Child health for PLAB 1

A 5 month old boy has had a runny nose for two days and now has a cough and noisy breathing. His respiratory rate is 58 breaths/minute with mild subcostal recession. He has widespread fine crackles and expiratory wheeze. His oxygen saturation is 95% on air and he is taking about 80% of his usual feeds. It is December. What is the SINGLE most likely diagnosis?

1. Whooping cough Paroxysmal cough with an inspiratory whoop or post-tussive vomiting, and apnoea in young infants. Mild recession with feeding at 80% and saturations of 95% raises it.
2. Tracheo-oesophageal fistula Choking and cyanosis with feeds from the first days of life, with recurrent aspiration. Mild recession with feeding at 80% and saturations of 95% does not fit this timing.
3. Inhaled foreign body Sudden onset in a previously well child with unilateral signs and no coryzal prodrome. Mild recession with feeding at 80% and saturations of 95% does not fit.
4. Congenital heart disease Poor feeding with sweating, tachypnoea and hepatomegaly, sometimes unmasked by an intercurrent viral illness. Mild recession with feeding at 80% and saturations of 95% raises it.
5. Bronchiolitis correct Correct. Under one year, coryza then cough and wheeze, fine inspiratory crackles, in winter. The fine crackles are the finding that distinguishes it from viral wheeze, which gives wheeze alone.

The point: Under one year, coryza for two or three days then cough, wheeze and fine inspiratory crackles, with feeding difficulty as the reason they attend. Nothing shortens it: not salbutamol, not steroids, not antibiotics, not nebulised saline. Management is oxygen and feeding support. Admit for apnoea, saturations persistently under 90 to 92%, feeding under half to three quarters of normal, marked recession or a respiratory rate over 60. Apnoea in a young infant may be the presenting feature and is a red flag.

Source: NICE NG9 — Bronchiolitis in children: diagnosis and management NICE · tier 1, national regulator or guidance

A 5 month old boy has had a runny nose for two days and now has a cough and noisy breathing. His respiratory rate is 58 breaths/minute with mild subcostal recession. He has widespread fine crackles and expiratory wheeze. His oxygen saturation is 95% on air and he is taking about 80% of his usual feeds. It is December. What is the SINGLE most appropriate initial investigation?

1. Assess feeding as a proportion of normal intake The most useful thing to ask a parent, and it drives the admission decision more than any number. Mild recession with feeding at 80% and saturations of 95% makes it central.
2. Chest radiograph Not routine. It looks like consolidation in bronchiolitis and leads to antibiotics that are not needed. Mild recession with feeding at 80% and saturations of 95% makes it counterproductive.
3. Pulse oximetry The one measurement that changes the decision, because saturations determine admission and oxygen. Mild recession with feeding at 80% and saturations of 95% makes it the useful test.
4. No investigation; this is a clinical diagnosis correct Correct. A chest radiograph would show changes that look like consolidation and lead to antibiotics he does not need. A viral swab is for ward cohorting rather than for his management.
5. Capillary blood gas For a child who is tiring, with rising carbon dioxide indicating impending failure. Mild recession with feeding at 80% and saturations of 95% indicates it.

The point: Under one year, coryza for two or three days then cough, wheeze and fine inspiratory crackles, with feeding difficulty as the reason they attend. Nothing shortens it: not salbutamol, not steroids, not antibiotics, not nebulised saline. Management is oxygen and feeding support. Admit for apnoea, saturations persistently under 90 to 92%, feeding under half to three quarters of normal, marked recession or a respiratory rate over 60. Apnoea in a young infant may be the presenting feature and is a red flag.

Source: NICE NG9 — Bronchiolitis in children: diagnosis and management NICE · tier 1, national regulator or guidance

A 5 month old boy has had a runny nose for two days and now has a cough and noisy breathing. His respiratory rate is 58 breaths/minute with mild subcostal recession. He has widespread fine crackles and expiratory wheeze. His oxygen saturation is 95% on air and he is taking about 80% of his usual feeds. It is December. What is the SINGLE most appropriate immediate management?

1. Nebulised salbutamol No benefit in bronchiolitis and specifically not recommended. Beta-2 receptors are immature under a year. Mild recession with feeding at 80% and saturations of 95% makes it ineffective.
2. Refer to paediatric intensive care For recurrent apnoea, exhaustion, rising carbon dioxide or failure of high-flow oxygen. Mild recession with feeding at 80% and saturations of 95% demands it.
3. Discharge with feeding advice and safety-netting correct Correct. He meets none of the admission criteria: saturations 95%, feeding at 80%, only mild recession, respiratory rate under 60 and no apnoea. Home with clear written thresholds for return.
4. Nasogastric or orogastric feeding For a child who cannot feed enough orally but does not need intravenous fluid. It is preferred over a drip. Mild recession with feeding at 80% and saturations of 95% makes it appropriate.
5. Oral prednisolone No benefit in bronchiolitis, in contrast to croup and to viral wheeze in older children. Mild recession with feeding at 80% and saturations of 95% makes it wrong here.

The point: Under one year, coryza for two or three days then cough, wheeze and fine inspiratory crackles, with feeding difficulty as the reason they attend. Nothing shortens it: not salbutamol, not steroids, not antibiotics, not nebulised saline. Management is oxygen and feeding support. Admit for apnoea, saturations persistently under 90 to 92%, feeding under half to three quarters of normal, marked recession or a respiratory rate over 60. Apnoea in a young infant may be the presenting feature and is a red flag.

Source: NICE NG9 — Bronchiolitis in children: diagnosis and management NICE · tier 1, national regulator or guidance