Causes

Presence of chest signs
Pneumonia
Bronchiolitis [0 to 12m; caused by Respiratory syncytial virus RSV]
Viral-induced wheeze (possible asthma) [6m to 5y]
Infective exacerbation of asthma
Bronchiectasis
Cystic Fibrosis
Foreign Body aspiration
Pertussis (inspiratory whoop)

Clear chest on examination
Coryza (‘common cold’)
Pharyngitis
Otitis media
Croup

Determine severity of child’s condition

Objective vital signs:

Temperature
Respiratory rate
Heart rate (+ Blood Pressure) and Capillary refill time (CRT<3s)
Assess dehydration: mucous membranes, skin turgor, urine output
Oxygen saturation (should be >95%)
PEFR

Clinical signs of work of breathing and exhaustion:

worsening work of breathing: grunting, nasal flaring, marked chest recession, use of accessory muscles while the child is at rest

exhaustion: not responding normally to social cues, wakes only with prolonged stimulation, decreased activity

apnoea or cyanosis or agitation or consciousness (signs of hypoxia)

Feeding, dehydration and perfusion:

Feeding, fluid intake, wet nappies in preceding 24hr (ideally>50%)

When to refer

Objective vital signs:

Raised respiratory rate (> 60/min):
0 to 5 months: >60
6-12m: >50
>12m: >40 +/- nasal flaring, crackles
Oxygen saturation ≤95% (administer supplemental oxygen if sats<92%)
PEFR< 50% in children with viral-induced wheeze/an infective asthma exacerbation.
Age<3m + temperature ≥38°C
or Age 3-6m + temperature >39°C

Heart rate (>160bpm)
<1yr: >160bpm
1-2yr: >150bpm
2-5yr:>140bpm

Clinical signs of work of breathing and exhaustion:

worsening work of breathing: grunting, nasal flaring, marked chest recession

exhaustion: not responding normally to social cues, wakes only with prolonged stimulation, decreased activity

Apnoea or cyanosis or pallor (skin, lips, tongue)

Auscultation:

Absent breath sounds with dull percussion note suggest pneumonia complicated by effusion

Poor feeding, dehydration and poor perfusion:

Poor feeding (<50% fluid intake in preceding 24 hours)
Fluid intake is 50–75% of normal or no wet nappy for 12 hours
Clinical dehydration: dry mucous membranes, reduced skin turgor, reduced urine output
Poor perfusion: Capillary refill time (CRT) ≥ 3s

Factors that lower the threshold for admission

• Chronic lung disease (including bronchopulmonary dysplasia)

• Congenital heart disease

• Neuromuscular disorders

• Immunodeficiency

• Age <3m

• Preterm infant<32w

• Carer cannot safely monitor child (lacks skill or adverse social circumstances)

• Longer distance to healthcare in case of deterioration.

Management

For all conditions, give supplemental oxygen if saturations <92%.

Pneumonia and treatment at home:

Antibiotics: Amoxicillin, Co-amoxiclav (flu+pneumonia), Erythromycin
7-14 day antibiotic course
paracetamol/ibuprofen

Bronchiolitis and treatment at home:

Self-limiting, symptoms peak 3-5d, paracetamol/ibuprofen

Viral-induced wheeze or infective exacerbation of asthma: HOSPITAL

Life-threatening
PEFR<33%
Exhaustion, poor respiratory effort
Altered consciousness
sat<92%

Severe
PEFR<50%
High RR (2-5y >40; 5-12y >30; >12y >25)
High HR (2-5y >140; 5-12y >125; >12y >110)
Inability to complete sentences
accessory muscles respiration
sat<92%

1. Nebulised 2.5mg/5mg salbutamol (oxygen driven)

2. Transfer to hospital

Viral-induced wheeze or infective exacerbation of asthma: HOME

Moderate severity: PEFR>50%, normal speech

1. PMDI puff, every 30-60s, each puff inhaled over 5 tidal breaths, 10 puffs total, via spacer

2. [Short course oral prednisolone: controversy, see below]
   <2y 10mg od 3d
   2-5y 20mg od 3d
   6-12y 30-40mg od 3d
   >12y 40-50mg od 5d

3. Amoxicillin, doxycycline, erythromycin; 5 day antibiotic course

4. Follow up child in 48hr

Viral wheeze in preschool children

1. Preschool wheeze should be divided into “episodic viral” and “multiple trigger” according to the history (check personal/family history of atopy)

2. No treatment has been shown to prevent progression of preschool wheeze to school age asthma

3. In all but the most severe cases, episodic symptoms should be treated with episodic treatment

4. Prednisolone is not indicated in preschool children with attacks of wheeze who are well enough to remain at home and in many such children, especially those with episodic viral wheeze, who are admitted to hospital

5. There is no evidence to support the use of regular inhaled corticosteroids in preschool children who do not wheeze between viral colds
   In those children with really severe episodic wheeze who require repeated admission to hospital or have prolonged disruptive symptoms managed at home, however, a trial of prophylactic inhaled corticosteroids can be given.

6. Nebulisers should not be used in preschool wheeze; inhaled drugs delivered by metered dose inhaler and spacer are at least as efficacious

7. First-line treatment
   Intermittent bronchodilator therapy (SABA or SAMA)

8. Second-line treatment
   Intermittent treatment with montelukast (started on the first day of URTI and discontinued when symptoms resolve), or,
   Intermittent inhaled cortisteroid
   In severe cases a combination of inhaled cortisteroid and montelukast can be used

Bush A, Griggs J, Saglani S. Managing wheeze in preschool children. BMJ 2014; 348: g15

Safety-netting

1. Monitor for 'red flag' symptoms:

   worsening work of breathing: grunting, nasal flaring, marked chest recession

   exhaustion: not responding normally to social cues, wakes only with prolonged stimulation

   apnoea or cyanosis

   fluid intake is 50–75% of normal or no wet nappy for 12 hours
   worsening of fever

2. Contact emergency medical services if any red flag symptoms develop

3. Avoid exposure to smoking

4. Arrangements for follow‑up if necessary.