A 38-year-old female presents to the ED with right shoulder pain after a fall directly onto that shoulder. She noticed immediate pain and difficulty moving the arm associated with mild tingling in her right fingers. The radiographs above were obtained in the ED (Image 1. AP and lateral radiographs of the right shoulder, author’s own images).
A 27-day-old female infant born at 34 weeks 4 days with a prenatal history of maternal syphilis treated with penicillin presented with an enlarging scalp mass since birth. Since birth, the patient has had a 1 cm erythematous and flat lesion on her scalp. Since that time, the lesion has continued to grow and develop scales. On the day of presentation, the lesion was noted to be 7-8cm in diameter with multiple surrounding smaller lesions. There is some clear to bloody drainage coming from the main lesion. The patient has otherwise been growing and developing normally. No fevers or other sick symptoms. Feeding well. Mom has no concerns with bowel movements or voiding habits.
General: She is active. She is not in acute distress. She is well-developed.
HEENT: No congestion or rhinorrhea. Mucous membranes are moist. No posterior oropharyngeal erythema.
Cardiovascular: Normal rate and regular rhythm. Normal pulses. No murmur heard.
Pulmonary: Respiratory effort is normal. No retractions. Normal breath sounds. No wheezing.
Skin: Skin is warm. Capillary refill takes less than 2 seconds. On the left side of the scalp, there is a large raised keratinized plaque with a stuck-on appearance. Some red blood is noted when tapped with a white sheet. The plaque is firm and non-tender. On the rest of the scalp, there are several peeling flat lesions with hair attached, and intermittent alopecia.
Neurological: No focal deficit present. She is alert. Suck is normal.
Scalp ultrasound: Posteriorly exophytic left parietal lesion is peripherally echogenic, possibly representing a calcified lesion or cephalohematoma. CT or MRI may be useful for further evaluation, as clinically indicated.
a. Seborrheic Dermatitis: A common, self-limiting eruption consisting of erythematous plaques with greasy, yellow-colored scales that distribute to the areas of the body with sebaceous glands.
b. Atopic Dermatitis: Erythematous, scaly, crusted lesions that are poorly demarcated. It is pruritic and commonly involves the cheeks, scalp, and extensor surfaces.
c. Psoriasis: Uncommon in infants, but can mimic seborrheic dermatitis with sharply demarcated, shiny, erythematous plaques with fine silvery scales in non-intertriginous regions.
d. Tinea Capitis: While rare, tinea can present with a scaly scalp rash in infants. There may be a mild to moderate inflammatory reaction associated as well as hair loss.
e. Langerhans Cell Histiocytosis (LCH): LCH can present as refractory seborrheic dermatitis. There may also be papules or reddish-brown nodules that appear with the rash.
Pityriasis Amiantacea secondary to Seborrheic Dermatitis with a significant build-up of crust and scale. Pityriasis amiantacea is an exaggerated inflammatory response to regional dermatitis, most often seborrheic dermatitis. Treatment consists of a keratinolytic and antibacterial ointment. In this patient, 1:4 part vinegar and water soaks were recommended twice daily, followed by mupirocin ointment until the resolution of the lesions.
A 20-year-old male distance runner who was jogging and happened to be running past the emergency department presented with severe bilateral leg pain, foot pain, and foot numbness that had resolved by the time he was evaluated in the ED. The x-ray above was obtained (Image 1. X-ray of the leg. Case courtesy of Andrew Murphy, Radiopaedia.org, rID: 41408).
The landscape of emergency medicine and critical care (EM/CC) blogs and podcasts has changed dramatically over the past 20 years. The number of free, open-access EM/CC blogs and podcasts has plummeted. As reported by Lin and colleagues in JMIR Education (2022), these sites decreased in number from 183 in 2014 to just 109 this year– a drop of 40.1% [1].
This comes after a period of rapid growth of these educational resources in the late 2000’s [2], with expectations that new sites would continue to come online. It is unclear when the combined number of EM/CC blogs and podcasts peaked, or how recently it declined.
The FOAM (free open-access medical education) movement has become an important component of EM curricula at many training programs. Online learning resources such as medical blogs and podcasts have all but replaced traditional textbooks, and research suggests that some trainees use these products as their primary study materials [3]. Therefore, the observed decrease in FOAM sites is alarming, as training programs and trainees have come to rely on their availability.
In our JMIR Medical Education paper, Lin et al. sought to identify active EM/CC blogs and podcasts during a 2-week period in May 2022. The authors found a total of 50 blogs, 25 podcasts, and 34 blogs + podcasts (n=109). The age of these FOAM sites ranged from 1-18 years and most were physician-led. Just over half had leadership teams of 5 or more individuals. Support was identified for approximately 75% of the sites and included advertisements, institutional sponsorship, or the sale of goods and services (though site access remained free).
The Christensen Theory of Disruptive Innovation may explain the recent decline in EM/CC blogs and podcasts. Using this lens, FOAM sites are considered ‘disruptors’ in medical education that quickly gained market share previously dominated by ‘incumbents’ such as medical textbooks, journals, and in-person conferences. Rather than cede their influence, incumbent organizations co-opted the disruptive innovation itself, in this case leveraging their assets to create their own online learning resources, blogs, and podcasts. As these incumbent offerings grew, there was less need for new, independent FOAM sites. Concurrently, FOAM sites continue to generate little-to-no revenue and academic value for the creators, making it difficult for the disruptors to challenge the market dominance of incumbents or to create its own unique, sustainable market space. We theorize that older sites likely succumbed to these financial and academic opportunity costs as well as high user expectations for design and functionality.
Though EM/CC blogs and podcasts changed the landscape of medical education in fundamental ways, they will likely not endure as independent entities without new business models for sustainability. A recent study suggests that the costs of FOAM might be offset by advertising or other revenues [4]. Based on our observations of current practices on existing FOAM sites, this might include at least incorporating any/all of the following:
In the meantime, we posit one of 3 potential futures of new and existing blogs and podcasts: hybridization, disappearance, and new-market independence.
It remains to be seen whether FOAM can withstand market and academic pressures or whether it is destined to be assimilated by better-resourced incumbent organizations.
We hope to stick around and hope the rest of the FOAM community will evolve with us.
Join the interesting discussion on Twitter. We are thrilled to bring this conversation to the forefront.
https://twitter.com/M_Lin/status/1582021848958500864?s=20&t=nBcJtrRvgML2QMRNnZkwwA
Read this tutorial on the use of point of care ultrasonography (POCUS) for Pediatric Focused Assessment with Sonography for Trauma. Then test your skills on the ALiEMU course page to receive your PEM POCUS badge worth 2 hours of ALiEMU course credit.
You receive an emergency medical services (EMS) notification that they are 2 minutes out from your ED with a 3-year-old boy who fell down a flight of 10 concrete stairs. He is awake and breathing spontaneously but irritable and crying with an obvious deformity to his right arm. EMS placed him in a cervical-collar and are bringing him to your ED.
| Vital Sign | Finding |
|---|---|
| Temperature | 37.5oC |
| Heart Rate | 158 bpm |
| Blood Pressure | 86/48 |
| Respiratory Rate | 32 |
| Oxygen Saturation | 98% room air |
| Trauma Algorithm | Assessment |
|---|---|
| Airway | Patent: Audibly crying; cervical collar in place |
| Breathing | Bilateral breath sounds heard |
| Circulation | Symmetric radial pulses palpable bilaterally; capillary refill 2-3 seconds |
| Disability | His eyes are open, but he is irritable and withdraws to touch (GCS= 13) |
| Exposure | Diffuse superficial abrasions to face and extremities; tenderness and swelling to right forearm; abdomen soft without distension although difficult to appreciate tenderness as patient is crying |
Trauma remains the leading cause of childhood death and disability in children >1 year of age [1]. While head and thoracic trauma account for most death and disability in children, missed abdominal injuries are a common cause of mortality [2]. Particularly in polytrauma scenarios, it can be difficult for children to locate the exact area of pain and assessing for abdominal injury can be difficult.
FAST is a rapid ultrasound examination of 4 locations (Figure 1) with the primary objective of detecting free fluid within the abdomen, pleural space, and pericardial sac. In injured adults, FAST is useful in rapidly triaging hemodynamically unstable patients to expedite operative management [3]. Free fluid in any one view deems the FAST positive. However, for a FAST to be determined as negative, each of the landmarks in each individual view must be interrogated and evaluated for the presence of free fluid. The role of FAST in the hemodynamically stable child after blunt abdominal trauma is nuanced.
Figure 1. Location of the 4 FAST views: Right upper quadrant (A), left upper quadrant (B), pelvic (C), subxiphoid (D). Illustration by Dr. Maytal Firnberg.
The FAST can be performed in parallel with the rest of the trauma evaluation. Serial FAST exams can be repeated as needed throughout the child’s ED stay, particularly if the child has an unexplained change in clinical status. For a complete FAST, each of the views needs to be assessed and every landmark in each view must be visualized. In addition to intra-abdominal hemorrhage and pericardial effusion, point-of-care ultrasound can be used to evaluate the thorax for hemothorax and pneumothorax. When included together, this exam is referred to as the extended FAST (E-FAST).
In general, the child should be positioned supine as free fluid will pool in dependent areas (Figure 2). In children, the recto-vesicular or recto-uterine pouch is the most common place for fluid to collect depending on the patient’s sex [4]. Fluid in the abdomen can move freely up the right pericolic gutter into the right upper quadrant. The left pericolic gutter is higher and the phrenicocolic ligament blocks the flow; consequently, fluid tends to flow to the right pericolic area over the left, regardless of injury type.
Some controversy exists about how much free fluid can be detected by the FAST, and most studies focused on adults. For pediatric patients, we are using 100 mL as it was the median quantity of fluid needed for ultrasound detection of the pelvic view [5].
Figure 2. Free fluid accumulates in dependent areas. In a supine patient, this is the hepato-renal pouch (right upper quadrant view), the spleno-renal pouch (left upper quadrant view), and recto-vesicular or recto-uterine pouch (pelvic view). Illustration by Dr. Maytal Firnberg.
Use a low frequency ultrasound probe: phased array probe (Figure 3) or curvilinear probe (Figure 4).
In order to obtain each landmark in the views discussed below, the ultrasound probe will often need to be manipulated in a number of orientations.
Figure 3 (left): Phased array ultrasound probe; Figure 4 (right): Curvilinear ultrasound probe
For the 4 scanning areas, each view must be interrogated completely, and the clinician should identify all key landmarks. The red dot on the probe correlates with the probe marker.
| Right Upper Quadrant (RUQ) View | |
|---|---|
| Probe Placement |  Figure 5. Place the probe in the right mid axillary line (around ribs 8-10) with the probe marker towards the head. Fan anterior and posterior and slide up or down a rib space to view the key landmarks. |
| Normal View and Landmarks |  Figure 6. Normal RUQ ultrasound view with labeled landmarks
|
| Normal Ultrasound Video | Video 1. Normal RUQ ultrasound view |
| Left Upper Quadrant (LUQ) View | |
|---|---|
| Probe Placement |  Figure 7. Place the probe in the left mid or posterior axillary line (around ribs 7-9) with the probe maker towards the head. Fan anterior and posterior and slide up or down a rib space to view the landmarks. In infants and smaller children, the midaxillary line generally provides the best view. |
| Normal View and Landmarks |  Figure 8. Normal LUQ ultrasound view with labeled landmarks
|
| Normal Ultrasound Video | Video 2. Normal LUQ ultrasound view |
| Pelvic View | |
|---|---|
| Probe Placement |  Figure 9. Place the probe in the midline below the umbilicus and fan or rock the probe down towards the feet until the bladder comes into view. Fan through the entire bladder in both transverse and sagittal orientations. For the transverse and sagittal views, the probe marker should be towards the patient’s right and head, respectively. |
| Normal View and Landmarks |  Figure 10. Normal sagittal (left) and transverse (right) views of the pelvic ultrasound with labeled bladder
|
| Normal Ultrasound Video | Video 3. Normal pelvic ultrasound view (sagittal)Video 4. Normal pelvic ultrasound view (transverse) |
| Pericardial View | |
|---|---|
| Probe Placement |  Figure 11. Place the probe under the sternum for a subxiphoid view. Point the probe towards the left shoulder and the probe marker towards the right shoulder. This view requires gentle downward pressure as you drop the angle of the probe down towards the patient. If unable to obtain this subxiphoid view, look parasternally. |
| Normal View and Landmarks |  Figure 12. Normal pericardial subxiphoid ultrasound view with labeled landmarks
|
| Normal Ultrasound Video | Video 5. Normal pericardial ultrasound view (no pericardial effusion and normal contractility) |
Free fluid will appear anechoic (black) and will pool in dependent, unobstructed areas. On the right side, fluid in the abdomen can move freely up the pericolic gutter into the right upper quadrant. On the left, the pericolic gutter is higher and the phrenicocolic ligament may impede its flow. The RUQ view is the most sensitive view in adults while the pelvic view is the most sensitive view in children [4]. The following are examples of free fluid identified within the various views of the FAST scan.
Figure 13. RUQ ultrasound view demonstrating free fluid in Morrison’s pouch in an unlabelled (A) and labelled (B) image
Figures 14 (left) and 15 (right). Abnormal RUQ ultrasound views with free fluid. Note that the right image demonstrates free fluid both above and below the diaphragm, meaning fluid that is in the peritoneal and pleural cavities, respectively.
Tip: In the LUQ view, the free fluid tends to collect just under the diaphragm. Be sure to look at the diaphragm-spleen interface.
Figure 16. Abnormal LUQ view with free fluid below the diaphragm and above the spleen
Tip: Free fluid can collect between the bladder and colon in male patients. In female patients, fluid can collect between the bladder and uterus or between the uterus and colon.
Figure 17. Abnormal pelvic view showing free fluid between the bladder and colon
Figure 18. Abnormal pericardial view showing pericardial free fluid
| Artifact | Ultrasound Image |
|---|---|
| Mirror Artifact These artifacts are cast above the diaphragm in the RUQ and LUQ views. |  Figure 19. The RUQ view shows liver parenchyma architecture cephalad of the diaphragm as a mirror artifact. |
| Spine Sign The spine is not typically seen cephalad to the diaphragm by ultrasound due to air artifact. If the spine is visualized above the diaphragm, this indicates the lungs are no longer filled with air, which normally causes the refraction/reflection of ultrasound waves. This occurs in instances where air is replaced by fluid, such as a pleural effusion or hemothorax, or by a dense consolidation or contusion. |  Figure 20. A – The spine is not visualized cephalad to the diaphragm in a normal RUQ ultrasound view. B – A pleural effusion results in a “spine sign” where the spine can be seen extended beyond the diaphragm. |
| Posterior Acoustic Enhancement Since the bladder is a fluid filled structure which transmits ultrasound waves well, the waves illuminate the posterior wall of the bladder in a phenomenon called posterior acoustic enhancement. This brightness can hide free fluid settled in the pelvis. Thus, decrease the far field gain (brightness) behind the bladder to avoid missing obscured free fluid. |  Figure 21. Bladder view with posterior acoustic enhancement artifact |
| Old Blood As blood pools, the ultrasound appearance of clotted blood may have similar echotexture to surrounding soft tissue or organs rather than appear anechoic (black) as typical free fluid. |  Figure 22. Bladder view showing hypoechoic clotted blood that may be confused as soft tissue |
| Edge Artifact Due to ultrasound physics and sound wave transmission between structures of different densities, edge artifacts are seen as a dark thin line tracing off the edge of this interface extending to the bottom of the screen. It can be misinterpreted as free fluid. |  Figure 23. RUQ view with an edge artifact |
| Stomach Sabotage A full stomach will appear as a rounded collection of fluid and air anterior to the spleen. It may mimic a free fluid collection. Fan posterior of the stomach to visualize the spleen and perisplenic spaces. |  Figure 24. The stomach obscures the LUQ view. Note the mix of bright (air) and dark (other gastric contents) inside the stomach. |
| Seminal Vesicles Seminal vesicles can appear as hypoechoic, contained, symmetric structures posterior to the bladder in the transverse view and can be mistaken for free fluid. |  Figure 25. Bladder view showing hypoechoic seminal vesicles posterior to the bladder |
For adults, the FAST is integral in the diagnostic evaluation after blunt and penetrating trauma [9]. It improves outcomesby decreasing the time to surgical intervention, patient length of stay, surgical complications, CT scan, and diagnostic peritoneal lavage rates [3].
For children, however, the literature is less clear cut. Pediatric injury patterns commonly result in solid organ lacerations without hemoperitoneum, making the FAST a less sensitive means for detecting important intra-abdominal injury [7]. Further, the test characteristics of the FAST have variable reliability and accuracy in children [7,10,11]. This variation contributes to uncertainty of how to use results of the FAST and decreases its impact on potentially important clinical outcomes such as rates of CT scans and ED length of stay [12]. However…
Studies that have shaped the pediatric FAST literature landscape:
| Study | Study Type, Location (Time Frame) | N, Ages | Notes |
|---|---|---|---|
| Menaker et al., J Trauma Acute Care Surg 2014 [7] | Secondary Analysis of a Prospective Observational Study Multicenter (May 2007 to January 2010) | 6,468 Median age, 11.8 yrs; interquartile range (IQR) 6.3-15.5 yrs |
|
| Holmes et al., JAMA 2017 [12] | Randomized Clinical Trial University of California, Davis Medical Center (April 2012-May 2015) | 925 Mean 9.7 yrs; SD 5.3 yrs |
|
| Kornblith et al., Acad Emerg Med 2020 [13] | Retrospective Review University of California, Benioff Children’s Hospital Oakland (November 2013 to July 2015) | 354 Median age 8 yr; IQR 4-12 yr |
|
| Liang et al., Pediatr. Emerg Care 2021 [11] | Systematic Review and Meta-Analysis Multicenter (January 1966- March 2018) | 2,135 Study dependent |
|
| Kornblith et al., JAMA 2022 [15] | Expert, consensus–based Modified Delphi International multicenter (May 2021 to June 2021) | n/a |
|
The use of FAST in pediatric trauma is an evolving area of active research. A clear consensus on the way the FAST fits into pediatric trauma protocols is yet to be determined. Studies will need to be performed to examine the benefits of serial FAST, patient factors that may influence its test characteristics, and effect on patient centered outcomes.
There are a number of strategies to incorporate the above studies into clinical care, and one example is illustrated in the algorithm below. Keep in mind that FAST should be used in conjunction with other signs and symptoms of intra-abdominal injury (vomiting, decrease breath sounds, abdominal pain, thoracic wall trauma). Also consider laboratory testing such as liver function tests and urinalysis, depending on the clinical context and consulting your surgical colleagues.
Zuckerberg San Francisco General Pediatric Blunt Torso Trauma Algorithm (shared with permission)
The primary survey is completed with airway, breathing, and circulation noted to be intact. As someone starts the secondary survey, you grab a phased array probe and perform a FAST . You observe the following:
| RUQ View | LUQ View |
| Pelvis View, Sagittal | Pelvis View, Transverse |
| Pericardial View |
You call out ‘FAST negative’ to the documenting nurse and team leader.
The patient has radiographs performed of his chest, pelvis, neck, and right forearm. He is diagnosed with a type 3 supracondylar humeral fracture but the other radiographs are negative for fracture and pneumothorax. The rest of his evaluation is reassuring. Orthopedics is consulted and they admit him for surgery. He is discharged home the next day with pediatrician follow up.
At her pediatrician clinic visit 1 week later, he is playful and active with his arm in a cast. He has been eating and drinking normally without any complaints of abdominal pain. He has orthopedics follow up scheduled for the following week.
Problem: Central venous line (CVL) placement is a key skill for emergency medicine providers. Sites for central line placement include the internal jugular vein, subclavian vein, and femoral vein. Indications include, but are not limited to fluid resuscitation, medication administration, central venous pressure monitoring, pulmonary artery catheter introduction, and transvenous pacing wire placement. Procedural complications can include catheter-associated infection and arterial puncture. Success rates for CVL placement vary based on location and provider experience [1-3]. Point-of-Care Ultrasound (POCUS) increases both success rate and patient safety when used to guide CVL placement [4].
Figure 1. Setup for ultrasound-capable, 3D-printed central line trainer
The ultrasound-capable, 3D-printed central line trainer was created to facilitate realistic training of POCUS-guided CVL placement, specifically utilizing the internal jugular vein. The trainer uses a ballistic gel insert that is ultrasound-capable and replaceable, as needed.
The model can be utilized by anyone needing practice and training on central line placement. This includes medical and physician assistant students, residents, and fellows. It will be particularly useful with students familiar with POCUS basics.
In our experience, 4-5 students were able to utilize the model before the wear from repeated use began to impact the imaging and structure of the model, necessitating replacement of the insert. The dilation step of the Seldinger technique can be skipped or simulated in order to prolong the life of the gel insert.
Figure 2. Screenshot of head being edited in Tinkercad software
Figure 3. Screenshot of neck mold being edited in Tinkercad software
Figure 4. Use of matte spray paint to paint the model
Figure 5. Preparation of the mold in which the heated gel will be poured
Figure 6. The heated, colored gel is poured into the mold
We are currently investigating how best to research this model. The model is inexpensive compared to available commercial CVL trainers. We estimate the cost at approximately $80 per model in materials. This, of course, does not include the price of a 3d printer, 18v drill, or drill bit. Two comparable models available for purchase are both listed for over $1000 [5, 6]. The build time is approximately 1 week with time spent printing, glue-drying, and ballistic gel setting. The model can be used repeatedly and the insert remade many times over.
If another model were to be designed, the top of the head could be sacrificed in favor of an elongated neck section. The top of the head provides no value and consumes 3d printing filament. Furthermore, an elongated neck may be preferable for a new learner by allowing more room to practice probe and hand placement.
Simulation as a means of teaching has been a firmly established practice across the landscape of medical education. The model in question is high-fidelity and offers the user a realistic experience in a low-stress environment. The model is small enough to be portable and can be used with little preparation, making it an ideal tool for just-in-time training in the emergency department.
Tools that allow the learner to practice multiple steps of a skill during one exercise are invaluable for skill development, competency-based medical education and mastery learning.
Led by series editor, Dr. Mary Haas, the IDEA series showcases examples of what programs worldwide have been doing to make residency conference more entertaining, engaging, and most of all, educational for residents. Read more publications from the series.
A 2-day-old female born at 41 weeks presents to the Emergency Department (ED) for an episode of apnea. Her parents noticed she stopped breathing, went limp, and turned blue. They are not sure for how long. The infant has had decreased urine output but is otherwise well without any other symptoms. Mom has an unspecified autoimmune condition and is taking hydroxychloroquine. The pregnancy and birth were largely uneventful. Mom was positive for Group B. Strep, had prolonged rupture of membranes, and was appropriately treated with antibiotics.
Vitals: The infant’s vital signs in the ED are within normal limits except for mild tachypnea.
Initial Exam: Her exam is nonfocal.
Apnea among infants occurs when an infant stops breathing for 20 seconds or longer or stops breathing, for any amount of time, with bradycardia, cyanosis, pallor, and/or hypotonia. The overall incidence of apnea is 1 in 1,000 full-term infants. Infants who are premature (<37 weeks) are at increased risk for apnea; the incidence is almost 100% in infants born less than 28 weeks. Apnea is more common in premature infants due to their immature respiratory systems and physiologic stressors often manifest as respiratory depression in infants [1].
For infants that are actively apneic, the approach is similar to any pediatric resuscitation: ABCs (see ED approach below for management).
For infants who had an apneic episode that has since resolved, one has more time to think about the differential.
Apnea can be benign and physiologic, typically lasting between 5-10 seconds and more often occurring between 2 weeks to 6 months of life. Because physiologic stressors can manifest as respiratory depression in infants, the differential for pathologic apnea is broad. The following are broad categories to consider (similar to “the misfits” mnemonic for the crashing neonate).
It’s important to note that apnea in infants may qualify as a BRUE (brief, resolved, unexplained event). However, in this case, the infant is less than 60 days old. This is NEVER a low-risk BRUE [2].
For the emergency provider, considering all of this can be overwhelming. Our job is to collect pertinent data, stabilize the infant, and start empiric treatment in order for the inpatient teams to further investigate the exact cause of the apnea. The following is a simplified ED approach:
Key history questions:
Key workup to initiate (in bold are items we wouldn’t typically send for adult workups and may be forgotten by ED providers who do not primarily care for children):
Key physical exam findings (undress the patient fully):
Management for infants currently apneic: ABCs.
Management for the infants who are not currently apneic:
Disposition is mainly to the Neonatal Intensive Care Unit (NICU).
While in the ED, the infant desaturates to the 80s with improvement on HFNC. She has a full sepsis workup and is started on empiric antibiotics (ampicillin/gentamicin) and antivirals (acyclovir). The infant is found to have hypoglycemia and metabolic acidosis. Her neurologic, cardiac, and infectious workups are unremarkable and she doesn’t have any apneic/cyanotic episodes while hospitalized. She is discharged home with suspected hypoglycemia from poor feeding as the cause.
