Useful Info

Neurologic emergencies
Recognizing a neurologic insult in neonates may be difficult. The clinical
symptoms may be nonspecific. The history may reveal only a change in feeding
pattern or subtle behavioral changes. A useful mnemonic to recall the broad
differential diagnosis of a neonate with altered mental status, ‘‘THE MISFITS,’’
is outlined in Box  Keeping this mnemonic in mind as well as a high index of
suspicion during the initial history and physical examination (non) will help
guide the evaluation and management
 Causes of altered mental status in a neonate: THE MISFITS

T–Trauma (nonaccidental and accidental)
H–Heart disease and hypovolemia
E–Endocrine (eg, congenital adrenal hyperplasia and thyrotoxicosis)
M–Metabolic (electrolyte imbalance)
I–Inborn errors of metabolism
S–Sepsis (eg, meningitis, pneumonia, and urinary tract infection)
F–Formula mishaps (eg, under- or overdilution)
I–Intestinal catastrophes (eg, volvulus, intussusception, and necrotizing enterocolitis)
T–Toxins and poisons



Several inborn errors of metabolism are characterized by a metabolic acidosis in which the major
anionic species is lactate. The lactic acid that circulates in the human body is a product of the
anaerobic metabolism of glucose that occurs primarily in the red cells, in kidney medulla and white
skeletal muscle. Some of the lactate is oxidized by red muscle and the kidney cortex, but the bulk
of it is taken up by the liver and converted to glucose or oxidized.
The only metabolic reaction which produces lactate is the NADH2-dependent reduction of pyruvate
which is catalyzed by lactate dehydrogenase, and lactate is always removed by a reversal of this
reaction. Therefore, any condition which results in the accumulation of pyruvate may lead to
inadequate removal of both pyruvate and lactate from the circulation with consequent lactic


Dr Archibald Edward Garrod

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