LMCC Review Course:NeonatologyGregory Moore, MD, FRCPCDivision of NeonatologyMarch 2012

OutlineResuscitation principlesTransition to ex-utero life

Normal newborn care and assessment

Small and Large-for-Gestational Age neonates and their problems

Prematurity and its complications

Problems of the term infant

For Starters Infant (< 1 yr old) mortality:5 deaths per 1000 live births (Canada)Due to congenital anomalies, prematurity, asphyxia, infections, SIDS

Normal vitals for a baby at term:HR: 120-160/min *RR: 40-60/min *BP: 50-80/30-40 mmHgSats: >95% by ~1 hr of age *

For Starters

Gestation (wks)Birth Weight (kg)271.0301.5332.0352.337-403.5 (2.5 4.5)

Newborn ResuscitationInitial steps: warm, dry, stimulateEvaluate respirationsEvaluate heart rateEvaluate toneEvaluate color

Remember - the key to a babys transition to the real world is opening the lungs: VENTILATION Oxygenation

1. Red blood from placenta2. Less red blood from right to left atrium via patent foramen ovale3. Small amount ofpink bloodgoing to lungsIn-utero4. Pink blood goes from thepulmonary artery to aorta via ductus arteriosus produces mixing ofpink and less red blood

1. Cord is clamped Increases SVR2. Foramen ovale functionally closes3. Pulmonary arteries vasodilate to increase blood flow to the lungsEx-utero4. Ductus arteriosus closes

Fluid-filled alveoli in uteroDiminished blood flow in-utero through fetal lungs

Importance of first breath

The End Product

Neonatal Resuscitation Program

90% of babies

9% of babies

0.9% of babies

0.1% of babies

Newborn ResuscitationA: AirwayB: BreathingC: CirculationD: DrugsE: EnvironmentF: FluidsG: Glucose

IV, O2, Monitor if distressed

NB. Newborn ResuscitationMECONIUM in the amniotic fluid AND depressed newborn (limp, not crying):Intubate and suction below cords FIRST

Suspect diaphragmatic hernia:Intubate ASAP

Pink when crying blue when not:Suspect choanal atresia and try an oral airway

The Apgar Score

Feature

0 points

1 point

2 points

Heart rate

0

< 100

> 100

Respiratory Effort

Apnea

Irregular, gasping

Regular, crying

Color

Pale, blue

Pale or blue extremities

Pink

Muscle tone

Absent

Weak, passive tone

Active movement

Reflex irritability

Absent

Grimace

Active avoidance

Ensure warmth and early nutrient intake

Support breastfeeding

Monitor weight and hydration status

Educate about infant care **

Anticipatory guidance **Principles of Routine Care

Principles of Routine CareProphylaxis for common problemsEye care: erythromycin ointmentVitamin K: 1 mg IM

Screening for disease: >24hNewborn screen (24-72 hr)PKU (1/15,000)Hypothyroidism (1/4000)24 other diseases (OA/AA/FA disorders, SCA, Hgbpathies, CAH, galactosemia, endocrinopathies)Neurosensory hearing loss (pre-d/c)Hyperbilirubinemia (pre-d/c)

Blood group and Coombs if mother Rh negative

The Newborn HistoryIdentificationMaternal History:AgePast medical/surgicalMedications, Drugs/Smoking/EtOHPast pregnancy(ies) (GTPAL)Current pregnancy (including screening test results, antenatal steroid use)Family HistorySocial HistoryLabour and Delivery HistoryResuscitation HistoryEarly Postnatal Course

Physical ExaminationVital signs

Measurements plot!

Gestational age assessment

Overall appearance (well/unwell)

System by system (or head to toe) **

The depressed newbornNeurological:Asphyxia, CNS Trauma

Respiratory:Apnea (secondary)

Cardiovascular:Hypovolemia/shock/hydrops

Congenital:Malformations

Drugs

The Basic TestsBlood gas (arterial or capillary)GlucoseElectrolytesComplete Blood Count + differentialBlood cultureChest X-ray

Consider:Lactate, CRP, echocardiogram, abdominal x-rayFull septic workup if > 72 hours old

Perinatal Asphyxia- Must be documented by cordocentesis, fetal scalp blood sampling, cord blood samplingpH < 7.00, base deficit > 15 mEq/LApgar less than 5 at 5 minutesEncephalopathyMultiorgan involvement (heart, kidneys, marrow, liver)

- Neonatal encephalopathy must be documented for perinatal asphyxia to be considered as a cause of later neurodevelopmental problems

Most common anomalies noted on initial exam

Skin tags

10-15/1000

Polydactyly

10-15/1000

Cleft lip or palate

1-4/1000

Congenital heart defect

1-4/1000

Congenital hip dysplasia

1-4/1000

Down Syndrome

1-4/1000

Talipes equinovarus

1-4/1000

Spina bifida

1-4/10,000

Most frequent birth injuriesAsphyxiaBroken clavicleFacial palsyBrachial plexus injuryFractures of humerus or skullLacerations or scalp injuriesRuptured internal organsTesticular traumaFat necrosis

Differentiating Scalp Injuries

Commonest Congenital Abdominal MassesRenal (55%)Genital (15%)Gastrointestinal (15%)Liver and Biliary (5%)Retroperitoneal (5%)Adrenal (5%)

Common physical findings of clinical significanceApnea, bradycardia, cyanosis (peripheral)Tachypnea, gruntingAbsent or decreased femoral pulsesHeart murmur, cyanosis (central)HypotoniaOrganomegalyAbsent red reflexJaundicePlethora or pallor or diffuse petechiae

Disorders of gestation length or of growth

Small for gestational age: 2SD above

Prematurity: 42 weeks gestation

Birth Weight Matters

Small for gestational age: EtiologiesConstitutional

MaternalIllness, Rx/EtOH/drugs/cigs, nutrition

Placental

FetalGenetic disorder, infections (TORCH)

Small for gestational age: complicationsAsphyxiaMeconium aspirationCongenital malformationsHypoglycemiaHypothermiaHypocalcemiaPolycythemia-hyperviscosityIncreased neonatal mortality (OR 2.77)Long term morbidity

Small for gestational age: ManagementOptimal resuscitationMaintenance of body temperatureEarly feeds or administration of glucoseMeticulous history and physical examination, including placentaWork-up for etiology

Disorders of gestation length or of growth

Small for gestational age: 2SD above

Prematurity: 42 weeks gestation

Large for gestational age: Etiologies

Constitutional

Abnormal maternal glucose tolerance

Syndromes: Beckwith-Wiedemann Sotos

Large for gestational age: Complications

Asphyxia

Birth trauma

Hypoglycemia

Large for gestational age: Management

Optimal resuscitation

Early feeds or administration of glucose

Disorders of gestation length or of growth

Small for gestational age: 2SD above

Prematurity: 42 weeks gestation

Causes/Risks for PrematurityFetal:Multiple gestationFetal hydrops (immune and non-immune)Congenital/Genetic anomaliesPlacental:Placenta praeviaAbruptio placentaPlacental insufficiencyUterine:Incompetent cervixExcessive enlargement (hydramnios)Malformations (leiomyomas, septate)Maternal:Previous history of premature deliveryPre-eclampsiaPremature rupture of membranesSmoking, substance abuseChronic medical illnesses, low weight, extremes of ageInfections (urinary, cervical, amniotic)-group B streptococcus, herpes, TORCH, etc.Iatrogenic (indicated induction of labor)

And then there was a baby Transfer to a level 2 nursery if:< 36 weeks GA< 2 kg

Transfer to a level 3 nursery if:< 32 weeks GARespiratory support required

Need for special care due to:Risk of complicationsNutritional needs

Transfer Mom prior to birth if at all possible

Prematurity: ComplicationsRespiratory distress syndromeBronchopulmonary dysplasiaApnea of prematurityPatent ductus arteriosusIntraventricular hemorrhagePeriventricular leukomalaciaNecrotizing enterocolitisSepsisAnemiaRetinopathy of prematurity

Respiratory Distress SyndromeEtiologyAnatomic immaturity of the lung

Increased interstitial and alveolar lung fluid

Surfactant deficiency

Courtesy of Professor Louis De Voshttp://www.ulb.ac.be/sciences/biodic/index.html17Weeks

Courtesy of Professor Louis De Voshttp://www.ulb.ac.be/sciences/biodic/index.html22Weeks

Courtesy of Professor Louis De Voshttp://www.ulb.ac.be/sciences/biodic/index.html25Weeks

CXR: poor aeration, ground-glass appearance, homogenous, air bronchograms

Respiratory Distress SyndromeManagement:Prevention - antenatal steroids

Positive pressure ventilation

Oxygen

+/- Surfactant (requires intubation)

Pressure (cmH20)Volume (ml)

Bronchopulmonary DysplasiaRespiratory symptoms, x-ray abnormalities, and O2 reqt for > 28 d and persisting at 36 wks corrected GAPathophysiology:Disturbed alveolarization with increased alveolar-to-capillary distance and decreased alveolar-to-capillary rationSecondary to:Lung inflammationMucociliary dysfunctionAirway narrowingHypertrophied airway smooth muscleAlveolar collapseConstriction of pulmonary vascular bed

Bronchopulmonary DysplasiaManagement:Prevention: IM Vitamin A, CaffeineNUTRITIONOxygen +/- ventilation+/- Diuretics+/- Steroids: systemic, inhaled+/- Bronchodilators

Prognosis:Increased respiratory illnesses in childhoodDecreased long-term lung functionBUT, fine in the playground by pre-school age (usually )

Apnea of PrematurityCentral, obstructive, or mixed **Majority of

Patent ductus arteriosusSeen in >60% of

Metabolic Problems of PrematurityHypoglycemiaFluid/electrolyte imbalanceHypocalcemia/hypomagnesemiaHyperbilirubinemiaHypothermia

Intraventricular hemorrhageCommon in < 1500 gm babiesUsually evident in 1st week of life

Reasons:highly vascularized germinal matrixless basement membrane to capillariesabnormal cerebral autoregulation

Prognosis:Good - small amounts of bleeding in the ventriclesPoorer - large amount intraparenchymally or if post-hemorrhagic hydrocephalus

Periventricular leukomalaciaPathophysiology:Ischemic lesion to watershed area around ventricles in premature infantsLink to inflammation?Most often shows up 3-4 wks after delivery

Prognosis:Correlated with cerebral palsy

Necrotizing Enterocolitis1-5% NICU admissionsMulti-factorial etiology:Feeds, Prematurity, Ischemia, InfectionDiagnosis: clinical and radiologicTreatment:Decompression (NPO, NG tube)AntibioticsSurgery prnPrognosis:30% mortality if

SepsisSuboptimal immune function in preemies plus poor skin barrier, indwelling catheters

GBS and coliforms cause early onset sepsis < 5-7 days of life

Nosocomial sepsis common in premsMost common = coagulase negative staphylococcusFungi can also be problematic in > 1 week of life

Anemia of PrematurityReasons:decreased hemoglobin at deliverydecreased RBC survivalblunted erythropoietin responseIATROGENIC

Treatment:preventioniron supplementationtransfusionEPO

Retinopathy of Prematurity40-70% NICU survivors < 1000 gEtiology:vasoconstriction leading to abnormal vascular proliferation

Diagnosis:Screening

Treatment:Close monitoring, laser if necessary

Long Term Outcomes 24 weeks

Disorders of gestation length or of growth

Small for gestational age: 2SD above

Prematurity: 42 weeks gestation

PostmaturityLabour tends to be induced to avoid problems of postmaturity, however if dates not accurate may still occur

Possible complicationsGrowth disturbancesAsphyxiaMeconium aspiration syndrome

Problems of the Term NewbornRespiratoryCardiacSepsisDigestiveJaundiceAnemia, polycythemia, hemorrhageRenalEndocrineNeurologic

Respiratory Distress in the NewbornRespiratoryCardiacInfectiousNeurologicMetabolicGastrointestinalHematologicalMusculoskeletal

Respiratory Problems in the Term NewbornTransient tachypnea of the newbornMeconium aspirationPersistent pulmonary hypertensionPulmonary air leaks/PneumothoraxCongenital malformationsPulmonary hemorrhagePneumonia

Transient Tachypnea of the NewbornFailure to clear lung fluidAssociated with:Absent labour (planned C/S or C/S without labour) or;Short labour or;Initial weak or absent respirationsImproves with time

PneumoniaCan initially be difficult to distinguish from TTN/RDS

Group B Strep #1

Consolidation may appear after a few days

Meconium Aspiration SyndromeMeconium-stained amniotic fluid Intrauterine insult may lead to gaspingMeconium aspiratedPneumonitisAirway occlusionPulmonary air leak syndromeMay lead to persistent pulmonary hypertension

Congenital MalformationsAnomalies anywhere along airways:Nose to alveoliExtrinsic or intrinsicAtresiasCystsDiaphragmatic hernia

Persistent Pulmonary HypertensionAssociated with:AsphyxiaMeconium aspirationSepsisRight to left shunting through PDA (i.e. persistent fetal circulation)Treatment:Oxygenation, ventilationMaintain blood pressurePulmonary vasodilators

Congenital Heart Disease: PresentationsCyanosis

Congestive heart failure

Murmurs

Dysrhytmias

Sepsis: Risk factorsPreterm rupture of membranese.g. weeksProlonged rupture of membranes>18 hoursMaternal group B strep carriageMaternal GBS bacteriuriaPrevious infant with GBS infectionChorioamnionitis

Neonatal SepsisTHINK OF IT!Signs may be subtle, non-specificIncidence bacterial sepsis = 1-5/1000 live birthsCommonest organisms:Group B streptococcusGram negatives (E coli, Klebsiella)Enterococcus, H flu, staph speciesListeriaWork up and treat if suspect sepsisUse broad spectrum antibiotics

Ophthalmia neonatorum 1st days - differentiate chemical vs infected2nd-3rd wk - viral or bacterial

Gonococcal:within 5 days of birthgram negative intracellular diplococciif suspect, Penicillin asaphighly contagious

Chlamydia:5-14 daysconjunctival scrapingtopical antibiotics

Congenital Infections **CMV:5-25/1,000 live birthsAsymptomatic vs severe symptomsMicrocephaly, thrombocytopenia, hepatosplenomegaly, chorioretinitisSequelae of hearing loss and developmental delay

Rubella0.5/1,000Cataracts, rash, congenital heart disease, developmental delay

Congenital InfectionsToxoplasmosis:0.5-1.0/1,000Hydrocephalus, cranial calcifications, chorioretinitis

Syphilis:0.1/1,000Snuffles, osteochondritis/periostitis, rash

Herpes Simplex Virus:Vesicles, keratoconjuntivitis, CNS findingsViral sepsis

Congenital syphilisTreat mother no matter what stage of pregnancy

If adequate maternal treatment and no signs of infection in newborn, give one dose IM penicillin

If inadequate maternal treatment, give 10 days of IV penicillin

Neonatal herpes simplexOnly about 1/3 mothers have overt signs

Infection can be disseminated or local

Usually present at 5-10 days of age

If suspect:Cultures, PCRTreat with Acylovir

Maternal hepatitis B carrierGive baby hepatitis vaccine as soon as possible after birth (first 12 hours)

Bath

Universal precautions

Immune globulin in first 7 days

HIVVirus can be transmitted transplacentally, intrapartum, or postpartumScreen mothersTreat mothers with antiretrovirals Treat babies with AZT for 6 wksUniversal precautionsLook for other infections (HepB/C)No breastfeeding in developed world

Vomiting in the NewbornNot uncommon for some vomiting in 1st few hours and days after birthOverfeeding, poor burping

DDx:GI: obstruction, reflux, milk allergy, NECInfection: Sepsis, Meningitis, UTIEndocrine: Adrenal hyperplasiaCNS: Increased ICPDrugs

Bilious vomiting is a medical emergency!

Upper GI problems vomitingEsophageal:first feed, soon after feedexcessive droolingif T-E fistula, risk of aspiration

Small bowel atresias

Malrotation and volvulus

AchalasiaChalasia/GERPyloric stenosis} Need to r/o

Lower GI ObstructionPresents with:DistentionFailure to pass meconiumVomiting is a later signExtrinsic vs intrinsic obstructionDDx: Imperforate anus, Hirschprung, meconium ileus, meconium plug, ileal atresia, colonic atresia

Constipation> 90% pass meconium in first 24 h

If constipation is present from birth:Consider causes of GI obstructionIf present after birth:Consider Hirschprungs, hypothyroidism, anal stenosis

NB:Some breastfed babies normally stool only once every 5-7 daysPremature infants often have delayed meconium passage

JaundiceFirst 24 h or conjugated at ANY time = ALWAYS abNEtiology: Unconjugated1. RBC destruction/hemolytic :Isoimmune, RBC membrane, enzymes, hgbinopathiesHematomaSepsis (mixed hemolytic and hepatocellular damage)Hypoxia2. Conjugation Abnormalities:Breast Milk JaundiceMetabolic/Genetic: Gilbert, Crigler-Najjar, Hypothyroidism3. Increased Enterohepatic Circulation:GI dysmotility or obstructionBreast feeding jaundice

Later onset: Conjugated1. Hepatocellular damage: ViralBacterialMetabolic: TPN, CF, tyrosinemia, other

2. Post hepatic: Biliary atresiaCholedochal cystJaundice

Jaundice - Work-UpHistory and physical examinationBilirubin - total and directBlood type and CoombsHemoglobinReticulocyte countSmearSeptic workup+/- Abdominal Ultrasound+/- Metabolic, Viral workup

Risk factors for kernicterusPrematurityHemolysisAsphyxiaAcidosisInfectionCold stressHypoglycemia

Treatment of JaundiceNutrition/hydration

Phototherapy

Exchange transfusion

AnemiaHemorrhageFeto-maternalFeto-placentalFeto-fetalIntracranial or extracranialRupture of internal organsHemolysisPrematurity

Treatment:Transfuse if necessary

Endocrine Issues - HypothyroidismScreen because too late for proper neurodevelopment if waitSigns:Poor feedingConstipationProlonged jaundiceLarge fontanellesUmbilical herniaDry skin

Endocrine Issues Ambiguous GenitaliaCongenital adrenal hyperplasia21-hydroxylase deficiency = most common enzyme abNSigns = vomiting, diarrhea, dehydration, shock, convulsions, clitoris or phallic enlargementWatch for electrolyte imbalancesIf suspect, send lab tests and treat with steroids

Endocrine Issues Infant of a Mom with DiabetesIncreased Risk of:Congenital malformationsIncreased incidence with poor glycemic controlGrowth disturbancesMetabolic disturbancesHypoglycemia, hypocalcemiaRespiratory:RDS, TTNHematologic:Polycythemia HyperbilirubinemiaCardiovascular problems:Hypertrophic cardiomyopathy

HypoglycemiaDefinition:BS

HypoglycemiaTreat by supplying glucose needs:Term: supply minimum of 4-6 mg/kg/minPreterm: supply minimum of 6-8 mg/kg/min

Look for cause if severe or persists beyond 48-72h of lifeCritical Sample of blood and urine

Neonatal seizures: Etiology

Asphyxia

46%

Infection

17%

Intracranial hemorrhage

7%

Intraventricular hemorrhage

6%

Infarction

6%

Hypoglycemia

5%

Congenital anomaly of CNS

4%

Inborn errors of metabolism

4%

Subarachnoid hemorrhage

2%

Thank you! Questions? gmoore@cheo.on.ca

N.B.These slides are all based on the LMCC website areas that related to my expertise and wasnt covered by my pediatric or obstetric colleagues talks (e.g. Resp, Cardio, Development, Gen Paeds, MFM)Covered: 19-1, 31-2, 36-1, 37-2, 49-1, 64, 65, 74-1, 82, 107-3, 118-3

This is quite exhaustive but not fully exhaustive!Glad to stop for questions any time on either what Im saying, or if you have some sample questions youd like to review with me.These slides are all based on the LMCC website areas that related to my expertise and wasnt covered by my pediatric or obstetric colleagues talks (e.g. Resp, Cardio, Development, Gen Paeds, MFM) (19-1, 31-2, 36-1, 37-2, 49-1, 64, 65, 74-1, 82, 107-3, 118-3)Im saying more than what is in the slides so pay attention to at least some degree!HR can be normal at 70 when asleep increases with alertness or stimulation. Also, some babies have a higher rate at 180RR = 35-50 according to LMCCTakes time for the sats to reach normal. Some babies will be saturating >95% by 5 minsThe key is not hyperoxia, fluid support, or cardiac supportC: may need UVC asapE: keep warmG: avoid hypoglycemiaA appearance, P pulse, G grimace, A activity, R respirations = Pneumonic** Feeding Routine discuss here** Feeding, Urinating, Stooling, Respiratory Pattern, Sleeping Pattern DISCUSS NORMAL

Comment briefly on each:ID: GA, hrs of age, bt wt, presenting problemMatl Hx: illnesses, amniotic fluid volume/colourFHx: neonatal deaths, DD, jaundiceSocial Hx: partner involvement, CASL&D: ROM, meconium, mode, placenta, cordResuscitation: Apgars, detailsEarly Postnatal: Feeding, Urinating, Stooling, Respiratory Pattern, Sleeping PatternOr use the dont wake a sleeping baby/dont make a happy baby cry methodsSystems: Head and Neck, Cardio, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Neurological, Skin/Integumentary** Key things: Fontanelles (timing of closure); Hip checking (repeatedly), Umbilicus (care and natural history); Eyes (colour not fixed until after 2 yrs); Depressed meaning minimal activity or responsivenessDrugs: think MgSO4 for PIH, opioids for labour pain, cocaine for placental abruption, GA for urgent C/S- Going to show some photos a bit graphic sorry!Cleft lip and palateDowns SyndromeSingle palmar crease and clinodactyly- Hypotonia- Sandal toe gap- Bruschfields spotsClub foot (talipes equinovarus)Meningocele N vertebrae, just meninges sticking out usually normal neurologically This lesion is not very commonMyelomeningocele vertebrae not posteriorly fused so meninges + spinal cord come out spinal cord malformed neurological sequelae This lesion is the most common form of spina bifida.- Microcephaly- Hydrocephalus- Clavicle fracture- R clavicle fracture- Asx Moro due to L brachial plexus injuryBilateral cephalohematomasContrast these with caput 2 babies of the same GA:Size matters!**There is a differential diagnosis Apnea of Prematurity is a diagnosis of exclusion. Must R/O: Infection/Sepsis, A/W abN, CNS abN, GER, Anemia, Drugs.30 week infant girl; 2 weeks old; treated for PDA with indomethacinTriplet 2, 30 weeks; unwell on day 8 with spells, abdominal distensionClassic: hyperinflated, streaky lung markings, fluid in the fissuresSo we often treat with antibiotics if uncertain and baby doesnt follow typical TTN clinical course- You get a talk from the Peds cardiologist ** TORCHES:Toxoplasmosis, Rubella, CMV, Chylamydia, HIV, HSV, Hepatitis, Enterovirus, SyphillisColonic atresiaHirshsprungDistal ileal volvulus- Focus on the fact that really there should be NO constipation in neonates or young infants Jaundice, usually mild unconjugated bilirubinemia, affects nearly all newborns. Up to 65% of full-term neonates have jaundice at 72 - 96 hours of age. Although some causes are ominous, the majority are transient and without consequences.dont label the babys sex if uncertainHx, P/E, Abdominal U/S, glucose, lytes, 17-OH Progesterone level, cortisol, other endocrinological tests, CONSULT and TRANSFER!Etiologies: Metabolic Disorder (Glycogen Storage Disease, Galactosemia), Endocrinologic (IDM, Hyperinsulinism)