Respiratory Tract Infection in the Pediatric Age Group
Rammadan Mahmoud Issa1, Reham Ahmad AlSharif2*, Aldhoha Ibrahim Hussein Heddawi3, Amani Khaled AlRefai4 , Faisal Yousef AlZaid5, Mohammad Owaidh Abu Zahirah6, Ibrahim Fahad AlFarhan5, Fehaid Mohammed AlGhtani7, Dina Ahmed AlJohani8, Maha Hani AlEnazi2, Omnia Owiad Abuzahirah9, Lujain Ahmed Faraj10
1Department of Pediatrics, Riyadh, Saudi Arabia.
2Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.
3Faculty of Medicine, King Fahad Hospital Jeddah, Jeddah, Saudi Arabia.
4Faculty of Medicine, Ibn Sina National College, Jeddah, Saudi Arabia.
5Faculty of Medicine, King Saud Bin Abdulaziz University, Riyadh, Saudi Arabia.
6Faculty of Medicine, King Faisal Hospital, Makkah, Saudi Arabia.
7Faculty of Medicine, King Salman Hospital, Riyadh, Saudi Arabia.
8Faculty of Medicine, Cairo University, Cairo, Egypt.
9Faculty of Medicine, Ajyad Hospital, Makkah, Saudi Arabia.
10Faculty of Medicine, Batterjee Medical College, Jeddah, Saudi Arabia.
Abstract
Respiratory infections are the most frequent reason for medical visits in children. Even though many respiratory disorders are self-limiting viral infections that get better with time and supportive care, it can be necessary to identify the pathogen that is causing the illness at an early stage in order to use effective antimicrobial therapy and infection control. In recent years, diagnostics for respiratory infections have experienced a substantial evolution due to the development of novel assays and the availability of updated tests for pathogen strains with more recent mutations. The Medline, Pubmed, Embase, NCBI, and Cochrane databases were searched for studies of patients with non-alcoholic fatty liver disease. Incidence, etiology, and management options were analyzed. Parents are warned that children's RTI symptoms might persist up to three weeks. Parents may seek primary care help for at least 1 in 12 diseases, which policymakers should be aware of. Knowledge of RTI symptom duration in a nonconsulting population may help GP practice and public health initiatives by helping parents know how long to expect their children's respiratory symptoms to last. Ideally, you should also advise parents about which symptoms warrant medical attention. In a similar vein, if children exhibit milder respiratory symptoms, such interventions could encourage parents to anticipate lengthier and more severe illnesses.
Keywords: Respiratory tract infection, Respiratory virus, Pediatric population, Respiratory infection diagnosis, Molecular diagnostics
Introduction
In Saudi Arabia, respiratory tract infections (RTIs) are the most common condition presenting to general practitioners (Kotsimbos et al., 2007). It is a significant source of morbidity, and young children (those under the age of 5) are particularly susceptible. Even though the majority of RTIs are minor and self-limiting, their great frequency places a large financial and health burden on society (Hollinghurst et al., 2008), especially when taking into consideration the time that caregivers spend away from their regular activities (O'Grady et al., 2004). For the treatment and management of the majority of RTIs, Saudi Arabian clinical recommendations advise fluid intake, relaxation, and the use of paracetamol to children with fevers greater than 38.5 °C (National Health and Medical Research Council, 2012). Due to the lack of data demonstrating their efficacy and the potential for adverse effects in children under the age of six, oral decongestants and cough syrups are no longer advised for use in this age range (National Health and Medical Research Council, 2012). Antibiotics are not necessary as a therapy for the majority of RTIs since viruses account for the majority of RTI causes.
Despite the establishment of clinical standards, it has been demonstrated that general practitioners' (GPs) care and management of RTIs in young children in Saudi Arabia is inconsistent. Depending on the presenting clinical condition, the age and sex of the GP, and the management of RTIs in children under the age of five, a recent analysis of GP management indicated that management differed substantially. Recent US research indicates that parents' misinterpretations of RTI symptoms and their awareness of antibiotic use affect how doctors handle RTIs in young children (Salazar et al., 2012). Despite being lower than suggested standards, Saudi Arabian antibiotic usage for RTIs in children compares favorably to data from other countries (Petersen & Hayward, 2007). Studies conducted abroad have revealed that variables including doctors' diagnostic ambiguity, parents' anticipation that their children would receive antibiotics, doctors' perceptions of what parents desire, and parents' pleasure with the visit may make prescription antibiotics more difficult (Watson et al., 1999).
Epidemiology
In the United States, 61% of children aged 0–6 years attend daycare, while 36.1% get center-based care, including 19.6% of infants aged 0–2 years (Federal Interagency Forum on Child, & Family Studies (US), 2017). Respiratory tract infections (RTIs) are the most common cause of illness among daycare attendees (Denny et al., 1986). RTIs are more common in children who attend childcare centers and result in more hospitalizations than in children who get home care (Dales et al., 2004). The germs that are harming children the most should receive the most attention given the frequency of RTIs in childcare settings. There have been very few longitudinal investigations on the epidemiology of viral RTIs in daycare, and none of them have made use of modern molecular diagnostic equipment. A prior epidemiological daycare study that spanned 16 years, from 1966 to 1982, found a viral agent in just 31% of illness occurrences using accepted methodology. The daycare environment has not been studied in the same way for human metapneumovirus (HMPV), recently discovered human coronaviruses, and difficult to grow viruses like rhinovirus (RhV) and parainfluenza virus (PIV) type 4 (Denny et al., 1986).
Symptoms and signs
Children with respiratory illnesses deteriorate faster than adults, and respiratory arrest requiring resuscitation is generally the first occurrence. There are several reasons why children are more prone to RTIs, which are mentioned in. The ability to arrange appropriate care for the child will depend on health experts who examine children with RTI for any "red flags." (Schaad, 2005). The occurrence of one or more of these indicators should encourage community health workers to send children to secondary care services as soon as possible. Additionally, hospital staff should use extra caution when dismissing such children or those with known risk factors for developing RTI, even if the initial presentation is mild to moderate (Paul et al., 2011). The following are the signs that are most common:
Diagnosis
Electron microscopy (EM): in industrialized nations, electron microscopy (EM) is one of the oldest direct inspection procedures used for clinical viral diagnosis as well as the research of viral ultrastructure and pathogenesis (Roingeard, 2008). For decades, detecting viruses in cell culture by examining the cytopathic effect and hemadsorption has been regarded the "gold standard" for diagnosing respiratory viral infections. The most frequent respiratory viruses identified and detected by cell culture are adenovirus, influenza A/B, RSV, and human parainfluenza viruses (Olsen et al., 1993).
Rapid immunoassays (RIAs), which are frequently carried out in a point-of-care setting, can provide test results in less than 30 minutes and enable the inclusion of test results into clinical decision-making (Weinberg & Walker, 2005). The most versatile and well-liked immunochromatographic method among the four fundamental RIA formats is the lateral-flow immunoassay (LFIA) (latex agglutination, horizontal flow devices, lateral flow devices, and optical immunoassays) (Weinberg & Walker, 2005).
Testing with Direct Fluorescent Antibodies: Testing with Direct Fluorescent Antibodies (DFA) on nasopharyngeal wash samples is thought to be a quick and accurate way to detect respiratory viral infections. Although the results can be subjective and require technical expertise for accurate interpretation, commercial DFA kits have demonstrated high sensitivity and specificity for a variety of respiratory viruses, including hMPV (95 and 100%), adenovirus (62 and 100%), RSV (94 and 96%), and parainfluenza viruses (88 and 99.7%) (Landry & Ferguson, 2000).
Pathogen-specific antibodies normally emerge approximately 2 weeks after infection and can be identified by serological assays. Except for infants, serological testing can successfully detect antibodies to the majority of respiratory pathogens, including RSV, adenovirus, influenza A and B, parainfluenza 1-3 virus, and others. It can also identify mixed infections in hospitalized children with acute respiratory illnesses (Hall et al., 1991).
Assays with a High-Complexity Multiplex Panel: Over the past ten years, there has been a significant increase in the detection of respiratory pathogens by NAATs, including PCR, nucleic acid sequence-based amplification (NASBA), transcription-mediated amplification (TMA), strand displacement amplification (SDA), loop-mediated isothermal amplification (LAMP), rolling circle amplification (RCA), and others. Infection management and early treatment decisions benefit from the use of large syndromic panels since they can identify numerous pathogens simultaneously and are substantially less expensive than utilizing monoplex real-time RT-PCR to identify specific pathogens (Reijans et al., 2008).
Waived Molecular Point-of-Care Tests: In the realm of respiratory virus detection, nucleic acid amplification-based POC testing is novel and has generated discussion over its application and clinical utility. Molecular POC tests offer exceptionally rapid turnaround times (30 min), requiring little hands-on time (1-2 min), and may be conveniently controlled by non-laboratory people, making them ideal for near patient installation and testing (Brendish et al., 2015).
Risk factors
Healthy newborns, toddlers, and children are at high risk of coming into contact with and becoming infected with respiratory viruses. Most, however, will have a mild sickness that will cause some immunity to build from later infections with the same or similar agents. Reexposure and reinfection are the norm for the majority of respiratory viruses (Tyeryar et al., 1978). Reinfections usually result in less severe illness and are less likely to generate LRTIs that culminate in bronchiolitis or pneumonia.
Risk factors include
Considerations include parental smoking, environmental pollution, age, parental immunologic experience, prematurity, low birth weight, chronic cardiopulmonary diseases, immunodeficiency syndromes, malnutrition, exposure, other children in the family, crowding, the care setting itself (family versus day care), and lack of breastfeeding.
These elements raise the risk of infection and, consequently, the degree of disease. Young age, low birth weight, prematurity, chronic cardiopulmonary disease, certain congenital or acquired immunodeficiency disorders, malnutrition (particularly vitamin A deficiency), crowding, the number of children living in the household, the presence of numerous susceptible people in the community, the absence of breastfeeding, and exposing the susceptible child to other infected individuals are among them (Fergusson et al., 1980). There is compelling evidence that children who are exposed to air pollution, particularly secondhand smoke in the baby's home, are more vulnerable to sickness and its effects (Fergusson et al., 1980).
Treatment
Current recommendations for children with severe pneumonia include co-trimoxazole twice daily for five days as well as injectable penicillin or chloramphenicol. Research into alternatives to the antibiotics currently used in ARI case management has been stimulated by the issues of rising co-trimoxazole resistance and needless referrals of children with any chest wall indrawing. According to one study, amoxicillin and co-trimoxazole are similarly helpful for nonsevere pneumonia (Catchup Study Group: co-Trimoxazole Amoxicillin Trial In Children Under 5 Years For Pneumonia, 2002). Despite the fact that amoxicillin is twice as expensive as co-trimoxazole. Three days of oral co-trimoxazole or amoxicillin are just as effective in treating children with non-severe pneumonia as five days of either medication, according to research from Bangladesh, India, and Indonesia (ISCAP Study Group, 2004). If there is enough oxygen available, the WHO advises giving it to children who have severe pneumonia, and if there isn't enough, to kids who exhibit any of the symptoms listed below: an inability to eat or drink; cyanosis; a respiratory rate of more than or equal to 70 breaths per minute; or severe chest wall retractions (World Health Organization, 1990). Oxygen should be administered at a rate of 0.5 liters per minute for infants under 2 months old and 1 liter per minute for older children. Because it is expensive and scarce, especially in distant rural areas of developing countries, the WHO advises utilizing simple clinical signs to detect and treat hypoxemia (World Health Organization, 1990).
CONCLUSION
Knowledge of RTI symptom duration in a nonconsulting population may help GP practice and public health initiatives by helping parents know how long to expect their children's respiratory symptoms to last. Ideally, you should also advise parents about which symptoms warrant medical attention. In a similar vein, if children exhibit milder respiratory symptoms, such interventions could encourage parents to anticipate lengthier and more severe illnesses. Parents who just report upper respiratory symptoms might receive additional comfort from clinicians doing telephone triage. Parents might be informed that a child's RTI symptoms could continue up to three weeks. Policymakers should be aware that in at least 1 in 12 diseases, parents may seek primary care help (Hay et al., 2019).
ACKNOWLEDGMENTS: None
CONFLICT OF INTEREST: None
FINANCIAL SUPPORT: None
ETHICS STATEMENT: None
Brendish, N. J., Schiff, H. F., & Clark, T. W. (2015). Point-of-care testing for respiratory viruses in adults: the current landscape and future potential. Journal of Infection, 71(5), 501-510.
Catchup Study Group: co-Trimoxazole Amoxicillin Trial In Children Under 5 Years For Pneumonia. (2002). Clinical efficacy of co-trimoxazole versus amoxicillin twice daily for treatment of pneumonia: a randomised controlled clinical trial in Pakistan. Archives of Disease in Childhood, 86(2), 113-118.
Dales, R. E., Cakmak, S., Brand, K., & Judek, S. (2004). Respiratory illness in children attending daycare. Pediatric Pulmonology, 38(1), 64-69.
Denny, F. W., Collier, A. M., & Henderson, F. W. (1986). Acute respiratory infections in day care. Clinical Infectious Diseases, 8(4), 527-532.
Federal Interagency Forum on Child, & Family Studies (US) (Eds.). (2017). America's Children: Key National Indicators of Well-Being, 2017. Government Printing Office.
Fergusson, D. M., Horwood, L. J., & Shannon, F. T. (1980). Parental smoking and respiratory illness in infancy. Archives of Disease in Childhood, 55(5), 358-361.
Hall, C. B., Walsh, E. E., Long, C. E., & Schnabel, K. C. (1991). Immunity to and frequency of reinfection with respiratory syncytial virus. Journal of Infectious Diseases, 163(4), 693-698.
Harris, M., Clark, J., Coote, N., Fletcher, P., Harnden, A., McKean, M., & Thomson, A. (2011). British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax, 66(Suppl 2), ii1-ii23.
Hay, A. D., Anderson, E., Ingle, S., Beck, C., & Hollingworth, W. (2019). Respiratory tract infections in children in the community: prospective online inception cohort study. The Annals of Family Medicine, 17(1), 14-22.
Hollinghurst, S., Gorst, C., Fahey, T., & Hay, A. D. (2008). Measuring the financial burden of acute cough in pre-school children: a cost of illness study. BMC Family Practice, 9(1), 1-6.
ISCAP Study Group. (2004). Three day versus five day treatment with amoxicillin for non-severe pneumonia in young children: a multicentre randomised controlled trial. Bmj, 328(7443), 791.
Kotsimbos, T., Armstrong, D., Buckmaster, N., de Looze, F., Hart, D., Holmes, P., Konstantinos, A., McGuire, G., & McCormack, J. G. (2007). Respiratory infectious disease burden in Saudi Arabia. Brisbane, Saudi Arabia: The Saudi Arabian Lung Foundation.
Landry, M. L., & Ferguson, D. (2000). SimulFluor respiratory screen for rapid detection of multiple respiratory viruses in clinical specimens by immunofluorescence staining. Journal of Clinical Microbiology, 38(2), 708-711.
National Health and Medical Research Council. (2012). Staying Healthy: Preventing Infectious Diseases in Early Childhood Education and Care Services. 5th edn, Canberra: Commonwealth of Saudi Arabia.
O'Grady, K. A., Nolan, T., Carter, R., Gabriel, S., & Lambert, S. (2004). The cost of seasonal respiratory illnesses in Saudi Arabian children: the dominance of patient and family costs and implications for vaccine use. Communicable Diseases Intelligence Quarterly Report, 28(4), 509–516.
Olsen, M. A., Shuck, K. M., Sambol, A. R., Flor, S. M., O'Brien, J., & Cabrera, B. J. (1993). Isolation of seven respiratory viruses in shell vials: a practical and highly sensitive method. Journal of Clinical Microbiology, 31(2), 422-425.
Paul, S., O’Callaghan, C., & McKee, N. (2011). Effective management of lower respiratory tract infections in childhood. Nursing Children and Young People, 23(9), 27–34.
Petersen, I., & Hayward, A. C. (2007). Antibacterial prescribing in primary care. Journal of Antimicrobial Chemotherapy, 60(suppl_1), i43-i47.
Reijans, M., Dingemans, G., Klaassen, C. H., Meis, J. F., Keijdener, J., Mulders, B., Eadie, K., Leeuwen, W. V., Belkum, A. V., Horrevorts, A. M., et al. (2008). RespiFinder: a new multiparameter test to differentially identify fifteen respiratory viruses. Journal of Clinical Microbiology, 46(4), 1232-1240.
Roingeard, P. (2008). Viral detection by electron microscopy: past, present and future. Biology of the Cell, 100(8), 491-501.
Salazar, M. L., English, T. M., & Eiland, L. S. (2012). Caregivers’ baseline understanding and expectations of antibiotic use for their children. Clinical Pediatrics, 51(7), 632-637.
Schaad, U. B. (2005). Prevention of paediatric respiratory tract infections: emphasis on the role of OM-85. European Respiratory Review, 14(95), 74-77.
Scottish Intercollegiate Guidelines Network. (2006). Bronchiolitis in children. SIGN guideline 91. Available from: http://www.sign.ac.uk/pdf/ sign91.pdf. Accessed June 20, 2014.
Tyeryar, F. J., Richardson, L. S., & Belshe, R. B. (1978). Report of a workshop on respiratory syncytial virus and parainfluenza viruses. The Journal of Infectious Diseases, 137(6), 835-846.
Watson, R. L., Dowell, S. F., Jayaraman, M., Keyserling, H., Kolczak, M., & Schwartz, B. (1999). Antimicrobial use for pediatric upper respiratory infections: reported practice, actual practice, and parent beliefs. Pediatrics, 104(6), 1251-1257.
Weinberg, A., & Walker, M. L. (2005). Evaluation of three immunoassay kits for rapid detection of influenza virus A and B. Clinical and Vaccine Immunology, 12(3), 367-370.
World Health Organization. (1990). Antibiotics in the treatment of acute respiratory infections in young children (No. WHO/ARI/90.10. Unpublished). World Health Organization.
