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Difficulty: EasyPediatric Infectious Diseases

An 8-month-old male infant is evaluated in the pediatric clinic in late January for a 3-day history of nasal congestion, clear rhinorrhea, and a low-grade fever. Over the past 24 hours, he has developed a harsh cough and increased work of breathing. He has no significant past medical history and is fully vaccinated for his age. Vital signs show a temperature of 37.8°C (100.0°F), heart rate of 145/min, respiratory rate of 55/min, and oxygen saturation of 96% on room air. Physical examination reveals an alert, well-perfused infant with mild intercostal retractions, flared nostrils, and diffuse bilateral expiratory wheezes with prolonged expiration. There is no focal consolidation or crackles. Which of the following is the most appropriate next step in the management of this patient?

  1. Supportive care with oral hydration and nasal suctioningAnswer
  2. B
    Administration of a nebulized albuterol treatment
  3. C
    Administration of a single dose of oral dexamethasone
  4. D
    Prescription of a course of oral amoxicillin
  5. E
    Prescription of a course of oral azithromycin

Answer

Supportive care with oral hydration and nasal suctioning
The patient's clinical presentation—an infant under two years of age during the winter season with preceding upper respiratory symptoms followed by diffuse wheezing, tachypnea, and increased work of breathing—is highly characteristic of acute viral bronchiolitis. This condition is most frequently caused by respiratory syncytial virus (RSV). The diagnosis is strictly clinical and does not require routine laboratory testing or radiography in typical cases. Because the disease is self-limiting and the infant is maintaining adequate oxygenation (oxygen saturation of 96%) without signs of severe dehydration, outpatient supportive management is the standard of care. This management primarily consists of maintaining oral hydration and providing nasal saline drops with suctioning to relieve airway congestion, which is particularly important since infants are obligate nose breathers.

Step-by-Step Solution

1
Identify the clinical syndrome
The infant presents during the winter season with a viral upper respiratory prodrome that has progressed to lower respiratory tract signs, including tachypnea, retractions, and wheezing.
Recognizing the expected symptom progression and characteristic physical exam findings in this age group is key to establishing the diagnosis.
2
Determine the most likely diagnosis
The presentation is classic for acute viral bronchiolitis, which is most commonly caused by respiratory syncytial virus (RSV).
Bronchiolitis is primarily a clinical diagnosis based on the patient's age (typically under 2 years), time of year, and absence of focal lung findings that would suggest pneumonia.
3
Select the appropriate management
Supportive care emphasizing hydration and relief of upper airway congestion is indicated. The patient's oxygen saturation is 96%, meaning supplemental oxygen is unnecessary.
Pharmacologic interventions such as bronchodilators, systemic corticosteroids, and antibiotics are not recommended for typical viral bronchiolitis in well-appearing infants.

Key Concept

Diagnosis and management of acute viral bronchiolitis in infants
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Topics

Pediatric Infectious Diseases

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