What is the best approach for managing upper respiratory infections in pediatric patients?

Management of Pediatric Upper Respiratory Infections

Most upper respiratory tract infections in children are viral and require supportive care rather than antibiotics, with antibiotics reserved only for specific bacterial infections diagnosed using stringent clinical criteria. 1, 2

Diagnostic Approach

• Upper respiratory infections (URIs) should be categorized based on specific diagnostic criteria to determine if they are bacterial or viral, as this guides appropriate management 1
• Acute Otitis Media (AOM) diagnosis requires both middle ear effusion AND signs of inflammation (moderate/severe bulging of tympanic membrane, otorrhea, or mild bulging with ear pain/erythema) 1, 2
• Acute Bacterial Sinusitis is diagnosed when URI symptoms are either worsening (new fever, daytime cough after improvement), severe (fever ≥39°C, purulent nasal discharge), or persistent (nasal discharge/daytime cough >10 days without improvement) 1, 2
• Group A Streptococcal (GAS) pharyngitis requires confirmation by rapid testing or culture, and testing should only be done if at least 2 of the following are present: fever, tonsillar exudate/swelling, swollen/tender anterior cervical nodes, or absence of cough 1, 2

Management of Viral URIs

• Supportive care is the mainstay of treatment for viral URIs, which constitute 75-90% of all pediatric respiratory infections 2, 3
• For children under 2 years, over-the-counter cough and cold medications should NOT be used due to lack of proven efficacy and potential for serious toxicity 4
• Adequate hydration is crucial to help thin secretions and prevent dehydration 2, 4
• Antipyretics and analgesics can be used to keep the child comfortable and help with coughing 1, 4
• Nasal saline irrigation may reduce symptom severity in children with URIs (Level of evidence: 2, Recommendation strength: B) 5
• Minimal handling may reduce metabolic and oxygen requirements in severely ill children 1

Antibiotic Management for Bacterial URIs

• Antibiotics should only be prescribed when bacterial infection is likely based on specific diagnostic criteria 1
• Amoxicillin remains the first-line agent for most pediatric bacterial URIs due to effectiveness against common pathogens and favorable safety profile 2, 6
• For AOM: First-line treatment is amoxicillin (90 mg/kg/day), with high-dose amoxicillin-clavulanate considered for children who received antibiotics in previous 4-6 weeks 2
• For Acute Bacterial Sinusitis: First-line treatment is amoxicillin with or without clavulanate 1, 2
• For confirmed GAS Pharyngitis: First-line treatment is amoxicillin or penicillin, only after confirmation by rapid testing or culture 1, 2
• Young children with mild symptoms of lower respiratory tract infection generally do not need antibiotics 1, 4

Monitoring and Follow-up

• Children treated at home should be reviewed by a healthcare provider if deteriorating or not improving after 48 hours on treatment 1, 4
• Families need information on managing fever, preventing dehydration, and identifying signs of deterioration 1, 4
• Indicators for hospital admission in infants include: oxygen saturation <92%, respiratory rate >70 breaths/min, difficulty breathing, intermittent apnea, grunting, not feeding, and family unable to provide appropriate supervision 1
• Indicators for hospital admission in older children include: oxygen saturation <92%, respiratory rate >50 breaths/min, difficulty breathing, grunting, signs of dehydration, and family unable to provide appropriate supervision 1

Important Considerations

• Chest physiotherapy is not beneficial and should not be performed in children with pneumonia 1
• Environmental factors like tobacco smoke exposure should be addressed as they can exacerbate respiratory symptoms 4
• Shorter courses of therapy (e.g., 7 days vs. 10 days) may be appropriate for older children with AOM 2
• For persistent cough beyond 4 weeks, further evaluation may be needed to identify underlying causes 4