This weekend's paper featured a story about a local family who received a visit from CPS after taking their newborn to urgent care and then declining treatment.

The couple wanted to consult their own pediatrician before agreeing to a spinal tap and intravenous antibiotics for their newborn.

I'm pasting a fully copy of a letter we received Monday in response to that story from Dr. Sze Ho, the child's pediatrician. Dr. Ho, who also specializes in care for critically ill newborns, refutes the hospital doctor's recommendation for a spinal tap and the decision to call CPS.

I'd welcome you to read the story and also weigh in on the issue. Who do you think was right -- the urgent care doctor or the parents?

In response to the front page article on April 5, 2009: Was doctor right to report parents?
Sze K. Ho, M.D.  April 5, 2009

With reference to Stacey Shepard’s front page article in Sunday’s paper (April 5, 2009) regarding Mercy hospital’s reporting a parent to CPS,  in my medical opinion,  Mercy Hospital and the urgent care Doctor were completely wrong.

Sound medical judgment does not call for a spinal tap to be done with so little information available to the urgent care doctor at that time. There is no justification for such a potentially dangerous, invasive procedure solely on being told the patient had a 100 degree “fever” at home earlier.  Telling the public that “…hospital protocol is to do a spinal tap to test for meningitis and start intravenous antibiotics on a newborn with fever” is also extremely wrong and ridiculous beyond any medical justification. 

Any prudent, careful and thorough Urgent Care physician should ask these questions and obtain credible answers before requesting a spinal tap:

(1)    Was this true fever?  100 degree might not be an actual, medical fever.  How was the infant’s temperature taken? Under the arm or rectally?  Was the baby over-dressed or being wrapped with too many blankets?  Was the thermostat setting too high at home?

 
(2)    The temperature should be re-measured in the hospital with more accurate equipment and extra clothing and blankets should be removed.  Secondly, was the baby feeding well and not being lethargic and unusually sleepy?  This part of the “history of the illness” is vitally important.  It takes two minutes to ascertain this information.

(3)    To justify a spinal tap, during the physical examination—if one was in fact conducted—the physician must find a bulging fontanel, which is a soft spot on the top of the head. Finding that bulge is mandatory if you want a spinal tap. 

(4)    However, if the fontanel is soft, neck is soft, all reflexes are normal with good muscle tone for the baby’s age; the chance of the baby having meningitis is rather low.  The chest should be checked with auscultation to see there is suspicious sign of pneumonia.  This physical exam only takes 3 minutes. Was that done?

       (5)  Basic lab tests must be obtained and include a CBC which would tell us whether the baby has a viral or bacterial infection.  The positive CRP test in a new born usual indicates bacterial infection.  A urinalysis should be done especially for girls to rule out bladder infection.  Chest X-ray should be done to rule out any pneumonia.

If the history does not indicate any problem, the physical exam is normal, the CBC shows either viral or normal numbers, the CRP is less than 0.5, the urinalysis and chest X-ray are all normal, then a spinal tap is definitely NOT indicated.  The baby should be seen by the pediatrician the next morning without being given any medicine by the hospital.
Melissa Kyles was absolutely correct to not to let the urgent care physician do the spinal tap without obtaining a decent history, good physical exam, and appropriate lab tests.  Likewise, the “hospital protocol” is totally wrong from the information reported in this article. 

The second issue about reporting parents to CPS because of refusing a spinal tap is absolutely ludicrous.  It is an attempt to punish the parents just because they do not let the doctor do a wrong procedure, when, if the article is accurate, it was clear to the parents that the child had no credible exam. 

While there could indeed be a situation where an urgent care doctor is justified in calling the authorities, this was not one of them, not in any way close.   Mercy hospital—and its physicians-- will learn from this experience. In a very real way, there are lessons for all ER and urgent care doctors in this incident.

Sze K. Ho, M.D.
Pediatrician and Neonatologist
San Dimas Pediatrics, Bakersfield