Rachael Batabyal MD, Children’s National Medical Center

Case: 2 week old, ex-FT, with an uncomplicated neonatal course presents with 1-2 days of hematochezia and 2 episodes of non-bloody, non-bilious emesis. She was afebrile and hemodynamically stable with a distended but soft abdomen and clearly bloody stools. Labs: CBC: 7/15/44/346, 10% bandemia, I:T ratio: 0.65. BMP is unremarkable. Blood Glucose was wnl. AXR was clearly abnormal concerning for obstruction.

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Discussion:

This case reminds me of the not so “good ole days” of the NICU. Neonates, not tolerating feeds, I:T ratios. Reaffirms my decision to go into PEM!

But all jokes aside, a bleeding neonate is never normal so deserves some sort of workup. How much or how little is the debate of this case. In an otherwise well appearing, afebrile neonate as in this case some providers offered to do no labs and/or imaging, however, the majority felt it was necessary. Dr. Ward stated that obtaining a cbc would help assess not only the cell lines, but, also screen for potential anemia. Dr. Chamberlain had another purpose for the CBC which was to screen for potential eosinophilia in the setting of milk protein allergy. As far as the sepsis evaluation, only one of the respondents felt it was necessary. In fact, Dr. Lindgren made the point that this child is likely not going to be discharged from the ED so the workup can be done as an inpatient if deemed necessary. In the same vane, the group agreed that this decision would not affect them covering with broad spectrum antibiotics.

Another poll question from Dr. Batabyal was regarding imaging and if people would obtain any in that matter. Four respondents felt that they would not, however, again the live group came to the consensus that imaging was a must for this child. Dr. Batabyal also posed the question of the utility of an abdominal ultrasound to assess for possible malrotation. Dr. Chapman felt it would not suffice and that this child truly needs an upper GI series immediately. Dr. Ward also made the astute point that in a gaseously distended child, you may not find an acoustic window easily to obtain adequate images.

In closing, Dr. Chamberlain with his many many wise years of experience reminded us that our major priorities for this child from an ED perspective are intesttional decompression and anticipation of fluid resuscitation as these children can have massive fluid losses from third spacing.

Denouement:

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