Upper RespiratoryInfections

Khaled Saad ZaghloulMD Pediatrics

The most common cause of The most common cause of cough in in children is represented by airways children is represented by airways respiratory infection, respiratory infection, mostly concerning the upper airway and of viral origin (URTI).

A healthy child is expected to present with 3.8–8 infective episodes per year, vs. the average of two episodes for an adult .

Monto AS. Epidemiol Rev 1994: 16: 351–73Monto AS. Epidemiol Rev 1994: 16: 351–73..Leder et al. Aust N Z J Public Health 2003: 27:399–404Leder et al. Aust N Z J Public Health 2003: 27:399–404..

Cough associated with a single infective episode may last from days to weeks, with an average of 1–3 weeks , and it has been demonstrated that 10% of children will be expected to be still coughing after 4 weeks from the beginning of the infection.

Hay & Wilson . Br J Gen Pract 2002: 52: 401–9.Hay et al. Fam Pract 2003:20: 696–705.

The infections may occur The infections may occur ‘‘back to back’’ and give the impression of a chronic and give the impression of a chronic persistent cough. However, these children persistent cough. However, these children should experience short breaks in their should experience short breaks in their symptoms in between infections.symptoms in between infections.

UPPER RESPIRATORY TRACT IFECTIONS

Common cold Pharyngitis Sinusitis Ear infections

The common cold Short, mild and usually self-limiting illness. Children may have up to12 colds per year. 200 types of viruses, the most common is

rhinovirus ( 40% ).

Clinical features of common cold:

Rhinorrhea, sore throat,cough,fever and malaise lasting up to 7 days and often lingering mucopurlant nasal discharge.

In infants cold may manifest as irritability, snuffles and difficulty with feeding.

Infants under 3 months of a age are susceptible to LRTI.

Treatment of common cold

Echinacea, humidified air, nasal decongestants, vitamin C and zinc have reported some positive results but there insufficient data to recommend any of these for treatment.

Hems and Henderson, Respiratory disorders. Forfar and

Arneil' Textbook of Pediatrcs, 715,2008

Acute sore throat

Pharyngitis

Bacterial infectionBacterial infection Viral infection Streptococcus pyogenes – most serious type

Scarlet fever Rheumatic fever Glomerulonephritis

Streptococcus pyogenesStreptococcus pyogenes

Group A is virulentStreptolysins - toxin (hemolysins)Erythrogenic – toxinToxins can act as superantigens

Over stimulate T cellsTumor necrosis factor

Ƅ Ƅ Bacterial infection:Bacterial infection:

Group A beta-hemolytic Streptococcus • Most common and important • Commonly presents in children aged 5–6 • Fever, dry sore throat, cervical adenopathy, dysphagia, and odynophagia • The tonsils and pharyngeal mucosa are erythematous and may be covered with purulent exudate • The tongue may also become red ("strawberry tongue") • Sequelae: acute rheumatic fever and poststreptococcal glomerulonephritis

The surface antigens of group A streptococcus serve as virulence factors.

Fig. 21.5 Cutaway view of group A streptococcus.

Streptococcus infection causing inflammation of the throat and tonsils.

Treatment of acute phryngitis Penicillin V 250 mg/dose for children and

500mg/dose for adolescents and adults. Amoxicillin; 750 mg once daily for10 days or

50 mg/kg/day for 6 days divided bid. A single IM injection of benzathine penicillin

(600,000U for children < 27 kg; 1,2 million U for larger children and adults.

Erythromycin 40 mg/kg in divided doses for 10 days.

Azithromycin offers convenience of once-daily administration and shorter length of therapy.

Cephalosporins appear to be as, good as or better than penicillin, perhaps because these drugs are more effective in eradicating streptococcal carriage. Evidence is not sufficient to recommend shorter courses of cephalosporins for routine therapy at this time

Pappas and Henley: Nelson textbook of pediatrics, 2007Pappas and Henley: Nelson textbook of pediatrics, 2007

Candida

Coxsackie virus: • Herpangina

ulcerative vesicles over the tonsils, posterior pharynx, and palate • Commonly occurs in children under the age of 16• Generalized symptoms of headache, high fever, anorexia, and odynophagia

EBVEBV

DiagnosisDiagnosisBy Clinical presentationCBC with differential (atypical lymphocytes –T

lymphocytes)Detection of heterophil antibodies (Monospot test)IgM titers

EBV petechiae

Herpes Simplex Virus-1Herpes Simplex Virus-1

Herpes labialis

• Recurrent infection

• -1HSV• vesicle at lip or

mucocutaneous junction

Acute herpes gingivostomatitis

Colour Atlas of Infectious Disease, 2003

Inflamed pharynx and tonsils marked by a grayish pseudomembrane formed by the bacteria are characteristic signs of diphtheria.

Sinuses

Sinuses are moist air spaces within the bones of the face around the nose

Human have 4 pairs of sinuses The ethmoid and the maxillary sinuses form in the

third to fourth gestational month The sphenoid sinuses are generally pneumatized

by 5 years of age the frontal sinuses appear at age 7 to 8 years but

are not completely developed until late adolescence.

Sinuses

Sinusitis

Microbial etiologyMicrobial etiology

Viruses are the most frequent cause of Viruses are the most frequent cause of rhinosinusitisrhinosinusitis

viruses are known to predispose to viruses are known to predispose to subsequent bacterial infection via such subsequent bacterial infection via such mechanisms as viral-induced impairment mechanisms as viral-induced impairment of the mucociliary apparatus. of the mucociliary apparatus.

Microbial etiology

Bacterial causes of sinusitis

OrganismOrganism%%

S. pneumoniaeS. pneumoniae30%30%

H. Influenzae (nontypable )H. Influenzae (nontypable )20%20%

M. catarrhalisM. catarrhalis2%2%

50% of H. Influenzae and 100% M. catarrhalis are B- lactamase positive

Sign and symptoms

In pediatric patients, most URIs last 5-7 days.By 10 days, the URI almost always improves.Most rhinoviral infections improve within 7-10

days so the complaint of persistent or worsening symptoms may indicate a developing bacterial sinusitis.

Pediatric patients may complain of a daytime cough and persistent nasal discharge.

Complaints of facial pain and headache are rare in children.

The clinical diagnosis of Bacterial sinusitis is based solely on history.

Persistent of symptoms of URI , including nasal discharge and cough, for >10-14 days,

or temp 39 C and purulent discharge for 3-4 days

Chronic sinusitisChronic sinusitis

CoughCoughNasal discharge or nasal congestion lasting

more than 90 days

Physical examination

- Facial tenderness to palpation is present

- Nasal mucosa is inflammation, redness and swelling

- Purulent secretions in the middle meatus (highly predictive of maxillary sinusitis)

- Complete opacification of sinus on transillumination is present..

Antibiotics for siuusitisAntibiotics for siuusitis

Risk factors:1. antibiotics treatment in the preceding1-3 mo,2. day care attendance, age ≤2 yr )3. resistant bacterial species4. failure to respond to initial amoxicillin within

72 hr

Frontal sinusitis can rapidly progress to Frontal sinusitis can rapidly progress to intracranial complication -parenteral intracranial complication -parenteral ceftriaxone until improvement then oral until improvement then oral antibiotic therapy.antibiotic therapy.

The use of decongestants, antihistamines, mucolytics and intranasal steroids have not adequately studied in children

POST-NASAL DRIP SYNDROMEPOST-NASAL DRIP SYNDROME

The leading cause of PND, is allergic rhinitis or, The leading cause of PND, is allergic rhinitis or, more appropriately, chronic rhinosinusitis. In more appropriately, chronic rhinosinusitis. In Hong Kong, the prevalence of allergic rhinitis Hong Kong, the prevalence of allergic rhinitis in children between 6 and 7 years old is 33%, in children between 6 and 7 years old is 33%, and this figure increases to 52% in children and this figure increases to 52% in children

between 13 and 14 years oldbetween 13 and 14 years old . .

Bousquet et al. J Allergy Clin Immunol 2001; 108:S147-334Bousquet et al. J Allergy Clin Immunol 2001; 108:S147-334..

Lau & Karlberg . J Paediatr Child Health 1998; 34:47-52Lau & Karlberg . J Paediatr Child Health 1998; 34:47-52..

Leung et al.Eur Resp J 1997; 10:354-60Leung et al.Eur Resp J 1997; 10:354-60..

The pathogenesis of PND induced cough is The pathogenesis of PND induced cough is probably due to the inflammatory nature of the probably due to the inflammatory nature of the nasal secretion and/or direct mechanical nasal secretion and/or direct mechanical stimulation of the cough receptors by stimulation of the cough receptors by secretions dripping from the nostrils down into secretions dripping from the nostrils down into the hypopharynx. Microaspiration of the the hypopharynx. Microaspiration of the secretions and nasobronchial reflex have also secretions and nasobronchial reflex have also been suggestedbeen suggested..

Bush A. Paediatric problems of cough. Pulm Pharmacol Ther 2002;15:309-15Bush A. Paediatric problems of cough. Pulm Pharmacol Ther 2002;15:309-15..

Lack G. Pediatric allergic rhinitis and comorbid disorders. J Allergy Clin Immunol 2001; 108:S9-15Lack G. Pediatric allergic rhinitis and comorbid disorders. J Allergy Clin Immunol 2001; 108:S9-15..

Acute Otitis MediaAcute Otitis Media

. Otitis media is one of the most common diagnosis made by pediatricians

30-60% of children have had at least one putative episode of AOM by age one.

10-20% have had three or more. 80% have had at least one episode by age

3 years.

Approximately 80-90% will have had at least one episode of either AOM or asymptomatic middle ear effusion in the first year of life.

Eustachian Tube

Connects middle ear and nasopharynxLumen shaped like two cones with apex

directed toward middleMucosa has mucous producing cells and

ciliated cells cells

Eustachian tube

Adults ant 2/3- cartilaginousant 2/3- cartilaginous

post 1/3- bonypost 1/3- bony 45 degree angle45 degree angle isthmus 1-2 mmisthmus 1-2 mm nasopharyngeal orifice nasopharyngeal orifice

8-9 mm8-9 mm

Children longer bony portion

10 degree angle isthmus larger nasopharyngeal orifice

4-5 mm in infants

Eustachian tube

Usually closedOpens during swallowing, yawning, and

sneezing Opening involves cartilaginous portionTensor veli palatini responsible for active tubal

openingNo constrictor function

Eustachian tube function

Protection from nasopharyngeal sound and secretions

clearance of middle ear secretionsventilation (pressure regulation) of middle

ear

Bacteria can migrate along the eustachian tube from the upper respiratory tract, and a buildup of mucus and fluids can cause inflammation and effusion.

Fig. 21.2 An infected middle ear.

Risk factors for AOM

Age Male genderMale genderExposure to group day care Exposure to environmental smoke or other

respiratory irritants and allergens that interfere with Eustachian tube function.

Lack of breast feeding. Supine feeding position.

Risk factors for AOM URIURI Winter season Siblings in household

Immunodeficiency

AllergiesAllergies Craniofacial abnormalitiesCraniofacial abnormalities Down syndromeDown syndrome PacifierPacifier

NEVER bottle-feed an infant on it’s back like this!

Large tonsils can obstruct the Eustachian tubes

How we are challengedHow we are challenged.….…

**Clinical History is a poor predictorClinical History is a poor predictor……

**A clear view isn’t always easyA clear view isn’t always easy……

**Examining a crying child can be toughExamining a crying child can be tough!!

Otalgia usually is associated with usually is associated with inflammation of the external or inflammation of the external or

middle ear, but it may represent pain middle ear, but it may represent pain referred from involvement of the referred from involvement of the

teeth, temporomandibular joint, or teeth, temporomandibular joint, or pharynx. pharynx.

In young infantsIn young infants , ,- - pulling or rubbing the ear along with pulling or rubbing the ear along with - - general irritability or poor sleep, especially general irritability or poor sleep, especially --when associated with when associated with fever, may be the only , may be the only

signs of ear pain. signs of ear pain. Ear pulling alone is not diagnostic of ear

pathology.

Three important keys to improving diagnostic accuracy for AOM centre around the following:

diligent cleaning of ear cerumen for better visualisation of the tympanic membrane.

use of nickel–cadmium or lithium rechargeable batteries.

and the use of original equipment full-length speculums.

Normal EarNormal Ear

Acute Otitis MediaAcute Otitis Media

Acute Otitis MediaAcute Otitis Media

Middle ear effusion(MEE)

YesYes YesYes

Diagnostic Criteria: OME and Diagnostic Criteria: OME and AOMAOMAt least two of:

1. Abnormal color of tympanic membrane (TM): white, yellow, amber, blue

2. Opacification not due to scarring

3. Decreased or absent motility

Bubbles or air-fluid interfaces

Adapted from Hoberman A, et al. Pediatr Ann. 2000;29:609-620.

Otitis media with effusion (OME)

No acute No acute inflammationinflammation

Acute Acute inflammationinflammation

At least one of:1. Distinct fullness or bulging of

the TM2. Marked redness of the TM3. New onset of ear pain

Acute otitis media(AOM)

YesYes

Acute purulent otorrhea not due to otitis externa

YesYes

OrOr

S. pneumoniae*50%

M. catarrhalis15%

Other5%

H. influenzae*30%

Predominant AOM Pathogens

Barnett ED, et al. Pediatr Clin North Am 1995;42:509–517. Jacobs MR. Pediatr Infect Dis J 1996;15:940–943.

Clinical GuidelinesClinical Guidelines

AMERICAN ACADEMY OF PEDIATRICS AMERICAN ACADEMY OF FAMILY

PHYSICIANS

Subcommittee on Management of Acute Otitis Media

CLINICAL PRACTICE GUIDELINE

Diagnosis and Management of Acute Otitis Media

AOM OutcomeAOM OutcomeInitial Initial AntibacteriaAntibacterial Therapyl Therapy

Initial Initial ObservatioObservationn

PP

Incidence of mastoiditis or Incidence of mastoiditis or suppurative complicationssuppurative complications

0.59%0.59%0.17%0.17%NSNS

Persistent MEE at 4–6 weeksPersistent MEE at 4–6 weeks45%45%48%48%NSNS

Persistent MEE at 3 monthsPersistent MEE at 3 months21%21%26%26%NSNS

Antibacterial agent–induced Antibacterial agent–induced diarrhea or vomitingdiarrhea or vomiting

16%16% — ———

Antibacterial agent–induced Antibacterial agent–induced skin rashskin rash

2%2%————

Is antibiotic therapy of AOM necessary?

Source: AAP/AAFP Clinical Practice Guideline on AOM, March 2004

AOM OutcomeAOM OutcomeInitial Initial AntibacteriaAntibacterial Therapyl Therapy

Initial Initial ObservatioObservationn

PP

Symptomatic relief at 24 Symptomatic relief at 24 hourshours

60%60%59%59%NSNS

Symptomatic relief at 2–3 Symptomatic relief at 2–3 daysdays

91%91%87%87%NSNS

Symptomatic relief at 4–7 Symptomatic relief at 4–7 daysdays

79%79%71%71%NSNS

Clinical resolution at 7–14 Clinical resolution at 7–14 daysdays

82%82%72%72%NSNS

Pain duration, mean daysPain duration, mean days2.82.83.33.3NSNS

Crying duration, mean daysCrying duration, mean days0.50.51.41.4.<.<000011

Analgesic use, mean dosesAnalgesic use, mean doses2.32.34.14.1..004004

Fever duration, median Fever duration, median daysdays

2.02.03.03.0..004004

Is antibiotic therapy of AOM necessary?

AOM spontaneous resolution rate AOM spontaneous resolution rate varies by pathogenvaries by pathogen

OrganismOrganismSpontaneous Spontaneous bacteriologic bacteriologic clearance rateclearance rate

S. pneumoniaeS. pneumoniae19%19%

H. influenzaeH. influenzae48%48%

M. catarrhalisM. catarrhalis75%75%

Howie VM. Clin Infect Dis 1992;14:S209-10; Klein JO. PIDJ 1993;12:973-5

2004 AAP/AAFP Clinical Practice Guideline on AOM

Released March 2004 Evidence-based clinical practice guideline:

3461 articles initially identified; 760 reviewed Extensively peer-reviewed

Scope: diagnosis and management of uncomplicated AOM in children aged 2 m to 12 y

Excludes children with: underlying conditions that predispose to AOM children with recurrence of AOM within 30 days of AOM

or underlying chronic OME

2004 AAP/AAFP Clinical Practice Guideline on AOM: Conclusions I I

1. To diagnose acute otitis media the clinician should confirm a history of acute onset, identify signs of middle–ear effusion, and evaluate for the presence of signs and symptoms of middle-ear inflammation (Recommendation).

2. The management of AOM should include an assessment of pain. If pain is present, the clinician should recommend treatment to reduce pain (Strong Recommendation).

3A. Observation without use of antibacterial agents in a child with uncomplicated AOM is an option for selected children based on diagnostic certainty, age, illness severity, and assurance of follow-up (Option).

3B. If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most children. (Recommendation). When amoxicillin is used, the dose should be 80–90 mg/kg/day (Option).

2004 AAP/AAFP Clinical Practice Guideline on AOM: Conclusions II

4. If the patient fails to respond to the initial management option within 48–72 hours, the clinician must reassess the patient to confirm AOM and exclude other causes of illness. If AOM is confirmed in the patient initially managed with observation, the clinician should begin antibacterial therapy. If the patient was initially managed with an antibacterial agent(s), the clinician should change the antibacterial agent(s) (Recommendation).

5. Clinicians should encourage the prevention of AOM through reduction of risk factors (Recommendation).

6. There is insufficient evidence to make a recommendation regarding the use of Complementary and Alternative Medicine (CAM) for AOM (No Recommendation).

The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

Criteria for initial antibacterial therapy vs. observation: 2004 AAP/AAFP AOM Guidelines

AgeAgeCertain DiagnosisCertain DiagnosisUncertain DiagnosisUncertain Diagnosis

<<66 momoAntibacterial therapyAntibacterial therapyAntibacterial therapyAntibacterial therapy

66 mo–2 ymo–2 yAntibacterial therapyAntibacterial therapyAntibacterial therapy if Antibacterial therapy if severe illness; observation severe illness; observation option* if non-severe illnessoption* if non-severe illness

=> =>22 yyAntibacterial therapy if Antibacterial therapy if severe illness; severe illness; observation option* if observation option* if non-severe illnessnon-severe illness

Observation optionObservation option**

*Observation is an appropriate option only when follow-up can be ensured and antibacterial agents started if symptoms persist or worsen.

Non-severe illness is mild otalgia and fever >39oC in the past 24 hours. A certain diagnosis of acute otitis media meets all 3 criteria: 1) rapid onset, 2) signs of middle-ear effusion, and 3) signs and symptoms of middle-ear inflammation.

Amoxicillin: first line therapy for AOM Recommended as the first line drug of choice by:Recommended as the first line drug of choice by:

CDC DRSP Working GroupCDC DRSP Working Group Pediatr Infect Dis JPediatr Infect Dis J 1999;18:1-9 1999;18:1-9

AAP/AAFP Subcommittee on AOM, March 2004AAP/AAFP Subcommittee on AOM, March 2004 Active against Active against S. pneumoniaeS. pneumoniae::

Recommended dose now is Recommended dose now is 90 mg/kg/day90 mg/kg/day divided BID: divided BID: achieves adequate MEF levels to kill pen-I and many pen-R achieves adequate MEF levels to kill pen-I and many pen-R pneumococcipneumococci

At this dose, superior to all other oral antibiotics against pen-At this dose, superior to all other oral antibiotics against pen-NS pneumococci in vitroNS pneumococci in vitro

NotNot effective against β-lactamase producing effective against β-lactamase producing H. H. influenzaeinfluenzae or or M. catarrhalisM. catarrhalis (but these are more (but these are more likely to resolve spontaneously)likely to resolve spontaneously)

Decades of experience: safe, effective, inexpensive, Decades of experience: safe, effective, inexpensive, narrow-spectrum; tastes goodnarrow-spectrum; tastes good

AOM is commonly over diagnosed. Thus, if clinicians are going to continue to overuse antibiotics—because of parental pressure or the lack of diagnostic accuracy—it is better to limit the mistake to less expensive drugs with a narrower spectrum.

Antibiotic therapy: at time of diagnosis2004 AAP/AAFP AOM Guidelines

Temperature <39Temperature <39ooC C and/or Severe Otalgiaand/or Severe Otalgia

At Diagnosis for Patients Being Treated At Diagnosis for Patients Being Treated Initially With Antibacterial AgentsInitially With Antibacterial Agents

RecommendedRecommendedAlternative for Alternative for Penicillin AllergyPenicillin Allergy

NoNoAmoxicillin 80–90 Amoxicillin 80–90 mg/kg/daymg/kg/day

Non-Type I: cefdinir, Non-Type I: cefdinir, cefuroxime, cefuroxime, cefpodoximecefpodoxime

Type I: azithromycin, Type I: azithromycin, clarithromycinclarithromycin

YesYesAmoxicillin-Amoxicillin-clavulanate (90 clavulanate (90 mg/kg/day of mg/kg/day of amoxicillin with amoxicillin with 6.4 mg/kg/day of 6.4 mg/kg/day of clavulanateclavulanate

Ceftriaxone—1 or 3 Ceftriaxone—1 or 3 daysdays

Antibiotic therapy: clinical failures, 48-72 hr2004 AAP/AAFP AOM Guidelines

Temperature <39Temperature <39ooC C and/or Severe Otalgiaand/or Severe Otalgia

Clinically Defined Treatment Failure at 48–Clinically Defined Treatment Failure at 48–72 Hours After Initial Management With 72 Hours After Initial Management With Antibacterial AgentsAntibacterial Agents

RecommendedRecommendedAlternative for Alternative for Penicillin AllergyPenicillin Allergy

NoNoAmoxicillin -Amoxicillin -clavulanate (90 clavulanate (90 mg/kg/day of mg/kg/day of amoxicillin, with amoxicillin, with 6.4 mg/kg/day of 6.4 mg/kg/day of clavulanate)clavulanate)

Non-Type I: Non-Type I: ceftriaxone—3 days ceftriaxone—3 days Type I: clindamycinType I: clindamycin

YesYesCeftriaxone— 3 Ceftriaxone— 3 daysdays

Tympanocentesis; Tympanocentesis; clindamycinclindamycin

Drugs chosen for second-line treatment should be effective against B lactamase- producing strains of H. influenzae and M. catarrhalisand against susceptible and most nonsusceptible strains of S. pneumoniae. Only 3 drugs have been shown clearly to meet that requirement: amoxicillin-clavulanate, cefuroxime axetil, and intramuscular ceftriaxone. Kersshner J E,Otitis Media In:Nelson Textbook of Pediatrics, 2641, 2007

Cefdinir was not available when the above recommendations were made. However, clinical Practice and efficacy with cefdinir suggest that it deserves consideration as a second line agent as well, with antibacterial spectrums similar to thoseof cefuroxime axetil, and good rates of compliance' as the medicationis quite palatable.

Kersshner J E,Otitis Media In:Nelson Textbook of Pediatrics, 2641, Kersshner J E,Otitis Media In:Nelson Textbook of Pediatrics, 2641, 20072007

Conjunctivitis–otitis syndrome: ß lactamase- producing H influenzae tends to be the predominant organism, causing both conjunctivitis and AOM.High-dose amoxicillin–clavulanate (90 mg/kg/day), cefdinir or cefpodoxime would be preferred choices.Block S L. Arch Dis Child 2006;91:959–961.

Ambulatory pneumonia (‘‘walking pneumonia’’ AND O M

As atypical pathogens (Chlamydia pneumoni , Mycoplasma pneumoniae) are such a common cause of milder pneumonias in children ≥ 2 years of age, macrolides such as azithromycin or clarithromycin are preferred.

Block S L. Arch Dis Child 2006;91:959–961.

ImpetigoImpetigo

Impetigo or skin infection and AOM:

Typically, impetigo and skin infections are caused by Staphylococcus aureus and only rarely by Streptococcus pyogenes. Staphylococcus aureus in the

produces b lactamase, rendering amoxicillin useless. Clinicians would be wiser to initiate treatment with a b

lactamase-stable antibiotic, such as amoxicillin-clavulanate, cefdinir or even cefuroxime,

which possess activity against both methicillin-susceptible Staphylococcus aureus and typical otopathogens.

Block S L. Arch Dis Child 2006;91:959–961.

Impetigo or skin infection and AOM:

Patients whose skin infection does

not respond in 24–28 h would then

additionally receive either clindamycin

or trimethoprim-sulfamethoxale

for presumptive methicillin-resistant

Staphylococcus aureus.Block S L. Arch Dis Child 2006;91:959–961.

AspirinNon-narcotic, anti-inflammatory; antiplatelet

Antipyretic, nonsteroidal agent.

Used in the treatment of pain, inflammation and fever by inhibition of prostaglandin synthesis.

Dose:-

10-15 mg/kg/dose q 4-6 hr

Aspirin

Cautions: contraindicated in children below 16yr with chickenpox or flu-like symptom due to risk of Reye syndrome. Distintinue if hearing loss or tinnitus occurs.

Adverse events: Bleeding from gums or GIT, gastric ulcers, bronchospasm in asthmatics, hearing loss or tinnitus.

Acetaminophen

Mechanism of actionInhibits the synthesis of prostaglandins in the central Inhibits the synthesis of prostaglandins in the central

nervous system and peripherally blocks pain impulse nervous system and peripherally blocks pain impulse generation.generation.

Acetaminophen produces antipyresis from inhibition of Acetaminophen produces antipyresis from inhibition of the hypothalamic heat regulating centre.the hypothalamic heat regulating centre.

Dosage:Dosage: 10-15 mg/kg every 4 to 6 hours P.O.10-15 mg/kg every 4 to 6 hours P.O.

Acetaminophen, 10-15mg/kg orally every4hr, is not associated with significant adverse effects; however, prolonged use may produce renal injury, and massive overdose may produce hepatic failure

Ibuprofen

Nonsteroidal anti-inflammatory agent that Nonsteroidal anti-inflammatory agent that inhibits prostaglandin synthesis and used to inhibits prostaglandin synthesis and used to treat pain fever and rheumatoid arthritistreat pain fever and rheumatoid arthritis..

DoseDose- :- :

Children: 5 -10 mg/kg/dose q6-8hrChildren: 5 -10 mg/kg/dose q6-8hr

Juvenile rheumatoid arthritisJuvenile rheumatoid arthritis : :

30-50mg/kg/24 hr in 4 divided doses30-50mg/kg/24 hr in 4 divided doses

Ibuprofen

Adverse eventsAdverse events::

Abdominal pain, heartburn, nausea, GIT Abdominal pain, heartburn, nausea, GIT bleeding and perforation, fluid retention, bleeding and perforation, fluid retention, edema, hypertension, tachycardia, acute renal edema, hypertension, tachycardia, acute renal failurefailure..

Nimesulid

Nimesulide has a disadvantage of long duration of action and Nimesulide has a disadvantage of long duration of action and hence ideally should be repeated 12 hourly. Its therapeutic hence ideally should be repeated 12 hourly. Its therapeutic dose is small (5 mg/kg/day) as compared to paracetamol (60 dose is small (5 mg/kg/day) as compared to paracetamol (60 mg/kg/day) and has small therapeutic window. These facts mg/kg/day) and has small therapeutic window. These facts result in easy overdosing by negligence or ignorance, leading result in easy overdosing by negligence or ignorance, leading to adverse effectsto adverse effects . .

nimesulide may cause lowering of body temperature to even nimesulide may cause lowering of body temperature to even subnormal levels that can be harmfulsubnormal levels that can be harmful . .

It has been found to have serious side effects, Maternal ingestion It has been found to have serious side effects, Maternal ingestion of nimesulide has been shown to result in end-stage renal of nimesulide has been shown to result in end-stage renal failure in a neonate(9failure in a neonate(9))

Diclofenac Sodium

Diclofenac, a nonselective nonsteroidal anti-inflammatory drug, exerts analgesic action both in the peripheral tissues and in the central nervous system by inhibiting cyclooxygenase enzymes COX-1/2 .

Diclofenac inhibits prostaglandin synthesis

What Can Be DoneWhat Can Be Done??

Options for reducing rates of severe otitis media: Additional hygiene

practices Immunisation Antibiotics