Brady baby

[shearernurse]

I hoope this is the right forum.

I had a situation the other night and need some insight on and also need to learn what was going on. I had a G2P1, come in @0030 and delivered by 0123. She only pushed for 20 minutes. Babe was a good size 3672Gm. UPon initial assess I thought he sounded a little "crunchy" on the left, while listening to left lung field. Heart rate good @ 136. A little extremity cyanosis, nothing I thought to be worried about. Mom attempted nursing, and with much difficulty got him to latch about 10 minutes each side. At 0300, I went to do a blood glucose, it was 2.1(in Canadian terms) approx 38 in US terms, which by our accounts is pretty low. Normal in infants, I think is 4-8. So I cup fed him 20cc of similac, mom was ok with this, she had to supplement 1st babe for the first few days. At 0400, babe blood sugar was 2.5(45 US). Not great I thought, but kid beared close observation. 2 hours post-delivery and kid had not mecced or voided. OK, I did frequent checks on sleeping baby. At 0600,whether it was a gut instinct, 6th sense or something just didn't right in my mind, I woke him up for a full assessment. Temp 36.2C, R 44. HEART RATE 96. My heart rate was faster than his. I double checked/triple checked. Then put him on telemetry to check again and I was correct. I then put him in our isolette, put an O2 sat monitor on him. Sats were,92-95%, okay now I'm nervous. I then called the Dr. and he said he would be right round to see him. (30 minutes later). Prior to calling him ,I tried to a blood sugar that would not read, said error for some reason. I then called lab and extra staff member. I am the only RN on nights, with and LPN. BLess her heart, she is one of the best, but their scope of practice is very limited in our facility. She made phone calls for me, got equipment AND took care of the other 10 patients on the floor. Our Lpn's cannot give meds,etc. As it turned out the blood sugar @ 0700 was 2.8(50). The DR showed up just as the lab tech was drawing blood and of course the kids heart rate increased to 120-130, but was still lethargic. I turned over care @ 0730, just as we were getting a B/P, 74/15. To say the least @ that time I got the hell out of there. Turns out our doc, phone the neonatal team in the city and they came and got the kid. Prior to the team getting there, day staff, did a CXR, started an IV and gave him some Amp and Gent.

Bottom line guys A) did I do ok? B) What the heck was a matter with him. I believe (correct me if I'm wrong), kids compensate very well, but when their heart rates go down, you can be looking a some serious trouble.

Thanks for listening to such a long-winded post, but your guidance and input are valued. Will keep you updated on kids condition if you like.

Thanks again:

[prmenrs, RN]

My first guess would be a heart issue, based on the low sat. If it was still low on O2, that would be more convincing. That's a really wide pulse pressure.

Or, he could have a pneumothorax. (based on the chest auscultation) Not sure why he's hypoglycemic.

Those are my guesses. I hope you're gonna find out what the problem was and let us know. You couldn't get a blood gas, I imagine?

[Gompers, BSN, RN]

Well, what you described could either be the beginning of something (like pnemonia, sepsis, heart defect) or it could be absolutely nothing.

In a way, everything you described is perfectly normal, at least to me. I need more evidence to show me that he really was sick. How was the x-ray? Was a CBC drawn? Any other problems you didn't mention?

Blood sugars...well he didn't eat all that much. First time breastfeeding might have been 20 minutes total, but mom might not have had any milk yet so maybe all he got to eat was that 20cc of formula - which probably wasn't enough to suffiently raise his sugars for the rest of the night. Plus I don't see anywhere that he ever had another feeding after the 0300 one, so why would the glucose level to be any higher at 0700?

Temperature - definitely on the lower side, but nothing a hat and extra blanket couldn't fix. How long was he under the warmer after birth? What was his initial temp before the 36.2?

Heart rate - you said you woke him up when he was sleeping. A heart rate of 90's in a sleeping full term newborn can be perfectly normal. We only consider it a bradycardia f the heart rate is under 80. Plus, he was on the cold side, so a lower heart rate is expected.

Blood pressure - normal BP for a term newborn. Yes, it's a widened pressure, so I'd have waited five minutes and taken it again to be sure. If it's still widened, it could just be that his PDA was still open, which has been known to cause bounding peripheral pulses and widened pressures.

Saturations and breath sounds - anything in the 90's is fine, especially on a baby that was precipitously delivered since he didn't have a lot of time being "squeezed out" in the birth canal. This could also explain his breath sounds shortly after birth. And again, he was on the cold side, so if his hands and feet were cold, the sats wouldn't be the best.

Lethargy - well, he was very newly born and hadn't had much too eat, plus he had borderline low sugars. Probably would be sleepy.

I mean, something might be wrong with the baby, but I personally didn't see anything that would convince me that an hour under the radiant warmer, some chest percussion therapy, suctioning, and a good solid formula feeding wouldn't cure.

[Gompers, BSN, RN]

My first guess would be a heart issue, based on the low sat. If it was still low on O2, that would be more convincing. That's a really wide pulse pressure.

Or, he could have a pneumothorax. (based on the chest auscultation) Not sure why he's hypoglycemic.

Those are my guesses. I hope you're gonna find out what the problem was and let us know. You couldn't get a blood gas, I imagine?

I think the kids PDA was probably still wide open, at the very least. But isn't it normal for it not to close until 24-48 hours? I keep thinking of all the heart babies we've gotten who were discharged home at 24 hours of age, only to be brought into the ER, cyanotic, less than 24 hours later because the PDA closed, wreaking havoc on an undiagnosed heart defect.

I thought about pneumo as well, but he wasn't tachypnic and there was no mention of retractions or anything like that.

I wish we had CBC or ABG results to analyze, as those results might be very telling.

[dawngloves, BSN, RN]

ITA agree Gompers. While that kid would get a septic w/u in our hospital, I'm not sure anything would come of it.Still some question to be answered.Why no serum glucose sent after an Accu Check of 38? Was he retracting, grunting,flaring?Mom's history? GBS?

No stool or void in the first few hours of life is not uncommon as are wide pulse pressures. Could still be closing that PDA.A resting HR of 95 in a term kid is no big deal and I'd bet the parents have that too. Even a POX of 95%, no biggy, BUT it is still borderline and given the big picture I don't see what you could have done different.

[prmenrs, RN]

You're both better than me! @ least you didn't jump to the conclusion that anything was wrong in the 1st place!! lol.

Might just wind up under the heading of "poor transistion", aka, dumb baby syndrome!

I hope Shearernurse comes back and tells us!

[dawngloves, BSN, RN]

You're both better than me! @ least you didn't jump to the conclusion that anything was wrong in the 1st place!! lol.

Might just wind up under the heading of "poor transistion", aka, dumb baby syndrome!

I hope Shearernurse comes back and tells us!

You're looking for a Zebra, Prmenrs!

I agree, but with a differential diagnosis of "Big Dumb Baby Syndrome"

Yes, Shearernurse! Call that other hospital and tell us how that kid is!

[Gompers, BSN, RN]

You're looking for a Zebra, Prmenrs!

I agree, but with a differential diagnosis of "Big Dumb Baby Syndrome"

Yes, Shearernurse! Call that other hospital and tell us how that kid is!

Don't forget that this is a BOY we're talking about, and probably a white one at that!!!

Hopefully it was nothing, but I hope we find out what happened to this little guy...

[prmenrs, RN]

"Big Wimpy White Boy Dumb Baby Syndrome" Kind of a mouthful don't you think?

[RNin2007]

Well, what you described could either be the beginning of something (like pnemonia, sepsis, heart defect) or it could be absolutely nothing.

In a way, everything you described is perfectly normal, at least to me. I need more evidence to show me that he really was sick. How was the x-ray? Was a CBC drawn? Any other problems you didn't mention?

Blood sugars...well he didn't eat all that much. First time breastfeeding might have been 20 minutes total, but mom might not have had any milk yet so maybe all he got to eat was that 20cc of formula - which probably wasn't enough to suffiently raise his sugars for the rest of the night. Plus I don't see anywhere that he ever had another feeding after the 0300 one, so why would the glucose level to be any higher at 0700?

Temperature - definitely on the lower side, but nothing a hat and extra blanket couldn't fix. How long was he under the warmer after birth? What was his initial temp before the 36.2?

Heart rate - you said you woke him up when he was sleeping. A heart rate of 90's in a sleeping full term newborn can be perfectly normal. We only consider it a bradycardia f the heart rate is under 80. Plus, he was on the cold side, so a lower heart rate is expected.

Blood pressure - normal BP for a term newborn. Yes, it's a widened pressure, so I'd have waited five minutes and taken it again to be sure. If it's still widened, it could just be that his PDA was still open, which has been known to cause bounding peripheral pulses and widened pressures.

Saturations and breath sounds - anything in the 90's is fine, especially on a baby that was precipitously delivered since he didn't have a lot of time being "squeezed out" in the birth canal. This could also explain his breath sounds shortly after birth. And again, he was on the cold side, so if his hands and feet were cold, the sats wouldn't be the best.

Lethargy - well, he was very newly born and hadn't had much too eat, plus he had borderline low sugars. Probably would be sleepy.

I mean, something might be wrong with the baby, but I personally didn't see anything that would convince me that an hour under the radiant warmer, some chest percussion therapy, suctioning, and a good solid formula feeding wouldn't cure.

Wow...great educational post for me to read....

Thanks Gompers...you helped me think this through with great rationales.

~J

[Jolie, BSN]

Well, what you described could either be the beginning of something (like pnemonia, sepsis, heart defect) or it could be absolutely nothing.

In a way, everything you described is perfectly normal, at least to me. I need more evidence to show me that he really was sick. How was the x-ray? Was a CBC drawn? Any other problems you didn't mention?

Blood sugars...well he didn't eat all that much. First time breastfeeding might have been 20 minutes total, but mom might not have had any milk yet so maybe all he got to eat was that 20cc of formula - which probably wasn't enough to suffiently raise his sugars for the rest of the night. Plus I don't see anywhere that he ever had another feeding after the 0300 one, so why would the glucose level to be any higher at 0700?

Temperature - definitely on the lower side, but nothing a hat and extra blanket couldn't fix. How long was he under the warmer after birth? What was his initial temp before the 36.2?

Heart rate - you said you woke him up when he was sleeping. A heart rate of 90's in a sleeping full term newborn can be perfectly normal. We only consider it a bradycardia f the heart rate is under 80. Plus, he was on the cold side, so a lower heart rate is expected.

Blood pressure - normal BP for a term newborn. Yes, it's a widened pressure, so I'd have waited five minutes and taken it again to be sure. If it's still widened, it could just be that his PDA was still open, which has been known to cause bounding peripheral pulses and widened pressures.

Saturations and breath sounds - anything in the 90's is fine, especially on a baby that was precipitously delivered since he didn't have a lot of time being "squeezed out" in the birth canal. This could also explain his breath sounds shortly after birth. And again, he was on the cold side, so if his hands and feet were cold, the sats wouldn't be the best.

Lethargy - well, he was very newly born and hadn't had much too eat, plus he had borderline low sugars. Probably would be sleepy.

I mean, something might be wrong with the baby, but I personally didn't see anything that would convince me that an hour under the radiant warmer, some chest percussion therapy, suctioning, and a good solid formula feeding wouldn't cure.

My thoughts, exactly. (well, except for I wouldnt have said it so well :).

How well the baby tolerated the ambulance ride to the tertiary care facility may be very telling. Nothing like bumping a kid over rough roads for 30 minutes to make a mildly ill newborn crump, or a perfectly normal newborn wake up and become vigorous!

[BittyBabyGrower, MSN, RN]

Gotta agree, but the nursery nurses where I work would have been with the OP. HR: fine BP: fine, PDA most likely open Pulseox: fine, anything over 89% in our unit is fine and this kid had cool hands and feet Glucose: eh, give him more to eat and recheck.

We would have sent him back after we checked him out. No risk factors, we would have sent a CBC and CRP, depending on the fellow that was on.