Case 3: Infant with Stridor

Abstract

A 3.74-kg term male infant is delivered at an outlying hospital via primary cesarean section because of a maternal history of hip surgery after prolonged rupture of membranes. The mother is a 26-year-old gravida 3, para 0, blood type A positive woman who is rubella equivocal, hepatitis B antibody negative, group B Streptococcus negative, Chlamydia trachomatis and Neisseria gonorrhoeae negative, rapid plasma reagin nonreactive, and human immunodeficiency virus negative. Rupture of membranes is unknown, but occurred at least 1 day before arrival. Significant finding at delivery includes thick, meconium-stained amniotic fluid. The infant’s 1-minute Apgar score is 5. He has stridor and respiratory distress. The DeLee suction is used on the stomach, and continuous positive airway pressure is initiated. His 5-minute Apgar score improves to 7, and he makes a successful transition to oxygen by nasal cannula. Due to the prolonged rupture of membranes, meconium-stained amniotic fluid, and persistence of respiratory distress, a blood culture specimen is obtained and he starts empiric treatment with ampicillin and gentamicin. He is transferred to the special care nursery, where he continues to have stridor at rest. The stridor worsens with agitation. Chest radiography shows pneumomediastinum and pneumothorax. Over the next few days he continues to require intermittent oxygen via nasal cannula to maintain his saturations above 90%. A dose of racemic epinephrine and then albuterol do not improve the stridor. He is able to feed up to 47 mL of breast milk or formula every 3 hours. Blood cultures remain negative, and he …