PEM Currents: The Pediatric Emergency Medicine Podcast

In this episode we dive into the resurgence of Mycoplasma pneumoniae—an atypical bacterial cause of community-acquired pneumonia that’s making waves in pediatric emergency medicine. We’ll cover its clinical presentation, epidemiology, diagnostic approach, and management, including why standard beta-lactam antibiotics won’t work. Plus, we’ll discuss whether M. pneumoniae even needs to be treated in the first place! Learning Objectives Describe the clinical presentation, epidemiology, and complications of Mycoplasma pneumoniae infections in pediatric patients, including its atypical manifestations. Differentiate Mycoplasma pneumoniae pneumonia from typical bacterial and viral pneumonia based on history, physical exam findings, and diagnostic testing. Assess the current evidence for antibiotic treatment of Mycoplasma pneumoniae and justify treatment decisions based on patient presentation, severity, and potential complications. Connect with Brad Sobolewski PEMBlog: PEMBlog.com Blue Sky: @bradsobo X (Twitter): @PEMTweets Instagram: Brad Sobolewski Mastodon: @bradsobo References Vallejo, Jesus G. “Mycoplasma Pneumoniae Infection in Children.” UpToDate, 1 Nov. 2024, www.uptodate.com/contents/mycoplasma-pneumoniae-infection-in-children. Garcia T, Florin TA, Leonard J, Shah SS, Ruddy RM, Wallihan R, Desai AP, Alter S, El-Assal O, Marzec S, Keaton M, Yun KW, Leber AL, Mejias A, Cohen DM, Ramilo O, Ambroggio L; Children’s Hospitals Initiative for Research in Pneumonia (CHIRP). Clinical Features and Management Strategies in Children With Mycoplasma Pneumoniae. Pediatr Emerg Care. 2025 Feb 17. doi: 10.1097/PEC.0000000000003338. Epub ahead of print. PMID: 39960098. Gao L, Sun Y. Laboratory diagnosis and treatment of Mycoplasma pneumoniae infection in children: a review. Ann Med. 2024 Dec;56(1):2386636. doi: 10.1080/07853890.2024.2386636. Epub 2024 Aug 3. PMID: 39097794; PMCID: PMC11299444. Shah SS. Mycoplasma pneumoniae as a Cause of Community-Acquired Pneumonia in Children. Clin Infect Dis 2019; 68:13. “Mycoplasma Pneumoniae Infections Have Been Increasing.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 18 Oct. 2024, www.cdc.gov/ncird/whats-new/mycoplasma-pneumoniae-infections-have-been-increasing.html. Transcript Note: This transcript was partially completed with the use of the Descript AI  Welcome to PEMCurrents, the Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski, and today we’re focusing on a pathogen that has been making waves in pediatric emergency departments across the country. Mycoplasma pneumoniae. Whether you know it or not, you’ve likely seen a surge where you work. Patients are presenting with community acquired pneumonia that isn’t responding to standard beta lactam antibiotics, or with parents who are just concerned that their child has walking pneumonia. That’s because mycoplasma pneumonia is just a little bit different than most of the pathogens that we deal with in children. So let’s dive in. So, what is it? Microbiology lecture. Warning, med school trigger. Uh, so Mycoplasma pneumoniae is a small, obligate intracellular bacterium and it lacks a cell wall. So that’s why it doesn’t respond to beta lactam antibiotics like penicillin and amoxicillin and cephalosporins. Instead, it requires macrolides, tetracyclines, or fluoroquinolones for treatment. It’s spread via respiratory droplets and thrives in crowded environments such as schools and daycare centers. It binds to the epithelial cells in the upper and lower respiratory tract, triggering an immune response that leads to mucosal damage, increased mucus production, and impaired gas exchange. So mycoplasma pneumonia infections have been on the rise, especially in children. After a lull during the COVID 19 pandemic, cases reemerged in 2023 and continued to climb into 2024. Historically, mycoplasma pneumonia has been most common in children aged 5 to 17 years and young adults. But what’s new is that we’ve seen a striking increase in infections among children aged 2 to 4. Per the CDC, diagnosed mycoplasma infections increased steadily through the summer of 2024, peaking in August for 2 to 4 year olds and 5 to 17 year old age groups. There’s also been an increase in diagnosis in those under 12 months of age. This is all notable because these infections have historically been thought to affect school aged children much, much more than younger children. All right, let’s talk about clinical features. So the incubation period for mycoplasma pneumonia can be around two to three weeks. Symptoms often start gradually, with fever, headache, malaise, and sore throat, preceding the onset of a persistent dry cough. Unlike classic or typical bacterial pneumonia, which has abrupt onset in focal lung findings, mycoplasma pneumonia patients often present with a prolonged worsening cough that can persist for weeks to months. The name walking pneumonia was coined because people with this mild form of respiratory infection can still walk around and do their normal activities. It’s attributed to, but not exclusive to, mycoplasma disease. Now some patients can develop severe pulmonary complications, fortunately those are rare. These include respiratory failure, pleural effusions, necrotizing pneumonia, and pyema. Beyond the lungs, mycoplasma pneumonia is a weird bug, and it can also cause some extra pulmonary manifestations. So you can get mucocutaneous disease, including erythema multiforme. and mycoplasma induced rash and mucositis, also known as RIME, and even Stevens Johnson syndrome. Patients can get joint pain, you can have a hemolytic anemia due to IgM antibodies causing an autoimmune hemolysis, or even neurological complications such as meningoencephalitis, seizures, transverse myelitis, or even Guillain Barre syndrome. Alright, so making the diagnosis starts with having a firm understanding of bacterial versus viral etiologies of pneumonia. And generally, we should make this diagnosis clinically. So typical bacterial pneumonia, like streptococcus pneumoniae, is more likely when symptoms such as fever, chills, cough, and focal chest pain start abruptly. These patients often have respiratory distress or tachypnea and focal lung findings like rails or crackles or decreased breath sounds. A typical bacterial pneumonia, like mycoplasma pneumonia, presents with a gradual onset of fever, headache, malaise, sore throat, followed by the worsening non productive cough. It’s often accompanied by wheezing and or rails, and fever and illness are typically milder. than in the classic bacterial pneumonia. Now viral pneumonia, which is also all over the place, and due to RSV, parainfluenza, influenza, adenovirus, and more, is more common in children under 5 years of age. The cough develops gradually following an upper respiratory tract infection, and lung findings are diffuse and bilateral, often with wheezing. Think of viral pneumonia like bronchiolitis, but in a preschooler instead of a baby. And so while mycoplasma pneumonia is often a clinical diagnosis based on presentation, there is some confirmatory testing. PCR testing of the nasopharynx, or throat, is highly sensitive and specific. You can get serology, which will detect IgM and IgG antibodies. It’s useful, but it takes longer to result. The caveat of these serologic tests is that There’s probably a lot of seropositivity without symptoms in the general population. So basically, many people could have positive mycoplasma without symptoms. There are no distinguishing features on blood labs like CBC and blood culture, which are generally not necessary in these patients unless they’re critically ill. And the chest x ray findings, if you need them, will typically show bilateral patchy infiltrates, though some cases can have unilateral lobar consolidations. So as you might imagine, chest x rays aren’t as useful as you’d think in diagnosing mycoplasma. When it comes to management, first and foremost, supportive care. Treat fever, ensure adequate hydration, and provide respiratory support as needed, like if kids need oxygen, that sort of stuff. Cough suppressants and cough medicines are generally ineffective and no better than honey, and really not recommended in many age groups, but if you’ve got a middle schooler or teenager and parents want to try it, eh, have at it. Or don’t. Before I talk about antibiotics, I do want to bring up the question as to whether or not we actually have to treat mycoplasma in the first place. Studies supporting antibiotic treatment of documented mycoplasma pneumoniae in children are limited. Supports provided predominantly by in vitro studies, a randomized trial in military recruits, and some observational studies in which inclusion of mycoplasma pneumoniae specific therapy was associated with a decreased risk of treatment failure. So, whether that’s a change in antimicrobial therapy or a hospital admission, or length of stay in children with community acquired pneumonia, but they didn’t have etiologic data in that study. There was a systematic review of 17 studies, including 4, 294 patients, where they found insufficient evidence for the efficacy of antimicrobial treatment of mycoplasma pneumonia, lower respiratory tract infection in children less than 17 years of age. There was publication bias, heterogeneity, and lack of blinding. We also don’t know whether administration of antibiotics decreases the incidence or severity of associated mucocutaneous disease. And I’m not even going to get into pans or pandas here. I can’t bear it. So, yes, I’m going to talk about antibiotics. But consider this scenario, you’ve got a kid, cough and wheezing, you think it’s a virus, maybe it actually is mycoplasma, there’s a good chance they’ll be fine anyway, even if you don’t treat it. So yes, think of mycoplasma pneumoniae, but don’t make it your sole focus when you’re really just dealing with viral pneumonia in a lot of kids. Okay, the first line treatment is azithromycin. The ZBA is actually all right, so it’s 10 milligram per kilogram in one dose, max dose of 500 milligrams. That could be orally or IV on the first day, and then five milligram per kilogram in one dose. Maximum dose of 250 milligrams for the next four days. If azithro is unavailable, or in the case of an allergy, you could use doxycycline two to four mgs per kg per day, orally or iv. in one or twice daily dosing. The max daily dose is 200 milligrams, and it’s done for seven days. Compared with other tetracycline antibiotics, doxy is much less likely to cause permanent tooth discoloration in young children, and it can be given safely for less than 21 days to children of all ages. Tetracycline for kids greater than eight years of age, and azithromycin are also options, but azithromycin has lots of GI side effects. For immunocompromised children, especially with previous exposure to macrolides, fluoroquinolones like levofloxacin are an alternative initial agent. Fluoroquinolones are bacteriocidal rather than bacteriostatic, and the dosing for levofloxacin varies according to age. So greater than six months but less than five years. Levofloxacin is 8 10 mg per kg per dose orally or IV every 12 hours. The max total daily dose is 750 mg and you treat for 7 10 days. For kids older than 5 years, you do Levofloxacin 10 mg per kg per dose once per day orally or IV. And that max dose is again, 750 milligrams per day for seven to 10 days. All right, so let’s talk about some take home points. So mycoplasma pneumonia is back with a vengeance after the COVID 19 pandemic, and it is affecting younger children more than ever before, especially kids, two to four years of age. For most patients, it is a clinical diagnosis. You should think about it, though, in kids with classic presentations, or in a child who has failed treatment with beta lactams for a presumed community acquired pneumonia. And don’t fear the Z Pak, right? If you diagnose mycoplasma pneumonia, macrolides and zithromycin are the first line treatment. Fluoroquinolones are good for immunocompromised children. Mycoplasma can cause extrapulmonary disease. So, go online and look up some pictures of the mucocutaneous manifestations. There are also hematologic and neurologic complications. And keep an eye on outbreaks and community trends. The epidemiology is shifting, and infections are rising, so your hospital should have a local plan to deal with infection in your community. Thank you so much for listening to this episode. If you found it helpful, let me know. Leave a review, send a message on social media or email, and share it with your colleagues and learners. And as always, as my 13 year old would say, don’t forget to like and subscribe. For PEMCurrents, the Pediatric Emergency Medicine Podcast, this has been Brad Sobolewski. See you next time.

In this episode of PEM Currents: The Pediatric Emergency Medicine Podcast, we explore the complex and often underrecognized issue of inhalant misuse. From the early days of glue sniffing to the recent rise of nitrous oxide misuse, fueled by brands like Galaxy Gas and viral trends on TikTok and Instagram, inhalant misuse has evolved into a growing concern among adolescents. We’ll dive into the clinical presentations, including acute and chronic symptoms, the dangers of “sudden sniffing death,” and the specific risks associated with nitrites, hydrocarbons, and nitrous oxide. Learn how to recognize and manage cases in the emergency department, ask the right questions to uncover inhalant use, and provide critical resources for prevention and support. Whether you’re a seasoned pediatrician or new to emergency medicine, this episode offers essential insights into tackling this hidden epidemic. Learning Objectives By the end of this episode, listeners will be able to: Recognize the clinical signs and symptoms of inhalant misuse, including acute intoxication and long-term complications. Differentiate between the risks and toxic effects associated with specific inhalants, such as hydrocarbons, nitrites, and nitrous oxide. Formulate effective strategies for identifying, managing, and preventing inhalant misuse in pediatric patients. Connect with Brad Sobolewski PEMBlog: PEMBlog.com Blue Sky: @bradsobo X (Twitter): @PEMTweets Instagram: Brad Sobolewski Mastodon: @bradsobo References Perry H, Burns MM. Inhalant misuse in children and adolescents. UpToDate. Ganetsky M (ed). Updated February 26, 2024. Accessed January 13, 2025. https://www.uptodate.com/contents/inhalant-misuse-in-children-and-adolescents Hogge RL, Spiller HA, Kistamgari S, et al. Inhalant misuse reported to America’s Poison Centers, 2001-2021. Clin Toxicol (Phila) 2023; 61:453. Marcus E. The next drug epidemic is blue raspberry flavored: How Galaxy Gas became synonymous with the country’s burgeoning addiction to gas. Intelligencer. Published January 6, 2025. Accessed January 13, 2025. https://nymag.com/intelligencer/article/galaxy-gas-flavored-nitrous-oxide-drug-epidemic.html Transcript Note: This transcript was partially completed with the use of the Descript AI  Welcome to PEMCurrents, the Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski, and today we’re diving into an important topic, inhalant misuse, with a special focus on nitrous oxide. Welcome Recently, there’s been a concerning rise in recreational use of nitrous oxide, often referred to as Galaxy Gas, which is actually a brand name, which has become synonymous with flavored nitrous oxide products. Even as that brand, Galaxy Gas, is being phased out of the market, its legacy persists, fueled in part by its viral presence on social media platforms like TikTok and Instagram. So, this episode is going to break down the symptoms, clinical presentations, and management of inhalant misuse in children and adolescents with a specific eye on how these trends are shaping a new wave of cases presenting to the ED across the globe. So, what are inhalants? Well, these are volatile substances that you’re not meant to breathe in. They produce vapors, which, when you inhale them, cause psychoactive effects. They include everyday household items like glue, paint thinner, and gasoline, as well as recreational substances such as nitrous oxide, often referred to as whippets or galaxy gas. Interestingly, when these are sold, either online or in physical stores, they’re marketed As additives to make your own whipped cream at home. The people that sell them in stores are told to specifically not refer to them as whippets or to refer to them as a drug. Oh no, they’re only for cooking. The customers and the people selling them know otherwise. Anyway, the recreational use of nitrous or whippets, it’s been around since the late 18th century, uh, when it was used in laughing gas parties among the immigrants. English elite. Fast forward to today, and nitrous remains one of the most commonly misused inhalants. It’s evolved from its medical and industrial applications to a recreational substance with a significant cultural footprint. And let’s face it, the prevalence of this inhalant misuse is concerning. In the US, about 11 percent of high school students have used inhalants at least once. And what’s striking is that inhalant use peaks in younger adolescents, particularly those in like 7th through 9th grades, middle schoolers. making it one of the earliest substances that are misused among young people. So, these inhalants are often used through sniffing, huffing, or bagging. Sniffing involves inhaling the fumes directly from the container. Huffing uses a cloth soaked with the substance. And bagging, or perhaps ballooning, involves inhaling fumes from a bag or balloon placed over the nose and mouth. So you decant the substance from the canister into a balloon, and then you inhale that into your mouth. The latter dramatically increases the risk of asphyxia. The mechanism of action is rapid and profound. These substances are absorbed through the lungs and distributed to the brain, where they act on GABA and glutamate receptors. The primary effects are euphoria, dizziness, and disorientation. They’re felt within seconds and last 15 to 30 minutes or less. And. Patients that use these will repeatedly use it throughout the day. You can either get one little individual canister of nitrous, or a big canister which costs about 120 to 120. Repeated use can sustain that intoxication. So the symptoms of inhalant misuse are important to recognize. So first and foremost are the neurological symptoms. Euphoria, ataxia, disorientation, and slurred speech are common in acute intoxication. Chronic misuse can be devastating and unfortunately we don’t know how much, or how long, or how frequent leads to these symptoms. But nevertheless, they’re pretty darn bad. It includes cerebellar dysfunction, peripheral neuropathy, and toxic leukoencephalopathy, which manifests as white matter degeneration visible on MRI. Basically, misuse of this stuff can paralyze you. The cardiovascular symptoms include sudden sniffing death syndrome, which is the generation of a fatal arrhythmia, which is particularly dangerous with halogenated hydrocarbons. Pulmonary symptoms include hypoxia, reactive airway dysfunction, and in severe cases, pulmonary edema or even a pneumothorax. Glue sniffer’s rash is a hallmark skin finding. It presents as erythema and inflammation around the mouth and nose. and nose. Chronic users may also see weight loss, abdominal pain, nausea and vomiting, and metabolic abnormalities like hypokalemia and acidosis, especially if they’re misusing toluene, which is fortunately less common. Further complicating matters is that each inhalant has its own special risks. Hydrocarbons, again found in solvents and glue, can lead to cranial neuropathy, cerebellar dysfunction, and cardiac arrhythmias. Chronic misuse of these results in profound hypokalemia and metabolic acidosis. Nitrous oxide, so whippets or galaxy gas, interferes with vitamin B12 metabolism, so it can lead to polyneuropathy, myelopathy, and hyperhomocystinemia, which increases the risk of venous thromboembolism. Nitrites, which are known as poppers, can cause intense vasodilation and methemoglobinemia. with symptoms ranging from headache to cyanosis and seizures. So management, unfortunately, of inhalant intoxication is primarily supportive. Stabilization, you have to ensure that the patient is removed from the exposure source and administer 100 percent oxygen if they’re hypoxic. If the patient is unconscious and in a tachyarrhythmia, the treatment is electricity! Amiodarone or lidocaine on the palsgar rhythm and avoid catecholamines like epinephrine unless the patient’s in cardiac arrest. For nitrous oxide neurotoxicity, administer high dose vitamin B12 intramuscularly or subcutaneously. I would consult a toxicologist because I know that this is rare. And if you have a patient with methemoglobinemia, chances are you’re actually taking a board test, but you would treat that with IV methylene blue. In cases of toluene misuse, monitor and correct the electrolyte imbalances carefully, avoid dextrose, which can actually worsen the hypokalemia. Again, I would call a toxicologist for help from this, because fortunately, it’s very rare. And listen, this problem isn’t going anywhere. So pediatricians, Educators and parents all play a crucial role in prevention. Frankly, these should not be so accessible. They should not be able to be sold easily online or in physical smoke shops. Also, we need to advocate for federal regulation on these as controlled substances, because currently right now they’re not. Everybody knows the dance that the retailers play in saying, Oh yeah, you can use these to make whipped cream at home, but they are marketed with with flavoring in brightly colored containers and they are very attractive to young children. They’re piggybacking off the same strategies that made vaping and vape cartridges so popular. Students should be educated about the dangers of inhalants. That means both local advocacy in schools and in medical care settings, but also using some of the same techniques that made getting high off these popular, like social media. We’ve got to reduce access. and curiosity. Schools should definitely replace solvent based products with safer alternatives and monitor students for signs of misuse. For those already misusing inhalants, referral to a substance use disorder program is essential. Chronic complications often resolve with cessation, but addressing coexisting mental health problems and comorbidities such as depression and suicidality is equally important. Okay, I know that that was just a whiff of a topic that you may be only a little bit familiar with. But trust me, you’ve probably met a patient That’s huffing or inhaling, and you just haven’t known it. So it starts with asking patients about what they’re doing. A good old heads exam. So when asking patients about inhalant misuse, it’s important to create a non judgmental and supportive environment. Start with broad, open ended questions, and normalize them. Say that this is something that you ask all patients about. Ask about substance use, like vaping or alcohol, and then introduce inhalants by mentioning specific examples, such as sniffing glue, huffing spray paint, or using nitrous oxides like whippets or galaxy gas. Again, normalize that conversation by acknowledging curiosity or peer influence, especially on social media. And, if they do disclose use, ask gently about frequency, Context and any symptoms like dizziness, headaches, or worse, emphasize that your goal is to support their health, not to judge or punish and provide reassurance and resources if needed. Thank you for listening. Inate misuse is often overlooked, especially in pediatric emergency care settings, but if you’re vigilant and you’re informed, you can better serve our patients and manage complications. If you found this episode helpful, well let me know about it. Leave a review on your favorite podcast site that helps people discover the show, or you can reach out and contact me directly via email or social media. Share it with your colleagues and learners and subscribe for more episodes. For PEMCurrents, the Pediatric Emergency Medicine Podcast, this has been Brad Sobolewski. See you next time.

In lieu of a traditional episode this holiday season I wanted to share a reading of the Pediatric Emergency Medicine version of a famous Christmas poem. Transcript ‘Twas the night before Christmas, and I’m working a shift, The symptoms were varied, the pace was quite swift. The screens glowed with orders, the rooms filled with care, In hopes that discharge summaries soon would be there. The nurses were moving with hustle and speed, While families recounted each child’s urgent need. And I at my computer, my coffee in hand, Prepared for the onslaught that none could have planned. When out in the lobby there arose such a clatter, I sprang from my chair to see what was the matter. Away to the triage I flew like a flash, Dodging spilled apple juice and a child with a rash. The ambulances were wailing, the scene quite a sight, As the complaints rolled in on this hectic night. When what to my weary eyes did appear, But a febrile infant, his parents in fear. A nursemaid’s elbow in need of a tug, And a kid with a cough wrapped tight in a hug. A forehead lac with blood streaming red, And a teen who proclaimed, “I think I’m half-dead!” With quick-thinking teamwork, the cases we tamed, And I whistled and shouted and called them by name: “Now flu! Now croup! Now migraines and pain! On seizures! On sepsis! That ankle is sprained! To the trauma bay stat, through triage with speed, Move quickly, move calmly, and meet every need!” As the snow flakes that fall when wild winter winds fly, We hustled and triaged as new patients arrived. And then, in a twinkling, I heard down the hall, The sound of retching – a vomiting call. Ondansetron ordered, the nurse prepping the dose, I saw a pale toddler, looking morose. He was sick from his tummy to the tip of his nose, And the sounds of his misery steadily rose. His eyes were all sunken, his cheeks far too pale, But a popsicle bribe led to a triumphant exhale. The shift rolled along with splints left and right, Broken forearms galore on this holiday night. And ketamine laughter soon filled the air, As a lac repair finished with great skill and care. Abdominal pains brought more to the bays, With parents repeating, “He’s been sick for days.” A scan ruled out danger, the appendix intact, While the next patient arrived with an asthma attack. The hours wore on, the crowd didn’t cease, Yet amidst all the chaos, we found moments of peace. A mom’s grateful smile, a child’s sleepy yawn, Reminded us why we keep carrying on. So I sat at the computer and typed one last note, Cleared my inbox of tasks and the orders I wrote. And I heard myself whisper as I turned off the light, “Merry Christmas to all, and to all a calm night!”

Dive into the world of pertussis, also known as whooping cough, and uncover its persistent public health challenges despite vaccination efforts. Learn about the disease's three distinct stages and key symptoms, especially in infants and older children. Discover effective management strategies, including supportive care and the importance of post-exposure prophylaxis. Additionally, the discussion highlights vaccination schedules and addresses concerns about vaccine hesitancy, all crucial for effective infection control in clinical settings.

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This episode of PEM Currents discusses ECPR (Extracorporeal Cardiopulmonary Resuscitation), an advanced procedure used in cases of cardiac arrest when traditional CPR fails. ECPR involves using ECMO (Extracorporeal Membrane Oxygenation) to take over heart and lung functions, offering a last-resort option that is becoming more common in large pediatric hospitals. While ECPR shows promise in […]

Syphilis has gone by many nicknames over the years including “The Great Pretender” and “The Great Imitator.” Emily Labudde, MD, a Pediatric Emergency Medicine fellow at Children’s Healthcare of Atlanta and recent pediatric residency graduate from Cincinnati Children’s discusses the various manifestations of this sexually transmitted infection, and how we can’t miss this very treatable, […]

Cervical Spine Injuries are fortunately rare in children. this episode is all about learning when to suspect them, how to immobilize the C-spine properly, and which imaging test to choose. It was inspired by a hot-off-the-presses publication from the Pediatric Emergency Care Applied Research Network (PECARN) focused on clinical decision rules for cervical spine imaging […]

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Join first-year resident Emily Groopman, with her expertise in genetic diagnosis and rare diseases, as she sheds light on managing children with inborn errors of metabolism in emergency settings. They discuss the genetic foundations of these conditions and the urgency of early recognition. Emily emphasizes the importance of newborn screening and biochemical testing due to non-specific symptoms. The conversation also covers critical management steps, including glucose administration and the role of genetic consultations in ensuring optimal care.