Ellen’s Story: A Review of Pediatric Care
Pediatrics is a scary topic for a lot of folks, but it doesn’t need to be. We spend a lot of time talking about how kids are just little adults, or how kids are not little adults, and how they compensate for a long time, and then omg, they fall of the cliff and die. EMS education has caught on a bit, at least where I work, in that we don’t just shove pediatrics into a chapter at the end of the program and say “kids are scary,” here’s a test. This is a bit of a long one, so stick with me, and I hope you can take something away from this post.
Let’s talk about my daughter. She was delivered via c-section at 38 weeks after my wife’s water broke. Her delivery was much less dramatic, and less traumatic, than her brother’s entry into the world, but that is another story for another day. She was a peanut, smaller than her brother, not tiny, but weighing in at 7 pounds and 13 ounces. She is still my little munchkin, much smaller than her big bro. She was a quiet baby, and had feeding issues from the start. We did the usual stay in L&D, and we were allowed to go home. Hindsight being what it is, we should have had some red flags going up, my wife certainly did, but I didn’t at the time. Ellen was exceptionally quiet, and not feeding well, one nurse even commenting “she’s such a good baby, she barely cries.” Coming home with Scott, Ellen’s older brother, was stressful as a new dad. They just let you take this new kid home, no owner’s manual, no return policy, no nothing. You’re just responsible for this tiny human that is entirely dependent on you for its survival, and, by the way, you’re doing it on no sleep. Coming home with Ellen was different. We were seasoned vets, we did this before, no sweat. But the feeding issues continued through the first night. The next morning Ellen was really quiet, and we took her to her routine check-in with our pediatrician. A pediatrician looked her over, said what we already knew, our little girl was perfect, ten fingers, ten toes, perfect little button nose. The lactation consultant came in, watched Ellen eat, and talked with my wife about some strategies to improve feeding. Then she noticed the slightest tremor in Ellen’s hand. She thought for a second, and called for a blood sugar check. It was somewhere around 40. They gave her some high protein, high carbohydrate concoction and sent us home, told us we got this, keep on doing what you’re doing, everything is great.
We got home and things were less than great. My wife took Ellen out of her car seat and was holding her and said, “John, she’s not really waking up.” I took her and that’s when I realized she was so dehydrated, her fontanelles were sunken, lips and tongue dry, and she was an almost listless baby. Being paramedic dad, we didn’t bother with 911, back in the car seat she went, and off to the pediatric ER we drove.
When we got there, the staff was great. I didn’t realize that Epic would tell your age in hours. Unfortunately, I remember my daughters age being listed as 72 hours old at one point and thought damn, that’s sad. Couldn’t even get you to days before we got you back in the hospital. In the ER she was found to be hypoglycemic, hypothermic, and have high bilirubin. I helped hold her for her IVs, and her straight catheter urine. Later, friends of ours, and my wife, were criticizing that they “made” me help, but honestly, I wouldn’t have been able to sit down and I needed to help. Nobody can care for my kids like I can. She stayed in the pediatric ICU for two days or so, and then we came home. Feeding issues persisted, everyone attributed them to GERD and a tongue tie, which we tried to treat with no real improvement.
A few months go by, and she’s getting hypothermic at night, waking up in the morning with temperatures of 95-96 degrees. She has some sweating with feeding and is just having a hard time. We talked to our pediatrician, and agree she needed a cardiology consult. She got an echocardiogram and was diagnosed with two atrial septal defects, one more significant that the other, but two nonetheless. Fun fact, these have about a 50/50 chance of being familial as they do being spontaneous. My wife, my two-year-old, and I all needed echocardiograms which were thankfully negative. The hope is that they close on their own, however we haven’t had much progress in their closure so far. The first time you have to give your baby furosemide hits you differently than you’d expect. My daughter has an abnormal EKG, she has right atrial enlargement. She gets Lasix which is supposed to help take some of the workload off her heart.
She is now thirteen months and change days old, and just the other day had a syncopal episode sitting in her high chair. No trigger, just a typical morning, this is definitely something new. Off to the pediatric ER we go. She gets diagnosed with a pediatric breath holding event, despite a lack of breath holding, but I digress. Her EKG gets called normal, which we already know her baseline is not, and we get sent home. Thankfully, her cardiologist worked her in, and she is on a 48 monitor and she will be followed closely. Let’s hope that doesn’t hold any New Year’s surprises for us and we can just focus on the problem we already know about, and not a new one.
So, all of that said to get to the point of this blog, which is learning something about pediatrics and taking the best care of kids, specifically neonatal hypoglycemia, congenital heart defects, pediatric breath holding events, and BRUEs.
First, let me tell you, the most important part about taking care of kids is taking care of their parents. If you never learn anything else from me ever again, it is never to judge a parent as an “eye roll” first time parent. Like I said, you get sent home with this tiny human that is entirely dependent on you for its survival. You’re sleep deprived, you’re hormonal, mom is potentially in a hell of a lot of pain, and this little bundle of joy has you questioning everything. I would rather respond to calls for overly concerned parents all day, every day over negligent ones. I thought I knew before I had kids, spoiler, I didn’t know. Parents need support, especially new parents. It’s not easy.
After we make sure mom and dad aren’t going to make this an MCI, lets focus on the patient. The pediatric assessment triangle has been around forever, and is an effective tool for an initial assessment on a kid, or anyone really. Here are two great articles that discuss that more deeply:
I could spend all day talking about all the things that can affect a kid, but I want to dive into pediatric hypoglycemia, congenital heart defects, breath holding events and BRUEs.
Neonatal Hypoglycemia
I know a lot of people that will run to the hospital with the first mention that mom is about to deliver a baby. Oh no, not in my truck. I don’t necessarily hold that view. 99% of the babies we help mom deliver are easy, it’s the 1% that go wrong that are terrifying and will keep you up at night. Besides, lets deliver this kid on your bathroom floor instead of me needing to mop my truck, or needing to traumatize anyone who might be on the L&D elevator with us. Delivering a happy, healthy baby is one of the most rewarding things we have the privilege to do in EMS, in my opinion. As a side note, mom doesn’t just hold baby for transport. Mom and baby need to both properly be secured.
Warm, dry, stimulate is all most babies need. No need to suction, most of the time, no need to rush to cut the cord, not a lot of intervention needed for most neonates. Recognition of when they need some help is the important part.
In the first few hours of life, there is an expected drop in the newborn’s blood sugar due to its body’s transition from intrauterine to extrauterine life. This is typically transient, asymptomatic, and not of concern. Abramowski, et al, states: “Infants are at risk for more severe or prolonged hypoglycemia due to one or a combination of the following underlying mechanisms: insufficient glucose supply, with low glycogen or fat stores or poor mechanisms of glucose production; increased glucose utilization caused by excessive insulin production or increased metabolic demand; or the failure of counter-regulatory mechanisms (i.e., pituitary, or adrenal failure). Neonatal hypoglycemia most commonly affects the following groups of infants:
Neonatal hypoglycemia most commonly affects the following groups of infants:
Intrauterine growth restriction or small compared to gestational age infants
Infants of diabetic mothers or large for gestational age infants
Late-preterm infants (34 to 36.6 weeks gestational age) “(1)
Where does Ellen potentially fit in with this, Abramowski, et al, continue: “Infants experiencing perinatal stress (e.g., fetal distress, perinatal ischemia, maternal preeclampsia/eclampsia, sepsis, hypothermia) or those with congenital heart disease have increased metabolic energy requirements, which puts them at risk for hypoglycemia. Perinatal stress causes a state of 'hypoglycemic hyperinsulinism' that can persist for days to weeks, resulting in persistently low glucose concentrations requiring ongoing interventions to maintain euglycemia.” (1) Beyond the first 48 hours of life, persistent hypoglycemia can include congenital hyperinsulinism, congenital metabolic syndromes, endocrine disorders, and errors of metabolism. Thankfully Ellen only had the one episode of hypoglycemia.
Roughly 25% of all deliveries were at risk for hypoglycemia, of those, 51% of those infants had at least one episode of hypoglycemia. (1) Authors of this paper defined hypoglycemia as <47mg/dL.
Like adult hypoglycemia, neonatal hypoglycemia shares generally the same features: depressed mental status, lethargy, sweating, difficulty feeding, weak cry, feeding difficulties, hypothermia, irritability, hypotonia, cyanosis, seizures, coma, apnea, grunting, tachypnea. When mom or dad tells you that they just aren’t acting “right.” Baby seems to not be interested in feeding, isn’t as interactive as usual, has been extra quiet, or not crying as loudly. Hypoglycemia is on the differential.
Prehospital treatment focuses on IV/IO access and administration of dextrose 10%. Depending on the resource, a bolus of 2-5mL/kg is recommended. Of course, follow your own local protocols. In North Carolina, the protocol for patients under 50kg is 5mL/kg. Keep these kiddos warm, make sure the air conditioning vents aren’t blowing on them, and bundle them up. Ensure that they are safely secured, and so are mom and/or dad.
So, the bonus, if you’re still reading, is that while researching and writing this post, I came across an inborn error of metabolism called maple syrup urine disease. No, Ellen does no have this, but how do you not look this up and read about it based off its name alone. It is given its name by the body’s production of sweet-smelling urine caused by the inability of the body to breakdown certain amino acids. This is very rare, however if diagnosed, it does require life long care. Delayed diagnosis and treatment can lead to seizures, coma, developmental delays, or brain damage. First line treatment is through a metabolic dietician to start a low protein diet. This diet is meant to reduce the amount of amino acids taken in. (2)
Thanks for sticking around to the end, learning a little about my little girl, and a little about pediatric hypoglycemia. Next time I’ll cover a crash course in congenital heart defects. By then, we will have our monitor results back so hopefully that won’t turn into a post about pediatric arrhythmias as well. Until then, thank you for the support, and be safe out there.
1. Abramowski A, Ward R, Hamdan AH. Neonatal Hypoglycemia. [Updated 2023 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537105/
2. NHS Choices, NHS, www.nhs.uk/conditions/maple-syrup-urine-disease/#:~:text=Maple%20syrup%20urine%20disease%20(MSUD,and%20fish%20into%20amino%20acids. Accessed 25 Dec. 2023.
