What is the appropriate management for a previously healthy child under 10 years old with four days of cough, vomiting, fever, and wheeze?

Management of Pediatric Patients Under 10 Years with Cough, Vomiting, Fever, and Wheeze for 4 Days

Immediate Assessment and Supportive Care

This child requires immediate clinical evaluation to determine severity and rule out bacterial pneumonia, with management focused on supportive care, oxygen supplementation if needed, and careful monitoring for deterioration. 1

Initial Clinical Evaluation

Assess the following key parameters immediately:

• Respiratory rate: Tachypnea >50 breaths/min in children under 5 years or >40 breaths/min in older children indicates potential pneumonia and requires urgent evaluation 2
• Oxygen saturation: SpO2 <92% on room air is a critical threshold requiring oxygen therapy and possible hospitalization 2, 1
• Work of breathing: Look for chest retractions, nasal flaring, or grunting—these indicate respiratory distress requiring immediate intervention 2, 3
• Fever pattern: High fever ≥38.5°C with tachypnea and chest recession strongly suggests bacterial pneumonia rather than viral illness 2
• General appearance: An ill-appearing or toxic-looking child requires immediate hospitalization regardless of other parameters 4

The Presence of Wheeze Changes Management Significantly

If wheeze is present in a preschool child, primary bacterial pneumonia is very unlikely. 2 This presentation suggests:

• Viral bronchiolitis (most common in children under 2 years) 2
• Post-viral reactive airway disease 2
• Mycoplasma pneumonia (more common in school-age children, can present with wheeze) 2
• Asthma exacerbation triggered by viral infection 2

Supportive Care Measures (First-Line for All Patients)

• Maintain oxygen saturation >92% using nasal cannulae, head box, or face mask as needed 2
• Ensure adequate hydration through oral fluids if tolerated, or intravenous fluids at 80% basal levels if the child cannot maintain intake 2, 1
• Use antipyretics and analgesics (acetaminophen or ibuprofen) for fever control and comfort, which may also help with coughing 2, 1
• Avoid over-the-counter cough and cold medications entirely—these have no proven efficacy and carry serious safety risks including fatalities in young children 1
• Position the child upright to improve breathing mechanics 1
• Eliminate environmental tobacco smoke exposure immediately 1, 5

Diagnostic Approach

When to Obtain Chest Radiograph

Order a chest radiograph if any of the following are present:

• Fever ≥38.5°C with tachypnea and chest recession 2
• Oxygen saturation <92% or requiring supplemental oxygen 2, 3
• Respiratory rate >70 breaths/min (infants) or >50 breaths/min (older children) 1, 3
• Crackles/rales on auscultation suggesting alveolar disease 2, 4
• Clinical suspicion of pneumonia based on ill appearance and respiratory distress 4, 6

Do not obtain chest radiograph if the child has isolated wheeze with normal oxygen saturation and no respiratory distress, as this likely represents viral bronchiolitis or reactive airway disease 2

Laboratory Testing

Consider the following if bacterial pneumonia is suspected:

• Complete blood count (leukocytosis with left shift suggests bacterial infection) 4
• C-reactive protein (elevated CRP increases probability of pneumonia) 4, 6
• Blood cultures if the child appears toxic or requires hospitalization 2

Treatment Decisions

Bronchodilator Trial

Consider a trial of inhaled albuterol (2.5 mg via nebulizer) only if clear wheezing is present and the child is ≥2 years old. 3, 7

• Assess response within 5-20 minutes by observing work of breathing and respiratory rate 7
• If significant improvement occurs, continue bronchodilator therapy every 4-6 hours as needed 7
• If no response after one dose, do not continue bronchodilators—this indicates a non-asthmatic etiology 1, 3

Antibiotic Therapy

Start antibiotics immediately if bacterial pneumonia is suspected based on:

• High fever (≥38.5°C) with tachypnea, chest recession, and no wheeze 2
• Chest radiograph showing lobar consolidation 2
• Oxygen requirement or respiratory distress 2

First-line antibiotic choice: Amoxicillin 80-90 mg/kg/day divided twice daily (targets Streptococcus pneumoniae, the most common bacterial pathogen) 2, 1

Do not start antibiotics if:

• The child has isolated wheeze with viral symptoms 2
• Symptoms have been present for only 4 days without signs of bacterial infection 2
• The clinical picture suggests viral bronchiolitis 1

Antiviral Therapy

Consider oseltamivir if:

• Influenza is circulating in the community 2
• The child is severely ill or at high risk for complications 2
• Symptoms began within the past 48 hours (maximum benefit) 2

Dose: 30-75 mg twice daily depending on weight, for 5 days 2

Hospitalization Criteria

Admit the child if any of the following are present:

• Oxygen saturation <92% on room air 2, 1
• Respiratory rate >70 breaths/min (infants) or >50 breaths/min (older children) 1
• Moderate to severe respiratory distress (retractions, grunting, nasal flaring) 2, 3
• Inability to maintain oral hydration 2
• Ill or toxic appearance 2, 4
• Age <6 months with suspected bacterial pneumonia 2
• Social factors preventing safe home care 2

Monitoring and Follow-Up

For Children Managed at Home

• Reassess within 48 hours if symptoms are not improving or are worsening 1, 5
• Instruct parents to return immediately if the child develops:
  • Difficulty breathing or increased work of breathing 1
  • Inability to feed or signs of dehydration 1
  • Worsening fever or lethargy 1
  • Cyanosis or grunting 1

For Hospitalized Children

• Monitor oxygen saturation, respiratory rate, heart rate, and work of breathing every 4 hours (or continuously if severely ill) 2
• Reassess for discharge readiness twice daily 2

Discharge criteria:

• Clear clinical improvement 2
• Oxygen saturation >92% on room air for 12-24 hours 2
• Respiratory rate <40/min (<50/min in infants) 2
• Able to tolerate oral feeds 2
• Stable mental status 2

Special Considerations

Pertussis Evaluation

Consider pertussis if the child has:

• Paroxysmal cough with post-tussive vomiting 2, 5, 8
• Inspiratory "whoop" after coughing episodes 5, 8
• Known contact with pertussis case (even if fully vaccinated, as vaccine failure occurs) 2, 8

If pertussis is suspected, obtain nasopharyngeal swab for PCR and start azithromycin 10 mg/kg on day 1, then 5 mg/kg daily for 4 more days 2, 8

Mycoplasma Pneumonia

Suspect Mycoplasma if:

• School-age child (>5 years) with gradual onset of symptoms 2
• Prominent headache, sore throat, or malaise 2
• Wheeze present with pneumonia on chest radiograph 2

If suspected, add azithromycin to treatment regimen 2

What NOT to Do

• Do not use chest physiotherapy—it provides no benefit in previously healthy children with pneumonia 2, 3
• Do not use antihistamines—they are ineffective for acute cough in children and may cause adverse effects 2, 1
• Do not use oral or inhaled corticosteroids unless there is clear evidence of asthma with reversible airway obstruction 2, 1
• Do not empirically treat for asthma based on cough alone without documented wheezing or bronchodilator responsiveness 2, 1, 5

If Symptoms Persist Beyond 4 Weeks

At 4 weeks duration, the cough transitions from acute to chronic and requires systematic evaluation:

• Obtain chest radiograph 2, 5
• Perform spirometry if the child is ≥6 years old and cooperative 2, 5
• Classify cough as wet/productive versus dry to guide further workup 2, 5
• For wet cough persisting >4 weeks, consider protracted bacterial bronchitis and treat with 2 weeks of amoxicillin-clavulanate 2, 1, 5