cough management issues in pediatric uri - dr gaurav gupta

Managing Cough in Pediatric URI

Dr Gaurav Gupta,Charak Clinics, Mohali

Author: Clippings, Indian Pediatrics

Scope of talk

• Acute Cough• Management issues• URI (to avoid discussing allergies, asthma,

pneumonia, TB etc.)

Case

• 4-year-old Japinjot, has cough for about 4 days; • She might have been feverish at the beginning of the

illness, but she is not feverish now. • She has a runny nose, & mother says she was pulling at

her ears yesterday. • Her cough sounded dry and barky; • she was not short of breath and her colour was always

normal. • Japinjot has been at home for 3 days, missing

playschool.

Case

• Past history shows that at the age of 3 months, she was hospitalized for bronchiolitis.

• She has twice been treated for otitis media & for infantile eczema.

• While on holiday 2 years ago, a GP in another town gave Japinjot antibiotics for pneumonia.

• Vaccination complete including Pneumonia, Hib & Influenza vaccines

• No other hospital admissions or surgical procedures.

Case

• As Japinjot is an otherwise healthy child and is not taking any regular respiratory medicines, it is probable that her cough is due to an acute viral infection, probably picked up in the playschool;

• the mother’s description of a “barky” cough makes you wonder whether she might have croup.

• Before you examine her, you consider what else it could be?

Case

We should not miss diagnosis like • asthma, bronchiolitis, whooping cough,

pneumonia, and foreign body aspiration.A brief focused history will usually give information about such conditions.• What time of year is it?Peak incidence of infective cough is January to March; epidemics of croup tend to occur in autumn and bronchiolitis in winter.

Alarm signs

• The child will look ill (with pneumonia or influenza)

• or be short of breath with tachypnea (with asthma or foreign body aspiration).

• The child will be working hard to breathe, perhaps with chest retractions.

• High fever (with pneumonia, but some children can run sudden high fevers with otherwise innocuous viral infections).

Case• Japinjot looks quite well to you. • She is not running a fever and she is not short of breath. • Her respiratory rate is 20 breaths/min; her pulse is 96

beats/min; and her temperature is 37.4°C. • She has a runny nose, but her ears and throat are

unremarkable. • Her chest is clear. During the 10 minutes she is in your office,

she coughs only once; the cough is dry and barky, but not spasmodic; the child barely seems to notice it, although her mother jumps!

• No alarm symptoms or signs are present.

Case – Presumptive Diagnosis

• Japinjot is too old to have bronchiolitis. • You make a presumptive diagnosis of mild

croup, following a viral upper respiratory tract infection, which is now recovering.

Is it likely to get worse?

• Up to 12% of children with cough experience complications,

• Usually mild and easily treated, some children do become very sick.

• Otitis media is the most common complication, followed by rash, diarrhea, and vomiting;

• only 5% of cases progress to bronchitis or pneumonia.

Is it likely to get worse?

• While children with neither fever nor chest signs had a probability of complications of only 6%,

• for children with chest signs it was 18%, • with fever it was 28%,• and when both fever and chest signs were

present the probability was 40%

Case

• You tell the mother that Japinjot will almost certainly continue to get better.

• Knowing her anxieties, you agree to check Japinjot again in 3 days to judge whether she is fit enough to resume playschool.

How long will the cough last?

• Between 35% and 40% of school age children continue to cough 10 days after the onset of a common cold,

• and 10% of preschool children continue to cough 25 days after a respiratory tract infection

how patterns of cough intensity vary over time

Thorax 2008;63(Suppl III):iii1–iii15.

1 2 34 Duration (Weeks)

Inte

nsity

of C

ough

Acute CoughRecurrent Acute Cough

Parental Concerns

• Parents worried children were going to die because of choking on phlegm or vomit;

• Also worried about asthma and crib death.• Some mothers also worried that their children would

develop long-term chest damage.• Mothers themselves had been affected by sleep

deprivation• First-time mothers and mothers with lower levels of

education are more likely to consult their physicians.

Case

• You ask the mother about her concern regarding Japinjot’s cough.

• She says she was worried that Japinjot might be developing pneumonia again; she is very relieved to hear that there is no sign of this.

Deciding on the best treatment

• Evidence-based guidelines have shown that there are no effective medications to either cure or relieve the symptoms of acute cough in children.

• Once you have confidently excluded the rarer and more serious conditions for which therapy is effective, explanation is required for the parent.

Deciding on best treatment

• Antibiotics have no effect on viral infections• Most parents will not be too concerned about

increasing antibiotic resistance; • However, they should be told that antibiotics

are at least as likely to cause side effects as they are to produce improvement.

• Serious adverse events and accidental poisonings have been recorded with CCM

SIDE EFFECTS of CCM

" 123 cough syrups in Davangere; from 9 pharmacies; 23 contained between 2.8 % to 20 % alcohol “

Ref: WHO 2001 FCH CAH 01.02: Cough & cold remedies for treatment of ARI in young children

• While 56% of those parents whose children received dextromethorphan plus albuterol

• and 66% of those whose children received dextromethorphan alone reported some to marked relief of symptoms,

• 73% of those in placebo group reported a similar level of improvement,

General concepts

In the majority of children presenting with cough, the etiology is related to URTI and requires only supportive measures (e.g., antipyretics, good hydration, and saline washes).

Management Approach

• Pharmaceutical Management– Cough formulations – Antibiotics– Antihistaminic drugs– Steroids

• Non Pharmaceutical Management– Avoidance– Nutraceuticals – Traditional therapies

When does a child need antibiotics?1. A cough does not get better in 14 days. 2. A bacterial form of pneumonia or whooping cough

(pertussis) is diagnosed.3. Symptoms of a sinus infection do not get better in ten days,

or they get better and then worse again.4. Child has a yellow-green nasal discharge and a fever of at

least 102° F for several days in a row.5. Child has strep throat, based on a rapid strep test or a throat

culture. Strep cannot be diagnosed just by looking at the throat.

Antibiotics for a sore throat, cough, or runny nose. 2013 [cited 2015 Nov 20]; Available from: http://consumerhealthchoices.org/wp-content/uploads/2013/02/ChoosingWiselyAntibioticsAAP-ER.pdf.

Reducing Antibiotic use• Overall, adult patients and parents/carers of children

with acute cough are satisfied with all three strategies (immediate, delayed and no prescribing) (86%, 77% and 72% satisfied, respectively).

• 40 % less antibiotic use reported when delayed prescriptions of Antibiotics used.

NICE. Respiratory tract infections – antibiotic prescribing Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. National Institute of Health and Clinical Excellence. 2008; 2008. p. 1-122.

Natural remedies

• Honey• Herbal teas• Tulsi

Other measures to help cough

• Saline Spray• Improve fluid intake• Rest• Steam inhalation• Aromatic vapor therapy

• Gargles• Prop up head• Hard candy• Petroleum jelly under

the nose• Warm fluids incl chicken

soup• Avoid second hand

smoke

Prevent recurrent cough (URI)

• Vit C, • Zinc, • Regular Hand washing,• Immune boosters

(Bovine colostrum, Echinacea, Turmeric, Honey, Amla,),

• Alternative meds• Vaccinations

• Proper sleeping,• Exercise, • Healthy balanced diet,• Avoid touching mouth

eyes nose

AAP Recommendations for cough1. For children ages 1 to 5 years, try half a teaspoon of

honey. Do not give honey to babies under one year—it is not safe.

2. Try one teaspoon of honey for children 6 to 11, and two teaspoons for children 12 or older.

3. Consider cough drops for children 4 and older.Over-the-counter cough and cold medicines: Do not give these to children under age 4.Many cold medicines already have acetaminophen in them, so beware of double dosing.

Antibiotics for a sore throat, cough, or runny nose. 2013 [cited 2015 Nov 20]; Available from: http://consumerhealthchoices.org/wp-content/uploads/2013/02/ChoosingWiselyAntibioticsAAP-ER.pdf.

Common issues in management

1. What to use in children below 2 years2. Overuse of Abs3. Cough at night4. Duration of cough in different illnesses -

counsel parents5. Wrong measurements - multidrug

ingredients, double dose of PCM

Quiz

Q: Of the 200+ viruses linked to the common cold, what is the most prevalent type?• Rhinovirus• Parvovirus• HerpesVirus• CMV

Quiz

Q: Of the 200+ viruses linked to the common cold, what is the most prevalent type?• Rhinovirus• Parvovirus• HerpesVirus• CMV

Q: How long can common cold virus survive on skin?

Q: How long can common cold virus survive on skin?• Up to 2 hours

• Q: Yellow or Green mucus is an indication for starting Antibiotics in a case of URI

• True / False

• Q: Yellow or Green mucus is an indication for starting Antibiotics in a case of URI

• True / False

Thank You