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Infant With Persistent Noisy Breathing

Infant With Persistent Noisy Breathing

A 2-month-old boy is brought to the emergency department (ED) because of “noisy breathing” that has been present since birth. The parents report that they occasionally see the child’s ribs during inspiration when he is lying down.

HISTORY
At a well-care visit 1 month earlier, the primary care pediatrician told the parents that findings from the infant’s examination were normal and that he would eventually outgrow these symptoms. One week before presentation, the infant’s breathing had worsened, and his parents brought him to an urgent care clinic with concerns that he was “breathing with his belly.” A chest radiograph was normal. The parents were told the infant had tracheomalacia and that the symptoms would abate as he grew older. Four days before presentation, the parents brought the infant to another ED, where he was given a dose of corticosteroids, after which a modest reduction in symptoms was noted.

PHYSICAL EXAMINATION
The infant is afebrile. Other vital signs and growth parameters are normal. Although the infant displays no signs of respiratory distress at rest, he is found to have inspiratory stridor that worsens with crying or when placed supine. He also has mild expiratory stridor heard on auscultation. Physical findings are otherwise unremarkable.

 

Which of the following would be the appropriate next step?

A. Parental reassurance.
B. Single dose of oral corticosteroid.
C. Otorhinolaryngology (ENT) evaluation for possible laryngoscopy/bronchoscopy.
D. Treatment with inhaled racemic epinephrine.

 

(Answer and discussion begin on next page.)

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