Winter has arrived and along with it comes cold and flu season. For parents with young children particularly those attending daycare and school, this can often be a difficult time with children experiencing frequent respiratory ailments. In this issue of Offshoot we talk about common winter illnesses and provide tips on when to seek further medical support.
Paediatricians are often asked how many infections are too many? It is not uncommon for parents of young children to feel concerned that their child is “sick all the time”. What we know from research is it is normal for children to have 6 to 8 colds per year and up to 6 ear infections per year within the first few years of life. We also know that these numbers may be even higher for children who attend daycare compared to those whom remain at home with a carer. With these figures in mind, it is understable why respiratory tract infections are the most common reason for childhood presentations to general practitioners or paediatricians. While the majority of these infections are caused by viruses and may simply require reassurance and symptomatic management, there are instances when further concern is warranted (see tables below). An improved understanding of the common types of infections during winter and how long you expect them to last aids this process.
Bronchiolitis is a common condition seen in infants under 12 months and results from inflammation in the smallest passages of the respiratory tree, the bronchioles. Bronchiolitis usually has a pattern of 2-3 days of cold-like symptoms followed by 3 days of rapid and increased work of breathing (chest wall retractions or nasal flaring); noisy breathing (wheeze); lethargy and poor feeding. Symptoms gradually subside over 7-10 days, with a dry cough sometimes persisting for several weeks. Treatment is usually supportive although admission is required when children are reluctant or unable to feed, working very hard (respiratory rate > 70bpm or severe chest wall recessions), becoming lethargic or require supplemental oxygen to maintain their oxygen levels (i.e., SaO2 <92%). Other groups at higher risk that may require admission include, premature infants, babies under 3- months of age and children with chronic diseases relating to the heart, lung or brain.
Croup is a condition usually seen in infants and young children typically beneath the age of 5-years. It results from inflammation narrowing the upper respiratory tree at the level of the larynx, trachea and bronchi. Croup presents with a barking, seal-like cough, sometimes along with a harsh sound on inhalation called “stridor”. All children with stridor require medical attention and benefit from short course of oral corticosteroids (e.g., Prednisolone 1mg/kg for 2 days). In circumstances where there is significant stridor at rest, marked work of breathing or lethargy parents should be directed towards the emergency department as they may require urgent nebulised adrenaline in addition to corticosteroids.
VIRAL INDUCED WHEEZE/ASTHMA
These conditions are similar to bronchiolitis in that they result from inflammation of the small airways and present with wheezing and a prolonged expiratory phase. Children may also present with tightness in the chest and increased work of breathing. Children with a viral-induced wheeze may be responsive to inhaled bronchodilators, such as Salbutamol (e.g., Ventolin). If children are working hard to breathe or require their Ventolin more frequently than 3-hourly then they should be observed in hospital to make sure that their Salbutamol requirement is able to be stretched safely to 3-4 hourly. Children with repeated episodes of bronchodilator responsive wheeze may benefit from a preventer, particularly if they experience interval symptoms requiring Salbultamol 3 or more times a week. You can download an asthma interval symptom chart from www.offspringhealth.com. For children with recurrent or chronic symptoms, it is important to liaise with their paediatrician to ensure an asthma action plan is developed and provided to day-care or schools.
In children, there is a potential for harm and no benefits with over-the-counter cough and cold medications; therefore, they should not be used in children younger than four years.
|When to be concerned about recurrent infections?|
|4 new ear infections in one year after age 2-3|
|2 or more serious sinus infections per year|
|2 months course of antibiotics with no significant improvement|
|2 episodes of pneumonia per year|
|Failure of an infant to gain weight or grow normally|
|Persistent thrush in the mouth or persistent fungal infection on the skin|
|2 or more blood stream infections (septicemia)|
|A family history of immune deficiency|
|Features of severe bronchiolitis|
|Poor feeding (fluid intake <50% of usual, poor urine output)|
|Respiratory rate > 70 breaths per minute or Apnoea|
|Nasal flaring, grunting or severe chest wall recessions|
|Oxygen saturations <92%|
Assessing severity of a child with croup
Mild: barking cough, no or intermittent stridor, no chest retractions 2 or more blood stream infections (septicemia) A family history of immune deficiency
Moderate: persisting stridor at rest, some chest wall recession or tracheal tug, child easily pacified and interested in surroundings
Severe: persisting stridor at rest, marked tracheal tug