COMMON

RESPIRATORY TRACT
INFECTION IN
CHILDREN
INTRODUCTION

RESPIRATORY TRACT

sinusitis
 PATHOPHYSIOLOGY
•touching a hand exposed to pathogens to the nose or
mouth
•inhaling respiratory droplets from an infected person

Invasion of pathogens to the mucosa lining the airway

BARRIERS
• Physical/mechanical
hair lining the nose, mucous,
ciliated cells production of
•Humoral immune defenses Ig A toxins,
•Cellular immune defenses proteases
 macrophages, monocytes,
neutrophils & eosinophils
•Cytokines

Symptoms: local swelling, erythema, edema,

secretions, and fever
PATHOPHYSIOLOGY
RESPIRATORY TRACT INFECTION
CLASSIFICATION
Based on time:
 ACUTE RESPIRATORY INFECTIONS
 Less than 14 days

 CHRONIC RESPIRATORY INFECTIONS

 More than 14 days
ACUTE RESPIRATORY
INFECTION
(ARI)
EPIDEMIOLOGY
• MORBIDITY
• 50% of all illness diseases in children under 5
years
• 30% in children 5-12 years

• EPISODE IN URBAN AREA: 5-8/YEAR

RURAL AREA: 3-5/YEAR
( WHO, 1992)

•Most infections are limited to upper tract, about 5%

involved lower tract

(Phelan, 1994)
• MORTALITY
– One of the commonest cause of death in
children
– Cause around 3 million child deaths worldwide
each year:
• Most are caused by PNEUMONIA
• 99% occur in developing countries
(WHO, 1999)
 35%

23%

6%
2% 2% 27%
5%
Pneumonia PNEUMONIA/MEASLES
MEASLES ARI/MEASLES
Malaria DIARRHOEA
OTHERS

Distribution of mortality under five years

children in developing countries
IN INDONESIA

• MORBIDITY
in children 5 years of age: 10-20%
(2.33 - 4.66 million)
• MORTALITY
>> PNEUMONIA
MORTALITY RATE IN 1992 :2.7/ 1000
(National Household Survey=SKRT,1992)
 Malnutrition
In adequate
Inadequate breast feeding
immunization Vitamin A deficiency

Low birth
Young age weight
ARI

Pollution
Crowded

RISK FACTORS OF ARI

CLASSIFICATION
Based on anatomical site

sinusitis
• AURI:
• common cold (rhinitis)
• pharyngitis-nasopharyngitis-tonsilopharyngitis
• sinusitis
• otitis media

• ALRI :
• epiglotitis
• laryngo-tracheobronchitis
• bronchitis
• bronchiolitis
• pneumonia
Common terms are defined as follows:

• Rhinitis - Inflammation of the nasal mucosa

• Rhinosinusitis or sinusitis - Inflammation of the nares and

paranasal sinuses, including frontal, ethmoid, maxillary,
and sphenoid

• Nasopharyngitis (rhinopharyngitis or the common cold) -

Inflammation of the nares, pharynx, hypopharynx, uvula,
and tonsils

• Pharyngitis - Inflammation of the pharynx, hypopharynx,

uvula, and tonsils
• Epiglottitis (supraglottitis) - Inflammation of the superior
portion of the larynx and supraglottic area

• Laryngitis - Inflammation of the larynx

• Laryngotracheitis - Inflammation of the larynx, trachea, and

subglottic area

• Tracheitis - Inflammation of the trachea and subglottic area

• Bronchitis – Inflammation of the bronchi

• Bronchiolitis – Inflammation of the bronchioli

• Penumonia – Inflammation of the alveoli, usualy also involve

bronchioli
EPIDEMIOLOGY ASPECT :

• Community acquired ARI

• Hospital acquired ARI

(Nosocomial infection)

(Torres, 1997)
ETIOLOGY
• AURI : VIRUS ( 90%)
• COMMON VIRUSES
AURI : Rhinovirus, Coronavirus,
Adenovirus, Enterovirus
ALRI : RSV, Para influenza 1,2,3;
Coronavirus, Adenovirus,
Enterovirus
PNEUMONIA
Etiology of Community acquired
Penumonia (CAP) in hospitalized children

Age No. Viral Bacteria Mixed All+

(yr) l
<2 108 80% 47% 34% 93%
2-5 84 58% 56% 33% 81%
>5 62 37% 58% 19% 76%
TOTAL 254 62% 53% 30% 85%

* Juven et al PIDJ 2000; 19

+ Total with etiology detected
Specific causes of CAP in hospitalized
children

Virus No. pts. Bacterial No. pts

(%) (%)
RSV 73 (29) S. pneumo 93 (37)
Rhino 58 (24) H. influ 22 ( 9)
Paraflu 25 (10) M. pneumo 17 ( 7)
Adeno 19 ( 7) M. cat 10 ( 4)
Influenza 10 ( 4) C. pneumo 7 ( 3)
Corona 7 ( 3) GAS 3 ( 1)
HHV6 7 ( 3) C. trachoma 2 ( 1)

* Juven et al PIDJ 2000; 19 (Apr)

 Rare etiology
Viral
•Varisela-zoster
•Coronavirus  SARS
•Paramyxovirus  SARS
•Enterovirus (coxsachie–echo)
•Cytomegalovirus
•Herpes simplex
Bacterial
Anaerob (S mileri,
peptostreptococ)
–Klebsiela pneumoniae
–E. coli
–Neiseria meningitidis
–Legionela
–Pseudomonas spp
–Leptospira

Fungal
•Histoplasma capsulatum
•Blastomises dermatitidis
Etiology in age of < 3 months

• Streptococcus group B
• Staphylococcus aureus
• Chlamyidia trachomatis
• Gram negative bacterials

Neonatus
• Related with labour process
- meconium aspiration
- mother’s leukorhoea
Etiology in age of 3 months - 5
years

Common
S. pneumoniae
H. influenzae
Rare
Streptococcus group
A
Etiology in age of > 5 years

Mycoplasma pneumoniae
Chlamydia pneumoniae
S. pneumoniae
H. influenzae
IN INDONESIA
• Etiology in 698 children with non severe pneumonia

• S. pneumoniae 67%
• Staphyloc.epidermidis 11.9%
• Alpha streptococcus 11.9%
• Hafnia alvei 3.4%
• Staphylococ.aureus 2.8%
• Moraxella catarhalis 1.1%
• Haemopphilus influenzae 0.6%
• Klebsiella pneumoniae 0.6%

(Kartasamita et al. Paediatr Indones 2001;41 :292-95)

CLINICAL MANIFESTATION
(Depends on age and etiology)

Fever Retraction/chest indrawing

Cough grunting
Chest pain Tachypneu
Dispneu Auscultation : rales, ronchi
CLINICAL MANIFESTION
(neonatus and young infant)

Not specific
• Retraction/chest indrawing
• grunting
• Tachypneu
• Auscultation : not specific
Neonatus
difficult to differentiate from sepsis & meningitis
 WHO/IMCI CLASSIFICATION
 entry point: cough
 the classification is based on respiratory
rate & chest indrawing

• 0 - 2 months of age
1. Severe pneumonia
2. No pneumonia

• 2 months - 5 years of age

1. Severe pneumonia
2. Pneumonia
3. No pneumonia
 Sensitivity and spesificity of respiratory rate and chest
indrawing to diagnose pneumonia in children

Sensitivity/spesificity

Reference RR >40 RR>40 + RR >50 RR > 50 +

chest indr. Chest indr

Shan et al 0.90/0.59 0.72/0.81

Cherian et al 0.86/0.78 0.75/0.95
Campbel et al 0.71/0.98 0.93/0.97
Manila 0.83/0.68 0.84/0.68 0.62/0.92 0.65/0.91
Swaziland 0.77/0.69 0.77/0.69 0.65/0.92 0.69/0.89

Pediatr Infect Dis 1992;11:77-81

 Sensitivity and spesificity of clinical sign
to diagnose pneumonia in children
Clinical sign Sensitivity (95%CI) Spesificity (95%CI)

Tachypnoea 74(60-88) 67(56-77)

Chest indrawing 71(56-86) 59(49-68)
Tachyp.& Chest indr 68(52-83) 69(58-79)
Tachyp.&alv.rales 46(29-62) 83(74-91)
Alveolar rales 46(29-62) 79(70-87)
Tachyp,chest indr.&al
veolar rales 43(26-59) 84(71-88)
Chest indr.& alv.rales 42(25-58) 80(71-88)

(Palafox et al., Arch Dis Child 2000;82 :41-5)

SIMPLE SIGN OF PNEUMONIA (WHO)

Fast Breathing (tachypnea)

NORMAL RESPIRATION RATE

< 2 MONTHS 60 X/min

2 - 12 MONTHS 50 X/min
1 - 5 YEARS 40
X/min

DYSPNEA
CHEST INDRAWING
INVESTIGATION
 Pulse oxymetry should be performed in
every children with pneumonia
Chest X-ray
 should not be performed routinely in mild uncomplicated LRI
 The findings are poor indicators of etiology
INVESTIGATION
Blood culture

Nasopharyngeal aspirates
 From all children under the age of 18 months should be sent for viral antigen
detection

Sputum culture  bronchoalveolar lavage

Pleural fluid culture if significant pleural efussion

present
 Severity assessment
• Indication for admission to hospital in infants
• Oxygen saturation < 92%, cyanosis
• Respiratory rate > 60 X/min
• Difficulty in breathing
• Intermittent apnoea, grunting
• Not feeding
• Family not able to provide appropriate
observation or supervision
•Indication for admission to hospital in
older children
•Oxygen saturation < 92%, cyanosis
•Respiratory rate > 40-50 X/min
•Difficulty in breathing
•Grunting
•Signs of dehydration
•Family not able to provide
appropriate observation or supervision
 General Management

• Not severe pneumonia  cared for at home by family:

Managing pyrexia
Preventing dehydration
Identifying any deterioration

• Oxygen, if SpO2 < 92% (in room air)

patients on oxygen therapy should have at least 4 hourly observation
including SpO2

• Antypiretics
 Antibiotic Management
• Young children with mild symptoms need not be
treated with antibiotics
• Children under the age of 5 years:
the first choice for oral antibiotic : amoxycillin
alternatives: co-amoxiclav, cefaclor, erythromycin,
clarithromycin & azithromycin.

• Children aged 5 years and above:

the first choice for oral antibiotic : macrolide
 Antibiotic Management
• Intravenous antibiotics:
Indication :

Unable to absorb oral antibiotic (e.g. due to

vomiting)
Severe pneumonia
Ampicillin, penicilline, chloramphenicol, coamoxiclav, cefuroxime,
cefotaxime.
COMMON COLD
• Traditional term used for self-limited acute
minor coryzal illness

• Etiological agents
• Rhinovirus 30 – 40%
• Influenza 10-15%
• Coronavirus > 10%
• RSV 5-10%
• Parainfluenza 5-10%
• Adenovirus 5%
• Enterovirus < 5%
• Mycoplasma < 5%
 Common cold – does it need
antibiotics?
• Uncomplicated common cold  NO
• Evidence of acute otitis media  YES
• Nasal discharge show no improvement in 10
days  may consider antibiotics (after
excluding foreign body)
• Antibiotics
• Target: pneumococci, Hib, GAS, anaerobic
• amoxicillin, 1st/2nd cephalosporin, amox-calvulanic acid
Pharyngitis

• An inflammation of the pharynx without any

localization in the tonsils and without signs of
a cold

• Etiology:
• Virus: rhinovirus, coronavirus, adenovirus, HSV,
parainfluenza, influenza

• Bacteria: Streptococcus pyogenes (15-20%),

corynbacterium diphteriae, mycoplasma
Rationale of managing
pharyngitis
• Most of pharyngitis are self-limiting
• Recognize those patient who suffered
from Group A streptococcus (GAS)
 to prevent GAS related complication
√Peritonsillar, retropharyngeal, and
parapharyngeal abcess
√Acute rheumatic fever
√Acute glomerulonephritis
Different features of pharyngitis caused by
Strep pyogenes & viruses
GAS pharyngitis Viral pharyngitis
season Late winter/early spring All seasons

age Peak: 5-11 y.o All ages

symptom Sudden onset Onset varies
Sore throat, mey be severe Sore throat, often mild
Fever Fever varies
Abdominal pain, nausea, Abdominal pain in influenza
vomiting
Headache Myalgia, arthalgia
signs Pharyngeal erythema & Usually no exudates
exudate
Palatal ptechiae Enathem
Tender, enlarge Minor, non tender
lymphonodes lymphomodes
Tonsilar hypertrophy Varies with agent
Absence of cough, coryza Often with cough, coryza
Treatment of GAS pharyngitis

• Not aiming to reduce symptom duration

• Prevent acute rheumatic fever

• Standard treatment
• Penicillin V for 10 days

• Alternate treatment
• Macrolides (higher chance of resistence)
• 1st generation cephalosporin
Thank you