18 The Neonate
Social h istory: Michael was born to a 32 - year - old mother. He lives at home with both parents.
Neither parent has any other children. The mother works as a secretary, and the father works in construction. Michael ’ s father is a smoker. The family has 2 cats.
Family m edical h istory: PGF (age 65): Type 2 diabetes mellitus; PGM (age 64): breast cancer at age 55; MGF (age 60): asthma; MGM (age 64): healthy; mother (age 32): asthma; father (age 32): seasonal allergies.
OBJECTIVE
Vital s igns: Weight: 4050 grams; length: 48 cm; temperature: 37.2 ° C (rectal); pulse oximeter reading:
93% on room air.
General: Alert baby; well - hydrated; well - nourished; in mild respiratory distress.
Skin: Clear with no lesions noted; no cyanosis of skin, lips, or nails; no diaphoresis noted; good skin turgor.
Head: Normocephalic; anterior fontanelle open and fl at (2 cm × 2 cm); posterior fontanelle open and fl at (0.5 cm × 0.5 cm).
Eyes: Red refl ex present bilaterally; pupils equal, round, and reactive to light; no discharge noted.
Ears: Pinnae normal; tympanic membranes gray bilaterally with positive light refl ex.
Nose: Both nostrils congested; cloudy discharge present in nares; mild nasal fl aring.
Oropharynx: Mucous membranes moist; no teeth present; no lesions.
Neck: Supple; no nodes.
Respiratory: RR = 42; expiratory wheezing present in all lobes; intercostal retractions present; no grunting; no deformities of the thoracic cage noted.
Cardiac/Peripheral v ascular: HR = 120; regular rhythm; no murmur noted; brachial and femoral pulses present and 2 + bilaterally.
Abdomen/Gastrointestinal: Soft, nontender, nondistended, no evidence of hepatosplenomegaly.
Genitourinary: Normal male genitalia; testes descended bilaterally.
Back: Spine straight.
Extremities: Full range of motion of all extremities; warm and well - perfused; capillary refi ll < 2 seconds; negative hip click.
Neurologic: Good suck and cry; good tone in all extremities; positive Moro, rooting, plantar, palmar, and Babinski refl exes.
CRITICAL THINKING
Which diagnostic or imaging studies should be considered to assist with or confi rm the diagnosis?
___Chest radiograph ( anterior - posterior [ AP ] and lateral views)
___ Direct fl uorescent antibody ( DFA ) test to detect respiratory syncytial virus ( RSV ) ___Complete blood count
Oxygenation 19
What is the most likely differential diagnosis and why?
___Bronchiolitis
___ Upper respiratory infection ( URI ) ___Chlamydial pneumonia
What is your plan of treatment, referral, and follow - up care?
What are demographic characteristics that might affect this case?
Does the patient ’ s psychosocial history impact how you might treat this patient?
What if the patient lived in a rural, isolated setting?
RESOLUTION
Diagnostic tests: The DFA test was positive for RSV. A complete blood count ( CBC ) is seldom useful since the white blood cell ( WBC ) count is usually within normal limits. Chest radiographs are not routinely necessary. The nonspecifi c fi ndings of hyperinfl ation and patchy infi ltrates may be seen on the chest radiograph.
What is the most likely differential diagnosis and why?
Bronchiolitis:
The most likely differential diagnosis is bronchiolitis related to an infection with RSV. Michael ’ s history and physical examination form the primary basis for the diagnosis of bronchiolitis. Bronchiolitis is usually due to a viral infection of the small lower airways (bronchioles). Infection is spread by direct contact with respiratory secretions. Previous infection does not confer immunity. Reinfection can be common. Early symptoms are those of a viral URI, including mild rhinorrhea, cough, and sometimes low - grade fever. It is unlikely to be chlamydial pneumonia since the mother was success- fully treated during the pregnancy. Scattered crackles with good breath sounds are characteristic of chlamydial pneumonia, and wheezing is usually absent. Conjunctivitis and middle - ear abnormality may be present in half the infants with chlamydial pneumonia. Chest radiographs will show bilateral interstitial infi ltrates with hyperinfl ation.
What is your plan of treatment, referral, and follow - up care?
• Begin oxygen therapy in the offi ce, and monitor Michael ’ s cardiac and respiratory status.
• Place Michael in an upright position to facilitate respirations.
• Consider a trial of a bronchodilator. (The use of bronchodilators is controversial. These agents relieve reversible bronchospasm by relaxing smooth muscles of the bronchi. Metaanalyses of clinical studies show little or no benefi t from treatment with inhaled beta - adrenergic agents [with or without ipratropium bromide]. Empiric treatment with beta - agonists seems to be the standard of care. Clinical trials demonstrate that corticosteroids have no benefi t in the treat- ment of bronchiolitis, and thus they should not be used routinely. Antibiotics are not routinely used unless a bacterial infection is present. Ribavarin, an antiviral drug specifi cally available for RSV treatment is reserved for cases of severe disease such as infants with complicated CHD or who are immunocompromised. Prophylaxis with Synagis is used for some infants at risk for RSV.)
• Refer patient and family to the local emergency department for support of the respiratory system, a workup for possible sepsis (complete blood count, blood cultures, lumbar puncture for culture of cerebrospinal fl uid, and urine culture), and consultation with a neonatologist. An ambulance should be called to transport the baby from the offi ce to the emergency department so that the baby ’ s airway and respiratory status may be maintained.
• Provide emotional support to the parents. Allow the parents to verbalize their concerns about their baby ’ s health status. Facilitate mother - infant attachment.
20 The Neonate
What are demographic characteristics that might affect this case?
Race and socioeconomic status may affect the frequency of contracting bronchiolitis. Lower socioeco- nomic status may increase the likelihood of hospitalization. Bronchiolitis occurs as much as 1.25 times more frequently in males than in females. Although infection with etiologic agents may occur at any age, the clinical entity of bronchiolitis includes only infants and young children. In cases of bronchi- olitis, 75% of the cases occur in children younger than 1 year, and 95% occur in children younger than 2 years. Incidence peaks in those aged 2 – 8 months.
Does the patient ’ s psychosocial history impact how you might treat this patient?
Michael ’ s father is a smoker; and the family has 2 cats. Both of these things may be lung irritants.
What if the patient lived in a rural, isolated setting?
Health care providers practicing in rural, isolated settings should have emergency offi ce plans in place for patients experiencing respiratory distress.
REFERENCES AND RESOURCES
Al - Ansari , K. , Sakran , M. , Davidson , B. , El Sayyed , R. , Mahjoub , H. , & Ibrahim , K. ( 2010 ). Nebulized 5% or 3%
hypertonic or 0.9% saline for treating acute bronchiolitis in infants . Journal of Pediatrics , 157 , 630 – 634 . Fernandes , R. , Bialy , L. , Vandermeer , B. , Tjosvold , L. , Plint , A. , Patel , H. , & Hartling , L. ( 2010 ). Glucocorticoids
for acute viral bronchiolitis in infants and young children . Cochrane Database of Systematic Reviews , ( 10 ), CD004878.
Petruzella , F. & Gorelick , M. ( 2010 ). Current therapies in bronchiolitis . Pediatric Emergency Care , 26 , 302 – 307 . Sumner , A. , Coyle , D. , Mitton , C. , Johnson , D. , Patel , H. , Klassen , T. & Pediatric Emergency Research Canada
( 2010 ). Cost - effectiveness of epinephrine and dexamethasone in children with bronchiolitis . Pediatrics , 126 , 623 – 631 .