#3 common newborn problems
DESCRIPTION
pediatrics ITRANSCRIPT
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COMMON PROBLEMS IN THE NEWBORN
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OUTLINE
Different birth injuries a neonate can incur Different causes of sepsis and its treatment
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BIRTH INJURIES or BIRTH TRAUMA
refers to avoidable and unavoidable injury affecting the infant during labor and delivery
Injury:MechanicalHypoxic ischemic
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BIRTH INJURIES or BIRTH TRAUMA
due to tremendous pressure incurred while passing through the birth canal
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BIRTH INJURIES Most often not serious Temporary loss of nerve or
muscular function caused by bruising, pressure or swelling around the nerves can similarly resolve itself within weeks or months.
However, if the nerves are torn, the resulting damage may be permanent.
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RISK FACTORS:
Macrosomia Prematurity Cephalopelvic disproportion Dystocia Prolonged labor Abnormal fetal presentation doctor procedures (i.e., the use of forceps)
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COMMON BIRTH INJURIES
Caput Succedaneum. Cephalhematoma Bruising / forceps marks Subconjunctival hemorrhage Fractures Facial paralysis Brachial palsy
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Soft tissue injury:
1. Erythema and abrasion
2. Petechiae
3. Ecchymosis
4. Laceration
5. Subcutaneous fat necrosis
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Erythema and abrasion
Frequently occurs with labor dystocia or forceps delivery
Resolve spontaneously Rx: clean area and avoid secondary
contamination
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Petechiae
Commonly occurs with breech or difficult delivery
Due to sudden intrathoracic and venous pressures during chest passage
Commonly found in neck, face, upper chest Resolve in 2-3 days Make sure underlying hemorrhagic disorders
are ruled out
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To rule out underlying hemorrhagic disorders:
Birth history Early appearance of petechiae which does
not increase in number Localized petechiae distribution in face and
chest No bleeding from other sites Normal platelet count
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Ecchymoses
Occurs in traumatic birth or breech Increase incidence in premature babies Resolve spontaneously within 1 week Complication: hyperbilirubinemia
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Laceration
Due to scalpel injury during CS Sites; buttocks, scalp, thigh (presenting part) Rapid healing If superficial: adhesives If deep: sutures used
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Subcutaneous fat necrosis Unknown etiology Well-circumscribed indurated lesion in skin and tissues Factors:
OB trauma Local ischemia Hypothermia Intrauterine asphyxia
Lesions appear 6-10 days of age Overlying skin is red or purple with local tenderness or warmth Rx: observe Takes weeks to months
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HEAD INJURIES
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Caput succedaneum
Vaguely demarcated area of edema over portion of scalp that was presenting part
External to periosteum Cross suture lines Resolve
spontaneously within days
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Cephalhematoma
Collection of blood in subperiosteum
Due to rupture of blood vessels traversing from skull to periosteum
No extension over suture lines
Parietal bones – most commonly involved
Complications: jaundice, skull fracture, intracranial hemorrhage
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Cephalhematoma
common among neonates delivered by vacuum extraction
Spontaneous resorption in 2-8 weeks
CEPHALHEMATOMA ASPIRATION is contraindicated
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Delivery through Vacuum Extraction (ventouse)
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CAPUT SUCCEDANEUM CEPHALHEMATOMA
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Subgaleal hemorrhage
most feared complication of Vacuum extraction and forceps delivery
potentially life threatening
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Subgaleal hemorrhage caused by rupture of the emissary veins, which are
connections between the dural sinuses and the scalp veins.
Blood accumulates between the epicranial aponeurosis of the scalp and the periosteum. This potential space extends forward to the orbital margins, backward to the nuchal ridge and laterally to the temporal fascia.
In term babies, this subaponeurotic space may hold as much as 260 mL of blood.
Subgaleal hemorrhage can therefore lead to severe hypovolemia
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Clinical findings: Generalized scalp
swelling and laxity scalp
Ballotable mass that extends beyond scalp sutures
May extend from orbit to ears and down the neck
Occurs insiduously
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Subconjunctival hemorrhage Bright red patches on
bulbar conjuctivae very common for
babies born vaginally The redness is usually
absorbed in a week to ten days.
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FRACTURES
Most common fracture: Fracture of the clavicle
The clavicle may break when there is difficulty delivering the baby's shoulder or during a breech delivery.
Parents are advised not to lie the infant on the affected side until the fracture has healed.
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CLAVICLE
It is particularly vulnerable when there is:
1. Difficulty in delivery
of the shoulder in
vertex presentations
2. The extended arms in
breech deliveryries.
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Fracture Humerus most common long bone
fracture Almost invariably heal with simple supportive
therapy & do not lead to permanent disability
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SKULL FRACTURES
Uncommon in newborns Skull bones are less
mineralized Bones are separated
by membranous sutures
Usually follows forceps delivery
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SKULL FRACTURES
types:
1. linear fracture - no Rx required
2. depressed fractures: Rx- surgical
* elevate severe depressions to prevent cortical injury from sustained pressure
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Intracranial hemorrhage
Periventricular Intraventricular hemorrhage Most serious Major cause of death in
prematures Incidence increases with
decreasing body weight and gestational age
Subdural hemorrhage Very rare Seen more in FT
infants Secondary to
precipitous delivery, high or midforceps delivery
Dx: CT scan / MRI
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Peripheral Nerve Injuries
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PERIPHERAL NERVE INJURIES
Results from excessive tension on one side of the neck
BRACHIAL PALSY PHRENIC NERVE
PARALYSIS FACIAL NERVE PALSY
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Brachial Plexus Palsy:It is due to over traction
on the neck as in:
1. Shoulder dystocia.
2. After-coming head in breech delivery.
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BRACHIAL PLEXUS INJURY
Forms:
1. Erb-Duchenne paralysis
2. Klumpke’s paralysis
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ERB-DUCHENNE PARALYSIS
Upper arm paralysis Injury to C5 and C6 Most common classical ‘waiter’s tip’
posture
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ERB-DUCHENNE PARALYSIS
the arm hangs by the side and is rotated medially; the forearm is extended and pronated.
The arm cannot be raised from the side;
The Moro reflex is absent on the involved side, and the hand grasp is intact
Good prognosis
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Klumpke paralysis Rare Lower arm paralysis Injury to C7 and C8 and
T1 (paralyzed hand) a characteristic sign is the
claw hand, due to loss of function of the ulnar nerve and the intrinsic muscles of the hand it supplies
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Klumpke paralysis Hands are paralyzed,
grasp reflex is absent if the sympathetic
nerves are injured, an ipsilateral Horner syndrome (ptosis, miosis, enophthalmos)
Poor prognosis
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PHRENIC NERVE PARALYSIS
Injury to C3, C4 and C5 may lead to diaphragmatic paralysis and
respiratory distress In difficult breech deliveries s/s: poor respiratory effort
breath sounds absent on affected side Treatment: supportive
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FACIAL PARALYSIS
During labor or birth, pressure on a baby's face may cause the facial nerve to be injured.
This may also occur with the use of forceps for delivery.
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Mosby items and derived items © 2006, 2002 by Mosby, Inc.
Facial Paralysis 15 Minutes after Forceps BirthFacial Paralysis 15 Minutes after Forceps BirthAbsence of movement on affected side is especially noticeable when infant criesAbsence of movement on affected side is especially noticeable when infant cries
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CENTRAL PARALYSIS PERIPHERAL PARALYSIS
Spastic Flaccid
Lower half to 2/3 of face Entire ½ of face
Contralateral side Ipsilateral side
Affected side is smooth Eyes persistently open
Nasolabial fold is obliterated Nasolabial fold obliterated
Mouth corner droops Mouth corner droops
Forehead and eyelid unaffected Forehead and eyelid affected
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Complete agenesis of the facial nucleus results in a central facial paralysis; when this is bilateral, as in Möbius syndrome, the face appears expressionless.
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Hypoplasia of the depressor anguli oris muscle
Should not be confused with facial palsy
Asymmetric crying facies No treatment is required
for this defect, but a thorough physical examination is warranted for all neonates to look for other malformations.
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SCIATIC NERVE INJURY Causes:
1. Breech deliveries with traction on the presenting leg
2. may follow IM injection
3. May follow umbilical artery catheterization s/s: foot drop, adductor paralysis and
sensory loss with intact urinary and rectal sphincters
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SPINAL CORD INJURIES Usually happens when there
is difficulty in the delivery of the shoulder in head presentations and the head in breech presentations
If complete transection: permanent paralysis of the parts below the level of injury
If paralysis due to compression by edema and hemorrhage: partial or complete recovery
PROGNOSIS: For those with severe
spinal cord injuries, they die in the early neonatal period
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INTRA-ABDOMINAL INJURIES
Uncommon Should be suspected in NB with pallor, irritability
and abnormal distention without evidence of external blood loss
Liver- most frequently injured abdominal organ in traumatic birth process
Mass maybe palpable in the RUQ and abdomen may appear blue
Also possible but rare: spleen rupture, adrenal hemorrhage, kidney injuries
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NEONATAL SEPSIS
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Neonatal sepsis
Clinical syndrome of bacteremia characterized by s/s of infection in the first 4 weeks of life
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CLASSIFICATION OF NEONATAL SEPSIS
EARLY ONSET LATE ONSET VERY LATE ONSET
Time of onset Birth-7 days (usually <72 hrs)
7 days -30 days >30 days
Maternal OB complications
Often present Usually absent Varies
Transmission/ organism source
Vertical: maternal genital tract
Vertical or postnatal environment
Environment/community
Clinical manifestation
Fulminant course; multisystem involvement, pneumonia common
Insiduous, focal infection, meningitis common
Multisystem or focal
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RSK FACTORS for SEPSIS
EARLY ONSET LATE ONSET
PrematurityLBWPROMMaternal feverChorioamnionitisMaternal UTIFunctional deficiencies of neonatal host defense mechanisms
PrematurityProlonged hospitalizationInvasive procedures: umbilical catheterizations, ET intubationParenteral alimentationPrior use of antibioticsMedications (H2 blockers)Functional deficiencies of host defense mechanisms
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PREMATURITY – most important factor predisposing to infection Usually have a 3 to 10 fold higher incidence of
infection than FT infants
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Why are NB prone to sepsis?
NB specific immune mechanism is competent BUT antigenically inexperienced and functionally deficient Antibody responses to infection are poor Complement levels are low Decreased ability of the granulocytes and
phagocytes to kill bacteria Deficient neutrophil chemotactic response
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TRANSMISSION of Infection
1. Transplacental- CMV & Rubella
- Listeria Monocytogenes ( the only bacteria)
- Treponema pallidum
2. Vertical- Ascending route ff rupture of membranes
- Passage through birth canal by colonization of normal flora by mother (GBS, E coli)
3. Postnatal- direct contact with caregiver
- environmental/contaminated equipment
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Predominant pathogens for Sepsis:
EARLY ONSET(usually normal flora of
genital tract and rectum)
LATE ONSET
E coliGroup B StrepL monocytogenesH influenzaEnterobacter aeruginosaKlebsiella pneumoniaeStaph aureus
Coagulase negative StaphStaph aureusGram negative enteric bacilliPseudomonas aeruginosaEnterococcus speciesFungal
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Clinical signs of sepsis:
Respiratory distress Abnormal skin perfusion Temperature instability Feeding intolerance Abnormal HR and BP Metabolic problems – hypo/hyperglycemia,
metabolic acidosis Abnormal neurologic status
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Neonatal Sepsis
Evaluation: History CBC with diff (suggests bacterial infection),
CXR, blood culture, urine culture, consider LP
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SEPSIS
Diagnosis: blood culture Management: early detection Treatment: antibiotics for 10-14 days
Early onset: combination of ampicillin and gentamicin or ampicillin and
amikacin
Late onset: vancomycin ( gram + )
meropenem, cephalosporins, carbapenem (gram - )
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Complications of Sepsis:
Bacterial meningitis DIC Septic shock Multiple organ failure
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CONGENITAL INFECTION
TORCHS Toxoplasmosis Others: Hep B, Varicella, HIV Rubella CMV Herpes simplex Syphilis
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TOXOPLASMOSIS
TRIAD: Chorioretinitis
obstructive hydrocephalus, intracranial calcifications
Confirmed by serologic testing
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SYPHILIS
Early s/sx: osteochondritis, hemolytic anemia, hemorrhagic retinitis (snuffles)
Late s/sx: hutchinson’s teeth, healed retinits, 8th nerve deafness, saddle nose, saber chin, hydrocephalus
Peeling of skin in NB is highly suggestive of SY
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RUBELLA
Sensorineural hearing loss, catarcats, congenital heart defects (PAS or PDA)
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CYTOMEGALOVIRUS
Jaundice with hepatosplenomegaly, thrombocytopenia, severe CNS disease (microcephaly, subependymal intracerebral , periventricular calcifications, chorioretinitis, progressive sensorineural hearing loss)
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HERPES SIMPLEX VIRUS
May be localized (discrete vesicles to large bullous lesions, keratoconjunctivitis, chorioretinitis) or disseminated involving the liver, adrenal and CNS
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Common shared features suggesting Intrauterine infections
Prematurity IUGR Hematologic – anemia, thrombocytopnia, petechiae,
purpura Ocular – microphthalmia, cataracts, keratoconjunctivitis CNS – microcephaly, hydrocephaly, intracranial
calcifications Other organ systems – pneumonia, myocarditis,
nephritis, hepatospenomegal, jaundice Non-immune hydrops
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Cutaneous manifestations of some organisms causing Sepsis:
Ecthyma gangrenosum – Pseudomonas sp. Salmon pink papules – Listeria
monocytogenes Vesicular rash – Herpes virus Blueberry muffin rash – CMV, Rubella,
Parvovirus
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Prevention and treatment:
SYPHILIS Penicillin
TOXOPLASMOSIS Sulfadiazine / pyrimethamine
RUBELLA Immunization is recommended
CMV Gancyclovir for severe cases
HSV Acyclovir CS (preferred route of delivery)
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Other Neonatal infections:INFECTION CAUSE S/SX
Omphalitis Inadequate care of cord Localized erythema, may spread to abdominal wall, peritoneum, umbilical or portal vessels
Oral thrush Candida albicans infection (DOC: nystatin)
Whitish patches on side of tongue, gingival or buccal mucosa
Neonatal tetanus Unclean delivery and unhygienic management of cord
Usually in mothers with no tetanus vaccine
Seen in 3-10 days
Inability to suck, spasms, stiffness, seizures
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Other Neonatal infections:INFECTION CAUSE S/SX
Pneumonia Diffuse alveolar or interstitial disease; usually asymmetric and localized
Poor feedingLethargyIrritabilityCyanosisResp distress
Meningitis Common in late onset sepsis
Poor activity, irritability, apnea, cyanosis, tense fontanels, seizures
Necrotizing enterocolitis Risk factors ( 6 Is)ImmaturityIschemiaInfectionIntakeImmunityInflammatory mediators
Abdominal distentionPassage of blood streaked stoolsPneumatosis intestinalisPneumoperitoneumPortal vein gas
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That’s all folks!!!That’s all folks!!!
Got questions?
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THANK YOU