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1- Over view
LRTI : infection below the level of larynx
The estimated incidence of LRTI is 30 per 1,000 children
per year in the UK.
Boys affected > than girls, (children born between 24-28
weeks compared to born at term.)
Haemophilus influenzae infection is uncomon because of
3 - Pathophysiology
Essentially, it is inflammation of the airways/pulmonary
tissue, due to viral or bacterial infection, below the level
of the larynx.
Gastro-oesophageal reflux may cause a chemical
Smoke and chemical inhalation may cause pulmonary
Bacterial infection :
Streptococcus pneumoniae (the majority of bacterial
Enterobacteria - eg, Escherichia coli
Secondary bacterial infection
relatively common following viral upper respiratory tract infection (URTI)
4 - Clinical Presentation
typical viral URTI
Bacterial pneumonia :++ in children (persistent or repetitive
fever > 38.5°C) with chest recession and a raised resp.rate
Audible wheezing is not seen very often in LRTI (common
with more diffuse infections ; M. pneumoniae and
Stridor or croup suggests URTI, epiglottitis or foreign body
5 – Clinical Approach
History :symptoms of LRTI is variable with age
Newborn and neonates present with:
Irritability or lethargy
Cyanosis (in severe infection)
In this age group beware:
Particularly of streptococcal sepsis and pneumonia in the first 24 hours
Chlamydial pneumonia, which may be accompanied by chlamydial
conjunctivitis (presents in the second or third week)
Infants present with:
Cough (the most common symptom after the first four weeks)
Tachypneic (according to severity)
Irritability and poor sleep
Breathing, which may be described as 'wheezy' (but usually upper
History of preceding URTI (very common)
Atypical and viral infections (especially pneumonia) may have
only low-grade fever or no fever
Preceding URTI is common
Cough is the most common symptom
Fever occurs most noticeably with bacterial organisms
Pain (chest and abdominal)
Vomiting with coughing is common (post-tussive vomiting)
Lower lobe pneumonias can cause abdominal pain
There will be additional symptoms to those above
More expressive and articulate children will report a wider
range of symptoms
Constitutional symptoms may be variable described
Atypical organisms are more likely in older children
Examination can be difficult in young children
A careful routine of observation is essential to identify
Pulse oximetry can be very useful in evaluation.
High fever over 38.5°C may occur often
signs of respiratory distress:
Cyanosis in severe cases
Nasal flaring. In children aged under 12 months this can
be a useful indicator of pneumonia
Chest indrawing (intercostal and suprasternal recession)
Other signs ;subcostal recession, abdominal 'see-saw'
breathing and tripod positioning
Reduced oxygen saturation (less than 95%)
In good light, with the chest and abdomen uncovered, is essential
Count respirations and note the respiratory rate (RR)
Child 15- 20/ minute
Observe the infant's feeding (to uncover decompensation during
Observe the chest movements (for example, looking for splinting of
Examine with warm hands and a stethoscope
Take the opportunity to examine a quiet sleeping child
Upper respiratory noises can be identified by listening at
the nose and chest
Crepitations in the chest may indicate pneumonia, +
when accompanied by fever
Consolidation is a later and less common finding than
the crepitation of a pneumonia
Later in older children there may be dullness to
percussion over zones of pneumonic consolidation
Bronchial breathing and signs of effusion occur late in
children and localization of consolidation can be difficult
7 - Investigations
White cell count is often elevated.
Blood cultures are seldom positive in pneumonia (fewer
than 10% are bacteraemic in pneumococcal disease).
Chest radiography (CXR) is not routinely indicated in
CXR cannot differentiate reliably between bacterial and
Tuberculin skin testing if tuberculosis is
Cold agglutinins when mycoplasmal infection
is suspected (50% sensitive and specific).
ESR , CRP
Drainage and culture of pleural effusions may
relieve symptoms and identify the infection.
8 - Management
Most children with lower respiratory tract infection
(LRTI) and pneumonia can be treated as outpatients,
with oral antibiotics.
Older children can be managed with close observation
at home if they are not distressed or significantly
dyspnoeic and parents can cope with the illness.
Viral bronchitis and croup do not require antibiotics
and mild cases can be treated at home
Admission of severe LRTI :
Oxygen saturation <92%
Respiratory rate >70 breaths/minute (≥50 breaths/minute in an older
Significant tachycardia for level of fever
Prolonged central capillary refill time >2 seconds
Difficulty in breathing as shown by intermittent apnea, grunting and
Presence of comorbidity :
congenital heart disease,
chronic lung disease of prematurity,
chronic respiratory conditions such as
- cystic fibrosis,
- bronchiectasis or
- immune deficiency
Admission should also be considered for:
All children under the age of 6 months
Children in whom treatment with antibiotics has failed (most
children improve after 48 hours of oral, outpatient antibiotics)
Patients with troublesome pleuritic pain
Be sure to offer the patient and parents general support,
explanation and reassurance.
Respiratory support as required, including oxygen
Pulse oximetry to guide management
Severe respiratory distress with ↓level of consciousness
and failure to maintain oxygenation indicates a need for
(avoid aspirin due to the danger of Reye's syndrome).
9 - Complication & prognosis
Complete resolution after treatment should be expected in
the vast majority of cases.
Bacterial invasion of the lung tissue can cause pneumonic
consolidation, septicemia, empyema, lung abscess
(especially S. aureus) and pleural effusion.
Respiratory failure, hypoxia and death are rare unless
there is previous lung disease or the patient is
10 - Prevention
Prevention of pneumococcal pneumonia and influenza by
vaccination, for high-risk individuals with pre-existing
heart or lung disease.
Smoking in the home is a major risk factor for all
childhood respiratory infection.
11 - Take Home massages
Understanding the pathophysiology of LRTI
Conducting proper History
Performing careful physical Examination
Comprehension the Impact of the disease on the family
Close follow up after discharge
Avoidance of bad Habit : Smoking
12 - References
Guidelines for the management of community acquired pneumonia in children;
British Thoracic Society (2011)
Pediatric Essntial Nelsom 2011
van Woensel JB, van Aalderen WM, Kimpen JL; Viral lower respiratory tract
infection in infants and young children. BMJ. 2003 Jul 5;327(7405):36-40.
Michelow IC, Olsen K, Lozano J, et al; Epidemiology and clinical
characteristics of community-acquired pneumonia in hospitalized children.
Pediatrics. 2004 Apr;113(4):701-7.
Krilov LR; Respiratory syncytial virus disease: update on treatment and
prevention. Expert Rev Anti Infect Ther. 2011 Jan;9(1):27-32.
Feverish illness in children - Assessment and initial management in children
younger than 5 years; NICE Guideline (May 2013)
Mahabee-Gittens EM, Grupp-Phelan J, Brody AS, et al; Identifying children
with pneumonia in the emergency department. Clin Pediatr (Phila). 2005
Haider BA, Saeed MA, Bhutta ZA; Short-course versus long-course antibiotic
therapy for non-severe Cochrane Database Syst Rev. 2008 Apr