ACUTE RESPIRATORY INFECTION

BY NIKITA V N

31

CHILD AGED 2 MONTHS TO 5 YEARSClassifying the illness means making decisions

about the type and severity of disease. The sick child should be put into one of the four classifications:

VERY SEVERE DISEASE SEVERE PNEUMONIA PNEUMONIA(not severe) NO PNEUMONIA

CLASSIFICATION

1. VERY SEVERE DISEASEThe danger signs and possible causes are:

a) Not able to drink: A child who is not able to drink could have severe pneumonia or bronchiolotis, septicaemia, throat abscess, meningitis or cerebral malaria.

b) Convulsions, abnormally sleepy or difficult to wake: A child with these signs may have severe pneumonia resulting in hypoxia, sepsis, cerebral malaria or meningitis. Meningitis can develop as a complication of pneumonia or it can occur on its own.

c) Stridor in calm child: If a child has stridor when calm, the child may be in danger of life threatening obstruction of the air-way from swelling of larynx, trachea or epiglottis.

d) Severe malnutrition: A severely malnourished child is at high risk of developing and dying from pneumonia. In addition, the child may not show typical signs of the illness.

2. SEVERE PNEUMONIAThe most important signs to consider when

deciding if the child has pneumonia are the child’s respiratory rate, and whether or not there is chest indrawing may not have fast breathing if the child becomes exhausted, and if the efforts needed to expand the lungs is too great.

In such cases , chest indrawing maybe the only sign in a child with severe pneumonia. A child with chest indrawing is at higher risk of pneumonia than a child with fast breathing alone.

A child classified as having severe pneumonia also has other signs such as;

. Nasal flaring, when the nose widens as the child breaths in

. Grunting, the short sounds made with the voice when the child has difficulty in breathing and

. Cyanosis, a dark bluish or purplish coloration of the skin caused by hypoxia

Children who have chest indrawing and a first episode of wheezing often have severe pneumonia, however with recurrent wheezing do not have severe pnuemonia.

3. Pneumonia (not severe)A child who has fast breathing and no chest

indrawing is classified as having pneumonia(not severe). Most children are classified in this category if they are brought early for treatment. Fever , cough, tachpnoea, crackles , signs of consolidation , and constitutional symptoms are the general clinical features seen in a patient suffering with pneumonia.

4. No pneumonia: cough or coldMost children with a cough or difficult

breathing do not have any danger signs or signs of pneumonia ( chest indrawing or fast breathing). These children have a simple cough or cold. They are classified as having ‘no pneumonia: cough or cold’. They do not need any antibiotic. Majority of such cases are viral infections where antibiotics are not effective. Normally a child with cold will get better within 1-2 weeks.

MANAGEMENT OF PNEUMONIA IN A CHILD AGED 2 MONTHS UPTO 5 YEARS

Infants less than 2 months of age are referred to as young infants. They have special characteristics that must be considered when their illness is classified. They can become sick and die very quickly from bacterial infections, are much less likely to cough with pneumonia, and frequently have only non specific signs such as poor feeding, fever or hypothermia.

Classifying illness of young infant

1) Further mild chest indrawing is normal in young infants because their chest wall bones are soft. The presence of these characteristics means that they will be classified and treated differently from older children.

2) Many of the cases may have added risk factor of low birth weight. Such children are very susceptible to temperature changes and even in tropical climates, death due to cold stress or hypothermia are common.

3) In young infants the cut off point for fast breathing is 60 breaths per minute. Any pneumonia in young infants is considered to be severe.

Some of the danger signs of very severe disease are:

a. convulsions, abnormally sleepy or difficult to wake: a young infant with these signs may have hypoxia from pneumonia, sepsis or meningitis. Malaria infection is unusual in children of this age, so antimalarial treatment is not advised.

b. Stridor when calm: infections causing stridor viz diphtheria, bacterial tracheitis, measles or epiglottitis are rare in young infants. A young infant who has stridor should be classified as having very severe disease.

c. Stopped feeding well : a young infant who stops feeding well(i.e takes less than half of the usual amount of milk) may have a serious infection and should be classified as having very severe disease.

d. wheezing: it is uncommon in infants and is usually associated with hypoxia.

e. Fever or low body temperature: fever(38 degree or more) is uncommon in young infants and more often means a serious bacterial infection. It may be the only sign of serious bacterial infection. Sometimes infection can cause hypothermia.

CLASSIFICATION AND MANAGEMENT OF ILLNESS IN YOUNG INFANTS

A. TREATMENT FOR CHILDREN AGED 2 MONTHS UPTO 5 YEARS

.PNEUMONIA (child with cough and fast breathing)

cotrimoxazole is the drug of choice for the treatment of pneumonia. Cure rates are 95%. It is less expensive with few side effects and can be used safely by health workers at the peripheral health facilities and at home by the mothers.

Treatment

The condition of the child should be assessed after 48 hours.

Cotrimoxazole should be continued for another 3 days in children who show improvement in clinical condition.

If there is no improvement in the condition then it should be continued for 48 hours and then reassesed.

If at 48 hours or earlier the condition worsens, the child should be hospitalised immediately.

Severe pneumonia (chest indrawing)

Children with severe pneumonia should be treated as inpatients with intramuscular injections of benzylpenicilline(after test dose) ampicillin or chloramphenicol.

The condition of the child must be monitored everyday and reviewed after 48hrs for antibiotic therapy.

Antibiotic therapy must be given for a minimum of 5 days and continued for atleast 3 days after the child gets well.

Very severe disease-Children with signs of very severe disease

are in imminent danger of death and should be treated in a health facility, with provision of oxygen therapy and intensive monitoring.

-Chloramphenicol IM is the doc in all such cases. Treat for 48 hrs ,if conditons improve switch over to oral chloramphenicol. It should be given for a total of 10 days.

-If condition worsens or does not improve after 48hrs switch to IM injections of cloxacillin and gentamicin.

B. PNEUMONIA IN YOUNG INFANTS UNDER 2 MONTHS OF AGE

The treatment in these condition is basically the same.

1.The child must be hospitaised.2.Treatment with cotrimoxazole maybe

started by the health worker before referring the child.

3. If pneumonia is suspected in the child should be treated with IM injection of bezylpenicilline or ampicillin, along with injection gentamycin.

Besides antibiotics, therapy for the associated conditions if any, must be instituted immediately. The child must be kept warm and dry. Breast feeding must be promoted strongly as the child who is not breast fed is at a much higher risk of diarrhoea.

Management of AURI (no pneumonia) -> Many children with presenting symptoms

of cough, cold and fever do not have pnenumonia and do not require treatment with antibiotics.

->They are not recommended as majority of cases are caused by viruses and antibiotics are not effective, they increase resistant strains and cause side effects while providing no clinical benefit, and are wasteful expenditure.

->Symptomatic treatment and care at home is generally enough for such cases.