Table 6, Differential diagnosis in a child presenting with cough or difficulty in breathing - Pocket Book of Hospital Care for Children

Diagnosis	In favour
Pneumonia	– Cough with fast breathing – Lower chest wall indrawing – Fever – Coarse crackles or bronchial breath sounds or dullness to percussion – Grunting
Effusion or empyema	– Reduced movement on affected side of chest – Stony dullness to percussion (over the effusion) – Air entry absent (over the effusion)
Asthma or wheeze	– Recurrent episodes of shortness of breath or wheeze – Night cough or cough and wheeze with exercise – Response to bronchodilators – Known or family history of allergy or asthma
Bronchiolitis	– Cough – Wheeze and crackles – Age usually < 1 year
Malaria	– Fast breathing in a febrile child – Blood smear or malaria rapid diagnostic test confirms parasitaemia – Anaemia or palmar pallor – Lives in or travelled to a malarious area – In severe malaria, deep (acidotic) breathing or lower chest indrawing – Chest clear on auscultation
Severe anaemia	– Shortness of breath on exertion – Severe palmar pallor – Hb < 6 g/dl
Cardiac failure	– Raised jugular venous pressure in older children – Apex beat displaced to the left – Heart murmur (in some cases) – Gallop rhythm – Fine crackles in the bases of the lung fields – Enlarged palpable liver
Congenital heart disease (cyanotic)	– Cyanosis – Finger clubbing – Heart murmur – Signs of cardiac failure
Congenital heart disease (acyanotic)	– Difficulty in feeding or breastfeeding with failure to thrive – Sweating of the forehead – Heaving precordium – Heart murmur (in some cases) – Signs of cardiac failure
Tuberculosis	– Chronic cough (> 14 days) – History of contact with TB patient – Poor growth, wasting or weight loss – Positive Mantoux test – Diagnostic chest X-ray may show primary complex or miliary TB – Sputum positive in older child
Pertussis	– Paroxysms of cough followed by whoop, vomiting, cyanosis or apnoea – No symptoms between bouts of cough – No fever – No history of DPT vaccination
Foreign body	– History of sudden choking – Sudden onset of stridor or respiratory distress – Focal areas of wheeze or reduced breath sounds
Pneumothorax	– Sudden onset, usually after major chest trauma – Hyper-resonance on percussion of one side of the chest – Shift in mediastinum to opposite side
Pneumocystis pneumonia	– 2–6-month-old child with central cyanosis – Hyperexpanded chest – Fast breathing (tachypnoea) – Finger clubbing – Chest X-ray changes, but chest clear on auscultation – HIV test positive in mother or child
Croup	– Inspiratory stridor – Current measles – Barking character to cough – Hoarse voice
Diphtheria	– No history of DPT vaccination – Inspiratory stridor – Grey pharyngeal membrane – Cardiac arrhythmia

Diagnosis

In favour

Pneumonia

–: Cough with fast breathing
–: Lower chest wall indrawing
–: Fever
–: Coarse crackles or bronchial breath sounds or dullness to percussion
–: Grunting

Effusion or empyema

–: Reduced movement on affected side of chest
–: Stony dullness to percussion (over the effusion)
–: Air entry absent (over the effusion)

Asthma or wheeze

–: Recurrent episodes of shortness of breath or wheeze
–: Night cough or cough and wheeze with exercise
–: Response to bronchodilators
–: Known or family history of allergy or asthma

Bronchiolitis

–: Cough
–: Wheeze and crackles
–: Age usually < 1 year

Malaria

–: Fast breathing in a febrile child
–: Blood smear or malaria rapid diagnostic test confirms parasitaemia
–: Anaemia or palmar pallor
–: Lives in or travelled to a malarious area
–: In severe malaria, deep (acidotic) breathing or lower chest indrawing
–: Chest clear on auscultation

Severe anaemia

–: Shortness of breath on exertion
–: Severe palmar pallor
–: Hb < 6 g/dl

Cardiac failure

–: Raised jugular venous pressure in older children
–: Apex beat displaced to the left
–: Heart murmur (in some cases)
–: Gallop rhythm
–: Fine crackles in the bases of the lung fields
–: Enlarged palpable liver

Congenital heart disease (cyanotic)

–: Cyanosis
–: Finger clubbing
–: Heart murmur
–: Signs of cardiac failure

Congenital heart disease (acyanotic)

–: Difficulty in feeding or breastfeeding with failure to thrive
–: Sweating of the forehead
–: Heaving precordium
–: Heart murmur (in some cases)
–: Signs of cardiac failure

Tuberculosis

–: Chronic cough (> 14 days)
–: History of contact with TB patient
–: Poor growth, wasting or weight loss
–: Positive Mantoux test
–: Diagnostic chest X-ray may show primary complex or miliary TB
–: Sputum positive in older child

Pertussis

–: Paroxysms of cough followed by whoop, vomiting, cyanosis or apnoea
–: No symptoms between bouts of cough
–: No fever
–: No history of DPT vaccination

Foreign body

–: History of sudden choking
–: Sudden onset of stridor or respiratory distress
–: Focal areas of wheeze or reduced breath sounds

Pneumothorax

–: Sudden onset, usually after major chest trauma
–: Hyper-resonance on percussion of one side of the chest
–: Shift in mediastinum to opposite side

Pneumocystis pneumonia

–: 2–6-month-old child with central cyanosis
–: Hyperexpanded chest
–: Fast breathing (tachypnoea)
–: Finger clubbing
–: Chest X-ray changes, but chest clear on auscultation
–: HIV test positive in mother or child

Croup

–: Inspiratory stridor
–: Current measles
–: Barking character to cough
–: Hoarse voice

Diphtheria

–: No history of DPT vaccination
–: Inspiratory stridor
–: Grey pharyngeal membrane
–: Cardiac arrhythmia

From: 4, Cough or difficulty in breathing

Cover of Pocket Book of Hospital Care for Children

Pocket Book of Hospital Care for Children: Guidelines for the Management of Common Childhood Illnesses. 2nd edition.

Geneva: World Health Organization; 2013.

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Table 6Differential diagnosis in a child presenting with cough or difficulty in breathing