Hot Seat #161: 3mo with poor feeding

Posted on: November 30, 2020, by :

Nicole Barbera, MD Inova Children’s Hospital

CC: Poor feeding, sleepy

HPI: 3 month old previously healthy male who presents to the ER with 2 days fussiness followed by increased sleepiness and poor feeding starting the night prior.  No fever.  He had 2 episodes of non-bloody nonbilious emesis.  No changes in voiding or stooling.  No cough or congestion.  No known sick contacts.  Born at 40 weeks gestation via NSVD, GBS and all prenatal labs negative, birth weight 3.2kg and gaining wait well since.  Immunizations UTD.

Exam: HR 140, BP 86/54, RR 40, SaO2 100% on room air, Temp 99.2, Wt 7.5kg

Well appearing in no acute distress, sleeping throughout exam except when lifted and held in a seated position. Anterior fontanelle is open/soft/flat, moist mucus membranes, no oral lesions. Lungs CTAB, heart RRR, strong femoral pulses, no murmurs, brisk capillary refill.  Abdomen is soft, nondistended, nontender, no hepatosplenomegaly or masses.  Uncircumcised, testes descended bilaterally.  Skin warm and dry, no rashes. 

Point of care glucose 113.

Abdominal x-ray and US are negative for intussusception. CBC unremarkable.  CMP notable for AST 228, ALT 174 otherwise within normal limits with total bilirubin of 1.2.  Vitals stable, patient remains sleepy but easily arousable on exam.

Further labs obtained with GGT 776, CK 97, LDH 490, alk phos 273, coags within normal limits.

RUQ US showed 7mm gallstone within the gallbladder which has multiple septations and wall thickening.  The common bile duct is 6mm and dilated to the pancreatic head.  Liver normal.

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Mary Beth Howard
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1 thought on “Hot Seat #161: 3mo with poor feeding

  1. Interesting case. Infants with lethargy/sleepiness are always tricky and often require a shotgun approach with a broad differential. Often like the neonate that does anything wrong may get an SBI workup easily, older infants can still hide bad stuff. Reminds me of Shilpa’s SPIT mnemonic (Serious, Probable, Interesting, Treatable). I’ll let someone else work through the many possibilities for this infant (cue: Matt? :))

    Fortunately, overall most of these infants wake up and start acting normally with an inconclusive or negative workup, this is one of those patients that justifies the broad workup. For those that just wake up, the real question is how long do you watch them after they are “normal” to make sure they stay normal. Generally, I would base that determination on how long they were not normal, or just use our usual, un-evidenced 4-6 hours of normal behavior to say ok, things look good – bye bye!

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