Pediatrics Expert Witness Advises On Misdiagnosis Prior to Discharge

new born babyThis case takes place in Vermont involves a female neonate who was discharged from the hospital and re-admitted within hours with an interrupted aortic arch and other serious heart defects. The infant was born on to a 27-year old G2P2 at 40+3 weeks EGA via uncomplicated SVD with Apgars of 9 and 9. The neonate went to nursery and roomed in with the mother for the duration of 2-days in the hospital prior to discharge. The mother described poor feeding during their hospitalization. A frenulectomy was performed prior to discharge to assist in better feeding. The mother was home only a few hours and grew concerned due to the infant’s poor feeding, listlessness and pallor. At the ED, she was found to be acidotic with a pH of 6.8, hypothermic (temp 96 rectal) and hypoglycemic with BG in the 30s. No pulse was palpated but HR 100 with BMV in the ED. She was resuscitated, intubated (2 attempts) and transferred to the PICU. Fluid resuscitation continued and dopamine initiated with prostaglandins started after initial echocardiogram revealed coarctation or interrupted aortic arch. She was transferred to another facility for interrupted aortic arch repair via approximation of ends and posterior patch, patch closure of VSD, and PDA ligation.

Question(s) For Expert Witness

  • 1. As a pediatrician, when you see a patient with this presentation, when do you refer them to a cardiologist for further testing?
  • 2. Have you ever had a patient develop the outcome described in the case?
  • 3. Do you believe this patient may have had a better outcome if the care rendered had been different?
  • 4. Have you ever served as an expert witness on a case similar to the one described above?

Expert Witness Response E-004685

My diagnosis varies depending on the lesion(s). For interrupted aortic arch (IAA), there may be no symptoms initially but, as the arterial duct (ductus arterioles) begins to close, which is a normal part of the post-natal changes in circulation, newborns will be come increasingly ill. Difficulty feeding is a potential symptom of that. When critical heart disease is undetected prior to birth, newborns often become acutely ill. This can occur in hospital or at home. I have seen both. I need more information in order to comment on this. In cases where critical heart disease is undetected until acute decompensation, there is often end-organ damage. Most of that (liver, kidneys) clears up over time. There may be brain injury as well. Since poorer neurodevelopment outcomes are inherent in babies with many congenital heart defects and relate to the open-heart surgery needed to repair those defects, it is not straightforward to parse the causality of those outcomes. I have been a witness only once. That was a case against the cardiothoracic surgeons for hypoplastic left heart syndrome with mortality. I am a pediatric cardiologist. Thus, I am familiar with this disorder and its treatment.

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