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EXPERIENCE & REASON |
a Department of Pediatrics, Bnai Zion Medical Center, The B. Rappaport Faculty of Medicine, Haifa, Israel
b Department of Otolaryngology, Bnai Zion Medical Center, The B. Rappaport Faculty of Medicine, Haifa, Israel
ABSTRACT
Severe failure to thrive (FTT) in a child with asthma and a persistent cough should not be explained solely by asthma and warrants a thorough and prompt evaluation. The finding of a foreign body in our case was surprising, because it does not usually present as or lead to FTT. Good clinical judgment and habits could prevent the course of events that we described in this case. Following are the key lessons to be learned from this presentation: (1) maintain a high index of suspicion for foreign body aspiration, even in toddlers with asthma, (2) pay special attention to a child with FTT, (3) be aware of localizing findings on physical examination and chest radiographs, and (4) perform a chest radiograph no later than after 1 month of chronic cough.
Key Words: asthma • cough • failure to thrive • foreign body
Abbreviations: FTT, failure to thrive • FBA, foreign body aspiration
The diagnosis of asthma at a young age may be problematic.1,2 Because the response of wheezing that is associated with recurrent upper respiratory tract infection to inhaled bronchodilators and steroids is questionable,1–3 the performance of a therapeutic trial also may be confusing. Nevertheless, the persistence of cough in a child with "asthma" despite optimal therapy should serve as a warning sign. It might be related to poor compliance or to a different diagnosis.
Failure to thrive (FTT) is a general term that is used to describe a child with a weight gain that is less than expected for children of similar age and gender. A child is regarded to have FTT when he or she is below the third percentile or has dropped below 2 major percentiles for weight over a short period of time for no apparent medical reason.4–6
Poor weight gain in a child with persistent cough may be associated with recurrent pneumonia as a result of a significant underling disease, such as cystic fibrosis, immunodeficiency, primary cilia dyskinesia, cardiac disease, gastroesophageal reflux disease, or congenital malformation.7,8 We describe a girl who had asthma, presented with persistent cough and severe FTT, and subsequently received a diagnosis of a foreign body aspiration (FBA).
CASE REPORT
A 24-month-old girl was admitted to our pediatric department because of persistent cough in the previous few months and lack of response to asthma medications. Pregnancy and delivery were uneventful. She was born at term with a birth weight of 3880 g. Her mother had a history of asthma. The clinical diagnosis of asthma was made at the age of 1 year, and she was treated for the previous 5 months (winter and spring) with 125 µg of fluticasone propionate twice daily via AeroChamber (Trudell Medical International, London, Ontario, Canada) by her pediatrician. Although she was compliant with the medications, her cough worsened; therefore, terbutaline sulfate 250 µg, 2 puffs 4 times daily, was added for the last 2 months. There was no history of choking, environmental change, pneumonia, or recent infection. The girl had decreased appetite, without vomiting or diarrhea. On physical examination, she was mildly tachypneic (20–40 breaths per minute) with no signs of respiratory distress. Oxygen saturation was 100% on room air, and heart rate was 112 beats per minutes. She had mild intercostal retractions, bilateral expiratory wheezes, and mildly decreased breath sound to the right lung, with no crepitations. No heart murmur was heard. Abdominal examination was normal, and she had no digital clubbing. Her weight was 9.8 kg, and she had been losing weight, 1.4 kg over the past 6 months (Fig 1). Her height was unchanged, growing on the 50th percentile. Laboratory examinations revealed hemoglobin of 11.9 g/dL, mean corpuscular volume of 74.8 µm3, leukocyte count of 9690 cells/µL, and platelet count of 322000/µL. Chest radiograph revealed hyperinflation of the right lung (Fig 2). Because she had no history of a choking event, the initial working diagnosis was severe asthma with suspected mucus plug. Therefore, she started intensive therapy with oral betamethasone 2 mg daily and continued the terbutaline sulfate inhalations. After 1 day of therapy, her respiratory status improved and her breath sounds became symmetric. A repeat chest radiograph also showed improvement (Fig 3). At the same time, because of her severe FTT, the following investigations were performed: diet history revealed a low energy intake (126 kJ/kg per day); sweat test (sodium 8 mEq/L and chloride 5 mEq/L in 351 mg of sweat) and serum immunoglobulins were normal; celiac serology (anti-endomysial and anti-transglutaminase IgA antibodies) was negative; serum albumin was 4.2 g/dL; and serum electrolytes and liver and renal functions were normal. Within 2 weeks, the cough continued, breath sounds were decreased again to the right lung, and repeat chest radiograph showed right lung hyperinflation (Fig 4). We performed a flexible bronchoscopy that revealed a peanut in the right main stem bronchus (Fig 5). The peanut was removed by a rigid bronchoscope, and within a few days the girl was discharged with a normal physical examination and chest radiograph (Fig 6). Her appetite improved dramatically. Her weight followed (Fig 1, arrow signifies the removal of the foreign body). Three months later, she has no respiratory symptoms, and she is on no medications.
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DISCUSSION
We described a case of foreign body aspiration in a child who had a diagnosis of "asthma" and presented with persistent cough and significant weight loss. This is an illustrative case with very clear messages.
Choking and acute cough are the most common presenting symptoms of FBA,9,10 with sensitivity and specificity of 91% and 45%, respectively. A foreign body was found in 9.5% of children who presented only with "doubtful" history of aspiration with normal physical examination and chest radiography.9 Parental suspicion of FBA occurred in only 59% of 53 children who were found to have FBA.10 Therefore, pediatricians should have a high index of suspicion for FBA in children. Chest radiograph should be performed in every child with cough that persists beyond 1 month.7,8 This routine may facilitate the diagnosis by signifying a "bronchus factor" (localizing signs that result from an obstructed or narrowed bronchus), as we have described.
The diagnosis of asthma in toddlers who attend child care in the winter is problematic.1,8 It is more of a clinical diagnosis. Family history of asthma or atopy may be helpful (in our child, the mother had asthma). A therapeutic trial is recommended,8 yet may be misleading because the response to treatment of viral induced wheezing is not consistent (a negative response does not rule out asthma) and a positive response may suggest underlying asthma.1–3,11–15 However, if cough persists, then the pediatrician should consider poor compliance, inadequate inhalation technique, or a diagnosis other than asthma, especially in the young age group. Furthermore, a child with asthma is not exempt from the hazard of FBA. If he or she responds to his therapy differently from usual, then suspicion for a different diagnosis should be raised, as in our case.
It is estimated that FTT accounts for 1% to 5% of pediatric hospital admissions. Efforts to evaluate and treat such patients can be time consuming and expensive and may not yield a diagnosis. In addition, the yield of laboratory tests and imaging studies in the diagnosis of FTT is very low.5,16 However, FTT combined with persistent cough should be a "red flag" and should be evaluated thoroughly and promptly. We found a report in a 1-year-old child of a foreign body that was removed from the esophagus and had led to persistent cough, feeding difficulty, and weight loss.17 It is unusual that FTT will be the presentation of FBA. Our literature search did not reveal similar reports. Our child did not present with recurrent pneumonia, yet increased work of breathing in combination with decreased intake (126 kJ/kg per day) secondary to poor appetite for a prolonged time could explain weight loss. In our child, the dramatic change in weight gain after the foreign body removal, with no other changes in diet apart from improved appetite, clearly demonstrates the relation between his FTT and FBA.
Good clinical judgment and habits could prevent the course of events that we have described. The key lessons are (1) high index of suspicion for FBA, even in toddlers with asthma, (2) special attention to FTT, (3) awareness to localizing findings in physical examination and chest radiographs, and (4) performance of a chest radiograph no later than after 1 month of chronic cough.
FOOTNOTES
Accepted Nov 8, 2006.
Address correspondence to Amir Kugelman, MD, Department of Pediatrics, Bnai Zion Medical Center, 47 Golomb St, Haifa, 31048, Israel. E-mail: dramir{at}netvision.net.il
The authors have indicated they have no financial relationships relevant to this article to disclose.
REFERENCES
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