The Child with Respiratory Dysfunction

Etiology and Characteristics

Respiratory tract infections account for the majority of acute illnesses in children. The etiology and course of these infections are influenced by the age of the child, the season, living conditions, and preexisting medical problems.

Clinical Manifestations

Infants and young children, especially those between 6 months and 3 years of age, react more severely to acute respiratory tract infection than older children. Young children display a number of generalized signs and symptoms, as well as local manifestations (Box 23-1).

Nursing Care Management

Assessment of the respiratory system follows the guidelines described in Chapter 6 (for assessment of the ears, nose, mouth and throat, chest, and lungs). Special attention should also be given to the components and observations listed in Box 23-2. The nursing process in the care of the child with acute respiratory tract infection is outlined in the Nursing Process box.

Therapeutic Management

Children with nasopharyngitis are managed at home. There is no specific treatment, and effective vaccines are not available. Antipyretics are prescribed for mild fever and discomfort (see Chapter 22 for management of fever). Rest is recommended until the child is free of fever for at least 1 day. The provision of a humidified environment and increasing oral fluids may be beneficial to some children with a cold. Decongestants may be prescribed for children and infants older than 6 months of age to shrink swollen nasal passages. The decongestants that exert their effect by vasoconstriction are usually less effective when taken orally than when applied topically as nose drops.

Cough suppressants containing dextromethorphan may be prescribed for a dry, hacking cough in older children. However, cough preparations can cause adverse effects such as confusion, hyperexcitability, and sedation; therefore parents should monitor the child carefully for potential adverse effects.

Antihistamines are largely ineffective in treatment of nasopharyngitis. These drugs have a weak atropine-like effect that dries secretions, but they can cause drowsiness or, paradoxically, have a stimulatory effect on children. There is no support for the usefulness of expectorants, and antibiotics are usually not indicated because most infections are viral.

Nursing Care Management

A cold is often the parents’ first introduction to an illness in their infant. Most discomfort of nasopharyngitis is related to the nasal obstruction, especially in small infants. Elevating the head of the bed or crib mattress assists with drainage of secretions. Suctioning and vaporization may also provide relief. Saline nose drops and gentle suction with a bulb syringe before feeding and sleep time is useful.

Maintaining adequate fluid intake is essential. Although a child’s appetite for solid foods is usually diminished for several days, it is important to offer favorite fluids to prevent dehydration. Fluids can be cool or warm, depending on individual preference.

Because nasopharyngitis is spread from secretions, the best means for prevention is avoiding contact with affected persons. This goal is difficult to accomplish in family settings, classrooms, and daycare centers. Family members with a cold should try to “keep it to themselves” by carefully disposing of tissues; not sharing towels, glasses, or eating utensils; covering the mouth and nose with tissues when coughing or sneezing; and washing the hands thoroughly after nose blowing or sneezing. The most frequent carriers of infection are the human hands, which deposit viruses on doorknobs, faucets, and other everyday objects. Children should be taught to wash their hands thoroughly and avoid touching their eyes, nose, or mouth.

Clinical Manifestations

GABHS infection is generally a relatively brief illness that varies in severity from subclinical (no symptoms) to severe toxicity. The onset is often abrupt and characterized by pharyngitis, headache, fever, and abdominal pain. The tonsils and pharynx may be inflamed and covered with exudate (Fig. 23-1), which usually appears by the second day of illness. However, streptococcal infections should be suspected in children older than 2 years of age who have pharyngitis without exudate. The tongue may appear edematous and red (strawberry tongue), and the child may have a characteristic erythematous fine sandpaper rash on the trunk, axillae, elbows, and groin; the uvula is edematous and red. Anterior cervical lymphadenopathy (in about 30% to 50% of cases) usually occurs early, and the nodes are often tender. Pain can be relatively mild to severe enough to make swallowing difficult. Clinical manifestations usually subside in 3 to 5 days unless complicated by sinusitis or parapharyngeal, peritonsillar, or retropharyngeal abscess. Nonsuppurative complications may appear after the onset of GABHS—AGN in about 10 days and RF in an average of 18 days.

Diagnostic Evaluation

Although 80% to 90% of all cases of acute pharyngitis are viral, a throat culture should be performed to rule out GABHS. Most streptococcal infections are short-term illnesses, and antibody responses appear later than symptoms and are useful only for retrospective diagnosis.

Rapid identification of GABHS with diagnostic test kits (rapid antigen detection test) is possible in the office or clinic setting. Because of the high specificity of these rapid tests, a positive test result generally does not require throat culture confirmation. However, the sensitivities of these kits vary considerably, and a confirmatory throat culture is recommended in patients who have a negative test result (American Academy of Pediatrics, 2006b).

Therapeutic Management

If streptococcal sore throat infection is present, oral penicillin is prescribed in a dose sufficient to control the acute local manifestations and to maintain an adequate level for at least 10 days to eliminate any organisms that might remain to initiate RF symptoms. Penicillin does not prevent the development of AGN in susceptible children; however, it may prevent the spread of a nephrogenic strain of GABHS to others in the family. Penicillin usually produces a prompt response within 24 hours. Patients who have a history of RF or who remain symptomatic after a full course of antibiotics may require a follow-up throat swab.

Intramuscular (IM) benzathine penicillin G is an appropriate therapy, but it is painful and is not the first choice for children. Oral erythromycin is indicated for children allergic to penicillin. Other antibiotics used to treat GABHS are azithromycin, clarithromycin, oral cephalosporins, amoxicillin, and amoxicillin with clavulanic acid (American Academy of Pediatrics, 2006b; Gerber, 2005).

Nursing Care Management

The nurse often obtains a throat swab for culture and instructs the parents about administering penicillin and analgesics as prescribed. Cold or warm compresses to the neck may provide relief. In children who can cooperate, warm saline gargles may offer relief of throat discomfort. Acetaminophen and ibuprofen may be effective in decreasing the throat pain; liquid preparations or chewable forms may be preferable because of the pain associated with swallowing. Pain may interfere with oral intake, and children should not be forced to eat, but fluid intake is essential. Cool liquids or ice chips are usually more acceptable than solids.

Special emphasis is placed on correct administration of oral medication and completion of the course of antibiotic therapy (see Administration of Medication, and Compliance, Chapter 22). If an injection is required, it must be administered deep into a large muscle mass (e.g., vastus lateralis or ventrogluteal muscle). To prevent pain, application of a topical anesthetic cream such as EMLA (an eutectic mix of lidocaine and prilocaine) or LMX 4 (4% lidocaine) over the injection site before the injection is helpful (see Administration of Medication: Intramuscular Administration, Chapter 22). Parents also need to be aware of residual tenderness at the injection site, which may cause the child to limp for a day or two. Local applications of heat are helpful in relieving this discomfort.

Children are considered infectious to others at the onset of symptoms and up to 24 hours after initiation of antibiotic therapy, but they should not return to school or daycare until they have been taking antibiotics for a full 24-hour period. Nurses should remind the children to discard their toothbrush and replace it with a new one after they have been taking antibiotics for 24 hours. Parents are cautioned to prevent other household members, especially if immunocompromised, from having close contact with the sick child and avoid sharing drinking or eating items.

If the child continues to have a high fever that does not respond to antipyretics, has an extremely sore throat, refuses liquids, and appears toxic 24 to 48 hours after starting antibiotics, further evaluation by the practitioner is recommended.

Pathophysiology

Several pairs of tonsils are part of a mass of lymphoid tissue encircling the nasal and oral pharynx, known as the Waldeyer tonsillar ring (Fig. 23-2). The palatine, or faucial, tonsils are located on either side of the oropharynx, behind and below the pillars of the fauces (opening from the mouth). A surface of the palatine tonsils is usually visible during oral examination. The palatine tonsils are those removed during tonsillectomy. The pharyngeal tonsils, also known as the adenoids, are located above the palatine tonsils on the posterior wall of the nasopharynx. Their proximity to the nares and eustachian tubes causes difficulties in instances of inflammation. The lingual tonsils are located at the base of the tongue. The tubal tonsils, found near the posterior nasopharyngeal opening of the eustachian tubes, are not part of the Waldeyer tonsillar ring.

Etiology

Tonsillitis often occurs with pharyngitis. The causative agent may be viral or bacterial. Because of the abundant lymphoid tissue and the frequency of URIs, tonsillitis is a common cause of illness in young children.

Clinical Manifestations

The manifestations of tonsillitis are caused by inflammation. As the palatine tonsils enlarge from edema, they may meet in the midline (kissing tonsils), obstructing the passage of air or food. The child has difficulty swallowing and breathing. When enlargement of the adenoids occurs, the space behind the posterior nares becomes blocked, making it difficult or impossible for air to pass from the nose to the throat. As a result, the child breathes through the mouth.

Therapeutic Management

Because tonsillitis is self-limiting, treatment of viral pharyngitis is symptomatic. Throat cultures positive for GABHS infection warrant antibiotic treatment. It is important to differentiate between viral and streptococcal infection in febrile exudative tonsillitis. Because most infections are of viral origin, early rapid tests can eliminate unnecessary antibiotic administration.

Tonsillectomy is the surgical removal of the palatine tonsils. Absolute indications for a tonsillectomy are malignancy, recurrent peritonsillar abscess, and airway obstruction. Adenoidectomy (the surgical removal of the adenoids) is recommended for children who have hypertrophied adenoids that obstruct nasal breathing; additional indications for adenoidectomy include recurrent adenoiditis and sinusitis, otitis media (OM) with effusion, airway obstruction and subsequent sleep-disordered breathing, and recurrent rhinorrhea (Benninger and Walner, 2007a). The American Academy of Otolaryngology—Head and Neck Surgery (2000) lists “3 or more infections of the tonsils or adenoids per year despite adequate medical therapy” as an indication for tonsillectomy or adenotonsillectomy. However, for some children the effectiveness of tonsillectomy or adenoidectomy is modest and may not justify the risk of surgery (van Staaij, van den Akker, Rover, and others, 2004). In practice, many physicians rely on individualized decision making and do not subscribe to an absolute set of eligibility criteria for these surgical procedures (Paradise, Bluestone, Colborn, and others, 2002). Contraindications to either tonsillectomy or adenoidectomy are (1) cleft palate because tonsils help minimize escape of air during speech, (2) acute infections at the time of surgery because locally inflamed tissues increase the risk of bleeding, and (3) uncontrolled systemic diseases or blood dyscrasias.

Nursing Care Management

Nursing care involves providing comfort and minimizing activities or interventions that precipitate bleeding. A soft to liquid diet is preferred. A cool-mist vaporizer keeps the mucous membranes moist during periods of mouth breathing. Warm salt-water gargles, throat lozenges, and analgesic-antipyretic drugs such as acetaminophen are used to promote comfort. Often opioids are needed to reduce pain for the child to drink. Combination nonopioid and opioid elixirs or tablets such as acetaminophen with codeine or with hydrocodone (Lortab) relieve pain and should be given routinely every 4 hours.

If surgery is required, the child requires the same psychologic preparation and physical care as for any other surgical procedure (see Chapters 21 and 22). Most tonsillectomy and adenoidectomy (T&A) surgeries now take place in outpatient settings; however, the priorities of preoperative and postoperative care remain the same. The following discussion focuses on postoperative nursing care for T&A, although both procedures may not be performed.

Until they are fully awake, children are placed on their abdomen or side to facilitate drainage of secretions. Routine suctioning is avoided, and, when performed, it is done carefully to avoid trauma to the oropharynx. When alert, children may prefer sitting up. They are discouraged from coughing frequently, clearing their throat, blowing their nose, or any other activity that may aggravate the operative site.

Some secretions are common, particularly dried blood from surgery. All secretions and vomitus are inspected for evidence of fresh bleeding (some blood-tinged mucus is expected). Dark brown (old) blood is usually present in the emesis, in the nose, and between the teeth. If parents do not expect this, they often become frightened at a time when they need to be calm and reassuring.

The throat is sore after surgery. An ice collar provides relief, but many children find it bothersome and refuse to use it. Most children experience moderate pain after a T&A and need pain medication for at least the first 24 hours. Analgesics may be given rectally or intravenously to avoid the oral route. Because pain is continuous, analgesics should be administered at regular intervals. An antiemetic such as ondansetron (Zofran) may be administered postoperatively (see Pain Management, Chapter 7).

Food and fluids are restricted until children are fully alert and there are no signs of hemorrhage. Cool water, crushed ice, flavored ice pops, or diluted fruit juice may be given, but fluids with a red or brown color are avoided to distinguish fresh or old blood in emesis from the ingested liquid. Citrus juice may cause discomfort and is usually poorly tolerated. Soft foods, particularly gelatin, cooked fruits, sherbet, soup, and mashed potatoes, are started on the first or second postoperative day or as the child tolerates feeding. The pain from surgery often inhibits fluid intake, reinforcing the need for adequate pain control. Milk, ice cream, and pudding are usually not offered, since milk products coat the mouth and throat and may cause the child to clear the throat, which can initiate bleeding.

Postoperative hemorrhage is uncommon but can occur. The nurse observes the throat directly for evidence of bleeding, using a good source of light and, if necessary, carefully inserting a tongue depressor. Other signs of hemorrhage are tachycardia, pallor, frequent clearing of the throat or swallowing by a younger child, and vomiting of bright red blood. Restlessness, an indication of hemorrhage, may be difficult to differentiate from general discomfort after surgery. Decreasing blood pressure is a late sign of shock.

Surgery may be required to ligate a bleeding vessel. Airway obstruction may also occur as a result of edema or accumulated secretions and is indicated by signs of respiratory distress, such as stridor, drooling, restlessness, agitation, increasing respiratory rate, and progressive cyanosis. Suction equipment and oxygen should be available after tonsillectomy.

Clinical Manifestations

The manifestations of influenza may be subclinical, mild, moderate, or severe. Most patients have a dry throat and nasal mucosa, a dry cough, and a tendency toward hoarseness. A flushed face, photophobia, myalgia, hyperesthesia, and sometimes exhaustion and lack of energy accompany a sudden onset of fever and chills. Subglottal croup is common, especially in infants. The symptoms of influenza last for 4 or 5 days. Complications include severe viral pneumonia (often hemorrhagic); encephalitis; and secondary bacterial infections such as OM, sinusitis, or pneumonia.

Therapeutic Management

Uncomplicated influenza in children usually requires only symptomatic treatment: acetaminophen or ibuprofen for fever and sufficient fluids to maintain hydration. Amantadine hydrochloride (Symmetrel) has been effective in reducing symptoms associated with type A disease if administered within 24 to 48 hours after their onset; the symptoms associated with influenza are reportedly shortened by 24 hours, but the drug does not “cure” the disease. It is ineffective against type B or C influenza or other viral diseases. It should not be given to children under 1 year of age but is recommended for unvaccinated high-risk children.

Zanamivir and rimantadine have been approved for the treatment of flu symptoms in children under 18 years of age. Both medications must also be started within 48 hours of symptom onset. Zanamivir is an inhaled medication effective for type A and B influenza. The drug is taken twice daily for 5 days and is administered by a specially designed oral inhaler (Diskhaler). Zanamivir cannot be used for children less than 5 years of age. A fourth drug, oseltamivir (Tamiflu), is a neuroaminidase inhibitor that may be administered orally for 5 days to children over 1 year (and adults) to decrease the flu symptoms; as with other antiviral drugs, this must be taken within 2 days of the onset of symptoms. It is reported to be effective for types A and B influenza (American Academy of Pediatrics, 2006b). Bronchospasm and a decline in lung function can occur when zanamivir is used in patients with underlying airway disease such as asthma or chronic obstructive pulmonary disease. Rimantadine is effective only for type A virus; this drug is taken orally in tablet or syrup twice daily for 7 days. Rimantadine cannot be used for children less than 1 year of age. Children with influenza (or other similar viruses) should not receive aspirin because of its possible link with Reye syndrome.

Nursing Care Management

Nursing care is the same as for any child with a URI, including implementing measures to relieve symptoms. The greatest danger to affected children is development of a secondary infection. Prolonged fever or appearance of fever during early convalescence is a sign of secondary bacterial infection and should be reported to the practitioner for antibiotic therapy.

Etiology

Streptococcus pneumoniae, H. influenzae, and Moraxella catarrhalis are the three most common bacteria causing AOM. The etiology of noninfectious OM is unknown, although OM may occur because of blocked eustachian tubes from the edema of URIs, allergic rhinitis, or hypertrophic adenoids. Chronic OM is frequently an extension of an acute episode.

A relationship has been observed between the incidence of OM and infant feeding methods. Infants fed breast milk have a lower incidence of OM compared with formula-fed infants. Breastfeeding may protect infants against respiratory viruses and allergy because it contains secretory immunoglobulin A, which limits the exposure of the eustachian tube and middle ear mucosa to microbial pathogens and foreign proteins. Reflux of milk up the eustachian tubes is less likely in breast-fed infants because of the semivertical positioning during breastfeeding compared with bottle-feeding.

Pathophysiology

OM is primarily a result of malfunctioning eustachian tubes. The eustachian tube is part of a contiguous system composed of the nares, nasopharynx, eustachian tube, middle ear, and mastoid antrum and air cells. Eustachian tubes have three functions relative to the middle ear: (1) protection of the middle ear from nasopharyngeal secretions, (2) drainage of secretions produced in the middle ear into the nasopharynx, and (3) ventilation of the middle ear to equalize air pressure within the middle ear and atmospheric pressure in the external ear canal and to replenish oxygen that has been absorbed.

Mechanical or functional obstruction of the eustachian tube causes accumulation of secretions in the middle ear. Intrinsic obstruction can be caused by infection or allergy; extrinsic obstruction is usually a result of enlarged adenoids or nasopharyngeal tumors. Persistent collapse of the tube during swallowing can cause functional obstruction associated with decreased stiffness or an inefficient opening mechanism. Eustachian tube obstruction results in negative middle ear pressure and, if persistent, produces a transudative middle ear effusion. Drainage is inhibited by sustained negative pressure and impaired ciliary transport within the tube. When the passage is not totally obstructed, contamination of the middle ear can take place by reflux, aspiration, or insufflation during crying, sneezing, nose blowing, and swallowing when the nose is obstructed.

Diagnostic Evaluation

Careful assessment of tympanic membrane mobility with a pneumatic otoscope is essential to differentiate AOM from OM with effusion (OME) (American Academy of Pediatrics, 2004b). A diagnosis of AOM is made if visual inspection of the tympanic membrane reveals a purulent discolored effusion and a bulging or full, opacified, or reddened immobile membrane. Some practitioners also consider the presence of acute onset of less than 48 hours of ear pain with the above criteria to be a diagnostic factor in AOM (Powers, 2007). An immobile tympanic membrane or an orange discolored membrane indicates OME. Clinical symptoms of otitis are also helpful in making the diagnosis (Box 23-6). In AOM, symptoms such as acute onset of ear pain, fever, and a bulging yellow or red tympanic membrane are usually present. In OME, these symptoms may be absent, and other nonspecific symptoms such as rhinitis, cough, or diarrhea are often present (American Academy of Pediatrics, 2004a, 2004b).

Therapeutic Management

Treatment for AOM is one of the most common reasons for antibiotic use in the ambulatory setting. Recently, however, concerns about drug-resistant S. pneumoniae and other drug resistances have led infectious disease authorities to recommend careful and judicious use of antibiotics for treatment of this illness. Current literature indicates that waiting up to 72 hours for spontaneous resolution is safe and appropriate management of AOM in healthy infants over 6 months and children (American Academy of Pediatrics, 2004a; Bhetwal and McConaghy, 2007). Furthermore some reviews of the treatment of AOM reveal no clear evidence that antibiotics improve outcomes in children younger than 2 years of age with uncomplicated AOM. However, the watchful waiting approach is not recommended for children younger than 2 years who have persistent acute symptoms of fever and severe ear pain (Carlson and Scudder, 2004). In addition, all cases of AOM in infants younger than 6 months of age should be treated with antibiotics because of the infant’s immature immune system and the potential for infection with bacteria other than the three most common organisms found in older infants and children with AOM.

When antibiotics are warranted, oral amoxicillin in high doses (80 to 90 mg/kg/day, divided twice daily) is the treatment of choice for initial episodes of AOM in children who have not received antibiotics within the past month (American Academy of Pediatrics, 2004a; Bhetwal and McConaghy, 2007; Pichichero and Casey, 2005). The recommendation for the duration of antibiotic therapy is 10 to 14 days; in children 6 years and older with uncomplicated AOM, shorter courses may be sufficient (American Academy of Pediatrics, 2006b).

Second-line antibiotics used to treat OM include amoxicillin–clavulanate; azithromycin; and cephalosporins such as cefdinir, cefuroxime, and cefpodoxime. IM ceftriaxone is used if the causative organism is a highly resistant pneumococcus or if the parents are noncompliant with the therapy. An important consideration with the use of single-dose IM injections is the pain involved in this therapy. One strategy to minimize pain at the injection site is to reconstitute the cephalosporin with 1% lidocaine. The use of steroids, decongestants, and antihistamines to treat AOM is not recommended.

Supportive care or symptomatic treatment of AOM includes treating the fever and pain. For fever or discomfort associated with OM, analgesic-antipyretic drugs such as acetaminophen or ibuprofen may be given. Topical pain relief is recommended by external application of heat or cold, or the practitioner may prescribe topical pain relief drops such as benzocaine drops. Antihistamines and decongestants are not recommended. Antibiotic ear drops have no value in treating AOM.

Myringotomy, a surgical incision of the eardrum, may be necessary to alleviate the severe pain of AOM. A myringotomy is also performed to provide drainage of infected middle ear fluid in the presence of complications (mastoiditis, labyrinthitis, or facial paralysis) or to allow purulent middle ear fluid to drain into the ear canal for culture. A minimally invasive laser-assisted myringotomy procedure may be performed in outpatient settings.

Tympanostomy tube placement and adenoidectomy are surgical procedures that may be done to treat recurrent OM. Tympanostomy tubes are pressure-equalizer (PE) tubes or grommets that facilitate continued drainage of fluid and allow ventilation of the middle ear. Adenoidectomy is not recommended for treatment of AOM and is performed only in children with recurrent AOM or chronic OME with postnasal obstruction, adenoiditis, or chronic sinusitis.

In some children, residual middle ear effusions remain after episodes of AOM. Some children have fluid that persists in the middle ear for weeks or months. Antibiotics are not required for initial treatment of OME, but may be indicated for children with persistent effusion for more than 3 months (American Academy of Pediatrics, 2004a). Placement of tympanostomy tubes is recommended after a total of 4 to 6 months of bilateral effusion with a bilateral hearing deficit (American Academy of Pediatrics, 2004b). This therapy allows for mechanical drainage of the fluid, which promotes healing of the membrane and prevents scar formation and loss of elasticity. Myringotomy with or without insertion of PE tubes should not be performed for initial management of OME but may be recommended for children who have recurrent episodes of OME with a long cumulative duration (American Academy of Pediatrics, 2004b). Tonsillectomy either alone or with adenoidectomy is not considered an effective treatment of OME (American Academy of Pediatrics, 2004b).

OME is frequently associated with mild to moderate impairment of hearing; therefore a hearing test should also be performed 3 months after the acute episode of AOM, if OME persists for 3 months or more, or if there is evidence of language or learning delays. Follow-up examinations of children with chronic OME should be maintained on a 3- to 6-month basis until the OME is resolved, a significant hearing loss is identified, or structural defect of the tympanic membrane or middle ear is identified (American Academy of Pediatrics, 2004a). Children with hearing loss should be referred to an otolaryngologist and should receive a speech and language evaluation as necessary.

Nursing Care Management

Nursing objectives for the child with AOM include (1) relieving pain, (2) facilitating drainage when possible, (3) preventing complications or recurrence, (4) educating the family in care of the child, and (5) providing emotional support to the child and family.

Analgesic drugs such as acetaminophen and ibuprofen are used to treat mild pain. For more severe pain, the American Academy of Pediatrics (2004a) guidelines recommend a stronger analgesic such as codeine.

If the ear is draining, the external canal may be cleaned with sterile cotton swabs or pledgets coupled with topical antibiotic treatment. If ear wicks or lightly rolled sterile gauze packs are placed in the ear after surgical treatment, they should be loose enough to allow accumulated drainage to flow out of the ear; otherwise, infection may be transferred to the mastoid process. The wicks need to stay dry during shampoos or baths. Occasionally, drainage is so profuse that the auricle and the skin surrounding the ear become excoriated from the exudate. This is usually prevented by frequent cleansing and application of various moisture barriers (e.g., Proshield Plus) or petrolatum jelly (e.g., Vaseline).

Tympanostomy tubes may allow water to enter the middle ear, but recommendations for earplugs are inconsistent. Research indicates that swimming without earplugs poses a slight increased risk of infection (Goldstein, Mandel, Kurs-Lasky, and others, 2005). However, lake and river water is potentially contaminated, and wearing earplugs while swimming in a lake prevents total flooding of the external canal. Bathwater and shampoo water should be kept out of the ear, if possible, because soap reduces the surface tension of water and facilitates entry through the tube. Parents should be aware of the appearance of a grommet (usually a tiny, white, plastic spool-shaped tube) so that they can recognize it if it falls out. They are reassured that this is normal and requires no immediate intervention, although they should notify the practitioner.

Prevention of recurrence requires adequate education regarding antibiotic therapy. The symptoms of pain and fever usually subside within 24 to 48 hours, but nurses must emphasize that all of the prescribed medication should be taken. Parents should be aware that potential complications of OM, such as hearing loss, can be prevented with adequate treatment and follow-up care.

Parents also need anticipatory guidance regarding methods to reduce the risks of OM, especially in children under 2 years of age. Reducing the chances of OM is possible with simple measures, such as sitting or holding an infant upright for feedings, maintaining routine childhood immunizations, and exclusively breastfeeding until at least 6 months of age. Propping bottles is discouraged to avoid pooling of milk while the child is in the supine position and to encourage human contact during feeding. Eliminating tobacco smoke and known allergens is also recommended. Early detection of middle ear effusion is essential to prevent complications. Infants and preschool children should be screened for effusion, and all schoolchildren, especially those with learning disabilities, should be tested for middle ear effusion. Frequent audiologic evaluations, medical consultation, and education of parents and children are advised when middle ear effusion is detected.

Etiology and Pathophysiology

The herpes-like Epstein-Barr virus (EBV) is the principal cause of infectious mononucleosis. It appears in both sporadic and epidemic forms, but the sporadic cases are more common. The mechanism of spread has not been proved, but it is believed to be transmitted in saliva by direct intimate contact. It is mildly contagious, but the period of communicability is unknown. There is evidence that the virus is spread through sexual contact, especially when multiple partners are involved (Rimsza and Kirk, 2005). The incubation period following exposure is approximately 30 to 50 days (American Academy of Pediatrics, 2006).

Diagnostic Tests

The onset of symptoms may be acute or insidious and may appear anywhere from 10 days to 6 weeks after exposure. The presenting symptoms vary greatly in type, severity, and duration (Box 23-7). The clinical manifestations of infectious mononucleosis are usually less severe (often subclinical or unapparent) and the convalescent phase is shorter in younger children than in older children and young adults. The leukocyte count may be normal or low. Usually lymphocytic leukocytosis develops, and there is an increase in atypical leukocytes in the peripheral blood smear. The heterophil antibody test determines the extent to which the patient’s serum will agglutinate sheep red blood cells; the response in this test is primarily to immunoglobulin M, which is present in the first 2 weeks of the illness in adolescents.

The spot test (Monospot) is a slide test of venous blood that has high specificity. It is rapid, sensitive, inexpensive, and easy to perform, and has the advantage over the heterophil antibody test that it can detect significant agglutinins at lower levels, thus allowing earlier diagnosis. Blood is usually obtained for the test by finger puncture or venous sampling and is placed on special paper. If the blood agglutinates, forming fragments or clumps, the test is positive for the infection.

Therapeutic Management

No specific treatment exists for infectious mononucleosis. Simple remedies ordinarily relieve the symptoms. A mild analgesic is often sufficient to relieve the headache, fever, and malaise. Rest is encouraged for fatigue but is not imposed for any specific period. Affected persons are instructed to regulate activities according to their own tolerance unless complicating factors are present. Contact sports are discouraged in the presence of splenomegaly.

Antibiotics are contraindicated unless β-hemolytic streptococci are present. If sore throat is severe, effective therapies include gargles; hot drinks; anesthetic troches; or analgesics, including opioids. Corticosteroids have been used to treat respiratory distress from significant tonsillar inflammation, hemolytic anemia, thrombocytopenia, and neurologic complications; however, routine use of steroids is not recommended (American Academy of Pediatrics, 2006).

Nursing Care Management

Nursing responsibilities are directed toward providing comfort measures to relieve symptoms and helping affected adolescents and their families to determine appropriate activities for the stage of the disease. The child is advised to limit exposure to persons outside the family, especially during the acute phase of illness. Children and adolescents may need diet counseling to select foods that contain sufficient calories to meet growth and energy needs but are easy to swallow. It may be more comfortable to limit intake to liquids during the acute phase; milk shakes are a good alternative to solid foods on a temporary basis. Throat pain may be severe enough to require a mild analgesic such as codeine. Careful nursing assessment of swallowing ability is essential because the edema may cause serious airway compromise in some children.

Clinical Manifestations

The onset of epiglottitis is abrupt, and it can rapidly progress to severe respiratory distress. The child usually goes to bed asymptomatic to awaken later, complaining of sore throat and pain on swallowing. The child has a fever; appears sicker than clinical findings suggest; and insists on sitting upright and leaning forward, with the chin thrust out, mouth open, and tongue protruding (tripod position). Drooling of saliva is common because of the difficulty or pain on swallowing and excessive secretions.

The child is irritable and extremely restless and has an anxious, apprehensive, and frightened expression. The voice is thick and muffled, with a froglike croaking sound on inspiration, but the child is not hoarse. Suprasternal and substernal retractions may be evident. The child seldom struggles to breathe, and slow, quiet breathing provides better air exchange. The sallow color of mild hypoxia may progress to frank cyanosis. The throat is red and inflamed, and a distinctive large, cherry red, edematous epiglottis is visible on careful throat inspection.

Therapeutic Management

The course of epiglottitis may be fulminant, with respiratory obstruction appearing suddenly. Progressive obstruction leads to hypoxia, hypercapnia, and acidosis followed by decreased muscular tone; reduced level of consciousness; and, when obstruction becomes more or less complete, a rather sudden death. A presumptive diagnosis of epiglottitis constitutes an emergency.

The child who is suspected of having epiglottitis should be examined in a setting where emergency airway equipment is readily available. Examination of the throat with a tongue depressor is contraindicated until experienced personnel and equipment are available to proceed with immediate intubation or tracheostomy in the event that the examination precipitates further or complete obstruction.

If a lateral neck film is indicated, experienced personnel should accompany the child to the radiology department. For a young child who is likely to become more agitated by the procedure, it is preferable that the child not be transported but remain on the parent’s lap in the examination area during portable radiology. Other procedures, such as insertion of an intravenous (IV) line, that are likely to further agitate the child are delayed until adequate airway is maintained.

Nasotracheal intubation or tracheostomy is usually considered for the child with epiglottitis with severe respiratory distress. It is recommended that the intubation or tracheostomy and any invasive procedure, such as starting an IV infusion, be performed in an area where emergency airway maintenance can be easily and quickly accomplished. Humidified oxygen is administered as necessary either via mask in older children or flowby in younger children to avoid further agitation. Whether or not there is an artificial airway, the child requires intensive observation by experienced personnel. The epiglottal swelling usually decreases after 24 hours of antibiotic therapy, and the epiglottis is near normal by the third day. Intubated children are generally extubated at this time. Additional treatment for children with moderate or severe disease includes administration of nebulized epinephrine (racemic epinephrine) or a mixture of helium and oxygen (heliox) to decrease edema. The use of corticosteroids for reducing edema has become a mainstay in the treatment of epiglottitis. Oral corticosteroid is preferred, but other routes of administration include IM, IV, and nebulized (Wright, Rowe, Arent, and others, 2005).

Children with suspected bacterial epiglottitis are given antibiotics intravenously, followed by oral administration to complete a 7- to 10-day course.

Nursing Care Management

Epiglottitis is a serious and frightening disease for the child and family. It is important to act quickly but calmly and to provide support without increasing anxiety. The child is allowed to remain in the position that provides the most comfort and security, and parents are reassured that everything possible is being done to obtain relief for their child.

Acute care of the child is the same as that described later for the child with LTB. Continuous monitoring of respiratory status, including pulse oximetry (and blood gases if the patient is intubated), is an important part of nursing observations, and the IV infusion is maintained as described in Chapter 22.

Therapeutic Management and Nursing Care Management

The disease is usually self-limited without long-term sequelae. Treatment is symptomatic with fluids and humidified air (see Nursing Care Plan, pp. 759–761).

Therapeutic Management

The major objective in medical management is maintaining the airway and providing adequate respiratory exchange. Children with mild croup (no stridor at rest) can be managed at home. Parents are taught the signs of respiratory distress and instructed to summon professional help early if needed. Children who progress to stage II respiratory symptoms should receive medical attention (see Box 23-8).

High humidity with cool mist provides relief for most children. A cool-air vaporizer can be used at home. In the hospital, a nebulized mist for older infants and toddlers may be used to provide increased humidity and supplemental oxygen. However, controversy surrounds the use of mist therapy to treat croup. Studies have failed to demonstrate any improvement in subglottic edema with mist therapy (Moore and Little, 2006).

Nebulized epinephrine (racemic epinephrine) is often used in children with severe disease, stridor at rest, retractions, or difficulty breathing. The α-adrenergic effects cause mucosal vasoconstriction and subsequently decrease subglottic edema. The onset of action is rapid, and the peak effect is observed in 2 hours. Children may be discharged home following racemic epinephrine after a 2- to 3-hour period of observation for return of acute symptoms

Oral steroids have proven effective in the treatment of croup; IM dexamethasone may be given to children who are unable to tolerate oral dosing. Nebulized budesonide may be administered in conjunction with IM dexamethasone. A single dose of oral corticosteroid has been shown to decrease hospitalizations and the need for multiple racemic epinephrine treatments in children with mild croup.

In severe cases of LTB the administration of heliox may serve to reduce the work of breathing and relieve airway obstruction. Because helium has a lower density than room air, it forms a respirable gas (with oxygen) that reduces airway turbulence.

Nursing Care Management

The most important nursing function in the care of children with LTB is continuous, vigilant observation and accurate assessment of respiratory status. Pulse oximetry is commonly used for monitoring oxygenation status. Changes in therapy are frequently based on the nurses’ observations and assessments, the child’s response to therapy, and tolerance of procedures. The trend away from early intubation of children with LTB emphasizes the importance of nursing observations and the ability to recognize impending respiratory failure so that intubation can be implemented without delay. Intubation equipment must be readily accessible and taken with the child during transport to other areas (e.g., radiology, operating room).

Infants or small children find that being enclosed in a tent, coughing, having laryngeal spasms, and needing IV therapy are additional sources of distress. In many acute care facilities the mist tent has been abandoned and the infant is allowed to be held by the parent; if cool mist is used in the treatment, it can be administered through a tube held in front of the patient while the child is held on the parent’s lap.

Children with mild croup are allowed to drink beverages they like as long as respiratory status is stable, and parents are encouraged to try whatever comforting measures work best (e.g., holding their child, rocking, singing). If the child is unable to take oral fluids, IV fluids may be required in addition to IV medications (dexamethasone).

The rapid progression of croup, the alarming sound of the cough and stridor, and the child’s apprehensive behavior and ill appearance combine to create a frightening experience for the parents. Parents need reassurance regarding their child’s progress and an explanation of treatments. The family should be allowed to remain with their child as much as possible.

The nurse should provide the parents with an opportunity to express their feelings and referrals as necessary. Parents need frequent reassurance provided in a calm, quiet manner and education regarding what they can do to make their child more comfortable. Home care includes continued humidity, adequate hydration, and nourishment.

Therapeutic Management and Nursing Care Management

Spasmodic croup is usually self-limiting, and most children are managed at home. A cool mist humidifier may be recommended for home treatment. Sometimes the spasm is relieved by sudden exposure to cold air (as when the child is taken out into the night air to see the practitioner). Parents are usually advised to have the child sleep in humidified air until the cough has subsided to prevent subsequent episodes. Children with moderately severe symptoms may be hospitalized for observation and therapy with cool mist and racemic epinephrine, as for LTB. Some patients respond to corticosteroid therapy.

Therapeutic Management and Nursing Care Management

Bacterial tracheitis requires vigorous management with antipyretics and antibiotics. Many children require endotracheal intubation and mechanical ventilation; patients are closely monitored for impending respiratory failure if not intubated. Early recognition to prevent life-threatening airway obstruction is essential.

Pathophysiology

RSV affects the epithelial cells of the respiratory tract. The ciliated cells swell, protrude into the lumen, and lose their cilia. RSV produces a fusion of the infected cell membrane with cell membranes of adjacent epithelial cells, thus forming a giant cell with multiple nuclei. At the cellular level this fusion results in multinucleated masses of protoplasm, or syncytia.

The bronchiolar mucosa swells, and lumina are subsequently filled with mucus and exudate. The walls of the bronchi and bronchioles are infiltrated with inflammatory cells, and peribronchiolar interstitial pneumonitis is usually present. Because luminal epithelial cells are shed into the bronchioles when they die, the lumina are frequently obstructed, particularly on expiration. The varying degrees of obstruction produced in small air passages lead to hyperinflation, obstructive emphysema resulting from partial obstruction, and patchy areas of atelectasis. Dilation of bronchial passages on inspiration allows sufficient space for intake of air, but narrowing of the passages on expiration prevents air from leaving the lungs. Thus air is trapped distal to the obstruction and causes progressive overinflation (emphysema).

Clinical Manifestations

The illness usually begins with a URI after an incubation of about 5 to 8 days. Symptoms such as rhinorrhea and low-grade fever often appear first. OM and conjunctivitis may also be present. In time a cough may develop. If the disease progresses, it becomes a lower respiratory tract infection and manifests typical symptoms (Box 23-9). Infants may have several days of URI symptoms or no symptoms except slight lethargy, poor feeding, or irritability.

Once the lower airway is involved, classic manifestations include signs of altered air exchange, such as wheezing, retractions, crackles, dyspnea, tachypnea, and diminished breath sounds. Apnea may be the first recognized indicator of RSV infection in very young infants.

Diagnostic Evaluation

Identification has been simplified by the development of tests done on nasal or nasopharyngeal secretions, using either a rapid immunofluorescent antibody—direct fluorescent antibody staining (DFA) or an enzyme-linked immunosorbent assay (ELISA) for RSV antigen detection (see Respiratory Secretion and Throat Specimens, Chapter 22).

Therapeutic Management

Bronchiolitis is treated symptomatically with cool humidified oxygen, adequate fluid intake, airway maintenance, and medications. Most children with bronchiolitis can be managed at home. Hospitalization is usually recommended for children with respiratory distress or those who cannot maintain adequate hydration. Other reasons for hospitalization include complicating conditions, such as underlying lung or heart disease or associated debilitated states, or a home environment where adequate management is questionable. The infant who is tachypneic or apneic, has marked retractions, seems listless, or has a history of poor fluid intake should be admitted.

Humidified oxygen is administered in concentrations sufficient to maintain adequate oxygenation (Spo₂) at or above 90% as measured by pulse oximetry. The administration of humidified mist is controversial. Routine chest physical therapy (CPT) is not recommended; infants with abundant nasal secretions benefit from periodic suctioning. Fluids by mouth may be contraindicated because of tachypnea, weakness, and fatigue; therefore IV fluids are preferred until the acute stage of the disease has passed.

Clinical assessments, noninvasive oxygen monitoring, and blood gas values guide therapy. Medical therapy for bronchiolitis is primarily supportive and aimed at decreasing airway hyperresonance and inflammation and promoting adequate fluid intake. Bronchodilators may provide short-term benefits, yet overall significant improvement in the child’s condition is not always appreciable. Racemic epinephrine has been shown to produce modest improvement in ventilation status. Corticosteroids and antihistamines have not been shown to be effective in controlled studies and are not recommended for routine use. Antibiotics are not part of the treatment of RSV unless there is a coexisting bacterial infection such as OM (American Academy of Pediatrics, 2006a). Additional treatment recommendations in the American Academy of Pediatrics (2006a) practice guideline are to encourage breastfeeding; avoid passive tobacco smoke exposure; and promote preventive measures, including hand washing and the administration of palivizumab (Synagis) to high-risk infants.

Ribavirin, an antiviral agent (synthetic nucleoside analog), is the only specific therapy approved for hospitalized children; however, use of this drug is controversial because of concerns about the high cost, aerosol route of administration, potential toxic effects among exposed health care personnel, and conflicting results of efficacy trials (American Academy of Pediatrics, 2006a; Chávez-Bueno, Mejías, Jafri, and others, 2005; Ventre and Randolph, 2007). This drug is aerosolized and delivered via a small-particle aerosol generator. It may be administered by hood, tent, or mask or through ventilator tubing for 12 to 20 hours daily; average duration of therapy is 3 days.

Prevention of RSV Infection

The only product available in the United States for prevention of RSV is palivizumab, a monoclonal antibody, which is given monthly in an IM injection. According to the American Academy of Pediatrics (2006a) practice guideline, candidates for palivizumab include infants born before 32 weeks’ gestation who required medical therapy such as supplemental oxygen or mechanical ventilation. Infants and children younger than 2 years of age with BPD who have received medical therapy (supplemental oxygen, bronchodilator, diuretic, or corticosteroid therapy) for BPD within 6 months before the anticipated RSV season may benefit from palivizumab prophylaxis. Children with more severe BPD may benefit from palivizumab prophylaxis for two RSV seasons. Children with severe immunodeficiencies (e.g., severe combined immunodeficiency or acquired immunodeficiency syndrome [AIDS]) may also benefit from prophylaxis. Infants and children younger than 2 years of age with hemodynamically significant congenital heart disease will benefit from 5 monthly IM injections of palivizumab. Prophylaxis for RSV should be initiated at the onset of the RSV season and terminated at the end of the season (November to March). Additional age and condition recommendations are outlined in the American Academy of Pediatrics practice guideline (2006a).

A second-generation monoclonal antibody, motavizumab, is currently undergoing phase III clinical trials; this drug is reported to be more effective in the prevention of RSV than palivizumab (De Vincenzo, 2008).

Nursing Care Management

Children admitted to the hospital with suspected RSV infection may be assigned separate rooms or grouped with other RSV-infected children. Contact and standard precautions are employed, including hand washing, not touching the nasal mucosa or conjunctiva, and using gloves and gowns when entering the patient’s room. Other isolation procedures of potential benefit are those aimed at diminishing the number of hospital personnel, visitors, and uninfected children in contact with the child. Another measure is to make patient assignments so that nurses assigned to children with RSV are not caring for other patients who are considered high risk.

Infants with RSV often have copious nasal secretions, making breathing and nursing or bottle-feeding difficult. This engenders concerns that the child will lose weight or stop breastfeeding altogether. Encourage breastfeeding mothers to continue feeding the infant or, if feedings are contraindicated due to the acuity of the illness, mothers should pump their milk and store appropriately for later use (see Chapter 8). Parents are taught how to instill normal saline drops into the nares and suction the mucus with a bulb syringe before feedings and before bedtime so the child may eat and rest better; unfortunately no medications appropriate for infants can help with these symptoms. To address the issue of decreased fluid intake, parents may offer small amounts of clear fluids, 5 to 10 ml at a time, with a medication syringe every 10 minutes or so to maintain adequate hydration. Infants may cough or vomit as the secretions settle in the stomach and make them prone to emesis of such secretions.

Additional nursing care is aimed at monitoring oxygenation with pulse oximetry, ensuring bronchodilator therapy is optimized by using a small mask for delivery, and providing information for the parent regarding the infant’s status. The unpredictability of the infant’s individual response to the disease compounds parental anxiety when they hear about children who had serious morbidity or died from RSV. However, for the most part infants recover quickly from the disease and resume normal daily activities, including fluid intake. Such infants are at risk for further episodes of wheezing that may or may not involve an RSV infection; parents, however, may be concerned that the infant has another serious case of RSV.

Lobar pneumonia—All or a large segment of one or more pulmonary lobes is involved.

Bronchopneumonia—This begins in the terminal bronchioles, which become clogged with mucopurulent exudate to form consolidated patches in nearby lobules; also called lobular pneumonia.

Interstitial pneumonia—The inflammatory process is more or less confined within the alveolar walls (interstitium) and the peribronchial and interlobular tissues.

Viral Pneumonia

Viral pneumonias, which occur more frequently than bacterial pneumonias, are seen in children of all ages and are often associated with viral URIs. Viruses that cause pneumonia include RSV in infants and parainfluenza, influenza, human metapneumovirus, and adenovirus in older children. There are few clinical symptoms that are unique to a specific virus, and differentiation among viruses is usually made by clinical features such as child’s age, past medical history, season of the year, and radiographic and laboratory examination (Box 23-10).

The prognosis is generally good, although viral infections of the respiratory tract render the affected child more susceptible to secondary bacterial invasion, especially when there is denuded bronchial mucosa. Treatment is symptomatic and includes measures to promote oxygenation and comfort, such as oxygen administration with cool mist, CPT and postural drainage, antipyretics for fever management, fluid intake, and family support. Some authorities recommend antimicrobial therapy in the hopes of reducing or preventing secondary bacterial infection, but this therapy should be reserved for children in whom a bacterial infection is demonstrated by appropriate cultures.

Primary Atypical Pneumonia

Atypical pneumonia refers to pneumonia that is caused by pathogens other than the traditionally most common and readily cultured bacteria (e.g., S. pneumoniae). In the category of atypical pneumonias, M. pneumoniae and Chlamydia pneumoniae are the most common cause of community-acquired pneumonia in children 5 years or older (Rafei and Lichenstein, 2006). It occurs in the fall and winter months and is more prevalent in crowded living conditions. Most affected persons recover from acute illness in 7 to 10 days with symptomatic treatment, followed by a week of convalescence. Hospitalization is rarely necessary.

Severe Acute Respiratory Syndrome

A severe form of atypical pneumonia identified as severe acute respiratory syndrome (SARS) was first reported in Asia in 2003. SARS is caused by a previously unrecognized coronavirus called SARS-associated coronavirus (SARS Co-V). Additional human coronavirus types have since been identified in Canada, Hong Kong, and the Netherlands. Clinical manifestations of this disorder include a fever greater than 38° C (100.4° F); headache; cough; shortness of breath; difficulty breathing; and, after 2 to 7 days, a dry, nonproductive cough and dyspnea. In some patients the symptoms are severe enough to require intubation and mechanical ventilation. The disease is spread by close contact with a person with SARS. Most cases have involved people who have cared for or lived with someone with SARS or people who have traveled to areas with reported cases of SARS.

In children, two distinct forms of the illness have been observed. Adolescents have malaise, myalgia, chills, and rigor, whereas young children have mainly cough and runny nose. In younger children the clinical course seems to be milder and the disease resolves more quickly than in adolescents or adults (Denison, 2005; Stockman, Massoudi, Helfand, and others, 2007).

Laboratory findings include lymphopenia; leukopenia; thrombocytopenia; and elevated lactate dehydrogenase, aspartate aminotransferase, and creatinine kinase levels. The most reliable laboratory diagnostic test is positive antibodies for the SARS Co-V. Chest radiographs in a substantial number of patients reveal focal interstitial infiltrates that progress to more generalized, patchy interstitial infiltrates.

Treatment of SARS involves predominantly supportive care measures. Other therapies such as antibiotics, antiviral drugs such as ribavirin, and steroids have been used with mixed results (O’Connor, 2003).

Avian Influenza Virus

Several types of influenza were identified in Asian countries that caused mild to severe disease in adults and children. The avian influenza that has resulted in several deaths in Hong Kong, Vietnam, and Thailand has been identified as subtypes H5 and H7 and has as its host chickens and wild ducks, in which the mortality rates range from 90% to 100% (Lee and Krilov, 2005). The virus has also been reported to spread among other animals such as pigs and tigers. In humans the viral manifestations of avian influenza often consist of fever and respiratory symptoms—sore throat, rhinorrhea, and cough—occurring within 3 to 5 days of illness (Chokephaibulkit, 2004). Laboratory findings include leukopenia and thrombocytopenia, and moderately elevated liver transaminases are often identified. Patients may rapidly progress to ARDS with acute lung injury. In some children the virus is manifest only as an eye infection (conjunctivitis).

Treatment is aimed at prompt diagnosis and intervention to reduce the onset of ARDS. The virus may respond to influenza drugs such as amantadine, rimantadine, oseltamivir, and zanamivir, but cases of avian flu in Southeast Asia were resistant to amantadine and rimantadine (Lee and Krilov, 2005). Rimantadine is not indicated for children. At present laboratory testing in the United States is indicated only in the case of a hospitalized patient with a severe respiratory illness without a diagnosis who has traveled to a country with documented avian influenza (Lee and Krilov, 2005). To obtain updated information on the emergence and progress in treatment of these and other respiratory viruses, the reader is encouraged to visit the Centers for Disease Control and Prevention website.^*

Bacterial Pneumonia

S. pneumoniae is the most common bacterial pathogen responsible for community-acquired pneumonia in both children and adults (Rafei and Lichenstein, 2006). Other bacteria that cause pneumonia in children are group A streptococcus, S. aureus, M. catarrhalis, M. pneumoniae, and C. pneumoniae.

Beyond the neonatal period, bacterial pneumonias display distinct clinical patterns that facilitate their differentiation from other forms of pneumonia. The onset of illness is abrupt and generally follows a viral infection that disturbs the natural defense mechanisms of the upper respiratory tract.

The child with bacterial pneumonia usually appears ill. Symptoms include fever, malaise, rapid and shallow respirations, cough, and chest pain. The pain of pneumonia may be referred to the abdomen and confused with appendicitis. Chills and meningeal symptoms (meningism) are common.

Most older children with pneumonia can be treated at home if the condition is recognized and treatment is initiated early. Antibiotic therapy, bed rest, liberal oral intake of fluid, and administration of an antipyretic for fever are the principal therapeutic measures. Follow-up examination is recommended for small infants and toddlers. Hospitalization is indicated when pleural effusion or empyema accompanies the disease, in situations where compliance with therapy is estimated to be poor, in infants less than 1 month old, and when there are chronic illnesses such as congenital heart disease or BPD (Rafei and Lichenstein, 2006). IV fluids may be necessary to ensure adequate hydration, and oxygen is required if the child is in respiratory distress; some children may require initial therapy with parenteral antibiotics due to the severity of illness.

Nursing Care Management

For the child being cared for at home the nurse educates the parent regarding antibiotic and antipyretic administration, assessment of respiratory status, and oral fluid intake. If the child is ill, solid foods may be rejected; fluid intake is encouraged until the child feels well enough to eat solids. Parents are reassured that the child’s appetite will return once the acute phase of the illness has passed. If the cough is disturbing, judicious use of antitussives, especially at bed time, is often helpful. Most sick children are adept at self-regulation of activity and rest; parents are encouraged to allow the child appropriate rest and discourage vigorous activities until the child has been afebrile for 24 hours or more. Return to school or daycare is usually permitted according to the type of pneumonia, severity of illness, and practitioner recommendation. It should be emphasized that the infection may be transmitted to other children with close contact.

Nursing care of the hospitalized child with pneumonia is primarily supportive and symptomatic but necessitates thorough respiratory assessment, antibiotics, and evaluation of hydration status; supplemental oxygen may be required if oxygenation status is compromised. The child’s respiratory rate and oxygenation status, as well as vital signs, pain level, and general disposition and level of activity, are frequently assessed. Isolation procedures are implemented according to hospital policy, but standard and contact precautions are recommended initially for all children with a URI until the exact cause is known. To prevent dehydration, fluids are frequently administered intravenously during the acute phase.

If needed, supplemental oxygen may be administered by nasal cannula or face mask (or face tent [bucket]); small infants may be given humidified oxygen via a plastic head hood or rarely via a mist tent. Children are usually more comfortable in a semierect position (Fig. 23-3) but should be allowed to determine the position of comfort. Lying on the affected side (if pneumonia is unilateral) splints the chest on that side and reduces the pleural rubbing that often causes discomfort. Fever is controlled by the cool environment and administration of antipyretic drugs.

Children, especially infants, with ineffectual cough or difficulty handling secretions require suctioning to maintain a patent airway. A simple bulb suction syringe is usually sufficient for clearing the nares and nasopharynx of infants, but mechanical suction should be readily available if needed. A noninvasive suction device may be used to suction the infant’s nares without the danger of causing nasal trauma; the device may be connected to mechanical suction for best results. Older children can usually handle secretions without assistance. Postural drainage, CPT, and nebulized bronchodilator treatments may be prescribed depending on the child’s condition.

The hospitalized child may be apprehensive, and the treatments and tests are frightening and stress producing. It is important to involve the entire family in the care as appropriate and to encourage questions and facilitate effective communication. Allowing the child to be involved in regular activities such as quiet play may help reduce the anxiety of hospitalization and separation from friends and family. Reducing anxiety and apprehension reduces psychologic distress in the child, and when the child is more relaxed, the respiratory efforts are lessened. Easing respiratory efforts makes the child less apprehensive, and encouraging the presence of the caregiver provides the child with a source of comfort and support.