Children frequently present with respiratory problems to general practitioners. The importance of these conditions is highlighted by the fact that they account for 20-35% of acute paediatric admissions and are the fifth most common cause of death in children between the age of one and 14 in the UK.

This article focuses on identifying the sick child and suggests underlying diagnoses.

Identifying the sick child¹

History

• What is the parent or carer worried about?
• What are the symptoms and how long have they been going on for?
• Specifically find out about recent activities suggesting foreign body ingestion (make no assumptions relating to a young baby's age: an older toddler may try to 'feed' the new baby), anaphylactic reaction.
  

  Foreign body ingestion2 Suggestive features: witnessed episode, sudden onset of coughing or choking, recent history of playing/eating small objects. Effective coughing suggested by: crying or verbal response to questions, being able to take breath in before coughing, loud cough, fully responsive child. Ineffective coughing suggested by: inability to vocalise, quiet or silent cough, inability to breathe, cyanosis, decreasing level of consciousness.

• Specifically find out about past respiratory disease.
  

  Past history of asthma3 Previous severe asthma. Previous hospitalisations. Dependence on inhaled or systemic corticosteroids. Non-compliance with medications. Labile asthma with pronounced diurnal obstruction. Brittle asthma with unexpected sudden deterioration of airway function. Chronic asthma with depressive symptoms/manipulative use of asthma.

• Complete usual paediatric history. When enquiring about social history in a young child, enquire about smokers in the house (relatives, frequent visitors).

Examination

• General observations
• Respiratory system

  Signs of respiratory distress
  Sign	Comment
  Tachypnoea	Normal respiratory rates: <1 year: 30-40 breaths per minute. 1-2 years: 25-35 breaths per minute. 2-5 years: 25-30 breaths per minute. 5-12 years: 20-25 breaths per minute. >12 years: 15-20 breaths per minute. Very slow respiratory rates in children suggest imminent respiratory arrest or poisoning with narcotic drugs.
  Intercostal and sternal recession	Intercostal and abdominal muscles are drawn in with each inspiration. This is seen more easily in very young children; therefore, if it is particularly significant if seen in the child over 6-7 years of age.
  Use of accessory muscles	Look for the head bobbing up and down in infants.
  Tripodding or anchoring	The child may sit forward and grasp their feet or hold on to the side of the bed.
  Nasal flaring	Particularly seen in infants.
  Inspiratory/expiratory noises	Stridor: high-pitched inspiratory noise - sign of upper airway obstruction. Wheezing: tends to be louder on expiration - sign of smaller-calibre lower airway obstruction. Grunting: exhalation against a partially closed glottis - sign of severe respiratory distress in infants.

  Assess chest expansion and auscultate: beware of the silent chest (this means that very little air is going in and out). Pulse oximetry should show an oxygen saturation close to 100% in normal healthy children breathing air. Acute severe asthma is defined by a SpO₂ ≤92%, respiration rate raised and the child being unable to talk in normal sentences.³

• Other systems - these need assessing to gauge to what extent the respiratory distress has affected them.
  • Cardiac system - tachycardia is generally seen (the heart rate should roughly be four times the normal respiratory rate), e.g. pulse ≥140 beats per minute (bpm) (2-5 years) or ≥150 bpm (≥5 years old) in acute severe asthma.
    NB: bradycardia occurs in the presence of severe or prolonged hypoxia and is a pre-terminal sign.
  • Skin colour - pallor occurs initially. Cyanosis is a late and pre-terminal sign.
  • Agitation ± drowsiness. This may be difficult to assess and the parents will need to be consulted in the case of the very young child or baby.

Causes of respiratory distress⁴

• Laryngomalacia.
• Foreign body ingestion.
• Laryngeal oedema: anaphylaxis, inhalation injury.
• Upper respiratory tract infection: epiglottitis, croup, retropharyngeal abscess.
• Lower respiratory tract causes: asthma, bronchiolitis and bronchitis, pneumonia, acute respiratory distress syndrome.

Management

This will be guided by the degree of respiratory distress and the underlying diagnosis (see above and follow links for management):

• Life-threatening respiratory distress warrants immediate initiation of life support measures (see links below) and immediate ambulance transfer to hospital.⁵
• Children with moderate-to-severe respiratory distress should be referred to the local paediatric team.
• Where the decision is made to treat the child at home, parental education and frequent reviews are mandatory.

Remember:

• Almost all ill (or injured) children will benefit from high-concentration oxygen therapy. The only small group of infants to be careful with are those with duct-dependent congenital heart disease.
• It is usually counterproductive to make an unwilling child wear an oxygen mask. Avoid any other action that may agitate the child (which worsens the respiratory distress) unless the child is critically ill. Most of the assessment and initiation of treatment can be done with the child in their parent's arms.
• Do not put anything (including a thermometer) in the mouth of a child with stridor as this may precipitate complete respiratory obstruction).

Document references

1. Sick child chart (2 months to 5 years), World Health Organization, last accessed September 2008
2. Paediatric Choking Treatment Algorithm, Resuscitation Council UK (2010)
3. British Guideline on the Management of Asthma, British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN), 2009
4. Asthma, Clinical Knowledge Summaries (2007)
5. Breathing Difficulty: An evidence-based guideline for the management of children presenting with acute breathing difficulty, Paediatric Accident and Emergency Research Group (2002)

Internet and further reading

• Newborn Life Support, Resuscitation Council UK Guideline (2010)
• Emergency treatment of anaphylactic reactions - guidelines for healthcare providers, Resuscitation Council UK (January 2008)

Acknowledgements