Index of Suspicion in the Nursery

Abstract

A term infant girl is born via vacuum-assisted vaginal delivery to a 28-year-old G1P0, now P1, rubella-nonimmune woman who has otherwise unremarkable serology results. Membranes ruptured approximately 6 hours prior to delivery and Apgar scores are 6 and 8 at 1 and 5 minutes, respectively. She is admitted to the neonatal intensive care unit at 35 hours of age for desaturations to 80% on room air associated with bottle feeding. She has a weak cry at birth for which supplemental blow-by oxygen is administered briefly. Subsequently, she has adequate oxygen saturations and is transferred to the mother when desaturations recur with feeding attempts. A nasogastric (NG) tube is placed without difficulty. Chest radiograph and complete blood count findings are unremarkable. Blood is drawn and antibiotics initiated until blood culture is negative at 48 hours. Upper gastrointestinal contrast study yields normal results without evidence of tracheoesophageal fistula or malrotation. Cardiac evaluation, including echocardiography, does not reveal anatomic abnormality. Results of head ultrasonography, brain magnetic resonance imaging, and electroencephalography are within normal limits. No desaturations occur with gavage feeding. Upon repeat attempt at oral feeding, the infant exhibits lack of appropriate suck and swallow coordination and persistent desaturations …