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Delayed elimination in the newborn period
Delayed elimination in the newborn period
F. Prekker (HHS) - 12/10/21
The AAP in their policy statement Hospital Stay for Health Term Newborn Infants (2015) recommends as part of discharge readiness criteria, "the infant has urinated regularly and passed at least 1 stool spontaneously." Typically we expect this to occur within the first 24 hours of life. So, what's your differential/evaluation if that doesn't happen?
Note that kids with trisomy 21 warrant more expedited workup as their risk for GI malformations is much higher than typical newborn!
3yo M with vomiting, diarrhea
3yo M with vomiting, diarrhea
P. Plager (IHS) - 12/7/2021
NBNB vomiting and diarrhea for 2 days, now presenting to the ED (his second ever medical contact) with the following exam:
VS: mild tachycardia, normal BP, RR, SpO2, afebrile
Gen: lethargic, reacts briefly to heel poke but then goes back to being quite listless, cachectic
Abd: soft, nondistended, nontender, bowel sounds active
CV: cap refill 4-5 s, RRR, no MRG
Exam otherwise unremarkable
Labs notable for a bicarb of 10, creatinine of ~2, BUN 54. WBC 13, Hgb 15, Plt 490. POC Glucose 97.
How would you characterize this child's clinical state? What interventions would you start?
What's your assessment and initial differential for this child?
Global health food for thought 🤔
How would your decision-making change if you did not have easy access to a PICU? If labs were delayed or unavailable? If nurses did not have the ability/experience to place an IV?
What if your nearest pediatric hospital was an hour away by ambulance? What if you needed to transport this child by fixed-wing aircraft?
Who should transport the child, and what would they need to bring with them?
How soon and by what means would you ask the family to follow up with this child who appears cachectic?
Signs of shock can be subtle when compensated (e.g. decreased urine output) to obvious when decompensated (altered mental status, hypotension. In a child with altered mental status and signs of poor perfusion, you must consider and treat shock emergently.
Pay attention to the bicarb on metabolic panels. They can be a sign of acidosis and severe metabolic disturbance, easy to overlook when we don't routinely order an accompanying blood gas. For AGMA (anion gap metabolic acidosis), some people use the mnemonic MUDPILES to remind them of possible causes (methanol, uremia, DKA, propylene glycol, INH/iron, lactic acid, ethanol/ethylene glycol, and salicylates
12yo F with altered mental status
12yo F with altered mental status
K. Solstad (HHS) - 11/29/2021
Awoke at 1am nauseous, told her parents she had taken some pills but couldn't say what kind. Last known normal ~10pm.
Household meds included sertraline, cetirizine, diphenhydramine, diabetes meds, and hypertension meds.
No recent behavior change, vomiting, recent trauma or illness.
PMH: depression, no prior suicide attempts
Meds: sertraline
Social: lives with parents, goes to school
On exam, mildly tachycardic, febrile, and satting well. Initially noted to have clonus on ED evaluation but later not found on peds evaluation. Patient has bowel sounds, is grabbing at things that aren't there, babbling. Skin is warm and dry.
When you suspect toxic ingestion, how do you differentiate possible causes?
In general, the approach to toxidromes is
Obtain evidence of ingestion (get collateral history, obtain pill bottles and pill counts, determine need for labs)
Is there ongoing exposure or absorption of toxins that can be stopped?
Is there an antidote than can be given, and what are the indications to give it?
How can we support the patient through the toxic symptoms? (e.g. treating agitation with lorazepam)
How long will the toxin be in their system, and what complications should we monitor for in that time?
How can we prevent this toxic exposure from happening again?
These are all things you can discuss with the Poison Control Center/toxicologist.
Try the toxicologist's handshake - feel in the axilla for moisture to evaluate for diaphoresis. Pupillary response is another great differentiator as well.
When differentiating serotonin syndrome/NMS/anticholinergic toxidromes, evaluate muscle tone and reflexes.
2 year old F with staring spells
2 year old F with staring spells
Jason Hoard (St. Paul) - 12/7/21
Jason Hoard (St. Paul) - 12/7/21
CC: 22 month old with new onset of staring spells for past two days.
HPI: Over the past 2 days, she has had multiple, short (<30 sec), self-limited times where her "eyes glaze over" and she doesn't seem to respond to stimuli. She goes right back to normal afterwards. No cyanosis or apnea, LOC, recent illnesses, fever, lethargy, confusion. Has been noticed by daycare teacher as well.
Birth History born at term, no complications
PMH: Fell down a few steps around age 15 months, went to ER and got Head CT which was negative. No issues afterwards.
FH: Negative for epilepsy, cardiac rhythm abnormalities, unexplained drowning, or single car accidents
Exam: Sleeping, but arouses appropriately. Normal muscle tone, negative (downgoing) Babinski, normal DTR, PERRL. Strength and gait unable to be assessed due patient sleeping.
Do you have a framework to formulate a differential for staring spells?
Do you have a framework to formulate a differential for staring spells?
Epileptic
Epileptic
There are dozens of sub-classifications of pediatric epilepsy*. But which don't involve LOC or a post-ictal phase?
Absence Seizures
Typically, these seizures abruptly come and go. If they last for >40 seconds, consider another diagnosis!
Average age: 6 years old
Patients are unresponsive during the seizure, but no postictal state
Board question: EEG shows 3 Hz spike-and-wave discharges
Good prognosis with ethosuximide. Many grow out of them, but some minority will go on to develop a different seizure semiology.
Complex Partial Seizures
Typically last 1-3 minutes, with a variable intensity and duration of a post-ictal phase.
Onset can be any age
EEG will show focal discharges
May be associated with aura, or oral or manual automatisms
Early age of onset and quickly responsive to treatment are good prognostic signs
*Provoked etiologies of seizure (i.e vascular, infectious, etc) are beyond the scope of this discussion.
Non-epileptic
Non-epileptic
If you put my 3 year old in front of an iPad, he definitely becomes non-responsive to external stimuli. Thus, in this age group, keep in mind variations of normal behavior.
Behavioral/ Normal (reassurance only!). These kids will often respond to external stimuli, such as removing the iPad from in front of their face.
Daydreaming: Literally what it sounds like!
Childhood preoccupation: Occurs when kids are engrossed in a task
Gratification disorder (aka infantile masturbation, aka Benign Idiopathic Infantile Dyskinesia): Self-stimulation seen in infants or toddlers. Examples include grunting, staring, rocking. Sometimes, it is related to exploring the sensations in the perineal area.
Breath-holding spells (can be pathologic or have serious consequences, but majority can be reassured)
Neurologic
Tic disorder
Migraines (especially in younger kids, presentation can be vague!)
Panic attacks
Parasomnias
Non-epileptic seizures
This child was admitted for video EEG, which turned out to be normal! The 'zoning out' turned out to be occurring when she was scolded. This could be a defense mechanism, or just being a toddler. Reassurance and discussion of normal toddler behavior was provided!
Laryngomalacia! A quick summary:
"-malacia" refers to abnormal softening of tissue; in this case, in the region of the larynx (whereas tracheomalacia refers to abnormally compliant trachea)
Etiology Can be caused by delayed maturation of cartilaginous structures in the larynx, neuromuscular disorders, redundant soft tissue, supraglottic inflammation or edema
History Stridor intensifies during URI and positional (worse when supine, better when prone), often loudest when feeding or sleeping
Exam Causes inspiratory stridor (whereas tracheomalacia, which is intrathoracic, causes expiratory or biphasic stridor)
Diagnosis Clinical, confirmed by laryngoscopy. Not all cases need to be referred.
Management Children who are otherwise healthy often grow out of laryngomalacia by 12-18 months. Those with neuromuscular or genetic disorders may have persistent issues.
Red flags: stridor with feeding difficulty, dyspnea, tachypnea, cyanosis, apnea - refer to ENT to consider whether surgical intervention is needed
Ensure good growth! Speech/feeding therapy and/or nutritional supplementation is helpful
Acid suppression (for some reason) is thought to be helpful
4wk old with increased secretions, cough x 2 days
4wk old with increased secretions, cough x 2 days
R. Becker (HHS) - 11/22/21
R. Becker (HHS) - 11/22/21
Has noisy breathing at baseline but otherwise no signs of respiratory distress. No sick contacts, nausea/vomiting, feeding difficulty, fevers, rashes, conjunctivitis.
Birth History born early term, discharged from NICU after 2 weeks of life - admitted for TTN and NOWS/NAS (+THC, opiates, methamphetamines); feeding difficulty initially and then resolved; passed newborn screening
PMH laryngomalacia (scoped by ENT during NICU stay)
Feeding formula-fed 24kcal, previously with preemie nipple due to VFSS showing aspiration of liquids with bottle. Transitioned 10 days ago to newborn nipple.
ED course - desat with feeding to 70%
Exam with normal vital signs and notable for stridor, noisy breathing at rest, lung exam with transmitted upper airway sounds
What's your differential for a 4-week-old with stridor?
4 wk old with umbilical drainage
4 wk old with umbilical drainage
Dr. Sabena Khan (St. Paul) - 11/12/21
Dr. Sabena Khan (St. Paul) - 11/12/21
A 4-week old, former term infant is referred to the ED from clinic due to new, purulent drainage from the umbilicus x 2 days. Redness is encircling the umbilicus as well. The cord stump fell off about 2 weeks ago, and parents have been bathing routinely with soap and water. This was not a Lotus birth (look it up!)
Birth history: Born full term, without complications. NSVD. No NICU stay.
ROS: No fever, eating well, peeing and pooping normally. No excessive sleepiness. ROS otherwise negative.
SH: No sick contacts. One parent works in healthcare.
Physical exam: Normal vital signs. Vigorous, well-appearing infant. The abdomen is soft, not distended. No active drainage from umbilicus. Erythema surrounds the umbilicus with a ~3 cm radius. No underlying induration or fluctuance.
Photo courtesy Children's Mercy Hospital
oomph
[ oomf ]
noun Informal.
energy; vitality; enthusiasm. [which is what Sabena brought to this morning report!]
What do I need to know about oomphalitis??
Signs/symptoms: May be obvious based on exam, may be accompanied by signs of sepsis in infants (lethargy, temperature instability, poor feeding)
Differential: Umbilical granuloma, cellulitis, abscess, patent urachus, umbilical hernia
Bugs: Staph aureus, strep, non-pseudomonal gram negatives
Workup: Culture of blood and drainage, +/- full sepsis eval pending infant's status.
Treatment: IV antibiotics initially, most infants can transition to oral
More to come: Due to not many studies on the topic, there is wide variation in workup and management. Dr. Steven Smedshammer (with Dr. Gabi Hester @ Children's) has done some lookin' into this and anticipates a publication soon. Way to go, Steveo!
Nursery Morning Report!
Nursery Morning Report!
F. Prekker (HHS) - 11/12/21
F. Prekker (HHS) - 11/12/21
Harlequin color change
Thought to be due to changes in vascular tone and normal in the newborn period. Resolves spontaneously. Consider workup if persists between the newborn period.
Image source: NEJM
Neonatal lupus
Erythematous annular lesions with raise active margins, usually on the face/scalp. Can have a "raccoon's eyes" appearance, appears from delivery or after exposure to UV light. MUST get an EKG to evaluate for heart block. (Note this infant also has trisomy 21.)
Image source: NEJM
Congenital dacryocystocele
Occurs when both ends of the nasolacrimal system are obstructed. Requires intervention by Ophthalmology. Can become infected, which warrants urgent evaluation to avoid disseminated infection.
Image source: University of Iowa
Preauricular pit
Not a problem unless it is draining - then it should be evaluated by ENT. Always evaluate hearing. Not associated with renal anomalies if found in isolation.
Image source: verywellhealth.com
Pediatric Obesity
Pediatric Obesity
M. Seitzer (Rosebud IHS) - 11/8/21
M. Seitzer (Rosebud IHS) - 11/8/21
School-aged child presenting with high BMI in a limited-resource setting.
Pearls
Defining obesity - for children above the age of 2 (for children below the age of 2, we use weight-for-length)
BMI ≥ 85%ile = overweight
BMI ≥ 95%ile = obesity
BMI ≥ 120% of the 95%ile = severe obesity
Obesity is a risk factor and also a symptom of metabolic disease - evaluate for potential comorbidities/underlying etiologies
CVD: blood pressure, lipid panel
Endo: diabetes/insulin resistance, metabolic syndrome, steroid/sex hormone excess, thyroid dysfunction
GI: fatty liver (ALT, ultrasound), GERD
Pulm: obstructive sleep apnea
MSK: activity tolerance, limitations due to body habitus
Neuro: pseudotumor cerebri
Genetic: syndromic appearance, developmental delay
Obesity and its complications/comorbidities disproportionately affect Indigenous peoples. Often the first step in management in counseling around behavior change with attention to food and activity. How might you adjust your counseling to address barriers to change your patients may face?
Access - provide transportation resources to decrease barriers to follow up, consider whether telemedicine visits may be appropriate to make access easier
Limited financial resources - do families have all the resources they need? SNAP? WIC? Employment?
Limited safe spaces for activity - help identify safe spaces or venues for activity and strategize around how they may be accessed
Food insecurity - how do families access food? Are your recommendations for change realistic? What food resources can you offer?
Rotate out at Rosebud Indian Health Services to learn more about caring for Indigenous families, working domestically in limited-resource settings, and the history that continues to impact the Indigenous folx.
Burn Management
Burn Management
C. Huun (HHS) - 11/1/21
C. Huun (HHS) - 11/1/21
5yo M presenting after burns from gasoline explosion - how do you assess and manage overnight?
Pearls
Attend to ABC's
Look for signs of inhalation injury (facial burns, sooty oropharynx or sputum/secretions, hoarseness) - patients may require prophylactic intubation before airway edema causes catastrophic loss of airway
Beware circumferential burns; IVs should not be placed distally
Remember if there is possible CO poisoning, you cannot trust pulse oximetry (need to send out ABG with CO-oximetric measurement)
Characterize burns
Depth
% Body Surface Area of non-superficial burns
Resuscitate: kids require significantly more fluid to account for insensible losses after burn injury
Modified Parkland formula tells you how much fluid is needed in addition to child's usual 24-hour maintenance requirements
LR is the preferred fluid (to avoid hyperchloremic acidosis from NaCl)
Manage complications
Pain control
Compartment syndrome - perform escharotomy in areas of circumferential burns
Prevent infection with antibiotic dressings, appropriate isolation
Burn Classification
Burn Classification
The monikers 1st-degree etc. are still used; however, more descriptive terms are coming into favor. The deeper the burn, the less likely it is to heal without intervention. While superficial burns take 3-6 days (think sunburns), superficial partial-thickness burns can take 7-21 days; deeper burns take longer and require surgical treatment.
Body Surface Area
Body Surface Area
Baby heads are relatively bigger, proportionally, so they account for double what an adult-sized head would. Using the palm of a patient's hand is a nice way to estimate 1% burns. We only count partial-thickness burns or worse.
Newborn Cross-Cover
Newborn Cross-Cover
F. Prekker (HHS) - 10/29/21
F. Prekker (HHS) - 10/29/21
You're called about a newborn in the nursery who's making abnormal movements. What's your approach?
Here's our differential:
Never forget about sepsis!
Never forget about sepsis!
Calculate the EOS risk online! Always remember, though, clinical exam is the biggest modifying factor.
What's normal??
What's normal??
Babies are kinda twitchy in general, and abnormalities can often be quite subtle. If worried, you're never wrong to check a glucose and consider risk for other underlying issues (e.g. withdrawal)
Neonatal withdrawal
Neonatal withdrawal
Turns out it's not just opioids that neonates can withdraw from. Multiple other meds/substances have been reported to cause withdrawal syndromes that variably affect 4 main neurobehavioral domains.
Brush up your newborn neurologic exam with these video examples of normal and abnormal findings from the University of Utah.
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