Revised June 2011
American College of Emergency Physicians Section of Pediatric Emergency Medicine
b. While all of the physical findings listed are concerning, the presence of grunting is most indicative of significant respiratory distress and potential decompensation.
c. Though similar in presentation to other serious upper airway infections, such as epiglottitis and retropharyngeal abscess, bacterial tracheitis is characterized by the production of copious amounts of sputum and secretions.
d. While many different viruses can cause bronchiolitis in infants (eg, adenovirus, parainfluenza, influenza, rhinovirus), RSV is the most common and is responsible for the majority of cases.
c. While FB ingestion is always important to consider, it is unlikely at this young age. A congenital airway anomaly is also possible but unlikely, particularly if no signs were present at birth and examination in the ED is normal. Bronchiolitis (as opposed to simply "RSV" infection," which can be fairly asymptomatic) is a clinical diagnosis characterized by tachypnea, retractions, abnormal breath sounds, and/or other signs of lower respiratory tract infection; a normal examination is sufficient to rule this out as a significant possibility. Similarly, a young infant with bacterial pneumonia should appear ill, be febrile, and/or have other have other abnormal physical findings. Petussis, on the other hand, is often subtle in young infants (the most susceptible population) and is usually associated with a normal examination in the ED. In addition, pertussis has become far more common (or at least more commonly diagnosed) in the United States since about 2005, reaching epidemic proportions in some states. As a result, testing for pertussis should be considered in young infants with a prolonged cough, even if they appear to be asymptomatic at the time of evaluation.
c. As "periodic breathing" with occasional pauses of up to 10 seconds or longer can be normal in young infants, it is important to have strict criteria for the evaluation of possible apnea in the absence of other concerning features in the history (eg, cyanosis or pallor, altered mental status, bradycardia, loss of muscle tone).
a. While all of the conditions listed are potentially serious, croup (viral laryngotracheobronchitis, a clinical diagnosis) is extremely unlikely to result in acute upper airway obstruction or precipitous deterioration. That is why most patients with croup are discharged home without any diagnostic testing, after treatment with steroids &/or nebulized racemic epinephrine followed by brief ED observation.
e. Peritonsillar abscesses are very uncommon in children <12 years old, and are more likely to present with severe sore throat and drooling than with stridor. In contrast, up to 50% of retropharyngeal abscesses occur in children less than 12 months old and should always be considered in an infant with stridor but without a cough consistent with croup (particularly if their symptoms have been prolonged, they look ill, and /or they fail to respond adequately to initial treatment for croup.
e. While most patients with any of the other findings on exam or CXR will need to be hospitalized, pneumomediastinum can be seen in otherwise uncomplicated RAD exacerbations. After a brief observation period (eg, 4-6 hours) and repeat CXR, these patients may be able to go home if symptomatically improved without worsening of the CXR findings.
TRUE. Numerous recent studies have shown that MDI's, when used properly with a spacer, are as effective as nebulizers in all age groups. Here are several papers on this topic: Leversha AM et al., Costs and effectiveness of spacer versus nebulizer in young children with moderate and severe asthma. J Pediatr 2000. 136: 497-502. Rubilar L et al., Randomized trial of salbutamol via metered-dose inhaler with spacer versus nebulizer for acute wheezing in children less than 2 years of age. Pediatr Pulmonol 2000. 29: 274-9. Mandelberg A et al., Is nebulized aerosol treatment necessary in the pediatric emergency department? Chest 2000. 117: 1309-13;Schuh S et al., Comparisons of albuterol delivered by a metered dose inhaler with a spacer versus a nebulizer in children with mild acute asthma. J Pediatr 1999. 135:22-7.
d. Although the treatment for bronchiolitis is in general supportive (eg, hydration and oxygen as needed), bronchodilators seem to result in significant improvement in some patients. While research is ongoing on the topic of steroids and bronchiolitis, no form of steroids has yet been shown to result in significant clinical improvement in simple bronchiolitis, however, so their use is not generally recommended. (See "Diagnosis and Management of Bronchiolitis" (2006) from the AAP for further details; Pediatrics Vol 118 (4); 1774-1793. http://pediatrics.aapublications.org/content/118/4/1774.full)
This has been shown to be TRUE, and has been generally accepted into clinical practice (unlike the use of albuterol MDI's instead of nebulizers, which is just now making its way from the literature into practice).
c. The knowledge that each of these patients has RSV might result in a change in clinical management except for the previously healthy 4-month-old infant with a URI and bronchiolitis. This patient can be treated according to the severity of his/her symptoms alone (ie, it doesn't matter whether he/she is RSV + or not). In contrast, a neonate or ex-preemie with underlying lung disease should probably be admitted for observation (the recommended cut-off for admission based on age alone varies in the literature from 4 to 8 weeks in term infants), and the critically-ill intubated patient's antimicrobial management may be guided by specific microbiologic testing, including RSV and influenza A and B.
d. Pertussis is typically a prolonged illness and is characterized by three stages. The first stage (Catarrhal) lasts for 1-2 weeks and involves non-specific URI symptoms. The second stage (Paroxysmal) lasts for 2-4 weeks and involves the classic paroxysms of coughing with severe difficulty breathing afterwards (hence the name "whooping cough"). The third stage (Convalescent) lasts another 1-4 weeks during which recovery occurs. These classic stages are unlikely to occur in young infants, however, which is the age group most susceptible to serious morbidity from Pertussis. While an elevated WBC with a marked lymphocytic predominance strongly supports the clinical diagnosis, the WBC can be normal as well (so this is very unreliable, especially in young infants – the age group that matters the most). Over 40% of [known] cases occur before the age of 1 year, and 65% of cases occur before age 4 (though this may be due to testing bias). Pertussis does not usually involve significant fever, however, and if significant fever is part of the presentation then other diagnoses should be more strongly considered. History of exposure to a known contact with prolonged cough increases the likelihood of Pertussis.
FALSE: Unless given during the prodromal (Catarrhal) stage of the illness, during which the cough has not yet developed, antibiotic treatment (with Azithromycin or trimethoprim/sulfamethoxazole) does not shorten the course of symptoms (which can last for up to 6 months). Antibiotic treatment is important, however, in order to limit the spread of the disease. Children with laboratory-confirmed pertussis should not return to school until completing the full course of antibiotics.
b. Even when promptly recognized and aggressively treated, pneumonia in the neonate still has a high mortality rate (up to 50% if GBS is the cause). Although not as common as in older children, viral infections including pneumonia are still relatively common in neonates and include RSV, influenza, varicella and CMV.
a. This is a classic case of Mycoplasma, which is the most likely cause of mild to moderate pneumonia in children older than 5 years. Treatment options include erythromycin, clarithromycin, and azithromycin.
d. Children who have received racemic epinephrine while in the ED should be observed for 1-2 hours for the recurrence of stridor. If it does recur, the racemic epinephrine can be repeated followed by a second observation period (after which they can still be discharged if stridor-free). If more than two rounds of racemic epinephrine are required for recurrent stridor, admission is usually warranted. Steroids (most commonly dexamethasone, 0.6 mg/kg, by mouth) should be given as soon as possible after assessment.