Respiratory problems in pre-

school children
Dr. Kevin Gruffydd-Jones
Box Surgery
Wilts.
Joint Policy Lead PCRS--UK
Respiratory Clinical Champion
Royal College of General
Practitioners.
 For your delight and delectation

Acute respiratory disorders

Chronic cough
 BEN

You are Duty Doctor on Monday morning

and just about to carry out an injection
for tennis elbow in the Surgery when
you get a call form a very distressed
mum that her 9 month old son is very
short of breath and wheezing. How do
you assess the situation?
 Initial Assessment on the phone
Airway wheeze or stridor?(drooling?) ,
possibility of foreign body.
Breathing. Signs of respiratory distress?
Rapid breathing ? Use of accessory
muscles?
Episodes Apnoea?
Circulation/Consciousness? blue lips ,
pallor, especially extremeties. , confusion?
Disability/Disease/Drugs?..... Feeding?
Feverish? Pre-existing problems(Brief
history) and treatment given
 Warning signs positive?

CALL 999

ISSUE FIRST AID

ADVICE
 WHAT IS LIKELY TO CAUSE ACUTE
RESPIRATORY DISTRESS IN PRE-SCHOOL
CHILDREN?

BROCHIOLITIS
CROUP (EPIGLOTITIS)
COMMUNITY ACQUIRED PNEUMONIA
INHALED FOREIGN BODY
ASTHMA
 BRONCHIOLITIS

Caused by Respiratory Syncitial Virus

(RSV) in 80% cases
Mainly infants 3-6 months (range 0-2
years) November March, Incubation 4-7
days
Often preceded by coryzal phase 1-3days
Peak 3-5 days, (90% resolve by 3 weeks)
 Bronchiolitis

Diagnose bronchiolitis if :

Coryzal illness 1-3 days: followed

by :

Persitent cough tachynoea

/chest recession

Wheezebilateral basal cracckles

on ausculattion.

Fever usually <39 deg C , may

have poor feeding
 Management of Bronchiolitis in Primary
Care .

No evidence for antibiotics, oral steroids ,

Inhaled corticosteroids, inhaled beta 2
agonists, ipratropium , steam

Advise paracetamol,fluids and avoidance

passive smoking
 Bronchiolitis
ADMIT IF:
OXYGEN SATURATIONS<92% IN
AIR

RESPIRATORY RATE >70 (60)

AND SIGNS RECESSION

FLUID INTAKE 50-70 %

NORMAL. NO WET NAPPIES IN
12 HRS, DEHYDRATED

LOOKS SYSTEMICALLY
UNWELL
Poor social circumstances
 Community Acquired Pneumonia
Usually caused by Viruses and Strep Pneumoniae
Consider if temperature > 38.5 deg C, poor
feeding , respiratory difficulty.
Often (but not always ) have asymmetrical
breathing and expiratory crackles.

Admit if Resp rate >70 (> 50 over age 1 ) respiratory

distress,O2 sats <92%, CRT > 2 secs
Amoxycillin (Clarithromycin ) if treated in the
Community
BTS Guidelines for CAP in children 2011
 CROUP

The Nicholas & Elisabeth Croupette.

 Croup
Acute laryngotracheo-bronchitis.cause by
parainfuenzae virus (also RSV, rhinovirus,
adeonvirus)
Peak incidence 12months -24 months
(up to age 6 ) most prevalent
in Spring
Gradual onset , worse at night,
children usually apyrexial and feed well.
 CROUP
Illness lasts 4-7 days

No evidence for steam but

dexamethasone 2mg (0.1mg/kg) or 2mg
nebulised Budesonide reduces severity
within 6 hours (Kelly et al Cochrane
Review 2011)
 OTHER CAUSES STRIDOR

INHALED FOREIGN BODY

laryngeal or aspirated into the lung

ACUTE EPIGLOTTITIS
Caused by H. Influenzae
Rapid onset, high fever
(>39 deg C) , drooling
Do not examine throat.
BTS/SIGN
GUIDELINES
2014
 Lucy

Lucy is an 18 month-old girl whose asthmatic mother bring

her to the Surgery with yet another cough
She has had several visits to the Surgery over the last few
months with a fruity cough worse at night ,
The cough has persisted in spite of 2 courses of Amoxicillin
and is currently on salbutamol inhaler prn. given via a large
volume spacer device as there was mention once that Lucy
had wheezed
 Lucy .

Lucys mum has asthma wants to know if Hannah

has got the same
1.What do you reply ?
2.How do you manage Hannah?
( and parents!)
BTS GUIDELINES
Recommendations for the assessment
and management of cough in children
M D Shields1, A Bush2, M L Everard3, S
McKenzie4, R Primhak3 on behalf of the
British Thoracic Society Cough Guideline
Group
 Recurrent/chronic cough(> 8
weeks)
1.Most post viral or recurrent viral
bronchitis
2.Red flag disorders
3.Asthma
4.Allergic rhinitis
5.Psychogenic
6. Persitent bacterial bronchitis
 Viral infections

Most due to Rhinovirus,RSV

(Tends to resolve within
21 days)
May be due to Pertussis
(32% persistent cough? )
May not have whoop
Median duration 112 days.
Macrolides only work first 3 weeks.
 Recurrent/chronic cough(> 8
weeks)
1.Most post viral or recurrent viral
bronchitis
2.Red flag disorders
3.Asthma
4.Allergic rhinitis
5.Psychogenic
6. Persitent bacterial bronchitis
RED FLAG problems

1. Acute on chronic cough (systemically

unwell) e.g TB pneumonia.

2. Weight loss, sweats, clubbing (TB,CF)

3. Neonatal (congenital abnormalities,
Cystic fibrosis)
 Recurrent/chronic cough(> 8
weeks)
1.Most post viral or recurrent viral
bronchitis
2.Red flag disorders
3.Asthma
4.Allergic rhinitis
5.Psychogenic
6. Persitent bacterial bronchitis
 ASTHMA
Consider if :FH or PH atopy
Associated wheeze but demonstrate this!
Variable symptoms with triggers other than
just viral infections e.g exercise

Cough variant asthma is rare and has different

risk factors (dust, smoking) most resolve by 6.
 TRIAL OF THERAPY

400 mcg Beclometasone or

equivalent via spacer or mask

Give up to 8 weeks of treatment

Withdraw therapy and review!

May use oral steroid (20mg for 3 days) or

Montelukast 4 mg od for 4 weeks

.
Management of Under 5s

BTS/SIGN Guidelines 2014

 Prognosis of pre-school wheezing
(Sly et al Lancet 2008)
Cohort Studies in Europe,
USA and Australia suggest
that early sensitisation with
aerollargens(house dust
mite , dog and cat fur) and
some food allergens strong
determinant persistence of
asthma into adulthood.
Especially if combined with
early onset-viral infections.
 PROGNOSIS
Asthma persistence into adulthood associated
with :
Female sex.
Maternal History of Asthma
Sensitisation to allergens in first year of life
Presence of Rhinitis.
Passive smoking in infancy.
Severity of Asthma in childhood
ALLERGIC RHINITIS
Have nasal salute ,
seasonal sneezing.
Less common than in adults

PSYCHOGENIC.
Honking , Disappears at night.
 Recurrent/chronic cough(> 8
weeks)
1.Most post viral or recurrent viral
bronchitis
2.Red flag disorders
3.Asthma
4.Allergic rhinitis
5.Psychogenic
6. Persistent bacterial bronchitis
 Persistent Bacterial Bronchitis.
Follow up of 81 children diagnosed
with persistent bacterial bronchitis
(wet cough > 1month with positive
response to antibiotics)

Is she like a 60/day smoker in the

morning?

30 % chest x ray normal.

4/14 who had HRCT had

bronchiectasis

Donnelly et al Thorax 2007

 Persistent Bacterial Bronchitis.
Give high dose co-amoxiclav
40mg/kg/day. 48% resolution
after 2 weeks(Marchant et al Thorax
2012)

Get dramatic improvement a

new child
May need 4-6 weeks.
If no better consider referral
The difficult coughing child: prolonged acute cough in children.
Michael Shields and Surendran Thavagnanam .COUGH 2013: 9.11
 Lucy
HISTORY
Nature of coughparoxysmal, wet, dry?
Associated wheeze, atopy.
Triggers.(INCLUDING SMOKE)
Thriving? Sweats? Upper airway symptoms

EXAM:Growth chart, Clubbed,CHEST signs, upper airway signs

e.g catarrh
TRIAL OF THERAPY?
Co-Amoxiclav 40MG/KG/DAY 2 WEEKS
? TRIAL ICS 400MCG/DAY 4-8 WEEKS. (May still have asthma
and PBB)
? REFER
 To Take away ?

In the Under 5s:Assessing pulse oximetry and

respiratory rate are key elements of acute
respiratory assessment

Recurrent cough without wheeze makes a

diagnosis of asthma unlikely.

Beware the child with the persis`tent fruity cough