Management of Cough and Cold with Crackles in Infants
Assess severity immediately using respiratory rate, work of breathing, and fever to determine if this infant requires hospital admission for suspected pneumonia versus outpatient management for a likely viral illness or protracted bacterial bronchitis. 1
Initial Severity Assessment
The presence of crackles in an infant with cough and cold symptoms requires urgent evaluation for pneumonia, as crackles have 75% sensitivity for radiographic pneumonia but only 57% specificity and cannot distinguish bacterial from viral causes. 2
Indicators requiring immediate hospital admission in infants include: 1
- Oxygen saturation <92% or cyanosis
- Respiratory rate >70 breaths/min (rates >50/min suggest pneumonia with 74% sensitivity) 1
- Difficulty breathing or chest indrawing
- Intermittent apnea or grunting
- Not feeding
- Family unable to provide appropriate observation
Key clinical decision point: If fever >38.5°C is present with chest recession and respiratory rate >50/min, bacterial pneumonia should be strongly considered. 1 However, if wheeze accompanies the crackles, primary bacterial pneumonia is very unlikely and suggests viral or mycoplasma infection instead. 1, 2
Outpatient Management for Mild Cases
For infants who are well-appearing, feeding adequately, maintaining oxygen saturation >92%, and have respiratory rate <70/min:
Most viral respiratory infections in infants are self-limited and do not require antibiotics. 1 The majority of respiratory viral infections in children under 2 years are asymptomatic or mild, with only 4% requiring emergency department visits or hospitalization. 3
Supportive care includes: 1
- Antipyretics for fever and comfort
- Ensuring adequate hydration
- Monitoring for deterioration
- Family education on warning signs
Mandatory follow-up: Review within 48 hours if not improving or immediately if deteriorating. 1
When to Initiate Antibiotic Therapy
For chronic wet cough (>4 weeks duration) with crackles but no specific cough pointers (feeding difficulties, digital clubbing, failure to thrive), initiate a 2-week course of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis). 1 This approach treats protracted bacterial bronchitis, which can present with persistent crackles after initial viral infection. 4
For acute presentation suggesting bacterial pneumonia (fever >38.5°C, tachypnea >50/min, chest recession without wheeze):
- First-line: Amoxicillin orally for children under 5 years, as it is effective against the majority of causative pathogens, well-tolerated, and inexpensive. 1
- Alternatives include co-amoxiclav, cefaclor, erythromycin, clarithromycin, or azithromycin. 1
If mycoplasma pneumonia is suspected (though less common in infants than school-age children), macrolide antibiotics should be used. 5, 6 Mycoplasma typically presents with fever, headache, arthralgia, cough, and crackles, with wheeze in 30% of cases. 5, 6
Hospital Management for Severe Cases
Oxygen therapy: Administer via nasal cannulae, head box, or face mask to maintain saturation >92%. 1
Intravenous antibiotics are indicated when the infant cannot absorb oral antibiotics (vomiting) or presents with severe signs. 1 Appropriate IV options include co-amoxiclav, cefuroxime, or cefotaxime. 1
Fluid management: If IV fluids needed, give at 80% basal levels and monitor electrolytes. 1
Avoid nasogastric tubes in severely ill infants as they may compromise breathing through small nasal passages. 1
Do not perform chest physiotherapy as it is not beneficial in pneumonia. 1
Diagnostic Testing Considerations
Chest radiography should be obtained when abnormal vital signs and abnormal breath sounds are present together, but is not routinely needed for mild cases. 2
Nasopharyngeal aspirates should be sent for viral antigen detection in all children under 18 months. 1
Blood cultures and acute serum samples should be obtained in hospitalized cases. 1
Critical Pitfalls to Avoid
Do not assume crackles equal bacterial pneumonia. Crackles occur in viral pneumonia, mycoplasma infection, and even after RSV infection causing prolonged epithelial damage. 2, 4 The clinical context—particularly fever pattern, respiratory rate, work of breathing, and presence/absence of wheeze—is essential for determining etiology.
Do not routinely prescribe antibiotics for mild upper respiratory symptoms. Young children with mild lower respiratory tract infection symptoms do not need antibiotics. 1 Most viral infections in this age group are self-limited. 3
Recognize that chronic crackles after viral infection may represent protracted bacterial bronchitis requiring a 2-4 week antibiotic course rather than repeated short courses. 1, 4 If cough persists after 2 weeks of appropriate antibiotics, extend treatment for an additional 2 weeks. 1