By C. Vidyashankar, MD
DELHI (Reuters Health) – A modification to the WHO algorithm for the management of childhood acute respiratory infections can help in differentiating infection from wheeze-related disorders–and in choosing appropriate empiric treatment in the primary care setting–according to a study from India.
The WHO-recommended case management protocol for children with difficulty breathing emphasizes treatment of pneumonia rather than acute asthma, Dr. H. P. S. Sachdev and colleagues write in the August issue of Indian Pediatrics. Since the incidence of asthma in children is on the rise, the management algorithm needs to be modified, they point out.
Dr. Sachdev and his team from Maulana Azad Medical College in Delhi performed clinical and radiological evaluations of 200 children, aged 6 months to 5 years, who presented with difficulty breathing. Nearly half of children were diagnosed with acute asthma, while pneumonia was the diagnosis in less than 10% of the children. Twenty-two percent of the children had a combination of pneumonia with bronchospasm.
From an analysis of the clinical data, they developed algorithms for treating children with cough and breathing difficulty. The algorithms included the presence or absence of audible wheeze, previous episodes of similar illness, and fever.
Application of these criteria to the study group made a significant difference in diagnosis and treatment of wheezing-related disorders, including acute asthma, compared with the WHO protocol. The researchers also noted that the use of these criteria ensured appropriate use of bronchodilators and reduced excess use of antibiotics by over 25%.
The researchers recommend that, in a child with cough and difficulty breathing, previous history of similar episodes or the presence of audible wheeze is an indication for use of bronchodilators. Presence of fever in this setting requires the addition of an antibiotic. Absence of audible wheeze and history of previous similar episodes in a child with cough and difficulty breathing is suggestive of pneumonia and requires starting antibiotics immediately.
Commenting on the use of bronchodilators in children less than 1 year of age, Dr. Sachdev told Reuters Health that trials are still in progress on the safety of aerosolized bronchodilators in primary care settings.
Dr. Paul J. Torzillo, from the University of Sydney in Australia, in a related editorial observes that "In regions with a high prevalence of wheezing illness, the specificity of the WHO pneumonia algorithms will be reduced, and this is likely to lead to some unnecessary use of antibiotics."
The modifications to the existing algorithms will improve the management of children with acute onset of wheezing, he adds. "The question of which children with wheeze can safely have antibiotics withheld remains a major question for further research."