Chapter 6: Pediatrics: The Case of Baby’s Busted Belly Level III

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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

• Use age-appropriate assessment parameters to recognize septic shock in a pediatric patient.

• Design an evidence-based pharmacotherapy plan for the child in septic shock, including medications, dosing, and monitoring.

• Determine the pediatric patient’s fluid and electrolyte requirements and make therapeutically sound recommendations for repletion.

• Use appropriate metrics to monitor the progress of the sick child and adjust therapy as indicated.

• Employ specific techniques to ensure that medications are deployed safely for pediatric patients.

• Recommend age-appropriate vaccinations for children.

PATIENT PRESENTATION

Chief Complaint

Mother reports vomiting, poor feeding, and fever in her 15-month-old adopted son.

HPI

David Williams is a 15-month-old boy who weighs 5.6 kg. He presents today with his foster mother, who reports poor oral intake, vomiting, and fever for 1 day. The patient underwent reversal of a colostomy and placement of a gastrostomy tube 5 days ago and was discharged home with foster mother 2 days ago. Yesterday he had four episodes of vomiting and was unable to retain any of the G-tube feedings. The foster mother took him to the PCP where he was found to be lethargic, ill appearing, and febrile, which prompted his admission directly to the pediatric intensive care unit.

PMH

Vaginal delivery at 35 weeks’ gestation

No prenatal care

Intrauterine growth restriction

Birth hypoxia

Imperforate anus requiring colostomy on second day of life

Single kidney

Bilateral undescended testes

Neonatal abstinence syndrome requiring a 12-day morphine taper

Colostomy reversal and gastrostomy tube placement 5 days PTA

Failure to thrive

Immunizations: hepatitis B immune globulin and hepatitis B vaccine administered at birth; DTaP, IPV, HepB, Hib, PCV13 administered 2 months PTA

FH

Unavailable

SH

The patient was referred to Child Protective Services at birth because of lack of prenatal care and prenatal drug exposure. He was lost to follow-up by them until 2 months ago when he presented to the PCP for the first time since birth with severe failure to thrive (weight and weight-for-height below 1% of expected). He was transferred to the custody of the current foster family at that time who, by report of the PCP, are appropriately attentive and have addressed the patient’s healthcare needs appropriately. Foster mother at bedside and appropriately concerned.

Current Meds

Omeprazole suspension 10 mg GT daily