Hot Seat Case #122: 10 day old with rapid breathing
Posted on: December 13, 2018, by : Michael Hrdy
Mike Hrdy, MD Children’s National Medical Center
with Rosemary Thomas, MD Children’s National Medical Center
HPI:
10 day old full-term female presents with a chief complaint of rapid breathing. Symptoms started two days ago with some fussiness and breathing that seemed faster than usual. The day prior to presentation the parents took the patient to the primary care doctor who noted the rapid breathing and referred them to the ED. A chest x-ray was obtained that was “consistent with bronchiolitis or reactive airway disease” but without focal opacities. The patient tolerated a feed and was not hypoxic or in notable respiratory distress during the period of observation in the ED.
On the day of presentation the patient again had symptoms concerning for increased work of breathing. The parents took videos that showed intercostal and sternal retractions. They returned to their primary care doctor who again referred them to the ER.
The parents report that the rapid breathing is more frequent after eating but doesn’t happen after every feeding. The baby is breastfed and appears to be latching and taking milk like normal with choking, coughing or sweating. >8 wet diapers in the last 24 hours.
ROS:
No fevers, no inconsolable crying, normal level of alertness, no vomiting or loose stool. No cough or cyanosis. Mild nasal congestion
PMHx: Born at 39.5 weeks via NSVD, has regained birth weight since last PMD visit
FHx: No family history of asthma. No one at home is sick.
SHx: Lives at home with mother and father, no other child at home
Physical Exam:
VS: T 37.2, HR 148, RR 36, BP 83/49, spO2 98% on RA
General: Alert. appropriate for age.
Skin: Warm. dry. pink.
Head: Normocephalic. atraumatic. anterior fontanelle soft and flat.
Neck: Supple
Eye: Normal conjunctiva. no discharge.
Ears, nose, mouth and throat: Oral mucosa moist
Cardiovascular: Regular rate and rhythm. No murmur. No gallop. 2+ femoral pulses, cap refill <2 distally
Respiratory: Lungs are clear to auscultation. Intermittent, mild subcostal retractions. breath sounds are equal.
Gastrointestinal: Soft. Nontender. Full, but non-distended. No organomegaly.
Genitourinary: Normal genitalia for age
Musculoskeletal: Normal ROM
Neurological: Alert. No focal neurological deficit observed.
The nurse tells you the blood was difficult to obtain, but she was able to get some tests as below.
POC Glucose: 74
VBG: 7.33/56.8/40.1/BE 2.9
POC lytes: Na 139, K 5.9, lactate 4.31
Repeat VBG overall similar except lactate of 1.71
CBC: 7.82>13.1/38<375
Flu A/B: negative
RSV: negative
It takes several hours for all the results to come back. During this period of observation, the patient’s highest respiratory rate is charted as 64, though most values are in the 30s-40s. He tolerates several feeds without difficulty. The parents admit the child looks different while in the hospital compared to how she looks at home. It’s now approaching midnight.
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Interesting case! If infant is looking well after several hours and family agrees, I would call PMD and try to d/c home, but make sure there isn’t something else the PMD is worried about as they have now been referred to the ED twice. I don’t think they need sepsis workup based on what you are describing. I would want to make sure there are no murmurs and that I have personally seen the CXR. Any concerns for tracheo or laryngomalacia? Thanks!
Respiratory distress is 95+% of the time pulmonary (bronchiolitis, pneumonia, pneumothorax, URI) in origin. The other <5% of the time, respiratory distress is cardiac (congestive failure, myocarditis), metabolic (IEM/acidosis, hypoglycemia), infectious (sepsis), or hematologic (anemia) in origin.
This patient had a reportedly normal CXR on visit #1, but apparently didn't get a repeat on visit #2. There was no murmur on exam, and no significant acidosis or anemia on laboratory evaluation. And, the child was witnessed to feed well in ED without respiratory distress, presumably without any audible stridor to address Dr. Isbey's final concerns. So, we are left with NOTHING!
I'd repeat the CXR on visit #2 (to look carefully at heart and lungs), obtain a full set of electrolytes to make sure that the K of 5.9 is not real and to assess the HCO3, obtain LFTs to evaluate for systemic HSV (this is a classic age of presentation!), and maybe consider a formal ECHO to assess cardiac function given the reported history of potential increased WOB following feeds at home. Having a blood and urine culture cooking is also reasonable.
Interesting case. Definitively a conundrum. We have a 10 day old with a negative prenatal history, with normal vitals, essentially normal exam, and importantly feeding and gaining weight well, presenting with intermittent WOB, possibly after feeds for 2 days.
Dewesh expressed the respiratory etiologies well; additionally I think of problems of breathing as stemming from the head (control center- post seizure, ICH/NAT), anatomy (nose/upper airway- i.e. nasal congestion, choanal atresia, TEF, GERD, foreign body), the lungs/heart, muscles (diaphragm or tone issues), or something systemic like Kussmal’s in metabolic acidosis, sepsis, withdrawal, pain.
My first pass would be a bedside glucose and BMP. I’d try to track down the newborn screen. I’m not inclined to repeat the CXR if it was done at our institution and the symptoms haven’t worsened, though intermittently persist. Regarding the workup that’s been done: It was a difficult blood draw- the VBG is borderline, I’m not overwhelmed by the pCO2 of 56 and mild acidosis. The first lactate is not worrisome in this scenario. K of 5.9 is not elevated in a newborn, up to 6.2 is considered normal. My vote was to observe in the ED (an admission to the hospital is essentially observe in the ED anyway). I would not pursue a sepsis workup or imaging like head CT at this time unless the baby worsens.
This case seems a bit much for periodic breathing since there are videos of retractions. Intermittent WOB makes me think of something episodic; i.e not sepsis or other etiologies mentioned above that persist/worsen. For example, our bronchiolitis babies start retracting again when the mucus builds up post suctioning. The association of the respiratory symptoms AFTER feeds makes me question some silent reflux potentially. It seems less likely cardiac in origin with a normal CXR, normal sats, good femoral pulses, no murmur and no HSM. Were any of these episodes witnessed in the ED? What is the baby doing during these episodes- is she alert? Post ictal? Look distressed? How long do these retractions last?