Lower Respiratory Tract Infections in Children

Lower Respiratory Tract
Infections in Children
Abdelaziz Elamin
Professor of Child Health
University of Khartoum
Sudan
Epidemiology
Incidence :
30–40 cases per 1000 children per year in the UK;
a GP will see, on average, 1-2 cases per year.
Prevalence :
Every year, pneumonia contributes to 750,000 –
1.2 million neonatal deaths worldwide:
 (60% due to S. pneumoniae/H. influenzae)
 H. influenzae infection is now quite rare
amongst UK children due to immunization.
Definition & Etiology
 There is no hard and fast definition of lower

respiratory tract infection (LRTI), that is
universally adopted.
 Essentially, it is inflammation of the
airways/pulmonary tissue, due to viral or
bacterial infection, below the level of the
larynx.
Viral causes
 Influenza A
 Respiratory Syncytial Virus (RSV)
 Human Metapneumovirus 4
 Varicella-Zoster Virus (VZV - Chickenpox)
 Adenovirus
 Para-influenza virus
Bacterial Agents
 Streptococcus pneumoniae
 Hemophilus Influenzae
 Staphylococcus aureus
 M
 Klebsiella pneumoniae
 Enterobacteria e.g. E. coli
 Anaerobes
Atypical Agents
 Mycoplasma pneumoniae
 Legionella pneumophila
 Chlamydia sp.
 Coxiella burnetii
Clinical Picture
 Presentation Acute febrile illness, possibly
preceded by typical viral URTI.
 Symptoms :
1. Cough
2. Breathlessness ( preventing feeding)
3. Irritability
4. Sleeplessness
5. Chest or abdominal pain in older patients
 Audible wheezing is rare in LRTI, but can occur
Physical Signs
1. Capillary blood oxygen saturation <95%
2. Intercostal and supra-sternal recession
3. Flushing
4. Tachypnea
5. High fever over 38.5 c
6. Nasal flaring in children under 1 yr of age
7. Dullness to percussion over zones of
pneumonia consolidation.
8. Cyanosis in advanced cases.
Differential Diagnosis
 Asthma
 Bronchiolitis (a form of LRTI)
 Inhaled foreign body
 Pneumothorax
 Cardiac dyspnoea
 Pneumonitis of other cause e.g.
extrinsic allergic alveolitis
Investigations
 Chest radiography if fever and tachypnea,
oxygen saturation to monitor condition.
 In hospital consider capillary or arterial
blood gases.
 Culture of sputum or nasopharyngeal
discharge/aspirate may be used in hospital
but has little to add in primary care.
 Blood cultures if evidence of septicemia.
 Blood urea and electrolytes
Management
 Admission for children under 5 years with
fever and breathlessness is mandatory.
 Older children can be managed with close
observation at home if not distressed
 Physiotherapy has no place in treatment
of uncomplicated pneumonia in children
without pre-existing respiratory disease.
Essential Measures
 Oxygen,
 IV fluids if unable to feed,
 Respiratory support in severe cases
 Cough medicines are not indicated and
may be used if cough interferes with
feeding or sleep. Honey with lemon may
be helpful.
 Antihistamines are dangerous in young
children & should be avoided.
Medications
 Antipyretics (avoid aspirin in young children due to
danger of Reye's syndrome).
 Antibiotic treatment for bacterial pneumonias.
 Pneumonia or LRTI following URTI is likely to be
viral and will not respond to antibiotic therapy.
However, it is difficult to distinguish between viral
and bacterial infection and young children can
deteriorate rapidly. so consider antibiotic therapy
depending on presentation and the clinical judgment
of the concerned child.
Antibiotics
 Streptococcal pneumonia is treated with oral
penicillin V, or synthetic penicillin such as
amoxicillin as first line drugs.
 Recent research indicates that children with
non-severe pneumonia on amoxicillin for 3 days
do as well as those who receive it for 5 days
 If a child is genuinely allergic to penicillin,
consider using a macrolide or quinolone.
 Cephalosporin often cross-react with penicillin.
Antibiotics/2
 For Hemophilus influenzae cephalosporins
or Amoxicillin/Calvulenic acid combination
are useful.
 For Staph pneumonia cloxacillin and
flucloxacillin are used and in severe cases
parenteral vancomycin is required.
 Injectable antibiotics are indicated in
severe cases
Complications
 Bacterial invasion of the lung tissue can
cause:
 pneumonic consolidation,
 septicemia,
 empyema,
 lung abscess(esp. S. Aureus)
 pleural effusion.
 Mycoplasma P. can cause hemolysis
 Rarely, respiratory failure, hypoxia and death.
Prevention
 It is achieved with pneumococcal vaccine
and influenza vaccine
 Stop indoor smoking. Smoking at home or
school is a major risk factor.
 Zinc supplementation reduces the
incidence of pneumonia by over 40% in
malnourished children.
The End

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 There is no hard and fast definition of lower

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