Children with Upper respiratory Infections, how to manage cough, with specific reference to India. Treatment options, studies and presentation

1. Managing Cough in Pediatric URI
Dr Gaurav Gupta,
Charak Clinics, Mohali
Author: Clippings, Indian Pediatrics

2. Scope of talk
• Acute Cough
• Management issues
• URI (to avoid discussing allergies, asthma,
pneumonia, TB etc.)

3. Case
• 4-year-old Japinjot, has cough for about 4 days;
• She might have been feverish at the beginning of
the illness, but she is not feverish now.
• She has a runny nose, & mother says she was
pulling at her ears yesterday.
• Her cough sounded dry and barky;
• she was not short of breath and her colour was
always normal.
• Japinjot has been at home for 3 days, missing
playschool.

4. Case
• Past history shows that at the age of 3 months,
she was hospitalized for bronchiolitis.
• She has twice been treated for otitis media & for
infantile eczema.
• While on holiday 2 years ago, a GP in another
town gave Japinjot antibiotics for pneumonia.
• Vaccination complete including Pneumonia, Hib
& Influenza vaccines
• No other hospital admissions or surgical
procedures.

5. Case
• As Japinjot is an otherwise healthy child and is
not taking any regular respiratory medicines, it is
probable that her cough is due to an acute viral
infection, probably picked up in the playschool;
• the mother’s description of a “barky” cough
makes you wonder whether she might have
croup.
• Before you examine her, you consider what else it
could be?

6. Case

7. We should not miss diagnosis like
• asthma, bronchiolitis, whooping cough,
pneumonia, and foreign body aspiration.
A brief focused history will usually give information
about such conditions.
• What time of year is it?
Peak incidence of infective cough is January to
March; epidemics of croup tend to occur in autumn
and bronchiolitis in winter.

8. Alarm signs
• The child will look ill (with pneumonia or
influenza)
• or be short of breath with tachypnea (with
asthma or foreign body aspiration).
• The child will be working hard to breathe,
perhaps with chest retractions.
• High fever (with pneumonia, but some
children can run sudden high fevers with
otherwise innocuous viral infections).

9. Case
• Japinjot looks quite well to you.
• She is not running a fever and she is not short of
breath.
• Her respiratory rate is 20 breaths/min; her pulse is 96
beats/min; and her temperature is 37.4°C.
• She has a runny nose, but her ears and throat are
unremarkable.
• Her chest is clear. During the 10 minutes she is in your
office, she coughs only once; the cough is dry and
barky, but not spasmodic; the child barely seems to
notice it, although her mother jumps!
• No alarm symptoms or signs are present.

10. Case – Presumptive Diagnosis
• Japinjot is too old to have bronchiolitis.
• You make a presumptive diagnosis of mild
croup, following a viral upper respiratory tract
infection, which is now recovering.

11. Is it likely to get worse?
• Up to 12% of children with cough experience
complications,
• Usually mild and easily treated, some children
do become very sick.
• Otitis media is the most common
complication, followed by rash, diarrhea, and
vomiting;
• only 5% of cases progress to bronchitis or
pneumonia.

12. Is it likely to get worse?
• While children with neither fever nor chest
signs had a probability of complications of
only 6%,
• for children with chest signs it was 18%,
• with fever it was 28%,
• and when both fever and chest signs were
present the probability was 40%

13. Case
• You tell the mother that Japinjot will almost
certainly continue to get better.
• Knowing her anxieties, you agree to check
Japinjot again in 3 days to judge whether she
is fit enough to resume playschool.

14. How long will the cough last?
• Between 35% and 40% of school age children
continue to cough 10 days after the onset of a
common cold,
• and 10% of preschool children continue to
cough 25 days after a respiratory tract
infection

15. how patterns of cough intensity
vary over time
Thorax 2008;63(Suppl III):iii1–iii15.
1 2 3
4Duration (Weeks)
IntensityofCough
Acute Cough
Recurrent Acute Cough

16. Parental Concerns
• Parents worried children were going to die
because of choking on phlegm or vomit;
• Also worried about asthma and crib death.
• Some mothers also worried that their children
would develop long-term chest damage.
• Mothers themselves had been affected by sleep
deprivation
• First-time mothers and mothers with lower levels
of education are more likely to consult their
physicians.

17. Case
• You ask the mother about her concern
regarding Japinjot’s cough.
• She says she was worried that Japinjot might
be developing pneumonia again; she is very
relieved to hear that there is no sign of this.

18. Deciding on the best treatment
• Evidence-based guidelines have shown that
there are no effective medications to either
cure or relieve the symptoms of acute cough
in children.
• Once you have confidently excluded the rarer
and more serious conditions for which therapy
is effective, explanation is required for the
parent.

19. Deciding on best treatment
• Antibiotics have no effect on viral infections
• Most parents will not be too concerned about
increasing antibiotic resistance;
• However, they should be told that antibiotics
are at least as likely to cause side effects as
they are to produce improvement.
• Serious adverse events and accidental
poisonings have been recorded with CCM

20. SIDE EFFECTS of CCM
" 123 cough syrups in Davangere; from 9
pharmacies; 23 contained between 2.8 % to 20
% alcohol “
Ref: WHO 2001 FCH CAH 01.02: Cough & cold remedies for treatment of ARI
in young children

21. • While 56% of those parents whose children
received dextromethorphan plus albuterol
• and 66% of those whose children received
dextromethorphan alone reported some to
marked relief of symptoms,
• 73% of those in placebo group reported a
similar level of improvement,

23. General concepts
In the majority of children presenting with
cough, the etiology is related to URTI and
requires only supportive measures (e.g.,
antipyretics, good hydration, and saline washes).

24. Management Approach
• Pharmaceutical Management
– Cough formulations
– Antibiotics
– Antihistaminic drugs
– Steroids
• Non Pharmaceutical Management
– Avoidance
– Nutraceuticals
– Traditional therapies

25. When does a child need antibiotics?
1. A cough does not get better in 14 days.
2. A bacterial form of pneumonia or whooping cough
(pertussis) is diagnosed.
3. Symptoms of a sinus infection do not get better in ten days,
or they get better and then worse again.
4. Child has a yellow-green nasal discharge and a fever of at
least 102° F for several days in a row.
5. Child has strep throat, based on a rapid strep test or a throat
culture. Strep cannot be diagnosed just by looking at the
throat.
Antibiotics for a sore throat, cough, or runny nose. 2013 [cited 2015 Nov 20];
Available from: http://consumerhealthchoices.org/wp-
content/uploads/2013/02/ChoosingWiselyAntibioticsAAP-ER.pdf.

26. Reducing Antibiotic use
• Overall, adult patients and parents/carers of children
with acute cough are satisfied with all three
strategies (immediate, delayed and no prescribing)
(86%, 77% and 72% satisfied, respectively).
• 40 % less antibiotic use reported when delayed
prescriptions of Antibiotics used.
NICE. Respiratory tract infections – antibiotic prescribing Prescribing of
antibiotics for self-limiting respiratory tract infections in adults and
children in primary care. National Institute of Health and Clinical
Excellence. 2008; 2008. p. 1-122.

27. Natural remedies
• Honey
• Herbal teas
• Tulsi

28. Other measures to help cough
• Saline Spray
• Improve fluid intake
• Rest
• Steam inhalation
• Aromatic vapor therapy
• Gargles
• Prop up head
• Hard candy
• Petroleum jelly under
the nose
• Warm fluids incl chicken
soup
• Avoid second hand
smoke

29. Prevent recurrent cough (URI)
• Vit C,
• Zinc,
• Regular Hand washing,
• Immune boosters
(Bovine colostrum,
Echinacea, Turmeric,
Honey, Amla,),
• Alternative meds
• Vaccinations
• Proper sleeping,
• Exercise,
• Healthy balanced diet,
• Avoid touching mouth
eyes nose

30. AAP Recommendations for cough
1. For children ages 1 to 5 years, try half a teaspoon of
honey. Do not give honey to babies under one
year—it is not safe.
2. Try one teaspoon of honey for children 6 to 11, and
two teaspoons for children 12 or older.
3. Consider cough drops for children 4 and older.
Over-the-counter cough and cold medicines: Do not
give these to children under age 4.
Many cold medicines already have acetaminophen in
them, so beware of double dosing.
Antibiotics for a sore throat, cough, or runny nose. 2013 [cited 2015 Nov 20];
Available from: http://consumerhealthchoices.org/wp-
content/uploads/2013/02/ChoosingWiselyAntibioticsAAP-ER.pdf.

31. Common issues in management
1. What to use in children below 2 years
2. Overuse of Abs
3. Cough at night
4. Duration of cough in different illnesses -
counsel parents
5. Wrong measurements - multidrug
ingredients, double dose of PCM

32. Quiz
Q: Of the 200+ viruses linked to the common
cold, what is the most prevalent type?
• Rhinovirus
• Parvovirus
• HerpesVirus
• CMV

33. Quiz
Q: Of the 200+ viruses linked to the common
cold, what is the most prevalent type?
• Rhinovirus
• Parvovirus
• HerpesVirus
• CMV

34. Q: How long can common cold virus survive on
skin?

35. Q: How long can common cold virus survive on
skin?
• Up to 2 hours

36. • Q: Yellow or Green mucus is an indication for
starting Antibiotics in a case of URI
• True / False

37. • Q: Yellow or Green mucus is an indication for
starting Antibiotics in a case of URI
• True / False

38. Thank You