What is the initial assessment and treatment approach for pediatric patients presenting with Acute Respiratory Infection (ARI)?

Initial Assessment and Management of Acute Respiratory Infection in Pediatric Patients

Immediate Assessment Priorities

Most pediatric ARIs are viral and self-limiting, requiring only supportive care; however, you must immediately screen for sepsis and respiratory distress at first contact to identify the minority who need urgent intervention. 1, 2

Red Flag Assessment at First Contact

At every initial encounter, actively ask yourself "could this be sepsis?" and assess for:

• Respiratory distress indicators: respiratory rate >70 breaths/min in infants or >50 breaths/min in older children, grunting, intercostal recession 1
• Signs of sepsis: altered mental status, poor perfusion, hemodynamic instability 3
• Danger signs: new or increased breathlessness, new confusion, inability to feed, severe chest in-drawing 3

Remote vs. Face-to-Face Decision

If a child is potentially ill enough to require antibiotics based on remote assessment, arrange a face-to-face evaluation rather than prescribing remotely—this should be standard practice. 3

Remote assessment has significant limitations in detecting severe illness, and clinical judgment must guide the urgency of face-to-face evaluation based on symptom severity and rate of deterioration 3.

Diagnostic Approach for Bacterial vs. Viral ARI

Apply Stringent Diagnostic Criteria

The vast majority of pediatric ARIs are viral and do not benefit from antibiotics; only prescribe antibiotics when specific bacterial infection criteria are met. 1, 2

Acute Otitis Media (AOM)

Requires BOTH middle ear effusion AND signs of inflammation (moderate/severe bulging tympanic membrane, OR mild bulging with ear pain or erythema) 2

Acute Bacterial Sinusitis

URI symptoms that are either worsening, severe, or persistent beyond 10 days 2

Group A Streptococcal Pharyngitis

Only test if at least 2 of the following: fever, tonsillar exudate/swelling, swollen/tender anterior cervical nodes, or absence of cough 2

Pneumonia

Clinical signs (tachypnea, chest in-drawing, hypoxia) with or without radiological confirmation 1, 4

Management Algorithm

For Viral ARI (Majority of Cases)

Provide supportive care only—antibiotics are not indicated and do not reduce symptom duration or prevent complications, even when risk factors are present. 1

Supportive Care Measures:

• For children >1 year: Honey is first-line treatment for cough (more effective than diphenhydramine or placebo) 1
• For infants <12 months: NEVER give honey due to botulism risk 1
• Hydration: Encourage adequate fluid intake 1, 2
• Fever management: Appropriate antipyretics (never aspirin in children <16 years) 1

Critical Medication Avoidance:

• DO NOT use OTC cough and cold medications in children <4-5 years due to lack of efficacy and risk of serious harm including mortality 1
• DO NOT use antihistamines for cough (no benefit, potential adverse events) 1
• DO NOT use codeine (contraindicated due to respiratory complications) 1
• DO NOT use dextromethorphan (no more effective than placebo) 1

For Bacterial ARI (When Diagnostic Criteria Met)

Acute Otitis Media:

• First-line: Amoxicillin 90 mg/kg/day divided into 2 doses 2, 5
• If recent antibiotic use (within 4-6 weeks) or moderate disease: High-dose amoxicillin-clavulanate (90 mg/6.4 mg per kg per day) 2
• Consider observation strategy ("wait and see") for uncomplicated cases in children >2 years with reliable follow-up 2

Acute Bacterial Sinusitis:

• First-line: Amoxicillin or amoxicillin-clavulanate 2, 5
• Consider observation for persistent symptoms only 2

Group A Streptococcal Pharyngitis:

• Only treat after positive rapid antigen test or throat culture 2
• First-line: Amoxicillin or penicillin 2, 5

Community-Acquired Pneumonia:

• First-line for outpatient management: Amoxicillin 90 mg/kg/day divided into 2 doses 4, 5
• For hospitalized patients: Ampicillin or penicillin G (if fully immunized and low penicillin resistance) 4
• For severe/life-threatening infections or empyema: Third-generation cephalosporins (ceftriaxone or cefotaxime) 4
• If atypical pathogens suspected: Macrolide antibiotics 2, 4

Important caveat: Antimicrobial therapy is not routinely required for preschool-aged children with community-acquired pneumonia because viral pathogens cause the majority of cases 4

Safety Netting and Follow-Up

Educate parents that common cold is viral and self-limited, typically resolving in 7-10 days, and provide specific instructions for when to return. 1

Return Immediately If:

• Symptoms worsen rapidly or significantly 3
• New or increased breathlessness or confusion 3
• Child becomes systemically very unwell 3
• Respiratory distress develops 1

Scheduled Review:

Review all children if deteriorating or not improving after 48 hours on treatment. 1, 2, 4

Common Pitfalls to Avoid

• Prescribing antibiotics due to parental pressure despite lack of indication 1
• Remote antibiotic prescribing without face-to-face assessment 3
• Using azithromycin as first-line for any pediatric URI (inadequate coverage for common AOM and sinusitis pathogens) 2
• Failing to assess environmental tobacco smoke exposure (major risk factor for respiratory infections) 1
• Not re-evaluating children whose symptoms persist beyond expected timeframe 1
• Applying adult cough management approaches to pediatric patients 1

Antibiotic Considerations

Be aware that antibiotic-associated adverse events range from mild (diarrhea, rash) to life-threatening (anaphylaxis), and early-life antibiotic exposure may contribute to long-term conditions including inflammatory bowel disease, obesity, eczema, and asthma 2. Amoxicillin-clavulanate has higher adverse event rates (particularly diarrhea) compared to amoxicillin alone 2. Inappropriate antibiotic use drives resistance at both individual and community levels 2.