A 1-hour-old boy is evaluated in the newborn nursery for feeding difficulty. The patient was born at 40 weeks gestation to a 22-year-old primigravida via spontaneous vaginal delivery. Apgars were 8 and 9 at 1 and 5 minutes, respectively. The boy was placed on his mother's chest for skin-to-skin care and has been attempting to breastfeed. He was able to latch and begin feeding but within 1 minute, his face developed a blue tinge. The boy cried, and his color improved. His mother tried repositioning the patient a few times, but his skin continued to turn blue shortly after feeding with return of normal color after crying. Temperature is 37.2 C (99 F), and pulse is 150/min. Pulse oximetry is 97% and 96% on room air, measured from the right hand and left foot, respectively. The palate appears intact. Lung examination shows equal sounds bilaterally. There are no murmurs or gallops. Peripheral pulses are strong. The abdomen is soft, and there is no organomegaly. The skin appears pink. Chest radiograph is normal. Which of the following is the best next step in evaluation of this patient's symptoms?

Question

A 1-hour-old boy is evaluated in the newborn nursery for feeding difficulty.  The patient was born at 40 weeks gestation to a 22-year-old primigravida via spontaneous vaginal delivery.  Apgars were 8 and 9 at 1 and 5 minutes, respectively.  The boy was placed on his mother's chest for skin-to-skin care and has been attempting to breastfeed.  He was able to latch and begin feeding but within 1 minute, his face developed a blue tinge.  The boy cried, and his color improved.  His mother tried repositioning the patient a few times, but his skin continued to turn blue shortly after feeding with return of normal color after crying.  Temperature is 37.2 C (99 F), and pulse is 150/min.  Pulse oximetry is 97% and 96% on room air, measured from the right hand and left foot, respectively.  The palate appears intact.  Lung examination shows equal sounds bilaterally.  There are no murmurs or gallops.  Peripheral pulses are strong.  The abdomen is soft, and there is no organomegaly.  The skin appears pink.  Chest radiograph is normal.  Which of the following is the best next step in evaluation of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d651_bb4b_bc81_05d741b547b4_MD0003_00 This newborn has cyanosis that occurs with feeding and is relieved by crying, consistent with choanal atresia. Choanal atresia is caused by the failure of the posterior nasal passage to canalize during the first trimester. The condition may occur in isolation or as part of the CHARGE syndrome (coloboma [missing eye tissue], heart defects, atresia choanae, growth retardation, genital abnormalities, and ear abnormalities). Obstruction may be unilateral (more common) or bilateral. Although unilateral disease typically causes chronic nasal discharge in childhood, bilateral choanal atresia presents shortly after birth, as with this patient. Because neonates are obligate nasal breathers (ie, preferentially breathe through the nose), the complete obstruction of bilateral choanal atresia causes intermittent cyanosis, even at rest. If the infant's mouth is fully occluded (eg, pacifier, feeding), the resultant hypoxia and cyanosis can be profound. The increasingly distressed and hypercapnic infant will begin to cry, relieving the airway obstruction and normalizing perfusion. When choanal atresia is suspected, the first step is to attempt to pass a catheter through the nares into the oropharynx. Inability to pass the catheter is suggestive of choanal atresia. CT scan or nasal endoscopy confirms the diagnosis. Treatment includes maintaining the airway (eg, oral airway, intubation) and orogastric tube feedings until corrective surgery. Inability to pass the catheter (Choice A) Blood cultures are drawn in evaluation for neonatal sepsis, which can present with a variety of clinical findings (eg, temperature instability, lethargy, irritability, cyanosis). This patient's isolated cyanosis associated only with feeding makes sepsis less likely. (Choice B) Methemoglobinemia can present with cyanosis due to rare genetic enzyme deficiencies or exposure to oxidizing substances. However, cyanosis is persistent and does not improve with crying. (Choice C) Echocardiography is indicated to evaluate for congenital cyanotic heart defects (eg, tetralogy of Fallot, transposition of the great vessels). This infant's cyanosis with feeding and otherwise normal perfusion, pulse oximetry, cardiac examination, and chest x-ray make these diagnoses less likely. (Choice E) Ultrasound of the head is a noninvasive screening test for intraventricular hemorrhage, which can cause lethargy, hypotonia, apnea/cyanosis, and seizures. This full-term infant has a normal physical examination with no apnea, making a central nervous system cause of cyanosis unlikely. Educational objective: Choanal atresia is a congenital obstruction of the posterior nasopharynx. Because neonates are obligate nasal breathers, bilateral choanal atresia presents with cyanosis that worsens during feeding and improves when crying. The diagnosis is supported if a small catheter cannot be passed from the nares into the oropharynx. References: Choanal atresia and other neonatal nasal anomalies. (http://www.ncbi.nlm.nih.gov/pubmed/30396416) Pediatric nasal obstruction. (http://www.ncbi.nlm.nih.gov/pubmed/30031550)

A 1-Hour-Old Boy Is Evaluated in the Newborn Nursery for Feeding