Management of persistent respiratory symptoms in pre-school children.
Recurrent wheeze and cough symptoms affect 13% of children under 5 years of age. Triggers include:
- Viral infections
- Exposure to tobacco smoke
- Environmental pollutants
Bronchiolitis can cause airways hyper-reactivity and respiratory symptoms for many years. Whilst the majority of these chidren do not have an increased risk of asthma or allergy in later life there is a progression from childhood from wheeze symptoms to adult asthma in some children.
Controversy and confusion exists over which treatments are effective in managing recurrent wheeze and coughs in pre-school children.
Assessment
Signs and Symptoms
Chronic cough
Differential Diagnoses
Differential diagnosis of recurrent wheeze and cough in pre-school children:
- Cigarette smoke exposure/ air pollution
- Chronic lung disease of prematurity
- Aspiration (dysfunction swallow, trache-oesophageal fistula/ laryngeal cleft etc.)
- Cystic fibrosis
- Tuberculosis
- Inhaled foreign body
- Tracheobronchomalacia/ congenital abnormality of lung. Airway or heart
- Immune deficiency
- Primary ciliary dskinesia
- Psychogenic
Features suggestive of underlying lung disease:
- Neonatal onset of respiratory symptoms
- Recurrent episodic/ moist cough lasting in excess of 4-6 weeks
- Onset after choking episode
- Occurs during/ after feeding
- Auscultatory finding i.e. clear with coughing
- Cardiac abnormalities
- Chest wall deformity
- Immune deficiency
- Feeding difficulties
- Haemoptysis
- Neurodevelopmental abnormality
- Faltering growth/ general ill health
- Finger clubbing
Recurrent lower respiratory tract infections – See Management of Community Acquired Pneumonia pathway
Investigations
Initial assessment
- The majority of pre-school children with respiratory symptoms lasting more than 4 weeks in duration can be managed in primary care by their GP as long as there are no worrying features suggestive of other diagnosis.
- There should be a low threshold for referral into hospital if there are worrying symptoms or signs, uncertainty about the underlying diagnosis or if there are medical or parental concerns.
- Chronic respiratory symptoms can cause significant distress to the whole family. It is therefore important to explore the reasons for parental anxiety and to reassure parents that a watch and wait approach is probably all that is needed
Management
Children with chronic cough with worrying features
- Refer to the on call Paediatrician
Once a child has been referred to the on call Paediatrician, investigative tests will be carried out to advise on case by case management plans to be followed up in primary care with the GP.
Treatment plans:
- Treatment plans are largely supportive. Parents should be advised
Follow up includes:
- Children commenced on any of these treatment strategies should be reviewed at 6-8 week intervals to assess progress. Ideally, this period of treatment should include an upper respiratory tract infection to assess effectiveness of treatment.
- Where these treatments are felt to produce no improvement in symptom control or are poorly tolerated, then they should be stopped and another treatment trialled for a further 6- 8 week period of time.
- Parents should be advised to return to their GP if there are increasing concerns and a low threshold should be maintained for onward referral to the paediatric respiratory team.
- Cessation of parental smoking has been shown to be a successful therapy for respiratory symptoms in children.
Referral
Referral Instructions
Children with chronic cough with worrying features
- Refer to the on call Paediatrician
Supporting Information
Pathway Group
This guideline has been signed off by the Eastern Locality on behalf of NEW Devon CCG.
Publication date: December 2016
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