Acute Respiratory Infection

The beginnings
The most serious problem was that of high ARI mortality
in young children in developing countries, mostly
attributable to bacterial pneumonia.

Central strategy of an ARI programme should involve

case management to prevent mortality

Pioneering work in ARI

Shann et al. on work done in Papua New Guinea, published a paper
that has become the cornerstone of the current case management
strategy for the control of ARIs in children
Shann F, Hart K, Thomas D. Acute lower respiratory tract infections in children:possible criteria for selection of
patients for antibiotic therapy and hospital admission. Bulletin of the World Health Organization 1984;62:749-53

Pioneering work in ARI

More objective and reliable criteria were employed in
subsequent studies:
radiology
a combination of radiological and clinical data
clinical judgement of paediatricians with access to radiology

Resp. rate
All of these studies suggested that
A single threshold of 50 was unsatisfactory as a sign of
pneumonia in children aged under 5 years.
The best combination of sensitivity (7882%) and
specificity (7389%) was achieved by using thresholds of
50 breaths per minute for children aged 211 mo
40 breaths per minute for 14 years

Resp. rate
WHO introduced the three age-related
definitions into the ARI protocol in order to
ensure the treatment of at least 80% of
children with pneumonia.

Resp. rate
The WHO definitions remained independent of
any other variable that might modify the
respiratory rate, such as the body temperature,
the nutrition status and the geographical altitude

Temperature and resp.rate

The respiratory rate, to some extent, depends on body
temperature in children with febrile illnesses.
Studies in the Gambia showed that
The mean respiratory rate increased by 2.5 breaths per minute
with every rise in temperature of 1oC in children with cough
The corresponding increase was 3.7 breaths per minute in
children with pneumonia or malaria

Nutrition and resp. rate

Malnourished children may not have the strength to
increase the respiratory rate adequately if their lungs are
affected by pneumonia.
For a given sensitivity and specificity they produce about
5 breaths per minute fewer than well-nourished children

Altitude and resp. rate

At over 2500 metres above sea level in Colombia and
Peru, fast breathing was less useful than at low altitudes
as an indicator of radiographic pneumonia because of
physiological adaptation to low oxygen pressure at the
age of 3 or 4 years.

WHO recommend that the cut-off rates be

used without adjustment.

Work in the Philippines and Swaziland - improve the

definition of chest indrawing as a sign of severe
pneumonia.
Intercostal or supraclavicular retractions - not signs of severe
pneumonia.
Chest indrawing is present if, in a calm child, the lower part of
the chest moves in or retracts when inhalation occurs. The
correct term, therefore, is lower chest wall indrawing
subcostal indrawing and subcostal retraction are
inappropriate expressions

The simple protocol was designed in Papua New Guinea for

identifying childhood pneumonia

Intervention studies conducted in Bangladesh, India, Indonesia,

Nepal, Pakistan, the Philippines, and the United Republic of
Tanzania
The protocol was applicable by properly trained health workers even in
the poorest rural areas
It produced an epidemiological impact despite differences in designs
and methods
A significant effect on pneumonia-specific mortality was reflected in
reduced overall childhood mortality

By the end of 1994 the original Papua

New Guinean guidelines on the case
management of pneumonia in children, as
recommended by WHO and UNICEF, had
been adopted, with slight modifications by
ARI programmes in 130 developing
countries

Pneumonia - Recognition
Recognize pneumonia based on two simple
clinical end points:
fast breathing
lower chest wall indrawing

Rely on the mother or caregiver to recognize

cough or difficult breathing thats the entry
point into assessment

 95 percent of children with pneumonia will have a cough

A small proportion will have no cough but will have
difficult breathing.
Therefore, when assessing for pneumonia, you use
cough OR difficult breathing

not cough AND difficult breathing

Many causes of difficult breathing not related to

cough.
Acidosis in children with diarrhoea
Chronic difficulty in breathing in children with congenital
heart disease
Rickets
Congenital malformations

Pneumonia Fast Breathing

Fast breathing based on age-specific thresholds
Respiratory rates to indicate pneumonia
> 50 per minute in infants up to 12 months of age
> 40 per minute in children aged 12 months up to 5 years

If the respiratory rate is below these cut-offs

+ There are no danger signs
+ No chest wall indrawing,
The classification is no pneumonia, cough and cold.

 The optimal method of obtaining a respiratory rate is the

use of a timing device
Important to count the respiratory rate for one full minute
Best time to count the respiratory rate is when the child
is in a quiet and alert state
Respiratory rate is also influenced by temperature
cut-off rates be used without adjustment

Severe Pneumonia
Lower Chest Wall Indrawing
multiple definitions of retractions
suprasternal retractions
intercostal retractions
xiphoid retractions
subcostal retractions

 Suprasternal and xiphoid retractions was very rare and

occurred in only the most severely ill children
Intercostal retractions are very subtle (even with blocked
noses and URTI)
Subcostal retractions indicate diaphragmatic and
abdominal muscle use in a distressed child
Lower chest wall indrawing best identifies these children

Rationale for choosing antibiotics to be used

Cotrimoxazole

Amoxicillin

Least expensive

Expensive

Twice a day good compliance

Thrice daily poor compliance

Drug rashes

Diarrhea

Drug eruptions

Effective clinically against resistant

BM suppression
Increasing resistance to S.
pneumoniae and H.influenza

S.pneumoniae

H.influenza reported to be resistant

Severe Pneumonia or Very Severe Disease

Antibiotics
Penicillin

Chloramphenicol

Inexpensive

PO, IV, IM

Widely available

Much broader range of organisms

Acts against S.pneumoniae and

Includes S. aureus and H.influenza

Penetrates intact and inflamed

H.influenza

Does not penetrate meninges well

Penetrates only in inflamed

meninges

meninges

Idiosyncratic aplastic anemia - rare

SIGNS
No chest indrawing
No fast breathing
Respiratory rate
< 50/mt (2-12 months)
< 40/mt (12 mo - 5 yrs)

TREATMENT
If coughing > 30 days refer for
assessment
Assess and treat ear problem or
sore throat, if present
Assess other problems
Advise mother to give home care
Treat fever, if present
Treat wheezing, if present

NO PNEUMONIA Cough or cold

SIGNS
No chest indrawing
No fast breathing
Respiratory rate
> 50/mt (2-12 months)
> 40/mt (12 mo - 5 yrs)

TREATMENT
Advise mother to give
home care
Give an antibiotic
Treat fever, if present
Treat wheezing, if present
(Return for reassessment after 2
days or earlier if the child is getting
worse)

PNEUMONIA
REASSESS in 2 days, a child who is
taking an antibiotic for pneumonia

TREATMENT

SIGNS
Chest Indrawing
If wheezing, go directly to
TREAT WHEEZING

Refer urgently to hospital

Give first dose of antibiotic
Treat fever, if present
Treat wheezing, if present
(If referral is not possible, treat with
antibiotic and watch closely)

SEVERE PNEUMONIA
REASSESS in 2 days, a child who is
taking an antibiotic for pneumonia

 Reassessment important to reduce

mortality due to
Inadequate treatment
Resistance to antimicrobials

REASSESS in 2 days, a child who is

taking an antibiotic for pneumonia
WORSE

SAME

IMPROVING

SIGNS

SIGNS

SIGNS

Not able to drink

Has chest indrawing

Has other danger

THE SAME

Breathing slower

Less fever

Eating better

signs

Refer urgently to
hospital

Change antibiotic
or refer

Finish 5 days of
antibiotic

SIGNS

TREATMENT

Not able to drink

Refer urgently to a hospital

Convulsions

Treat with an antibiotic

Abnormally sleepy or

Treat fever, if present

difficult to wake
Stridor in a calm child
Severe malnutrition

Treat wheezing, if present

Treat with antimalarial, if malaria
possible

VERY SEVERE DISEASE

Reassessment of very severe disease

Reassessment after 48 hrs

Improving
Change to oral drugs
Treat for 10 days

Not improving
Probable Staph pneumonia
Change to Clox + Genta

Recommendations for treatment of

Pneumonia in infants below 2 months of age
Labeled as severe or very severe disease
Danger of disease dissemination and risk of complications
Should be admitted and treated
Benzyl penicillin and gentamicin
Term infants older than 1 week of age, chloramphenicol if no
aminoglycoside
Benzylpenicillin + cotrimoxazole if not preterm or jaundiced.

Supportive management
Oxygen

Central cyanosis
Child is not able to drink
Restlessness which improves on oxygen
Severe chest indrawing

Oxygen can be administered by nasal cannula or nasal

catheter
Rate of flow
< 2 months of age the flow rate is kept at 0.5 litres/min
> 2 months of age 1 litre/min by a catheter
rate of 5 litres/min if it is given by a cannula

Supportive management
Feeding
1. Breast mild should be given frequently to these
infants
2. If a baby is unable suckle at the breast expressed breast milk
3. Frequent small calorie rich food like dalia,
khichdi can be given

Supportive management
4.

Children requiring oxygen should not be fed since

there is a risk of aspiration

5.

As soon as oxygen therapy is discontinued, oral or

nasogastric feeding should be initiated

6.

After recovery from the illness, additional feeds must

be given to enable catch up growth

7.

Growth monitoring of children recovering from measles

pneumonia, whooping cough or those who are
undernourished is vital.

Supportive management
IV fluids

Cyanosis;

Excessive irritability;

Severe lower chest indrawing

Grunting

Shock and dehydration and poor oral intake

Signs indicating need for admission in

children who may have pneumonia

Pneumonia in children < 2 months of age

Chest indrawing in a child who is not wheezing

Unable to feed

Convulsions

Abnormally sleepy or lethargic child

Stridor in a calm child

Signs indicating need for admission in

children who may have pneumonia
Severe undernutrition
Central cyanosis
Wheezing child with respiratory distress
not relieved with bronchodilators
Measles

Signs indicating need for admission in

children who may have pneumonia
Pertussis in infants < 6 months of age
Any child with
Apneic or cyanotic spells
Pneumonia
Convulsions
Dehydration
Severe undernutrition
Diphtheria
Severe dehydration or shock

Assessment of the wheezing child

Occurs when air flow from lungs is obstructed
due to narrowing of small airways.
Common causes of wheeze include
Asthma
Bronchiolitis
Respiratory infections including pneumonia.

Both pneumonia and wheezing can cause chest

indrawing and fast breathing.

Central cyanosis or
Not able to drink

ADMIT
Give oxygen
Give rapid-acting bronchodilators
Give an antibiotic chloramphenicol
Treat fever, if present
Supportive care

Respiratory distress persists with

No central cyanosis and
Able to drink

No respiratory distress +
Fast breathing

ADMIT
Give rapid-acting bronchodilators
Give an antibiotic benzylpenicillin
Treat fever, if present
Supportive care

ADVISE MOTHER TO GIVE HOME CARE

Give oral salbutamol at home
Give an antibiotic (at home)
(Cotrimoxazole, amoxycillin, ampicillin or Procaine penicillin)

No fast breathing

ADVISE MOTHER TO GIVE HOME CARE

Give oral salbutamol at home

Guidelines for the management of

acute upper respiratory infections

Nasopharyngitis common cold

Fever
Nasal discharge

Treat at home
No antibiotics
Treat fever
Normal saline drops for nasal
block
No cough/cold remedies
Rule out ASOM, pneumonia

Sinusitis
Persistent purulent nasal
discharge
+
Sinus tenderness, facial
or
Periorbital swelling
or
Persistent fever
Cough

Sinusitis - treatment
Treat at home
Continue feeding
Antibiotics (cotrimoxazole, ampicillin or amoxycillin)
only if
suggestive of bacterial sinusitis
sinus tenderness
facial or periorbital swelling
persistent fever

This is uncommon in children < 5 yrs of age

Acute otitis media (ASOM)

Sudden persistent ear
ache
Pus discharge less
than 2 weeks duration
Ear rubbing is not a
reliable sign in infants

Acute otitis media (ASOM)

Treat at home
Treat fever
Keep ear dry
Start antibiotics - cotrimoxazole, ampicillin or
Amoxycillin
Reassess after 5 days.
If pain, fever, pus discharge are present, antibiotics
are continued for another 5 days.
Refer if no response after 10 days

Mastoiditis
Painful swelling behind the ear
Or
Above the ear in infants
Admit
Start antibiotics
-chloramphenicol x 10 days
If the child has signs of brain
involvement refer for
neurosurgical evaluation

Pharyngitis

Fever
Throat ache
Treat at home
Treat fever
Antibiotics only if
streptococcal pharyngitis
suspected
Tender enlarged cervical
lymphnodes
White pharyngeal exudates
Absence of signs
suggestive of viral infection

Pharyngitis
Give benzyl penicillin single dose
0.6 lakhs in children < 5 yrs.
1.2 lakhs in children > 5 yrs of age
Or

Ampicillin.
Amoxycillin
Penicillin V
Not cotrimoxazole.

Acute epiglottitis
Fever
Drooling of saliva
Stridor
Admit
Antibiotics - chloramphenicol
Watch for signs of obstruction
Severe chest indrawing
Restlessness
Cyanosis

to decide for tracheostomy

If tracheostomy available, avoid oxygen
as it may mask signs of obstruction.

National ARI control programme

in India

National ARI Control programme

The Govt. of India launched National ARI
Control programme in 1989
Primary objective to reduce infant and
child mortality due to ARI
By 20% by 1995
By 40% by 2000.

National ARI Control programme

Taken up as a pilot project in 14 districts of the country in 1990.
10 more districts were added during 1991.
Initially district teams of core trainers were trained
They trained the doctors at sub-district level and the Primary
Health Centres.
Training of paramedical staff was undertaken by the medical
officers.

National ARI Control programme

51 districts were taken up in 1992-93 and 103 in 1993-94.
10 new districts were covered from 1994.
An integrated clinical skills training course for physicians has
been started from June 1993.
The training programme not only includes clinical practices
but also focuses on the need to improve referral services
from the peripheral health institutions.

Objectives
The National ARI Control Programme aims at:
1.

Improving treatment practices in hospitals and health

centers to reduce mortality rates due to pneumonia and
to reduce the use of unnecessary and potentially harmful
drugs and overuse of antibiotics for the treatment of ARI
in children

Objectives
2.

Early recognition and appropriate treatment of pneumonia

by the paramedical staff at the community level and timely
referral of the severe cases for treatment under medical
supervision and hospitalization when required

Objectives
3. Prevention of measles, pertussis, diphtheria
and tuberculosis with effective immunization.

Programme implementation
ARI Control Programme is monitored by Ministry of Health
and Family Welfare with Joint Secretary (MCH) and
Dy.Commissioner (MCH) in the Ministry Head Quarters.

The programme is implemented as part of the package of

MCH services by the State/UT Govt. in the identified districts
within the existing infrastructure of district hospitals, primary
health centers and other health facilities.

Programme implementation
The flag bearer of the programme in the community is the
health/anganwadi worker.
The implementation of the programme has been integrated
with the Child Survival and Safe Motherhood (CSSM)
programme after 1992.
Operational research is still underway to evaluate the actual
implementation and impact of the programme in the Indian
setting.