A newborn boy is brought to the emergency department for coughing and difficulty feeding. The patient was born at home 3 hours ago via spontaneous vaginal delivery. When the mother, a 24-year-old primigravida, attempted to breastfeed him, the patient coughed and vomited. The mother had no prenatal care. She has a history of illicit drug use but says she did not use any substances during the pregnancy. Temperature is 37 C (98.6 F), pulse is 120/min, and respirations are 50/min. Oxygen saturation is 95%. Ballard score estimates the boy was born at 37 weeks gestation. Weight and length are at the 25th and 50th percentiles for age, respectively. After attempting another feed with 10 mL of formula, the patient has a coughing fit; there is formula mixed with saliva in his mouth. Coarse breath sounds are noted bilaterally on pulmonary examination with intercostal retractions. Cardiac examination reveals a grade 2/6 systolic murmur at the upper left sternal border. There is no hepatomegaly. Neurologic examination shows normal tone. Which of the following is the best next step in the management of this patient?

Question

A newborn boy is brought to the emergency department for coughing and difficulty feeding.  The patient was born at home 3 hours ago via spontaneous vaginal delivery.  When the mother, a 24-year-old primigravida, attempted to breastfeed him, the patient coughed and vomited.  The mother had no prenatal care.  She has a history of illicit drug use but says she did not use any substances during the pregnancy.  Temperature is 37 C (98.6 F), pulse is 120/min, and respirations are 50/min.  Oxygen saturation is 95%.  Ballard score estimates the boy was born at 37 weeks gestation.  Weight and length are at the 25th and 50th percentiles for age, respectively.  After attempting another feed with 10 mL of formula, the patient has a coughing fit; there is formula mixed with saliva in his mouth.  Coarse breath sounds are noted bilaterally on pulmonary examination with intercostal retractions.  Cardiac examination reveals a grade 2/6 systolic murmur at the upper left sternal border.  There is no hepatomegaly.  Neurologic examination shows normal tone.  Which of the following is the best next step in the management of this patient?

Quizplus · Accepted Answer

11ec25c8_d618_f79a_bc81_07045097ffbf_MD0003_00 This newborn's feeding difficulties are concerning for a tracheoesophageal fistula with esophageal atresia, a congenital anomaly that most commonly involves a proximal esophageal pouch and a fistula between the distal trachea and the esophagus. tracheoesophageal fistula with esophageal atresia In utero, the affected fetus is unable to swallow amniotic fluid, often causing polyhydramnios on prenatal ultrasound. However, the anomaly is frequently undetected until shortly after delivery when the patient develops copious oral secretions and choking, coughing, and/or vomiting with feeding attempts. Aspiration of pooled milk and secretions from the esophageal pouch and oropharynx leads to coarse lung sounds and respiratory distress (eg, retractions), as seen here. The first step in management is to attempt nasogastric tube placement. Inability to pass the tube into the stomach due to resistance at the esophageal pouch is consistent with the diagnosis; chest x-ray confirms the tip of the catheter in the proximal esophagus (black arrow). Esophagography, if performed, may reveal pooling of water-soluble contrast medium in the esophageal pouch. chest x-ray (Choice A) Congenital heart disease can present with difficulty feeding and a harsh murmur. However, cyanosis and sweating with feeds are typical, and excessive oral secretions are not expected. This newborn's murmur is likely due to a physiologic patent ductus arteriosus. (Choice B) Thickening of the epiglottis with a thumbprint sign on lateral neck x-ray is diagnostic of epiglottitis. Although this condition can cause pooling of saliva and respiratory distress, it is usually associated with fever and stridor in school-aged children, not newborns. (Choice C) Morphine can be used to treat neonatal abstinence syndrome (NAS), which often causes poor feeding, vomiting, and irritability in infants born to mothers with opioid use disorder. However, NAS does not cause coughing during feeds, excessive oral secretions, or coarse breath sounds. In addition, NAS (which reflects withdrawal symptoms) typically develops ≥24 hours of life, not immediately after birth. (Choice E) Although it causes projectile vomiting, pyloric stenosis (eg, thickened pylorus on ultrasound) usually presents at age 3-6 weeks (after hypertrophy of the pylorus has developed), not in the newborn period. (Choice F) Surfactant may be administered for respiratory distress syndrome, a condition in which premature infants have alveolar collapse due to surfactant deficiency. In contrast, this boy appears to have been born at term, not preterm. Educational objective: Tracheoesophageal fistula with esophageal atresia presents shortly after birth with copious oral secretions and choking, coughing, and/or vomiting with feeding. Diagnosis can be confirmed by inserting a nasogastric tube, which encounters resistance at the proximal esophageal pouch. References: Basic knowledge of tracheoesophageal fistula and esophageal atresia. (http://www.ncbi.nlm.nih.gov/pubmed/29373345)

A Newborn Boy Is Brought to the Emergency Department for Coughing