Pediatrics: Causes of Wheezing in Infants and Toddlers

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Questions and Answers

Which of the following is listed as one of the most common causes of wheezing in infants and toddlers?

Cystic fibrosis (correct)

Tracheomalacia

Asthma (correct)

Gastroesophageal reflux

Paradoxical breathing is a sign of very severe respiratory distress.

True

What is the mainstay of treatment for an acute episode of asthma?

anti-inflammatory therapy with corticosteroids and bronchodilation with beta-2 agonists such as albuterol

______ syncytial virus (RSV) is the most common cause of acute bronchiolitis in infants.

Respiratory Signup and view all the answers

What is the common peak age of incidence for croup?

2 years Signup and view all the answers

Which of the following are common viruses that can cause croup?

RSV Signup and view all the answers

Viral pneumonia is typically treated with antibiotics.

False Signup and view all the answers

The treatment for bacterial pneumonia includes appropriate ____________ and supportive care.

antibiotics Signup and view all the answers

Match the lung exam finding with its description:

Stridor = Due to airway narrowing above the thoracic inlet Wheezing = Typically due to airway narrowing below the thoracic inlet Rhonchi = Coarse, low-pitched rattling sounds heard best in expiration Crackles = Finer breath sounds associated with fluid in the alveoli or with opening and closing of stiff alveoli Signup and view all the answers

What radiographic findings would you expect with an aspiration obstructing the right airway?

Flattened right hemidiaphragm on PA film, mediastinal structures remain in midline on right decubitus, shift towards left lung on left decubitus, hyperinflation with 'ball valve' effect causing air trapping and expiratory wheeze Signup and view all the answers

Asymmetric wheezing is a key finding in the radiographic diagnosis of foreign body aspiration.

False Signup and view all the answers

Which history question helps assess for dysphagia and potential aspiration?

Did the cough begin suddenly? Did you see her choke on anything? Signup and view all the answers

What is the significance of asking about the child's birth history in clinical reasoning?

Identification of underlying conditions like bronchopulmonary dysplasia that can contribute to cough and wheezing Signup and view all the answers

Study Notes

Causes of Wheezing in Infants and Toddlers

Viral bronchiolitis
Asthma
Foreign body aspiration
Gastroesophageal (GE) reflux
Tracheomalacia
Extrinsic compression (e.g. due to adenopathy, mass, vascular ring or sling or other anatomic airway lesion)
Cystic fibrosis

Diagnosing Wheezing Episodes

Ask about:
- Timing of the wheeze
- Association of symptoms with feeding
- Change of symptoms with position or activity
- Other exacerbating factors
Past history of wheezing episodes and response to treatment with bronchodilators or steroids

Signs of Respiratory Distress

Paradoxical breathing (thoracoabdominal dissociation): almost always a sign of severe respiratory distress due to respiratory muscle fatigue
Tachypnea: mild, moderate, or severe depending on the severity of the underlying process
Retractions: use of accessory muscles to augment breathing during respiratory distress
- Suprasternal, supraclavicular, and intercostal retractions
- Subcostal retractions
Nasal flaring: seen in younger children with significant respiratory distress, indicating use of accessory muscles
Grunting: forced expiration against a partially closed glottis, helping infants generate positive pressure to stent airways open
Head bobbing: use of accessory muscles of respiration (neck strap muscles) in young infants

Causes of Cough

Viral upper respiratory tract illnesses
Pneumonia
Post-nasal drip due to allergies and/or sinusitis
Foreign body aspiration
Gastroesophageal reflux
Cough can be dry or wet/junky, with different implications for diagnosis and treatment

Bacterial Respiratory Infections in Children

Bordetella Pertussis (Whooping Cough)
- Triphasic course: catarrhal stage, paroxysmal stage, and convalescent stage
- Complications: difficulty feeding, central nervous system complications such as apnea
- Immunization: acellular pertussis vaccine, but even with full immunization, vaccine efficacy is only 70-90%
Epiglottitis
- Life-threatening emergency, rare due to widespread immunization
- Etiology: Haemophilus influenzae type b (Hib), staphylococcal or streptococcal organisms
- Signs and symptoms: fever, stridor, drooling, dysphonia, dysphagia, respiratory distress
- Emergent intervention: prompt intervention in a controlled environment to secure the airway

Asthma

Pathophysiology: airway obstruction due to inflammation, mucus hypersecretion, and mucosal edema
Signs and symptoms:
- Acute exacerbations: cough, wheezing, tachypnea, dyspnea
- Chronic symptoms: recurrent episodes of dyspnea and/or cough
Radiographic findings: hyperinflation due to air trapping, increased interstitial markings, patchy atelectasis
Treatment:
- Acute exacerbations: anti-inflammatory therapy with corticosteroids, bronchodilation with beta-2 agonists
- Maintenance therapy: daily controller medication (inhaled corticosteroid), with an inhaled beta-agonist as needed for breakthrough symptoms

Bronchiolitis

Acute viral disease of the lower respiratory tract, most common cause of wheezing in infants
Pathophysiology: bronchiolar obstruction due to edema, mucus, and cellular debris
Signs and symptoms: wide spectrum of disease, including mild upper respiratory tract symptoms, fever, cough, wheezing, dyspnea
Radiographic findings: hyperinflation, increased interstitial markings, peribronchial cuffing, scattered atelectasis
Treatment: supportive, aimed at maintaining adequate oxygenation and hydration### Choking in Children
Choking is a significant injury risk in children, particularly in older infants and toddlers who explore the world by putting things in their mouths.
The risk of choking is greatest in this age group, and parents should be advised on methods to reduce this risk.

Vital Signs in Children

When evaluating a pediatric patient, it's essential to assess the stability of their condition to initiate urgent interventions or treatments.
Vital signs vary by age in children; for example, a respiratory rate of 55 may be normal in a newborn, but not in a 10-month-old.

History Considerations with Cough

When taking a family history, ask about heritable conditions that affect the respiratory tract, such as asthma, environmental allergies, and cystic fibrosis.
Explore social and environmental history, including:
- Exposure to sick contacts, which increases the likelihood of an infectious process.
- Childcare, which increases the risk of sick contacts.
- Tobacco smoke exposure, which can cause or contribute to a chronic cough.

Examining an Infant or Toddler

Adjust your approach to the child according to their age.
Infants (9-10 months) may develop stranger anxiety and cry when approached by strangers; having the parent hold the patient can reduce anxiety.
Older infants, toddlers, and some preschoolers can also become frightened when approached; use a calm and unhurried approach to examine them.

Anticipatory Guidance

After treating a child for an incident involving their safety at home, provide anticipatory guidance to prevent future events.
Counsel the family on how to prevent future events in a gentle, non-accusatory manner.

Radiographic Findings in Foreign Object Aspiration

In foreign object aspiration, radiographic findings may include:
- Flattened right hemidiaphragm on PA film, suggesting unilateral hyperexpansion on the right.
- Fixed hyperinflation of the right lung on right decubitus.
- Hyperinflation and air trapping with each breath, causing an expiratory wheeze.

Radiographic Diagnosis of Foreign Body Aspiration

Asymmetric wheezing is key to diagnosing foreign body aspiration, but it can also be caused by mucus plugging from asthma or bronchiolitis.
Radiography is necessary to further evaluate the etiology of wheezing, including inspiratory and expiratory films to demonstrate unilateral air trapping.

Clinical Reasoning

Key information in the cough history includes:
- "Is she still drinking?" to assess hydration status, breathing difficulty, and dysphagia.
- "Has she had a fever?" to assess for infectious processes.
- "Did the cough begin suddenly? Did you see her choke on anything?" to assess for foreign body aspiration.
- "Has her voice or cry been hoarse?" to assess for upper airway problems.
- "Has her cough been barky? Does she make any noises when she breathes?" to assess for croup or laryngotracheobronchitis.

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Description

This quiz covers the common and less common causes of wheezing in infants and toddlers, including viral bronchiolitis, asthma, and extrinsic compression.