GPAtlas🧭 When to suspect
Suspect an acute lower respiratory tract infection in a child whose cough is accompanied by chest signs – wheeze, crackles, or increased work of breathing. The core primary-care skill is threefold: distinguish the three common causes clinically, recognise the seriously unwell child early, and reserve antibiotics for pneumonia. Most presentations are viral and self-limiting; the danger lies in missing hypoxia, dehydration, or impending respiratory failure.
Two distinctions matter. Viral-induced wheeze is wheeze occurring only with viral infection in a child aged roughly 6 months to 5 years, with no symptoms between episodes. An infective exacerbation of asthma is suggested by a prior asthma diagnosis, or wheeze occurring without infection and in response to typical triggers (exercise, allergen). Under 5 years the two are often clinically indistinguishable and are managed similarly in the acute setting.
| Feature | Bronchiolitis | Viral-induced wheeze | Pneumonia |
|---|---|---|---|
| Typical age | < 1 year (peak 3–6 months) | 6 months–5 years | Any age |
| Pattern | Coryzal prodrome 1–3 days, then cough & breathlessness | Recurrent wheeze, only with colds, no interval symptoms | Often abrupt, with sustained high fever |
| Auscultation | Widespread fine crackles ± wheeze | Widespread expiratory wheeze | Focal crackles or bronchial breathing |
| Fever | Low-grade | Usually low-grade | Often > 38.5°C |
| Antibiotics | No | No (unless secondary pneumonia) | Yes if pneumonia is the clinical diagnosis |
|
🧠 Clinical pearl Let response to a bronchodilator help you separate the wheezes. The wheeze of bronchiolitis is not bronchodilator-responsive – salbutamol does not work in true infant bronchiolitis. In an older wheezy child (over 1 year), a clear improvement after a salbutamol trial points towards viral-induced wheeze or asthma. Age and treatment response together are more useful than auscultation alone. |
Source: NICE NG9 · NICE NG143 · NICE NG245
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