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.
I see many newborns in the ED, sometimes newborns who are just a few hours old and were born via home birth. Newborns are challenging for several reasons, some obvious, some less so.
The biggest challenge? Physical exam of a newborn is often simply unreliable. HPI is often limited as well simply due to age and the patient’s inability to communicate.
This is why the following Rules play a major role in my assessment of the newborn. In the end, it all comes back to Rule Number One and Rule Number Two (see previous issues).
Rule Number 6: The white rule
Babies / newborns are only allowed to vomit white stuff; never bloody, never green
Spitting up and/or vomiting is a very common chief complaint in the Pediatric ED and I often find myself providing reassurance for those parents and sending the child home without much workup or intervention.
As with other scenarios, I find it most important to focus on ruling out surgical or serious causes of vomiting vs making the exact diagnosis during the ED encounter (see Rule Number Two: “You’re not here to win, you simply don’t want to lose,” from previous issue).
Most vomiting is simple reflux and the vomit associated with it is the color of the breast milk or formula. Therefore, it is important to verify with the parents that the vomit is in fact white or white-ish. Anything green (bilious) or bloody may indicate surgical or other serious causes of vomiting, such as malrotation with volvulus, sepsis etc.
Of course, there are exceptions to any rule. One example is the well-appearing, breastfed infant whose mom reports bleeding from the nipples. Hematemesis under these circumstances would be acceptable, and the child can be discharged assuming everything else (rest of the history, VS, exam etc.) is within normal limits.
Rule Number 8: The Rule of 7
7 bowel movements a day, or no bowel movement for 7 days, is normal in a newborn
Constipation is a common chief complaint in pediatrics and sometimes requires intervention in the ED. However, this same chief complaint means something very different in newborns.
Newborns do not have the same stooling pattern as children and adults. I share Rule Number 8 with parents of a newborn very often, leaving the child alone instead of intervening. I learned it as a general pediatric resident as part of my anticipatory guidance to young / new parents and have adopted to my “reassurance’ talk to parents in the ED.
As always, I try to keep Rule Number One (“It’s not the patient’s job to prove that they’re sick, it’s your job to prove that they’re not”) in the back of my mind and ask the parents about any red flags: the White Rule (see above) isn’t violated, the patient is growing (see Rule Number 9 below) and there is no blood in the stool. If these red flags are not present, I provide reassurance and anticipatory guidance only.
As a PEM physician, I try to avoid making recommendations on formula changes (“formula roulette”). If the baby is not experiencing any of the red flags, he or she is likely on the right formula. An exemption is a child with hematochezia who has milk protein allergy and needs hydrolyzed formula only.
Rule Number 9: The single most important indicator that a newborn (or child) is healthy is weight gain
Having done residency in General Pediatrics and not EM, I often think like a general pediatrician. The pediatrician’s biggest nightmare is the child with Failure to Thrive (FTT) whose differential diagnosis is as wide as Nelson’s Textbook of Pediatrics.
The etiology for Failure to Thrive can range from cardiovascular to metabolic and beyond. Now that I only practice PEM I am less concerned with making the diagnosis, and I simply try to do the best I can and rule out the possibility of a serious cause of FTT with my history, physical and maybe workup.
One of the biggest red flags in pediatrics (and especially in newborn medicine) is lack of weight gain or even worse, weight loss. That is why I have a low threshold to ask about the patient’s weight, and if available in your hospital’s EMR, compare the growth chart with what the parent is telling you about the newborn’s weight.
This rule also comes into play when assessing other age groups presenting with chronic or long-lasting chief complaints.
Example A
8 y/o p/w abdominal pain for the last several months or weeks. Given the timeline, a surgical abdomen is not very high on the differential diagnosis. However, things like Inflammatory bowel disease (IBD) certainly come to mind. Bearing in mind that IBD is often accompanied by FTT or weight loss, asking about possible weight loss is very important in the HPI.
Example B
Another example is the child / infant or toddler that according to mom or dad is “always sick”. Parents often complain of very frequent febrile illnesses and sometime even say “I worry his / her immune system is not working.”
This is a teaching opportunity for parents to understand that children with immunodeficiencies often don’t grow and don’t thrive simply because the body is consumed with fighting infections. A child that has frequent febrile illness but is thriving and gaining weight is very unlikely to have an immunodeficiency. Rather, it is likely they have frequent viral illness like many other children.
References
www.pemrules.com Episode 3
3 Comments
Awesome!! Common sense and good use of your background and your brain are the cornerstone of our job. I really love the way you draw the clinical scenarios
First, I truly appreciate you providing us this information. Is there a way you can post all the Rules for us to read, I’ve missed out on some of the earlier rules..
Mike Davila FNP-C
Hello,
Here’s the link to all of Dr. Ivan’s previous articles on Ped Rules: https://epmonthly.online/contributor/yaron-ivan-md/