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Cough - acute with chest signs in children - Management
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The correct clinical scenario for a child presenting 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. For children with distinguishing features of asthma, see the CKS topic on Asthma.
- Scenario: Viral-induced wheeze/possible asthma: covers the management of a child less than 5 years of age presenting with wheeze in association with a respiratory tract infection. It includes children with viral-induced wheeze, and children presenting for the first time with an infective exacerbation of asthma when it may not be possible to distinguish asthma from viral-induced wheeze.
- Scenario: Bronchiolitis: covers the management of infants presenting in primary care with bronchiolitis.
- Scenario: Community-acquired pneumonia: covers the management a child presenting in primary care with pneumonia.
Scenario: Viral-induced wheeze/possible asthma
Introduction
- 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.
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 a child with viral-induced wheeze or possible asthma?
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
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 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.
Scenario: Bronchiolitis
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.
Scenario: Community-acquired pneumonia
Introduction
- Community-acquired pneumonia is an acute infection of the lung parenchyma, acquired in the community, that may be caused by bacteria, atypical bacteria, or viral infections.
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 a child with community-acquired pneumonia?
- Children with community-acquired pneumonia and any high risk features — admit immediately.
- Children with community-acquired pneumonia at intermediate risk — consider hospital assessment. The threshold for arranging this should be low. Arrange if the child has any significant health problems such as chronic respiratory disease or congenital heart disease, or the carers are not able to cope.
- Prescribe an antibiotic for children managed at home:
- For children less than 5 years of age — amoxicillin is the first-choice. For a child allergic to penicillin, a macrolide (erythromycin or clarithromycin) is an alternative.
- For a child over 5 years of age — prescribe either amoxicillin or a macrolide. Prescribe a macrolide for children allergic to penicillin and at times when there is a known Mycoplasma outbreak.
- For children who are 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:
- The 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, or there are signs of dehydration such as dry mouth or infrequent passage of urine.
- The child becomes less responsive or difficult to rouse.
- A persistent increase in fever develops.
- If a child deteriorates on treatment or does not improve after 48 hours of treatment, review and refer for hospital assessment.
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.
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