Inborn errors of metabolism

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  • Suspect in any sick neonate
  • Newborn screening varies by state
  • May present as late as early childhood
  • Clinical manifestations are due to accumulation of toxic metabolites
  • Must rule-out sepsis (more common in these patients)

Clinical Features

Exam and history:

Differential Diagnosis

Sick Neonate



  • Glucose level
  • Ammonia
    • Should be <200 in normal neonate (higher suggests urea cycle disorders)
  • Lactate
  • Chemistry
  • Urinalysis (ketones)
  • LFT
  • VBG


Must stop catabolism and acculmulation of toxins/ammonia

  1. Keep NPO
    • Removes potential inciting metabolic substrates
  2. IVF
    • Normal saline 20 mL/kg boluses
    • Once rehydrated, switch to IVF with dextrose (D10) at 1-2x maintenance
    • Increases renal excretion of toxic metabolites
  3. Hyperammonemia
  4. Sodium bicarbonate if acidotic

Cerebral edema

  • Hyperammonemia is risk factor
    • Mannitol 0.5gm/kg IV/IO
    • Do not give steroids (worsens hyperammonemia)

If seizing

Subsequent Management

  • Consider L-carnitine in conjunction with specialist, as some diseases may respond (but has side effects)

See Also


  1. Brousseau T, Sharieff GQ. Newborn emergencies: the first 30 days of life. Pediatr Clin North Am. 2006 Feb;53(1):69-84, vi.