I saw a seven-year old boy today, at home with his mum, because she was concerned about his breathing.
Respiratory symptoms, inclusive of ear, nose, and throat problems, remain predominate manifestations of illness throughout childhood. Newborns suffer from transient tachypnoea and may go on to chronic lung disease, infants are prone to pertussis and bronchiolitis, toddlers croup and middle ear infections, older children bronchitis and tonsillitis. Pneumonia can afflict children of all ages. A nice, concise and convenient, approach to examination of the child’s respiratory system stands the health care practitioner in good stead.
Such an approach might be to consider the pathophysiology stratified by age group. When you see a child with respiratory manifestations, the first and perhaps most important clue to the underlying cause is their … age.
Pneumonia:
In children, the absence of respiratory distress (tachypnoea), crepitations, and diminished breath sounds, excludes pneumonia.
Rule-of-thumb guide to tachypnoea in children:
- > 60 in neonate
- > 50 in 1 month to 1 year old
- > 40 1 year – 5 years old
Indication for CXR in febrile child > 3 months old:
- Tachypnoea > 50 (3-12 months) or > 40 (12 months – 5 years)
- nasal flaring
- retractions
- grunting
- reduced breath sounds or crepitations
Consider, then, the following common causes of childhood respiratory distress presenting in the general practice setting.
Fever 3-36 Months
- clinically identifiable viral infection
- clinically identifiable bacterial infection
- other infectious illness (presumably viral)
- occult bacterial infection
Clinically identifiable infections:
Apart from croup, characteristic rashes define most of these. Other exanthema are usually viral (roseola rash appears only once fever resolves), allergic, heat rash, and local irritation.
| varicella | otitis media |
| measles | pneumonia |
| HSV gingivostomatitis | meningitis |
| croup | septic arthritis / osteomyelitis |
| herpangina | lymphadenitis |
| hand, foot, and mouth disease (HFMD) | dysentery-like bacterial enteritis |
Non-specific Viral Infections:
- URTI
- bronchiolitis / asthma exacerbation
- viral gastroenteritis
- mixed respiratory and gastrointestinal infections
- fever accompanied by rash
- rare fungal infections
- malaria
- other parasitic diseases
- fever only
Kawasaki Disease: criteria
- fever for at least 5 days
- bilateral conjunctival injection (painless, non-exudative)
- mucous membrane changes: pharyngitis; red, fissured, or cracked lips
- oedema or erythema of palms and soles
- rash: polymorphous and truncal
- cervical adenopathy with at least > 1.5 cm nodes
Occult bacterial infections
Occult bacteraemia is present in 1-3% of non-toxic febrile children (BT > 39C), and 3% of these will go on to have serious bacterial infection (SBI).
- UTI: 5.3% of febrile infants, especially < 12 months old, seen in ED
- up to 17% of white female infants with core BT > 39 have UTI
- pneumonia: “silent”
- meningitis: especially < 12 months old
- septic arthritis / osteomyelitis
- bacterial enteritis
- sinusitis: especially > 2 years old
- (abdominopelvic abscess)
Therefore, 1 child in 10,000 (3% x 3%, or 0.03 x 0.03 = 0.0009) with a febrile illness (BT > 39C) who looks clinically well and without focus will develop SBI.
