September in the NICU: A Down syndrome newborn is feeding poorly

DR. GUIANG is an assistant professor of pediatrics in the neonatology division at the University of Minnesota Medical School and medical director of the newborn intensive care unit at Fairview University Medical Center, Minneapolis.

DR. SIBERRY is an assistant professor of pediatrics in the divisions of general pediatric and adolescent medicine and pediatric infectious diseases at Johns Hopkins Hospital, Baltimore.

The authors and section editor have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.

Her mother was scheduled for induction when labor began spontaneously. Your patient was delivered vaginally; Apgar score was 8 at one minute and 9 at five minutes; birth weight was a healthy 3,995 g. She required bulb suctioning and three minutes of blow-by oxygen at birth, and was admitted to the NICU because of low O₂ saturation-in the 70s and 80s.

You learn that the baby had a stable first night on the unit, however, with O₂ saturation improving to 90% to 95%.

You grab a morning cup of coffee and head down the hall to see your new patient. Here is a well-nourished, acyanotic newborn who appears her recorded gestational age. Facial features are consistent with Down syndrome, including a depressed nasal bridge, prominent epicanthal folds, low-set ears, right transverse palmar crease, widely spaced first toes, a nuchal fold, and decreased overall tone.

Vital signs are normal: heart rate, 150/min; respiratory rate, 30/min; and O₂ saturation, 94% on room air. You detect occasional coarse breath sounds by stethoscope, but no murmur. She has 2+ pulses bilaterally. Abdominal examination is unremarkable.

After reviewing the plan for the day for this patient with the attending staff during rounds, you order an echocardiogram, complete blood count, tests of serum electrolytes, chromosomal analysis, chest radiograph, and routine newborn metabolic screening tests. You institute total parenteral nutrition and then head down to the cafeteria for a quick bite to eat for yourself.

Difficulties pile on

Climbing the stairs back up the unit, you remind yourself of the problems that your patient might develop. Down syndrome puts her at elevated risk of a host of associated disorders and difficulties, including gastrointestinal tract anomalies such as esophageal atresia and Hirschsprung disease; diabetes; hypothyroidism; congenital heart disease; an immune deficiency; acute leukemia; feeding difficulties; and visual and hearing deficits. Seems this baby is going to test your mettle, but you feel up to a challenge.

Later that afternoon, a telephone call from the cardiologist brings you the findings of the echocardiogram: a complete atrioventricular (AV) canal defect with mild mitral valve insufficiency, mild aortic insufficiency, an additional small secundum atrial septal defect, and a large patent ductus arteriosus.

You check on the patient again, and find her stable on room air, with an O₂ saturation of 94%. This time, you hear a soft grade I/IV systolic murmur. The liver edge is palpable 1 cm below the right costal margin. The chest radiograph shows mild cardiomegaly.

Chances are good, you know, that this baby will develop congestive heart failure as pulmonary vascular resistance continues to drop. You can only be hopeful that surgery can be postponed until she is at least a few months old.

You sit down to review the rest of the day's test results. The basic metabolic panel is normal throughout: sodium, 137 mEq/L; potassium, 4.7 mEq/L; chloride, 102 mEq/L; bicarbonate, 29 mEq/L; blood urea nitrogen, 12 mg/dL; creatinine, 1 mg/dL; glucose, 70 mg/dL; and calcium, 9.4 mg/dL.

The CBC gives you pause, however: At 62.9%, hematocrit is elevated. You order additional IV fluids in the hope that this will improve the polycythemia. Confident that your patient is stable for now, you sign out your patients and head home.

Asleep at the meal

The next morning, you meet with your patient's parents and encourage the mother's plan to start breastfeeding. Initial attempts meet with little success; the baby appears to have a weak suck and falls asleep often soon after she starts to nurse.