Introduction

Respiratory illnesses, affecting the upper and lower respiratory tract, are the commonest cause of hospital admission in childhood. They are also an extremely common cause of primary care consultation. Coughing and snuffles are very common in children, especially during the winter months. Many children suffer wheeze and breathlessness as well. These symptoms are often caused by common viral infections, as the child acquires immunity in the early years. A complex interaction of inherited, environmental, allergic and social factors leads to significant morbidity in a few. The ability to distinguish mild from severe, and acute from recurrent, is the key to successful management.

History

Cough, snuffles, wheeze, breathlessness and stridor are the common respiratory symptoms in children. Wheeze is an expiratory whistling noise, but members of the public do not always understand the term. Even experienced doctors may on occasion get confused between expiratory wheeze and inspiratory stridor. Be careful, then, not to make assumptions. Ask about the nature of any cough as this is helpful in reaching a differential diagnosis. Upper airway coughs are often ‘barking’ in nature – like a seal rather than a dog. The cough associated with lower airway obstruction, such as bronchiolitis or asthma, is often described as ‘hacking’ or ‘dry’. A ‘fruity’ cough may indicate suppurative lung disease such as bronchiectasis.

Noisy breathing and rattly chests are common in younger children and do not necessarily indicate troublesome underlying pathology. They may upset parents or grandparents more than they do the child. Consider whether the symptoms affect the child’s day-to-day life and activities. Do they sleep normally, or are they woken by cough or wheeze? Do they manage regular attendance at school or nursery? Can they exercise normally, particularly PE and games? The infant equivalent of exercise is feeding, so ask if there is any difficulty with feeding, or slow weight gain.

Enquire particularly about the pattern and duration of any symptoms. Do they persist every day, or only occur episodically, e.g. with viral upper respiratory tract infections (URTIs)? A family or personal history of asthma or allergy such as eczema, hay fever or food allergy, may point towards asthma as the diagnosis. Ask about environmental precipitants such as passive smoking and exposure to dust or other inhaled allergens, including pollen and pet dander. Psychological and emotional factors need to be considered, as these are common triggers of airways obstruction.

Less common symptoms from respiratory disease include chest pain, vomiting and, in infants, apnoea. Young children with airways obstruction will sometimes refer to chest tightness as pain. Severe pain localized to the chest wall on deep breathing or coughing is called pleuritic pain, and is characteristic of acute lobar pneumonia with pleural involvement. Vomiting is frequent in young children with respiratory disease. Babies with gastro-oesophageal reflux may present with wheeze and cough; conversely, children with other respiratory conditions may vomit as a result of the large intrathoracic pressure swings affecting lower oesophageal (‘cardiac’) sphincter tone. Very young children, with conditions that usually cause cough, may present with apnoea instead. It is a common symptom in whooping cough and may be the presenting symptom in bronchiolitis, especially in ex preterm infants.

Remember that children with non-respiratory disease, such as diabetic ketoacidosis or panic attacks, may present with respiratory symptoms. On the other hand, some children with respiratory disease, especially pneumonia, may present with abdominal pain, or high fever alone, and little or nothing in the way of respiratory symptoms.

Examination

Use the scheme ‘inspection, percussion, palpation and auscultation’. Start your examination by observing the child at rest. Is there tachypnoea (see Table 10.1), recession or other evidence of respiratory distress, e.g. head bobbing in a baby or nostril flaring in a toddler? Does the child look anxious? Is there an audible noise during respiration (see Table 10.2)? Do not forget that tachypnoea may be due to fever or acidosis when there is no respiratory tract pathology.

Table 10.1 Respiratory rates at different ages

Recession is a key physical sign in infants and young children. It describes the in-drawing of soft tissues around the chest by negative intrathoracic pressure generated by airway obstruction or reduced lung compliance. It may be seen in adults but is common in children because both soft tissues and the thoracic cage are more compliant. The resultant recession may be subcostal, intercostal or suprasternal. In addition, in neonates, the whole sternum may be sucked in – sternal recession, sometimes associated with grunting.

In older children you should complete a formal examination of the respiratory system including checking for clubbing (see Table 10.3) and cyanosis, percussion and auscultation. Look for chest deformity – Harrison’s sulci or pectus carinatum (‘pigeon chest’). These indicate chronically increased airway resistance – most commonly due to asthma.

Table 10.3 Causes of clubbing

In young children, particularly under 2 years, respiratory examination needs to be opportunistic and percussion is rarely of value. Audible crackles in the chest do not always mean lung consolidation or infection, particularly in the young child. They are often heard in wheezy children where they may be due to oedema and mucus in the small airways (see Table 10.4). Think about whether there are other signs of consolidation, such as reduced air entry or bronchial breathing. Examination of the ears and throat is a challenge in a fractious toddler – it is best left until last.

Table 10.4 Severity of respiratory distress

Ears, nose and throat

A successful ENT examination requires younger children to be held gently but firmly by the parents (Figure 10.1).

Figure 10.1 Positions for the ear and throat in the ENT examination.

Ears

Ask the parents to sit the child on their lap at 90° to their chest. With one arm, ask them to gently hold the child’s head against their chest. Their other arm should hold onto the child’s free arm. Gentle traction should be applied to the ear. The pinna should be pulled in an upward and outward direction. The auriscope should be gently held in a pincer grip. The ring finger of this hand should rest on the cheek of the child while the auriscope is within the ear. This allows the examiner’s hand to quickly follow any sudden movements the child may make.

Throat

This is an unpleasant examination. It should be left until last. A tongue depressor is necessary for a complete examination. If throat disease is suspected, it is useful to have a swab to hand. A child may comply with throat examination once. They may resist a further request a few minutes later for a throat swab.

Investigations

Upper respiratory tract infections

Upper respiratory tract infections (URTIs) may be summarized as snuffles, fever and misery.

Viral URTIs are the commonest conditions encountered in primary care. Adults are immune to most of the upper respiratory tract viruses in their immediate environment – they only produce symptoms when they contract a new virus. Children have to acquire immunity to a host of viruses in their first few years, and have, on average, six to ten episodes of infection annually. Changes of environment – such as starting at the nursery or school – will produce an even higher infection rate. Although often trivial illnesses in medical terms, the symptoms of snuffles, fever and sore throat may make young children thoroughly miserable.

Nasal obstruction may cause feeding problems in babies as they are obligate nose breathers. Symptomatic treatment includes paracetamol for the relief of discomfort and fever. Decongestant nose drops and oral decongestants are ineffective and best avoided. Saline nose drops are probably as effective as more expensive proprietary remedies.