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The Respiratory System

A 3-hour-old neonate is seen by the pediatrician for initial evaluation. The neonate was born vaginally, at term to a 33-year-old mother whose pregnancy was complicated by poorly controlled insulin-dependent gestational diabetes and gestational hypertension. On physical examination the temperature is 37°C (98.6°F), heart rate is 155 beats per minute, respiratory rate is 55 breaths per minute, O2 saturation is 85% on room air, and 99% on 5 L/min nasal cannula. Weight, length, and head circumference are at the 95th percentile. The head has molding and a left-sided cephalohematoma. The chest has irregular, labored breathing, and decreased breath sounds on the right side. Heart has normal S1 and S2 without murmur. Abdomen is soft, nontender, and without hepatosplenomegaly. Extremities show decreased tone and no spontaneous movement of the right arm. A stat portable chest radiograph is normal. Which of the following is the most appropriate next step?

a. Obtain nasal wash for viral culture.

b. Perform fiberoptic bronchoscopy of the airways.

c. Order chest CT.

d. Obtain ultrasound of chest and diaphragm.

e. Start antibiotics for presumed group B Streptococcus infection.

The answer is d. (Hay et al, pp 885-886. Kliegman et al, pp 3406-3408. Rudolph et al, p 1998.) Neonates born to mothers with gestational diabetes are at risk for being large for gestational age and thus at increased risk for difficult deliveries such as shoulder dystocia, leading to peripheral nerve injuries such as Erb palsy (C5-C6, upper trunk of the brachial plexus), Klumpke palsy (C8-T1, lower trunk) and phrenic nerve (C3, C4, and C5) paralysis. An ultrasound or fluoroscopy of the chest would reveal asymmetric diaphragmatic motion in a seesaw manner. While a chest film can be normal as in this case, an elevated hemidiaphragm may be observed. With a negative chest radiograph, a chest CT would not be helpful at this point. Bronchoscopy would help delineate airway abnormalities and foreign bodies, but would not identify phrenic nerve paralysis.

A 10-month-old infant is seen by the pediatrician for poor weight gain, a persistent cough, and a history of several bouts of pneumonitis. The mother also reports the infant as having a several months’ history of very large, foul-smelling stools. The infant was born vaginally at term to a 29-year-old woman whose pregnancy was complicated by gestational diabetes. The infant was breast-fed, voided in the first day, and stooled just before discharge on the third day of life. On physical examination temperature is 37°C (98.6°F), heart rate is 90 beats per minute, and respiratory rate is 24 breaths per minute. Weight is at the 10th percentile; length, and head circumference are at the ...

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