Authors

Bimpe Adewusi, MD
St. Christopher’s Hospital for Children, Philadelphia, PA

Leena Shrivasta Dev, MD
Assistant Professor of Pediatrics, Drexel University College of Medicine; Faculty Pediatrician, St. Christopher’s Hospital for Children, Philadelphia, PA

Maria D. McColgan, MD, MSEd
Director, Child Protection Program, St. Christopher’s Hospital for Children; Assistant Professor, Drexel University College of Medicine, Philadelphia, PA

Peer Reviewers 

Angelo P. Giardino, MD, PhD, MPH
Medical Director, Texas Children’s Health Plan; Clinical Professor Pediatrics, Baylor College of Medicine, Houston, TX

Jon Mason MD, FAAP, FACEP
Assistant Professor of Pediatrics, Eastern Virginia Medical School, Norfolk, VA

Publication Date: April 2010; Volume 7, Number 4

Excerpt from the issue...

At 3 am, a mother brings her 4-week-old daughter to the emergency department (ED) with the chief complaint of “stopped breathing.” The mother describes the event by stating that the baby was “lying there, turned blue all over, then was not breathing.” The mother picked up the baby, who subsequently started breathing again and regained her color. There is no history of recent feeds or reflux prior to the episode. The birth history is significant for a full-term baby, with a normal spontaneous vaginal delivery, poor prenatal care, and urine drug screen results positive for marijuana. Because of the finding on the drug screen, Child Protective Services (CPS) is already involved in the child’s life. The mom describes the infant as developmentally appropriate for a 1-month-old and notes that her immunizations are up-to-date. The social history reveals the child lives with her mother, maternal grandmother, and 1-year-old sister. The mother and father are not together. There is smoking in the home but no pets.

On physical examination, the patient’s pulse oximetry value is 100%, and she appears comfortable, in no acute distress; the rest of the physical examination is unremarkable. Examination of her skin shows no marks or bruises. Complete blood cell count and complete metabolic panel results are within normal limits for the patient’s age, except for a hemoglobin level of 10.2 gm/dL. Results of a chest radiograph are also normal. The patient is admitted for 24-hour observation due to her concerning history of cyanosis, the patient’s young age, and mild anemia. The admission diagnosis is apparent life-threatening event (ALTE).

During admission, the patient is placed on a cardiorespiratory monitor, with no apneic events noted. She feeds well and gains weight during her admission. The mother is difficult to contact during this admission, but she is eventually notified to come and pick up her child. Upon discharge, as the mother prepares to leave the hospital room with her infant, she suddenly discuscomes running to the nurses’ station, saying her child is not breathing again. The nurse runs into the child’s room to find a blue, limp infant. The nurse subsequently initiates the rapid response team and stimulates the infant, who then starts breathing. Pulse oximetry is initially 89%, but it slowly returns to 98% with oxygen via facemask. By the time the rapid response team arrives, the patient has recovered. No chest compressions are required. The infant is then readmitted. A sepsis workup is initiated, and a repeated chest radiograph shows a possible small right lower lobe infiltrate. The infant is started on ampicillin and gentamicin while blood, urine, and cerebrospinal fluid cultures are pending. She is also placed on iron therapy for anemia.

Two days later, results of all studies are negative, the infant remains afebrile, and a 5-channel pneumogram is done to rule out an obstructive versus central process for the baby’s continued apneic events. Results of this study are also negative.

The mother is not present during most of her daughter’s second admission to the hospital. At time of discharge, the mother is again difficult to contact. When the mother finally arrives, she momentarily leaves the child’s room; when she returns, she immediately calls for help, saying the infant is again limp and blue. The nurse enters the room, finds the infant cyanotic and limp, and again calls for the rescue response team. The nurse stimulates the patient, whose oxygen saturation is 84%. By the time the rescue response team arrives, the patient has recovered. The nurses note a drop of blood near the patient’s right nares.