Authors: Marc Zosky, DO (EM Chief Resident, LSUHSC Emergency Medicine Residency) and Christopher Woodward, DO (Pediatric Emergency Medicine Physician, LSUHSC Emergency Medicine Residency, Our Lady of the Lake Children’s Hospital) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Stephen Alerhand MD (@SAlerhand)

As emergency medicine physicians we routinely evaluate pediatric patients, often when frantic parents rush them in, desperate for answers. However, our training does not typically include the many hours of well-baby exams that pediatricians receive. This leaves a gap in our knowledge of normal baby behavior. Therefore, this article serves to educate emergency medicine physicians on normal baby behavior that could be perceived as dangerous.

Complaint 1 : “Help, my son just isn’t breathing right!”

Case : A worried father brings his 1-week-old son into the emergency department concerned for difficulty breathing. This is his first child, who was born at 39 weeks, after an uncomplicated pregnancy and vaginal birth. His breathing pattern was marked by several rapid breaths that slowed, then the child would stop breathing for 3-5 seconds, take a big breath, and the cycle would repeat. Other than this, the child has been feeding well and making ample wet diapers. Vitals are within normal limits, and the exam is completely unremarkable.

Answer : This is a case of periodic breathing, which is a normal breathing pattern for neonates, especially premature babies. They require no workup or observation and can be discharged home.

Pitfalls : Take a careful history focusing on concerning elements. Evaluate for apnea, which is defined by the American Academy of Pediatrics as no breathing for >20 seconds.1 Losses in muscle tone, skin color changes, bradycardia, or seizure-like activity represent an apparent life-threatening event (ALTE). ALTE’s require appropriate diagnostic studies and hospital admission.2

Complaint 2 : “She won’t stop vomiting every time I feed her!”

Case : You walk into the exam room and see a pleasantly plump 2-month-old girl. The worried mother reports that every time she feeds her, the child vomits up formula. The mother is quite concerned about reflux. Thickening the formula has not helped. She was born full term at 3 kg and is 4 kg on today’s visit. When you see the child’s bottle, you gasp. It is a full 8 oz bottle of formula, and the mother says she feeds her nearly the entire bottle every 4 hours.

Answer : This is a case of overfeeding regurgitation. The stomach holds about 1 oz/kg, so in this particular case that would be 4 oz. It is a normal reaction that if you overfill the stomach, it will lead to regurgitation. It is exacerbated if the child is fed in the supine position or if the child is not burped afterward in an upright position. Parents will often confuse regurgitation with vomiting. Vomiting involves forceful contraction of the diaphragm and abdominal muscles, which is not present in regurgitation. Babies need 120 cal/kg/day, and formula has 20cal/oz.3 Therefore in this child, feeding every 4 hours (six times a day) would amount to 4 oz per feeding or 1 oz/kg. After counseling the mother on proper feeding, you observe the child take 3 oz of formula without problems and discharge her home.

Pitfalls : Always take a detailed history regarding the amount of feeding, frequency of feeding, and any weight changes. Parents typically remember precisely how much their baby weighed when they were born. Compare their birth weight with the ER visit weight, and plot it on a growth curve. An accurate weight requires the baby to be completely undressed. Dropping significant weight is of high concern, and the child needs to be admitted and the cause explored. The emergency medicine physician must also understand the normal progression of weight in early life. Normal newborns may lose up to 10% of their birth weight during the first 1-2 weeks, but will then start gaining 20-30 grams/day in the first 3 months. Also, take a detailed history regarding the vomiting episodes. Bilious vomiting in this age group is never normal, and surgical consultation is typically indicated for concern of pathology such as volvulus.4 Never assume parents can accurately identify bilious vomiting, as parents often mistake the color yellow with bile.5 Additionally, question the parents about projectile vomiting, which is concerning for pyloric stenosis. Scared parents will often initially describe their child’s vomit as “shooting out,” or “explosive,” but tease out the history. Ask the parents if the child’s vomit would shoot clear across the exam room. When you define what projectile means, they typically will deny that it is that severe. Lastly, never discharge a baby home that cannot tolerate oral feeds, as dehydration can develop quickly in this age group.

Complaint 3 : “Doctor… she turned blue!”

Case : Chief complaint: Cyanosis. You immediately review the vitals signs, which are all within normal limits. As you enter the room, you are rapidly reviewing the differential diagnosis for cyanosis, but are surprised to see an active 5 day-old vigorously drinking from her bottle. The mother shows you a photo from her phone, revealing a blue color around the baby’s mouth that spares the tongue and also the hands and feet. This occurred at rest while the child was in no apparent discomfort. The child has no significant past medical history, and the exam is unremarkable.

Answer : This is a case of acrocyanosis. This is a transient phenomenon in young neonates where their skin will turn blue around the hands, feet, and perioral area. It is often due to cool ambient temperatures and reflects benign vasomotor changes.3 Patients do not need a work up or observation, and can safely be discharged home.

Pitfalls : Just as discussed in case 1, always take a detailed history and evaluate for more serious pathology or an ALTE. If there is diffuse cyanosis, significant pathology such as cyanotic congenital heart defects must be explored.

References / Further Reading

Committee on Fetus and Newborn, American Academy of Pediatrics. Apnea, sudden infant death syndrome, and home monitoring. 2003;111(4 Pt 1):914-917. McGovern MC, Smith MB. Causes of apparent life threatening events in children: a systematic review. Arch Dis Child. 2004;89(11):1043-1048. Doan QH, Kissoon N. Neonatal emergencies and common neonatal problems. In: Tintinalli JE, ed. Tintinalli’s Emergency Medicine: A comprehensive study guide. 7th ed. McGraw-Hill; 2011:733-748. Malhotra A, Lakkundi A, Carse E. Bilious vomiting in the newborn: 6 years data from a Level III Centre. J Paediatr Child Health. 2010;46(5):259-261. Walker GM, Neilson A, Young D, et al. Colour of bile vomiting in intestinal obstruction in the newborn: questionnaire study. BMJ. 2006;332(7554):1363.