The history is provided by Mary, the mother of Toby. Toby is a four day old infant who has been vomiting since birth, and she is brings him to her pediatrician for evaluation.
Toby has vomited with every feed since he was born. Mom was told in the hospital that he was spitting up and that it might be because of intolerance to her breast milk, and he was switched to a soy formula. He was discharged from the hospital on the second day after being born when mom was discharged. She is bringing him in because he has continued to vomit at home with progressively increasing frequency. In addition, when he vomited this morning, his vomit was bright green like grass.
She has only fed him the soy formula since leaving the hospital, and he has had at least one bowel movement since leaving the hospital. Mom is not sure if he had a bowel movement in the hospital before being discharged. She didn’t notice any blood in his bowel movement but it was black and sticky like tar, and did not notice any blood in his vomit.
He was having plenty of wet diapers when she brought him home from the hospital, but he’s only had 1 or 2 wet diapers in the last day. He has been really fussy for the last day or so and only sleeps for a few minutes before waking up and crying as if he is hungry. When she offers him a bottle, he sucks strongly and eats it all quickly, but a few minutes after finishing his bottle he vomits repeatedly. It looks to her as if all the formula she fed him comes back up, if not even more than she fed him. She has been giving him 2 ounces at a time.
She has not taken his temperature, because she only had a rectal thermometer and was not comfortable using it.
Pregnancy was complicated by gestational diabetes which was managed with dietary changes. Mom was told that she had too much amniotic fluid at one point. Toby was born vaginally at 39 weeks and Mom had an epidural for anesthesia. She did have to be on Pitocin to move labor along, but delivered without problems.
Toby’s birth weight was 7 lbs 4 ounces (3300 grams) Toby did not have any other ill symptoms in the nursery, just the vomiting. Mom was breastfeeding prior to leaving the hospital, but the baby has received formula feeds since. Mom smoked during pregnancy, although she cut down from her prior amount of smoking to 5 cigarettes a day. She received prenatal care throughout her pregnancy and was not told of any infections associated with the pregnancy. Mom has no chronic diseases.
No family history of similar problems in other babies. A cousin was born with a congenital heart problem and died early in life.
Toby is a fussy, pale infant with a weight of 2780 grams (6 lbs 2 ounces.)
Vital signs: HR 180 BP 80/40 T 99.7 rectally.
HEENT: His anterior fontanelle is sunken, and he has a vigorous suck with tacky mucus membranes. He has a normal palate and uvula. He is jaundiced and his sclera are yellow.
CHEST/CV: His lungs are clear. He is mildly tachycardic with no audible murmurs. His pulses are palpable in all four extremities. Capillary refill is prolonged at 4 seconds on his extremities.
ABDOMEN: His abdominal evaluation showed a soft, non-tender, non-distended abdomen with good bowel sounds. There are no masses and no hepatosplenomegaly.
GU: Genitourinary examination shows a circumcised male with bilateral descended testes and no hernias noted. His muscle tone is normal, with normal neonatal reflexes. No diaper rash is noted.
MUSCULOSKELETAL: His arms and legs are in the flexed position normal for a newborn. His skin turgor appears reduced, with skin creases slow to rebound when pinched together. No deformities or signs of trauma are noted.
The pediatrician explains to Toby’s mom that she needs to take him to the hospital for more testing to figure out the cause of his problem, and calls ahead to the ER to tell them about Toby’s history.
In the ER, Toby is revaluated by the physician and blood tests are done as well as an x-ray followed by a upper and lower GI study, shown below.
Hgb 17.1 g/dL
Sodium 142 mEq/L
Potassium 3.1 mEq/L
Chloride 89 mEq/L
BUN 26 mg/dL
Creatinine 1.3 mg/dL
AST 32 IU/L
ALT 28 IU/L
Bilirubin 10.1 mg/dL
Albumin 4.1 g/dL
PT 11 sec
aPTT 22 sec
Blood Type A-