[dr.Ira]

A 7-week-old girl of Middle Eastern descent is admitted to the hospital for a cough of 10 days’ duration that is worsening and has produced posttussive emesis for the last 7 days. An episode of perioral cyanosis lasting less than 1 minute was noted 5 minutes after a feeding. There has been no fever, rhinorrhea, emesis, or diarrhea. The baby was born at term without perinatal complications.

Three days into her illness, the child’s pediatrician had placed her on nebulized bronchodilator therapy for presumed viral bronchiolitis. Re-evaluation on the day of admission shows no improvement. A chest radiograph reveals marked cardiomegaly with clear lung fields.

The physical examination reveals a well-nourished baby who looks alert but manifests slightly decreased activity. Her heart rate is 130 beats/min, respiratory rate is 35 breaths/min, blood pressure is 85/45 mm Hg, and pulse oximetry saturation is 100% in room air. The child’s length is at the 95th percentile, and her weight and head circumference are at the 75th percentile. Auscultation reveals scattered end-expiratory wheezes, more prominent at the bases, but no grunting, retractions, or nasal flaring. A soft grade I/VI systolic flow murmur that does not radiate is audible at the left sternal border. Both heart sounds are normal. The baby appears well perfused and has normal femoral pulses. The rest of her physical findings are normal.

CBC, electrolyte levels, and liver function tests all yield normal results.

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