COUGH OR DIFFICULTY IN BREATHING IN CHILDREN

Cough and difficulty in breathing are common problems in young children. They range from a mild, self-limited illness to severe, life-threatening disease.

Common cold – most common
Pneumonia,
Effusion or empyema
Croup
Asthma
Bronchiolitis
Tuberculosis
Pertussis
Diphtheria
COVID19

Signs and symptoms

General

Central cyanosis
Severe palmar pallor

Chest

Respiratory rate (count during 1 min when the child is calm)
Fast breathing:

*Age*	*Respiratory rate per minute*
< 2 months	≥ 60 breaths
2–11 months	≥ 50 breaths
1–5 years	≥ 40 breaths

Lower chest wall indrawing
Hyperinflated chest
Apex beat displaced or trachea shifted from the midline
Raised jugular venous pressure
On auscultation, coarse crackles, no air entry or bronchial breath sounds or wheeze
Abnormal heart rhythm on auscultation
Percussion signs of pleural effusion (stony dullness) or pneumothorax (hyper-resonance)
Apnoea
Gasping
Grunting
Nasal flaring
Audible wheeze
Stridor
Head nodding (a movement of the head synchronous with inspiration indicating severe respiratory distress)
Tachycardia

Abdomen

Abdominal masses (e.g. lymphadenopathy)
Enlarged liver and spleen

Investigations

Pulse oximetry to detect hypoxia
Full blood count
Chest X-ray only for children with severe pneumonia or pneumonia that does not respond to treatment or complications or unclear diagnosis or associated with HIV
Gene-Xpert

Differential diagnosis

*Diagnosis*	*Signs* *and* *symptoms*
*Pneumonia*	- Cough with fast breathing - Lower chest wall indrawing - Fever - Coarse crackles or bronchial breath sounds or dullness to percussion – Grunting
*Asthma or wheeze*	- Recurrent episodes of shortness of breath or wheeze - Night cough or cough and wheeze with exercise - Response to bronchodilators - Known or family history of allergy or asthma
*Bronchiolitis*	- Cough - Wheeze and crackles - Age usually < 1 year
*Malaria*	- Fast breathing in a febrile child - Blood smear or malaria rapid diagnostic test confirms parasitaemia - Anaemia or palmar pallor - In severe malaria, deep (acidotic) breathing or lower chest indrawing - Chest clear on auscultation
*Severe anaemia*	- Shortness of breath on exertion - Severe palmar pallor - Hb < 6 g/dl
*Tuberculosis*	- Chronic cough (> 14 days) - History of contact with TB patient - Poor growth, wasting or weight loss - Positive Mantoux test - Diagnostic chest X-ray may show primary complex or miliary TB - Sputum positive in older child
*Pertussis*	- Paroxysms of cough followed by whoop - Vomiting - Cyanosis or apnoea - No symptoms between bouts of cough - No fever - No history of DPT vaccination
*Foreign body*	- History of sudden choking - Sudden onset of stridor or respiratory distress - Focal areas of wheeze or reduced breath sounds
Pneumothorax*	- onset, usually after major chest trauma - Hyper-resonance on percussion of one side of the chest - Shift in mediastinum to opposite side
*Pneumocystis pneumonia*	- 2–6-month-old child with central cyanosis - Hyperexpanded chest - Fast breathing (tachypnoea) - Finger clubbing - Chest X-ray changes, but chest clear on auscultation - HIV test positive in mother or child
*Croup*	- Inspiratory stridor - Current measles - Barking character to cough - Hoarse voice
*Diphtheria*	- No history of DPT vaccination - Inspiratory stridor - Grey pharyngeal membrane - Cardiac arrhythmia

*S. aureus as an etiologic agent causing pneumothorax in children