Question
7d old child presents with difficulty feeding,vomiting one time, and now with intermittent apneic episodes. What's the diagnosis? (Careful....this one is tricky!)
Answer
Answer: Workup should include an ALTE and sepsis evaluation PLUS evaluation for non-accidental trauma
Non-accidental trauma (NAT)
NAT is most prevalent in children 0-3 months of age.
Classic metaphyseal lesions, rib fractures, and fractures in various stages of healing are most commonly described in children.
How do we know this is not just birth trauma from a shoulder dystocia, large for gestational age, or difficult vaginal delivery?
- Key is dating the fracture (see referenced article for more info)
- Callus not present prior to 8 days of life and callus thickness decreases inversely with fracture age.
- Subperiosteal new bone formation is highly unlikely in fractures less than 7 days old
Subperiosteal new bone formation appears as a:
- hazy cortical margin or a thin layer of bone separated from the original cortex by a discrete lucent interval
- linear hyperdensity parallel to the cortex of the bone
- see referenced article for images
NAT Work-up:
- CT head without contrast if 2 yo
- Skeletal survey if 2 yo
- AST, ALT, amylase, lipase, CBC with manual diff, BMP, urinalysis, urine toxicology
- Consults (Ophthalmology, Social Work, Child Protection, etc.)
References
Follow me on Twitter (@criticalcarenow) or Google+ (+criticalcarenow)