Each month Yaron Ivan, MD shares some of the rules from his popular podcast about Pediatric
Emergency Medicine, PEM Rules. To learn more about all of the rules, visit pemrules.com or on
your favorite podcast platform.
Last time I discussed some helpful rules that help me with the management of my newborn patients. This month I would like to discuss two more. The last one is particularly important as newborns represent our most tenuous, fragile patients with the least physiologic reserve.
Rule Number 10: A feed is like a stress test for a baby.
One of the challenges of being a PEM physician is to identify the infant with respiratory distress
secondary to a cardiovascular etiology among the sea of infants with bronchiolitis, URI and
other respiratory complaints. Chief complaints that are secondary to true cardiovascular
etiologies are uncommon in the Pediatric ED, however, “missing’ these children can actually
have some serious ramification.
Bearing in mind that feeding (especially breastfeeding) is hard work for a baby, I find it helpful
to ask the parents if the child seems to struggle while he or she feeds. Specifically, I ask if the
child sweats while feeding (it is uncommon for newborns to sweat) or struggles with feeds to
the point of needing to take frequent breaks in order to finish the bottle.
If the parent / caregiver reports such symptoms I personally have a very low threshold to
consider the possibly of congenital heart disease. The next steps are to:
1. Ask the parents about weight loss or lack of weight gain (PEM Rule Number 9) or check the growth chart if it is available in the electronic medical records.
2. Obtain a CXR and EKG – I call these two tests together my poor man’s echo. Keeping in
mind that if the child’s respiratory symptoms are of a cardiovascular etiology, one
should identify vascular congestion and / or cardiomegaly on a CXR. In addition, some
congenital heart diseases present with odd shaped hearts (for example the classic boot
shaped heart of Tetralogy of Fallot)
Rule number 11: Newborns are black boxes, be as conservative as you need
Those of you who follow this column (or my podcast) probably know by now that I am not a big
fan of extensive workups and a very big fan of Rule Number 4 “Less is more.” Having said all
that, Rule Number 11 helps me “stay in check.”
I try to stay mindful of how challenging it is to manage newborn patients. To start, a newborn
HPI is entirely subjective since it is provided by the parent / caregiver perspective and
newborns can’t in any way communicate what they feel etc.
In addition, the physical exam in the newborn is often minimally contributory at best. We have
all had our share of febrile newborns with a none-focal exam who ends up with a positive
lumbar puncture or even just urinalysis (which represents pyelonephritis in a significant number
of patients).
Often the crying interferes with the respiratory exam, abdominal exam and more. VS of a child
with a viral illness can often be identical to the child with compensated shock etc. So, with my
newborn patients I try to take fewer risks and don’t beat myself up over ordering tests and
“playing it safe.”
Newborns tend to get sick quickly and deteriorate more rapidly, so
misdiagnosing or under-diagnosing a newborn can go a long way (in the wrong way).
So, the next time you see a newborn in your ED, remember, it is ok to be conservative and rely
(to some extent) on labs, imaging and other helpful modalities. And remember the following….
- The white rule – babies / newborns are only allowed to vomit white stuff, never bloody
never green
The Rule of 7 – 7 bowl movements a day or no BM for 7 days is normal in a newborn as
long as there are no red flags, the white rule I not violated, patient is growing, and no
blood in the stool. - The single most important indicator that a child / newborn is healthy is weight gain
A feed is like a stress test for a baby.
References
www.pemrules.com Episode 3
