Pediatric Upper Respiratory Tract Infections

• Pediatric upper respiratory tract infections are being discussed
• Dr. Leigh Anne Allwood Newhook MD FRCPC is presenting

Learning Objectives

• Recognize the various forms and causes of upper respiratory tract infections (URTI's) in children
• List the major differences between the pediatric and adult upper respiratory tract that predispose children to increased symptoms
• Outline the management of pediatric URTI's, including appropriate use of antibiotics
• List preventative measures for pediatric URTI's

Pediatric vs Adult Upper Respiratory Tract

• In children, the smaller nasopharynx is easily occluded during infection
• Lymph tissue (tonsils, adenoids) grows rapidly in early childhood and atrophies after age 12
• Smaller nares are easily occluded
• A smaller oral cavity and large tongue increase risk of obstruction
• A long, floppy epiglottis is vulnerable to swelling with resulting obstruction
• The larynx and glottis are higher in neck, increasing risk of aspiration
• Because thyroid, cricoid, and tracheal cartilages are immature, they may easily collapse when neck is flexed
• Fewer muscles are functional in airway, so children are less able to compensate for edema, spasm, and trauma
• Large amounts of soft tissue and loosely anchored mucous membranes lining the airway increase risk of edema and obstruction

Case 1

• A 14-month-old girl presents with a 2-day history of green nasal discharge and a low-grade fever
• The patient is feeding well
• On examination, the patient is alert, afebrile, and has normal vital signs, nasal discharge, and no distress; the physical examination is normal
• The most likely diagnosis is Viral Rhinitis/rhinopharyngitis, also known as the "common cold."
• Viral Rhinitis/rhinopharyngitis symptoms include nasal congestion, rhinorrhea, and cough
• They are common complaints in children
• Young children may experience 6-8 episodes of viral URIs yearly, and most episodes do not require antibiotic treatment

Case 1 Follow Up

• Same 14-month-old girl returns to clinic 24 hours later with fever of 39°C and pain in left ear
• The patient's temperature is 39°C axilla, irritable, runny nose, rest of physical exam normal
• Most likely suffering from Acute Otitis Media
• Rapid onset of symptoms like ear pain and irritability are key
• Signs of middle ear inflammation/effusion include immobile tympanic membrane, with or without opacification, bulging, discolored, loss of boney landmarks, and ruptured tympanic membrane
• Viral Acute Otitis Media (AOM) is likely to have spontaneous resolution without therapy
• Watchful waiting for 24–48 is appropriate for otherwise healthy child older than six months of age, no craniofacial abnormalities, mild clinical signs and symptoms, no perforation, fever less than 39 degrees in the absence of antipyretics, less than 48 hours of illness, alert, responsive, able to sleep, and follow-up by family is likely to occur
• Provide advice regarding analgesia (acetaminophen) and instruct family to return if the child is not improved in 48 hours
• If antibiotics are prescribed, first-line therapy is high-dose amoxicillin at 75 mg/kg/day to 90 mg/kg/day divided bid for five days if the child is older than 2 years of age
• 10 days treatment for younger children or those with frequent or complicated AOM (i.e., perforation)

Acute Otitis Media Causes

• Viral causes include RSV, rhinovirus, coronavirus, parainfluenza, adenovirus, and enterovirus (up to 75%)
• Bacterial causes include Streptococcus pneumoniae, decreased with use of pneumococcal vaccine, Non-typable Haemophilus influenzae, and Moraxella catarrhalis

Case 2

• A 6-year-old boy presents with painful left ear and green, foul-smelling discharge
• The patient was swimming all day yesterday
• Most likely the patient has acute otitis externa, also known as swimmer's ear.
• A key factor in Acute otitis externa is rapid onset (generally within 48 h)
• Symptoms include ear canal otalgia (often severe), itching, or fullness and potential hearing loss or jaw pain
• Signs of ear canal inflammation include tenderness of the tragus, pinna, diffuse ear canal edema, erythema, otorrhea, regional lymphadenitis, tympanic membrane erythema, cellulitis of the pinna and adjacent skin

Acute otitis externa (swimmers ear) causes

• Pseudomonas aeruginosa
• Staphylococcus aureus
• Polymicrobial including Gram-negative bacteria are less common
• Rare fungal infections like Aspergillus, Candida
• Treat with topical antibiotic with or without topical steroids for 7 to 10 days
• Pain control includes acetaminophen and non-steroidal anti-inflammatory medications or oral opioid
• Cases are considered more severe if systemic antibiotics that cover S aureus and P. aeruginosa needed
• If the clinician cannot see the ear canal, try an expandable wick to decrease canal edema and facilitate topical medication delivery

Case 3

• An 8-year-old boy presents with a 10-day history of yellow nasal discharge, facial pain, headache, low-grade fevers, and daytime cough presenting
• The patient's past medical history includes environmental allergies to dust mites, pollen, and cats
• On examination, finds temperature of 38°C axilla, VSS, and pain to palpation of forehead
• Likely contracted Acute Bacterial Sinusitis
• Consider for children with an acute URI
• It presents as persistent illness, i.e., nasal discharge or daytime cough, lasting more than 10 days without improvement, or it presents as worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement
• Or severe onset, i.e., fever of 39°C or higher, and purulent nasal discharge for at least 3 consecutive days

Acute Bacterial Sinusitis (ABS) causes

• Bacterial causes include Strep pneumoniae, H influenzae, and M catarrhalis
• Staphylococci and respiratory anaerobes are uncommon
• Viral causes include Adenovirus, parainfluenza, influenza, and rhinovirus
• X-rays do not contribute to the diagnosis
• A contrast-enhanced CT scan of the paranasal sinuses is used if the child is suspected of having orbital or central nervous system complications
• Treat with antibiotic therapy (10 days) if severe onset or worsening course
• Reassess initial management if there is worsening or failure to improve within 72 hours

Sinus Development

• Maxillary and ethmoid sinuses are present at birth
• Frontal sinuses develop from ethmoid cells by age 5-6

Case 4

• A 7-year-old girl presents with a sore throat, runny nose, and cough, but no fever
• The patient also indicates that Mom also has a cough
• On examination, vital signs are stable, and notes runny nose, red throat, and conjunctivitis
• Most likely acute viral pharyngitis Supportive treatment includes gargling salt water, honey, fluids.

Case 5

• A 6-year-old girl presents with sore throat, fever, and difficulty swallowing, but no cough
• On examination, temperature is 38.7°C axilla, with tender cervical lymphadenopathy and sandpaper rash
• Likely suffering from Acute streptococcal pharyngitis/tonsillitis
• Classic symptoms of strep throat are pharyngeal or tonsillar exudate, swollen anterior cervical lymph nodes, temperature greater than 38°C, and no cough
• Patients with all 4 symptoms have a 56% chance of having strep infection

Acute streptococcal pharyngitis/tonsillitis treatment

• Throat swab recommended if no viral symptoms present and delay treatment if possible until culture confirmed
• Consider treating empirically if all four symptoms present
• First-line treatment is Penicillin for 10 days
• 15% to 30% of sore throats in children are strep

Case 6

• A 2-year-old girl presents to the ER with difficulty breathing, "barky" cough, fevers, and runny nose
• On examination, temperature is 38.3 axilla and inspiratory stridor
• Likely Croup
• Croup typically has viral URI symptoms 12-48 hours prior to cough with fever, "Barking cough," and stridor usually lasting 3-5 days.
• Peak fall and winter, more common ages 1-6
• Males are more prone
• Viral causes include Parainfluenza, Influenza A & B, Adenovirus, RSV
• Racemic epinephrine constricts arterioles to the airway thus reducing further edema
• Dexamethasone at 0.6mg/kg (IM or PO)

Case 7

• A 4-year-old girl presents with respiratory distress, inspiratory stridor, drooling, and high fever
• The patient is unimmunized and toxic appearing with a temperature of 40° C axilla Likely Epiglottis
• Dysphagia
• Drooling
• Tripoding/sword-swallowing
• Prefer to sit leaning forward and resists lying on back
• Goes straight to OR for evaluation/intubation

Croup Vs. Epiglottitis

• Croup Etiology is parainfluenza virus while Epiglottitis is Hemophilus influenza
• Croup onset is subacute exacerbation of preexistent URI and Epiglottitis is acute
• Croup temperature has low-grade fever, while Epiglottitis is High fever
• Croup course is Usually mild and stridor may worsen at night, while Epiglottitis is a rapid progress of symptoms
• Croup has barky cough and stridor whereas Epiglottitis displays Dysphagia, sore throat, dysphonia, respiratory distress Children also can be diagnosed with Bacterial tracheitis, Fever/resp distress/Dysphagia/Odynophagia

Retropharyngeal/peritonsilar abscess

• Fever
• Odynophagia
• Also associated to Prodrome of sore throat
• Commonly swollen, tender anterior cervical lymph nodes
• Resistance to neck movement and typically requires surgical management

Prevention of URTI's

• Breastfeeding (immunoglobulins)
• Elimination of tobacco smoke
• Vaccinations: influenza, pneumococcal, Hib
• Hand hygiene