Hot Seat Case #125: 12 day old with lethargy
Posted on: February 7, 2019, by : Mary Beth Howard
Mary Beth Howard, MD Children’s National Medical Center
with Katie Donnelly, MD Children’s National Medical Center
HPI:
16-day old ex full term male presented with poor feeding and increased lethargy. He presented to the ED 2 days prior for frequent spit ups, had a normal exam, tolerated feeds in ED so was discharged home. Parents followed up with the PMD on the day of arrival, who felt that infant was sleepier that usual, had decreased PO intake by parental history so was referred back to the ED.
Parents reported that he had been taking 1-2oz of formula every 1-4 hours with NBNB emesis after each feed. Vomiting started on DOL4, and the parents are not sure if it has worsened. Per report, he has had occasional choking and regurgitation of formula through his nose. His last wet diaper was 5 hours ago. Per mother, he seems sleepier than usual – mother had to wake to feed him twice today as he slept >4 hours.
ROS: No measured fevers. No diaphoresis or cyanosis with feeding. No decreased tone. Stools seedy yellow, about 3-4 stools/day.
PMHx: Born at 40.1 weeks via NSVD. Mother GBS+, received abx 1 hour prior to delivery, remainder of prenatal labs negative. Denies history of HSV. Normal prenatal and nursery course. Regained birthweight at DOL10
FHx: No relevant family history. No one at home is sick.
SHx: Lives at home with mother, father, and two older siblings. No other caretakers.
PE: T 36.2, HR 160, RR 40, BP 95/56, spO2 98% on RA, 3.45kg G
General: Sleeping in mother’s arms in bed, no acute distress.
Skin: Warm. Dry. Looks pale.
Head: Normocephalic, atraumatic, anterior fontanelle soft and flat.
Eye: Normal conjunctiva. no discharge.
Ears, nose, mouth and throat: Oral mucosa moist.
Cardiovascular: Regular rate and rhythm. No murmur. No gallop. 2+ femoral pulses, cap refill 3 seconds
Respiratory: Normal work of breathing, good aeration, lungs are clear to auscultation. Gastrointestinal: Soft. Nontender, non-distended. No organomegaly.
Genitourinary: Normal genitalia for age
Musculoskeletal: Normal ROM
Neurological: Sleeping, arousable to vigorous stim. Poor suck, normal grasp, upgoing Babinski.
A full sepsis work up is initiated with initial labs: CBC: 10.82>15/45<393, normal diff UA: negative WBC/bacteria, RBC, SG 1.004, negative ketones LP: 3WBC, 70RBC, glucose 48, protein 52 Prelim blood, urine and CSF cultures: no growth
Ampicillin and gentamicin are given. Following change of shift, his new nurse calls you while antibiotics are infusing because the infant “doesn’t look right.” On repeat exam, the baby appears mottled, cap refill is now 3-4 seconds, neuro exam is overall unchanged – still sleepy, but wakes with stimulation. He has a wet diaper. He has not fed since arrival to ED 3.5 hours ago.
Labs return with: POC glucose: 92
Lactate: 0.6 mmol/L CMP: Na 139 K 4.8 Cl 103 CO2 22 BUN 6 Cr 0.27 Gluc 96, Ca 10.2, ALT 27, AST 36, Tbili1.2
He takes about 3oz of formula with moderate NBNB emesis following.
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Interesting case…a 2 week-old with poor feeding, NBNB emesis and lethargy with unremarkable ED evaluation (CBC, UA, LP, CMP). At this point sepsis has been worked up. Metabolic decompensation from an inborn error of metabolism should be considered. The normal HCO3 argues against an amino-acidopathy or organic academia. Normal lactate and glucose argue against a disorder of carbohydrate or fatty acid metabolism. However, urea cycle defects in this male infant (i.e., X-linked OTC deficiency) still haven’t been excluded, and an ammonia level should be obtained. If that is normal, I’d consider head and belly imaging with a Head CT (looking for subdural hemorrhage), abdominal 2-view Xray (looking for obstruction, NEC, etc.), and an abdominal US (looking for pyloric stenosis, hydronephrosis). Then admission for observation is still warranted given his concerning presentation (bounce-back and lethargy), despite the fact that he did feed 3 oz once in the ED.
Agree with Dewesh. One other thing to consider, common things being common, is reflux. Granted the above case seems extreme for this but I have seen a neonate presenting similar and after admission and extensive work up was discharged with the ‘GERD’ diagnosis and Zantac.
I’ve seen 1 case of neonatal intussusception too which was found by ultrasound.
Another thing to keep in mind is that there are 2 older siblings at home…poisoning maybe??…social work involvement at some point. Either way this is not the kind of patient I would feel comfortable sending home.
I’d also closely examine the emesis and have low threshold for AXR and UGI, unless I was very confident it was spit up/NBNB emesis. Have to consider malrotation/volvulus. Also, be sure to loop back with PCP to properly hear their concerns since they sent them into the ED.
Agree with the above astute attendings. It seems like this baby has reassuring labs but continues to be more ill appearing clinically, which makes me wonder what we are missing. I agree that imaging needs to be done to rule out obstruction with repeated episodes of emesis. I also think that it’s worth calling the inpatient team after imaging if it’s normal as this patient is 16 days old and continuing to vomit so needs more careful observation. Consider an EKG – seems more tired but fussiness and vomiting could be initial cardiac presentation as well!
I was also thinking of NAT with the head CT. I also thought about push/pull bolus when the vitals changed, on the logic that if we are covering with abx we are expressing concern about infection, and so when vitals change have to treat as sepsis (among other considerations, unless we are worried about heart function, but this case was not very strong for that).
Aaron
Geez guys, leave the hot seat attending with nothing to say!
Differential
–Sepsis
–Metabolic (check that newborn screen!)
–Endocrine (hypothyroid)
–Malrotation/volvulus
–Reflux (too early for pyloric stenosis)
–Nothing wrong. You know you’ve definitely had a “mottled” infant that gets a big workup and you find nothing and they go home. Dang newborns.
I think the sepsis work up is indicated. A glucose, ammonia and lactic acid would make me feel much less worried about a metabolic disease if normal. Consider sending thyroid studies. KUB likely followed by an upper GI. Empiric abx. Admit (to the floor if they will take them)
I agree with the above thoughts. It can sometimes be easy to ignore complaints of poor feeding since that’s such a common complaint in older children with nausea, however, in someone so young, poor feeding is much more concerning.
Overall I think the workup as performed was thorough and appropriate, keeping in mind the additions of the previous comments (ammonia, thyroid studies). However, most medical causes should respond to fluids and dextrose.
The next step, in my opinion, is to evaluate for an anatomic/physical cause of the patient’s decreased arousal, poor feeding and PO intolerance. This would include a careful cardiac exam (as performed) with low threshold for EKG and chest XR. Additionally, the abdomen should be evaluated with ultrasound +/ KUB/UGI. Without bilious emesis, I would likely pursue the US and KUB first with UGI as back up.
On a separate note, infants in the ED are often left unbundled and can become mottled in the cold rooms to maintain their core temperature. I agree with giving a bolus, checking additional labs and repeating vital signs but while these things are happening a warm blanket can be very effective in treating mottling in the otherwise well infant.