Causes of the most common ailments in children and ways to solve them
Introduction
URTI is one of the most common diseases encountered in practice by both pediatricians and family doctors. Globally recognized, these infections are known to disrupt daily life the most [1].
URTI includes non-specific upper respiratory tract infections - nose, paranasal sinuses, throat, pharynx, larynx, trachea, and bronchi - inflammatory diseases. Therefore, the clinical manifestation of URTI can be very diverse [1, 2].
Uncomplicated Acute Upper Respiratory Tract Infection (AURI) symptoms include nasal congestion, runny nose, sneezing, sore throat, cough, wheezing, fever, headache, general weakness, fatigue. Patients may also experience episodes of vomiting, decreased appetite, and watery eyes. In more severe cases, symptoms of acute rhinosinusitis, pharyngotonsillitis, laryngitis, or tracheitis may occur. Symptoms typically last 7-10 days on average, but in some cases, they can persist longer [1, 3].
Most AURIs are of viral origin. Cases of bacterial etiology are much less common. The main causative agents of AURIs are: rhinoviruses, respiratory syncytial virus (RSV), coronaviruses, adenoviruses, influenza, and parainfluenza viruses. Only a few patients with AURI have bacteria such as Streptococcus pneumoniae or Haemophilus influenzae cultured from nasopharyngeal swabs [2].
It is important to note that due to the frequent viral etiology, the use of antibiotics in many cases of AURI is not indicated. Irrational use of antibiotics leads to more frequent adverse effects of these drugs, promotes the development of bacterial resistance to antibiotics, and also increases costs [4].
An important factor contributing to inappropriate antibiotic prescription for children with AURI is the inability to quickly and reliably determine the cause of the disease clinically. Indeed, differential diagnosis is one of the most challenging tasks for a physician.
In autumn, AURI poses a significant challenge for pediatricians. For many AURI cases, it is recommended to choose symptomatic pharmacological and non-pharmacological treatment measures to improve the patient's condition and shorten the duration of symptoms [5].
Fever Reduction
Fever in infants and young children is one of the most common reasons for seeking medical attention. Almost half of the patients arriving at emergency departments are aged 3-36 months, with 15-25% of them having a fever. The most common cause of fever is the normal response of a child's body to a viral infection.
Fever means an elevated core body temperature above normal levels due to the action of inflammatory mediators. Consider fever when a child under 3 months has a body temperature over 38°C, a child from 3 to 36 months has over 38.1°C, and a child over 3 years has over 38.4°C [6, 7].
Fever is a normal body response to an inflammatory process, activating the body's resistance. The body kills pathogenic bacteria and viruses with the elevated temperature.
The main harmful effect of fever is the discomfort it causes. Fever is also quite dangerous for children with underlying heart or lung diseases because metabolism, blood circulation, and oxygen consumption increase with fever.
Measures to reduce fever can be divided into 2 groups:
l Physical measures. This includes moistening the child's skin with a damp cloth or towel when the water temperature is around 30 °C. Alcohol-containing fluids are not used. This method should not be routine. Physical measures are only recommended for children with good peripheral circulation and those who cannot be given antipyretics. The best effect is achieved when they are administered 30 minutes after taking antipyretics;
l Antipyretics.
Caregivers use acetaminophen (paracetamol) and ibuprofen to manage fever in infants and children. They avoid giving aspirin due to the risk of Reye's syndrome, which affects the brain and liver. They also prohibit the use of Analgin because of its severe side effects. Give antipyretics if the child feels discomfort, the temperature exceeds 40°C, there are fluid and electrolyte imbalances, signs of shock, or concurrent neurological and cardiopulmonary symptoms, and in conditions where metabolism is increased.
Do not give antipyretics solely to reduce body temperature or prevent febrile seizures. Avoid giving antipyretics to a febrile infant under 6 months without a doctor's guidance. It is important to dose antipyretics based on the child's weight, not age, to avoid improper dosages.
Paracetamol not only reduces fever but also alleviates pain. Dosage: 10-15 mg/kg every 4 hours. Do not exceed 5 doses per day. The maximum daily dose for infants under 3 months is 60 mg/kg, for children older than 3 months is 80 mg/kg. Paracetamol starts to take effect within 30-60 minutes, peaks at 3-4 hours, and lasts up to 6 hours. For better absorption, paracetamol is recommended to be administered orally. Overdosing on paracetamol can damage the liver. Paracetamol should not be given to infants under 3 months without a doctor's permission.
Ibuprofen is known for its strong antipyretic, pain-relieving, and anti-inflammatory effects. Dosage: 5–10 mg/kg every 6 hours. Maximum daily dose – 40 mg/kg. Ibuprofen starts to work within 60 minutes, reaches peak effect at 3–4 hours, and lasts up to 6–8 hours. Ibuprofen can be prescribed to infants from 3 months (> 5 kg weight). It is not recommended for children with impaired kidney function or severe dehydration [6, 7].
The combination of acetaminophen and ibuprofen is often used to treat febrile children. Studies show that temperature changes are similar between groups treated with only one of these drugs and the group receiving the combination. However, 4–5 hours after drug intake, the temperature is lower in the group that took both acetaminophen and ibuprofen together.
The effectiveness and safety of treatment with drug combinations remain uncertain. Parents often do not understand the dosing rules, increasing the risk of incorrect dosing and overdose.
There is also a lack of evidence that combination therapy is more effective in increasing the overall comfort level of the child. More evidence is needed to determine whether febrile children can be regularly treated with drug combinations [8].
Parents, caring for a febrile child at home, should ensure an adequate intake of fluids (breastfed infants should continue to be breastfed) and monitor signs of dehydration (Table 1). Parents should be informed about the use of fever-reducing measures. Situations where parents should seek medical help are indicated in Table 2. Parents should seek medical help again if the child's condition does not improve within 2 days of the initial medical consultation [6, 7].
Suppression of Rhinitis Symptoms
Rhinitis symptoms (nasal congestion, runny nose) can bother a child, especially an infant, as they disrupt breathing through the nose. The first choice measures are non-pharmacological. Initially, the nose is cleaned with a twisted cotton wool or a special nasal cleaner. It is important to pay attention to cleaning the noses of small children, as they need assistance. Before blowing the child's nose, one of his nostrils is closed. This prevents secretions from entering the middle ear and causing inflammation [9].
Non-pharmacological measures include sterile saline nasal sprays, isotonic and hypertonic salt solutions. By rinsing the nasal cavity with such a solution, it is possible to temporarily remove bothersome nasal secretions, moisten the nasal mucosa, improve mucociliary clearance, and induce vasoconstriction [9, 10]. Saline preparations are particularly suitable for infants and children up to 2 years old, as they cannot remove nasal secretions themselves. These preparations can irritate the nasal mucosa and cause nosebleeds. A 2015 review, which included 5 randomized controlled trials, stated that moisturizing the nasal mucosa with a salt solution may be beneficial in reducing symptoms of upper respiratory tract infections [11].
Topical decongestants cause vasoconstriction of the mucosal blood vessels by binding to alpha-1 and alpha-2 adrenoceptors. This reduces swelling of the nasal mucosa. They are administered as drops or sprays. The effect occurs within 1–3 minutes. When using topical decongestants for 5–10 days, irreversible damage to the vibratory epithelium may develop – medicamentous rhinitis. The recommended duration of use is no more than 3 days. If a child overdoses and swallows the drops, systemic signs of poisoning may appear: nausea, headache, tachycardia, collapse, in severe cases – coma, seizures.
Xylometazoline (alpha-2 adrenomimetic) is most commonly prescribed for children over 7 years of age. Oxymetazoline – alpha-2 adrenomimetic, prescribed from 6 years of age. In Lithuania, there are registered xylometazoline preparations suitable for younger patients – children from 2 to 11 years old [9, 12].
Compound oral medications contain systemic decongestants, such as pseudoephedrine. Preparations containing it are only prescribed for children over 12 years of age [12].
Antihistamines, by binding to H1 receptors, block the binding of histamine, but do not activate it themselves.
First-generation antihistamines such as chlorpheniramine and triprolidine are most commonly included in compound oral medications. They are suitable for treating upper respiratory tract infections, as they have an anticholinergic effect – reducing secretion from the nose, tear, and saliva glands. First-generation antihistamines are associated with decreased sneezing and runny nose, but often come with unwanted sedative effects. Second-generation antihistamines (e.g., loratadine, cetirizine) selectively block histamine receptors and do not have anticholinergic effects, therefore they do not affect upper respiratory tract infection symptoms [9, 13]. Antihistamines are prescribed for children over 6 years of age. Compound preparations containing chlorpheniramine, triprolidine are only prescribed from 12 years of age [9, 12].
Treatment of Cough
Cough is one of the most common and bothersome symptoms in children. Nighttime cough, disrupting sleep, particularly worsens the condition [14]. If cough causes discomfort to the child, makes them tired, cough suppressants should be used.
Cough suppressants are used to treat dry, unproductive cough. Currently, in Lithuania, there are several registered products suitable for children. Levodropropizine is a non-narcotic peripheral acting cough suppressant given in syrup form to children over 2 years old. Codeine is a narcotic central acting cough suppressant. Codeine-containing combination products registered in Lithuania are prescribed for children over 12 years old [9, 12].
A meta-analysis including 7 clinical studies compared the effectiveness of levodropropizine and central acting drugs. Evaluating standardized efficacy parameters, it was found that levodropropizine significantly more effectively reduced cough intensity, frequency, and nighttime awakenings. This meta-analysis showed that the peripheral acting levodropropizine more effectively suppresses cough than central acting drugs [15].
In a prospective study, the reduction of acute cough symptoms was compared when prescribing only cough suppressants, only antibiotics, or these products together. It was found that peripheral acting cough suppressants significantly more effectively reduced cough symptoms compared to antibiotics. The duration of cough symptoms did not differ between those receiving only cough suppressants and antibiotics compared to those receiving both cough suppressants and antibiotics [16].
Expectorants promoting cough reflex belong to plant-based products (e.g., ivy, thyme, licorice, elderberry, etc.). Their action is based on stimulating cough receptors reflexively. These products can be used as herbal teas or as creams, balms, ointments applied to the chest and back. These products are also restricted by age [9, 12].
Mucolytics are medications that liquefy thick and sticky respiratory tract secretions. They break the bonds between mucus structural polysaccharides and disulfide glycoprotein linkages. Mucolytics are prescribed when there are many difficult-to-expel secretions in the respiratory tract, but are most commonly chosen for lower respiratory tract infections. They can also be useful in cases of rhinosinusitis as they thin the secretion in the facial sinuses, facilitating its drainage. From the age of 2, acetylcysteine, bromhexine, carbocysteine, ambroxol can be orally administered [9, 12].
However, water remains the safest and most effective expectorant in pediatrics. Sufficient water intake helps to liquefy and remove mucus, promoting expectoration [13].
Treatment of Sore Throat with Antiseptics
Throat lozenges, pastilles, local sprays containing pain relievers (e.g., local anesthetics lidocaine, benzocaine) are suitable for suppressing throat pain.
These remedies are recommended for children over 6 years old [9, 17]. Preparations with antiseptic properties can also suppress inflammation and soothe throat pain. Many antiseptic substances are used in their composition: ambazone, dichlorobenzyl alcohol, chlorhexidine, chlorquinaldol, etc. Lozenges and tablets can only be given to children aged 5-7 years [9, 12]. There is also evidence of the effectiveness of herbal products in suppressing throat pain [5].
Etiological Treatment
Antibiotics. Currently, excessive use of antibiotics is receiving a lot of attention. Due to the predominant viral origin of URTIs, these drugs are often not indicated. When prescribing antibiotics to treat URTIs, it is advisable to assess the likelihood of a bacterial infection. The benefit of prescribing antibiotics should outweigh the potential harm. Inappropriate use of these drugs is associated not only with specific adverse effects on the patient but also with increasing bacterial resistance [4, 9].
Antibiotics should be prescribed when a bacterial origin of URTI is suspected or confirmed (e.g., during streptococcal pharyngotonsillitis), using symptomatic treatment, the disease lasts longer than it should, worsening the patient's condition [9, 17].
Another problem is related to the excessive prescription of antibiotics - parents' inability to adequately assess the need for antibiotics. Surveying more than 600 pediatricians revealed that parents requested antibiotics in 96% of cases when they were not needed at all [18].
Antiviral Treatment
Drugs in this group are rarely prescribed for children with normally functioning immune systems. Antiviral drugs like rimantadine, zanamivir, and oseltamivir are prescribed for flu and used for flu chemoprophylaxis. Antiviral treatment for URTIs is necessary for immunosuppressed children, such as those with immunodeficiency diseases, undergoing chemotherapy, bone marrow transplantation, or suffering from oncological and hematological conditions [9, 17]. Delaying the administration of medications can result in a high mortality rate among such patients, as described in the literature. A retrospective study evaluated the effectiveness of ribavirin for patients who developed parainfluenza infection after hematopoietic stem cell transplantation. The mortality rate of patients treated with ribavirin was not significantly different from those treated without it. The authors believe these results can be attributed to ribavirin being administered in very severe cases or advanced infections [19].
Prevention of Acute Respiratory Tract Infections (ARTIs)
l Adequate sleep duration. Sleep promotes immune system functions. Younger children should sleep more than older ones. Adequate sleep duration is considered to be 10-12 hours per night [15].
l Breastfeeding. Maternal antibodies present in breast milk are transferred from the mother to the child. They can help fight infection even if breastfeeding is discontinued.
l Avoiding passive smoking or other air pollutants. Passive smoking is associated with respiratory system impairments in children. The frequency of ARTIs among children from smoking and non-smoking households was evaluated in a study. Significantly more children in smoking households experienced ARTIs at least once a year and had more ARTI episodes [20].
l Vitamin D3. A study of 600 students in a random sample. Groups were compared between those taking vitamin D3, placebo, or gargling. ARTI infections were confirmed by laboratory tests. The use of vitamin D3 was significantly associated with a lower confirmation of ARTI by laboratory tests. Therefore, the authors suggest that vitamin D3 could become one of the preventive measures for ARTIs [21].
Summary
Children with ARTIs usually recover on their own, but comprehensive treatment often alleviates their condition and symptoms. Symptomatic treatment measures, selected based on the prevailing symptoms, form the basis of this approach. Non-pharmacological measures are often chosen first, and it's important to ensure adequate hydration to meet the child's fluid needs.
Avoid excessive antibiotic administration in ARTIs, as most of these diseases are viral. Use antibiotics only when clear indications exist, as their use in non-bacterial infections can cause more harm than benefit.
Source: "Pediatrics".
