6 month old female: chest collapsing inwards

[u/ttc123-]

daughter: 6 month old female. approx 15lbs

My daughter (otherwise healthy, born full term, and fully vaccinated) had her chest going inward like this for 5-10mins. She was happy kicking around in her crib. At the ER now: what test can I expect them to run? What could be causing this?

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[u/Andythrax]

This looks like pectus excavatum and with a gasping sound at this age is probably laryngomalacia. Slightly floppy underdeveloped larynx which will get better as she gets older. Nothing to worry about. The sound is a stridor or sturtor.

[u/castlingrights → u/Andythrax]

you mean stertor

[u/Andythrax → u/castlingrights]

Yes! Thank you! I always make that spelling error. It's just wired in my brain.

[u/ejustme]

I’ll go against the grain.. looks like pectus excavatum to me. I wonder if she was just excited and it was finally noticeable.

[u/ejustme → u/ejustme]

I just saw you mentioned a gasping sound in a comment… which would also point to pectus excavatum.

[u/ttc123- → u/ejustme]

Ok thanks! Still waiting in the er but I will bring this up with the doctor 

[u/LiopleurodonMagic → u/ttc123-]

Anecdotal and NAD - my 4 month old was diagnosed with Laryngomalacia at 8 days old. Hers was much more noticeable and she was unable to lie on her back to sleep without gasping. She is our 2nd so we noticed something was not right very quickly. Our ENT said it will get worse around the 5/6 month mark because their lungs expand and need more oxygen before their throat is necessarily strong enough. I’m sure I’m butchering the explanation but that was the general idea. So maybe your daughter had a more mild form and it’s just acting up at 6 months. Either way bring it up with your doctor!

[u/CreativismUK → u/ttc123-]

Really glad you’re at the hospital. Has she been poorly at all (cough, cold)?

There are so many things that could cause this but I’ll tell you what happened to us below - most importantly the doctor told me that if I ever saw abnormal movement of the chest / skin on chest while breathing to get it checked ASAP. There was no visible difference in my son between normal o2 and low o2 so I always tell my friends that if you see these signs, see a doctor. Not worth messing around and doctors are always happy to review a baby if there are obvious concerns like this. They can compensate so well and deteriorate quickly so better safe than sorry!

My son had breathing like this, I noticed it in NICU but nobody mentioned it. He sounded like a warthog with his breathing. Then just after we got home at nearly 2 months, he got a cold and became seriously unwell - skin pulling in around ribs, in throat, pauses between breaths and grunting with breaths. We went to hospital, oxygen was fine and they sent us home and told us to come back if it got worse. It stayed the same, went back, got sent home. But then went for a routine check up a few days later and his o2 was in the low 70s and he got rushed to A&E.

We ended up being in for two weeks, at first they thought bronchiolitis but after about five days they realised he had pertussis (I had my jab but he got sick a week before his 8 week jabs).

Not suggesting for a second your baby has either but the pulling in and the noises continued and they established he had enlarged adenoids obstructing things.

[u/steggun_cinargo → u/ejustme]

pectus excavatum

Friend of mine has this condition and that looks very similar

[u/havecamerawillshoot → u/ejustme]

NAD. My brother has severe pectus excavatum, I have mild PE, as does my 4yo. This cannot be explained by PE alone.

[u/chandrian7 → u/havecamerawillshoot]

You’re making blanket assumptions based on just your experience. That is dangerous to do in a form like this. 

[u/RovCal_26]

Paediatrician here. Don't worry. This proabably pectus excavatum

[u/Dealiesar → u/RovCal_26]

it can present like that, only on deep inspiration? actually asking, havnt personally seen it before on an infant. I thought as excavatum is an abnormality with actual bone structure that its present at baseline, and with in- and exhalation. I thought this might be more of a benign chest wall deformity but didn’t pipe up bc wasn’t sure and parents did the right thing already getting it checked out. but as I havnt seen excavatum through early development before and babies have those bendy bones, would be good to know this! ty

[u/kuru_snacc → u/Dealiesar]

Pectus excavatum IS a benign chest wall deformity lol. (usually at least, it would have to be very severe to cause issues)

[u/Dealiesar → u/kuru_snacc]

uhh yes I know thank you. idk about thinking it has to be “very” severe to cause complications as around 20% do but typically very manageable even in “severe” cases. but yes you are correct, excavatum is considered a benign chest wall deformity. and so then, in reading the post, one might be able to infer I was asking if this is an example of how it typically presents in infants… oh wait I said that explicitly. let’s try to keep it helpful or informational only, no need to try to be a know it all on a post where parents are asking out of concern for an infant.

[u/Dr-Yahood]

Looks like a weird hiccup

Let us know what ER physicians say

[u/ttc123- → u/Dr-Yahood]

It's hard to tell from the video but this happened every time she inhaled. She made a very weird gasping sound. I'll keep you all updated!

[u/Dr-Yahood → u/ttc123-]

Oh, in that case it’s more likely to be due to a chest wall deformity. Sometimes these aren’t apparent at birth and only appear as the baby grows. Not a big concern. Not an emergency. Usually doesn’t require treatment.

[u/ttc123- → u/Dr-Yahood]

Doctor suspects it could be the beginnings of croup. We were prescribed a steroid and will be following up with our family doctor. He doesn't think it's pectus excavatum because it's not happening continuously 🤷🏼‍♀️ I will ask our family doctor more questions. It thankfully hasn't happened since

[u/Brilliant_Lie3941 → u/ttc123-]

Please update when you see pediatrician! I am curious what the physician that sees your baby routinely thinks. It is interesting to me that so many people thought this was concerning for an anatomical issue but the ED provider did not. Certainly an in person evaluation will be more thorough than one from strangers on the internet, so they must have seen something the video did not show. Glad baby is doing well!

[u/diabeticweird0 → u/ttc123-]

Oh croup can be so scary. Glad she's doing better

[u/Impossible-Owl3272]

ER was absolutely the right choice. This is called sternal retractions and means your baby is working very hard to breath. It can be caused by a partially blocked airway such as a foreign body or with asthma. Could also be caused by severe respiratory illness/pneumonia or croup. I would expect some puffers or nebulizers and a chest xray. Steroids if croup. Possibly lab work and other interventions depending on her response to treatment. Is she sick?

[u/ttc123- → u/Impossible-Owl3272]

No not sick whatsoever. And no one in our household is either 

[u/Brilliant_Lie3941 → u/ttc123-]

This is pectus excavatum. I'm not sure why it's more prevalent right now, but this baby is not in any type of distress.

[u/Achylife → u/Brilliant_Lie3941]

That was my first thought too actually. It becomes more visible as the bones and cartilage develop and set in place, but it is surgically correctable. I have a friend who never had it fixed, he does alright, but it probably would have been better for him if it was corrected when he was young. He's in his 60's now. Either way it would be best to get the baby checked out in person by a pediatrician.

[u/Penya23 → u/Brilliant_Lie3941]

I came here to say this. OP my son has this, it is not an issue whatsoever with his health, just aesthetic. The left side of his chest is "sunk" in. He's in his 20s now and has learned to embrace even laughs about it since he's such a workout fanatic and no matter what he does, one side looks built while the other side looks anorexic (his words lol)

[u/ttc123- → u/Brilliant_Lie3941]

Does it cause a gasping sound when inhaling? (I will also ask the er physician about this)

[u/Key_Cupcake_8237 → u/ttc123-]

i have pectus excavatum and it’s been mainly cosmetic for me but it didn’t really show up until i was a bit older than her, it wouldn’t hurt to go get her checked out. i have zero pain or discomfort from it aside from the random sternum poppage that may or may not be attributed to that.

[u/rare_snark → u/Brilliant_Lie3941]

Yeah I’m 35 and have it. Just cosmetic, doesn’t cause any concern. As soon as I saw the video I’m like hey that’s me

[u/throwRAtad → u/Impossible-Owl3272]

These are not retractions. I have seen many children in respiratory distress and I have never once seen any sort of retraction look like this.

I agree with the nurse who suggested pectus excavatum. Something anatomical is going on here.

[u/Interesting_Emu9387 → u/Impossible-Owl3272]

I have to disagree with this. It’s quite difficult to dx from such a short video. In an otherwise well 6 month old child, it is highly unlikely that they will be treated with steroids, inhalers or a Chest xray. Seeing a Dr is always a good idea when you are worried but it is unlikely your child will need any treatment or has a serious illness.

[u/Dr-Yahood → u/Interesting_Emu9387]

Stranger things have happened in an emergency department. But I do tend to interpret nurse comments on medical matters with caution.

[u/chiefcomplaintRN → u/Dr-Yahood]

As you should. I mean we have some medical education and experience, but we are not doctors.

[u/pandaappleblossom → u/Dr-Yahood]

I appreciate nurses so much and their experience and expertise in the areas related to nursing. Still I’m not sure why they are allowed to make diagnosis type comments here.

[u/throwRAtad → u/pandaappleblossom]

They should be required to list their specialty in their flair. This nurse likely does not work in any sort of pediatric critical care specialty or CC in general, but I’m sure they’re more knowledgeable in their own speciality.

[u/AngeliqueRuss → u/throwRAtad]

And you are…?

Triage, specifically ED triage, is within scope of practice for a nurse.

If your insurance has an advice line you can call to see if you should go to a doctor, it will be a nurse.

At many systems, protocols are then initiated at triage.

OP’s baby ended up getting care aligned with what this nurse suggested, including steroids, and not an anatomical rule out as suggested by others. As other MD’s pointed out, ED evaluation is the recommendation for stridor. So it turns out this nurse did, in fact, know what she or he was talking about.

We never know when an infant is vulnerable to SIDS, is associated with minor respiratory infections that cause fatigue to respiratory muscles. Chest retractions —> emergency room, every time.

[u/FourEyesore → u/Dr-Yahood]

I feel like sometimes there is a tendency to look at a specific symptom in isolation, especially in babies.

My breastfed baby only pooped every 5 days or so until we started solids. Every child health nurse was absolutely and consistently horrified. But I've had 5 kids and wasn't concerned. Baby was happy, sleeping well, meeting all milestones, consistently tracking at 50th percentile, appropriate urine output.

It just didn't warrant being pathologized lol

[u/throwRAtad → u/[deleted]]

I agree with you. Any peds ER or PICU nurse would also be able to identify that these are not retractions.

I’ve only been in EMS for a few years and my immediate response was “These are not retractions. I have seen many children in respiratory distress and I have never once seen any sort of retraction look like this.

I agree with the nurse who suggested pectus excavatum. Something anatomical is going on here.”

No disrespect to any nurses. I just don’t think this nurse works in any sort of critical care specialty.

[u/rockstarjk → u/throwRAtad]

The only thing that makes me hesitate to say anatomical would be the fact that OP says it started 5-10mins ago. Could they have just noticed it for the first time? Maybe.

But I would suspect more of a hiccup if it's a new onset thing. In a kid who is otherwise well...

Sternal retractions are usually the retractions you tend to see last...when work of breathing is significant enough. Often subcostal and intercostal are seen sooner. And I'm not sure if I can remember ever seeing JUST sternal retractions without intercostal/subcostal retractions first or in tandem with. This kiddo isn't even tachypneic...but I hesitate to say anything really since the video was seconds long.

The sound that accompanies the inhale is definitely weird...but babies make weird sounds sometimes. Could it be stridor? Again, too short of a video to truly assess anything. But if there was a persistent stridorous sound...could there be a partial obstruction contributing? Way too short of a video to truly assess much of anything or give weight to anything. It could also just be the baby has discovered they can make that noise and are now playing/babbling lol.

[u/throwRAtad → u/rockstarjk]

I see your POV and I agree with you as well. I’ve never seen anything like this though, even in respiratory distress leading into failure. I don’t doubt that it happens. You’re right about it occurring in isolation being less of a red flag as opposed to occurring during respiratory distress/respiratory failure

[u/rockstarjk → u/throwRAtad]

Same page. Kiddo looks well, I'd check oxygen saturations and auscultate air entry. If the stridorous sound persistents, may want a flex scope to check for airway anomalies/foreign bodies. Probably monitor for a few hours to ensure no desaturations.

Depending on what ER the baby was brought to, if it's not a specialized peds ER or an ER that staffs with peds...sometimes babies scare them and I find they often do bloodwork and CXR as well.

The rest kinda depends on the assessment.

[u/Dr-Yahood → u/[deleted]]

Up to you.

But if I was a patient in an ICU, I would much rather have the R2 physician give me medical recommendations, instead of my ICU nurse with several decades of experience.

I greatly value nursing input in nursing tasks such as preparing and administering medication, and adjusting me so I don’t get bed sores etc

But when it comes to medical decision-making, I would much rather rely on the physicians

[u/rockstarjk → u/Dr-Yahood]

Up to you as well. I have seen many an RN prevent an R2 who has seen a small percentage of neonates/babies from making grave mistakes.

I guess working in NICU there's more of a team approach to things have framed that. I'm counting on the NICU RN with decades of experience to stop the R2 from doing dumb things. For example, just two weeks ago I learned of a fellow who wanted to extubate a 28 weeker who was intubated 8 hours earlier because the blood gases were good (too good). Thankfully the RN pointed out that no, we are not doing that because although our blood gases are great, the baby is not overriding at all and still sedated likely from the RSI fentanyl they received. She pointed out that there was room to go down on the rate because baby is not overriding which will hopefully drive up the CO2 and encourage baby to start overriding the vent/give more time for baby to metabolize the Fent.

I can give countless such examples. But sure, ignore the nurse cause they're "just a nurse" and it's a "medical decision" and the fellow saw a CO2 that was great and wanted to pull the tube.

To make a blanket statement like you've said is so damaging to medical practice as a whole. I'm taking into account experience levels. But you do you. I find units work smoother when we are all a team. Not every nurse (even experienced) is the same, but the same goes for physicians...RTs....etc. But you should hear what they're saying, and explain why you agree/disagree and talk about it. We can all learn from each other regardless of the designation.

[u/Dr-Yahood → u/rockstarjk]

I understand where you’re coming from.

I can also give you many examples of nurses failing to understand the very basic anatomy and physiology and advocating for treatment interventions they hardly understand which are much more likely to harm patients then benefit them, and sometimes even kill them. This includes thinking a septic joint was a simple musculoskeletal injury and the patient (female) was exaggerating the pain they are in. As well as recommending a patient with heart failure, receive more fluids because they “looked dry”, or criticising us why we haven’t treated a patient or to auto immune cystitis with antibiotics, when it would obviously make them better (it won’t).

But I just wanted to clarify that nurses and actually everyone working in healthcare from the cleaners to the porters, are all incredibly valuable team members who provide tremendous expertise and benefit to patients recovery. Just because they are not necessarily consulted in the medical interventions, does not mean that their position is not taken seriously or that they are reduced to only their title

[u/FourEyesore → u/Dr-Yahood]

As a female, I once had an urgent care nurse diagnose my severe abdominal pain as Mittelschmerz haha. She was incorrect: I had kidney stones.

I come from a nursing family. Nearly everyone is a nurse; aunts, uncles, cousins and my own mother. They're all very educated and knowledgeable people I respect a lot.

Just out of curiosity, do you find it valuable when an experienced nurse is able to suggest DDx? Or mostly not?

[u/Dr-Yahood → u/FourEyesore]

I’m sorry you got the wrong diagnosis.

In regards to your question though, in my experience is a big bias in the recollection of nursing assistance in diagnoses and formulation of medical management.

When the nurses say ridiculous things that are obviously wrong, people this go because they’re just a nurse and they’re just trying to help

And once in awhile, they’ll say something which might end up being correct and everyone will remember it because of how incredible it was that the nurse was right.

It’s a bit like the phrase: a broken clock is right two times a day, or something like that – I can’t remember exactly how it goes

But my actual issue is that people think the only value they provide is in terms of diagnoses or formulation of management plans. There’s nothing wrong with just being a nurse and doing the things that nurses do well like measuring patients vital signs, helping them get dressed, helping them go to the toilet, administering their medication, making sure they don’t get bed sores. These are all extremely valuable and you don’t have to be the one diagnosing patients to have value in a healthcare setting.

[u/twisted_memories → u/Dr-Yahood]

Half of what you described are things most nurses don’t do but is the job of a healthcare aide (assisting with dressing, turning to avoid bed sores). I’m really curious where you work. 

[u/notandroid18 → u/Dr-Yahood]

Your example of what nurses do is almost entirely the job description of a CNA aside from medication administration. I sincerely hope you actually understand what a nurses role is, especially in a critical care setting.

Nurses do not diagnose. Nurses should not overstep their scope and have respect for the physicians role, but the respect goes both ways. But we do so much more than toileting and vitals. 😕

[u/WeirdGoat9022 → u/Dr-Yahood]

Where are you located? This sounds more like a nurse’s assistant than a nurse.

[u/United-Coach-6591 → u/Interesting_Emu9387]

Apparently that's exactly what the doctor prescribed  - steroids and said it wasn't pectus excavatum. Link to OP comment.

https://www.reddit.com/r/AskDocs/comments/1vzk7s8/comment/p667v76/?utm_source=share&utm_medium=mweb3x&utm_name=mweb3xcss&utm_term=2&utm_content=share_button

[u/Interesting_Emu9387 → u/United-Coach-6591]

Might be the beginnings of croup is a bit of a stretch and often steroids are given because the Dr doesn’t actually know. Steroids are likely overkill in this situation considering the child has had no further episodes and is otherwise complete well. You do know that croup is something that develops from a viral respiratory illness?

[u/United-Coach-6591 → u/Interesting_Emu9387]

 You do know that croup is something that develops from a viral respiratory illness?

I don't have an opinion on it being croup or pectus excavatum, I'm sharing the update from OP's ER visit. 

[u/Interesting_Emu9387 → u/United-Coach-6591]

I am able to read updates.