Tuesday, February 06, 2007

Problems Breathing

Dear Lisa,

My son is 2 years old. Since he was born he had problems breathing, he is "always" sick and every time I take him to the doctor and it’s always a flu and it will go away soon. A flu goes away 1 week the most 2 but my son has had a flu I would say most of his short life. I really think there's more to this flu but how can I make the doctor understand?

“Yayo”

Dear “Yayo”,

On average most children develop 7 Colds or Viruses per year during the first few years of life.(1) A child in daycare is expected to develop more episodes than average. Most of these Colds and Viruses tend to occur during the winter months. Viral or Cold symptoms including a runny nose or cough can last 10 to 14 days with each episode. Therefore it can appear that a young child is "constantly sick" during the winter months when in reality they are experiencing symptoms of recurring Colds and Viruses.

On the other hand, symptoms that do not go away in between episodes may be due to a different cause. You are correct, a "flu" or Cold should resolve in 1 to 2 weeks. When respiratory symptoms linger beyond the 3 to 4 week mark a further investigation is warranted. Unlike adults, children do not need to have a cough for 8 weeks before it is considered to be chronic. In a child a daily cough that persists for more than 4 weeks is considered to be chronic. (2) Any child with a chronic cough needs to be evaluated in order to determine its cause. (3)

There are many childhood respiratory conditions that cause a chronic cough, with Asthma being high on the list. Other conditions that commonly cause a chronic cough in the pediatric population include Sinusitis, Gastroesophageal reflux and Allergies. In particular the most common cause for chronic cough in the 18 month to 6 year old age group is Sinusitis. Asthma is the second most common cause in this age group.(3)

There are some infectious agents that invade the respiratory system that can cause a mild onset and persistent respiratory symptoms. These infectious agents include Mycoplasma (“Walking Pneumonia”), Bordetella pertussis (Whooping Cough), Cytomegalovirus, Ureaplasma, Urealyticum, Chlamydia trachomatis and Mycobacterium tuberculosis (TB).(3) A child with persistent respiratory symptoms should be evaluated for these infections.

Rare causes of chronic respiratory symptoms include Vascular anomalies, Tracheomalacia, Subglottic Stenosis (the air tube it too small), Bronchogenic cyst, Cystic Fibrosis, Immune deficiency, Immotile Cilia Syndrome and Foreign Body Aspiration. (3) Foreign bodies can become lodged in a child's airway for a length of time without the parent ever knowing it. Chronic cough can be the presenting symptom if the diagnosis was missed. (2)

Lastly, but not the least important, children exposed to second hand cigarette smoke can also develop a chronic cough and respiratory symptoms. Cigarette smoke exposure increases a child’s risk of developing Otitis Media(Middle ear infection), triggers Asthma and increases an infant’s risk for Sudden Infant Death Syndrome(SIDS).(4,5)

If you feel that your child’s respiratory symptoms are chronic in nature and not the result of recurrent acute infections, an evaluation to help determine the cause is necessary. In order to make your Doctor understand the chronicity of your son’s symptoms and how they affect his daily activities, you may need to write down the information and read it to him. For example, instead of bringing in your child into the doctor’s office saying, “He has a runny nose and cough”, it would be more effective to say:

“My son has a continuous runny nose for 28 days with no relief from his symptoms. He has a daily cough which causes him to gag, choke and vomit. He coughs every night which wakes up him and the whole household. The cough has been going on for 6 weeks straight. Whenever he runs around the house he becomes short of breath and winded.”

In other words, give your doctor a very specific description of his symptoms, including how they affect his life. In some cases, it may be helpful to keep a diary so that you can relay an accurate description of his day to day symptoms. If you use this approach and you still feel that your concerns are not being addressed you may want to seek a second opinion with a Pediatric Pulmonologist.

A Pediatric Pulmonologist is a Doctor who specializes in pediatric respiratory conditions and will be able to determine the cause of your son’s symptoms. The work-up for chronic respiratory symptoms or a Chronic Cough includes information about your child’s medical history and family history as well as a physical examination and diagnostic testing.

Pediatric respiratory specialists recommend that all children with a chronic cough receive a Chest x-ray as part of the work up.(2) A Chest x-ray will be able to identify any pulmonary, cardiac or thoracic abnormalites that warrant a further investigation. Spirometry is another important test performed on children. It determines a child's lung function and helps with the diagnosis of Asthma. Traditional Pulmonary Function testing is difficult to obtain in children under five years old because of their lack of cooperation and the unavailability of machinery appropriate for this age group.

Testing for Tuberculosis is recommended for children who live in or travel to countries where Tuberculosis is endemic.(2) For example, Tuberculosis is the second most common cause of chronic cough in 1 to 12 year old children who live in India.(5) Therefore it is very important to report the types of travel your child is involved with. Tuberculosis testing is also recommended in children who have been exposed to high risk adults. High risk adults include those born in countries in which Tuberculosis is endemic, residents of correctional facilities, shelters, or nursing homes, illicit drug users, persons infected with HIV, health care workers, and the homeless.

In addition, a child with chronic respiratory symptoms may need to be tested for Allergies, an Immune deficiency or Cystic Fibrosis. In some cases a Barium Swallow may be recommended if a Vascular anomaly is suspected.

I hope this information helps and you get to the bottom of your son’s respiratory symptoms real soon.

If you would like further information about topics discussed, read other Pediatric Advice Stories:

Baby with Cold Symptoms

Chronic Cough

Sinusitis

Asthma Treatment

Asthma Triggers

Allergies

Allergy Treatment

Gastroesophageal Reflux in Infancy

Gastroesophageal Reflux

Pneumonia

Sudden Infant Death Syndrome

Foreign Body Aspiration

The Surgeon Generals Report on
the Effects of Second Hand Cigarette Smoke

References:
(1) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:707-708.
(2)Chang AB, Glomb WB. Guidelines for evaluating chronic cough in pediatrics. ACCP evidence-based clinical practice guidelines. Chest. 2006. 129:260S-283S.
(3)Nield L, Kamat D. How to Handle Chronic Cough in Kids: A Practical Approach to the Workup. Consultant for Pediatricians. 2003. Sept:315-321.
(4)Alper B, Fox G. Acute Otitis Media. The Clinical Advisor. 2005. April:78-85.
(5)The United States Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Available at: www.surgeongeneral.gov/library/secondhandsmoke/. Accessed Jan 2007.
(6)Mogre VS, Mogre SS, Saoji R. Evaluation of chronic cough in children: clinical and diagnostic spectrum and outcome of specific therapy. Indian Pediatr. 2002.39:63-69.

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

Pediatric Advice For Parents with Sick Kids

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