David Dorfman

GEORGE K. SIBERRY, MD, MPH, SECTION EDITOR

 Grunting, hot, and vomiting:
  What's the bother in Baby's belly? 

 Susan Hayden, MD, and David Dorfman, MD 

 This account of an ill 6-month-old boy began earlier todayabout noon,   before you became involvedwhen his concerned mother brought the infant   to an urgent care center with complaints of fever and vomiting. He had had a   cough and runny nose for one week, she reported, but this morning was different:   several episodes of nonbloody, nonbilious vomiting. The physician on duty at   the center recorded an axillary temperature of 102º F and noted that the   boy appeared irritable and was grunting. She referred Mother and child to your   emergency room. 

 Now, in the afternoon in the ER, you obtain a more thorough history from the   mother. Her son has been sleepier than usual, hasn't been drinking well for   two days, and has urinated only once today. He is not making tears when he cries.   He has not had diarrheain fact, he hasn't passed a stool for three days.   Mother has not sensed that he was in any abdominal pain until today; now, it   seems to her, "his belly is bothering him." At home is a 2-year-old sister,   also with a runny nose and a cough for two weeks. Both children attend day care. 

 This baby was delivered at term by cesarean section because of fetal distress;   heart tones were lost briefly during labor. Birth weight was eight pounds. He   has been exclusively bottlefed. He rolled at four months, sat at six, and recently   started babbling. He has not been hospitalized or undergone surgery, is not   taking any medications, and has no known allergies. Immunizations (including   pneumococcal conjugate vaccine) are up to date. 

 The infant's only ongoing medical problem has been constipation. Usually,   he has a bowel movement every two or three days, Mother reports; sometimes,   a week goes by without his passing a stool, after which he has an "explosive"   bowel movement. She also senses that passing those stools causes him pain. 

 On examination, the child appears fussy, but is consolable. He is grunting   intermittentlyless when his mother holds him in a standing position and   more when he is held in a sitting position. Rectal temperature is 102.2°   F; heart rate, 184/min; respirations, 30/min; blood pressure, 90/40 mm Hg; and   oxygen saturation, 99%. 

 The anterior fontanelle is open, soft, and flat. Mucous membranes are tacky.   Ears appear normal, the neck is supple, and the chest is clear. The cardiovascular   exam is notable for tachycardia without murmur. Peripheral pulses are strong;   capillary refill is two seconds. Bowel sounds are present but decreased. The   abdomen is soft and undistended but somewhat tender. Sphincter tone is normal   and stool is guaiac negative. 

 Hoof beats, horses . . . what was that advice? 

 At this point, you are evaluating an ill-appearing, febrile, vomiting infant   who is intermittently grunting and moderately dehydrated. You recall what you   learned in medical school: An atypical presentation of an extremely common illness   is more common than a typical presentation of a rare illness. The history is   probably consistent with viral gastroenteritis, which certainly is common. But   you are bothered by the absence of diarrhea, the child's ill appearance, and   the grunting, so, in assembling an initial differential diagnosis, you also   consider sepsis, pneumonia, and an intraabdominal process. The only localizing   symptom is abdominal tenderness. The history of constipation coupled with explosive   stooling could suggest Hirschsprung disease. 

 You place an intravenous line and order lab tests and blood cultures. The   child is given a bolus of normal saline and IV fluids are started at one and   a half times maintenance. Lab results arrive but only add to the puzzle: The   white blood cell count is surprisingly low at 2.4 x 10

/µL,   with 30% neutrophils, 1% bands, 63% lymphocytes, and 6% monocytes. The hematocrit   is low at 31%, with the mean corpuscular volume, 74. Platelets are normal at   288 x 10

/µL. Electrolytes are reassuringly normal. Serum bicarbonate   is 24 mmol/L; blood urea nitrogen, 10 mg/dL; and creatinine, 0.2 mg/dL. Urinalysis   performed on a catheterized specimen is trace-positive for blood, without evidence   of WBCs or nitrites. 

 You are still concerned about a potential pneumonia or an abdominal process,   but initial radiographs don't help much. The chest film is normal, without infiltrate.   A series of KUB studies in the supine, prone, and left lateral decubitus positions   shows gas throughout the abdomen and into the rectum, with filling of the ascending   and transverse colon, findings that make intussusception less likely. There   is copious stool in the proximal colon but no dilation that would suggest Hirschsprung   disease (Figure 1). 

 You are concerned enough about the child's degree of illness to perform a   lumbar puncture, which reveals one lymphocyte and two RBCs (per microliter)   in the cerebrospinal fluid; glucose and protein levels are normal. You order   IV ceftriaxone, 50 mg/kg. 

 Still you wonder about an intraabdominal processgiven the focality of   the examso you consult a pediatric surgeon. His initially worry is intussusception   versus gastroenteritis, and so he recommends IV antibiotics, IV hydration, and   a barium enema. 

 During the long period in which the child remains in the ED, however, his   condition improves markedly with IV hydration. He stops grunting, becomes much   less fussy, tolerates multiple abdominal exams, and is smiling and responsive.   You decide to forego the barium enema and admit the child for observation, serial   examinations, and IV hydration with a presumptive diagnosis of viral gastroenteritis. 

 By the time you reexamine the baby when he arrives on the floor, however,   he seems to have deteriorated. Temperature is 101.2° F; heart rate, 178/min;   blood pressure, 83/43 mm Hg; and respirations, 56/min. He appears listless and   does not interact with his mother or the examiner. Mucous membranes are moist   and peripheral perfusion appears fine, but he is persistently tachycardic. The   chest is clear, but he is tachypneic. He has hypoactive bowel sounds and his   abdomen is diffusely tender. He demonstrates some voluntary guarding and is   very irritable on examination. A genital exam is unremarkablehe is circumcised,   with normal testes and no apparent hernias. On rectal exam, he has normal sphincter   tone with stool palpable in the vault. His stool is guaiac negative. He does   not have skin lesions. 

 Because the child's condition has now deteriorated clinically, your concern   that he has an intussusception is renewed and you order a barium enema. The   test shows good filling of the entire colon, which reassures you (Figure 2).   The radiologist detects a mass effect in the right lower quadrant, however,   and a follow-up abdominal sonogram reveals that there is a nondistensible loop   of bowel and free fluid in the abdomen. You notify the surgeon and order a preoperative   dose of IV piperacillin and tazobactam. 

 At laparoscopy, the infant's appendix is adult-sized (Figure 3), and so is   removed. It is covered in fibrin, suggesting microperforation, but is not grossly   perforated. The peritoneal fluid is clear. The child tolerates the procedure   well and is discharged home on the fourth hospital day without complications. 

 Appendicitis is rare before 2 years of age. In a recent study of more than   3,000 consecutive cases of appendicitis in children, fewer than 3% of cases   were seen in children younger than 2 years and fewer than 1% in children younger   than 1 year.

 Neonatal appendicitis is rare but not unheard ofespecially   in premature infants. Because it is rare and symptoms are nonspecific, infantile   appendicitis is often misdiagnosed initially (time to diagnosis is, on average,   four days). Common misdiagnoses include gastroenteritis, urinary tract infection,   pneumonia, and bowel obstruction

 (Table 1). Common presenting symptoms   are listed in Table 2. In this child, your concern about intussusception was   appropriate; the condition has an incidence of 1.5 to 4 for every 1,000 live   births, male predominance, and peak incidence between 5 and 9 months of age.

Differential diagnosis of acute abdomen in an infant

Common findings in infantile appendicitis

 The incidence of perforated appendicitis is much higher in infants than it   is in older children, probably because the diagnosis is delayed in infants.   The reported rate of appendiceal perforation in infants ranges from 70% to 95%,   compared to a rate of 10% to 20% in older children.

 Perforation   is associated with significant postoperative morbidity, independent of age.   Complications include major abscess that requires operative or percutaneous   drainage, phlegmon, enterocutaneous fistula, peritonitis, and partial bowel   obstruction.

 To sum up: Appendicitis in infants is rare and often difficult to diagnose,   but is an important element of the differential diagnosis. Keeping this condition   in mind may minimize delay in diagnosis and reduce the likelihood of perforation   and associated morbidity. What transpired with this patient illustrates how   important it is to broaden and revise the differential diagnosis to include   a zebra when an infant looks particularly ill and something in the presentation   just doesn't fit, or feel right about, a common diagnosis like gastroenteritis.   And that can make all the difference, because Baby just isn't going to tell   you what's in his belly! 

 1. Kokoska ER, Minkes RK, Silen ML, et al: Effect of pediatric   surgical practice on the treatment of children with appendicitis. 

 2. Rothrock SG, Pagane J: Acute appendicitis in children:   Emergency department diagnosis and management. 

 3. Irish MS, Pearl RH, Caty MG, et al: The approach to common   abdominal diagnoses in infants and children. 

 4. Barker AP, Davey RV: Appendicitis in the first three years   of life. 

 5. Grosfeld JL, Weinberger M, Clatworthy HW: Acute appendicitis   in the first two years of life. 

 6. Horwitz JR, Gursoy M, Jaksic T, et al: Importance of diarrhea   as a presenting symptom of appendicitis in very young children. 

 7. Pearl RH, Hale DA, Molloy M, et al: Pediatric appendectomy.   

 DR. HAYDEN is a third-year resident in the Boston Combined Residency Program,   Harvard University School of Medicine, Cambidge, Mass. 

 DR. DORFMAN is an associate professor in the division of pediatric emergency   medicine, Boston Medical Center, Boston, Mass. 

 DR. SIBERRY is a fellow in pediatric infectious disease at The Johns Hopkins   Hospital, Baltimore, Md.

Some of our most satisfying moments in pediatricsand some of our best   clinical pearlsresult from solving perplexing cases. If you have a favorite,   send it to

 If it is used, you will be cited as the contributor. 



George Siberry, ed. Susan Hayden, David Dorfman. Pediatric Puzzler: Vomiting and abdominal discomfort. 

Articles

Grunting, hot, and vomiting:What's the bother in Baby's belly?