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

Age	Breaths per minute
Neonate	40–60
Infant	30–40
5 years	20–25
10 years	15–20

Table 10.2 Audible respiratory sounds

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

System	Cause
Cardiac	Cyanotic congenital heart disease Bacterial endocarditis
Respiratory	Bronchiectasis Cystic fibrosis/ciliary dyskinesia Tuberculosis Empyema/abscess, malignancy
Gastrointestinal	Inflammatory bowel disease, chronic active hepatitis Primary sclerosing cholangitis
Other	Familial

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

Grade	Characteristics
Mild	Tachypnoea Mild recession No effect on feeding or speech
Moderate	Tachypnoea Moderate or severe recession, struggles to feed, cannot speak in full sentences Oxygen may be needed to maintain saturation
Severe	Tachycardia, gasping, speechless, frightened May be pale and quiet or agitated and hypoxic despite oxygen Chest may be silent and respiratory effort flagging Impaired consciousness

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

Chest X-ray

This simple investigation is easily obtained in hospital but may be over-used. Consider what you hope to learn before requesting a radiograph. It is not necessary, for instance, to X-ray every wheezy child, unless the episode is moderate or severe, or there are focal signs. Do not send an unstable child, particularly with upper airway obstruction, across the hospital to the X-ray department – stabilize the child first or request a portable X-ray. If there is any question of an inhaled foreign body, a single film is never sufficient. Except in those who require immediate bronchoscopy, X-ray screening in the young child, or inspiratory and expiratory films in the cooperative older child, are needed to confidently exclude or confirm a foreign body.

Blood gas

Blood gas is a useful examination to assess the severity of a respiratory illness but is only needed in those with severe distress. Capillary samples are normally adequate, unless there are concerns about hypoxia, but arterial punctures are difficult and painful, and may aggravate hypoxia. Radial or brachial samples should be collected where needed.

Other blood tests

Blood tests are generally over-used. A blood count and C-reactive protein measurements in children with fever and cough are unhelpful at distinguishing common viral infections from more significant bacterial lower respiratory tract infections. A high lymphocyte count will help corroborate a diagnosis of whooping cough. Urea and electrolyte measurement is really only needed if there is coexistent severe vomiting or dehydration, or in children requiring intravenous fluids. Blood cultures are necessary if a child with pneumonia is very toxic and there are concerns about associated septicaemia. IgE and blood allergy tests may help confirm atopy in the child with probable asthma. Only occasionally does it directly influence management, e.g. the wheezy baby with eczema and milk allergy. Rarely, immune function testing may be required in children with true recurrent bacterial lower respiratory tract infections (see Chapter 16, p. 241).

Respiratory secretions

These are under-used. They are often forgotten as young children either cannot or will not produce sputum. Sputum culture, if available, is more helpful than blood culture. If persistent bacterial bronchitis is suspected a cough swab is a useful alternative to sputum culture and is invaluable in monitoring conditions such as cystic fibrosis and other forms of bronchiectasis. Immunofluorescence testing of nasopharyngeal aspirates is useful in infants with bronchiolitis to confirm or exclude respiratory syncytial virus (RSV) infection. A nasopharyngeal aspirate or pernasal swab is used to test for whooping cough.

Lung function testing

Peak flow measurements can be used in most children from about 5–7 years and are helpful in diagnosing and monitoring the severity of asthma. The child takes a deep breath, and then breathes out quickly through the mouthpiece of the peak flow meter, ensuring a good seal. The best of three measurements is taken.

Spirometers are now available in simple portable format, with computerized screens, which are fun for young children to use. They enable children as young as 5 years to perform previously complex lung function measurements. Analysis of a flow volume curve from such a spirometer can be very helpful in excluding or confirming airways obstruction.

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.

Influenza

Flu, caused by the influenza virus types A, B and C, is a seasonal infection striking in the autumn and winter months. Influenza A is classified according to two key proteins – haemaglutinin (types H1–H3), important for infectivity, and neuraminidase (two types, N1 and N2), which determines viral replication. Neuraminidase is the target for the drugs oseltamivir and zanamivir. Influenza B also expresses neuraminidase, and hence is susceptible to antivirals. Influenza type C is a very mild, non-epidemic infection.

Type A is marked by antigenic drift, ensuring on-going susceptibility to seasonal flu, from year to year. Periodically, major antigenic shift occurs, probably due to recombination with avian and human flu types in pigs. Major antigenic changes herald worldwide pandemics, such as the recent H1N1 ‘swine flu’ pandemic. This predominantly affected young people (peak age 12–17 years) and was, for the most part, a mild disease, with symptoms indistinguishable from seasonal flu. However, in those with pre-existing conditions, the disease could be severe or fatal.

Influenza has a short incubation period (1–3 days), followed by sudden onset of fever, cough, coryza and myalgia. Vomiting, and less commonly diarrhoea, may occur. Myalgia is more common with influenza B, and creatine kinase may be elevated. Influenza is highly infectious, with rapid spread by respiratory droplet transmission. Symptoms typically remit in 5–7 days.

In those with severe disease, symptoms of rapidly progressive respiratory failure develop, typically 3–5 days after symptom onset, principally due to viral pneumonitis, but, in a third bacterial super-infection occurs. Multi-organ failure may supervene, and extracorporeal membrane oxygenation is required in severe cases.

Mortality

Aside from viral pneumonitis, death follows secondary bacterial pneumonia, notably with pneumococcus (particularly serotype 1), Haemophilus influenzae B and Staphylococcus. Rarely, frank myocarditis occurs, and is rapidly fatal. A necrotizing encephalopathy, characterized by widespread changes in the brain stem, thalamus and cerebellum, with normal cerebrospinal fluid (CSF) and negative virological studies in CSF, also occurs rarely.

Prevention and treatment

Immunization of vulnerable children (e.g. those with asthma, congenital heart disease, diabetes or renal disease) is recommended. Pregnant women are at high risk of severe complications of influenza and should be offered immunization. Immunization of pregnant women also affords some protection to infants in the first few months after birth.

In epidemic situations, for children over 12 months, with increased vulnerability to infection, presenting within 48 hours of onset of flu symptoms, NICE recommends use of oseltamivir or zanamivir to ameliorate the illness. Post-exposure prophylaxis is recommended in unimmunized children 13 years and over, in at-risk groups.

Tonsillitis

Bacterial tonsillitis is hard to distinguish on clinical grounds from viral URTI as both conditions may produce a red throat with enlargement of local glands. It is often assumed that a white exudate over enlarged and inflamed tonsils is suggestive of bacterial infection but controlled studies have not shown this. Most tonsillitis in young children is viral and even if streptococcal infection is confirmed there is little evidence that antibiotics do anything other than reduce the risk of post-infective complications such as rheumatic fever or nephritis. Antibiotics are only necessary if the infection is slow to settle and there are concerns about secondary problems such as quinsy or nephritis. Avoid ampicillin or amoxicillin, as glandular fever may be the cause – look for generalized lymphadenopathy or hepatosplenomegaly (see Chapter 16, p. 237).

Otitis media

This presents with fever, misery and acute pain in the involved ear. Any viral URTI may produce a pink or red drum, but check for pain and look for evidence of loss of light reflex and bulging of the drum. The evidence suggests that paracetamol is as effective as antibiotics in treating otitis media and an initial period of observation with analgesia is recommended. Nevertheless it is hard not to treat children with acutely inflamed tympanic membranes with antibiotics. Amoxicillin is usually the first-line treatment. Sometimes the tympanic membrane perforates during an acute infection, releasing a little pus which discharges from the ear. Perforation produces dramatic relief of symptoms and the damaged tympanic membrane usually heals spontaneously. Provided the ear discharge is transient and other symptoms resolve promptly no additional measures are needed. Glue ear may be a chronic consequence of otitis media or occur without acute infection. Hearing loss is the commonest symptom, and evidence suggests that prophylactic antibiotics for a few months can reduce the need for grommets or other surgery.

Upper airways obstruction

Stridor and croup are important paediatric problems. The upper airway of children, being smaller than in adults, is more likely to obstruct with oedema of local tissues. Infections or allergies, which might produce hoarseness or loss of voice in an adult, may therefore produce alarming respiratory obstruction in a child. Acute severe stridor is an acute medical emergency. Management is described in Appendix I, p. 296.

Differential diagnosis of stridor

Croup, as is the diagnosis in Case 10.1, is the commonest cause of acute stridor. It occurs mainly in preschool children.

Case 10.1

A boy with a barking cough

Ahmed, aged 3 years, presented to hospital at 2 a.m. with his family. He was snuffly and miserable the day before, and was given some paracetamol for a mild fever at bedtime. At 1 a.m. he awoke with an alarming ‘crowing’ noise on inspiration, and a very loud, unusual cough – like a seal ‘barking’. He and his parents were panic-stricken as he gasped for breath. On examination he was pale and frightened with a loud inspiratory stridor. He looked pink and well perfused. He was alert and cried when approached. He and his family were reassured by the calm gentle approach of the staff. He was persuaded to tolerate a saturation monitor which showed an oxygen saturation of 94% in air. As examination showed moderate recession, he was treated with nebulized budesonide.

There is usually a viral prodrome, commonly with a barking cough. Parainfluenza virus is the commonest causative organism, and steroids are the mainstay of management. Meta-analysis of many trials has confirmed their efficacy and any child with croup severe enough to need hospital admission should receive steroids. Nebulized budesonide works more quickly than oral or parenteral steroids. In severe stridor, nebulized 1:1000 adrenaline (epinephrine), repeated as necessary, is useful as an emergency measure (see also Appendix I, p. 296).

Spasmodic croup describes the condition of a group of children with recurrent but often short-lived stridor. The condition is thought to be allergic – being commoner in those with other evidence of atopy.

Epiglottitis has become very rare following the introduction of Haemophilus influenzae b immunization. However, effectiveness of the vaccine has waned recently, prompting a booster, and children born abroad may not be immunized. Epiglottitis is a septicaemic illness, and good supportive care – as for any child with septicaemia – is needed. A third-generation cephalosporin such as ceftriaxone is used.

See Table 10.5 for the differences between croup and epiglottitis.

Table 10.5 The important differences between croup and epiglottitis

	Croup	Epiglottitis
Organism	Parainfluenza virus	Haemophilus influenzae b
Age	6 months to 3 years	3–7 years
Prodrome URTI	Usual	Uncommmon
Onset	Days	Hours
Cough	Present	Often absent
Dysphagia	Absent	Severe with dribbling
Systemic	Mildly unwell	Toxic and ill
Posture	No preference	Sitting/leaning forward

Bacterial tracheitis is a rare cause of stridor. The child is usually extremely ill with co-existent septicaemia and pneumonia. Pus is seen in the trachea at intubation. Staphylococcus aureus is the most likely organism, but other organisms, such as Haemophilus, Moraxella or Streptococcus may be responsible.

Inhaled foreign bodies may present with stridor. Other presentations include the asymptomatic child following a choking episode, cough, wheeze or hoarseness. The history may not be definite but the diagnosis should always be considered in such children. Prompt recognition and removal is essential, as they may prove fatal. Delay in removal may also cause long-term morbidity, such as bronchiectasis. Ninety-five per cent of inhaled foreign bodies in children are organic, most commonly peanuts, and are not radio-opaque.

Anaphylaxis can present with severe upper airways oedema leading to obstruction. Wheezing and collapse with hypotension may also occur. Severe cases may require intubation. Adrenaline (epinephrine), given either intramuscularly or intravenously, may be life-saving (see also Appendix I, p. 286). Steroids may be required for the wheeze but anti- histamines really only offer symptomatic relief for itching. Recent studies in young children have shown that milk and egg are the commonest causes, as opposed to nuts in older children and adults. Following an episode of anaphylaxis, thought should be given to allergy tests to help delineate the cause. Adrenaline (epinephrine) pens are also dispensed in increasing quantities for use in the community. Although seemingly a sensible precaution, they require thorough training, with a care plan in place for use in the school or nursery, and evidence suggests that they are rarely used.

Chronic upper airways obstruction

Congenital stridor is seen in infants, and is most commonly due to laryngomalacia. The cartilaginous parts of the larynx and trachea are less firm than usual, and partly obstruct the airway on inspiration. If severe it may cause failure to thrive due to feeding difficulties, and is often worse with viral URTIs.

Rarer causes include vascular rings compressing the trachea from outside, mediastinal masses such as neuroblastoma (see Chapter 7, p. 74) and intrinsic airway conditions such as haemangiomas and webs. Babies with anything other than very mild stridor should have a plain chest X-ray and a barium swallow. A barium swallow is more effective than echocardiography in picking up vascular rings. Moderate to severe stridor requires direct laryngoscopy to look for intrinsic lesions such as airway haemangiomas. The prognosis for laryngomalacia is excellent, with the noisy breathing diminishing with age as the cartilage strengthens.

Snoring and obstructive sleep apnoea

Snoring is relatively common in children, and is usually benign. Snoring is characteristically episodic, and associated with upper respiratory tract infection, rhinitis or nasal obstruction. The commonest cause of chronic snoring is adenotonsillar hypertrophy. Snoring that is persistent and loud may be indicative of airway obstruction, which, in turn, may predispose to obstructive sleep apnoea (OSA).

OSA is relatively uncommon in children (incidence 0.8–2.0%). The commonest cause is marked adenotonsillar hypertrophy, typically presenting between 3 and 6 years of age. Congenital disorders that narrow the airway, such as achondroplasia, and disorders with reduced muscle tone, such as Down syndrome, predispose to OSA. In older children, morbid obesity is the commonest cause.

OSA may produce a range of symptoms. In the younger child, failure to thrive and behavioural problems may result. In severe cases, particularly in association with obesity, pulmonary hypertension and cor pulmonale may result from chronic hypoxia.

In addition to snoring, parents may report gasping, or pauses in breathing during sleep. Behavioural problems such as headaches, ADHD and enuresis are more common in children with OSA. Day-time sleepiness is less common than in adults.

Clinical signs may include visible tonsillar enlargement, glue ear (secondary to adenoidal hypertrophy), nasal obstruction with mouth breathing, and nasal speech and obesity.

Any child with chronic snoring should be evaluated with overnight pulse oximetry. Recurrent desaturations below 92% are suggestive of OSA. In the first instance, adenotonsillectomy is recommended. If symptoms of OSA persist, a formal sleep study in a specialist centre is usually recommended to confirm the diagnosis. Overnight continuous positive airway pressure (CPAP) may be appropriate for refractory cases.

Chronic cough

Chronic cough is defined as being present for more than 3 weeks. It has many causes. It may be associated with infection or inflammation, or it may be habitual, in which case the cough has a characteristic ‘honking’ or ‘brassy’ quality.

The assessment should inquire about the nature of the cough, any sputum production, and any associated symptoms or relevant past medical history. A paroxysmal cough suggests pertussis; night-time, or exercise-induced cough might suggest asthma; sputum production and fever suggest bronchiectasis or tuberculosis. Relationship to posture or feeds may occur with gastro-oesophageal reflux. A history of choking may indicate an inhaled foreign body. Immune deficiency or cystic fibrosis will usually cause failure to thrive. Tracheo-oesophageal fistula (see Chapter 17, p. 259), is associated with a characteristic ‘TOF cough’.

Pertussis

Pertussis, or whooping cough, is caused by Bordatella pertussis. It invades the pulmonary ciliary epithelium causing bronchial congestion and inflammation, with peribronchial lymphoid hyperplasia (catarrhal stage 1–2 weeks). Wide-spread epithelial necrosis then ensues, with the characteristic coughing bouts (paroxysmal stage 2–4 weeks), and predisposes to atelectasis and bronchopneumonia. Paroxysms of coughing with a terminal ‘whoop’ are characteristic (as in Case 10.2). Children are unable to catch their breath and may become cyanosed. Apnoea occurs in young infants. Vomiting is common. Pneumonia accounts for 80–90% of deaths from pertussis. Seizures (3%) and encephalopathy (1%) may occur. The convalescent phase lasts from 1–2 weeks to many months. Use of antibiotics in the catarrhal stage may shorten the illness but, if started in the convalescent stage, has no effect on the duration of illness, although infectivity to others is alleviated. In adults and older children, who are the usual sources of infection, the cough is a dry, repetitive, ‘staccato’ cough.

Case 10.2

A boy with coughing paroxysms

John, aged 5 months, was taken to his GP with a 2-week history of persistent coughing bouts. The bouts were associated with him going blue, and sometimes with vomiting. He was feeding poorly. His older sister also had a severe cough, which had been present for several weeks. Of note, John had not received pertussis immunization owing to parental concerns about vaccine safety. Whilst in the consultation, John had a coughing paroxysm with a classical whoop. He was referred to hospital for assessment where, after obtaining a pernasal swab, he was treated with clarithromycin. A blood count showed a marked lymphocytosis.

Large-scale outbreaks of whooping cough in Britain and the USA in 2011-12, to levels not seen for over 50 years, have led to concerns that the current whooping cough immunization schedule (see Chapter 1, p. 3) does not provide long-lasting immunity. The introduction of a further booster immunization for secondary school children and pregnant women is under consideration. Booster immunizations for healthcare workers have now been recommended.

The wheezy child

Wheezing is an extremely common symptom, occurring in about half of all children at some time in childhood. Many of these children have isolated episodes of wheezing in association with viral infections. Twenty to thirty per cent of children have either persistent or recurrent wheezing and only half of these turn out to have true ‘asthma’. Attempts to delineate diagnostic groups more clearly are hampered by the lack of a truly robust definition of asthma in childhood. There is a group of children who wheeze only with viruses and who respond to bronchodilators, but lack interval symptoms and fail to respond to inhaled steroids. Definitions of asthma relying purely on bronchial hyper-reactivity will include those children with viral wheezing and overestimate asthma prevalence. Questionnaire studies of asthma prevalence are hampered by the same difficulties.

In practice this means that any child with acute wheezing can be treated in a similar fashion, but chronic management will depend more on the likely cause of the wheezing.

Acute wheezing

Bronchodilators through a large volume spacer have largely replaced nebulized treatment as the preferred option for initial treatment of acute wheezing in childhood. Careful assessment is needed and measures including oxygen and systemic steroids are needed in moderate to severe wheezing. See Figures I.14 and I.15 in Appendix I for full assessment and management.

Case 10.3

A baby with acute respiratory distress

Marcus was born at 30 weeks’ gestation and needed ventilation for 3 days with respiratory distress syndrome. He was discharged at 6 weeks of age, 2 weeks before term. He was admitted at 8 p.m. one cold November evening aged 10 weeks. He had been chesty and snuffly for 48 hours with increasing cough and breathlessness. His feeding was disrupted. On examination he was breathing rapidly at 60 breaths per minute. He had severe recession. Auscultation revealed scattered fine crackles and some expiratory wheeze. He needed 40% inhaled oxygen to maintain oxygen saturation above 92%.

Bronchiolitis

Bronchiolitis is a term used to describe an acute respiratory infection, in children under 1 year, where wheezing may be present (as in Case 10.3). The cardinal signs are crepitations and expiratory wheeze with recession and, if severe, cyanosis. The baby initially has snuffles, which progress to a characteristic dry, hacking cough. RSV is the commonest cause of bronchiolitis, but is not a prerequisite for diagnosis. Treatment is supportive therapy with oxygen, nasogastric feeding and occasionally CPAP or even ventilation in those most severely affected (1–2%). Bronchodilators may help those with prominent wheeze, but controlled trials have failed to show clinical benefit of these or other treatments such as steroids, antibiotics, adrenaline (epinephrine) or specific antiviral treatment. Prophylactic treatment with the monoclonal antibody palivizumab is advocated for some high-risk infants, particularly those on home oxygen, to prevent life-threatening bronchiolitis.

In some parts of the world, the term bronchiolitis is used to describe any wheezy young child, which makes interpretation of the literature difficult. However, 50% of infants with bronchiolitis wheeze with subsequent viruses, as in the episodic wheezing group below. A proportion of these have atopy and would develop asthma anyway, so diagnostic categories are further blurred!

Persistent wheezing

Symptoms of chronic wheezing follow two common patterns, but with some crossover: episodic wheeze and chronic wheeze.

Episodic wheeze

Some children wheeze only with intercurrent infections with normal exercise and sleep symptoms in between times. This pattern tends to settle as the child gets bigger and is associated with small airways disease, whatever the cause. Low birth weight, prematurity, parental smoking and viruses such as RSV are common antecedents. They respond variably to bronchodilators. Steroids have not been shown to help children with mild to moderate viral wheezing. They should be used in severe wheezing as it is almost impossible to distinguish from acute asthma, but there is no evidence of benefit from prophylactic inhaled steroids in this group. Ongoing studies are examining the role of montelukast in this group. Management should focus on the acute episodes with bronchodilators early in the course of any infections and management plans, including the use of short-course oral steroids, but only for the more severely affected.

Chronic wheeze

This is classical asthma with frequent, often daily, symptoms, affecting sleep and exercise (as in Case 10.4). Background atopy is common. Management is as outlined in current British guidelines for asthma management, with inhaled steroids being the mainstay. If there is doubt over a diagnosis of asthma, particularly in children too young to provide peak flows, a trial of inhaled steroids is a sensible way forward. Review the situation after 6 to 8 weeks – do not continue inhaled steroids if they are not helping.

See Figures 10.2 and 10.3 for a summary of stepwise management in children.