Paediatric Cough

Presenting Complaint

• Zara’s mother, Holly, reports that she has been struggling to breathe and has had a worsening cough over the past few days. “She’s been really unsettled, coughing a lot, and she sounds so wheezy. It’s worse at night, and she’s not feeding well.”

Symptoms (SOCRATES):

• Site: Diffuse respiratory distress – “She just seems to be struggling all over when she breathes.”
• Onset: Gradual onset over 3 days – “It started as a bit of a cough, but it’s been getting worse.” 
• Character: Wheezing and difficulty breathing – “She makes this whistling sound when she breathes.”
• Radiation: No referred pain – “It’s just her breathing that’s the problem.”
• Associated symptoms: Poor feeding, increased work of breathing, fever, and coryzal prodrome – “She’s barely drinking her milk, she’s been quite warm, and she’s had a runny nose for a few days before the cough started.”
• Time: Worse at night and during feeds – “She’s worse when lying down, especially at night.”
• Exacerbating/Alleviating factors: Worse when lying flat, improved slightly when upright – “Holding her upright helps a little.”
• Severity: Moderate respiratory distress – “She looks really uncomfortable and is breathing so fast.”

Systems Review

• Fatigue: Mild – “She seems more tired than usual.”
• Fever: Mild (38.3°C) – “She’s warm but not burning up.”
• Night Sweats: None – “She hasn’t been sweating.”
• Unintended Weight Loss: None – “She hasn’t lost weight, but she’s not feeding well.”
• Shortness of Breath or Cough: Present, moderate dyspnoea, persistent cough
• Oedema: None – “No swelling anywhere.”
• Rashes or Skin Changes: None – “Her skin looks normal.”
• Mood Changes: Irritable – “She’s more fussy than usual.”
• Sleep Disturbances: Yes, due to cough and congestion
• Change in Bowel Habits: None – “Her nappies are normal.”
• Urinary Symptoms: None – “She’s still having wet nappies as usual.”

Past Medical History:

• Born at 40+1 weeks via spontaneous vaginal delivery, with no complications or admission to NICU
• All developmental milestones have been met on time
• No known respiratory conditions
• Fully vaccinated, including routine immunisations up to date
• No previous hospital admissions
• No significant past medical history

Drug History:

• No regular medications
• No use of herbal supplements

Allergies:

• NKDA

Family History:

• No history of asthma or atopy
• No history of cystic fibrosis or other respiratory conditions

Social History:

• Lifestyle: Cared for at home by mum and dad, no siblings at home
• No recent ill contacts
• Pets: No pets at home
• Smoking: No exposure to smoking or vaping
• Diet: Exclusively breastfed with some introduction of solid foods
• Exercise: Normal for age
• Recent Travel: None

Ideas, Concerns, and Expectations:

• Ideas: Mother suspects a chest infection – “I think she’s got a bad cold or maybe a chest infection.”
• Concerns: Worried about breathing difficulties and dehydration – “I’m scared she’ll struggle too much to breathe or get dehydrated.”
• Expectations: Wants reassurance and possible treatment – “I just want to know she’ll be okay and get something to help her breathe.

Observations:

• Respirations (Breaths/min): 50 breaths/min
• Oxygen Saturation (%): 94%
• Air or Oxygen: Room air
• Blood Pressure (mmHg): 92/58mmHg
• Pulse (Beats/min): 135 bpm
• Consciousness (AVPU):  Alert
•  Temperature (Celsius): 38.3 °C
•  Capillary refill: <2s

General Inspection: Signs of mild agitation, nasal flaring, head bobbing, no cyanosis, jaundice or pallor. No rashes.

Chest Examination: Mild intercostal and subcostal recession. Normal heart sounds. Lung auscultation: widespread expiratory wheeze with mild bilateral crackles. 

Abdomen: Soft, non-tender, no hepatosplenomegaly

Other: No peripheral oedema, well-perfused

Paediatric Early Warning Score (PEWS) Chart

Total PEWS score = 5

Choose EITHER examiner viva questions OR patient communication questions

Patient questions:

1. Is my baby going to get worse?

It’s understandable to be worried, but most babies with bronchiolitis tend to improve within a week or two with supportive care such as supplemental oxygen or feeds. The first few days are usually the hardest, as the symptoms - like the cough and difficulty breathing, can worsen before they get better. We will closely monitor Zara's condition to make sure she’s improving.

2. Can bronchiolitis happen again?

Yes, it is possible for Zara to get bronchiolitis again, as it’s caused by a viral infection, most commonly respiratory syncytial virus (RSV). However, repeated infections generally tend to be less severe as children build up immunity over time. Bronchiolitis typically affects children up to 2 years old, particularly babies aged 1-6 months, but severity and frequency tend to decrease with age.

3. Is my baby going to need intensive care?

At the moment, Zara’s symptoms are moderate, and we are managing her here with supportive care, including monitoring her oxygen levels and helping with her breathing. We are keeping a close eye on her, and intensive care would only be necessary if her symptoms worsen. If Zara’s breathing becomes more labored, if she becomes excessively fatigued, or if she develops severe hypoxia, we would consider escalating her care.

4. Can I do anything to prevent this in the future?

There are a few things you can do to reduce the risk of respiratory infections like bronchiolitis in the future. Frequent handwashing can help prevent the spread of viruses. Additionally, try to avoid exposing Zara to people who are sick, especially during the peak seasons of viral infections in winter. It’s also important to keep her away from smoke exposure, as smoke can irritate the airways and increase the risk of respiratory problems.

Examiner questions:

1. What are your top differentials and most likely diagnosis?

• Most likely diagnosis: Bronchiolitis. 

This is the most likely diagnosis given Zara’s age (5 months), the presence of wheezing, difficulty breathing, fever, poor feeding, a progressive cough, and a coryzal prodrome. The worsening symptoms over a few days, worsening at night, and physical examination findings (e.g., intercostal recession, wheezing, crackles) all point to bronchiolitis. 

• Other Differentials:

Croup: Also has symptoms of cough, dyspnoea and fever but typically presents with characteristic ‘barking cough’ and stridor. Commonly caused by parainfluenza virus, and managed with oxygen, dexamethasone +/- nebulised adrenaline.

Pneumonia: This could cause fever, cough, tachypnea, and poor feeding, but it would more commonly present with focal crackles. 

Viral-induced Wheeze: Often seen in infants, this condition presents with wheezing and breathing difficulties due to viral infections like RSV, but it may not necessarily be associated with the other signs of bronchiolitis like intercostal recession or the severity of respiratory distress seen in Zara.

2. What is the most common cause of bronchiolitis?

"Respiratory syncytial virus (RSV) is the most common cause of Bronchiolitis. Other causes include rhinovirus, adenovirus, MPV and parainfluenza"

3. What is the pathophysiology of bronchiolitis?

"Bronchiolitis is typically caused by a viral infection (most commonly RSV) that affects the lower respiratory tract, specifically the bronchioles. The virus causes damage to the epithelial cells of the bronchioles, leading to inflammation, mucus production, and edema. This results in airway narrowing and obstruction, impairing airflow and gas exchange. The airway obstruction can lead to wheezing, hypoxia, and increased work of breathing. As the body attempts to clear the virus, the immune response causes further airway inflammation, contributing to worsening symptoms, including tachypnea (fast breathing), intercostal recession, and nasal flaring, with symptoms peaking around days 3-5”.

4. What are the indications for hospital admission in bronchiolitis?

"Severe respiratory distress: grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute. Hypoxia (SpO2 <92%), dehydration (e.g. fewer wet nappies, dry mucous membranes), or significant apnoea episodes (cessation of breathing for more than 20 seconds)”.