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Morning Report

4/12/13

The Scenario
Resident in the Newborn Nursery, called to patient’s bedside overnight

The Patient
CC: poor feeding HPI: Previously healthy 24 hour old male infant. Called to bedside to assess nurse's and mother's concern for poor feeding. Nurse noted that infant has not been latching well for the last few feeds. Vital signs have been stable up until this time with no concern for hypo/hyper-thermia, tachycardia, bradycardia, or hypotension.

Birth History
Birth History: Born at 38 weeks gestation via csection for repeat c-section. Only required w/d/s at birth. APGARs 7,8. Stayed in the OR with mom and transitioned well with no significant issues. Of note: c-section at 38 weeks due to onset of contractions/LOF, no intrauterine concerns. Patient did receive ABX prior to delivery.

Maternal History
Maternal History: Pregnancy complicated by maternal obesity. Mother with RA, treated with methotrexate. Mother also notes there was some concern with her 1hr GTT but she never was assessed with a 3hr GTT. Mom has been receiving narcotic pain medication while inpatient, but was not on any chronic pain medication previously.

Other
Family History: father with obesity, hypertension. This is the fourth child, all other children are healthy. Social History: plan to discharge to parents' care. No smoking exposure.

Physical Exam
Physical Exam: T36 HR155 RR36 BP73/43 weight 3.2 kg (BW) GEN: infant bundled, sleeping in mom's lap HEENT: AFSF, red reflex present, PERRL, ears appropriately positioned, palate intact, "normal" frenulum, no micrognathia CV: RRR, S1, S2, soft I/IV systolic murmur heard best in the LUSB, distal pulses appropriate, cap refill 3 seconds centrally RESP: CTAB, no wheeze, rales, stridor, retractions ABD: soft, nontender, +BS, no masses appreciated, umbilical cord still intact noted to be three vessel cord GU: normal appearing male genitalia, uncircumcised SKIN: jaundice to the nipple line, mild erythema toxicum NEURO: arouses with exam, appropriate startle, suck reflexes, appropriate tone, does not latch to mother's breast

The story continues
24h events: Resident called back later to assess patient due to concern for hypothermia, poor tone... Patient progressively more “floppy.” Must be transitioned to NYI in an isolette when can no longer maintain temperature. Sepsis rule-out initiated.

Assessment
Term 24 hour old infant with poor feeding, poor tone, and hypothermia.

Differential Diagnosis
1. 2. 3. 4. 5. Infectious
1. 1. 1. 1. 1. Sepsis: GBS, HSV, E.Coli CDH, meconium aspiration, spontaneous PTX, ARDS Congenital anomalies, particularly duct dependent lesions, pericarditis Hypoglycemia, Hypocalcemia, Inborn error of metabolism NAT, birth trauma NEC, bowel obstruction

Respiratory Cardiac Metabolic Trauma

6.

GI
1.

Congenital Hypothyroidism
• Studies of populations from North America, Europe, Japan, and Australia, indicate that congenital hypothyroidism affects 1 in 3,000 to 4,000 newborns.
– Most common preventable cause of intellectual disability!

• For reasons that remain unclear, congenital hypothyroidism affects more than twice as many females as males. • An estimated 15 to 20 percent of cases are inherited. Most are autosomal recessive

Congenital Hypothyroidism
• Congenital hypothyroidism occurs when the thyroid gland fails to develop or function properly. • In 80 to 85 percent of cases, the thyroid gland is absent, abnormally located, or severely reduced in size (hypoplastic). • In the remaining cases, a normal-sized or enlarged thyroid gland is present, but production of thyroid hormones is decreased or absent.

More pathophysiology
• In a study of 230 infants with permanent primary hypothyroidism, representing 90 percent of all infants identified by newborn screening in Quebec from 1988 to 1997, 61 percent had ectopic thyroid tissue, 16 percent had thyroid agenesis, 4 percent had a normalsized thyroid and 18 percent had a goiter, as determined by radionuclide imaging

Other Causes to Think About
• Iodine deficiency (developing world) • Medication use in mothers with thyroid disease • Undiagnosed maternal HYPERthyroidism
– Can persist beyond/up to 6 months of age, particularly if maternal thyrotoxicosis prior to 32 weeks gestation; may have longer lasting results due to thyroid “dys-integration”

Manifestations
• Normal birth weight (may be big), height, head circumference (may be big) • Lack of calcification of knee epiphysis (boys) • lethargy, slow movement, hoarse cry, feeding problems, constipation, macroglossia, umbilical hernia, large fontanels, hypotonia, dry skin, hypothermia, and prolonged jaundice

Treatment Outcomes
• If treated in the first two years of life, can achieve normal IQ
– Poor language, visual-spatial skills – Ataxia, poor muscle tone, short attention span, strabismus

• Can achieve normal growth patterns • Can improve cardiac function