• Respiratory tract infections with wheeze occur in children with asthma, and children less than 5 years of age with viral-induced wheeze. When a child less than 5 years of age presents for the first time with wheeze associated with infection, it may not be possible to distinguish the cause.

• 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

Note: for children with an established diagnosis of asthma, see the CKS topic on Asthma.

First episode of cough of wheeze in a child aged under 5 years

• Children with wheeze and any high risk features — admit immediately. Treat with a bronchodilator whilst awaiting transfer.
• Children with wheeze at intermediate risk — treat with a bronchodilator and assess 15–30 minutes after completing treatment.
• Children who respond to bronchodilators — prescribe a bronchodilator and spacer device to use as required. Manage at home.
• Children who do not respond to bronchodilators — arrange hospital assessment.
• Children with wheeze at low risk — consider a trial of treatment with bronchodilators. Manage at home.
• For children managed at home advise carers to check on the child regularly, including through the night, and seek medical advice if they are unable to cope, or if the child deteriorates, particularly if:
• Breathing rate increases, or there are any episodes of apnoea or signs of increased effort of breathing.
• A baby takes less than 50% of its normal feeds, or 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.

Management of further episodes

• The management of further episodes of cough and wheeze in children under the age of 5 years depends upon whether symptoms occur only in association with a viral infection, or whether they also wheeze in response to other triggers (possible asthma).
• For children with further episodes of viral-induced cough and wheeze, management with bronchodilators should be guided by the child's response to an initial trial of therapy.
• In children under 2 years of age who do not respond to bronchodilators, consider repeating a trial of therapy intermittently to determine whether they have become more responsive as they have become older.
• For children with suspected asthma, see the CKS topic on Asthma.

In depth

• 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

• 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.