It has been a busy, but otherwise completely banal Monday so far. "Shall I send the next patient in, doctor?", the nurse asks. A couple of seconds after you nod "yes", a mother and baby are in front of you. Thirty-three year old Jacqui is well known to you. You first saw her around a year ago, when she became pregnant for the first time. Following an uncomplicated pregnancy, her daughter Lily was delivered vaginally, at term. Thus far, both mother and baby have been healthy.
Three-month-old Lily is the patient today. "She has been coughing quite a lot lately", Jacqui says, and continues, "She is also a little unsettled, especially during feeding, and sometimes she vomits right after feeding, and now I'm short on breast milk." "She is hungry and fussy, but she won't latch on, so I tried formula, but she hasn't been too keen on that either. Do you think she is getting sick?", Jacqui asks worriedly.
Jacqui describes her baby's cough as non-productive, with white-colored vomitus. No other symptoms are present, her growth and development are age-appropriate, and all immunizations are up to date.
Upon examination, you note that Lily's heart rate is 140 bpm, respiratory rate is 30 cycles per minute, and temperature is 37°C. Her anterior fontanelle is open, and tympanic membranes and throat are of normal appearance. Auscultation of her chest reveals no untoward findings. Lily cries loudly during the physical examination, but shows good head support, and establishes brief eye contact. "Well, my guess is that Lily's cough is due to milk reflux", you say.
What will you recommend?
Jacqui doesn't look very happy with your suggestion. "She is only 3 months old, Doctor. Must I really start her on medication?" she asks. Her hesitance makes you realize that conservative management is probably a better option right now.
Two weeks later Jacqui brings Lily in again. "Lily's cough seems to have improved, Doctor", she begins. "But since two days ago, she has refused to feed, her stools are green, and last night, her cough was really bad!" Further questioning reveals that Lily's diapers are being changed five times a day, which is the same as before the onset of the green colored stools. No other symptoms are present.
Lily is visibly unsettled and continues to cry throughout the consultation. On physical examination, you note that her heart rate is 150 bpm, respiratory rate is 35 cycles per minute, and temperature is 37.7°C. Lily's anterior fontanelle is open, throat is red, and anterior lymph glands are swollen. The remainder of the examination, including auscultation of the chest and palpation of the abdomen, is unremarkable.
You realize that this is a typical presentation of an acute upper respiratory tract infection (URTI) and reassure Jacqui. "She sounds like she's got a cold, Jacqui," you tell her. She looks at you in disbelief. "But what about the green stuff, Doctor? Is her stomach upset as well?" "Green feces are usually a sign of not feeding well," you explain, and continue, "In Lily's case, it could be due to her sore throat. It's nothing to be alarmed about as long as she's has more than four wet diapers each day." "Be persistent at breastfeeding her, since she requires plenty of fluids. Unless her milk intake is less than half normal, you can treat her at home", you end. Jacqui is convinced by your explanation, and leaves contentedly.
A couple of days later, Jacqui is once more in your office, complaining that Lily's cough hasn't been getting any better, and that it now happens to be worse at night. On examination, Lily isn't unsettled, but does have what sounds like a productive cough. The physical examination is normal. "What do you think is wrong with her, Doctor?", Jacqui asks.
You open your mouth to respond, and then close it quickly, as your latent knowledge of medicine suddenly re-asserts itself ....
You explain that it is not unusual for children who have had a cold to develop such a cough, and that it will fade away on its own. No further tests or treatments are necessary. A relieved Jacqui thanks you for your explanation and leaves.
Several months later, you are in the middle of busy workday, when Jacqui returns to your office with the now eight-month-old Lily, who coincidentally, has a cough once more. "She was well earlier, doctor, but started coughing again and feeling warm since two days ago.", Jacqui says, looking very distraught. "I assumed she had a cold, but last night the cough was really bad and we were up all night. I think that she is struggling to breathe". As Lily coughs once more, you notice that it is a dry cough. On examination, Lily continues hugging her mother, while sitting in her lap, although Jacqui says that Lily is now able to sit on her own and has a very social babble. Her height and weight are age-appropriate. Lily's heart rate is 150 bpm, respiratory rate is 55 cycles per minute, temperature is 37.8°C, and SpO2 is 93%. There are noticeable subcostal recessions, and on auscultation of the chest widespread crackling and prominent wheezing can be heard. You realize that Lily needs hospitalization, and ask your staff to make the necessary arrangements, while you take care of her immediate management.
You hand Lily over to the pediatrics department. Not too long afterward, the resident pediatrician is on the phone, wanting to discuss Lily's case. "I think she's got bronchiolitis and have ordered a PCR for respiratory syncytial virus", your colleague says, and continues, "I've instructed the staff to ensure adequate hydration and monitor her for hypoxia." "Got it, thanks", you respond, while appreciating what he left unsaid. There was no need for corticosteroids in the first place ...
You hand Lily over to a nurse in pediatrics, who seems confused when she sees the order. "Are we treating her for croup, Doctor? Her cough doesn't sound very hoarse," she says doubtfully. Her reaction makes you re-evaluate your differentials. "Ah, of course not, I'm sorry! I'll correct that chart. She's got bronchiolitis. Please make sure she's getting enough fluids and monitor her for hypoxia," you say.
Thanks to excellent care from the pediatric team, Lily makes a good recovery from the episode of bronchiolitis and is discharged from the hospital 12 days later.
Jacqui comes to see you once more, just a few weeks before Lily turns one. "It's been a tough year, Doctor," she sighs. "Lily's cough just won't go away! She recently started going to child care, and every month for the last three months, she's had a cold and it's made her cough moist and much worse", she continues. "Sometimes I can hear her wheeze, Doctor" On further questioning, Jacqui denies a family history of asthma.
You examine Lily and discover normal chest and HEENT findings. You cannot detect any wheezing. You hear the child's cough and, given her history, you wonder if this might be airway hyperreactivity.
How will you manage Lily?
You start explaining the rationale behind prescribing sodium cromoglycate, but then change your mind, as you realize that you might be overtreating Lily.
Around a week later, Jacqui and Lily are back in front of you, this time with a letter from the pediatric pulmonologist. "I believe that a therapeutic trial with salbutamol is the best next step in this child. Please note that she is currently best managed at the primary care level", the letter states. You feel a little embarrassed, as you realize that the specialist has politely rebuked you for an unnecessary referral.
Subsequently, you start Lily on a short trial of inhaled salbutamol therapy. Two weeks later, Jacqui returns to inform you that the cough hasn't really gone away and seems disappointed. However, she visibly brightens up when you relay the good news: the failure of therapy means that Lily is unlikely to have asthma.
With the help of an anatomical chart, you explain that Lily's cough and occasional wheezes are due to the increased airway sensitivity some children experience. You also explain how URTIs can worsen this, and that it is not unusual for children of this age to get infected multiple times per year, as they are exposed to other children at childcare facilities. Jacqui nods in understanding as you further explain how acute URTIs can cause a postnasal drip and perpetuate the cough. You take care to stress that this is both very common and thus nothing to worry about. You conclude by stating that Lily will very likely outgrow her symptoms over time.
Jacqui seems relieved. It all makes sense to her now. She leaves your office excited about celebrating her daughter's first birthday the following day. As you glance at the calendar, you cannot believe that an entire year has elapsed since you held baby Lily in your hands. You are also reminded of one of the great privileges of being in pediatrics: seeing your patients grow up from tiny babies to healthy and independent young men and women. Well done!
You reassure Jacqui that the reflux will cease as her daughter grows older, but ask her to continue observing Lily, and bring her back if the symptoms continue to worsen. You then proceed to advise Jacqui on proper breastfeeding technique and positioning.