Concerns from Parents and Caregivers: What They See, What They Fear
Parents and caregivers will often describe their child as having “trouble breathing”. However, the description of “trouble breathing” means something different to medical providers. There is a spectrum of images that materializes in our heads when that statement comes up. We immediately jump to the idea of respiratory distress which denotes a child in very bad shape and our brain wanders to the concept of respiratory failure. Respiratory failure describes a condition where an infant, child, or adolescent can’t breathe on their own and may need to have a breathing tube placed into their trachea through their mouth with the device being connected to a mechanical ventilator which assumes the function of breathing for the patient.
Most parents and caregivers would not necessarily jump to the concept of respiratory failure and the need for mechanical ventilation in their head, but they are definitely concerned about how their child is breathing because it is not normal for their child. With that said, on a side note, all clinicians should come to the conversation and understand that the parent or caregiver knows their child best and sees something that is not normal for their child. The medical team needs to acknowledge that and take parents’ and caregivers’ concerns seriously because they will pick up on things about their children that we would miss. After all, we don’t know their children as well as they do. But, what is a parent or caregiver seeing that makes them concerned about their child’s breathing?
Symptoms of “Trouble Breathing”
The common symptoms that are described by parents and caregivers as “trouble breathing” have to do with congestion or obstruction to airflow, different breathing noises, rapid breathing, and tummy breathing. All of these symptoms are legitimate causes for concern because they can represent something more serious at play. Nevertheless, the symptoms may not represent something more serious at that time, and it is our job as clinicians to carefully evaluate the child and provide reassurance or, conversely, recognize that the child requires a higher level of care and is truly having respiratory distress defined by objective medical criteria. But, whatever the interpretation, the symptoms that their children are experiencing are of concern to their parents or caregivers and need to be understood from their perspective.
Congestion: Mucous Matters
When a child has congestion, there is obstruction of the airways to varying degrees from mucous. The most common place is the nose and nasal passages. While this does not pose a threat to older children, it can be more of a problem for infants. Infants are obligate nose breathers and don’t often breathe through their mouths. With this in mind, they may have trouble feeding and can become dehydrated because they won’t be able to feed/drink orally and breathe through their nose at the same time. In most cases, nasal congestion may cause noisy breathing or the appearance of uncomfortable breathing patterns but usually does not result in serious respiratory distress or failure. Many families reflect that their child has difficulty sleeping because the congestion makes it more challenging for them to breathe normally. Removal of the mucous usually relieves the obstruction and the breathing improves. This is very commonly seen with respiratory syncytial virus (RSV) in infants. However, in this instance, the mucous is not necessarily limited to the nose and can include the mouth and lower airways which can result in more serious breathing issues.
Mucous congestion can also be located in the mouth and throat because it is not uncommon for a runny nose or nasal mucous to drip down from the nasal passages into the back of the throat. This will subsequently cause coughing and difficulty breathing. Again, for younger kids and infants, their ability to clear their airways is not as good as older children. This is commonly seen in RSV, as it affects younger children and infants to a more significant degree. So, they develop increased work of breathing and more symptomatic breathing issues. If there is too much nasal and mouth/throat congestion, combined, this can lead to serious respiratory difficulties and even respiratory failure. So, the degree to which upper airway mucous is causing obstruction to airflow is important to be assessed by the medical team.
Deciphering Different Breathing Noises
Another concern for parents is different breathing noises. There is often a described “wheezing” that is occurring. For families with children who have asthma or who have had reactive airway disease, their description is quite accurate. But, wheezing can be a catchall term for the musical squeaking that takes place while an infant, child, or adolescent is breathing. The importance is to differentiate it from stridor because the two noises have different causes and treatments. Wheezing is a musical squeaking sound that occurs with breathing outward. Often, it is just appreciated with a stethoscope while listening to the lungs. However, if severe, it can be audible to the naked ear without a stethoscope. The wheezing most commonly takes place in the lungs from lower airway obstruction that is manifested when an infant, child, or adolescent is breathing out. Also, one can notice that there is a prolonged exhalation phase of breathing and more of an effort breathing out. Wheezing spans the age groups, and it can be caused by a variety of things.
Stridor, on the other hand, is often mistaken for wheezing. However, again, for parents whose children have experienced episodes of croup in the past, stridor can be accurately identified. The musical squeaking sound occurs when an infant, child, or adolescent takes a breath inward. Significant stridor is heard universally without a stethoscope. Furthermore, it is best heard in the neck area. While any age can have stridor, it is most commonly found in young children and infants who develop croup from a viral infection. However, there are other causes as well, such as foreign body aspiration, anatomic abnormalities, and a variety of other infections.
Rapid Breathing and Belly Breathing: Signs of Distress
Other symptoms that are commonly noticed by parents and caregivers as trouble breathing include breathing faster than normal, also called tachypnea, and belly breathing (when the abdomen paradoxically moves outward when the breath is taken inward, instead of the abdomen sucking inward when a breath is taken inward). Both of these symptoms can represent respiratory distress, for sure. However, it must be noted that fever and agitation can cause the respiratory rate to increase. In the absence of fever or agitation, breathing faster than normal is concerning. Nevertheless, a child should always be evaluated with these symptoms because breathing faster and having belly breathing can represent increased work of breathing and a sign that there is something more seriously wrong. The best assessment is done while a child is sleeping or calm. If these symptoms are present under these circumstances, immediate evaluation is warranted.
Bridging the Divide with Collaboration and Understanding
While there is an array of respiratory symptoms with varying levels of severity and dependent upon context, we should not expect parents or caregivers to understand all of the nuances. As medical professionals, it is easy for us to gloss over minor breathing anomalies because we don’t see them as threatening, based on our education and experience. However, we must be aware that most parents and caregivers have not experienced these symptoms in their children, and it is often scary at worst and concerning at least. However, children progressing to respiratory failure is something that both parents or caregivers and medical professionals wish to avoid.
So, as parents and caregivers often use the term “trouble breathing” fairly easily, it is important to not gloss over it. The medical team must approach their concerns with genuine consideration because their observations, even if they don’t align with medical terminology, are invaluable insights into their children’s health. Ultimately, understanding what “trouble breathing” means to the parents or caregivers allows for more effective communication and collaboration between medical professionals and parents or caregivers. This communication and collaboration, in turn, will ensure the best outcomes for children experiencing breathing problems and safeguard the precious gift of a child’s health.
As a parent or caregiver, what do you wish medical professionals understood better regarding your concerns about your child’s health?
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