Recognising respiratory distress in a child
Children have smaller airways, more compliant chest walls and higher oxygen demands, so small amounts of oedema or secretions produce disproportionate obstruction. The exam expects you to identify distress before saturation falls, because oxygen desaturation in a child is a late sign. Early indicators are tachypnoea, nasal flaring, intercostal and subcostal retractions, head bobbing in infants and expiratory grunting, which is the infant's attempt to generate positive end-expiratory pressure.
Late and ominous signs are the ones that must trigger immediate escalation: bradycardia, a decreasing respiratory rate in a child who was previously tachypnoeic, lethargy or decreased responsiveness, cyanosis and a silent chest. A previously agitated child who becomes quiet and sleepy is deteriorating, not improving, and that pattern appears repeatedly in stems.
Normal respiratory rates by age anchor these judgements: newborns 30 to 60 breaths per minute, infants 30 to 53, toddlers 22 to 37, preschoolers 20 to 28, school-age 18 to 25 and adolescents 12 to 20. A rate at the upper limit with retractions is more concerning than a marginally high rate in a calm, comfortable child.
Positioning answers favour comfort and airway patency: allow the child to assume a position of comfort, often sitting upright or held by a caregiver, avoid forcing a supine position, minimise crying and agitation which increase oxygen demand, and keep emergency airway equipment nearby when obstruction is possible.
- •Early: tachypnoea, nasal flaring, retractions, grunting
- •Late: bradycardia, lethargy, cyanosis, silent chest
- •Oxygen desaturation is a late finding in children
- •Allow a position of comfort; avoid agitation
Croup versus epiglottitis and other upper airway conditions
Croup, or laryngotracheobronchitis, is usually viral, affects children between about six months and three years, and develops gradually, often worsening at night. The hallmark is a harsh barking cough described as seal-like, accompanied by inspiratory stridor and hoarseness with a low-grade fever. Management is supportive: cool humidified air or a cool night-air walk, oral or intramuscular corticosteroids such as dexamethasone, nebulised racemic epinephrine for moderate to severe cases, fluids and rest.
Epiglottitis is the emergency counterpart, typically bacterial and now less common because of Haemophilus influenzae type b vaccination. It develops abruptly with a high fever and the four Ds: drooling, dysphagia, dysphonia and distress, with the child sitting forward in a tripod position with the chin thrust out. The exam's key action is what not to do — never inspect the throat, never use a tongue blade, never obtain a throat culture, and never place the child supine, because any of these can precipitate complete laryngospasm. Keep the child calm, call for immediate airway support and prepare for intubation.
Other upper airway topics include tonsillitis and post-tonsillectomy care, where frequent swallowing is the earliest sign of bleeding and the child must avoid straws, coughing, throat clearing and red or brown fluids. Bacterial tracheitis and foreign body aspiration also appear, the latter suggested by sudden onset choking in a toddler with unilateral decreased breath sounds.
| Feature | Croup | Epiglottitis |
|---|---|---|
| Onset | Gradual, worse at night | Abrupt, hours |
| Cough | Barking, seal-like | Absent or minimal |
| Fever | Low grade | High |
| Position | Any | Tripod, chin forward |
| Drooling | No | Yes, with dysphagia |
| Nursing action | Humidified air, steroids, epinephrine | Do not inspect the throat; secure the airway |
Lower airway conditions: RSV, asthma and cystic fibrosis
Respiratory syncytial virus causes bronchiolitis in infants and presents with copious nasal secretions, wheezing, tachypnoea, poor feeding and, in young infants, apnoea. Care is supportive: contact and droplet precautions with a private room or cohorting, nasal suctioning before feeds and sleep, small frequent feeds or intravenous hydration, humidified oxygen, and elevation of the head of the bed. Palivizumab is a monoclonal antibody given monthly during the season to high-risk infants for prevention, not treatment.
Paediatric asthma follows adult principles with important differences. Children may not wheeze audibly when obstruction is severe, so a quiet chest with increasing work of breathing means deterioration. Teach spacer use with metered-dose inhalers for all young children, peak flow monitoring with a personal best and zone plan for school-age children, trigger avoidance including tobacco smoke and pets, rinsing the mouth after inhaled corticosteroids, and having a written action plan at school.
Cystic fibrosis is an autosomal recessive disorder producing thick secretions that obstruct airways and pancreatic ducts. Findings include a salty taste to the skin, meconium ileus in the newborn, steatorrhoea, failure to thrive despite a good appetite, chronic cough and recurrent infection. Management involves pancreatic enzyme replacement taken with every meal and snack, a high-calorie high-protein diet with fat-soluble vitamin supplementation, generous fluid and salt intake, daily airway clearance with chest physiotherapy or a vest, and bronchodilators before dornase alfa and chest therapy.
Reinforce this content with our paediatric growth and development post, the oxygenation article and the child health question sets, which contain NGN case studies on infant respiratory deterioration.
- •RSV: contact precautions, suction before feeds, monitor for apnoea
- •Palivizumab prevents severe RSV; it does not treat it
- •Paediatric asthma: spacer, action plan, trigger control
- •Cystic fibrosis: enzymes with every meal, airway clearance daily
- •High-calorie, high-protein diet with extra salt in cystic fibrosis