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great. Thanks very much. Thanks, Hannah. Um, I looked at this lecture, and, as always, I've put probably far too much to get through, um, in an hour, because there was so much I wanted to tell you, but hopefully by the end of this, um, you will have some idea of the background and importance of acute respiratory infections in Children. The cause is, um, how to diagnose it. What investigations To use, um, how to manage and treat it. And, um, prevention and control. So this is not a completely exhaustive, um, presentation. Rather, the most important fact that you need to know and an approach to working out the rest. So let's look at pneumonia and acute respiratory infections. This is a huge burden of disease worldwide, and it is mainly concentration, the developing or resource constrained world. Um, if you look at under five mortality or understand why it's so important for those of us who are pediatricians, because with an under five mortality of one in 10 live births, two of those will die before the age of five from pneumonia and of the causes of pneumonia. Pneumococcal disease is the most important. Um, of the bacterial causes and RSV of the viral causes. So we're going to talk quite a bit about both of those and the importance of viral respiratory infections. It's not just because it causes severe disease and can and kill, but also because it predisposes to invasive bacteria disease. So, in fact, it's a double whammy that once you get a viral infection, even if it's mild, it will predispose you to potentially getting a really severe bacterial pneumonia that could kill you. So let's look at this a bit more closely and you'll see that in fact, pneumonia is, if anything, even more important, um, than those statistics. If you look at this pie chart, uh, 20% of deaths in the under fives are caused by pneumonia, um, and 37 by neonatal causes, and that's that is a grab bag of a number of different things. But if you break it down your disaggregated, you'll see that pneumonia is a subset, um, of neonatal deaths as well, and of neonatal deaths. A quarter of them are caused by sepsis slash pneumonia. So, in fact, um, if we look at under five mortality, about 30% is caused by, um, pneumonia. So let's look at what's happened over the years since 1990 up until 2019. Pre covid. And you can see that there has been a gradual decrease in mortality in the under fives. Um, from pneumonia, which is really good. But if you look at the absolute numbers were still looking at one million Children every year dying of pneumonia, Um, and that is really important. It's important to decrease that, um, and to do the best we can to limit that in order to improve the chances of Children and young people across the world once you get to five, uh, pneumonia is not such a big deal. Um, slightly more important when you are an adolescent and moving into middle age, Um, and then it increases again. This decrease in mortality started, um, a while back. But can some of it can be attributed to the introduction of vaccination against pneumococcal disease, which was introduced in this age group in the under ones. Um, in the two thousands, uh, it became W H O policy and recommendation in 2007, and today 100 and 48 of 100 and 94 countries are vaccinating their, um, neonate. They're babies against pneumococcal disease. So hopefully that will continue, um, to decrease mortality. So let's look at what other strategies on place to control the problem and how successful they've been because there has been limited success. But it's not the whole story. We're not there yet. We can't be complacent, and first and foremost is case management. But by the time you get to case management, you've really failed in the other strategies that you've put in place. So really, it's about looking at preventing low birth way to preventing malnutrition, both of which predisposed to severe disease, um, and death, uh, independently. But we'll make an ammonia much worse. Um, and the potential for death from pneumonia more likely optimize micronutrients. We've talked about vaccines, and what I'm going to spend a minute or so on is something that we don't really think about, uh at all, um, in most of our environments and in most of our medical schools. But it's really important in resource constrained settings and with a focus on climate change is becoming increasingly important. And those of you in the UK will know um, of the tragic case in Manchester of a two year old who died of, um, of respiratory disease, secondary to mold. And yes, that was chronic over time. But it just highlights the importance of indoor air pollution. Now, the majority of indoor air pollution is caused by smoke from biomass fuels, which are used in cooking and heating, um, in large parts of the world, and it causes pneumonia by a number of different methods. One is direct action of toxins on the respiratory tract in mucosa, which it damages, um, and therefore makes it more difficult to breathe. And it also affects the immunity and the ability of the respiratory tract to repel pathogens. And it reduces birth weight through its impact on placental circulation. If you think of the impact of smoking on placental circulation, smoke from indoor air pollution, biomass feels is no different. Now let's change tack and just talk about which respiratory infections are most important in this population, understanding the context within which they occur so we can divide them broadly into bacterial, viral, fungal and parasitic causes. With our viral and bacterial causes being most important, if you look at our bacterial causes. We have staphylococcus, which is causes severe disease, um, and streptococcus, of which pneumococcus is the most important. Um uh, of those we mustn't forget. Pertussis, which is decreasing, has decreased. Um, and in most parts of the world, uh, has almost disappeared, thanks to vaccination. Um, although it doesn't occur, and we mustn't forget that. And I've put in parentheses mycobacterium tuberculosis because it tends to cause more chronic disease, but is an extremely important cause, um, of mortality and death worldwide. And I'm sure that you're going to be having a lecture on TB devoted completely to TB. So it's here for completeness, rather than because I'm going to be talking about it. I can't do justice of our viral causes, RSV is probably the most important. Um, in terms of severe disease, we mustn't forget influenza. Um, Parit, which occurs, tends to occur around, um, winter time, Um, the end of autumn beginning of winter parainfluenza viruses, which we see in the spring adenoviruses, which we see, um, throughout the year, Rhinovirus, which, uh, is always touted as the cause of the common cold but actually can cause lower respiratory tract infections. Um, in, uh, Children, particularly in babies and measles. Measles is a hugely important cause of, um, pneumonia, both because it causes a viral pneumonia, which can be severe. Um, and almost universally, these Children have a brassy cough and some element of viral pneumonia, but also predisposes to severe bacterial infection. Um, not just because it damages the respiratory tract, but also because it suppresses the immune system. So again, um, a double double blow. I've included Pneumocystis Jiroveci A which, um, in the old days record PCP and your cl my slides. It's called PCP because it's an important cause, um, of respiratory infection that very often goes unrecognized. Um, when there are milder cases but in, um but can cause extremely severe disease. In immunocompromised Children, of which there are many across the globe, mainly immunocompromised through HIV and then we mustn't forget are parasites, of which malaria is the most important cause of respiratory disease. So let's have a look at viral, um, infections. And, um, don't worry too much about, um, about the graph itself. What I want you to see is the huge burden of RSV um, within the community. Um, and these this graph really has been divided into, um, the first half way there's not much are is where there was little testing in the community. Um, and in these countries, testing was done looking, um, specifically for viral pathogens. And, as you can see, the majority of the burden of respiratory disease. Viral disease in the community is caused by RSV. Samata is RSV. Let's talk about it's an enveloped RNA virus, and it's a paramyxovirus. And for those of you who came to the vaccine, uh, infection lecture that I gave a while ago, you'll recognize that measles is also a member of the paramyxovirus family are humans are the only source of infection It spread by droplets. It sticks to surfaces and normally occurs in the autumn and early winter and temperate climates. And I'm going to talk a bit about that in tropical climates that can occur any time. Virus shedding occurs from 3 to 8 days, which is important because it is, um, therefore infectious for that period, plus 2 to 8 days before um, symptoms occur, which is really important. And if you think it persists on surfaces for hours ago, gives you a feel for how infectious this actually is. Now Covid has really upended a lot of our, um, estimates and a lot of, uh, of the seasonality of different viruses, both through lockdown and, uh, through for other reasons. But we're now seeing RSV at different times of year. And when um, lockdown was eased in this country, we start to see RSV, uh, in the late summer early early autumn, which was rather strange And really, um, surprised all of us. There was a huge peak of that. So you need to think of RSV when you see, um, a severe, uh, lower respiratory tract infection in a young child. It does cause disease in all ages, but it manifests differently depending on the age of the child and the most important disease caused by RSV bronchiolitis in young infants and toddlers. Um, it causes upper respiratory tract infections and older Children and adults. And so it is an important cause of what we regard as the common cold alongside Run a virus. But we've seen again post covid really severe RSV infections in, um, the older age group and and adults. And that is important, um, when looking at your young child, because obviously interact with, uh, lots of adults, and therefore you need to be aware that passing on that infection can have a huge knock on effect for the adults around them and cause a various, uh, severe disease. You do get reinfection throughout life, Um, as evidenced by the fact you can get it as an adult. But what is really important in young Children is that it causes a hypersensitivity of the bronchi um, which can persist for up to a year. So what you'll find is that after an RSV infection, where, UM, a baby has had bronchiolitis every time they get another viral infection, there were wheeze, and that's because of the hypersensitivity caused by the initial RSV infection. And that's why, as pediatricians were quite reluctant to make diagnoses of asthma very early on, because a lot of these wheezy Children who wheeze with respiratory infections are suffering from the fallout of their RSV infection when they were babies or toddlers. Now, in the neonatal age group, um, they do not necessarily present as we would expect them to want them to are used to people presenting with respiratory diseases, particularly if we're used to dealing with adults. And, um, there are separate e symptoms might be minimal, but they'll be very lethargic. They'll be irritable. They would be feeding poorly, and they'll have apneic episodes. And again, for those of you who came to the diarrhea, um, lecture, you will notice that these are common to that as well. Uh, so it can be quite challenging to make a diagnosis and to determine exactly what is causing an illness in a child. When you look at them, what you what you'll see is an increased respiratory rate. They will be hot. Uh, and when you look at their chest, you'll see intercostal session. You'll see track your tug. You'll see nasal flaring, and I'm going to try and show you some pictures of those in a bit. When you listen to them, you'll hear crackles and wheeze in their chests, and there might be hyperinflated. Some of them do require oxygen, which again would then need admission to hospital. Now all young Children are vulnerable, but particularly vulnerable will be those who are premature. Those babies who might have been on ventilators or required, um, a lot of, uh, intensive care input in early life who have compromised lungs already. Those who have congenital heart disease or chronic pulmonary disease who are immunocompromised and then the elderly. And if you think back to the first graph I showed you, um, with an increase in death in in the elderly, the over seventies, that was almost the same, um, as in the under fives. So we mustn't forget that because they often live cheek by jowl, Um, in multigenerational families. So how how do we diagnose it? And a lot of this is historical. And a lot of this is not possible to do, um, in the majority of laboratories around the world, because the resources and the expertise is not there but for completeness, you can isolate the virus itself, which is very time consuming. And frankly, um, today very few people actually do that outside of a research setting. PCR is useful, particularly in immunocompromised, um, and tertiary settings where you would want to know how much virus is actually circulating. But in the majority of laboratories, you would use an antigen detection immune, a fluorescent essay, and you would use nasal pharyngeal aspirants. That's in those settings where you would, um, where you wouldn't make a presumptive clinical diagnosis. And there really isn't a treatment for this. You provide supportive therapy with oxygen. You might need to to feed them because they are using all their energy, uh, to breathe. And therefore, um will stop feeding. So that is really important to know and keep them hydrated. And it then becomes a self limiting disease. Um, over 5 to 10 days and they get better, and then we use every time they have a respiratory infection. In severe cases, we've tried ribavirin. We've tried, um, nebulized ribavirin. Um, intravenous ribavirin doesn't work that well. It is a huge half, and very few people do it, um, these days, because the results are not particularly good. So we really are very reliant on excellent supportive management in those babies who are most vulnerable, who are immunosuppressed. We would use prophylaxis. So we would use, um, Pahlavi, Eczema AB, which is a monoclonal antibody that is given just before the start of the season. Which is why seasonality is important. Um, and which is why, uh, it was so problematic when we had, um a, uh, spring and summer. Um uh huh. Uh, sorry. Um, Spike in RSV because that caught us unawares. And obviously we couldn't, um, prophylaxis those who are vulnerable. I'm going to show you a few x rays, um, of RSV. And as you can see in this x ray, you have hyperinflated lung fields. Here. You have some patchy consolidation throughout the lung fields, and I'm gonna go through these quickly. Um, and here you will have. You have, um, upper lobe pneumonic infiltrates. And this really just shows you the extent, um, and the heterogeneity of presentation, Um, with RSV infection. But there are other viral path pathogens that you need to consider. Influenza causes nonspecific symptoms and signs and can cause both upper and lower respiratory tract infections. Parainfluenza viruses 12, and three Course croup. Which you tend to see in the springtime. Um, and those those babies who come in, um, in at A and E. And it's very, very frightening, literally hooping because they are struggling to move I/O of a of a an inflamed, um, trachea and then measles. You get brassy cough, which is quite characteristic of viral pneumonia, um, and predisposes to bacterial pneumonia as well. Uh, not on this list. but should be as rhinovirus, which in young Children, um, and particularly babies can cause lower respiratory tract infections, even though classically, we think of it as a cold upper respiratory tract infection. And here's some pictures of Children with measles, and you can see they're very, very lethargic, um, irritable. And it is a really awful disease that can cause quite severe, um, pneumonia as well as a generalized illness. Now let's look at the most common cause of bacterial, um, pneumonia worldwide, and this is a map of pneumococcal disease. And as you can see, there's a huge burden of disease in, um in on the Indian subcontinent, Uh, and throughout Africa with less elsewhere in the world. But it is still important. It's a grand positive organism. It's encapsulated, which is important for vaccination, because it was quite difficult, um, to develop a conjugated um uh immunogenic vaccine for young babies, which has now been done. They're about 90 serotypes, which have been identified, but only seven of those will cause the majority of invasive disease. Um, and five of them are associated with penicillin resistance, so that's really important when treating these patient's, it is ubiquitous in the environment, there isn't a seasonality, so it can occur any time. And you can have colonization in the upper respiratory tract. Now, in about 15% of those who are newly colonized, uh, you will have invasive disease. Those who are most vulnerable, um, to severe invasive disease are the sickle cell patients', um, HIV patient's those with congenital immune deficiencies, cardiac disease, nephrotic syndrome, diabetes, Pommery disease. Um, sorry, Diabetes twice for those of you with sharp eyes. And it doesn't just cause pneumonia, it can cause meningitis. It is an important cause of otitis media and sinusitis. It can cause osteomyelitis, arthritis, endocarditis and cellulitis. So, um, it's a very successful pathogen. But when it causes pneumonia, what you see is fever. You see a a septic child and lots of systemic signs, and when you look more closely, you will find a lobar consolidation plus minus a pleural effusion. So how do you diagnose? And the majority of these need to be identified? Clinically, you can do a chest X ray. It's not going to tell you what the pathogen is, but it will tell you the extent and severity of your disease. Blood cultures are not particularly useful because it's an end organ disease and the and the pathogen is sitting in the lungs. Uh, the majority of cases you have very little that are circulating in your blood system unless they are septic as well. So you have low yield. The absence of pneumococcus and blood culture is not reason to discount it as the cause of your disease. Sputum is difficult to get from Children. Um, and the yield is low. So really, what you're left with is managing your illness dependent on the most likely pathogen based on your clinical judgment, how unwell the child is clinically and whether you think you should give IV or oral antibiotics whether you need to keep the patient in hospital or can manage them as an outpatient. And that's based not on the pathogen, but on how well or ill your patient is when you see them and we're going to talk more about how you do that. Now here's some pictures of pneumococcal disease. Um, here you have a severe Lobel ammonia. You have hyperinflation. Um, and what looks like the beginning of, um, Cavitation starting here. Uh, here it looks like we have an infusion and perhaps some collapse of that lung. And here you have again, some patchy consolidation, so it can present in a number of different ways, which is not always that helpful, Um, in determining how to manage your patient. Now let's change track, attack again and talk about PCP. Now, we think of this as a pathogen that is related to, um and is seen exclusively in the immunocompromised, Um, and an HIV patient's. But in fact, that's not the case. Um, you see it as an a sip. It occurs as an asymptomatic infection in a number of Children. Uh, and there was a study done in, um, Children who died of pneumonia in Sierra Leone and PCP was found in the lungs of 85% of them. Um, but in a lot of them had actually been, um, had been present, and they had died of other causes as well. But it is an important cause, um, of infection, uh, in the under two years of age. So, um, it's it should not be discounted. It's ubiquitous and mammal, so it doesn't just occur in humans, and it likes the respiratory tissue, particularly because so much of it is a symptomatic. We don't know how long the incubation period is. We don't use antifungals for it. It's resistant, like some of the other fungal infections that we see, particularly in South America. Um, and we'll talk about what we used to treat it. So in those that are symptomatic you have a fever. You have a non productive dry cough. They'll seem to be quite breathless at rest, uh, and breathe quite fast with, uh, markedly decreased oxygen saturations. And this is really a hallmark of PCP. Um, is that the, uh, low oxygen? Um, saturation seems almost out of proportion with the clinical presentation, and it is severe in those who immunocompromised classically, you see a bat swing appearance, but you can't rely on that. And you tend to have a diffuse interstitial al viola shadowing on your chest X ray. So how do you diagnose it? And you need to go high tech for this. You need, um, a, uh, an aspirate, a bronchia a viola lavage, uh, to get a decent lower respiratory, um, system, uh, sample or a lung biopsy. You make the diagnosis histologically. Um and all micro biologically and today we tend to use PCP, although on histology we can stain for it. So how do you treat it? It has a very high mortality rate and sometimes is co infected with CMV E. And what you need to do is two things. You want to decrease any inflammation associated with it, Uh, the disease, which can cause as much damage as the pathogen itself. So you would give steroids and you would give high dose trimethoprim sulfamethoxazole So, uh, co-trimoxazole or Bactrim, um, you would use. And in those with milder disease, you can use that orally. There are alternatives pentamidine, which is a very clumsy and difficult drug to use because it has to be nebulized. Um, and you can use atovaquone, which we, um, associate much more with the treatment of malaria. And dapsone can be used in those patient's who have allergies. So here we have, um, a diffuse alveolar pattern, which is quite characteristic of PCP. Um, and again, you see widespread al Viola involvement in this chest X ray. I'm sorry. It feels like a cook's tour through, um, different types of, um, respiratory infections. But we've come to the last, um group, which is our parasites. And of those malaria is the most important. And respiratory complications occur in severe malaria. Um, and what you get is, you get a cough, you get palm, no edema, and you get respiratory failure and metabolic acidosis. So really, um, your respiratory symptoms are secondary to the severity of the malaria and to the other disease. Um, the generalized disease that is occurring. So sorry. Um, nobody's somebody's answer that, Um So how do we recognize it? How do we recognize, um and make this diagnosis? You have to have a high index of suspicion If you're working endemic or epidemic areas. Um, there's no point in making a diagnosis or considering it if there is no malaria in the region that you work, um, so and you need to remember to major killer of Children under four. Um, all Children under former spear regarded as non immune, and you would do a malarious mayor in order to find it. So if you think back to what I've shown you, you have a number of different pathogens that can cause very similar symptoms and signs, um, with chest X rays that depending on your level of expertise and interpreting them can be helpful. But again, they're not definitive. They can point you in a direction, but they won't give you a definitive answer. Uh, microbiological diagnoses, um, and techniques are imperfect. And so therefore, what you're left with is your clinical judgment and making decisions based on putting together all those different pieces of information you have and looking to see. Um, what the most likely cause would be based on that which is quite an ask, um, of a lot of people. And even when you're you're experienced, it is quite difficult to make that call. So what you want, um, in order to help you is first you determine how severe the disease in this child is. You want to have defined the specific signs they're presenting with not just respiratory, but all the other signs that would point you in one direction or another. Think about what diseases are occurring in your particular community that you're working in, both in gen. And at that particular time of year. So you need to think about season and seasonality. What is the age of the patient? Which of those different pathogens are they going to be more susceptible to based on their age. And then you want to think about your very specific patient in front of you. What are their susceptibilities? Is this a malnourished child? Is this a child with HIV? Is this a child who has another underlying immunodeficiency or congenital cardiac disease? Um, what do you need to think about? Uh, is this a child with sickle cell disease? So you need to add that to the mix, and then you need to think about who they've been in contact with. Who do they live with? What kind of an environment are they exposed to and who else in their immediate vicinity is unwell? And what are they unwell with? So how do we start unraveling this? We need to take a history first and foremost and gather that information in order to make a judgment. How long have they been ill? That might give us a clue. Contacts, coinfections. And we've been through this immunization status again. Some things will be more or less likely depending on what they've been immunized with. And then let's look at the symptoms. What is the pattern of fever? How long have they had a fever for. Are they lethargic? Um, what kind of cough do they have? Are they sweating? Um, and if so, how long has that been happening for? Has there been weight loss and loss of appetite? Uh, do they have pleuritic pain? And this is really important when you're thinking about bacterial disease because our bacterial infections can cause plural effusions, which can cause pleuritic pain. And then you want to look at them and see how they are breathing are they is their stride or, um, and that is a high pitch sound caused by the difficulty in moving air back and forth across swollen vocal cords. Are they grunting? Which is, um, what they need to do in order to help move air I/O of there. Um, respiratory, uh, tree, Are there hooping, which is characteristic of prosthesis but can also occur in Edna virus infections. And then what you need to do is stand back and look, and this is really important with young Children, and it's quite difficult for us as medics to do because we feel that we have not completed an examination until we've laid hands on on our patient, and we've put a stethoscope on them. But with Children, it's different because, um, you gain a huge amount of information by just looking at your child. In fact, far more information than you do by laying hands on them once you lay hands on them, you have a potential for a screaming child, Um, which means that not only can you do you mask a lot of the signs that you would see if you observe, but you also won't be able to hear any abnormal signs in the chest because they're screaming. Um, and there's very little to find on percussion, particularly in small Children, because, um, those the dullness can resonate or lack of dullness can resonate throughout the chest. Um, so our normal parameters for examination, which we would use for um for adults are not all as useful in Children. So let's think about what we would observe if we just looked at a child and there's an enormous amount. When you listen, you will hear granting. You will hear stride, or you will hear cough and you will hear whoop, All of which will give you a clue as to what the underlying pathology is and what you would need to do to manage that child effectively. Then you would look at them. And what would you see? You might see nasal flaring, which is a sign of distress. Trachea tug, Um, the use of accessory muscles into costal recessions, seat or breathing, which is end stage, Um, pre, uh, mortal. You would be able to count the respiratory rate, which is important, and pick up any cyanosis, any blueness, Um, in that child and head nodding, which is also a sign of extreme distress. Now, I have some pictures here which are not, um, wonderful, but I can point out what you would look like Look for. So if you see with the eye of faith um, the nasal flaring here, So you get you get your, um your Nair is that that go I/O. So you would you would see them moving I/O, I/O so you would look at that part of the nose, which would be nasal flaring. You would look at the trachea here and you would see an in drawing of that at that point. What you see in severe respiratory disease This is a better picture intercostal session. Now the muscles are the skin is thin and muscles are close to the surface, as are the ribs. And if you see this baby, their muscles between all the ribs and what happens when you have severe disease is that those muscles have to work really hard. And you see that you see them being drawn in with every breath the child takes, which is not normal and is a sign of distress. Likewise, you'd see sub cost or recessions if you look under the rib cage. Um, and particularly at those iffy sternum, when a child is working very hard to breathe that you will see that going I/O, Um, and will be very prominent again with the eye of faith. You would look for the accessory muscles here, the sternocleidal muscle, um, sternocleidomastoid muscles, which become very prominent, and you would see them being tensed and released, uh, in a baby who is working very hard to breathe. And then, if you feel absolutely moved to it, um, you can continue feel for a pulse. Um, and you would have tachycardia in a in a child with severe disease who is possibly, uh, septic and an older child. You might be able to elicit downers, Um, and the stony of a consolidation of the stony donors of a clearly fusion. Um, but that would be in an older child. It's unlikely you would be able to pick that up in a small child. Um, when you auscultate, you might hear decreased breath sounds because of a pleural effusion. Importantly, no breath sounds if there is a pneumothorax, which you also should be able to pick up on your percussion, which would be the major reason to do either of these parts of the examination. And then you might get increased breath sounds in bronchial breathing, which, um, suggest consolidation. And of course, we, um, which is the easiest sound to hear. But you'd very often, uh, here it without the benefit of a stethoscope, because Children will often have an audible. We's. So how do you make sense of this? How do you put this all together? How do you, um, even begin to make a decision about what is going on with your patient and how you're going to manage it? And now I'm going to talk about something that I did talk about. I think during the day really lecture because I'm a big proponent of it and I don't think we focus on enough. But really, the I N. C. I philosophy, which is the integrate management of childhood illness, is something that is used in resource constrained settings. But really, um, in some way summarizes the way we function almost subconsciously when we have a great deal of experience. This is really breaking down what we do and how we think and how we approach a child with an infection. And really, it's about improving, um, your ability to assess a child's illness and to manage them without a lot of, um, technology and to use your skills and your knowledge and your brain, um, but also provide those who are less experienced, um, with a structure within which to think, um, and in which to approach your patient. So the rationale for this is there's a very high burden of disease and under fives, and there's an unequal distribution in mortality rates. So it's a symptomatic approach, which is basically common sense. It's effective. It uses resource as well, and it helps to standardize care. Now, this is a W h, o and, um, UNICEF tool. So you can download it from the websites, um, and have a closer look at it in your own time and a leisure, which I think is worthwhile. Um, I'm going to do a bit of a rush through it because I only have 15 minutes to, um, finish talking to you. So it really is about improving health care for Children, increasing access to timely treatment and management, increase the recognition of severe illness, um, and decreased child mortality and also morbidity. So it helps to classify illness, decide what's going on and decide how you're going to treat Children as well as involving those people who are looking after them. And looking after Children is different to managing adults because you're managing not just the child, but you're empowering the caretakers who will be responsible for them when they take them home, um, and will help with that in hospital and by educating them. You can help the recognition of illness earlier, um, and encourage caretakers to bring their Children, um, to healthcare earlier on in their illness, so it targets the under five age group and we talked about most of this. Um, So what does it do? It looks for general danger signs. And we've already talked about the fact that a lot of different types of illnesses will present in Children with the same types of signs. Um, and those are signs and symptoms that really just tell that's how ill or otherwise that child is. Um, you need to know nutrition status, an immune status. Because that also will inform, um, how you treat that patient and how quickly you can expect them to get better. Um, and of course, feeding issues will give an indication of severity. So I'm going to show you two pictures, Um, which really illustrate the point. So this is the first one. And, um, I don't know whether anybody wants to chip in, Um, and this is the second one. And this really is the first decision that you make and the first observation and judgment call that you will make, um, as a clinician, which is how ill or otherwise is your child. Now you can see that child is lying in its mother's arms. It is lethargic. You can see there's some un enjoying, um, sub cost or in drawing, and this child just looks unwell. Take it back. That child doesn't look particularly and, well alert, Um, allowing an examination sitting on its mother's lap pretty comfortable. So there's a big difference between those two Children, which is the first distinction that you're going to be making regardless of the underlying disease. And then you're going to make a decision about whether this child needs inpatient care, urgent care or whether this can be managed at home, a specific treatment or sent home with some advice. Um, and I'm not going to belabor the point. But this is, um, one of the algorithms that you can work your way through, uh, traffic, using a traffic light system to help you determine that, um, this is the particular pneumonias related one, which really walks you through the symptoms and signs that you need to be looking for and how to classify them as severe, moderate or mild, and then looking again. If you're in a malaria area at the risk of malaria, um, and looking for underlying vulnerability such as malnutrition and anemia, which will make your outcome worse and means that you might, uh, need to classify a child slightly differently. So what this really does is it helps. Um it's a tool that helps your clinical judgment. It helps you to make decisions with limited investigations, um, and according to local circumstances, and you want to keep the child safe Now, um, going back to, uh to that and to making a decision about whether to give antibiotics or not. Um, there are limited antibiotics that are available in most parts of the world, and co-trimoxazole is probably one of the one of those that is used most commonly, which would treat your bacterial infections, um, as well as your PCP. So you can make a decision, um, without necessarily knowing what the underlying bacterial pathogen is. Um, as long as you have a reasonable idea that it is a bacterial pathogen which you would do so Pneumoniae A really remains the most important cause of illness and death for Children around the world. Um, despite vaccination, we still have a long way to go. And it's quite sobering as healthcare professionals to realize that even, um, with all our skills, really what we are seeing when we see a sick child is the failure of a number of other systematic, um, public health strategies that have failed. So if we want to improve our mortality from pneumonia, we need to improve nutrition. We need to improve housing. We need to, um, provide vaccinations. Now, I've skimmed over pneumococcal vaccination, but that was a really, really important introduction into the global vaccination schedule, which has had a huge impact on the number of deaths from pneumonia worldwide. The Holy Grail now of vaccination, um, is a vaccine against RSV, which is the most important respiratory cause of morbidity and mortality in young Children. Um, and that is something that is the subject of a great deal of research. Uh, we do have a very, very new malaria vaccine, which is starting to be rolled out across parts of the world. Um, and we have yet to see the impact of that in the under fives. But, um, it is a very exciting advance, uh, and look forward to being able to share that information in a few years' time. So, um, really, what we need to do as medical professionals is to deal, um, with the Children who come to us hopefully in smaller numbers. Um, who despite, uh, everything else have become unwell. I am going to, um so thank you. I rush that slightly more than I needed to. So any of you who would like to ask questions, please do. I can see some in the chat? Um, I think there's no questions in the chat. Okay. Any questions from anyone? Okay, I either put everybody to sleep or answered every question. Um, anyone else? OK, somebody said could I repeat management? Um, I'm not sure. Uh, management of what? But I think, um, let me take you back then to some of, um sorry. Uh, let me get rid of the chat, okay. Management in general. Okay, let's let's have a look at that. Um, I think it's very difficult what you need to do broadly in terms of management when your child comes. Um and that's why I wanted to show you, um uh, the I M c I, um algorithms, because I think these are very useful when you have a child who comes, um, to see you. The first assessment you need to make is how unwell is this child? Now, the most important part of this is standing back and looking at your patient. So what you want to do is say, um what are the danger signs and what clues are there that will point me in the direction of which system, um, is most affected. And I should, um, focus on. So for pneumonias to you would stand back, you would look at your child and you would say, Okay, is this child breathing fast? And if so, how fast? And you would count the number of breaths. Is this child lethargic? Does this child have a fever? Um, is this child irritable? Is this child, um, having difficulty in breathing? So you would need to look at all of those things. Now, Children who are breathing very fast choose to breathe rather than to eat. Um, so that's something that you need you need to be aware of, and it's an indication of severity of disease. Then you would say, Is this child coughing? Um, and does this child look septic? Because that will help you to decide whether it's more likely to be bacterial or more likely to be viral. Now, if a child has a cough or has a woop but has normal oxygen levels. So and sometimes you might not be able to measure, but who looks pink? Doesn't look particularly unwell. Like the first child I showed you in. Um, in that picture, Um, then you would say right. It seems this child has an infection. A respiratory infection. The respiratory rate is our, um, but they don't have nasal flaring, then don't have a trachea tug. They're not using accessory muscles. Um, they're just breathing a little bit faster. They've got a bit of a calf. They've got a mild temp, which is this is most likely viral. So I'm going to advise the patient's, um, to support of therapy. Just make sure the child has plenty to drink. Um, plenty to eat. Um, and this should settle on its own within, um, the next a few days if the child becomes unable to eat. If the child looks uncomfortable, if the child is breathing very fast or breathing, um, or making a lot of respiratory sounds and noises that indicate, um, uh, the child is having difficulty breathing. Then bring that child back. If the child sitting in front of you has got nasal flaring. Um, isn't eating. Isn't drinking? Is using intercostal muscles is breathing very fast, has a fever. Then that is a child you need to consider, um, starting, uh, making a decision. About what? Whether it's more likely to be bacterial or viral. You would want to do an X ray. Yeah. Um, you might hear bronchial breathing. Um, you might see a consolidation, and then, um and you would have a child who looks a lot more septic. And that's a child. Who you would say, Right, I'm going to give this child antibiotics because it looks like, um and is behaving like a bacterial infection. Um, you have a number of choices. Um, pneumococcal disease is the one that is most common and is the one you would worry about most. So what you would want to do is give an antibiotic that would, um, cover pneumococcus, which is often, um, not susceptible to penicillin. So you would use something like flu cloxacillin or clindamycin or co-trimoxazole. Um, if you feel it is a a viral infection, um, your child is wheezy. Um, has an oxygen requirement is not feeding. That child would need to be admitted. Um to hospital for oxygen for tube feeding, Um, and supportive therapy, Um, through that. So you need to to make those distinctions. And I think that the difference between bacterial and viral infection, which can be quite difficult to make, is, um, the degree of fever and other signs of, um, of sepsis. So and those patients' you would need to treat urgently, um, with antibiotics as well as supportive therapy. Those Children who have respiratory symptoms only are more likely, um, and and milder are more likely to have a viral. But it is. It's a difficult decision to make, which is why this particular tool is so useful. And I think even if it's not used as such, um, in settings with, um, more resources, it still is a very good, um, structure and approach to the SEC child and approach the child with pneumonia That will give you the confidence to know that you have, um, you have an approach to managing the child and differentiating between the different types of, um, infection and making a decision. That's an appropriate decision. But it's, um it's not necessarily straightforward or clear cut with every child. Um, and I think that, you know, as you develop experience, those Children have bronchiolitis are very obvious. They come and wheezing. They come in with intercostal session, purely respiratory symptoms and signs, perhaps with a little bit of fever. And they're not not feeding, um, in the middle of, um, of sort of late autumn. Um and, you know, it looks and feels, um, like RSV. And then, of course, you can do your your nasal aspirate and confirm that, um, you have laboratory. Yeah. Sorry, Doctor. We do have a lecture in starting one minute. Okay, Um, apologies. Right. So I hope that answered your question on management. Sputum does can differentiate between viral and bacterial pneumonia if you actually, um uh if your culture it if you do immuna essays, But it's quite difficult to look at sputum and say, Okay, this is green sputum, and therefore it's bacterial. Um uh, rather than viral, because you certainly can get green sputum with viral infections. Thank you very much, Doctor, for your lecture. Um, I am going to stop the