Index of Suspicion in the Nursery

Abstract

A 5-week-old previously well female born at 41 weeks gestational age presents to the pediatric emergency department in the winter with a 2-day history of poor feeding. Her mother is concerned that the baby is more tired than usual, “is not getting enough to eat,” and is having difficulty latching on to the breast. The mother explains that 2 weeks ago, the infant developed a dry cough and began having emesis after each feeding. She describes the emesis as nonbilious and nonbloody and approximately 1 ounce. An outside pediatrician prescribed a cough and cold medication and told the mother that the emesis was “normal baby spit-up.” Three days ago, the infant developed projectile vomiting immediately following each feeding. Today, the mother reports that the infant is breathing much harder and deeper than usual, with continued and more frequent coughs. She describes the cough as paroxysmal, although she experiences no color changes. The mother is concerned that her baby does not look like herself and is difficult to arouse. A review of systems reveals that the baby has not taken any human milk today, although her urine output has remained the same, with heavy, wet diapers. Her 2-year-old sister, who attends child care, has a cough and upper respiratory tract infection. The infant has no diarrhea, and her bowel movements are normal. There were no complications during the pregnancy. Her birthweight was 2,722 g, and she has been gaining weight appropriately, although the mother describes her as “scrawny” at birth. Physical examination of the infant in the emergency department shows a temperature …