Neonatal Emergencies and Common Neonatal Problems

1. Neonatal Emergencies and Common Neonatal Problems Tintinalli Chap. 111

2. Neonatal Visits • Symptoms usually vague, nonspecific • Signs usually subtle • Majority of visits are nonurgent and related to caretaker inexperience • Complaints usually symptom complexes • Respiratory symptoms (27.5%) • GI/GU complaints (21%) • Normal infant queries (18%) • Fever (11%) • Jaundice (8%) • Skin lesions (5.5%)

3. Common Concerns of Caregivers • Feeding Patterns • Weight Gain • Stool Patterns • Breathing Patterns • Sleeping Patterns • Crying • Intestinal Colic • Birthmarks & Skin Rashes

4. Birthmarks Nevus flammeus Mongolian spots

5. Neonatal Rashes Erythema toxicum Neonatal acne

6. Critically Ill Neonate • Congenital Heart Disease • Inborn errors of metabolism • Congenital adrenal hyperplasia • Sepsis • Intracranial Hemorrhage • Congenital malrotation and volvulus

7. Management • Early positive pressure ventilation • Consider intubation and NG decompression • Hydrocortisone 12.5-25 mg IV/IM/IO for suspected adrenal insufficiency • Empiric ampicillin and gentamicin for sepsis

8. Diaper Rash Contact Dermatitis Candidal dermatitis

9. Diaper Rash and Thrush • Contact Dermatitis • Irritating substances in infant stool or diaper • Macular erythematous w/ sharply demarcated edges • Treat with air drying and zinc oxide • Candidal Diaper Dermatitis • Erythematous plaque w/ satellite lesions • Treat w/ nystatin cream and zinc oxide or oral fluconazole for resistant cases • Superinfectionrequires oral antibiotics • Admit patients w/ blistering or peeling • Thrush • Treat with oral nystatin/gentian violet and anesthetic gel

10. The Irritable Neonate • Thorough history • Head-to-toe examination • Palpate fontanelles • Check for corneal abrasion • Inspect for thrush/diaper rash • Check for hair tourniquets • Examine scrotum for hernias/torsion • Auscultate heart • Observe respiratory effort • Examine and palpate abdomen/extremities

11. Cough and Nasal Congestion • Usually viral URI • Other causes • Reflux and aspiration • Congenital tracheoesophageal fistula • Choanal atresia • Treatment • OTC cold medications contraindicated • Saline drops w/ bulb suction

12. Noisy Breathing and Stridor • Stertor • Inspiratory snoring/snorting localizedc to nose or nasopharynx • Usually benign • Inability to pass NG diagnostic of choanal stenosis • Stridor • Upper airway obstruction • Inspiratory and expiratory • Laryngomalacia most common in neonates • Other Causes • Congenital anomalies • Subglottic stenosis in previously intubated • Infection is rare

13. Cyanosis • Congenital Heart Disease • “quiet tachypnea” • Methemoglobinemia • Sepsis/meningitis • Cerebral edema/intracranial hemorrhage • Pneumonia/brochiolitis

14. Pneumonia • Most common neonatal infection • Causes • Bacterial • Group B strep, E. coli, Listeria, H. influenzae, Strep. pneumo, Klebsiella, Enterobactor • w/i 48 hours of life • Ampicillin and gentamicin • Chlamydia • After 3 weeks • Afebrile, tachypneic, staccato cough, conjunctivitis • Azithromycin • Bordetellapertussis • Cough, cyanosis, post-tussiveemesis • Apnea may be only symptom • Adult caregiver also has persistent cough • Azithromycin • Mycobacterium tuberculosis • Half of actively infected mothers • Viral • RSV, adenovirus, hymanmetapneumovirus influenza, parainfluenza

15. Bronchiolitis • Peak incidence during winter months • RSV most common • Clinical diagnosis • Associated w/ apnea in neonates and preterm infants < 34 weeks gestational age • Admit all infants < 1 month positive for RSV • Racemic epinephrine

16. Congenital Heart Disease • Tachypnea w/o retractions or use of accessory muscles • Two types • Ductal-dependent lesions • Shock and acidosis in first week of life • Left-to-right shunting (ASD, VSD) • CHF • Treatment • Prostaglandin E1 0.05-1 microgram/kg/min

17. Neuromuscular Disease • Infantile botulism • Weak cry and feeding difficulties followed by weakness, lethargy, hypotonia, ocular palsies, and apnea • Preceded by constipation • Other causes • Down syndrome • Hypoxic-ischemic encephalopathy • Spinal cord lesions (myelomeningocele) • Spinal muscular atrophy • Peripheral nerve diseases (myasthenia gravis; myotonic dystrophy)

18. Feeding Difficulties • Pattern of intake not established until 1 month • Acute change usually due to infection • Causes • Parental concern • GI abnormalities(stenoses, strictures, cleft palate) • Extrinsic compression (double aortic arch)

19. Gastroesophageal Reflux • Common in neonates • Reduced LES pressure • Increased intragastric pressure • Parents confuse regurgitation with vomiting • Weight gain? • Reassure parents • Thicken feeds, upright feeding

20. Vomiting • Rarely isolated symptom • Often confused w/ normal regurgitation • Causes • Anatomic abnormality • Tracheoesophageal fistula • Duodenal atresia (Down’s) • Midgutmalrotation • Increased ICP • Metabolic disorders • Infection (sepsis, UTI, gastroenteritis)

21. Pyloric Stenosis • Projectile vomiting after the second and third week of life • Classically presents b/n 6 weeks and 6 months • Occurs at the end of feeding • Emesis does not contain bile or blood • Diagnosis • Prominent gastric waves progressing from left to right • Firm olive-shaped mass under liver edge • Ultrasound/barium studies • Hypochloremic alkalosis

22. Malrotation and Volvulus • Presents in first month of life • Bilious vomiting • 1/500 live births • Upper GI series • Immediate surgical consult

23. Necrotizing Enterocolitis • High incidence in premature infants • Clinical Findings • Feeding intolerance • Abdominal distention • Bloody stools • Apnea • Shock • Xray • Pneumatosisintestinalis, hepatic portal air • Free air • Management • Bowel rest • Ampicillin, gentamicin, and clindamycin

24. Blood in the Diaper • First confirm w/ guaiac • May be vaginal in females (placental estrogen) • Inspect for anal fissure • 1st 1 or 2 days of life • Most are d/t swallowed maternal blood • Later • Most are idiopathic • Consider coagulopathies, necrotizing enterocolitis, allergic/infectious colitis, congenital defects

25. Diarrhea and Dehydration • Neonates are particularly susceptible to dehydration and electrolyte abnormalities • ECF comprises 25% total body weight • If true diarrhea, consider admission • Causes include food allergy and infection • If bloody or contains mucous • volvulus, intussusception, necrotizing enterocolitis • Weigh child unclothed for baseline weight

26. Diarrhea and Dehydration • Evaluate mucous membranes, anterior fontanel, eyes, skin turgor, temperature, pulse, BP, abdomen • Rectal exam for stool sample/hemoccult • Labs • Serum electrolytes • Stool for culture, leukocytes, pH, reducing substances • UA/culture • Oral rehydration if < 5% dehydrated (150mL/kg/day) • Supplement breastfed infants with electrolyte solution • IV hydration if signs of dehydration or vomiting

27. Abdominal Distention • May be normal in neonates • Lax abdominal muscles • Large intra-abdominal organs • Swallowed air • Pathologic Causes • Bowel obstruction • Constipation • Necrotizing enterocolitis • Ileus • Congenital organomegaly

28. Constipation • Infants may go 5-7 days without BM • Abnormal if w/i first 48 hours of life • Intestinal stenosis • Hirschsprung disease • Meconium ileus (cystic fibrosis) • Hypothyroidism • Anal stenosis • Anteriorly displaced anus • Occult dysraphism

29. Jaundice • Normal physiology or pathologic process • Timing of Onset • < 24 hours • Hemolysis (ABO,Rh incompatibility) • Infection (rubella, CMV, toxoplasmosis) • Excessive bruising • 2-3 days • Physiologic • 3 days – 1 week • Infection • Decreased glucuronyltransferase • > 1 week • Breast milk jaundice • Infection • Biliary atresia • Hepatitis • RBC membrane defects • G6PD deficiency • Hemolysis

30. Jaundice • Physiologic Jaundice • Bilirubin rises < 5 mg/dl per day • Peaks at 5-6 mg/dL at day 2-4 • < 2 mg/dL at day 5-7 • Causes • Decreased glucuronyltransferase activity • Shortened life span of neonatal RBCs • Relative polycythemia • Decreased intestinal bacterial colonization

31. Jaundice • History • Maternal infections • Maternal blood type/RhoGAM • Estimated gestational age • Feeding patterns • Stool history • Regurgitation/vomiting • Urine output • Fever • Exam • Degree of jaundice • Sclera • Cephalohematoma • Fontanelles • Abdomen

32. Jaundice • Labs • Direct and indirect bilirubin • CBC • Blood smear • Reticulocyte count • LFTs

33. Jaundice • Conjugated hyperbilirubinemia • Inability to excrete bilirubin • Always pathologic • Presents later in neonatal period with jaundice, acholic stools, and dark urine • Causes include biliary atresia and hepatitis

34. Jaundice • Breast milk jaundice • Presence of substances that inhibit glucuronyltransferase • Starts at day 3-4 • Peaks by third week (10-27 mg/dL) • Unlikely to cause kernicterus • Treated w/ phototherapy • Breastfeeding jaundice – starvation jaundice • Mother’s milk supply is inadequate • Reduced BM’s and relative dehydration • Controlled supplementation (breast pump, formula)

35. Jaundice • Treatment • Phototherapy • Exchange transfusion • Dispo • Bilirubin level • Risk factors • Hemolysis risks (ABO, G6PD) • Sepsis • Asphyxia • Hypoalbuminemia • Acidosis

36. Neonatal Ocular Complaints • Watery Eyes • Obstructed nasolacrimal ducts • Clear discharge/crusting • 6% of newborns • Usually resolves spontaneously • Red Eye • Corneal irritation/abrasion • From eyelash or fingernail • Fluorescein stain • Acute glaucoma • Rare • Red, teary eye w/ cloudy cornea • Check IOP • Ophthalmologic referral

37. Neonatal Conjunctivitis • Chemical • Irritation from antimicrobial prophylaxis • 1st day of life • Herpes • Presence of vesicles anywhere on the body warrants full septic evaluation • Acyclovir

38. Neonatal Conjunctivitis Neisseria gonorrhoeae Chlamydia trachomatis End of first week through 1st month Thick mucopurulent discharge, pseudomembrane formation PO erythromycin (50 mg/kg/day) Treat mom and sexual partners • Day 3-5 • Severe lid edema • Can invade causing corneal ulceration and permanent loss of vision • Cefotaxime 100 mg/kg IV • Admit and consult ophtho

39. Neonatal Conjunctivitis

40. Neonatal Sepsis • Twice the risk of serious bacterial infection • Early Onset • First few days of life • Fulminant • Usually secondary to maternal/perinatal risk factors • Late Onset • After 1 week of age • More gradual • Sepsis, meningitis

41. Neonatal Sepsis • Causes • Bacterial • Group B strep • E. coli • Klebsiella • H. influenzae • Listeria • Viral • Coxsackievirus • Echovirus • RSV • Influenza A

42. Neonatal Sepsis • Management • Empiric antibiotics • IV ampicillin (50 mg/kg) and gentamicin (2.5 mg/kg) • Gram-negative meningitis • Replace gent w/ cefotaxime • Maternal hx of herpes or suspicious CSF • IV acyclovir

43. Neonatal Seizures • Distinguish from benign sleep myoclonus and normal startle reflex • Suppressed with touching or waking the infant • Tetany • Hypocalcemia (DiGeorge) • Seizures • Usually indicate severe underlying structural or metabolic problem • Subtle presentation • Eye deviation, tongue thrusting, eyelid fluttering, apnea, pedaling movements, or arching

44. Question 1 • Which of the following is true regarding malrotation/volvulus? • A. Symptoms of abdominal pain and vomiting are rare • B. Vascular supply to the midgut is never in danger when this condition occurs • C. A “double bubble” sign may be seen on plain films • D. Blood in the stool is necessary to make the diagnosis

45. Question 2 • What is one symptom that helps to differentiate malrotation/volvulus from pyloric stenosis? • A. Abdominal Pain • B. Bilious Vomiting • C. Fever • D.Constipation

46. Question 3 • All of the following are seen in pts with pyloric stenosis EXCEPT? • A. Dehydration • B. Projectile Emesis • C. Non-bilious vomiting • D.Normal weight gain

47. Question 4 • Which of the following is true regarding pyloric stenosis? • A. A palpable “olive” is always present on physical exam • B. Hypochloremic, hypokalemic, metabolic alkalosis is common • C. Abdominal plain films are diagnostic • D. This condition classiclly presents after 6 months of age