CH WK1 CASE 2

Ask about the volumes of milk taken before and now

Mum tells you that he fed very well previously, bottle feeding from birth, taking 3 oz of S26(infant formula) milk every 3 hours with only the occasional posset

The timescale of the decline in feeding is important to get an idea of the duration of illness as feeding is often an important first sign

Mum says that this last week his feeding had slowly declined to a point where he now only takes 2oz every 4hours.

It is important to establish why he stops feeding as this may give you a clue to the diagnosis

“He looks like he is out of breath and has to stop taking his bottle. He also goes pale and clammy “ and then stops “

Sleepiness is a VERY worrying sign so you need to explore this more especially if affecting feeding

“He looked a bit tired towards the end of his bottle for the last few days but this morning for the first time morning he didn’t wake up and cry as usual for his feed. He slept for 5 hours, he has never managed longer than 3 before ”

Does Mum have any other ideas about a precipitating factor – parents often have more time than you do to think around the problem, they may not know the medical reason but are often very good at giving possible clues.

“We have all had a cold and Adam started with a snuffly nose a week ago at the same time as he started having problems with his feeds”.

·          85mls/kg/day

.Correct answer.

28 x 2 (mls per feed) x 6 (remember feeds every 3 hours over 24hour period ) / weight 4.02kg = 85mls/kg/day

Until a baby meets their birth weight continue using this not their current weight.

Up to a month of age the minimum milk requirement to provide enough calories to grow is 150mls/kg/day.

After 1 month this can be down to 100/mls/kg minimum so long as they are gaining weight.

Adam is therefore not currently meeting his requirements.

·          130mls/kg/day

·          180mls/kg/day

·          258mls/kg/day

·          682mls/kg/day

The antenatal history:

This area is really important as it accounts for 8/9th of Adam’s life.

In particular about any scans and screening - This could help with a possible congenital anomaly diagnosis.

Maternal health - looking for congenital infections, vascular episodes following antenatal bleeds, trauma, medication, teratogenic agents including high sugar

Mum tells you that she had all her scans and screening which were all fine. She is normally very healthy and was so during pregnancy until she developed gestational diabetes in the last trimester controlled by medication. She did not have any bleeds nor did she take any medication other than folic acid and metformin.

Delivery –looking for increased risk of infection with prolonged rupture of membranes.

The gestation, mode of delivery and weight

Post delivery – any time on the neonatal unit, looking at respiratory causes, hypoglycaemic screening, concerns around sepsis.

Adam was born at 37+1 weeks by normal vaginal delivery, He weighed 4.02kg. Mum tells you that her membranes ruptured 3 hours prior to delivery.

He spent 48 hrs following delivery on the post natal ward having his bloods sugars checked. On the first day he was a bit jittery with low blood sugars but he improved with more regular feeds.

Mum tells you that he had his heel test done as well which was normal.

In KSA the routine immunisation schedule starts at birth. He is expected to have had TB and hepatitis B vaccination

Hearing and communication:

· "He jumps when his sister shouts"

· "He is soothed when I talk to him"

· "He is just starting to make quiet noises rather than just crying"

Fine motor/sight:

· "His hands are starting to relax open more,."

· "He likes looking at the blinds in the window but isn’t really looking at me yet."

Gross motor:

· "He still holds onto my fingers when I put them in his palm, when I turn his head to the side to wash behind his ears in the bath the other arm comes out. Changing his nappy is easier as he is not so curled up as he was when he was born and he moves all his arms and legs equally."

Social and emotional:

"Before today he would really let you know if he was hungry that is why I knew something was wrong today"

VASCULAR

Family history of AVSD (associated with Trisomy 21 so not significant), symptomatic on exercise i.e. feeding, clammy, sleepy, no history of antenatal/perinatal trauma. Normal anomaly scan.

INFECTIVE, INFLAMMATION, IMMUNE

Sleepy, snuffly, poor feeding, not yet immunised, new-borns are always at high risk as immature immune system, Length of symptoms would fit with an infection. No history of PROM /maternal illness.

TRAUMATIC (includes child protection)

No history of trauma but not present in non-accidental injuries!

AUTOIMMUNE

Family history  of thyroid disease

METABOLIC (this includes inborn errors of metabolism)

Parents are first cousins which increases risk of inborn errors of metabolism.

Sleepy, poor feeding.

However had normal 'heel test' - but this does not test for everything.

Initial poor glycaemic control due to maternal gestational diabetes will have corrected by this age.

IATROGENIC/IDIOPATHIC

No known teratogenic medication in pregnancy. Gestational diabetes does NOT increase chances of congenital abnormalities as seen in pregesational diabetes.

NEOPLASTIC

Unlikely in this age group

CONGENITAL/GENETIC

Normal antenatal screening and scans are encouraging but do not pick up everything. Consanguinity increases risk of problems, posseting.

DEGENERATIVE/DEVELOPMENTAL

Sleepy and poor feeding. Encouraging factors development appropriate up to now.

ENDOCRINE/ENVIRONMENTAL

Maternal and grandmother diabetes, monitored for blood sugars at birth, family history of thyroid problem, sleepy, not feeding, breathless, clammy.

FUNCTIONAL

No history of maternal post natal depression

General dysmorphism

Adam does not have any dysmorphic features

Neurology (i.e. is he alert, happy, interacting, responding to voice, pain, unresponsive)

He is very sleepy but responds when mum stimulates him. His tone is reduced when left lying in mums arms but when stimulated flexes appropriately moving all limbs symmetrically.

There are no abnormal movements of face or limbs

What colour is he?

He is not jaundice - his face and hands are mottled and pale, there is no central cyanosis

Is he making any extra noises?

Grunting. No stridor. No wheeze. No crying.

He coughs once with a dry cough and is slightly snuffly.

Does he have any signs of pain (i.e. holding himself very still, abnormal posturing, grimacing etc?)

No. He has a relaxed facial expression

Does he have any obvious marks rashes etc present on his face?

There are no obvious bruises to his face or ear and no facial rash, lip or orbital swelling.

Are there any secretions?

His eyes have no crusting. He has slight nasal secretions.

He has a small milky posset in front of you but shows no distress. Mum confirms this is what it is always like.

Is he showing any signs of increased work of breathing?

He has mild nasal flaring, head bobbing and evidence of tracheal tug visible above the top of his baby grow.

As his breathing can be seen through his baby grow you decide to check his respiratory rate as he is so settled:

56 breaths per minute

Length - 52 cm

Head circumference - 36.2 cm

Check head for any bruising - none found

Blood Pressure - 65/45

Check lower limbs for bruising – none found

On moving each limb independently checking for signs of injury or infection such as septic arthritis. The only sign often is crying. Adam was settled.

1.    Abnormal breathing

2.    Increased Heart rate

3.    Increased respiratory rate

4.    History of poor feeding

5.    History of becoming breathless and clammy on feedng

6.    Cold extremities

7.    Sleepy

8.    Pale

9.    Decreased saturations

10. Grunting

11. Picture of further acute deterioration today

12. Unclear heart sounds

13. These are all signs of an acutely unwell child who is in some form of failure and these are the result of the effect, effort and degree of efficiency in correction.

1.    Upset - not the full reason as tachycardic continued even when settled

2.    Pyrexia - not in this case as apyrexial

3.    Pain - no obvious other signs of this

4.    Fear - too young for stranger fear

5.    Cardiac arrhythmia ie SVT-HR would normally be > 220 in this age with an SVT but would need to assess rate and look at ECG

6.    Increase work – this would be similar to exercise , Adam is needing to use his accessory muscles to help with his breathing and oxygenation

7.    Cardiac/circulatory failure - most likely due to associated prolonged capillary refill, enlarged liver, cool peripheries, history of becoming clammy on feeding, murmur

8.    Shock, including hypovolaemia secondary to an accidental or non accidental injury always consider this

9.    Shock hypovolaemia secondary to third space loss such as sepsis this would cause cool extremities

10. Endocrine ie hyperthyroid

1.    Primary respiratory disease such as bronchiolitis

2.    Congenital abnormity causing respiratory compromise such as diagphragmatic hernia

3.    Cardiac disease- compensating for poor perfusion and hypoxia and also an element of pulmonary oedema

4.    Shock due to hypovolaemia –compensating for poor perfusion,hypoxia and probable acidosis

5.    Acute blood loss secondary to an accidental or non accidental injury, ie subdural

· sepsis,

· 3rd space loss ie intersuseption

6.Metabolic conditions with compensatory breathing for either metabolic acidosis or metabolic alkalosis

7.Endocrine eg DKA, always consider is it Kussmaul breathing

1.    Hypoglycaemic due to poor feeding

2.    Exhausted due to work of breathing and feeding

3.    Encephalopathic due to infection both viral and bacterial

4.    Encephalopathic due a high ammonia secondary to a metabolic condition

5.    Neurological secondary to a head injury as could occur in an NAI, poor cerebral perfusion

6. Hypoxia - less likely in this case as saturations are 94%

1.    Clammy when feeding

2.    Sleepy

3.    Not gained birthweight

4.    Lack of history of significant cough

5.    Cool extremities

6. Enlarged liver, not just displaced due to hyperventilation

1.    Sepsis

2.    Congenital Heart Disease / heart failure

3.    Bronchiolitic illness

4.    Non-accidental head injury with hypovolaemia

5.    DKA

6.    Metabolic condition ie proprionic acidaemia

7.  Meningoencephalitis 

FBC - essentially normal

U&E - essentially normal

LFT - normal

CRP - 13 ( 0-10 normal)

Glucose - 3.1 ( 3.5 Normal)

Blood cultures - this result takes 48 hours!

LACTATE 4 ( 0.5-1 mmol/l)

AMMONIA - normal

ECG - This shows sinus tachycardia

The x-ray shows a Large Ventricular Septal Defect (VSD).

The heart is dilated (Cardiomegaly) with plethoric lung fields.

 Metabolic acidosis with partial respiratory compensation

.Correct answer.

There is a metabolic acidosis with partial respiratory compensation. This is a capillary sample so the pO2 is lower than an arterial gases. 

Congenital heart disease with bronchiolitis and mild reflux.

Cannot exclude SEPSIS and this should always be presumed to be present and treated as such.

The normal ammonia helps exclude time critical metabolic conditions.

·          IV Antibiotics

.Correct answer.

Always consider sepsis.

·          Consider extra respiratory support e.g. CPAP

.Correct answer.

O2 would help with general oxygenation of the tissues but needs to be used with caution as can close duct in duct dependent cardiac lesions.

·          Inform senior colleagues

.Correct answer.

Always let senior members of the team know about a sick child as soon as possible.

·          Prostaglandins

.A ventricular septal defect (VSD) is not duct dependent and therefore this will not help the cardiac condition.

·          Stop oral feeds and consider NGT feeds when more stable.

.Correct answer.

Bottle feeding is too tiring, a small volume of feed could be give regularly down an NGT but too much may restrict lung expansion due to the stomachs proximity to the lungs.

·          Oxygen

.Correct answer.

O2 would help with general oxygenation of the tissues but needs to be used with caution as can close duct in duct dependent cardiac lesions.

·          Fluid bolus 20mls/kg

.The capillary refill was 2 seconds, a large fluid bolus mould worsen the cardiac failure. If fluid is to be tried then a smaller allocate of 10mls/kg should be given slowly and the effect of the heart rate and general condition observed.

·          Start IV maintenance containing glucose

.Correct answer.

The Mild hypoglycaemia needs correcting and maintaining. 

Exhausted and decompensating

· Sleepy and hypotonic

· Tracheal tug, nasal flaring, head bobbing significant intercostal, subcostal recession

Always make sure you assess the whole child not just a recorded isolated clinical observations 

·          Trisomy 13 Edwards'

·          Trisomy 18 Patau's

·          Turner's

·          Kartagener's Syndrome

·          DiGeorge

·          MCAD

.Correct answer.

·          HCU

.Correct answer.

·          Sickle cell

.Correct answer.

·          Isovalaric acidaemia

.Correct answer.

·          Cystic fibrosis

.Correct answer.

·          Hypothyroidism

.Correct answer.

·          Phenylketonuria

.Correct answer.

·          Patients with Inborn errors of metabolism resulting in high ammonia levels need time critical recognition and treatment

.Correct answer.

.          Saturations less than 90%

.Correct answer.

Cyanosis shows at 85% saturations.

·          Robertsonian translocation

Correct answer.

·          Diastolic blood pressure

.Correct answer.

    If you can not feel femoral pulses in a well seeming baby who is moving a lot then ask a senior paediatrician to RV before discharge

.Correct answer.