Upper Respiratory Tract Infections
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Upper respiratory tract infections (URTI) account for up to 80% of all respiratory tract infections in children. The rest are due to lower respiratory tract infections (LRTI) – mainly pneumonia.
An URTI can involve the ears, nose, throat and sinuses. They are rarely serious and will not often require hospitalisation. They can become an issue when:
  • A very young child has an RTI that causes a severely ‘blocked nose’ as this can affect feeding. This may result in hospitalisation.
  • There are associated febrile convulsions
  • The RTI causes an exacerbation of asthma
  • Tonsillitis can result in dehydration requiring IV rehydration if unable to tolerate oral fluids

It can sometimes be difficult to differentiate an URTI from an LRTI, especially in young children. It is best o be cautious if there is doubt over the diagnosis.

Bronchiolitis is also an important differential in any child under 12 months with respiratory symptoms. Other potentially more serious differential presentations include epiglottis and croup – these are covered under laryngeal and tracheal infections.

Summary Table

Common cold (coryza)
Viral. Most commonly rhinovirus, but may also be coronavirus and RSV.
  • Colourless nasal discharge
  • ‘blocked nose’
The most common childhood infection. Good parental education can help to reduce and anxiety and unnecessary GP appointments.
Self limiting infection. Antibiotics are of no use due to viral nature of the infection.
Symptomatic relief including paracetomol and ibuprofen may be used.
Sore Throat (pharyngitis)
Usually viral. In older children, β-haemolytic streptococcus may be present.
  • Soft palate and tonsils may be inflamed and tender
Cannot differentiate between viral and bacterial causes clinically.
Viral cases are most common in younger children, and bacterial causes become more common in older children
See tolsilitis below
2/3 of cases are viral (e.g. EBV) and 1/3 are bacterial (e.g. β-haemolytic streptococcus).
  • Same as above, +/-
  • May have tonsilar exudates
  • Headache
  • Abdominal pain
  • Fever
  • Cervical lymphadenopathy
  • Lethargy
This is a subtype of pharyngitis, where the tonsils are particularly badly affected.
Clinical signs are more common in bacterial cases.
Possible to partially differentiate between bacterial and viral causes uses the centor criteria
Depends on the centor criteria. Antibiotic recommended if a score of 4 (50% chance of bacterial infection in these cases).
Often antibiotics prescribed, despite only 1/3 of all infections being bacterial. 10 days treatment required to eradicate streptococcus and risk of rheumatic fever.
Amoxicillin should be avoided – can cause macuopapular rash if tonsillitis is due to infectious mononucleosis (EBV).
Many cases are viral, including RSV and rhinovirus. Bacterial causes are usually haemophilus influenzae and Moraxella catarrhais.
  • Fever
  • Ear pain
  • Child may tug at affected ear
  • Otoscopic findings: red, inflamed tympanic membrane. Loss of light reflex
All children with a fever should have tympanic membrane examined with otoscope.
Rarely, the tympanic membrane may perforate. In these cases, pus may be visible in the external canal on otoscopy.
Complications (e.g. mastoiditis and meningitis) are rare.
Very common – most children will suffer from otitis media at some stage due to the short length of the Eustachian tube in this stage of development. 20% of children will suffer recurrent episodes.
80% of cases resolve spontaneously.
Antibioitcs reduce the duration of pain, but do not reduce the risk of perforation. Typically antibiotic treatment is given if symptoms are not improving after several days. Amoxicillin is the recommended antibiotic of choice if indicated.
Otitis media with effusion (OME) – aka Glue ear
Caused by recurrent otitis media. Very common at <1 years age. Persists up to around 10 years of age.
  • Hearing loss on affected side
  • Other symptoms (e.g. pain) are rare
  • Tympanic membrane may be dull and retracted. Flud level may be visible

The condution hearing loss caused by OME can result in delayed development, particularly of speech and language. As a result, some children are considered for insertion of grommets. These are essentially tubes that ensure the Eustachian tube remains patents to allow fuller hearing.

Again, usually resolve spontaneously. Antibiotics have no long-term benefit, although they may improve the tympanic membrane appearance at first.
Grommets may be used in certain cases (see left)
In some cases, adenoidectomy may also be performed.*
Acute Sinusitis
Usually viral, occasionally bacterial
  • Pain
  • Swelling
  • Tenderness
  • (all over zygomatic/cheek region)

The sinuses do not formally develop until the end of the first decade of life, as a result, sinusitis is not usually present in those <10 years of age

Symptom relief with paracetomol and ibuprofen. Some cases may be treated with antibiotics.
*Adenoid gland – lymphoid tissue found at the back and base of the nasal cavity, just behind the uvula. Could be thought of as the ‘tonsils’ of the nose.
Surgical Treatments
Tonsillectomy and adenoidectomy. These treatments have declined in popularity, but are still some of the most common surgical treatments in childhood. These glands grow proportionately faster than the surrounding airway up to the age of 8, and thus may appear large on examination. However, this is not an indication for surgery! After the age of 10, the glands reduce in size to their adult proportions.
Indications for surgery are controversial, but may include:
Removal of tonsils only:
  • Recurrent tonsillitis – removal of the tonsils reduces the incidence of recurrent tonsillitis by around 30%
  • Peritonsilar abscess (rare)
  • Obstructive sleep apnoea – if the glands are so large that they affect normal breathing. Sometimes they may also be removed in cases of excessive snoring (aka sleep disordered breathing – see below)
Removal of tonsils and adenoids
  • OME – certain cases may benefit from gland removal to allow better placing of grommets
  • Obstructive sleep apnoea
Sleep disordered breathing
About 10% of children will snore, but only 1% will be considered serious enough to have sleep disordered breathing. There are two main types of sleep disordered breathing, both of which are usually due to obstructive deficits:
  • Adeno-tonsilar hypertrophy – Often there is a history of loud snoring, and periods of apnoea (Obstructive sleep apnoea). Quality of sleep is often affected. Some affected children are obese, other may have growth disorders (and in such cases, there may be daytime hyperactivity)although often there is no other underlying abnormality or disease. These cases can be treated by tonsillectomy +- adenoidectomy. The success rate is good.
  • Craniofacial / neuromuscular /other congenital disorder (e.g. Down’s syndrome) – these patients are not suitable for surgery, but may be treated with ventilation.

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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) FRACGP currently works as a GP and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University, and is studying for a Masters of Sports Medicine at the University of Queensland. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

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