Hot Seat #67: 5wo F with vomiting
Posted on: January 11, 2016, by : Sam Zhao
Sam Zhao MD, Children’s National Health System
with Shilpa Patel MD, Children’s National Health System
The Case
A 5wk ex-FT girl with a PMH of poor weight gain is transferred to our ED for worsening vomiting over the past three days. Mom states that the vomiting is “forceful” and follows every feed. The patient was first seen at an outside ED, where an initial workup (EKG, KUB) was unrevealing, and an abdominal ultrasound was indeterminate for pyloric stenosis. She was transferred to our ED for surgical evaluation. The patient is transported by the NICU due to her size, and you have no records of the OSH documentation.
ROS: positive for vomiting, otherwise negative
PMH: failure to thrive
BH: full term, born via C-section; birth weight 7lb 11oz
No significant family or social history
Physical Exam: Vital Signs: T 36.9, HR 166, BP 95/70, RR 36, O2 sat 99% on RA, 3.79kg (8lb5oz)
The patient is small for age but alert, well-appearing, and developmentally appropriate. She has moist mucous membranes. Her cardiac and pulmonary exams are unrevealing. Abdomen is soft, nontender, and nondistended, and no organomegaly or masses are appreciated.
An abdominal ultrasound is repeated, and surgery determines that there is no evidence of pyloric stenosis. An ammonia level is collected to rule out urea cycle defect, and this is normal.
The patient remains well-appearing and has taken PO without difficulty. You are about to discharge the patient with close PMD follow-up for weight checks, when the parents ask you, “What should we do about her urinary tract infection?” At this point, you learn that the OSH had done a partial sepsis workup with a catheterized urinalysis that showed 20 WBC/hpf and trace LEs. Additionally, CBC showed WBC 7.8 with 25% N, 65% L, 4% M, 3% E, and 3% B with no bands. You call the lab at the OSH, which has a blood culture but no urine culture.
Question:
Repeat catheterized UA at our ED shows no LEs , nitrites, RBCs, WBCs, or bacteria. On further review of the patient’s records, you learn that he received ceftriaxone prior to transfer, approximately four hours ago. No lumbar puncture was performed.
More questions:
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
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First, I would ignore all the stuff about the urine and the ceftriaxone.
I would not ignore the diet history, weight gain, and presence of vomiting in a 5 week old that sounds inconsistent with reflux. It’s important to determine if the baby is gaining weight or not, and what the baby is eating. An infant should gain about an ounce/day. it looks like this infant has only grown 10 oz since birth. even if back at birth weight by 1-2 weeks, this infant should be up about twice that. And that’s assuming this weight is a naked weight (which it probably isn’t).
So failure to gain weight and vomiting requires a workup. This includes a diet history (formula mixing, total intake, etc) followed by a head circumference, social history (abuse), and good exam. Consider neuroimaging, electrolytes, and an UGI if the intake history is good. Lots of reasons for vomiting that aren’t called pyloric stenosis.
Agree with above. Using the approach that the baby should gain 1/2-1oz each day after the first week, she should be 15-25 oz above birthweight.
In terms of big buckets, I would like to know her head circumference and height, to help figure out if she has symmetric FTT (genetic anomaly, in-utero insult, just the way she is) or asymmetric (insufficient calories, increased loss/energy expenditure).
In terms of causes of vomiting and asymmetric FTT, obstructive lesions include malrotation and partial web/atresias along GI tract. The negative US makes PS unlikely. Different IEMs frequently cause vomiting and FTT as important early symptoms. Specifically, galactosemia can cause this constellation of symptoms and has a well-described association with Ecoli infections. Trauma either to head or to abdomen also leads to vomiting, so need to do careful exam for signs of bruising/swelling. In addition, need to check for dysmorphisms and for GU anomalies (virilization in CAH, hernia causing obstruction).
My choice is also to admit to hospital for a calorie count and initial observation, especially since she drank well in ED. In-hospital:
– review newborn screen results;
– review KUB for evidence of obstruction;
– may need UGI to look at quality of swallowing and to look for obstruction/narrowing/malrotation;
– if concern for injury, LFTs, neuroimaging, further abd imaging.
I appreciate and agree above comments by Dave and Jennifer. There is a broad differential for neonatal vomiting. First branch point is “sick” vs. “not sick”. For the “sick” infant, we are thinking sepsis, sepsis, sepsis, inborn errors, CAH, intestinal obstruction, severe NAT. Our kid appears “not sick.” Second branch point is “bilious” vs “non-bilious.” And although non-bilious vomiting in this age group does not automatically rule out more severe causes of vomiting in the neonate, it helps. Our kid has non-bilious vomiting. Non-bilious emesis points more towards a higher obstruction (HPS, antral web, circular pancreas, other higher atresias), GERD (though in our case it would be pathologic with FTT), head injury (or other causes of increased intracranial pressure), early presentation of IEM. Also, as I mentioned earlier, this could still be malrotation (without volvulus or intermittent volvulus in the well appearing infant). Finally, I am in complete agreement with Jennifer and Dave that poor weight gain is a definite red flag.
Having said all that however, with this well appearing baby, having taken PO in the ED twice with no emesis, negative ultrasound for HPS, with the right PMD and the right patient with close outpatient follow-up, with weight checks and further ongoing (it seems) investigation into poor weight gain is a reasonable option. Though with our patient population and usual poor outpatient follow-up, I think admission for failure to thrive is a better option. And considering further investigation with UGI, calorie counting/weight check, following up on newborn screen, etc. not unreasonable at all.
Finally, what to make of the UA…chronic UTIs (mainly in older infants I think) can be a cause of FTT but not sure I would jump to that as the cause of the FTT. Agree with Jennifer on thinking of galactosemia/Ecoli. UTIs can also present with vomiting alone, I suspect, without fever in a neonate. So it is not completely unreasonable that this is a UTI. The infant already received CFTX, would likely send a culture (though pre-treated) and strongly consider admitting if 24 hour follow-up cannot be arranged.