1. Lower Respiratory Tract Infections in Children Abdelaziz Elamin Professor of Child Health University of Khartoum Sudan

2. 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.

3. 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.

4. Viral causes   Influenza A  Respiratory Syncytial Virus (RSV)  Human Metapneumovirus 4  Varicella-Zoster Virus (VZV - Chickenpox)  Adenovirus  Para-influenza virus

5. Bacterial Agents  Streptococcus pneumoniae  Hemophilus Influenzae  Staphylococcus aureus  M  Klebsiella pneumoniae  Enterobacteria e.g. E. coli  Anaerobes

6. Atypical Agents  Mycoplasma pneumoniae  Legionella pneumophila  Chlamydia sp.  Coxiella burnetii

7. 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

8. 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.

9. Differential Diagnosis  Asthma Asthma  Bronchiolitis (a form of LRTI) Bronchiolitis  Inhaled foreign body Inhaled foreign body Inhaled foreign body  Pneumothorax Pneumothorax  Cardiac dyspnoea Cardiac dyspnoea Cardiac dyspnoea  Pneumonitis of other cause e.g. extrinsic allergic alveolitis extrinsic allergic alveolitisextrinsic allergic alveolitis

10. Investigations  Chest radiography if fever and tachypnea, oxygen saturation to monitor condition. Chest radiography Chest radiography  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

11. 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.

12. 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.

13. Medications   Antipyretics (avoid aspirin in young children due to danger of Reye's syndrome).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.

14. 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.

15. 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

16. Complications  Bacterial invasion of the lung tissue can cause: pneumonic consolidation, pneumonic consolidation, pneumonic consolidation pneumonic consolidation septicemia, septicemia, empyema, empyema, lung abscess(esp. S. Aureus) lung abscess(esp. S. Aureus) lung abscess lung abscess pleural effusion. pleural effusion. pleural effusion pleural effusion Mycoplasma P. can cause hemolysis Mycoplasma P. can cause hemolysis Rarely, respiratory failure, hypoxia and death. Rarely, respiratory failure, hypoxia and death.

17. Prevention  It is achieved with pneumococcal vaccine and influenza vaccine influenza vaccineinfluenza 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.

18. The End