This post covers tachypnea (abnormally fast respiratory rate without or with obvious respiratory difficulty [meaning abnormal respiratory effort], tachycardia (abnormally fast heart rate), and apnea (apparent life-threatening events [ALTE]) in newborns, infants, and children.
Effortless rapid breathing (tachypnea) as well as respiratory distress [shown in Dr. Mellick’s two videos below] can be the first sign of a serious medical problem even if the patient looks well otherwise [This is true of patients of every age (newborn, infant, child, or adult)]. Thus, it is the obligation of the doctor to diagnose the cause of the rapid breathing. And if he or she cannot diagnose the cause, then the patient should optimally be under close medical observation until a cause is determined or all the vital signs return to normal.
For example, a newborn with an effortless rapid breathing rate of greater than 60 who looks otherwise well could just have transient tachypnea of the newborn [which, I think, is always a retrospective diagnosis]. But the baby could have hypoglycemia, early sepsis, early heart failure, an inborn error of metabolism, or other serious problems which need to be considered.
Another potentially important sign easy to miss, if the heart rate was simply guesstimated (especially in the baby who doesn’t look sick), would be an inappropriate tachycardia. Perhaps using an oximeter for the pulse (assuming a good pulse) or a pediatric transport monitor would be the best way to measure heart rate.
An inappropriate tachycardia needs to be evaluated and explained just as does a tachypnea. The cause of the tachycardia could also be hypoglycemia, early sepsis, early heart failure, an inborn error of metabolism, or other serious problems which need to be considered. And if he or she cannot diagnose the cause, then the patient should optimally be under close medical observation until a cause is determined or all the vital signs return to normal.
For more resources on pediatric vital signs, please see my post For Every Pediatric Patient–Think of the Paediatric Sepsis 6 And The Pediatric Early Warning Score,
Posted on May 31, 2015
See also the post “More Resources On the Pediatric Early Warning Score“
Posted on May 16, 2015 by Tom Wade MD. This post has direct links to outstanding Pediatric Early Warning Forms (pdfs) for each pediatric age group. And each form has age specific vital signs and suggested specific actions.
And finally, what about the baby rushed in to your office because the parent is afraid he almost died? What should you think and do?
Dr. Sean Fox of Pediatric EM Morsels – Pediatric Emergency Medical Education – has three excellent relevant posts. Each takes only a few minutes to review and is worthwhile as a kind of checklist.
D. Fox’s first post is related to tachypnea:
Dr. Fox summarizes:
Who needs to stay?
There are no well-drawn guidelines on this as the disease process of bronchiolitis is so varied, often has overlap with other entities (reactive airway disease), and is relatively difficult to study… but that means your CLINICAL EXAM is paramount (I love when that happens).
Unable to maintain adequate hydration
- Working too hard to drink or too ill to care about drinking.
They don’t need to be drinking as much as “normal” – remember that they are normally consuming enough to grow; during times or illness, we don’t care about growing as much as staying hydrated. So assess hydration clinically (see ORT Morsels [ORT Is Faster, ORT for Acute Gastroenteritis]).
Hypoxia
- No single Pox value to help determine admission for everyone.
- Healthy kids on RA should have Pox >95%
- Oxyhemoglobin dissociation curve has significant inflection point at ~90%, so we’d like everyone to stay above that. But that curve gets shifted to the right with fever, so I usually aim for >92% on RA.
Important to consider the dynamic nature of the disease and observe child at rest, while active, and while eating.- The alert child with Pox 91% who feeds easily and has no significant work of breathing is better off than the one who cannot feed and has retractions with a Pox of 93%.
Have High Risk Factors
- Prematurity
- GA < 37 weeks
- Post-Conception Age < 42 weeks
- Age < 3 months
- Chronic Lung Disease (ex. CLD, requiring Home Oxygen therapy, Cystic Fibrosis)
- Hemodynamically significant heart disease
- Neurological disease (with hypotonia particularly)
- Immunocompromised state
- Airway Anomalies
Consider the disease course
- Typically Bronchiolitis symptoms peak on days 3-5.
- If the patient has moderate symptoms on day 2… day 3 will likely be worse.
- If the child is doing fairly well on day 3, then the tough part is likely beyond them.
Consider family ability to care for the kid (subjective I know…)
Dr. Fox’s second and third posts relate to apnea and/or apparent life-threatening event (ALTE):
Dr. Fox states that for ALTE:
- All patients that you have deemed have a history consistent with ALTE warrant admission.
- Some have advocated for disposition from the ED if the child is not a neonate and had only one isolated ALTE episode and have no other concerning findings. The study that is the basis of this approach included only 59 patients, which is a really small sample size to account for the great diversity of conditions that are encompassed by the term ALTE. It also does not account for the fact that there is not a standardized approach for these patients which could help offset some of the significant medicolegal liability. Additionally, even patients with the “benign” diagnosis of GERD have been shown to have benefited from hospitalization.
Here are Dr. Mellick’s three videos:
Infant Respiratory Distress Signs – YouTube Video from Dr. Larry Mellick
Two RSV Patients – YouTube Video from Dr. Larry Mellick
Neonatal Apnea and RSV Infection -YouTube Video by Dr. Larry Mellick
