Sam Zhao MD, Children’s National Health System
with Shilpa Patel MD, Children’s National Health System

The Case
This is a case of a 5 week old with vomiting and poor weight gain who was found to have a positive UA at an outside hospital and given antibiotics prior to transfer to our ED. The questions posed asked readers how they would proceed with regard to the infant’s infectious workup and disposition given that the infant had already been treated with antibiotics.

Here’s How You Answered Our Questions

Denouement
After discussion with several ED attendings, the hospitalist attending, and the patient’s PMD, it is decided that we should not admit the patient, because there is no definitive endpoint to the observation. The parents feel comfortable taking the patient home. She is given her first dose of Omnicef and discharged home with PMD follow-up the next afternoon.

At that appointment, he notes that she continues to be alert and well-appearing and has gained 20g in the past 24 hours. He calls the OSH lab, where they have found the urine sample sent from the ED for culture. The blood culture continues to show no growth. He will follow up with speciation and appropriate antibiotic therapy.

While the author’s intention was to discuss how to proceed with the infectious workup in this patient, most of the discussion focused on the concern regarding the patient’s vomiting and FTT, despite having ruled out hypertrophic pyloric stenosis.

Teaching Points

• When considering discharge in a well-appearing infant who has received antibiotics for any reason, ensuring good follow up is essential. If a provider is not available to examine the patient and obtain culture results in 24 hours, admission for observation is reasonable.
• Vomiting in neonates has a broad differential. In this case, the child was not ill-appearing and had non-bilious emesis, which suggests a higher obstruction (e.g. pyloric stenosis), GERD, increased ICP (e.g. head injury), or an inborn error of metabolism. Shilpa’s comment in the original post provides an excellent walkthrough of this workup.
• In well-appearing neonates with ongoing FTT, consider admission for an expedited and comprehensive workup.