Pediatric Primary Care Case Studies, 1st Ed.

Chapter 24. The Child Presenting with Cough

Jennifer Newcombe

Respiratory problems are the leading cause of illness in children. Viral infections are the primary causative agents and seasonal variations are noted. Children with respiratory infections are commonly seen in the primary care setting and are brought in by parents who are concerned about relieving their child’s associated respiratory symptoms. Children typically do well with outpatient treatment. However, it is important to recognize circumstances that warrant hospitalization.

Educational Objectives

1.  Explain the findings of pneumonia typically found upon physical examination.

2.  List differential diagnoses for pneumonia.

3.  Outline the antibiotics used to treat Mycoplasma pneumoniae in an outpatient setting.

4.  Describe circumstances that warrant hospitalization for an infant or child with pneumonia.

  Case Presentation and Discussion

Mary Dixon, a previously healthy 5-year-old white female, is brought to your clinic by her father because of difficulty breathing for 1 day. Two days prior she developed a runny nose, cough, and low grade fever; her maximum temperature was 101°F (38.3°C) yesterday. Her temperature this morning was 103°F (39.4°C) and she was breathing fast, working hard to breathe. Her mother was concerned and had Mary’s father bring her in to be seen because she had to go to work. Mary’s appetite is fair. She takes liquids well, but her solid intake has decreased. Mary’s father denies that his daughter has had any nausea, vomiting, or diarrhea. Her activity level is good. She has had no recent contact with others with respiratory or other illnesses and does not attend daycare or preschool. Her past medical history is negative for allergies or asthma. She is not taking medications other than Tylenol (acetaminophen). Her last dose of Tylenol was yesterday evening before bedtime. Her immunizations are up to date by record review, and she has no known drug allergies, hospitalizations, or surgeries.

What other questions will you ask her father related to her illness? image

The main symptoms of pneumonia are fever and cough; although children with these two symptoms don’t necessarily have pneumonia, clinicians should always consider the possibility of pneumonia if these symptoms are present (Durbin & Stille, 2008). A typical history should focus on the duration of illness, respiratory symptoms (i.e., quality of cough, wheezing, difficulty with breathing), and extra respiratory symptoms such as fever, headache, sore throat, lethargy, or rash (Durbin & Stille).

Her father states her cough is wet sounding, productive, and is persistent throughout the day. He describes the sputum as yellowish in color. Her father said Mary complained of a mild headache earlier this morning but said she didn’t have a sore throat or lethargy.

Pathophysiology of Pneumonia

Pneumonia is a lower respiratory tract infection that is associated with consolidation of the alveolar space and lung parenchyma involvement. It usually follows an upper respiratory tract infection that permits invasion of the lower respiratory tract by bacteria, viruses, or other pathogens. This invasion triggers the immune response to produce inflammation (Jenson & Baltimore, 2006). Agents that cause lower respiratory tract infections are usually transmitted by droplets spread directly from close personal contact or indirectly by contaminated fomites (Durbin & Stille, 2008). S. pneumoniae is responsible for 90% of childhood bacterial pneumonias and is common in all age groups. Mycoplasma pneumonia is common after 5 years of age (Brady, 2009). The incubation period after exposure for mycoplasma pneumonia averages 3 weeks (Pickering, Baker, Long, & McMillan, 2006). If the normal host defense mechanisms does not function properly and effectively, pneumonia can occur. The normal respiratory defense functions include: nasopharyngeal air filtration; laryngeal protection of the airway to prevent aspiration of oral and gastric fluid; mucociliary clearing of particles and pathogens from the upper and lower airways; a strong defensive cough reflex; anatomically correct and unobstructed airway drainage; normal immune function at both the humoral and cellular levels; and normal innate biochemical and redox-based host defense mechanism (Gaston, 2002). However, defects in the host defenses increase the risk of pneumonia.

The infectious agents that commonly cause pneumonia vary by age of the child and setting in which the infection is acquired (community or nosocomial), along with the presence of any underlying disease. (See Table 24-1.) The most common infecting agents by age are respiratory syncytial virus (RSV) in infants; RSV, parainfluenza viruses, influenza viruses, adenoviruses in children younger than 5 years old; and M. pneumonia and S. pneumoniae in children older than five (Jensen & Baltimore, 2006).

Complications that may result from acute bacterial pneumonia include pleuritis (inflammation of the pleura), pleural effusion, pyothorax (pus in the pleural cavity), empyema (organized pyothorax with fibrous walls), and bacteremia (Jenson & Baltimore, 2006).

Epidemiology of Pneumonia

According to the World Health Organization, there are 150.7 million cases of pneumonia every year in children younger than 5 years (Rudan et al., 2004). In the United States, the annual incidence of pneumonia in children younger than 5 years is estimated to be 34 to 40 cases per 1,000, while the incidence decreases to 7 cases per 1,000 in adolescents 12 to 15 years of age. The mortality rate in developed countries remains low, at less than 1 per 1,000 per year; however, in third world countries, respiratory tract infections are more prevalent and severe. Pneumonia in these countries accounts for more than 4 million deaths annually (Durbin & Stille, 2008).

Viral and bacterial pneumonia occur throughout the year; however, they are more prevalent in fall and winter. Many speculate that during cooler months there is enhanced person-to-person droplet spread of respiratory pathogens due to crowding, along with diminished host resistance due to impaired mucociliary clearance from dry indoor air (Durbin & Stille, 2008).

Children who have underlying cardiopulmonary disorders and other medical conditions are at higher risk for pneumonia and its complications. These conditions include congenital heart disease, bronchopulmonary dysplasia, asthma, sickle cell disease, gastroesophageal reflux, and acquired immunodeficiency disorders. Also, children exposed to cigarette smoke are at higher risk for acquiring pneumonia as a result of impaired mucociliary clearance and increased risk of aspiration. In addition, the use of alcohol has been associated with increased colonization of the oropharynx with aerobic gram-negative bacilli (Durbin & Stille, 2008).

Table 24–1 Childhood Community-Acquired Pneumonia: Common Pathogens

Age

Pathogen

 

3 weeks to 3 months

Chlamydia trachomatis

 

Respiratory syncytial virus

 

Parainfluenza

 

Streptococcus pneumoniae

 

Bordetella pertussis

 

3 months to 4 years

Respiratory syncytial virus

 

Parainfluenza

 

Human metapneumovirus

 

Influenza

 

Rhinovirus

 

S. pneumoniae

 

Mycoplasma pneumoniae

 

5 years through adolescence

Mycoplasma pneumoniae

 

Chlamydophila pneumoniae

 

S. pneumoniae

 

Mycobacterium tuberculosis

Clinical Manifestations

Typical clinical findings of pneumonia depend somewhat on the infecting agents. Bacterial and viral pneumonias occur at all ages and can have an acute or gradual onset with mild URI symptoms a few days beforehand. In contrast, mycoplasmal pneumonia typically occurs after 5 years of age and tends to have a slow onset. A temperature of ≥ 102°F (≥ 39°C), chills, cough and dyspnea are suggestive of bacterial pneumonia. Viral pneumonias commonly have a slower onset and a less prominent fever compared to what occurs with bacterial pneumonia. Cough, wheezing, and stridor may also be found in viral pneumonia. A dry persistent cough, a prodrome of chills, headache, sore throat, gastrointestinal complaints, and malaise are characteristic of mycoplasmal pneumonia (Brady, 2009).

What diagnoses would you consider with this history and physical examination? image

Differential Diagnosis

You consider the following diagnoses:

•  Bronchiolitis

•  Foreign body aspiration

•  Cystic fibrosis

•  Asthma

•  Tuberculosis

These are the typical conditions to consider. Other possibilities, although remote in this case, include congestive heart failure, acute bronchiectasis, and pulmonary abscess.

Given those diagnostic possibilities, what other information would help you make the diagnosis? image

From the above review, some other information you should obtain includes the following:

•  History of previous episodes of respiratory illness (immuncompromised)

•  History of travel

•  History of contacts with confirmed or suspected infectious tuberculosis

•  History of choking (foreign body aspiration)

•  History of foul smelling stools (cystic fibrosis)

•  Results of prior purified protein derivative (PPD) skin testing (tuberculosis)

•  History of animal exposure/insect bites

Mr. Dixon reports that Mary has no previous history of pneumonia or significant respiratory illness—just the usual colds. The family has no history of recent travel nor a history of contacts with confirmed or suspected TB infections. Her PPD skin test was negative at 12 months of age. Mary has not experienced any episodes of choking, and her stools are not foul smelling. The family does not have pets, and she has not had contact with animals and has had no recent insect bites.

Physical Examination

Vital signs: Temperature 103°F, pulse 130, respiratory rate 32, O2 saturation 96% on room air. Her weight is 23 kg (75th percentile) and length is 115 cm (95th percentile). Body mass index is at the 85th percentile for age.

General: She is awake and alert, in mild respiratory distress. Head/eyes/ears/throat: Her conjunctiva and tympanic membranes (TMs) are normal. Her nasal mucosa is erythematous with yellowish discharge. There is mild maxillary sinus tenderness. Her lips and mucous membranes are moist. Tonsils are 1+, pharynx with mild erythema, no exudates noted. Tachycardia is present with regular rhythm and no murmurs noted.

Mild intercostal retractions are noted with decreased air entry over left lower lobe with fine crackles. No expiratory wheezes are auscultated. There is increased vocal fremitus over the left base with dullness to percussion. Exam of the abdomen reveals bowel sounds present; it is soft and nontender to palpation.

Her skin and neurologic examinations are unremarkable.

The physical exam should focus on the respiratory system. The clinician should assess for tachypnea, retractions (intercostal, subcostal, suprasternal), wheezing, nasal flaring, or grunting. Tachypnea is a significant, although at times subtle, clinical finding associated with lower airway illness. Durbin and Stille (2008) use the following criteria as key indicators of the presence of pneumonia in a pediatric patient: > 50 breaths/min at 2 to 12 months of age, > 40 breaths/min at 1 to 5 years, > 20 breaths/min for those older than 5 years, subtracting 10 if the child is febrile. They emphasize that tachypnea is the most sensitive and specific sign of pneumonia, found twice as frequently in children who have evidence of pneumonia on chest radiography as in those who have no such findings (Durbin & Stille, 2008).

“The most common signs of pneumonia detected by office-based clinicians are dullness to percussion, crackles, decreased breath sounds and bronchial breath sounds (louder than normal tubular breath sounds often accompanied by egophony)” (Durbin & Stille, 2008, p. 150). New onset wheezing is not typically associated with bacterial pneumonias (Durbin & Stille).

Making the Diagnosis

This history and physical examination are consistent with a diagnosis of pneumonia. There are three child and adolescent pneumonia syndromes: bacterial, atypical, and viral. (See Table 24-2.) Viruses are the most common etiology of pneumonia in older infants and children younger than 5 years of age. However, bacterial pathogens including M. pneumoniae and C. pneumoniae are most prevalent in school-age children (Gaston, 2002). Determination of the precise etiology of pneumonia is difficult due to a lack of sensitive and specific tests. Many clinicians treat pneumonia empirically with minimal laboratory or radiographic evaluation.

Do you need to do anything to confirm the diagnosis, such as a chest X-ray or laboratory studies? image

In most instances, blood tests such as a complete blood count with differential (CBC), chemistries, or serology will not help to identify the cause of pneumonia or aid in the treatment. However, in a highly febrile child or infant less than 3 months, a blood culture and CBC may be warranted (Brady, 2009). The white blood cell count is usually normal or mildly elevated with neutrophil predominance (Brady). When a more precise diagnosis is necessary, more invasive techniques are required. Bacteria found in blood, pleural fluid (thoracentesis), or lung tissue are considered diagnostic in a patient presumed to have pneumonia (Nohynek, Valkeila, Leinonen, & Eskola, 1995). Chest radiograph can be used to verify the clinical suspicion of pneumonia and characterize the disease process, but is not necessary for every patient.

Table 24–2 Common Clinical Pneumonia Syndromes

image

This child’s history and symptoms are typical of mycoplasmal pneumonia. Therefore, you decide that a chest radiograph is not needed at this time.

Management

Treatment must first be directed at whether the child needs to be admitted to the hospital or remain at home. The decision to hospitalize a child with pneumonia must be individualized and based upon age and several clinical factors. Typically, children who are less than 3 months old are hospitalized because they can deteriorate rapidly and are prone to hypoxemia and bacteremia (Durbin & Stille, 2008). A child of any age whose family cannot provide appropriate care and assure compliance with the therapeutic plan needs to be hospitalized. Other indications for hospitalization include:

•  Hypoxemia: Oxygen saturation consistently less than 92% on room air

•  Dehydration or inability to maintain oral hydration

•  Moderate to severe respiratory distress: Respiratory rate > 70 breaths/min in infants less than 12 months or > 50 breaths/min in older children, difficulty breathing, apnea, or grunting

•  Toxic appearance

•  Failure of outpatient therapy: Worsening or no response in 24 to 72 hours

Children who have none of these features can be treated as outpatients.

How do you plan to treat this patient’s pneumonia? image

Based on the patient’s age, history, and physical exam, the most likely organism for her pneumonia is Mycoplasma. A macrolide is the drug of choice. Azithromycin is recommended most often because of its ease of administration, with once daily dosing for 5 days (Durbin & Stille, 2008). Usual dosage for azithromycin is 10 mg/kg QD day 1, then 5 mg/kg QD days 2–5. A more cost-effective alternative is erythromycin 50 mg/kg per day divided Q 6 hours for 10 days; maximum dose 2 g/day. For children who are older than 8 years, doxycycline is an alternative. The dose for doxycycline is 4 mg/kg per day in two divided doses for 10 days; maximum 200 mg/day.

You write a prescription for azithromycin 230 mg PO day 1, then 115 mg PO days 2–5 for pneumonia and instruct the father to follow up with you in 24 hours either by phone or office visit if either parent has concerns.

Most children have an uneventful recovery, but it is important to inform parents that their child’s cough can last for several weeks (Brady, 2009).

Educational plan: What will you do to educate the father about pneumonia and its management?image

You discuss the following with Mr. Dixon:

image  Explain the diagnosis and pathophysiology of pneumonia.

image  Inform the father of the name, dose, frequency, and duration of the antibiotic. Review the dosage of acetaminophen and frequency of its administration.

image  Discuss that over-the-counter decongestants should not be given to the child because of dangerous side effects

image  Emphasize the need to finish all antibiotics, even if the child is feeling better and fever subsides. Alert Mr. Dixon to the fact that with azithromycin exposure to sunlight (photosensitivity) may cause severe sunburn and skin rashes. Protection from the sun is advisable (e.g., use of sunscreen and wearing of protective clothing).

image  Advise the father that uncomplicated bacterial pneumonia should improve within 48 hours.

image  Teach the father how to monitor for signs of increased respiratory distress.

image  Educate the father that cough can last several weeks.

image  Discuss the need to keep Mary hydrated, and emphasize that he should not be worried about her appetite, which should return in 2 to 3 days when she is feeling better.

When do you want to see this patient back again? image

Tell Mrs. Smith to call and ask for a same-day appointment if Mary is not better in 48 hours or to return sooner (or at any time) if her symptoms worsen. It is important to provide an immediate recheck if there is no improvement within 48 hours because this generally indicates the need to rethink the diagnosis and management plan. If her condition has worsened at follow-up, she should be evaluated for potential complications and the need for a chest X-ray, complete blood count, and/or hospitalization. If improved, schedule a recheck at the completion of antibiotic therapy.

Is this child infectious to others and what is the typical progression of recovery? image

Transmission of Mycoplasma pneumoniae is by person-to-person contact with respiratory secretion. Its incubation period is 1 to 4 weeks. Typically, within 24 to 48 hours of antibiotic coverage the child will no longer be considered contagious (Centers for Disease Control and Prevention, 2005).

Overall outcomes in children with pneumonia are excellent. A change in respiratory sounds is typically noted by the second or third day with consolidation of the infection. Resolution occurs around the seventh day (Brady, 2009). The majority of children recover without complications. Radiographs may be abnormal for 6 weeks; therefore, serial X-rays are not recommended in uncomplicated pneumonia (Durbin & Stille, 2008). Follow-up radiographs 2 to 3 weeks after completion of therapy may be helpful in assessing alternate diagnoses or coincident conditions in children with recurrent pneumonia, persistent symptoms, severe atelectasis, or unusually located infiltrates.

Key Points from this Case

1. A macrolide is the drug of choice for the treatment of Mycoplasma pneumoniae.

2. The decision to hospitalize a child with pneumonia must be individualized and is based on age, underlying conditions, and severity of illness.

3. Children who are treated for pneumonia as outpatients should have follow-up within 24 hours. Those whose complications have worsened at follow-up should be evaluated for potential complications and hospitalization.

REFERENCES

Brady, M. A. (2009). Respiratory disorders. In: C. E. Burns, A. M. Dunn, M. A. Brady, N. B. Starr, & C. G. Blosser (Eds.), Pediatric primary care (4th ed., pp. 767–794). St. Louis, MO: Saunders Elsevier.

Centers for Disease Control and Prevention. (2005). Mycoplasma pneumoniae. Retrieved May 11, 2009, from http://www.cdc.gov/ncidod/dbmd/diseaseinfo/mycoplasmapneum_t.htm

Durbin, J. W., & Stille, C. (2008). Pneumonia. Pediatrics in Review, 2, 147–160.

Gaston, B. (2002). Pneumonia. Pediatrics in Review, 23, 132–140.

Jenson, H. B. & Baltimore, H. J. (2006). Pneumonia. In: R. M. Kliegan, K. J. Marcdante, H. B. Jenson, R. E. Behrman (Eds.), Nelson essentials of pediatrics (5th ed., pp. 503–509). Philadelphia: Elsevier Saunders.

Nohynek, H., Valkeila, E., Leinonen, M., & Eskola, J. (1995). Erythrocyte sedimentation rate, white blood cell count and serum C-reactive protein in assessing etiologic diagnosis of acute lower respiratory infections in children. Pediatric Infectious Disease Journal, 14(6), 484–490.

Pickering, L. K., Baker, C. J., Long, S. S., & McMillan, J. A. (Eds.). (2006). Red book: 2006 report of the Committee on Infectious Diseases (27th ed.). Elk Grove Village, IL: American Academy of Pediatrics.

Rudan, I., Tomaskovic, L., Boschi-Pinto, C., & Campbell, H. (2004). Global estimate of the incidence of clinical pneumonia among children under five years of age. Bulletin of the World Health Organization, 82, 895–903.