COUGH OR DIFFICULTY IN BREATHING IN CHILDREN

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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