The ‘Chesty’ Child
Children commonly present with coryza, breathlessness, cough, wheeze or noisy breathing. This is often due to a viral URTI (see Chapter 21) or asthma (see Chapter 26).
Pneumonia (lower respiratory tract infection), can be either bacterial or viral:
- Viral causes include respiratory syncytial virus (RSV), influenza, parainfluenza, adenovirus and Coxsackie virus.
- Bacterial causes are Streptococcus pneumoniae, Haemophilus influenzae, staphylococcus, Mycoplasma pneumoniae and, in the newborn, group B beta-haemolytic streptococcus.
- Pseudomonas aeruginosa and Staphylococcus aureus are more common in those with underlying respiratory disease, such as cystic fibrosis (see Chapter 27).
- Predisposing factors include a congenital anomaly of the bronchi, inhaled foreign body, immunosuppression, recurrent aspiration (e.g. with a tracheo-oesophageal fistula) or cystic fibrosis.
Pneumonia usually presents with a short history of fever, cough and respiratory distress, including tachypnoea and intercostal recession. Grunting is common in infants. Signs include dullness to percussion, bronchial breathing and crackles, reflecting the underlying consolidation. Clinical signs are often not reliable in infants and the diagnosis should always be confirmed by chest radiograph. This may show a lobar pneumonia or a more widespread bronchopneumonia.
Blood and sputum cultures may reveal the organism. Antibody titres may be useful in diagnosing mycoplasma pneumonia, which often has a more insidious onset and requires treatment with erythromycin. Penicillin is the first-line antibiotic for lobar pneumonia.
Complications of pneumonia include pleural effusion, septicaemia, bronchiectasis, empyema (infected pleural effusion) or lung abscess (may follow staphylococcal pneumonia).
Bronchiolitis is an acute cause of respiratory distress and wheezing in infants, due to obstruction of the small airways. It is usually caused by RSV and occurs in epidemics in the winter months. RSV is highly infectious, and spreads rapidly in daycare nurseries. Adenovirus, influenza and parainfluenza virus can also cause bronchiolitis. Coryza is followed by cough, respiratory distress and wheeze. Some infants have difficulty feeding or may have apnoea. Examination reveals widespread wheeze and fine crackles and overexpansion of the chest. Chest radiograph will show hyperinflation and patchy collapse or consolidation. A nasopharyngeal aspirate (NPA) can identify RSV using immunofluoresence.
Most children do not require any specific treatment but indications for admission to hospital include poor feeding, apnoea, increasing respiratory distress or the need for oxygen. The illness usually lasts 7–10 days and most recover fully although there may be recurrent wheezing during infancy. A minority, particularly those with chronic lung disease or an underlying congenital heart defect, will require intensive care. There is no effective treatment other than oxygen, bronchodilators and supportive therapy. Bronchiolitis has a mortality of 1–2%. A monoclonal antibody (palivizumab) against RSV can be given prophylactically to high-risk infants throughout the winter months to provide passive immunity against infection.
Bordetella pertussis pneumonia tends to occur in young infants or in those who are not fully vaccinated. Paradoxical coughing spasms during expiration are followed by a sharp intake of breath—the whoop. In infants it can cause apnoea. Diagnosis is mainly clinical, although a lymphocytosis (>20 × 109/L) is suggestive. The organism may be cultured from a per-nasal swab. Treatment is supportive. The paroxysms of coughing can continue for months (the 100-day cough).
Croup (Acute Laryngotracheobronchitis)
This common condition affects children aged 6 months to 3 years and is due to a parainfluenza infection of all the upper airways. It is most common in winter and can be recurrent. Croup starts with coryzal symptoms, then proceeds to stridor (Chapter 24), wheeze and a barking cough. Children may have a hoarse voice. It is usually self-limiting but can occasionally be very severe, requiring intubation and ventilation. Signs of severe croup include increased work of breathing, cyanosis and restlessness. Milder cases can be managed by observation and maintaining good hydration. Nebulized budesonide and oral dexamethasone reduce the severity of symptoms and the need for hospital admission. Steam and humidity have not been proven to be beneficial but may provide some symptomatic relief.
This life-threatening infection is caused by Haemophilus influenzae and is now rare thanks to immunization with the Hib vaccine. It presents in children (2–4 years) with signs of sepsis and an inability to swallow or talk. Children often lean forwards to maintain a patent airway and may drool saliva. If epiglottitis is suspected, examination of the throat is contraindicated as it may precipitate complete airway obstruction. The child should be transferred immediately to an operating theatre for intubation by an experienced anaesthetist. At laryngoscopy a ‘cherry red’ swollen epiglottis confirms the diagnosis. Once the airway is protected, blood cultures can be taken and intrevenous antibiotics (cefotaxime) given.
- The majority of children with ‘chestiness’ have a self-limiting viral URTI and do not require antibiotics.
- If a child has recurrent episodes of pneumonia, an underlying cause should be sought.
- Bronchiolitis is very common in winter, especially among infants with chest or cardiac disease.
- Whooping cough is diagnosed by the characteristic paroxysmal cough and associated colour change.
- Croup causes a barking cough and stridor, usually following a coryzal illness.
- Epiglottitis is a life-threatening infection.