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NeoReviews Vol.10 No.1 2009 e36
© 2009 American Academy of Pediatrics

Index of Suspicion in the Nursery

Abbreviations: CDPH: California Department of Public Health • CPAP: continuous positive airway pressure • CSF: cerebrospinal fluid • IB: infant botulism • IBTPP: Infant Botulism Treatment and Prevention Program • NICU: neonatal intensive care unit • PCR: polymerase chain reaction

The first 300 words of the full text of this article appear below.

	Case 1 Presentation

 
Twins conceived by in vitro fertilization are delivered at 25–5/7 weeks’ gestation. Twin A has a birthweight of 1,025 g, receives surfactant at 12 hours after birth for respiratory distress syndrome, and is extubated to nasal continuous positive airway pressure (CPAP) on the second postnatal day. She receives ampicillin and cefotaxime for 10 days due to suspected sepsis and placental cultures positive for viridans group streptococci. Gavage feedings using the mother's milk are initiated on postnatal day 4 and increased gradually over 5 days. On postnatal day 9, the baby is transferred to the neonatal intensive care unit (NICU) for evaluation of apnea, continued respiratory distress, and feeding intolerance. She is maintained on caffeine therapy.

On postnatal day 12, nasal CPAP is discontinued; she is placed on nasal cannula oxygen and later is weaned to room air. Gavage feedings using expressed mother's milk are continued and slowly advanced to full-volume feedings over 14 days. On postnatal day 16, human milk fortifier is added to expressed human milk. On postnatal day 28, a premature formula is used in addition to human milk for caloric supplementation. On postnatal day 34, because of insufficient lactation, the infant receives premature formula (24 cal/oz). She continues to tolerate her feedings, showing adequate weight gain.

On postnatal day 55 (33 weeks postconception), the infant begins having frequent oxygen desaturations detected by pulse oximetry, loss of head control, reduced swallowing with retained oral secretions, and choking. Her symptoms persist despite supplemental oxygen by nasal cannula and head positioning. Bowel movements decrease from her usual three to four per day to one to two small smears. The baby's respiratory status continues to decline, with worsening episodes of apnea, bradycardia, and oxygen desaturations, and she is placed on nasal CPAP. She appears mottled and lethargic, with global hypotonia. Sepsis . . . [Full Text of this Article]

Yomna Ibrahim, MD
T. Allen Merritt, MD

Division of Neonatology, Loma Linda University School of Medicine, Loma Linda, Calif

Jason R. Barash, CLS, MT (ASCP)
Stephen S. Arnon, MD

Infant Botulism Treatment and Prevention Program, California Department of Public Health, Richmond, Calif

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