Acute cough with chest signs in children can be caused by a number of different conditions including viral-induced wheeze, infective exacerbations of asthma, bronchiolitis and community-acquired pneumonia. 

It is important to note that it can be difficult to be definite about the cause of an acute cough in children. This is because no combination of symptoms or signs has been shown to give absolute clinical certainty in diagnosing these conditions, particularly in the early stages of an illness.

Background

Studies have shown that respiratory tract infection is associated with at least one episode of wheeze in approximately 50% of children before six years of age.¹ 

Ireland has the fourth highest prevalence of asthma in the world, with around 39% of 13 to 15-year-olds reporting wheezing.² Most acute asthma attacks are triggered by viral infection.³

Bronchiolitis most commonly occurs in Ireland from November to March, with most infections occurring in an epidemic lasting around six weeks, the exact timing of which varies from year to year.⁴ Approximately one in every three infants will develop clinical bronchiolitis in the first year of life and 2-3% of these infants will require hospitalisation.⁴ Around 29 per 10,000 children younger than five years of age require admission to hospital for community-acquired pneumonia.⁵

Viral respiratory tract infections are self-limiting conditions. On average, fever settles after three to seven days and the cough resolves within three weeks in most children. 

Infective exacerbations of asthma and viral-induced wheeze are often indistinguishable in children under five years of age who present with wheeze and a respiratory tract infection. The risk of a child dying from an acute asthma exacerbation is low.³

Bronchiolitis affects children aged less than two years, with a peak incidence between the ages of three and six months.⁴ Bronchiolitis is usually precipitated by cold symptoms which last one to three days, followed by a persistent cough. It is uncommon for bronchiolitis to cause death.⁴

Community-acquired pneumonia can be caused by bacterial or viral infection and usually presents without wheeze, but coarse crackles can be heard when listening to the chest. It is uncommon for children in developed countries to die from community- acquired pneumonia. 

Diagnosis

Although it can be difficult to make a specific diagnosis in children, it is usually based on history and examination. Microbiological investigations and chest X-ray are not routinely done in these children. 

The distinguishing features of conditions causing acute cough in children are provided in the Table above. 

Assessment

It is important to determine the severity of the child’s condition, bearing in mind that children who have severe or life-threatening conditions sometimes do not appear to be distressed. In particular, observe the child’s degree of agitation and level of consciousness. 

Agitation and behavioural changes in a child can be a sign of low oxygen levels. Look for signs of exhaustion (inability to complete sentences, for example), cyanosis (bluish lips or extremities) and use of accessory chest muscles to breathe, while the child is at rest. 

Examine the child’s chest and record their respiratory rate, pulse and blood pressure. Measure the child’s oxygen saturation in room air using a paediatric pulse oximeter. Assess the child’s hydration status by measuring capillary refill time, examining skin turgor and dryness of mucous membranes, and asking about urine output.^3,4,7,6

Children should be admitted to hospital (usually by emergency ambulance) if there are any life-threatening features. These include: the child looking seriously unwell, if there is severe respiratory distress such as grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute, if there is persistent oxygen saturation of less than 92% when breathing air, if a severe wheezing attack persists after bronchodilator treatment, or if a child with a moderate attack has worsening symptoms despite initial bronchodilator treatment.^3,4,7

Children who were born prematurely or have significant previous medical history should have a lower threshold for admission.⁴ The ability of the parent or carer to cope with the ill child should be assessed, including their level of experience and anxiety and the time they have available to care for the child.⁴

Management in primary care

Children with low blood oxygen saturation levels (hypoxia) who are awaiting transfer to hospital should be given controlled supplementary oxygen using a face mask, Venturi mask or nasal cannulae. Flow should be adjusted to maintain an oxygen saturation of 94-98%, but oxygen administration should not be delayed in the absence of pulse oximetry.³

Viral-induced wheeze/possible asthma

Children who are suffering life-threatening or severe wheezing/asthma attacks should be given nebulised salbutamol, while waiting admission to hospital. A 5mg dosage should be given to all children aged over five years and 2.5mg to children aged two to five years. Ideally, nebulisers should be oxygen driven (flow rate of 6L /min usually needed) to avoid worsening hypoxia.³

If a nebuliser is not available, or if the attack is of moderate severity, use a pressurised metered-dose inhaler with a large-volume spacer to deliver the salbutamol dose. 

Children under the age of three years are likely to require a face mask connected to the mouthpiece of a spacer for successful drug delivery. A short pause between puffs may be necessary to avoid hyperventilation with puffs given one at a time and inhaled with five tidal breaths. Give a puff every 30-60 seconds, up to 10 puffs. 

If the response is poor, give further doses while awaiting hospital admission and switch to a nebuliser if available. Monitor peak expiratory flow rate (if the child can comply) and oxygen saturation (if available) to assess response to treatment.³

If the child does not require hospital admission a short-acting beta-2 agonist (salbutamol) via a large volume spacer should be given to relieve acute symptoms. Give a puff every 30-60 seconds, up to 10 puffs. Each puff should be given one at a time and inhaled with five tidal breaths. Repeat every 10-20 minutes according to clinical response. If the child has an existing asthma diagnosis, or if asthma is suspected, a short course of oral prednisolone can also be prescribed.³

If there are symptoms and signs that suggest a bacterial infection oral antibiotics should be prescribed.³ Amoxicillin is first-line treatment, with doxycycline an alternative for those aged 12 years and over, if amoxicillin is contraindicated or not tolerated. Other alternatives include cephalosporins, or a macrolide such as erythromycin, azithromycin, or clarithromycin. Duration of treatment is usually five days. 

Bronchiolitis

Children with suspected bronchiolitis should be referred to hospital urgently if they are suffering from respiratory distress or appear seriously ill. If the child does not require hospital admission self-care advice can be provided and parents advised that bronchiolitis is usually a self-limiting illness with symptoms tending to peak around three to five days after onset.⁴

Community-acquired pneumonia

Children with community-acquired pneumonia who do not require hospital admission should be prescribed oral antibiotics, as bacterial and viral pneumonia cannot reliably be distinguished from each other.⁷ Children younger than two years of age presenting with mild symptoms of lower respiratory tract infection do not usually have pneumonia and therefore do not need to be treated with antibiotics, but should be reviewed if symptoms persist.⁷

A history of conjugate pneumococcal vaccination gives greater confidence to this decision. Amoxicillin is recommended as first choice for oral antibiotic therapy. Alternatives are co-amoxiclav, cephalosporins or a macrolide such as erythromycin, azithromycin and clarithromycin. Macrolide antibiotics may be added at any age if there is no response to first-line empirical therapy. 

In pneumonia associated with influenza, co-amoxiclav is recommended. Prescribe antibiotics for between seven and 14 days, depending on the response to treatment.⁷

Self-care advice

Advise the parents/carers to use either paracetamol or ibuprofen to treat a child who is distressed due to fever. These antipyretic medications should not be used with the sole aim of reducing body temperature and should be continued only while the child appears distressed. 

Advise the parents/carers to consider changing from paracetamol to ibuprofen, or vice versa if the child’s distress is not alleviated, but not to give both simultaneously. Advise the parent not to attempt to reduce fever by under-dressing the child or with use of tepid sponging. The child should be encouraged to take fluids regularly. For infants who are breastfed advise continued breastfeeding.⁶

For children managed at home, advise parents/carers to check on the child regularly, including through the night. Advise that they seek medical advice if they are unable to cope, or if the child deteriorates, particularly if breathing rate increases or there are any episodes of apnoea or signs of increased effort of breathing. 

If a baby takes less than 50% of its normal feeds, or there are signs of dehydration such as dry mouth or infrequent passage of urine, it becomes difficult to rouse or has a persistent worsening of fever advise the parent to seek medical advice.⁶ 

Parents who smoke should be advised to stop.

Clarity Informatics is contracted by the National Institute for Health and Care Excellence (NICE) to provide clinical content for the Clinical Knowledge Summaries service available through the Clarity Informatics Prodigy website at: http://prodigy.clarity.co.uk/

References

1. Martinez F, Wright A, Taussig L, et al. (1995) Asthma and wheezing in the first six years of life. New England Journal of Medicine. 332(3): 133-138
2. Asthma Society of Ireland. Facts and figures on asthma. Published 2017. Available from: https://www.asthma.ie/get-help/resources/facts-figures-asthma [Accessed April 4, 2017]
3. British Thoracic Society and Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Published 2016. Available from: https://www.brit-thoracic.org.uk/standards-of-care/guidelines/btssign-british-guideline-on-the-management-of-asthma/ [Accessed April 4, 2017]
4. NICE. Bronchiolitis in children: diagnosis and management. Published 2015. Available from: https://www.nice.org.uk/guidance/ng9 [Accessed April 4, 2017].
5. Clark J, Hammal D, Hampton F, et al. (2007) Epidemiology of community-acquired pneumonia in children seen in hospital. Epidemiology and Infection. 135(2): 262-269
6. NICE. Fever in under 5s: assessment and initial management. Published 2013. Available from: https://www.nice.org.uk/guidance/CG160 [Accessed April 4, 2017]
7. BTS. British Thoracic Society guidelines for the management of community acquired pneumonia in children. Published 2011. Available from: https://www.brit-thoracic.org.uk/document-library/clinical-information/pneumonia/paediatric-pneumonia/bts-guidelines-for-the-management-of-community-acquired-pneumonia-in-children-update-2011/ [Accessed April 4, 2017]