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Suggest treatment for repeated upper and lower respiratory tract infection and ear infection

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Posted on Mon, 2 Jun 2014
Question: Hello, my son is 10 year old premature birth at 36 weeks. Was born with a PFO which closed, but he has a sub aortic membrane and now they have found blockage at the valve also. He also has mild non allergic asthma but is allergic to Hay and Ky bluegrass. He has always had this problem with coughing. I mean he will cough for 2+ hours straight. When he coughs his ears get very red and the doctors keep putting him on prednisone, antibiotics, solu-medrol nebulized inhaler, pro-air, benzonotate and now they have given him narcotic pain med to stop the coughing at night so we can get him to school since he has missed almost 30 days due to his coughing spells. They start with a runny nose and are precipitated by sickness. He has bronchomalacia, tracheomalacia and laryngomalacia. But what could be causing all this coughing? Our home is in an uproar because no one is sleeping. We have propped his bed six inches. Also these attacks only happen at night. He had a severe pneumonia this year. He usually gets it every year, and in the last 2 months has had 2 ear infections which have just begun. We are taking him to an ENT next week but I hate the idea of narcotic medicine to stop this and to get him to sleep because once he is asleep the coughing stops and not a peep. I also hate all the steroids. This last round he has had 2 antibiotics and 2 rounds of prednisone. The round before he did 3 different antibiotics and prednisone. He is also taking singulair for allergy.
doctor
Answered by Dr. Deepak Kishore Kaltari (58 minutes later)
Brief Answer:
To Rule out primary ciliary dyskinesia

Detailed Answer:
Hi
Welcome to Healthcare-Magic
Greetings of the day

Dear Ms,

Being a parent myself I understand your concern and apprehensions.

As the child is having repeated upper and lower respiratory tract infection along with presence of ear infection( I assume it could be otitis media that is infection of middle ear cavity, I would consider the possibility of following

1. Primary Ciliary Dyskinesia
2. Aspiration from Gastro-oesophageal reflux
3. Allergic Rhinitis/Bronchitis.


I)
In my opinion I would Consider Primary Ciliary dyskinesia more likely and rule it out. Primary ciliary dyskinesia (PCD) comprises those respiratory disorders having in common the malfunction of airway cilia. The abnormality results from various inherited primary structural defects in the cilia that lead to repeated and chronic lung and sinus infections. The ciliary malfunction in PCD is not a result of acquired repeated pulmonary infections, conditions in which the ciliary abnormalities revert to normal, unlike in PCD.
The clinical presentation of PCD: Individuals with PCD may have unexplained respiratory distress during the newborn period or may survive to adulthood without overt chronic sinusitis and airway disease symptoms. In one study of PCD, 100% of children had productive cough, sinusitis, and otitis. Many present as neonates with nasal congestion, rhinitis, and cough.
As the child is having repeated nasal congestion, cough and otitis I would consider it one of the important differential diagnosis for the symptoms.

II): Aspiration of gastric contents in the airway could lead to hypersensitivity of the airway and cause repeated Lower respiratory tract infection . The presentation of night cough could also suggest diagnosis of gastro-oesophageal reflux

III) Allergic: Possibility of allergic sinusitis/ cough also needs to be considered.

I would suggest you discussing these probabilities with your son's Pediatrician and rule out these as the cause.

In the meantime I would suggest the following



1. Steam inhalation: It will be a good habit to cultivate. Steam inhalation for 10-15 minutes each session twice a day. Give it regularly even if she is alright. It helps reduce nasal congestion and also clears the nose. You can buy a good quality electronic steamer
2. Monticope suspension: It has antihistaminic and mast cell stabilizer which will help reduce airway hyper reactivity and reduce the incidence of future attacks. It has to be used for 4- 6 months after which it can be stopped. 2.5 mg of Montelukast once daily
3. Wash the bed sheets pillow covers and cloth of baby in hot boiling water: It will remove the dust , mites and allergic substance present in it.
4. Decoction: To a cup of milk + 20 tulsi leaves( Holy basel)+ 1 spoon of turmeric + small piece of ginger + 4 black pepper + 2 spoon of sugar. Bring it to boil. Filter it and feed her warm daily. It will reduce airway congestion and also Tulsi will boost immunity. Depending on your geographical location holy basel may or may not be available
5. Chyawanprash : 1 teaspoon twice a day will be beneficial to build up immunity
6. Himalaya Septilin syrup 5 ml twice a day will also boost immunity. Continue giving her for 3-4 months.
7. Chest Physiotherapy
8. Head elevation while sleeping

Do get back to me for any further assistance, will be glad to assist you.
Do keep me updated

Take Care
Best Regards
Dr Deepak Kishore
MBBS,MS,MCH
Consultant Pediatric Surgeon

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Deepak Kishore Kaltari (10 minutes later)
It may have been misleading . My son is 10 years old and this has been going on since birth, beginning with croup diagnosis, pneumonia, asthma etc. The cough only starts when he gets a cold. But now he is developing ear infections as well and all these meds they put him on , he ends up being on them for 3 weeks or more till the cough goes away. When he gets a runny nose, or sore throat, I know I am in for it for approx. a month of coughing which is a non-productive cough and seal like barking cough. Very deep chested cough. My son does take Prilosec 2 x a day. He is also propped six inches and the coughing is mostly at night. His epiglottis is omega shaped. At age of 2 mos. he had stridor and was rushed lifeline by helicopter while we were on vacation to a hospital and was given epinephrine which quieted him and allowed us to get him home at that time. But for 10 years now we have been dealing with this and nothing seems to help.
doctor
Answered by Dr. Deepak Kishore Kaltari (7 minutes later)
Brief Answer:
Primary ciliary dyskinesia needs to be considered

Detailed Answer:
Hi
Greetings

That is the reason I have mentioned that Primary Ciliary dyskinesia has to be strongly considered and ruled out as the cause.especially with the history dating back to neonatal age group. As nothing seems to have helped, I would suggest you to consider this probability and discuss it with Pediatrician. Laryngomalacia/bronchomalacia could be contributing factors, but the symptoms attributable to them improve with growing age.

I would also require additional information
1. What re the X ray findings?
2. Has CT scan be done?
3. Was the child evaluated for Gastro-oesophageal reflux?


Awaiting your reply

Take Care

Regards
Deepak
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Deepak Kishore Kaltari (4 minutes later)
Yes he has mild reflux and does take the Prilosec 2 x a day. His last chest xray showed retrocardiac infiltrate/atelectasis which was also found at age 4 along with his heart condition. NO CT has been done recently altho he may be getting one when we see the ENT at Children's on May 22. My son is also overweight and we are working with a nutritionist to help him lose the weight he gained from all the steroids they keep putting him on.
Before this last round of 2 antibiotics , he had the cough so bad, they did 4 antibiotics and 3 rounds of prednisone which was 3 months ago. WE also live at an elevation of 8000 feet in Colorado. Planning a move to Arizona where its drier hoping to help him...and get to a lower elevation.
doctor
Answered by Dr. Deepak Kishore Kaltari (33 minutes later)
Brief Answer:
Will require further investigation

Detailed Answer:
Hi
Greetings

I come across such patients and I routinely document the severity of reflux and also demonstrate reflux into tracheobronchial tree.
He would require following workup/investigation

1. Workup for Primary ciliary dyskinesia
2. HRCT (High resolution Computerized Tomography)
3. Tube Oesphagogram and Barium swallow study to document reflux grading and reflux into tracheobronchial tree
4. Immunology study to rule out Primary immunodeficiency
5. CT scan of Para nasal sinus and Mastoid and middle ear cavity.


It would be very helpful if you could discuss this with your Physician and plan accordingly.
Do start warm saline gargling and steam inhalation. I am quite sure it will provide much relief.

Keep posted.

Wishing you and your family a very happy and healthy life.

Take care
Best Regards
Deepak
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Deepak Kishore Kaltari

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Practicing since :2002

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Suggest treatment for repeated upper and lower respiratory tract infection and ear infection

Brief Answer: To Rule out primary ciliary dyskinesia Detailed Answer: Hi Welcome to Healthcare-Magic Greetings of the day Dear Ms, Being a parent myself I understand your concern and apprehensions. As the child is having repeated upper and lower respiratory tract infection along with presence of ear infection( I assume it could be otitis media that is infection of middle ear cavity, I would consider the possibility of following 1. Primary Ciliary Dyskinesia 2. Aspiration from Gastro-oesophageal reflux 3. Allergic Rhinitis/Bronchitis. I) In my opinion I would Consider Primary Ciliary dyskinesia more likely and rule it out. Primary ciliary dyskinesia (PCD) comprises those respiratory disorders having in common the malfunction of airway cilia. The abnormality results from various inherited primary structural defects in the cilia that lead to repeated and chronic lung and sinus infections. The ciliary malfunction in PCD is not a result of acquired repeated pulmonary infections, conditions in which the ciliary abnormalities revert to normal, unlike in PCD. The clinical presentation of PCD: Individuals with PCD may have unexplained respiratory distress during the newborn period or may survive to adulthood without overt chronic sinusitis and airway disease symptoms. In one study of PCD, 100% of children had productive cough, sinusitis, and otitis. Many present as neonates with nasal congestion, rhinitis, and cough. As the child is having repeated nasal congestion, cough and otitis I would consider it one of the important differential diagnosis for the symptoms. II): Aspiration of gastric contents in the airway could lead to hypersensitivity of the airway and cause repeated Lower respiratory tract infection . The presentation of night cough could also suggest diagnosis of gastro-oesophageal reflux III) Allergic: Possibility of allergic sinusitis/ cough also needs to be considered. I would suggest you discussing these probabilities with your son's Pediatrician and rule out these as the cause. In the meantime I would suggest the following 1. Steam inhalation: It will be a good habit to cultivate. Steam inhalation for 10-15 minutes each session twice a day. Give it regularly even if she is alright. It helps reduce nasal congestion and also clears the nose. You can buy a good quality electronic steamer 2. Monticope suspension: It has antihistaminic and mast cell stabilizer which will help reduce airway hyper reactivity and reduce the incidence of future attacks. It has to be used for 4- 6 months after which it can be stopped. 2.5 mg of Montelukast once daily 3. Wash the bed sheets pillow covers and cloth of baby in hot boiling water: It will remove the dust , mites and allergic substance present in it. 4. Decoction: To a cup of milk + 20 tulsi leaves( Holy basel)+ 1 spoon of turmeric + small piece of ginger + 4 black pepper + 2 spoon of sugar. Bring it to boil. Filter it and feed her warm daily. It will reduce airway congestion and also Tulsi will boost immunity. Depending on your geographical location holy basel may or may not be available 5. Chyawanprash : 1 teaspoon twice a day will be beneficial to build up immunity 6. Himalaya Septilin syrup 5 ml twice a day will also boost immunity. Continue giving her for 3-4 months. 7. Chest Physiotherapy 8. Head elevation while sleeping Do get back to me for any further assistance, will be glad to assist you. Do keep me updated Take Care Best Regards Dr Deepak Kishore MBBS,MS,MCH Consultant Pediatric Surgeon