Pediatrics Tea

mWor
43
K
7
Respiratory
Infections
Done by:
Munira Almasaad

Revised by:
Aseel Badukhon

Team Leader:
Aseel Badukhon

Notes Previous Notes Book Important!

 Overview

Respiratory tract infection in children

● To know how common this problem in pediatric medicine.
● How to differentiate between upper respiratory tract infection and lower respiratory tract infection.
● To know epiglottitis in details (History, physical examination, etiology, differential diagnosis, management).
● To know the pneumonia (bacterial vs viral)

MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA IN CHILDREN

● Clinical features (How do children with CAP present?) community acquired pneumonia
● Etiology - Causes of CAP (virus, bacterial, atypical organism) does the etiology alter by age.
● Investigations.
● Severity assessment
● Managements
● Complications of CAP pneumonia (pneumatocele necrotizing pneumonia)

Pulmonary TB
● Local Epidemiology vs. inherited epidemiology
● Diagnosis, Intervention, managements,
● How to approach children with PPD (children and family)

Introduction

● Children have about 6 respiratory infection per year (normal)

● They are the the greatest of all causes of medical morbidity in pediatrics.
● Majority of acute respiratory infections are URTI but infection of lower respiratory tract are sufficiently
frequent to pose almost daily problems for clinician caring for children
● Large number of different microorganisms are capable of infecting the lower respiratory tract produces
several respiratory syndromes and illnesses.

Etiology of URTIs

● Viral: Influenza, Parainfluenza,RSV,Rhinovirus,Entero, Corona, Measles, Varicella, Adeno, EBV,CMV,

Herpes

● Mycoplasma: M. pneumoniae School age kids

● Rickettsia: Coxiella burnetii (Q fever)

● Chlamydia

● Bacterial: staph, H flu Pneumococcus

● Fungi: Candida, Histoplasma, Aspergillus

● Parasites: Pneumocystis carinii, Toxoplasmosis

- Staph. A is Very bad in children less than a year, it

destroys all the lung
- H. Flu not seen a lot after vaccines (atypical
infection)
- Pneumococcus is the most common cause of
pneumonia in all age groups
- Fungi & parasites are common in
immunocompromised children
 Secondary to anesthesia and ICU

The doctor went through them

Hypothyroidism & mucopolysaccharides
Any lesions on the vocal cords & post aggressive intubation

Upper airway
obstruction illness

Causes

Infectious
- Epiglottis
Non-infectious
-Laryngotracheobronchitis
- Foreign body (Croup)

- Trauma - Bacterial tracheitis

- Angioneurotic edema - Diphtheria

- Hypocalcemic tetany - Retropharyngeal abscess

- Caustic burns - Peritonsillar abscess

 Acute Epiglottitis

● Life- threatening condition characterized by upper airway inflammation and obstruction.

● Infection of epiglottis and supraglottic structures

● High risk of death (7%)

● Most common in male (ration of 2.5 to 1).

● may occur at any age.

● Age incidence 2-7 Y

● Vulnerable population include lower immunity

○ infants less than 12 months
○ elderly more than 85 years old

● Caused by almost always H.Influenzae type B(HIB) 90%

● No seasonal predilection in incidence of epiglottitis (Croup: more in fall and winter)

● Risk factors:
○ Absence of immunization against HIB
○ Immunocompromised state
○ Smoking
You can see it now a days in pt who didn't take vaccine

Pathology Life threatening

Direct invasion by HIB

Cellulitis with marked edema of the epiglottis, aryepiglottic folds, ventricular band and arytenoid.

Edema increase the epiglottis curls posteriorly and inferiorly

Airway obstruction

(Inspiration tend to draw the inflamed supraglottic ring into the laryngeal inlet)
 Clinical features

● Sore throat, followed by Odynophagia accompanied by drooling, retching and difficulty

breathing

● Voice is not hoarse but speech is muffled

● Cough is not croupy

● Stridor

● Marked Fever (38.8-40C)

● Child assuming posture that maximize the increase in diameter of the obstructed airway/
Sitting & leaning forward with hyperextension of the neck and protrusion of the chin)

● Lateral Neck: Thumb sign (in OSCE) this atypical the x-ray should not be done

- Thumb sign imp

If you see a child like this in the ER it Normal Inflamed
- X-ray is not done
is Epiglottis until proven otherwise epiglottis, inlet
routinely, only when the
is almost
case is atypical
obstructed
- green arrow: air is not
going down
Treatment No investigation is done

● Avoid stimulation of the child. This includes radiographs, drawing bloods, starting IV until secure airway
established don't do x-ray

Stabilization first then intubation

● Emergency Intubation: Elective* nasopharyngeal** intubation (ETT 0.5mm smaller than that required is
recommended)

● I.V Cefuroxime or cefotaxime for 7 days Second or third generation cephalosporins

● NO steroid

● Criteria for extubation:

○ Afebrile
○ Swallowing comfortable

* B.C emergency crush the odontoid fold

** Not oropharyngeal B.C its uncuffed so the child will remove it
 CROUP

● Age: 6 months - 3 years

● More in fall winter and spring

● URI (Rhinorrhea, Mild to moderate fever)

● Progress to inspiratory stridor, hoarseness and croupy cough

● Rib cage and abdominal asynchrony occurs as the condition deteriorates RED
FLAG this is a sign that he will have respiratory failure soon

● Most children have mild disease

● Last 7-14 days

● Among children admitted with croup less than 1% require intubation

● Lateral neck X-ray: Narrowing of subglottic area OSCE

Steeple or Rat tail sign, X-ray is not usually done it’s a clinical diagnosis
but know it for the exam
Q: 6 months old child come with respiratory stridor and low grade fever
this is his x-ray

Etiology
● Parainfluenza most common
○ Parainfluenza 1 (most common)
○ Parainfluenza 2 (less frequent)
○ Parainfluenza 3 (less common)
● Influenza
● RSV
● Adeno, rhino, entero,herpes
● M Pneumoniae if other family member have it

Treatment

● Moist air
● Oxygen
● IV fluid
● Steroid therapy: IM,PO, Inhalation (suppression of the local inflammatory reaction, shrinking of
lymphoid swelling and reduction in capillary permeability) Mainstay of treatment IM: in the thigh
○ 0.6mg/kg IM
● Aerosols: Recemic epi.: increase the airway diameter within 30 mints, however the effect is short
lived lasting for 2 hours Beware or rebound phenomenon (in two hours) observe for 2 hrs before
discharge
 Imp. For MCQs and OSCE
Know how to differentiate Already took them in ENT, you’re expected to
between them know them

Signs and Symptoms of MERS

● Fever > 38C (100.4F)
● Cough
● Shortness of breath
● Malaise
● Vomiting
● Diarrhea
● Pneumonia
● Incubation period about 5.2 days but can range up to 14 days
● Symptoms range from mild - severe
● Mean age: 56

PNEUMONIA

Factor relating to the etiology:

Host normal or Age preterm Season viral in the winter, Environment: animate (human
compromised babies bacterial in the summer and animals) and inanimate

For your information

Innate immunity in the lung is truly amazing. The lung has ~100 square meters of surface area (roughly the
size of a tennis court) and is directly exposed to the outside environment with every breath we take. Despite
this, the lower airway is normally sterile. There are many levels of innate immunity that keep the lung free of
pathogens, including

● filtering in the upper airways

● mucociliary clearance Causes primary ciliary dyskinesia
● antimicrobial factors
 Etiology

Bacterial S. pneumonia, H flu, Staph, GAS, TB

Viral RSV, parainfl (1,2,3), Inf, adeno, rhino especially type C, entero

Broader spectrum of etiological agents: fungi, gram negative bacilli,

Immunocompromised
pneumocystis carinii. anaerobes, CMV Very strange organisms

Most Common Causes of Pneumonia in Immunocompetent and Immunocompromised Children

over 1 month of Age

Immunocompetent Immunocompromised

● Streptococcus pneumonia
● Haemophilus influenzae
● Staphylococcus aureus ● Pseudomonas spp.
● Group A Streprococci ● Enterobacteriaceae
● Bordetella pertussis ● Legionella pneumophilia
● Moraxella catarrhalis ● Nocardia spp.
Bacterial
● Yersinia pestis ● Rhodococcus equi
● Pasteurella multocida ● Actinomyces spp.
● Brucella spp. ● Anaerobic bacteria
● Francisella tularensis ● Enterococcus spp.
● Neisseria meningitidis
● Salmonella spp.

● Mycoplasma pneumonia
● Chlamydia pneumonia
Bacteria- like
● Chlamydia trachomatis -
agents
● Chlamydia psittaci
● Coxiella burnetii

Bronchiolitis

VIRAL PNEUMONIA Viral pneumonia = Bronchiolitis

Most common cause of LRTI, RSV, parainfl (1,2,3), inf, adeno, rhino, entero
Know RSV Bronchiolitis from A-Z it’s very important

Treatment:

● Difficult to distinguish from bacterial pneumonia.

● Oxygenation and ventilator assistance in severe cases.

Clinical case

- January… ahmed 1 months…

- An older brother with an upper respiratory tract infection
- 3 days of rhinorrhoea and cough accompanied by low grade fever.
- Admitted to the Emergency Department for an episode of apnea with mild respiratory distress with
retractions and reduced oral intake of fluid (<50%) need an admission in the last 12 hrs.
Classical case of bronchiolitis
Clinical definition

● The diagnosis of bronchiolitis is a clinical one based on typical history and findings on physical
examination.
● Clinicians in different countries use different criteria to diagnose acute bronchiolitis.

The definition
● A consensus guidelines panel reported a 90% consensus on the definition of bronchiolitis as a seasonal
viral illness characterized by fever, nasal discharge and dry, wheezy cough.
● On examination there are fine respiratory crackles and / on high pitched expiratory wheeze.

Bronchiolitis definition

European:
American: 1. Age <12 months
1. Age <24 months 2. Signs of viral infection +
2. Signs of viral infection + wheeze widespread crackles +/- wheeze

Overview

● Lower respiratory tract infection in children <24 months of age.

● It involves large and small airways

○ tracheobronchitis, bronchiolitis and alveolar and interstitial lung involvement (pneumonia).

● Etiology:
○ Viral: RSV Respiratory syncytial virus, the most common cause ; adenovirus (3,7,21) if these
strains infect the child (or adult) they will destroy the lung (broncholitis obliterans) and he
will need a transplant influenza; , parainfluenza (3); rhinovirus; mumps.
○ Others: Mycoplasma pneumoniae

● RSV season?
○ Ubiquitous throughout the world
○ Seasonal outbreaks
■ Temperate Northern hemisphere ‫اﻟﺳﻌودﯾﺔ‬: November to April, peak January or February
■ Temperate Southern hemisphere ‫ اﺳﺗراﻟﯾﺎ‬: May to September, peak May, June or July
■ Tropical Climates: rainy season
■ In Saudi Arabia RSV appears in November and the seasonal peak occurs during Jan. &
Feb.

CXR
P/E
C/P - Tachypnea, chest
- Usually in Non-specific, air
retractions and
mid-winter trapping, atelectasis,
wheezing
and consolidation.
- Fever, rhinitis, - Mild conj. and otitis
cough, dyspnea poor media.
feeding and vomiting.
Clinical manifestations

● Exposure to children or adults with a respiratory viral infection.

● The initial symptoms are rhinorrhoea, cough and sometimes low grade fever. In 18% of cases
the first clinical symptom could be episodes of apnoea one of indication of ICU admission.

● With the relief of fever the child manifests tachypnoea, retractions, nasal flaring, rales and
hypoxemia

● Dehydration and metabolic acidosis.

● Syndrome of inappropriate secretion of antidiuretic hormone is common with severe respiratory

distress that's why we use ⅔ of maintenance.

● It is a dynamic disease and its clinical characteristics can quickly change

Pathophysiology

● Upper -> lower airways

● Peribronchiolar mononuclear infiltration
● Epithelial necrosis
● Airway plugging
● Hyperinflation, atelectasis, V/Q mismatching
● Hypoxemia, work of breathing

Pathology: RSV is number 1

Inflammation of small bronchi and bronchioles, sloughing of resp. ciliated epi.

The bronchioles are plugged with fibrin and mucus

bronchial obstruction

increase work of breathing + V/Q mismatching

hypoxemia

CO, retention is uncommon, but if present it may lead to assisted ventilation. It may lead to death

Pathogenesis know it for OSCE

● Mechanical occlusion of terminal and respiratory bronchiole with mucus, fibrin, epithelial cells
and inflammatory cells.

● Effects of the immunological reaction and of inflammatory mediators.

 Medium-size airway intraluminal cell fragments composed of
Missing pic dead epithelium, inflammatory cells and amorphous debris

Intraluminal debris includes mucus, fibrin, epithelial cells and

Missing pic inflammatory cells.

Missing pic Intrabronchiolar syncytia adjacent to intraluminal cellular debris

● Exposure to RSV first to an innate immunoregulatory

cascade beginning with airway responses from cells
constitutively present in airways. (Innate immune
response)

● These cells release a variety of mediators, which recruit

circulating monocytes, N cells and granulocytes that
participate in the inflammatory response. (Adaptive
immune response)

Consolidation + atelectasis + hyperinflated lung

(wide space between the ribs)

Air bronchogram

RSV bronchitis
Complications

Apnea because they get tired,

Bronch obliterans (esp.
Atelectasis they have small muscles and myocarditis
with adeno 1, 2, 3, 7 , 21)
respiratory failure

● Majority: Mild to moderate disease lasting 3-10 days, 2% require hospitalization; of those
3-7% develop respiratory failure and 1% die.

● High risk: Children with Cardiopulmonary disease (e.g. BPD bronchopulmonary dysplasia, CF,
VSD), immune deficiency and neonates.

Risk factors for severity Environmental risk factors

● Prematurity
● Low birth weight
● Age less than 6-12 weeks ● Older siblings primary infection to baby
● Chronic pulmonary disease ● Concurrent birth siblings
● Hemodynamically significant cardiac ● Native American heritage
disease CHF ● Passive smoke exposure
● Immunodeficiency ● Household crowding
● Neurologic disease ● Child care attendance
● Anatomical defects of the airways ● High altitude
Laryngotracheomalacia,tracheoesophag
eal fistula

Indications for hospitalization

● Prematurity
● Age <3 months
● Apnoea
● Severe underlying conditions
● Poor feeding (less than 50%) Not feeding because of respiratory distress
● Respiratory distress (RR > 60/min, nasal flaring, retractions) and cyanosis
● Oxygen saturation <92%

Phase of illness should be considered in the decision for timing of review or admission to hospital

Treatment
- X-ray (if needed): Look for
atelectasis or secondary infection
● Admit: if sig respiratory distress, dehydration, underlying disease. - Aspirate: to know if they have
● 02 sat, CXR, NP aspirate. Oxygen, IPPV (apnea, fatigue) IV fluid additional organisms (other than
● BD: 30% respond to salbutamol. RSV)
● Steroids: not recommended.
● Ribvirin The only antiviral for RSV : for RSV, Inf A & B to high risk group, given nebulization 12-18
hr/day for 3-7 days
● Recemic epi: Not used anymore
Case report

Prophylaxis for high risk patients, (CHF, CF,

Immunodeficiency, preterm babies)

After vigorous chest physiotherapy

Prevention of spread

● In hospital :
○ Meticulous infection control Isaacs D. Arch Dis Child 66,p226;1991
● At home:
○ Immunization? No vaccines available Only monoclonal antibodies
■ Formalin inactivated-> worse disease
■ Heat inactivated?
○ Passive immunity?
■ RSV-IG
■ Palivizimub For high risk, before winter, expensive (each dose 3000SR)
Discharge criteria

● Oxygen saturation stably remains ›90-94%

● Absence of respiratory distress
● Adequately oral intake to prevent (>75% of usual intake) to prevent dehydration
● Adequate parental care and family education very imp

Mycoplasma
pneumonia

● Peak incidence 5-15 year (account for 75% of pneumonia in this age group)

● C/P: Insidious onset of fever, headache and sore throat followed by dry cough that can last for months.

● Other organs: Meningoencephalitis, carditis, migratory arthralgia and arthritis, hemolytic anemia, +ve
coomb's and cold agglutinins. All can be caused by mycoplasma infection

● Investigations:
○ CXR: Not specific, unilateral or bilateral disease, 20% has pleural effusion
○ CBC: WBC is usually normal WBCs normal or slightly high
○ Cold agglutinin > 1:64
○ Serology: 4 fold increase in CFT

● Treatment: Erythromycin, may not alter the duration or sequela (may decrease the duration of cough).
Treatment: macrolides for 10 days

Bacterial
pneumonia

Etiology

Bacterial adhesion and invasion:

Very imp (even for OSCE). For antibiotics choice
- Streptococcus pneumoniae
● Neonatal period 1 month: GBS, listeria
monocytogenes and gram -ve bacilli All people
aspirate during
sleep
● After neonatal period: S pneumoniae, H.
flu type B, staph. Aureus, GAS.

● Mycoplasma is quite common >5y.

● After age of 4 - 5 years: S. pneumoniae

and mycoplasma responsible for the
majority of cases.
Pneumonia
The doctor went through it
Pathology

1. Normally the resp. tract is sterile below the vocal cords.

2. Pneumonia result from asp. Of pathogen to lower resp. tract.

3. Concurrent viral infection aid this process (present in 30-50% of cases) esp. RSV, because of a lot of
mucus measles and influenza.

C/P

● Fever
● Chills
● Cough
● chest and abdominal Pain
● Younger infants less specific symptom and signs they don't complain

Right upper lobe

Diagnosis

● CBC - dif, cold agglutinin WBCs very high 30-40,000

● CXR Lobar/bronchopneumonia

● Blood culture, sputum in older children Blood culture 30% positive (septicemia)

Treatment

1. Adequate oxygenation.

2. Depends on severity and age oral if mild, sever need admission + IV ABx: Ampi or amoxacillin (10-30%
of H flu are resistance) cefuroxime 75- 100 mg/kg/day Augmentin if resistant to amoxicillin

3. Older child: Pen or macrolides =>erythro (clarythromycine or zithromax)

- Child with RUL pneumonia, he will need antibiotics for longer periods (14 days) because if he doesn’t take
them orally the infection will spread
- Killing an infection in the lung is difficult because it’s difficult to penetrate
- if the child cannot take the ABx or not complaint you need to admit him

What are the indications for referral and admission to hospital?

● Significant tachycardia for level of fever (values to define tachycardia vary with age and with
temperature

● Prolonged central capillary refill time >2 s

● Difficulty in breathing

● Intermittent apnea, grunting

● Not feeding

● Chronic conditions (eg, congenital heart disease, chronic lung disease of prematurity, chronic respiratory
conditions leading to infection such as cystic fibrosis, bronchiectasis, immune deficiency).
Features of severe disease in an older child include:

● Oxygen saturation <92%, cyanosis

● Respiratory rate >50 breaths/min

● Significant tachycardia for level of fever (values to define Tachycardia vary with age and with
temperature

● Prolonged central capillary refill time >2 s

● Difficulty in breathing; grunting

● Signs of dehydration

● chronic conditions (eg, congenital heart disease, chronic lung disease of prematurity, chronic respiratory
conditions leading to infection such as cystic fibrosis, bronchiectasis, immune deficiency).

Complications

- Esp. with S. aureus, H flu, S pneumoniae. Can be thin transudate or thick exudates
(empyema)

- Send pl fluid for cell count, glucose, protein, pH, LDH and culture.
Parapneumonic - Empyema WBC > 15,000/mm3, protein >3 g/dI, pH <7.2
effusion
- Management: ABX + drainage, recovery is slow, fever continue for 1 - 2 weeks.

- Pleural tap: Usually exudate (revise light criteria please!!)

- Empyema: treatment for 6-8 weeks IV antibiotics

- Thin wall cavity

- complicate 40% of staph pneumonia

Pneumatoceles - unusual with other types

- Usually asymptomatic unless rupture pneumothorax or pyothorax With sports

- Resolve spontaneously within 3 months

- Esp in aspiration pneumonia in mentally retarded children.

- Esp. in the dependent portion of the lung.

Lung abscess
- Growth: mixed anaerobic bacteria

- Treatment: Pen G, clinda or flagyl.

- Children can present with symptoms and signs of pneumonia but also have features of
systemic infection.

Septicemia and - Children with septicemia and pneumonia are likely to require high dependency or intensive
care management.
metastatic infection
- Metastatic infection can rarely occur as a result of the septicemia associated with pneumonia.

- Osteomyelitis or septic arthritis should be considered, particularly with S aureus infections.

 - S pneumoniae is a rare cause of haemolytic uraemic syndrome.

- A recent case series found that, of 43 cases of pneumococcal haemolytic uremic

syndrome, 35 presented with pneumonia and 23 presented with
Hemolytic uraemic
syndrome
empyema. Although a rare complication.

Don’t forget to read about - in cases with pallor, profound anemia and anuria “renal shutdown”, this should be
HUS in general (this is a
common peds topic!!!!!!) considered.

Chest
tube 1 2

4 3

4 cysts

Eaten lung, takes time to recover

Right Effusion, air bronchogram (3,4 months

The predisposing factors to necrotizing pneumonia include

● Congenital cysts
● Sequestrations
● Bronchiectasis
● Neurological disorders
● Immunodeficiency

Certain serotypes of pneumococcal disease are more likely to lead to necrotizing pneumonia and abscess
formation than others
● S aureus with Pantone Valentine leukocidin toxin can lead to severe lung necrosis with a high risk of
mortality
 TUBERCULOSIS

● The vast majority of childhood TB occur in children < 4 y usually after exposure to an infected adults.
(i.e. children infected with TB always have an adult with active TB in their environment).

● Transmission is by droplet nuclei

● Its distribution is worldwide

● Multi-drug resistance has emerged as an important clinical problem direct observed therapy is needed

● Infection in patients with HIV infection initially lead to increases in the number of cases

● Adults with cavity harbor a great no. of bacilli for long time. They become non- infectious 2 weeks after
therapy.

● Children with primary TB are rarely infectious, TB bacilli are sparse, but they are the long term reservoir
of infection in the population.

TB always is a differential to pneumonia in a child you have to

mention it in the OSCE

Etiology

● Mycobacterium tuberculosis & M. bovis Culture takes 4-6 w, sensitivity another 4 w.

● Radiometric methods, detection & sensitivity 4-10 d.

● By DNA proves detection within 2 hrs.

Problems in the diagnosis of TB

Active disease Latent infection

M. tuberculosis is difficult to isolate: even with M. tuberculosis cannot be cultured from
good microbiological facilities, the bacillus is latently infected individuals: no gold standard
recovered in only 50-60% of cases

Clinical manifestations

● Insidious onset
● Weight loss
● Anorexia
● Fever
● Hepatosplenomegaly
● Headache almost always = meningitis
● Abdominal pain and tenderness usually = peritonitis
● Skin and eye tubercles (Tuberculous Uveitis )

PPD - ve in 30% CXR May be characteristic

Smear examination diagnosis

● Strongly consider TB in patients with smears containing acid-fast bacilli (AFB)

● Results should be available within 24 hours of specimen collection

● Presumptive diagnosis of TB

● Sensitivity 5-10000 bacilli/ml speciment

Risk factors for TB in children

● Most children acquire infection from adults, thus the epidemiology of TB in children follows that of
adults

● The distribution of TB in children is a marker of recent ongoing transmission in the community

● The diagnosis of TB is difficult in children, and children are usually not infectious

● This underlines the importance of contact tracing

Bacteriologic confirmation

● Problematic in children
○ Pauci-bacillary disease, often poor yield
○ NB! BUT still do culture if possible

● Which specimen to collect?

○ Gastric aspirate (fasting, early morning)

■ Induced sputum / Assisted sputum
■ Broncho-alveolar lavage
■ String test

○ Fine needle aspiration or excision biopsy Not incision biopsy

Timetable of disease after primary infection in children

- TST response
3-8 weeks - Hypersensitivity reactions
- Erythema nodosum

1-3 months - Hematogenous spread (meningitis and miliary in infants)

- Bronchial disease (< 5 years)

3-7 months
- Pleural effusions (>5 years)

- Osteo-articular disease
1-3 years - Calcifications
- Adult-type disease

>3 years - Reactivation

BCG
● BCG vaccination is effective against severe forms of TB (meningitis and miliary TB)

● TB testing is not required before BCG vaccination in young children

● BCG can be used as a diagnostic test for TB (Koch phenomenon)

● Complications are rare and are not more common in TB patients (10371 / 1.5 billion BCG)

● BCG vaccination is not recommended in HIV-positive children

TB can’t be differentiated from other

pneumonia You have to rule it out

Complications

Most occur in the 1st year.

● Miliary TB & TB meningitis: not later than 3-6 mo. after initial infection.

● Endobronchial TB: within 9 mo.

● Bones or joints: within 1 y.

● Renal: 5-25 y.

● Secondary reactivation.

Suggested criteria for diagnosis of TB in children

(Suspected/probable)
Any three of the following:

1. History of contact with an adult with suspected or proven

2. Symptoms and signs of TB such as persistent fever, cough, ,weight loss, failure to thrive, anorexia,
respiratory distress, decreased breath sounds, rales on chest examination, lymphadenopathy, etc.
3. Positive Mantoux or PPD more than 10 mm of indurations Not redness
4. Chest radiographic Findings such as an infiltrate or Lymphadenopathy

Confirmed:

● A positive AFB smear or culture of gastric aspirate or other body Fluid OR

● Histological Findings consistent with TB
Treatment

First line Second line

● NH
● Rifampin
● Para-aminosalicylic acid
● Pyrazinamide
● Ethionamide
● Ethambutol
● Caperomycin
● Streptomycin
● Kanamycin
You have to know the side effects of these
● Cylcoserine
medications like hepatitis, change in urine color
and vision

● INH + rifampin X 9 mos. Will cure 98%.

● Shorter courses (6 mos.) using more drugs; INH, rifampin and pyrazinamide for 2 mos. followed by 4
mos. of INH and rifampin.

The 9 mos. approach is the one recommended for children. The course is 9 months in children not 6 months

● STEROIDS
○ Use only with anti-TB med not alone indicated in:
1. TB meningitis and increased ICP due to brainstem inflam and resultant HC.
2. Endobronchial TB => collapse or air trapping.
3. Miliary TB with pericarditis, pleural effusion or peritonitis.

Treatment of latent TB infection

● Regimens
○ INH 6 months (since 1965)
○ RIF + PYR 2 months
○ RIF + INH 3 months (France and Britain)
○ (RIF 4 months)
○ (CDC trial with a long acting RIF: rifapentine)

● INH recommended worldwide

○ efficacy 93%

● A shorter and safer regimen would increase and physician acceptance and patient adherence
● Isoniazid is safe for latent TB infection

Adverse effects Number (%) Events per 1000 patients completing treatment

Hepatotoxicity 10 (0.3) 4

Rash 130 (3.4) 54

Itching (no rash) 117 (3.1) 48

Nausea, vomiting 131 (3.5) 54

Abdominal pain 176 (4.6) 73

Headache 338 (9) 140

parasthesias 177 (4.7) 73

Dizziness 17 (0.4) 7

Treatment of contact

All contact PPD

- I NH (<4 yrs. HIV)

- Repeated PPD
Positive Negative
- 3 months contact
- Was broken

CXR
Positive Negative

Positive Negative
(disease) (infection)
Reassurance

TB treatment INH prophylaxis

(3 drugs x 6 mos.) 6-9 months
 Conclusion

● TB remains a permanent threat

● Importance of contact tracing and treatment adherence

● Future perspectives

○ Improved efficacy of TB vaccination

○ Improved diagnosis of TB infection (ELISPOT)

○ Shorter treatment for latent TB infection (and TB): new drugs

Book!

● Chest recession: it is an important indicator of increased work of breathing. In children,

when the work of breathing increases, the breathing pattern becomes abdominal
(see-sawing of chest and abdomen ) due to weak chest wall muscles and strong
diaphragm. This is not seen in adults.
● Impending respiratory failure is suggested by:
- Cyanosis persistent grunting
- Reduced oxygen saturation despite oxygen therapy
- Rising pCO2 on blood gas
- Exhaustion, confusion, reduced conscious level
 Book!

Upper respiratory tract infections

-The most common infection of childhood

-Classical features: mucopurulent nasal discharge and nasal blockage.
The common cold (coryza) -The most common pathogens are viruses (rhinovirus, coronavirus, RSV
-Self limiting (paracetamol/ ibuprofen for pain if any)
-Cough may persist for up to 4 weeks after a common cold

-Commonly is viral origin (adenovirus, enterovirus, rhinovirus)

-They may develop also lymphadenopathy (tender)
-Tonsillitis: inflamed tonsils often with purulent exudate and maybe caused
by group A beta hemolytic streptococci and EBV
-Marked constitutional symptoms are more common with bacterial infection
(headache, apathy and abdominal pain)
-Can we differentiate clinically between viral or bact infection? NO
-Countries with high incidences of rheumatic fever or children with high risk
of severe infection need antibiotics to eradicate beta hemolytic streptococci.
Sore throat (pharyngitis & tonsillitis) Unable to swallow solids or liquids require hospital admissions for IV fluids
-Amoxicillin is BEST AVOIDED as it may cause a widespread
maculopapular rash if the tonsillitis is due to infectious mononucleosis
(IMPORTANT!!!)
-Indications of tonsillectomy:
1.Recurrent tonsillitis (7 or more episodes of significant sore throat in the
preceding 12 months or 5 or more episodes in each of the two previous
years, or 3 or more episodes in each of the previous three years)
2.Complications (e.g. peritonsillar abscess - quinsy. Sleep disordered
breathing e.g. OSA )

-Children and infants are prone to AOM because their Eustachian tubes are
short, horizontal and function poorly
-It is most common at 6-12 months of age
-Most children will have at least one episode
-It causes earache and fever
-Every child with a fever should have their tympanic membranes examined
-Otoscopic findings: tympanic membrane is bright red and bulging with
loss of the normal light reflection. There could acute perforation of eardrum
with pus visible in the external canal
-Pathogens: RSV, rhinovirus, pneumococcus, Haemophilus influenzae and
Moraxella catarrhalis
Acute otitis media -Complications: mastoiditis and meningitis (refer to ENT lecture if you want to
recall complications)
-Antibiotics marginally shorten the duration of pain but no effect on
preventing hearing loss
-Pain should be treated with regular analgesia and may be required for up to
a week
-Recurrent otitis media can lead to otitis media with effusion (usually
asymptomatic apart from possible decreased hearing, eardrum is dull and
retracted often with visible fluid level. It may resolve spontaneously, but may
cause conductive hearing loss and interfere with normal speech
development). If hearing doesn’t improve surgery may be considered with
insertion of tympanostomy tubes.

-It may occur with viral URTIs

-There could be secondary bacterial infection, with pain and tenderness
over the cheek from infection of the maxillary sinus
Sinusitis
-Frontal sinus doesn’t develop until late childhood so frontal sinusitis is
uncommon in first decade of life
-Antibiotics (if bacterial) and analgesia are used for acute sinusitis

● URTIs may cause: difficulty in feeding in infants as their noses are blocked and this
obstructs breathing, febrile seizures
● Hospital admission may be required if feeding and fluid intake is inadequate
 Book!

Upper airway obstruction

● Fixed partial airway obstruction leads to stridor (the most common cause is viral
laryngotracheobronchitis “croup”). Other causes of stridor are:

-Acute stridor with atypical features or a poor response to treatment , you

should consider other causes
-Abrupt onset of stridor without infection consider anaphylaxis or inhaled
foreign body
-Chronic stridor is usually due to a structural problem: intrinsic narrowing or
collapse of the laryngotracheal airway, subglottic stenosis or external
compression
-Laryngomalacia is common and is due to the soft immature cartilage of the
upper larynx collapsing on inspiration causing airway obstruction. Usually it
presents at about 4 weeks of age when imspiratory flow rates are sufficient to
generate stridor, worse when infant is agitated, feeding or lying on their back.
No treatment or investigations if the child is thriving. Resolve by 2 years

● Severity of upper airway obstruction is assessed clinically by: characteristics of the

stridor (none, only on crying, at rest, or biphasic), the degree of accompanying chest
retraction (none, only on crying, at rest)
● Central cyanosis, drooling of saliva from inability to swallow it or reduced level of
consciousness suggest impending complete airway obstruction and the need for
intubation
● Hypoxia is a late feature in upper airway obstruction unlike parenchymal lung disease
● Steroids in croup are used when there is a chest recession at rest.
● Croup: If the upper airway obstruction is severe, nebulized epinephrine with oxygen by
face mask provides rapid but transient improvement (it is useful whilst waiting for
corticosteroids to take effect)
● Croup: recurrent croup may be related to atopy
● Bacterial tracheitis can cause copious thick airway secretions and is typically caused by
staph. aureus
 Book!

Lower respiratory tract infections

● Pulse oximetry should be performed on all children with suspected broncholitis. No

other investigations are routinely recommended

● RSV is highly infectious, and infection control measures, particularly good hand hygiene,
cohort nursing, and gowns and gloves, have been shown to prevent cross- infection to
other infants in hospital
● Prevention of broncholitis: a monoclonal antibody to RSV (palivizumab) given monthly by IM
injection reduces the number of hospital admissions in high risk preterm infants
● At all ages Mycobacterium tuberculosis should be considered as cause of bacterial
pneumonia
● The most sensitive clinical sign of pneumonia is raised respiratory rate so this MUST be
measured in a febrile child
● The classic signs of consolidation are often absent in children
● Antibiotic choice depends on age and severy: newborn (broad spectrum IV antibiotics) older
infants (oral amoxicillin with broader spectrum antibiotics such as conamoxicla reseved for
compicated or unresponsive pneumonia) , children > 5 years either amoxicillin or an oral
macrolide such as clarithromycin. If child has mild / moderate pneumonia we give oral
unless he is vomiting
● Small sterile parapneumonic effusions occur in up to one-third of children with
pneumonia and usually resolve once the pneumonia is treated
● Pneumonia: Those with a lobar collapse or persistent symptoms should have a repeat
chest X-ray after 4–6 weeks to confirm resolution

Whooping cough (pertussis)

1# Catarrhal phase Coryza for a week

Then they develop spasmodic cough followed by characteristic inspiratory whoop. Those spams
are worse at night and may culminate in vomiting (tussive vomiting) . During paroxysm, the child
goes red or blue in the face and mucus flow from the nose and mouth. The whoop may be absent
2# Paroxysmal phase in infant and apnea is common. Epistaxis and subconjunctival hemorrhage can occur due to
vigorous coughing. This phase lasts for 3 months.
Infants and young children suffering severe spasms of cough or cyanotic attacks should be
admitted to hospital and isolated from other children

3# Convalescent phase Decrease of symptoms but may persist for many months

● Although macrolide antibiotics eradicate the organism,

they decrease symptoms only if started during the
catarrhal phase. Siblings, parents and school contacts are
at risk and close contacts should receive macrolide
prophylaxis. Unimmunized infant contacts should be
vaccinated
● Reimmunization of mothers during pregnancy is
recommended in the UK and a number of other countries as it
reduces the risk of pertussis in the first few months of the
infant’s life, when it is most dangerous.