Morning Report

Veronica Janhunen, MD
July 9
th
2014
Chief Complaint
F.V is a 44 day old with emesis and failure to thrive who is
coming via life flight from Outside Hospital
History of Present Illness
F.V. is a 44 day old who developed emesis at two weeks of life
when his mother changed his formula.
The emesis slowly worsened and now he has emesis after every
feed. It is non-bloody and non-bilious.
He also has coughing with the emesis at times and his mother
thinks it may be hard for him to breath.
His mother thought he was just sick and the emesis would improve
but it hasnt so she took him to the outside hospital where labs
were significant for metabolic alkalosis and platelets of 800.
Outside hospital was unable to place an IV and called PCH for
transfer.
Transport
En route with life flight and IV was placed and IV fluids were
started at 1.25 x maintenance rate.
No bolus was given.
The patient did not have any emesis but he did desaturate to
84-87% and was placed on blow by oxygen.
The transport team noted that he appeared to have periodic
breathing but no respiratory distress.
Past Medical History
Born full term with minimal pre-natal care
Hypoglycemia during neonatal period
Mother was GBS+ but received 3 doses of PCN. Maternal labs
otherwise negative
History Continued
Family History: Negative for congenital heart disease,
seizures, asthma, metabolic disorders. Three older sibs and
parents are healthy.
Social History: Recent move from Tennessee to Utah.
His father found work in the oil fields and they have some
extended family.
F.V. has 3 older siblings under the age of 4.
Parents are Spanish speaking.
Physical Exam
T 36.7; HR 120; RR 32; BP 84/55; Sat 99% RA
BW 2.981 kg; Current weight 2.570 kg


Gen: Cachectic infant lying in crib, eyes are bright and he is vigorously sucking on a pacifier
HEENT: Over-riding sutures, AFSF, Red reflex present and pupils reactive to light, ears appear
in appropriate position, no nasal discharge, no cleft palate, no oral lesions
CV: Regular rate and rhythm, no murmurs, cap refill 2 seconds, 2+ femoral and brachial pulses
Pulm: Clear to auscultation bilaterally, no wheezes or crackles
Abd: Scaphoid abdomen, soft, non-tender, no masses or hepatomegaly
GU: Circumcised, bilateral testes descended, no hydrocele or hernia, notable lack of
subcutaneous buttock fat
Ext: Very thin extremities, warm and dry, low muscle bulk
Skin: No rashes or jaundice
Neuro: Awake and alert, vigorous suck, grossly normal tone and strength, up going babinski

Differential Diagnosis
44 day old with history of progressively worsening emesis
since 14 days of life and failure to thrive
Differential Diagnosis
GERD
Pyloric Stenosis
Cows milk protein intolerance
Inborn errors of metabolism
Congenital Adrenal Hypoplasia
Volvulus
Malrotation
Hisrchsprung disease
Intussusception with bowel obstruction
Biliary Atresia
Improper mixing of formula
Gastroenteritis
Mixing formula with dirty water
Work Up Results
Na 135; K 2.2; Cl 78; HCO3 44; glucose 91; BUN 31; Cr 0.47; Ca
11.1; Prot 6.5; Alb 3.9; Tbili 1.6; Alk Phos 228; ALT 37; AST 45
WBC 7.6; Hgb 11.7; Hct 31.7; Plts 632
Abdominal U/S: Enlarged pyloris with channel length 1.9cm
with single layer muscular thickness of 0.7cm. Consistent
with pyloric stenosis.
Hospital Course
Made NPO with fluid management to correct hypochloremic
metabolic alkalosis.
Surgery consulted and scheduled for OR on hospital day #2
Developed murmur on hospital day 1
Hypokalemia requiring IV replacement. Given thiamine x 1
due to concern for severe failure to thrive and potential re-
feeding syndrome.
Pyloric Stenosis
1/300 males vs 1/1200 females
If mother had pyloric stenosis, increased risk for her children
compared to father having it
Rarely feel the olive mass
Labs show hypochloremic metabolic alkalosis
Normalize electrolytes prior to surgery
Failure to Thrive in Neonates
Ways to think about it
Inadequate intakeMost common
Inadequate absorption
Increased losses (intestinal or urinary)
Increased metabolic demand
Causes in infants < 1 month old
Poor quality of suck
Incorrect formula preparation
Poor feeding interactions or inadequate number of feeds per day
Neglect
Metabolic/chromosomal or anatomical anomalies
Re-feeding Syndrome in Young infants
Thiamine
For infants over the age of 1 month, thiamine should be considered
prior to initiating D5 if the infant appears to have severe failure to
thrive
Monitoring is the same as in anorexic kids/teens
Kincreased intake into cells, triggered by insulin
Mgincreased intake into cells, triggered by insulin
Phosdue to fast uptake of phosphate to make ATP, triggered by
insulin
Camonitored to ensure adequate levels for cardiac stabilization
because above electrolyte abnormalities can lead to myocardial
dysfunction
References
UpToDate
MedStudy
Questions?