Breathless Baby Flashcards
How do you assess poor feeding?
The volumes of milk taken before and now.
The timescale of the decline in feeding is important to get an idea of the duration of illness as feeding is often an important first sign.
Establish why he stops feeding i.e. if he is out of breath
Does the parent have any other ideas about a precipitating factor (ICE).
Up to a month of age the minimum milk requirement to provide enough calories to grow is 150mls/kg/day.
After 1 month this can be down to 100/mls/kg minimum so long as they are gaining weight.
So asking about the volume of milk taken and weight is important to work out if the baby is meeting their nutritional need.
What should you ask about the presenting complaint in a paediatrics history?
What to ask about the current illness
- When and how did it start?
- Was the child well before?
- Have there been any previous episodes of similar illness?
- How did it develop?
- What aggravates or relieves the symptom(s)?
- Any contact with similar illness in others/siblings, or infectious outbreaks?
- Any recent overseas travel?
- How has the illness affected the family?
-Have the symptoms kept the child from attending nursery/school?
In infants
- Pattern of feeding, bowel movements, and number and wetness of nappies.
- Sleeping/waking cycle, alertness and activity.
- Whether there has been weight loss or gain.
Further directed questioning
- Having established these facts:
- Form hypotheses about the possible diagnoses/problem.
- Test the hypothesis with appropriate further enquiry.
What should you ask in the past medical history in a paediatrics history?
Peri-conceptual history
o Establish whether there was any parental illness around the time of conception that may be relevant.
o Note whether the child was conceived naturally or by assisted reproduction.
o If relevant, establish whether the child is adopted (or in foster care) with due sensitivity to the child’s awareness of the facts.
History of pregnancy
Any factors relevant to fetal well-being should be recorded. For example:
o Antenatal infections (for example, rubella).
o Rhesus incompatibility and haemolytic disease.
o Exposure to prescribed, recreational drugs or over-the-counter (OTC) medication.
o Any maternal illness or problems in pregnancy.
Peri-natal history Factors pertinent to the child's health should be identified. For example: o Gestation. o Duration of labour- looking for increased risk of infection with prolonged rupture of membranes. o Mode of delivery o Birth weight. o Resuscitation required. o Birth injury. o Congenital malformations identified.
Neonatal period Relevant examples include: o Jaundice. o Fits. o Febrile illnesses. o Bleeding disorders. o Feeding problems.
Other relevant past history
This will include:
o Any subsequent illnesses, surgery, accidents or trauma.
o Results and any concerns from screening tests at child health clinics or school.
o Immunisation record.
o Travel details.
What should you ask about developmental history?
Parental recall of major milestones will usually give important information (such as sitting up, crawling, walking, talking, toilet training, reading).
It may be useful to ask how the child’s progress and milestones compare with siblings and peers.
Observations from other carers (school, nursery and extended family) may be helpful.
Which questions should you ask in the family history?
Relevant history. For example: o Previous miscarriages or stillbirths. o Diabetes mellitus. o Hypertension. o Renal disease. o Seizures. o Jaundice. o Congenital malformations. o Infections such as tuberculosis. • Note whether siblings and parents are all alive and well.
Consider conditions which may have a genetic component (such as coronary heart disease and cerebrovascular disease). Occasionally it is appropriate to address risk factors (such as familial hypercholesterolaemia) during childhood.
Consanguinity occurs more commonly in some cultures and may be relevant to inherited disease (particularly autosomal recessive conditions).
It can be useful to present findings by using a two-generation family tree.
Which questions do you ask in the social history?
Take care not to offend, when enquiring about the structure of the family unit, by making assumptions about who may or may not be present or ‘involved’.
Be prepared to allow information to come out gradually. Information may come from others (for example, nursing staff, play specialists, educationalists). Ask about:
o Who lives at home (and any role in childcare).
o Siblings (ages, health, problems).
o Play.
o Eating and sleeping patterns.
o Schooling and any problems.
o Pets.
o Housing issues or problems.
o Childcare (if a parent works or both parents work).
o Parental occupation(s).
o Smoking in the home.
Child abuse is a common problem. Child abuse comes in many guises and harm is inflicted in many different ways. Any such concerns may emerge from the social and family history and any concerns should be shared with colleagues and Social Services.
Which questions do you ask in the educational and emotional history?
It may be appropriate to ask specific questions about a child’s experience and attainments at school. This may include, for example, asking about ability to concentrate and to make progress with learning in reading, spelling and mathematics.
Any fear or anxiety about school should be explored. Bullying is common and can interfere with learning. Reports from teachers can be enlightening and supplement the history.
Emotional history:
Specific questions may be asked about mood, eating and sleeping habits, interests, hobbies and other activities.
Life events and emotionally disturbing events can have a major effect on well-being and general development.
What are the causes of tachycardia?
Upset baby
Pyrexia
Pain
Fear - stranger fear
Cardiac arrhythmia ie SVT-HR would normally be > 220 in this age with an SVT but would need to assess rate and look at ECG
Increase work – this would be similar to exercise. Adam is needing to use his accessory muscles to help with his breathing and oxygenation
Cardiac/circulatory failure - most likely due to associated prolonged capillary refill, enlarged liver, cool peripheries, history of becoming clammy on feeding, murmur.
Shock, including hypovolaemia secondary to an accidental or non-accidental injury always consider this.
Shock hypovolaemia secondary to third space loss such as sepsis this would cause cool extremities.
Endocrine i.e. hyperthyroid
What are the causes of abnormal respiratory examination?
Primary respiratory disease such as bronchiolitis
Congenital abnormality causing respiratory compromise such as diaphragmatic hernia
Cardiac disease- compensating for poor perfusion and hypoxia and also an element of pulmonary oedema
Shock due to hypovolaemia –compensating for poor perfusion, hypoxia and probable acidosis
Acute blood loss secondary to an accidental or non-accidental injury, i.e. subdural
o sepsis,
o 3rd space loss i.e. intersuseption
Metabolic conditions with compensatory breathing for either metabolic acidosis or metabolic alkalosis
Endocrine e.g. DKA, always consider is it Kussmaul’s breathing
Causes of increased sleepiness in a baby?
Hypoglycaemic due to poor feeding
Exhausted due to work of breathing and feeding
Encephalopathic due to infection both viral and bacterial
Encephalopathic due a high ammonia secondary to a metabolic condition
Neurological secondary to a head injury as could occur in an NAI, poor cerebral perfusion
Hypoxia - less likely in this case as saturations are 94%
What is bronchiolitis?
Bronchiolitis is an acute viral infection of the lower respiratory tract that occurs primarily in the very young. It is a clinical diagnosis based upon typical symptoms and signs.
Bronchiolitis is generally a self-limiting illness, and management is mostly supportive.
In the UK, the term describes an illness in infants, beginning as an upper respiratory tract infection (URTI) that evolves with signs of respiratory distress, cough, wheeze, and often bilateral crepitations.
What is the cause of bronchiolitis?
Bronchiolitis is caused by a viral infection, most often respiratory syncytial virus (RSV).
This is responsible for up to 80% of cases. Other possible viral causative agents include human metapneumovirus (hMPV), adenovirus, rhinovirus, and parainfluenza and influenza viruses.
In some cases, there may be infection with more than one virus.
What are the risk factors for bronchiolitis?
Environmental and social risk factors: o Older siblings. o Nursery attendance. o Passive smoke, particularly maternal. o Overcrowding.
Breastfeeding is considered protective and should be encouraged for this and other reasons.
Most admissions (85%) for bronchiolitis are in infants born at term with no risk factors.
What are the risk factors for severe bronchiolitis and/or complications?
o Prematurity (<37 weeks). o Low birth weight. o Mechanical ventilation when a neonate. o Age less than 12 weeks. o Chronic lung disease (e.g., cystic fibrosis, bronchopulmonary dysplasia). o Congenital heart disease. o Neurological disease with hypotonia and pharyngeal discoordination. o Epilepsy. o Insulin-dependent diabetes. o Immunocompromise. o Congenital defects of the airways. o Down's syndrome.
What is the presentation of bronchiolitis?
NICE advise that bronchiolitis should be considered in children under the age of 2 years who present with a 1- to 3-day history of coryzal symptoms, followed by:
o Persistent cough; and
o Either tachypnoea or chest recession (or both); and
o Either wheeze or crackles on chest auscultation (or both).
Other typical features include fever (usually of less than 39°C) and poor feeding.
Consider an alternative diagnosis such as pneumonia if temperature is higher and crackles are focal.
Consider viral-induced wheeze if there is wheeze without crackles, episodic symptoms and/or a family history of atopy.
Very young babies may present with apnoea alone, with no other signs.
What is included in the assessment of a child presenting with bronchiolitis?
Take a history, and examine the child, making note of capillary refill time, respiratory rate, heart rate, chest signs, etc. Following examination, measure oxygen saturation in any child with suspected bronchiolitis.
Consider referral to secondary care if the respiratory rate is >60 breaths/minute, or if there is inadequate fluid intake or there are signs of dehydration; also, if the child is less than 3 months of age or was born prematurely, or there is comorbidity (particularly respiratory or heart disease, or immunodeficiency).
Take into account social circumstances and the ability of the carer to assess deterioration.
Refer immediately if any of the following are present:
o Apnoea (observed or reported).
o Marked chest recession or grunting.
o Respiratory rate >70 breaths/minute.
o Central cyanosis.
o Oxygen saturation of less than 92%.
o The child looks seriously unwell to a healthcare professional
Differentials of bronchiolitis
Viral-induced wheeze- consider if there is wheeze but no crackles, a history of episodic wheeze, and/or a family or personal history of atopy.
Pneumonia.
Asthma
Bronchitis
Pulmonary oedema
Foreign body inhalation
Oesophageal reflux
Aspiration
Cystic fibrosis
Kartagener’s syndrome
Tracheomalacia
Pneumothorax
Investigations for bronchiolitis
- Pulse oximetry
- Viral throat swabs for respiratory viruses
- Fever >39°C or focal chest signs would prompt investigations such as a chest X-ray to rule out alternative diagnoses such as pneumonia, or complications.
Management of bronchiolitis in primary care
Most infants with acute bronchiolitis will have mild, self-limiting illness and can be managed at home. Supportive measures are the mainstay of treatment, with attention to fluid input, nutrition and temperature control.
Advise the parents that the illness is self-limiting and symptoms tend to peak between 3-5 days of onset.
Anti-pyretic agents are needed only if a raised temperature is causing distress to the child.
If referring to hospital, give supplementary oxygen whilst awaiting admission in children whose oxygen saturations are persistently below 92%.
Careful safety netting is important, teaching parents to spot deterioration and to seek medical review should this occur.
Management of bronchiolitis in secondary care
Even amongst hospitalised children, supportive care is the mainstay of treatment, including oxygen and nasogastric feeding where necessary.
Upper airway suction may be useful if there is difficulty feeding or a history of apnoea. Continuous positive airway pressure (CPAP) may be considered in those who have impending respiratory failure.
NICE advise not using bronchodilators, corticosteroids, epinephrine, antibiotics, montelukast, ribavirin and chest physiotherapy techniques.
Prognosis of bronchiolitis
Most children with bronchiolitis make a full recovery.
The illness is typically self-limiting, lasting 3-7 days. The cough settles within three weeks in most.
Bronchiolitis is more likely to be severe in children with chronic lung disease, who are under 3 months of age or who were born <32 weeks of gestation.
There is an association with long-term respiratory conditions such as asthma but it is not known if there is causality.
