You have been referred a 3-day old, 4.1 kg baby who was born by normal vaginal delivery after an uncomplicated antenatal course. Her parents had attended the A&E the day before with concerns regarding poor feeding but were discharged home, as first-time parents, with advice. They re-presented the following day with increasing concern regarding lethargy and not feeding. On admission to A&E the baby was grunting but had no other signs of respiratory distress. He was mottled and cool peripherally, with normal heart sounds and palpable femoral pulses. He was floppy and very difficult to rouse, only crying feebly to painful stimuli. On arrival in A&E he had capillary glucose and gas performed. The glucose was just in normal range at 2.8 mmol/L but lactate was elevated at 4.3 mmol/L. Initial management in A&E comprised of starting the baby on high flow nasal cannula oxygen, IV access was sited and he was given three 10 ml/kg boluses of normal saline as volume resuscitation. The local team remained concerned and had escalated management to an anaesthetic review but felt he would need transfer to somewhere with a higher level of care, hence the referral.