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Neonatal Emergencies and Common Neonatal Problems. Tintinalli Chap. 111. 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%)
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Neonatal Emergencies and Common Neonatal Problems Tintinalli Chap. 111
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%)
Common Concerns of Caregivers • Feeding Patterns • Weight Gain • Stool Patterns • Breathing Patterns • Sleeping Patterns • Crying • Intestinal Colic • Birthmarks & Skin Rashes
Birthmarks Nevus flammeus Mongolian spots
Neonatal Rashes Erythema toxicum Neonatal acne
Critically Ill Neonate • Congenital Heart Disease • Inborn errors of metabolism • Congenital adrenal hyperplasia • Sepsis • Intracranial Hemorrhage • Congenital malrotation and volvulus
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
Diaper Rash Contact Dermatitis Candidal dermatitis
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
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
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
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
Cyanosis • Congenital Heart Disease • “quiet tachypnea” • Methemoglobinemia • Sepsis/meningitis • Cerebral edema/intracranial hemorrhage • Pneumonia/brochiolitis
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
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
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
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)
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)
Gastroesophageal Reflux • Common in neonates • Reduced LES pressure • Increased intragastric pressure • Parents confuse regurgitation with vomiting • Weight gain? • Reassure parents • Thicken feeds, upright feeding
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)
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
Malrotation and Volvulus • Presents in first month of life • Bilious vomiting • 1/500 live births • Upper GI series • Immediate surgical consult
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
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
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
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
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
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
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
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
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
Jaundice • Labs • Direct and indirect bilirubin • CBC • Blood smear • Reticulocyte count • LFTs
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
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)
Jaundice • Treatment • Phototherapy • Exchange transfusion • Dispo • Bilirubin level • Risk factors • Hemolysis risks (ABO, G6PD) • Sepsis • Asphyxia • Hypoalbuminemia • Acidosis
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
Neonatal Conjunctivitis • Chemical • Irritation from antimicrobial prophylaxis • 1st day of life • Herpes • Presence of vesicles anywhere on the body warrants full septic evaluation • Acyclovir
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
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
Neonatal Sepsis • Causes • Bacterial • Group B strep • E. coli • Klebsiella • H. influenzae • Listeria • Viral • Coxsackievirus • Echovirus • RSV • Influenza A
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
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
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
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
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
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