Mohamed Khashaba, MD

Professor of Pediatrics /Neonatology

Director of NICU

Mansoura University

A 38-week gestation baby with a birth A 38-week gestation baby with a birth

weight of 3.2 kg developed cyanosis and weight of 3.2 kg developed cyanosis and

respiratory distress at 15 min of life.respiratory distress at 15 min of life.

He was ventilated and put on IV He was ventilated and put on IV

dextrose infusion and was pink and stable dextrose infusion and was pink and stable

on ventilator.on ventilator.

Case (1)Case (1)

M.Khashaba,MD professor of Pediatrics,Mansoura

Ventilator settings – pressure Ventilator settings – pressure 20/320/3

Inspiratory time- 0.4 secInspiratory time- 0.4 sec Ventilatory rate – 40/minVentilatory rate – 40/min

M.Khashaba,MD professor of Pediatrics,Mansoura

ABG was done about 20 ABG was done about 20

minutes after ventilation minutes after ventilation

showed:showed:

pH – 7.3pH – 7.3

POPO22 – 60 mm Hg (7.8 k Pa) – 60 mm Hg (7.8 k Pa)

PCOPCO22 – 35 mm Hg (3.9 k Pa) – 35 mm Hg (3.9 k Pa)M.Khashaba,MD professor of Pediatrics,Mansoura

The baby was pink, but at 10 The baby was pink, but at 10

hours of life the baby suddenly hours of life the baby suddenly

became blue and limp. Management became blue and limp. Management

was instituted and within 5 minutes was instituted and within 5 minutes

he was back to his activity again.he was back to his activity again.

M.Khashaba,MD professor of Pediatrics,Mansoura

Give 4 possible causes for the Give 4 possible causes for the

sudden deterioration of the infant.sudden deterioration of the infant.

M.Khashaba,MD professor of Pediatrics,Mansoura

DOPEDOPE DD-dislodged tube-dislodged tube

OO-Obstructed tube-Obstructed tube

PP-Pneumothorax-Pneumothorax

EE-Equipment malfunction-Equipment malfunction

M.Khashaba,MD professor of Pediatrics,Mansoura

A 4-day-old, exclusively breast fed A 4-day-old, exclusively breast fed

baby was noted to be pale, with heart rate baby was noted to be pale, with heart rate

of 180 with gallop rhythm, palpable liver of 180 with gallop rhythm, palpable liver

of 2 cm and black sticky stools. of 2 cm and black sticky stools.

Case (2)Case (2)

M.Khashaba,MD professor of Pediatrics,Mansoura

Baby was born in an ambulance, Baby was born in an ambulance,

from where she was transferred to post-from where she was transferred to post-

natal ward. natal ward.

Pregnancy was uneventful, but Pregnancy was uneventful, but

delivery was quick. This was mother’s delivery was quick. This was mother’s

fourth child. fourth child.

Baby was discharged home after 24 Baby was discharged home after 24

hourshoursM.Khashaba,MD professor of Pediatrics,Mansoura

A.A. What 2 investigations would you do What 2 investigations would you do

to establish your suspected diagnosis?to establish your suspected diagnosis?

B.B. What is the first therapeutic What is the first therapeutic

intervention would you undertake ?intervention would you undertake ?

C.C. What is the diagnosis ?What is the diagnosis ?

M.Khashaba,MD professor of Pediatrics,Mansoura

A. CBS, Coagulation study.A. CBS, Coagulation study. B. Blood transfusion,Fresh B. Blood transfusion,Fresh

frozen plasma.frozen plasma. C. Hemorrhagic Disease of C. Hemorrhagic Disease of

Newborn.Newborn.

Clue: exclusive breast fed baby.Clue: exclusive breast fed baby. Fresh frozen plasma and not Fresh frozen plasma and not

vitamin K is effective to stop vitamin K is effective to stop bleeding.bleeding.

M.Khashaba,MD professor of Pediatrics,Mansoura

A 6-month-old girl presents with A 6-month-old girl presents with two-month history of failure to two-month history of failure to gain weight and dehydration.gain weight and dehydration.

Sodium – 128Sodium – 128 Potassium – 3.2Potassium – 3.2 Urea – 7Urea – 7 Bicarbonate – 11Bicarbonate – 11

Which single investigation is Which single investigation is urgently needed?urgently needed?

Case (3)Case (3)

M.Khashaba,MD professor of Pediatrics,Mansoura

Serum 17-Serum 17-

hydoxyprogesterone assayhydoxyprogesterone assay

Salt losing crisis with Salt losing crisis with

acidosis is a common feature acidosis is a common feature

of Congenital Adrenal of Congenital Adrenal

hyperplasia.hyperplasia.M.Khashaba,MD professor of Pediatrics,Mansoura

A 1 1/2 -year-old child presents with A 1 1/2 -year-old child presents with mild diarrhea and not putting on mild diarrhea and not putting on weight.weight.

Na – 128Na – 128 K – 3.5K – 3.5 Cl – 98Cl – 98 HCO3 – 11HCO3 – 11 Urea – 24Urea – 24 Serum osmolality – 330Serum osmolality – 330

What other biochemical investigations What other biochemical investigations you need urgently?you need urgently?

Case (4)Case (4)

M.Khashaba,MD professor of Pediatrics,Mansoura

Blood sugarBlood sugarDiabetic ketoacidosis is Diabetic ketoacidosis is the likely diagnosis.the likely diagnosis.

M.Khashaba,MD professor of Pediatrics,Mansoura

Serum osmolality in mOsm/kg =Serum osmolality in mOsm/kg =

[Serum Na[Serum Na++ (mEq/L) + K (mEq/L) + K + + (mEq/L)(mEq/L) χχ 2] + 2] +

Glucose mg/dLGlucose mg/dL

++BUN mg/ dLBUN mg/ dL

181833

M.Khashaba,MD professor of Pediatrics,Mansoura

Case (5)Case (5)

M.Khashaba,MD professor of Pediatrics,Mansoura

Nevus flammus in the region of 1Nevus flammus in the region of 1stst

branch of Trigeminal nerve is usually branch of Trigeminal nerve is usually

associated with cortical brain lesion associated with cortical brain lesion

(ophthalmic area).(ophthalmic area).

Brain imaging & eyes evaluation are Brain imaging & eyes evaluation are

requiredrequired..

Sturge Weber Sturge Weber syndromesyndrome

M.Khashaba,MD professor of Pediatrics,Mansoura

Case (6)Case (6)

M.Khashaba,MD professor of Pediatrics,Mansoura

Pilonidal dimple & Pilonidal dimple & sinussinus

DimpleDimple:: D Depression in the skin.epression in the skin.

Sinus:Sinus: Connected to deeper structures in Connected to deeper structures in

sacral area.sacral area.

Cyst:Cyst: Forms at puberty when hair grows in Forms at puberty when hair grows in

the depth of the sinus occasionally gets the depth of the sinus occasionally gets

infected & needs excision. infected & needs excision.

M.Khashaba,MD professor of Pediatrics,Mansoura

Case (7)Case (7)

M.Khashaba,MD professor of Pediatrics,Mansoura

Preauricular Sinus Preauricular Sinus & tag& tag

Remnant of the first branchial Remnant of the first branchial cleft.cleft.

In the most anterior upper In the most anterior upper portion of the tragus of portion of the tragus of external ear.external ear.

An isolated anomaly , may be An isolated anomaly , may be bilateral.bilateral.

No treatment except if infectedNo treatment except if infectedM.Khashaba,MD professor of Pediatrics,Mansoura

Case (8)Case (8)

M.Khashaba,MD professor of Pediatrics,Mansoura

Sucking blistersSucking blisters Present at birthPresent at birth

Usually on a hand or wristUsually on a hand or wrist

Prenatal U/S: fetus sucks in Prenatal U/S: fetus sucks in

utero any part that comes easily utero any part that comes easily

to his mouthto his mouth

M.Khashaba,MD professor of Pediatrics,Mansoura

Case (9)Case (9)

M.Khashaba,MD professor of Pediatrics,Mansoura

Subcutaneous Fat Subcutaneous Fat NecrosisNecrosis

More common in Asphyxiated babies Multiple firm non-tender

subcutaneous nodules or large plaques that appear one to four weeks after birth.

Commonly affect the cheeks, buttocks, back, and limbs.

It often occurs over bony prominences. The anterior trunk tends to be spared.

M.Khashaba,MD professor of Pediatrics,Mansoura

Subcutaneous Fat Subcutaneous Fat NecrosisNecrosis

The overlying skin may be erythematous.

Lesions may become fluctuant as fat liquefies; some become calcified.

It usually resolves completely within 1-2 months, although it may persist up to 6 months, especially when lesions are calcifiedM.Khashaba,MD professor of Pediatrics,Mansoura

Case (10)Case (10)

Fever in a 1 month Fever in a 1 month aged babyaged baby

A 1- month- old infant was A 1- month- old infant was brought to the physician by his brought to the physician by his parents because of a fever 38c parents because of a fever 38c (taken rectally) earlier that (taken rectally) earlier that morning. He had no associated morning. He had no associated symptoms of cough, runny nose, symptoms of cough, runny nose, vomiting, diarrhea, or unusual vomiting, diarrhea, or unusual fussiness. He was bottle-fed , and fussiness. He was bottle-fed , and his mother had noticed that he was his mother had noticed that he was taking a little less than usual. His taking a little less than usual. His urination had decreased. urination had decreased. M.Khashaba,MD professor of Pediatrics,Mansoura

The obstetrical and birth histories The obstetrical and birth histories

were unremarkable, and infant had were unremarkable, and infant had

been well until now. The parents had been well until now. The parents had

been about to leave town to visit been about to leave town to visit

relatives for their summer vacation relatives for their summer vacation

but changed their plans. but changed their plans.

M.Khashaba,MD professor of Pediatrics,Mansoura

1.1. Are there any other questions Are there any other questions

the physician should ask the the physician should ask the

parents while taking the parents while taking the

history?history?

Exposure to illness in the family Exposure to illness in the family

and other contacts.and other contacts.

M.Khashaba,MD professor of Pediatrics,Mansoura

2.2. What should be the physician’s What should be the physician’s

issue of concern? issue of concern?

Whether the infant may have a Whether the infant may have a

serious bacterial infection, serious bacterial infection,

particularly bacteremia or particularly bacteremia or

meningitis.meningitis.

How to proceed with the patient’s How to proceed with the patient’s

management while attempting to management while attempting to

exclude serious infections.exclude serious infections.M.Khashaba,MD professor of Pediatrics,Mansoura

Physical ExaminationPhysical Examination

The infant’s rectal The infant’s rectal temperature in the office was 38 c. temperature in the office was 38 c. Other vital signs were normal. He Other vital signs were normal. He was slightly fussy on examination. was slightly fussy on examination. His color was good, and he did not His color was good, and he did not seem to be in severe distress. The seem to be in severe distress. The anterior fontanelle was soft. Tone, anterior fontanelle was soft. Tone, cry, and suck were normal, and cry, and suck were normal, and Moro’s reflex was intact. Moro’s reflex was intact.

M.Khashaba,MD professor of Pediatrics,Mansoura

Physical ExaminationPhysical Examination

The rest of the examination, The rest of the examination, including head, eyes, ears, nose, including head, eyes, ears, nose, throat (HEENT), neck, heart, throat (HEENT), neck, heart, lungs, abdomen, extremities, lungs, abdomen, extremities, skin, and external genitalia, were skin, and external genitalia, were unremarkable.unremarkable.

M.Khashaba,MD professor of Pediatrics,Mansoura

3)3) What are your management options?What are your management options? Admit the patient, perform a septic Admit the patient, perform a septic

workup, and initate antibiotic therapy workup, and initate antibiotic therapy pending the results of the septic pending the results of the septic workup.workup.

Admit the patient, perform a septic Admit the patient, perform a septic workup, and observe the infant in the workup, and observe the infant in the hospital.hospital.

The parents may observe the infant at The parents may observe the infant at home with close follow-up. home with close follow-up.

M.Khashaba,MD professor of Pediatrics,Mansoura

4.4. What laboratory tests or studies What laboratory tests or studies should be ordered to exclude a should be ordered to exclude a serious bacterial infection, including serious bacterial infection, including bacteremia and meningitis?bacteremia and meningitis?

A complete blood count, urinalysis, A complete blood count, urinalysis, urine culture, blood culture, lumbar urine culture, blood culture, lumbar puncture, and chest x-ray included puncture, and chest x-ray included if the infant has respiratory if the infant has respiratory symptoms and signs.symptoms and signs.

M.Khashaba,MD professor of Pediatrics,Mansoura

5.5. What bacterial pathogens are likely What bacterial pathogens are likely to be encountered in a 1-month-old to be encountered in a 1-month-old infant with sepsis or bacterial infant with sepsis or bacterial meningitis or both?meningitis or both?

Group B streptococci, listeria Group B streptococci, listeria monocytogenes, and Ecoli are the monocytogenes, and Ecoli are the pathogens most often encountered pathogens most often encountered in neonates.in neonates.

M.Khashaba,MD professor of Pediatrics,Mansoura

6.6. Which antibiotic should be chosen Which antibiotic should be chosen

for initial coverage and why?for initial coverage and why?

Intravenous ampicillin and Intravenous ampicillin and

gentamicingentamicin

M.Khashaba,MD professor of Pediatrics,Mansoura

Low risk criteriaLow risk criteria

Absence of infection in the Absence of infection in the Bone,joint Bone,joint

No major respiratory or No major respiratory or cardiovascular problems.cardiovascular problems.

WBC 5000-15000/mm3.WBC 5000-15000/mm3. Band count < 1500/mm3Band count < 1500/mm3 Normal urine analysis.Normal urine analysis.

M.Khashaba,MD professor of Pediatrics,Mansoura

A male baby was born as A male baby was born as preterm. He was delivered preterm. He was delivered vaginally. The birth weight of vaginally. The birth weight of the baby was 1.4kg. Gestational the baby was 1.4kg. Gestational age corresponded to 32 weeks. age corresponded to 32 weeks. The Apgar score was 4 at one The Apgar score was 4 at one minute and 6 at five minutes.minute and 6 at five minutes.

Case (11)Case (11)

M.Khashaba,MD professor of Pediatrics,Mansoura

He developed RD and was He developed RD and was referred to neonatal intensive referred to neonatal intensive care unit . He started care unit . He started improving without assisted improving without assisted ventilation. ventilation.

Standard low birth weight Standard low birth weight formula feed was given on formula feed was given on third day of life. third day of life.

M.Khashaba,MD professor of Pediatrics,Mansoura

On the eighth day, distension of On the eighth day, distension of the abdomen was noted. Abdomen the abdomen was noted. Abdomen was painful on palpation. Feeding was painful on palpation. Feeding chart showed the presence of 5 ml chart showed the presence of 5 ml of residual milk from the last of residual milk from the last feeding. feeding.

Nurse in charge noticed that Nurse in charge noticed that higher incubator temperature was higher incubator temperature was required to maintain body required to maintain body temperature.temperature.

M.Khashaba,MD professor of Pediatrics,Mansoura

A low birth weight baby was A low birth weight baby was lying sick in the incubator.lying sick in the incubator.

Features of IUGR were Features of IUGR were present. There was distension of present. There was distension of the abdomen. Anthropometric the abdomen. Anthropometric measurements included the length measurements included the length 45 cm (345 cm (3rdrd centile), the weight 1.3 centile), the weight 1.3 kg, and the head circumference kg, and the head circumference was 32 cm. was 32 cm.

M.Khashaba,MD professor of Pediatrics,Mansoura

Activity of the baby was not Activity of the baby was not

satisfactory. He was a febrile. satisfactory. He was a febrile.

The heart rate was 130 per The heart rate was 130 per

minute. The respiratory rate was minute. The respiratory rate was

40 per minute. The blood 40 per minute. The blood

pressure recorded was 50/40 pressure recorded was 50/40

mm Hg. mm Hg.

M.Khashaba,MD professor of Pediatrics,Mansoura

Abdomen examination Abdomen examination revealed mild distension and revealed mild distension and mild tenderness. Bowel sounds mild tenderness. Bowel sounds were sluggish. No were sluggish. No organomegaly. Other system organomegaly. Other system examination were normal.examination were normal.

M.Khashaba,MD professor of Pediatrics,Mansoura

HemoglobinHemoglobin : 14g/dl : 14g/dl

TLCTLC : 20.000 cells/cu mm : 20.000 cells/cu mm

DLCDLC : P : P8888 L L2828 E E22 M M22 B B00

Blood c/sBlood c/s : Sterile : Sterile

Urine c/sUrine c/s : Sterile : Sterile

Stool c/sStool c/s : Sterile : Sterile

BTBT : 6 min (1-6 min) : 6 min (1-6 min)

CTCT : 5 min (4-8 min) : 5 min (4-8 min)

Platelet countPlatelet count : 4.00.000 cell/cu m : 4.00.000 cell/cu m

Peripheral blood smear: normal picture with Peripheral blood smear: normal picture with leucocytosisleucocytosis

M.Khashaba,MD professor of Pediatrics,Mansoura

Serum electrolytesSerum electrolytes: Na: 120 mEq/L: Na: 120 mEq/L

K: 4 mEq/LK: 4 mEq/L

Cl: 98 mEq/LCl: 98 mEq/L

Arterial blood gasesArterial blood gases: PH: 7.1: PH: 7.1

PPaaOO22: 45 mm of Hg: 45 mm of Hg

PPaaCOCO2: 2: 35 mm of Hg35 mm of Hg

HCOHCO33: 16 mEq/L: 16 mEq/L

Erect abdomen X-ray:Erect abdomen X-ray: Shows Shows pneumatosis pneumatosis

intestinalisintestinalisM.Khashaba,MD professor of Pediatrics,Mansoura

Up to 12% of VLBWt babies are Up to 12% of VLBWt babies are afflicted with definite NECafflicted with definite NEC

Significant morbiditySignificant morbidity Financial impactFinancial impact Important cause of death in Important cause of death in

preterms beyond 1preterms beyond 1stst week. week.

M.Khashaba,MD professor of Pediatrics,Mansoura

Typical PresentationTypical Presentation

Preterm in the 2Preterm in the 2ndnd – 3 – 3rdrd week of week of life & began feedinglife & began feeding

M.Khashaba,MD professor of Pediatrics,Mansoura

Factors Implicated in Factors Implicated in NECNEC

A.A. Mucosal InjuryMucosal Injury

B.B. Formula feedingFormula feeding

C.C. InfectionInfection

M.Khashaba,MD professor of Pediatrics,Mansoura

Mucosal InjuryMucosal Injury

1.1. Ischemic DamageIschemic Damage• Fetal distressFetal distress• Perinatal asphyxiaPerinatal asphyxia• RDSRDS• HypothermiaHypothermia• Vascular spasmVascular spasm• Exchange transfusionExchange transfusion

M.Khashaba,MD professor of Pediatrics,Mansoura

Bowel IschemiaBowel Ischemia

May be an end result of injury May be an end result of injury rather than the initiating factor.rather than the initiating factor.

M.Khashaba,MD professor of Pediatrics,Mansoura

FeedingFeeding

Factors involved include:Factors involved include:1.1. Timing of initiation Timing of initiation

2.2. Rapidity of advancementRapidity of advancement

3.3. Type of milk (breast versus Type of milk (breast versus formula)formula)

M.Khashaba,MD professor of Pediatrics,Mansoura

InfectionInfection

• E ColiE Coli• KlebsiellaKlebsiella• PseudomonasPseudomonas• SalmonellaSalmonella• Clostridium Clostridium

Risk FactorsRisk Factors

Preterm birth is the over- Preterm birth is the over- whelming risk factorwhelming risk factor

M.Khashaba,MD professor of Pediatrics,Mansoura

Why in Preterms Why in Preterms

1.1. Decreased gastric acid secretionDecreased gastric acid secretion

2.2. Immaturity of digestive enzymes.Immaturity of digestive enzymes.

3.3. Decreased mobility & incomplete Decreased mobility & incomplete innervationinnervation

4.4. Immature epithelial barrierImmature epithelial barrier

5.5. Immature immune functionImmature immune function

M.Khashaba,MD professor of Pediatrics,Mansoura

Clinical featuresClinical features Onset usually in 1-2 daysOnset usually in 1-2 days Main featuresMain features

Unstable temperatureUnstable temperature Abdominal distensionAbdominal distension Abdominal tendernessAbdominal tenderness Low blood pressure Low blood pressure BradycardiaBradycardia Disseminated intravascular Disseminated intravascular

coagulation coagulation M.Khashaba,MD professor of Pediatrics,Mansoura

Abdominal RadiographsAbdominal Radiographs

Dilated loops Dilated loops Pneumatosis intestinalisPneumatosis intestinalis Portal venous gasPortal venous gas Perforation Perforation

M.Khashaba,MD professor of Pediatrics,Mansoura

Lab- Studies Lab- Studies

May be normalMay be normal May show abnormal neutrophil May show abnormal neutrophil

count, thrombocytopenia or acidosiscount, thrombocytopenia or acidosis

M.Khashaba,MD professor of Pediatrics,Mansoura

Differential DiagnosisDifferential Diagnosis

SepticemiaSepticemia Meconium plug syndromeMeconium plug syndrome MalrotationMalrotation Hirschsprung diseaseHirschsprung disease

M.Khashaba,MD professor of Pediatrics,Mansoura

M.Khashaba,MD professor of Pediatrics,Mansoura

M.Khashaba,MD professor of Pediatrics,Mansoura

M.Khashaba,MD professor of Pediatrics,Mansoura

M.Khashaba,MD professor of Pediatrics,Mansoura

ManagementManagement All oral feeds should be stopped.All oral feeds should be stopped. Relief gastric distensionRelief gastric distension Total parentral nutrition startedTotal parentral nutrition started Control of electrolyte & acid-base balanceControl of electrolyte & acid-base balance Management of hemodynamic disturbancesManagement of hemodynamic disturbances Plasma or platelet transfusion as neededPlasma or platelet transfusion as needed Combination AntibioticsCombination Antibiotics follow up for possible perforation follow up for possible perforation

M.Khashaba,MD professor of Pediatrics,Mansoura

1.1. Gastro Intestinal perforationGastro Intestinal perforation Occur in 20-30% of babiesOccur in 20-30% of babies Onset early 10-48 hrs after onsetOnset early 10-48 hrs after onset

2.2. Peritonitis Peritonitis AscitesAscites Abdominal massAbdominal mass Abdominal wall erythemaAbdominal wall erythema Induration Induration

M.Khashaba,MD professor of Pediatrics,Mansoura