Paediatrics
Tobias Hunt
Outline
Station 9.1: Acute bronchiolitis
Station 9.2: Respiratory distress in the new born
Station 9.3: Viral-induced wheeze
Station 9.4: Infective exacerbation of cystic fibrosis
Station 9.6: Sickle cell chest crisis
Station 9.1: Acute bronchiolitis
You are a junior doctor in the emergency department. A 6-month-old baby, Sara Smith, is brought in with a 3-day history of cough, runny nose and red eyes. Today she has become very breathless, and is not feeding. Please assess the baby and instigate appropriate management.
Initial Assessment
Airway
‘The airway is patent, with no obstruction. No apnoeas or cyanotic spells are seen or reported.’
No additional airway support is required, though CPAP or intubation might be considered if the baby deteriorates.
Breathing
‘RR 70/min, oxygen saturations are 90%, with intercostal recession, tracheal tug, nasal flaring, and abdominal breathing. Crackles are heard throughout the lung fields bilaterally, with occasional wheeze, and reduced air entry at the lung bases. Mum is breast-feeding, and normally feeds for 15 minutes every 3 hours, but today has only managed to feed for 5 minutes in 6 hours.’
Don’t forget that crepitations could be a sign of heart failure. 
Given the above, you give supplementary nasal cannulae oxygen (since saturations are below 94%), and you prescribe a hypertonic sodium chloride nebulizer. A trial of salbutamol may be considered in older babies but this should not be continued if the initial trial is ineffective.
We had an un-immunized patient present to A&E that was treated as a presumed bronchiolitis. They had a significant cough, and started developing apnoeas. However, the blood results showed significant lymphocytosis. This was then recognized as a case of pertussis, and confirmed on pernasal swab. The lymphocyte count is an important clue to this diagnosis. 
Figure 9.1
Figure 9.2
Figure 9.3
Circulation
‘HR 180 bpm, BP 60/40 mmHg, CRT 4 seconds centrally, 6 seconds peripherally. Anterior fontanelle is slightly sunken, as are the eyes, and the mucous membranes are dry. Sara has only had one wet nappy today, when usually she would have three by this time. Cardiovascular exam shows normal heart sounds with no murmurs or hepatomegaly.’
The baby has signs of dehydration, and will require IV access and a fluid bolus, given as 20 mL/kg 0.9% sodium chloride, followed by reassessment. Bloods and a blood gas can be sent at the same time.
Initial Investigations
Bloods: FBC, U&Es, CRP. Look for evidence of infection, assess renal function and hydration status
CXR: Will potentially show patchy changes consistent with bronchiolitis or pneumonia (though these are difficult to differentiate radiologically). Other respiratory pathology such as pneumothorax can be ruled out. The cardiac shadow may be suggestive of congenital heart disease (such as cardiomegaly or a boot-shaped heart in tetralogy of Fallot), which is an important differential. A CXR is not always required and is best reserved for severe cases or if the diagnosis is in doubt
‘Capillary blood gas shows a respiratory acidosis, with no metabolic compensation. pH 7.28, PaCO2of 7.5 kPa, HCO322 mmol/L, BE−0.5 mmol/L. Hb is 145 g/L, WCC 15×109/L, neutrophils 8×109/L, lymphocytes 4.5×109/L. Na 131 mmol/L, urea 9.3 mmol/L, creatinine 45 µmol/L. CRP is 20 mg/L. NPA is positive for RSV. CXR shows diffuse patchy changes in both lung fields. Weight is 6 kg.’
Table 9.1
Sara’s blood test results and ABG
| Parameter | Value | Normal range (Units for 6 month olds) |
| Haemoglobin | 145 g/L | 105–150 (g/L) |
| WCC | 15×109/L | 6–14 (×109/L) |
| Neutrophil | 8×109/L | 3.7–6.7 (×109/L) |
| Lymphocyte | 4.5×109/L | 1.7–4.1 (×109/L) |
| Platelet | 160×109/L | 150–400 (×109/L) |
| CRP | 20 mg/L | 0.8–11.2 (mg/L) |
| Urea | 9.3 mmol/L | 1.8–6.4 (mmol/L) |
| Creatinine | 45 μmol/L | 2.65–44.2 (μmol/L) |
| Sodium | 131 mmol/L | 134–144 (mmol/L) |
| Potassium | 4.0 mmol/L | 3.5–5.6 (mmol/L) |
| pH | 7.28 | 7.35–7.45 |
| PaCO2 | 7.5 kPa | 4.7–6.0 (kPa) |
| HCO3 | 22 mmol/L | 22–26 (mmol/L) |
| BE | −0.5 mmol/L | ±2 mmol/L |
Initial Management [1]
Calculating 24-hour volume requirements
e.g. if 25 kg:
100×10 for first 10 kg
50×10 for second 10 kg
20×5 for rest
=1600 mL/24 h 
Two-thirds maintenance of 600 mL=400 mL/24 h, prescribed as 16.7 mL/h.
Reassessment
‘Sara looks significantly improved. Her airway is patent. RR 55/min, oxygen saturations are 95%, on 2 L of nasal cannula oxygen, with mild intercostal recession, and nasal flaring. Crackles are heard throughout the lung fields bilaterally, but air entry is much improved. HR 140 bpm, BP 90/60 mmHg, CRT 1 second centrally, 2 seconds peripherally. Anterior fontanelle is normal, eyeballs are not sunken, and the mucous membranes are moist. It is worth noting that the salbutamol did not result in any improvement and should be discontinued.’
Handing over the Patient
‘Baby Smith is a 6 month old with RSV positive bronchiolitis.
She presented with significant respiratory distress and poor feeding following a 3-day history of coryzal symptoms. From a respiratory point of view, she has required supplementary oxygen and hypertonic sodium chloride, given with ipratropium. In terms of circulation, she was significantly dehydrated requiring a fluid bolus to which she responded well. RR 55/min, oxygen saturations are 95% on 2 L of nasal cannula oxygen, with only mild respiratory distress. She is haemodynamically stable and well hydrated.
Investigations show an initial respiratory acidosis, with a pH 7.28, PaCO2 7.5 kPa, BE−0.5 mmol/L on capillary gas. She initially was hyponatraemic with a Na+ of 131 mmol/L, and dehydrated (urea 9.3 mmol/L, creatinine 45 µmol/L). CRP 20 mg/L. CXR shows diffuse patchy changes in both lung fields, consistent with bronchiolitis.
The plan is to transfer to the ward in a cubicle, NBM on two-thirds maintenance fluids IV and 6-hourly hypertonic sodium chloride with ipratropium. She will need a repeat capillary gas, U&Es and blood sugar later this evening. Supplementary oxygen should be continued to keep saturations above 94%.’
Station 9.2: Respiratory distress in the newborn
You are a junior doctor working on a postnatal ward. You are called to assess a baby (male infant Jones) who is 12 hours old with a rapid respiratory rate. He was born by emergency C-section for failure to progress. Mum had antibiotics during labour due to fever. The baby was born in good condition, with no resuscitation required.
Differential diagnosis of respiratory distress in a newborn 
Initial Assessment
Airway
‘The airway is patent, and the baby can cry. There is no evidence of meconium staining.’
The baby does not require any airway support.
Breathing
‘The baby is pink, but has increased work of breathing with grunting, nasal flaring, tracheal tug and subcostal/intercostal recession. Air entry is good throughout the chest with no added sounds. His respiratory rate is 70/min, and his oxygen saturations are 92%. The baby has been unable to latch to the breast for the last 6 hours.’
Given the above, the baby is in need of respiratory support and further investigation. He will need admission to the special care baby unit (SCBU) and supplemental oxygen.
Circulation
‘HR 160 bpm, CRT 2 seconds centrally, 2 seconds peripherally. The apex is felt at fifth intercostal space, mid-clavicular line. The heart sounds are normal with no audible murmurs. Both femoral pulses are palpable.’
Disability
‘The baby is not alert and responds only to handling. He has a blood sugar of 1.7 mmol/L.’
The baby will require a bolus of glucose, given as 2.5 mL/kg of 10% glucose.
Figure 9.4
Figure 9.5
Figure 9.6
Figure 9.7
Initial Investigations
‘Capillary blood gas shows a pH 7.22, PaCO2 of 8.2 kPa, HCO318 mmol/L, BE−4 mmol/L. Hb is 190 g/L, WCC 36×109/L, neutrophils 22×109/L. CRP is 75 mg/L. Bilirubin is 95 mg/dL, which plots below the threshold for phototherapy. CXR shows lobar left-sided consolidation consistent with congenital pneumonia. The weight is 3.5 kg, which plots on the fiftieth centile.’
Table 9.2
Male infant Jones’s blood test results and ABG
| Parameter | Value | Normal range (Units) |
| Haemoglobin | 190 g/L | 150–240 (g/L) |
| WCC | 36×109/L | 9.1–34 (×109/L) |
| Neutrophils | 22×109/L | 5.6–21 (×109/L) |
| Lymphocytes | 10×109/L | 2.6–9.9 (×109/L) |
| Platelet | 145×109/L | 84–478 (×109/L) |
| CRP | 75 mg/L | 0.8–15.8 (mg/L) |
| Urea | 4 mmol/L | 1.1–4.3 (mmol/L) |
| Creatinine | 40 μmol/L | 2.65–44.2 (μmol/L) |
| Sodium | 131 mmol/L | 133–146 (mmol/L) |
| Potassium | 4.0 mmol/L | 3.5–5.5 (mmol/L) |
| Bilirubin | 95 mg/dL | <150 (phototherapy)<200 (exchange transfusion) (mg/dL) |
| pH | 7.22 | 7.35–7.45 |
| PaCO2 | 8.2 kPa | 4.7–6.0 (kPa) |
| HCO3 | 18 mmol/L | 22–26 (mmol/L) |
| BE | −4 mmol/L | ±2 (mmol/L) |
Initial Management [2]
Reassessment
‘The baby looks more alert, and the airway remains patent. RR 65/min, oxygen saturations are 97% in ambient incubator oxygen of 28%. The grunting has stopped but the work of breathing remains high. HR 160 bpm, BP 62/28 mmHg, CRT 1 second centrally, 2 seconds peripherally. Glucose is now 3.6 mmol/L, and the temperature is 37.0°C.’
Handing over the Patient
‘Baby Smith is a term newborn, currently 18 hours old, being treated for congenital pneumonia.
He was born by emergency caesarean for maternal chorioamnionitis. There were no other antenatal concerns. He developed respiratory distress over the first 12 hours of life, and required admission to SCBU.
From a respiratory point of view, he is in 28% ambient oxygen. His initial gas showed a mixed acidosis. His CXR shows congenital pneumonia. Cardiovascularly, he remains stable on monitoring. He initially required a glucose bolus for hypoglycaemia, and now remains NBM on 60 mL/kg/day 10% glucose with stable sugars. His bloods are also suggestive of infection and he is on benzylpenicillin and gentamicin. His bilirubin is well below the treatment line. He has received IM vitamin K. Mum has been updated.
The plan is to wean oxygen as tolerated, repeat a capillary gas, continue antibiotics for 5 days, chase blood cultures and repeat FBC U&Es, SBR and CRP in the morning. He will require a lumbar puncture now that he is stable in view of his raised CRP. Gentamicin levels are due to be taken before the third dose.’
Station 9.3: Viral-induced wheeze
You are a junior doctor in the emergency department. A 6-year-old named Emily is brought in with a 3-day history of runny nose and worsening wheeze. This is her first wheezing episode. Today she is becoming progressively more breathless. Please assess Emily and instigate appropriate management.
Discriminators between viral wheeze and asthma 
The presence of the following features suggest asthma:
Initial Assessment
Breathing
‘RR 50/min, oxygen saturations are 88%, with marked intercostal and subcostal recession, tracheal tug and abdominal breathing. The chest is hyperexpanded with increased anteroposterior diameter. On auscultation, there is minimal wheeze and reduced air entry throughout, with a very long expiratory phase. The child is not able to talk in sentences and can count to two only.’
Given the above features consistent with severe to life-threatening wheeze, you give facemask oxygen and nebulized salbutamol and ipratropium bromide (Atrovent®).
Figure 9.8
Figure 9.9
Circulation
‘HR 120 bpm, BP 110/65 mmHg, CRT 1 second. Cardiovascular examination is normal.’
Emily is cardiovascularly stable. Given the severity of the asthma attack it is worth siting IV access early for a blood gas and in case IV medication is required.
