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The WHO has recently updated its guidelines for the management of acute respiratory infections (ARIs) in children. These guidelines include the differential diagnosis of cough and difficult breathing, and separate guidelines for the management of pneumonia, bronchiolitis and asthma. This recognises the core issue behind the study in this edition of Archives by Dr Vishwanath Gowraiah and colleagues from four hospitals in India; that many children who fulfil WHO's traditional criteria for pneumonia (cough and difficult breathing with or without chest in-drawing) have wheezy viral infections.1 The WHO guideline, contained in the second edition of the Pocket Book of Hospital Care for Children,2 lists the clinical features in favour of pneumonia, bronchiolitis, asthma and other common and less common causes of cough and respiratory distress.
The relevance of making the distinction between acute wheezy bronchiolitis, asthma and pneumonia is that there are groups of children who do not need antibiotics and wheezy older infants and children who would benefit from bronchodilator therapy. The implication of not making this distinction is the overuse of antibiotics and the undertreatment of asthma. This has significant public health implications in developed and developing countries.
But it is not as easy as it may seem. Some of the issues are whether there is a reliable way for health workers in resource-limited settings to distinguish viral bronchiolitis from bacterial pneumonia; and what are the rates and risks of bacterial coinfection in viral respiratory syndromes, in different settings and different risk groups?
The study by Gowraiah et al concluded that using a stethoscope to detect wheeze on auscultation was the most reliable way to distinguish pneumonia from wheezy viral infection.1 This might be true, but it is arguable. First, the health workers who identified wheeze were an emergency physician (on day 1) and …