‘It started with a blocked nose and a bit of a cold. But now he has a temperature and a nasty cough and his breathing is very chesty. I’m wondering if the infection has gone down into his chest. Should he have antibiotics?’
Most parents call them chest infections. Doctors call them respiratory illnesses. When you consult your doctor about a ‘chest infection’, it’s not a simple matter of prescribing antibiotics. You are both looking at a fistful of possibilities and the answer may not even lie in your child’s chest. (Have you noticed that the symptoms are a little different each time?)
Things to remember:
- Over 90 per cent of respiratory infections are viral and do not need antibiotics, even if they drag on (the coughing can last up to three weeks). Unless a bacterial infection joins in and makes things worse.
- As a rule of thumb, if your child has a temperature, is breathing quickly and it is an effort, it’s most likely an infection in the chest. If your child is sniffling and sneezing, it’s not.
- Quite often the ‘cough that won’t go away’ is asthma.
- Watch out for worsening. Most chest infections will self-cure, but sometimes the virus spreads down the lungs (or mucus gets infected by bacteria).
Is It a Common Cold?
Common colds are upper respiratory infections in the nose and throat.
- The child is sniffling and sneezing.
- He may cough a little and have a sore throat.
- He may have a mild temperature.
- Apart from a little grumpiness, he will go about his business.
All that coughing and sneezing is an effort to expel a virus (most often a rhinovirus). After a day or two and with no help it will be gone. As the child grows, the immune system will toughen and produce antibodies to many of the viruses. But he won’t outgrow colds because the prevalent virus in your area is (very cleverly) always changing.
Home Treatment: Cold
A common cold self-cures. It is all helped along by a little tender loving care.
Make him cosy and soothe him with hot drinks (most cold ‘remedies’ simply do this).
If his nose is blocked, menthol drops on his pyjamas (or menthol inhaling if he is older) can help.
A little paracetamol can help him to sleep if he is restless.
Decongestants (antihistamine) do not help children. Studies have found that they work no better for colds than a placebo.
Antibiotics are never needed for colds or upper respiratory infections.
Cold remedies treat the symptoms, but don’t cure colds. Cough suppressants and probiotics have little effect, but recent evidence shows that traditional honey does help. But never give honey to babies under one year, because of infantile botulism.
Vitamins won’t prevent (but they may shorten) a cold.
Chest clapping (chest physio), to release mucus from the lungs, has no effect on colds.
He is okay to go to school, unless he is very miserable. The virus is probably around the school already.
IS IT FLU?
Flu – or influenza – is quite another matter:
Your child simply won’t get up.
There will be a temperature, usually over 39°C. ե His head will be sore and he will ache all over. ե He may have a dry cough.
He will have no interest whatsoever in food or playing.
Influenza viruses cause flu and your school-going child is most likely to catch it.
Each winter a different strain of virus does the rounds and this year’s vaccine will be developed for this year’s virus. When there is a sizeable change in the circulating strain of virus, you get an epidemic or (luckily more rarely) a worldwide pandemic.
Influenza will normally self-cure but it may take over a week.
Home Treatment: Flu
Talk to your doctor and make sure it is influenza.
Lower his temperature with ibuprofen or paracetamol.
Cool his body if need be, by stripping him down to his vest. Try sponging him with a facecloth and lukewarm (not cold!) water.
Give him regular (but small) sips of water. Ice pops can go down easily too.
Watch him for other symptoms and for a temperature rise.
Antibiotics are not needed as the infection is viral.
Keep him off school and in bed until his temperature is normal and he feels much better. It can take five days or more.
Is It Bronchiolitis?
Bronchiolitis is mainly a baby infection and a real pest – nearly a third of all babies will develop it before their first birthday. There are epidemics every year in the colder months.
- It starts like a cold, with a temperature, runny nose and cough.
- Then the cough gets worse. He may wheeze too.
- Then his breathing gets faster than normal and becomes an effort.
- He may find it hard to feed properly because he cannot breathe.
- He may even frighten you with short pauses in his breathing.
If your doctor examines his lungs, they will squeak and crackle. It is a viral infection (usually a virus known as RSV) which has spread into the lungs – down into the tiniest air passages, the bronchi and bronchioli. These have become swollen and this makes it more difficult for your baby to breathe.
Most babies get better within two weeks, although the cough can take longer to die down.
BUT: Watch carefully for signs of worsening.
Home Treatment: Bronchitis
Is he a nice pink colour, still smiling at you and drinking his bottles? Then the bronchiolitis is very likely mild and can be treated at home.
Give lots of liquids as he may have a temperature.
If feeding is difficult, try breastfeeding or bottles, ‘little and often’.
Lower any temperature with ibuprofen or paracetamol.
If your child is coughing a lot, prop him up a little with a rolled blanket under the mattress. Don’t give cough medicine – sips of water are just as effective and much safer. Steam and menthol will not help.
Antibiotics do not help; and they won’t prevent it getting worse.
Keep washing your hands as your child is infectious (disinfectant sprays are of no value as the virus is airborne).
Keep him away from day care until he’s back to his normal self.
It is normal to feel worse on Day Two, when the infection peaks, then dies down.
Watch carefully for signs of worsening. If it is still Day One and he is getting worse, contact your doctor. If there are serious breathing problems or he is feeding badly, get emergency help.
If it’s severe, he will be admitted to hospital. He may need oxygen and (if he is not feeding) intravenous fluids.
Apart from oxygen for severe cases, nothing will ease his breathing until the virus works itself out. So I don’t advise steroids, asthma inhalers, antiviral treatments or chest physiotherapy.
Don’t change his milk feeding routines as milk has not been proved to cause excessive mucus.
When bronchiolitis gets bad, it can be a little hard to distinguish from pneumonia
Is It Pneumonia?
Pneumonia, which is a bacterial infection, strikes fear into parents. Signs that an infection may have moved down into his chest include:
- Fast breathing (remember that younger children have a higher breathing rate).
- A temperature of over 38.5°C.
- Constant coughing.
- The ribcage pulled in sharply and maybe grunting sounds when he breathes.
- Sometimes there are chest pains.
- Nostrils that are flared open to let in more air.
- Lips and tongue have turned blue or purple because of lack of oxygen.
- If the pneumonia is severe, your child will be quite limp (not eating or drinking) and will not notice what is going on around him.
He may have some (but not all) of these symptoms. Fast breathing is the one symptom that is a certainty – if your child is not breathing quickly then it is probably not pneumonia.
If he is pre-school age, the bacterium Streptococcus pneumoniae is the most likely cause of pneumonia. If he is school-going, it is more likely to be an atypical bacterium, Mycoplasma pneumoniae. This one is often called ‘walking pneumonia’ as he may seem quite well but a chest X-ray will show quite dramatic changes.
Home Treatment: Pneumonia
Call your doctor. If pneumonia is severe, your child will be treated in hospital. More often, it will be mild and he will be treated at home under the care of your doctor.
Antibiotics will be needed.
He will need plenty of fluids and paracetamol because of the temperature.
Other treatments such as steam, back clapping and herbal remedies will not solve the problem.
Children usually recover completely from pneumonia, without any after effects. He should not need a follow-up X-ray if he is back to full health and if the pneumonia was uncomplicated. The new pneumococcal vaccine is proving very successful in countries where it is available.
Is It Croup?
Adults get laryngitis – children get croup. It is very frightening (you will always remember the first time), and it is often worse in the lonely hours of night. Most croup is mild and a brief episode, but it can worsen. You are unlikely to miss the signs:
- He has a very distinctive barking cough (like a seal).
- There’s a ‘hee’ sound as he breathes in, known as ‘stridor’.
- There is usually a low temperature.
Croup (laryngotracheobronchitis) is not a chest infection. It is caused by a parainfluenza virus, which makes the walls of his windpipe temporarily swell so it narrows. All that noise is from his efforts to breathe in more air. Young children are most affected because their windpipes are small and soft, which is why croup gets less common as they get older.
Or could it be whooping cough? If you are unsure, then it is probably not. The coughing spasms of whooping cough are quite frightening and the whoops are very definite.
Home Treatment: Croup
Steam was the traditional solution for croup. A short stay in the bathroom with the hot taps pouring was believed to open the airways (it certainly calmed everyone down!). Closer examination, sadly, has found that it has no effect on the airways and it is not medically recommended any more. The hospital steam-tent is now a thing of the past.
Prop your child up in bed with a pile of pillows. If he is a baby, prop him with a rolled blanket under the mattress.
Stay with your child and reassure him until the breathing eases.
Antibiotics are not needed.
He can go to the crèche or playschool if breathing has returned to normal and he is not too tired. It is usually a night affair that clears by morning.
WHEN YOUR CHILD IS SICK
Call your doctor if you are concerned or the ‘hee’ sound gets worse. Either an oral steroid or a nebuliser with a steroid will be given.
Get emergency help if your child is finding it hard to breathe or drink and his colour changes.
Is It Whooping Cough?
Whooping cough (pertussis) is now rare but we still see cases of it, in spite of vaccination. It is quite a dramatic illness, very upsetting to see and one to watch very carefully. These are the signs:
- He had a ‘normal cold’ for a week or two. Then the classic symptoms started.
- There are fits of uncontrollable coughing and a red face.
- Each fit is followed by a whooping sound (trying to get air) and vomiting.
- He usually has a slight temperature.
- He seems well (but weak) between spasms.
- The coughing spasms can go on for at least six weeks, and then they start to fade.
It’s very infectious, but mostly before the coughing starts. It stays infectious until the antibiotics take hold. The condition is caused by Bordatella pertussis. Your doctor may diagnose it or send a nasal swab for laboratory testing.
Or Something Else?
- A foreign body breathed into lungs, a speciality of toddlers; tiny pieces of Lego and peanuts are the usual offenders.
- If he gets chesty symptoms regularly (with a wheeze) he may have asthma.
- Tuberculosis is still a problem in Western Europe. But if your child had a BCG vaccination, he should be immune or, at worst, get a mild version. He will have a chronic cough, have night sweats with a temperature, lose weight and usually (but not always) be quite sick.
- Cystic fibrosis and problems with the immune system are rare. But if his ‘chest problems’ are not going away and he is not gaining weight, your doctor may need to look at the possibility.
Are chest X-rays useful?
They can be disappointing because they often cannot tell you what has caused the infection – whether a virus or bacteria. So we usually limit them to children with serious breathing problems.
Always remember that chest and breathing infections are easily spread through droplets. Keep out of the line of fire and keep hands washed.
This is an extract from When Your Child is Sick by Professor Alf Nicholson, Professor of Paediatrics at Temple Street Children’s University Hospital and Grainne Malley.
