A 3-month-old, previously healthy Amish boy presents to the emergency department with decreased oral intake, fussiness, and concern for dehydration. Two days before presentation the patient began to show less interest in breastfeeding. He initially exhibited feeding cues, but his suck was weak and he appeared to have difficulty swallowing. That same afternoon, his cry was weaker than usual. The next day, his mother noticed “gurgling” sounds whenever he cried. He has been fussy and difficult to console. He has not had fever, congestion, vomiting, respiratory distress, sweating, or cyanosis with feeds.

Two weeks before presentation, the patient started stooling less frequently; he previously stooled at least once daily, but now he stools once every 3 days. There have been no sick contacts or recent travel. The family has been building a house on the lot next to their current home, and dirt is frequently tracked inside from the construction...

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