Pneumonia

Dear Lisa,

My 19 month old has a mucus filled cough followed by mucus filled vomiting she has no fever, no appetite, but she is very tired and groggy what should I do?

“Child with mucus filled Cough”

Dear “Child with mucus filled Cough”,

A child can develop mucus in her airway due to a respiratory infection. When a germ enters the airway the immune system responds by making antibodies and mucus in order to combat the germ. In some cases the mucus drips down the back of the throat and causes a post-nasal drip. This post nasal drip can cause a child to gag and vomit.

Mucus can also develop in the lower airways or in the lungs. Potential causes of mucus production in the lower airway in young child include Pneumonia, Bronchiolitis or Asthma. Signs of Pneumonia typically include a fever, fast breathing, lethargy(tiredness), shortness of breath, coughing, wheezing, decreased appetite, vomiting and abdominal pain. A child does not need to have all of these symptoms in order to be diagnosed with Pneumonia. Fever and fast breathing may be the only sign found in a young infant or toddler.(1)

Even though fever is usually present when a child has Pneumonia it does not have to be present. There are certain types of Pneumonia referred to as “Atypical Pneumonia” that present with minimal fever or no fever at all. (1) Even though Atypical Pneumonias are considered to be more prevalent in 5 to 10 year old children, preschool children are also at risk. A study performed by Michelow showed that preschool aged children experienced as many episodes of Atypical Pneumonia as older children.(2)

Bronchiolitis is one of the most common and serious viral infections that affects the lower respiratory tract in young children.(3) Almost 85% of cases are caused by RSV. Other potential pathogens include Parainfluenza Virus, Adenovirus, Influenza Virus and Rhinovirus. The symptoms of Bronchiolitis include a several day history of clear nasal discharge and nasal congestion followed by cough, fever, wheezing, retractions, poor feeding and in some cases respiratory distress.(4) Signs and symptoms of Bronchiolitis last for 10 to 14 days with the most intense symptoms occurring by the fifth day.(4)

Bronchiolitis is usually a mild and self limiting disorder, but in some cases it can become quite serious. It is the most common cause of hospitalization among infants. In the United States, 2 out of every 100,00 infants affected dies due to complications related to Bronchiolitis.(4) Those children at risk for developing severe disease include the very young, premature and those who are chronically ill.(5) All young children with symptoms consistent with Bronchiolitis should be evaluated and closely followed by a health care professional.

Asthma has many presentations, the most common in young children being chronic chough, nighttime cough, exercise intolerance, increased work of breathing, wheezing in a child with eczema and difficulty breathing.(6,7) Asthma is a chronic inflammatory disease that involves airflow limitation, bronchoconstriction, airway edema, mucus plug formation, airway hyperresponsiveness and airway wall remodeling. Excess mucus production, coughing up mucus and vomiting mucus are frequently found in children with Asthma.

Asthma is the most common chronic illness of childhood. It affects approximately 5 million children in the United States. Those at risk for developing Asthma include children with allergies and those with a family history of Asthma.(8) A Viral respiratory tract infection is one of the major triggers for an exacerbation of Asthma.(9) Therefore if a child with Asthma develops a respiratory infection, she should be evaluated by her Physician and have an action plan implemented in order to prevent deterioration of her health.

Since a mucusy cough can represent a wide range of disorders, a child presenting with this symptom needs to be evaluated by a Health Care Professional so that the correct diagnosis and treatment plan can be initiated. Young children are at a particular risk for developing complications from respiratory tract infections. Therefore, children under 3 years old with respiratory symptoms should be examined by a Physician or Nurse Practitioner.

Since your child is only 19 months old it would be important to have her seen by her Physician. Her decreased appetite and lethargy may be signs of worsening of her respiratory condition or they may represent a complication such as dehydration. Young children can easily become dehydrated when they are ill. Changes in diet and insensible water loss due to coughing and increased respiratory rate can quickly lead to dehydration in a young child. Sign of dehydration include dry tacky mucus membranes (inside of the mouth looks dry), poor skin turgor(non-elastic skin), decreased urine production, sunken fontanelle (soft spot), sunken eyeballs, reduction in amount of tears, increased heart rate, thirst, weight loss and listlessness.(10)

It is not a good idea to treat a young child suffering from respiratory symptoms with over-the-counter products. Over-the-counter products can cause side effects, fail to treat the cause of a cough and can mask symptoms of an underlying problem. There are many over-the-counter medications that are labeled to be used for cough. Many of these products are marketed as expectorants or a treatment for thinning mucusy secretions. Guaifenesin is a common component in many of these products.

At very high doses, Guaifenesin has mucokinetic effects and can thin respiratory secretions. The problem is at these high doses, significant side effects can occur. (11) In addition, controlled studies have shown that Guaifenesin has no benefit in the treatment of children with cough. It did not change volume or quantity of sputum, nor did it reduce cough frequency.(11)

The officials with the American College of Chest Physicians published Evidence–based Clinical Practice Guidelines regarding the treatment of a cough. These guidelines stressed that most over-the-counter syrups do not treat the underlying cause of the cough. The Guidelines’ authors do not recommend giving over-the-counter cough syrups to children under 14 years old.

Cough suppressants such as codeine and dextromethorphan can also cause significant side effects in children and are not recommended. They have the potential to cause breathing difficulties or respiratory arrest.(12) In addition no clinically evidence from controlled studies has documented their efficacy in the pediatric population.(13)

When a child has a mucusy cough the best thing that you can do is let the child cough and not give over-the-counter cough preparations. A cough is the body’s natural mechanism to protect and clear the airway. The force of a cough moves secretions in the respiratory tree upwards and thins the mucus. If a chid has excessive coughing, she should be evaluated by a Physician.

A natural way to help thin a child’s respiratory secretions is to increase the amount of fluids that your child drinks. This includes solids that melt to a liquid state at room temperature such as ice pops, Jell-O and sherbet. The application of saline nasal spray to the nasal passages can help liquefy and remove mucus from a child’s nose. Gargling with warm salt water can be performed in an older child. This can also aid in liquefying mucus that drips down the throat.

Concerning signs in a child with a respiratory symptoms include; difficulty breathing, pale or blue skin color, listlessness, irritability, accessory muscle use(the skin in between the ribs sucks inwards during breathing or the shoulders rise and fall), nasal flaring (the nostrils flare open with breathing), increased respiratory rate, clipped speech (the child cannot say the ABC’s without pausing to take breaths), back pain, chest pain, leaning forward and drooling or fever. These symptoms can represent worsening of a child’s condition or another serious health condition. If any of these symptoms occur when a child is suffering from symptoms of a respiratory infection, medical attention should be sought without delay.

I hope this information helps and that your daughter recovers quickly.

If you are interested in other Pediatric Advice Stories covering these topics:

Nasal Congestion

Chronic Cough

Baby with Cold symptoms

Asthma Treatment

Asthma Triggers

Adenovirus

References:
(1)Nield L. Pneumonia: Update on Causes-and Treatment Options. Consultant for Pediatricians. 2005.Sept:365-370.
(2)Michelow IC, Olsen, Lozano J. Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children. Pediatrics. 2004; 113:701-707.
(3)Linzer JF, Guthrie CG. Managing a winter season risk: bronchiolitis in Children. Pediat Emerg Med Rep. 2003.8:13—24.
(4)Bradin SA. Croup and Bronchiolitis: Classic Childhood Maladies Still Pack a Punch. Consultant for Pediatricians. 2006. Jan:23-30.
(5)Gorelick MH, Singh SB. Respiratory emergencies. In; Selbst SM, Cronan K. Pediatric Emergency Medicine Secrets. Philadelphia, PA: Hanley & Belfus. 2001. 241-252.
(6)Stephenson M. Be aware of the myriad conditions that trigger chronic cough in children. Infectious Disease in Children. 2006. March:38.
(7)Castro-Rodriguez JA, Holberg GJ, Wright AL, Martinex FD. A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Respir Crit Care Med. 2000.162:1403-1406.
(8)Kumar R. The Wheezing Infant: Diagnosis and Treatment. Pediatric Annals. 2003. 32(1):30-36.
(9)Johnson NW. Viral Infections Increase Asthma Hospitalizations. Journal of Allergy and Clinical Immunology. 2006. 117:557-562.
(10)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:921.
(11)Franco ME. Evaluation of chronic cough in children. Presented at: Miami Children’s Hospital’s 41st Annual Postgraduate Course “Perspectives in Pediatrics. Feb 6-9 2006:Miami Beach, Fla.
(12)Chang AB, Glomb WB. Guidelines for evaluating chronic cough in pediatrics. ACCP evidence based clinical practice guidelines. Chest. 2006.129:260S-283S.
(13)Bell E. Is codeine a useful medication in pediatrics? Infectious Diseases in Children. 2006. July:12.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice For Parents with Sick Children