Hot Seat #69: 6 do female w/ dehydration and weight loss
Posted on: February 15, 2016, by : Astrid Sarvis
Astrid Sarvis MD, Children’s National Health System
with Karen O’Connell MD, Children’s National Health System
The Case
6 do FT F sent to the ED by her pediatrician for severe dehydration and weight loss. Pt discharged on DOL 2 and followed up with PMD 2 days later at which time the patient’s weight loss was within the normal range. Returned to PMD today for weight check and noted to be severely dehydrated with 21% weight loss. Baby has been exclusively breast fed since birth, but hasn’t been latching well and has become increasingly fussy with feeds. Denies fever, vomiting or diarrhea. Making several wet diapers a day. One stool since discharge resembling meconium. At PMD’s office, labs were drawn and an IVF bolus given prior to transfer to the ED.
ROS: As per HPI.
Birth hx: FT, no complications during pregnancy or delivery, SVD, GBS negative. Mom denies having herpes or genital lesions.
Fmhx: Noncontributory.
Surgical history: Negative.
Pertinent Physical Exam:
VS: T 36.3 (rectal)/ HR 122/ RR 35/ BP 86/51 / Sats 100% on RA
General: Thin, listless, vigorously sucks bottle offered
Skin: No rash. Cool to touch. No appreciable jaundice.
HEENT: NCAT. AF slightly sunken. PERRL. No scleral icterus. Dry mucous membranes. No oral lesions.
Lungs: No distress. CTAB.
Cardiovascular: RRR, no MRG. 2+ central and peripheral pulses
Gastrointestinal: Soft, nontender, nondistended. No appreciable HSM. Normal bowel sounds.
Lymphatics: No lymphadenopathy
Musculoskeletal: Normal ROM. Moves all extremities.
Neurologic: Good tone.
Remainder of exam within normal limits.
You give a NS bolus and continue to allow po adlib.
Pt found to be hypoglycemic to 49 via bedside glucose. Other POC labs: CBG+ lytes pH 7.31/ pCO2 20/ pO2 104/ HCO3 10/ Base deficit 13/ Na 164/ K4.4/ ical 1.5/ Hb17/ Hct 50/ Lactate 2.5. You give a D10 bolus and order repeat glucose in 30 mins. You also order a CMP.
Questions for you:
Update:
Repeat temp is 35.4C, so the patient is placed under a warmer. Glucose improved from 49 to 135 after two D10 boluses.
Labs: Na 160, K 4.5, Cl 127, CO2 12, Glucose 138 (post D10), BUN 64, Creat 0.59, Ca 10
Tp 7, Alb 3.5, AP 162, ALT 30, AST 65, TBili 2.4,
CBC- WBC 7, segs 39, lymph 35, mono 11, H/H 17/50, PLT 367
UA wnl
The patient remains vigorous. Has had 3 oz of formula total over 2 feeds. Temp improves with the warmer; other vitals stable.
More questions:
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.
First, I’d like to know what PCP office in our area can place an IV in a 6-day old. just curious 🙂
Evaluation – start with the hypoglycemia……….need to see whether patient is acidotic or not. Seems like YES with a bicarb of 10. Then need to know if making ketones or not. urinalysis “normal” isn’t helpful here. very different metabolic path if infant is able to make ketones or not in the presence of acidosis and hypoglycemia. so this is a ketone(?)-lactic-acidosis-with-hypoglycemia (and hypernatremia), right? maybe an organic acidemia?
Always ask about infant feeding (formula mixing, supplements, etc).
Yes, any 6d infant with a core temp of 35 and severe acidosis gets a sepsis eval. no questions asked. yes to LP and antibiotics. warm the baby.
iCa=1.5 is pretty hypercalcemic. no idea what that means in a 6d old.
dex bolus, saline bolus, D10 fluids for a while. calculate out fluid replacement for hypernatremic dehydration. send a boatload of metabolic labs.
And there is no way this baby would have a RR=35. blowing off all that CO2 with a HCO3=10, would be breathing 50s at least.
The 3 labs not to forget when concerned about a metabolic disease in a lethargic infant: Urine Ketones, Lactate and Ammonia. In a sick infant, I’ll easily remember a VBG and a POC glucose, but these tend to be forgotten. If these are normal, metabolic moves lower on my list and I am more assured I don’t have a critical need to talk to genetics! Peds in Review does a nice article about once every 5 years that is remarkably straightforward on this topic. http://pedsinreview.aappublications.org/content/37/1/3
As for the septic workup, my initial gut instinct was full septic workup, yet I found myself hemming and hawing about it. Perhaps it was that the infant was described as vigorously sucking when offered a bottle? The normal temp on arrival? A false sense that this is dehydration/metabolic and not infection? I’m not sure. I do think that there is no role for a “rule out” CBC and UA. Unlikely previous discussions, we’ve had on here, If you are going to go partial, I would go all out for a 6 day old.
My major concerns are sepsis (although the reassuring baby after first set of labs is nice, I don’t think a newborn can ever totally truly “reassure” you), new onset metabolic baby (need lactate and ammonia and urine ketones, per Katie, plus I’d be calling to get the results of the newborn screen), and CAH (give the weird Na and K – I don’t see a GU exam documented, so need to take a peek, but even that may not be enough), and very last, and very lowest on my list – a feeding issue – is mother trying ot nurse as often as required? is she refusing to give bottle due to fears of bottle confusion? does she have milk? is she depressed? (cue Lenore…) There is so much confusion around those early baby days and what a baby truly needs versus what’s “best” for the baby that I can absolutely see this level of metabolic derangement from a parent who is committed to nursing, but is also unable to nurse…
I held off on antibx, but after reading dave’s comments, I’m starting them.
Great case! Agree with above to send metabolic screens, full septic w/u and abx, Most likely dx?
Plain old dehydration (and early acute renal failure) – breast is best, except when the baby is not getting any. Do not be reassured by wet diapers, no matter how many of them they tell you they have per day. I saw one last month like this case Na in the high 150’s and “15 wet diapers per day” but only 2 stools by day 7. In the first week, stool is your key indicator, along with weight, that will tell you whether the baby is actually getting anything. Acute renal failure wise, assuming an avg height of 50 cm at birth, http://www-users.med.cornell.edu/~spon/picu/calc/crclschw.htm calculator tells me he’s got a CrCl of 28. Get renal involved? I would discuss first with hospitalists and see if they want to wait until repeat labs in 6-12 hours after fluid resuscitation to see if this CrCL comes back up on it’s own.
Only other thing to start working up is that high ICa – Maybe a PTH problem? Familial hyperCa+ syndrome? Call endocrine to see what else to add on to the workup for other Vit D and urine tests, etc. Or repeat it right after the bolus and if it’s normalized to <1.25, than nevermind it is likely resolving on its own. Cue in the hospitalists to follow this closely.
Admit to floor. Feed with formula to measure what's going in, or have mother pump and give by bottle, with maintenance IVF as well once done fluid resuscitating clinically.
Paul
This is always a topic of great conversation. Is this infant simply presenting with severe dehydration, or does this patient have a life-threatening infectious or metabolic etiology. I echo Dave’s comments regarding pmd workup – would have been helpful, however, to know the glucose prior to receiving IVF in their office and transport decisions. I cannot remember the particulars, but hope they did not come by POV. The combination of tests (ketones, lactate, bicarb, glucose) can sometimes help with decifering between pre-renal/renal/systemic causes of dehydration, but in newborns it is often not so clear cut. Kuddos to Katie for keeping metabolic in the back of her mind and sending off the additional labs that may be helpful. Unfortunately, with the repeat rectal temp of 35.4 (normal range 36.3-37.5, or 37.9 for sticklers), this infant needs a full sepsis workup and coverage for potential sepsis. Risk/benefit ratio in my clinical practice does not fall outside this plan. I am also of the camp that screening cbcs have no room in the evaluation of possible need for further workup with an LP for infants less than 4 weeks of age (the 6 weekers are more gray). So, as a group, we should discuss giving guidance based on evidence about the utility of using the wbc 15,000. Who can we use this approach on?
Looking forward to good conversation. (Dewesh, I’m sure you have the most current febrile infant data. Was it Lise’s research that discussed the use of the screening cbc for LP decisions? My neurons are misfiring! Can you send the info to the group?)
Thanks
Karen