An approach to a child with
Dr. Pushpa Raj Sharma
Professor of Child Health
Institute of Medicine
Common respiratory symptoms
Cough Chest pain
Runny nose Chest indrawing
Snoring Bluish discoloration
The most important sign: Tachypnea
Cut off rate per minute
Less than 1 week up to 2 months: 60 or more
2 months up to 12 months: 50 or more
12 months up to 5 years: 40 or more.
The most severe sign: Apnoea
Acute life threatening event:
Apnoea > 20 second or associated with pallor,
cyanosis, convulsion or limpness.
Abnormal muscle tone
Commonest respiratory symptom.
Physiological to remove excess secretions or
Cough receptors in the posterior pharynx and large
Vagus/ glossopharyngeal: afferent to cough centre
–pons /medulla. Efferent to - larynx/ diaphragm/
chest wall/abdominal wall/pelvic
Acute: lasts less than 2 weeks.
Chronic: lasts more than 2 weeks.
Cough relating to time/ posture
During or after feeding: aspiration
Night: asthma/ post nasal drip
With exercise: asthma
Absence during play: psychogenic
Differential diagnosis of
Bronchiolitis Post nasal drip/sinusitis
Non infectious Non infectious
Domestic smoke Foreign body
pollution/passive smoke Tropical eosiniphilia
Gasro-eso. Reflux Environmental irritants
Foreign body Psychogenic
Treatment of chronic cough
Over the counter cold preparation:
no beneficial effect in children under 5 years.
Post nasal drip:
Propped up position at 30 degree.
Treat accordingly for Allergic/non allergic rhinitis;
Macrolides: if Mycoplasma / chlamydia
Nasal steroids/ decongestant
School aged children.
The child is often a high achiever; family
Fixed timing but disappears during sleep and
Diagnosis by observation and exclusion of
Treatment: Counseling, Normal saline gargle
Inspiratory harsh sound irregularly
Associated with: large tonsils and adenoids;
micrognathia, macroglossia, palatal palsy,
pharyngeal hypotonia, obesity
Sleep study, flexible bronchoscopy, lateral x-ray neck
Treatment needed if:
Sleeping difficulty; daytime somnolence, enuresis,
growth failure, morning headache.
Inspiratory harsh sound continuously.
Can occur during expiration (intrathoracic) or both phase of respiration.
Asses the severity
Drooling of saliva, respiratory distress, unable to swallow,
Infective: epiglottitis, laryngotracheobronchitis, tracheitis,
retropharyngeal abscess (rare)
Malignancy: tumor compression, papilloma
Allergic: angioneurotic oedema.
Congenital: laryngomalacia, laryngeal web, vascular ring,
Aspiration: foreign body.
Neuronal: paralysis of vocal cord.
Blood count; Lateral neck X-ray; flexible bronchoscopy.
Low pitched expiratory sound.
Protective phenomenon to prevent collapse
of alveoli: PEEP
Respiratory distress syndrome
Severe pneumonia, ARDS, severe sepsis
CXR; O2 saturation, blood gas
A child who wheezes: All wheezes are
Cough could be the only symptom.
Worse at night
History of repeated problem.
Symptomatic improvement with
Gastro-esophageal reflux: Prokinetic.
Causes of Wheeze/Ronchi
Bronchiolitis Foreign body
Mycoplasma Mediastinal mass
Cystic fibrosis Tuberculosis
Alpha 1 antitrypsin Bronchiectasis
deficiency Vascualr ring
Chest Pain: Rarely cardiac origin in
Pneumonia; pleural effusion, pneumothorax.
Born Holm disease
The severe signs: Chest Indrawing and
Chest in drawing: Cyanosis:
Increased airway Vasomotor instability in
Contraction of diaphragm Defective perfusion.
and pulling of ribs inside. Defective ventilation.
Negative pressure inside Defective diffusion.
Breathing in and lower Methhaemoglobinemia
chest wall goes in. Hyperoxia test
Supra sternal, inter costal
Haemoptysis: not common
Blood from posterior naso-pharynx or
hematemesis: the difference.
Haemangioma/ AV malformation