The new BTS guidelines on CAP in childhood will support GPs' decisions on management, says Dr Matthew Lockyer
The British Thoracic Society Guidelines for the Management of Community Acquired Pneumonia in Childhood advocate using traditional clinical skills and accessible new technology to strengthen the decision-making process for GPs treating childhood lower respiratory tract infection.
The guidelines appealed to me because they do not conflict with the commonsense experience of most family doctors. Childhood respiratory disease is common and most cases can be successfully managed in the community, adverse outcomes are rare and secondary care investigations such as chest X-rays are not often available.
The section on diagnosis takes us right back to bedside teaching at medical school. After a good history comes observation. My GP trainer advised me always to undress small children before examining them. Not only does this improve the detection of rashes, but it also allows respiratory pattern, rate and the presence of recession to be observed.
I describe what I am seeing to the parent, partly because it reassures them and partly because I think it accustoms small children to the sound of my voice, which sometimes helps make for a calmer examination to follow.
Those children who require admission may often be picked out at the observation stage because of tachypnoea and respiratory distress. Examination for fever and signs of wheeze or consolidation in the chest also helps to confirm the diagnosis. Wheezing is usually associated with a viral aetiology.
Although not directly relevant to chest pathology, the ears, nose and throat should always be examined in these situations.
The use of a pulse oximeter is recommended for children who give cause for concern; a saturation of less than 92% on air is an indicator to admit. Our practice has had an oximeter for several years and it has proved useful in assessing adult chest pathology, especially during the influenza season and in COPD patients. I have used it in children but suspect we may need to see if there is a paediatric attachment that will fit toddler fingers better!
The oximeter is always used after clinical assessment because it must be interpreted against the clinical findings. Oximetry can detect hypoxia, and this is useful because hypoxia is not always readily apparent clinically. Low readings on the oximeter can also be caused by dirt or nail varnish, and shivering or peripheral shutdown, or even bright sunshine.
The guidelinesê recommendations on treatment are simple and useful. In younger children a viral cause is most likely and mild cases can have a trial with symptomatic treatment.
If a high fever is present with respiratory signs, a bacterial cause is more likely. In children under 5 years old, amoxicillin is recommended as first-line treatment if an antibacterial is needed. For those over 5 years, a macrolide may be selected to cover the possibility of mycoplasma infection, although Streptococcus pneumoniae is the most common bacterial pathogen at all ages.
Safe management of lower respiratory tract infections depends on follow up if the child is worsening. As with acute otitis media managed conservatively, 48-hour review is often indicated. These are proper clinical indications for 48-hour access and will need to be given priority.
These guidelines will appeal to GPs because they validate what we are doing already, and build on the framework of examination and the best use of simple antibiotic intervention.
- See also 'BTS guideline will help GPs identify CAP in childhood' in this issue.