A new mother presents to the Emergency Department with her four-day-old child, concerned about his breathing and colour. Initial observations are as follows:

- Temperature 36.8°C
- Heart rate 200 bpm
- Blood pressure 80/50 mmHg
- Respiratory rate 80 bpm
- Oxygen saturations 80% (on room air), which improves to 85% on 100% oxygen.

The neonate is a mottled blue colour, but lung fields are clear on auscultation, and heart sounds are normal. Alongside your initial A-E assessment, what other treatment is important to initiate in this case?

Options:
explanation: A single dose of oral corticosteroid (such as prednisolone or dexamethasone) may be given in the initial treatment of croup. If the child is too unwell to take the steroid orally, it is reasonable to administer it intramuscular (such as dexamethasone) or nebulised (such as budesonide). However, croup is not the most likely diagnosis here as there is no cough, stridor or temperature
name: Nebulised corticosteroids
label: e
answer: no
explanation: Antibiotics would be indicated if you felt that this was an acute infective respiratory diagnosis; however, at four days old and without any other signs of infection and no temperature, this is not the likely diagnosis here. If bronchiolitis was suspected, this would also not necessarily be an indication for antibiotics as bronchiolitis is usually viral in origin, with the management being mainly supportive
name: Intravenous antibiotics
label: b
answer: no
explanation: This baby is likely to have a cyanotic congenital heart abnormality such as transposition of great arteries or tetralogy of Fallot. There is not always a clinically audible murmur present. This typically presents as an increasingly cyanotic newborn in the first few days of life, as the previously patent ductus arteriosus closes and the newborn can no longer rely on it to allow oxygenated blood into the systemic circulation. These babies don't appear to work so hard to breathe compared with babies with lung disease. Another clue that this is less likely to be a respiratory condition is the minimal improvement with high flow oxygen. A prostaglandin infusion will help keep the ductus arteriosus open whilst awaiting specialist input
name: Prostaglandin E infusion
label: a
answer: yes
explanation: The use of CPAP may be indicated in those children with impending respiratory failure, for example, due to bronchiolitis. However, this clinical presentation is more in keeping with a cardiac cause for cyanosis as opposed to a respiratory cause. Although there is minimal improvement with high flow oxygen, and there is a temptation to start a more intense form of respiratory support, it is unlikely to improve the neonate's clinical picture
name: Start continuous positive airway pressure (CPAP)
label: d
answer: no
explanation: Nebulised bronchodilators such as salbutamol are used to treat reversible airway obstruction, such as acute asthma exacerbations. As this neonate is only four days old, the concern here is of a cyanotic congenital heart abnormality, and therefore salbutamol is not indicated
name: Nebulised salbutamol
label: c
answer: no

Correct answer: a


Learning point: Prostaglandin E infusion is used in cyanotic cardiac conditions, such as transposition of the great arteries or tetralogy of Fallot, to maintain the patency of the ductus arteriosus, which helps ensure adequate mixing of oxygenated and deoxygenated blood