Stiffness with stridor
Author:
Pediatric Oncall
Question
A one and a half months old boy presented with noisy breathing since birth and an episode of pneumonia 20 days ago for which he was hospitalized for 10 days. There was no suck-rest-suck cycle, excessive sweating over the forehead, or breathlessness. He was the only child of his parents and his birth weight was 2.5 kg with a present weight of 3.5 kg. He was full-term breech delivery and required NICU stay for 7 days for respiratory distress. He was on exclusive breastfeeds. On examination, he was found to have inspiratory stridor with substernal and suprasternal retraction. The chest was clear. The mother noticed that stridor would increase in sleep. The baby was found to have flexed hands and extended legs with increased tone in both upper and lower limbs. The mother also noticed that the baby appeared stiff. The child had achieved a social smile but had not achieved head holding as yet. The child was suspected to have spasticity due to stiffman syndrome or perinatal insult.
Is the diagnosis of spasticity correct in this child?
Expert Opinion :
This child is suspected to have spasticity in view of increased tone. Spasticity would lead to early head holding in the baby which this has not achieved. Babies generally tend to keep their hands in flexed positions and tone is always more than that in older children. Lower limbs may be in an extended position as the child was a breech delivery. This child has inspiratory stridor which is classically suggestive of laryngotracheomalacia especially since it worsens in sleep and there is no breathlessness. Laryngotracheomalacia is basically due to collapse of trachea while inspiring air either due to poor tracheal cartilages or poor tone of the airway. Thus, it is unusual to have a skeletal muscle increased tone and a smooth muscle decreased tone. Thus, increased tone in this child is unlikely. Regarding the mother finding the baby stiff, it may be due to the mother having first child and not too experienced handling babies.
This child was confirmed to have laryngotracheomalacia and on follow up tone was normal and milestones were achieved normally.
Thus, on suspicion of increased tone, one should always correlate with clinical symptoms.
