Letters to the Editor

Indian Pediatrics 2002; 39:1172

Clinical Evaluation of Acute Respiratory Distress and Chest Wheezing in Infants: A Few Practical Difficulties

I read with great interest the article by Kumar et al(1). I have a few queries and comments.

(a) How the authors have excluded the Chlamydia pneumonia in infants which is very common in this age group and usually presents with an afebrile course, persistent cough, occasional wheeze and nonspecific radiological features(2). According to the authors’ management, this would not fall in bronchopneumonia group and hence miss the opportunity of an antibiotic (e.g. a macrolide) which is essential in its management.

(b) How was the diagnosis of gastroesophageal reflux (GER) excluded, which very commonly manifests as persistent wheezing in infancy(3).

(c) Is it always true that the diagnosis of bronchiolitis is simply absence of fever or less than 100ºF fever with respiratory distress and wheezing. Does absence of polymorphonuclear leucocytosis always exclude acute bronchiolitis?

(d) I wish to know how the authors have excluded double pathology e.g. bronchial asthma with viral/bacterial infection, bronchopneumonia which later turned out to be case of bronchial asthma with acute bacterial infection or recurrent attacks of bronchiolitis.

(e) I am confused with the statement that "in infants with respiratory distress and wheezing if fever is more than or equal to 100º F one can "safely" assume a diagnosis of bronchopneumonia’. How safe is this "safe" diagnosis? Will antibiotics cure them as suggested by the authors? Do the authors mean acute bacterial pneumonia by the term bronchopneumonia?

(f) Finally, the most important clinical feature that they have used is documentation of wheeze (audible/auscultable). Those who work in infant acute admission wards will certainly agree that this is a very difficult job specially in crying infants. Hospitalized cases of bronchial asthma are also expected to be in severe stages with a silent chest during first few hours of admission.

References

1. Kumar N, Singh N, Locham KK, Garg R, Sarwal D. Clinical evaluation of acute respiratory distress and chest wheezing in infants. Indian Pediatr 2002; 39: 478-483.

2. Hammerschiag MR, Chlamydia. In: Nelson’s Textbook of Pediatrics.16th edn. Eds. Behrman RE, Kleigman RM, Jenson HB. Philadelphia: W.B. Saunders Compnay, 2000; pp 827-829.

3. Herbst JJ. Gastroesophageal reflux. In: Nelson’s Textbook of Pediatrics. 16th edn. Eds. Behrman RE, Kleigman RM, Jenson HB. Philadelphia. W.B. Saunders Company, 2000; pp 1125-1126.