Acute Paediatrics — MCQs
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According to the NICE traffic light system for assessing febrile illness in children under 5 years, which of the following features would place a child in the high-risk 'red' category requiring urgent specialist assessment?
A 3-year-old boy with recurrent viral-induced wheeze attends the emergency department with increased work of breathing, expiratory wheeze, and respiratory rate of 45/min. Oxygen saturation is 94% on air. He has had similar episodes in the past which responded to bronchodilators. What is the key clinical feature that distinguishes viral-induced wheeze from multi-trigger wheeze in preschool children?
An 8-year-old girl with asthma is brought to the emergency department with severe breathlessness. She is sitting upright, unable to complete sentences, with respiratory rate 38/min, heart rate 140/min, and oxygen saturation 91% on air. She has widespread wheeze with reduced air entry bilaterally. Peak expiratory flow is 35% of predicted. She has received three doses of back-to-back salbutamol nebulisers with oxygen and ipratropium bromide. What defines this as life-threatening asthma requiring escalation of care?
A 19-month-old child presents with a 6-day history of persistent high fever ranging from 39.5°C to 40.4°C despite regular paracetamol. The child is irritable and has bilateral non-purulent conjunctivitis, cracked red lips, a polymorphous rash on the trunk, and cervical lymphadenopathy. Blood tests show: Hb 100 g/L, WCC 16.5 × 10⁹/L, platelets 485 × 10⁹/L, CRP 125 mg/L, ALT 65 U/L. What is the most likely diagnosis?
A 7-year-old boy with known asthma presents to the emergency department with an acute exacerbation. He has received three doses of salbutamol via a spacer and has shown some improvement. His respiratory rate is 28/min, oxygen saturation 94% on air, and he can speak in sentences. Peak expiratory flow is 65% of predicted. What is the most appropriate next step in management?
Understanding the pathophysiology of viral-induced wheeze in young children, which of the following statements best explains why this condition is more common in infants and toddlers compared to older children and tends to improve with age?
A 9-year-old boy with asthma is brought to the emergency department in severe respiratory distress. On arrival, he has a respiratory rate of 8/min, heart rate 150/min, oxygen saturation 85% on high-flow oxygen. He appears exhausted with minimal chest wall movement, and his chest is silent on auscultation with no wheeze audible. He has altered level of consciousness and is difficult to rouse. What is the most appropriate immediate management?
A 13-month-old child presents to the emergency department with fever of 39.7°C for 7 hours. The child appears unwell with reduced activity and is refusing to drink. On examination, temperature is 39.5°C, heart rate 165/min, respiratory rate 45/min, capillary refill time 3 seconds centrally, and blood pressure 85/50 mmHg. The child is irritable but rousable. There is a non-blanching purpuric rash with three lesions (2-3mm) on the lower limbs. What is the single most important immediate management step?
A 6-year-old boy with asthma is being reviewed following an acute exacerbation requiring hospital admission. He is currently on beclometasone 200 micrograms twice daily and montelukast 5mg once daily, with salbutamol as needed. His mother reports he has needed his blue inhaler 5-6 times per week over the past month and wakes at night with cough about twice a week. He missed 3 days of school last month due to asthma symptoms. What is the most appropriate next step in his asthma management according to current guidelines?
An 8-month-old infant born at 26 weeks gestation with chronic lung disease of prematurity presents with a 3-day history of increased work of breathing, poor feeding, and low-grade fever. On examination, respiratory rate is 68/min, oxygen saturation 88% on air, with widespread fine inspiratory crackles and expiratory wheeze. The infant has subcostal and intercostal recession. A diagnosis of bronchiolitis is suspected. Which pathogen is this infant at particular risk of severe disease from, and what preventive measure should have been considered?
Acute Paediatrics UK Medical PG Practice Questions and MCQs
Question 11: According to the NICE traffic light system for assessing febrile illness in children under 5 years, which of the following features would place a child in the high-risk 'red' category requiring urgent specialist assessment?
- A. Temperature greater than 39°C in a child aged 6-12 months
- B. Non-blanching rash appearing during the consultation (Correct Answer)
- C. Capillary refill time of 2 seconds centrally
- D. Respiratory rate of 55 breaths per minute in a 6-month-old infant
- E. Reduced activity and not responding normally to social cues
Explanation: ***Non-blanching rash appearing during the consultation*** - A **non-blanching rash** is a critical **high-risk (red)** feature in the **NICE traffic light system** as it is a strong indicator of serious invasive bacterial infection, such as **meningococcal disease**. - Its appearance or progression during observation necessitates **urgent specialist assessment** and immediate medical intervention. *Temperature greater than 39°C in a child aged 6-12 months* - A temperature of **39°C or greater** in a child aged **6-12 months** is classified as an **intermediate-risk (amber)** feature, not a high-risk (red) feature. - A high temperature (38°C or above) in infants **under 3 months** is, however, considered a **high-risk (red)** feature. *Capillary refill time of 2 seconds centrally* - A **capillary refill time (CRT)** of **2 seconds** is considered normal and does not indicate a high-risk status. - The NICE traffic light system defines a CRT of **3 seconds or more** as a **high-risk (red)** feature, suggesting poor perfusion. *Respiratory rate of 55 breaths per minute in a 6-month-old infant* - For a 6-month-old infant, a respiratory rate of **55 breaths per minute** is within the normal physiological range, which is typically **25-60 breaths per minute**. - Tachypnoea is considered a **high-risk (red)** feature only if the respiratory rate is **>60 breaths per minute** in any age group, or if there is moderate or severe **chest indrawing** or **grunting**. *Reduced activity and not responding normally to social cues* - **Reduced activity** and **not responding normally to social cues** are classified as **intermediate-risk (amber)** features in the NICE traffic light system. - High-risk (red) neurological features include **decreased conscious level**, **bulging fontanelle** in infants, or **neck stiffness**.
Question 12: A 3-year-old boy with recurrent viral-induced wheeze attends the emergency department with increased work of breathing, expiratory wheeze, and respiratory rate of 45/min. Oxygen saturation is 94% on air. He has had similar episodes in the past which responded to bronchodilators. What is the key clinical feature that distinguishes viral-induced wheeze from multi-trigger wheeze in preschool children?
- A. Presence of interval symptoms between acute episodes (Correct Answer)
- B. Age of onset before 3 years
- C. Response to inhaled bronchodilators during acute episodes
- D. Family history of atopy
- E. Evidence of atopic sensitization on allergy testing
Explanation: ***Presence of interval symptoms between acute episodes***- In **episodic viral wheeze**, symptoms only occur during viral infections and the child is **asymptomatic between episodes**.- In **multi-trigger wheeze**, the child experiences symptoms during viral infections as well as **interval symptoms** triggered by exercise, cold air, or allergens.*Age of onset before 3 years*- Both **episodic viral-induced wheeze** and **multi-trigger wheeze** typically present in children under the age of 3 years.- Because they share this timing, **age of onset** cannot be used to clinically distinguish between the two phenotypes.*Response to inhaled bronchodilators during acute episodes*- Both conditions involve **bronchoconstriction** that usually responds well to **Beta-2 agonists** like salbutamol during an acute flare.- A positive response confirms the presence of **reversible airway obstruction** but does not clarify the underlying trigger pattern.*Family history of atopy*- While a family history of **asthma or atopy** may be more frequent in multi-trigger wheeze, it is not the diagnostic discriminator.- Children with either phenotype may have a **genetic predisposition** to atopic diseases without it defining the trigger pattern.*Evidence of atopic sensitization on allergy testing*- **Atopic sensitization** (positive skin prick or IgE) is more common in multi-trigger wheeze but is not a definitive clinical feature for classification.- The distinction is primarily based on the **clinical history** of symptoms between viral episodes rather than laboratory or allergy results.
Question 13: An 8-year-old girl with asthma is brought to the emergency department with severe breathlessness. She is sitting upright, unable to complete sentences, with respiratory rate 38/min, heart rate 140/min, and oxygen saturation 91% on air. She has widespread wheeze with reduced air entry bilaterally. Peak expiratory flow is 35% of predicted. She has received three doses of back-to-back salbutamol nebulisers with oxygen and ipratropium bromide. What defines this as life-threatening asthma requiring escalation of care?
- A. Peak expiratory flow less than 50% of predicted value
- B. Oxygen saturation less than 92% on air (Correct Answer)
- C. Inability to complete sentences in one breath
- D. Respiratory rate greater than 30 breaths per minute
- E. Heart rate greater than 130 beats per minute
Explanation: ***Oxygen saturation less than 92% on air***- In children, an **SpO2 <92%** on air is a critical marker of **life-threatening asthma**, indicating severe hypoxemia and the need for immediate, aggressive intervention.- This level of desaturation reflects significant ventilation-perfusion mismatch, requiring rapid escalation of care beyond standard bronchodilators, potentially including **IV magnesium sulfate**, aminophylline, or consideration for **intensive care unit (ICU)** admission.*Peak expiratory flow less than 50% of predicted value*- A **PEF <50%** of predicted (or best) is a criterion for **acute severe asthma**, not life-threatening asthma.- For a diagnosis of **life-threatening asthma** specifically based on peak flow, the value must be **less than 33%** of the predicted or best value.*Inability to complete sentences in one breath*- Being **unable to complete sentences** is a significant sign of **acute severe asthma** in children over 5 years old, indicating severe respiratory distress.- While serious, it does not by itself meet the **life-threatening** threshold unless accompanied by other specific criteria like **silent chest**, cyanosis, or exhaustion.*Respiratory rate greater than 30 breaths per minute*- A **respiratory rate >30/min** in a child over 5 years old is a diagnostic criterion for **acute severe asthma**.- In **life-threatening asthma**, the respiratory rate may initially be very high but can paradoxically decrease due to **respiratory muscle fatigue** and impending respiratory arrest, which is an ominous sign.*Heart rate greater than 130 beats per minute*- A **heart rate >125-130/min** (depending on age) is a marker for **acute severe asthma** in children, reflecting physiological stress.- High heart rates are often present in severe asthma, but **life-threatening** status is primarily defined by objective measures of hypoxia, **altered consciousness**, hypotension, or more severe physiological decompensation rather than heart rate alone.
Question 14: A 19-month-old child presents with a 6-day history of persistent high fever ranging from 39.5°C to 40.4°C despite regular paracetamol. The child is irritable and has bilateral non-purulent conjunctivitis, cracked red lips, a polymorphous rash on the trunk, and cervical lymphadenopathy. Blood tests show: Hb 100 g/L, WCC 16.5 × 10⁹/L, platelets 485 × 10⁹/L, CRP 125 mg/L, ALT 65 U/L. What is the most likely diagnosis?
- A. Kawasaki disease (Correct Answer)
- B. Epstein-Barr virus infection
- C. Scarlet fever
- D. Measles
- E. Staphylococcal toxic shock syndrome
Explanation: ***Kawasaki disease*** - This child meets the criteria of **persistent fever for ≥5 days** along with four clinical signs: **non-purulent conjunctivitis**, **cracked red lips**, **polymorphous rash**, and **cervical lymphadenopathy**. - Laboratory findings of **thrombocytosis** (high platelets), **elevated CRP**, and **mild transaminitis** (elevated ALT) further support this systemic vasculitis diagnosis. *Epstein-Barr virus infection* - Typically presents with **exudative pharyngitis**, significant **splenomegaly**, and **generalized lymphadenopathy** rather than localized cervical nodes. - While it causes fever and rash (especially after amoxicillin), it lacks the specific **mucocutaneous manifestations** like cracked lips and non-purulent conjunctivitis. *Scarlet fever* - Characterized by a **sandpaper-like rash** and a **strawberry tongue**, but it does not typically present with **conjunctivitis**. - It is caused by **Group A Streptococcus** and usually lacks the extreme irritability and multi-system laboratory abnormalities seen in Kawasaki disease. *Measles* - Presents with the classic triad of **cough, coryza, and conjunctivitis**, accompanied by pathognomonic **Koplik spots** on the buccal mucosa. - The **maculopapular rash** in measles typically begins at the hairline and spreads cephalocaudally, which differs from the trunk-centered polymorphous rash described. *Staphylococcal toxic shock syndrome* - Characterized by **rapid clinical deterioration**, severe **hypotension (shock)**, and multi-organ failure, which are not present in this stable, albeit irritable, child. - While it features a rash and fever, the laboratory profile would usually show more severe **renal or hepatic impairment** and evidence of localized **Staphylococcal infection**.
Question 15: A 7-year-old boy with known asthma presents to the emergency department with an acute exacerbation. He has received three doses of salbutamol via a spacer and has shown some improvement. His respiratory rate is 28/min, oxygen saturation 94% on air, and he can speak in sentences. Peak expiratory flow is 65% of predicted. What is the most appropriate next step in management?
- A. Discharge home with advice to continue regular salbutamol via spacer
- B. Administer oral prednisolone and continue salbutamol nebulisers every 4 hours
- C. Admit for observation with oxygen therapy and intravenous hydrocortisone
- D. Discharge with oral prednisolone and asthma action plan for follow-up (Correct Answer)
- E. Administer intravenous magnesium sulphate and consider ICU referral
Explanation: ***Discharge with oral prednisolone and asthma action plan for follow-up*** - The patient presents with a **moderate asthma exacerbation** (PEF 65% of predicted, SpO2 94%, speaking in sentences) and has shown improvement after initial salbutamol, making **discharge** an appropriate next step. - For moderate exacerbations, a short course of **oral corticosteroids** (e.g., prednisolone for 3-5 days) is essential, along with a personalized **asthma action plan** and arrangement for follow-up to prevent relapse. *Discharge home with advice to continue regular salbutamol via spacer* - Discharging a patient with a moderate asthma exacerbation solely on **salbutamol** without systemic corticosteroids is inappropriate, as steroids are crucial to reduce **airway inflammation** and prevent recurrence. - Omitting the **oral prednisolone course** deviates from standard management guidelines for a moderate asthma exacerbation. *Administer oral prednisolone and continue salbutamol nebulisers every 4 hours* - For moderate exacerbations, **nebulisers** are not superior to a metered-dose inhaler (MDI) with a **spacer** and are typically reserved for severe cases or those unable to use an MDI effectively. - Continuing 4-hourly treatments in a hospital setting is generally unnecessary for a child who has stabilized and can be managed effectively at home with oral steroids and as-needed bronchodilators. *Admit for observation with oxygen therapy and intravenous hydrocortisone* - Admission is not indicated as the child's **oxygen saturation** (94%) is acceptable for discharge, and clinical stability does not meet criteria for **inpatient care** for a moderate exacerbation. - **Intravenous hydrocortisone** is reserved for severe or life-threatening asthma, or when oral corticosteroids cannot be tolerated, which is not the case here. *Administer intravenous magnesium sulphate and consider ICU referral* - **Intravenous magnesium sulphate** is a second-line therapy for severe or **life-threatening asthma** that is refractory to initial treatment, which does not align with this child's moderate and improving condition. - **ICU referral** is indicated for signs of impending respiratory failure (e.g., exhaustion, rising pCO2), which are absent in this stable patient.
Question 16: Understanding the pathophysiology of viral-induced wheeze in young children, which of the following statements best explains why this condition is more common in infants and toddlers compared to older children and tends to improve with age?
- A. Viral infections cause permanent airway remodelling that resolves as the immune system matures
- B. Infants have proportionally smaller airway diameter and increased airway resistance, making them more susceptible to obstruction from inflammation and mucus (Correct Answer)
- C. Young children have deficient immunoglobulin production that normalizes by school age
- D. The diaphragm is not fully developed until age 5 years, limiting respiratory reserve during viral infections
- E. Viral-induced wheeze is caused by IgE-mediated hypersensitivity that resolves with allergen tolerance development
Explanation: ***Infants have proportionally smaller airway diameter and increased airway resistance, making them more susceptible to obstruction from inflammation and mucus*** - According to **Poiseuille's law**, airway resistance is inversely proportional to the fourth power of the radius, meaning even small amounts of **inflammation or mucus** significantly increase resistance in tiny airways. - As children grow, the **absolute diameter** of the airways increases (growth of the airway caliber), which naturally reduces the clinical impact of viral-induced swelling and causes the condition to improve with age. *Viral infections cause permanent airway remodelling that resolves as the immune system matures* - **Airway remodeling** refers to structural changes (like basement membrane thickening) often seen in chronic asthma, but these changes are generally considered **irreversible** rather than self-resolving. - Viral-induced wheeze is primarily an **acute inflammatory** response to a trigger, not a permanent structural defect that disappears with maturity. *Young children have deficient immunoglobulin production that normalizes by school age* - While infants have a period of **physiological nadir** in IgG, viral wheezing is a mechanical issue of **airway physics** rather than a primary immunodeficiency disorder. - Most children with episodic viral wheeze have **normal immunoglobulin levels** for their age and do not suffer from recurrent systemic bacterial infections. *The diaphragm is not fully developed until age 5 years, limiting respiratory reserve during viral infections* - While infants have a more **horizontal rib cage** and a more compliant chest wall, the **diaphragm** is fully formed and functional at birth. - Respiratory distress in these children is driven by the **increased work of breathing** required to overcome high airway resistance, not a lack of diaphragmatic development. *Viral-induced wheeze is caused by IgE-mediated hypersensitivity that resolves with allergen tolerance development* - **Episodic viral wheeze** is triggered by respiratory viruses (like Rhinovirus) and is typically **non-atopic**, meaning it does not involve the IgE-mediated pathways seen in allergic asthma. - The resolution of symptoms with age is due to **increased airway size**, not the development of immunological tolerance to allergens.
Question 17: A 9-year-old boy with asthma is brought to the emergency department in severe respiratory distress. On arrival, he has a respiratory rate of 8/min, heart rate 150/min, oxygen saturation 85% on high-flow oxygen. He appears exhausted with minimal chest wall movement, and his chest is silent on auscultation with no wheeze audible. He has altered level of consciousness and is difficult to rouse. What is the most appropriate immediate management?
- A. Administer nebulised salbutamol and ipratropium bromide and reassess in 15 minutes
- B. Commence intravenous magnesium sulphate infusion urgently
- C. Call for senior anaesthetic support and prepare for emergency intubation and ventilation (Correct Answer)
- D. Give subcutaneous adrenaline 1:1000 and commence aminophylline infusion
- E. Administer intravenous salbutamol infusion and high-dose methylprednisolone
Explanation: ***Call for senior anaesthetic support and prepare for emergency intubation and ventilation*** - This patient exhibits signs of **near-fatal asthma**, including severe **bradypnea (RR 8/min)**, **silent chest** (no wheeze audible), **exhaustion**, and **altered level of consciousness**, indicating impending respiratory arrest. - **Emergency intubation and mechanical ventilation** are crucial immediate interventions when a child with asthma is in respiratory failure and can no longer maintain adequate breathing or oxygenation. *Administer nebulised salbutamol and ipratropium bromide and reassess in 15 minutes* - The presence of a **silent chest** with minimal air movement suggests that nebulized medications would be ineffective as they cannot reach the lower airways. - Reassessing in 15 minutes is too long for a patient with **imminent respiratory arrest** and declining neurological status, who requires immediate life-saving interventions. *Commence intravenous magnesium sulphate infusion urgently* - **Intravenous magnesium sulphate** is an important adjunctive treatment for severe asthma, but it does not address the immediate need for **airway protection** and **ventilatory support** in a patient with respiratory collapse. - The patient's **exhaustion**, **bradypnea**, and **altered consciousness** indicate that bronchodilators alone are insufficient and direct ventilatory assistance is required. *Give subcutaneous adrenaline 1:1000 and commence aminophylline infusion* - **Subcutaneous adrenaline** is not the primary intervention for acute severe asthma with impending respiratory arrest; it's more commonly used in anaphylaxis or if other routes are unavailable. - **Aminophylline infusions** are a third-line therapy with a narrow therapeutic index and are too slow to act in an acute emergency requiring immediate **respiratory support**. *Administer intravenous salbutamol infusion and high-dose methylprednisolone* - While **intravenous salbutamol** and **high-dose corticosteroids** are essential components of severe asthma management, their effects are not immediate enough to prevent **respiratory arrest**. - The immediate priority in a patient with **hypoxia**, **hypoventilation**, and **altered consciousness** is to secure the airway and provide ventilatory support, adhering to the **ABC (Airway, Breathing, Circulation)** principles.
Question 18: A 13-month-old child presents to the emergency department with fever of 39.7°C for 7 hours. The child appears unwell with reduced activity and is refusing to drink. On examination, temperature is 39.5°C, heart rate 165/min, respiratory rate 45/min, capillary refill time 3 seconds centrally, and blood pressure 85/50 mmHg. The child is irritable but rousable. There is a non-blanching purpuric rash with three lesions (2-3mm) on the lower limbs. What is the single most important immediate management step?
- A. Obtain blood cultures and perform lumbar puncture before starting antibiotics
- B. Administer intravenous ceftriaxone immediately after obtaining blood cultures only
- C. Give intramuscular benzylpenicillin immediately without delay for any investigations (Correct Answer)
- D. Commence fluid resuscitation with 20ml/kg 0.9% sodium chloride bolus over 10 minutes
- E. Administer intravenous dexamethasone followed by antibiotics
Explanation: ***Give intramuscular benzylpenicillin immediately without delay for any investigations*** - This child presents with signs highly suggestive of **meningococcal sepsis**, including fever, irritability, signs of shock, and crucially, a **non-blanching purpuric rash**. - **Immediate administration of parenteral antibiotics** (like IM benzylpenicillin) is the most critical intervention to reduce mortality and morbidity in suspected meningococcal disease; any delay for investigations is unacceptable. *Obtain blood cultures and perform lumbar puncture before starting antibiotics* - Delaying antibiotic administration for **blood cultures** and a **lumbar puncture** in a child with suspected severe sepsis and a purpuric rash can be fatal. - A **lumbar puncture** is often **contraindicated** in unstable patients or those with signs of shock (as seen with prolonged CRT and tachycardia) due to the risk of neurological deterioration. *Administer intravenous ceftriaxone immediately after obtaining blood cultures only* - While **ceftriaxone** is an appropriate antibiotic for meningococcal disease, prioritizing blood cultures to the point of delaying antibiotic administration is incorrect in this critical scenario. - If **IV access** is not instantly achievable, an **intramuscular antibiotic** (like benzylpenicillin) should be given without hesitation to ensure prompt drug delivery. *Commence fluid resuscitation with 20ml/kg 0.9% sodium chloride bolus over 10 minutes* - This child shows signs of **compensated shock**, making fluid resuscitation important for hemodynamic support. - However, for suspected **meningococcal sepsis**, stopping the underlying infection with antibiotics takes precedence as the single most immediate life-saving intervention, with fluids following or given concurrently. *Administer intravenous dexamethasone followed by antibiotics* - **Dexamethasone** is an **adjunctive therapy** for certain types of bacterial meningitis to reduce inflammation and neurological complications, not the primary immediate treatment for sepsis with purpura. - The priority is prompt **eradication of the infection** with antibiotics; steroids are a secondary consideration and should not delay antibiotic administration.
Question 19: A 6-year-old boy with asthma is being reviewed following an acute exacerbation requiring hospital admission. He is currently on beclometasone 200 micrograms twice daily and montelukast 5mg once daily, with salbutamol as needed. His mother reports he has needed his blue inhaler 5-6 times per week over the past month and wakes at night with cough about twice a week. He missed 3 days of school last month due to asthma symptoms. What is the most appropriate next step in his asthma management according to current guidelines?
- A. Increase beclometasone to 400 micrograms twice daily
- B. Add salmeterol (long-acting beta-2 agonist) to current regimen
- C. Stop montelukast and start salmeterol instead
- D. Continue current treatment but review inhaler technique and adherence (Correct Answer)
- E. Add theophylline to current treatment
Explanation: ***Continue current treatment but review inhaler technique and adherence***- Before escalating therapy for poor asthma control, guidelines emphasize the necessity of checking **inhaler technique**, **medication adherence**, and **trigger avoidance**.- Since poor technique and non-adherence are major contributors to treatment failure in children, addressing these issues is the **highest priority** next step before pharmacological escalation.*Increase beclometasone to 400 micrograms twice daily*- Increasing to a **moderate-dose ICS** is a later step in management and should not be done without first verifying that the current low-dose ICS is being administered correctly.- High doses of corticosteroids in children increase the risk of **systemic side effects** like growth suppression, making it crucial to ensure they are actually needed.*Add salmeterol (long-acting beta-2 agonist) to current regimen*- Adding a **Long-Acting Beta-2 Agonist (LABA)** is a consideration for Step 4 of pediatric guidelines, but it must be preceded by an assessment of **basics** like adherence and technique.- Adding more medication to a regimen where the current medication may not be inhaled properly is clinically **ineffective and costly**.*Stop montelukast and start salmeterol instead*- While some guidelines suggest swapping a **Leukotriene Receptor Antagonist (LTRA)** for a LABA if there is no response, this child is already experiencing severe enough symptoms to warrant clinical review first.- Switching medication classes does not solve the underlying issue if the child's **inhaler technique** is the reason for the frequent nights with cough.*Add theophylline to current treatment*- **Theophylline** is typically reserved as a much later-stage add-on therapy due to its **narrow therapeutic index** and the requirement for serum monitoring.- It is not indicated at this stage of management, especially when simpler interventions like **technique optimization** have not yet been performed.
Question 20: An 8-month-old infant born at 26 weeks gestation with chronic lung disease of prematurity presents with a 3-day history of increased work of breathing, poor feeding, and low-grade fever. On examination, respiratory rate is 68/min, oxygen saturation 88% on air, with widespread fine inspiratory crackles and expiratory wheeze. The infant has subcostal and intercostal recession. A diagnosis of bronchiolitis is suspected. Which pathogen is this infant at particular risk of severe disease from, and what preventive measure should have been considered?
- A. Respiratory syncytial virus (RSV); prophylactic palivizumab during RSV season (Correct Answer)
- B. Influenza A virus; annual influenza vaccination from 6 months
- C. Human metapneumovirus; prophylactic immunoglobulin therapy
- D. Parainfluenza virus; palivizumab prophylaxis during winter months
- E. Respiratory syncytial virus; monthly RSV vaccination during first year of life
Explanation: ***Respiratory syncytial virus (RSV); prophylactic palivizumab during RSV season*** - **Respiratory syncytial virus (RSV)** is the most common cause of **bronchiolitis**, accounting for 70-80% of cases, and leads to severe disease in infants with **bronchopulmonary dysplasia (BPD)**. - **Palivizumab**, a humanized **monoclonal antibody**, is indicated for high-risk infants such as those born before 29 weeks gestation or those with **chronic lung disease of prematurity** to reduce hospitalization. *Influenza A virus; annual influenza vaccination from 6 months* - While **Influenza A** can cause respiratory illness, it typically presents with higher fever and systemic symptoms rather than the classic clinical picture of **bronchiolitis**. - Although vaccination is recommended from age 6 months, it does not provide protection against **RSV**, which is the primary pathogen associated with this clinical presentation. *Human metapneumovirus; prophylactic immunoglobulin therapy* - **Human metapneumovirus (hMPV)** is a known cause of bronchiolitis, but it is less prevalent than **RSV** and lacks a specific approved prophylactic antibody. - Standard **immunoglobulin therapy** is not used for the prevention of bronchiolitis in premature infants; specific **monoclonal antibodies** are required. *Parainfluenza virus; palivizumab prophylaxis during winter months* - **Parainfluenza virus** is primarily associated with **croup** (laryngotracheobronchitis) rather than the fine crackles and wheezing characteristic of bronchiolitis. - **Palivizumab** is a targeted therapy specifically designed against the **RSV fusion protein** and has no clinical efficacy against parainfluenza viruses. *Respiratory syncytial virus; monthly RSV vaccination during first year of life* - While RSV is the correct pathogen, **Palivizumab** provides **passive immunity** via monoclonal antibodies rather than active immunity through a vaccine. - There is currently no routine **monthly vaccination** schedule for infants; prophylaxis is achieved through monthly **antibody injections** during the peak viral season.
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