Chest infections (2 months to 5 years)

                        

For child over 5 — see Chest infections — over 5 years
  • Child with cough and fast breathing probably has a chest infection
  • Best indicator of pneumonia in children is fast breathing (high RR)
  • Influenza (flu) is a viral chest infection that presents in different ways. Manage based on presenting symptoms and local recommendations for current flu season
  • If available, chest x-ray may help with diagnosis

Most important decisions are

  • Which children need antibiotics
  • Which children need to go to hospital

Consider if child could have chronic suppurative lung disease CSLD check file notes for 

  • 2 or more chest infections in last year
  • Treatment for pneumonia in last 4 weeks
  • Wet or productive cough for more than 4 weeks
  • 3 or more hospital admissions for chest problems
  • Episode of severe pneumonia (in ICU)
  • Chest deformity (puffed up)
  • Signs of abnormality when listening with stethoscope — crackles, unequal air entry, bronchial breathing, wheeze

Table 3.19   Fast breathing in children

Look, ask and listen before touching and disturbing child. Child should be calm, not crying, better if not feeding

Look and listen

  • At breathing
    • RR — count for 1 minute, do at least twice to be sure and take the average
    • Is the child short of breath
    • For sternal or rib recession (chest indrawing)
    • For nasal flaring — nostrils widen when child breathes in. Sign they are working hard to breathe
    • Look for sniffing posture, tripod positioning, head bobbing, grunting, gasping, tachypnoea (fast breathing)
  • Listen for abnormal audible airway sounds (snoring, hoarse speech, grunting, wheezing)
  • Tone — is the child active, moving around or listless
  • Interactivity/mental status — how alert is child, are they interacting with the care giver
  • Can the child be comforted by caregiver
  • Look/gaze — does the child fix their gaze on a face or is there a glassy-eyed stare, abnormal gaze
  • Speech/cry — is the child’s speech or cry weak, high pitched or hoarse

Ask

  • How long has child been sick
  • Does child have a cough — wet or dry, for how long
  • How long has child had trouble breathing
  • Diarrhoea and/or vomiting
  • Have they stopped feeding or drinking
  • Urine output (wet nappies or last urine)

Check

  • Calculate age-appropriate REWS — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL

Do

Assessment

Flowchart 3.4   Assessment of chest infections — child 4–11 months

Flowchart 3.5   Assessment of chest infections — child 1–5 years

Pneumonia treatment

Severe pneumonia

  • Medical consult to send to hospital
  • Give oxygen to target O2 sats 94–98%
  • Give benzylpenicillin IV/IM — child 50mg/kg/dose up to 1.2g — doses — single dose
  • AND gentamicin IM — doses — single dose
  • If allergy — medical consult

Moderate pneumonia

  • Medical consult about need to send to hospital
  • If fast breathing for age and chest indrawing OR O2 sats less than 95% on room air
    • Give oxygen to target O2 sats 94–98%
  • Give benzylpenicillin IV/IM — child 50mg/kg/dose up to 1.2g — doses — every 6 hours (qid) for 1 day then review
  • If allergy — medical consult
  • Treat initial fever to allow assessment of respiratory distress
  • Keep child in clinic until O2 sats consistently 95% or more and can feed well
  • If stays in community and improves to mild after 24 hours give  
    • Procaine benzylpenicillin (procaine penicillin) IM — child 50mg/kg/dose up to 1.5g — doses — every 24 hours for total of 5 days
    • OR amoxicillin oral — child 40mg/kg/dose up to 1.5g — doses — twice a day (bd) for 5 days
    • If allergy — medical consult
  • If no better after 24 hours or gets worse on any day — medical consult

Mild pneumonia

  • Give Procaine benzylpenicillin (procaine penicillin) IM — child 50mg/kg/dose up to 1.5g — doses — every 24 hours for 3 days
  • OR amoxicillin oral — child 40mg/kg/dose up to 1.5g — doses — twice a day (bd) for 3 days
  • If allergy — medical consult
  • Both antibiotics work well if whole course of medicine completed. IM procaine benzylpenicillin (procaine penicillin) better unless very sure all oral medicine will be taken
  • Review daily while on treatment
  • If not getting better — medical consult
    • May need to treat for a total of 5 days
    • May need to review diagnosis

Follow-up — pneumonia and chest infections sent to hospital

  • Review after 1 week — should be well, may still have cough
    • If still has wet cough that is not getting better — give amoxicillin-clavulanic acid oral — child 22.5+3.2mg/kg/dose up to 875+125mg — doses — twice a day (bd) for 14 days then review
    • If still has wet cough on second review — continue amoxicillin-clavulanic acid for another 14 days then review
    • If allergy — medical consult
  • If still has wheeze — medical consult. See Chronic suppurative lung disease and bronchiectasis in children, Asthma in children
  • Medical consult if 
    • 2 or more chest infections in last year
    • OR persistent cough after 4 weeks of antibiotics
  • Check immunisations up to date including flu immunisation
  • Health education including hygiene and smoke-free environment

Cold (upper respiratory tract infection — URTI)

  • Give paracetamol — child 15mg/kg/dose up to 1g, up to 4 times a day (qid) if needed
  • Review in 1 day — if RR still less than 40/min AND no danger signs review as needed

Fast breathing with wheeze treatment

Wheeze heard with ear or stethoscope, if not sure — treat as child without wheeze

Under 12 months

  • Relievers (eg Salbutamol) not recommended — this age group rarely responds. See Bronchiolitis

1–2 years

  • Give salbutamol puffer with spacer and mask — 100microgram/dose (4 puffs)
  • If no difference after at least 10 minutes — child very likely has bronchiolitis. Do not give any more salbutamol — see Bronchiolitis
  • If difference (child better — still has fast breathing but less)
    • Give up to 3 doses 20 minutes apart (1 dose = 4 puffs)
    • Each puff is sprayed into spacer and inhaled for a few breaths before next puff
  • If child no longer has fast breathing or chest indrawing — treat as asthma
  • If child still has fast breathing and chest indrawing 20 minutes after third dose — treat as pneumonia

3–5 years 

  • Give salbutamol puffer with spacer — 100microgram/dose (4 puffs)
    • Up to 3 doses 20 minutes apart (1 dose = 4 puffs)
    • Each puff is sprayed into spacer and inhaled for a few breaths before next puff
  • If child no longer has fast breathing or chest indrawing — treat as asthma
  • If child still has fast breathing and chest indrawing 20 minutes after third dose — treat as pneumonia

Bronchiolitis

Viral lower respiratory tract infection common in babies under 12 months. Diagnosis based on history and examination. If diagnosis confirmed, antibiotics not needed 

  • Usually starts as cold then cough, fast breathing and wheeze
  • Most severe on days 2–3, resolves in 7–10 days. Cough may last 2–3 weeks
  • Monitor for signs of developing chronic cough or asthma 
  • Medical consult — if not sure if pneumonia, especially in children at risk

Croup

Stridor (barking cough and vibration noise) when breathing in — medical consult

Pertussis (whooping cough)

Coughing in spells, with or without a whoop. Vomiting, going red in face, cyanosis (blue lips), or apnoea (stopping breathing) with coughing spells — medical consult

Inhaled foreign body

Noisy breathing, wheeze on unilateral (1 side), story of choking on something — medical consult

Supporting resources

  • Lung health for kids app
  • Bronchiolitis (lower respiratory tract infection) flipchart
  • Pneumonia (paediatric) flipchart