Let’s look at a common case-scenario. A
two-year-old presents with recurrent episodes of fever, cold, cough and
wheezing since the age of 6 months. Each time, the episode begins with
high fever that lasts for 2 to 3 days, accompanied with cold and
progressively worsening cough, followed by wheezing. Wheezing settles
down within a short time but the cough continues for two weeks. Routine
investigations are normal. The child remains well in between episodes,
and maintains good growth and development. No one in family has history
suggestive of asthma or atopy. The child receives repeated courses of
antibiotics and inhaled steroids for 3 months, but there is no change in
frequency of episodes. Each and every time pediatrician’s ‘mann ki
baat’ rotates around questions like…Is it viral?...Is it
bacterial?...Can I label it as asthma?...Kahin ye ‘woh’ toh nahin?
(Tuberculosis!)... finally realizing that it is Wheeze Associated Lower
Respiratory Infection (WALRI)!
Respiratory complaints are the commonest reason for
visits by our young patients to us (barring well baby visits of course).
The disease pattern presenting to the pediatricians ranges from
self-limiting upper respiratory tract infection (URTI) to severe
complicated pneumonia; and with acute, sub-acute, recurring, relapsing,
or chronic presentations. Pediatricians face problems and difficulties
in diagnosing, investigating and treating wide range of respiratory
illnesses. ‘Clearing Pediatrics Airways’ is a program under Indian
Academy of Pediatric (IAP) Action Plan 2016 wherein the general
pediatrician has a chance to revise, refresh and review the knowledge
about the conditions (common as well as not so common) affecting a
child’s respiratory system. The aim is to ‘clear’ the confusion while
dealing with congested and irritated respiratory tracts of children, and
remove the ‘hypoxia’ of ignorance.
Recurring respiratory symptoms is a common problem
that a pediatrician faces in a busy clinic. Do all such children warrant
a battery of investigations and treatment, including antibiotics? A
pediatrician needs to be aware that 6-8 episodes of acute respiratory
infections (most of which are simple cold and cough) are a normal
phenomenon in preschool- and school-age [1], and one needs to counsel
the anxious parents that there is nothing wrong with the child’s
immunity. They must be clearly told that there are no drugs which
‘build’ or enhance immunity. At the same time, the conditions which are
likely to increase the frequency of these episodes need to be borne in
the mind. Conditions like allergic rhinitis and obstructive sleep apnea
need to be picked up in time. Subtle clues to identify rare disorders
like immunodeficiencies or ciliary dysfunction are also important in
such situations. Parental counseling forms the main stay of approach in
the management of majority of URTI as the episodes tend to recur in the
first five years of life. Recurring URTI may be benign in nature, while
recurring lower respiratory tract infections (LRTI) may have significant
underlying diseases. Evaluation of a patient with respiratory tract
infection calls for a detailed history encompassing the source of
infection (for example, another child in the family), onset of the
disease (for example; sudden onset of high grade fever in the viral
URTI, disappearance of fever followed by troublesome cough as in acute
viral URTI), detailed information on host factors including nutrition,
growth, and immunization status, or valuable information about the
environmental factors such as parental smoking, day-care admissions,
bottle feeding and hand-hygiene practices.
Under-five children presenting with a wheeze is a
conundrum that we commonly find ourselves in. We need to remember that
almost 50% of children wheeze in the first three years while only 20%
will experience continued wheezing. The common and often asked questions
which one has to answer are ‘Is it asthma?; Does he/she need a
controller?; What is the long-term outlook?’ For answering these, we
need to find out if the child is a transient wheezer, or is going to
have a persistent wheezing. From the days of residency, we have been
listening to the dictum – All that wheezes is not asthma. History of a
forgotten episode of choking (foreign body aspiration), and a close
contact with patient of pulmonary tuberculosis needs to be elicited. One
has to really be a ‘Wheezard’ while dealing with a child with
wheeze, and have the knowledge as to What age did it begin…Way
it took forward…Whether it is WALRI...Is there Weight
gain…Are there any Weird findings like clubbing…Whether
the wheeze is generalized or localized, and Waiting till getting
enough proof before putting a child with recurrent respiratory symptoms
on anti-tubercular therapy. One must remember that any recurrent wheeze
that is not getting controlled warrants search for alternate diagnosis.
Sizeable number of our patients have problems ranging
from leaky nostrils to itchy rashes, and from sneeze to wheeze. The
prevalence of allergic diseases is increasing worldwide, in both
developing and developed countries. Allergic rhinitis (AR) is an
important co-morbidity with asthma; 30% of patients with AR have asthma,
and 80% of those with asthma have AR. The four major cardinal symptoms
of AR are sneezing, nasal itching, rhinorrhea and congestion. AR and
asthma share common allergens. Proper treatment of AR along with
allergen control improves control of asthma.
The approach and management of asthma is a dynamic
science. This is best illustrated by updates in the recent Global
Initiative for Asthma (GINA) guidelines, which now emphasize on
individualizing patient management not only by using genomics or
proteomics, but also with ‘humanomics’, taking into account the
behavioral, social and cultural factors that shape outcomes. When we
have a child with asthma, we are inflicting five shocks to the family –
the child has asthma, we will treat with inhalers, the
preventers are steroids, the treatment is long-term, and
we can at the best control as there is no cure. Time is what
parents need second to our expertise, and the time spent is directly
proportional to the success in therapy and disease outcome. For each of
the shock, we have five shock absorbers! We get them to Accept
the diagnosis of asthma, we get them to Agree to the line of
treatment, we get them to Adhere to the treatment planned, we get
them to recognize an Acute attack and home management, and we
teach them to identify and Avoid triggers. One must remember
these five ‘A’s of counseling in Asthma.
The itch to write an antibiotic for a child (or more
commonly a parent) is one that needs to be avoided. In this era of
antibiotic resistance, and when hardly any new antibiotic has been
discovered in the last many years, rational antibiotic therapy is
definitely the need of the hour. Understanding that only a few upper
respiratory conditions like acute bacterial tonsillitis or sinusitis
warrant antibiotic treatment, is of utmost importance [2]. Once the need
for antibiotic is confirmed, the choice, route and appropriate dosage is
of paramount importance. A haphazardly chosen antibiotic like cefixime
for bacterial tonsillitis will not only contribute to the emergence of
resistant strains but the child will also not improve, resulting in the
parents losing faith in the doctor. A simple drug like amoxicillin may
be sufficient in most of the respiratory infections in our day-to-day
practice. Also, if the appropriately chosen antibiotic does not seem to
be working, rather than changing the antibiotic at the drop of the hat,
possibility of wrong diagnosis and/or complication needs to be
considered. To alleviate symptoms of cough, a large number of
formulations are available and the pediatrician is often tempted to
prescribe one or the other of these, many a times just for the
satisfaction of the anxious parents. There is nothing like a cough- and
cold-remedy for children below six years of age. There is no true
suppressant or expectorant. There is a general consensus amongst experts
that these medicines have hardly any role in improving the symptoms, and
may in fact have many undesirable effects, especially in young children.
In rare situations, when a child becomes exhausted, or has insomnia or
repeated vomiting due to cough, a safe cough suppressant may be
justified. Many a times, simple demulcent syrups (not containing
alcohol) soothe the throat and may provide some relief from cough.
Childhood tuberculosis (TB), in spite of all efforts
remains difficult to diagnose and confirm. Some clinicians tend to
overdiagnose it in any child with recurrent respiratory symptoms. At the
same time, an over-enthusiastic newbie may completely miss a case with
atypical presentation in his overzealous effort to isolate the
Mycobacterium tuberculosis. The lack of an accurate diagnostic test
for TB in young children is a major challenge, and adds to the potential
for both under-diagnosis and over-diagnosis [3]. With these practical
problems in mind, a relatively easy to follow algorithm for diagnosis of
childhood TB can be followed. The IAP module covers special situations
like BCG adenitis, drug toxicity and chemoprophylaxis, and also
highlights simple techniques such as induced sputum and gastric aspirate
for better chances of isolation of the organism.
Respiratory emergencies are the commonest emergencies
faced by a pediatrician. When to call it respiratory distress or
respiratory failure – is a common question in the minds of many. Rapid
assessment of respiratory distress and triaging is the need of the hour.
Even upper airway emergencies like croup, or laryngospasm due to
anaphylaxis can be life threatening, and identifying them goes a long
way in early and appropriate management. The do’s and don’ts in acute
severe asthma and other non-respiratory conditions presenting as
respiratory emergencies are crucial, and can make a difference between
life and death.
The knowledge of inhalation therapy and oxygen
administration still needs to be upgraded for many of us, as errors can
result in failure of therapy and can prove very costly. It has become a
common practice to offer nebulization (like a welcome drink) for any
respiratory disease, including URTI! Nebulization is to be used for an
acute episode of asthma. Even in asthma, it is recommended in a hospital
setting for severe exacerbation. In mild-to-moderate exacerbations,
spacer with mask is as effective as nebulizer, and should be preferred.
Indoor children with respiratory distress due to etiology other than
asthma are also commonly nebulized for prolonged period without any
justification. We also have to be rational in using the medications for
nebulization therapy, and have to be specially vigilant about doses and
schedule while using preparations with a combination of drugs. The
cleanliness and sterility of devices used for nebulization and oxygen
therapy also warrants attention. Ideally a new mask should be used for
each patient to avoid cross-infection. Nebulization without oxygen may
increase hypoxia in a sick child. Nebulizing solution should always be
diluted with normal saline, and never with distilled water, as is
practiced many times, particularly at home. Many times wrong dose is
administered because of confusion between respule and ‘nebulizing
solution.’ Nebulizing with saline for common cold or a blocked nose is
irrational.
While pneumonia, including that caused by S.
pneumoniae, is a major threat to child health and survival,
it is also preventable. We have the tools to significantly reduce
pneumonia morbidity and mortality in India, using a comprehensive
approach recommended by the WHO/UNICEF Integrated Global Action Plan for
the Prevention and Control of Pneumonia and Diarrhoea that incorporates
protection, prevention and treatment, which includes breastfeeding and
vitamin A supplementation, vaccines and improved indoor air quality, in
addition to treatment with antibiotics and oxygen [4]. With the support
from the Global Alliance for Vaccines and Immunization (GAVI), vaccines
are now becoming increasingly available in the poorest countries.
Pneumococcal conjugate vaccines (PCV) have been shown to be a critical
tool for pneumonia prevention and control around the world, and more
than 130 countries have introduced PCV in their national immunization
programs. The Government of India recently joined more than190 countries
in introducing Haemophilus influenzae b (Hib) vaccine. However,
PCV is not yet a part of India’s Universal Immunization Program.
World Pneumonia Day is observed on 12th November.
This year’s theme — ‘Keep the Promise. Stop Pneumonia Now’ – focuses on
the intersection of pneumonia and the Sustainable Development Goals
(SDGs). We have an opportunity to keep the promise of the SDGs by
stopping pneumonia and saving thousands of young lives. Let’s work
together to send a strong message – we can keep the promise of
the SDGs by working together to improve child health. Too many young
lives are at stake to ignore this silent killer.
References
