Chapter 4.1 Child presenting with cough


Pay particular attention to:

  • cough
    • duration in days
    • paroxysms with whoops or vomiting or central cyanosis
  • exposure to someone with TB (or chronic cough) in the family
  • history of choking or sudden onset of symptoms
  • known or possible HIV infection
  • vaccination history: BCG, diphtheria, pertussis, tetanus (DPT); measles; Haemophilus influenzae type b and pneumococcus
  • personal or family history of asthma.


The symptoms and signs listed below are a guide for the clinician to reach a diagnosis.  Not all children will show every symptom or sign.


  • central cyanosis
  • apnoea, gasping, grunting, nasal flaring, audible wheeze, stridor
  • head nodding (a movement of the head synchronous with inspiration indicating severe respiratory distress)
  • tachycardia
  • severe palmar pallor


  • respiratory rate (count during 1 min when the child is calm)
  • fast breathing:
    • < 2 months, 60 breaths
    • 2 - 11 months, > 50 breaths
    • 1 - 5 years, > 40 breaths
  • lower chest wall indrawing
  • hyperinflated chest
  • apex beat displaced or trachea shifted from midline
  • raised jugular venous pressure
  • on auscultation, coarse crackles, no air entry or bronchial breath sounds or wheeze
  • abnormal heart rhythm on auscultation
  • percussion signs of pleural effusion (stony dullness) or pneumothorax (hyper-resonance)

Note: Lower chest wall indrawing is when the lower chest wall goes in when the child breaths in; if only the soft tissue between the ribs or above the clavicle goes in when the child breathes, this is not lower chest wall indrawing.


  • abdominal masses (e.g. lymphadenopathy)
  • enlarged liver and spleen


  • pulse oximetry to detect hypoxia and as a guide to when to start or stop oxygen therapy
  • full blood count
  • chest X-ray only for children with severe pneumonia or pneumonia that does not respond to treatment or complications or unclear diagnosis or associated with HIV.