Index of Suspicion in The Nursery

Abstract

A 2½-day-old full term infant born by induced vaginal delivery to a 33-year-old G1P1 female with an uncomplicated pregnancy presents to the emergency department because of feeding refusal and severe apnea. She is found to have severe hypoglycemia and dehydration, but despite resuscitative efforts dies. Before presentation, at home the infant spit up yellow mucus-like material and had several episodes described as “lethargy” with stiffening of the legs. Appropriately vigorous at birth (Apgar scores of 9 at both 1 and 5 minutes), the infant received an initial feeding at the breast at 1 to 2 hours after birth. However, during the mother and infant's hospital stay, subsequent feedings were erratic with markedly decreased interest in feeding and decreased vigor noted in the nursery. A sepsis evaluation in the nursery was negative. Tests including a second newborn screen and urine organic acids were sent to the lab and the infant went home with results pending. A 39-week, 4.4-kg, male infant born to a 29-year-old primigravida woman with unremarkable serologies is admitted to the special care nursery due to tachypnea and persistent hypoglycemia. The pregnancy was complicated by fetal macrosomia, although the mother had a normal 1-hour glucose tolerance test. Delivery was complicated by fetal macrosomia requiring primary C-section and thick meconium at the time of artificial rupture of membranes. The patient cried at the abdomen and did not require further resuscitation. Blood sugar checked at 15 minutes after birth due to macrosomia was 43 and a repeat at 30 minutes after birth was 33. The patient was given oral formula with repeat dextrostix of 30 at 1 hour of age, prompting admission to nursery for intravenous dextrose administration and further evaluation. Admission weight is 4,470 g (>90%), length 56 cm (>90%), and head circumference 38 cm (>90%). Examination showed tachypnea with …