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Cough - acute with chest signs in children - Management
How do I assess a child with a respiratory tract infection and chest signs on examination?
The management of a child with a respiratory tract infection and chest signs on examination requires an assessment to determine:
- The underlying condition: bronchiolitis, pneumonia, viral-induced wheeze, or an infective exacerbation of asthma. See Determining the cause.
- For children with distinguishing features of asthma, see the CKS topic on Asthma.
- For children with viral-induced wheeze, and children presenting for the first time with wheeze in association with a respiratory tract infection when the diagnosis is uncertain, see Viral-induced wheeze or possible asthma.
- The level of risk to the child is outlined in Table 1:
- Risk is higher in infants who are young or who were premature, and in children with any significant past medical history, such as chronic lung disease or congenital heart disease. This additional risk must be considered when using the assessment in Table 1, and the overall risk adjusted according to clinical judgement.
- If any single feature of high risk is present, consider the child to be at high risk.
- If any single feature of intermediate risk present, and none of high risk, consider the child to be at intermediate risk.
- If no features of intermediate or high risk are present, consider the child to be at low risk.
- The ability of the child's carers to cope with the ill child.
Table 1. Assessment of risk in a child with a cough and signs in the chest on examination.
| Intermediate risk | High risk |
|---|
Respiratory rate (RR) | Age < 12 months and RR > 50/minute Age > 12 months and RR > 40/minute | RR > 60/minute |
Other respiratory features | Nasal flaring Crackles (pneumonia or bronchiolitis) Oxygen saturation < 95% on air* | Apnoea or grunting Moderate or severe chest indrawing Oxygen saturations < 90% on air* |
Colour | Pallor reported by parent/carer | Pale/mottled/ashen/blue |
Activity† | No response to normal social cues† Awakes only with prolonged stimulation† Decreased activity† | No response to social cues† Unable to be roused, or if rousable does not stay awake† Appears ill to healthcare professional† |
Hydration/feeding | Poor feeding in infants (less than 50% of normal fluid intake in preceding 24 hours) Dry mucous membrane Reduced urine output Capillary refill time > 3 seconds | Reduced skin turgor |
Temperature | Fever > 5 days duration | Age < 3 months and temperature > 38°C Age 3–6 months and temperature > 39°C |
* May not be available in primary care. † Activity and appearance are highly subjective and are considered poor markers of severity by some experts. |
|
Clarification / Additional information
Assessment of severity:
Assessment of carer's ability to cope with an ill child:
- Assess the carer's experience, their level of anxiety, and the time thay have available to care for the child.
Basis for recommendation
- The recommendations contained in the table have been adapted from the National Institute for Health and Clinical Excellence (NICE) traffic-light system for identifying likelihood of serious illness in a feverish child [National Collaborating Centre for Women's and Children's Health, 2007]. The NICE recommendations are based upon a number of cohort studies that have reported on the relationship between individual symptoms, signs, and a combination of symptoms and signs, in predicting the likely presence of serious illness in a child with fever.
- These recommendations have been adapted by:
- Omitting elements of the NICE assessment that are not relevant to a child with a chest infection.
- Incorporating specific assessment recommendations relevant to a child with bronchiolitis from the Scottish Intercollegiate Guidelines Network [SIGN, 2006].
- Incorporating specific assessment recommendations relevant to a child with community-acquired pneumonia from the British Thoracic Society [British Thoracic Society, 2002].
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