Causes of Difficulty Breathing in Infants and Children

An infant or young child with difficulty breathing may have an infectious or noninfectious cause. Every parent should be familiar with the common causes of pediatric breathing difficulties discussed below.

Croup:

Croup is a viral infection of the upper respiratory tract. The most common infectious agent causing croup is the parainfluenza virus. Croup occurs most commonly in the fall and winter seasons. The most striking symptoms of croup are a barking cough and stridor. These symptoms are usually worse at night.

A child with croup may need to be admitted to the hospital if he or she has progressive or severe stridor at rest, respiratory distress, hypoxemia, cyanosis (blue coloring), pallor, high fever or suspected epiglottis.

Most children with croup do not require hospitalization and recover completely with time. Treatment for mild croup is mist therapy with a humidifier. A child with more severe symptoms of croup may require racemic epinephrine and/or dexamethasone. In the most severe croup cases a child may need to be admitted to the ICU.

Epiglottitis:

Epiglottitis is an acute, life-threatening infection of supraglottic tissues in the throat. The most common infectious agents in epiglottitis are Group A Strep, Strep pneumonia, and Staph aureus. H. influenza b was a very common cause of epiglottitis before the Hib vaccine.

Symptoms of epiglottitis include a hot potato voice, leaning forward and drooling, stridor, and tachycardia. A lateral neck x-ray may show the swollen epiglottic tissue. Direct visualization with laryngoscopy will reveal a big, cherry-red epiglottis.

Treatment for epiglottitis often requires endotracheal intubation, usually placed in the operating room, to support the airway. Antibiotic therapy of epiglottitis includes Ceftraixone for 7 to 10 days, as well as Rifampin for individuals who were in close contact with the sick child.

Foreign body inhalation:

Children ages 6 months to 3 years are most likely to inhale an object. Boys are two times more likely than girls to have a foreign body as the cause of their respiratory distress.

This diagnosis of inhaled foreign body is suggested if the child was left alone, has a sudden onset croupy cough with or without wheezing, can't speak, is coughing up blood, or is cyanotic (blue). However, if the object is stuck in the bronchi, the child may have a latent period with cough, recurrent lobar pneumonia, and/or intractable asthma.

Laryngoscopy or bronchoscopy, or sometimes chest x-ray, can assist in this diagnosis. Treatment is to remove the object and treat any secondary infection with antibiotics. Prevention counseling for the parents is a must.

Asthma:

The median age of asthma onset is 4 years, but 20% of pediatric asthma cases can present in the 1st year of life. There is often a history of triggers of an asthma exacerbation, such as respiratory illness, air pollutants (such as cigarette smoke), and/or allergens.

Symptoms of asthma include cough, wheezing, dyspnea, increased work of breathing, and long expiratory phase. The diagnosis of childhood asthma is usually clinical. A complete blood count may show eosinophilia. Often a test trial showing a positive response to Albuterol will suggest the diagnosis of asthma.

Treatment for asthma depends on the acuity of the situation. Possible therapeutic options include oxygen, beta agonists, oral and inhaled corticosteroids, leukotriene receptor antagonists and ipratropium.

Viral bronchiolitis:

Viral bronchiolitis is an infection of the upper and lower respiratory tract. More than 50% of cases of viral bronchiolitis are caused by RSV (respiratory syncticial virus). Other possible causes are adenovirus, parainfluenza, and influenza viruses. Most cases occur before 9 months of age, but this illness can occur up to age 2.

Most cases of viral bronchiolitis occur in winter or early spring and children have often been around someone sick. High risk kids are premature infants, immunocompromised children, or those who have cardiac, pulmonary, or neuromuscular disease.

Symptoms of bronchiolitis include a worsening respiratory illness, wheezing, cough, and dyspnea. A nasal swab PCR for viruses should be done. A chest x-ray should be obtained and oxygen saturation should be monitored

Bronchiolitis treatment includes oxygen if needed, a trial of albuterol, and respiratory isolation. Bronchiolitis can be prevented in high risk children less than 2 years of age by the administration of RSV IVIG (palivizumab, "Synagis").

Pneumonia:

Pneumonia is an infectious inflammation of lung tissue. In ages 4 months to 5 years, pneumonia is usually caused by a virus RSV, adenovirus, influenza virus, parainfluenza virus, and rhinovirus. Other community-acquired bugs to consider are S. pneumoniae (most common), C. pneumoniae, and M. pneumoniae.

Pneumonia infection is more common in children who are in daycare and have been exposed to sick contacts. They usually have a fever, and often an associated infection such as otitis media, pharyngitis, or rhinitis.

The diagnosis of pneumonia is based on the presence of fever, cyanosis, and more than one of the signs of respiratory distress, such as tachypnea (fast breathing), cough, nasal flaring, retractions, rales, and decreased breath sounds. A complete blood count may show a normal white blood cell count, increased lymphocytes in a viral pneumonia, or increased neutrophils in a bacterial pneumonia. A chest x-ray should be obtained.

The treatment of pneumonia is similar to the treatment of bronchiolitis (ie supportive therapy). However, if bacterial pneumonia is suspected then antibiotic therapy may include ampicillin or cefuroxime (inpatient) or amoxicillin or erythromycin (outpatient).

Pertussis:

Also known as "whooping cough", pertussis is a highly infectious bronchitis. Pertussis has become less common since wide spread immunization against pertussis in the United States

Symptoms of pertussis include an inspiratory whoop that follows the cough. This is usually worse at night. The stages of pertussis include: catarrhal (congestion and runny nose), paroxysmal (whooping cough, post-cough vomiting) and convalescent (severe).

The diagnosis of pertussis is clinical but a complete blood count should show increased lymphocytes and a chest x-ray may show perhilar infiltrate or edema in a "butterfly pattern". Treatment of pertussis includes the antibiotic Erythromycin for the child and close contacts. Respiratory isolation is required.

There are other possible diagnoses that can cause breathing difficulty in an young child or infant including:

-gastroesophageal reflux or GERD

-cardiomyopathy (congestive heart failure, etc)

-chemical pneumonitis

-things that can mimic croup such as tracheomalacia, extrinsic airway compression (vascular ring, tumor) and -intraluminal obstruction (papilloma, hemangioma).