Pediatric respiratory care, infant to teen

The parent of a 3-year-old with a viral upper respiratory infection and nighttime cough asks what to give for the cough. Which recommendation is MOST appropriate?

1. Codeine-containing cough syrup
   Codeine is contraindicated under 12 years because ultrarapid metabolizers can develop fatal respiratory depression.
2. Dextromethorphan cough syrup
   OTC cough suppressants have not helped young children in trials and have caused serious toxicity, so they are not used under 4 years.
3. Diphenhydramine at bedtime
   Sedating antihistamines do not treat viral cough and can cause paradoxical agitation or oversedation in toddlers.
4. A teaspoon of honey at bedtime
   For a child over 1 year, honey modestly reduces nighttime cough and helps the child and parents sleep, with no drug risks.

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A 7-year-old has had fever to 38.9 °C, productive cough, and decreased appetite for 3 days. The child is alert and drinking, with a respiratory rate of 32 breaths/min, SpO₂ 97%, and focal crackles at the right base. Which diagnostic approach is MOST appropriate?

1. blood culture before antibiotics
   Blood cultures are rarely positive in children well enough for outpatient care and do not change management.
2. clinical diagnosis without imaging
   A well-appearing child with suspected pneumonia, normal oxygen saturation, and outpatient care does not need a routine chest radiograph, cultures, or labs; the diagnosis is clinical.
3. chest radiograph to confirm the diagnosis
   A routine radiograph is not needed to confirm uncomplicated pneumonia in a well child treated at home.
4. CBC with C-reactive protein
   Inflammatory markers cannot separate bacterial from viral pneumonia well enough to guide outpatient treatment.

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Parents of a 5-year-old whose persistent asthma is well controlled on a low-dose inhaled corticosteroid ask whether it will affect height. Which counseling is MOST accurate?

1. Growth velocity is not affected
   Saying there is no effect is inaccurate; a small early slowing is documented.
2. Any early slowing is regained by adulthood
   The early slowing is not regained: follow-up into adulthood shows the small deficit of about 1 cm persists.
3. Adult height is reduced by about 5 cm
   A 5-cm loss overstates the effect several times over and can scare families away from an essential controller.
4. Adult height averages about 1 cm lower
   Long-term follow-up of children on inhaled steroids shows a small drop in growth velocity, mostly in the first year, leaving adult height about 1 cm lower on average, and less at the lowest doses; controlled asthma outweighs this, with the lowest effective dose and height checks.

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A 15-year-old runner has throat tightness and noisy inspiratory breathing during races that resolves within 5 minutes of stopping. Pre-exercise albuterol has not helped, and resting spirometry is normal. The MOST LIKELY diagnosis is:

1. exercise-induced bronchoconstriction
   Bronchoconstriction gives expiratory wheeze and cough that peak 5 to 15 minutes after exercise and are prevented by pretreatment with albuterol.
2. subglottic stenosis
   Subglottic stenosis causes fixed stridor that is present at rest or with any illness, not only at peak effort, usually after intubation.
3. paradoxical vocal fold motion
   Throat tightness with noisy inspiration during exertion that ends within minutes of stopping, no response to albuterol, and normal spirometry point to paradoxical vocal fold motion, confirmed by laryngoscopy during symptoms.
4. exercise-induced anaphylaxis
   Exercise-induced anaphylaxis brings hives, angioedema, or hypotension along with breathing symptoms.

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A 3-year-old has had a daily wet cough for 6 weeks since a cold. There is no wheeze, no cough with feeding, and growth is normal. The examination and a chest radiograph are normal. Which is the MOST appropriate next step?

1. Recheck the cough in 3 months
   A wet cough already past 4 weeks is chronic, so waiting longer delays treatment of a likely bacterial bronchitis.
2. Inhaled corticosteroid trial
   Inhaled steroids treat asthma, which causes a dry cough with wheeze or exercise symptoms; they are not recommended for chronic wet cough.
3. Amoxicillin-clavulanate for 2 weeks
   A wet cough lasting more than 4 weeks in a thriving child with no specific pointers and a normal radiograph is most often protracted bacterial bronchitis; CHEST guidance advises 2 weeks of an antibiotic that covers the usual respiratory bacteria.
4. Daily montelukast for 4 weeks
   Montelukast targets allergic airway inflammation, does not treat bacterial bronchitis, and carries a boxed warning for neuropsychiatric effects.

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Parents of a 6-month-old on day 2 of bronchiolitis ask what to expect. Which counseling is MOST accurate?

1. Cough beyond 7 days signals pneumonia
   A lingering cough is expected after bronchiolitis and is not a sign of pneumonia by itself.
2. Symptoms peak on the first day of illness
   Expecting the worst to be over on day 1 leads families to miss the decline that typically follows.
3. Most symptoms resolve by days 2–3
   Bronchiolitis does not settle in the first 2 to 3 days; that is usually when it is getting worse, and cough commonly lasts 2 to 3 weeks.
4. Symptoms peak around days 3–5
   Bronchiolitis usually worsens and peaks around days 3 to 5, so an infant seen on day 2 may get worse and the family needs clear return precautions.

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A 5-month-old has bronchiolitis on day 3 of illness. Which finding MOST indicates the need for hospital admission?

1. Diffuse wheezes and crackles
   Wheezes and crackles are expected findings in bronchiolitis and do not measure severity.
2. Temperature of 38.7 °C
   Fever is common in bronchiolitis and does not mark severe disease.
3. Respiratory rate of 48/min
   A rate of 48/min is within the normal range for a 5-month-old and does not by itself indicate admission.
4. SpO₂ of 88% on room air
   Oxygen saturation persistently below 90% on room air needs supplemental oxygen, which means hospital care; poor feeding and severe distress are the other usual reasons to admit.

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A 13-year-old with cystic fibrosis has 1 week of increased cough and sputum, and FEV1 has dropped from 88% to 72% predicted. Which is the MOST appropriate action?

1. refer promptly to the CF center
   More cough and sputum with a drop in FEV1 from 88% to 72% is a pulmonary exacerbation; it needs antibiotics chosen from prior cultures and more airway clearance, coordinated promptly with the CF center.
2. add a daily inhaled corticosteroid
   Inhaled steroids are not routine in CF without coexisting asthma and do not treat infection-driven decline.
3. increase the pancreatic enzyme dose
   Pancreatic enzymes treat fat malabsorption and weight gain, not a lung exacerbation.
4. repeat spirometry in 3 months
   Waiting 3 months risks permanent loss of lung function that prompt treatment could recover.

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A 4-year-old with chronic wet cough and poor weight gain has a sweat chloride of 45 mmol/L on a valid test. The MOST appropriate interpretation is:

1. Borderline; CFTR gene analysis
   A sweat chloride of 30 to 59 mmol/L is intermediate, so a symptomatic child with 45 mmol/L needs CFTR gene analysis and possibly a repeat sweat test.
2. Normal; cystic fibrosis is excluded
   Values below 30 make CF unlikely; calling 45 normal misses atypical CF.
3. Repeat if symptoms worsen later
   The child already has wet cough and poor weight gain, so waiting for worsening delays diagnosis and treatment.
4. Diagnostic of cystic fibrosis
   The diagnostic threshold is 60 mmol/L or more; 45 does not confirm CF by itself.

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A 5-year-old with incomplete immunizations has had 10 days of paroxysmal cough with an inspiratory whoop and post-tussive vomiting, appearing well between episodes. Which test BEST confirms the MOST likely diagnosis?

1. Pertussis PCR on NP swab
   Paroxysms with a whoop and post-tussive vomiting in an underimmunized child suggest pertussis, and a nasopharyngeal PCR is the preferred test in the first 3 to 4 weeks of cough.
2. Pertussis IgG antibody
   Serology is used late in the illness, mainly in adolescents and adults, and vaccination confounds the result.
3. CBC for lymphocytosis
   Lymphocytosis supports pertussis in infants but is not specific enough to confirm it.
4. Chest radiograph
   The radiograph in pertussis is usually normal or nonspecific and does not identify the organism.

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A 3-month-old born at 39 weeks had a 20-second episode at home of pallor and limpness that ended on its own; no CPR was given. It is the first such event. In the office the infant is well-appearing, and the vital signs and examination are normal. Which is the MOST appropriate management?

1. Educate the family and arrange follow-up
   A first, sub-minute episode that resolved on its own in a well term infant over 60 days old, with a normal exam and no CPR, is a lower-risk BRUE; the AAP advises educating the family, offering CPR training resources, and arranging follow-up rather than routine testing.
2. Order an EEG and head CT
   Neuroimaging and EEG have low yield after a single lower-risk event, and CT adds radiation to an infant with a normal exam.
3. Admit overnight for cardiorespiratory monitoring
   Admission solely for monitoring is not recommended for a lower-risk BRUE, because serious underlying causes are rare and hospital stays add cost and false alarms.
4. Prescribe a home apnea monitor
   Home apnea monitors have not been shown to prevent sudden infant death and are not recommended after a lower-risk event.

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A 2-year-old with global developmental delay and hypotonia has a chronic wet cough, coughs and gags during meals, and has had 2 pneumonias in the right lower lobe. Which is the MOST appropriate next step?

1. sweat chloride test
   Cystic fibrosis causes chronic wet cough too, but symptoms tied to feeding and pneumonias in the dependent right lower lobe point to aspiration.
2. serum allergen-specific IgE panel
   Allergy testing has no role in aspiration and often returns misleading positives.
3. trial of inhaled corticosteroid
   An inhaled steroid treats asthma and does nothing for food and liquid entering the airway.
4. videofluoroscopic swallow study
   Coughing and gagging with meals and repeated right lower lobe pneumonia in a hypotonic child with developmental delay point to oropharyngeal dysphagia with aspiration; a videofluoroscopic swallow study defines safe textures and positioning.

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A 3-year-old has had a barking cough and hoarse voice since last night. In urgent care the child has inspiratory stridor at rest, mild suprasternal retractions, and an SpO₂ of 96%, and is drinking. Which management is MOST appropriate?

1. Oral amoxicillin and humidified air
   Croup is viral, so an antibiotic does not help, and humidified air has not shown benefit in trials.
2. Dexamethasone plus nebulized epinephrine
   Barking cough with stridor at rest is moderate croup: a single dose of dexamethasone reduces airway swelling over the next hours, and nebulized epinephrine relieves the stridor within minutes.
3. Lateral neck radiograph before treatment
   Croup is a clinical diagnosis; a neck film adds nothing in typical cases and delays treatment of an inflamed airway.
4. Oral dexamethasone, then discharge home
   A single steroid dose is right for mild croup without stridor at rest, but sending this child home before stridor at rest is treated and observed is unsafe.

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A 2-year-old choked and coughed while eating peanuts 2 days ago and has coughed ever since. Breath sounds are decreased over the right lung with a localized wheeze. A chest radiograph is read as normal. Which is the MOST appropriate next step?

1. Oral amoxicillin for presumed pneumonia
   Treating as pneumonia leaves the object in place; post-obstructive infection keeps recurring until it is removed.
2. Trial of albuterol for new-onset asthma
   A first wheeze that is localized to one lung after choking points to an obstructed bronchus, not asthma, and albuterol would delay removal.
3. Referral for rigid bronchoscopy
   A witnessed choking episode with a persistent cough and one-sided findings is foreign body aspiration until proven otherwise; a normal radiograph does not exclude a nut, so the child is referred for rigid bronchoscopy.
4. Reassure, since the radiograph is normal
   Most aspirated foods are radiolucent and early films are often normal, so a negative radiograph is the classic false reassurance.

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A 4-year-old who started preschool this year has had 7 colds. Growth is normal, and there have been no pneumonias or hospitalizations. The parents fear an immune problem. Which is the MOST appropriate response?

1. Reassure that this is typical
   Preschoolers starting group care commonly catch 6 to 8 viral colds a year; normal growth with no pneumonias or hospital stays is reassuring and needs no immune workup.
2. Order serum immunoglobulin levels today
   Immune testing is for red flags such as two or more pneumonias in a year, deep infections, or poor growth, none of which this child has.
3. Refer to a pediatric immunologist
   Referral is for a child with warning signs of immunodeficiency, not for frequent colds in a thriving preschooler.
4. Start daily antibiotics for the winter
   Antibiotics do not prevent viral colds and breed resistant bacteria.

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