Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
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
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.
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.
Antibiotic therapy should not be given for purulent nasal discharge, high fever or a congested
throat.
2
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.
Culture
Blood culture
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.
3
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.
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.
4
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.
White blood cell count and its differential, erythrocyte sedimentation rate and C-reactive protein do
not differentiate between viral and bacterial etiology
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
5
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.
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.
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:
Recommendations for hospital management of very severe and severe pneumonia in children 2
months up to 5 years
7
Steps in the treatment of children with very severe pneumonia
Treat as an inpatient
Initial antibiotic treatment:
Treat as an inpatient
Initial antibiotic treatment:
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.
Subsiding fever
Less severe chest indrawing, it should almost disappear by 48 hours.
Decreasing respiratory rate.
8
Child begins to drink and eat better.
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
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.
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)
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.
10
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.
Fever (axillary temperature >37.5 °c) or low body temperature) (axillary temperature <35.5 °c)
Recommendations for treatment of possible serious bacterial infection in infants less than 2 months
of age
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
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.
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
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.
feeding in children with measles pneumonia, whooping cough and in those undernourished.
Use growth charts to monitor growth.
After 6 hours:
frequent breast feeding
If there are indications for use of maintenance IV fluids, give amounts as below:
Causes of wheezing
Bronchiolitis
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
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
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.
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.
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.
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.
17
. 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.
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.
Stridor is a harsh inspiratory noise caused by inflammation of the oropharynx, epiglottis, larynx or
trachea. Croup is the clinical syndrome characterized by stridor.
Severe croup
18
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.
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.
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.
This possibility should be considered even when the history is not volunteered, particularly in
children beyond 6-9 months of age.
19
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
CHRONIC COUGH
20
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