The coughing, wheezing or snuffly child
The coughing, wheezing or snuffly child
Background
If you haven’t already seen uncountable numbers of preschool children with coughs and wheezing and everything that can go with a viral illness, then the bad news is that you will. Catching viral coughs and colds is a normal part of growing up. There is even evidence that doing so helps the immune system to develop healthily and may reduce a child’s chances of becoming atopic. For the parent, however, it can seem to be a disaster when their child catches a cold. Even when a child is relatively well, you are usually faced with a barrage of hyperbole by whoever accompanies the child:
•‘He can’t breathe, doctor’; or
•‘She won’t eat/drink/walk’ etc.
You shouldn’t be put off at this point by the fact that the child may be smiling at you (while they empty your sharps bin onto your desk, which they have nimbly climbed onto). This is not factitious illness that you are faced with but a parent who needs your help and reassurance.
Many children in these circumstances are prescribed antibiotics, or inhalers, or steroids, when often no such treatment is needed nor would be helpful. Now, I know you would never do this but some doctors feel pressured in these circumstances to give something so the parents feel that they have been taken seriously. Sadly, this approach doesn’t work. Prescribing unnecessary treatments causes parents to re-attend more often and takes the emphasis away from the simple over-the-counter medication that is genuinely effective for these children. If you’re having a really unlucky day, they might even have a bad reaction to the treatment (that you administered in the hope that you might be preventing an ‘early pneumonia’). Worse still, if you are the doctor who tends to prescribe more, these snotty children will come to see you more often and tend to avoid your colleagues who prefer explanation and reassurance to antibiotics as a rule.
How to assess
•Do they look well? Are they breathing comfortably? This initial ‘eyeballing’ of the child will give you the best assessment of whether they should worry you or not. From there on, you are working towards a specific diagnosis, while remaining open-minded that your initial assessment may need to change in the light of further information.
•Have they had a fever? If so was it severe (>39ºC)?
•Have they had any floppy or blue episodes?
•Have they had any treatments (eg medicine, inhalers)? Did they help?
•Have they had previous episodes of this problem?
•Do they have any symptoms between episodes (eg cough, wheeze, nocturnal or exercise-related symptoms)?
•Do any of the parents or carers smoke? If so, when are they stopping?
•Is there a family history of asthma/eczema/hayfever?
•Examine the ears and throat.
•Examine the chest and cardiovascular system.
•Are they well hydrated?
•Are they playing/cheerful, or subdued?
It is important to note that assessing respiratory problems requires the clinician to sometimes act on information as they gather it. The first point of assessment is the ‘Do they look well?’ question. If the answer is no, then it is inappropriate to get as far as asking about pets before examining the child. In the cases where you find yourself faced with a significantly distressed child, ask about symptoms, onset, and medication (including allergies) before examining the child to assess the cause of the distress and the efficacy of breathing.
Any child who is given a treatment for their breathing or circulation should be reassessed within ten minutes from such an intervention. Here is a golden opportunity to do so at no inconvenience. If you are seeing a wheezy child over 12 months old, give inhalers or nebulisers if they are obviously needed and then take a full history. Then, when you have finished, you will be ready to do a more thorough examination. By doing a before and after examination you can determine whether your initial treatment has helped.
The ‘must do’s
For the sake of emphasis, I am going to give just one ‘must do’ for this section, albeit a big one. When a child presents with a respiratory problem, parents will tend to put a great deal of emphasis on the cough and the wheeze. Although these are useful clues as to what you are dealing with, they are common symptoms in quite well children. You should be considering not the presence of such symptoms but the effect which they are having. In other words, the cough, wheeze or ruttle are not nearly as important as the child’s degree of respiratory distress or general unwellness.
Remember:
Respiratory distress should be considered an early warning sign that, eventually, the child may deteriorate and potentially do so rapidly.
When a child shows signs of reduced efficacy of breathing, this is a sign of impending disaster.
(See the section at the beginning for a guide to assessing work and adequacy of breathing.)
Pitfalls to avoid
Do not allow yourself to forget your initial impression. If the child looks well, then they probably are. If they look unwell, then try to assess how badly and consider why the child has become unwell. Of course it is also appropriate to act on the additional information you gather. For example a six-month-old may look well, however even if they clinically have just a cold, if the parent tells you that the child had an episode where they went blue at home (ie had an apparent life-threatening episode) they should be observed and further assessed by an experienced paediatrician.
Accepting someone’s initial description of symptoms at face value can be very misleading. What do they mean by a ‘wheeze’? Experience tells us that people mean many different things when they refer to a ‘wheeze’. Make sure that the parent or child understands the question, and that you understand the answer. Can they do an impression or description of what the ‘wheeze’ sounds like for you?
Due to the frequency with which circumstances change and new symptoms develop, it is good to ‘keep the door open’ for children with respiratory symptoms. It is imperative to make a confident clinical decision to begin with but also to be aware that, for example, bacterial pneumonias are often preceded by a viral upper respiratory tract infection. I find that the safest solution to this potential for change is to tell the parents what they should expect to happen.
Then they can come back if something changes and the child’s clinical course takes an unexpected turn.
Mistaking focal signs for pneumonia is a very common mistake in children. Children with any respiratory infection often have crackles focally in their chest. This is due to intermittent mucous plugging, rather than true pneumonia in most cases. If a child has pneumonia, you will be able to tell that this is the case by the fact that they have a significant fever, a cough, respiratory distress and are unwell to some degree. If they are snotty but well and have no respiratory distress then you can usually ignore focal crackles.
Thinking that a clear chest rules out pneumonia is just as likely to lead to a wrong diagnosis. In fact, the unwell looking child with fever, cough and respiratory distress should make you very suspicious of pneumonia, even if you cannot hear any focal chest signs.
Not looking properly at the ears and throat will leave you without a vital piece of the jigsaw. An ear, nose and throat (ENT) examination is definitely a challenge in some children, but by not doing a good ENT examination, you will be missing important signs.
You should now have all the information that you need to make an assessment and decide how to manage the child. Wait a second though. It’s still very easy to put too much emphasis on the wrong findings. Much of the process of assessing these children is counter-intuitive and although it is tempting for example to treat crackles heard in a chest, you should become comfortable with the idea that these can be very misleading. Bizarrely enough, your assessment of the chest from the outside is probably more consistent than your assessment with the stethoscope. So I have produced some generic patients who will, I am sure, be familiar to you. With them is my suggested approach for how to manage each patient group.
Once you have decided which group your child best fits into, use that as a starting point for further assessment and management. It is preferable not to diagnose asthma too readily since many asthma treatments are not effective for other causes of wheeze. However, consider this: these conditions all represent different manifestations of similar processes. This is especially true of wheeze associated viral episodes (WAVE) and asthma. Being absolutely certain of which of these is the correct diagnosis is not always necessary. Treating the respiratory distress is the first priority, which will be in the form of bronchodilators for WAVE and asthma and with oxygen (if available and saturation below 90%) for bronchiolitis, as well as severe WAVE or asthma. In the acute setting, the exact diagnosis matters less than treating symptoms. The classification may well be best kept as ‘wheezy/viral episode’ until a pattern emerges, at which point the specific diagnosis will help to guide long-term treatment.
Flowchart for classifying wheezy children
Figure 3.1 Flowchart for classifying wheezy children
The following sections provide approaches to treating the various subgroups outlined in Figure 3.1. If a bacterial lower respiratory tract infection is suspected, this is covered in Chapter 5.
The upper respiratory tract infection (URTI)
Assessment
This is what to expect when a child has an upper respiratory tract infection (URTI):
•Any age.
•Looks well, though may be miserable.
•No respiratory distress (though children may breathe quickly when febrile and be significantly tachycardic, this resolves with the fever unless there is also true distress.)
•Fever usually <39°C and responds well to paracetamol +/- ibuprofen.
•Snotty, inflamed ears or pharynx/tonsils.
•May have a non-specific blanching rash.
•May have crackles in the chest. These are likely to be transmitted from the upper airways. They are often intermittent. Only if they sound like true crepitations, and are consistent and focal, should they lead you to a diagnosis of pneumonia when a child has an apparent URTI. Also look for other signs that you would expect in a child with pneumonia: poor air entry or dullness. If respiratory distress is absent, pneumonia is unlikely.
•If the child is cheerful, active, playing and especially if they have not had a fever, you can be fairly confident that they do not have pneumonia or sepsis.
Management
•Reassure. But don’t say ‘it’s just a virus’ unless you want a sleep-deprived parent to start crying in your consulting room.
•Explain that these infections are a normal part of childhood, and will happen frequently (about 12 per year for many children) and that these infections strengthen the immune system.
•Encourage fluids (if possible, not sugar free drinks – sick children need calories!) and paracetamol +/- ibuprofen.
•Explain that the infection may take days to clear but as long as their child is slowly improving, they should continue to let the recovery period take as long as it needs.
•Any viral URTI can be a precursor to a bacterial infection, so warn them that sometimes other infections develop. Request that if their child seems worse despite their medicines, they should get the child seen again.
De-mystifying the role of the paediatrician: what the paediatrician might do
•Paediatricians also see children with uncomplicated URTI. The management in secondary care should be no different to that in a general practice or emergency department setting.
•In my experience there are two common reasons for children to be seen with URTI in secondary care.
The first is that the child has been seen by a doctor who has not found a focus for the fever. In these cases it is simply a matter of a more determined doctor looking in the ears and throat.
The second reason is that an unexpected rash has appeared on the child’s skin. They are otherwise well and have all the signs of a URTI. Most of these rashes are non-specific but some have occasional petechiae. In the case of the latter, a period of observation is advisable, even if the end result is that the clinician (experienced enough to do so) decides that the rash is due to a viral infection.
How to be a know-it-all
•Not all earache is otitis media. Any URTI can block the Eustachian tube. This causes a difference in ear pressure that can be quite painful. The best way to determine true otitis media is to convincingly see a bulging, inflamed, dull tympanic membrane. A perforation and discharge is also a give-away. Even if there is a pink ear drum, if the tympanic membrane is shiny, then Eustachian tube blockage is more likely and so antibiotics are not indicated.
•Just because the child has signs of a URTI does not mean that they do not have another infection elsewhere. So in order to be a clever doctor, you need to consider the child who presents with unusual signs and symptoms, yet has signs of an URTI, as possibly having a second pathology. Especially worth considering is a urinary tract infection (UTI) if antibiotics have been given, since antibiotics may lead to urinary tract infections.
•Conversely, consider the child who does present with unrelated symptoms, and yet no-one can find a cause. For example, a three year old complains of tummy pain yet no pathology has been found, because, so far, doctors have been examining only what seemed to them to be the relevant part of the child. Because children are peculiar beings, ear pain can manifest as a miserable child, an abdominal pain or headache. There is nothing quite so satisfying (except perhaps lancing a boil) as being the first doctor to bother to look in this child’s ears or throat. When you find a tense, red, bulging tympanic membrane or massive tonsillitis, you can explain that children often complain of abdominal pain, or head pain, or any pain for that matter, when in fact the pain is coming from their ears or throat.
Also worth knowing
•For the first few months of life, babies are obligate nose-breathers. This is thought to be an arrangement designed to prevent choking. If the mouth is involved with anything, the baby is programmed to swallow. If breathing is required, this must come from the nostrils. This effect is so strongly programmed that a newborn who has congenitally blocked nasal passages (choanal atresia) will be completely unable to breathe without help. Similarly, but thankfully not so dangerously, if you are unlucky enough to be a few weeks old and catch a cold, you will struggle. Babies can look quite distressed with nothing more than a snuffly nose to cause their troubles. With a baby who is more than just a few weeks old, has no risk factors (eg prematurity, heart disease) and is otherwise well, it can be worth getting a friendly nurse to do some gentle nasal suction (if the facilities are available). If this completely resolves the distress then you are able to reassure and advise. If the baby is very small, then ‘snotty and distressed’ is still unlikely to be harmful, but you may wish to refer the very little babies for observation on the grounds that they may have early bronchiolitis.
•While we often worry about minor infections progressing to more severe infections, we sometimes forget that minor illnesses can be serious for other reasons. One example is that children occasionally develop hypoglycaemia during a URTI or episodes of diarrhoea and vomiting. Children metabolise large amounts of energy during viral illnesses, especially when they have a fever. When their liver glycogen is all consumed, they rapidly become hypoglycaemic. This is why a child who is suffering with any infection and suddenly becomes drowsy should always have a blood sugar checked. Also be aware that in order to correct this, only oral, buccal or intravenous (IV) sugar will work since glycogen stores have been exhausted.
•It is sometimes reasonable to refer a baby for paediatric assessment, even if you are moderately happy with the baby. One possible reason for this is unfavourable social circumstances. That doesn’t have to mean that you are concerned at a child protection level. Anyone can find themselves with their child looked after in hospital for ‘social reasons’. If for example you saw a professional couple who were first-time parents, with a snotty two week old, and they had just moved house, the boiler had broken and the phones weren’t connected, with no local support network… well, you could just reassure them and send them on their way but you probably should offer referral for further assessment. (As emphasised elsewhere in this book, please do not tell the parents that you are admitting them. Circumstances may change and your paediatric colleagues will make the final decision as to whether further observation is indicated.)
FAQs
When should I give antibiotics?
There are a quite a few things in medicine which are rather subjective, allowing the doctor to make the findings fit the outcome that they have already decided on. Ears, chests and throats are three of the most common examples. If you really want to give antibiotics to a child, it is fairly easy to find an excuse to do so.
However, there is a wealth of evidence that most childhood infections are viral and that even when upper respiratory tract infections are bacterial, they usually resolve without treatment and respond disappointingly to antibiotics. At the same time, we know that a proportion of these children go on to develop serious and even life-threatening illnesses. There is no doubt that antibiotics should be used in a subgroup of children with upper and lower respiratory tract infections. The number of potential complications of streptococcal infections is endless, and yet most children with streptococcal infections do not develop any complications. So how do we decide when to give antibiotics to a child for what is likely to resolve without treatment?
Instead I use a simple two stage approach to deciding whether to use antibiotics for a sore throat and/or ear infection:
1.First, rule out the children who are too well to consider giving antibiotics to. Children who take broad spectrum antibiotics get side effects such as vomiting or diarrhoea quite often. If simple analgesia is doing a reasonable job then antibiotics are more likely to do harm than good.
2.Secondly I rule out the children who are so unwell that they may have a more significant infection or even sepsis.
What you are left with is a very small cohort of children who are quite unwell, not improved significantly by analgesia yet do not raise suspicion of sepsis.
This child seems to be having too many minor illnesses. How many infections can a normal child have?
Many books will give a flat answer that 12 to 15 minor illnesses every year is an acceptable rate of infections in early childhood. To make a sensible assessment however requires a little time considering the whole child. True immunodeficiency is uncommon in childhood.
Most children who are having frequent infections are doing what normal children do. They develop immunity by becoming infected. This is an important part of maturing the immune system and the end result is beneficial. If not exposed to infections in childhood then the consequences include greater likelihood of becoming atopic. In some cases it is actually safer to have certain infections as a child. For example, if you catch chickenpox (varicella) for the first time in adulthood, your immune system is no longer in its heightened, developing state so the infection affects you much more severely than having it as a child.
To get an idea as to whether a child is having an abnormal number of minor infections then I would consider the following:
•Is the child thriving and developing normally? If not then underlying immunodeficiency is more likely.
•Consider the frequency of infections but be aware that you cannot really expect anyone to be accurate when you ask questions of this sort. Instead you might need to accept that parents will give us a number because you have asked for one, and that it can be used to get an idea of how many infections it feels like the child has had.
•Has the child had even a couple of significant infections (bacterial infections requiring hospital admission)? Especially if these have progressed to complications, then multiple infections such as pneumonia and cellulitis should raise your suspicion that the child may have an immunodeficiency.
•Is there a good explanation for a period of repeated infections? Probably the most common example is the child who has started nursery a few months previously. These children then get infection after infection after infection before suggesting to the GP that there may be something wrong with the child’s immune system. However, the clue is there in the timing of the illnesses, and the fact that the child was well prior to starting nursery. Thankfully, acquired immunodeficiency in children is very rare in the UK, so children who are initially well and then later start to have repeated infections rarely have an underlying immunodeficiency.
What do I tell the parents?
When I have diagnosed a URTI:
‘Having examined your child, I am pleased to say that I have not found any signs of serious infections. Your child has all the signs of a cold/sore throat/ear infection, but their chest is clear. Because the tubes to the chest are shorter in children, any mucous in the nose or throat can make it seem like there is a problem in the chest. The kind of infection will usually last a few days and because most of them are viral, antibiotics are just as likely to cause problems (such as diarrhoea) as they are to help. The main aim with treating this kind of infection is to make your child feel as well as possible until they fight the infection off. I can’t tell you how long that will take exactly, but children will only be this unwell with a cold/sore throat/ear infection for a couple of days usually. After that the child will usually get better in themselves over the space of a few days, though they may be snuffly and have a cough for a lot longer.’
‘It is important to make sure that they drink plenty of fluids, and while they are ill I would advise avoiding sugar-free drinks. Water is fine if that is what they will drink, but milk or a weak sugary drink of some kind, such as diluted fruit cordial, is even better. Do not worry if your child doesn’t feel like eating, as long as they are drinking well. Regular paracetamol and/or ibuprofen will help to control any temperature and make them feel more like their usual selves. As long as you don’t exceed the amount recommended on the bottle, you can keep giving these until your child seems better. If you are unsure about what medicines to give, it is always best to ask for advice.’
‘These infections happen a lot in childhood and sometimes children go from one infection to another. However if your child seems very unwell despite doing all the things we have talked about then you should bring them to be seen again. In particular, if they are working hard to breathe, or seem floppy or drowsy, you should make sure you get them assessed as soon as possible. If your child seems significantly worse, it is likely that there is a new problem on top of this illness.’
‘I am quite happy that your child is well enough to go home at the moment but you should not hesitate to bring them to be checked again, if something becomes worse or doesn’t get better when it should have done.’
Flowchart for assessing the child with an upper respiratory tract infection (URTI)
Figure 3.3 Flowchart for assessing the child with an upper respiratory tract infection (URTI)
Summary for upper respiratory tract infection (URTI)
•In a child with cough, coryza, sore throat, or painful ears then URTI is most likely.
•It is easy to allow chest auscultation to mislead you. In the absence of respiratory distress and a significant fever, lower respiratory tract infection is unlikely.
•Adequate analgesia will suffice in most cases and may also demonstrate how well the child can be during a period of observation and further assessment.
•With patients who are seen and sent home, remember that you are only seeing a snapshot of how they are. Listen to the parents and make sure that they feel that they could bring their child back for further assessment.
•A child with an apparent URTI may later develop a more serious infection. The early stages of some serious illnesses may have the same signs and symptoms as an URTI. Always keep the door open for reassessment.
The bronchiolitic baby
Assessment
Basic criteria for likely bronchiolitis:
•Age from a few weeks to around 12 months old
•Tight, wet, high-pitched cough
•Wheeze
•Fine crepitations
Further information:
•Does the child look well?
•Is there respiratory distress? Is it mild, moderate or severe?
•Is the baby febrile? (If temp >38ºC then simple bronchiolitis is less likely.)
•Is the baby drinking well?
•Is the baby well hydrated? (Wet nappies and wet mucous membranes.)
•Does the baby have other lung problems (eg prematurity)?
•Is there good air entry throughout on auscultation?
•Has the baby had any apnoeas or blue episodes?
•Are the parents able to cope and seek further attention if needed?
Management
•Hospital admission for bronchiolitis is usually to support feeding or because the baby needs oxygen therapy for respiratory distress. If the baby is well hydrated, only mildly distressed, and there are no other worrying findings in the history or examination, then it is reasonable to allow the baby home. Advise the parents that no medication helps, and that they should allow the baby to take smaller feeds more often. If anything worsens they should seek a medical review.
•If there is significant distress (eg respiratory rate >60 breaths per minute, moderate recession, looks tired), poor feeding, dehydration or anything complicating an otherwise straightforward bronchiolitis, then I would advise referral.
•I would advise against giving babies with bronchiolitis steroids or antibiotics. Steroids do not help and are to be avoided when possible under the age of 12 months old. Bacterial infection does not commonly complicate bronchiolitis infections. As for a URTI, it is easy to misinterpret the chest signs of these babies as being indicative of pneumonia. If a baby does have bacterial infection on top of bronchiolitis then they could get very unwell indeed, so I feel that sending a child home on antibiotics is inadvisable, as well as generally unnecessary for bronchiolitis. If you feel the baby you are seeing is well enough to go home they are very unlikely to have a bacterial pneumonia.
•The evidence is very much against any benefit from ipratropium inhalers.
De-mystifying the role of the paediatrician: what the paediatrician might do
•Each child is assessed on their own merits as above. Many children are allowed home with advice about when to seek reassessment. In most cases blood tests and X-rays do not add useful further information.
1. Some children will be feeding poorly enough to need their oral feeds supported. This is done by frequent small nasogastric bolus feeds. If the child is recessing severely then intravenous fluids may be preferred.
2. If the child has low oxygen saturations then supplementary oxygen is given, often by nasal cannula.
3. In the most severe cases, the child will reach a point where due to severity or exhaustion, respiratory failure necessitates ventilatory support and high dependency unit/intensive care unit admission.
How to be a know-it-all
•Firstly, learn to recognise the cough. There are only a few conditions that can be diagnosed with reasonable reliability by recognising a particular sign. The distinctive cough of bronchiolitis is one example, and the sound of it quickly becomes familiar when heard a few times. It sounds moist, it has a ‘tight’ sound to it as you would expect with airways constriction, and it is high-pitched. Another way to describe it is as though a sneeze came out as a cough. When you recognise this cough, you can start to recognise bronchiolitis before the wheeze or crepitations have appeared, which can be very useful indeed.
1. You can advise parents about what to expect.
2. It will help you to make sensible clinical decisions. For example, if a baby is borderline for referral on day two, you are more likely to refer than if they are borderline on day seven of the illness, when they are about to get better.
3. It helps you to spot the unexpected. If a child with bronchiolitis is getting worse on day seven, you should wonder why. Could they be developing a secondary bacterial infection?
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