Hot Seat #87: 12do M with abnormal movements
Posted on: January 30, 2017, by : Sam Zhao
Sam Zhao MD, Children’s National Medical Center
with Alyssa Abo MD, Children’s National Medical Center
The Case
A 12do ex-FT boy born via NSVD presents with two episodes of vomiting and shaking today. Mom had been concerned that she wasn’t making enough breast milk, so she gave him Enfamil Newborn for the first time today. He had two feeds that were followed by NBNB emesis, and then he had shaking over his body that lasted a few seconds. He was acting normally immediately afterward. A few hours later, he had another episode of generalized shaking. He never stopped breathing or turned blue. He is currently back to acting like himself.
ROS: + cough but no fever, rash, or diarrhea
PMH:thrombocytopenia
BH: born at 39 weeks via C-section; mother had ITP during pregnancy treated with IVIG; patient had screening CBC at birth with platelet count of 10k and was treated with PO steroids and IVIG and was discharged from the hospital a week later with up trending platelet count to 52k.
FH: ITP in mother
SH: first child; lives with mother and father; no known sick contacts
PE:
T 36.7, HR 150, BP 69/39, RR 44, O2 sat 100% on room air
The patient is alert, well-appearing, and neurologically appropriate for his age. He has strong distal pulses and normal capillary refill. His cardiac, respiratory, and gastrointestinal exams are all unrevealing.
Question:
A CBC was sent and showed 9.1 > 14.7 / 41 < 28.
Another Question:
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
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Shaking in a 12 day old can be normal or pathologic. Sometimes difficult to know without a video from the parents or directly witnessing the event. In the setting of recent thrombocytopenia and change in formula, it seems appropriate to start with and CBC and electrolytes. If witnessed to be having a seizure, then more work up is indicated including head imaging. If electrolytes and CBC are normal and patient continues to have shaking would think of other neurologic and metabolic conditions and would send more laboratory tests such as ammonia.
I think the money lies in clarifying the witnessed “shaking” episode. Did it involve all extremities, face, trunk? Was there associated reflux in the mouth/nares? Was it rhythmic? Did it look like a startle reflex? Were both episodes similar (ie, stereotyped)?
Any respectable pediatric neurologist will tell you that the brain of a 12 day-old isn’t myelinated enough to have a generalized tonic-clonic seizure like we witness in older individuals. Generalized seizures in this age group are not organized enough to cause whole-body tonic or clonic movements. So, it is highly unlike that these “shaking” episode are seizures if the whole body was shaking.
Nevertheless, I think any respectable pediatric EM physician when there is a concern for neonatal seizures in a child with h/o thrombocytopenia requiring treatment would check a CBC (mainly for platelet count), electrolytes (Na, Glucose, Ca), and probably image the head to r/o bleed.
I’d argue strongly against the Head US in favor of the Head CT. Head US are done in the NICU to screen for intra-ventricular hemorrhage. They are not definitive tests for subdural/epidural bleeding or intraparenchymal bleeding. If there is concern for a head bleed, a CT is a must (not an US).
Finally, if you are convinced that this is a seizure, then I would strongly argue for obtaining an LP in this 12 day-old, which is a peak age for presentation of neonatal HSV disease (although this would be rare without something else in the H&P — fever, rash, maternal history, etc. — and the fact that this child is acting normally now after 2 shaking episodes really argues against a CNS infection!).
Just my $0.02.
My initial thoughts were checking an immediate finger stick glucose, confirming that the patient had a normal newborn screen and repeating a CBC given the history of thrombocytopenia. A fontanel exam and head circumference would also be helpful and may push me to immediate CT scan if it was grossly abnormal/changed from birth. At this point I’d be worried an LP would cause more harm than be diagnostically helpful given the risk of bleeding with a PLT count of 28. If an LP was deemed necessary, than we would need to optimize conditions for a successful one, which may mean considering a platelet transfusion.