Comments by Dr. Mark Mannenbach, M.D.:

This is certainly an interesting case to share.

I have been fooled by the child with altered mental status and vomiting to the point where I have done LP’s with concern for meningitis only to find intussusception as the true diagnosis.

Great to see that you used the “TIPS FROM THE VOWELS” mnemonic for AMS in children. I adopted this earlier in my career after doing unnecessary LP’s.

A few things to consider:

1) Most of our children have had Minnesota newborn screening which is very comprehensive and points away from most of the inborn error issues.
2) Although I don’t do rectal exams on many children, I do recommend that infants with this picture have rectal exams done. 80% of children with intussusception will have Hemoccult positive stools (not grossly bloody or “currant jelly” stools). This might have taken you down the path of intussusception and spared the head CT.
3) I encourage everyone to consider the use of bedside ultrasound to make the diagnosis. Although ultrasound is a great tool, a recent case in the department of a false negative formal ultrasound study has encouraged me to learn more about taking a look myself.
4) I have attached our guideline for management of intussusception to this message. Pediatric surgery rarely needs to be involved unless the child appears ill or if the enema reduction is unsuccessful. If easily reduced, drinking well in the ER, and parents are reliable, many of these children can be sent home. We used this approach during my training and have adopted that approach here.
5) Great to have Tom Hellmich here on staff with us!

Happy to answer any question along the way.

Mark