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Approach to the sick Infant

Approach to the sick Infant. Arun Abbi MD. Neonatal Physiology/Anatomy. Infants have different Physiology and anatomy than adults They are dependant on their primary caregiver for hydration and nutrition

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Approach to the sick Infant

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  1. Approach to the sick Infant Arun Abbi MD

  2. Neonatal Physiology/Anatomy • Infants have different Physiology and anatomy than adults • They are dependant on their primary caregiver for hydration and nutrition • They are also unable to communicate to adults and therefore often present later in the course of an illness • They have less cardiorespiratory reserve than adults

  3. Airway • 1. Primarily a Nasal Breather • This is relevant when an infant presents with URI Sx and has trouble breathing due to nasal congestion • 2. Larger tongue • Makes intubation harder • prone to upper airway obstruction when bagging and when infant becomes obtunded

  4. Breathing • Normal Respiratory rate for • Newborns - 30 - 60 /min • Infants (1-6 months) - 30 - 50 /min • Tachypnea, Accessory muscle use and Grunting are signs of Respiratory distress • FEEDING is the most physically demanding thing that infants do. • When they present with diseases causing respiratory compromise, they stop feeding - this is a sign of a SICK INFANT • BRADYCARDIA - late sign of hypoxia

  5. Circulation • Normal • HR - • Neonate- 90 - 150 • Infant - 100 -130 • BP - (70 + 2 X age) • Neonate - 60 - 80 - syst • Infant - 80 - 100 • Infants can not increase their stroke volume. They increase their cardiac output by becoming tachycardic (compensatory mechanism of shock)

  6. Circulation • The Ductus closes in the first 2 weeks of life • Infants with right to left shunts will present with cyanosis. • Infants with left to right shunts will present with CHF (coarctation of the Aorta, VSD, ASD)

  7. Circulation • Signs of Shock • 1. LETHARGY • 2. POOR FEEDING • 3. DELAYED CAP REFILL • 4. HYPOTHERMIA • 5. TACHYCARDIA • 6. HYPOTENSION (Late Sign)

  8. Metabolic • The infant has diminished glycogen stores and a high metabolic rate. • Hypoglycemia is a common symptom for a sick infant when they are not feeding • CHECK A CHEMSTRIP in an infant who has not been feeding for > 12 hrs and is lethargic • Hypoglycemia - glucose 4 cc/kg of D10W • Infants have a high surface area to body weight ratio • This predisposes them to hypothermia due to much greater heat loss

  9. Approach to the sick infant • Perform an initial brief assessment and determine LOC and stability • Get a chemstrip quickly while getting the history • Hx from time of discharge till ED presentation • Discharge weight/gestational age • Length of labour • Rupture of Membranes • Group B step? • FEEDING HX (how much and how often)

  10. Assessment • Overall appearance • Alert versus lethargic • Vital signs • Fontanalle • Cardiac exam/peripheral pulses • Abdomen • Tender • Palbable liver? • Genitals • Any ambiguous genitalia?

  11. Differential Diagnosis • There are a multitude of different causes for a SICK APPEARING INFANT • 1. Infection • 2. Cardiac diseases • 3. Metabolic disorders • 4. Gastrointestinal disorders • 5. Child abuse

  12. PNEUMONIC FOR SICK INFANT • THE MISFITS • T rauma • H eart disease and Hypovolemia • E ndocrine • M etabolic (electrolyte disturbance) • I nborn Errors of Metabolism • S epsis • F ormula Mishaps (under/overdilution) • I ntestinal Catastrophes (volvulus,intussusception,NEC) • T oxins and poisons • S eizures

  13. Case 1 • 6 day old male presents with increased lethargy and decreased feeding for 24 hours • Mother brings in child to ER • Patient born at term NSVD (no complications

  14. Exam • Child appears mildly jaundiced • Child is slightly lethargic but not irritable • Vitals • RR - 46 P - 144 BP 73/35 T - 36.2 Sat 95% (RA)

  15. Labs • BGL - 4.4 • WBC - 13.2 • Neuts 9.5 • Lymphs - 3.6 • CH6 - normal • Bili - 404 (normal < 340)

  16. What do you want to do? • 1. Phototherapy • 2. Send home and encourage more breast feeding with formula supplementation • 3. More tests

  17. Tests • Cath Urine • Moderate bacteria • 10 - 20 wbc • CXR - nil acute

  18. LP • WBC - 150 • RBC - 1 • Gram Stain - gram neg rods

  19. Treatment • Ampiciliin - 50mg/kg/dose Q6h • Cefotaxime - 50mg/kg/dose Q6h • Consider acyclovir 10mg/kg if conerned about neonatal herpes • No Dexamethasone for neonates

  20. Infection • Bacterial • UTI, pneumonia, Meningitis. • Group B strept, Listeria, E Coli, Staph • Viral • RSV, enterovirus, neonatal herpes

  21. Infections • Infants will present with lethargy, poor feeding, tachycardia and tachypnea • They may have a fever (>38.0 C) or be hypothermic • Infants do not have the ability to localize infections till about 3 months of age. • Meningitis can’t be ruled out clinically < 3 months of age

  22. Infections • UTI is the most common infection • Get a catheter specimen if an infant is sick • Respiratory infections present with tachypnea, grunting/wheezing (RSV) • Meningitis will have nonspecific signs and will be diagnosed on LP • Bugs - Group B Strept, E coli, Listeria

  23. Infections • Treat infants if they appear sick • Drugs - • Amp/Gent • Cefotaxime/ampicillin

  24. Case 2 • 10 day old male who presents to the ER with decreased feeding for 24 hours • Mother states the child has only taken 4 oz in the last 24 hours • Child had one bloody mucousy BM • Born at term and no complications

  25. Case 2 Exam • Child appears lethargic • Pt is tachypneic with some accessory muscle use

  26. Case 2 Cont’d • Any Concerns??? • What do you want to check? • What else do you want to know?

  27. BGL - 1.1

  28. Treatment of hypoglycemia • Give 4 cc/kg of D10W (10% glucose) and reassess BGL Q 30 minutes

  29. CXR • Mild increased perhilar markings

  30. DDX • Query pneumonia versus cardiac • Patient has a palpable liver and has diminished pulses peripherally

  31. Case 2

  32. Cardiac Diseases • The Patent Ductus Arteriosis closes and 7 - 14 days. • Infants with Right - Left shunts present with cyanosis - not relieved with oxygen • Infants with Left - Right shunts/ Coarct present with signs of CHF

  33. Cardiac Diseases • Other presentations can include SVT - causing CHF. The rate is usually around 240 and there is minimal variation (239 - 241) • Viral myocarditis can present at any age with cardiogenic shock

  34. Cardiac Diseases - CHF • Infants presenting with CHF will have signs of • 1. Respiratory distress • Tachypnea, indrawing, accessory muscle use, crackles • 2. Hepatomegaly • 3. JVD • 4. Peripheral edema • CXR will show signs of CHF- usually increased perihilar markings with an enlarged heart • A Cap gas is useful to determine if the infant is in shock

  35. Cardiac Diseases- Treatment CHF • 1. Oxygen • 2. If BP is low - initiate inotropes - dopamine or epinephrine • 3. Lasix 1mg/kg iv • 4. PGE 1 - 0.05 - 0.1 units/kg • 5. Intubate if infant is in persistent shock • 6. Arrange for echocardiogram

  36. Cardiac Diseases - Right to Left Shunt • These infants present with cyanosis that is unresponsive to oxygen. • Oxygen saturations will be low • Treatment is PGE 1 - 0.05 - 0.1 units/kg/min to keep the ductus open • Transfer to a centre where a permanent shunt can be inserted in the heart

  37. Case 3 • 2 week old child presents with lethargy and fatigue • Patient has been vomiting for 16 hours and mother is concerned about dehydration • Nurse places child on the monitor

  38. Exam • Child is dehydrated • Child is lethargic and had decreased cap refill • Chest is clear • Abdomen is soft and nontender

  39. Concerns? • DDX • Get a stat Cap gas to look at the K+ • Will see low Na+ with a high K+ and a normal anion gap

  40. Metabolic Disorders • 1. Dehydration - • hypernatremia, hyponatremia • 2. Congenital adrenal hyperplasia • 3. Urea cycle defects • 4. Hypothyroidism • 5. Toxins - ASA, ETOH

  41. Metabolic Disorders • 1. Dehydration - • Will see delayed cap refill. Decreased skin turgor, lethargy, tachycardia, dry mucous membranes • Tx - fluids - 20 cc/kg of NS - then reassess

  42. Metabolic Disorders • 2. Congenital Adrenal Hyperplasia • Will see ambiguous genitaliain females but males may have a hyperpigmented scrotum • 1 - fluids 20 cc/kg- fluids • 2. - Insulin/glucose for K+ (often resolves with fluids) • 3. Dexamethasone 0.2 mg/kg iv • 3. Urea Cycle Defects • Check the glucose • - need to draw an “ammonia” level, serum ketones,Urine for reducing substances, ketones and pH, serum lactate

  43. Case 4 • 2 day old presents with vomiting after feeding • Patient was sent home day of birth and presents 36 hours later as he is vomiting with feeding for the last 12hours

  44. Case 4 • Child is alert and looking around • Chest is clear • Abdomen is mildly distended and moderately tender

  45. DDX?

  46. Gastrointestinal disorders • 1. Gastroenteritis • 2. Pyloric Stenosis • 3. Intussusception • 4. Appendicitis • 5. Necrotizing Enterocolitis • 6. Midgut volvulus • 7. Duodenal atresia

  47. Initial Management • Check BGL • Start IV D10W NS at 4 cc/kg/hr • Check Urine • If abdomen is quite tender - surgical consult • If not sure - then get Upper GI/US of abdomen • Start antibiotics (cefotaxime)

  48. Gastrointestinal • 1. Gastroenteritis - • presents with vomiting and diarrhea • Rotavirus is a common cause • Tx - oral rehydration if possible - otherwise IV • 2. Pyloric stenosis - • presents with projectile vomiting. Often bilious. 3- 6 weeks of age • Diagnosis is made by US

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