Pediatric Primary Care (63 page)

F.  Differential diagnosis.

1.  Other lower respiratory illness (e.g., bronchiolitis, laryngotracheobronchitis, pneumonia).

G.  Treatment.

1.  Encourage fluids.

2.  Antipyretics for fever (never use salicylates in children or adolescents).

3.  Monitor for complications of influenza.

4.  Antiviral therapy.

a.  Recommendations for selection of antiviral drugs are made annually:
www.cdc.gov
.

b.  Must be administered within 48 hours of onset of illness.

c.  Relenza (Zanamivir): administered by inhalation for treatment of influenza A and B for children > 7 years of age; side effects include dizziness, runny or stuffy nose, cough, diarrhea, or headache. Can cause bronchospasm; not recommended for use in persons with underlying lung disease such as asthma.

d.  Tamiflu (Oseltamivir): administered orally (liquid for children or capsule formulation) for treatment of influenza A and B for children and adults > 1 year of age; adverse effects nausea, vomiting in first 2 days of treatment. Taking Tamiflu with food can reduce these side effects.

e.  Confusion and abnormal behavior have been reported with both antiviral drugs and may be more common in children.

H.  Follow up.

1.  Call healthcare provider immediately if signs of respiratory distress increase.

a.  Increased respiratory rate, shortness of breath.

b.  Increased retractions.

c.  Change in level of consciousness, restlessness, or anxiety.

d.  Cyanosis.

2.  Close telephone follow up for those at high risk for flu-related complications.

I.  Complications.

1.  Viral and bacterial pneumonia.

2.  Severe illness requiring hospitalization.

3.  Dehydration.

4.  Worsening of chronic illness, including CHF, asthma, or diabetes.

5.  Death.

J.  Education.

1.  Prevention.

a.  Annual intranasal vaccine (LAIV–live attenuated intranasal vaccine) is an option for healthy children and adults 2-49 years of age.

b.  Yearly influenza vaccine in fall for all children 6 months to 18 years of age with special attention to those at high risk of complications and their close contacts.

•  Trivalent inactivated vaccine is administered IM and is approved for children 6 months of age or older.

•  Children younger than 9 years of age require 2 doses of vaccine in the first year they received the vaccine, administered 1 month apart to produce sufficient antibody response.

c.  Good handwashing, avoidance of ill contacts during influenza outbreaks.

2.  Post-illness.

a.  Treat with antiviral agents within 48 hours after onset of symptoms to reduce duration of illness.

b.  Recognize signs of severe illness requiring medical intervention including shortness of breath, dyspnea, cyanosis, change in level of consciousness.

c.  Encourage fluids to maintain adequate hydration and urine output.

d.  Acetaminophen for treatment of myalgia, headache, fever.

e.  Recurrent wheezing is common, especially with URIs.

f.  Avoid secondhand smoke exposure.

IV. BRONCHITIS

A.  Etiology.

1.  Bronchitis is a common respiratory problem of childhood characterized by cough.

2.  Most commonly occurs after viral infection.

a.  Rhinovirus, RSV, influenza, parainfluenza, adenovirus, coxsackievirus, paramyxoviruses can be etiologic agent.

3.  May occur with bacterial, mycoplasmal, or fungal infection.

4.  May occur as result of inflammation caused by frequent viral infection, secondhand smoke exposure, and air pollution.

5.  Chronic bronchitis is poorly defined in children.

B.  Occurrence.

1.  Peak months in young children are related to high RSV activity.

2.  Peak incidence is in winter months.

3.  Chronic/recurrent bronchitis: cough lasting > 1 month or 4 episodes within 1 year.

C.  Clinical manifestations.

1.  Mild URI symptoms including rhinitis and pharyngitis.

2.  Dry hacking cough begins 3-4 days after onset of rhinitis.

3.  Cough often becomes productive after a few days.

4.  Older patients may complain of chest pain, worse with coughing.

5.  As cough progressively worsens, the child has more signs of generalized illness.

6.  Younger children may have post-tussive vomiting.

7.  Normal temperature or mild elevation.

D.  Physical findings.

1.  Physical findings vary with phase of illness.

2.  Initially clear or mucopurulent nasal secretions.

3.  Auscultation initially may be normal.

4.  Cough is dry, hacking in nature.

5.  Normal or slightly elevated temperature.

6.  Over next week, cough becomes productive as condition progresses to include lower respiratory symptoms.

a.  Coarse crackles with variable wheezing may be present.

b.  Moderate to severe productive cough, chest pain.

c.  Post-tussive vomiting, thick yellow mucopurulent sputum.

7.  Elevated temperature is likely during this time.

E.  Diagnostic tests.

1.  Diagnosis is often diagnosis of exclusion (see “Differential Diagnosis”).

2.  Assessment of general health status including height, weight, signs of chronic pulmonary disease.

3.  Elevated neutrophil count or C-reactive protein is suggestive of bacterial etiology.

4.  CXR is usually normal, but may show peribronchial thickening.

5.  RSV wash for rapid testing.

F.  Differential diagnosis.

1.  Asthma: pattern of symptoms, absence of fever, expiratory wheezing, prolonged expiratory phase.

2.  Bronchiectasis: recurrent pulmonary infections, anorexia, irritability, poor growth, digital clubbing, rule out other chronic pulmonary disorders.

3.  Bronchopulmonary dysplasia: history of prematurity, treatment with oxygen therapy, and/or mechanical ventilation during neonatal period.

4.  Immunodeficiency: systemic illness following vaccination with live virus; severe life-threatening illness with viral infection.

5.  Gastroesophageal reflux: barium swallow demonstrates reflux of barium into esophagus; esophageal pH monitoring.

6.  Congenital heart disease: accompanied by heart murmur, signs of CHF, poor feeding, poor growth.

7.  Sinusitis: purulent rhinitis lasting 2 weeks, facial/dental pain, headache, pressure over affected area.