What is the appropriate evaluation and management for a 12‑year‑old child with a worsening cough and a recurrent fever?

Evaluation and Management of a 12-Year-Old with Worsening Cough and Returning Fever

This child requires immediate systematic evaluation with chest radiograph and spirometry to rule out bacterial pneumonia, and if clinical features suggest bacterial infection (persistent fever, tachypnea, respiratory distress), empiric antibiotic therapy with amoxicillin should be initiated promptly. 1, 2

Immediate Assessment for Red Flags

Assess for life-threatening conditions first:

• Respiratory distress: Check for respiratory rate >50 breaths/min, use of accessory muscles, oxygen saturation <92%, or inability to speak in full sentences 1, 3
• Bacterial pneumonia indicators: High fever ≥39°C, tachypnea, hypoxia, focal crackles on auscultation, or chest indrawing 4, 5
• Pertussis: Look for paroxysmal cough with post-tussive vomiting or inspiratory "whoop" (the clinical triad has 93% sensitivity for pertussis) 6, 7
• Foreign body aspiration: Sudden onset with unilateral wheeze or asymmetric breath sounds 6

The combination of worsening cough and returning fever is particularly concerning and suggests either bacterial pneumonia or an inadequately treated initial infection. 2, 8

Mandatory Initial Investigations

Obtain these tests immediately:

• Chest radiograph to detect pneumonia, structural abnormalities, foreign body, or bronchiectasis 1
• Spirometry (pre- and post-bronchodilator) since this 12-year-old can reliably perform the test 1
• Classify the cough as wet/productive versus dry as this fundamentally directs management 1, 6

The absence of tachypnea is the best individual finding for ruling out pneumonia, but if all clinical signs are negative (normal respiratory rate, clear auscultation, no increased work of breathing), chest x-ray findings are unlikely to be positive. 4

Management Based on Cough Characteristics

If Wet/Productive Cough (Protracted Bacterial Bronchitis or Pneumonia)

Initiate antibiotics immediately:

• First-line: Amoxicillin targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 9, 2
• Duration: 2-week course initially 6, 9
• If cough persists after 2 weeks: Extend antibiotics for an additional 2 weeks 6, 9
• If cough persists after 4 weeks of antibiotics: Refer to pediatric pulmonology for bronchoscopy, chest CT, and evaluation for bronchiectasis, cystic fibrosis, or immunodeficiency 6, 9

For children 5 years or older with community-acquired pneumonia, macrolides (azithromycin or clarithromycin) are drugs of choice if atypical pathogens (Mycoplasma pneumoniae, Chlamydophila pneumoniae) are suspected. 2

If Dry Cough

Do not empirically treat as asthma unless specific features are present:

• Asthma requires recurrent wheeze, nocturnal symptoms, exercise intolerance, family history of atopy, AND reversible airflow obstruction on spirometry 1, 6
• The majority of children with isolated chronic cough do not have asthma 1, 6
• Over-diagnosing asthma based solely on cough is a critical pitfall to avoid 6, 9

Specific Considerations for Returning Fever

Returning fever after initial improvement suggests:

1. Bacterial superinfection following viral illness—most common scenario requiring antibiotics 8
2. Inadequate treatment of initial bacterial pneumonia—consider resistant organisms 2
3. Complications such as parapneumonic effusion or empyema—chest radiograph will identify 2
4. Alternative diagnosis such as pertussis, mycoplasma, or tuberculosis (if endemic) 7, 2

Viruses (RSV, rhinovirus, metapneumovirus, influenza) commonly cause pneumonia in children but may predispose to bacterial superinfection. 8 However, bacterial and viral pneumonia cannot be reliably distinguished on clinical grounds alone. 2

Critical Management Pitfalls to Avoid

• Do not use over-the-counter cough medications in children under 6 years—no proven efficacy and risk of serious adverse events 3, 9
• Do not prescribe codeine—risk of severe respiratory depression 6
• Do not diagnose "cough variant asthma" in children—isolated chronic cough is rarely asthma 6, 9
• Do not empirically treat for GERD without gastrointestinal symptoms 9
• Do not delay antibiotics if clinical features suggest bacterial pneumonia—mortality and morbidity increase with delayed treatment 2, 5

Follow-Up and Escalation Criteria

Arrange follow-up within 48-72 hours if managed as outpatient 9

Immediate referral to hospital if:

• Respiratory rate >50 breaths/min 3
• Oxygen saturation <92% 3
• Inability to feed or signs of dehydration 3
• Severe respiratory distress with accessory muscle use 3, 4

Refer to pediatric pulmonology if:

• Chronic wet cough >4 weeks unresponsive to antibiotics 6, 9
• Recurrent pneumonia in the same lobe 9
• Failure to thrive or digital clubbing 1
• Hemoptysis 1
• Diagnostic uncertainty after appropriate work-up 9

Parent Education

Explain clearly:

• This presentation with worsening cough and returning fever requires investigation and likely antibiotic treatment 2
• Warning signs requiring immediate return: respiratory distress, inability to feed, worsening fever, oxygen desaturation 3
• Expected improvement within 48-72 hours of appropriate antibiotic therapy 2
• Eliminate environmental tobacco smoke exposure—it worsens respiratory symptoms and impairs recovery 1, 6