Acute respiratory infections

Thisppt explains about commonly encountered infant and child problems.

1. ACUTE RESPIRATORY INFECTIONS Dr Mallikarjuna D Study Physician Department of Community Medicine KMC,Manipal

2. Learning Objectives Introduction Epidemiological determinants Mode of Transmission Clinical Assessment Classification of Illness Treatment Prevention of Acute respiratory infections

3. INTRODUCTION It causes inflammation of the respiratory tract anywhere from nose to alveoli with combination of signs and symptoms It is classified depending upon the site: Acute Upper Respiratory Infections (AURI) Acute Lower Respiratory Infections (ALRI)

4. Introduction… AURI includes common cold, pharyngitis and otitis media ALRI includes epiglottitis , laryngitis, laryngotracheitis , bronchitis, bronchiolitis and pneumonia.

5. Burden of ARI

6. ARI deaths attributable to Undernutrition

7. Importance

8. Epidemiological Determinants AGENT FACTORS: The microbial agents that cause ARI are numerous and include bacteria and viruses Even within species they show wide diversity of antigenic type Severity of illness is determined by whether secondary bacterial infection occurs or not

9. Bacterial agents Agent Age groups frequently affected Characteristic clinical features Bordetella pertusis Infant, young children Paroxysmal cough Corynebacterium diphtheriae children Nasal/ tonsillar /pharyngeal membraneous exudate , severe toxemia Streptococcus pneumoniae All ages specifically under 5 children Lobar and multilobular pneumonia, acute exacerbations of chronic bronchitis Streptococcus pyogenes All ages Acute pharyngitis and tonsillitis Staphylococcus pyogenes All ages Lobar and bronchopneumonia, lung abscess Haemophilus inflenzae children Acute epiglottitis (type B) Klebsiella pneumoniae Adults Lobar pneumonia , lung abscess Legionella pneumoniae Adults Pneumonia

10. Viral agents Agent Age group frequently affected Characteristic clinical features Adenovirus endemic types(1,2,5) Young children LRTI Epidemic types(3,4,7) Older children , young adults Pharyngitis , flu like illness Influenza A, B,C All ages, school children Variable respiratory symptoms, occasional primary pneumonia Parainfluenza 1,2,3 Young children and infants Croup Respiratory syncytial virus Infants, young children Severe bronchilitis and pneumonia Rhinovirus All ages Common cold Corona virus All ages Common cold Measles Young children Variable respiratory with rash

11. Host factors Case fatality rates are higher in young infants and malnourished children In developing countries like India, malnutrition and low birth weight is often a major problem, the rates are highest in those children The rates of pharyngitis and otitis media increase from infancy to peak at the age of 5 years

12. Risk factors Climatic conditions Housing Level of industrialization Socio economic development Overcrowded dwellings Poor nutrition Low birth weight Intense indoor smoke pollution

13. Mode of transmission Air borne route Chain of transmission is maintained by direct person-person contact

14. Clinical assessment History to be elicited: Age of the child Since how long the child is coughing Young infant stopped feeding well (less than 2 months) The child is able to drink (2 months to 5 years) H/O fever Child is excessively drowsy/difficult to wake Irregular breathing Convulsions The child turning blue

15. Physical examination Count the breaths in one minute Fast breathing depend upon the age of the child It should be seen for 1 full minute looking at the abdominal movement or lower chest when the child is calm

16. Fast Breathing Age Fast breathing Less than 2months 60 breaths /more 2months to 1 year 50 breaths/more 1 to 5 years 40 breaths/more

17. Look for chest indrawing The child has chest indrawing if the lower chest wall goes in when the child breathes in It occurs when the effort required to breathe in is much greater than normal

18. Look and listen for stridor Stridor makes a harsh noise when the child breaths IN It occurs when there is narrowing of the larynx, trachea or epiglottis which interferes with air entering the lungs This condition is called croup

19. Look for wheeze Wheezing is soft whistling noise when the child breathes OUT It is caused by narrowing of air passage in lung Breathing out phase takes longer than normal and effort Elicit H/O previous history of wheezing If so, the child is classified as having recurrent wheeze

20. Other Signs See if the child is abnormally sleepy or difficult to wake Feel for fever or lower body temperature Cyanosis is a sign of hypoxia, must be checked in good light

21. Check for severe malnutrition High risk factor Case fatality rates are higher in these children In a severely malnourished children with pneumonia, fast breathing and chest indrawing may not be as evident Impaired/absent response to hypoxia and a weak/absent cough reflex These children need careful evaluation and management for pneumonia

22. Classification of illness Child aged 2 months – 5 years: Very severe disease Severe pneumonia Pneumonia No pneumonia Infants less than 2 months: Very severe pneumonia Severe pneumonia No pneumonia

23. Child aged 2 months to 5 years Very severe disease : Signs : not able to drink, convulsions, abnormally sleepy or difficult to wake, Stridor in calm child and Severe malnutrition Treatment : Refer urgently to hospital Give first dose of antibiotic Treat fever, if present Treat wheezing ,if present If cerebral malaria is present, give an antimalarial

24. Severe pneumonia Signs : chest indrawing , recurrent wheezing Treatment : Refer urgently to hospital Give first dose of antibiotic Treat fever, wheezing if present If referral is not feasible treat with an antibiotic and follow closely

25. Pneumonia Signs : fast breathing and no chest indrawing Treatment : Advice mother to give home care Give an antibiotic Treat wheezing / fever if present Advice mother to return with child after 2 days for reassessment/ earlier if the child is getting worst

26. Reassessment Re-assess the child after 2 days Worse same improving Not able to drink Breathing slower,less Has chest indrawing fever, eating better danger signs Refer URGENTLY to change antibiotic / refer finish 5 days of Hospital antibiotic

27. Infants less than 2 years Very severe pneumonia : Signs : stopped feeding well, convulsions, abnormally sleepy, stridor , wheezing, fever or hypothermia Treatment : Refer URGENTLY to hospital Keep young infant warm Give first dose of an antibiotic

28. Severe pneumonia Signs : severe chest indrawing or fast breathing (60 breaths per minute or more) Treatment : Refer URGENTLY to hospital Keep young infant warm Give first dose of antibiotic If referral is not feasible treat with an antibiotic and follow closely

29. No pneumonia: cough or cold Signs : no chest indrawing and no fast breathing Treatment : Advice mother to give the following home care – keep young infant warm, breast feed frequently, clear nose if it interferes with feeding Return if any danger signs- breathing becomes difficult/fast, not feeding, and infant becomes sicker

30. Treatment - Pneumonia Age/weight Paediatric tablet Sulfamethoxazole 100 mg, Trimethoprim 20 mg Paediatric syrup 5ml – sulfamethoxazole 200mg, trimethoprim 40 mg <2 months/3-5 kg 1 tablet twice a day Half spoon (2.5 ml) twice a day 2- 12 months/6-9 kg 2 tablets twice a day One spoon (5ml) twice a day 1-5 years/10-19 kg 3 tablets twice a day One and half spoon (7.5ml) twice a day

31. Treatment of severe pneumonia Antibiotics Dose Interval Mode A. First 48 hours Benzyl penicillin OR 50000 IU/kg/dose 6 hourly IM Ampicillin 50mg/kg/dose 6 hourly IM Chloramphenicol 25mg/kg/dose 6 hourly IM B. If condition IMPROVES Then for the next 48 hours Procaine penicillin 50,000 IU/kg once IM Ampicillin 50mg/kg/dose 6 hourly oral Chloramphenicol 25mg/kg/dose 6 hourly oral

32. Treatment of severe pneumonia… If there is no improvement ,then for the next 48 hours change antibiotic Provide symptomatic treatment for fever and wheezing Monitor fluid and food intake Advice mother on home management on discharge

33. Infants less than 2 months Antibiotic Dose Frequency in age <7days Frequency in age 7 days to 2 months Inj.Benzyl penicillin 50000 IU/kg/dose 12 hourly 6 hourly Inj.Ampicillin 50mg/kg/dose 12 hourly 8 hourly Inj.Gentamycin 2.5mg/kg/dose 12 hourly 8 hourly

34. Management of AURI DO NOT require treatment with antibiotics Causative agents are viruses Increase resistant strains and cause side effects Symptomatic treatment and care at home

35. Prevention of ARI

36. Prevention of ARI ARI control programme is the part of RCH programme Improved living conditions Better nutrition Reduction of smoke pollution indoors Better Maternal Child Health care Immunization Health promotional activities

37. Immunization Measles vaccine HIB vaccine Pneumococcal pneumonia vaccine

38. Pneumococcal Pneumonia vaccine PPV23: It is a polysaccharide, non conjugate vaccine containing capsular antigens of 23 serotypes, available for children above 2 years and adults Single IM / subcutaneous dose is given in deltoid muscle It should never be mixed with other vaccines in the same syringe, it can be given at the same time as separate injection in other arm

39. PCV Two conjugate vaccines are available PCV10 and PCV 13 Storage temperature : 2-8degrees It is given in infants as 3 primary doses/2 primary and 1 booster dose Initiated as early as 6 weeks with an interval of 4-8 weeks Doses at 6,10,14 weeks/2,4,6 months One booster dose is given at 9-15 months

40. PCV… HIV positive and preterm babies who have received 3 primary doses in 1 year, require booster dose in 2 nd year When primary immunization is initiated with one of vaccines, it is recommended that remaining doses are administered with the same product WHO recommends inclusion of PCVs in UIP worldwide, particularly in countries with high under5 mortalities

41. Thank you