Cough, and not finishing her bottles

A 5-month-old with three days of a cold is breathing fast and has stopped feeding well. Her mother is worried about the pauses.

Age5 monthsWeight6.8 kgVitals read against the infant band

Pediatrics

5 months old· infant6.8 kggirl, Pediatric emergency, bay 3Fictitious educational patient

Caregiver: Mother: 'She started with a runny nose on Sunday. Since yesterday she is breathing really fast and only takes half her bottle, then comes off to breathe. Last night she went quiet for a few seconds and I got scared.'
Feeding: Usually 150 mL formula every 3 to 4 hours; today about 60 mL per feed.
Intake and output: Three wet diapers in the last 24 hours (usually six or more).
Birth: Born at 36 weeks, 2.6 kg, no special care.
Immunizations: Up to date for age.

Born at 36 weeksNo other history

Day 3 of illness · 19:40

Triage

The triage nurse has her on the monitor. She is on her mother's lap, awake, with visible subcostal and intercostal retractions and nasal flaring. Her nose is full of secretions.

Vitals

HR 168RR 62SpO2 91Infant band · HR 100 to 180 · RR 30 to 53

HR168BP88/52RR62high for ageSpO291%T38.1high for age

Read against the infant band (1 to 12 months): HR 100 to 180 awake, RR 30 to 53, hypotension below 70 systolic at the youngest age in the band. Fever, crying and pain move these numbers.

Read the vital signs for a 5-month-old. Which is the finding that most changes what happens next?

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