Posts for category: Symptoms
CDC.gov/rsv on 1/6/13 for picture credit
Sally is 9-months old; she developed a runny nose after a holiday party she attended with the family last week. Now her mom has been struggling all day to keep Sally comfortable. The doctors in the ED told her last night, Sally had bronchiolitis and she should administer these nebulizer medications to her at home and follow up with her primary care doctor.
What is Bronchiolitis, Doc?
Bronchiolitis is inflammation of a portion of the lower airways, most often triggered by viral infections of the lower airway. The term coined in a seminal article published in 1940 distinctly described this condition frequently seen in children < 2 years old in the winter months in temperate climates around the world. Medical jargon frequently makes its way into colloquial language and gets distorted. Bronchiolitis has suffered similar fate with however less distortion in its meaning and attendant respiratory implication. Most of us intuitively associate the term with respiratory problems even though; it is frequently used interchangeably and incorrectly with another distinct medical condition called, Bronchitis.
Why my baby, Doc? She’s so little and having a lot of trouble with the coughing and breathing.
The number of cases diagnosed with bronchiolitis goes up in the winter months, in tandem with the seasonal spread of the viruses that trigger the illness. These viruses reproduce very quickly once they get access to the cooler portions of the nasal passages and the cascade of lower airway inflammation begins shortly afterwards. The upper respiratory infection symptoms make it difficult for infants as obligate nose breathers to breathe. The mucus partially blocks the nasal passages and the need for gentle suctioning becomes a key portion of supportive therapy. The RSV (Respiratory Syncytial Virus) virus is perhaps the most commonly isolated culprit in the ranks of viruses that frequently make infants and young children come down with Bronchiolitis. Some members of Influenza virus family and a relatively newcomer called, human metapneumovirus are other potential big players.
The lower airway inflammation caused by these germs cause a lot of airway secretion, congestion and copious mucus production which narrows the lumen in these tiny airways even further and presents resistance to the flow of air and gas exchange which we all remember is the primary function of the lungs. Inhaling air is comparatively easier than exhaling air in these patients. Large portions of the inhaled air along with the other gases exchanged get trapped behind the mucus plugging in the lower airways. A narrowed airway creates a four-fold increase in resistance to airflow, which only worsens as the degree of airway obstruction, and narrowing worsens with the disease progression. Coughing and wheezing follow as symptoms of a process where the body tries to forcefully expel the air trapped in the lungs past these areas of airway obstruction. This is a compensatory mechanism in-built by nature to relieve the airway trapping and excessive lung stretching. It is possible though not common for an infant suffering from bronchiolitis to be infected by more than one type of virus.
What about the nebulizer? It doesn’t seem to help!
Bronchiolitis is indeed one of those illnesses where the cornerstone of therapy in infants is oddly aimed at relieving the most pressing symptoms and not the root cause. Home nebulizer kits are part of this limited scope arsenal. These kits are powered and generate a mist usually from instilled medications often prescribed for bronchiolitis, like Albuterol. Some infants respond favorably to these class of medications. They are designed to relieve the airway narrowing and obstructions described above and hopefully enhance airflow in and out of the lungs and provide comfort for the patient. The expectation is that the sequelae of the airway obstruction process like cough, wheezing will attenuate and maybe resolve with use. Many infants however do not respond as anticipated to these medications. Many patient factors beyond the scope of our discussion and the infant’s genetic legacy determine who might respond favorably to Albuterol and this remains an area of intense scientific scrutiny due to the huge disease burden presented by Bronchiolitis annually. Bronchiolitis caused by RSV and the potential for complications can be controlled to an extent with specific medications and antibody injections in select groups of patients. Steroid medications have also been shown to have limited use for many cases of bronchiolitis.
What do I do? Baby’s not breathing well!
Recognition of the signs of respiratory distress is a key part of the management of these infants. Premature infants are especially vulnerable to the severe complications of bronchiolitis. One of the most feared complications is Apnea. This refers to the cessation of breathing, which occurs insidiously over time in the affected infant. Increased work of breathing and increased rate of breathing are universally the key hallmarks- these situations warrant immediate medical attention. Any perception of impending respiratory failure is extreme and is truly a medical emergency and should be treated as such. Parents frequently pay more attention to the noisy breath sounds emanating from the nasal passages. These are often amenable to gentle suctioning and use of comfort measures like saline nose drops, positioning etc. A visit to your healthcare provider for evaluation is necessary in these cases to be sure signs of respiratory distress when present are not missed.
I’m so scared about her breathing and this RSV thing! Shouldn’t the hospital have admitted Sally? Isn’t the RSV supposed to be serious?
Hospital admission for bronchiolitis would be appropriate whenever skilled healthcare personnel make that determination. This is often based on the severity of Infants presentation and other factors directly affecting care of the patient. The isolation of RSV or Influenza viruses during testing at the point of care either in your primary care clinic or in the emergency department does not always mandate hospitalization. Average duration of hospital stay is between 3 to 7days and only patients sick enough to benefit from hospitalization should be admitted. These often involves patients needing oxygen support or other risk factors that make a more severe outcome likely for them. Other groups of patients would need frequent monitoring and access to their primary care provider to ensure a sustained pattern of improvement is established in the medical home.
Does this mean my baby will now have Asthma?
Attacks of bronchiolitis, especially those where the RSV virus is the infectious agent certainly increase the likelihood of reversible airway obstruction occurring time and again after the acute illness is over. This is what construes, asthma and yes there is a link with bronchiolitis. A host of other factors, especially family history of allergy based diseases and genetics and environmental factors like cigarette smoke, domestic pest infestation also affect the possibility of developing asthma after an episode of bronchiolitis. This is a possibility still and time with close monitoring will determine those who would go on to develop chronic airway problems.
There is no known cure for many of the viruses capable of causing bronchiolitis in infants. Infection control and prevention are very important. These viruses spread as droplets and do not float in the air we breathe contrary to the general impression. They travel no more than 3 feet even when aerosolized after a cough or sneeze. The infectious droplets linger on surfaces for extended periods and poor hand hygiene inevitably brings them to areas of the body like the face; nose etc. from these surfaces like : cordless handsets in the home, TV remote control, Door knobs, faucets etc. From here they gain access to the body’s airway tract and begin the illness. Clean hands will go a long way in controlling spread of viral infections. Common sense interventions, such as avoidance of kissing, cuddling sick persons would also stand to reason for the same reason stated above.
The concerns regarding the safety of routine OTC (Over The Counter) cold/cough medications in children < 4years are well known. Parents are frequently saddled with a difficult choice when children come down with cold symptoms and the need for something more than traditional comfort measures arises. We've had a number of questions regarding the safety to vapor rub and related medications as an adjunct from parents this season. Researchers at the Penn State College of Medicine, Hershey PA had a similar question and were able to demonstrate the benefit of vapor rub applications in treating some of the symptoms noted during an acute upper respiratory tract infection. In their study results published in the November 2010 issue of Pediatrics journal, vapor rub administration was described aptly as an attempt to “fill the therapeutic void” created by FDA restrictions for OTC cold/cough medication administration in very young children in 2007. Vapor rub was shown to better than no treatment in relieving the symptoms of nasal congestion and cough severity and cough frequency in this study. These symptoms tend to be some of the more disturbing ones in parents of children with acute upper respiratory tract infections. Vapor rub was shown to be a valuable adjunct in alleviating these symptoms, and sleep problems that characterize upper respiratory tract infections . VapoRub, Vicks is an example of this class of OTC medications and is licensed for topical use only and contains camphor along with other ingredients like eucalyptus oil and menthol. Camphor can be toxic when ingested and can lead to fatal outcomes in young children. This reinforces the need to review treatment options with your physician and ensure proper adherence to medication administration instructions and keeping all medications out of the reach of children.
Mom: Doc, Johnny has been pushing hard to go! each time he tries to poop, he strains to go because he’s constipated and I think the formula I switched to after I stopped breastfeeding when he turned 4 months, three weeks ago is responsible. I want you to give me a note for WIC to change his milk to soy formula. My neighbor says that helped her baby when he was younger.
This mother is expressing an often stated concern in clinical practice. She breastfed exclusively for the first 4 months and switched to cow-milk based formula when she found it harder to express adequate amounts of breast milk after resuming work. Breastfeeding is recommended exclusively for the first 6 months and through the first year of life. Other circumstances as in this mother affect adherence to this key recommendation. The urge to change formulas as a direct response to address perceived constipation problems as in the above scenario are very common. We’ll examine the facts together in this post.
The type of sugar in proprietary soy formulas is different from the lactose sugar commonly found in mammalian milk. The sugar type in soy formulas usually are slightly compounded forms of glucose or sucrose. These are more efficiently absorbed from the gut of young infants and are more likely as a matter of fact to result in firmer stools being passed when compared to lactose sugar based milk. They may actually make the defecation more exerting for the infant and trend towards true constipation by increasing the stool consistency.
Parents need to be counseled appropriately on newborn stool patterns. Straining in infancy is due to the developing maturation process which requires the infant to coordinate stool evacuation on many levels. This process starts by bearing down during closed expiration, followed by relaxation of the muscles lining the pelvic floor to straighten the bowel loop formed by the anal canal, all in someone lying down flat on their back! - this is usually no cake walk for the infant. Advances in age and maturation with development of trunk strength with time often make this process easier.
Pediatricians refer to stool consistency when talking about constipation in the newborn period. The passage of hard pellet-like stools, or adult-like formed stools are other clues to the possibility of true constipation in an infant. It is normal for infants like Johnny above to strain and grunt during the passage of soft-formed stools which are often pasty or “mustard-like” during infancy. The frequency of stool passage varies when breastfed and formula fed infants are compared. This variation is more marked in the first 4- 6 months of life before dietary supplements are introduced. Stool passage frequency can range from one small stool passed shortly after every feed in response to the in-built reflex that propels the gut after eating to once in a 5-7 day period in some exclusively breast fed infants.
The rush to home remedies for perceived constipation is just as as popular as formula changes and is often not warranted. Poorly absorbed carbohydrates like sorbitol in some fruit juices in the gut may aid true constipation, malt extract, Prune & prune juice etc are popular options lacking in direct evidence recommending routine use . Their use as with any intervention needs to be discussed first with your doctor if contemplating administration.
This information is for educational purposes only and not a substitute for professional medical care or advice. Always follow your healthcare provider’s instructions.
Children are not small-sized adults; newborn infants certainly have their own peculiar body functions that distinguish them from older children as well. We’ll look at the key body function of breathing and sleep in infants in this article, after all some authorities have estimated about a third of the average human life time is spent sleeping.
Obligatory nose breathing is found in infants and this makes them uninterested in breathing through their mouths if for whatever reason their noses are blocked partially from a cold, formula reflux etc. They sometimes generate increased effort to breathe past these partially blocked nostrils and generate harsh sounds as the air whistles past. The air passages behind the nose and pharynx leading into the lungs downstream make it easier for these sounds to be amplified which often causes a lot of concerns for the parent. Clearing the nostril with gentle suction devices along with comfort measures as directed by your physician go a long way to reduce the nasal congestion, reduce the turbulence and improve infants comfort. Better feeding outcomes commonly follow since when the infant is able to breathe better, sucking and swallowing through the mouth becomes easier.
Infant breathing patterns are different too. A number of factors including airway anatomy and prematurity may affect breathing patterns in other ways too. We will concern ourselves with newborns who are born full-term and with no existing medical problems who often demonstrate a normal breathing pattern described as, Periodic Breathing in the medical literature.
Periodic breathing is defined as 3 breathing pauses usually lasting about 3 seconds or more within a 20 second portion of the normal breathing cycle. This time-based definition is useful but the overall breathing pattern and condition of the infant while the event occurs gives a complete picture and will alert the parent to the presence of a problem if one exists. Sometimes several of such pauses occur after one another and are quickly followed by another set of shorter, rapid breathing cycles before the sleep rhythm is restored once again to steady pattern. Sleep is divided by experts into two phases called REM( rapid eye movement) and non-REM. These respiratory pauses are more frequent and shorter during the REM sleep phase. These brief pauses and breathing irregularity as described above are normal and seen in healthy newborns. They do not require any form of stimulation as the infant resumes normal breathing on its own. Never shake baby in an effort to restart breathing, this can cause severe injury to the developing brain. Periodic breathing episodes are not associated with changes in skin color or other body functions and are normal in infants. The events get fewer and farther apart as the infant gets older. The popularity of smart phones with video recording capability has been useful for me in my practice and I encourage parents sometimes to record portions of the sleeping infant for me to review with them.
Prolonged episodes of breathing cessation from any cause can be life threatening and should be discussed immediately with your physician. A time-based criteria for medical intervention has been set at 20 seconds of breathing cessation in newborns- a term called Apnea. Medical evaluation is warranted even if these episodes of breathing cessation are less than 20 seconds and are accompanied by changes in body function which may include, skin color changes around the mouth, limpness, pulse changes etc but not limited to these. Parental concerns about airway symptoms especially that persist or change from previously assessed as normal state, or worsen need to be brought to medical attention immediately.
Infants should always be put to sleep on their backs for sleep, along with use of a firm mattress. Stuffed toy animals while pretty and nice should not be used in a baby’s crib; neither should pillows. Infants do not need these items and their use may actually increase the likelihood of accidental smothering and the dreaded, Sudden Infant Death Syndrome (SIDS). Co-sleeping with infant is discouraged for similar reasons. Airway irritants like cigarette smoke increase risk of SIDS and adversely affect the local defense mechanisms along the airway, ear, nose and throat. Infants exposed to these irritants have more frequent episodes of respiratory illnesses and ear infections.
This information is for educational purposes only and not a substitute for professional medical care or advice. Always follow your healthcare provider’s instructions.
Airway Injury Associated With Humidifier “White Dust”
Physicians at the University of Utah, Respiratory medicine department reported a case involving a patient seen in their facility in the January 2011 issue of, Pediatrics. After exposure to “white dust” dispersed incidentally from the use of an ultrasonic home humidifier machine, the 6-month old infant went on to have lower respiratory tract injury with attendant clinical features and a prolonged recovery.
Home Humidifiers are commonly used to relieve symptoms associated with acute respiratory tract infections in young children and are especially popular in the winter months annually. Benefits with the use of these devices have not been documented. It is noteworthy that the Environmental Protection Agency has not found any adverse health effects related to humidifier use as well.
Humidifier white dust can be generated as part of the normal functioning of these devices and while in full adherence to manufacturer specifications for usage. This may represent a concern for airway injury or reactivity in infants and young children, yet the true risks of home humidifier use have not been well studied and the case report mentioned above rank lower in the hierarchy of medical evidence and do not prove causality. Humidification may reduce patient discomfort in the setting of cold symptoms and nasal congestion, further evaluation by a medical professional is recommended if parental concerns should arise or symptoms worsen.
This case however raises important questions about the safety of exposing infants and young children to humidifiers and emphasizes the need for further study.