You see an 18month old girl presenting with cough, fever and loss of appetite for the last 2 days.
Parents are worried today because she now has a ‘wheeze’ and seems breathless.
She is ordinarily fit and well aside from frequent coughs and colds. UTD imms, born term + 3 by spontaneous vaginal delivery. Attends local Petri dish (pre school) 3 days a week.
You see her with her parents, she looks well, is interactive, contented and appears well hydrated.
RR 30, hr 120, t38.7c, crt <3sec, spo2- unsuitable sized probe to get accurate value and she keeps pulling it off anyway despite best efforts to distract her.
I wanted to unpick this case a little bit to give you added confidence to assess and manage this kind of presentation.
Children are not small adults. We are always taught this, but why?
They are physically different to adults of course, but their physiology changes with age, so too does their immunology. This changes the likelihood of different illness depending on their age. You also need to assess children differently to adults. This sounds obvious but here’s why.
There are a couple of things to consider-
- Unlike adults, you are getting a subjective history 2nd hand.
- Are the parents reporting a true clinical wheeze. Yes they have used the word ‘wheeze’ but have they described one. They often mean ‘chesty’, ‘rattling’, ‘noisy’ or ‘mouth breathing’. If in doubt I usually demonstrate a forced expiratory wheeze and say, ‘does it sound like this? [insert wheeze]. The answer is often, no.
- The age of child helps enormously in determining the likely cause, because of what their immune system does at different ages. Remember to take into account their gestational age at birth too. If born premature this will change things a little, but for now let’s keep it as straight forward as possible.
- Is there any respiratory distress? recession, nasal flaring, accessory muscle use, tracheal tug, grunting. If not, their lungs are fine.
- Are they well or unwell (to the health professional rather than the parent). Fluctuating wellness/ unwellness through the day suggests self-limiting illness most likely.
Clues in the history
Sick kids behave sick (broadly speaking)- i.e persistently subdued, drowsy (not simply sleeping more), may have reduced level of consciousness. A child who is up + down (playing + active, but next minute clingy and subdued) probably doesn’t have a serious infection. Children with sepsis aren’t running around, aren’t particularly alert, and generally look crap!
In the context of an acutely ‘wheezy’ (actually wheezy) or coughing child, it will probably be one of 5 things, all of which you could diagnose without touching them (but of course you wouldn’t). Bronchiolitis, viral induced wheeze, pneumonia, croup or other upper respiratory tract infection (e.g a cold, throat infection).
Bronchiolitis
Between 6 months and 2yo (most cases occur in children under 1) with cold symptoms and gradually increasing respiratory distress over a few days is probably bronchiolitis. Bronchiolitis is a viral type pneumonia in which the child is typically reasonably well with fluctuating wellness, sometimes active and playing other times not. I like to think of them as cheerfully breathless.
Viral induced wheeze
Viral induced wheeze is more likely if the child is >1yo, snotty with upper respiratory tract infection with abrupt onset of respiratory distress. It doesn’t matter if you can hear a wheeze. If they are febrile with acute onset respiratory distress, consider viral induced bronchospasm or ‘wheeze’
Pneumonia
A child of any age with gradually worsening cough, fever, respiratory distress and persistently miserable and unwell (without marked ups and downs) is likely to be pneumonia aka chest infection.
Croup
A young child with ‘a cold’ with acute onset of stridor cough that sounds like a donkey or sea lion is probably croup. I don’t know if there is any evidence that it is most likely to occur at night, but I honestly don’t think I’ve ever seen croup during the day. If they’re drooling with severe respiratory distress, they either have epiglottitis (rare) or they’re choking! NB. Croup can occur in older children and young adolescents up to 15yo, although uncommonly. In fact I’ve had a 12 yo with croup very recently.
Im going to do a blog on croup soon, so for now, I won’t got any further.
Clinical assessment
Most of your physical examination could be done from 6 feet away with your hands in your pockets. Granted it wouldn’t look very professional and the parents would question your ability to do your job, but it is true. You will get most of the information you need to manage the child simply from observation.
Exposing the child’s torso and observing their breathing rate and effort at rest without being restrained and mauled with a cold stethoscope will determine whether or not they have a lung pathology. It is very difficult to ascertain the presence or otherwise of respiratory distress in a child who is kicking and crying and trying to escape the clutches of the nasty clinician.
I deliberately withheld SPo2 from the case, again because the clinical appearance and findings will tell you everything. An active well child who is hydrated, has no respiratory distress and is well perfused is not going to have crap o2 sats. A low reading of 88% in this context is very likely to be A dodgy reading, so don’t get hung up on it. The ‘evidence’ you are seeing is far more reassuring. It comes back to treat the patient and not the monitor.
Similarly a child with marked respiratory distress, poorly perfused, subdued and listless, with Spo2 99%. Are the good sats changing the fact that they are not very well at all and will need admitting.
In fact, the NICE guideline for viral induced wheeze + LRTI in children doesn’t actually mandate SPo2 in the diagnosis and treatment. Their phrasing on the use of spo2 is “measure spo2 (if available)”. If it was crucial, it would say absolutely measure SPo2, or base decisions on spo2 alone. If you do get a sats, then you needn’t start flapping unless they are both unwell and persistently below 92%, honestly!
Hypoxaemia is often visible in the sense that you will be able to see evidence of hypoperfusion of the organs. Namely the brain.
A hypoxic child will usually exhibit impaired cognition (e.g drowsiness, agitation) if their brains are hypoxic and their SPo2 won’t change how you manage this. You can see this in the amber and red boxes below.
Conversely, if a child is well, is playing and content, has a cough but no respiratory distress and no clinical evidence of dehydration but their spo2 is 90%, ask yourself, am I worried that this child’s brain hypoxic or hypoperfused? Probably not!
Don’t rely too heavily on chest auscultation either. In adults and older children it is really useful to determine any focal chest sounds that may suggest pneumonia. But when you auscultate small children with small chests, it isn’t particularly helpful, as they often exhibit transmitted upper airway sounds. So, if crackles are heard on auscultation but no resp distress, it makes little logical sense that the lungs are full of snot. It’s probably more likely that the child is snotty, and what you are actually hearing is the echoing of sounds into the chest from an upper respiratory tract infection.
Management
Treatment for the most part consists of nothing more complicated than analgesia for comfort (no need to treat fever alone regardless of the number, honestly!) and maintaining hydration.
Bronchiolitis babies are normally fairly well and happy despite often marked respiratory distress.
They are admitted if they need O2 or feeding support. If the child is feeding well, they unlikely have sufficient respiratory distress to restrict feeding and not so hypoxic that they are drowsy.
If you’ve been able to distinguish a likely viral induced wheeze you could try salbutamol (5+ puffs (up to 10 if marked distress, via inhaler and spacer) or nebuliser. Bear in mind that small children may get more distressed with a nebuliser and increase their oxygen demand. It will also give the parents the impression that they should attend for a nebuliser every time this happens. If you can use inhaler and spacer, it will empower the parents/ carers to self-manage initially, before presenting acutely to health care.
Bronchiolitis or pneumonia is unlikely to respond to salbutamol and its nothing to do with presence of B receptors etc. This is because it is an inflammatory process that is underlying rather than bronchospasm. So, no bronchospasm= no relief from a bronchodilator. Simples.
If you can’t distinguish bronchiolitis v viral wheeze, you can try inhaled salbutamol and see if it makes a difference.
Pneumonia is diagnosed on clinical grounds without the need for chest x-ray or bloods etc. persistently subdued unwell child with cough + respiratory distress. If not drowsy and they are feeding (infant)/ well hydrated, consider managing in community with antibiotics. If auscultation reveals unequal or absent unilateral breath sounds suggestive of pleural effusion, they are drowsy, poor feeding infant or dehydrated then admit them acutely.
Risk groups
Adopt a lower threshold for referring infants who were born premature or those with chronic respiratory, cardiovascular or neuromuscular disorders that place them at greater risk of deterioration and complications. Similarly children with immunosuppression e.g. diabetes, long term steroids, chemotherapy etc.
Safety netting
Like everything in medicine there is no certainty and, while most children with recover as expected, a very small number who appeared at first presentation to have a minor illness, will go on to develop more serious or even life threatening sequelae. This is a risk that we accept, but we mitigate against uncertainty with careful safety netting.
- How long you expect most cases to last or how long until they should start getting better
- What signs, symptoms should prompt the child to be reviewed
- Who to contact or how to get further advice
There are some really good leaflets and safety netting guidance for parents and carers from What 0-18
Take away message
If they look sick, they probably are. If they look well and they are alert and active, they probably aren’t sick. Trust your eyes. Observations will support your thinking rather than the be all and end all.
If you’ve enjoyed the blog, then why not come and learn more about this and other acute paediatric presentations on one of our Paediatric minor illness CPD study days.
Sources of further information
https://what0-18.nhs.uk/professionals
https://cks.nice.org.uk/topics/cough-acute-with-chest-signs-in-children/
Bronchiolitis pathway https://what0-18.nhs.uk/application/files/2216/2920/1452/CS52646_NHS_Bronchiolitis_Pathway_Primary_and_Community_Care_April_21v2_2.pdf
Management of viral induced wheeze https://what0-18.nhs.uk/application/files/2516/0372/8616/Wessex_paediatric_wheeze_pathway_v15_09_09_2020_grouped_HT_PDF_1.pdf
