Chapter 4. Cough or difficult breathing

Cough and difficult breathing are common problems in young children. The causes range from a mild, self-limited illness to severe, life-threatening disease. This chapter provides guidelines for managing the most important conditions that cause cough, difficult breathing, or both in children aged 2 months to 5 years. The differential diagnosis of these conditions is described in Chapter 2.  Management of these problems in infants < 2 months of age is described in Chapter 3 and management in severely malnourished children in Chapter 7.

Most episodes of cough are due to the common cold, each child having several episodes a year. The commonest severe illness presenting with cough or difficult breathing is pneumonia, which should be considered first in any differential diagnosis.


  • fever
  • lymphadenopathy (generalized and localized, e.g. in the neck)
  • wasting
  • wheeze or prolonged expiration
  • clubbing
  • apnoeic episodes (with pertussis)
  • subconjunctival haemorrhages
  • signs associated with foreign body aspiration:
    • unilateral wheeze
    • area of decreased breath sounds that is either dull or hyper-resonant on percussion
    • deviation of the trachea or apex beat
  • signs associated with HIV infection
  • Treatment guidelines for the most common causes of chronic cough are indicated below: