By Traci Bouchard MD
Nationwide Children’s Hospital
Columbus OH
Chief Complaint
5-week-old vomiting
History
It is the end of the shift on a busy weekday evening; the Urgent Care is scheduled to close soon, but there is still a full waiting room. Your astute triage nurse comes to you and lets you know that she just put a 5-week-old in room 1 that she thinks you should see promptly – chief complaint from mom is vomiting 2x this evening, and baby “not acting right”, is difficult to feed and has a red spot in one of her eyes.
Vomiting that began that day – two episodes, non-bilious, but one episode was blood tinged. Baby reported to be fussy, and difficult to feed, which is unusual for her; infant is exclusively breastfed. Infant reported to be irritable – only in the past 24hrs – and seemed inconsolable at times and now sleepier. No cough or upper respiratory symptoms, no fever, no increased work of breathing, no diarrhea, normal voids and stools, no home medications, no known sick contacts. In the Urgent Care – there is no fever and vital signs are normal, but you agree with the nurse – the infant has relatively high-pitched cry, is awake and cries appropriately when examined, but does not make appropriate eye contact.
Physical with vital signs:
- T 98.5 HR 148 RR 32 Weight 4.6Kg
- General appearance: poor eye contact even with eyes open, sleepy, arouses with stimulation, fussy and crying with exam
- HEAD Atraumatic, no swelling or cephalohematoma, AFOF, no dysmorphic features
- EYES: PERRL, + red reflex bilat OD subconjunctival hemorrhage
- EARS: no external ear swelling or erythema TM normal position and appearance bilat
- NOSE: small amount of dried blood at right nare, no rhinorrhea
- OROPHARYNX: mucous membranes moist, palatal petechiae, no other lesions
- NECK: No mass, supple
- CHEST: breath sounds clear and equal bilaterally, no respiratory distress
- CVS: RRR S1/S2 no murmur
- ABDOMEN: soft nondistended no masses no HSM
- GU: normal female no rash or lesions
- EXT: no swelling or deformity
- SKIN: No rash, noted small purpuric area to anterior chest
- NEURO: Normal tone, moves all ext equally, awake and active, fussy with high-pitched cry
Urgent Care Work Up
Labs you obtain at the Urgent Care include a point of care blood glucose (“finger stick”) which is 120.
Further history reveals this infant was born FT NSVD at a local hospital. The parents had planned for a home birth but were transferred to deliver at a local hospital due to failure to progress. Parents declined several routine newborn protocols including Vitamin K intramuscular administration and Hepatitis B vaccine. The infant has been doing well since newborn nursery until the past 24hrs. Infant is unvaccinated by parental choice.
Your initial differential diagnosis includes…. You are probably thinking of neurologic and infectious causes including sepsis, meningitis, non-accidental trauma, seizures, bleeding diathesis, metabolic disorder, acute gastroenteritis, with swallowed blood from breastfeeding, dehydration, other causes to consider small bowel obstruction, pyloric stenosis.
Based on your differential diagnosis this infant will require higher level of care for further evaluation and management. You arrange for appropriate transfer to our local Children’s Hospital.
Ultimate Diagnosis
Late-onset Vitamin K Deficiency Bleeding
Shortly after arriving at the Children’s Hospital Emergency Department, the infant’s Glasgow Coma Scale (GCS) dropped from 14 to 8 with a noted episode of increased work of breathing and right head and right eye deviation with concern for seizures. A STAT head CT was ordered showing a large intraventricular hemorrhage with associated communicating hydrocephalus, transependymal edema, and diminished cortical sulcation pattern. The infant was admitted to the Pediatric Intensive Care Unit (PICU). An additional work up for sepsis, non-accidental trauma, and coagulopathy was undertaken, revealing a prolonged PT and INR consistent with vitamin K deficiency bleeding. The infant received vitamin K, fresh frozen plasma, and Factor VII. Neurosurgery was consulted and an emergent external ventricular drain was placed and eventually replaced with a ventriculoperitoneal shunt four weeks later due to hydrocephalus.
Learning Pearls:
- Those most at risk are breastfed infants who do not receive intramuscular vitamin K administration at birth. Infants can easily develop vitamin K deficiency due to poor placental transfer, low vitamin K content in breastmilk, and poor intestinal absorption due to immature gut flora and malabsorption.
- Early-onset VKDB develops within the first 24 hours of life, classic VKDB develops between the second and seventh day of life, while late-onset VKDB develops between three weeks and eight months of age. Clinical signs and symptoms of late-onset VKDB include vomiting and seizures
- Late-onset VKDB often results in intraventricular hemorrhage, (50% in some series) and thus present with associated central nervous symptoms.
- Always remember to take a good birth history on newborn patients.