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 Coughing fits with a gasping whoop breathing in, or vomiting after coughing, and pauses in breathing in young babies. Here, mild chest recession with feeding at 80% and oxygen at 95% points elsewhere.
2. Tracheo-oesophageal fistula Choking and turning blue (cyanosis) with feeds from the first days of life, with milk going into the lungs again and again. It does not fit mild chest recession with feeding at 80% and oxygen at 95%.
3. Inhaled foreign body A sudden start in a child who was well before, with signs on one side only and no runny-nose phase first. That does not match mild chest recession with feeding at 80% and oxygen at 95%.
4. Congenital heart disease Poor feeding with sweating, fast breathing and an enlarged liver, sometimes only showing up once a virus hits. But mild chest recession with feeding at 80% and oxygen at 95% does not point to it.
5. Bronchiolitis correct Correct. Under one year old, a runny nose (coryza) then cough and wheeze, fine crackles when breathing in, in winter. The fine crackles are what tell it apart from viral wheeze, which causes wheeze alone.

The point: This happens in babies under one year old. They get a runny nose (coryza) for two or three days, then a cough, wheeze, and fine crackling sounds when breathing in (fine inspiratory crackles). Parents usually bring the baby in because feeding has become hard, and that is often the real reason for the visit. Nothing makes the illness go away faster. Salbutamol does not help. Steroids do not help. Antibiotics do not help. Nebulised saline does not help. Treatment means giving oxygen and helping the baby feed. Admit the baby for a pause in breathing (apnoea), for oxygen staying under 90 to 92%, for feeding below half to three quarters of normal, for the chest pulling in hard (marked recession), or for a breathing rate over 60 a minute. In a very young baby, a pause in breathing can be the first sign of illness rather than a late one, so treat it as 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 question to ask a parent. It guides the decision to admit more than any single number does. But mild chest recession with feeding at 80% and oxygen at 95% does not point to it.
2. Chest radiograph Not done routinely. In bronchiolitis it can look like infected, filled-in lung tissue (consolidation) and lead to antibiotics the baby does not need. It does not fit mild chest recession with feeding at 80% and oxygen at 95%.
3. Pulse oximetry The one measurement that changes the plan, because the oxygen reading decides whether the baby is admitted and given oxygen. That does not match mild chest recession with feeding at 80% and oxygen at 95%.
4. No investigation; this is a clinical diagnosis correct Correct. A chest x-ray would show changes that look like infected lung tissue and lead to antibiotics he does not need. A virus swab is for grouping babies on the ward, not for his own treatment.
5. Capillary blood gas For a baby who is getting tired, where a rising carbon dioxide level shows the breathing is starting to fail. Here, mild chest recession with feeding at 80% and oxygen at 95% points elsewhere.

The point: This happens in babies under one year old. They get a runny nose (coryza) for two or three days, then a cough, wheeze, and fine crackling sounds when breathing in (fine inspiratory crackles). Parents usually bring the baby in because feeding has become hard, and that is often the real reason for the visit. Nothing makes the illness go away faster. Salbutamol does not help. Steroids do not help. Antibiotics do not help. Nebulised saline does not help. Treatment means giving oxygen and helping the baby feed. Admit the baby for a pause in breathing (apnoea), for oxygen staying under 90 to 92%, for feeding below half to three quarters of normal, for the chest pulling in hard (marked recession), or for a breathing rate over 60 a minute. In a very young baby, a pause in breathing can be the first sign of illness rather than a late one, so treat it as 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 Gives no benefit in bronchiolitis and is specifically not recommended. The airway-opening receptors (beta-2 receptors) are not fully developed under a year old. It does not fit mild chest recession with feeding at 80% and oxygen at 95%.
2. Refer to paediatric intensive care For pauses in breathing that keep happening, exhaustion, rising carbon dioxide, or high-flow oxygen not working. But mild chest recession with feeding at 80% and oxygen at 95% does not point to it.
3. Discharge with feeding advice and safety-netting correct Correct. He does not meet any of the admission signs: oxygen at 95%, feeding at 80%, only mild chest recession, breathing rate under 60, and no pauses in breathing. He can go home with clear written signs to watch for.
4. Nasogastric or orogastric feeding For a baby who cannot take in enough milk by mouth but does not need fluids through a drip. This is tried before a drip. That does not match mild chest recession with feeding at 80% and oxygen at 95%.
5. Oral prednisolone Gives no benefit in bronchiolitis, unlike in croup and in wheeze from a virus in older children. Here, mild chest recession with feeding at 80% and oxygen at 95% points elsewhere.

The point: This happens in babies under one year old. They get a runny nose (coryza) for two or three days, then a cough, wheeze, and fine crackling sounds when breathing in (fine inspiratory crackles). Parents usually bring the baby in because feeding has become hard, and that is often the real reason for the visit. Nothing makes the illness go away faster. Salbutamol does not help. Steroids do not help. Antibiotics do not help. Nebulised saline does not help. Treatment means giving oxygen and helping the baby feed. Admit the baby for a pause in breathing (apnoea), for oxygen staying under 90 to 92%, for feeding below half to three quarters of normal, for the chest pulling in hard (marked recession), or for a breathing rate over 60 a minute. In a very young baby, a pause in breathing can be the first sign of illness rather than a late one, so treat it as a red flag.

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