs involve direct invasion of the mucosa lining the upper airway. Inoculation of bacteria or viruses occurs when a person’s hand comes in contact with pathogens and the person then touches the nose or mouth or when a person directly inhales respiratory droplets from an infected person who is coughing or sneezing.

After inoculation, viruses and bacteria encounter several barriers, including physical, mechanical, humoral, and cellular immune defenses. Physical and mechanical barriers include the following:

• Hair lining the nose filters and traps some pathogens
• Mucus coats much of the upper respiratory tract, trapping potential invaders
• The angle resulting from the junction of the posterior nose to the pharynx causes large particles to impinge on the back of the throat
• Ciliated cells lower in the respiratory tract trap and transport pathogens up to the pharynx; from there they are swallowed into the stomach

Adenoids and tonsils contain immune cells that respond to pathogens. Humoral immunity (immunoglobulin A) and cellular immunity act to reduce infections throughout the entire respiratory tract. Resident and recruited macrophages, monocytes, neutrophils, and eosinophils coordinate to engulf and destroy invaders.

A host of inflammatory cytokines mediates the immune response to invading pathogens. Normal nasopharyngeal flora, including various staphylococcal and streptococcal species, help to defend against potential pathogens. Patients with suboptimal humoral and phagocytic immune function are at increased risk for contracting a URI, and they are at increased risk for a severe or prolonged course of disease.

Inflammation (chronic or acute) from allergy predisposes to URI. Children with allergy are particularly subject to frequent URIs.

INFECTION: Person-to-person spread of viruses accounts for most URIs. Household and child care settings can serve as reservoirs for infection. Bacterial infections may develop de novo or as a superinfection of a viral URI.

Viral agents occurring in URIs include a vast number of serotypes, which undergo frequent changes in antigenicity, posing challenges to immune defense. Pathogens resist destruction by a variety of mechanisms, including the production of toxins, proteases, and bacterial adherence factors, as well as the formation of capsules that resist phagocytosis.

Incubation times before the appearance of symptoms vary among pathogens. Rhinoviruses and group A streptococci may incubate for 1-5 days, influenza and parainfluenza may incubate for 1-4 days, and respiratory syncytial virus (RSV) may incubate for a week. Pertussis typically incubates for 7-10 days, or even as long as 21 days, before causing symptoms. Diphtheria incubates for 1-10 days. The incubation period of Epstein-Barr virus (EBV) is 4-6 weeks.

Most symptoms of URIs—including local swelling, erythema, edema, secretions, and fever, result from the inflammatory response of the immune system to invading pathogens and from toxins produced by pathogens.

An initial nasopharyngeal infection may spread to adjacent structures, resulting in the following:

• Sinusitis
• Otitis media
• Epiglottitis
• Laryngitis
• Tracheobronchitis
• Pneumonia

Inflammatory narrowing at the level of the epiglottis and larynx may result in a dangerous compromise of airflow, especially in children, in whom a small reduction in the luminal diameter of the subglottic larynx and trachea may be critical. Beyond childhood, laryngotracheal inflammation may also pose serious threats to individuals with congenital or acquired subglottic stenosis.

SUSCEPTIBILITY: Genetic susceptibility is involved in determining which patients have more severe disease courses than others. There are some recognized candidate gene polymorphisms with known functional changes in genes that may lead to immunosuppression.⁽⁵⁾ It has also been shown that host immunogenetic variation plays a role in the immune response to H1N1 and H5N1 viruses, thereby influencing disease severity and outcome in influenza caused by these viruses.^(6,7)

TRANSMISSION:

RTIs are spread through one or more of three main routes.

DROPLET TRANSMISSION: Droplets greater than five microns in size may be generated from the respiratory tract during coughing, sneezing or talking. If droplets from an infected person come into contact with the mucous membranes (mouth or nose) or surface of the eye of a recipient, they can transmit infection. These droplets remain in the air for a short period and travel one to two metres, so physical closeness is required for transmission.

AIRBORNE TRANSMISSION: Aerosol generating procedures (AGP) are considered to have a greater likelihood of producing aerosols compared to coughing for instance. Aerosols are smaller than the droplets described above and can remain in the air for longer and, therefore, potentially transmit infection by mucous membrane contact or inhalation. Infection control precautions to minimise transmission of acute respiratory tract infections in healthcare settings

CONTACT TRANSMISSION: Contact transmission may be direct or indirect. Infectious agents can be inadvertently passed directly from an infected person (for example after coughing into their hands) to a recipient who, in the absence of correct hand hygiene, may then transfer the organism to the mucous membranes of their mouth, nose or eyes. Indirect contact transmission takes place when a recipient has contact with a contaminated object, such as furniture or equipment that an infected person may have coughed or sneezed on. In the absence of correct hand hygiene, the recipient may transfer organisms from the contaminated object to the mucous membranes of their mouth, nose or eyes.

SIGN AND SYMPTOMS:

When viruses invade cells of the respiratory tract, they trigger inflammation and production of mucus. This situation leads to:

• Nasal congestion,
• A runny nose,
• Scratchy throat, and
• Cough

Symptoms may last up to 14 days. Some children may continue to cough for weeks after the URI has resolved. Fever, with a temperature as high as 101 to 102° F (about 38.3 to 38.9° C), is common in young children or those with influenza. The child's temperature may even rise to 104° F (40° C).

Other typical symptoms in children include

• Decreased appetite,
• Lethargy,
• A general feeling of illness (malaise),
• Headaches and body aches develop, particularly with influenza.

Infants and young children are usually not able to communicate their specific symptoms and just appear cranky and uncomfortable.

COMPLICATIONS OF VIRAL RESPIRATORY TRACT INFECTIONS:

Because newborns and young infants prefer to breathe through their nose, even moderate nasal congestion can create difficulty breathing. Nasal congestion leads to feeding problems as well, because infants cannot breathe while suckling from the breast or bottle. Because infants are unable to spit out mucus that they cough up, they often gag and choke.

The small airways of young children can be significantly narrowed by inflammation and mucus, making breathing difficult. Children breathe rapidly and may develop a high-pitched noise heard on breathing out (wheezing) or a similar noise heard on breathing in (stridor). Severe airway narrowing may cause children to gasp for breath and turn blue (cyanosis). Such airway problems are most common with infection caused by parainfluenza viruses, Respiratory syncytial virus (RSV), and human metapneumovirus infection. Affected children need to be seen urgently by a doctor.

Some children with a viral respiratory tract infection also develop an infection of the middle ear (otitis media) or the lung tissue (pneumonia). Otitis media and pneumonia may be caused by the virus itself or by a bacterial infection that develops because the inflammation caused by the virus makes tissue more susceptible to invasion by other germs. In children with asthma,respiratory tract infections often lead to an asthma attack.

DIAGNOSTIC TESTS:

COMMON COLD:

The diagnosis of the common cold is made clinically, based upon history and examination findings, including exposure to someone with a cold, nasal congestion, nasal discharge, sore throat, fever (in young children), anterior cervical adenopathy, and erythema of nasal mucosa and oropharynx.⁽⁸⁾ Laboratory tests are not helpful in making the diagnosis.

Chest radiography may be warranted in children with focal findings on lung examination, relentlessly progressive cough, hemoptysis, or features of an undiagnosed chronic respiratory disorder.⁽⁹⁾

Laboratory testing can identify the viral pathogen if it is necessary to do so.⁽¹⁰⁾

PHARYNGITIS AND TONSILITIS:

RAPID TESTING AND THROAT CULTURE: A throat culture remains the standard for diagnosis, though results can take as long as 48 hours. Throat culture results are highly sensitive and specific for group A beta-hemolytic streptococci (GABHS).

Rapid screening followed by culture has become the standard in most institutions, especially in developed countries. This approach potentially minimizes unnecessary antibiotic administration by helping limit antibiotic use to cases with positive rapid screen findings or those with subsequent positive culture findings.⁽¹¹⁾

TESTING FOR VIRAL CAUSES: If Epstein-Barr virus (EBV) is considered, obtain a complete blood count (CBC) to detect atypical cells in the white blood cell (WBC) differential, along with a Monospot test (or another rapid heterophile antibody test).

RADIOGRAPHY: Imaging studies are usually not necessary unless a retropharyngeal, parapharyngeal, or peritonsillar abscess is suspected. In such cases, a plain lateral neck film can be used as an initial screening tool.
A rapid antigen detection test (RADT), also known as the rapid streptococcal test, detects the presence of GABHS cell wall carbohydrate from swabbed material and is considered less sensitive than throat cultures; however, the test has a specificity of 95% or more and produces a result in significantly less time than that required for throat cultures. A negative RADT requires that a throat culture be obtained before excluding GABHS infection.

OTITIS MEDIA (OM):

LABORATORY STUDIES: Laboratory evaluation is usually unnecessary, although many experts recommend a full sepsis workup in infants younger than 12 weeks who present with fever and associated acute otitis media (AOM).

IMAGING STUDIES: Imaging studies are not indicated in patients with OM unless intratemporal or intracranial complications are suspected.
When an OM complication is suspected, the imaging study of choice is contrast-enhanced computed tomography (CT) of the temporal bones.

MAGNETIC RESONANCE IMAGING: (MRI) is more helpful in depicting fluid collections, especially small middle ear collections. MRI is usually performed after CT if further information is needed for definitive diagnosis.

TYMPANOCENTESIS: In clinical trials, the criterion standard in the diagnosis of AOM is tympanocentesis to determine the presence of middle ear fluid, followed by culture of the fluid to identify causative pathogens. Because of the expense, effort, and lack of availability, no consensus guidelines call for routine use of tympanocentesis to manage AOM and OM with effusion (OME).

OTHER TESTS: Tympanometry may help with diagnosis in patients who OME. Some practitioners also use acoustic reflectometry to evaluate for middle ear effusion (MEE) in patients with OM.

SINUSITIS:

LABORATORY STUDIES: Laboratory tests are normally not particularly helpful in making the diagnosis of sinusitis. However, they can be essential in determining whether associated conditions such as allergic rhinitis, cystic fibrosis, or immunodeficiency are present.

IMAGING STUDIES:

CT SCANNING: CT scanning is the criterion standard for evaluation of both mucosal inflammation and anatomic abnormalities in the paranasal sinuses. CT scanning provides a reliable picture of the ostiomeatal complex in a noninvasive fashion.

PLAIN RADIOGRAPHY / SINUS SERIES: These studies have a poor correlation with CT scanning; as many as 75% of them either underestimate or overestimate disease. Plain radiography is a fairly inaccurate screening method even for maxillary sinus disease.

MRI: MRI is useful when intracranial complications are suggested or when allergic fungal sinusitis is suggested.

ULTRASONOGRAPHY: Ultrasonography can be used to evaluate the maxillary sinuses, but results have been somewhat inconsistent, that is why it is not recommended.

RIGID OR FLEXIBLE NASAL ENDOSCOPY: Nasal endoscopy provides an excellent view of the osteomeatal complex (OMC).

MAXILLARY SINUS PUNCTURE: This test is the criterion standard for obtaining maxillary sinus cultures.

MIDDLE MEATAL SWAB: Cultures taken from the middle meatus or anterior middle turbinate have good (>80%) correlation with cultures taken from ipsilateral maxillary or ethmoid sinuses.

LARYNGOTRACHEITIS (CROUP):

LABORATORY TEST: Laboratory test results rarely contribute to confirm diagnosis. The complete blood cell (CBC) count is usually nonspecific, although the white blood cell (WBC) count and differential may suggest a viral etiology with lymphocytosis.

PULSE OXIMETRY: readings are within the normal reference range for most patients; however, this monitoring is helpful to assess for the need for supplemental oxygen support and to monitor for worsening respiratory compromise as evident with tachypnea and poor maintenance of oxygen saturations.

ARTERIAL BLOOD GAS (ABG): measurements are unnecessary and do not reveal hypoxia or hypercarbia, unless respiratory fatigue ensues.

LARYNGOSCOPY: is indicated only in unusual circumstances (e.g. the course of illness is not typical; the child has symptoms that suggest an underlying anatomic or congenital disorder). This procedure may also be required for those patients with bacterial tracheitis to obtain the necessary cultures, in an attempt to properly tailor antibiotic treatment.

RADIOGRAPHY: Plain films can verify a presumptive diagnosis or exclude other disorders causing stridor and hence, mimic croup. Most importantly, croup is a clinical diagnosis. Radiographs can be used as a tool to help confirm this diagnosis, but are not required in uncomplicated cases.⁽¹²⁾

EPIGLOTTITIS:

BLOOD AND EPIGLOTTIS CULTURES: Blood cultures and culture of the epiglottis should be performed only after the airway is secured. Blood cultures may show Haemophilus influenzae type b (Hib) between 12-15% and 90% of cases. Cultures of the surface of the epiglottis obtained during endotracheal intubation are positive in 50-75% of cases.⁽¹³⁾

RADIOGRAPHY: If epiglottitis is seriously considered, no imaging studies are required. In less-clear cases, imaging studies are occasionally helpful in establishing the diagnosis or excluding epiglottitis.

LATERAL NECK RADIOGRAPHY: Never obtain a lateral neck radiograph before achieving definitive airway control. If radiography is required, the safest procedure is to perform portable radiography at the bedside.

CHEST RADIOGRAPHY: Chest radiography may reveal concomitant pneumonia in as many as 15% of patients. Postintubation chest radiographs occasionally show pulmonary edema.

FIBEROPTIC LARYNGOSCOPY: Laryngoscopy can help exclude other diagnoses in an older child who is cooperative. However, do not perform a laryngoscopy if the procedure might increase anxiety, which can exacerbate the airway obstruction.

PERCUTANEOUS TRANSTRACHEAL VENTILATION: Also termed needle cricothyrotomy or translaryngeal ventilation, percutaneous transtracheal ventilation is a temporizing method used to treat cases of severe epiglottitis when the patient cannot be intubated before a formal tracheostomy.

BRONCHITIS:

TESTING IN HOSPITALIZED CHILDREN: For hospitalized children, serum C-reactive protein screen, respiratory culture, rapid diagnostic studies, and serum cold agglutinin testing (at the appropriate age) help to classify whether the infection is caused by bacteria, atypical pathogens (e.g. Chlamydia pneumoniae, Mycoplasma pneumoniae), or viruses. Obtain a blood or sputum culture if antibiotic therapy is under consideration.

ASTHMA TESTING: A clinical response to daily high-dose oral corticosteroids may be considered as a diagnostic and therapeutic trial to confirm asthma. Evidence of reversible airflow obstruction revealed by pulmonary function testing confirms the diagnosis of asthma.

CYSTIC FIBROSIS TESTING: Many states are now using tests for immunoreactive trypsinogen (IRT) coupled with cystic fibrosis transmembrane receptor (CFTR) mutational analyses in newborn screening programs. In newborns with positive results, sweat testing is required to diagnose or rule out cystic fibrosis.

IMMUNODEFICIENCY TESTING: For children in whom immunodeficiency is suspected, measurement of total serum immunoglobulins, immunoglobulin G (IgG) subclasses, and specific antibody production is recommended to establish the diagnosis.

CHEST RADIOGRAPHY: Chest radiography is typically not warranted but, if obtained, appears normal in most patients with uncomplicated bronchitis.

PULMONARY FUNCTION TESTING: Pulmonary function tests may show airflow obstruction that is reversible with bronchodilators. Bronchial challenge, such as with exercise or with histamine or methacholine exposure, may demonstrate the airway hyperreactivity characteristic of asthma.

BRONCHIOLITIS:

Diagnosis of bronchiolitis is suspected by history, examination, and occurrence of the illness as part of an epidemic.

Patients suspected of having bronchiolitis should undergo pulse oximetry to evaluate oxygenation. No further testing is required for mild cases with normal oxygen levels, but in cases of hypoxemia and severe respiratory distress, a chest x-ray supports the diagnosis and typically shows hyperinflated lungs, depressed diaphragm, and prominent hilar markings.

RSV rapid antigen testing done on nasal washings or nasal aspirates is diagnostic but not generally necessary; it may be reserved for patients with illness severe enough to require hospitalization.

PNEUMONIA:

COMPLETE BLOOD CELL COUNT (CBC): For hospitalized patients, laboratory testing can be helpful to document and trend improvement or worsening over time. Testing should include a CBC count with differential and evaluation of acute-phase reactants (ESR, CRP, or both) and sedimentation rate. The total white blood cell (WBC) count and differential may aid in determining if an infection is bacterial or viral, and, together with clinical symptoms, chest radiography, and ESR can be useful in monitoring the course of pneumonia. In cases of pneumococcal pneumonia, the WBC count is often elevated.

SPUTUM GRAM STAIN AND CULTURE: Sputum is rarely produced in children younger than 10 years, and samples are always contaminated by oral flora. In the cooperative older child with a productive cough, a sputum Gram stain may be obtained; however, very few children are able to cooperate with such a test. In situations in which a microbiologic diagnosis is essential, endotracheal cultures and / or bronchoalveolar lavage culture can be sent for the isolation of offending pathogens. Routine cultures for respiratory pathogens should be requested.

BLOOD CULTURE: In general, blood culture results are positive in less than 5% of patients with pneumococcal pneumonia. The percentage is even less in patients with Staphylococcus infection. However, a blood culture is still recommended in complicated cases of pneumonia. It may be the only way to identify the pathogen and its antimicrobial susceptibility patterns.

INFLAMMATORY MARKERS: Quantitative measurements of CRP, procalcitonin, cytokines (e.g. interleukin [IL]-6), inter-alpha inhibitor proteins (IaIp),⁽¹⁴⁾ and batteries of acute-phase reactants have been touted to be more specific but are limited by suboptimal positive predictive value.

POLYMERASE CHAIN REACTION: PCR is more sensitive than antigen assays, and for some viruses (e.g. hMPV), this study may be the only test available. PCR is noninvasive, an advantage over lung aspirate or bronchoalveolar lavage (BAL) cultures. PCR testing for TB is also widely available and is helpful in early identification of TB from other mycobacteria in acid-fast cultures.

SKIN TESTING: These tests are used in diagnosing TB. Mantoux skin test (intradermal [ID] inoculation of 5 tuberculin units [TU] of purified protein derivative [PPD]) results should be read 48-72 hours after placement.

GASTRIC ASPIRATES: In a child with suspected pulmonary TB, the cough may be scarce or nonproductive. Therefore, the best test for diagnosis is an early-morning gastric aspirate sent for acid-fast bacilli (AFB) stain, culture, and, if available, PCR.

COLD AGGLUTININ TESTING: In the young child or school-aged child with pneumonia, particularly the patient with a gradual onset of symptoms and a prodrome consisting of headache and abdominal symptoms, a bedside cold agglutinins test may help confirm the clinical suspicion of mycoplasmal infection.

URINE LATEX AGGLUTINATION TESTING: Although antigen detection assays for S pneumoniae lack a high specificity in children, Neuman and Harper observed that 76% of febrile children with a lobar infiltrate on chest radiograph had a positive rapid urine antigen assay.⁽¹⁵⁾

CHEST RADIOGRAPHY: Chest radiography is indicated primarily in children with complications such as pleural effusions and in those in whom antibiotic treatment fails to elicit a response. Computed tomography (CT) scanning of the chest and ultrasonography are indicated in children with complications such as pleural effusions and in those in whom antibiotic treatment fails to elicit a response.

BRONCHOSCOPY: Flexible fiberoptic bronchoscopy is occasionally useful to obtain lower airway secretions for culture or cytology. This procedure is most useful in immunocompromised patients who are believed to be infected with unusual organisms (Pneumocystis, other fungi) or in patients who are severely ill.

BRONCHOSCOPIC ALVEOLAR LAVAGE: Quantitative culture techniques, such as bronchoscopic alveolar lavage have been assessed in non-neonatal populations and reportedly offer a specificity of more than 80%, depending on the threshold selected (values from >100-100,000 colony-forming units [CFU]/mL have been used).^(16,17)

PROTECTED BRUSH TRACHEAL ASPIRATE SAMPLING: Nondirected specimens have been obtained through endotracheal tubes 3 mm or greater in internal diameter and intuitively appear to offer decreased probability of contamination.

LUNG ASPIRATION: Lung aspiration is underused and is a significantly more efficient method of obtaining a culture. If a prominent infiltrate can be adequately localized in multiple planes, direct aspiration of the infected lung may be performed for culture or biopsy. Lung CT scanning may facilitate such localization.

LUNG PUNCTURE: Although used much less frequently than in previous decades, diagnostic lung puncture may still be useful in circumstances in which pleural and subpleural lung surfaces are visibly involved and can be well localized.

THORACENTESIS: This procedure is performed for diagnostic and therapeutic purposes in children with pleural effusions (e.g. when pleural fluid is impinging on lung or cardiac function).

THERAPY CONSIDERATION

An immediate antibiotic prescription and / or further appropriate investigation and management should only be offered to patients (both adults and children) in the following situations:

• If the patient is systemically very unwell
• If the patient has symptoms and signs suggestive of serious illness and / or complications (particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital and intracranial complications)
• If the patient is at high risk of serious complications because of pre-existing comorbidity. This includes patients with significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis, and young children who were born prematurely

TREATMENT OPTIONS:

COMMON COLD:

SUPPORTIVE CARE: One or a combination of the following interventions is generally recommended as first-line therapy for children with the common cold.^(19-24)

• Maintaining adequate hydration
• Ingestion of warm fluids e.g. tea, chicken soup)
• Topical saline
• Humidified air

OVER-THE-COUNTER MEDICATIONS: Over-the-counter (OTC) products for symptomatic relief of the common cold in children include antihistamines, decongestants, antitussives, expectorants, mucolytics, antipyretics/analgesics, and combinations of these medications.

• Children <6 years – Except for antipyretics / analgesics, OTC medications for the common cold should be avoided in children <6 years of age.^(25-27)
• 6 to 12 years – Except for antipyretics / analgesics, OTC medications for the common cold should not be used in children 6 to 12 years of age.
• Adolescents ≥12 years – OTC decongestants may provide symptomatic relief of nasal symptoms in adolescents ≥12 years.

SYMPTOMATIC THERAPY: Symptomatic therapies have associated risks and benefits, particularly in young children.

• Discomfort due to fever: Discomfort due to fever in the first few days of the common cold should be treated with acetaminophen (for children older than three months) or ibuprofen (for children older than six months).⁽²⁸⁾
• Nasal symptoms: For first-line therapy of bothersome nasal symptoms, one or more supportive interventions (e.g. nasal suction; saline nasal drops, spray, or irrigation; adequate hydration; cool mist humidifier) should be suggested rather than OTC medications or topical aromatic therapies.

Second-line interventions for bothersome nasal symptoms that do not improve with supportive care vary according to age:

• Children <6 years - It is suggested to increase the frequency of nasal suction, sprays, or irrigation. Ipratropium nasal spray 0.06% is available by prescription for children older than five years and may be warranted on a case-by-case basis. Two sprays are administered to each nostril three times per day for four days.
• Children 6 to 12 years – It is generally suggested to increase the frequency of nasal suction, sprays, or irrigation rather than other interventions. OTC decongestants or decongestant / antihistamine combinations should not be used.
• Children ≥12 years –OTC decongestants (oral or topical) or ipratropium nasal spray is suggested in this situation.

COUGH: Airway irritation contributing to cough should be relieved with oral hydration, warm fluids (e.g. tea, chicken soup), honey (in children older than one year), or cough lozenges or hard candy (in children in whom they are not an aspiration risk) rather than OTC or prescription antitussives, antihistamines, expectorants, or mucolytics. Fluids, honey, cough lozenges, and hard candy are inexpensive and unlikely to be harmful, although they may provide only placebo effect.⁽²⁹⁾

UNPROVEN THERAPIES:

• Antibiotics: There is no role for antibiotics in the treatment of the common cold.⁽⁹⁾ The use of antibiotics should be reserved for clearly diagnosed secondary bacterial infections, including bacterial otitis media, sinusitis, and pneumonia.
• Antihistamines: Antihistamines for the treatment of the common cold is not suggested.
• Intranasal glucocorticoids: Intranasal corticosteroids for the treatment of nasal symptoms of the common cold is not suggested.
• Antitussives: Prescription (codeine) or OTC (dextromethorphan) antitussive medications is not suggested to treat cough in children with the common cold.
• Expectorants and mucolytics: OTC expectorants (e.g. guaifenesin) or mucolytics (e.g. acetylcysteine, bromhexine, letosteine) to treat cough in children with the common cold is not suggested. Expectorants and mucolytics increase mucus production and thin respiratory secretions, respectively, to make the secretions easier to expel.⁽³⁰⁾
• Bronchodilators: Bronchodilators to treat cough in nonasthmatic children with the common cold is not suggested.
• Aromatic vapors: (for external rub): Topical aromatic agents / external rubs (e.g. menthol, camphor, eucalyptus oil) for the treatment of nasal congestion or cough in children with the common cold is not recommended.

PHARYNGITIS AND TONSILLITIS:

Antibiotics generally are indicated for laboratory-documented bacterial pharyngitis. They are not helpful in viral pharyngitis and may be associated with adverse effects including diarrhea, allergy, increased bacterial resistance, unnecessary expense, etc.

SUPPORTIVE CARE: General supportive measures that can be suggested for most patients with infectious pharyngitis include:^(31-34)

• Getting adequate rest
• Consuming an adequate volume of fluids
• Avoiding cigarette smoke (including second hand smoke) and other respiratory irritants
• Avoiding acidic foods and beverages (particularly for those with oral or pharyngeal ulcers)
• Eating a soft diet (may be more palatable for those with difficulty swallowing due to pain or enlarged tonsils)

SYMPTOMATIC TREATMENT:

SOOTHING MEASURES:

• Sipping cold or warm beverages (e.g. tea with honey or lemon): Honey should be avoided in children <12 months because of the possible contamination of honey with Clostridium botulinum spores, potentially leading to infantile botulism.
• Eating cold or frozen desserts (e.g. ice cream, popsicles)
• Sucking on ice
• Sucking on hard candy: For children ≥5 years and adolescents, sucking on hard candy rather than medicated throat lozenges (e.g. cough drops, troches, or pastilles) or medicated sprays is suggested.
• Gargling with warm salt water: For children ≥6 years of age and adolescents, gargling with warm salt water is suggested rather than other medicated oral rinses.

SYSTEMIC ANALGESIA: Systemic analgesia for children and adolescents with throat pain is recommended, particularly if it decreases oral intake. Acetaminophen or ibuprofen is generally suggested rather than other systemic analgesic agents.  Aspirin should be avoided in children because of the risk of Reye syndrome, as well as its antiplatelet effect.

OTHER THERAPIES:

MEDICATED LOZENGES AND SPRAYS: Medicated lozenges usually are designed to relieve dryness or pain. Medicated throat lozenges and sprays have the potential to cause allergic reactions, and those that contain benzocaine may cause methemoglobinemia. Lozenges that contain benzocaine should not be used in children younger than four years (they are a choking hazard); sprays that contain benzocaine should not be used in children younger than two years.⁽³⁵⁾

MEDICATED ORAL RINSES: It is not suggested to routinely use topical oral therapies containing lidocaine or other topical therapies (e.g. diphenhydramine, Kaolin pectin, magnesia-alumina) to coat oral lesions and / or soothe pain in children with throat pain due to oral ulcers (e.g.  herpetic gingivostomatitis; hand, foot, and mouth disease) given the lack of evidence of benefit from clinical trials,⁽³⁶⁾ the potential for harm (e.g. toxicity from systemic absorption, allergic reaction),^(35,37) and difficulty of application in young children.⁽³⁸⁾

GLUCOCORTICOIDS: Glucocorticoids for the symptomatic relief of throat pain in children and adolescents is not suggested. Evidence regarding the safety and efficacy of glucocorticoids for acute pharyngitis in children is limited; safe and effective alternatives are available (e.g. ibuprofen, acetaminophen).⁽³⁹⁾

ALTERNATIVE THERAPIES: Complementary alternative therapies (e.g. herbal therapies, homeopathic therapies, dietary supplements, etc.) in the treatment of sore throat in children and adolescents is not recommended.

OTITIS MEDIA:

SYMPTOMATIC THERAPY:

SYSTEMIC AND TOPICAL ANALGESICS: Pain is a common feature of acute otitis media (AOM) and may be severe. Treatment to reduce ear pain in children with AOM whether or not they are treated with antibiotics is usually recommended.⁽⁴⁰⁾

Oral ibuprofen or acetaminophen for pain control in children with AOM is recommended. Topical benzocaine, procaine, or lidocaine preparations (if available) are an alternative for children ≥2 years but should not be used in children with tympanic membrane perforation. Topical benzocaine is avoided in children <2 years because of the risk of methemoglobinemia.⁽³⁵⁾

DECONGESTANTS AND ANTIHISTAMINES: Decongestants and / or antihistamines in the symptomatic management of AOM in children is not recommended.

OTHER THERAPIES: Distraction, external application of heat or cold, or instillation of olive oil or herbal extracts into the external auditory canal to treat pain in children with AOM is not suggested.

INITIAL ANTIMICROBIAL THERAPY:

FIRST-LINE THERAPY:

• No recent beta-lactam therapy, no concomitant purulent conjunctivitis, and no history of recurrent AOM: Amoxicillinas the first-line therapy for children with AOM who are treated with antibiotics and at low-risk for amoxicillin resistance is suggested.
• Recent beta-lactam therapy, concomitant purulent conjunctivitis, or history of recurrent AOM: Amoxicillin-clavulanateas the first-line therapy for children with AOM who are treated with antibiotics and at increased risk of beta-lactam resistance is recommended.^(41-44)

PENICILLIN ALLERGY: Acceptable alternatives to penicillin in patients with allergy to penicillin depend upon the type of the previous hypersensitivity reaction.

DELAYED REACTION: For children who report penicillin allergy but who did not experience an immediate type 1 hypersensitivity reaction (anaphylaxis, angioedema, bronchospasm, or urticaria), one of the following is suggested:

• Cefdinir
• Cefpodoxime
• Cefuroxime
• Cefuroxime
• Ceftriaxone

The oral regimens do not achieve sufficient concentration in the middle ear to eradicate penicillin-resistant S. pneumoniae.

IMMEDIATE REACTION: Macrolide or lincosamide antibiotics can be used to treat AOM in children who have had an immediate type 1 hypersensitivity reaction (anaphylaxis, angioedema, bronchospasm, or urticaria) to amoxicillin or other beta-lactam antimicrobial agents. However, macrolide or lincosamide resistance is common (approximately 25 to 35 percent) among isolates of S. pneumoniae, and macrolides and lincosamides generally are not effective for eradication of H. influenza.^(45-47)

Macrolides and lincosamides available for the treatment of AOM include:

• Azithromycin
• Clarithromycin
• Erythromycin-sulfisoxazole
• clindamycin

SINUSITIS:

ANTIBIOTICS: Indications for antibiotic therapy for acute sinusitis are as follow:

• Persistent acute sinusitis
• Severe acute sinusitis
• Toxic child with suspected complications

Typically, uncomplicated cases of acute sinusitis are responsive to amoxicillin. Most patients respond to this initial regimen. For children allergic to penicillin, a second- or third-generation cephalosporin can be used (only if the allergic reaction is not a type 1 hypersensitivity reaction). In cases of serious allergic reaction, a macrolide or clindamycin can be used. Second-line antibiotics should account for bacterial resistance and should be safe in the pediatric population. For chronic sinusitis, a 4-week course of a broad-spectrum beta-lactam–stable antibiotic should be administered. This should allow treatment for more than a week beyond symptom resolution and ensure restoration of mucociliary function and resolution of mucosal edema.

IRRIGATION: Saline sinus irrigation has demonstrated efficacy in the treatment of acute and chronic sinusitis. It increases mucociliary flow rates and aids in vasoconstriction. It mechanically clears secretions, decreases bacterial counts, and clears allergens and environmental irritants from the nose.^(48,49)

STEROIDS: Nasal steroids are essential for patients with concurrent allergic rhinitis. Of patients with allergic rhinitis, 90% report improvement in symptoms, including nasal congestion.

DECONGESTANTS AND ANTIHISTAMINES: Nasal decongestants are variably effective. Topical decongestants may improve patients' level of comfort. Restricting use to the first 4-5 days of medical treatment is best in order to avoid rebound vasodilatation.

IMMUNOTHERAPY: Immunotherapy is effective for patients with known specific allergies who have symptoms not responsive to other forms of traditional medical therapy.

SURGICAL CARE:

Surgical approaches include the following:

• Adenoidectomy
• Functional endoscopic sinus surgery
• Uncinate removal, anterior ethmoidectomy, and maxillary antrostomy - The most common forms of surgery
• Balloon sinuplasty

LARYNGOTRACHEITIS (CROUP):

Treatment of croup may involve a variety of pharmacologic and nonpharmacologic interventions.

GLUCOCORTICOIDS: Glucocorticoids provide long-lasting and effective treatment of mild, moderate, and severe croup.^(50-53) The anti-inflammatory actions of glucocorticoids are thought to decrease edema in the laryngeal mucosa of children with croup. Improvement is usually evident within six hours of administration but seldom is dramatic.^(51,54)

DEXAMETHASONE: Among the available glucocorticoids, dexamethasone has been used most frequently, is the least expensive, has the longest duration of action, and is the easiest to administer.

BUDESONIDE: Nebulized budesonide has been shown to be more effective than placebo and as effective as IM or oral dexamethasone for the treatment of croup.^(51,55) However, nebulized budesonide is more expensive and more difficult to administer than IM or oral dexamethasone and is not routinely indicated in the treatment of croup.

PREDNISOLONE: Some authorities suggest that for children who are treated as outpatients, oral prednisolone (2 mg / kg per day for three days) is an alternative to oral dexamethasone.⁽⁵⁶⁾

PREDNISONE: The use of prednisone in the management of croup has not been evaluated in clinical trials. However, it has equivalent potency to prednisolone and, in theory, should have similar effects. Despite its lack of proven benefit, prednisone is widely used in the outpatient management of croup.⁽⁵⁷⁾

NEBULIZED EPINEPHRINE: The administration of nebulized epinephrine to patients with moderate to severe croup often results in rapid improvement of upper airway obstruction. Epinephrine constricts precapillary arterioles in the upper airway mucosa and decreases capillary hydrostatic pressure, leading to fluid resorption and improvement in airway edema.⁽⁵⁸⁾ Even a small increase in airway diameter can lead to significant clinical improvement.

OXYGEN:  Oxygen is not known to have any direct impact on the subglottic edema or airway narrowing, but should be administered to children who are hypoxemic (oxygen saturation of <92 percent in room air) and / or in moderate to severe respiratory distress.^(59,60) Supplemental oxygen should be humidified to decrease drying effects on the airways, since drying may impede the physiologic removal of airway secretions via mucociliary and cough mechanisms.

MIST THERAPY: Humidified air is frequently used in the treatment of croup, although there have been no studies supporting its efficacy in reducing symptoms.⁽⁶¹⁾

Although humidified air does not reduce subglottic edema, it may provide other benefits. Inhalation of moist air, relative to dry air, may decrease drying of inflamed mucosal surfaces and reduce inspissation of secretions.⁽⁶²⁾

OTHER THERAPIES:

ANTIBIOTICS: Antibiotics have no role in the routine management of uncomplicated croup, since most cases are caused by viruses.⁽⁵⁹⁾ Antibiotics should be used only to treat specific bacterial complications, such as tracheitis.

ANTITUSSIVES: Nonprescription antitussive agents are of unproven benefit for croup (or other respiratory tract infections). Codeine, which is a more potent cough suppressant, can alter the child's sensorium, making it difficult to follow the clinical course.

DECONGESTANTS: Decongestants also are of unproven benefit for croup.^(59,60)

SEDATIVES: The routine use of sedative agents in effort to improve airway obstruction by relieving anxiety and apprehension is not recommended. Sedatives may treat the symptom of agitation while masking the underlying causes of air hunger and hypoxia. They also may decrease respiratory effort (and therefore croup scores), without improving ventilation.^(59,63)

EPIGLOTTITIS:

Treatment in patients with epiglottitis is directed toward relieving the airway obstruction and eradicating the infectious agent.

MANAGING RESPIRATORY ARREST: When a child has respiratory arrest, the first step is to administer bag-valve-mask ventilation with 100% oxygen. All of these children can be oxygenated and ventilated with good bag-valve-mask technique. Once the child is oxygenated and ventilated, the airway can be secured with an endotracheal tube, cricothyrotomy, or tracheostomy. These treatments should prevent cerebral anoxia, arrest, and death, the most feared complications.

AIRWAY, BREATHING, AND CIRCULATION: Medical treatment begins by evaluating airway, breathing, and circulation. Supplemental oxygen administration, a nonthreatening initial step, is easily accomplished with blow-by oxygen administered by a parent.

Alternative methods to gain immediate control of the airway, such as needle cricothyrotomy, are considered temporary until a more permanent procedure (e.g. tracheostomy) can be performed.

ENDOTRACHEAL INTUBATION: Once supplemental oxygen is provided, the next crucial step is to mobilize a team to establish an appropriate airway via endotracheal intubation.

TRACHEOSTOMY: If endotracheal intubation is unsuccessful, perform a tracheostomy with percutaneous translaryngeal ventilation used as a temporizing measure.

ANTIMICROBIAL THERAPY: Whenever possible, a blood culture and, in intubated patients, an epiglottic culture should be obtained prior to antibiotic administration.

After airway management is complete, patients with infectious epiglottitis should receive empiric antimicrobial therapy directed toward the most likely organisms.

• Haemophilus influenzaetype b
• Streptococcus pneumoniae, including strains that may be penicillin-resistant
• Group AStreptococcus
• Staphylococcus aureus, including community-acquired methicillin-resistant aureus (MRSA) strains

It is suggested that patients with epiglottitis receive empiric combination therapy with a third-generation cephalosporin (e.g. ceftriaxone or cefotaxime) AND an antistaphylococcal agent (e.g. vancomycin or as determined by the local prevalence and sensitivities of MRSA isolates).^(64,65)

When the patient history suggests potential for severe hypersensitivity reaction to penicillin or cephalosporin antibiotics, vancomycin plus a quinolone or carbapenem antibiotic is a potential option.

ADDITIONAL THERAPIES: Bronchodilators and parenteral glucocorticoids have both been used as adjunctive treatments for patients with epiglottitis, but these agents are not routinely necessary:

• Glucocorticoids: Use of glucocorticoids in the initial treatment of patients with epiglottitis is not recommended. In retrospective studies, glucocorticoid therapy has not been associated with reduced length of stay, duration of intubation, or duration of stay in the intensive care unit, perhaps because glucocorticoids were administered selectively to sicker patients.⁽⁶⁶⁾
• Racemic epinephrine: The benefit of administration of racemic epinephrine as a means to reduce edema in patients with epiglottitis prior to definitive airway intervention is not established.^(67-69) Prompt, effective airway management is the key intervention. The use of nebulized medications in young children may cause some to become frightened and anxious, which may exacerbate the airway compromise.

BRONCHIOLITIS:

Infants and children with nonsevere bronchiolitis usually can be managed in the outpatient setting, unless there are concerns about the caregivers' ability to care for them at home. Supportive care and anticipatory guidance are the mainstays of management of nonsevere bronchiolitis. Supportive care includes maintenance of adequate hydration, relief of nasal congestion / obstruction, and monitoring for disease progression.

SEVERE BRONCHIOLITIS: Infants and children severe bronchiolitis usually require treatment in the emergency department or inpatient setting.

EMERGENCY DEPARTMENT MANAGEMENT: Emergency department management of severe bronchiolitis centers on stabilization of respiratory and fluid status and determining the appropriate setting for continuation of care (i.e. observation unit, general inpatient ward, or intensive care unit [ICU]).

• Trial of inhaled bronchodilator: Inhaled bronchodilators for the management of the first episode of bronchiolitis in children are not recommended. However, a one-time trial of inhaled bronchodilators (albuterol [salbutamol] or epinephrine) may be warranted for infants and children with severe bronchiolitis.
• Nebulized hypertonic saline: For infants and children with severe bronchiolitis who are treated in the emergency department, it is not suggested to routinely treat with nebulized hypertonic saline.
• Glucocorticoids: It is not recommended to use glucocorticoids routinely in the management of the first episode of bronchiolitis.

INPATIENT MANAGEMENT: Inpatient management of severe bronchiolitis centers on support of hydration and respiratory status as necessary.

• Fluid management: The fluid intake and output of infants and children with bronchiolitis should be assessed regularly. Exclusive parenteral fluid administration may be necessary to ensure adequate hydration and avoid the risk of aspiration in infants and children who are hospitalized with bronchiolitis and have moderate to severe respiratory distress.
• Respiratory support: Respiratory support for infants and young children with bronchiolitis generally is provided in a stepwise fashion. Most children require nasal suctioning. Supplemental oxygen is provided as necessary to maintain SpO2 >90 to 92 percent. Infants who are at risk for progression to respiratory failure often receive a trial of heated humidified high-flow nasal cannula (HFNC) therapy and / or continuous positive airway pressure (CPAP) before endotracheal intubation. However, initial endotracheal intubation is more appropriate than HFNC or CPAP for children with hemodynamic instability, intractable apnea, or loss of protective airway reflexes.
• Other therapies: Chest physiotherapy, inhaled bronchodilators, nebulized hypertonic saline, or leukotriene inhibitors (e.g. montelukast) to relieve lower airway obstruction in infants and children with first episode of bronchiolitis is not routinely recommended. Glucocorticoids in the management of a first episode of bronchiolitis is not recommended.

PNEUMONIA:

HOSPITALIZATION: Pulse oximetry should be performed during the prehospital evaluation of children with suspected pneumonia, and supplemental oxygen should be administered, if necessary; however, many school-aged children do not require hospitalization and respond well to oral antibiotics. Usually, these patients are not toxic or hypoxic enough to require supplemental oxygen. Unless they are vomiting, they do not require intravenous fluids or antibiotics. A parapneumonic effusion that requires drainage usually dictates a hospital admission.

Children younger than 5 years are hospitalized more often, but their clinical status, degree of hydration, degree of hypoxia, and need for intravenous therapy dictate this decision. Hospitalization should be considered for infants who are younger than 2 months or premature because of the risk of apnea in this age group.⁽⁷¹⁾

HEMODYNAMIC SUPPORT: RBCs should be administered to ensure a hemoglobin concentration of 13-16 g / dL in the acutely ill infant to ensure optimal oxygen delivery to the tissues. Delivery of adequate amounts of glucose and maintenance of thermoregulation, electrolyte balance, and other elements of neonatal supportive care are also essential aspects of clinical care.

RESPIRATORY MANAGEMENT: Initial priorities in children with pneumonia include the identification and treatment of respiratory distress, hypoxemia, and hypercarbia. Grunting, flaring, severe tachypnea, and retractions should prompt immediate respiratory support. Children who are in severe respiratory distress should undergo tracheal intubation if they are unable to maintain oxygenation or have decreasing levels of consciousness. Increased respiratory support requirements such as increased inhaled oxygen concentration, positive pressure ventilation, or CPAP are commonly required before recovery begins.

PHARMACOLOGIC THERAPY:

The choice of an initial, empiric agent is selected according to the susceptibility and resistance patterns of the likely pathogens and experience at the institution, and the selection is tempered by knowledge of delivery of drugs to the suspected infected sites within the lung.

ANTIBIOTIC AGENTS: The vast majority of children diagnosed with pneumonia in the outpatient setting are treated with oral antibiotics.

High-dose amoxicillin is used as a first-line agent for children with uncomplicated community-acquired pneumonia, which provides coverage for S pneumoniae. Second- or third-generation cephalosporins and macrolide antibiotics such as azithromycin are acceptable alternatives but should not be used as first-line agents because of lower systemic absorption of the cephalosporins and pneumococcal resistance to macrolides.

Macrolide antibiotics are useful in school-aged children, because they cover the most common bacteriologic and atypical agents (Mycoplasma, Chlamydophila, Legionella). However, increasing levels of resistance to macrolides among pneumococcal isolates should be considered (depending on local resistance rates). One study suggests that penicillin and macrolide resistance among S pneumoniae isolates has been increasing.⁽⁷²⁾

Hospitalized patients can be safely treated with narrow-spectrum agents such as ampicillin, and this is the mainstay of current guidelines for pediatric community-acquired pneumonia.^(73-75) Children who are toxic appearing should receive antibiotic therapy that includes vancomycin (particularly in areas where penicillin-resistant pneumococci and methicillin-resistant S aureus [MRSA] are prevalent) along with a second- or third-generation cephalosporin.

ANTI-INFLAMMATORY THERAPY: Evidence-supported options for targeted treatment of inflammation independent of antimicrobial therapy are severely limited.⁽⁷⁶⁾ Considerable speculation suggests that current antimicrobial agents, directed at killing invasive organisms, may transiently worsen inflammatory cascades and associated host injury because dying organisms release proinflammatory structural and metabolic constituents into the surrounding microenvironment. This is not to imply that eradicating invasive microbes should not be a goal; however, other methods of eradication or methods of directly dealing with the pathologic inflammatory cascades await further definition.

ANTIVIRAL AGENTS: Most infants with respiratory syncytial virus (RSV) pneumonia do not require antimicrobials. Serious infections with this organism usually occur in infants with underlying lung disease.

Influenza A viruses, including 2 subtypes (H1N1) and (H3N2), and influenza B viruses currently circulate worldwide, but the prevalence of each can vary among communities and within a single community over the course of an influenza season.

Influenza A pneumonia that is particularly severe or when it occurs in a high-risk patient may be treated with zanamivir or oseltamivir. The neuraminidase inhibitors have activity against influenza A and B viruses, whereas the adamantanes have activity against only influenza A viruses.

Since January 2006, the neuraminidase inhibitors (oseltamivir, zanamivir) have been the only recommended influenza antiviral drugs because of widespread resistance to the adamantanes (amantadine, rimantadine) among influenza A (H3N2) virus strains.

A second-line alternative is a combination of oseltamivir plus rimantadine rather than oseltamivir alone. Local influenza surveillance data and laboratory testing can assist the physician regarding antiviral agent choice.

Herpes simplex virus pneumonia is treated with parenteral acyclovir.

CMV pneumonitis should be treated with intravenous ganciclovir or foscarnet.

Invasive fungal infections, such as those caused by Aspergillus or Zygomycetes species, are treated with amphotericin B or voriconazole.

BRONCHODILATORS: Bronchodilators should not be routinely used. Bacterial lower respiratory tract infections rarely trigger asthma attacks, and the wheezing that is sometimes heard in patients with pneumonia is usually caused by airway inflammation, mucus plugging, or both and does not respond to bronchodilator. However, infants or children with reactive airway disease or asthma may react to a viral infection with bronchospasm, which responds to bronchodilators.

MANAGEMENT OF PLEURAL EFFUSIONS:

When a child with pneumonia develops a pleural effusion, thoracentesis should be performed for diagnostic and therapeutic purposes. Drainage of parapneumonic effusions with or without intrapleural instillation of a fibrinolytic agent (e.g. tissue plasminogen activator [TPA]) may be indicated. Chest tube placement for drainage of an effusion or empyema may be performed. Video-assisted thoracic surgery (VATS) procedure may be performed for decortication of organized empyema or loculated effusions.

GOALS OF THERAPY:

The goal of therapy is to prevent secondary infection, treat and prevent complication and relief symptoms.

GUIDELINES:

To view respective guidelines, please click on link below.

• British Thoracic Society (BTS) Recommendations for the assessment and management of cough in children
• http://thorax.bmj.com/content/thoraxjnl/63/Suppl_3/iii1.full.pdfGuidelines for Evaluating Chronic Cough in Pediatrics : American College of Chest Physicians (ACCP) Evidence-Based Clinical Practice Guidelines

http://journal.publications.chestnet.org/article.aspx?articleid=1084264

• American Academy of Pediatrics : Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years

http://pediatrics.aappublications.org/content/pediatrics/early/2013/06/19/peds.2013-1071.full.pdf

• American Academy of Pediatrics: Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract Infections in Pediatrics

http://pediatrics.aappublications.org/content/pediatrics/132/6/1146.full.pdf

• American Family Physician Guidelines for the Use of Antibiotics in Acute Upper Respiratory Tract Infections

http://www.aafp.org/afp/2006/0915/p956.html

• Infectious Disease Society of America (IDSA): Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults

https://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/IDSA%20Clinical%20Practice%20Guideline%20for%20Acute%20Bacterial%20Rhinosinusitis%20in%20Children%20and%20Adults.pdf

• Centers for disease control and prevention: Pediatric Treatment Recommendations (antibiotic prescribing)

https://www.cdc.gov/getsmart/community/for-hcp/outpatient-hcp/pediatric-treatment-rec.html

CONSULTATION:

Airway obstruction from epiglottitis, tonsillar hypertrophy, peritonsillar abscess, retropharyngeal abscess, or other causes of an obstructive mass requires emergency consultation with a surgeon. Sleep apnea associated with tonsillar hypertrophy may also prompt surgical consultation. Neurologic findings or mental status changes in the setting of suspected intracranial suppurative complications warrant emergency consultation with a neurosurgeon.

Consider consulting an infectious disease specialist when patients have any of the following:

• HIV infection
• Cancer-related or congenital immunodeficiency
• Other immunocompromise

Patients with a chronic cough after a URI may benefit from a consultation with a pulmonologist or otorhinolaryngologist to evaluate persistent infection, asthma, gastroesophageal reflux disease, or other causes of chronic cough. Patients who have had 4-5 confirmed group A streptococcal infections in a single year or those with a chronic sore throat and adenopathy unresponsive to treatment over 6 months should be examined by an infectious disease specialist and / or surgeon.

Persistent hoarseness after 2 weeks warrants consultation with an otorhinolaryngologist. Patients with complex, persistent cases of rhinosinusitis should also be referred to an otorhinolaryngologist, for consideration of sinus puncture and aspiration.

LONG TERM MONITORING:

In general, patients with URI should follow up with a physician if their symptoms do not improve, worsen within 72 hours, or recur. Patients with infectious mononucleosis should be instructed to follow up with their physician after a week. In patients with diphtheria, elimination of the organism should be documented with 2 consecutive negative culture results after the completion of therapy.

Follow-up testing is not routinely necessary in cases of group A streptococcal pharyngitis that resolve. However, follow-up may be advisable in the setting of recurrent group A streptococcal disease, rheumatic fever, poststreptococcal glomerulonephritis, or outbreaks in semiclosed environments. 

PRECAUTIONS:

The risk of spread can be decreased by following prevention measures:

NUTRITION: In older children, adolescents, and adults, an adequate diet is necessary for overall health and optimal immune function. Eating 5 servings of fruits and vegetables each day is commonly recommended. Various vitamins and minerals are necessary for immunity. Obtaining these from food may have more nutritional benefit than taking individual supplements.

In newborns, the practice of breastfeeding transfers protective antibodies through the mother's milk, providing passive immunization against numerous pathogens.

HYGIENE: The best methods for preventing transmission of the respiratory infections are frequent handwashing and avoiding touching one's mouth, nose, and eyes.

Viruses can be transmitted from the hands to objects in the environment or to other people. To avoid contaminating their hands, children with the respiratory infections can be instructed to cough into a tissue or the crook of their elbow rather than into their hands. Used tissues should be discarded in a waste basket.

DISINFECTANTS: Decontamination of environmental surfaces with virucidal disinfectants such as phenol / alcohol may help decrease the rate of transmission of viruses.

IMMUNIZATIONS: Yearly influenza immunization is recommended for all individuals older than six months to prevent influenza infection and its complications.

Vaccination for diphtheria, tetanus, and pertussis (DTaP) are also recommended.

PALIVIZUMAB AGAINST RESPIRATORY SYNCYTIAL VIRUS (RSV): Monthly injection of palivizumab (a monoclonal antibody preparation) is recommended to prevent respiratory syncytial virus (RSV) lower respiratory tract infection in high risk infants. Palivizumab 15 mg / kg is administered intramuscularly once per month for a maximum of five doses. The first dose is administered before the RSV season begins (usually in November for infants in the northern hemisphere). When palivizumab prophylaxis is initiated at the beginning of RSV season, all five doses should be administered. However, prophylaxis should be discontinued if the infant experiences breakthrough infection requiring hospitalization.

AVOID SMOKING: Avoid smoking or use other tobacco products.  Secondhand smoke irritates the mucous membranes of child's nose, sinuses, and lungs and increases risk for respiratory infections

SWALLOWED OR INHALED OBJECTS: Avoid giving young children food or objects that may be improperly swallowed and inhaled, such as nuts, popcorn, small candies, or small toys. An inhaled object can lead to a respiratory infection.

UNPROVEN PREVENTIVE MEASURES: Herbal products, vitamins, minerals, or probiotics to prevent respiratory infections in children are not suggested. These agents have not been proven beneficial and may be harmful.

• Herbal products: Meta-analyses have not found conclusive evidence thatEchinacea purpurea or Allium sativum (garlic) prevents the common cold in children.^(77,78)
• Vitamin D: In randomized trials, neither daily nor monthly administration of vitamin D reduced the incidence or severity of the common cold in adults; studies in children are lacking.
• Vitamin C: A 2013 meta-analysis of 24 trials (10,708 participants) found no evidence that daily vitamin C supplementation prevents the common cold in the general community.⁽⁷⁹⁾ However, daily vitamin C supplementation may shorten the duration of the common cold in children.
• Zinc: Although randomized trials indicate that oral zinc may provide some benefit in preventing colds and decreasing cold duration and severity,^(80,81) the benefits are limited by the need for prolonged daily administration (≥5 months) and adverse effects including bad taste and nausea.
• Probiotics: Probiotics for the prevention of common cold in children is not suggested.

REFERENCES:

• http://www.who.int/bulletin/volumes/86/5/07-048769/en/ [Accessed on 13-Mar-17]
• World health statistics. Geneva: WHO; 2007. Available from: http://www.who.int/whosis/whostat2007.pdf [accessed on 13-Mar-17].
• Bste, J.R. Etiology and epidemiology of acute respiratory tract infection in children in developing countries. Rev, Infect Dis., 1990; 12 (Suppl 8):5861-S1090.
• Anne Meneghetti,"Upper Respiratory Tract Infection":Pathophysiology, Emedicine.medscape.com,2017
• Chung LP, Waterer GW. Genetic predisposition to respiratory infection and sepsis.Crit Rev Clin Lab Sci. 2011 Sep-Dec. 48(5-6):250-68.
• Horby P, Nguyen NY, Dunstan SJ, Baillie JK. The role of host genetics in susceptibility to influenza: a systematic review.PLoS One. 2012. 7(3):e33180.
• Juno J, Fowke KR, Keynan Y. Immunogenetic factors associated with severe respiratory illness caused by zoonotic H1N1 and H5N1 influenza viruses.Clin Dev Immunol. 2012. 2012:797180.
• Pappas DE, Hendley JO. The common cold and decongestant therapy. Pediatr Rev 2011; 32:47.
• Shields MD, Bush A, Everard ML, et al. BTS guidelines: Recommendations for the assessment and management of cough in children. Thorax 2008; 63 Suppl 3:iii1.
• Heikkinen T, Järvinen A. The common cold. Lancet 2003; 361:51.
• [Guideline] Ayanruoh S, Waseem M, Quee F, Humphrey A, Reynolds T. Impact of rapid streptococcal test on antibiotic use in a pediatric emergency department.Pediatr Emerg Care. 2009 Nov. 25(11):748-50
• Swingler GH, Zwarenstein M. Chest radiograph in acute respiratory infections.Cochrane Database Syst Rev. 2008. (1):CD001268.
• Glynn F, Fenton JE. Diagnosis and management of supraglottitis (epiglottitis).Curr Infect Dis Rep. 2008 May. 10(3):200-4.
• Chaaban H, Singh K, Huang J, Siryaporn E, Lim YP, Padbury JF. The role of inter-alpha inhibitor proteins in the diagnosis of neonatal sepsis.J Pediatr. 2009 Apr. 154(4):620-622.e1.
• Neuman MI, Harper MB. Evaluation of a rapid urine antigen assay for the detection of invasive pneumococcal disease in children.Pediatrics. 2003 Dec. 112(6 Pt 1):1279-82.
• Gauvin F, Dassa C, Chaïbou M, Proulx F, Farrell CA, Lacroix J. Ventilator-associated pneumonia in intubated children: comparison of different diagnostic methods.Pediatr Crit Care Med. 2003 Oct. 4(4):437-43
• Gauvin F, Lacroix J, Guertin MC, Proulx F, Farrell CA, Moghrabi A, et al. Reproducibility of blind protected bronchoalveolar lavage in mechanically ventilated children.Am J Respir Crit Care Med. 2002 Jun 15. 165(12):1618-23.
• Klein JO. Diagnostic lung puncture in the pneumonias of infants and children.Pediatrics. 1969 Oct. 44(4):486-92.
• Use of codeine- and dextromethorphan-containing cough remedies in children. American Academy of Pediatrics. Committee on Drugs. Pediatrics 1997; 99:918.
• Bell EA, Tunkel DE. Over-the-counter cough and cold medications in children: are they helpful? Otolaryngol Head Neck Surg 2010; 142:647.
• Kelly LF. Pediatric cough and cold preparations. Pediatr Rev 2004; 25:115.
• Saketkhoo K, Januszkiewicz A, Sackner MA. Effects of drinking hot water, cold water, and chicken soup on nasal mucus velocity and nasal airflow resistance. Chest 1978; 74:408.
• World Health Organization. Cough and cold remedies for the treatment of acute respiratory infections in young children, 2001. http://whqlibdoc.who.int/hq/2001/WHO_FCH_CAH_01.02.pdf.
• Parental instruction sheets. The common cold. In: Textbook of Pediatric Emergency Medicine, 6th, Fleisher GR, Ludwig S. (Eds), Lippincott Williams & Wilkins, Philadelphia 2010. p.1894.
• US Food and Drug Administration. Public Health Advisory. Nonprescription cough and cold medicine use in children. FDA recommends that over-the-counter (OTC) cough and cold products not be used for infants and children under 2 years of age. www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/DrugSafetyInformationforHeathcareProfessionals/PublicHealthAdvisories/UCM051137 (Accessed on August 31, 2011).
• Sharfstein JM, North M, Serwint JR. Over the counter but no longer under the radar--pediatric cough and cold medications. N Engl J Med 2007; 357:2321.
• American Academy of Pediatrics. Withdrawal of cold medicines: Addressing parent concerns. http://practice.aap.org/content.aspx?aid=2254 (Accessed on August 23, 2011).
• Kim SY, Chang YJ, Cho HM, et al. Non-steroidal anti-inflammatory drugs for the common cold. Cochrane Database Syst Rev 2015; :CD006362.
• Paul IM, Beiler JS, Vallati JR, et al. Placebo effect in the treatment of acute cough in infants and toddlers: a randomized clinical trial. JAMA Pediatr 2014; 168:1107.
• Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC) medications for acute cough in children and adults in community settings. Cochrane Database Syst Rev 2014; :CD001831.
• Bisno AL. Acute pharyngitis. N Engl J Med 2001; 344:205.
• Schmitt BD. Sore throat (pharyngitis). In: Instructions for Pediatric Patients, WB Saunders, Philadelphia 1999. p.91.
• Snellman L, Adams W, Anderson G, et al. Institute for Clinical Systems Improvement. Diagnosis and treatment of respiratory illness in children an adults. Updated January 2013. https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_respiratory_guidelines/respiratory_illness/
• Weglowski J. An evidence-based approach to the evaluation and treatment of pharyngitis in children. Pediatric Emerg Med Practice 2011; 8:1.
• Questions & Answers: Reports of a rare, but serious and potentially fatal adverse effect with the use of over-the-counter (OTC) benzocaine gels and liquids applied to the gums or mouth www.fda.gov/Drugs/DrugSafety/ucm250029.htm
• Hopper SM, McCarthy M, Tancharoen C, et al. Topical lidocaine to improve oral intake in children with painful infectious mouth ulcers: a blinded, randomized, placebo-controlled trial. Ann Emerg Med 2014; 63:292.
• Hess GP, Walson PD. Seizures secondary to oral viscous lidocaine. Ann Emerg Med 1988; 17:725.
• Faden H. Management of primary herpetic gingivostomatitis in young children. Pediatr Emerg Care 2006; 22:268.
• Pierce CA, Voss B. Efficacy and safety of ibuprofen and acetaminophen in children and adults: a meta-analysis and qualitative review. Ann Pharmacother 2010; 44:489.
• Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics 2013; 131:e964.
• Wald ER, Mason EO Jr, Bradley JS, et al. Acute otitis media caused by Streptococcus pneumoniae in children's hospitals between 1994 and 1997. Pediatr Infect Dis J 2001; 20:34.
• Kellner JD, Ford-Jones EL. Streptococcus pneumoniae carriage in children attending 59 Canadian child care centers. Toronto Child Care Centre Study Group. Arch Pediatr Adolesc Med 1999; 153:495.
• Chung A, Perera R, Brueggemann AB, et al. Effect of antibiotic prescribing on antibiotic resistance in individual children in primary care: prospective cohort study. BMJ 2007; 335:429.
• Wroe PC, Lee GM, Finkelstein JA, et al. Pneumococcal carriage and antibiotic resistance in young children before 13-valent conjugate vaccine. Pediatr Infect Dis J 2012; 31:249.
• Tristram S, Jacobs MR, Appelbaum PC. Antimicrobial resistance in Haemophilus influenzae. Clin Microbiol Rev 2007; 20:368.
• Critchley IA, Jacobs MR, Brown SD, et al. Prevalence of serotype 19A Streptococcus pneumoniae among isolates from U.S. children in 2005-2006 and activity of faropenem. Antimicrob Agents Chemother 2008; 52:2639.
• Jacobs MR. Antimicrobial-resistant Streptococcus pneumoniae: trends and management. Expert Rev Anti Infect Ther 2008; 6:619.
• Jeffe JS, Bhushan B, Schroeder JW Jr. Nasal saline irrigation in children: a study of compliance and tolerance.Int J Pediatr Otorhinolaryngol. 2012 Mar. 76(3):409-13.
• Wei JL, Sykes KJ, Johnson P, He J, Mayo MS. Safety and efficacy of once-daily nasal irrigation for the treatment of pediatric chronic rhinosinusitis.Laryngoscope. 2011 Sep. 121(9):1989-2000.
• Kairys SW, Olmstead EM, O'Connor GT. Steroid treatment of laryngotracheitis: a meta-analysis of the evidence from randomized trials. Pediatrics 1989; 83:683.
• Russell KF, Liang Y, O'Gorman K, et al. Glucocorticoids for croup. Cochrane Database Syst Rev 2011; :CD001955.
• Tibballs J, Shann FA, Landau LI. Placebo-controlled trial of prednisolone in children intubated for croup. Lancet 1992; 340:745.
• Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med 2004; 351:1306.
• Geelhoed GC, Macdonald WB. Oral and inhaled steroids in croup: a randomized, placebo-controlled trial. Pediatr Pulmonol 1995; 20:355.
• Cetinkaya F, Tüfekçi BS, Kutluk G. A comparison of nebulized budesonide, and intramuscular, and oral dexamethasone for treatment of croup. Int J Pediatr Otorhinolaryngol 2004; 68:453.
• Garbutt JM, Conlon B, Sterkel R, et al. The comparative effectiveness of prednisolone and dexamethasone for children with croup: a community-based randomized trial. Clin Pediatr (Phila) 2013; 52:1014.
• Connors K, Gavula D, Terndrup T. The use of corticosteroids in croup: a survey. Pediatr Emerg Care 1994; 10:197.
• Kaditis AG, Wald ER. Viral croup: current diagnosis and treatment. Pediatr Infect Dis J 1998; 17:827.
• Johnson D. Croup. Clin Evid 2005; :310.
• Alberta Clinical Practice Guideline WorkingGroup. Guideline for the diagnosis and management of croup. 2008. www.topalbertadoctors.org/download/252/croup_guideline.pdf
• Skolnik NS. Treatment of croup. A critical review. Am J Dis Child 1989; 143:1045.
• Dulfano MJ, Adler K, Wooten O. Physical properties of sputum. IV. Effects of 100 per cent humidity and water mist. Am Rev Respir Dis 1973; 107:130.
• Fanconi S, Burger R, Maurer H, et al. Transcutaneous carbon dioxide pressure for monitoring patients with severe croup. J Pediatr 1990; 117:701.
• Ward MA. Emergency department management of acute respiratory infections. Semin Respir Infect 2002; 17:65.
• Shah RK, Roberson DW, Jones DT. Epiglottitis in the Hemophilus influenzae type B vaccine era: changing trends. Laryngoscope 2004; 114:557.
• Glynn F, Fenton JE. Diagnosis and management of supraglottitis (epiglottitis). Curr Infect Dis Rep 2008; 10:200.
• Sobol SE, Zapata S. Epiglottitis and croup. Otolaryngol Clin North Am 2008; 41:551.
• Cherry JD. Epiglottitis (supraglottitis). In: Textbook of Pediatric Infectious Diseases, 6th, Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL. (Eds), Saunders, Philadelphia 2009. p.244.
• Asher MI. Infections of the upper respiratory tract. In: Pediatric Respiratory Medicine, Taussig LM, Landau LI. (Eds), Mosby, St. Louis 1999. p.540.
• Panitch HB. Respiratory syncytial virus bronchiolitis: supportive care and therapies designed to overcome airway obstruction. Pediatr Infect Dis J 2003; 22:S83.
• Willwerth BM, Harper MB, Greenes DS. Identifying hospitalized infants who have bronchiolitis and are at high risk for apnea.Ann Emerg Med. 2006 Oct. 48(4):441-7.
• Neuman MI, Kelley M, Harper MB, File TM Jr, Camargo CA Jr. Factors associated with antimicrobial resistance and mortality in pneumococcal bacteremia.J Emerg Med. 2007 May. 32(4):349-57
• Barber J Jr. Narrow-Spectrum Antibiotics Effective for Pediatric Pneumonia.Medscape Medical News. Oct 29 2013.
• Williams DJ, Hall M, Shah SS, et al. Narrow Vs broad-spectrum antimicrobial therapy for children hospitalized with pneumonia.Pediatrics. 2013 Nov. 132(5):e1141-8.
• Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the pediatric infectious diseases society and the infectious diseases society of america.Clin Infect Dis. 2011 Oct. 53(7):e25-76.
• Clark RH, Bloom BT, Spitzer AR, Gerstmann DR. Empiric use of ampicillin and cefotaxime, compared with ampicillin and gentamicin, for neonates at risk for sepsis is associated with an increased risk of neonatal death. Pediatrics. 2006 Jan. 117(1):67-74
• Karsch-Völk M, Barrett B, Kiefer D, et al. Echinacea for preventing and treating the common cold. Cochrane Database Syst Rev 2014; :CD000530.
• Lissiman E, Bhasale AL, Cohen M. Garlic for the common cold. Cochrane Database Syst Rev 2014; :CD006206.
• Hemilä H, Chalker E. Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev 2013; :CD000980.
• Kurugöl Z, Akilli M, Bayram N, Koturoglu G. The prophylactic and therapeutic effectiveness of zinc sulphate on common cold in children. Acta Paediatr 2006; 95:1175.
• Vakili R, Vahedian M, Khodaei GH, Mahmoudi M. Effects of zinc supplementation in occurrence and duration of common cold in school aged children during cold season: a double-blind placebo-controlled trial. Iran J Pediatr 2009; 19:376.