Acute respiratory infections in children (ALRI control programme)

Acute respiratory infections in children

Every year 12 million children in developing countries die in the first five years of life.

Acute respiratory infections (ARI) are responsible for 19% of these deaths

25% of ARI deaths occur in young infants (less than 2 months of age)

50% occur in infants.

acute respiratory infections occur more frequently than diarrhea

25 percent of outpatient visits and 15% of all hospital admissions in young children are for ARI

Terms used to define acute respiratory infections

Acute Respiratory Infections (ARI) are classified as

Acute upper respiratory tract infections (AURI)

-         common cold

-         otitis media

-         pharyngitis.

Acute lower respiratory tract infections (ALRI)

-         croup, which includes epiglottitis, laryngitis and laryngotracheitis

-         bronchitis,

-         bronchiolitis,

-         Pneumonia

ARI include all the above conditions which are of less than 30 days duration

acute otitis media is an ear infection of less than 14 days duration.

GUIDELINES FOR THE MANAGEMENT OF ACUTE UPPER RESPIRATORY INFECTIONS

Acute upper respiratory infections include

-         acute otitis media

-         mastoiditits

-         sinusitis

-         common cough and cold.

Colds causes fever in young child, can last from a few hours to 3 days.

Nasal discharge can lead to nasal obstruction, can interfere with breast feeding and cause difficult breathing.

The nasal discharge often starts as a clear discharge and then becomes thick, yellow and purulent in appearance.

Treatment of cough and cold

Antibiotic therapy should not be given for purulent nasal discharge, high fever or a congested throat.

Use of antibiotic prophylactically to avoid complications is not beneficial.

A thick yellow discharge during a common cold can be either thick mucus (containing sloughed epithelial cells from intense viral infections) or mucopurulent discharge containing leukocytes. Antibiotics do not help in such cases.

For high fever or pain, give paracetamol.

Clear the nose if discharge interferes with feeding.

If the nose is blocked with dry or thick mucus, put drops of salted water into the nose or use a moistened wick to help soften the mucus.

Advise the mother not to buy medicated nose drops as these can be harmful.

Soothe the throat and relieve the cough with safe remedies such as tea with sugar or other warm fluids; these should not be given to very young infants.

Cough and cold remedies that contain atropine, codeine, alcohol, phenergan or high doses of antihistaminics should be avoided.

Cough and cold remedies and antibiotics do not alter the duration of cold nor they prevent pnuemonia or otitis media.

Simple cough syrups free of codeine, such as dextromethorphan syrup, may be used only in children with exhausting cough associated with severe vomiting.

Etiology of pneumonia in children

Culture

            Blood culture

nasopharyngeal aspirates or washings for Viral agents

bacteria cause a large proportion of pneumonia in developing countries.

two most common bacterial agents causing pneumonia in children aged 2 months to 5 years

Streptococcus pneumoniae

Haemophilus influenzae

Mixed bacterial and viral infections may also occur

children diagnosed to have pneumonia by definition should receive antibiotic treatment.

pneumonia in less than 2 months of age

            Gram positive cocci and Gram negative bacilli

            antibiotics must provide a broad-spectrum coverage against gram positive and gram negative organisms.

Effectiveness of the standard case management algorithm

lack of antibiotic treatment is an important reason for the high mortality rates from pneumonia

duration of illness, from the appearance of signs of pneumonia to death is 3 - 4 days.

Infants and children who have cough or difficult breathing should be assessed for possible pneumonia.

Young infants may have pneumonia even when they do not have cough or difficult breathing

Clinical definition of pneumonia is based on fast breathing and lower chest indrawing .

Fast breathing

Less than 2 months                   60 or more

2 months up to 12 months         50 or more

12 months up to 5                     40 or more

Auscultation - crepitations may be heard

By auscultation lobar consolidation may be missed in infants.

Fever is not a good predictor of pneumonia

malnourished children may not have fever during pneumonia

Fever >37.5°C

The degree and the duration of fever or the response of fever to antipyretics are not helpful in differentiating viral from bacterial lower respiratory tract infections.

presence of fast breathing or chest indrawing can identify pneumonia

auscultation is important to detect complications

-         pleural effusion

-         pneumothorax

-         associated cardiac defects

hypoxia, indicates greater severity of pneumonia

Lower chest indrawing indicates severe pneumonia.

Inability to drink and lethargy or unconsciousness appear later - when present indicate hypoxia

Head nodding indicates severe respiratory distress.

Respiratory grunting is sign of hypoxia in young infants.

Central cyanosis is seen in terminal stages of hypoxia

Age less than 2 months and severe malnutrition - poor outcome

Value of chest radiology - Routine use of chest X-ray is therefore not recommended.

Segmental or lobar consolidation on chest X-ray, which is considered typical of bacterial pneumonia, may frequently be caused by viruses.

Conversely, diffuse or disseminated infiltrates, which suggest a viral infection, are often caused by bacteria or by a combination of bacteria and viruses.

What is the role of chest X-ray in differentiating bronchiolitis from wheezing primarily due to bacterial pneumonia?

X-ray chest fails to differentiate these clinical sub groups. H. influenzae or S. pneumoniae pneumonia have wheezing.

Thus presence of wheezing does not indicate that the child does not have pneumonia.

The common practice among experienced pediatricians of giving antibiotics to all children with wheezing and fast breathing or respiratory distress irrespective of X-ray findings is sound and practicaL.

Role of other laboratory investigations in the diagnosis of pneumonia

White blood cell count and its differential, erythrocyte sedimentation rate and C-reactive protein do not differentiate between viral and bacterial etiology

ASSESSMENT, CLASSIFICATION AND TREATMENT OF CHILDREN AGED 2 MONTHS TO 5 YEARS WITH COUGH OR DIFFICULT BREATHING

Assessment of the child

Age of the child

Cough and its duration

Ability to drink or breast feed

History of convulsions during the current illness

Fever and its duration

Recent measles

Assessment of physical signs

The two most important signs during physical examination are the respiratory rate and chest indrawing.

Respiratory rate

Look at movement of the abdomen or the lower chest

Respiratory rates counted for 60 or 30 seconds

Counting for only 15 seconds is unreliable.

Count breaths by marking time with a wrist watch. Place one hand on abdomen feel the abdominal movement-  look at the watch in the other hand

Chest indrawing

Chest indrawing is defined as a definite inward motion of the lower chest wall on breathing in. Intercostal or supraclavicular retractions, in which only the soft tissue between the ribs or above the clavicles goes in when the child breathes in, do not indicate chest indrawing.

Nasal flaring

Nasal flaring is defined as outward movement of the side of the nostrils on breathing in.

Central cyanosis

Cyanosis of the tongue suggests hypoxia. It should be looked for in good light. Cyanosis may not be present in a hypoxic child who is anemic. Peripheral cyanosis can occur as a result of chilling or shock.

Head nodding

Head nodding is a movement of the head synchronous with inspiration indicating use of accessory muscles in severe respiratory distress.

Wheezing

It is important to determine if the child with cough is wheezing.

hear the wheeze by putting the ear close to the child's mouth.

Wheezing could be recognized by watching the child breathe.

A child with wheeze takes longer than normal to breathe out (prolonged expiratory phase)

In wheezing children, chest indrawing may be present even with mild bronchospasm or small airway obstruction from bronchiolitis.

Children with wheezing may have fast breathing -but chest indrawing may be present even at lower respiratory rates.

In a child with wheezing the presence of chest indrawing does not always indicate severe pneumonia.

Stridor

is a harsh noise on breathing in. Stridor is considered to be significant only if heard in a calm child. Children, who have stridor even when calm, must be hospitalized.

Assessment of severely malnourished children

Severely malnourished children may have pneumonia and yet have neither fast breathing nor chest indrawing

muscular effort is lacking in the severely malnourished child.

ALL severely malnourished children must be carefully evaluated for the presence of pneumonia, septicemia or urinary tract infection.

Chest X-ray not obtained routinely to confirm pneumonia

the treatment decision is made before seeing the X-ray.

Chest radiography may be obtained whenever additional information is essential.

Like

Very severe and severe pneumonia

            to exclude empyema and pneumothorax

staphylococcal pneumonia

Non response to initial antibiotic therapy

Cases of persistent cough (>30 days)

History of foreign body inhalation

evaluation of cardiac status e.g. to exclude congestive heart failure or

pericarditis.

Who should be hospitalized among those screened for pneumonia?

Those who need

-         intravenous drugs

-         monitoring

-         x-ray chest for detection of complications,

-         oxygen for hypoxia.

-         bronchodilators for wheezing and airway management for severe stridor

Treatment of non-severe pneumonia in children aged 2 months to 5 years

Which antimicrobials can be initially used to treat pneumonia that is not severe?

S. pneumoniae and H. infLuenzae are the two commonest bacterial causes of pneumonia in children older than 2 months

initial antibiotic for pneumonia –

cotrimoxazole is usually used for the following reasons:

S. pneumoniae and H.influenzae are generally sensitive to Cotrimoxazole.

Clinical efficacy of Cotrimoxazole in the treatment of pneumonia –

cure rates similar to ampicillin, amoxicillin and procaine penicillin.

The time taken for recovery did not show any differences with these three antibiotics.

Resistance to Cotrimoxazole not reported so far

low cost

 administered in two daily doses

. Serious side effects to Cotrimoxazole are rare in children.

oral cotrimoxazole, ampicillin, amoxycillin

Treat high fever (above 38.5°C) with paracetamoL.

Treat wheezing if present.

Advise the mother to watch for

- is not able to drink

- becomes sicker

- develops a fever (if not present earlier)

On day 3, most cases will be improving.

Recommendations for hospital management of very severe and severe pneumonia in children 2 months up to 5 years

Steps in the treatment of children with very severe pneumonia

Treat as an inpatient

Initial antibiotic treatment:

chloramphenicol 25 mg/kg 1M or IV every 8 hours

or Benzyl Penicillin 50,000 units/kg 1M or IV 6 hourly plus an aminoglycoside (for example, gentamicin 7.5 mg/kg once a day).

Chloramphenicol 1M or IV is used for the initial 3-5 days and as the child is better by then, changed to oral chloramphenicol thereafter for a total duration of 10 days.

Assess response to antibiotics at 48 hours:

If the child is not improving by then or when there is suggestion of staphylococcal etiology, treat with cloxacillin 50 mg/kg 1M or IV every 6 hours plus gentamicin 7.5 mg/kg 1M once a day.

Vancomycin is a highly effective anti staphyloccocal agent but its use is limited because of its cost. The indicators of staphyloccocal etiology are:

a) rapid progression of clinical disease despite treatment b) empyema

c) pneumothorax with effusion or pneumatocoeles seen on X-ray chest

d) multiple skin pustules or soft tissue infection

Steps in the treatment of severe pneumonia

Treat as an inpatient

Initial antibiotic treatment:

give benzyl penicillin (or ampicillin) 1M 6 hourly.

If beta lactamase producing H.influenzae are common in the region, use chloramphenicol 1M as initial treatment for both very severe and severe pneumonia.

Assess response to antibiotics after 48 hours:

If the child is improving, switch to oral amoxycillin or ampicillin or daily procaine penicillin 1M injections.

Antibiotic treatment should be given for at least 5 days and for 3 days after the child is well.

If the child is not improving by 48 hours,

            change benzyl penicillin/amoxycillin to chloramphenicol 1M as one may be dealing with a beta lactamase producing H.influenzae. In case of non-response to chloramphenicol, then as for very severe pneumonia, change to parenteral cloxacillin plus an aminoglycoside like gentamicin; this latter combination provides cover against staphylococci and gram negative bacilli. Cloxacillin is administered 1M or IV 50 mg/kg every 6 hours.

Indicators of good response to antibiotics in severe and very severe pneumonia:

Subsiding fever

Less severe chest indrawing, it should almost disappear by 48 hours.

Decreasing respiratory rate.

Child begins to drink and eat better.

Why is chloramphenicol used as initial therapy for very severe pneumonia?

Chloramphenicol is active against nearly all the bacterial species that cause pneumonia in young infants and children. These include S.pneumoniae, S.aureus, S.pyogenes, Group B

streptococcus, L. monocytogenes, H. influenzae (including beta lactamase producing strains), and most Gram negative enteric bacteria such as E.coli and Klebsiella spp. Chloramphenicol resistant H.influenzae strains occur but are rare; a survey of 426 isolates of Haemophilus spp. in developing nations showed that 1.6% were resistant to the drug

What is the optimal route for chloramphenicol administration?

In severe pneumonia, chloramphenicol may be given intramuscularly or intravenously,

there is no difference in absorption between intramuscular and intravenous administration of chloramphenicol sodium succinate.

Chloramphenicol is efficiently absorbed by the oral route and as the child's condition begins to improve it should be administered orally.

25 mg per kg every 8 hoursimaximum 1 gm per dose

Vial of 1 g; mix with 4 ml sterile water

25 mg per kg every 8 hours, maximum 1 gm per dose

125 mg/5ml suspension (palmitate)

250 mg capsule

Monitoring of the child's progress

Children with very severe pneumonia should be monitored by a nurse 3 hourly and by a physician at least twice a day. Children with severe pneumonia should be monitored by a nurse 6 hourly and by a physician at least once a day.

Discharge from the hospital

The child should not be discharged too early as the child may worsen at home and may even die. The child should be considered for discharge only after: .

. The clinical condition has improved markedly

1. No lower chest indrawing or fast breathing

2. Afebrile

3. Alert

4. Eating and sleeping normally

Oral antibiotic treatment has been started

In case the patient is a malnourished infant or child or is 'a non-breastfed infant, weight gain on 2 consecutive days has been observed

ASSESSMENT AND TREATMENT OF SICK YOUNG INFANTS (0-2 MONTHS OF AGE)'FOR EVIDENCE OF POSSIBLE SERIOUS BACTERIAL INFECTION

Symptoms and signs of pneumonia, septicemia or meningitis are often indistinguishable during the first two months of life and it is necessary to look for certain non-specific signs that indicate that the young infant may have a possible serious bacterial infection. These features include:

Convulsions

Bulging fontanelle Lethargy or unconsciousness

Less than normal movement

Fever'(axillary temperature 37 .5°Cor more) or low body temperature (axillary temperature       below 35.5°C)

Many or severe skin pustules

Umbilical redness extending to the skin

Fast breathing (respiratory rate  60 per minute) . Severe lower chest indrawing

Nasal flaring

Grunting

Not able to feed at all Abdominal distension

Cough and severe undernutrition (weight <2.0 kg during the first month, <2.5 kg during the second month, or presence of visible severe wasting)

Points to remember while assessing young infants

As cough may be absent, respiratory rate should be measured in all neonates

Cough is not an essential criterion for screening for pneumonia in this age group.

The normal resting respiratory rate is higher and more variable than in the older infant,

the diagnosis of pneumonia is 60 breaths per minute or more.

In the young infant the respiratory rate should be measured for a full minute since they may have periods of apnea or irregular breathing normally.

normal young infants have mild chest indrawing because their chest wall is soft.

severe chest indrawing, is very deep and easy to see, is sign of severe pneumonia.

observe in different positions, lying flat in the mother's lap or .on a bed.

Chest indrawing is significant if it is present all the time, in all positions and not only when the child is crying or upset but also when calm and peaceful.

In case the mother complains that the infant is feeding less than normal, then observe breast feeding for 4 minutes and look for attachment to the breast and sucking.

Good attachment means chin touching breast, mouth wide open, lower lip turned outward and more areola visible above than below the mouth.

Good sucking is indicated by slow deep sucks, with some pauses.

If there is no attachment with breast at all or no sucking at all, possible serious bacterial infection should be suspected.

Value of laboratory investigations in diagnosis of serious bacterial infection in young infants

blood culture

X-ray chest

- findings suggestive of meningitis indicate the need for a cerebrospinal fluid examination.

- Blood sugar and calcium estimation may be required if convulsions occur.

Clinical classification of sick young infants

Possible serious bacterial infection - pneumonia, septicemia or meningibs

Presence of any of the following in a young infant thought to be sick by the mother:

Convulsions

Bulging fontanelle Lethargic or unconscious

Less than normal movement

Fever (axillary temperature >37.5 °c) or low body temperature)            (axillary temperature <35.5 °c)

Many or severe skin pustules

Umbilical redness extending to the skin

Fast breathing (respiratory rate  60 per minute)

Severe chest indrawing Nasal flaring

Respiratory grunting

Cough and severe undernutrition (weight <2.0 first month, <2.5 kg in the second month, or visible severe wasting)

Not able to feed at all, or no

or no sucking at all

Local bacterial infection

Red umbilicus or umbilicus draining pus, or Skin pustules­

Recommendations for treatment of possible serious bacterial infection in infants less than 2 months of age

Rationale for choice of antibiotics

common isolates were Gram-positive cocci, especially Streptococcus pneumoniae

group A streptococci

Staphylococcus aureus

Gram-negative rods including E.coli

Salmonella

Streptococcus pneumoniae emerged as the most common organism in the second and third month of life and an important pathogen in the first month

antibiotics should be effective against both Gram-positive and Gram-negative organisms.

A combination of benzylpenicillin and gentamicin provides this wide coverage.

Specific steps in treatment:

.Give ampicillin 50 mg/kg or benzylpenicillin 50,000 units/kg every 6 hours 1M or IV plus gentamicin (7.5 mg/kg once daily).

In the first week of life, give the benzylpenicillin every 12 hours.

Continue the treatment for 4 days after the child is well.

After the infant's condition has substantially improved, give

            oral amoxicillin (15 mg/kg every 8 hours) plus 1M gentamicin (7.5 mg/kg once daily).

If meningitis is suspected, treat for 14 days or until infant has remained well for 4 days, whichever is longer.

            Ampicillin plus Gentamicin more effective

Staphylococcal etiology, treat with Cloxacillin plus Gentamicin.

            The dose of Cloxacillin is 50 mg/kg every 6 hours while that of Gentamicin 7.5 mg/kg every 24 hours. Vancomycin is highly effective against Cloxacillin resistant staphylococci but is very expensive. The indicators of staphylococcal etiology are:

(a) rapid progression of clinical disease despite treatment

(b) empyema

(c) pneumothorax with effusion or pneumatocoeles on X-ray

(d) presence of multiple skin pustules or soft tissue infection supports the diagnosis

If there is no response in the first 48 hours or if infant's condition deteriorates

change to 1M or IV cefotaxime (50 mg/kg every 6 hours) plus 1M ampicillin (50 mgjkg every 6 hours).

In administering Gentamicin, it is preferable to calculate the exact dose based on the child's weight          and to avoid using undiluted 40mgjml Gentamicin.

Additional supportive care essential for young infants

Maintain a good thermal environment

Keep in a warm room (25°C). - Small with a low ceiling and has curtains over the windows.

infants keep dry and well wrapped and hold close to the mother's body.

A cap to prevent heat loss from the head.

heat lamp or a radiant warmer

The hands and feet of the infant should be warm to touch.

Careful fluid management

breast feed frequently

give 20 ml of milk per kg of body weight by nasogastric tube 6 times a day (total 120mL/kg/day). Expressed breast milk is the best.

SUPPORTIVE MANAGEMENT FOR INFANTS AND CHILDREN WITH ACUTE LOWER RESPIRATORY TRACT INFECTIONS

Oxygen therapy

The indications for oxygen therapy in infants and children with ALRI are: 

-         central cyanosis

-         inability to drink or breast feed .

-         severe lower chest indrawing

-         head nodding

-         grunting with every breath

-         respiratory rate of 70 breaths per minute or more

Administration of oxygen

given through nasal prongs or a nasal or nasopharyngeal catheter.

Keep the child's nose clean and free of mucus;

Clean by putting 2 drops of saline in each nostril and clearing the nose with a soft rubber bulb syringe before feeding and sleeping. Excessive use of the bulb syringe or a suction catheter can cause irritation and swelling and should be avoided.

If giving oxygen by a nasal catheter:

Use an 8 FG catheter

If a nasogastric tube is required for feeding, it should be inserted through the same nostril as the oxygen catheter

catheter should be removed and cleaned daily.

Humidification -Change the water daily

Distension of the stomach with oxygen can worsen breathing difficulty.

If a nasogastric tube is required for feeding, it should be inserted through the same nostril as the oxygen catheter and the other nostril kept clear of mucus.

 Take care that the mucus does not plug the catheter.

Flow rate of oxygen

Young infants (below 2 months) 2 months up to 5 years

0.5 liters per minute 1-2 liters per minute

If a flow meter is not available, - the flow can just be felt on your cheek.

Monitoring a child on oxygen therapy

Nasal catheter or prongs out of position

leak in the oxygen delivery system

Oxygen flow rate not correct

Airway obstructed by mucus

Gastric distension

Feeding during acute respiratory infection

Common feeding problems during ARI are:

.Anorexia - when fever is present.

several episodes of ARI in a year à weight loss results if feeding is not optimal.

Difficulty in feeding due to respiratory distress.

Risk of aspiration in children with severe respiratory distress.

Restriction of certain foods or curtailment of feeding during ARI due to certain traditional beliefs and practices by the mothers and other family members.

Recommendations on feeding during pneumonia

Breast milk is accepted, even by anorexic children.

If the baby is unable to suck breast milk, express it and feed by cup and spoon.

In children with pneumonia, not requiring oxygen, give small calorie dense feeds every 2-3 hours. These may be milk cereal mixtures with added sugar + rice or biscuits)or cereal legume mixtures with added oil

Do not force feed as this may cause aspiration.

Avoid feeding children while they are on oxygen therapy

After recovery from pneumonia offer an additional feed to ensure catch up growth.

feeding in children with measles pneumonia, whooping cough and in those undernourished.

Use growth charts to monitor growth.

Fluid therapy in patients with ARI who have dehydration

Initial 6 hours:

If in shock, give Ringers Lactate 30mL/kg over 1 hour. Repeat if signs of shock persist.

If not in shock, give ORS 15-20mL/kg/hour for 2 hours

Give ORS at 10mL/kg/hour for the next 4 hours.

After 6 hours:

frequent breast feeding

If there are indications for use of maintenance IV fluids, give amounts as below:

Body weight                                          Maintenance fluid requirement mljday

<10 kg             100-120 mL/kg

10-19 kg          90-120 mL/kg

>20 kg             50-90 mL/kg

Indications for administering maintenance intravenous fluids

pneumonia - sick enough to receive oxygen is not fit to receive oral or nasogastric feeding.

Such patients require intravenous fluids. These children usually have one or more of the following:

Cyanosis

Restlessness

Severe lower chest indrawing Grunting

Shock and dehydration

Poor acceptance of oral fluids

MANAGEMENT OF WHEEZING IN A CHILD AGED 2 MONTHS TO 5 YEARS

Wheezing occurs when the flow of air from the lungs is obstructed due to narrowing of the small airways.

Infection or an allergic response cause narrowing of the airways by two mechanisms:

bronchospasm as a reaction to an infection or an allergic response

Swelling of the lining of the bronchioles

Causes of wheezing

The main causes of wheezing are:

Bronchiolitis

Asthma (recurrent wheezing), most common.

An inhaled foreign body

tuberculous nodes compressing a bronchus

Wheezing can also occur during respiratory infections including cases of pneumonia.

Both pneumonia and wheezing can cause chest indrawing and fast breathing..

Clinical signs

Audible wheeze

Prolonged expiratory phase of respiration

Effort in breathing out

Recommendations for treatment of an acutely wheezing child

First episode of wheezing but no respiratory distress

treated at home with supportive care

Children with wheezing and respiratory distress or those with recurrent wheezing

rapidly acting bronchodilator (salbutamol metered dose inhaler or nebulizer) repeated at 15-20 minutes

Doses of rapid acting bronchodilators

Nebulised Salbutamol (5 mg/ml) 0.5 ml Salbutamol plus 2.0 mL. Sterile water

Subcutaneous Epinephrine(adrenaline) 1:1000 (1mg/ml =,p.1% solution)

0.01 ml per 'kg

body weigpt; may be repeated after 20 minutes

Subcutaneous

Terbutaline 1:1000 dilution (lmg/ml)

0.01 mLjkg maximum dose 0.25 mL; may be repeated once after 20 minutes

Assess response 30 minutes after the last administration to decide whether the child needs inpatient care; some children may respond within 10-15 minutes only to relapse again, hence the need for reassessment after 30 minutes. If the child responds well, treat at home with oral salbutamol.

If respiratory distress persists,

treat as inpatient and

Give salbutamol inhalation, one dose every hour till response occurs for a maximum of three doses.

Give oxygen to all children whose difficulty in breathing interferes with talking, eating or breastfeeding.

Give first dose of oral or intravenous steroids; hydrocortisone 7mg per kilogram initially followed by 3mg/kg every 6-8 hours or prednisolone 1 mg/kg/day as soon as the child accepts orally.

Most cases require steroids only for 3-5 days as a short course.

Children with chronic asthma may require inhaled steroids for maintenance therapy

If there is no response after 3 hourly doses of salbutamol,

give an initial dose of aminophylline 5 mg/kg.

The dose should be given as an IV infusion over at least 20 minutes.

Give subsequent 6 hourly doses 5 mg/kg diluted as a slowinfusion over 6 hours.

Stop giving aminophylline if the child starts to vomit, develops a headache, has a very fast heart rate (more than 180 per minute) or has convulsions. Aminophylline is supplied as 250 mg in a 10 ml ampoule.

Indications for antibiotics

In the first episode of wheezing treat the child with antibiotics

the choice of antibiotics is similar to that for home treatment of pneumonia and inpatient treatment of severe pneumonia.

Antibiotics are not routinely indicated in children with recurrent wheezing even if they have fast breathing.

Such children should be given antibiotics only if they have fever or signs of severe pneumonia, e.g. lower chest indrawing, nasal flaring.

Indicators of good response to Nebulised salbutamol

Less respiratory distress

Less chest indrawing

Improved air entry

If a child fails to respond to the above therapy, or the child's condition worsens suddenly, obtain a chest X-ray to look for evidence of pneumothorax.

First episode of wheezing.

In infants less than 6 months of age, the first episode of wheezing is usually caused by bronchiolitis.

At 18 months or later, asthma is more likely.

The first episode of wheezing can also be due to bronchospasm induced by a viral, parasitic or bacterial respiratory infection.

In children with suspected bronchiolitis, inhalations of salbutamol should be continued only if there is evidence of response to its initial administration.

If nebulized salbutamol is ineffective, do not treat with epinephrine or aminophylline as they have a similar mode of action.

Good response to bronchodilators indicates that wheezing is caused by bronchospasm

the lack of response indicates that wheezing was caused only by mucosal edema.

Rapid acting bronchodilators and their administration

Salbutamol by metered dose inhaler

Recent evaluations suggest that salbutamol by metered dose inhaler is as efficient as by a nebulizer.

Infants and young children Lack the coordination to use a metered dose inhaler by themselves. Metered dose inhalers with a spacer device can be used for such children. Spacer devices are available commercially (750 ml volume) or can be made by modifying locally available containers (750-1000 ml):

If the older child can cooperate and breathe through a mouthpiece, an effective spacer can be made by placing the metered dose inhaler in the broad end of a one liter plastic bottle and using the mouth of the bottle as the mouth-piece.

Another simple device can be made by using a one liter polythene bag and inserting a mouth piece in one end of the bag and the inhaler in the other. Activate the inhaler to generate 2 puffs and instruct the child to inhale with the mouth closed around the mouthpiece for 5 breaths.

. Younger children, who are unable to use a mouthpiece, can inhale salbutamol from a spacer device with an opening that covers the child's nose and mouth. Insert the metered dose inhaler into the opposite end of the device and generate 3-4 puffs and let the child breathe for 30 seconds. Locally adapted spacer devices have included two plastic cups taped together or a plastic intravenous bottle.

Salbutamol by nebulizer

Liquid salbutamol can be nebulized by means of a foot pump or an electric air compressor. The flow should be at least 6-9 liters per minute. A continuous flow of oxygen can also be used but this wastes a large amount of oxygen.

Unscrew the top of the plastic nebulizer and add the salbutamol and 2 ml of normal saline or sterile water.

Attach one end of the tubing to the bottom of the nebulizer and the other to the foot pump or the electric air compressor.

Attach the mask (or T-piece) to the top of the nebulizer.

For infants and younger children who cannot cooperate, use the aerosol mask. It is not necessary for the mask to be tightly sealed to the child's face.

 The child should be treated until the liquid in the nebulizer has been nearly used up.        This usually takes 10-15 minutes.

Wash the mask with non-residue soap (such as dish washing detergent) prior to reuse. Wash the tubing and nebulizer daily.

Sterilization can be done by immersing in cidex solution for 4 hours.

MANAGEMENT OF A CHILD WITH STRIDOR

Stridor is a harsh inspiratory noise caused by inflammation of the oropharynx, epiglottis, larynx or trachea. Croup is the clinical syndrome characterized by stridor.

Stridor may be caused by

viral croup due to para-infLuenzae or respiratory syncytial virus.

Congenital malformation

a foreign body

measles, diphtheria (in some countries) or bacterial croup.

Bacterial croup can involve the epiglottis (acute epiglottitis, which is usually caused by H.influenzae) or the trachea (bacterial tracheitis).

Severe croup

Severe croup is characterized by:

Stridor in a calm child

Lower chest indrawing

In bacterial croup, there may be copious purulent sputum, high fever, drooling, severe airway obstruction and a prolonged course.

Examination of the throat should be avoided or done very cautiously since gagging can precipitate acute obstruction.

Treatment of severe croup

Admit to the hospital.

Give Chloramphenicol 1M or IV.

child is carefully supervised

tracheostomy equipment available.

Watch for signs of obstruction, - include severe chest indrawing, agitation and anxiety (air hunger) cyanosis.

If any of these signs are present, perform a tracheostomy.

Cold steam, cough suppressants and mucolytics are not effective.

Mild croup

Mild croup is characterized by a hoarse voice, a harsh barking cough and stridor only when the child is agitated. Stridor in a child with measles is an indication for admission, even if it occurs only when the child is upset or crying.

Treatment of mild croup

Treat at home.

ive home remedies as for cough and cold.

Antibiotic therapy is not indicated as most cases have a viral etiology.

PERSISTENT PNEUMONIA

In a small proportion of children pneumonia persists despite appropriate antibiotic therapy. The etiology in such cases may be

-         foreign body inhalation

-         unusual pathogens such as chlamydia and pneumocystis

-         Mycobacterium tuberculosis.

Foreign body inhalation

This possibility should be considered even when the history is not volunteered, particularly in children beyond 6-9 months of age.

Auscultation reveals localized wheeze or decreased air entry.

Chest X-rays may show unilateral (occasionally bilateral) obstructive emphysema (over inflation) due to partial obstruction or lobar/segmental atelectasis following complete obstruction of the lumen.

The foreign body must be removed through a bronchoscope.

Chlamydia pneumonia

This type of pneumonia usually occurs in infants less than 6 months of age.

prolonged duration not severe.

Erythromycin is effective

pneumocystjs carinjj pneumonia

immunologically impaired individuals

-         malnourished children

-         in those with immunodeficiency due to a malignancy, cytotoxic drugs or AIDS.

pulmonary findings disproportionate to severity of disease.

X-ray chest shows

            hyper expanded lung fields

            a generalized granular pattern,

            bilateral pulmonary infiltrates which originate at the hilum

Treatment is with trimethoprim (20mg/kg/24h) and sulpha methoxazole (100mgjkgj24h). If there is improvement after 1-2 weeks, continue for a total duration of 3 weeks.

Other causes of persistent pneumonia

If the above reasons for persistence are unlikely

Think of

            beta lactamase producing staphylococci,

            H.influenzae

            Klebsiella,

            tuberculosis

Look for segmental or lobar atelectasis

Bronchoscopic may be required.

Atelectasis may result from

            pressure of tubercular glands,

            luminal obstruction by thick purulent secretions

            a foreign body.

Treat with cloxacillin and an aminoglycoside such as gentamicin or amikacin for 4-6 weeks

chest physiotherapy.

CHRONIC COUGH

The common causes of chronic cough, defined as cough lasting longer than 30 days, in children are:

Asthma

Per:tussis

Tuberculosis

Foreign body inhalation

Drainage of secretions from upper airways

Indicators of severe lower respiratory tract disease in children with chronic cough

In the absence of the following signs, the respiratory problem is usually benign:

Persistent fever

failure to gain weight or grow

Clubbing

Persistent hyper inflation

persistent infiltrates on chest X-ray

Asthma

Many children with a chronic cough have asthma.

The cough is more common during the night.

If the other causes of chronic cough are not present, give oral salbutamoL.

If cough improves, it is likely to be asthma

the duration of bronchodilator therapy depends upon how the child does without it

if symptoms recur, it may have to be given for many weeks.