This document provides guidance on assessing and managing children under 5 years of age presenting with cough or difficult breathing. It outlines the IMNCI case management strategy which evaluates all problems, provides a classification, and offers treatment algorithms. General danger signs indicate severe disease and mean the child needs referral. Respiratory rate, chest indrawing, stridor, and wheeze are assessed. Potential causes like pneumonia, bronchiolitis, and asthma are considered. Investigations may include CBC, CRP, and chest X-ray. Severe pneumonia requires referral while mild cases can be treated with antibiotics, paracetamol, or salbutamol. Prevention emphasizes vaccination, breastfeeding, handwashing, and controlling pollution.

1. A practical approach to the child with
Cough and Difficult Breathing
Prof. Imran Iqbal
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

3. IMNCI
A Strategy for
Outpatient Case Management
of Children
under five years of age

4. Benefits of
IMNCI Case Management Strategy
• Evaluates all the problems the child is having
• Simple guidelines to find relevant symptoms and signs
• Gives a Classification (provisional diagnosis)
• Practical algorithms for decision-making
• Helps in deciding clinical management
• Saves time of Health Care Provider and patient
• Can be practiced by clinical assistants and paramedics
• Can be practiced in remote areas with inadequate facilities

5. Step 1
General Danger Signs
General Danger Signs indicate severe disease
Presence of any one of the General Danger Signs
means that the child needs to be
referred / admitted to the emergency

6. Check for General Danger Signs
• Unable to drink or breastfeed
• Vomiting everything
• Lethargic or unconscious
• Convulsions
• General Danger Signs indicate severity of illness
• Not diagnostic but suggests acuity of situation

7. Step 2
Assess for
Cough or Difficult Breathing

8. Common Causes of Cough in Children
• Infections –
URTI -- (nose, throat) – usually viral
LRTI -- (bronchi, lungs) – viral / bacterial / mixed
• Allergy – allergic rhinitis, asthma
• Environment – household smoking / air pollution

9. Acute Respiratory Infections

10. Types of Cough in Children
• Dry – URTI, Pharyngitis, Influenza
• Wet – Bronchitis, Pneumonia
• Croupy – Laryngitis , ALTB (Acute LaryngoTracheoBronchitis)
• Wheezy – Asthma, Viral bronchitis

11. Assess for Cough or Difficult Breathing
• ASK: Does the child have Cough or Difficult Breathing ?
• IF YES
• ASK: for how long ?
• Look, Listen, Feel:
 Count the breaths in one minute (Respiratory Rate)
 Look for Chest Indrawing (subcostal recessions)
 Look and listen for Stridor (harsh inspiratory sound)
 Look and listen for Wheeze (musical expiratory sound)
 Other signs:
o ……. Chest Auscultation
o ……. Pulse Oximetry

12. Respiratory Rate
• Age average/normal Fast breathing
• Less than
2 months 50 60 or more
• 2-12 months 40 50 or more
• 1- 5 years 30 40 or more

14. Causes of Fast Breathing or Chest Indrawing
• Pneumonia
• Bronchiolitis
• Asthma
• Airway obstruction (causes stridor)
• Pleural effusion / empyema
• Congestive heart failure
• Renal failure
• Metabolic acidosis

15. STRIDOR
A harsh inspiratory sound
produced due to
Obstruction
In or around the
LARYNX

16. Severity of stridor
• Stridor when child is agitated
• (less severe)
• Stridor in the calm child
• (more severe)

17. Causes of STRIDOR
• ALTB (Acute laryngotracheobronchitis) or Croup
• Diphtheria
• Foreign body in larynx or trachea
• Acute epiglottitis
• Allergic laryngitis
• Enlarged Tonsils (meeting in midline)
• Laryngomalacia (infants)

18. WHEEZE
A musical expiratory sound
produced due to
Narrowing
of the
bronchi and bronchioles

19. Causes of WHEEZE
• Asthma
• Bronchiolitis (infants)
• Acute bronchitis
• Cystic fibrosis
• Congestive Heart Failure (in infancy)

20. Assess for Cough or Difficult Breathing
• ASK: Does the child have Cough or Difficult Breathing ?
• IF YES
• ASK: for how long ?
• Look, Listen, Feel:
 Count the breaths in one minute (Respiratory Rate)
 Look for Chest Indrawing (subcostal recessions)
 Look and listen for Stridor (harsh inspiratory sound)
 Look and listen for Wheeze (musical expiratory sound)
 Other signs:
o ……. Chest Auscultation
o ……. Pulse Oximetry

26. Investigations
• Admitted / serious patients may need investigations
• CBC
• CRP
• X – ray Chest
• Blood Culture

27. Chest X - ray
Bronchopneumonia Lobar Pneumonia

28. Complications
Paraneumonic Pleural Effusion (Empyema)

29. Treat Cough or Difficult Breathing
• Severe Pneumonia or Very Severe Disease – Referral / Admit
• Pneumonia -- Amoxycillin (oral)
-- Paracetamol (if fever)
-- Salbutamol (if wheezing)
• Cough and Cold -- Salbutamol (if wheezing)
-- safe, soothing remedies for cough

30. PREVENTION

32. Prevention of Acute Respiratory Infection
• Vaccination –
Penta (DPT, Hib, Hep B),
Pneumococcal, Measles,
Influenza
• Breastfeeding, Nutrition
• Avoid contact with diseased patients
• Hand washing
• Control smoking, air pollution

33. 30-Jun-20 Prepared By: Medical and Compliance 33
Prevention:Vaccination
Age Vaccine
At Birth BCG and OPV-0
6 Week Penta-I, Pneumo-I and OPV-I
10 Week Penta-II, Pneumo-II and OPV-II
14 Week Penta-III, Pneumo-III, IPV and OPV-III
9 Months Measles-I
15 Months Measles-II
http://epi.gov.pk/?page_id=139
EPI: Expanded Program on Immunzation (Pakistan)

34. Vaccination prevents Pneumococcal Infections