ICU AND YOU · Superquiz #61 — The postneonatal infant

1A four-month-old is brought in mottled and lethargic. Heart rate 190, capillary refill 4 seconds, blood pressure 88/54. The blood pressure is:

AReassuring, and suggests shock is unlikely BLow for age, and confirms decompensated shock CUnreliable in infants and should not be measured DNormal for age, and does not exclude shock

An infant maintains blood pressure by vasoconstriction and tachycardia until compensation fails, so a normal reading tells you almost nothing about how sick they are. Hypotension in a child is a late, pre-terminal sign — by the time it appears you have lost the part of the illness you could most usefully have influenced. Judge perfusion instead: capillary refill, skin, conscious state, urine output.

Standard paediatric resuscitation teaching; see the mind map for this topic, first station.

2The same infant weighs 6 kg and needs fluid resuscitation. The appropriate initial bolus is:

A120 mL of 0.9% sodium chloride B60 mL of 0.9% sodium chloride C60 mL of 4% albumin D600 mL of 0.9% sodium chloride over an hour

Ten mL/kg, which is 60 mL here — not the 20 mL/kg many of us carry over from adult practice. Reassess after every bolus rather than prescribing a total in advance, and be more cautious still if there is any suggestion of cardiac disease or severe malnutrition, where the tolerance for volume is lower again.

Australian and New Zealand paediatric resuscitation guidance; confirm against your local protocol.

3A three-month-old has classic bronchiolitis: coryza for two days, now tachypnoea, subcostal recession and reduced feeding. Regarding a chest radiograph:

AIt is not routinely indicated and often misleads BIt should be obtained in all admitted infants CIt reliably distinguishes bronchiolitis from bacterial pneumonia DIt is required before starting high-flow oxygen

Bronchiolitis is a clinical diagnosis. Films in these infants frequently show atelectasis and perihilar changes that get reported as possible consolidation, which drives antibiotics that were never needed. Imaging is for the atypical course, the focal signs, or the child who is not doing what bronchiolitis does.

Australasian bronchiolitis guideline; PREDICT network.

4A five-month-old, not yet rolling or sitting unsupported, has two bruises over the left cheek. The parents cannot account for them. Your first action is:

AReassure the parents, as bruising is common at this age BArrange outpatient review in two weeks CUndress and examine the infant fully, document the findings, and escalate the same day DRequest clotting studies and act only if they are abnormal

A bruise in an infant who is not yet mobile is a red flag until proven otherwise, and facial bruising with no history is among the most concerning patterns. Full examination and same-day escalation come first; coagulation studies are part of the workup, not a reason to delay it. Every clinician in New South Wales is a mandatory reporter, and the threshold is reasonable suspicion, not proof.

NSW child protection guidance; and see the mind map for this topic, child protection station.

5Parents of a two-month-old ask about safe sleeping. Which single statement is correct?

ASide-lying is an acceptable alternative to back-lying BA dummy is associated with an increased risk of sudden infant death CSleeping prone is acceptable once the infant can lift their head DBack-lying for every sleep, in the parents' room, with the head uncovered

Back-lying for every sleep, every time. Side-lying is not a safe alternative — it is itself a risk factor, because infants roll from side to front. Room-sharing without bed-sharing is protective for the first six to twelve months, and the face and head should stay uncovered. And a dummy at sleep is associated with a reduced risk, which surprises almost everybody.

Red Nose Australia safe sleeping advice, which takes precedence over anything here.

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