Index of Suspicion in the Nursery

Abstract

A 2,435-g male infant is born at 38 weeks gestational age to a 22-year-old G2P1001 woman who is blood group O+ and negative for group B Streptococcus. Labor had been induced for intrauterine growth restriction. Rupture of membranes with clear fluid occurred 3 hours before delivery, and the baby is delivered by emergency cesarean section for fetal bradycardia. Apgar scores are 8 at 1 minute and 8 at 5 minutes. The baby is suctioned by bulb and nasogastric tube. At 8 minutes of age, the baby's lungs sound wet, with a pulse oximetry reading of 68%, and 40% blow-by oxygen is started. By 15 minutes of age, he is breathing room air with a pulse oximetry reading of 98%. Physical examination in the newborn nursery yields normal results, with a Ballard score of 39 weeks, weight between the 10th and 25th percentiles, length at the 75th percentile, and head circumference at the 25th percentile. He has one low temperature of 35.4°C initially, but the capillary blood glucose measurements are 59 mg/dL (3.3 mmol/L) or more. He does well on formula feedings, with a weight loss of 15 g at 12 hours and 40 g at 36 hours. At 45 hours of age, after an uneventful hospital stay, the baby develops tachypnea and moderate intercostal and subcostal retractions. His pulse oximetry reading is 85% to 89%. He is placed on oxygen by nasal cannula, and an evaluation is undertaken that reveals the source of his respiratory distress. A 23-day-old male infant presents to the clinic because of persistent crying. Yesterday, he was seen in the emergency department, where colic was diagnosed. Today, his mother appears overwhelmed, stating that the baby cries throughout the day and night. She is concerned that the infant has abdominal pain or pain in his left …