What are the differential diagnoses for a toddler presenting with excessive crying, drooling, and difficulty breathing?

Differential Diagnosis for a Toddler with Excessive Crying, Drooling, and Difficulty Breathing

The most critical life-threatening diagnosis to exclude immediately is foreign body aspiration, followed by epiglottitis/bacterial tracheitis, and croup—all of which require urgent airway assessment and can rapidly progress to complete airway obstruction. 1, 2, 3

Immediate Life-Threatening Conditions

Foreign Body Aspiration

• Most common in children under 3 years and the leading cause of death in infants 3
• Classic presentation includes sudden onset of choking, gagging, excessive drooling (inability to swallow secretions), respiratory distress, and stridor 2, 3
• May present with paroxysmal cough, wheezing, and decreased air entry 3
• Critical pitfall: Never perform blind finger sweeps of the pharynx as this can impact the foreign body into the larynx 1, 2
• Diagnosis requires high clinical suspicion; witnessed aspiration is diagnostic 3

Epiglottitis/Bacterial Tracheitis

• Presents with drooling (inability to swallow secretions), respiratory distress, stridor, and toxic appearance 2
• Child typically assumes tripod positioning and refuses to lie down 2
• Bacterial tracheitis should be considered when standard croup treatment fails 2
• Requires immediate otolaryngology consultation and potential surgical airway 2

Severe Croup

• Presents with barking cough, inspiratory stridor, and respiratory distress 2
• Life-threatening features include silent chest, cyanosis, fatigue/exhaustion, poor respiratory effort, or irregular breathing 1, 2
• Drooling and irregular breathing should alert clinicians to complex seizures or impending respiratory failure 1
• Median age of presentation is 23 months, predominantly males 2

Moderate-Risk Conditions

Severe Asthma Exacerbation

• Presents with too breathless to talk or feed, respirations >50 breaths/min, pulse >140 beats/min 1
• Life-threatening features: PEF <33% predicted, silent chest, cyanosis, exhaustion, agitation or reduced consciousness 1
• Assessment in very young children may be difficult; presence of any life-threatening feature should alert the physician 1

Laryngomalacia/Tracheomalacia

• Most common congenital laryngeal anomaly causing persistent stridor in infants 4
• Red flags requiring urgent evaluation: severe respiratory distress, oxygen desaturation, apnea, associated hoarseness, poor feeding, or failure to thrive 4
• Up to 68% have concomitant lower airway abnormalities 4

Pneumonia

• Presents with fever, tachypnea (>50 breaths/min in toddlers), increased work of breathing 1
• May have crackles, decreased breath sounds, or respiratory distress 1
• Chest radiograph indicated if clinical signs of pulmonary disease present 1

Initial Assessment Algorithm

Airway and Breathing Assessment (Priority #1)

• Assess for irregular breathing or drooling—indicates potential airway obstruction or complex seizures 1
• Check respiratory rate: >50 breaths/min indicates severe distress 1
• Look for signs of impending respiratory failure: grunting, nasal flaring, head nodding, tracheal tugging, intercostal retractions 5, 6
• Assess oxygen saturation: <92-95% indicates hypoxemia requiring immediate intervention 1, 5

Circulation Assessment (Priority #2)

• Check pulse rate: >140-160 bpm (age-dependent) suggests shock or severe distress 1
• Assess capillary refill time: >2 seconds indicates poor perfusion 1

Neurological Assessment (Priority #3)

• Assess level of consciousness: agitation may indicate hypoxia; decreased consciousness suggests severe compromise 1
• Exclude seizures and hypoglycemia 1

Immediate Management Priorities

If Foreign Body Suspected

• Deliver 5 back blows with child prone and head lower than chest 1
• Follow with 5 chest thrusts (similar to chest compressions but sharper, ~20/min) 1
• Check mouth and remove visible foreign bodies only 1
• In children >1 year, use abdominal thrusts after second round of back blows 1
• Continue cycle until airway cleared 1

If Severe Croup Suspected

• Administer oral dexamethasone 0.15-0.60 mg/kg (max 10 mg) immediately 2
• For moderate-severe cases with stridor at rest: nebulized epinephrine 0.5 ml/kg of 1:1000 solution 2
• High-flow oxygen via face mask to maintain SpO₂ >92-94% 1, 2
• Observe for minimum 2 hours after last epinephrine dose due to rebound risk 2
• Consider admission after 3 doses of racemic epinephrine or if age <18 months with severe symptoms 2

If Epiglottitis/Bacterial Tracheitis Suspected

• Do not examine throat or agitate child—may precipitate complete obstruction 2
• Immediate otolaryngology and anesthesia consultation 2
• Prepare for emergency surgical airway 2

If Severe Asthma Suspected

• High-flow oxygen 40-60% 1
• Nebulized salbutamol 5 mg or terbutaline 10 mg (half doses in very young) 1
• Intravenous hydrocortisone or oral prednisolone 1-2 mg/kg (max 40 mg) 1
• Add ipratropium 100 mcg nebulized if not improving after 15-30 minutes 1

Critical Pitfalls to Avoid

• Never delay emergency airway management while awaiting diagnostic confirmation 1, 6
• Never discharge within 2 hours of nebulized epinephrine administration 2
• Never perform blind finger sweeps in suspected foreign body aspiration 1, 2
• Never examine the throat in suspected epiglottitis without airway equipment immediately available 2
• Assessment in very young children is difficult; any life-threatening feature should prompt immediate intervention 1