As these authors note, infants are evil.
Well, more specifically, they note infants with non-specific complaints as benign as “crying” can be harboring serious pathologic diagnoses. Therefore, the diagnostic work-up for such complaints as “lethargy” or “poor feeding” varies widely by clinician and comfort level.
These authors retrospectively reviewed charts for 352 infants 0 – 6 months with presenting complaint of “lethargy” or “poor feeding”. They exclude the chronically ill/premature, abnormal vital signs, and those with recent trauma, and review the laboratory testing and ultimate diagnoses for each remaining patient. Of the 272 remaining, 34 patients ultimately had a diagnosis requiring intervention or monitoring. These included hematologic disorders, dehydration, intracranial bleeding and SBI. Of these 34, 26 were otherwise well-appearing. However, these authors note each of the well-appearing patients had some obvious focal finding on physical examination – mostly jaundice, leading to treatment for hyperbilirubinemia – leading to directed testing. They conclude, therefore, a well-appearing infant with a reassuring examination does not need any specific testing or monitoring.
This study is limited by its retrospective nature, as well the lack of comprehensive follow-up. That said, their algorithm for focused evaluation of “lethargy” and “poor feeding” is probably reasonable. Fishing expeditions in the otherwise well infant are certain to be costly and low-yield, with continued caregiver observation and follow-up a more prudent plan.
“Diagnostic Findings in Infants Presenting to a Pediatric Emergency Department for Lethargy or Feeding Complaints“
http://www.ncbi.nlm.nih.gov/pubmed/24583575
One thought on “Focused Evaluation for “Lethargy & Poor Feeding””
Comments are closed.
Ryan – thanks for the great post. We like to think our clinical assessment, especially on kids, is good enough to determine who is sick and needs a workup and who is well and can go home without much of anything. This study defends those abilities.
However, follow up here was terribly suboptimal. They basically checked the patient's records for return visits to their hospital within 7 days. They note that they were the only children's hospital in the area and that any child with a severe disorder would end up back with them but this clearly isn't a good way to do follow up. A prospective study on the same question with real follow up should be the next step.
Thanks again for the post
Swami