Fussy Baby Jeopardy

1. Fussy Baby Jeopardy Maya S. Iyer, MD OSU EM Small Groups October 18, 2017

2. Fussy Neonate Jeopardy Fever SIDS BRUE/ ALTE NAT Misc $100 $100 $100 $100 $100 $200 $200 $200 $200 $200 $300 $300 $300 $300 $300 $400 $400 $400 $400 $400 $500 $500 $500 $500 $500 Final Jeopardy

3. A DOL 5 term infant presents to the ED with seizures. The seizure started in the right arm and then progressed to GTCs and lasted 5 minutes. The baby has also had a temperature of 39°C at home. POC glucose is 120 mg/dL. After seizure control, what is the next priority in management of this patient? This patient should be started on empiric ampicillin, gentamicin and acyclovir. Seizures at this age is concerning for herpes simplex virus encephalitis and mortality is 15% from CNS disease.1 1 - $100

4. 1 - $200 A DOL 3 term infant is brought to the ED with concerns for bilateral eye redness. Temperature is 37.8°C and on exam, the baby has purulent drainage from the bilateral eyes with scleral injection. What bacterial organism is responsible for this presentation and how would you treat the patient? Copious eye drainage at this age is concerning for gonoccal conjunctivitis. Patients should undergo a rule out sepsis work up and be treated with topical erythromycin and an IV third generation cephalosporin. Chlamydial conjunctivitis presents around day of life 14 to 6 weeks and is treated with both systemic (oral)and topical antibiotics.2

5. 1 - $300 You swiftly resuscitate a DOL 6 term male who presents to the ED with cyanosis and lethargy. You suspect a cyanotic cardiac lesion and initiate prostaglandins with improvement in the patient’s color. However, one hour after starting this medication, the patient develops a temperature of 38.1°C. What should you do? What is this patient at risk for? Know side effects of prostaglandins (PGE1) are fever, flushing and tachycardia. These patients need to be followed closely and do not necessarily need a rule out sepsis work up if they did not have temperature instability prior and are diagnosed with a cardiac lesion on ECHO. However, prostaglandin use increases the risk of apnea and the respiratory status of these patients need to be monitored closely. Interestingly, elective intubation prior to transport increases the odds of major transport related complications and needs to be considered carefully in otherwise stable infants on PGE1. 3,4

6. 1 - $400 For rule out sepsis workup in infants < 30 days of age, we start ampicillin, gentamicin and acyclovir. What organisms do each of these antibiotics cover? What antibiotics do we use when the patient is > 6 weeks of age? Ampicillin is used to cover Listeria monocytogenes. Gentamicin is used to cover G- organisms such as Escherichia coli. Acyclovir is used to cover herpes simplex virus. After 6 weeks of age, the risk of Listeria decreases and therefore ampicillin may not be needed. In addition, the risk of biliary sludging decreases, so ceftriaxone can be used. 5

7. 1 - $500 A DOL 4 term male infant is brought into the ED for significant fussiness. He was born at home and his umbilical cord remains in place. You notice the following on exam. What antibiotics do you use to treat this condition? What complications are you worried about? Omphalitis is caused by an ascending infection from the umbilical stump that causes an abdominal wall cellulitis. Implicated organisms include S. aureus, GAS, pseudomonas and anaerobes. Initial antibiotics should include vancomycin, aminoglycoside and metronidazole/clindamycin. Complications include necrotizing fasciitis and sepsis.6

8. 2 - $100 • Which of the following is not a risk factor for SIDS? • Smoking • Co-sleeping • Pacifier Use • Blankets in the crib C. Pacifier use is actually thought to be protective from SIDS. 7

9. 2 - $200 What should you make sure that the nurses and/or you do and discuss prior to discharge for infants < 6 months from Nationwide Children’s Hospital? Make sure the families watch the Safe Sleep Video (available on the iPADs) and that they receive the helping hands form about SIDS.

10. 2 - $300 Which of the following images show a safe sleep space for infants < 1 year of age? A crib without extra pillows, bumpers, stuffed animals or blankets is the safest sleep space. Babies should be placed on their back to sleep in such a crib.7

11. 2 - $400 • What do the “ABCs” of safe sleep stand for? 8 • A: Always alone in a separate space for naps and sleep at night. • B: On their back • C: In a crib without extraneous materials such as pillows, stuffed animals, blankets or bumpers.

12. 2 - $500 • What does the acronym SIDS stand for and what is the definition of SIDS? Sudden Infant Death Syndrome (SIDS) is the sudden, unexplained death of a baby younger than 1 year of age that doesn’t have a known cause even after a complete investigation. This investigation includes performing a complete autopsy, examining the death scene, and reviewing the clinical history. SUID includes all unexpected deaths: those without a clear cause, such as SIDS, and those from a known cause, such as suffocation. One-half of all SUID cases are SIDS. Many unexpected infant deaths are accidents, but a disease or something intentionally done can also cause a baby to die suddenly and unexpectedly. 7

13. 3 - $100 What is the difference between an ALTE and a BRUE? BRUE is not a specific diagnosis but a description of a sudden, brief, and now resolved episode. Apparent life-threatening event (ALTE) is a broader term that may include prolonged events or those that are explained by an underlying disorder. The term BRUE should be used instead of ALTE whenever possible (ie: when episodes are brief, resolved, and unexplained). For events that do not fit the definition of BRUE, guidelines encourage the use of event characteristics rather than the term "ALTE" to describe the event. 9

14. 3 - $200 What are the 7 risk criteria that make a BRUE low risk? 9 • Age > 60 days • Gestational age > 32 weeks and post-conceptual age > 45 weeks • Occurrence of only one BRUE • BRUE< 1 minute • No CPR or rescue breaths • No concerning historical features • No concerning physical exam findings

15. 3 - $300 A 5 month old is brought in for an episode of choking and turning purple in the face. Mother reports that the episode occurred 30 minutes after a feed. The patient was not responsive and required rescue breaths and father did CPR for 30 seconds. On exam, the patient is very well appearing and smiling and babbling. What is your disposition for this patient? This patient requires an admission for observation. The fact that the patient received rescue breaths and CPR automatically stratifies this as not “low-risk.”9

16. 3 - $400 A 3 month old term male infant is brought to the ED with concerns for coughing and turning blue. The patient is afebrile, coughing intermittently on exam, and otherwise appears well. He has not had any apneic events at home, but mother is afraid that the cough is progressing. How do you manage this patient. A cough associated with cyanosis at this age is concerning for B. pertussis. This patient warrants empiric azithromycin while PCR results are pending. In addition, the risk of apnea is increased < 6 months of age, so inpatient admission should be considered. 10

17. 3 - $500 A 4 month old term male is brought to the ED with a choking episode that occurred 30 minutes after a feed. No interventions were done at home and resolved spontaneously under one minute. The patient is very well appearing on exam and is gaining weight well by the growth chart. How do you counsel the parents? This BRUE appears to be related to GERD. You can counsel the parents on reflux precautions, such as appropriate volume of feeds, burping after each ounce given and also keeping the patient in an upright position for 30 minutes after a feed.

18. 4 - $100 • Which of the following fractures is NOT associated with non-accidental trauma (NAT)? • Posterior rib fractures in a 12 month old • Femur fracture in a 6 month old • Toddler’s fracture in a 2 year old • Buckle fracture in a 8 month old C. A toddler’s fracture is a spiral fracture of the tibia that is generally caused by a torqueing mechanism. This could be an accidental finding in an ambulatory child. 11, 12

19. 4 - $200 What does the non-accidental trauma (NAT) work up involve for a 12 month old male who is noted to have a bruise on his cheek and a torn frenulum? You need to complete a NAT for a child that has bruising in unusual locations. This includes a skeletal survey and blood work (CBC, coagulation profile, fibrinogen, von Willebrand panel). A SW consult should be placed after you let the parents know you will be reporting these injuries. 13, 14

20. 4 - $300 • Which of the following burn injuries is most concerning for child abuse? • A 4 yo with a 2nd degree burn to his shoulder and upper chest after pulling hot tea off a counter • A 2 yo with a single irregular superficial 1st degree cigarette burn to the upper arm • An 8 month old with circumferential partial thickness burns to both feet and lower ankles sustained after climbing into the bathtub • A 9 yo with 1st and 2nd degree burns to his face after taking hot soup out of the microwave D. An 8-month old would be incapable of climbing into a bathtub. The burn pattern would be different if the baby fell into the bathtub. This injury is concerning for abuse. 15

21. 4 - $400 You are evaluating a 2 yo male for viral gastroenteritis. After you discuss your plan for zofran and an oral challenge with the parents, you notice this on the 4 year old sibling. What do you do now? Ear bruising is almost always pathognomic of child abuse (due to pulling on the ear). This patient warrants a child abuse evaluate with labs and a social work consult. Remember as health care providers, you are mandated reporters! 13

22. 4 - $500 An 18 month old girl is brought to the ED with vomiting and increasing somnolence. A CT of the head is obtained and shows multiple acute on chronic subdural hemorrhages. Her skeletal survey is negative and she has no retinal hemorrhages on fundoscopic exam. In what condition (think genetics) would this NOT be considered NAT? SDHs are estimated to be present, without significant trauma, in 20–30 % of children with glutaric aciduria type 1 (GA1). GA1 is a rare, autosomal recessive, metabolic disorder caused by a deficiency of riboflavin-dependent glutaryl-CoA dehydrogenase. The deficiency of this enzyme results in accumulation of the neurotoxic breakdown products glutaric acid and 3-hydroxy-glutaric acid. Children with GA1 do not have the other features of NAT. 16

23. 5 - $100 A DOL 2 term female is brought into the ED for “spitting up blood.” The patient is afebrile and her vital signs are stable. She is 4% down from birth weight and mother is breastfeeding. Her physical examination is within normal limits and the patient is not fussy and is sleeping comfortably. What could be the source of the hematemesis/spit up? A common cause of spitting up blood in this age is swallowed maternal blood. Be sure to ask mother how nursing is going and if she has cracked nipples, which could be contributing to the hematemesis. In older infants, hematemesis (in a well appearing child) could be a sign of a milk-protein allergy. 17

24. 5 - $200 A DOL 50 term male is brought into the ED for crying and refusal to open his eyes. When you examine the patient, you notice that he opens his eyes when the lights are off and has abrasions on his nose. What do you need to perform to confirm your diagnosis? • Perform a fluorescein/Woods Lamp exam to evaluate for corneal abrasions. Patients should be discharged home on erythromycin eye ointment for 7 days. Also, ensure that the baby’s fingernails are trimmed. 18

25. 5 - $300 A DOL 28 term female infant is brought into the ED for fussiness. Parents report that she was in her normal state of health until she was given a bath. They noticed the following shown in the photo. What is the best way to take care of this condition? • Remove the hair tourniquet manually or with NAIR. Complicated conditions may require a vertical incision to remove the hair. Patients generally require close follow up in one day. 19

26. 5 - $400 A 6-month-old boy is brought to the ED with fussiness for the past day. On examination, you notice a bulge in his groin that is not easily reducible. What should be your first step in management? • You should attempt bedside manual reduction with sedation (morphine). 20

27. 5 - $500 A former 24 week gestational age infant, now corrected to 1 month, comes to the ED with abdominal distension and fussiness. The patient had a complicated course in the NICU. Parents report that the patient has had three “blood-like stools” in the last hour and has not been taking oral intake. What is the first imaging study that you should obtain? Premature infants are at risk for necrotizing enterocolitis, particularly if they present with bloody stools. Obtain a 2-view xrays of the abdomen to evaluate for free air and portal-venous air. Patients with NEC should have immediate fluid resuscitation, antibiotics and surgical consultation. 21

28. Final Jeopardy • A 8 month old girl with a known history of cystic fibrosis comes to the ED with the following. What is that best way to manage this patient? • Social work consult • Child Abuse Evaluation • Laboratory Testing • Sitz baths • D. Urethral prolapse is common among young females, particularly of African ancestry. Treatment includes sitz baths and topical steroids. If the prolapse appears nectrocic, a surgical consult is warranted. 22

29. References 1.Rudnick, C.M. and Koekzema, G.S. Neonatal Herpes Simplex Virus Infections. Am Fam Physician. 2002. 15; 65(6): 1138-1142. 2.American Academy of Pediatrics. Gonococcal Infections. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th. Kimberlin DW (ed), American Academy of Pediatrics, Elk Grove Village, IL 2015. 3.Lewis, A.B., Freed, M.D., Heymann, M.A., Roehl, S.L., Kensey, R.C., Side effects of therapy with prostaglandin E1 in infants with critical congenital heart disease. Circulation.1981. 64(5): 893-898. 4. Meckler, G.D. and Lowe, C. To Intubate or Not to Intubate? Transporting Infants on Prostaglandin E1. Pediatrics. 2009. 123(1): e25-e30. 5. “Antibiotics for Early-Onset Neonatal Infection: Antibiotics for the Prevention and Treatment of Early-Onset Neonatal Infections. 2012. NICE Clinical Guidelines No 149. London: RCOG Press. 6. Cushing, A.H. Omphalitis: A Review. Pediatr Infect Dis. 1985. 4(3):282-285. 7. “Sudden infant Death Syndrome (SIDS).” Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/sudden-infant-death-syndrome/symptoms-causes/syc-20352800 (Accessed on October 10, 2017). 8. “Safe Sleep Practices.” Retrieved from: http://www.nationwidechildrens.org/safe-sleep (Accessed on October 9, 2017).

30. References 9. Tieder, J.S., Bonkowsky, J.L., Etzel, R.A., et al. Brief Resolved Unexplained Events (Formerly Apparent Life Threatening Events) and Evaluation of Lower Risk Infants. Pediatrics. 2016; 137(5): e20160590. 10. “Pertussis (Whooping Cough).” Red Book, 2012 Report of the Committee on Infectious Disease. 29th Edition. American Academy of Pediatrics: Elk Grove, IL: p.553. 11. Kemp, A.M., Dunstan, F., Morris, S. et al. Patterns of skeletal fractures in child abuse: systematic review. BMJ. 2008; 337. 12. Gaillard, F. “Toddler Fracture.” Retrieved from https://radiopaedia.org/articles/toddler-fracture (Accessed on October 8, 2017). 13. Pierce, M.C., Kaczor, K., Aldridge, S., et al. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics. 2010; 125: 67-74. 14. Kellogg, N.D. Evaluation of suspected physical child abuse. Pediatrics. 2007; 119(6): 1232-1241. 15. Moulton, S.L. “Pediatric Burns.” July 23, 2014. Retrieved from http://www.pedtrauma.org/wp-content/uploads/2014/07/23.Moulton.Burns_.pdf (Accessed on November 1, 2017). 16. Vester, M.E.M., Bilo, R., Kars, W.A., et al. Subdural hematomas: glutaric aciduria type 1 or abusive head trauma? A systematic review. Forensic Sci Med Pathol. 2015. 11(3): 405-415.

31. References 17. Fleisher, G. and Ludwig, S. “Gastrointestinal Bleeding.” The Textbook of Pediatric Emergency Medicine, 6th edition. Wolters Kluwer: Lippincott Williams and Wilkins, p. 258. 18. Shope, T.R., Rieg, T.S., Kathiria, N.N. Corneal abrasions in young infants. Pediatrics. 2010; 125(3): e565-e569. 19. Plesa, J.A., Shoup, K., Manole, M.D., Hickey, R.W. Effect of a depilatory agent on cotton, polyester, and rayon versus human hair in a laboratory setting. Ann Emerg Med. 2015; 65(3): 256-269. 20. Fleisher, G. and Ludwig, S. “Abdominal Emergencies.” The Textbook of Pediatric Emergency Medicine, 6th edition. Wolters Kluwer: Lippincott Williams and Wilkins, p. 1523. 21. Lin, P.W. and Stoll, B.J. Necrotising enterocolitis. Lancet. 2006. 368: 1271. 22. Fleisher, G. and Ludwig, S. “Pediatric and Adolescent Gynecology.” The Textbook of Pediatric Emergency Medicine, 6th edition. Wolters Kluwer: Lippincott Williams and Wilkins, p. 843

32. References for Images “Omphalitis.” Retrieved: from https://pedclerk.bsd.uchicago.edu/page/omphalitis (Accessed on October 10, 2017). “Rock ‘n Play.” Retrieved from: https://www.amazon.com/Fisher-Price-Rock-Sleeper-Rainforest-Friends/dp/B00BUO4664 “Crib.” Retrieved from: https://www.landofnod.com/maple-andersen-crib/s171479 “DockATot.” Retrieved from: https://www.target.com/p/dockatot-deluxe-plus-dock-silver/-/A-51818635 “Ear Bruising.” Retrieved from: https://img.medscapestatic.com/pi/meds/ckb/99/40699tn.jpg Klein, J.D. and Lee, C.C. “Hair Tourniquet Syndrome.” (2015). Retrieved from: https://www.consultant360.com/articles/hair-tourniquet-syndrome-0 (Accessed on November 1, 2017). “Urethral Prolapse.” Retrieved from http://pemcincinnati.com/blog/quick-case-1-blood-on-the-tracks/ (Accessed on November 1, 2017).