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Evaluation and treatment of the Neonate

Evaluation and treatment of the Neonate. Chapters 117 and 13. The Basics. Feeding: every 6-9 hrs, more if breastfed Weight gain: may lose at d/c up to 10% then gain 20-30g/d for 1 st 3m then 15-20g/d Stool: Breastfed 6/day but may go up to 1 week without and formula 2/day

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Evaluation and treatment of the Neonate

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  1. Evaluation and treatment of the Neonate Chapters 117 and 13

  2. The Basics • Feeding: every 6-9 hrs, more if breastfed • Weight gain: may lose at d/c up to 10% then gain 20-30g/d for 1st 3m then 15-20g/d • Stool: Breastfed 6/day but may go up to 1 week without and formula 2/day • Respirations: 30-60/m belly breathes • Sleeping: initially awake Q 20min-6h but are able to sleep thru the night by 6m

  3. Common ED presentations • Colic: crying for 3h/d for 3d/w over a 3 week period; Usually starts 1st week of life but not beyond 3 months • Abuse/Trauma/Neglect • Infections: <1m should be admitted • Surgical Lesions i.e. tracheoesophageal fistula, pyloric stenosis etc • Improper feeding habits

  4. Gastrointestinal Tract Symptoms • GERD • Is not “vomiting” • Can be resolved with elevation of the head following feeding or thickening fluids • Feeding difficulties • Frustration with feeding pattern • Always check to see that weight is up • Consider esophageal obstruction if appear malnourished or dehydrated

  5. GI tract symptoms cont • Necrotizing Enterocolitis • Bowel wall inflammation associated with infection and hypoxic-ischemic insult • Sx: feeding intolerance, abdominal distention, bloody stools, apnea, shock • Xray: pneumatosis intestinalis and hepatic portal air • Tx: consult pediatric surgeon

  6. PneumatosisIntestinalis

  7. GI tract symptoms cont • Vomiting differential • Infection: UTI, gastro • ICP incr.: hydrocephalus, shunt malfxn • Pyloric stenosis • Anatomic abnl: midgut rotation, tracheo-esophageal fistula Evaluate for hypoglycemia and metabolic acidosis

  8. GI tract sx cont • Blood in diaper: • Swallowed maternal blood • Coagulopathies • Necrotizing enterocolitis • Fissures • Allergies • Cow’s milk

  9. Diarrhea and Dehydration • Rotavirus and adenoviruses in winter • E.coli, Salmonella, Shigella in summer • PE for signs of dehydration • Labs esp for Na and bicarb • Stool for blood • IVF if greater than 5% dehydration • Admit for rehydration

  10. GI tract sx cont • Abdominal distention: consider obstruction and hepatosplenomegaly • Constipation: Ask if problems from birth to help r/o Hirschprung; also consider hypothyroid and anal stenosis

  11. Cardiorespiratory Symptoms • Rapid breathing or grunting is considered a medical emergency until proven otherwise • Full septic workup is warranted • Cyanosis and tachypnea esp without retractions suspect congenital cardiac and consider Prostaglandin @

  12. Pneumonia • Viral: • RSV • Adenovirus • Parainfluenza virus • Bacterial: • Group B strep • Listeria • H. Influenza • Chlamydia (conjunctivitis & staccato cough) • Pertussis

  13. Bronchiolitis • RSV 60-90%; parainfluenza virus • Apnea more common in premies and usu. presents in 1st three days of illness • Sx: tachypnea, cyanosis, air hunger, wheezing, retractions, nasal secretion • Tx: Albuterol, racemic epi • Admit if <3m, O2 sat< 92%, premie, or underlying heart/lung disease

  14. Jaundice • Physiologic jaundice • Secondary to sepsis • Breast-milk jaundice • Hemolysis due to autoimmune disease • Full term/healthy infants should have phototherapy if 25-48hr old & bili >15, 49-72h & bili of 20

  15. Conjunctivitis • Chlamydia biggest concern after 1st week • Gonorrhea is prophylactically tx in OB, but onset is 3-5 days • Always consider herpes and possibility of CSF invasion • If conjunctivitis on first day, due to antibiotic prophylaxis

  16. Diaper rash and Thrush • Candidal dermatitis has sharply demarcated scalloped border with satellite lesions • Tx with nystatin cream followed by zinc oxide paste • Thrush is white and flaky and on tongue, lips, & mucous membranes • Tx with oral nystatin and if breast feeding, tx use topical on mother’s nipples

  17. Thrush and Diaper Dermatitis

  18. Neonatal Resuscitation • Single most common reason for resuscitation is prematurity • Perinatal asphyxia is defined as: • umbilical artery acidemia pH<7 • 5 min apgar of 0-3 • Neonatal neurologic sequelae • Multiorgan dysfunction

  19. Resuscitiation Steps • Maintain Body Temperature • Clear the Airway • Initiate Breathing • If heart rate is <100 bpm or irregular • Maintain rate of 40-60 breaths/min • No improvement in 30s intubate • Meconium Staining • Severe respiratory disease • Assoc with persistent pulmonary htn

  20. Resuscitation Continued • Cardiac Massage • If heart rate <60bpm • Compress 3:1 with respirations • Umbilical vein cath • inserted 10cm • 1vein 2arteries • Umbilical artery cath for art line/gases

  21. Drugs • Dextrose • D10W 5-10ml/kg IV push or • D10W 100ml/kg a day • Epinephrine • 0.1-0,3nl/kg of 1:10,000 IV • Volume expansion • NS 10ml/kg slow push, repeat if needed • O neg 10ml/kg if suspected blood loss • Bicarbonate • Controversial • Naloxone • 0.1mg/kg of 0.4mg/ml solution

  22. Disposition • Terminate code if >15min or 10 min of asystole • Transfer to NICU • Be advised neonatal seizures 1:200 • Assoc with low blood sugar, Ca, Mg, Na and high ammonia • May also be due to TORCH or bacterial meningitis, & congenital brain disorders

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