Respiratory Distress and Vomiting in a 1-month-old Boy.

Abstract

1. Brandon Palmer, MD*,† 2. Anika Nelson, MD‡,§ 1. *Children’s Hospital Los Angeles, Los Angeles, CA 2. †Keck School of Medicine, University of Southern California, Los Angeles, CA 3. ‡Medical College of Wisconsin, Milwaukee, WI 4. §Children’s Wisconsin, Milwaukee, WI A 37-day-old term boy presents to the emergency department with acute onset of emesis and severe respiratory distress. Symptoms began 1 day earlier with multiple episodes of nonbilious emesis occurring after feeds and between feeds. Two hours before arrival, he developed respiratory distress. He has not had urine or stool output in the past 24 hours. However, he has multiple “watery,” nonbloody stools per day since the first few days after birth. He weighed 3,067 g at birth (30th percentile) and is 3,100 g (<1st percentile) on presentation. He had an average weight gain of 3 g/day since birth until he started losing weight, with a 25-g weight loss since his last weight check 2 weeks ago. He reportedly takes 4 oz every 3 hours of standard cow milk formula at 20 kcal/oz. He takes no medications but was given benzocaine 2 days before presentation for “teething.” He has not had fever, cough, abdominal distention, or sweating with feeds. On arrival he is afebrile; heart rate, 141 beats/min; respiratory rate, 70 breaths/min; blood pressure, 100/58 mm Hg; and oxygen saturation, 85% on room air. On examination he has skin tenting, cool extremities, and delayed capillary refill. He appears “grey to ashen-blue” and is in severe respiratory distress with belly breathing, retractions, and tracheal tugging. On auscultation his lungs are clear and he has no murmurs. A capillary blood gas analysis reveals a pH of 6.98, a bicarbonate level of 4.1 mEq/L (4.1 mmol/L), and partial pressure of carbon dioxide of 17.4 mm Hg (2.31 kPa). He is given 60 mL/kg of normal saline, with improvement in perfusion. However, he continues …