Amir Toib, MD, MSC

DR. TOIB is a third-year resident in the department of pediatrics at Albert Einstein Medical center, Philadelphia, Pa. 

DR. ROBINSON is an associate professor of pediatrics at Thomas Jefferson Medical College, Philadelphia, and a pediatric cardiologist at the Nemours Cardiac Center, Alfred I du Pont Hospital for Children, Wilmington, Del. 

One of your appointments on this summer day in the pediatric clinic is  a 4-month-old African-American child, previously healthy, who is in for a well-child visit. But all is not well: When you ask his mother whether she has any concerns, she tells you that her son has been having "noisy breathing" for the past week. 

Her description is accurate: You hear the patient wheezing while you take the history. 

Mother denies noticing any rapid breathing, although she did notice unusual movement of his ribs. She did not have the impression that the child was getting worse, so she waited for today's visit to report what's been happening. 

At first glance, your patient appears to be a healthy "happy wheezer." You obtain additional important details. He has not had a fever. Appetite has been good; according to Mother, he eats approximately 6 oz of regular formula every 4 hours, in about 10 minutes. No change in sleep or activity patterns or the pattern of bowel movements-one or two a day. Urinary output is good-seven wet diapers a day. Mother cannot recall any sick contacts. 

But both parents smoke, even though Mother insists that they are "only smoking outside the house." And there is a family cat in the house. The infant is cared for by Mother at home; he does not attend day care. 

The medical history is of an uncomplicated pregnancy of 36 weeks and 6 days; vaginal delivery was normal and spontaneous. He has no previous illnesses or complaints and no history of colic as a newborn. 

The family history is significant for asthma and seasonal allergy in the Mother and sickle-cell trait in his sister. 

Your initial physical examination reveals an alert and smiling infant. Temperature is 37.5°C, rectally; heart rate, 144/min; respiratory rate, 68/min; weight, 6 kg (50th percentile for age); height, 64 cm (50th percentile); and head circumference, 41 cm (25th percentile). Oxygen saturation is 100% on room air. 

Examination of the chest and lung reveals bilateral expiratory wheezing with subcostal and intercostal retractions. The abdomen is soft; there is no hepatosplenomegaly; and you detect a small, reducible umbilical hernia. Heart sounds are normal, without murmur. Femoral pulses are palpated bilaterally.  

You've seen many children with a similar presentation; this seems a straightforward case of a first episode of wheezing, with the awareness that he has a prior URI, a family history of asthma, and likely exposure to secondhand tobacco smoke in the home. And, even though it is summer, plenty of viruses are flying around that could trigger an episode of wheezing. You keep aspiration and food allergy in mind but think that these are less likely, for now.  

You collect a nasopharyngeal wash specimen to test for respiratory-tract viruses, and administer two nebulizer treatments of 1.25 mg of albuterol each. 

Upon reassessment, the respiratory rate has fallen to 50/min, the heart rate is 135/min, and O

 remains 100%. You auscultate the lungs; he is still wheezing, but your judgment is that he has improved.  

You give the patient his 4-month immunizations and decide to treat with oral prednisolone, at 2 mg/kg of body weight. To Mother, you give a nebulizer and prescriptions for prednisolone and an albuterol nebulization solution, with instructions to give the boy a nebulizer treatment every four hours. You send him home and plan for close follow-up the next day. 

At the next day's follow-up visit, Mother first reports that she was not able to fill the prescription for the albuterol solution: The pharmacy was out of 1.25 mg vials. The patient did not have a fever overnight, however, and he remained alert and active, had a good appetite, and slept well. 

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