Upper Respiratory Tract Infections - Sheffield Children's Hospital
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Upper Respiratory Tract Infections Reference: 1836v2 Written by: Judith Gilchrist Peer reviewer: Sally Gibbs Approved: April 2018 Review Due: May 2021 Purpose To guide the management of upper respiratory tract infections in children. Intended Audience Clinicians involved in the management of upper respiratory tract infections Author: Judith Gilchrist Review date: May 2021 © SC(NHS)FT 2018. Not for use outside the Trust. Page 1 of 5
CAEC Registration Identifier: 1836 Sheffield Children’s (NHS) Foundation Trust
Upper Respiratory Tract Infections
Table of Contents
1. Introduction
2. Intended Audience
3. Guideline Content
a. Sore Throat
b. Otitis Media
c. Stomatitis
4. References
1. Introduction
Upper respiratory tract infections are usually mild, self limiting infections. The following
guideline is aimed at ensuring appropriate use of antibiotics in these conditions and
recognizing complications
2. Intended Audience
Clinicians involved in the management of upper respiratory tract infections
3. Guideline Content
A. SORE THROAT
1. Assessment
2. Investigation
3. Management
1. Assessment
Acute sore throat (including pharyngitis and tonsillitis) is self-limiting and often triggered by
a viral infection of the upper respiratory tract. Symptoms can last for around 1 week, but
most people will get better within this time without antibiotics, regardless of cause (bacteria
or virus).
Use the FeverPAIN clinical score to aid your treatment decision. Score 1 point each for
presence of:-
- Fever - history of fever in last 24 hours
- Purulent tonsillar exudate
- Acute onset of illness – 0-3 days
- Inflamed tonsils – must be severe inflammation to score
- No cough
•Score 0-1 - use NO antibiotic strategy
•Score 2-3 and symptoms are present for 3 days or less
use NO antibiotic strategy.
advise will need review by GP if no improvement after 3 days, or symptoms worsen.
Author: Judith Gilchrist Review date: May 2021
© SC(NHS)FT 2018. Not for use outside the Trust. Page 2 of 5CAEC Registration Identifier: 1836 Sheffield Children’s (NHS) Foundation Trust
Upper Respiratory Tract Infections
Score 2-3 and symptoms are present and not improving after 3 days
prescribe antibiotics.
Score ≥4 - prescribe antibiotics
2. Investigation
DO NOT TAKE ROUTINE THROAT SWABS IF CHILD WELL ENOUGH TO BE
DISCHARGED – it is unpleasant, costs money, generates work and rarely changes
management. If a child is unwell enough for admission a swab may be useful.
3. Management
NO antibiotic strategy – oral analgesia with Paracetamol and Ibuprofen, and possibly
Difflam spray. Advise:
• antibiotic is not needed
tonsillitis usually lasts around 1 week
seek medical help if symptoms worsen rapidly or significantly, do not start to
improve after 1 week (after 3 days if FeverPAIN score 2-3) or the person becomes
very unwell
Antibiotic treatment - Penicillin V for 10 days or Clarithromycin if penicillin allergic.
If recurrent tonsillitis or the tonsils are large with snoring and sleep disruption /
apnoea advise to see GP for evaluation and possible referral to ENT. Do not refer
direct or tell the parents their child needs a tonsillectomy.
Children occasionally need admission for rehydration and IV antibiotics if they are
becoming dehydrated secondary to poor oral intake. This can usually be avoided
by optimising analgesia and a short period of observation for reassurance.
Other reasons for admission
respiratory distress, drooling, systemically very unwell, stridor / signs of upper
airway obstruction. In these cases consider differential diagnoses
rare suppurative complications (peritonsillar abscess, retropharyngeal
abscess, parapharyngeal abscess)
epiglottitis / bacterial tracheitis
very rare – Diphtheria, Yersinia pharyngitis
Call for help early from ENT / Anaesthetics.
B. ACUTE OTITIS MEDIA
You will often see just a red eardrum, but more typical of focal otitis media is a
deformed / irregular or bulging eardrum with pus (opaque fluid) visible behind the
drum.
This is often very painful. The pain often abates if the eardrum perforates.
Author: Judith Gilchrist Review date: May 2021
© SC(NHS)FT 2018. Not for use outside the Trust. Page 3 of 5CAEC Registration Identifier: 1836 Sheffield Children’s (NHS) Foundation Trust
Upper Respiratory Tract Infections
Most cases will resolve spontaneously and require simple analgesia alone.
Generally otitis media will last around 4 days
Adequate analgesia with paracetamol / ibuprofen is the most important aspect of
management.
NB. Exceptions are children with a cochlear implant. These patients are at
increased risk of an otitis media leading to bacterial (particularly
pneumococcal) meningitis and will require treatment with oral antibiotics
amoxicillin, or clarithromycin in penicillin allergic, for 5 days.
NICE also suggest that children with immunosuppression, cystic fibrosis, young
children who were born prematurely and those with significant heart, lung, renal or
liver disease are also at higher risk of complications and should also have oral
antibiotics
Other groups that may benefit from treatment with antibiotic (oral amoxicillin)
include; under 6 months of age, worsening symptoms after 3 days, continuously
discharging ear >7 days.
Always look for clinical evidence of mastoiditis (tender or red over mastoid, or ear
protruding) and if present the child should be seen by the on-call ENT surgeon.
Otitis media is not always associated with mastoiditis, but mastoiditis is ALWAYS
associated with middle ear infection.
C. STOMATITIS
1. Assessment
2. Management
1. Assessment
In the child with an inflamed mouth and gums consider:
Primary Herpes Simplex (HSV) infection
Hand Foot and Mouth disease ( usually isolated skin /oral lesions in well child)
Bacterial infection from the mouth flora (including anaerobic bacteria)
o may accompany poor dental hygiene
o dental infections should be excluded.
If there are other features, outside the mouth, consider systemic conditions such as
Kawasaki disease, Crohn's disease, Stevens-Johnson syndrome and Behçet's
disease.
2. Management
Primary HSV infection:
o Little data exists on the use of Aciclovir in children with HSV apart from
immunocompromised and neonatal patients
o IV Aciclovir can be used in severe cases of primary HSV stomatitis where
oral hydration cannot be maintained. Only likely to be of benefit if used early.
Bacterial infection:
o If an antibiotic is indicated, penicillin V is an appropriate choice as most oral
Author: Judith Gilchrist Review date: May 2021
© SC(NHS)FT 2018. Not for use outside the Trust. Page 4 of 5CAEC Registration Identifier: 1836 Sheffield Children’s (NHS) Foundation Trust
Upper Respiratory Tract Infections
commensals (including anaerobes) are sensitive.
o Use paracetamol for pain relief.
o Oral antiseptic agents and anaesthetic agents should be used with caution
(as the former may exacerbate symptoms and the latter result in injury of the
anaesthetised area). However, given careful clinical monitoring, a
combination of Corsodyl (Chlorhexidine) mouthwash and Difflam
(Benzydamine) spray can produce substantial symptomatic relief.
4. References
References
Clinical score and rapid antigen detection test to guide antibiotic use for sore
throats: randomised controlled trial of PRISM (primary care streptococcal
management) : BMJ 2013;347:f5806
Public Health England : Management of common infections (Oct 2017)
https://ctu1.phc.ox.ac.uk/feverpain/index.php Oct 2017
https://www.nice.org.uk/guidance/ng84 Jan 2018
https://www.nice.org.uk/guidance/ng84/resources/visual-summary-pdf-4723226606
Jan 2018
Antibiotics for acute otitis media in children – Cochrane review 2013
NICE Clinical Knowledge Summary – Otitis Media – Acute July 2015
Author: Judith Gilchrist Review date: May 2021
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