There are no absolute rules. This is paediatrics so there are special circumstances.
- Small infants and babies should be considered to have a higher probability of serious bacterial infection whenever they present. However, that should not mean a liberal use of oral antibiotics in a community setting. If you are treating them differently because they have that higher risk of serious infections, they are also high risk for other reasons and should usually be referred if LRTI is suspected.
- Children with complex medical problems may not demonstrate abnormal breathing or unwellness in the way that normal children do.
- Children with chronic LRTI may be less unwell and have little in the way of respiratory abnormality. Parents will often seem less anxious if the problem is developing more gradually. Daily cough for several weeks should be taken seriously. It is not unreasonable to try a course of broad-spectrum oral antibiotics but be aware that this may not be the end of the problem. Underlying causes including foreign objects, bronchiectasis and simply unresolved LRTI may need to be ruled out in which case referral will be necessary.
Bringing all of these things together shows that there are two key features. The first of these is abnormal breathing in the context of an unwell child with cough. The presence of abnormal breathing almost immediately makes it overwhelmingly likely that the problem is LRTI, bronchiolitis or viral wheeze. The second feature is wheeze, which largely rules out LRTI. It’s almost that simple. Almost…