Managing acute respiratory tract
infections in children
Catherine Schuster Bruce, Clare Hoare, Atanu Mukherjee and Siba Prosad Paul
ABSTRACT
Respiratory tract infections (RTIs), including community-acquired pneumonia
(CAP), bronchiolitis, viral-induced wheeze and croup, account for more primary
care consultations than any other illness group and are the most likely
reason for a parent or carer to contact a health professional. The majority of
RTIs in fully immunised children are usually self-limiting. However, in a small
percentage of children RTIs may become life threatening and it is crucial that
all front-line health professionals are able to recognise and identify these
children who are at risk of deterioration. To ensure this, fast recognition of
symptoms is important, with care taken to exclude any red flag features that
may prompt a referral to secondary care. Nurses are well placed to reassure
and support families, and to provide education regarding the facts about
fever, the appropriate use of a single antipyretic medication, how to avoid
dehydration in children with RTIs, and the beneficial role of immunisation in
preventing infection. It is also important to explain in cases of CAP where
antibiotics are necessary about how soon to expect a response, any side
effects from antibiotics, and to provide safety net advice on when to consider
reassessment for the child. An illustrative case study is included to highlight
some of the challenges that are likely to be encountered in clinical practice.
Key words: Airways Pneumonia Deterioration Paediatric nursing
Immunisation
R
espiratory tract infections (RTIs) are defined as any
infection of the sinuses, airway, throat or lungs (NHS
Choices, 2015). RTIs account for more paediatric
primary care consultations than any other illness
group (Thompson et al, 2013).This is especially true
in winter when children are more likely to stay indoors and close
contact increases pathogen transmission (NHS Choices, 2015).
A cohort study from Germany with 1314 children followed up
for 12 years reported that children typically experienced 4-11
Catherine Schuster Bruce, Foundation Trainee Year 1, Royal
London Hospital
Clare Hoare, Paediatric Respiratory and Allergy Nurse, Torbay
Hospital, Torquay
Atanu Mukherjee, Consultant Paediatrician, Torbay Hospital,
Torquay
Siba Prosad Paul, Consultant Paediatrician, Torbay Hospital,
Torquay
Accepted for publication: May 2017
602
MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 147.188.128.074 on June 13, 2017.
episodes of respiratory illness per year (Grber et al, 2008).The
annual incidence of lower respiratory tract infection (LRTI) in
the UK is 30 per 1000 children (Tidy, 2016).
Most RTIs are self-limiting and the risk of complications
is low. However, in a small percentage of children an RTI can
become life threatening. In a UK paediatric study between 2001
and 2010 involving children aged 28days to 18years, using
death certificates linked to a longitudinal hospital admission
database, 22.5% of 22509 deaths (n=5039) were related to an
RTI (Hardelid et al, 2014).Worldwide, RTIs remain the leading
cause of childhood mortality (Harris et al, 2011; Barson, 2016).
All frontline nurses working with children should be able to
manage RTIs and identify early the small percentage of children
who are at risk of deterioration. This article will describe
and explain how to assess and manage RTIs in children. An
illustrative case study is included along with some useful tools
for nurses to consider using in clinical practice.
Pathophysiology and epidemiology of RTIs
RTIs are typically classified according to the location of
pathology in the respiratory tract i.e. upper and lower. The
upper respiratory tract consists of the airways from the nostrils
and mouth to the epiglottis, including the paranasal sinuses and
middle ear. The lower respiratory tract comprises everything
below the epiglottis and into the lungs, including the bronchi,
bronchioles, and alveoli.A mixed picture is often seen in children
and it may be difficult to label an RTI presentation as being
only upper or lower RTI clinically.
Children are at higher risk of RTI than adults. Shorter
respiratory tracts and a lesser functional reserve in the lower
airway can also lead to quick dissemination of infection, fast
compromise and rapid deterioration of symptoms. Respiratory
arrest requiring resuscitation, although rare, is seen in clinical
practice (Paul et al, 2014). Epidemiology of various RTIs is
described in Table 1.
Physiological variations and risk factors
Vital parameters in children such as the heart and respiratory
rate vary with age.To competently assess a child, familiarity with
the normal reference ranges is important and is highlighted in
2017 MA Healthcare Ltd
Table2 (Samuels and Wieteska, 2016).
Children are a diverse population and some are more
susceptible to RTIs than others. When taking a history and
assessing a child, it is useful to take into account various risk
factors (Table 3). Children with known risk factors are likely to
British Journal of Nursing, 2017, Vol 26, No 11
Use for licensed purposes only. No other uses without permission. All rights reserved.
 PAEDIATRICS

Table 1. Epidemiology of respiratory tract infections in children

Community- Affects all ages. More common in children under five years of age. A study from the UK with 750 children estimated
acquired an overall incidence of CAP to be 13.3/10000 a year for children 015years old and 33.8/10000 a year for
pneumonia children aged under 5years (Clark et al, 2007). The aetiology of CAP varies according to age, with viral causes
(CAP) accounting for the majority of CAP cases in the younger age group

Bronchiolitis Affects infants <1 year old. In the UK, approximately 1 in 3 infants develop clinical bronchiolitis in their first year of
life and 23% of these require hospitalisation (National Institute for Health and Care Excellence (NICE), 2015). This
amounts to approximately 20000 hospital admissions annually (Paul et al, 2011), the majority of which are infants
aged 26months (NICE, 2015)

Viral-induced VIW typically occurs in 2538% of children aged 15 years (Paul et al, 2011). VIW is not asthma but is often misdiagnosed
wheeze (VIW) as asthma. A 2016 retrospective study by researchers at the University Medical Centre in Utrecht, Netherlands, looking at
the medical records of 656 children diagnosed with asthma at 4 centres, found 53% of children had no clinical signs of
asthma (Looijmans-van den Akker et al, 2016)
There are two subtypes of VIW: episodic viral wheeze (EVW) and multiple trigger wheeze (MTW). For EVW, a viral
infection is the trigger and there are no interval symptoms. MTW has multiple triggers including viral infection,
exercise, allergens, passive smoking and cold air. Children with MTW experience symptoms between episodes of
exacerbation. Typically, children with EVW outgrow their wheezy symptoms by the end of preschool years. However,
remission in MTW is often not achieved and these children may develop asthma in later life (Paul et al, 2014)

Croup Croup commonly affects children aged between 6 months and 3 years, with a peak incidence in the second year of
life, although it can still occur after this age (NICE, 2012). There are 5 cases per 100 children per year during the
second year of life (South and Isaacs, 2012)
The epiglottis is a flap of tissue that sits at the base of the tongue and prevents aspiration of food into the trachea during
swallowing. Epiglottitis, inflammation and infection of the epiglottis, is a medical emergency as it can obstruct the trachea
and can be fatal and management remains time critical. It is an important differential diagnosis to consider in a child who
appears very unwell at presentation, especially if the child has not been fully immunised (Paul et al, 2014)

Table 2. Normal ranges in children for respiratory rate (RR), heart rate (HR) and blood pressure (BP)

Guide weight (kg) RR at rest HR BP systolic

Breaths per minute Beats per minute
Age Boys Girls 5th95th centile 5th95th centile 5th centile 50th centile 95th centile

Birth 3.5 3.5 2550 120170 6575 8090 105

1 month 4.5 4.5

3 months 6.5 6 2545 115160

6 months 8 7 2040 110160

12 months 9.5 9 7075 8595

18 months 11 10 2035 100155

2 years 12 12 2030 100150 7080 85100 110

3 years 14 14 9040

4 years 16 16 80135

5 years 18 18 8090 90110 111120

6 years 21 20 80130

7 years 23 22

8 years 25 25 1525 70120

9 years 28 28

10 years 31 32

11 years 35 35
2017 MA Healthcare Ltd

12 years 43 43 1224 65115 90105 100120 125140

14 years 50 50 60110

Adult 70 70

Source: Samuels and Wieteska, 2016 (reproduced with permission of The Licensor through PLSclear)

British Journal of Nursing, 2017, Vol 26, No 11 603

MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 147.188.128.074 on June 13, 2017.
Use for licensed purposes only. No other uses without permission. All rights reserved.
 Table 3. Respiratory tract infections: risk factors
Childcare attendance or siblingsincreased exposure to pathogens
Environmental risk factors including passive smoking and pollutants
Absence of breast-feeding
Young agechildren aged <12 weeks at presentation
Underlying health condition including immune deficienciescongenital or acquired
Supplemental home oxygenmay alter the inflammatory response to respiratory
pathogens. The need for increase in supplemental oxygen may reflect deterioration
in respiratory status
Premature birth, particularly under 32 weeks (transplacental transfer of maternal
antibodies is lacking)
Source: adapted from Harris et al, 2011; Paul et al, 2011; Paul et al, 2014
Table 4. Red flags elicited during assessment
Oxygen saturations <92%
Significantly increased tachycardia for level of fever
Rapid respiratory rate (Table 2)
Increased work of breathing (chest wall recession or subcostal recession)
Intermittent apnoea (cessation of external breathing manifested by pauses in chest
wall movement) or grunting (protective mechanism, heard in expiration, to keep air in
the lungs so that they will stay open)
Children with pre-existing risk factors (Table 3)
Reduced feeding <50% of their daily requirement or deemed clinically dehydrated
(fast heart rate, minimal or no urine output/no wet nappy for 12 hours, vomiting)
Family unable to safely observe or supervise child during illness
Source: adapted from Harris et al, 2011; NICE, 2013; Paul et al, 2014; NICE, 2015
deteriorate faster. It is therefore important to carefully consider
discharge, even if the initial presentation is considered mild or
moderate (Paul et al, 2014).
Management of RTIs in children
Diagnosis remains largely clinical, being supported by an
accurate but focused history and examination. Unwell children
are not always compliant and assessment will comprise astute
observation and opportunistic examination. Table 4 highlights
some red flag features, which when identified in the history
should trigger consideration for referral or admission to hospital.
Management of different conditions is described in Table 5.
Nurses play a vital role in managing children with RTIs and
their role in different clinical set-ups is discussed in Table 6.
Additional considerations in managing children with RTIs
A child with community-acquired pneumonia (CAP) who
has pleuritic pain, is aged less than 6months or who has not
improved after 48 hours of oral outpatient antibiotics is at
increased risk of deterioration and may require referral to
secondary care (Harris et al, 2011).
If the child is more than 3 years old with a temperature above
38.5C, increased work of breathing and a raised respiratory
rate, the pneumonia is most likely to be bacterial (Harris et al,
2011).Viral causes are more likely when the child is less than
3years old and presents with wheeze, low-grade pyrexia (below
38.5C), hyperinflation and marked recession of the chest wall.
Signs of exhaustion (not responding to normal social cues
or waking only with prolonged stimulation) are an additional
consideration for those presenting with bronchiolitis (National
Institute for Health and Care Excellence (NICE), 2015).
604
MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 147.188.128.074 on June 13, 2017.
A child with suspected croup who appears to have worsening
of stridor is likely to be at risk of impending airway obstruction.
It is vital to seek urgent medical, ear, nose and throat (ENT) and
anaesthetic specialists attention and avoid interventions such as
insertion of intravenous cannulas or examination with tongue
depressorspainful procedures can upset the child, which in
turn can worsen oedema of the respiratory tract and lead to
sudden obstruction with potentially fatal outcomes (NICE,
2012; Paul et al, 2014)
Possible complications while in hospital or
after discharge
The following should raise suspicion of complications and the
child should be referred back urgently to hospital. In CAP, absent
breath sounds on auscultation coupled with a dull percussion
note, high C-reactive protein (CRP) at diagnosis, recurrent
fevers, prolonged respiratory distress after 48 hours of treatment
with antibiotics (Paul and Linney, 2011). Follow up chest X-ray
is not indicated in all cases but may be requested:
For those with a round pneumonia, collapse or persisting
symptoms
For children who had developed complications e.g. pleural
effusion (Harris et al, 2011)
In bronchiolitis, worrying features are: recurrent apnoea,
failure to maintain oxygen saturation despite oxygen
supplementation, signs of exhaustion (listlessness or decreased
respiratory effort) (NICE, 2015). Post bronchiolitic cough and
wheeze is common and usually improves over weeks (Paul et
al, 2014).
In cases of croup, there is a risk of recurrence of stridor
after discharge, especially within the next couple of days, and
if this reoccurs the child should be brought back to hospital
for reassessment (NICE, 2012; Paul et al, 2014).
In cases of VIW, it is worth noting that there is a future risk
of asthma in children with the multi-trigger subtype (Paul et
al, 2014).
Discharge planning
As most children with RTIs will be managed in the community,
nurses need to provide guidance on the use of single antipyretics
for management of fever at home as recommended by the
NICE (2013) guidelines. Nurses need to be emphasising that
antipyretic agents do not prevent febrile convulsions and it
should not be used specifically for this purpose (NICE, 2013).
Choice of a single appropriate antipyretic agent (paracetamol or
ibuprofen) remains empirical and is best guided by the childs
response to the antipyretic chosen (NICE, 2013). However, if
the child is not drinking well and there is concern regarding
adequacy of hydration, paracetamol may be a safer option (Paul
et al, 2014).
Advice on offering the child regular fluids (continuation
of breastfeeding where the infant/child is still on breast milk)
2017 MA Healthcare Ltd
needs to be discussed. Parents should be advised to encourage
their child to drink more fluids and to seek further advice if
they feel their child is getting dehydrated (cool extremities,
drinking less than usual, sunken fontanelle, dry mouth and
tongue, no wet nappies) (NICE, 2013; NICE, 2015).
British Journal of Nursing, 2017, Vol 26, No 11
Use for licensed purposes only. No other uses without permission. All rights reserved.
 PAEDIATRICS

Table 5. Management of respiratory tract infections in children

Community-acquired pneumonia Bronchiolitis Viral-induced wheeze (VIW) Laryngotracheobronchitis
(CAP) (croup)

Definition An infective condition of the lungs Inflammation of the small airways, An intermittent airway Diffuse inflammation with
acquired outside hospital or bronchioles obstruction manifested exudate and oedema of the
by bouts of coughing and subglottic area (NICE, 2012)
wheezing.

Cause Bacterial: Viral: Viral: Most likely viral

Typical bacterial causes include
Streptococcus pneumoniae and
Mycoplasma pneumoniae
Viral:
Most commonly encountered
RSV is the most commonly
detected viral pathogen in
hospitalised infants (Rogers et
al, 2017)
Other pathogens include:
RSV is the most common.
Other causes include
rhinovirus
Parainfluenzae 1, 2,
3; paramyxovirus and
influenzaA are the most
common causes
Haemophilus influenzae

viruses are respiratory syncytial
virus (RSV) and rhinovirus (Paul
et al, 2014).Combinations of viral
and bacterial pathogens also exist
(Harris et al, 2011).
rhinovirus, adenovirus, human typeb (Hib) can cause
metapneumovirus, bocavirus and epiglottitis
influenza (Rogers et al, 2017)

Clinical High fever (>39C) Coryzal prodrome lasting
features Nasal flaring 13days
Cyanosis, blue lips/tongue. Persistent cough
Breathlessness Breathlessness
Respiratory distress (chest Apnoea (especially in premature
recessions and use of accessory babies)infants <6 weeks may
muscles) (NICE, 2013) present with no clinical signs aside
from apnoea
Inability to feed and dehydration
Symptoms typically peak between
3 and 5 days, and the cough
lasts around 3weeks (NICE,
2015)
Persistent coughcan be
so severe that it induces
vomiting of phlegm or
mucus (Paul et al, 2011)
Recurrent episodic wheeze
Personal or family history
of atopy
14 day prodromal symptoms
of non-specific cough,
rhinorrhoea and fever
Sudden onset seal-like
barking cough
Stridor (predominantly
inspiratory)
Symptoms worse at middle
of night
Hoarse voice
Respiratory distress due
to partial upper airway
obstruction

History Work of breathing: severity of breathlessness? Is it on exertion or at rest?

(this will be Cough: is it dry or productive? If productive, determine volume/colour/consistency of sputum
similar for all Wheeze or stridor: are there any triggers? Is there a pattern to symptoms e.g. time of day?
causes) Haemoptysis: what is the volume?
Chest pain: where is it? How quickly does it come on? What does it feel like? Does it radiate anywhere? Are there associated symptoms?
How long does it last? Are there exacerbating/relieving factors?
Systemic symptoms: do they have a fever, night sweats, sleep apnoea, cyanosis, fatigue or weight loss? Are they eating and drinking?
Previous antibiotic use and vaccination history: when? Did they complete the course/vaccination schedule?

If any of these symptoms are present, gather further details such as: onset, duration, symptom course, severity, precipitating factors, relieving
factors, associated features, and previous episodes

Examination Record observations (respiratory rate, heart rate, temperature, oxygen saturations) and compare with normal ranges for the childs age
(this will be (Table2). Measure central capillary refill time (on forehead or over sternum) to assess perfusion (normal is <2 seconds)
similar for all For nurses with an advanced role e.g. emergency nurse practitioners (ENP), practice nurses, a clinical examination should include:
causes) Stridor (in croup)
Chest wall recession, use of accessory muscle
Chest wall expansion
Differential air entry, wheeze, crackles on auscultation, location of apex beat

Investigations Usually a clinical diagnosis
Chest X-rays can substantiate or
confirm clinical suspicion of CAP
in few selected cases (Paul et
al, 2011)
Ultrasound scan if suspicion of
2017 MA Healthcare Ltd
Usually no investigations
Consider nasopharyngeal aspirate
if needing advanced respiratory
support
Chest X-ray if clinical
deteriorationfor secondary
Usually no investigations
If suspicion of CAP, other
respiratory pathology or
foreign body inhalation,
a chest X-ray may be
necessary
Usually no investigations
Blood cultures and blood
tests if suspicion of bacterial
tracheitis or epiglottitis
(only when expert ENT and
anaesthetic cover available)

pleural effusion pneumonia

Blood tests and blood cultures
are advised if intravenous
antibiotics planned (Harris et al,
2011)

British Journal of Nursing, 2017, Vol 26, No 11 605

MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 147.188.128.074 on June 13, 2017.
Use for licensed purposes only. No other uses without permission. All rights reserved.
 Table 5. Management of respiratory tract infections in children continued
Community-acquired pneumonia Bronchiolitis Viral-induced wheeze (VIW) Laryngotracheobronchitis
(CAP) (croup)

Treatment The World Health Organization
(WHO) traffic light system will
guide management (Figure 1)
Viral pneumonia is managed
with explanation, reassurance,
antipyretics, and fluids
For bacterial CAP, amoxicillin
is the drug of choice and
a macrolide antibiotic
(erythromycin, azithromycin) can
be used in cases if there is
penicillin allergy, no response
to amoxicillin, atypical pathogen
suspected, and very severe
cases
Unwell children unable to
tolerate oral administration may
need intravenous antibiotics
Supportive management with
small-volume, frequent feeds,
supplementary oxygen (aiming
for oxygen saturations >92%),
nasogastric tube or intravenous
fluid support
Few cases will need advanced
respiratory support with high-flow
nasal cannula-delivered oxygen
therapy, continuous positive
airway pressure (CPAP), or
ventilation (NICE, 2015)
Usually treated with
inhaled or nebulised
salbutamol, antipyretics
and fluids
Steroids may be used
in selected patients if
needing advanced care
in high-dependency or
paediatric intensive care
units
Supportive management with
antipyretics
Those with stridor may be
given oral dexamethasone
(preferred as faster onset of
action) or prednisolone (as
alternative, if dexamethasone
is not available)
If severe respiratory
distress and stridor,
nebulised adrenaline may be
considered
Anaesthetic and ENT support
may be required in these
cases
If bacterial tracheitis is
suspected, treat with
intravenous antibiotics

Children admitted with moderate to severe RTIs will benefit The features are:
from a discharge planning and this should include medical as Short (3 days) illness
well as non-medical factors. The latter may be issues such as high Temperature
the ability of the childs carers to look after the child at home Age (<24 months)
after discharge, amount of modifications that need to be made Recession
in home environment (e.g. home oxygen, nebulisers, etc.) and Wheeze
the geographical location of where the child lives and their Asthma
distance from a specialist or a healthcare facility. Vomiting.
STARWAVe is a mnemonic devised at the University In children with bronchiolitis discharge planning needs to
of Bristol to help recall seven characteristics to assess re- be started when the child is clinically stable, taking an adequate
hospitalisation risk for children with cough and RTIs, and amount of oral fluid and maintained oxygen saturations above
to help inform discharge and follow-up provision (Hay et al, 92% in air for more than 4hours (including during sleep)
2016). Using the characteristics, children are stratified as low (NICE, 2015).
(01 features), medium (2 features) or high risk (3 or more
features) for hospitalisation in the following 30 days. Those Immunisation
with a higher risk may require support from community health The introduction of different vaccines, such as pneumococcal
professionals, which will need to be organised before discharge. and Haemophilus influenzae type B (Hib) has significantly
decreased hospitalisation, morbidity, and possibly mortality
in younger children with CAP (Barson, 2016). Availability
of Hib vaccination has significantly reduced the number of
Cough and cold: no
Home-care advice cases of epiglottitis although this should still be considered as a
pneumonia
possibility in very sick children who are unimmunised or recent
immigrants where the immunisation schedule and the vaccines
Child age
offered may not be the same as is followed in the UK (Paul et
259months
with cough
Fast breathing and/
Oral amoxicillin and
al, 2014). Madhi et al (2004) in a double-blind, randomised,
or chest indrawing: placebo-controlled trial with 37107 fully immunised infants in
and/or home-care advice
pneumonia
difficult South Africa, showed that a 9-valent pneumococcal conjugate
breathing vaccine prevents one-third of pneumonias associated with any
First dose antibiotic
respiratory viruses in children in hospital.
General danger signs*: Nurses are suitably placed to identify those children who
and referral to facility
severe pneumonia or
for injectable antibiotic/ may not have completed their immunisation schedule, and
2017 MA Healthcare Ltd

very severe disease

supportive therapy encourage parents to improve uptake of immunisations before
*
discharge from hospital.This can be best achieved by explaining
Not able to drink, persistent vomiting, convulsions, lethargic or unconscious, stridor
in a calm child or severe malnutrition. the benefits and dispelling myths and preconceptions which
parents may have.
Figure 1. WHO Traffic Light System for management of CAP (WHO, 2014) Following a discussion with the medical team, children from

606 British Journal of Nursing, 2017, Vol 26, No 11

MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 147.188.128.074 on June 13, 2017.

Use for licensed purposes only. No other uses without permission. All rights reserved.
 PAEDIATRICS

Table 6. Role of nurses in managing respiratory tract infections in children

School and Early identification and referral of unwell children
community nurses Encourage uptake of immunisations for child and siblings including dispelling myths
Parental support and advice including advising parents of the importance of adequate nutrition and a smoke-free environment

Practice nurses Early identification and referral of unwell children

Encourage and administer vaccination of child and siblings even after LRTI
Explanation of antibiotic side effects including: gastrointestinal discomfort, diarrhoea, nappy rash, yeast infection and risk of
development of antibiotic resistant strains of bacteria
Parental advice including safety net advice, what to do if childs condition deteriorates at home

Emergency Identification and triage of sick patients in appropriate categories

department nurses Regular observations and recognition of deteriorating clinical condition of the child
Respiratory support e.g. oxygen, continuous positive airway pressure (CPAP) for sick children
Ensure requested investigations are completed e.g. a chest X-ray performed and acted upon
Parental support and regular updates of childs progress
Start paediatric early warning score (PEWS) recording as this will allow early identification of deterioration and initiation of
appropriate management in a timely manner

Childrens nurses Regular observations including PEWS recording to recognise deterioration in a child managed with RTI and request appropriate
medical review
Start advanced respiratory support such as continuous positive airway pressure, non-invasive ventilation or high-flow humidified
oxygen early where indicated
Administer fluids (intravenous if vomiting or not able to drink) and medication including antipyretics (single agent preferred) and antibiotics
Strict fluid input and output charting as children with severe RTIs are as risk of developing syndrome of inappropriate antidiuretic
hormone secretion leading to hyponatremia and hypo-osmolality resulting in impaired water excretion (Barson, 2016)
Parental support and regular updates of childs progress
Discharge planning including ensuring follow-up at GP or outpatient clinic
Safety netting information to parents including informing the family of what to do if child deteriorates and any follow up if indicated
Encourage uptake of immunisations if missed or outstanding

Community Support infants and families after discharge from neonatal intensive care units
neonatal nurses Arrange home oxygen and nasogastric feeding support, medication supply and organise palivizumab injections over the RSV season
Support with application for disability living allowance where appropriate

Advanced Autonomously assess and manage children with LRTI and request senior support where necessary
paediatric nurse Order investigations, initiate management plans and prescribe medication (in a nurse prescriber role)
practitioners Guidance on long-term respiratory management e.g. in cases of multiple trigger wheeze (in an advanced role such as respiratory or
asthma nurse specialist)

Health visitors Through education and reassurance improve parental confidence in supporting children with mild RTIs in the community
Advise to attend GP or emergency department for assessment of RTIs if a parent called or attended a drop-in clinic and the child looked
unwell
Encourage uptake of immunisation by providing appropriate information and dispelling myths
Identify migrant children from countries with a high incidence of tuberculosis and ensure the completion of appropriate immunisation
including BCG if age appropriate
Offer advice about smoking cessation and its harmful effects on children, especially those with chronic respiratory conditions e.g.
asthma, chronic lung disease of prematurity

Source: adapted from Paul et al, 2011; Harris et al, 2011; NICE, 2013; Paul et al, 2014; Irwin et al, 2015; NICE, 2015

high-risk groups with an underlying health condition (e.g.
chronic lung disease of prematurity or congenital heart disease)
are offered passive protection against RSV bronchiolitis with
palivizumab (Paul et al, 2014; Rogers et al, 2017). This does
not prevent an active RSV infection but reduces the chances
of needing hospitalisation for bronchiolitis and associated
morbidities (Rogers et al, 2017).
Conclusion
Nurses, being frontline health professionals, will encounter
2017 MA Healthcare Ltd
escalation of care for children who may have a severe RTI and
hence will need a hospital admission. Assessment of the childs
clinical condition in the context of risk factors is an important
skill to remember and effective assessment to identify red flag
features will facilitate time-critical management in vulnerable
children. Appropriate diagnosis and early referral will ensure
prompt treatment and overall improved outcomes for children
presenting with RTIs. BJN
Declaration of interest: none

children presenting with RTIs routinely in their clinical practice.
The majority of these RTIs will improve with conservative
management, explanation and simple guidance on fluids, use of
single antipyretics, and monitoring. Nurses in community and
hospital settings play a vital role in the early identification and
Acknowledgements:Table 2 is reproduced with the permission of John Wiley and Sons,
The Licensor through PLSclear
Barson WJ (2016) Pneumonia in children: epidemiology, pathogenesis, and
etiology. UpToDate http://tinyurl.com/klnf358 (accessed 23 May 2017)
Clark JE, Hammal D, Hampton F, Spencer D, Parker L (2007) Epidemiology of
community-acquired pneumonia in children seen in hospital. Epidemiol Infect

British Journal of Nursing, 2017, Vol 26, No 11 607

MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 147.188.128.074 on June 13, 2017.
Use for licensed purposes only. No other uses without permission. All rights reserved.
 Case study. A challenging case of CAP
A 6-year-old boy was referred to the surgical team by the practice nurse after
discussion with the general practitioner. He presented with a 48-hour history of
abdominal pain and fever with a provisional diagnosis of appendicitis. At presentation
to the emergency department, history revealed high fever (not measured at home but
felt very hot) and abdominal pain in the left iliac fossa radiating beneath his ribcage.
He was febrile (temperature 38.7C), respiratory rate 28 breaths/minute and heart
rate 130 beats/minute, and oxygen saturations 97% in air.
Clinical examination of the abdomen within 30 minutes of arrival by the surgical
team was unremarkable. The child was immediately referred to the paediatric team.
The advanced paediatric nurse practitioner (APNP) urgently reviewed the child,
rechecked the history with the parents and performed further detailed examination.
This revealed differential and slightly decreased air entry on the left side of the
chest. A chest X-ray (Figure 2) was requested by the APNP after discussion with the
paediatric registrar and this showed left lower lobe consolidation and possibly a
small associated effusion. Parents initially found it difficult to accept the diagnosis
and demanded that further abdominal investigations be undertaken as the childs
original presentation was one of abdominal pain. A clear explanation to the parents
(including display of the chest X-ray) and reassurance provided by the consultant
paediatrician later in the day enabled parents to accept the diagnosis.
A diagnosis of left lower lobe pneumonia was made; the child was admitted and
was treated with 5days of intravenous co-amoxiclav and oral azithromycin for
initial 3days. Blood investigations showed a white cell count of 20.3 x 109/ Figure 2. Chest X-ray showed left lower lobe
9
litre, neutrophils 14.4 x 10 /litre, and C-reactive protein (CRP) level of 329 mg/ pneumonia
litre. An ultrasound scan of the chest on day 3 showed extensive left lower lobe
consolidation but no pleural effusion. The condition of the boy improved, his temperature settled and he was discharged home on day 5
with advice to complete a further 5 days of oral co-amoxiclav at home. He was found to be doing well at a clinic review 10weeks later
and a repeat chest X-ray showed complete resolution.
This case highlights some of the challenges with paediatric RTIs:
At initial presentation respiratory symptoms may not be clearly evident and observations may be otherwise within normal limits
Importance of considering pneumonia as a potential diagnosis where abdominal signs are absent in a child presenting with
abdominalpain
Consideration for suspected sepsis may have been delayed at initial presentation in this case as the referral was made for suspected
appendicitis from primary care
Importance of thorough physical examination of children by experienced health professionals as the abdominal symptoms masked the
actual aetiology in this case, which the APNP could elicit during a later examination
Importance of addressing parental expectations and concerns by a senior health professional as otherwise parents may have had
difficulty accepting the diagnosis

135(2): 262-9. https://doi.org/10.1017/S0950268806006741 update 2011. Thorax 66(Suppl 2):ii1-ii23. https://doi.org/10.1136/

Grber C, Keil T, Kulig M, Roll S, Wahn U, Wahn V for the MAS-90 Study
Group (2008) History of respiratory infections in the first 12 yr among
children from birth cohort. Pediatr Allergy Immunol 19(6): 505-1. https://doi.
org/10.1111/j.1399-3038.2007.00688.x
Hardelid P, Dattani N, Cortina-Borja M, Gilbert R (2014) Contribution of
respiratory tract infections to child deaths: a data linkage study. BMC Public
Health 14: 1191. https://doi.org/10.1186/1471-2458-14-1191
Harris M, Clark J, Coote N et al (2011) British Thoracic Society guidelines
for the management of community acquired pneumonia in children:
KEY POINTS
Respiratory tract infections (RTIs) are the most common reason for a
childs parent or carer to contact a health professional
Immunisations have led to significant reduction in serious RTIs in children,
e.g. epiglottitis, pneumonias
Most RTIs can be managed in the community with advice regarding fluids,
antipyretics and occasionally antibiotics are needed
thoraxjnl-2011-200598)
Hay A, Redmond N, Turnball S, Christensen H, Thornton H, Little P (2016)
Development and internal validation of a clinical rule to improve antibiotic
use in children presenting to primary care with acute respiratory tract
infection and cough: a prognostic cohort study. Lancet Respir Med 4(11): 902-
10 https://doi.org/10.1016/S2213-2600(16)30223-5)
Irwin AC, Fernando AM, Paul SP (2015) At a glance: respiratory tract infections
in children. J Fam Health Care 25(1): 22-5
Looijmans-van den Akker I, van Luijn K,Verheij T (2016) Overdiagnosis of
asthma in children in primary care: a retrospective analysis. Br J Gen Pract
66(644): e152-7. https://doi.org/10.3399/bjgp16X683965
Madhi SA, Klugman KP for the Vaccine Trialist Group (2004) A role for
Streptococcus pneumoniae in virus-associated pneumonia. Nat Med 10(8):811-
3. https://doi.org/10.1038/nm1077
NHS Choices (2015) Respiratory tract infections. http://tinyurl.com/l3uz6e3
(accessed 23 May 2017)
National Institute for Health and Care Excellence (2012) Croup. Clinical
Knowledge Summary. http://tinyurl.com/mh4phuc (accessed 23 May 2017)
National Institute for Health and Care Excellence (2013) Fever in under 5s:
assessment and initial management. Clinical guideline 160. http://tinyurl.
com/kp2r5sk (accessed 23 May 2017)
National Institute for Health and Care Excellence (2015) Bronchiolitis in
children: diagnosis and management. NICE guideline 9. http://tinyurl.com/
2017 MA Healthcare Ltd

hmdc9yy (accessed 23 May 2017)

Children with known risk factors or who present with red flag features
should be considered for admission to hospital
Verbal and written advice should be provided to parents when discharging
children with RTIs
Paul S, Linney M (2011) Significance of very high C-reactive protein (CRP)
values in the paediatric practice: a retrospective study. Clinical Biochemistry
44(7): 540-1. https://doi.org/10.1016/j.clinbiochem.2011.03.099
Paul S, Barratt F, Wilkinson R (2011) Treating lower respiratory ailments in
children and infants. Emergency Nurse 19(18): 21-5. https://doi.org/10.7748/
en2011.12.19.8.21.c8853

608 British Journal of Nursing, 2017, Vol 26, No 11

MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 147.188.128.074 on June 13, 2017.

Use for licensed purposes only. No other uses without permission. All rights reserved.
 PAEDIATRICS

Paul S, Wilkinson R, Routley C (2014) Management of respiratory tract
infection. Nursing: Research and Reviews 4: 13548. https://doi.org/10.2147/
NRR.S43033
Rogers E, Greaves K, Paul SP (2017) A clinical companion to the NICE
guide on bronchiolitis. Nurs Child Young People 29(3):14-16. https://doi.
org/10.7748/ncyp.29.3.14.s15
Samuels M, Wieteska S, eds (2016) Advanced Paediatric Life Support: A Practical
Approach to Emergencies. 6th edn. John Wiley & Sons, Chichester
South M, Isaacs D (2012) Practical Paediatrics. 7th edn. Elsevier, London: 479
Tidy C (2016) Lower Respiratory Tract Infection in Children. http://tinyurl.
com/lyudhgt (accessed 23 May 2016)
Thompson M,Vodicka T, Blair PS et al (2013) Duration of symptoms of
respiratory tract infections in children: systematic review. BMJ 347: f7027.
https://doi.org/10.1136/bmj.f7027
World Health Organization (2014) Revised WHO Classification and Treatment of
Childhood Pneumonia at Health Facilities. Evidence Summaries. http://tinyurl.
com/mf5dd9z (accessed 23 May 2017)

CPD reflective questions

Why is it important to identify children with respiratory tract infections (RTIs) early and refer for an urgent assessment to the paediatric
team any children with known risk factors or red flag features?
From your previous experience, think about a few of the challenges you have encountered while managing children with RTIs
Reflecting on the case study, list a few scenarios where you have identified that nurses working in different clinical set-ups have made a
difference either in recognising children with RTIs early or have picked up deterioration in clinical status e.g. through regular observations,
clinical assessment, escalating concerns to senior health professionals
List a few common strategies that nurses working in different clinical settings can discuss with families while discharging children with
RTIs to identify deterioration in condition of the child early and minimise risk of RTIs in the future

Fundamental Aspects of Infection

Prevention and Control
About the book
Infection prevention and control is a
vital for all practitioners to understand
major aspect of healthcare provision
how to ensure safe, hygienic and e
and thus it is
ective patient
Fundamental Aspects of
care in their daily practice. This practic

Infection Prevention
al, handy text aims to provide essent
Infection prevention and control is a major aspect of healthcare ial information
Infection Prevention and Control

on infection prevention, control and

Fundamental Aspects of

management in any health care setting

.
The book will be an invaluable tool
provision and thus it is vital for all practitioners to understand
to help sta reduce avoidable health
infections. It provides healthcare practit care associated
ioners with a basic understanding of

and Control
how to ensure safe, hygienic and effective patient care in their
agents, their physiology, classications
management of infections, presenting
and transmission. It also covers the
infectious
clinical
best practice guidelines and precau
daily practice. This practical, handy text aims to provide essential
measures as well as useful tips and
tools to safeguard patients from infectio
tionary
ns. In
addition, it presents the practical consid
information on infection prevention, control and management in any
infections, such as sta roles and respon
erations for the management and treatm
sibilities, environmental hygiene, steriliz
ent of
management of invasive devices and ation,
health care setting. much more.
Edited by Vinice Thomas
The content is designed be clear, concise
and highly practical. The user-friendly
features learning outcomes, checkli format
sts, tables, bullet points and practic
The book will be an invaluable tool to help staff reduce avoidable
throughout. Chapters include relevan al examples
t case studies, reective practice activiti
es and
discussion questions to aid learning.
health care associated infections. It provides healthcare practitioners
with a basic understanding of infectious agents, their physiology,
About the editor
classifications and transmission. It also covers the clinical
Vinice Thomas is Assistant Director
of Nursing/Clinical Governance at Harrow
management
Care Trust andof infections,
acted presenting
in the role of Directo
the Infection Control Team. She had
best
r of Infection Preven practice Primarguidelines
y
tion and Control, managing
and
worked within the Chief Nursing O
precautionary measures
Englands Directo as well as
rate as part of the HCAI and Cleanli useful
ness division
tips and
cer for tools
as a Portfolio Manager
to safeguard
responsible for supporting NHS Trusts
patientscontro
from infections.
l proces ses. In addition,
across the countrit presents
y to strengthen theirthe practical
infectio n
considerations for the management and treatment of infections, such
as staffPart
roles andsfulresponsibilities,
of the succes Fundamental Aspects of Nursin environmental hygiene, sterilization,
g series aimed at providing nurses
with clinical, practical guidelines to
management
Fundamental of invasive
Aspect devices and much
better treat patients. Other titles in
s of Palliative Care Nursing 2nd edition
more.
the series include:
Fundamental Aspects of Research for
Nurses
Fundamental Aspect
s of Long-Term Conditions
The content is designed be clear, concise and highly practical. The
user-friendly format features learning outcomes, checklists, tables,
Edited by Vinice Thomas

bullet points and practical examples throughout. Chapters

ISBN 1-85642 include
*Low cost for landlines and mobiles

-415-4

relevant case studies, reflective practice activities and discussion

questions to aid learning.
ISBN-13: 978-1-85642-415-8; 234 x 156 mm; paperback;
9 7 8 250
1 8 5 6 pages;
424158

publication 2010; 24.99

www.quaybooks.co.uk Fundamental Aspects in Nursing seri
2017 MA Healthcare Ltd

es

Order your copies by visiting or call our Hotline

FA InfectionControl press.indd 1

www.quaybooks.co.uk +44 (0) 333 800 1900* 11/11/2010 15:53

British Journal of Nursing, 2017, Vol 26, No 11 609

MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 147.188.128.074 on June 13, 2017.
Use for licensed purposes only. No other uses without permission. All rights reserved.