Cough - acute with chest signs in children
Exam Tips
- Age pattern is high-yield: bronchiolitis is mainly infants (peak 3-6 months), viral-induced wheeze is usually 6 months-5 years, pneumonia can occur at any age.
- Do not over-rely on one sign: wheeze does not exclude pneumonia, and crackles can occur in bronchiolitis; use the full clinical pattern plus physiology (SpO2, work of breathing).
- In OSCEs, state red flags early: cyanosis, exhaustion, altered consciousness, silent chest, apnoea, and feeding failure mandate urgent escalation.
- Primary care investigations are usually minimal: diagnosis is clinical; chest X-ray and microbiology are not routine in uncomplicated cases.
- Management marks often depend on avoiding inappropriate treatment: no routine antibiotics, bronchodilators, or steroids for uncomplicated bronchiolitis.
- Visual memory aid: review a paediatric airway diagram showing bronchiolar epithelial sloughing and mucus plugging in bronchiolitis, and an alveolar consolidation diagram for pneumonia.
Definition
Acute cough with chest signs in children is a clinical presentation (not a single diagnosis) where cough is accompanied by lower respiratory findings such as wheeze, crackles, increased work of breathing, or hypoxaemia. In UK primary care and urgent assessment, the key serious causes to separate are viral-induced wheeze/infective asthma exacerbation, bronchiolitis, and community-acquired pneumonia, while also considering COVID-19 and non-infective differentials.
Pathophysiology
The mechanism depends on the cause. In viral-induced wheeze (typically 6 months to 5 years), viral infection triggers airway inflammation in relatively narrow paediatric airways, causing expiratory flow limitation and wheeze; in asthma exacerbation, infection precipitates bronchoconstriction plus airway inflammation and mucus production. In bronchiolitis (usually <12 months), viral infection (classically RSV) causes epithelial injury and sloughing in small bronchioles with mucus plugging, producing variable obstruction, air trapping/collapse, V/Q mismatch, hypoxia, and feeding difficulty. In pneumonia, infection of lung parenchyma causes alveolar inflammation and consolidation with impaired gas exchange; viruses are common overall, while Streptococcus pneumoniae is the leading typical bacterial pathogen, with Mycoplasma/Chlamydia more relevant in older children.
Risk Factors
- Age-specific susceptibility: bronchiolitis in infants (peak 3-6 months), viral-induced wheeze mainly 6 months-5 years
- Previous asthma diagnosis or wheeze outside viral infections (exercise/allergen-triggered)
- Atopy or family history of atopy/asthma
- Prematurity (especially <32 weeks) and age under 3 months
- Chronic lung disease (including bronchopulmonary dysplasia), haemodynamically significant congenital heart disease, neuromuscular disease, immunodeficiency
- Seasonal viral circulation (bronchiolitis commonly October-March in the UK)
- Exposure to tobacco smoke and indoor air pollutants
- Incomplete vaccination (e. g, pertussis, pneumococcal, influenza)
Clinical Features
Symptoms
- Acute cough following coryzal prodrome (especially bronchiolitis)
- Breathlessness or rapid breathing
- Wheeze (common in viral-induced wheeze/asthma; may occur in bronchiolitis)
- Fever (high fever >39 C raises suspicion of pneumonia)
- Poor feeding, reduced oral intake, or vomiting after cough
- Nocturnal cough or cough with exertion/allergen exposure (supports asthma phenotype)
- Apnoea episodes in very young infants
Signs
- Tachypnoea: >60/min (0-5 months), >50/min (6-12 months), >40/min (>12 months)
- Chest recession/indrawing, nasal flaring, use of accessory muscles
- Wheeze on auscultation (viral-induced wheeze/asthma; can occur in bronchiolitis)
- Crackles: diffuse fine crackles in bronchiolitis, focal coarse crackles in pneumonia
- Cyanosis or low oxygen saturation (including SpO2 <=95% in air as pneumonia red flag)
- Reduced air entry or absent breath sounds with dull percussion (possible pleural effusion with pneumonia)
- Agitation, altered behaviour, exhaustion, reduced consciousness (possible hypoxia/severe attack)
Investigations
Management
Lifestyle Modifications
- Give safety-net advice: worsening breathlessness, persistent fever, cyanosis, poor feeding, reduced urine output, apnoea, lethargy, or inability to speak/feed normally should prompt urgent review
- Encourage fluids and age-appropriate antipyretic comfort care; avoid over-the-counter cough suppressants in young children
- Smoke-free environment and avoidance of known asthma triggers
- In bronchiolitis, use supportive care (minimal handling, feeding support, oxygen if hypoxic) rather than routine medicines
- Arrange same-day assessment/admission if red flags or oxygen saturation concerns are present
Pharmacological Treatment
Short-acting beta2-agonist (acute wheeze/asthma phenotype)
- Salbutamol 100 micrograms/puff via spacer: typically 2-10 puffs, one puff at a time, repeated every 20-30 minutes according to response/severity
- Nebulised salbutamol: 2.5 mg (<5 years) or 2.5-5 mg (>=5 years), repeated in severe attacks
Use for viral-induced wheeze/possible asthma, not routine bronchiolitis. Monitor for tachycardia, tremor, and hypokalaemia (higher doses/nebulised therapy). Escalate urgently if poor response.
Antimuscarinic bronchodilator (severe acute asthma)
- Ipratropium bromide nebuliser 250 micrograms (<12 years) or 500 micrograms (12-17 years), usually every 20-30 minutes initially in severe/life-threatening attacks
Add-on in severe asthma presentations; not routine treatment for bronchiolitis.
Systemic corticosteroid (asthma exacerbation)
- Prednisolone oral 1-2 mg/kg once daily (usual max 40 mg) for up to 3 days
- Dexamethasone oral (local protocol alternative): 150 micrograms/kg single dose in some paediatric pathways
Indicated for moderate/severe asthma exacerbations; not routinely indicated in bronchiolitis. Use caution in varicella exposure and significant immunosuppression risk.
Antibiotics (suspected bacterial community-acquired pneumonia)
- Amoxicillin oral first line (5 days typical): 1-11 months 125 mg three times daily; 1-4 years 250 mg three times daily; 5-11 years 500 mg three times daily; 12-17 years 500 mg three times daily (up to 1 g three times daily in severe infection)
- If penicillin allergy or atypical pathogen suspected: Clarithromycin oral 7.5 mg/kg twice daily (max 500 mg twice daily) in 1 month-11 years; 12-17 years 250-500 mg twice daily
Do not give antibiotics for isolated viral wheeze or uncomplicated bronchiolitis. Check allergy status, interactions (notably macrolides), and local antimicrobial guidance.
Oxygen therapy
- Humidified oxygen titrated to maintain age-appropriate oxygen saturation targets (commonly 94-98% in acute asthma pathways)
Urgent escalation if persistent hypoxaemia, exhaustion, or altered consciousness. In bronchiolitis, thresholds for oxygen/admission are lower in very young infants and high-risk comorbidity groups.
Antipyretic/analgesic comfort treatment
- Paracetamol: 15 mg/kg per dose every 4-6 hours (max 4 doses in 24 hours)
- Ibuprofen: 5-10 mg/kg per dose every 6-8 hours (max 30 mg/kg/day)
For fever discomfort only; does not treat the underlying chest pathology. Avoid ibuprofen in dehydration/renal risk; avoid aspirin in children under 16 years (Reye syndrome risk).
Surgical / Interventional
- Pleural drainage/chest drain for parapneumonic effusion or empyema complicating pneumonia
- Airway endoscopy for suspected foreign body aspiration when clinically indicated
Complications
- Hypoxaemia and acute respiratory failure
- Dehydration due to poor feeding, especially in bronchiolitis
- Apnoea in young infants
- Progression to severe/life-threatening asthma attack
- Parapneumonic effusion or empyema
- Sepsis (bacterial pneumonia)
- Recurrent wheeze and later asthma association after bronchiolitis
- Hospital admission and, rarely, death (higher risk with major comorbidity)
Prognosis
Most viral lower respiratory illnesses in children are self-limiting: fever often settles within 3-7 days and cough usually improves within 3 weeks. About 90% of bronchiolitis-related cough resolves by 3 weeks, though infants with prematurity, cardiopulmonary disease, neuromuscular disease, or immunodeficiency can have severe courses. Many preschool wheezers improve by school age, but a minority continue with asthma symptoms; mortality in high-income settings is low but rises with severe comorbidity and delayed recognition of deterioration.
Sources & References
💊BNF Drug References(1)
- Clarithromycin[management.pharmacological]
✅NICE Guidelines(1)
📖Textbook References(2)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 581)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 580, 581)[context]