12_10-month cough.pdf

Pediatrics 12: 10-month-old female with a cough User: Rohit Makol Email: [email protected] Date: July 13, 2024 7:42 PM Learning Objectives Knowledge Causes of Wheezing in Infants and Toddlers Most Common Less Common Viral bronchiolitis Tracheom...

Pediatrics 12: 10-month-old female with a cough User: Rohit Makol Email: [email protected] Date: July 13, 2024 7:42 PM Learning Objectives Knowledge Causes of Wheezing in Infants and Toddlers Most Common Less Common Viral bronchiolitis Tracheomalacia Asthma Extrinsic compression (for example, due to adenopathy, mass, vascular ring or sling or other anatomic airway lesion) Foreign body aspiration Cystic fibrosis Gastroesophageal (GE) reflux In order to distinguish between some of these causes, it is important to ask about: The timing of the wheeze Association of symptoms with feeding Change of symptoms with position or activity Other exacerbating factors It is important to find out if a child has wheezed in the past and, if so, whether the wheezing responded to treatment with a bronchodilator, such as albuterol, or steroids. If a child has a history of recurrent episodes of wheezing that respond to traditional asthma therapies, regardless of whether a diagnosis of asthma has actually been made, a subsequent similar wheezing episode is quite likely to be an asthma exacerbation. In a child with previous episodes of wheezing, it is also important to ascertain the severity of the child's asthma by asking about symptom control, prior hospitalizations, intensive care unit admissions, and intubations. Of course, other diagnoses always need to be considered as well. For a child's first episode of wheezing, diagnoses other than asthma need to be higher on your differential diagnosis until the diagnosis becomes clear. Signs of Respiratory Distress Paradoxical breathing Paradoxical breathing, also known as thoracoabdominal dissociation, is almost always a sign of very severe respiratory distress due to respiratory muscle fatigue. Paradoxical breathing occurs when the force of contraction generated by the diaphragm exceeds the ability of the chest wall muscles to expand the rib cage. As a result, the chest is drawn inward, or collapses, with inspiration, while the abdomen rises, or protrudes, due to downward displacement of abdominal contents. Paradoxical breathing is seen more commonly in infants and young children than in older individuals due to the greater compliance of the chest wall. Tachypnea Tachypnea may be mild, moderate, or severe depending on the severity of the underlying process. When assessing tachypnea, the depth and degree of effort should also be noted: Hyperpnea (increased depth of respiration) without respiratory distress may suggest a non-pulmonary condition such as fever, acidosis or extreme anxiety (hyperventilation syndrome). Hypopnea (reduced tidal volume) increases the proportion of each breath used to ventilate dead space, so may result in hypoventilation even in the setting of a normal or elevated respiratory rate. Retractions Retractions represent the use of accessory muscles to augment breathing during respiratory distress. Suprasternal, supraclavicular, and intercostal retractions occur due to excessive negative pleural pressure, and subcostal retractions occur when the diaphragm is flattened during inward pulling on the chest wall. Nasal flaring © 2024 Aquifer, Inc. - Rohit Makol ([email protected]) - 2024-07-13 19:42 EDT 1/8  Nasal flaring (enlargement of both nares during inspiration) is seen in younger children with significant respiratory distress and indicates that accessory muscles are being used for respiration. Grunting Grunting, another sign of respiratory distress seen in infants, consists of forced expiration against a partially closed glottis and is thought to help infants generate the positive pressure necessary to stent airways open. Head bobbing Another sign of respiratory distress in young infants is head bobbing, which is also due to use of the accessory muscles of respiration (in this instance, the neck strap muscles). In synchrony with each inspiration, the head is noted to bob forward owing to neck flexion caused by use of the neck strap muscles. Head bobbing is best observed during sleep. It is important to note that respiratory muscle fatigue will reduce the signs of respiratory distress even though a patient's condition is in fact deteriorating. In this situation, a blood gas may reveal elevation of PCO2 indicative of hypoventilation. Causes of Cough Cough can be seen in a large variety of conditions, such as: Viral upper respiratory tract illnesses Pneumonia Post-nasal drip due to allergies and/or sinusitis Foreign body aspiration Gastroesophageal reflux The timing of the cough and presence of exacerbating factors is helpful in distinguishing between these conditions. Cough is often described as either dry or wet/junky. A dry cough is typical of chronic asthma, whereas a wet cough suggests the presence of secretions in the airway, whether due to a viral or bacterial infection, post-nasal drip, gastroesophageal reflux or bronchiectatic disease such as cystic fibrosis. Bacterial Respiratory Infections in Children - Special Considerations While the most common infectious etiology of respiratory diseases are viral illnesses, several bacterial infections are important to keep in the back of your mind: Bordetella Pertussis Course Pertussis has a triphasic course: The initial catarrhal stage lasts 1-2 weeks and is characterized by upper respiratory tract infection symptoms. The paroxysmal stage that follows lasts 4-6 weeks and is characterized by repetitive, forceful coughing episodes followed by massive inspiratory effort, which results in the characteristic "whoop." Infants generally do not develop a "whoop" due to relative weakness of their inspiratory effort. The paroxysms of cough gradually decrease in frequency and severity as the convalescent stage is entered. Episodic cough may persist for months. Complications Infants with pertussis tend to have more complications than older children with pertussis. They may have difficulty feeding because of their cough, and they can also have central nervous system complications such as apnea. Immunization The acellular pertussis vaccine is recommended for all children. However, even with full immunization, vaccine efficacy is only 70-90%. Additionally, protection from the vaccine wanes with time such that many adolescents are unprotected from pertussis unless reimmunized as is currently recommended. Epiglottitis Epiglottitis is uncommon thanks to widespread immunization, but is important to consider in any child with stridor and respiratory distress. Etiology Epiglottitis is a life-threatening emergency that has historically almost always been due to infection with Haemophilus influenzae type b (Hib). Invasive infections with Hib, such as acute epiglottitis and pneumonia, are no longer common since the introduction of the conjugate Hib vaccine in the late 1980s. However, rare cases of epiglottitis still occur and, in immunized populations, are more commonly due to staphylococcal or streptococcal organisms than Hib. Epidemiology Epiglottitis presents most often in children between the ages of 2 and 5 years. © 2024 Aquifer, Inc. - Rohit Makol ([email protected]) - 2024-07-13 19:42 EDT 2/8  Signs and symptoms The diagnosis should be considered in a child or adult of any age with the presence of: Fever Stridor Drooling Dysphonia Dysphagia Respiratory distress Most patients will appear toxic and may position their airway in a sniffing position (sitting, leaning forward, with neck hyperextended and chin protruding). Emergent intervention When epiglottitis is suspected on clinical grounds, acute airway obstruction may be imminent. Prompt intervention in a controlled environment to secure the airway is mandatory. This is most often accomplished in the operating room by individuals skilled in airway management, usually an anesthesiologist and either a general surgeon or otolaryngologist. While awaiting these individuals, the child should not be disturbed or examined due to the risk of acute deterioration. Radiology Airway films are usually not indicated and may put the patient at risk. If done, the films may show thickening of the epiglottis (the "thumb sign") and thickening of the aryepiglottic folds. Diphtheria Although immunization has resulted in diphtheria being an uncommon disease in the U.S., this diagnosis should nonetheless be considered in a child with pharyngitis and a low-grade fever, particularly if stridor or hoarseness is present. The diagnosis is made when the characteristic gray pseudomembrane is seen in the pharynx. Your index of suspicion should be raised if the child is not immunized. Asthma Asthma is a disease of inflammation of the airways that results in airway obstruction. Pathophysiology Asthma is characterized by infiltration of inflammatory cells into the airway mucosa, mucus hypersecretion, and mucosal edema, accompanied by bronchoconstriction. Signs and symptoms Clinically, patients may present with an acute exacerbation or with more chronic symptoms. Acute presentations include cough, wheezing, tachypnea and dyspnea, with wheezing and diminished air exchange on chest exam. Although wheezing due to asthma is typically diffuse, focal wheeze may be heard in some settings such as mucus plugging. Signs of a more severe exacerbation may include minimal air exchange and absence of wheezing due to poor airflow, cyanosis and pulsus paradoxus. Chronic symptoms include recurrent episodes of dyspnea and/or cough. Radiographic findings Chest x-ray findings in asthma include hyperinflation due to air trapping, increased interstitial markings and patchy atelectasis. The primary goals of asthma therapy are to: Reduce airway inflammation Dilate the airways Treatment Acute The mainstays of treatment for an acute episode are anti-inflammatory therapy with corticosteroids and bronchodilation with exacerbation beta-2 agonists such as albuterol, together with supportive care for hypoxemia or dehydration. Choice of therapy for chronic asthma is based on the frequency, severity, and type of symptoms, as well as by other comorbidities. Maintenance Children with frequent symptoms are prescribed an inhaled corticosteroid as a daily controller medication, with an inhaled beta- therapy agonist such as albuterol as needed for breakthrough symptoms. Alternative and additional medications (such as montelukast) are also used under appropriate circumstances at older ages (> 4 years of age) as adjunctive therapy. Prognosis Prognosis is generally good but is highly dependent on ongoing medical management and patient adherence to therapy. © 2024 Aquifer, Inc. - Rohit Makol ([email protected]) - 2024-07-13 19:42 EDT 3/8  Bronchiolitis Acute bronchiolitis is a viral disease of the lower respiratory tract of infants and represents the most common cause of wheezing in infants. Pathophysiology It is characterized by bronchiolar obstruction due to edema, mucus, and cellular debris. Respiratory syncytial virus (RSV) is the most common cause, but other viruses such as influenza and parainfluenza can cause bronchiolitis as well. Signs and symptoms There is a wide spectrum of disease. Most children initially have mild upper respiratory tract symptoms and often a fever of 38.5-39 C. Respiratory symptoms can progress to cough, wheezing, dyspnea. Radiographic findings Chest radiographs may show hyperinflation, increased interstitial markings, peribronchial cuffing, and scattered atelectasis from bronchial obstruction. Treatment Treatment of bronchiolitis is supportive, aimed at maintaining adequate oxygenation and hydration. The use of additional therapies such as corticosteroids, bronchodilators, and hypertonic saline has been controversial, with some clinicians adhering to the principle that they are ineffective and other believing that they can be helpful under certain circumstances (such as a strong family history of asthma). Antibiotics may be indicated if there is evidence of secondary bacterial infection. See Ralston, et al. for more. Pneumonia Pathophysiology Pneumonia is due to inflammation of the lung parenchyma. It is generally caused by microorganisms, but noninfectious causes include aspiration of gastric contents or hydrocarbons. Etiology The most common cause of pneumonia in children is a respiratory virus, including: Adenovirus RSV Parainfluenza Influenza Bacterial infections are less common causes of pneumonia than viruses but tend to be more severe: In the neonatal period, bacteria transmitted from the maternal genital tract must be considered, including group B streptococcus, E. coli, and Klebsiella. Pneumonia due to Chlamydia pneumoniae usually presents with a staccato cough between 4 and 12 weeks of age. Streptococcus pneumoniae is the most common bacterial cause of pneumonia in the U.S. among infants beyond the neonatal period and children up to 5 or 6 years of age. In school-aged and older children, Mycoplasma pneumoniae is the predominant cause, followed by S. pneumoniae. Signs and symptoms The symptoms of viral pneumonia begin with a prodrome of upper respiratory tract infection symptoms including cough and rhinorrhea. The cough frequently progresses, and is accompanied by fever, tachypnea, and crackles on chest exam. Radiographic findings Viral Bacterial Chest x-rays in bacterial pneumonia typically show Radiographic Findings of viral pneumonia on chest x-ray are variable and may show diffuse airspace disease with lobar or segmental consolidation findings or patchy interstitial infiltrates, hyperinflation and small pleural effusions. and air bronchograms. In viral pneumonia, peripheral white blood cell counts tend to be normal or only slightly elevated. There may also be a lymphocytic predominance in the In bacterial pneumonia, peripheral white blood cell Lab findings white blood count differential. counts are usually elevated and have a neutrophilic predominance. Viral antigen or PCR testing of respiratory secretions may be helpful in making the diagnosis but is usually not necessary. Treatment of viral pneumonia Treatment of viral pneumonia is supportive, and the majority of children recover without sequelae. © 2024 Aquifer, Inc. - Rohit Makol ([email protected]) - 2024-07-13 19:42 EDT 4/8  Treatment of bacterial pneumonia Treatment of bacterial pneumonia includes appropriate antibiotics and supportive care. Prognosis for treated patients is usually excellent in previously healthy children, but varies depending on the bacterial etiology. Croup "Laryngotracheobronchitis" (aka croup) is a viral disease of the upper respiratory tract and is a common cause of cough and stridor in children, with a peak age of incidence of 2 years. Pathophysiology Most cases are due to parainfluenza. Other common viruses such as rhinovirus, RSV, influenza, and adenovirus can also cause croup. There is inflammation and edema of the pharynx and upper airways, with maximal airway narrowing occurring in the subglottic region. Signs and Symptoms Croup often starts with cold-like symptoms (congestion, coryza, sore throat, cough, and fever). This may progress to inspiratory stridor and a "seal- like" or "barky" cough. Radiographic findings A chest radiograph may demonstrate narrowing in the subglottic region ("steeple sign"). Treatment Treatment is generally supportive. Breathing humidified air or mist therapy can improve laryngospasm. Racemic aerosolized epinephrine can be used for acute improvement, and oral or IM dexamethasone can reduce the severity of symptoms. Key Findings on Lung Exam Stridor Due to airway narrowing above the thoracic inlet. Usually heard with inspiration, but can be biphasic if obstruction is severe. Wheezing Typically due to airway narrowing below the thoracic inlet. With mild airway obstruction, wheezing is usually heard only in expiration. With increasing obstruction, wheezing may become biphasic and may even disappear altogether when obstruction is severe. Although typically diffuse, focal wheeze may be heard in focal airway obstruction such as mucus plugging and foreign body aspiration. Wheezing can also be characterized as polyphonic or monophonic: Polyphonic wheeze is characterized by multiple pitches and is typical of asthma; monophonic wheeze is characterized by only a single pitch and is typical of focal airway obstruction. Rhonchi Coarse, low-pitched rattling sounds heard best in expiration. Thought to be due to secretions and narrowing of airways. Crackles Finer breath sounds heard on inspiration. Associated with either fluid in the alveoli or with opening and closing of stiff alveoli (as in interstitial disease). Sometimes described as either coarse or fine. (Coarse crackles are usually thought to be associated with purulent secretions in the alveoli as with pneumonia; fine crackles are often associated with pulmonary edema or interstitial lung disease.) Air entry The amount of air entry should be noted during every lung exam. Decreased air entry can be a sign of consolidation, atelectasis, pneumothorax, pleural effusion or airway obstruction. Bronchial breath sounds Lower in pitch and more hollow-sounding than normal breath sounds. Caused by air moving through areas of consolidated lung. Arterial PCO2 Arterial PCO2 is a clinical indicator of ventilation rate. As long as CO 2 production remains constant, alveolar ventilation rate is inversely proportional to arterial PCO2. Therefore, during hyperventilation there is low PCO 2, and during hypoventilation there is high PCO 2. Sequelae of Foreign Body Aspiration © 2024 Aquifer, Inc. - Rohit Makol ([email protected]) - 2024-07-13 19:42 EDT 5/8  The most commonly aspirated foods include hot dogs, hard candy, nuts, grapes, and popcorn. The composition of the foreign body determines the local tissue reaction. The fatty oils in aspirated food (such as peanuts) create a more severe pneumonitis than a similarly sized object made of plastic or metal, while a disc battery (such as a watch battery) may erode through the bronchial wall. Foreign bodies that lodge in the upper airway (trachea and bronchi) can be immediately life-threatening and are responsible for over 500 childhood deaths a year in the U.S. More than half of these deaths are in children under the age of 2 years. Choking Choking is just one of the many types of injuries for which children are at risk. The risk of different types of injuries changes during growth and development. For example, the risk of choking is greatest in older infants and toddlers who tend to explore the world by putting things in their mouths. Similarly, the risk of falls increases dramatically once children develop independent mobility. Parents should be advised of these risks and informed of methods for reducing those risks as much as possible. Clinical Skills Vital Signs in Children When evaluating a pediatric patient, it is always important to assess the stability of the patient's condition at the outset so that any urgent interventions or treatments such as oxygen or antipyretic therapy can be initiated. It is also important to recognize that vital signs vary by age in children. For example, although a respiratory rate of 55 may be normal in a newborn, the normal rate of a 10-month-old is 24 to 30 breaths per minute. History Considerations with Cough When soliciting the family history, it is important to ask about heritable conditions that affect the respiratory tract such as: Asthma Environmental allergies Cystic fibrosis Components of the social and environmental history that are important to explore include: Exposure to sick contacts Childcare Tobacco smoke The presence of sick contacts increases the likelihood of an infectious process. Daycare increases the likelihood of sick contacts dramatically even in the absence of known sick contacts. Cigarette smoke is an irritant to the respiratory system and can cause or contribute to a chronic cough in children. In a less acute setting, consider asking in more detail about the cigarette smoke exposure. Ask if anyone has ever smoked indoors or in the car and if those who smoke outdoors change their clothes before coming inside. That said, Anna's cough is not likely to be due to cigarette smoke exposure because she does not have a cough at baseline. But in a child with a chronic cough or with asthma that is difficult to control, you must consider secondhand-smoke exposure. Examining an Infant or Toddler It is important to adjust your approach to the child according to their age: At 9-10 months, infants frequently develop stranger anxiety and often cry when approached by strangers. Having the parent hold the patient in their lap and asking the parents to help with removing or putting on gowns or clothing may reduce the child's anxiety. Older infants, toddlers and some preschoolers can also become frightened when approached for the examination. Use a calm and unhurried approach, you will be able to examine most infants without causing them to cry. Anticipatory Guidance Even if you are not a child's usual clinician, after treating the child for an incident involving his or her safety in the home, it is probably best to give some anticipatory guidance before the child is discharged home with the parent or guardian. In some instances, such as if there were recurrent ingestions or signs of abuse or neglect, it might be necessary to contact social services for a home visit. When counseling the family on how to prevent future events it is important to do so gently in a non-accusatory manner. (The precise method will © 2024 Aquifer, Inc. - Rohit Makol ([email protected]) - 2024-07-13 19:42 EDT 6/8  depend somewhat on your relationship with them.) Finally, it is important to communicate with the primary care physician (PCP) regarding this patient. Initial counseling provided by you can later be reinforced by the child's PCP. Studies Radiographic Findings in Foreign Object Aspiration These are the findings you would expect with an aspiration obstructing the right airway: PA film (with the child in a sitting position): Right hemidiaphragm is flattened, suggesting unilateral hyperexpansion on the right. Right decubitus: With the child on her right side, the mediastinal structures remain in the midline, rather than shifting towards the right lung due to gravity, further demonstrating the fixed hyperinflation of the right lung. Left decubitus: With the child on her left side, the mediastinal structures shift towards the left lung as expected. Hyperinflation is seen in those foreign body aspirations that result in a "ball valve" effect, in which the aspirated object creates a partial obstruction to airflow during inspiration but fully obstructs the airway during exhalation. The result is air trapping with each breath and an expiratory wheeze. Alternatively, when an aspirated object causes a complete airway obstruction, the result is a total lack of airflow to the bronchus, which can lead to atelectasis and signs of volume loss on x-ray (e.g., mediastinal shift towards the affected side or elevation of the hemidiaphragm on the affected side). Wheezing may not be present in this scenario. Radiographic Diagnosis of Foreign Body Aspiration The key part of the exam that makes a foreign body aspiration the most likely is asymmetric wheezing. However, asymmetric wheezing can also be caused by mucus plugging from asthma or bronchiolitis. Radiography is needed to further evaluate the etiology of the wheezing. Inspiratory and expiratory films, which compare the relative inflation of the two lungs at each extreme of the respiratory cycle, can demonstrate unilateral air trapping, suggestive of a foreign body in one of the mainstem bronchi. Other causes of large airway obstruction include airway tumors and extrinsic compression as may occur with lymphadenopathy. (These causes are more common in adults than children, however, and are rare causes of airway obstruction in infants. One exception is in children from areas in which tuberculosis (TB) is endemic, as TB may manifest as airway obstruction.) Clinical Reasoning Key Information in the Cough History Question Comment This is an important question. Not only does it give you a sense of the child's hydration status, but it also provides information about her degree of breathing difficulty. Due to the need to coordinate breathing with sucking and swallowing, infants with respiratory distress or tachypnea often demonstrate some degree of distress with feeding, and they may require frequent pauses to catch their breath. Another reason this is a useful question is that it helps assess for dysphagia. Infants and children with difficulty swallowing may have a pharyngeal or esophageal foreign body, or they may have an infection in the epiglottis, pharynx, tonsils, or peritonsillar region. Finally, the presence of choking, coughing or gagging during feeds is "Is she still drinking?" suggestive of aspiration, as can occur with a laryngeal cleft or tracheoesophageal fistula. Of note, many parents become alarmed when their children do not eat well during illnesses, but this is a common and generic response to illness and malaise. With some exceptions (e.g., diabetes), it is less important that a child is eating solid food over a brief period of time than it is that a child is drinking fluids. That said, it can be helpful to distinguish difficulty with solid foods from that with liquids because the clinical implications are different. Coughing with liquids is suggestive of aspiration, whereas dysphagia with solids is suggestive of narrowing the posterior oropharynx or esophagus. A history of a fever would make an infectious process more likely but would not rule out other processes. "Has she had a fever?" Recurrence of fever several days into a respiratory illness can be seen with superimposed bacterial infections, including pneumonia. In any infant or child with a cough or wheezing, especially the first episode, it is important to find out if aspiration of "Did the cough begin a foreign body (e.g., toy parts, nuts, popcorn) is likely. suddenly? Did you see Even if there is no specific history of choking, foreign body aspiration always remains in the differential, particularly her choke on anything?" in infants and toddlers who tend to put everything in their mouths. In fact, most cases of foreign body aspiration in this age group are unwitnessed. © 2024 Aquifer, Inc. - Rohit Makol ([email protected]) - 2024-07-13 19:42 EDT 7/8  Particularly important in toddlers and older children, as it helps sort out whether the reason for her cough and wheezing is due to a problem in the upper airway (especially the pharynx and larynx) or her lower airway. "Has her voice or her cry Problems of the larynx and pharynx—such as pharyngitis, tonsillitis, epiglottitis, and other infections—often present been hoarse?" with a hoarse or muffled voice or cry. Problems isolated to the lower airway typically do not affect the quality of the voice or cry. A barky or seal-like cough would suggest a diagnosis of croup, or laryngotracheobronchitis, in a child this age. Croup occurs throughout the year but is most common in winter months. It is most common in children 2-5 years of age. It is usually due to a viral infection (most commonly parainfluenza virus type 1) that begins with non-specific URI symptoms and progresses to some degree of airway obstruction. Children typically have a barky cough and may "Has her cough been also develop inspiratory stridor. barky? Does she make With mild croup, inspiratory stridor may be heard only during agitation. As the severity of obstruction increases, any noises when she inspiratory stridor may be present even at rest and may progress to include expiratory stridor as well in severe breathes?" cases. Parents or caregivers often use the term "wheeze" to refer to many different respiratory sounds. It is therefore important to determine the timing in the respiratory cycle both by history and by physical examination in order to distinguish between wheezing and stridor; wheezing is more likely to be expiratory whereas stridor is typically inspiratory, but both can be heard throughout the respiratory cycle in more severe cases. (Listen to a recording of inspiratory and expiratory stridor.) It is important to gather information about other significant medical or developmental problems. "Does she have other Birth history is very important because a child born prematurely may have underlying respiratory conditions such as medical problems? Ear bronchopulmonary dysplasia that contribute to cough and wheezing. infections? Pneumonia? Spitting up? Chronic Asking about recurrent infections, stool pattern and difficulty gaining weight helps assess whether diarrhea? Trouble immunodeficiency or malabsorptive conditions such as cystic fibrosis may be present. gaining weight?" Asking about reflux symptoms is important in any child with a cough, although reflux usually contributes to a chronic rather than an acute cough. It is always important to know the immunization status of a child with a cough, because unimmunized or partially "Has she received all of immunized children have a significantly higher risk of acquiring infections such as pertussis, pneumococcal her immunizations?" pneumonia, influenza, etc. References Castro D, Patil SM, Keenaghan M. Arterial Blood Gas. In: StatPearls. Treasure Island (FL): StatPearls Publishing; September 12, 2022. Kaufman DA. Interpretation of ABGs. American Thoracic Society. https://www.thoracic.org/professionals/clinical-resources/critical-care/clinical- education/abgs.php. Accessed September 25 2023. Lone NA. Respiratory Acidosis. Medscape. https://emedicine.medscape.com/article/301574-overview. Accessed September 25, 2023. Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis [published correction appears in Pediatrics. 2015 Oct;136(4):782]. Pediatrics. 2014;134(5):e1474-e1502. doi:10.1542/peds.2014-2742 © 2024 Aquifer, Inc. - Rohit Makol ([email protected]) - 2024-07-13 19:42 EDT 8/8