lmcc review course “neonatology” lmcc review course “neonatology” brigitte lemyre, md, frcpc

LMCC Review CourseLMCC Review Course“Neonatology”“Neonatology”

Brigitte Lemyre, MD, FRCPCBrigitte Lemyre, MD, FRCPC

OutlineOutline

Resuscitation principles, transition Resuscitation principles, transition to lifeto life

Normal newborn care and Normal newborn care and assessmentassessment

IUGR and LGA and their problemsIUGR and LGA and their problems Prematurity and its complicationsPrematurity and its complications Problems of the term infantProblems of the term infant

Infant mortality:

9-10: 1000 birthsDue to congenital anomalies, prematurity, asphyxia, infections, SIDS

Normal baby at term:

HR: 120-160/minRR: 40-60/minWeight: 2.5-4.5 kgBP: 50-80/30-40 mmHg

Gestational age and sizeGestational age and size

GestationGestation SizeSize

28 weeks28 weeks 1.0 kg1.0 kg




37-40 weeks37-40 weeks 2.5 – 4.5 kg2.5 – 4.5 kg

Newborn ResuscitationNewborn Resuscitation

Initial stepsInitial steps Evaluate respirationEvaluate respiration Evaluate heart rateEvaluate heart rate Evaluate colorEvaluate color

Remember - the usual problem Remember - the usual problem in the neonate is the lungs: in the neonate is the lungs: VENTILATION!VENTILATION!

Fluid filled alveoli in utero

Diminished blood flow through fetal lungs

Importance of first breath

Newborn ResuscitationNewborn Resuscitation

A: AirwayA: Airway B: BreathingB: Breathing C: CirculationC: Circulation D: DrugsD: Drugs E: EnvironmentE: Environment F: FluidsF: Fluids G: GlucoseG: Glucose

Special Circumstances in Special Circumstances in Newborn ResuscitationNewborn Resuscitation

Meconium in amniotic fluid AND Meconium in amniotic fluid AND depressed newborn (not crying, depressed newborn (not crying, limp): limp): Intubate and suction Intubate and suction below cordsbelow cords

Suspect diaphragmatic hernia: Suspect diaphragmatic hernia: IntubateIntubate

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

The Apgar ScoreThe Apgar ScoreFeature 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 adequate Ensure warmth and adequate nutrient intakenutrient intake

Monitor weight, hydration statusMonitor weight, hydration status Support breastfeedingSupport breastfeeding Educate about infant careEducate about infant care Anticipatory guidanceAnticipatory guidance

Principles of Routine CarePrinciples of Routine Care

Principles of Routine CarePrinciples of Routine Care Prophylaxis for common problemsProphylaxis for common problems

– Eye care: erythromycin ointmentEye care: erythromycin ointment– Vitamin K: 1 mg IMVitamin K: 1 mg IM

Screening for disease: >24hScreening for disease: >24h– PKU (1/15,000)PKU (1/15,000)– Hypothyroidism (1/4000)Hypothyroidism (1/4000)– Neurosensory hearing lossNeurosensory hearing loss– 24 other metabolic diseases (organic acid 24 other metabolic diseases (organic acid

disorders, FAOD, aminoacid disorders, sickle cell disorders, FAOD, aminoacid disorders, sickle cell and hemoglobinopathies, CAH, galactosemia, and hemoglobinopathies, CAH, galactosemia, endocrinopathies)endocrinopathies)

Blood group and Coombs if mother rH negBlood group and Coombs if mother rH neg

The depressed newbornThe depressed newborn

AsphyxiaAsphyxia Respiratory conditionRespiratory condition Hypovolemia/shockHypovolemia/shock DrugsDrugs CNS TraumaCNS Trauma Congenital malformationsCongenital malformations

Perinatal AsphyxiaPerinatal Asphyxia

Must be documented by cordocentesis, fetal Must be documented by cordocentesis, fetal scalp blood sampling, cord blood samplingscalp blood sampling, cord blood sampling

pH pH << 7.00, base deficit 7.00, base deficit >> 15 mEq/L 15 mEq/L EncephalopathyEncephalopathy Multiorgan involvement (heart, kidneys, Multiorgan involvement (heart, kidneys,

marrow, liver)marrow, liver)

For perinatal asphyxia to have been cause ofFor perinatal asphyxia to have been cause oflater neurodevelopmental problem, mustlater neurodevelopmental problem, mustdocument neonatal encephalopathydocument neonatal encephalopathy

The Newborn HistoryThe Newborn History

The baby’s history is:The baby’s history is:– the family historythe family history– the mother’s past medical historythe mother’s past medical history– the mother’s pregnancy history the mother’s pregnancy history

(including any information about (including any information about screening tests, amniotic fluid)screening tests, amniotic fluid)

– the labor and delivery history (including the labor and delivery history (including the placenta and umbilical cord)the placenta and umbilical cord)

– the resuscitation historythe resuscitation history

Physical ExaminationPhysical Examination

Vital signsVital signs Measurements: plot on curvesMeasurements: plot on curves Gestational age assessmentGestational age assessment Overall appearanceOverall appearance System by systemSystem by system

Most common anomalies Most common anomalies noted on initial examnoted on initial exam

Skin tags 10-15/1000Polydactyly 10-15/1000

Cleft lip or palate 1-4/1000Congenital 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 Most frequent birth injuriesinjuries

AsphyxiaAsphyxia Broken clavicleBroken clavicle Facial palsyFacial palsy Brachial plexus injuryBrachial plexus injury Fractures of humerus or skullFractures of humerus or skull Lacerations or scalp injuriesLacerations or scalp injuries Ruptured internal organsRuptured internal organs Testicular traumaTesticular trauma Fat necrosisFat necrosis

Commonest Congenital Commonest Congenital Abdominal MassesAbdominal Masses

Renal (55%)Renal (55%) Genital (15%)Genital (15%) Gastrointestinal (15%)Gastrointestinal (15%) Liver and Biliary (5%)Liver and Biliary (5%) Retroperitoneal (5%)Retroperitoneal (5%) Adrenal (5%)Adrenal (5%)

Common physical findings Common physical findings of clinical significanceof clinical significance

Apnea, tachypnea, gruntingApnea, tachypnea, grunting Bradycardia, cyanosisBradycardia, cyanosis HypotoniaHypotonia Absent or decreased femoral pulsesAbsent or decreased femoral pulses Heart murmurHeart murmur OrganomegalyOrganomegaly Absent red reflexAbsent red reflex JaundiceJaundice Plethora or pallor or diffuse petechiaePlethora or pallor or diffuse petechiae

Disorders of gestation Disorders of gestation length or of growthlength or of growth

Small for gestational age: <2SD Small for gestational age: <2SD belowbelow

Large for gestational age: >2SD Large for gestational age: >2SD aboveabove

Prematurity: <37 weeks gestationPrematurity: <37 weeks gestation Postmaturity: >42 weeks gestationPostmaturity: >42 weeks gestation

Small for gestational age: Small for gestational age: etiologiesetiologies

Constitutional: ethnicityConstitutional: ethnicity Maternal: illness, Rx/R-OH/drugs,Maternal: illness, Rx/R-OH/drugs,

nutritionnutrition PlacentalPlacental Fetal: genetic disorder, infections Fetal: genetic disorder, infections

(TORCH)(TORCH)

Small for gestational age: Small for gestational age: complicationscomplications

AsphyxiaAsphyxia Meconium aspirationMeconium aspiration Congenital malformationsCongenital malformations HypoglycemiaHypoglycemia HypothermiaHypothermia HypocalcemiaHypocalcemia Polycythemia-hyperviscosityPolycythemia-hyperviscosity

Small for gestational age: Small for gestational age: ManagementManagement

Optimal resuscitationOptimal resuscitation Maintenance of body temperatureMaintenance of body temperature Early feeds or administration of Early feeds or administration of

glucoseglucose Meticulous history and physical Meticulous history and physical

examination, including placentaexamination, including placenta Work-up for etiologyWork-up for etiology

Large for gestational age: Large for gestational age: EtiologiesEtiologies

ConstitutionalConstitutional Abnormal maternal glucose Abnormal maternal glucose

tolerancetolerance Syndromes: Beckwith-WiedemannSyndromes: Beckwith-Wiedemann

SotosSotos

Large for gestational age: Large for gestational age: ComplicationsComplications

AsphyxiaAsphyxia Birth traumaBirth trauma HypoglycemiaHypoglycemia

Large for gestational age: Large for gestational age: ManagementManagement

Optimal resuscitationOptimal resuscitation Early feeds or administration of Early feeds or administration of

glucoseglucose




Prematurity: <37 weeks Prematurity: <37 weeks gestationgestation

Postmaturity: >42 weeks gestationPostmaturity: >42 weeks gestation

Risk Factors for PrematurityRisk Factors for Prematurity

-previous preterm birth/labour-previous preterm birth/labour-cervical/placental anomalies-cervical/placental anomalies-chorioamnionitis-chorioamnionitis-uterine distention-uterine distention-twins/multiple pregnancy -twins/multiple pregnancy -maternal medical conditions -maternal medical conditions -low pre-pregnancy weight-low pre-pregnancy weight-maternal age-maternal age

–cigarette smoking–high perceived stress –bacterial vaginoses–cocaine use –urinary tract infection–asymptomatic bacteriuria

Risk Factors for Risk Factors for PrematurityPrematurity

Prematurity: Prematurity: ComplicationsComplications

Respiratory distress syndromeRespiratory distress syndrome Bronchopulmonary dysplasiaBronchopulmonary dysplasia Apnea of prematurityApnea of prematurity Patent ductus arteriosusPatent ductus arteriosus Intraventricular hemorrhageIntraventricular hemorrhage Periventricular leukomalaciaPeriventricular leukomalacia Necrotizing enterocolitisNecrotizing enterocolitis SepsisSepsis AnemiaAnemia Retinopathy of prematurityRetinopathy of prematurity

Respiratory Distress Respiratory Distress SyndromeSyndrome

EtiologyEtiology– Anatomic immaturity of the lungAnatomic immaturity of the lung– Increased interstitial and alveolar lung Increased interstitial and alveolar lung

fluidfluid– Surfactant deficiencySurfactant deficiency

ManagementManagement– Prevention: antenatal steroidsPrevention: antenatal steroids– OxygenOxygen– Positive pressurePositive pressure– SurfactantSurfactant

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

17Weeks


22Weeks


25Weeks

Bronchopulmonary Bronchopulmonary DysplasiaDysplasia

Respiratory symptoms, oxygen Respiratory symptoms, oxygen requirement for at least 28 days, and X-requirement for at least 28 days, and X-ray abnormalities at 36 wks ray abnormalities at 36 wks postconceptional agepostconceptional age

Pathophysiology: disturbed alveolarization

-Lung inflammation -Mucociliary dysfunction

-Airway narrowing-Hypertrophied airway smooth muscle-Alveolar collapse-Constriction of pulmonary vascular bed

Management:Management:

–PreventionPrevention

–NutritionNutrition

–Oxygen +/- ventilationOxygen +/- ventilation

–BronchodilatorsBronchodilators

–DiureticsDiuretics

–Steroids: inhaled vs systemicSteroids: inhaled vs systemic

Bronchopulmonary Bronchopulmonary DysplasiaDysplasia

Apnea of PrematurityApnea of Prematurity

Central, obstructive, or mixedCentral, obstructive, or mixed Majority of <32 weeksMajority of <32 weeks Treat withTreat with

– Adequate positioningAdequate positioning– OxygenOxygen– MethylxanthinesMethylxanthines– CPAPCPAP– Ventilation if necessaryVentilation if necessary

Patent ductus arteriosusPatent ductus arteriosus

Up to 42% of < 1500 g babiesUp to 42% of < 1500 g babies Management strategies:Management strategies:

-preload/afterload reduction-preload/afterload reduction

-Adequate oxygenation-Adequate oxygenation

-Optimize pH-Optimize pH

-indomethacin -indomethacin

-surgery-surgery

-conservative management-conservative management

Metabolic Problems of Metabolic Problems of PrematurityPrematurity

HypoglycemiaHypoglycemia Fluid/electrolyte imbalanceFluid/electrolyte imbalance Hypocalcemia/hypomagnesemiaHypocalcemia/hypomagnesemia HyperbilirubinemiaHyperbilirubinemia HypothermiaHypothermia

Intraventricular Intraventricular hemorrhagehemorrhage

Common in < 1500 gm babiesCommon in < 1500 gm babies Usually evident in 1st week of lifeUsually evident in 1st week of life Reasons:Reasons:

– highly vascularized germinal matrixhighly vascularized germinal matrix– less basement membrane to capillariesless basement membrane to capillaries– abnormal autoregulationabnormal autoregulation

Prognosis good for small amount bleeding Prognosis good for small amount bleeding in ventricles but poorer if large amount in ventricles but poorer if large amount intraparenchymally or if posthemorrhagic intraparenchymally or if posthemorrhagic hydrocephalushydrocephalus

Periventricular Periventricular leukomalacialeukomalacia

Ischemic lesion to watershed area Ischemic lesion to watershed area around ventricles in premature infantsaround ventricles in premature infants

Link to inflammation?Link to inflammation? Most often shows up 3-4 wks after Most often shows up 3-4 wks after

deliverydelivery Correlated with cerebral palsyCorrelated with cerebral palsy

Necrotizing EnterocolitisNecrotizing Enterocolitis

1-5% NICU admissions1-5% NICU admissions Multifactorial etiologyMultifactorial etiology

feeds, prematurity, ischemia, infectionfeeds, prematurity, ischemia, infection Diagnosis: clinical and radiologicDiagnosis: clinical and radiologic Treatment:Treatment:

– Decompression (NPO, NG tube)Decompression (NPO, NG tube)– antibioticsantibiotics– surgery if necessarysurgery if necessary

SepsisSepsis Suboptimal immune function in preemies Suboptimal immune function in preemies

plus poor skin barrier, indwelling cathetersplus poor skin barrier, indwelling catheters GBS and coliforms cause early onset sepsisGBS and coliforms cause early onset sepsis

< 5-7 days of life< 5-7 days of life Nosocomial sepsis common in prems with Nosocomial sepsis common in prems with

most common organism = coagulase most common organism = coagulase negative staphylococcus; fungi can also be negative staphylococcus; fungi can also be problematic problematic

in > 1 week of lifein > 1 week of life

Anemia of PrematurityAnemia of Prematurity Reasons:Reasons:

– decreased hemoglobin at deliverydecreased hemoglobin at delivery– decreased RBC survivaldecreased RBC survival– blunted erythropoietin responseblunted erythropoietin response– IATROGENICIATROGENIC

Treatment:Treatment:– preventionprevention– iron supplementationiron supplementation– transfusiontransfusion– EPOEPO

Retinopathy of Retinopathy of PrematurityPrematurity

40-70% NICU survivors < 1000 g40-70% NICU survivors < 1000 g Etiology: vasoconstriction leading to Etiology: vasoconstriction leading to

abnormal vascular proliferationabnormal vascular proliferation Diagnosis: screeningDiagnosis: screening Treatment: close monitoring, laser if Treatment: close monitoring, laser if

necessarynecessary

PostmaturityPostmaturity

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

Possible complicationsPossible complications– growth disturbancesgrowth disturbances– asphyxiaasphyxia– meconium aspiration syndromemeconium aspiration syndrome

Problems of the Term Problems of the Term NewbornNewborn

RespiratoryRespiratory CardiacCardiac SepsisSepsis DigestiveDigestive JaundiceJaundice Anemia, polycythemia, hemorrhageAnemia, polycythemia, hemorrhage RenalRenal EndocrineEndocrine NeurologicNeurologic

Respiratory Distress in the Respiratory Distress in the NewbornNewborn

Respiratory systemRespiratory system CardiacCardiac InfectiousInfectious NeurologicNeurologic MetabolicMetabolic Upper airwayUpper airway Maternal RxMaternal Rx MusculoskeletalMusculoskeletal

Respiratory Problems in Respiratory Problems in the Term Newbornthe Term Newborn

Transient tachypnea of the newbornTransient tachypnea of the newborn PneumoniaPneumonia Meconium aspirationMeconium aspiration Pulmonary air leaksPulmonary air leaks Congenital malformationsCongenital malformations Persistent pulmonary hypertensionPersistent pulmonary hypertension Pulmonary hemorrhagePulmonary hemorrhage

Transient Tachypnea of Transient Tachypnea of the Newbornthe Newborn

Failure to clear lung fluidFailure to clear lung fluid Associated with absent or short Associated with absent or short

labour or initial weak or absent labour or initial weak or absent respirationsrespirations

Improves with timeImproves with time

PneumoniaPneumonia

Can initially be difficult to Can initially be difficult to distinguish from TTN/RDSdistinguish from TTN/RDS

Group B Strep #1Group B Strep #1 Consolidation may appear after a Consolidation may appear after a

few daysfew days

Meconium Aspiration Meconium Aspiration SyndromeSyndrome

Meconium-stained amniotic fluid Meconium-stained amniotic fluid Intrauterine insult may lead to gaspingIntrauterine insult may lead to gasping Meconium aspiratedMeconium aspirated

– PneumonitisPneumonitis– Airway occlusionAirway occlusion– Pulmonary air leak syndromePulmonary air leak syndrome

May lead to persistent pulmonary May lead to persistent pulmonary hypertensionhypertension

Congenital MalformationsCongenital Malformations

Anomalies anywhere along Anomalies anywhere along airways, extrinsic or intrinsicairways, extrinsic or intrinsic

AtresiasAtresias CystsCysts Diaphragmatic herniaDiaphragmatic hernia

Persistent Pulmonary Persistent Pulmonary HypertensionHypertension

Associated withAssociated with– asphyxiaasphyxia– meconium aspirationmeconium aspiration– sepsissepsis

Right to left shunting, Right to left shunting, persistent fetal persistent fetal circulationcirculation

Treatment:Treatment:– oxygenation, ventilationoxygenation, ventilation– maintain blood pressuremaintain blood pressure– pulmonary vasodilatorspulmonary vasodilators

Congenital Heart Disease: Congenital Heart Disease: presentationspresentations

Cyanosis– presents earlypresents early– defects with right to left shuntsdefects with right to left shunts– TOF, tricuspic atresia, TGA, TAPVR, truncus TOF, tricuspic atresia, TGA, TAPVR, truncus

arteriosus, pulm. atresiaarteriosus, pulm. atresia Congestive heart failureCongestive heart failure

– fewer compensatory mechanisms so fewer compensatory mechanisms so common and can occur very quicklycommon and can occur very quickly

– tachycardia, tachypnea, hepatomegaly, tachycardia, tachypnea, hepatomegaly, feeding difficulty, cardiomegaly, diaphoresisfeeding difficulty, cardiomegaly, diaphoresis

MurmursMurmurs

DysrhythmiasDysrhythmias

Presentations of Presentations of Congenital Heart DiseaseCongenital Heart Disease

Congenital heart disease: Congenital heart disease: Most commonly diagnosedMost commonly diagnosed

Ventricular Septal DefectVentricular Septal Defect Transposition of the Great VesselsTransposition of the Great Vessels Tetralogy of FallotTetralogy of Fallot Coarctation of the AortaCoarctation of the Aorta Patent Ductus ArteriosusPatent Ductus Arteriosus Endocardial Cushion DefectEndocardial Cushion Defect Hypoplastic Left HeartHypoplastic Left Heart

Sepsis: risk factorsSepsis: risk factors

Preterm rupture of membranesPreterm rupture of membranes Prolonged rupture of membranesProlonged rupture of membranes Maternal group B strep carriageMaternal group B strep carriage ChorioamnionitisChorioamnionitis

Neonatal SepsisNeonatal Sepsis THINK OF IT!THINK OF IT!

– Signs may be subtle, non-specificSigns may be subtle, non-specific– Incidence bacterial sepsis = 1-5/1000 live birthsIncidence bacterial sepsis = 1-5/1000 live births– Commonest organisms:Commonest organisms:

group B streptococcusgroup B streptococcus gram negatives (gram negatives (E coliE coli, Klebsiella), Klebsiella) enterococcus, H flu, staph speciesenterococcus, H flu, staph species listerialisteria

Work up and treatWork up and treat if suspect sepsis if suspect sepsis– Use broad spectrum antibioticsUse broad spectrum antibiotics

Ophthalmia neonatorum Ophthalmia neonatorum 1st days - differentiate chemical vs infected1st days - differentiate chemical vs infected 2nd-3rd wk - viral or bacterial2nd-3rd wk - viral or bacterial Gonococcal:Gonococcal:

– within 5 days of birthwithin 5 days of birth– gram negative intracellular diplococcigram negative intracellular diplococci– if suspect, Penicillin asapif suspect, Penicillin asap– highly contagioushighly contagious

Chlamydia:Chlamydia:– 5-14 days5-14 days– conjunctival scrapingconjunctival scraping– topical antibioticstopical antibiotics

Congenital InfectionsCongenital Infections CMV:

– 5-25/1,000 live births5-25/1,000 live births– asymptomatic vs severe symptomsasymptomatic vs severe symptoms– microcephaly, thrombocytopenia, microcephaly, thrombocytopenia,

hepatosplenomegaly, chorioretinitishepatosplenomegaly, chorioretinitis– sequelae of hearing loss and developmental sequelae of hearing loss and developmental

delaydelay RubellaRubella

– 0.5/1,0000.5/1,000– cataracts, rash, congenital heart disease, cataracts, rash, congenital heart disease,

developmental delaydevelopmental delay

Congenital InfectionsCongenital Infections ToxoplasmosisToxoplasmosis::

– 0.5-1.0/1,0000.5-1.0/1,000– hydrocephalus, cranial calcifications, hydrocephalus, cranial calcifications,

chorioretinitischorioretinitis SyphilisSyphilis::

– 0.1/1,0000.1/1,000– snuffles, osteochondritis/periostitis, rashsnuffles, osteochondritis/periostitis, rash

HerpesHerpes::– vesicles, keratoconjuntivitis, CNS vesicles, keratoconjuntivitis, CNS

findingsfindings

Congenital syphilisCongenital syphilis

Treat mother no matter what stage Treat mother no matter what stage of pregnancyof pregnancy

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

If inadequate maternal treatment, If inadequate maternal treatment, give 10 days of IV penicillingive 10 days of IV penicillin

Neonatal herpes simplexNeonatal herpes simplex

Only about 1/3 mothers have overt Only about 1/3 mothers have overt signssigns

Infection can be disseminated or Infection can be disseminated or locallocal

Usually present at 5-10 days of ageUsually present at 5-10 days of age If suspect:If suspect:

– Cultures, PCRCultures, PCR– Treat with acylovirTreat with acylovir

Maternal hepatitis B Maternal hepatitis B carriercarrier

Give baby hepatitis vaccine as Give baby hepatitis vaccine as soon as possible after birth (first soon as possible after birth (first 12 hours)12 hours)

BathBath Universal precautionsUniversal precautions Immune globulin in first 7 daysImmune globulin in first 7 days

HIVHIV Virus can be transmitted Virus can be transmitted

transplacentally, transplacentally, intrapartumintrapartum, or , or postpartumpostpartum

Screen mothersScreen mothers Treat mothers with antiretrovirals Treat mothers with antiretrovirals Treat babies with AZT for 6 wksTreat babies with AZT for 6 wks Universal precautionsUniversal precautions Look for other infections (HepB, HepC)Look for other infections (HepB, HepC)

Digestive DisordersDigestive Disorders

VomitingVomiting DiarrheaDiarrhea ConstipationConstipation

Vomiting in the NewbornVomiting in the Newborn

Not uncommon for some vomiting in Not uncommon for some vomiting in 1st few hours after birth1st few hours after birth

Overfeeding, poor burpingOverfeeding, poor burping DDx: Gastrointestinal obstructionDDx: Gastrointestinal obstruction

Increased intracranial Increased intracranial pressurepressure

Bilious vomiting is a medical Bilious vomiting is a medical emergency!emergency!

Upper G-I problems Upper G-I problems causing vomitingcausing vomiting

EsophagealEsophageal::– first feed, soon after feedfirst feed, soon after feed– excessive droolingexcessive drooling– if T-E fistula, risk aspirationif T-E fistula, risk aspiration

Small bowel atresiasSmall bowel atresias Malrotation and volvulusMalrotation and volvulus AchalasiaAchalasia Chalasia/GERChalasia/GER Pyloric stenosisPyloric stenosis

}Need to r/o

Non-GI causes of vomitingNon-GI causes of vomiting

SepsisSepsis Adrenal hyperplasiaAdrenal hyperplasia MeningitisMeningitis UTIUTI Milk allergyMilk allergy

Lower GI ObstructionLower GI Obstruction

Initially, distention, failure to pass Initially, distention, failure to pass meconium… vomiting is later signmeconium… vomiting is later sign

Extrinsic vs intrinsic obstructionExtrinsic vs intrinsic obstruction DDx: Imperforate anus, DDx: Imperforate anus,

Hirschprung, meconium ileus, Hirschprung, meconium ileus, meconium plugs, ileal atresia, meconium plugs, ileal atresia, colonic atresiacolonic atresia

ConstipationConstipation

> 90% pass meconium in first 24 h> 90% pass meconium in first 24 h Present at birth, consider causes of Present at birth, consider causes of

GI obstructionGI obstruction Present after birth, consider Present after birth, consider

Hirschprung, hypothyroidism, anal Hirschprung, hypothyroidism, anal stenosisstenosis

NB some breastfed babies normally NB some breastfed babies normally stool only once every 5-7 daysstool only once every 5-7 days

DiarrheaDiarrhea

InfectionInfection– E coli, salmonella, echovirus, E coli, salmonella, echovirus,

rotavirus, adenovirusrotavirus, adenovirus Watch for fluid and electrolyte Watch for fluid and electrolyte

imbalanceimbalance

JaundiceJaundice First 24 h, always abnormalFirst 24 h, always abnormal Etiology: Etiology: unconjugatedunconjugated

1. 1. RBC destruction/hemolyticRBC destruction/hemolytic : :– isoimmune, RBC membrane, enzymes, isoimmune, RBC membrane, enzymes,

hemoglobinopathieshemoglobinopathies– HematomaHematoma– Sepsis (mixed hemolytic and hepatocellular damageSepsis (mixed hemolytic and hepatocellular damage– HypoxiaHypoxia2. 2. Congenital/metabolicCongenital/metabolic::– Criggler-NajarCriggler-Najar– Hypothyroidism, galactosemiaHypothyroidism, galactosemia

Later onset: conjugated1.1. Hepatocellular damageHepatocellular damage: : • ViralViral• bacterialbacterial• Metabolic: CF, tyrosinemiaMetabolic: CF, tyrosinemia2. 2. Post hepaticPost hepatic: : • biliary atresiabiliary atresia• choledochal cystcholedochal cyst

JaundiceJaundice

Jaundice - Work-UpJaundice - Work-Up

History and physical examinationHistory and physical examination Bilirubin - total and directBilirubin - total and direct Blood type and Coomb’sBlood type and Coomb’s HemoglobinHemoglobin Reticulocyte countReticulocyte count SmearSmear Septic workupSeptic workup

Risk factors for kernicterusRisk factors for kernicterus

PrematurityPrematurity HemolysisHemolysis AsphyxiaAsphyxia AcidosisAcidosis InfectionInfection Cold stressCold stress HypoglycemiaHypoglycemia

Treatment of JaundiceTreatment of Jaundice

Nutrition/hydrationNutrition/hydration PhototherapyPhototherapy Exchange transfusionExchange transfusion

AnemiaAnemia

HemorrhageHemorrhage– feto-maternalfeto-maternal– feto-placentalfeto-placental– feto-fetalfeto-fetal– intracranial or extracranialintracranial or extracranial– rupture of internal organsrupture of internal organs

HemolysisHemolysis Treatment:Treatment:

– Transfuse if necessaryTransfuse if necessary

Polycythemia-Polycythemia-Hyperviscosity SyndromeHyperviscosity Syndrome

Hematocrit > 65 or 70%Hematocrit > 65 or 70% ““Sludging” of blood in organSludging” of blood in organ May present with:May present with:

– respiratory symptomsrespiratory symptoms– CNS symptomsCNS symptoms– thrombocytopeniathrombocytopenia

Treat by partial exchange transfusionTreat by partial exchange transfusion

Bleeding in the NewbornBleeding in the Newborn

Hemorrhagic disease of the newbornHemorrhagic disease of the newborn ThrombocytopeniaThrombocytopenia

– immuneimmune– infection relatedinfection related– congenitalcongenital

Disseminated intravascular Disseminated intravascular coagulationcoagulation

Renal issues in the Renal issues in the NewbornNewborn

Most common site of congenital Most common site of congenital malformations and hence abdominal massesmalformations and hence abdominal masses

Renal vein thrombosis: complication of infant Renal vein thrombosis: complication of infant of diabetic mother or polycythemiaof diabetic mother or polycythemia

Increased risk of UTI’s in uncircumcised Increased risk of UTI’s in uncircumcised males (but still not as high as infant females) males (but still not as high as infant females)

All newborns have poor concentrating ability; All newborns have poor concentrating ability; small prematures at high risk for small prematures at high risk for fluid/electrolyte imbalancefluid/electrolyte imbalance

Endocrine issues in the Endocrine issues in the NewbornNewborn

Congenital hypothyroidismCongenital hypothyroidism– Screen because too late if waitScreen because too late if wait– Signs = poor feeding, constipation, Signs = poor feeding, constipation,

prolonged jaundice, large fontanelles, prolonged jaundice, large fontanelles, umbilical hernia, dry skinumbilical hernia, dry skin

Endocrine Issues in the Endocrine Issues in the NewbornNewborn

Congenital adrenal hyperplasiaCongenital adrenal hyperplasia– 21-hydroxylase deficiency most 21-hydroxylase deficiency most

commoncommon– Signs = vomiting, diarrhea, Signs = vomiting, diarrhea,

dehydration, shock, convulsions, dehydration, shock, convulsions, clitoris or phallic enlargementclitoris or phallic enlargement

– Watch for electrolyte imbalanceWatch for electrolyte imbalance– If suspect, send lab tests and treatIf suspect, send lab tests and treat

Endocrine issues in the Endocrine issues in the NewbornNewborn

Infant of diabetic motherInfant of diabetic mother– Congenital malformations (especially Congenital malformations (especially

important to have good control preconception)important to have good control preconception)– Growth disturbancesGrowth disturbances– Metabolic disturbances: glucose, CaMetabolic disturbances: glucose, Ca+ +

– Respiratory distress syndrome and transient Respiratory distress syndrome and transient tachypnea of the newborn: more pronetachypnea of the newborn: more prone

– Polycythemia: jaundicePolycythemia: jaundice– Cardiovascular problems: hypertrophic Cardiovascular problems: hypertrophic

cardiomyopathycardiomyopathy

HypoglycemiaHypoglycemia

BS <2.6 prem and bottle fed termBS <2.6 prem and bottle fed term

BS <2.0 breastfedBS <2.0 breastfed

** No clear safe cutoff for all** No clear safe cutoff for all Lack of supplyLack of supply Lack of reserve (low glycogen): IUGRLack of reserve (low glycogen): IUGR Inability to use/produce: metabolicInability to use/produce: metabolic Increased utilization: sepsisIncreased utilization: sepsis Increased insulin productionIncreased insulin production

HypoglycemiaHypoglycemia

Treat: supply 4-6 mg/kg/min termTreat: supply 4-6 mg/kg/min term

6-8 mg/kg/min prem6-8 mg/kg/min prem Look for cause, especially if severe Look for cause, especially if severe

oror

persists beyond 48-72h of lifepersists beyond 48-72h of life

Neonatal seizures: Neonatal seizures: etiologyetiology

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%

The Hypotonic Infant: The Hypotonic Infant: EtiologiesEtiologies

Central nervous system diseaseCentral nervous system disease Spinal cord diseasesSpinal cord diseases Diseases of the peripheral nerveDiseases of the peripheral nerve Diseases of the neuromuscular Diseases of the neuromuscular

junctionjunction Muscle DiseasesMuscle Diseases Systemic diseasesSystemic diseases Metabolic diseasesMetabolic diseases

Work-up of Hypotonic Work-up of Hypotonic InfantInfant

Exhaustive history Exhaustive history Complete physical examinationComplete physical examination Imaging: CXR, U/S, CT, MRIImaging: CXR, U/S, CT, MRI Nerve conduction velocity, electromyographyNerve conduction velocity, electromyography Serum CPK, AST, CSF proteinSerum CPK, AST, CSF protein Muscle biopsy, nerve biopsyMuscle biopsy, nerve biopsy Molecular genetics (myotonic dystrophy, Molecular genetics (myotonic dystrophy,

Prader-Willi)Prader-Willi) OtherOther

lmcc review course “neonatology” lmcc review course “neonatology” brigitte lemyre, md, frcpc

Documents

newborn resuscitationmeconium

lifenormal newborn care

family historythe mothers

delivery history

systemmost common anomalies

fetal scalp blood sampling

common problemseye care

congenital anomalies