An Evidence-Based Review Of Neonatal Emergencies

A 5-day-old boy is brought into the emergency department for poor feeding and lethargy. The patient is the full-term product of a vaginal delivery to a healthy mother who received routine prenatal care. He had been eating well—2 oz of formula every 2 hours—until today, when he began sucking poorly and taking less than half an ounce with each feeding. He has been afebrile, and the review of his systems is otherwise negative. On examination, the baby is notably difficult to arouse. He appears slightly jaundiced and mottled, which the mother believes are new findings. His temperature is low at 35.5oC (95.9oF), his heart rate is 190 beats per minute, his respiratory rate is 50 breaths per minute, and his blood pressure reading is 66/38 mm Hg. His anterior fontanel is open and flat, his lungs are clear, the cardiac examination reveals significant tachycardia, the liver is palpable 1 cm below the costal margin, results of the abdominal examination are unremarkable, and the capillary refill time is poor at 5 seconds. It has been some time since you reviewed the differential diagnosis of the ill neonate, but you recall the mnemonic THE MISFITS and generate an extensive list: trauma, heart disease, electrolyte disturbances, metabolic, inborn errors, sepsis, formula mishaps, intestinal catastrophes, toxins, and seizures.1 You have pediatric colleagues available, but this newborn looks like he needs some intervention before they are likely to return your page. Where should you start with the resuscitation? If little blood is available, what are the high-yield laboratory tests? What if the nurses can’t obtain access in this critical patient? And what illnesses are most likely (ie, to help you establish a diagnosis and start disease-specific treatment as quickly as possible)?