Hot Seat Case #120: 3 week old male with apnea
Posted on: November 9, 2018, by : Amie Cahill
Raj Sood, MD INOVA Children’s Hospital
with Emily Willner, MD Children’s National Medical Center
HPI: 22 day old male presents with parental report of apnea to a community ED. Parents describe an episode where he “stopped breathing” for approximately 90 seconds. He was sleeping face up in a bed with his mother lying next to him she noticed he stopped breathing and appeared to be gasping for air with his face turning a deep red. There was no emesis, reflux, or seizure-like activity noted. His last feed was approximately 2 hours prior. His mother picked him up immediately and patted his back after which he began crying and returned to his normal color within 2-3 minutes. No cyanosis was ever noted.
He has been afebrile. His mother reports that he had congestion since birth that appears worse over the past few days. She is currently recovering from an episode of bronchitis for which she was treated with antibiotics.
PMHx: Born full term via SVD to a GBS negative mother with unremarkable prenatal labs. He had no complications after birth and was discharged within two days. He is being formula fed and has gained weight appropriately.
ROS: +reflux, -vomiting, -diarrhea, +congestion, – fevers, – seizures, otherwise negative
PE: VS: T 37.2, HR 150, RR 35, BP 78/50, O2 Sat 100% on Room Air
General: Well appearing, No acute distre
HEENT: NC/AT. AFOSF, PERRL, copious mucoid nasal discharge, MMM, OP clear with erythema or exudates
Lymph: No LAD.
CV: RRR no murmurs or rubs. Cap refill < 2 secs.
Pulm: Good air entry bilaterally, no wheezing or crackles. No retractions
Abd: +BS, soft, NTND, no HSM
GU: Circumcised, tanner 1 genitalia
Neuro: normal strength and tone, good suck, +grasp, +Moro, MAE
Skin: no rashes.
The baby is placed on a monitor for observation.
CBC, CMP, and EKG were within normal limits. RSV was negative. The baby was feeding well in the emergency room without any recurrences of this event. Given the patient’s age, the physician recommends that the baby be transferred to a children’s hospital for further monitoring and possibly additional testing. The mother refuses and requests to leave AMA. You explain the importance of your recommendation. You call the baby’s PCP and leave a message to receive a call back.
The mother leaves AMA and CPS is notified. CPS calls the mother and requests that she take her child back to the ED immediately. About 8 hours later (16 hours from the initial event), the mother shows up at a children’s ED. The baby has not had any further episodes and apart from having copious nasal discharge he is smiling and appears very well.
After a lengthy discussion with the mother, she agrees to hospital admission overnight for observation. The child had no further events and was discharged the following morning with his mother.
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The most important thing in this case is that the child is well appearing and remains well appearing throughout all of your clinical encounters. I agree with RSV testing and I would add on Flu. I may even consider pertussis and I would definitely ask about potential exposures. I would not do more of a work up at this point. I think that given this child’s age, he should be observed overnight to ensure no further apnea.
I selected other in the above selections because I would really try to sit down with the mom and figure out why she wants to leave? Is it because she has other children at home and no one to take care of them? Is it because she does not have insurance and feels as though she cannot afford the hospitalization? There are so many additional factors that need to be teased out. Furthermore, it is important to explain to the mother what our concerns as physicians are and why we would like to keep this child here in the hospital overnight. I don’t think that follow up with the pediatrician is a good option here given that our concern for this child is apnea as opposed to progression of disease.
On re-presentation I think it is extremely challenging because the child has been stable for the last 16 hours and once they been brought back by CPS it is tough not to admit them.