CKS is no longer commissioned by the National Institute for Health and Clinical Excellence (NICE). NICE remains committed to providing a replacement service for CKS and is currently reviewing its options. In the meantime, although CKS content is now not being maintained, it still remains relevant and will continue to be made available. CKS content was generated under a programme of topic creation and update. To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?' link in the left hand menu on individual topic pages.
Cough - acute with chest signs in children - Management
View full scenario
Introduction
- Bronchiolitis is a seasonal condition, predominately seen in infants less than 12 months of age, caused by a viral infection. It is characterized by fine crackles throughout the lung fields, an increased respiratory rate, and in some infants by wheeze.
How do I assess a child with a respiratory tract infection and chest signs on examination?
- A child is considered to be at high risk if any of the following features are present:
- Respiratory rate (RR) > 60/minute, apnoea or grunting, moderate or severe chest indrawing
- Oxygen saturations < 90% on air
- No response to social cues, they are unable to be roused, or if rousable they do not stay awake
- Appears ill to healthcare professional
- Reduced skin turgor
- Age < 3 months and temperature > 38°C, or age 3–6 months and temperature > 39°C
- A child is considered to be at intermediate risk if they have no high risk features and have any of the following features:
- Age < 12 months and RR > 50/minute, or age > 12 months and RR > 40/minute, nasal flaring, crackles (pneumonia or bronchiolitis)
- Oxygen saturation < 95% on air
- Pallor reported by parent/carer
- No response to normal social cues, awakes only with prolonged stimulation, decreased activity
- 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
- Fever > 5 days duration
- A child is considered to be at low risk if no features of intermediate or high risk are present.
- Note: risk is higher in young infants, infants with syndromes or who were premature, and in children with any significant medical history, such as chronic lung disease or congenital heart disease. These additional factors should be considered before deciding on the level of risk.
- Assess the ability of the child's carers to cope with the ill child.
In depth
How do I manage an infant with bronchiolitis?
- Infants with bronchiolitis and any high risk features — admit immediately.
- Infants with bronchiolitis at intermediate risk — consider hospital assessment. The threshold for arranging this should be low. Arrange hospital assessment if:
- The infant was born prematurely, or has any significant health problems such as chronic respiratory disease or congenital heart disease.
- The carers are not able to cope with the ill child.
- There is any deterioration in the child's condition.
- Infants with bronchiolitis at low risk can be managed at home.
- For children managed at home, antibiotics and bronchodilators are not recommended. Advise carers that bronchiolitis is a self-limiting condition but occasionally children deteriorate. Advise checking on the child regularly, including through the night, and to call a doctor if they are unable to cope or if the child deteriorates, in particular if:
- Breathing rate increases, or if there are any episodes of apnoea or signs of increased effort of breathing.
- A baby takes less than 50% of its normal feeds, there are signs of dehydration such as dry mouth or infrequent passage of urine.
- A baby becomes less responsive or difficult to rouse.
- There is persistent worsening of fever.
In depth
What self-care advice should I give to a carer of a child with viral-induced wheeze, bronchiolitis, or pneumonia?
- Treat a child who is feeling miserable due to fever with either paracetamol or ibuprofen. Do not try to reduce fever by under-dressing the child or by tepid sponging.
- If there is a lack of effect with one treatment alone then consider alternate use of ibuprofen and paracetamol every 4 hours.
- Encourage the child to take fluids regularly. Continue breastfeeding as normal.
In depth
Table: Risk assessment of a child with a respiratory tract infection
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. |
- A child is considered to be at low risk if no features of intermediate or high risk are present.
- Note: risk is higher in young infants, infants with syndromes or who were premature, and in children with any significant medical history, such as chronic lung disease or congenital heart disease. These additional factors should be considered before deciding on the level of risk.
- Assess the ability of the child's carers to cope with the ill child.
Prescriptions
Analgesia/antipyretic: use when required
Age from 1 month to 2 months
Paracetamol s/f susp: 30 to 60mg up to three times a day
Paracetamol 120mg/5ml oral suspension paediatric sugar free
Take 1.25ml to 2.5ml every 8 hours when required for relief of pain or high temperature. Maximum of three doses in 24 hours.
Supply 100 ml.
Ibuprofen s/f susp: 5mg/kg three to four times a day (> 5kg)
Ibuprofen 100mg/5ml oral suspension sugar free
*WEIGHT REQUIRED* Take 5mg per kg bodyweight three to four times a day when required to relieve pain or high temperature. Do not exceed the stated dose.
Supply 50 ml.
Age from 3 to 5 months
Ibuprofen s/f susp: 50mg three times a day
Ibuprofen 100mg/5ml oral suspension sugar free
Take 2.5ml three times a day when required for relief of pain or high temperature. Do not exceed the stated dose.
Supply 50 ml.
Age from 3 to 11 months
Paracetamol s/f susp: 60 to 120mg up to four times a day
Paracetamol 120mg/5ml oral suspension paediatric sugar free
Take 2.5ml to 5ml every 4 to 6 hours when required for relief of pain or high temperature. Maximum of 4 doses in 24 hours.
Supply 150 ml.
Age from 6 to 11 months
Ibuprofen s/f susp: 50mg three to four times a day
Ibuprofen 100mg/5ml oral suspension sugar free
Take 2.5ml three to four times a day when required for relief of pain or high temperature. Do not exceed the stated dose.
Supply 100 ml.
Age from 1 year to 3 years 11 months
Ibuprofen s/f susp: 100mg three times a day
Ibuprofen 100mg/5ml oral suspension sugar free
Take one 5ml spoonful three times a day when required for relief of pain or high temperature. Do not exceed the stated dose.
Supply 100 ml.
Age from 1 year to 5 years 11 months
Paracetamol s/f susp: 120mg to 240mg up to four times a day
Paracetamol 120mg/5ml oral suspension paediatric sugar free
Take one to two 5ml spoonfuls every 4 to 6 hours when required for relief of pain or high temperature. Maximum of 4 doses in 24 hours.
Supply 300 ml.
Age from 4 years to 6 years 11 months
Ibuprofen s/f susp: 150mg three times a day
Ibuprofen 100mg/5ml oral suspension sugar free
Take 7.5ml three times a day when required for the relief of pain or high temperature. Do not exceed the stated dose.
Supply 150 ml.
Age from 6 years to 11 years 11 months
Paracetamol s/f susp: 250mg to 500mg up to four times a day
Paracetamol 250mg/5ml oral suspension sugar free
Take one to two 5ml spoonfuls every 4 to 6 hours when required for relief of pain or high temperature. Maximum of 4 doses in 24 hours.
Supply 300 ml.
Age from 7 years to 9 years 11 months
Ibuprofen s/f susp: 200mg three times a day
Ibuprofen 100mg/5ml oral suspension sugar free
Take two 5ml spoonfuls three times a day when required for the relief of pain or high temperature. Do not exceed the stated dose.
Supply 300 ml.
Age from 10 years to 11 years 11 months
Ibuprofen s/f susp: 300mg three times a day
Ibuprofen 100mg/5ml oral suspension sugar free
Take three 5ml spoonfuls three times a day when required for the relief of pain or high temperature. Do not exceed the stated dose.
Supply 300 ml.
© NHS Institute for Innovation and Improvement