Intercostal Recession Research Articles

Spectrum of respiratory distress and outcome in neonates admitted in National Institute of Child Health, Karachi, Pakistan.

Objective: To find out the spectrum of respiratory distress and outcome in neonates admitted to Neonatal Intensive care unit (NICU) of National Institute of Child Health (NICH), Karachi, Pakistan. Study Design: Cross-sectional study. Setting: NICU of NICH, Karachi, Pakistan. Period: June 2022 to May 2023. Methods: We analyzed 148 neonates of either gender presenting with respiratory distress. At the time of enrollment, demographic and clinical information was noted in all neonates along with detailed maternal history. Relevant laboratory and radiological studies were performed. Final outcomes were recorded in terms of discharged, expired or referred. Results: In a total of 148 neonates, 96 (64.9%) were boys. The mean age was 4.04±5.65 days. Tachypnea, nasal flaring, intercostal recession, subcostal recession, grunting, and cyanosis 148 (100%), 146 (98.6%), 138 (93.2%), 133 (89.9%), 97 (65.5%), and 83 (56.1%) were the most frequent clinical presentations among neonates with respiratory distress. The most frequent causes behind respiratory distress were noted to be respiratory distress syndrome, sepsis, and meconium staining of labour in 31 (20.9%), 25 (16.9%), and 24 (16.2%) neonates. Mortality was observed in 21 (14.2%) neonates. Significant association of neonates presenting with congenital pneumonia (p=0.048), or congenital anomalies (p<0.001) were found to with poor outcomes. Mechanical ventilation was found to have significant relationship with poor outcomes (p<0.001). Conclusion: Tachypnea, Nasal flaring, intercostal and subcostal recessions, grunting, and cyanosis were the primary clinical presentations among the neonates with respiratory distress. Congenital pneumonia, and congenital anomalies emerged as key predictors of poor outcomes.

The identification of WHO emergency signs in children by nurses at triage in an emergency department

ABSTRACT Background The World Health Organization recommends the use of a three-tier triage system to recognise a sick child in low- and middle-income countries. The three tiers are based on standardised emergency and priority signs. No studies have evaluated the prevalence or reliable detection of these emergency signs. Aims To determine the prevalence of WHO emergency signs and the underlying causes, and to determine whether nurses could reliably detect these signs in children presenting to the emergency department at Port Moresby General Hospital in Papua New Guinea. Methods A prospective study measured inter-rater agreement between nurses at triage and a blinded second assessor trained in paediatrics. Results The prevalence of emergency signs was 16.7%: 32 of 192 children had these signs at presentation; 18 (9.4%) had severe respiratory distress; 10 (5.2%) had severe dehydration; and 3 (1.6%) had convulsions. There was an acceptable inter-rater agreement between nurses and doctors (Cohen’s Kappa score >0.4) for some signs: subcostal recession, intercostal recession, nasal flaring, lethargy, weak volume pulses, convulsions, sunken eyes and a poor conscious state. Obstructed breathing, cyanosis, tracheal tug and cold hands and feet were less commonly detected and had poor inter-rater agreement (Kappa score <0.4). Conclusions Effective screening at triage can enable prompt emergency treatment by nurses and can help focus doctors’ attention on children who require it most. There is a need for additional training in the identification of some emergency signs. Abbreviations CED: children’s emergency department; ETAT: emergency triage assessment and treatment; HCC: Hospital Care for Children; PMGH: Port Moresby General Hospital; PNG: Papua New Guinea; WHO: World Health Organization

Intercostal Recession and Bulging during Pendelluft Detected in Four-Dimensional Computed Tomography.

Intercostal Recession and Bulging during Pendelluft Detected in Four-Dimensional Computed Tomography.

Autoimmune hemolytic anemia, a rare disease in newborns: a case report.

A one-hour-old male neonate weighing 3kg who was born at 38 weeks of gestation presented to the pediatric department with the complaint of respiratory distress. Examination revealed obvious respiratory distress with subcostal and intercostal recessions and a continuous grade 2 murmur at the left upper chest; the liver was palpable 1cm below the right subcostal margin with a palpable splenic tip. Laboratory investigations were ordered, which showed hemoglobin was decreasing continuously and bilirubin was raised, suspecting AIHA. A positive blood culture, tachycardia, tachypnea, and a raised leukocyte count showed that the baby was in sepsis. The baby improved clinically, and the complete blood count showed improved Hb. Cardiac examination findings and a second-grade continuous murmur at the left upper chest were further investigated through echocardiography, which showed a grade 2 atrial septal defect, a muscular ventricular septal defect, and a patent ductus arteriosus. Childhood AIHA is a rare and underrated disease that differs from the adult form. The disease's initial manifestation and subsequent course are both poorly understood. It affects mostly young children, and a high prevalence (21%) is found in infants. In some patients, there is a genetic predisposition to the development of this disease, and there is underlying immune deregulation in more than half of the cases, necessitating long-term homogeneous multidisciplinary follow-up. It is of two types, primary and secondary, and according to the study conducted in France, AIHA is associated not only with other autoimmune diseases but with some systemic diseases as well, like neurological, digestive, chromosomal abnormalities, and cardiac diseases, as in our case. There is a scarcity of data on clinical management and treatment strategies. More research should be done to know the environmental factors that can trigger the immune response against red blood cells. Moreover, a therapeutic trial is essential for a better outcome and helps prevent serious complications.

A large pericardial cystic lymphangioma presenting as acute-onset respiratory distress in a child: a case report

BackgroundLymphangiomas are rare benign malformations of the lymphatics that occur due to blockage of the lymphatic system during fetal development. They commonly occur in the neck and axilla, while involvement of the pericardium is rare. We report herein the case of a 16-month-old Sri Lankan child with a large pericardial cystic lymphangioma presenting with sudden-onset shortness of breath.Case presentationA 16-month-old Sri Lankan boy presented with sudden-onset dyspnea for 1-day duration following a febrile illness that lasted 2 days. On examination, he was afebrile and had subcostal, intercostal, and suprasternal recessions, with a respiratory rate of 50 breaths per minute. He had a loud expiratory grunt. The chest expansion was reduced on the right side, which was dull to percussion. Auscultation revealed a marked reduction of air entry over the right lower and mid zones. Chest X-ray showed a well-demarcated opacity involving the lower and mid zones of the right hemithorax associated with a tracheal shift to the opposite side. Ultrasound scan of the chest revealed fluid-filled right hemithorax suggesting a septate pleural effusion. A contrast-enhanced computed tomography scan of the thorax showed a large multiloculated extrapulmonary cystic lesion involving the right hemithorax with a mediastinal shift towards the left side associated with displacement of the right-side mediastinal structures. He underwent mini-thoracotomy and surgical excision of the cyst. A large cyst originating from the pericardium was observed and excised during surgery. Histological examination revealed a lesion composed of cysts devoid of a lining epithelium but separated by connective tissue, mature adipose tissue, and lymphoid aggregates. The child showed complete recovery postoperatively with full expansion of the ipsilateral lung.ConclusionWe report the case of a patient with cystic lymphangioma who was perfectly well and asymptomatic until 16 months of age. This case report presents the very rare occurrence of a large cystic lymphangioma originating from the pericardium. It highlights the importance of considering rare possibilities and performing prompt imaging in situations of diagnostic uncertainty to arrive at an accurate diagnosis that can be lifesaving.

Kagami–Ogata syndrome: a case report

BackgroundKagami–Ogata syndrome is a rare genetic imprinting disorder involving the 14q32.2 genomic location of chromosome 14. The estimated incidence is less than 1 per 1 million. Here we report a male neonate with Kagami–Ogata syndrome presenting with severe respiratory distress requiring mechanical ventilation since birth.Case presentationA Sri Lankan male neonate born at term via caesarean section to a mother with type 1 diabetes mellitus and hypothyroidism developed respiratory distress immediately after birth. On examination, the baby had facial dysmorphism with a hirsute forehead, full cheeks, flat nasal bridge, elongated protruding philtrum, and micrognathia. His chest was small and bell shaped, and he had severe intercostal and subcostal recessions. His abdominal wall was lax and thin, with evidence of divarication of the recti. Bowel peristalsis was easily visible through the abdominal wall. The chest x-ray showed narrowing of the rib cage with crowding of the ribs in a “coat-hanger” appearance. The coat-hanger angle was 32°, and the mid-to-widest thoracic diameter was 68%. On the basis of facial dysmorphism, chest and anterior abdominal wall abnormalities, coat-hanger appearance of the rib cage, increased coat-hanger angle, and reduced mid-to-widest thoracic diameter, a clinical diagnosis of Kagami–Ogata syndrome was made. Owing to severe respiratory distress, the baby required intubation and ventilation immediately after birth. He was ventilator-dependent for 3 weeks; however, he was successfully weaned off the ventilator on day 22 after several failed extubation attempts. At 3-month follow-up, he had generalized hypotonia and mild global developmental delay. His developmental age corresponded to 2 months.ConclusionsWe report a patient with Kagami–Ogata syndrome presenting with respiratory distress immediately after birth. This case report highlights the importance of being aware of this rare condition, which could present as severe respiratory distress in term and preterm newborns. A positive diagnosis could avoid unnecessary treatment and aid in accurate prognostication.

Assessment of surveillance predictors for suspected respiratory syncytial virus, influenza and Streptococcus pneumoniae infections in children aged

The lack of rapid, sensitive and affordable diagnostic tests that can distinguish a wide variety of respiratory pathogens at the point of care is an obstacle to the rapid implementation of control measures following events and epidemics. In addition, the absence of a standardized case definition to differentiate putative aetiologies is a challenge to assessing the burden of disease. This study aimed to identify the clinical spectrum of respiratory pathogens commonly associated with respiratory tract infections in the context of disease surveillance. Data obtained from prospective hospital-based severe acute respiratory infection surveillance among children aged <5 years from November 2010 to July 2013 were used in this study. Intercostal recession and dyspnoea were predictive of respiratory syncytial virus (RSV) infection, whereas headache and chills were more often observed during influenza A infection. Male patients were at a higher risk for RSV infection than female patients. Productive cough, chills, sweating and weight loss were significantly associated with Streptococcus pneumoniae infection. The presence of fever did not necessarily indicate RSV infection. Combined with other examinations, this study shows the value of including the syndromic approach in the panel of diagnostic criteria for rapid identification of the risk of infectious diseases in areas where laboratory diagnostics are challenging. Given the current situation with coronavirus disease 2019, this approach may help decision makers to implement appropriate control measures.

1640 Stridor in An Infant with Double Aortic Arch

Abstract An eleven-month-old infant presented to our casualty with stridor that had been noticed by the parents a few weeks earlier and became increasingly evident lately. They did not recall a specific event when the infant “chocked”, but they denied any recent history of respiratory tract infection. The infant had no relevant medical or surgical history, and he was born full term with normal vaginal delivery. Examination of the infant showed moderate biphasic stridor with both suprasternal and intercostal recessions. Oxygen saturation on room air was 94% and temperature was 37.1°. Chest auscultation revealed bilateral equal air entry, though decreased, with transmitted stridor. No lung crepitations were appreciated. Suspicion of unwitnessed foreign body aspiration arose, and a decision of diagnostic rigid bronchoscopy was taken. Rigid bronchoscopy revealed no foreign body along the tracheobronchial tree, but evident circumferential constriction of the lower trachea was noted with tendency of the tracheal wall to collapse upon withdrawal of the bronchoscope. Following recovery, computed tomography with contrast of the neck and chest was done and a vascular ring, consisting of double aortic arch, was found compressing and narrowing the trachea. Further follow up over the following 6 months showed marked improvement of his distress, and active observation was continued. Conclusions Although foreign body aspiration is the commonest cause of stridor in infants and young children, external compression of the trachea, particularly with vascular rings, should be considered in children with otherwise unexplained stridor.

Diagnosing pneumomediastinum in a neonate using a lung ultrasound

A preterm baby—delivered by caesarean section at 36 weeks and 5 days due to pathological trace on cardiotocography—presented immediately after birth with tachypnoea, and sternal, intercostal, and subcostal recessions.

Self-assessment

A 19-year-old mother presents in established labour to a labour ward in a large teaching hospital following a concealed pregnancy. It is her first pregnancy. At delivery, the baby gives a cry but is noted to have significantly increased work-of-breathing and remains deeply cyanosed. The midwifery team provide PEEP via a face mask and place a crash-call for medical assistance. At the time of the neonatal crash team's arrival at 4 minutes of life the baby boy is receiving facemask PEEP 5 cm H2O in FiO2 0.45. He has deep subcostal and intercostal recessions with grunting and intermittent apnoea. Pre-ductal saturations are 49%. At a glance he appears of a good birth weight with features typical of a term infant. He is noted to have a scaphoid abdomen.

Cannot intubate and cannot ventilate scenario in an infant for airway assessment.

Sir, Cannot intubate and cannot ventilate scenario, in general, is rare, especially in infant age group, but results in calamitous events if it occurs. Here, we report the management of a case of cannot intubate and cannot ventilate in an infant with a history of stridor. Case A 6-month-old girl was brought by an ambulance to our tertiary care hospital with difficulty in breathing and severe stridor. It was decided to perform airway assessment by ENT surgeon to determine the possible causes of stridor due to failure of improvement despite maximum medications given by pediatrician. Preoperative assessment showed an infant with mixed stridor requiring about 4 L of oxygen to maintain oxygen saturation above 90%. Suprasternal and intercostal recessions with conducted sounds could be heard on the chest. Chest X-ray was normal. No premedication was given and she was shifted to the operation theatre. Supraglottic airway assessment was done awake with topical anesthesia using flexible fiberoptic endoscope which was normal. Subglottic endoscopic examination was decided under general anesthesia. She was induced with sevoflurane to maintain spontaneous ventilation for dynamic airway assessment. The spontaneous ventilation was assisted with great difficulty after loss of consciousness. The ENT surgeon used pediatric rigid endoscope. It revealed subglottic mass occluding 90% of the area, and it was not possible to bypass the mass with the smallest endoscope available (size 2.7 mm) [Figure 1]. The infant started to desaturate after endoscopic manipulations with difficulty to ventilate. Intubation failed with the smallest tube size 2. Ventilation was tried but was not effective. The saturation and heart rate started to drop with the scenario of cannot intubate and cannot ventilate. Atropine was given and external cardiac massage started as saturation dropped to less than 50% and heart rate fell to less than 60 beats per minute. Emergency tracheostomy was done successfully in 7 min and saturation improved to 99%. Infant regained consciousness and spontaneous breathing. Computed tomography was done which revealed a small hypodense area measuring 0.5 cm in diameter in the region of glottis. LASER marsupialization of the subglottic cyst was done successfully after 2 days from emergency tracheostomy.Figure 1: Subglottic mass obstructing 90% of the airwayUnfortunately, there is no definitive algorithm to follow for difficult airway in case of patients aged less than 1 year of age. Difficult airway society (DAS) published algorithm of cannot intubate and cannot ventilate in a paralyzed anesthetized child aged 1–8 years in 2015.[1] In the present case, we skipped insertion of supraglottic devices, percutaneous transtracheal jet ventilation (PTJV), rigid bronchoscopy ventilation, and percutaneous cannula cricothyroidotomy (PCC) for different reasons. Supraglottic devices cannot be used due to distal mechanical obstruction. PTJV is relatively contraindicated due to near total airway obstruction below vocal cord.[2] In addition to risk of serious complications such as air embolism, extensive cervical emphysema, pneumothorax, and damage to the esophagus occur if jet ventilation is tried with misplaced cannula.[3] Rigid bronchoscopy ventilation was impossible as the smallest endoscope of size 2.7 mm could not bypass the mass. PCC is not easy in infants. Moreover, it is challenging to obtain a proper angle to insert PCC without the risk of perforation of posterior tracheal wall.[4] Emergent tracheostomy should be considered as the first step if an ENT surgeon is available.[5] The management of cannot intubate, cannot ventilate scenario needs vast experience in airway assessment, unshaken confidence, with extreme cooperation between anesthetists and ENT surgeons. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Comment on published article: Cannot intubate and cannot ventilate scenario in an infant for airway assessment

Sir, We read with interest the article by Mahfouz et al.[1] on cannot intubate cannot ventilate (CICV) scenario in an infant for airway assessment. We congratulate the authors for their successful management of CICV in this case. However, we have a few concerns regarding the management of this case. This 6-month-old baby was brought to the hospital with difficulty in breathing and severe stridor, and having suprasternal and intercostal recessions with conducted sounds on auscultation. The child was not maintaining oxygen saturation above 90% with 4 L of oxygen. In such a condition, a preoperative computed tomography scan which can clearly show the airway anatomy and if facility is present, an added virtual bronchoscopy (VB) can obviate the need for airway assessment under general anesthesia. VB is a noninvasive, uncomplicated and reproducible method in patients with an indication for airway assessment and could be used clinically as a safer alternative.[2] Airway guidelines for children are for an unanticipated difficult airway and not for anticipated difficult airway or lower airway obstruction as in the present case.[3] Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Case 1: The Impact of Methylergometrin Maleate Toxicity on Neonates

A full-term male neonate of 2.6 kg birthweight is born via a spontaneous vaginal delivery to a mother who denies any unfavorable obstetric or medical history. The delivery occurs at a peripheral hospital without any labor challenges. Approximately 20 minutes after delivery, the neonate develops central cyanosis and respiratory distress, for which he receives respiratory support in the form of oxygen through a nasal cannula. A decision is made to refer him to a tertiary NICU. On arrival at the NICU, lung auscultation reveals bilateral equal air entry, no adventitious sounds, subcostal and intercostal recessions, a respiratory rate of 70 breaths/min, and oxygen saturation above 95% in room air. Normal first and second heart sounds are heard, plus a systolic 3/6 murmur over the left upper sternal border; the heart rate is 155 beats/min, mean blood pressure is 60 mm Hg (75/50 mm Hg), and echocardiography shows an insignificant patent ductus arteriosus and small atrial septal defect secundum. The abdomen is soft and lax with no organomegaly detected. Neurologic examination shows lethargy, hypotonia, hyporeflexia of the deep tendon reflexes, and diminished primitive reflexes; the pupils are 2 mm in diameter with sluggish reaction to light bilaterally. Cranial ultrasonography depicts partially effaced ventricles as well as cerebrospinal fluid spaces denoting the possibility of …

Case report on Tracheoesophageal Fistula with review of current literature

Major structural anomalies occur in 2-3% of live births all around the World. The reported global incidence of tracheoesophageal fistula (TEF) is roughly 1 in 2,500 live births varying by region. In Pakistan, incidence is reported only by those tertiary care centers that have pediatric surgery facilities available, making it an underreported and often mismanaged condition. We report a case of esophageal atresia (EA), rectovaginal fistula and tracheoesophageal fistula associated with Meconium Aspiration Syndrome (MAS) in an infant. The baby was 2 days old when she arrived at our center, born at 34 weeks, and weighed 2.3 kilograms. There was no significant antenatal history except that the mother was on antihypertensive drugs. The baby had an Apgar score of 3 and 4 at 1 and 5 minutes respectively, severe respiratory distress and cyanosis. Her chest examination revealed subcostal and intercostal recessions, bilateral crepitation and tachycardia at 180/minute. She was immediately put on ventilator and required frequent suctioning due to excessive secretion, developed abdominal distension, and had multiple episodes of desaturation and cyanosis. Complete blood picture showed leukocytosis and arterial blood gases signifying metabolic acidosis. Upon trying to pass to a catheter, baby passed stool through vagina. Contrast esophagogram showed evidence of distended stomach and proximal small bowel loops. No evidence of air was seen in the rectum. On passing the nasogastric tube into the esophagus, it curled on itself at D4 level with evidence of blind-ending proximal esophageal pouch that dilated with contrast medium. On 10th day of life baby’s condition deteriorated despite all efforts. Eventually she stopped breathing, her pupils dilated and all efforts to resuscitate her failed. This report highlights the importance of thorough clinical examination and availability of support facilities in a pediatric unit. TEF/EA should be suspected in any newborn who presents with respiratory distress, drooling, history of polyhydramnios with an inability to pass nasogastric tube. The parents should also be counselled as TEF/EA carries a 1% risk of recurrence.

Frequency of foreign body inhalation in eight month duration admitted in Paediatric intensive care unit of Abbasi Shaheed hospital (tertiary care centre)

We present four cases of foreign body inhalation in eight month period (May-Dec 2016) admitted in pediatric intensive care unit (p.i.c.u) of Abassi Shaheed Hospital. Age range was eleven months to four years. Male gender was predominant among the case series. All of the cases presented with sudden onset of respiratory distress along with fever and cough. On examination all patients were febrile, tachpneic, tachycardic with subcostal and intercostal recessions. A working diagnosis of severe pneumonia was made and child was put on intravenous antibiotics and nebulizations. After 48 hours of admission, there was no improvement clinically so suspicion of foreign body was made on the basis chest of x-ray. Rigid bronchoscopy was done; foreign body peanut (1), chicken bone (1) and betel nut (2) were found. All children showed rapid improvement after removal of foreign body and were discharged soon after. Parents were counseled regarding addiction of betel nut and avoidance of foreign body inhalation in growing children. Hence we conclude that foreign body inhalation should be kept as a differential diagnosis in every child presenting with respiratory distress without improvement despite treatment. Parents should also be counseled for being vigilant around their children. There is no conflict of interest.

Tertiary center experience with primary endoscopic laryngoplasty in pediatric acquired subglottic stenosis and literature review.

Background and objectivesTo share our experience with primary endoscopic laryngoplasty in pediatric acquired subglottic stenosis and critically review the previously published studies.SettingTertiary Referral Centers, King Abdulaziz Medical City, Riyadh, Saudi Arabia.Patients and methodsA retrospective case series study was conducted, where the case notes of all pediatric patients who underwent endoscopic management as a primary surgical intervention for acquired subglottic stenosis (SGS) from 2004 to 2014 were reviewed. All patients who underwent surgical correction with primary open laryngoplasty for congenital subglottic stenosis had been excluded.ResultsA total of 60 patients with a workable diagnosis of subglottic stenosis were reviewed. Forty-five patients were included in the study and 15 patients were excluded because they underwent open laryngoplasty as a primary treatment modality for congenital subglottic stenosis. The majority of the patients were males 29 (64%), with 16 (36%) females. The main presentation was stridor and intercostal recession. Thirty-nine (86%) patients had subglottic stenosis due to prolonged intubation; 5 (11%) patients were idiopathic and one patient (3%) had inflammatory reasons. The site of stenosis was isolated SGS in 41 while 4 patients had glottic-subglottic stenosis (GSGS). In terms of the grade of stenosis: 13 patients had grade I; 23 had grade II and 9 had grade III. The character of stenosis was soft except in 5 patients with hard (mature) scar. The number of dilatation procedures ranged from 1 to 6 with a mean of 2. The endoscopic management was considered to be successful when the patient is completely asymptomatic after the follow up period of one year. No major complications were recorded among the patients. Thirty-seven (82.3%) patients had a benign course post endoscopic intervention without complications and 8 (17.7%) underwent a secondary open surgical management due to re-stenosis (P value < 0.01).ConclusionOur study showed that primary endoscopic management was successful in 82.3% of cases of acquired subglottic stenosis including those with high grade stenosis and long segment of more than 12 mm in terms of the craniocaudal length. CO2 laser was an important tool to convert mature hard stenotic segment into a soft one. The latter yielded to the lateral pressure created by balloon dilatation better.

Development and internal validation of a clinical rule to improve antibiotic use in children presenting to primary care with acute respiratory tract infection and cough: a prognostic cohort study

SummaryBackgroundAntimicrobial resistance is a serious threat to public health, with most antibiotics prescribed in primary care. General practitioners (GPs) report defensive antibiotic prescribing to mitigate perceived risk of future hospital admission in children with respiratory tract infections. We developed a clinical rule aimed to reduce clinical uncertainty by stratifying risk of future hospital admission.Methods8394 children aged between 3 months and 16 years presenting with acute cough (for ≤28 days) and respiratory tract infection were recruited to a prognostic cohort study from 247 general practitioner practices in England. Exposure variables included demographic characteristics, parent-reported symptoms, and physical examination signs. The outcome was hospital admission for respiratory tract infection within 30 days, collected using a structured, blinded review of medical records.Findings8394 (100%) children were included in the analysis, with 78 (0·9%, 95% CI 0·7%–1·2%) admitted to hospital: 15 (19%) were admitted on the day of recruitment (day 1), 33 (42%) on days 2–7; and 30 (39%) on days 8–30. Seven characteristics were independently associated (p<0·01) with hospital admission: age <2 years, current asthma, illness duration of 3 days or less, parent-reported moderate or severe vomiting in the previous 24 h, parent-reported severe fever in the previous 24 h or a body temperature of 37·8°C or more at presentation, clinician-reported intercostal or subcostal recession, and clinician-reported wheeze on auscultation. The area under the receiver operating characteristic (AUROC) curve for the coefficient-based clinical rule was 0·82 (95% CI 0·77–0·87, bootstrap validated 0·81). Assigning one point per characteristic, a points-based clinical rule consisting of short illness, temperature, age, recession, wheeze, asthma, and vomiting (mnemonic STARWAVe; AUROC 0·81, 0·76–0·85) distinguished three hospital admission risk strata: very low (0·3%, 0·2–0·4%) with 1 point or less, normal (1·5%, 1·0–1·9%) with 2 or 3 points, and high (11·8%, 7·3–16·2%) with 4 points or more.InterpretationClinical characteristics can distinguish children at very low, normal, and high risk of future hospital admission for respiratory tract infection and could be used to reduce antibiotic prescriptions in primary care for children at very low risk.FundingNational Institute for Health Research (NIHR).

Cases for paediatrics and child health (March 2016)

Case 1 and note that she is tachycardic and has a peripheral capillary refill time of 4 seconds. You request an ECG (Figure 1): What does this ECG show (Figure 1)? A 6-week-old baby, Danny, presents to A&E with cough, respiratory distress and reduced feeding. Danny was born at term by spontaneous vaginal delivery, following an uneventful pregnancy, other than Mum missed some pregnancy blood tests and immunizations. Danny was discharged home well, 8 hours after birth. Danny’s older brother has had coryzal symptoms this week but has been generally well in himself. On arrival in A&E Danny demonstrates subcostal & intercostal recessions with head bobbing and has saturations of 89% in air. Which of the following actions would you include in your initial management plan: (choose 2): 1. Start face mask oxygen 2. Start optiflow 3. Intubate and ventilate 4. Give him a bottle 5. Insert an NG and give him 150 ml/k/day milk 3 hourly 6. Stop his feeds and observe him for 1 hour 7. Insert a central line and start TPN 8. Prescribe a hypertonic saline nebulizer What is the most likely diagnosis: (choose 1)? 1. Pneumonia 2. Bronchiolitis 3. Congential heart disease 4. Pertussis 5. Viral induced wheeze After 48hours,Danny is noted tobehavingboutsof coughing during which he becomes very distressed and develops a very red face. He desaturates during these episodes and then developed apnoeas. A pernasal swab is sent and he is diagnosed with Bordetella pertussis. You start him on erythromycin. What are the concerns for starting a macrolide antibiotic in this age group: (choose 2) 1. Increased risk of developing hypertrophic pyloric stenosis 2. Increased risk of developing asthma 3. Increased risk of developing cardiac arrhythmias 4. Increased risk of apnoeas 5. Increased risk of developing diabetes mellitus type 1

Case 1: A Newborn with Acute-Onset Respiratory Distress and Encephalopathy

A term male infant is born to a consanguineous couple by emergency cesarean section for nonprogressive labor. The mother’s antenatal period was uncomplicated. Her first pregnancy resulted in an abortion in the second month of gestation. The newborn’s Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. The infant appears normal soon after birth and formula feeding is started. On the second day, he is noted to have fast breathing for which he is admitted to a local hospital and receives intravenous fluids, antibiotics, and oxygen. However, in view of worsening respiratory distress, the infant is referred to our center on the third day after birth. On admission to our NICU, the infant’s temperature is 97.2oF (36.2oC), he has tachypnea, with a respiratory rate of 90 breaths per minute and minimal intercostal recessions, oxygen saturation is 94% on room air, heart rate is 160 beats per minute, peripheral extremities are warm, capillary refill time is less than 3 seconds, and blood pressure in the right upper limb is 62/29 mm Hg (mean arterial pressure, 40 mm Hg). There is no dysmorphism, weight is 2.7 kg, and head circumference is 36 cm (90th percentile). On systemic examination, the liver edge is felt 3 cm below the right costal margin, and auscultatory …

Index of Suspicion in the Nursery

A term male infant born to a second gravida mother is referred to our hospital for new-onset respiratory distress. He was born by normal vaginal delivery and had Apgar scores of 8, 9, and 9 at 1, 5, and 10 minutes, respectively. The newborn begins breastfeeding immediately after birth and is shifted to the mother’s side. After 18 hours of delivery, he is noted to have fast breathing. A pediatric consultation is sought; a provisional diagnosis of congenital heart disease is made, and the patient is referred to our hospital. The antenatal period is uncomplicated. The results of targeted imaging for fetal anomalies performed at 20 weeks of gestation are reportedly normal. At admission, the newborn weighs 2.74 kg and has a temperature of 96.8°F (36oC), a heart rate of 175 beats per minute, a respiratory rate of 70 breaths per minute, and a blood pressure in the right upper limb of 58/26 mm Hg. The capillary filling time is prolonged to 4 seconds with weak and feeble pulses, and there is moderate to severe intercostal and subcostal recessions with an audible grunt. The baseline saturation is 85% in room air, which improves to greater than 95% on hood oxygen. On systemic examination, he has an …