Acute respiratory Infection & IMNCI

there were described for ARI and as well as about IMNCI
and there will be about how to approach children for for respiratory infection.

1. ACUTE RESPIRATORY INFECTION PRSENTED BY- RISHABH NAHAR ROHIT MAHESHWARI INDEX MEDICAL COLLEGE HOSPITAL & RESEARCH CENTER INDORE, M.P.

2. CONTENT INTRODUCTION EPIDEMIOLOGY CLASSIFICATION FACTORS AFFECTING UPPER RESPIRATORY INFECTION COMMON COLD TONSILITIS LOWER RESPIRATORY INFECTION BRONCHI LITIS PNEUMONIA IMNCI OBJECTIVE IMNCI COMPONENT ADVANTAGE OF INTREGETED APPROACH REFERENCES

3. ACUTE RESPIRATORY INFECTIONS Infections of the respiratory tract are described in a number of different ways according to the general areas of involvement in the more common infections . The upper respiratory tract or upper airway consists of primarily of the nose and pharynx . The lower respiratory tract consists of bronchi and bronchioles.

4. CHILDREN WITH ARI PRESENTING IN OPD Place % of children London (UK) 35.0 Herston (Australia) 34 Ethiopia (Whole country) 25.5 Sau aulo (Brazil) 41.8 India 38.9 Nepal 37.6

5. EPIDEMIOLOGY Varied agents – Bacteria and viruses Clinical picture may vary with etiological agent May be present in normal people but may cause disease in only few.

6. Factors Affecting Acute Respiratory Infections: Nature of infectious agent: The respiratory tract subjected to a wide variety of infectious agents. Age of child: Children of preschool and school age are more often exposed to infectious agents generally after 3 months of age infants have less resistance to infections. Size of child: Airways are smaller in young children and more subjected to considerable narrowing from edema . Ability to resist invading organisms: School age children have greater resistance to infection than infants and young children.

7. Presence of great conditions: Malnutrition, anemia, fatigue, chilling of the body and immune deficiencies decrease normal resistance to infection. Presence of disorders affecting respiratory tract: Allergies, cardiac abnormalities and cystic fibrosis weaken respiratory defense mechanism. Seasons: The most common respiratory tract pathogens appear in epidemics during winter and spring months.

8. ARI IS CLASSIFIED AS-

9. UPPER RESPIRATORY TRACT INFECTIONS; THE COMMON COLD Children average 8 episodes per year, adults 3 episodes per year Etiologies : Rhinoviruses 30 to 35% Coronaviruses about 10% Miscellaneous known viruses about 20% Influenza and adenovirus-30% Presumed undiscovered viruses up to 35% Group A streptococci 5% to 10%

10. THE COMMON COLD Common symptoms are sore throat, runny nose, nasal congestion, sneezing. Sometimes accompanied by conjunctivitis, fatigue. Sinusitis often present by CT scan; “rhinosinusitis” might be a better term

11. THE COMMON COLD

12. THE COMMON COLD CLINICAL FEATURES:- Incubation period 12-72 hours Nasal obstruction, drainage, sneezing, scratchy throat Median duration 1 week but 25% can last 2 weeks Pharyngeal erythema is commoner with adenovirus than with rhino or coronavirus

13. TREATMENT Rapid antigen tests for group A streptococcus. Rapid techniques for influenza, RSV, para influenza. Treat with NSAIDs. And prevent from cold atmosphere.

14. UPPER RESPIRATORY TRACT INFECTIONS : TONSILLITIS Tonsillitis is a viral or bacterial infection in the throat that causes inflammation of the tonsils. In the first six months of life tonsils provide a useful defense against infections. Tonsillitis is one of the most common ailments in pre-school children, but it can also occur at any age. Children are most often affected from around the age of three or four, when they start nursery or school and come into contact with many new infections. A child may have tonsillitis if he/she has a sore throat, a fever and is off food.

15.  PALATINE TONSILS (Visible during oral examination)

16. CAUSES OF TONSILITIS Tonsillitis is caused by a variety of contagious viral and bacterial infections. It is spread by close contact with other individuals and occurs more during winter periods. The most common bacterium causing tonsillitis is streptococcus.

17. ADVICE AND TREATMENT: Encourage bed rest. Introduce soft liquid diet according to the child’s preferences. Provide cool mist atmosphere to keep the mucous membranes moist during periods of mouth breathing. Warm saline gargles & paracetamol are useful to promote comfort. If antibiotics are prescribed, counsel the child’s parents regarding the necessity of completing the treatment period

18. Surgical removal of chronic tonsillitis (tonsillectomy) is controversial. Generally, tonsils should not removed before 3 or 4 yrs of age, because of the problem of excessive blood loss & the possibility of re-growth or hypertrophy of lymphoid tissue, in young children. MANAGEMENT

19. LOWER RESPIRATORY TRACT INFECTIONS BRONCHITIS/BRONCHIOLITIS PNEUMONIA

20. LOWER RESPIRATORY TRACT INFECTIONS: BRONCHIOLITIS Inflammatory disease of the bronchioles Peak age of onset : 6 months Male : female :- 2:1 Occurs mostly in winter/spring

21. BRONCHIOLITIS : CLINICAL FEATURES Coryza with cough followed by worsening breathlessness Vomiting Irritability Wheeze Feeding difficulty Episodes of apnoea

22. A chest X-ray demonstrating lung hyperinflation with a flattened diaphragm and bilateral atelectasis in the right apical and left basal regions in a 16-day-old infant with severe bronchiolitis

23. MANAGEMENT TREATMENT Mainly supportive Prop up (30 – 40 degrees) Oxygen inhalation (achieve o2 >92%) If tachypneic , limit the oral feeds and use a nasogastic tube for feeding Parenteral fluids to limit dehydration Correct resp. acidosis and electrolyte imbalance Bronchodilators for wheeze ( nebulized adrenaline) Mechanical ventilation (severe resp. distress )

24. PREVENTION

25. LOWER RESPIRATORY TRACT INFECTIONS: PNEUMONIA -Inflammation of the lung parenchyma and is associated with the consolidation of the alveolar spaces -Developed world -Viral infections - Low morbidity and mortality -Developing world -Common cause of death -Bacteria and PCP in 65% -ARI case management WHO -84% reduction in mortality -Respiratory rate, recession, ability to drink -Cheap, oral and effective antibiotics, Co-trimoxazole -Maternal education

26. PNEUMONIA: ETIOLOGY Vary according to- Age, immune status, where contracted Developing countries S. pneumoniae, H. influenzae, S aureus Viruses 40% Other: Mycoplasma, Chlamydia, Moraxella Developed countries Viruses: RSV, Adenovirus, Parainfluenza, Influenza Mycoplasma pneumoniae and Chlamydia Pneumoniae Bacteria : 5-10%

27. PNEUMONIA: HIGH RISK CHILDREN FOR PNEUMONIA Significant risk factors are younger age (2-6 months), low parental education, smoking at home, prematurity, low birth weight, weaning from breast milk at < 6 months, a negative history of diphtheria, pertussis and tetanus vaccination, anemia, malnutrition and overcrowding. Infection rate higher in siblings of school children who introduce infection in the household. Other risk factors  Immunodeficiency  Cystic fibrosis  Sickle cell disease  Tracheostomy in situ

28. PNEUMONIA: DANGER SIGNS Sign of respiratory distress; nasal flaring & chest Indrawing Younger than 2 months Decreased level of consciousness Stridor when calm Severe malnutrition Associated symptomatic HIV/AIDS

29. PNEUMONIA: SIGNS OF RESPIRATORY DISTRESS

30. PNEUMONIA: SIGNS OF RESPIRATORY DISTRESS

31. PNEUMONIA: RADIOLOGY Bacterial – Poorly demarcated alveolar opacities with air bronchograms – Lobar or segmental opacification

32. PNEUMONIA: RADIOLOGY Viral – Perihilar streaking, Interstitial changes, air trapping

33. COMPLICATIONS OF PNEUMONIA Empyema  Lung abscess Pneumothorax  Pleural effusion  Delayed resolution  Respiratory failure  Metastatic septic lesions  Meningitis  Otitis media  Sinusitis

34. PNEUMONIA: TREATMENT Antibiotics Under 5 yrs -First line treatment :- amoxicillin -Alternatives : coamoxiclav , cefaclor ,(for typical) macrolides (for atypical) Over 5 yrs -First line treatment :- Erythromycin 6 hourly daily/ doxacyclin 12 hourly -Alternatives :- macrolide or flucloxacillin + amoxicillin - Modrately :- ceftriaxone IV or erythromycin -severely :- ceftriaxone IV and azithromycin IV ones day

35. PNEUMONIA: TREATMENT CONT.. Oxygen - intranasaly Hydration -50 – 80ml/kg/day Temperature control Airway obstruction management Chest drain :- for fluid or pus collection in chest ( empyema )

36. PNEUMONIA: PROGNOSIS Most children recover without residual damage  Incorrect treatment leads to tissue destruction and Bronchiectasis  Half of children with pneumonia secondary to measles or adenovirus have persistent airway obstruction

37. PNEUMONIA: PREVENTION AND CONTROL OF ARIs  Early diagnosis of pneumonia and the warning signs of severe disease and prompt management – key factors which determine the outcome of disease  Guidelines have been given by WHO regarding management and use of antibiotics.  Recent changes – Management as per the IMNCI protocol

38. PNEUMONIA: VACCINATION  MEASLES  HIB VACCINE  PNEUMOCOCCAL PNEUMONIA

39. THE INTEGRATYED MANAGEMENT OF NEONATAL AND CHILDHOOD ILLNESS ( IMNCI )

40. INTRODUCTION - 10 million children/ year- die in developing countries due to acute respiratory infections, diarrhoea, malaria , malnutrition - 1990-WHO+UNICEF +other agencies- (IMCI) - India adopted as (IMNCI ). - According to PSM(park)- NFHS.III report highlight that ARI 17%, Diarrhoea 13%, malnutrition 43%

41. IMNCI HAVE TWO GROUPS OF CHILDREN 0-2 months Young infants. 2 months to 5 years Children

42. OBJECTIVE IMPROVE GROWTH AND DEVELOPMENT DURING THE FIRST 5 YEARS OF A CHILD'S LIFE REDUCE FREQUENCY AND SEVERITY OF ILLNESS AND DISABILITY REDUCE MORTALITY

43. COMPONENTS IMNCI

44. Principle of IMNCI 1. All sick children under 5 years of age must be examined for conditions which indicate immediate referral or hospitalization. 2. Children must be routinely assessed for major symptoms, nutritional and immunization status, feeding problems and other potential problems. 3. Based on the presence of selected clinical signs, the child is placed in a ‘classifications’.

45. 4. A limited number of essential drugs are used. 5. Counseling of caretakers about home care including feeding, fluids and when to return to health facility 6. IMNCI guidelines address most common but not all pediatric problems.

46. Care of Newborns and Young Infants (infants under 2 months) 1. Keeping the child warm. 2. Initiation of breastfeeding immediately after birth and counseling for exclusive breastfeeding and non-use of pre lacteal feeds. 3. Cord, skin and eye care. 4. Recognition of illness in newborn and management and/or referral). 5. Immunization 6. Home visits in the postnatal period.

47. Care of Infants (2 months to 5 years) 1. Management of diarrhea, acute respiratory infections, malaria, measles, acute ear infection, malnutrition and anemia. 2. Recognition of illness and at risk conditions and management/referral) 3. Prevention and management of Iron and Vitamin A deficiency. 4. Counseling on feeding for all children below 2 years 5. Counseling on feeding for malnourished children between 2 to 5 years. 6. Immunization

48. IMNCI CASE MANAGEMENT PROCESS Steps of case management process are the following: Asses the young infant/ child. 2. Classify the illness. 3. Identify the treatment. 4. Treat the young infant/child. 5. Counsel the mother./ Provide follow up care.

49. ADVANTAGE OF INTEGRATED APPROACH

50. • Speeds up the urgent treatment and treatment seeking practices. • Prompt recognition of serious condition, hence prompt referral. • Involves parents in effective care of baby at home. • Partial Success of Individual disease control program. ADVANTAGES OF INTEGRATED APPROACH

51. CONT… • Involves prevention of diseases by active immunization, Improved nutrition and exclusive Breastfeeding practices. • Highly cost effective. • It avoids wastages of resources by using most appropriate medicines and treatment. • It reduces duplication of effort.

52. Thank you

53. REFERENCES Community medicine and recent advances.- AH Suryakanta . Global recommendation on physical health activity for health.- www.who.int en.wikipedia.org/wiki/ARI Textbook of medicine – Davidson Review of Pharmacology Medicine text book – review Mathew www. who.nic.child.imnci