1. Respiratory Disorders in Children
Dr Varsha Atul Shah

2. Respiratory disorders are
important as
 They account for 50% of consultations with general
practitioners for acute illness in young children and
one-third of consultations in older children
 Respiratory illness leads to 20-35% of acute
paediatric admissions to hospital
 They are the fifth most common cause of death in
children ages between one and 14 years in the UK
 Asthma is the most common chronic illness of
childhood in the UK and the most frequent single
cause for emergency hospital admission
 Cystic fibrosis is the most common lethal inherited
disorder in Caucasians

3. Respiratory infections
 most frequent infections of childhood.
 The pre-school child has on average 6-8
respiratory infections a year.
 Most are mild, self-limiting illness but some,
such as bronchiolitis or epiglottitis, are
potentially life-threatening

4. Pathogens
 Viruses: cause 80-90% of childhood respiratory
infections. The most important are the respiratory
syncycial virus (RSV), rhinoviruses, parainfluenza,
influenza and adenovirus. An individual virus can cause
several different patterns of illness, e.g. RSV can cause
bronchiolitis, croup, pneumonia or a common cold.
 The important bacterial respiratory pathogens are
Streptococcus pneumoniae and other streptococci,
Haemophilus influenzae, Bordetella pertussis which
cause whooping cough, and mycoplasma pneumoniae.
Mycobacterium tuberculosis remains an important
pathogen. Some pathogens cause predictable epidemics,
such as RSV bronchiolitis every winter, whereas others,
e.g. pneumococcus, show little seasonal variation.

5. Host and environmental
factors
 Poor socio-economic status (such as overcrowded,
damp housing and poor nutrition)
 Larger family size
 Maternal smoking
 Boys more than girls
 Prematurity-especially infants who have required
artificial ventilation
 Congenital abnormalities of the heart or lungs
 Rarely, immune deficiency, either congenital,
e.g.agmmaglobulinaemia, or acquired, e.g. malignant
disease or HIV infection.

6. The child’s age
 The child’s age influences the prevalence and
severity of infections.
 It is in infancy that serious respiratory illness
requiring hospital admission is the most
common and the risk of death is great.
 There is an increased frequency of infections
when the child or older siblings start nursery
or school. Repeated upper respiratory tract
infections are rarely an indication of
underlying disease

7. Classification of respiratory
infections
 Upper respiratory tract infection
 Laryngeal/tracheal infection
 Bronchitis
 Brochiolitis
 Pneumonia

8. Upper respiratory tract
infection (URTI)
 80% of respiratory infections involve only
the nose, throat, ears and sinuses
 The term URTI embraces a number of
different conditions:
 common cold (coryza)
 sore throat (pharyngitis, including
tonsillitis)
 acute otitis media
 sinusitis

9. Clinical Presentation
The most common presentation is a
child with a combination of a painful
throat, fever, nasal blockage and
discharge and earache.
 Cough is troublesome in many cases

10. URTIs may cause
 Difficulty in feeding in infants as their
noses are blocked and this obstructs
breathing
 Febrile convulsions
 Precipitation of acute asthma
 In infants, hospital admission may be
required exclude a more serious
infection

11. Brochiolitis
 Brochiolitis is the most common serious
respiratory infection of infancy. Two to
three per cent of all infants are
admitted to hospital with the disease
each year during annual winter
epidemics. Ninety per cent are aged 1-9
months brochiolitis is rare after one
year old. Respiratory syncitial virus
(RSV) is the pathogen in 75-80% cases

12. Clinical features
 Coryzal symptoms precede a dry cough and increasing
breathlessness. Wheezing is often but not always
present. Feeding difficulties associated with increasing
dyspnoea are often the reason for admission to hospital.
Recurrent apnoea is a serious complication in infants in
the first few months of life. Infants born prematurely
who develop bronchopulmonary dysplasia and infants
with congenital heart disease are more severely
affected. The finding on examination are characteristic:
 Sharp, dry cough
 Tachypnoea
 Subcostal and intercostals recession
 Hyperinflation of the chest

13. Investigations
 RSV can be identified rapidly using a
fluorescent antibody test on
nasopharyngeal secretions. The chest
X-ray shows hyperinflation of the lungs
due to small airways obstruction and air
trapping. Blood gas analysis, which is
required in only the most severe cases,
shows lowered arterial oxygen and
raised CO2 tension

14. Management
 Is supportive. Humidified oxygen is delivered into a
head-box, the concentration required is ascertained
using a pulse oximeter. The child is monitored for
apnoea.
 Mist, antibiotics and steroids are not helpful.
 Nebulised bronchodialators do not reduce the severity
or duration of the illness.
 The antiviral drug ribavirin only marginally shortens
viral excretion and clinical symptoms, and should be
considered only for infants with underlying
cardiopulmonary disorders or immunodeficiency.
 Fluids may need to be given by nasogastric tube or
intravenously.
 Mechanical ventilation is required in about 2% of
infants admitted to hospital

15. Prognosis
 Most infants recover from he acute
infection within two weeks. However, as
many as half will have recurrent
episodes of cough and wheeze over the
next 3-5 years. Rarely, the illness is
very severe and results in permanent
damage o the airway

16. Pneumonia
 A wide range of pathogens cause
pneumonia in childhood and different
organisms affect different age groups

17. In newborns
 The newborns is infected by organisms
from the mother’s genital tract. The
most common is the Group B β
haemolytic streptococcus. Other
pathogens are E.coli and other Gram-
negative bacilli. Chlamydia trachomatis
is an unusual but important pathogen.

18. In infancy
 In infancy, respiratory viruses,
particularly RSV, are the most frequent
cause but bacterial infection from
Streptococcus pneumoniae and
Haemophilus influenzae are also
important. Staphylococcus aureus is
uncommon but causes severe infection

19. Older Children
 As children become older, viruses become
less frequent pathogens and bacterial
infection more prominent. Mycoplasma
pneumoniae is a common cause of
pneumonia in school age children.
Tuberculosis should be considered at all
ages

20. Clinical Features
 Fever, cough breathlessness and lethargy
following an upper respiratory tract infection
are the usual presenting symptoms.
 Breathing is rapid, shallow and gives the
impression that the child is afraid to breathe
deeply.
 Pleuritic chest pain, neck stiffness and
abdominal pain may be present if there is
pleural inflammation.

21. Clinical Features
 Classical signs of consolidation with impaired
percussion, decreased breath sound and
brochial breathing are often absent,
particularly in infants
 The chest X-ray may slow lobar consolidation,
patchy bronchopneumonia or, less commonly,
cavitation of the lung.
 Pleural effusions are quite common,
particularly in bacterial pneumonia.
 Blood cultures, nasopharyngeal aspirates of
viral isolation and a full blood count also be
performed in children needing hospitalisation.

22. Management
 It is not possible to differentiate reliably between
bacterial or viral infection on clinical or radiological
grounds, so all children diagnosed as have pneumonia
should receive antibiotics.
 As it is unlikely for the pathogen to be known when
treatment is started, the choice of antibiotic is
determined by the child’s age, severity of illness and
appearance of the chest X-ray.
 If intravenous therapy is required, activity against
pneumococci, H. influenzae and Staph. aures can be
achieved with a second-generation cephalosporin.

23. Management
 Oral antibiotics are given for less severe
infections.
 If M.pneumoniae or Chlamydia trachomatis
pneumonia is suspected, erythromycin is given.
 Physiotherpy, an adequate fluid intake and
oxygen in severe pneumonia may be required. If
a child has recurrent or persistent pneumonia,
investigations to exclude an underlying condition
such as cystic fibrosis or immunodeficiency is
indicated