Cough: Peads

Front 1

How many resp tract infections with young children normally get each year?

How long do they normally last?

When do you need to consider other causes?

Back 1

Young children develop 6-12 respiratory tract infections per year, usually accompanied by cough. In most children, the cough is self-limiting (1-3 weeks), but it is sometimes prolonged. In general, if a child presents with a history of daily cough for greater than 3 weeks duration, one needs to consider other possible causes.

Front 2

The predominant cause of cough in children of all ages is upper respiratory infection, but other causes are more likely to be age related.
Infants ?
Toddlers ?
Children ?
Adolescents?

Back 2

The predominant cause of cough in children of all ages is upper respiratory infection, but other causes are more likely to be age related.
Infants may have structural abnormalities of the airways, tracheo-oesophageal fistula, vascular rings or other anomalies.

Toddlers may have a foreign body or asthma.

Children may have asthma or chronic rhinitis.

Adolescents may have a cough caused by smoking or psychogenic factors.

Front 3

what should you ask in history of cough?

Back 3

History

Distinguish recurrent episodes from continuous cough.
Ask about
Onset (eg. sudden onset of cough without a viral prodrome may suggest foreign body inhalation).
Type of cough (eg. paroxysmal cough may suggest pertussis, chlamydia, or foreign body. Honking cough may suggest psychogenic cough).
Pattern of cough (eg. cough which is absent during sleep is suggestive of habit cough).
Symptoms of sinusitis, chronic rhinitis, atopic conditions and asthma.
Exercise tolerance.
Any other medical concerns.
Exposure to passive smoking.

Front 4

What should you look for on exam?

Back 4

Examination

Look for evidence of any abnormalities on general and respiratory examination, including fever, failure to thrive, clubbing, tachypnoea, wheeze, differential air entry or crepitations.

Front 5

There is generally a history of dry cough and nasal discharge for approximately one week, followed by a more pronounced cough which may occur in spells or paroxysms
Vomiting often follows a coughing spasm.
Young infants may develop apnoea.
Other family members frequently also have a cough (70 - 100% of household contacts are usually infected).

Back 5

Whooping Cough (Pertussis)

Front 6

What is Whooping Cough (Pertussis) caused by?

Back 6

Bordetella pertussis.

Front 7

Who is most at risk?

Back 7

Infants less than 6 months of age are at greatest risk of complications (eg. apnoea, severe pneumonia, encephalopathy) and death.

Front 8

But doctor I'm not a muppet so I immunised my child can they still get it?

Back 8

Can occur in immunised children but illness is generally less severe.

Front 9

How do you diagnose Hooping cough?

Back 9

Diagnosis

Laboratory confirmation is not necessary for diagnosis.
Clinical diagnosis can be made on the basis of
an acute presentation with features as outlined above
a longer history of cough lasting 14 days without another apparent cause and any one of: paroxysms; whoop; or post-tussive vomiting.

Front 10

What Abx do you give in Whooping chough?

Back 10

The recommended antibiotic is

Clarithromycin (child more than 1 month) 7.5 mg/kg, up to 500mg twice daily for 7 days.
Azithromycin (child < 1 month) 10 mg/kg orally, daily for 5 days

Front 11

When should you give Abx in whooping cough?

Back 11

Antibiotics

Treatment with macrolide antibiotics reduces the period of infectivity but has not been shown to alter the course of the illness unless commenced before the paroxysmal phase.
When treated with antibiotics, the period of infectivity usually lasts 5 days or less after commencement of therapy.
Which children with a diagnosis of pertussis should be treated?

In general antibiotics should be considered for
Any child admitted to hospital.
Any child with a history of cough for less than 14 days (treatment in these cases will reduce the period of school/day-care exclusion.)

Front 12

Can my child still go to daycare and you you need to report little johnny to any one?

Back 12

Control of case

The child should be excluded from school and from the presence of others outside the home (especially infants and young children) until he/she has received at least 5 days of a 7-day course of clarithromycin.
NOTE: A child who has been coughing for more than 21 days is no longer infectious; therefore antibiotic treatment and school exclusion are not necessary.

And yes it is notifiable

Front 13

Pregnant Mother of child with whooping cough asks "Will Little johnny's brothers need to have any Abx too?"

Back 13

Antibiotics

Contacts - Who should be treated?

Antibiotics should be given to all household contacts and to other contacts in high-risk settings who have had direct contact with an infectious case i.e:

Infants <12 months of age who have not received 3 documented doses of pertussis-containing vaccine (maternal antibodies do not protect against pertussis).
Any unvaccinated or partially vaccinated person with chronic cardio-respiratory illness.
Any women in the last month of pregnancy.
The recommended antibiotic is

Clarithromycin 7.5 mg/ kg twice daily for 7 days
NOTE: Antibiotics should be given within 14 days * of the recipient's first contact with an infectious case.
(*In special circumstances, such as a high-risk exposure for an infant contact, antibiotics may be given within 21 days of first contact with an infectious case.)

Front 14

Mother of child with whooping cough asks "will his friends need to be vaccinated?"

Back 14

Vaccination

Close contacts under 7 yrs of age who are not up to date with their pertussis immunisation should be given DTPa as soon after exposure as possible.

Front 15

child presents with:
History

There may have been an episode of choking, coughing or wheezing while eating or playing but many episodes are unwitnessed.
Symptoms may include persistent wheeze, cough, fever or dyspneoa not otherwise explained. Recurrent or persistent pneumonia may be the presenting feature.
The child may be asymptomatic after the initial event.

OE

Asymmetrical chest movement
Tracheal deviation
Chest signs such as wheeze or decreased breath sounds.
The respiratory examination may be completely normal.

Back 15

Foreign Body Inhaled

Front 16

What In would you order and what would you look for?

Back 16

Expiration CRX Look for:

an opaque foreign body
segmental or lobar collapse
localised emphysema in expiration (ball valve obstruction)The CXR may be normal.

notes on this xray
On expiration the foreign body can obstruct the bronchii as the diameter of the bronchii decreases slightly on expiration. The greatest difference in lung aeration will therefore be seen on the expiration image as air is exhaled from the normal lung (right lung) but not from the affected lung (left lung). The pressure in the affected lung (left lung) remains relatively constant throughout respiration.

This child is likely to have a foreign body in the left main bronchus.

Front 17

Mx of inhaled foreign body?

Back 17

If not totally obstructed:

DO NOT try to remove.
Place child upright in the position they feel most comfortable.
Arrange for urgent removal of foreign body in the operating theatre.

Front 18

Child presents with Persistent nasal discharge (beyond 10 days) following a viral infection

Symptoms include:
Nasal discharge (purulence is of little significance)
Nasal obstruction
Maxillary toothache Unilateral facial pain
Headache
Fever

What could it be?

Back 18

Acute Bacterial Sinusitis

But There are a number of causes of this presentation including sequential URTI's, allergic rhinitis and adenoidal hypertrophy.

Front 19

What signs would you expect in Acute bacterial sinusitis?

Back 19

Inflamed nasal mucosa
puss exuding from the middle meatus
Maxillary transillumination (over 9yo)
Associated middle ear changes

Front 20

What kind of complications can it lead to?

Back 20

Complications

Orbital Complications:
Periorbital cellulitis , orbital cellulitis
(see Orbital Cellulitis Guideline)

Intracranial Complications:
Cerebral abscess, cavernous sinus thrombosis, meningitis, encephalitis, subdural / epidural empyema

Front 21

What Ix can be done and when should they be done?

Back 21

Investigations

CT is the imaging modality of choice. Air-fluid levels, opacification and mucosal thickening may be seen, however, these findings are non-specific.

CT is not used routinely but may be indicated in the following situations:

failed medical management
possible orbital / intracranial complication
if surgery is being contemplated
Culturing nasal secretions is not indicative of sinus flora and is therefore not helpful. The 'Gold Standard' would be sinus puncture for culture. This is invasive and painful and should only be done in an ENT setting.

Front 22

What is the first line management?

Back 22

Treatment

1st line amoxycillin (15mg/kg/dose tds) for 10days
(Cephalexin if penicillin allergic)

2nd line amoxycillin/clavulanic acid (if pt has had amoxycillin in the last month)

If orbital / intracranial signs IV flucoxacillin (50mg/kg/dose 6 hourly) and IV cefotaxime (50mg/kg/dose 6 hourly) and refer to ophthalmolgy/neurosurgery

The addition of steroid sprays, decongestants, or antihistamines to antibiotic treatment has been shown to have no benefit in sinusitis.

Surgery is very rarely needed.

Front 23

Child presents with a coryzal prodrome, hoarseness (or husky voice in those old enough to speak), inspiratory stridor, a harsh barking 'brassy' cough and variable airway obstruction due to inflammatory oedema within the subglottis.
- barking cough
- inspiratory stridor
- may have associated widespread wheeze
- increased work of breathing
- may have fever, but no signs of toxicity

Back 23

Croup (laryngotracheobronchitis)

Front 24

How do you assess the severity of croup?

Mild:

Moderate:

Servere:

Back 24

mild: airway obstruction: mild chest wall retractions and tachycardia (see Table 14.17), but no stridor at rest

moderate: airway obstruction: stridor at rest, chest wall retractions, use of accessory respiratory muscles and tachycardia

severe: airway obstruction: persisting stridor at rest, increasing fatigue, markedly decreased air entry, marked tachycardia. Restlessness, decreased level of consciousness, hypotonia, cyanosis and pallor are signs of life-threatening airway obstruction.

Front 25

What examination should be done in croup?

Back 25

Children with croup should have minimal examination. Do not examine throat. Do not upset child further.

Front 26

Ix in croup?

Back 26

Investigations - None!

investigations including NPA, CXR, blood tests are NOT usually indicated and may cause the child distress and worsening of symptoms

Front 27

What treatment for croup if only has cough?

Back 27

None

Front 28

What treatment for mild to moderate croup?

Back 28

Mild to Moderate Croup

Prednisolone 1mg/kg, AND prescribe a second dose for the next evening.
OR
a single dose of Oral Dexamethasone 0.15mg/kg.

(NB. Oral dexamethasone suspension ONLY available in hospitals, NOT available at commercial pharmacies)

Observe for half an hour post steroid administration. Discharge once stridor-free at rest.

Front 29

What treatment for severe croup?

Back 29

Severe croup

Nebulised adrenaline (1 mL of 1% adrenaline diluted to 4 ml with Normal Saline, or 5ml of adrenaline 1:1000.)

AND

Give 0.6mg/kg (max 12mg) IM/IV dexamethasone

Improvement

If good improvement, observe for 4 hours post adrenaline. Consider discharge once stridor free at rest.

Improvement then deterioration

Give further doses of adrenaline. Consider admission/transfer as appropriate.

No improvement

Reconsider diagnosis. Acute upper airway obstruction.

Front 30

Child 4 months old presents with 1 week of cough, rhinorrhoea, worsening of wheeze

2 days of respiratory distress
nasal discharge, fever and wheezy cough, and

examination findings of inspiratory crackles and/or expiratory wheeze

Back 30

Bronchiolitis

Front 31

What are the clinical indications for admission to hospital with bronch?

Back 31

Clinical indications for admission to hospital are:

SpO2 less than 94%
difficulty feeding
moderate to severe work of breathing
increased respiratory rate

Front 32

Mx of bronch:

Back 32

If needs admission then O2 support and rehydration if needed or severe. Neb Saline and bronchodilators can be of some help.
Only short breast feeds or NG to stop SOB.

Front 33

What are the normal resp rates in children?

Term infant?

Back 33

Age
Respiratory rate (per minute)
Term infant
40 to 60

Front 34

What are the normal resp rates in children?

6 months

Back 34

6 months
30 to 50

Front 35

What are the normal resp rates in children?

1 year?

Back 35

1 year
30 to 40

Front 36

What are the normal resp rates in children?

2 years

Back 36

2 years
20 to 30

Front 37

What are the normal resp rates in children?

4 years

Back 37

4 years
20

Front 38

What are the normal resp rates in children?

6 years?

Back 38

6 years or older
16