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Resuscitation and Critical Care

A2.3 Management of a Moribund Infant

Dr Wa-keung Chiu
Chief of Service,
Department of Paediatrics and Adolescent Medicine,
United Christian Hospital

Dr Wa-keung Chiu is currently the Chief of Service of the Department of Paediatrics and Adolescent Medicine of United Christian Hospital. He is also the consultant of PICU/ NICU/ Paediatric Respiratory service of the department. He received his overseas training in paediatric respiratory medicine and paediatric intensive care in Hospital for Sick Children, Great Ormond Street of United Kingdom in 1994-1995. He started working in United Christian Hospital since 1996. He is currently the Vice-President of Hong Kong Society of Paediatric Respirology and the instructor of the Paediatric Advanced Life Support Course of the Hong Kong College of Paediatricians. His publications included Severe Acute Respiraory Syndrome in children, asthma education programme, Kawasaki disease, tuberculosis lymph node, lumbar puncture in children and congenital central hypoventilation syndrome.

Whenever an infant die, it is a tragedy – first and foremost for the infant and family, but also for all those who knew the infant and family, including those professionals who may have worked with them, and for society as a whole. Every infant who dies deserves to be treated with respect and care. This includes the right, in an unexpected death, to have the death fully and sensitively investigated in order to identify, where possible, a cause of death and to learn lessons for the prevention of future infant deaths. Thorough and sensitive investigations go hand in hand with a supportive approach to the family in their grief, and can help to ensure that all statutory requirements are met, and that family members, the community and all professionals are supported through the process.

SUDI/SUDC (sudden unexpected death in infancy)
This encompasses all cases in which there is death (or collapse leading to death) of an infant, which would not have been reasonably expected to occur 24 hours previously and in whom no pre-existing medical cause of death is apparent. This is a descriptive term used at the point of presentation, and will include those deaths for which a cause is ultimately found (‘explained SUDI’) and those that remain unexplained following investigation.

SIDS (sudden infant death syndrome)
This refers to the sudden and unexpected death of an infant under 12 months of age, with onset of the lethal episode apparently occurring during normal sleep, which remains unexplained after a thorough investigation including performance of a complete post- mortem examination and review of the circumstances of death and the clinical history.

Management of a moribund infant
For the initial management of a moribund infant, resuscitation and stabilization is essential. The infant who was successfully resuscitated infant should be admit to PICU. For the unsuccessful one, it is important to perform metabolic screen for inborn error of metabolism with or without peri-mortem biopsy. For the subsequent management, a detailed clinical history and thorough clinical examination should be done. It is important to maintain an unbiased, non-accusatory approach to parents during history taking. Thorough physical examination to look for any marks, abrasions, skin rashes, evidence of dehydration or identifiable injuries, hepatomegaly, discoloration of the skin, particularly dependent livido, skin livido and pallor from local pressure. To look for any bloodstained fluid around the nose and or mouth. Fundoscopy should be done to look for retinal haemorrhage. Clinical photos should be taken once patient is stabilized. Possible differential diagnoses would include suffocation, asphyxia, entrapment, infection, ingestions, metabolic diseases, arrhythmia-associated cardiac channelopathies, trauma, SIDS and SUDI (after exclusion of above). Imaging studies including CT brain, MRI brain and skeletal survey should be done to look for any underlying injuries. ECG has to be done to look for any underlying rhythm problems. EEG should be considered for evidence of seizure or encephalopathy. For other workup, it would include dried blood spot test, or metabolic workups, urine, stool, nasopharyngeal aspirates, gastric aspirates, blood gases, urea, electrolytes, CBC, glucose, blood culture, lumbar puncture as well as urine and blood for toxicology. Social worker should be referred for psychosocial support for the family as well as concern of the circumstances leading to the moribund state (eg suspected child abuse or neglect). Report to the police as well if the latter condition. Refer to the coroner if the patient finally succumbed. A multi-disciplinary case conference should be held to discuss for subsequent management and establish the case’s nature.

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