Medical Mystery: What caused baby’s shallow breathing, unconsciousness?

Three years ago, a 10-month-old boy was rushed into our emergency room by his distraught parents with lethargy and slowed breathing.

Little did we know at the time that this child, and others like him around the nation, would alter the way we take care of children with a change of consciousness coming to our emergency rooms, and bring to light an epidemic that is sweeping every corner of our country.

One of our first lessons in medical school is about the care of a patient with altered consciousness. We’re taught the ABCDEs, which save lives on a daily basis.

A is for airway. Make sure the patient’s airway is clear and not blocked or damaged. Our patient’s airway was intact.

B is for breathing. Check for adequate chest rise, listen for equal breath sounds, and check rate of breathing. The boy’s lungs sounded clear, but his respiratory rate was a little slower then normal. He was given oxygen, which helped his breathing almost immediately.

C is for circulation. His pulse was normal. When pressing on his fingernail — a technique called capillary refill time — it turned white, a normal response, but took three seconds to come back to a healthy pink color (it should be less than two seconds). That helped us determine that the boy was a little dehydrated. IV fluids were initiated.

D is for disability. Check for consciousness. Does the patient respond to voices? The boy was unconscious.

E is for exposure. Take all clothes off to determine any outward signs of trauma. The boy had none.

Labs and a chest X-ray were ordered, which all came back normal. A CT scan of the boy’s head was also ordered to make sure there were no abnormalities that would cause slow breathing, such as bleeding in the brain from abuse or tumors. The CT scan was also normal.

Besides his slow breathing and mild dehydration, there was nothing else abnormal.

We forced the boy’s eyes open to check for any abnormalities. A penlight focused on his pupils gave us an answer.

His pupils were smaller then normal. Constricted pupils, or miosis, can occur from numerous causes, among them poisonous mushrooms, certain medications, strokes and other brain injuries or infections, and opioid ingestion.

There have been many news reports of children ingesting opioids left out on kitchen counters, in purses, and under the sofa cushions.

The rise in fatal and near-fatal unintentional overdoses in children follows the adult epidemic. In 2017, 70,000 Americans died of opioid overdoses, contributing to a decrease in life expectancy, which hasn’t been seen since World War II.

In a study published in the journal Pediatrics in April 2018, researchers found that opioid-related hospitalizations and admissions into pediatric intensive-care units increased significantly. Also in this study, the highest-risk children were teenagers and children under age 6. Another 2018 study, from the Centers for Disease Control and Prevention, looked at opioid-related deaths in children from 1999 to 2016 and demonstrated an almost three-fold increase to nearly 9,000 children.

We gave our patient a dose of the opioid reversal drug naloxone (Narcan) and he quickly woke up confused and crying, reaching for his mother.

We alerted the city’s child protection team to investigate how this child was exposed to an opioid that could have easily killed him. A tragedy was averted with a penlight.

Daniel R. Taylor, D.O., is an associate professor at Drexel University College of Medicine and director of community pediatrics and child advocacy at St. Christopher’s Hospital for Children.