Difficult dilemma with newborn baby. Your opinion please!

[livi]

This is not one of my 'bad day at work' threads. However, I have the night shift tonight and I was just called urgently to a delivery room. I was presented with a story about this baby just delivered a few minutes ago. He had breathing difficulties and the heart would stop beating periodically.

I approach the baby on the table and start assisting ventilation (and a lot of other medical stuff) and I immediately notice several typical sign with a mongoloid baby. Neither the staff nor the parents had mentioned this.

I finished the resuscitation successfully and the baby was now breathing spontaneously and had a good heart rate - but looking pretty mongoloid.

Now this is a syndrome that immediately after birth can be very difficult to diagnose with certainty. Many children may look rather odd the first day and you do not want to alarm the parents. The next day it may be obvious that the baby is perfectly healthy!

Being in the middle of the night and seeing as nobody else mentioned it, I chose to NOT say anything, but wait until tomorrow morning to have another look.

Comments?

[azasadny]

Markus,
I saw something very similar when I was a surgical tech and assisted with several c-sections. I'm glad everything is OK!

[Hugh R]

Unless there is something beneficial you can do between now and the morning, why alarm parents the first night of their child's life.

[on2wheels52]

My wife (an RT) wonders if you mean the baby is on a ventilator (I'm thinking not). She hates to see babies on a vent, wants them shipped (what a terrible word) to a children's hospital.
Jim

[alf]

Down Syndrome?

[Nathans_Dad]

Personally I'd wait. I would run the karyotype and confirm it before I mentioned Down Syndrome. If they ask about whether their kid is "normal" then I would say that there are a few features that I noted that are consistent with Down Syndrome but I would wait until the tests come back.

Same thing happens in adult medicine. Patient comes in and has a mass on CT, family asks if it is cancer. I usually say that the scan looks concerning but we need a biopsy to make the diagnosis.

[alf]

I am not a doc so could only offer what I would do in a business situation. If witholding uncertian/unconfirmed information that is bad does not make the problem worse till you confirm it then withold it. No point getting everyone stressed for what might be a non-issue. I would however ask a peer or manager to help work through the confirmation process to make sure you cover your basis.

[Moses]

Cardiac malformations are much more common in Downs babies. In California that baby would get an echocardiogram and full evaluation. I've never seen a baby that looked "mildly" Down's syndrome that didn't have it.

The earlier you tell the patients of the possibility, the sooner they can reach out to their families for support and arrange counseling and specialty care that they need. It is far easier for the patients to begin the difficult adjustment while the mother is still in the hospital. She will have lots of questions and it's better to make those first inquiries with her medical team close by. If she is discharged from the hospital without any idea that there may be a problem it will be more difficult for the family.

[livi]

Thanks everyone for your input!

Yes, I am talking about Downs syndrom. It is actually not that rare that a baby is born with features that elicit suspicion with the staff (experienced pediatric docs and nurses). As Moses say, often the suspicion is correct, but far from always. Likewise, the other way around. A couple of years ago we made the diagnos on a 10 months old child! The syndrom is not homogenous in terms of typical signs or degree of features. There are "mild" genetic forms as well as full blown variants and everything in between.

During the first hours after delivery, particularly with a distressed child, a definite diagnose is not always easy. The signs can be subtle and the baby can be severely deformed and swollen in the face and head.

If the suspicion remains this morning a full investigation will be instituted of course.

Thanks again!

[Cdnone1]

As parents of a special needs child that spent a long time in the hospital, I say let the parents sleep one night. There will be too many nights ahead of them that they will not sleep, and lots of times that they will be awoken in the middle of night with things no one should have to deal with, so let them have this one night to sleep.
They may have a very long path in front of them, they have probably already had a long day. Let them have one night of sleep.
Steve

[dtw]

Can't offer any advice but just wanted to say thanks, Markus, for what you do. Enormous heart. Really, really, enormous.

[JavaBrewer]

Originally Posted by Cdnone1

As parents of a special needs child that spent a long time in the hospital, I say let the parents sleep one night. There will be too many nights ahead of them that they will not sleep, and lots of times that they will be awoken in the middle of night with things no one should have to deal with, so let them have this one night to sleep.
They may have a very long path in front of them, they have probably already had a long day. Let them have one night of sleep.
Steve

+1. We have friends facing this challenge daily and cannot begin to imagine their worry/stress.

[aap1966]

Review the FLK in the cold light of day when you are not fatigued and can make a more reasoned assessment.
Unless it's unequivocal.

5hitty part of the job, eh?

[KFC911]

Originally Posted by dtw

Can't offer any advice but just wanted to say thanks, Markus, for what you do. Enormous heart. Really, really, enormous.

+1!!! There are many on this board who fit that description imo...

[Tobra]

Originally Posted by Hugh R

Unless there is something beneficial you can do between now and the morning, why alarm parents the first night of their child's life.

do no harm,

look again in the morning when you have slept

sooner is better than later with bad news

[livi]

Thanks!

I just woke up (first things first - PPOT ), after sleeping most of the day. I was completely bushed this morning after 16 hours non stop work last night. Had to leave the evaluation of the child to a colleague. I will make sure to update you later, whether my 'suspicion' was correct or not.

Thanks again for all your thoughtful posts!

Time for some grub, a few beer and getting ready for the soccer final tonight. Spain vs Germany.

[Flatbutt1]

FWIW Markus I believe leaving such a determination till the light of day is the right choice. Heavens bless you for having the heart to consider such options. Those children are blessed to have a physician such as you.

[livi]

Thanks!

You would think that with modern medicine, all the evidence and experience collected, would make every decision an easy clear cut one. Not so. Almost every single decision is a judgment call. Mentally calculating the pros and cons, risk vs gain etc. Every single situation is unique.

[Kroggers]

Having just had our little boy, this is not fun to read I wish the parents the best of luck and support. Thank you Markus for the great job you do...