DISORDERS OF THE UPPER RESPIRATORY TRACT
Group A beta
Choanal atresia is congenital obstruction of the
posterior nares by an obstructing membrane of bony
growth , preventing a newborn from drawing air
through the nose and down into the nasopharynx. It
may be either unilateral or bilateral.
Acute Nasopharyngitis (Common Cold) is the most
frequent infectious disease in children-in fact, toddlers
have an average of 10-12 colds a year. School-age
children and adolescents have as many as four or five
yearly. The incubation period is typically 2 to 3 days.
Most occur in the fall and winter.
They are caused by one of several viruses, most
predominantly by rhinovirus, coxsackievirus, RSV,
adenovirus, and parainfluenza and influenza viruses.
Pharyngitis is infection and inflammation of the
throat. The peak inicidence occurs between 4-7 years
of age. It may be either bacterial or viral in origin. It
may occur as a result of a chronic allergy in which
there is constant postnatal discharge that results in
secondary irritation. At least a slight pharyngitis
usually accompanies all common upper respiratory
infections.
Viral Pharyngitis. The causative agent of
pharyngitis is usually adenovirus. The symptoms are
generally mild: a sore throat, fever, and general
malaise. On physical assessment, a regional lymph
nodes may be noticeably enlarged. Erythema will be
present in the back of the pharynx and the palatine
arch. Laboratory studies will indicate an increased
white blood cell count.
Streptococcal Pharyngitis.
hemolytic streptococcus is the organism most
frequently involved in bacterial pharyngitis in children.
All streptococcal infections must be taken seriously
because they can lead to cardiac and kidney damage
from the accompanying autoimmune process.
Retropharyngeal Abscess. In infants, the
lymph nodes that drain the nasopharynx are located
just behind the posterior pharynx wall. These nodes
may become infected following an acute
nasopharyngitis or pharyngitis. Since these nodes
disappear by preschool age, the problem is usually
limited to young infants.
Tonsillitis refers to infection and inflammation of the
palatine tonsils. “Adenitis” refers to infection and
inflammation of the adenoid (pharyngeal) tonsils.
Epsitaxis (nosebleed) is extremely common in
children and usually occurs from trauma, such as
picking at the nose, from falling, of from being hit on
the nose by another child.
Sinusitis is infection and inflammation of the sinus
cavities. It is rare in children younger than 6 years of
age because the frontal sinuses do not develop fully
until age 6. It can occur as a primary infection or a
secondary one in older children when streptococcal,
staphylococcal, or H. influenza organisms spread from
the nasal cavity. Children develop a fever, a purulent
nasal discharge, headache, and tenderness over the
affected sinus. A nose and throat culture will identify
the infectious organism.
Laryngitis is inflammation of the larynx. It results in
brassy, hoarse voice sounds or inability to make
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audible voice sounds. It may occur as a complication of
pharyngitis or from excessive use of the voice, as in
shouting or loud cheering. Laryngitis is as annoying for
children as it is for adults.
Congenital Laryngomalacia/Tracheomalacia
means that an infant’s laryngeal structure is weaker
that normal and collapses more than usual on
inspiration. This produces laryngeal stridor (a high
pitched crowning sound on inspiration) present from
birth, possibly intensified when the infant is in a supine
position or when sucking.
Croup (Laryngotracheobronchitis). Croup
(inflammation of the larynx, trachea, and major
bronchi) is one of the most frightening diseases of
early childhood for both parents and children. In
children between 6 months and 3 years of age, the
cause of croup is usually a viral infection such as
parainfluenza virus. In previous years, the most
common cause was H. influenza. However, since
immunization against this organism has been included
in a routine immunization series, the incidence of
croup from this cause has declined by 90%.
*Ineffective airway clearance related to edema and
constriction of airway
Epiglottis is inflammation of the epiglottis (the flap of
tissue that covers the opening to the larynx to keep
out food and fluid during swallowing). Although this is
rare, inflammation of the epiglottis is an emergency
because the swollen epiglottis cannot rise and allow
the airway to open. It occurs most frequently in
children from 2 to about 7 years of age.
Epiglottis can be either bacterial or viral in
origin. H. influenza type B has been replaced as the
most common bacterial cause of the disorder by
pneumococci, streptococci, or staphylococci. Echovirus
and RSV also can cause the disorder.
Aspiration (inhalation of a foreign object into the
airway) occurs most frequently in infants and toddlers.
Bronchial Obstruction. The right main bronchus is
straighter and has a larger lumen than the left
bronchus in children older than 2 years of age. For this
reason, an inspirited foreign object that is not large
enough to obstruct the trachea may lodge in the right
bronchus, obstructing a portion or all of the right lung.
The alveoli distal to the obstruction will collapse as the
air remaining in them becomes absorbed (atelectasis),
or hyperinflation and pnemothorax may occur if the
foreign body serves as a ball valve, allowing air to
enter but not leave the alveoli.
DISORDERS OF THE LOWER RESPIRATORY TRACT
Influenza involves inflammation and infection of the
major airways. It is caused by the orthomyxovirus
influenza type A, B, or C. It is marked by a cough,
fever, fatigue, aching pains, a sore throat,and often
accompanying gastrointestinal symptoms such as
vomiting or diarrhea. The disease spreads readily
through a home or a classroom because children are
contagious on the day before symptoms appear and
for about the next 5 days.
Children usually need an antipyretic such as
acetaminophen (Tylenol) to control fever. Oseltamivir
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(TamiFlu), a new antiviral drug that halts viral
proliferation, can be taken by children over 1 year of
age.
Bronchiolitis is inflammation of the fine bronchioles
and small bronchi. It is the most common lower
respiratory illness in children younger than 2 years,
peaking in incidence at 6 months of age. The infection
occurs most often in the winter and spring. Many
children who develop asthma later in life have
numerous instances of bronchiolitis during their first
year of life. Viruses, such as adenovirus, parainfluenza
virus, and RSV, in particular, appear to be the
pathogens most responsible for this illness.
Bronchitis, or inflammation of the major bronchi and
trachea, is one of the more common illness affecting
preschool and school-age children. It is characterized
by fever and cough, usually in conjunction with nasal
congestion. Causative agents include the influenza
viruses, adenovirus, and Mycoplasma pneumonia,
among others.
*Parental anxiety related to respiratory distress in
child
Respiratory Syncytial Virus Bronchiolitis. RSV is a
pathogenic RNS virus that is the most common cause
of bronchiolitis in young children. Symptoms begin as
a mild upper respiratory infection that quickly extends
to include the bronchioles. The infant becomes
lethargic and possibly cyanotic. Dehydration occurs as
the child becomes too fatigued to suck. Respiratory
distress with nasal flaring, retractions, grunting, rales,
rhonchi, and expiratory wheezing noted on
auscultation occur. All infants with an RSV infection
must be monitored closely because the virus tends to
cause apnea or periodic halting of respirations. The
diagnosis is confirmed by throat or nasal culture.
Asthma, an immediate hypersensitivity (type 1)
response, is the most common chronic illness in
children, accounting for a large number of days of
absenteeism from school and many hospital
admissions each year. It primarily affects the small
airways and involves three separate processes:
bronchospasm, inflammation of bronchial mucosa, and
increased bronchial secretions. All three processes act
to reduce the size of the airway lumen, leading to
acute respiratory distress. Bronchial constriction
occurs because of stimulation of the parasympathetic
nervous system, which initiates smooth muscle
constriction.
Status Asthmaticus. Under ordinary circumstances,
an asthma attack, responds readily to the aerosol
administration of a bronchodilator such as albuterol,
terbutaline, levalbuterol, or salmetarol. When children
fail to respond and an attack continues, they are in
status asthmaticus. This is an extreme emergency
because, if the attack cannot be relieved, a child may
die of heart failure caused by the combination of
exhaustion, atelectasis, and respiratory acidosis fro,
bronchial plugging.
Brochiectasis is chronic dilatation and plugging of
the bronchi. It may follow pneumonia, aspiration of
foreign body, pertussis, or asthma. Children develop a
chronic cough with mucopurulent sputum. Young
infants may have accompanying wheezing or stridor.
Pneumonia (infection and inflammation of alveoli)
occurs at a rate of 2 to 4 children in 100. It may be of
bacterial origin (pneumococcal, streptococcal,
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staphylococcal, or chlamydial) or viral in origin, such
as RSV. Aspiration of lipid or hydrocarbon substances
also causes pneumonia. The disease is commonly
divided into two types: hospital acquired
(pneumococcal or streptococcal pneumonia) and
community acquired (Chlamydia, viral pneumonias).
Pneumococcal Pneumonia. It’s onset is
generally abrupt and follows an upper respiratory tract
infection. In infants, pneumonia tends to remain
bronchopneumonia with poor consolidation(infiltration
of exudate into the alveoli). In older children,
pneumonia may localize in a single lobe, and
consolidation may occur.
Chlamydial Pneumonia (Chlamydia
trachomatis pneumonia) is most often seen in newborn
up to 12 weeks of age because the chlamydial
organism is contracted from the mother’s vagina
during birth. Symptoms usually begin gradually with
nasal congestion and a sharp cough; infants fail to
gain back their weight. Symptoms progress to
tachypnea, with wheezing and rales audible on
auscultation.
Viral Pneumonia is generally caused by the
viruses of upper respiratory tract infection: the RSV’s,
myxoviruses, or adenoviruses. Symptoms begin as an
upper respiratory tract infection. After a day or two,
additional symptoms such as a low grade fever, non
productive cough, and tachypnea begin. There may be
diminished breath sounds and fine rales on chest
auscultation. RSV may cause apnea. Chest radiographs
will show diffuse infiltrated areas.
Mycoplasmal Pneumonia. Mycoplasmal
organisms are similar yet larger than viruses.
Mycoplasmal pneumonia occurs more frequently in
older children (over 5 yrs) and more often during the
winter. The symptoms make it difficult to differentiate
from other pneumonias. The child has a fever and
cough and feels ill. Cervical lymph nodes are enlarged.
The child may have a persistent rhinitis.
Lipid Pneumonia is caused by the aspiration of
an oily or lipid substance. It is much less common than
it once was because children are not given oil-based
tonics. A proliferative inflammatory response occurs
when lung lipases act on the aspirated oil. It is
followed by diffuse fibrosis of the bronchi or alveoli.
Hydrocarbon Pneumonia. Several common
household products such as furniture polish, cleaning
fluids, turpentine, kerosene, gasoline, lighter fluid, and
insect sprays have hydrocarbon bases. These products
are a common cause of childhood poisonings and
result in hydrocarbon pneumonia.
Atelectasis is the collapse of lung alveoli. IT may
occur in children as a primary or secondary condition.
It must be considered as a possibility in all children
with respiratory distress.
Primary Atelectasis occurs in newborn who do
not breathe with enough respiratory strength at birth
to inflate lung tissue or whose alveoli are so immature
or so lacking in surfactant that alveoli cannot expand.
This is seen most commonly in immature infants or in
infants with CNS damage. It may occur if infants have
mucus or meconium plugs in the trachea.
Secondary Atelectasis occurs in children
when they have a respiratory tract obstruction that
prevents air from entering a portion of the alveoli. As
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the residual air in the alveoli is absorbed, the alveoli
collapse. The causes of obstruction in children include
mucus plugs that may occur with chronic respiratory
disease or aspiration of foreign objects. In some
children, atelectasis occurs because of pressure on
lung tissue from outside forces.
Pneumothorax is the presence of atmospheric air in
the pleural space; its presence causes the alveoli to
collapse (atelectasis). Pneumothorax in children
usually occurs when air seeps from ruptured alveoli
and collects in the pleural activity. It also can occur
when external puncture wounds allow air to enter the
chest.
Bronchopulmonary Dysplasia (BPD) is chronic
pulmonary involvement that occurs in 10% to 40% of
infants who are treated for acute respiratory distress
in the first days of life. The condition most often occurs
in infants who received mechanical ventilation for
respiratory distress syndrome at birth. Infants with
BPD, develop tachypnea, retractions, nasal flaring,
tachycardia, oxygen dependence, and abnormal
radiograph findings that show areas of overinflation,
inflammation, and atelectasis.
Tuberculosis is a highly contagious pulmonary
disease. The causative agent is Mycobacterium
tuberculosis (tubercle bacillus). The mode of
transmission is inhalation of infected droplets. The
incubation period is 2 to 10 weeks.
Cystic Fibrosis. Children with CF have a generalized
dysfunction of the exocrine glands. Mucus secretions
of the body, particularly in the pancreas and the lungs,
are so tenacious that they have difficulty flowing
through gland ducts. The cause of the disorder is an
abnormality of the long arm of chromosome 7. This
results in the inability to transport small molecules
across cell membranes; this leads to dehydration of
epithelial cells in the airway and pancreas and dried
secretions.
COMMON DISORDERS OF THE STOMACH AND
DUODENUM
Gastroesophageal Reflux or the regurgitation of
stomach secretions into the esophagus through the
gastroesophageal (cardiac) valve occurs mainly in
infants and adolescents.
Gastroesophageal reflux in infants occurs from a
neuromuscular disturbance in which the
gastroesophageal (cardiac) sphincter and lower
portion of the esophagus spasm and allow easy
regurgitation of gastric contents into the esophagus. It
usually starts within 1 week after birth and may be
associated with a hiatal hernia.
Gastroesophageal reflux disease (GERD) affects
20% of adults; symptoms frequently begin in
adolescence. Irritation to esophagus occurs when
stomach contents, including hydrochloric acid, reflux
through the lower esophageal sphincter and irritate
the esophageal lining. Reflux occurs because of an
incompetent sphincter especially when the adolescent
lies supine or when intra abdominal pressure is
increased by a full stomach, lifting or bending, or tight
clothing.
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Pyloric Stenosis. The pyloric sphincter is the opening
between the lower portion of the stomach and the
beginning portion of the intestine, the duodenum. If
hypertrophy or hyperplasia of the muscle surrounding
the sphincter occurs, it is difficult for the stomach to
empty, a condition called pyloric stenosis. With this
condition, at 4-6 weeks of age, infants begin to vomit
almost immediately after each feeding. The vomiting
grows increasingly forceful until it is projectile, possibly
projecting as much as 3 to 4 feet.
Hiatal Hernia is the intermittent protrusion of the
stomach up through the esophageal opening in the
diaphragm. When this occurs, the volume of the
stomach is suddenly restricted, leading to periodic
vomiting similar to that of gastroesophageal reflux.
With a hiatal hernia, pain usually accompanies the
vomiting. Shortness of breath may occur from
compression of the lung space by the stomach.
Peptic Ulcer Disease is a shallow excavation formed
in the mucosal wall of the stomach, the pylorus, or the
duodenum. In infants, ulcers tend to be gastric; in
adolescents, they are usually duodenal. Such ulcers
occur in a primary form caused by infection of H. pylori
bacteria and secondary form that follows severe stress
such as acetylsalicylic acid or prednisone.
INTESTINAL DISORDERS
Intussuception, the invagination of one portion of
the intestine into another, usually occurs in the second
half of the the first year of life.
Volvulus is a twisting of the intestine. The twist leads
to obstruction of the passage of feces, and
compromise of the blood supply to the loop of
intestineinvolved. This occurs most often because, in
fetal life, a portion of the intestine first protrudes into
the base of the umbilical cord at approximately 6
weeks of the intrauterine life. At approximately 10
weeks of intrauterine life, it returns to the abdominal
cavity.
Necrotizing Enterocolitis (NEC) is a condition that
develops in approximately 5% of all infants in intensive
care nurseries. The bowel develops necrotic patches,
interfering with digestion and possibly leading to a
paralytic ileus. Perforation and peritonitis may follow.
The necrosis appears to result from ischemia or poor
perfusion of blood vessels in secretions of the bowel.
Appendicitis (inflammation of the appendix) is the
most common of abdominal surgery in children. It
occurs most frequently in school-age children and
adolescents, although it can occur in preschoolers and
even in newborns.
Celiac Disease (Malabsorption Syndrome;
Gluten-Induced Enteropathy). The basic problem in
celiac disease is a sensitivity or abnormal immunologic
response to protein, particularly the gluten factor of
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protein found in grains. When children with the
disorder ingest gluten, changes occur in their intestinal
mucosa or villi that prevent the absorption of foods,
especially fat, across the intestinal villi into the
bloodstream. As a result, children develop steatorrhea
(bulky, foul smelling, fatty stools); deficiency of fat
soluble vitamins A, D, K, and E; malnutrition, and a
distended abdomen from the fat.
DISORDERS OF THE LOWER BOWEL
Inguinal Hernia is a protrusion of a section of the
bowel into the inguinal ring. It occurs usually in boys
(9:1) because, as testes descend from the abdominal
cavity into the scrotum late in fetal life, a fold of
parietal peritoneum also descends, forming a tube
from the abdomen to the scrotum.
Hirschsprung’s Disease (Aganglionic
Megacolon), is absence of ganglionic innervations to
the muscle of a section of the bowel- in most
instances, the lower portion of the sigmoid colon just
above the anus. The absence of nerve cells means
there are no peristaltic waves in this section to move
fecal material through the segment of intestine. The
incidence of aganglionic disease is higher in the
siblings of a child with the disorder than in other
children. IT also occurs more often in males. It is
caused by an abnormal gene on chromosome 10. It is
approximately 1 in 5k live births.
Irritable Bowel Syndrome involves intermittent
episodes of loose and normal stools or recurrent
abdominal pain. It appears slightly more often in girls.
It is most often seen in infants 6 to 36 months of age.
The cause is unknown, but it is associated with low fat
intake. Excessive fluid intake also may play a role.
STRUCTURAL ABNORMALITIES OF THE URINARY
TRACT
Patent Urachus. When the bladder first forms in
utero, it is joined to the umbilicus by a narrow tube,
the urachus. When this fails to close properly during
embryologic development, a fistula is left between the
bladder and umbilicus (patent urachus). This occurs
more commonly in males.
Exstrophy of the Bladder is a midline closure defect
that occurs during the embryonic period of gestation
(first 8 weeks). As a result, the bladder lies open and
exposed on the abdomen. It occurs more frequently in
males, ratio of 2:1.
Hypospadias is a urethral defect in which the urethral
opening is not at the end of the penis but on the
ventral (lower) aspect of the penis. The meatus may
be near the glans, midway back, or at the base of the
penis. It tends to be familial or may occur from a
multifactorial genetic focus. Epispadias is a similar
defect in which the opening is on the dorsal surface of
the penis, it is corrected the same way.
INFECTIONS OF THE URINARY SYSTEM AND
RELATED DISORDERS
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Urinary Tract Infection occurs more often in female
at a rate of about 8% to 2%. Pathogens appear to
enter the urinary tract most often as an ascending
infection from the perineum. Most urinary pathogens
are gram negative rods. E. coli is a frequent offender.
UTIs also are a common cause of nosocomial or health
care acquired infections in children with urinary
catheters.
“Honeymoon” Cystitis refers to lower UTI seen in
young women shortly after they initiate a first sexual
relationship. Such infections occur in connection with
the local irritation and inflammation caused by initial
coitus.
Vesicoureteral Reflux refers to retrograde flow of
urine from the bladder into the ureters. This reflux
occurs because the valve that guards the entrance
form the bladder to the ureter is defective, either from
birth or because of scarring from repeated UTIs ,
bladder pressure that is stronger than usual, or ureters
that are implanted at abnormal sites or angles. This
backflow of urine happens at micturition(voiding) when
the bladder contracts.
Hydronephrosis is enlargement of the pelvis of the
kidney with urine as a result of back pressure in the
ureter. The back pressure is generally caused by
obstruction, either of the ureter or of the point where
the ureter joints the bladder, as with vesicoureteral
reflux. It occurs most often in the first 6 months of life.
If it occurs during intrauterine life, it will be revealed
by fetal ultrasound.
DISORDERS AFFECTING NORMAL URINARY
ELIMINATION
Enuresis is involuntary passage of urine past the age
when a child should be expected to have attained
bladder control. Because this is expected at age 2 to 3
years of age for daytime and age 4 years for
nighttime, enuresis is said to occur at approximately 5
to 7 years. Enuresis may be nocturnal (occurs only at
night), diurnal (occurs during the day), or both. It is
primarily if bladder training was never achieved,
acquired or secondary if control was established but
has now been lost.
Postural (Orthostatic) Proteinuria. Few children
will spill albumin into the urine when they stand
upright for an extended period (postural proteinuria,
also called postural albuminuria). The amount of
spilling decreases when they rest in a supine position.
Children with this condition have no apparent damage
to glomeruli; the phenomenon is apparently
attributable to the effect of gravity on glumerular
function.
Kidney Agenesis. Agenesis means lack of
growth(lack of beginning) or that no organ formed in
utero. Absence of kidneys in a newborn is suggested
when the volume of amniotic fluid on ultrasound or at
birth is less than normal (oligohydramnios). This
occurs because urine normally adds to the volume of
amniotic fluid in utero. The infant with kidney agenesis
often has Potter’s syndrome or accompanying
missharpen, low set ears and hypoplastic (stiff,
inflexible) lungs from the lack of amniotic fluid In
utero.
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Polycystic Kidney means that large, fluid filled cysts
have formed in place of normal kidney tissue. The
most frequent type of polycystic kidney seen in
children is inherited as an autosomal recessive trait. A
more rare form is inherited as an autosomal dominant
trait.
Renal Hypoplasia. Hypoplasia means reduced
growth. Hypoplastic kidneys contain fewer lobes than
normal kidneys and are small and underdeveloped.
The child with hypoplastic kidneys, in addition to
having poor kidney function, may develop
hypertension afrom stenosis of the renal arteries. If
hypoplasia is bilateral, the child may need a kidney
transplant in later life to maintain kidney function and
prevent extreme hypertension.
Prune Belly Syndrome is severe urinary tract
dilation that develops as early as untrauterine life from
an unknown cause. Occurring mainly in boys, the
severe dilation causes back pressure and destruction
of kidneys. The infant is born with oligohydramnios
and pulmonary dysplasia because of the lack of
amniotic fluid in utero.
3 Symptoms: deficiency of usual abdominal
muscle tone, bilateral undescended testes, and the
dilated faulty development of the bladder and upper
urinary tract.
Tissue damage occurs from a complement fixation
reaction in the glomeruli. IgG antibodies against
streptococci may be detected in the bloodstream of
children with acute glomerulonephritis, proof that
illness follows a streptococcal infection.
IGA Glomerulonephritis may occur when there is no
evidence of a prior infection. IN these children,
immunoglobulin A is elevated. The gross hematuria
resolves within a few days and is not apt to produce
serioua sequelae.
Chronic Glomerulonephritis. Although
glumerulonephritis occasionally follows acute
glumerulonephritis or nephrotic syndrome, it also
occurs as a primary disease (or after acute
glomerulonephritis that was clinically so mild it was
undiagnosed). The child is found to have proteinuria at
a routine checkup.
Nephrotic Syndrome
Autoimmune process
↓
Increased glomeruli permeability
↓

Acute Poststreptococcal Glomerulonephritis. Increased albumin in urine

Glomerulonephritis, inflammation of the glomeruli of
the kidney, may occur as a separate entity but usually ↓
occurs as an immune complex disease after infection
with nephritogenic streptococci (most commonly Hypoalbuminemia
subtypes of group A beta hemolytic streptococci).
↓
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 Edema Hemolytic-Uremic Syndrome, the lining of
glomerular arterioles becomes inflamed, swollen, and
↓ occluded with particles of platelets and fibrin. The
child’s RBC and platelets are damaged as they flow
Hyperlipidemia through the partially occluded blood vessels. As the
damaged cells reach the spleen, they are destroyed by
Nephrosis, altered glomerular permeability due to the spleen and removed from circulation. This leads to
fusion of the glomeruli membrane surfaces, causes hemolytic anemia.
abnormal loss of protein in urine. Immunologic
mechanisms are involved in instigating the process.
The cause may be responsible. The highest incidence
is at 3 years of age, and it occurs more often in boys.

Nephrotic syndrome in children occurs on three

forms: (a) congenital, which occurs as an autosomal
recessive disorder; (b) secondary, as a progression of
glumerulonephritis or in connection with systemic
diseases such as sickle cell anemia or systemic lupus
erythematosus (SLE); (c) idiopathic.

Henoch-Schönlein Syndrome Nephritis.

Approximately one quarter of the children who develop
this type of purpura develop renal disease as a
secondary complication. The renal involvement
becomes apparent within a few days after the
manifestations of purpuric symptoms. Children may
show only urinary abnormalities such as proteinuria or
may have a rapidly progressing glumerulonephritis.

Systemic Lupus Erythematosus is an autoimmune

disease is which autoantibodies and antigens cause
deposits of complement in the kidney glumerulus.
Because of this, some children with SLE develop
symptoms of acute or chronic glomerulonephritis, the
ultimate cause of death in many adults with SLE.

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