Cough and Difficult

Breathing in
Children
Departement of Child Health
Faculty of Medicine
Universitas Gadjah Mada
 Introduction
• Cough: daily phenomenon, universal experience
• function:
– respiratory defense mechanism
– symptom
alarm, something wrong
• the most common clinical symptom, main chief
complain
• Chronic cough in children, many cases
• Chronicity/recurrency: disturbing
– child: activity, study , G&D, QoL
– parents: worry, sleepy in the office
2
• Cough, part of respiratory defense mechanism
• In synergy with mucociliary clearence (MC)
• Normally, respiratory tract produce secretion up to
30 mL (adult)
• Entrapment of foreign material, brought by MC,
swallowed
• Cough does not always mean abnormal or clinically
significant

3
 Definition of cough

a sudden explosive expiratory maneuver

that tends to clear materials from the
airways and prevent aspiration of food or
fluid

4
• Involves variety of complex reflex
• It has a reflex arc that consist of:
Receptor
Afferent nerve
Cough control center
Efferent nerve
Respiratory muscles

5
The Cough Reflex
How do we cough ?
inspiratory compressive expiratory

insp’tory muscles
glottic closure 0.2’
exp’tory muscles

contraction contraction

contraction of

deep inspiration thoracic & abdminal
sudden glottic
(150-200% tidal vol) muscles vs fixed opening
diaphragm

maximal dilation
explosive release
of tracheo-
 intrathoracic of intrathoracic air
bronchial tree pressure
 Difficult breathing

• The sensation of abnormal or

uncomfortable breathing in the
context of what is normal for a
person according to his/her level
of fitness and exertional threshold
for breathless
Other terminologies:
 Shortness of breath  Labored breathing
 Breathlessness  Troubled breathing
 Dyspnea  Getting winded
 Breathing difficulties  Constriction
 Breathing discomfort  Uncomfortable breathing
 Chest tightness  Unusual awareness of
breathing
 Breath stops
 Increased breathing effort
 Air hunger
 Increased muscular effort to
breath
 The need to breath more
• afferent activation: from many sites
– pulmonary stretch receptors
– rib joint
– respiratory muscles, inc’l diaphragm
– others: visceral, neural, emotion
• no specific receptor
• respiratory receptors related to cough center
• dyspnea receptor
– chemoreceptor: hypercapnia, hypoxia
– mechanoreceptors : upper airways, lung
receptors (pulmonary stretch receptor, irritant
receptor)
– chest wall receptors
Fast breathing and chest indrawing
Fast breathing
Age respiratory rate
< 2 mo ≥ 60
2 - 12 mo ≥50
1 - 5 yr ≥40

Chest indrawing
Diiferential diagnosis of child with
cough and/or difficult breathing
•Cough with fast
breathing
Pneumonia •Lower chest indrawing
•Fever
•Coarse crackle on
auscultation
•Nasal flaring,Head nodding
•Cyanosis, grunting
•First episode of wheeze in a
Bronkiolitis child aged 2 years
•Hyperinflation of the chest
 •Prolong expiration
•Poor/no respons to bronchodilator

Asthma •History of recurrent wheezing

•Hyperinflation of the chest
•Prolong expiration
•Reduced air entry (if very severe)
•Good respons to bronchodilator
Cardiac failure •Raised jugular venous pressure
•Apex beat displaced to the left
•Gallop rhythm
•Heart murmur
•Basal fine crackle
•Enlarge palpable liver
Congenital heart •Cyanosis
•Difficult of feeding or breasfeeding
disease •Enlarge liver
•Heart murmur

•Chronic cough (> 21 days)

Tuberculosis •Poor growth/wasting or weight
loss
•Positive mantoux test
•Positive contact history with adult
tuberculosis patient
•Fever > 2 weeks
•Limphadenopathy
(cervical,inguinal,axillar)
Foreign bodies •History of suddn chooking
•Sudden onset of stridor or
respiratory distress
•Focal areas of wheeze or reduced
breath sound
Pleural effusion
•Stony dullness to percussion
/empyema •Air entry absent

Pneumothorax •Suddent onset

•Hiper resonance on percussion on
one side of the chest
•Sift in mediastinum
Pertussis •Paroxysms of cough followwed
by whoop, vomiting,cyanosis or
apnoea
•Well between bouts of cough
•Less or no fever
•No history/incomplete of DPT
immunization

Severe anaemia •Severe palmar pallor

•Haemoglobin < 5 g/dl
 ACUTE RESPIRATORY
INFECTIONS IN CHILDREN
 ACUTE RESPIRATORY
INFECTIONS (ARI= ISPA)
CLASSIFICATION

• ACUTE UPPER RESPIRATORY

INFECTIONS ( AURI)

• ACUTE LOWER RESPIRATORY

INFECTIONS ( ALRI)
• AURI :
• COMMON COLD (RHINITIS)
• PHARYNGITIS - NASOPARYNGITIS -
TONSILOPHARYNGITIS
• SINUSITIS
• OTITIS MEDIA
• ALRI :
• EPIGLOTITIS
• LARYNGO TRACHEOBRONCHITIS
• BRONCHITIS
• BRONCHILOITIS
• PNEUMONIA
• WHO ARI control program (included in
IMCI Algorythm ) uses simple clinical sign
are Respiratory rate and Chest
indrawing for ARI classification
• WHO ARI classfication :
2 months - 5 tahun of age
1. SEVERE PNEUMONIA
2. PNEUMONIA
3. NO PNEUMONIA
until 2 months of age
1.SEVERE PNEUMONIA
2.NO PNEUMONIA
 ARI classification

Signs Classification
• Fast breathing Severe pneumonia
• Chest indrawing

• Fast breathing Non-severe pneumonia

• No fast breathing Other respiratory illness

 ETIOLOGY
• AURI : >> VIRUS ( 90%)
• COMMON VIRUSES
AURI (IRA -A) : RhInovirus, Corona virus,
Adenovirus, Entero virus
ALRI (IRA -B) : RSV, Para influenza 1,2,3;
Corona virus,
Adeno virus, Enterovirus
Child with Pneumonia
PNEUMONIA
Pneumonia in children (<5 yr)
• Morbidity rate 10-20%
• Mortality rate 6/1000
• Pneumonia kills
– 50.000 children/year
– 12.500 children/month
– 416 children/day passengers
of a jumbo jet plane
Garuda Indonesia

crash
 Unicef - WHO, Pneumonia the forgotten killer, 2006
UNICEF/WHO, Pneumonia: The forgotten killer of children 2006
Rudan I et al. Bull WHO 2008
Pneumonia is
the no 1 killer
of children
 ETIOLOGY

Viral, bacterial, or
mixed infection

Most common :
S. pneumoniae and H. influenzae
 clinically and radiologically
hard to differentiate
Jadavji T et al,1997, Alberta Medical Association, 2001
Developing country 
± 60% pneumonia cases
caused by bacterial

Developed country
 mostly viral

Jadavji T et al,1997, Alberta Medical Association, 2001

In Developing countries
S.pneumonia and H.influenza
remain the leading causes of
childhood bacterial pneumonia
 Etiology
Pathogen Role Discussion
Streptococcus Leading S. pneumoniae is the leading pathogen in almost all
pneumoniae studies from around the world. This proportion may vary in
different parts of the world.

Haemophilus Major Most disease is caused by type b (Hib). Vaccine studies

influenzae from Bangladesh, Chile and the Gambia suggest that Hib
causes around 20% of severe pneumonia cases, although
the proportion may vary in different parts of the world.

Other important Less These pathogens include important viruses such as

pathogens common respiratory synctitial virus (RSV) and influenza; other
bacteria, such as Staphylococcus aureus and Klebsiella
pneumoniae

Unicef - WHO, Pneumonia the forgotten killer, 2006

34
 Risk factors
Low birth weight

Not breastfed Malnutrition

Incomplete Vit A deficiency
immunization

PNEUMONIA
Young children Cold weather

High prevalence
Crowdedness pathogen carrier
Exposure to
indoor & outdoor
pollution
ETS, biomass fuel, vehicle
& industry pollution
 Transmission
• Pathogens causing pneumonia may reach
the child’s lungs through different routes.
• Pathogenesis of is widely believed that
common pathogens causing pneumonia
are often already present in a child’s
throat and are then inhaled into the lungs,
causing infection.
• Pathogens may also be spread through
contaminated air droplets or may result
from blood-
blood-borne infections.
 Transmissions
Nasopharyngeal carriage may occur in up to 60% of healthy pre-school
children and up to 30% of healthy older children and adults
Nasal cavity
Asymptomatic
carrier

Nasopharynx: site
of colonisation

Aerosol
Inhalation Trachea

Patient with
pneumococcal
disease
Dissemination
 Symptoms
• Children with pneumonia may have a range of
symptoms depending on their age and the
cause of the infection.
• Common symptoms include rapid or difficult
breathing, cough, fever, chills, headaches, loss
of appetite and wheezing.
• Children under five with severe cases of
pneumonia may struggle to breathe, with their
chests moving in or retracting during inspiration
(known as ‘lower chest wall indrawing’).
• Young infants may suffer convulsions,
unconsciousness, hypothermia, lethargy and
feeding problems.
 Diagnosis
• Chest X X--rays and laboratory tests are
used to confirm the presence of
pneumonia, including the extent and
location of the infection and prediction of
its cause.
• But in resource
resource--poor settings, suspected
cases of pneumonia are diagnosed by
their clinical symptoms.
• Children and infants are presumed to
have pneumonia if they exhibit a cough
and fast or difficult breathing.
Simple clinical manifestation
Fast breathing

Age respiratory rate

< 2 mo 60
2 - 12 mo 50
1 - 5 yr 40

Chest indrawing
 Treatment
• Prompt treatment of pneumonia with
a full course of appropriate antibiotics
is lifesaving.

• UNICEF & WHO have published

guidelines for diagnosing and treating
pneumonia in community settings in
the developing world
To decrease morbidity &
mortality

Strategic guidelines for

pneumonia (WHO)

Integrated Management of
Childhood Illness (IMCI)
program ( Revised in 2008)
Jadavji T et al,1997 , Alberta Medical Association, 2001
 Pocket book of Child
Healthcare in Hospital
 Non-Severe Pneumonia

Non-severe
pneumonia Treated at
WHO
(tachypnea, home with
without chest oral
wall antibiotics
retraction)

Ostapachuck M et al, 2004;Greenberg D et al, 2005

 Severe
Admission
pneumonia
to hospital,
WHO (tachypnea,
parenteral
with chest wall
antibiotics
retraction)

McIntosh K, 2002; Ostapchuck M et al, 2004

Antibiotics for Non-Severe
Pneumonia
Choosing antibiotics

Bacterial etiology
classified based
on the child age
Alberta Medical Association, 2001
 Antibiotics for Non
Severe Pneumonia
• Oral Amoxicilin (15 mg/kg
Pharmacokin tid)
etic Research • Oral Amoxicilin (25 mg/kg
bid)

• Oral amoxicillin twice a day

Amoxicillin more susceptible
dose • Given for 3 days in non-
endemic HIV

Pakistan MASCOT, 2002; Fonseca W, 2003; Pakistan MASCOT 2003; ISCAP study group,
2004; Awasthi S et al, 2004; WHO, 2005; Ayieko P et al, 2007
 Cochrane Database of
Systematic Review

A short course (3 days) of antibiotic

therapy is as effective as a longer
treatment (5 days) for non severe
pneumonia in children under five years of
age.

Haider BA, Saeed MA, Bhutta ZA, 2007

 Indication for
Hospitalized

Less than 6 months Looks toxic,

old
dehydrated, or
vomiting

Hipoxemia (O2 sat Difficulty of

<93-94% on room air) breathing

Alberta Medical Association, 2001; WHO , 2008

Antibiotics for Hospitalized
Pneumonia
WHO  severe pneumonia & very
severe pneumonia in developing
country

IV chloramphenicol

or Benzylpenicillin and
aminoglycoside

Pakistan MASCOT, 2002; Fonseca W, 2003

Antibiotics for Severe Pneumonia
(Hospitalized patients)

Cochrane Database of Systematic

Reviews , 2009
Combination of
Injectable
Procaine penicillin and
penicillin and
penicillin better gentamycin
oral amoxycillin
than co- better than
had similar
trimoxazole chloramphenicol
failure rates
alone

Kabra SK et al. 2009

Tuberculosis in children
 Definition

Tuberculosis is a disease caused

by Mycobacterium tuberculosis.
The site of primary infection is
usually the lung and it may spread
hematogenously to almost all
organs
TB proportion in the world
Indonesia 10 % China
Bangladesh 4% 15 %
Pakistan 4%

Philipines 3% India
Nigeria 3% 30%
South Africa 2%
Russia 1% Others
28%
 Epidemiology of childhood TB
Actual global disease burden of childhood TB not
known - estimates assume that 10% of total
caseload are children

Problems:
•Diagnostic difficulties
•Not well recorded
and reported
 Epidemiology of childhood TB

• Infection usually from close household contact

with smear-positive PTB

• Most infected children do not develop disease

• Of children who develop disease, most will do so

within 1 year after infection
 Risk of Infection and Disease

• Duration of exposure
• Closeness of contact
• Microbial load – degree of smear positivity
• Young age
• Malnutrition
• HIV
• Other immunosuppressive illnesses e.g.
measles
• No BCG
Concept of risk
Natural history of disease (1920-
(1920-1950)

Exposure

Infection

Disease
Marais et.al. IJTLD 2004
 Tuberculosis infection among children
by type of contact and bacteriologic status of index case

40 Close
35
30
Per cent infected

25
20
15 Casual Close
10
5 Casual

0
Smear + Smear -

Grzybowski S, et al. Bull Int Union Tuberc 1975;50:90-106

Average age specific risk for disease development
following primary infection (pre-BCG)
100%
90%
80%
70%
60%
Miliary or TBM
50% Pulmonary
40% No disease
30%
20%
10%
0%
0-1 year 1-2 years 2-5 years 5-10 years >10 years

Adapted from Marais B, et al. Int J Tuberc Lung Dis 2004

Mycobacterium tuberculosis
 Mycobacterium tuberculosis

• TB is caused by an infective organism

• Discovered in 1882 by Robert Koch
• Mycobacterium tuberculosis
– It is a small rod-like bacillus
– It is not classified as being either Gram-
positive of Gram-negative
– Instead, using Zeihl-Nielson stain the
organisms can be seen as acid-fast bacilli
Robert Koch 1843-1910
Discovered M. Tuberculosis 1882
TB droplet nuclei
 Acid-Fast bacilli

•Aerobic organism
•Very slow growing
 Divides every 16 to 20 hours
 Among the fastest growing bacteria is a strain of E. Coli that can
divide roughly every 20 minutes.
 Makes it difficult to culture.
 M. tuberculosis inhalation

phagocytosis by PAM bacilli dead

TB pathogenesis live bacilli

incubation period
multiplies (2-12 weeks)

primary focus formation

lymphogenic spread
hematogenic spread1)

Primary complex2)
TST (+) Cell mediated immunity (+) P
r
i
m
TB disease Low immunity TB infection a
primary complex complication r
Optimal immunity
hematogenic spread complication y
lymphogenic complication
T
B
Dead
3)

immunity 
reactivation

Cured TB disease4)
 Pathogenesis
Simon focus lymphadenitis

lymphangitis

primary focus
Ghon focus
 Cell mediated immunity

• Bacilli replication continues until the development

of effective cell-mediated immunity
• Normally takes 6-12 weeks
• Demonstrated by tuberculin skin test conversion
• Lymphatic and haematogenous spread can occur
in this period
• To: lungs, brain, lymph nodes bones, kidneys
 Exposure to TB

No infection Infection
(70-90%) (10-30%)

Latent TB (90%) TB disease (10%)

-never TB disease -5% within 2yrs
-NOT infectious -5% years later

Untreated Treated

50% die within 2 yrs Cured

 Transmission rate
adult
TB patient

AFB(-) culture(-)
AFB(+) culture(+) CXR (+)

65% 26% 17%

12/13/2010 71
Diagnosing TB in children
 Problems in diagnosing TB in children

• Gold standard: acid fast bacilli in sputum.

Problems:
– Specimen (sputum) collection
– The number of bacilli is low  not detected
– Cough is not the main symptoms in children

• Clinical symptoms are unspecific

 overdiagnosis
 Clinical symptoms

• Decreased or low appetite

• Malnourished or undernourished
• Recurrent fever
• Chronic cough
 Clinical signs
• Not specific
• Usualy normal respiratory examination
• Cervical lymphadenopathy
• Extrapulmonary TB  based on the
organs involved
Scrofuloderma
Spondilitis TB
Chest X-ray

•Normal
•Hilar lymphadenopathy
•Pleural effusion
•Miliary TB
Ghon focus Lymph node disease

Complicated Ghon focus

Pleural effusion Miliary disease

Adult-type disease
 Tuberculin Skin Test

• Mantoux test
– Purified protein derivative (PPD)
– Injected intradermally
– Strength of 2-5 TU
– “Read” 48-72 hours later
– Measure palpable induration, not redness
 Positive TST
• TST > 15 mm (got BCG within 5 years)

• TST >10 mm (got BCG within 10 years)

• TST > 5mm in a child at risk of TB, and no

BCG vaccination
 Diagnosis
TB infection
• Positive TST

Latent TB
• TB infection (positive TST) without illness

TB disease
• TB infection (positive TST) with:
– Symptoms
– Signs
– CXR changes
 TB infection & TB disease

• TB infection: CMI can control infection

– primary complex (+)
– cell mediated immunity (+)
– tuberculin sensitivity (DTH) (+)
– limited amount of TB bacilli
– no clinical or radiological manifestation
• TB disease: CMI failed to control TB infection
TB infection + clinical and/
and/or
or radiological
manifestation
Infection without disease
Progressive disease
 TB score

• Start TB therapy if score > 6

• Tb score is used as entry-point not end-point

 IDAI Pediatric TB scoring system
Feature 0 1 2 3 Score
Contact not clear - reported, AFB(+)
AFB(--)
AFB(
TST - - - positive
BW (KMS) - <red line, severe -
BW
BW  malnutrition
Fever - unexplained - -
Cough <3weeks >3weeks - -
Node - >1 node, - -
enlargemnt >1cm,painless
Bone,joint - swelling - -
CXR normal sugestive - -
Total score
Refer to hospital as soon as possible if
1. CXR: Milier TB
2. Gibbus
3. Scrofuloderma
4. Danger signs: Convulsion, neckstiffness, deteriorating consciousness, and other danger sign
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 Standard Regimen
2 RHZ 4 RH
– Intensive phase (first 2 month)
• INH, Rif and PZA
• Given daily
– Advance phase (4 months)
• INH and Rifampicine
• Given daily
 Treatment
Drug dosages for children
• Isoniazid (H)
– 10-20mg/kg/dose
– Max 300mg
• Rifampicine (R)
– 10-20mg/kg/dose
– Max 600mg
• Pyrazinamide (Z)
– 15-30mg/kg/dose
– Max 2000mg (2 grams)
 TB therapy regimen
2 mo 6 mo 9 mo 12mo

INH
RIF
PZA

ETB
SM

PRED
Management of childhood contacts
 Management of childhood contacts
No TST Clinical sign & Treatment
symptoms
1 Negative None preventive INH
5 mg/kg/day
for 6 months
2 Positive None preventive INH
5 mg/kg/day
for 6 months
3 Negative Positive preventive Repeat TST
at least after
2 weeks
4 Positive Positive Specific 2RHZ 4RH
therapy