Case 16

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A 3-month-old male infant presents to the emergency department with a history of turning blue while sleeping. The baby was born at 40 weeks of gestation and there were no birth complications except for mild jaundice on day 3 of life. There is an older sister that is healthy. This is the third episode of cyanosis and the mother is concerned that "no one is listening to her." The baby was admitted to the hospital at one month of age with a similar episode and was sent home on a cardiac/apnea monitor. At that time, a sepsis work-up and brain imaging were performed and all tests were negative for disease. Since one month ago, the baby has been seen at the primary care office for 12 visits and multiple phone calls regarding various concerns, including spitting up, twitching movements, a question of a cyanotic episode and an episode of limpness. The baby is growing well and has had a normal examination on all prior visits. He is scheduled for a barium swallow test next week and has an appointment with a gastroenterologist. There is no family history of infant deaths or congenital abnormalities and no history of seizures. The mother states that the monitor is not working correctly because it did not alarm when the baby was turning blue. On examination, the baby is afebrile, smiling and cooing, is well hydrated and has a normal examination.

Which one of the following is an appropriate next step?

A. Admission to the hospital after an evaluation for possible sepsis.

B. Send the baby home and advise that the parents to follow up with the primary care provider in the morning.

C. Admission to the hospital for observation of the baby, review of all records and observation of the maternal/infant interactions.

D. Send the baby home and notify child protective services.