cough or difficult breathing

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COMMON CHILD ILLNESS---

Chapter 2

Cough or difficult breathing

Cough and difficult breathing are common problems in

young children. The causes range from a mild, self-limitedillness to severe, life-threatening disease.

This section focuses on the most important causes ofacute

cough (common cold and pneumonia), chronic cough

(tuberculosis), and wheeze (asthma).


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Chapter 2


Definitions:

Cough. The major cause of cough in young

children is a respiratory infection. Acute

respiratory infections present with cough of less

than 30 days duration. Chronic cough is defined

as cough lasting continuously for 30 days or more


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Chapter 2


Definitions:

Difficult breathing.

Difficult breathing can present as lower chest wall

indrawing (i.e. an inward movement of the lower chest

on inspiration) or respiratory distress (i.e. inability toeat, drink or speak due to breathlessness.


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Chapter 2Cough or difficult breathing

Definitions:

Wheezing: is a musical noise when breathing out

(expiration) and stridor is a harsh noise when

breathing in (inspiration).


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Chapter 2


Definitions:

Very severe pneumonia: is defined as a condition in a childwith cough or difficult breathing with at least one of the

following: central cyanosis, severe respiratory distress,

inability to breastfeed or drink, vomiting everything,

convulsions, lethargy, or unconsciousness.


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Chapter 2


Definitions:

Severe pneumonia: is defined as a condition in a child

with cough or difficult breathing with at least one of the

following: lower chest wall indrawing, nasal flaring or

grunting (in young infants) but with no signs of verysevere pneumonia.


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Chapter 2Cough or difficult breathing

Definitions:

Pneumonia:On auscultation with a stethoscope,

crepitations or signs of consolidation such as bronchial

breathing might be heard, but this is not used for the

classification of severity


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Chapter 2


Burden of disease:

The common cold is the commonest infection inchildhood and children experience about 48 episodes

per year. The incidence of pneumonia among under-5-

year-olds in developing countries is about 0.3 new

episodes per child per year, or about 150 million newepisodes each year globally. Pneumonia is the most

important cause of death in young children globally.


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Cough or difficult breathingBurden of disease:

The case fatality rate is particularly high in the first 6 months

of life.

The most important causes of wheeze in the first 5 years of

life are bronchiolitis, asthma, and wheeze associated with

the common cold.

Asthma is less common in developing than in industrialized

countries, and it appears to increase as countries undergo

economic development.


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Cough or difficult breathingBurden of disease:

Stridor is not a common presentation in most developing

countries where diphtheria has been controlled byimmunization


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Differential diagnosis of the child presenting with stridor.


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Pneumonia:

Etiology. the main causes of pneumonia are bacterial

rather than viral.

-The main causes in children aged 2 months to 5 years are

Streptococcus pneumoniae (pneumococcus), Haemophilus

influenzae type b (and to a lesser extent Staphylococcus

aureus). Pneumonia in young infants under 2 months ofage is associated with a bacterial agents including

Staphylococcus aureus and gram-negative bacteria such as

E.coli and Klebsiella.


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Pneumonia:

Etiology.

- The most important viral pneumonia is caused byrespiratory syncytial virus (RSV). This virus can also cause a

severe illness called bronchiolitis.

HIV infection increases the risk of bacterial pneumonia.


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Pneumonia:

Pathophysiology. The infection and inflammation in the

alveoli (pneumonia) and small airways (bronchiolitis)lead to decreased compliance (increased stiffness) of the

lungs, an increase in the respiratory rate, and lower

chest wall indrawing. A combination of inflammatory

fluid in the alveoli and a mismatch between ventilationand perfusion in the lungs can interfere with the transfer

of oxygen into the blood and cause hypoxia.


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Cough or difficult breathingPneumonia:

Clinical presentation. Chest X-ray appearances of

pneumonia can be confined to one lobe or segment orbe diffuse throughout the lungs of the child. However,

the most important clinical presentations are fast

breathing and/or lower chest wall indrawing. Fast

breathing detects a higher proportion of pneumoniacases in young children than auscultatory signs such as

reduced air entry, bronchial breathing or crepitations.


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Pneumonia:

Clinical presentation. The respiratory rates vary with age

(60 for young infants under 2 months, 50 in children 2

months to 1 year, 40 in children 12 months up to 5

years) since normal respiratory rate falls with age.

Schematic representation of the X-ray finding of a lobar

consolidation of the right lower zone


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Pneumonia:

Clinical presentation: Schematic representation of the X-ray

finding of a lobar consolidation of the right lower zone


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Pneumonia:

Clinical presentation: Lower chest wall indrawing withinspiration, the lower chest wall moves in


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Pneumonia:

Clinical presentation


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Pneumonia:

Clinical presentation: Children with RSV bronchiolitis also presentwith fast breathing and lower chest wall in-drawing, as in pneumonia,

but in addition have wheeze and hyperinflation of the chest.

Hypoxia is best identified by use of a pulse oximeter (which measures

reduced oxygen saturation in the blood) but can be recognized clinically

by signs such as central cyanosis, respiratory distress causing inability to

drink, severe lower chest wall in-drawing, very fast breathing (70 perminute), grunting with every breath or head nodding.


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Pneumonia:

Management: Antimicrobial treatment. Clinical tests to

identify the cause of pneumonia perform poorly, so the

treatment has to be based empirically on clinical signs. Most

cases of pneumonia in children aged over 2 months can be

treated at home with simple, inexpensive oral antibiotics such

as cotrimoxazole or amoxicillin. Activity of penicillin V

(phenoxymethyl penicillin) is not good against Haemophilus

influenzae type b and so is not recommended. Children with

severe pneumonia have a poorer prognosis and so should be

admitted to hospital for treatment with parenteral antibiotics.


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Pneumonia:

Management: Benzyl penicillin is the first-line treatment as

it is effective against the two major bacterial pathogens,

Chloramphenicol should be restricted to the few children

who have very severe pneumonia in order to limit the

development of drug resistance, and because its use is

sometimes associated with rare but serious adverse effects.


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Pneumonia:

Management: A second-line treatment would be benzyl

penicillin plus gentamicin, which also has broad spectrum

activity against bacteria.

Pneumonia in young infants under 2 months of age is

associated with a much higher case-fatality rate, so all cases

should be admitted to hospital for parenteral treatment. Inaddition, since the range of bacterial agents causing

pneumonia is much wider, the first-line treatment is benzyl

penicillin and gentamicin.


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How to manage the airway in a choking child (foreign

body aspiration with increasing respiratory distress)

Infants

lay the infant on your arm or thigh in a head down position

give 5 blows to the infants back with heel of hand

if obstruction persists, turn infant over and give 5 chest thrusts

with 2 fingers, one finger breadth below nipple level in midline


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How to manage the airway in a choking child (foreign

body aspiration with increasing respiratory distress)

Infants

lif obstruction persists, check infants mouth for any obstruction

which can be removed

if necessary, repeat sequence with back slaps again


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Children

give 5 blows to the childs back with heel of hand with child

sitting, kneeling or lying

if the obstruction persists, go behind the child and pass your

arms around the childs body; form a fist with one hand

immediately below the childs sternum; place the other hand over

the fist and pull upwards into the abdomen (see diagram); repeat

this Heimlich manoeuvre 5 times.


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How to manage the airway in child with obstructed

breathing or who has just stopped breathing

No neck trauma suspected

Child conscious

1. inspect mouth and remove foreign body, if present

2. clear secretions from throat

3. let child assume position of maximal comfort


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No neck trauma suspected

Child unconscious

1. tilt the head .

inspect mouth and

remove foreign body


2. check the airway by looking

for chest movements,

listening for breath sounds

and feeling for breath


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Neck trauma suspected (possible cervical spine injury)

1. stabilize the neck,

2. inspect mouth and remove foreign body,


4. check the airway by looking for

chest movements, listening for breath sounds,

And feeling for breath

If the child is still not breathing after carrying

out the above, give oxygen to ventilate.


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Pneumonia:

Management: Oxygen therapy.

Children with hypoxia have a higher mortality.The low-flow methods (12 litres per minute) of oxygen

delivery are effective at treating hypoxia, and that nasal

prongs and the nasal catheter perform as well as the

nasopharyngeal catheter and do not cause the serious side-

effect of gastric distension.


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Classification of the severity of pneumonia.


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Tuberculosis

Aetiology. Tuberculosis is an infection usually caused by the

bacterium Mycobacterium tuberculosis.

Pathophysiology. Pulmonary tuberculosis starts with

infection in the lung, with associated infection in a draining

lymph node. Subsequent natural history depends on the

immune status of the child . In a severely malnourished orotherwise immuno-compromised child, progression to

miliary tuberculosis can occur with dissemination of

infection throughout the lung. Spread by


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Tuberculosis

Pathophysiology-- the bloodstream may lead to infection in

other sites (e.g.meninges, vertebrae, joints or kidneys). In achild with good immune responsiveness, the infection

will be contained and then regress or may result in a

post-primary infection of the lung.

Primary infections lead to sensitivity to tubercular protein, asshown by the response to purified protein derivative (PPD),

for example by a positive Mantoux test.


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Appearance of miliary tuberculosis: widespread small

patchy infiltrates throughout both lungs: snow storm

appearance (X-ray)


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Tuberculosis

Clinical presentation. The diagnosis of tuberculosis in young

children remains very problematic. Sputum is usually not

present and gastric aspirates and laryngeal swabs are often

negative in children with TB.

the Mantoux test can be difficult to interpret in children who

have been immunized with BCG (a reaction less than 10 mmcan be due to BCG) or who have miliary TB, severe

malnutrition or recent measles; the Mantoux test may be

negative in a child with TB.


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Tuberculosis

Clinical presentation. In summary, the three key clinical

features which may point towards a diagnosis of TB in

children are:

1. Contact with a pulmonary TB case.

2. Lack of response of respiratory symptoms and signs to

broad-spectrum antibiotics.

3. Weight loss or failure to thrive.


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Tuberculosis

Management. Antimicrobial treatment. It is essential

to follow exactly the national TB guidelines, and to register a

child with TB with the national TB control programme.

Failure to do so leads to a risk that the treatment will be less

effective and there will be more drug resistance. Drug

resistant (or multidrug-resistant) TB is becoming a majorproblem in some developing countries since second-line

drugs are much more expensive and may not be easily

affordable.


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Tuberculosis

Management. Antimicrobial treatment. Monitoring of

treatment is also essential for the same reasons. Directly

observed treatment strategy (DOTS) has many advantages

and been adopted by many countries.

Public health measures such as contact tracing are an

essential part of the management of a case of TB.


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Tuberculosis

Management.Other treatment.

It is important to pay attention to the nutrition of thesechildren. Attempts should be made to identify the index case

and then to screen all household contacts of the index case

(usually an adult with pulmonary TB).


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Differential diagnosis of the child presenting with chronic cough


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Asthma

Aetiology.Asthma is an immune disorder whose precise

cause is not known. It is commoner in atopic

families where eczema, hay fever and allergic

rhinitis are commonly found. Triggers to asthmaticattacks vary widely and can include animal dander,

pollen, house fomites (house dust

mite exposure), exposure to tobacco smoke, and

viral respiratory infections.


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Asthma

Pathophysiology.Asthma is an inflammatory condition

of the small airways which involves smooth muscle

spasm, mucosal oedema and hyper-secretion of mucus.

Clinical presentation.Asthma presents with bronchial

hyper reactivity and reversible airways obstruction

leading to recurrent episodes of cough, wheeze andbreathlessness. Diagnosis can be very difficult as

asthma may not be apparent until the child is older and

had several episodes of wheeze


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Asthma

Management

- Reliever therapy. Reliever drugs should be used to

reverse airways obstruction (salbutamol, Aminophyllineand corticosteroids)

-Preventive therapy. The main preventive drugs are

inhaled corticosteroids and sodium cromoglycate, This

treatment aims to decrease bronchial hyper-reactivityand airway inflammation

- Oxygen therapy. Children who have acute severe

asthma and show signs of hypoxia may require oxygen

therapy.

Diff ti l di i f th hild ti ith h


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Differential diagnosis of the child presenting with wheeze

Diff ti l di i f th hild ti ith h diffi lt b thi


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Differential diagnosis of the child presenting with cough or difficult breathing..

cough or difficult breathing

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