Module 5

Cough
Transcript
5.1 Key concepts and facts

5.1.1 Opening video

Hello, Dumela, Lotchane

In this section we will be covering the symptom ‘cough’ and reviewing the IMCI chart “Does the child
have a cough?”.

All caregivers of sick children presenting to the health centre are asked about the presence of a cough,
immediately after having been assessed for any general danger sign.

We begin with a brief introduction about the burden of lower respiratory tract infections, particularly
pneumonia, its aetiology, some successes in its management, why it continues to exact such a high
death toll, and key actions required to reduce its burden.

5.1.2 Deaths from pneumonia, by age, World, 1990 to 2019

The burden of any disease is measured by the number of deaths it is responsible for and its morbidity
(which means the amount of illness) it causes.

The graph presented, shows the number of deaths from pneumonia each year from 1990 to 2019,
stratified by age group.

Children under 5 years are represented in blue at the bottom of the chart.

Much progress has been made in reducing deaths caused by childhood pneumonia.

Improved socioeconomic status and vaccinations, primarily the conjugate vaccines (haemophilus
influenzae and pneumococcus), have led to substantial reductions in the incidence and severity of
childhood pneumonia. Stronger implementation efforts to prevent and manage HIV have reduced HIV-
associated pneumonia deaths.

5.1.3 Pneumonia under-5 admissions, deaths and case fatality rates, South Africa, 2014-20

This figure shows under-5 pneumonia related admissions (in turquois), deaths (in orange) and case
fatality rates (in dark blue) in South Africa from 2014 to 2020.

The number of children admitted with pneumonia has remained relatively constant over the period.
In contrast, deaths and pneumonia case fatality rates have declined over the period.

The pneumonia case fatality rate (in blue) reflects the proportion of all children under-5 admitted to
hospital with pneumonia who died. It was 2.9% in 2014 but decreased to 1.6% in 2020. The national
data, however, hide wide interprovincial and district variations.

The reduction in pneumonia deaths and the reduction in the case fatality rate possibly reflect earlier
entry of children into the health service, less advanced disease on presentation, or better care within
the health service.

Most pneumonia deaths occur in district hospitals, indicating that there is scope for reducing the
number of pneumonia deaths by ensuring better quality of care at this level and referring the sickest
children to higher levels of care for interventions such as assisted ventilation.

5.1.4 Number of child deaths from pneumonia diseases by risk factor, South Africa, 2017

Markers of undernutrition are strong risk factors for pneumonia in South Africa and other low- and
middle-income countries.

Child wasting (another way of describing severe malnutrition) is the single greatest risk factor for a
child dying from pneumonia.

Low birth weight is associated with 3.2 times increased odds of severe pneumonia in low- and middle-
income countries. Similarly, lack of exclusive breastfeeding for the first 4 months of life increases odds
of severe pneumonia by 2.7 times

Household overcrowding doubles the odds of having pneumonia in both low- and middle-income
countries and high-income countries. Indoor air pollution from use of solid or biomass fuels increases
the chance of developing pneumonia.

The single strongest risk factor for pneumonia is HIV infection. HIV-infected children have a six-fold
higher odds of developing severe pneumonia or dying compared to HIV-uninfected children.

Since the introduction of effective strategies to prevent mother-to-child transmission of HIV, there is a
growing population of children who are HIV-exposed but uninfected. The excess risk of pneumonia for
HIV-exposed compared to HIV unexposed children, is about 1.3- to 3.4-fold higher.

It is estimated that the prevalence of these critical risk factors in low- and middle-income countries
decreased by 25% between 2000 and 2010, contributing to reductions in pneumonia incidence and
mortality, even in countries where conjugate vaccines were not available.

Because of the effectiveness of pneumococcal conjugate and Haemophilus influenzae type B conjugate
vaccines for preventing pneumonia, incomplete or inadequate immunisation must be considered as a
major preventable risk factor for childhood pneumonia.

5.2 Introductory video

5.2 Introductory video

To assess a child with cough or difficult breathing, we follow the IMCI assessment steps of ASK, LOOK,
LISTEN and FEEL.

In this module, you will be introduced to the application of each of these four steps for the first time.
We will therefore spend some time exploring each step.

We begin by ASKING the caregiver if the child has a cough or difficult breathing. If this symptom is
present, proceed with its further assessment. If there is no cough or difficult breathing, move on to the
next question, which is if the child has diarrhoea.

You will ASK two further questions. We often need to know the duration of any presenting symptom
and any associated symptoms - in this case, wheezing.

ASSESMENT of a cough involves counting the respiratory rate, looking for signs of respiratory distress,
including chest sounds such as wheezing and stridor, and considering the oximeter saturation reading
when available.

CLASSIFICATION of a cough follows two pathways. The first involves determining the presence and
severity of pneumonia, and the other classifying any wheeze.

In the TREATMENT section, you will learn more about the management of a child with a cough or
difficult breathing. We also discuss the management of wheezing. We will explore the appropriate use
of a few antibiotics such as amoxicillin, ceftriaxone and cotrimoxazole.

You will be re-introduced to the principles of managing any child with a RED classification, including
starting oxygen, testing for and treating a low blood sugar, and keeping the child warm, before
referring to a hospital.

The benefit of administering medication such as salbutamol and adrenaline via nebulisation will be
explained. You will also learn about safe home remedies for managing a cough, and what not to
prescribe.

In the next section, there will be instruction on how to COUNSEL the caregiver of a child with a cough
or difficult breathing. You will learn about counselling on home management, especially on how to
give oral medicines at home, and when the child should return for a follow up visit, as well as when to
return immediately. You will ensure that the caregiver understands the child’s condition and provide
opportunities for her to ask questions and address any of her concerns.

At any FOLLOW UP visit, you will re-assess the child for improvement and refer any child who is not
getting better. Specific activities to be performed at this visit will be outlined.

Let us proceed.

5.3 Assess
5.3.1 Ask
The first main symptom to ask about, after checking for general danger signs, is cough or difficult
breathing. Ask the caregiver if the child has cough or difficult breathing. If this symptom is present,
proceed with the assessment.

5.3.2 Count the breaths (video)

When a child develops pneumonia the lungs become stiff, making it more difficult to breathe. The
child’s breathing rate increases as the child’s body tries to make up for lung stiffness and lack of
oxygen.

5.3.3 Fast breathing

If the child is aged 2 months to 12 months, the child has fast breathing if you count 50 breaths or more
in one minute.

If the child is aged 12 months up to 5 years, the child has fast breathing if you count 40 breaths or
more per minute.

For the child who is exactly 12 months old, we use the higher age category, that is 40 breaths per
minute or more as a cut-off for fast breathing.

5.3.4 Count the breaths

1. Prepare to start counting. Start counting now. [After 60 seconds] Stop counting.
2. Prepare to start counting. Start counting now. [After 60 seconds] Stop counting.

5.3.5 Chest indrawing (animation)

To look for chest indrawing you must recognise when the child is breathing in.

When the child breathes in the upper chest and abdomen move out.

Breathing in, breathing out. Breathing in, breathing out.

5.3.6 Chest indrawing (video)

This child has chest indrawing.

When the child breathes in the upper chest and abdomen move out as in the healthy child, but the
lower chest moves in.

Chest indrawing is this inward movement of the lower chest wall when the child breathes in.
Look again. When the child breathes in the upper chest and abdomen move out while the lower chest
moves inward.

5.3.7 Chest indrawing

Does this child have chest indrawing?

We can see that the lower part of her chest moves in as she breathes in, while her upper chest and
abdomen move out. We decided that this child does have chest indrawing.

Does this child have chest indrawing?

As he breathes in the lower part of his chest draws inward rather than expanding outward with the
upper chest and abdomen as the lungs fill and expand. We decided that he does have chest indrawing.

Does this child have chest indrawing?

She is sleeping comfortably and we see that her chest and abdomen move out as she breathes in. We
decided that she does not have chest indrawing.

5.3.8 Wheeze and stridor

Wheezing is a whistling sound that can be heard when breathing out. Wheezing occurs when the small
airways are narrowed such as in asthma and bronchiolitis.

Stridor is a harsh noise made when the child breaths in. Stridor in a calm child indicates airway
obstruction that is severe. When the airway obstruction is less severe, the stridor will only be present
when the child is crying or upset. Therefore, always listen for stridor when the child is calm.

Stridor and wheezing must be distinguished from each other as the causes and treatment differ.

A child with a blocked or runny nose often has noisy breathing that can be mistaken for a wheeze or
stridor. This is a wet noise, that will disappear when the nose is cleared.

If a wheeze is present, ask the questions below to make the conditional classification of wheeze or
recurrent wheeze.

5.3.9 Wheezing or stridor (video)

Does Sakhile have stridor or wheezing?

What did you decide?

We heard a harsh sound when Sakhile breathed in. Therefore, we decided that Sakhile does have
stridor.

Listen again.
 Here is the second child, her name is Lerato.

Does Lerato have stridor or wheezing?

What did you decide? We heard a grunting noise as Lerato was breathing out and established that the
child was having difficulty in breathing.

We therefore decided that Lerato does not have stridor or wheezing, but difficult breathing.

Here is the third child. Her name is Tebogo. Look and listen to her breathing. Does Tebogo have stridor
or wheezing?

What did you decide? We heard a wet noise as Tebogo was breathing in and out. Therefore, we
decided that Tebogo did not have stridor or wheezing, but a blocked nose.

Here is the fourth child. His name is Mandla. Look and listen to his breathing. Does Mandla have
stridor or wheezing?

What did you decide?

We heard a wheezing sound when breathing out. Therefore, we decided that Mandla did not have
stridor. Stridor is a harsh sound when breathing in, this child has a wheeze when breathing out. Listen
again.

5.4 Classify
5.4.1 IMCI approach to classification of cough or difficult breathing

Now we will learn how to classify using the signs assessed for. There are three possible classifications
for a child with cough or difficult breathing:

1. SEVERE PNEUMONIA OR VERY SEVERE DISEASE

2. PNEUMONIA

3. COUGH OR COLD

The severity of the classification depends on the signs observed: if there is a general danger sign, chest
indrawing, stridor, low oxygen saturation or fast breathing present.

If you observe any ONE of the following signs, the child will get a classification of severe pneumonia or
very severe disease:

• Any general danger sign OR

• Chest indrawing OR
• Stridor in a calm child OR
• Oxygen saturation less than 90% in room air

A child classified as having SEVERE PNEUMONIA OR VERY SEVERE DISEASE is seriously ill. He or she
needs urgent referral to a hospital.
Fast breathing alone is enough to classify the child as having pneumonia.
If none of the above signs are observed, the child will get a classification of cough or cold.

5.4.2 Classify wheeze

1. If the caregiver responded ‘yes’ to any of the questions regarding wheeze – this child will get a
classification of recurrent wheeze.

2. For all other children, they will get a classification of wheeze (first episode)

5.5 Treat
5.5.1 Treat for cough or difficult breathing
Shortly, you will be guided through the management of the different classifications, and the individual
treatment needed.

First, scan through the chart below to get an overall impression about the management of a child with
a cough or difficult breathing.

Further detail about each of the three classifications, and the relevant medication or treatment
modalities will follow as you proceed through the module.

5.5.2 Severe pneumonia or very severe disease

You have previously learnt the significance of a RED classification, and what signs lead to this
classification in a child with a cough or difficult breathing. You will now learn about the actions
required for a child with severe pneumonia or very severe disease. We will go through each item
individually, as this will be the first time you may be encountering this.

Review the advice on how to administer oxygen in the Danger signs module if you do not remember
how to do this )

You will learn about offering salbutamol via nebulisation later in this module. Similarly for stridor
management.

The preferred antibiotic to be administered for a RED classification is ceftriaxone. a broad-spectrum

cephalosporin antibiotic used for the treatment of bacterial infections in various locations, such as in
the respiratory tract, skin, soft tissue, and urinary tract.

Cotrimoxazole is indicated for the management of a particular organism, pneumocystis jirovecci, an

organism found particularly in children who are HIV-infected.

As always, blood sugar and body temperature management are important.

5.5.3 Pneumonia
Given the high mortality from pneumonia in low- and middle-income countries, the lack of easy access
to care, and the high prevalence of risk factors for severe disease, revised World Health Organization
pneumonia guidelines still recommend antibiotic treatment for all children who meet the WHO
pneumonia case definitions. The preferred antibiotic is amoxicillin, given orally for 5 days.

The TREAT THE CHILD chart has the schedule and dose for giving antibiotics.

The SCHEDULE tells you how many days and how many times each day to give the antibiotic. Most
antibiotics should be given for 5 days. The number of times to give an antibiotic each day varies
depending on the type of antibiotic. Amoxicillin is given twice a day for 5 days.

The CORRECT DOSAGE of amoxicillin is determined by:

1. Identifying the column of the type of syrup or capsule available in your clinic.

2. Choosing the row for the child’s weight or age. Use weight preferably rather than age.

3. The correct dose is listed at the intersection of the column and row.

You should always enquire about a known allergy to penicillin when prescribing a penicillin-class
antibiotic. Amoxicillin is a penicillin-class of antibiotic. If a penicillin allergy exists, azithromycin is
offered as an alternative.

5.5.4 Cough or cold

To soothe the throat or relieve a cough, use a safe remedy. Such remedies can be homemade, given at
the clinic, or bought at a pharmacy. It is important that they are safe.

Cough medicines are not recommended for any child under six years since they are not effective at
relieving a cough. Cough mixtures contain products that cause side effects in children and can easily
result in an overdose.

For children over the age of one, you can encourage use of a homemade cough recipe of honey
dissolved in warm water and lemon juice.

If the child is exclusively breastfed, do not give other drinks or remedies. Breastmilk is the best
soothing remedy for an exclusively breastfed child.

Never use remedies that contain harmful ingredients, such as atropine, codeine or codeine derivatives,
or alcohol. These items may sedate the child. They may interfere with the child’s feeding. They may
also interfere with the child’s ability to cough up secretions from the lungs.

Medicated nose drops (that is, nose drops that contain anything other than saline [salt]) should also
not be used. An example is Vicks nasal spray or drops.

When explaining how to give the safe remedy, it is not necessary to watch the mother practice giving
the medicine to the child. Exact dosing is not important with this treatment.

A child with a cough or cold that is not resolving should return to the clinic in 5 days.

5.5.5 Wheeze
A child with wheezing requires inhaler treatment in the clinic or at home.

Review the TREAT THE CHILD chart for inhaled salbutamol for wheezing.

• From salbutamol metered dose inhaler (100 μg per puff) give 1 to 2 puffs.

Allow 4 breaths per puff

• Repeat up to 3 times every 15–20 minutes.

A spacer is a way of delivering the bronchodilator medicines effectively into the lungs. A spacer works
as well as a nebuliser if correctly used. No child under 5 should be given an inhaler without a spacer.

If commercial spacers are not available, spacers can be easily made with a 500 ml cold drink bottle or
something similar.

Some tips on how to use a metered dose inhaler with a spacer are offered.

5.6 Counselling and follow up care

5.6.1 Introduction to Counselling /Counsel on the classification and treatment

After we have classified the child’s condition, we counsel the caregiver on the following:

1. The child's condition and the treatment thereof.

2. Explain and discuss the need for referral if the child has a severe classification and take time to
counsel the caregiver on the home management of pneumonia, or cough or cold, and/or wheeze if
the child is being sent home.
3. Counsel the caregiver on follow-up care - when to return for a follow up visit and when to return
immediately.

5.6.2 Counsel on home care

Take time to teach the caregiver how to give oral medicines at home. Counsel on the general
instructions for every oral medicine to be given at home, as well as the instructions specific to any
prescribed medicines. In this case, amoxicillin or azithromycin if the child is allergic to penicillin.
5.6.3 Counsel on follow up care

Besides the general danger signs to look for in any sick child, the caregiver should bring the child to the
clinic immediately if there is fast breathing, difficult breathing or a wheeze.

5.6.4 When to return for a follow up visit

For pneumonia, the child should return in 2 days, including if there is a wheeze present.

For cough or cold, the child should return in 5 days if there is no improvement, including if there is a
wheeze.

5.6.5 What to do at the follow up visit

Pneumonia and cough or cold:

• At the follow up visit, check for general danger signs and assess for cough or difficult breathing
• If there is a general danger sign or the child has chest indrawing, give a first dose of
ceftriaxone IM. Also, give a first dose of cotrimoxazole unless the child is known to be HIV
negative. Then refer urgently
• Check how the caregiver has been administering treatment at home. Refer if the child’s
condition has not improved despite the correct administration of treatment at home
• If the antibiotic was not administered correctly, counsel the caregiver on the correct
administration and follow up in 2 days.
• If the child is improving, counsel the caregiver on completing the course of antibiotics and to
give the child an extra meal daily for one week.

Wheeze:

• Refer the child if the wheezing has not improved

• If no longer wheezing, the caregiver can stop the salbutamol. Advise the caregiver to restart
the salbutamol via a spacer if the wheezing returns and to come back to the clinic immediately
if the child has not improved in 4 hours of doing so.

5.7 Concluding video

5.7 Concluding video

You have now completed learning about the ASSESSMENT, CLASSIFICATION, TREATMENT,
COUNSELLING AND FOLLOW-UP of a child presenting with a cough. We will summarise some key
messages.

All caregivers of sick children presenting to the health centre are asked about the presence of a cough.
Accurate measurement of the respiratory rate and knowing what constitutes fast breathing at
different ages is important in making a classification of pneumonia.

The presence of chest indrawing or stridor in a calm child indicates severe pneumonia or very severe
disease.

If a wheeze is present, additional questions must be asked to make the conditional classification of
wheeze or recurrent wheeze.

The preferred antibiotic to be administered for a RED classification is ceftriaxone. For a YELLOW
classification (that is PNEUMONIA), amoxicillin is given for 5 days.

To soothe the throat or relieve a cough, use a safe remedy. Breast milk is the best cough remedy for
breastfed children. Cough medicines are not recommended for any child under five years since they
are not effective at relieving a cough and can have serious side effects.

A child with wheezing requires inhaler treatment in the clinic or at home. A child under 5 must be
given an inhaler together with a spacer device.

Other than any general danger signs, the caregiver should bring the child back to the clinic
immediately if there is fast breathing, difficult breathing or a wheeze.

Every child with PNEUMONIA should return in 2 days for a follow-up visit.

This concludes the assessment and management of a child with a cough. Next you will watch a video
and check your knowledge related to this.