Signs of Respiratory Distress in Children

Original Editor - Jagunath Selvanathan Top Contributors - Jagunath Selvanathan, Romy Hageman, Kim Jackson and Yvonne Yap  

Introduction[edit | edit source]

One of the most common reasons an infant is admitted to the neonatal intensive care unit is due to Respiratory distress[1]. Respiratory distress can be recognised as one or more signs of increased work of breathing which will be discussed below.

The ability to identify signs of respiratory distress in children is important for people working in pediatric healthcare, but also for parents and caregivers. Respiratory distress can manifest through a spectrum of signs, ranging from subtle cues to more obvious symptoms. The early identification of these signs and symptoms plays an important role in ensuring timely intervention[2], which can be critical in preventing further complications[3].

Signs and Symptoms[edit | edit source]

Below are the more common signs and symptoms and their causes:[4][5]

  • Weak cry
    • Sign of fatigue and shows the child is prioritising energy expenditure for work of breathing.
  • Grunting
    • Grunting is an increased positive and expiratory pressure (PEEP) by closing of the glottis (therefore increasing Functional Residual Capacity (FRC)[6].
  • Tachypnea
    • Tachypnea is a medical term that refers to an abnormally rapid breathing rate. An individual may breathe more frequently per minute than what is considered typical for their age group[6].
    • Tachypnea occurs when the infant is unable to increase tidal volume, thus leading to an increase in respiratory rate.
    • The breathing rate in typically healthy children undergoes significant changes during the initial year of life. It decreases from an average of around 50 breaths per minute in full-term newborns to about 40 breaths per minute at 6 months of age and 30 breaths per minute at 12 months[7][8].
    • If tachypnea is present, it means that the respiratory rate exceeds 60 breaths per minute[9]in infants aged 0-2 months, >50 breaths in infants 2-12 months, >40 in children 1-5 years and >20 in children above 5 years[10].
  • Cricoid Tug/Tracheal tug
    • As the diaphragm contracts more forcefully to draw in air, it exerts a downward pull on the trachea, resulting in a visible tug.
  • Sternal recession
    • Sternal recession occurs when the space between the ribs and the sternum moves more inward than usual during breathing[11]. This inward movement happens as the body exerts extra effort to draw air into the lungs.
    • This phenomenon is a response to high negative pressures during inspiration.
  • Sub-costal and intercostal recession
    • Sub-costal and intercostal refer to observable signs of respiratory distress in which the soft tissues in the areas beneath and between the ribs exhibit inward movement during the breathing process. These recessions in the soft tissues occur when the respiratory muscles must work harder than usual to draw air in[11].
    • This heightened effort is a response to high negative pressures experienced during inspiration.
  • Nasal flaring
    • Nasal flaring is an indication of respiratory distress characterized by the widening of the nostrils during breathing. This occurs as the body responds to the increased demand for air, attempting to reduce airflow resistance in the nasal passages[6].
    • The dilation of the nostrils allows for more air intake, facilitating a more efficient exchange of oxygen and carbon dioxide.
  • Head bopping
    • This behavior, characterized by repetitive up-and-down movements of the head, is attributed to the increased use of sternocleidomastoid and scalene muscles.
    • Head bopping serves as a signal that the infant is experiencing breathing difficulties.
  • Clammy
    • The skin can feel cool, moist, and slightly sticky to the touch.
    • This is a physiological response from the body to attempt to regulate the temperature during increased respiratory effort.
    • When an infant is experiencing respiratory distress, they may expend considerable energy and effort in the act of breathing. This can lead to increased sweating as the body works to maintain an optimal temperature.
  • Pallor
    • Pallor refers to a pale or whitish skin tone and can indicate reduced oxygen levels in the blood. The paleness is particularly around the lips and face.
  • Cyanosis
    • The term cyanosis is used to describe a bluish discoloration of the skin and mucous membranes, typically noticeable around the lips, face and extremities[6].
    • In the context of respiratory distress, cyanosis is a critical indicator that warrants immediate attention.
    • When an infant experiences respiratory difficulties, such as inadequate oxygenation of the blood, the level of oxygen in the arterial blood decreases. This deminished oxygen saturation becomes evident through the bluish tint seen in the skin. Cyanosis is particularly noticeable in areas where blood vessels are close to the skin surface.
  • Stridor
    • A stridor is a distinctive, high-pitched sound that occurs during breathing. This audible indicator typically results from turbulent airflow due to partial obstruction in the upper airways, such as the larynx or trachea[12].
    • The sound is particulary noticeable during inhalation and can vary in intensity. It can be audible without the aid of medical equipment.
  • Wheezes
    • Wheezing often signals a constriction or blockage in the small airways of the lungs, typically the result of inflammation, secretions, or bronchoconstriction[1].
    • The wheezing sound is audible during both inhalation and exhalation. It can be described as a whistling of rattling sound and is a key indicator that the air passages are encountering increased resistance.
  • Lethargy
    • Characterized by extreme tiredness and a lack of energy. This can be a subtle, yet very conserning sign of respiratory distress. When infants struggle to breathe, the increased efford required for each breath can lead to fatigue, causing them to appear unusually quiet, drowsy of unresponsive.
  • Tachycardia
    • Tachycardia is an abnormally fast heart rate.
    • When infants experience difficulties in breathing, the heart often responds by beating faster to compensate for the decreased oxygen levels in the blood. A normal heart rate for a newborn or infant typically ranges from 120 to 160 beats per minute, but may exceed these limits in the presence of respiratory challenges.
    • Tachycardia serves as a vital physiological response, aiming to enhance oxygen delivery to vital organs.
  • Hypoxaemia
    • Hypoxaemia is a condition characterized by abnormally low levels of oxygen in the blood[13].
    • Hypoxaemia manifests as a reduction in the levels of oxygen-carrying hemoglobin, resulting in insufficient oxygen delivery to the body's tissues.
  • Hypercarbia
    • Hypercarbia refers to an elevated level of carbon dioxide in the bloodstream. When infants face challenges in breathing, the exchange of gases in the lungs may be compromised, leading to an accumulation of carbon dioxide[13].

How can Physiotherapy help?[edit | edit source]

The goals of physiotherapy are to help increase tidal volumes, help clear secretions, help improve oxygenation around the body and manage ventilation.[1]

  • Manual techniques such as vibrations and percussion
  • Postural drainage
  • Saline and Suctioning (saline helps clear secretions)
  • Therapeutic exercise
  • Central Lavage
  • Bronchoalveolar lavage (BAL)
  • Use of various types of equipment to assist in respiratory care e.g. Acapella / PEP mask / Cough Assist devices.
  • Education and advice on self-management.

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Reuter S, Moser C, Baack M. Respiratory distress in the newborn. Pediatrics in review. 2014 Oct;35(10):417.
  2. ↑ Ullah, K., Khan, M., Suleman, M., Khan, M., Khan, M., & Shah, K. (2023). A prospective study on the clinical characteristics of respiratory distress in neonates at Mardan Medical Complex. Journal of Population Therapeutics & Clinical Pharmacology, pp. Vol. 30 No. 18. (1713-1719).
  3. ↑ Sarnaik JA, Clark AP. Respiratory distress and failure. In: Kliegman RM, Stanton BF, St. Geme JW III, Schor NF, Behrman RE, editors. Nelson text book of paediatrics. 19. Philadelphia: Elsevier; 2011. pp. 314–33
  4. ↑ Taussig LM, Landau LI. Pediatric respiratory medicine. Elsevier Health Sciences; 2008.
  5. ↑ Edwards MO, Kotecha SJ, Kotecha S. Respiratory distress of the term newborn infant. Paediatr Respir Rev. 2013 Mar; 14(1):29-36; quiz 36-7.
  6. ↑ 6.0 6.1 6.2 6.3 Pramanik, A. K., Rangaswamy, N., & Gates, T. (2015). Neonatal Respiratory Distress. Pediatric Clinics of North America, 62(2), 453–469.
  7. ↑ Ashton R, Connolly K. The relation of respiration rate and heart rate to sleep states in the human newborn. Dev Med Child Neurol.1971;13:180–187
  8. ↑ Iliff A, Lee VA. Pulse rate, respiratory rate, and body temperature of children between two months and eighteen years of age. Child Dev.1952;23:237–245
  9. ↑ Warren JB, Anderson JM. Newborn respiratory disorders. Pediatr Rev. 2010;31(12):487–495
  10. ↑ McGann, K., & Long, S. (2022). Principles and Practice of Pediatric Infectious Diseases. Elsevier.
  11. ↑ 11.0 11.1 Thangavelu, S., Sharada, R., & Balamurugan, N. (2015). Respiratory Emergencies in Children. Clinical Pathways in Emergency Medicine, pp. 251-263.
  12. ↑ Bohadana A, Izbicki G, Kraman SS. Fundamentals of lung auscultation. N Engl J Med. 2014;370:744–51.
  13. ↑ 13.0 13.1 Fraser, J., Walls, M., & McGuire, W. (2004). Respiratory complications of preterm birth. BMJ, 329(7472), 962–965.
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