Steroids-Consultant

You contact the consultant with some reluctance because of the lateness of your call. You explain the situation to her and describe the radiograph. She asks about the size of the liver below the costal margin. She suggests also that an echocardiogram is booked for the next day “to decide about the ibuprofen”.

At the end of the discussion she suggests you start some frusemide and spironolactone, then give some antibiotics if there is any other instability.

Dom Barton is given 1mg/kg of Frusemide and spironolactone immediately and it is prescribed regularly three times a day. 

Within a few hours his nurses note that he has a very wet nappy, and a little later that his breathing is easier, with better oxygen saturation levels than before the diuretic.

You reexamine him:

Respiratory: RR 35/min, minimal recession, equal chest movement. Clear chest. SaO₂ 98% in 35% oxygen.

Cardiovascular: HR 140/min, good capillary refill time. Bounding pulses and easy to feel femoral arteries. BP 85/30, Heart sounds normal, with an unchanged systolic murmur still heard under the left clavicle.

Because of the change in fluid turnover, you take some blood to check the electrolytes at the end of your shift.

The following day, at the consultant ward round the results are reviewed:

Urea    3.8 mmol/L

Na       141 mmol/L

K         3.7 mmol/L

Creat   31  micromol/L

The echocardiogram has been done and it shows an enlarged heart with a big patent ductus arteriosus. The consultant asks for Dominic to be started on a course of ibuprofen to close the ductus.

You next meet baby Dominic Barton when he is three weeks old; he has done well and is preparing to go home and you have been asked to do his discharge check. His nurse notes that she thinks he has become a little jaundiced. 

Since you last saw him, he has had a follow up echo showed that the ductus had closed.

He is now feeding well independently and his mother has established him on breast milk. He is now off all medication apart from vitamins. His parents are keen to get him home as soon as possible. 

They have looked up some of his treatments on the internet and are concerned that the steroids that he had in the immediate newborn period may have affected his growth and brain development.

Mild jaundice, visible in sclera and on skin. Nappy – yellow urine and slightly pale stool. Weight 1.80 kg. 

Respiratory: RR 30/min, no recession, equal chest movement. Clear chest. SaO₂ 98% in air.

Cardiovascular: HR 135/min, good capillary refill time. Normal

femoral arteries. BP 85/40, Heart sounds normal, no murmurs heard.

Abdominal: Full, but soft on palpation, liver edge palpable at 2cm below costal margin, no other organs felt.

Neurological: Active and alert, moving all limbs. Able to fix eyes on objects. Anterior fontanelle soft.

His right leg appears swollen compared to the left, although the perfusion and pulses are normal.

You arrange an ultrasound of the leg veins to look for a deep venous thrombosis.

What is the most appropriate action at this stage?

A         Check bilirubin and discharge if not requiring phototherapy, see in clinic next week.

B         Check bilirubin (split into conjugated and unconjugated), liver function tests, direct combes test, thyroid function test and urine culture; keep as inpatient until these results are available.

C         Check bilirubin, then transfer to liver specialist centre