Age: 0.08
Sex: F
Vaccine: DTAPHEPBIP, HIBV, PNC13, RV1
Symptoms: Mean platelet volume normal, Metabolic function test, Monocyte count increased, Monocyte percentage increased, Musculoskeletal stiffness
Clinical narrative: Presented because of brief (seconds long) episode of difficulty breathing (sounded congested and maybe SOB), self-resolved, no peri-oral cyanosis, was breathing the entire time. Brought to ED via EMS.  No decreased PO, no fevers, no emesis, no increased spit-ups.  Upon arrival to the ED, patient was noted to be hypothermic (on repeat) on 35.3 C.  Sepsis work up was initiated including blood culture, urine culture, urinalysis, BMP, CBC and LP was unsuccessful x3.  CBC was reassuring.  COVID screen sent and negative  Temps up to 36.3 prior to transfer to NICU with bundling and hat.  Admission Date: 11/19/2020 Discharge Date:  12/4/2020  Patient was admitted for rule out sepsis workup given episode of hypothermia following a transient brief respiratory distress episode at home which was concerning for BRUE   FEN: Continued on home regimen of 24 kcal FBM/Enfamil PO ad lib. Given persistent reflux , trial of Similac total comfort 24 kcal  Formula on 11/27 with no improvement. Trial on chilled  22 kcal FBM/ Enfacare on 11/30 and continued until discharge.    Resp: Remained stable on room air.   CV: Remained hemodynamically stable.   ID: Admitted for rule out sepsis workup given hypothermia in ED. She received at 48 hour course of  Vancomycin and ceftriaxone (11/19-11/21).. Blood , CSF and urine cultures negative .US guided LP obtained on unit and CSF analysis not consistent with infectious etiology.    Neuro: Baby had an event on day of admission - 45 second episode of desaturation and bradycardia with color change along with posturing/stiffening of body and eye deviation requiring stimulation and CPAP. Due to concern for seizure, obtained neurology consult and started on VEEG which showed background consistent with prematurity but  no seizures and  HUS which was unremarkable. Neurology signed off.   GI: An apnea study with pH monitoring  performed given concern for reflux with Sandifer syndrome , results as follows:"very mild desaturation events are associated with brief central apnea. I doubt that these are clinically relevant. Reflux index is higher than expected for age. There are no associated vital sign changes, except for occasional mild desaturations as described above. The combination of the description of the BRUE and the increased reflux index makes it plausible that the infant had a reflux associated event and appropriately protected her airway. Please keep in mind that none of the events that are charted by nursing were captured on this study "   Given likelihood of reflux being etiology of events  , patient started on omeprazole on 11/23 and continued until discharge . Continued to have apnea/bradycardia/desaturation events on omeprazole sporadically , with one significant event requiring PPV. Plan to discharge after remaining event free for 7 days and with home apnea monitor . Last event was on 11/27 and patient discharged on 12/4, event free with home monitor. Parents received bedside teaching and spent 12 hours at bedside for practice with usage of monitor. Home nursing visits to asses for comfort level/concerns with monitor use to be scheduled for parents ( representative will reach out after discharge)