Advancing Learners Pediatric Clinical Reasoning and Knowledge

Key Points

Cough is a frequent problem that parents come to seek help for. The differential diagnosis of cough is large, but cough often starts because of an infectious disease like upper respiratory infections (URIs) with cold-like symptoms, bronchiolitis, pneumonia, seasonal allergies, bronchospasm or asthma. Congenital anatomic problems in infants (e.g. tracheoesophageal fistula, etc.) and aspiration in children with special needs are just some of the more common causes.

Parents worry about the cough because it can cause sleeping problems in children and therefore the parents also get awoken themselves. Parents also complain that the “child is always coughing” or the “cough never goes away.” Multiple, serial, URIs can make it seem like the child is always sick. For children who are in child care or are early school age, it is not uncommon for them to catch one URI and then by the time the coughing is improving, two-several weeks later, the child catches another URI and the process begins again. Normal healthy children have 4-8 coughs or colds/year that last a week or longer, so they likely seem sick all the time to parents.

Coughing also can last a long time. The body has many ways to keep itself healthy and to rid itself of disease. Lungs are like a damp sponge. They have some fluid which helps to clean out the airways. The fluid moves by ciliary action and chest wall movement. When there is an infectious process or the lungs are irritated, they make more fluid. There is more fluid to move which can build up in areas. Coughing helps to keep the fluid moving and keep the airways clear. Coughing is highly protective for the patient. If the airways are not protected then airflow can be diminished or cut off. The body knows this is not good and tries to clear the airway. This protective mechanism of coughing can continue for a long time after the infection or irritation of the lungs actually stops. There can also be lung inflammation occurring that is not perceptible to the patient – they feel fine and their examination is normal – but there still is inflammation going on. Therefore, coughing can still be occurring.

Treatment for cough is treating the underlying cause along with symptomatic treatment. Humidified air, frequent moistening of the mouth/nose by sucking on lozenges or saline, nasal suction and adequate overall hydration can help. Honey can be used in patients > 1 year old to help soothe the mouth and throat. Children under age 1 are at risk of botulism so honey is not recommended for them. Over-the-counter cough medications are not recommended for children < 4 years old. Antipyretics for discomfort can also be used especially if there are other symptoms that are bothering the child.

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Cough Podcast

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Advancing Learners Pediatric Clinical Reasoning and Knowledge

Key Points

Wheezing does not mean someone has asthma.
Wheezing generally means that someone has bronchospasm which can occur once or twice at any age.

Asthma is a chronic condition where there is bronchospasm (i.e. spasms of the muscles that control the flow of air in the lung airways) and inflammation (of the lining of the airways). As it is a chronic condition, it has to occur more than once over time, with 3 times or more sometimes used as a functional definition.

Lung airways are like a balloon.
Bronchospasm and inflammation decrease the size of the airways just like stretching the top part of a balloon. When the balloon’s top is stretched, the balloon makes a wheezing sound. If stretched too tight, there actually is no sound as all the airflow is blocked. When medications are used, it is like the top of the balloon not being stretched. All the air escapes and the wheezing sound also stops because there is free flow of air.

Asthma medications work differently. Bronchodilators are used to stop the muscle spasms. Steroids are used to decrease inflammation and swelling of the airway lining. Both of these open up the airway and allow more air to flow. Patients should feel better because air is flowing and the wheezing should decrease. N.B. if wheezing is decreasing it could be because the airflow is improving or actually getting worse, so overall patient clinical status is very important to assess.

Today bronchodilator-steroids combination medications are often used. If used separately, bronchodilators are used first to help open up the airways quickly, and allow the steroid to better penetrate the airways.

Metered-dose inhalers can be difficult to use properly, especially having enough distance between the inhaler and the back of the mouth. Therefore spacers are recommended to be used by many adults and almost all children. Plastic spacers have an electrostatic charge which may cause the medication to stick to the inside of the spacer and not pass to the patient. “Priming” the spacer with ~6 puffs of bronchodilator usually suffices to block this charge and allows the medication to pass to the patient. Priming should be done again after about 1-2 weeks of daily use, if the spacer has not been used after 1-2 weeks, and after washing.

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Respiratory Failure Podcast

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Today, 22 years to the week after starting PediatricEducation.org we are launching our next educational creation with Mastering Pediatrics.

Mastering Pediatrics’ goal is to advance learners’ pediatric clinical reasoning and knowledge. Experienced clinicians know that there is lots to learn that is not written down that helps us evaluate and treat patients. These Key Points and Cases can help learners analyze their current scientific knowledge, expand that knowledge and then apply it to clinical situations moving them from the novice to an intermediate or advanced learner stage. These Key Points are what experienced clinicians may discuss with learners in the short time frame of a clinical encounter. And experienced clinicians continue to learn or solidify their own knowledge.

In addition to imparting clinical experience, study materials including quizzes, study guides and a podcast at different learner levels are also included. Mastering Pediatrics Key Points and Cases are created by the authors, and the information is referenced and reviewed. Podcasts, study guides and quizzes are created by Gemini Artificial Intelligence. They are NOT REVIEWED for accuracy nor edited. The basic AI prompt will be available on the Archive page.

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We promised to be back soon and we will be back on October 5th!

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We know that people learn differently and we think everyone will find something for themselves with the new cases and ways of following PediatricEducation.org including through social media.

Until October 5th, why not try a random case and see if you can answer the question!

Donna M. D’Alessandro and Michael P. D’Alessandro
Curators, PediatricEducation.org