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Lower Respiratory Tract Infections: Are You Correctly Managing Your Pediatric Patients?

By Dr. Nwamaka Osakwe

Respiratory tract infection is a diagnosis frequently made in medical practice. It is classified into upper respiratory tract infection and lower respiratory tract infection.

Upper respiratory tract infection refers to infections in the sinuses, nasal passage, pharynx, and larynx. Lower respiratory tract infections (LRTIs), the focus of this blog, refer to infections in the lower airway (trachea, bronchi, bronchioles, lungs). Examples of LRTI are:

• Tracheitis

• Bronchitis

• Bronchiolitis

• Pneumonia

Pneumonia is the single most significant cause of death in children; in 2019, 14% of deaths in children less than five years were due to pneumonia.

In general, LRTIs are caused by viruses, bacteria, or fungi. Viruses cause most respiratory tract infections, with respiratory syncytial virus implicated in about 22% of cases.

Although viruses cause many respiratory tract infections presenting to health practitioners, antibiotics are frequently prescribed even though they would be ineffective.

For example, most bronchitis and pharyngitis are viral in origin. Still, research showed that 73% of adults with bronchitis and 60% of children with pharyngitis received an antibiotic prescription. Inappropriate use of antibiotics increases the risk of drug resistance. 

Today antibiotic resistance is a substantial public health problem with high economic costs. In Europe, for example, antibiotic resistance is estimated to increase health care costs by more than nine million euros annually.

Can you properly manage LRTI in your paediatric patients without contributing to this public health issue?

Here is what you should know about LRTI in children

Viruses are the most common cause of LRTI. Children spread viruses faster than adults, especially when children are in proximity. Consequently, respiratory tract infections spread quickly in schools.

Another factor to consider is that children have a shorter respiratory tract than adults, so infection spreads quickly. Furthermore, LRTI can progress rapidly in children, so they should be carefully monitored and promptly treated.

Clinical Features of LRTI

  • Cough
  • Fever
  • Laboured breathing
  • Wheezing
  • Irregular breathing

When assessing a child with a respiratory tract infection, a careful history and detailed examination are crucial. Below are essential points to consider when evaluating a patient.

Explore clinical features of the current condition. For example, you may uncover severe disease symptoms such as convulsions and the inability to feed.

Ask about previous medical history. Some children are prone to severe LRTI, such as those with heart and lung conditions. Other factors contributing to disease severity include immune deficiency, gastroesophageal reflux disease, and neuromuscular disorders. 

Ask about living conditions to uncover risk factors predisposing a child to recurrent lower respiratory tract infection. For example, research suggests that biofuel, passive smoking, overcrowding, and unhygienic living conditions can make a child vulnerable. Other factors include low birth weight, no breastfeeding, lower maternal education, and incomplete immunization.

Also, ask about treatment already initiated by the parents at home. 

Examine the child following the conventional method; palpation, percussion, and auscultation. Observe the child and pay attention to the breathing pattern, effort, and sounds, the colour of the child, and their activity level. Carefully record the temperature, pulse, and respiratory rate. Auscultate and listen to the breath sounds, including stridor and rhonchi.

Look out for features that indicate severe disease, which may warrant hospital referral. 

Red flag signs of LRTI suggestive of severe disease

  • Labored breathing
  • Grunting
  • Poor feeding
  • Lethargy
  • Chest indrawing
  • Convulsion
  • Altered consciousness

Management

It is essential first to determine the cause of LRTI. Pulse oximetry chest X-ray, blood tests, and mucus sample are used to diagnose LRTI and determine the underlying infectious cause.

Most patients with LRTI can be managed at home with fluids and antipyretics. Before sending a child home, educate the parent about the expected course of the disease. Parents should also be educated on danger signs and the need to return to the health facility if the child’s condition deteriorates.

Children with a wheeze are likely to have a viral infection. Therefore, a trial of bronchodilator may be helpful.

Antibiotics should not be prescribed in patients likely to have LRTI from a viral infection. Antibiotics have not been shown to reduce disease severity or duration of symptoms. In addition, antibiotics may cause diarrhoea abdominal discomfort and predispose a child to yeast infections.

Children with less than 92% blood oxygen saturation should receive supplemental oxygen in a hospital setting.

Nasogastric tube feeding is indicated in children unable to feed. 

Admit to hospital children who are systemically unwell or have red flag signs.

Children with viral croup and stridor may benefit from steroids.

Patients who require antibiotics

Children with LRTI are classified into the following groups based on the clinician’s judgment.

  • No antibiotic
  • Delayed antibiotic therapy
  • Immediate antibiotic therapy

Children at risk of developing complications should be offered immediate antibiotic therapy. The following should prompt immediate antibiotic treatment.

  • Systemically unwell
  • Signs of serious illness like pneumonia 
  • Pre-existing comorbidity like heart, lung, renal, liver or neuromuscular disease, immunosuppression, or preterm children.

Children with a persistent fever above 38.5C with increased respiratory rate and chest recession should be suspected of having bacterial pneumonia and be given antibiotics.

The World Health Organization and the National Institute of Clinical Excellence recommend using antibiotics in children with pneumonia.

The World Health Organization recommends oral antibiotics for children with pneumonia presenting with fast breathing but without chest indrawing or red flag signs. Parenteral antibiotics should be used for patients with pneumonia and red flag signs. 

Causes of unnecessary antibiotic prescription in LRTI

  • Patient demographics
  • Follow up availability
  • Patient’s preference
  • Clinician’s preference
  • Clinician’s specialty
  • Knowledge and experience
  • Peer group influences

Parents worried about their child may pressure their health provider to prescribe antibiotics. However, antibiotics do not reduce the duration of symptoms. In one study, 432 children aged six months to 12 years with respiratory tract infections were stratified into two groups. One group received antibiotics, and the other group received a placebo. The results showed no difference in the duration of symptoms between both groups.

Clinicians sometimes prescribe antibiotics because of parental concerns that the child may deteriorate. In contrast, some clinicians offer antibiotics because they are unsure of follow-up visits. 

Health practitioners concerned about a patient’s satisfaction with their consultation may offer antibiotics even when they know the LRTI is likely viral.

The clinician’s specialty, knowledge, and experience also contribute to the decision to prescribe or not to prescribe antibiotics.

What can health practitioners do?

Medical education: Healthcare practitioners can update their knowledge about best practices in managing LRTIs. Being aware of the current evidence-based recommendations and the supporting data provides the correct information to treat your patients properly. Click here and here to learn more. 

Health education for parents. Use posters and pamphlets in the clinics to educate parents about respiratory tract infections. For example, when parents know antibiotics are not helpful in viral infections, they are less likely to pressure the practitioner to prescribe an antibiotic. Practitioners can also use an educational video, such as the one below in the clinic or on their website, translated or customized to the local dialect.

Improve communication skills. Research shows that if parents are provided with information about respiratory tract infection and are reassured of the treatment, they will accept the no antibiotics strategy.

The bottom line

Not all cases of LRTI require antibiotics. A careful history and examination will allow you to decide whether to use no antibiotics, delayed antibiotics, or immediate antibiotics strategy. Caregivers of patients offered no antibiotics should be educated on the natural course of the condition and clinical features that should prompt a return to the health facility.

Nwamaka Osakwe, FWACP, MBBS, is an award-winning physician who loves writing about health and wellness. You can reach her here

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