Upper respiratory tract infections

6.1 Upper respiratory tract infections



Peter L.J. Barnett




Essentials



1 Over 95% of childhood URTIs are viral and do not require antibiotics.

2 Upper respiratory tract infections are common; children have between six and eight URTIs per year.

3 In the child with presumed URTI who has significant constitutional symptomatology one needs to consider alternative diagnoses.

4 Symptomatic nasal obstruction in infants should be treated with saline drops and gentle bulb aspiration. It is uncommon for simple URTIs to compromise feeding in infants; in this situation one needs to consider LRT involvement.

5 Stomatitis in children is usually caused by herpes simplex or coxsackie virus and symptomatic treatment to aid fluid intake is all that is required.

6 Tonsillitis in children under four years is usually viral in aetiology.

7 Tonsillitis is a feature of Epstein-Barr virus (EBV), thus always examine for node enlargement and organomegaly and features in the pharynx to suggest possible EBV.


Introduction


Infections involving the upper respiratory tract are the commonest infections seen in children and the most frequent reason for presenting to emergency departments (EDs). These infections may involve anatomical structures including the nasopharynx, mouth, ear and upper airway. Specific diagnosis needs to be made to decide whether antibiotic treatment is necessary. Most of these infections are mild and self-limiting, but complications can occur, leading to more serious disease.



Nasopharyngitis



Introduction


Nasopharyngitis or the common cold is a viral illness of the upper respiratory tract. This is commonly called an upper respiratory tract infection (URTI) even though it only affects part of the upper respiratory tract. An URTI is usually caused by rhino- and coronaviruses, but during the winter season, parainfluenza, respiratory syncytial virus (RSV) and metapneumovirus are also common. These later viruses may progress to croup, bronchiolitis or pneumonia. Other specific infections may begin with URTI symptoms and progress to involve the lower respiratory tract, e.g. influenza, Bordetella pertussis. If symptoms are persistent, an open mind regarding alternative diagnoses is required. In their first 6 years, children generally have between six and eight URTIs per year and children attending day care may have more. Not infrequently these may occur one after the other, leading to the impression of persistent symptoms rather than two to three separate infections. Breast feeding of babies may offer some protection, particularly in the first 6 months.



History


This illness is characterised by mild to moderate fever, blocked or runny nose, sneezing, mild cough (generally dry in the first few days) with an irritating sore throat if the child is able to verbalise this symptom. Infants may also become restless and irritable. Nasal congestion may interfere with feeding in infants under 6 months due to mechanical obstruction. Over the first few days the watery nasal discharge will become thicker and more mucopurulent. Nasal obstruction leads to mouth breathing and increased throat discomfort. The characteristic of the cough may change, becoming moist after a few days. Sputum production occurs but in small children is generally swallowed rather than expectorated and hence will not be reported by parents. The child is not particularly unwell. If a child has significant constitutional symptoms, one needs to consider alternative diagnoses such as lower respiratory infection or an influenza-like illness. Other family members may have or be recovering from cold symptoms. Symptoms usually peak around 1–3 days and disappear by 7–10 days although the cough may persist (up to 8 weeks – postviral cough). Bacterial complications are uncommon but should be considered if fever persist for longer than 3–5 days, ongoing mucopurulent nasal discharge for more than 2 weeks, child appears unwell or has lower respiratory tract signs (e.g. tachypnoea, grunting, wheeze, O2 requirement).



Examination


The child appears well with nasal discharge, which may cause obstruction (particularly in babies). Mucopurulent discharge does not indicate a bacterial cause. The tympanic membranes may be slightly dull or pink in appearance with no evidence of fluid in the middle ear. The throat may be red but not associated with exudate or cervical lymphadenopathy. The chest is clear to auscultation, although there may be transmitted upper airway sounds, originating from the nasal passages. The cough may be dry or moist depending on the length of symptoms.



Investigations


There is no indication for investigations in a child with common cold.



Treatment


Therapy is supportive, with explanation and a management plan for parents. Parents need to ensure the child has adequate rest and fluids to maintain hydration. Nasal congestion/obstruction in infants may be improved with saline drops (one teaspoon salt in one cup boiled water and allowed to cool and kept in refrigerator for a few days only or commercial saline preparations) into the nares prior to feeds or sleeping. In addition, aspiration of mucus using a bulb suction device is generally helpful. While feeding difficulty may occur due to nasal obstruction, infants with a presumed simple URTI who are unable to take normal feeds need to be carefully checked for features of lower respiratory tract (LRT) involvement.


The routine use of oral decongestants in infants is generally unhelpful and may cause side effects. In older children symptomatic of nasal obstruction, topical or oral decongestants may be used judiciously and topical decongestants never longer than 3 days, to avoid rebound nasal mucosal swelling.


There is no indication for antibiotics in this setting. Pharyngitis or tonsillitis associated with a URTI is viral in nature and will not respond to antibiotics. The inappropriate use of antibiotics in these patients may be a contributory factor to antibiotic resistance. Herbal remedies such as echinacea, vitamin C, or zinc have not been shown to benefit resolution of symptoms.


An explanation to parents of the expected natural history may decrease the likelihood of inappropriate seeking of antibiotics. Early review should be encouraged if their child’s course deviates from that expected. Paracetamol is indicated if a child is symptomatic of fever or to diminish the discomfort of a sore throat.

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Sep 7, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Upper respiratory tract infections

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