lmcc review course: “neonatology”
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LMCC Review Course: “Neonatology”. Gregory Moore, MD, FRCPC Division of Neonatology March 2012. Outline. Resuscitation principles Transition to ex-utero life Normal newborn care and assessment Small and Large-for-Gestational Age neonates and their problems - PowerPoint PPT PresentationTRANSCRIPT
LMCC Review Course:LMCC Review Course:“Neonatology”“Neonatology”
Gregory Moore, MD, FRCPCGregory Moore, MD, FRCPC
Division of NeonatologyDivision of Neonatology
March 2012March 2012
OutlineOutline
1.1. Resuscitation principlesResuscitation principles1.1. Transition to ex-utero lifeTransition to ex-utero life
2.2. Normal newborn care and assessmentNormal newborn care and assessment
3.3. Small and Large-for-Gestational Age neonates Small and Large-for-Gestational Age neonates and their problemsand their problems
4.4. Prematurity and its complicationsPrematurity and its complications
5.5. Problems of the term infantProblems of the term infant
For Starters …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 mmHg Sats: >95% by ~1 hr of age *
For Starters …For Starters …
Gestation (wks)Gestation (wks) Birth Weight (kg)Birth Weight (kg)
2727 1.01.0
3030 1.51.5
3333 2.02.0
3535 2.32.3
37-4037-40 3.5 (2.5 – 4.5)3.5 (2.5 – 4.5)
Newborn ResuscitationNewborn Resuscitation
Initial steps: warm, dry, ‘stimulate’Initial steps: warm, dry, ‘stimulate’ Evaluate respirationsEvaluate respirations Evaluate heart rateEvaluate heart rate Evaluate toneEvaluate tone Evaluate colorEvaluate color
RememberRemember - the key to a baby’s - the key to a baby’s transition to the real world is transition to the real world is ‘‘openingopening’ the lungs: ’ the lungs: VENTILATION VENTILATION OxygenationOxygenation
1. ‘Red’ blood from placenta
2. ‘Less red’ blood from right to left atrium via patent
foramen ovale
3. Small amount of‘pink’ blood
going to lungs
In-uteroIn-utero
4. Pink blood goes from the
pulmonary artery to aorta via
ductus arteriosus …
produces mixing of
pink and less red blood
1. Cord is clamped
Increases SVR
2. Foramen ovale functionally closes
3. Pulmonary arteries
vasodilate to increase blood
flow to the lungs
Ex-uteroEx-utero
4. Ductus arteriosus closes
Fluid-filled alveoli in utero
Diminished blood flow in-utero through fetal lungs
Importance of first breath
The End ProductThe End Product
Neonatal Resuscitation Neonatal Resuscitation ProgramProgram
90% of babies
9% of babies
0.9% of babies
0.1% of babies
Newborn ResuscitationNewborn Resuscitation
A: AirwayA: Airway B: BreathingB: Breathing C: CirculationC: Circulation D: DrugsD: Drugs E: EnvironmentE: Environment F: FluidsF: Fluids G: GlucoseG: Glucose
““IV, O2, Monitor” … if distressedIV, O2, Monitor” … if distressed
NB. Newborn ResuscitationNB. Newborn Resuscitation
MECONIUMMECONIUM in the amniotic fluid AND in the amniotic fluid AND depressed newborn (limp, not crying):depressed newborn (limp, not crying): Intubate and suction below cords FIRSTIntubate and suction below cords FIRST
Suspect Suspect diaphragmatic herniadiaphragmatic hernia:: Intubate ASAPIntubate ASAP
Pink when crying … blue when not:Pink when crying … blue when not: Suspect Suspect choanal atresiachoanal atresia and try an oral and try an oral
airwayairway
The Apgar ScoreThe 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 intakeEnsure warmth and early nutrient intake
Support breastfeedingSupport breastfeeding
Monitor weight and hydration statusMonitor weight and hydration status
Educate about infant care **Educate about infant care **
Anticipatory guidance **Anticipatory 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 Newborn screen (24-72 hr)Newborn screen (24-72 hr)
• PKU (1/15,000)PKU (1/15,000)• Hypothyroidism (1/4000)Hypothyroidism (1/4000)• 24 other diseases (OA/AA/FA disorders, SCA, Hgb’pathies’, CAH, 24 other diseases (OA/AA/FA disorders, SCA, Hgb’pathies’, CAH,
galactosemia, endocrinopathies)galactosemia, endocrinopathies) Neurosensory hearing loss (pre-d/c)Neurosensory hearing loss (pre-d/c) Hyperbilirubinemia (pre-d/c)Hyperbilirubinemia (pre-d/c)
Blood group and Coombs if mother Rh negativeBlood group and Coombs if mother Rh negative
The Newborn HistoryThe Newborn History IdentificationIdentification Maternal History:Maternal History:
• AgeAge• Past medical/surgicalPast medical/surgical• Medications, Drugs/Smoking/EtOHMedications, Drugs/Smoking/EtOH• Past pregnancy(ies) (GTPAL)Past pregnancy(ies) (GTPAL)• Current pregnancy (including screening test results, Current pregnancy (including screening test results,
antenatal steroid use)antenatal steroid use) Family HistoryFamily History Social HistorySocial History Labour and Delivery HistoryLabour and Delivery History Resuscitation HistoryResuscitation History Early Postnatal CourseEarly Postnatal Course
Physical ExaminationPhysical Examination
Vital signsVital signs
Measurements Measurements plot! plot!
Gestational age assessmentGestational age assessment
Overall appearance (well/unwell)Overall appearance (well/unwell)
System by system (or head to toe) **System by system (or head to toe) **
The depressed newbornThe depressed newborn Neurological:Neurological:
Asphyxia, CNS TraumaAsphyxia, CNS Trauma
Respiratory:Respiratory: Apnea (secondary)Apnea (secondary)
Cardiovascular:Cardiovascular: Hypovolemia/shock/hydropsHypovolemia/shock/hydrops
Congenital:Congenital: MalformationsMalformations
DrugsDrugs
The Basic TestsThe Basic Tests Blood gas (arterial or capillary) Glucose Electrolytes Complete Blood Count + differential Blood culture Chest X-ray
Consider: Lactate, CRP, echocardiogram, abdominal x-ray Full septic workup if > 72 hours old
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 Apgar less than 5 at 5 minutesApgar less than 5 at 5 minutes EncephalopathyEncephalopathy Multiorgan involvement (heart, kidneys, Multiorgan involvement (heart, kidneys,
marrow, liver)marrow, liver)
- Neonatal encephalopathy must be documented - Neonatal encephalopathy must be documented for perinatal asphyxia to be considered as a for perinatal asphyxia to be considered as a cause of later neurodevelopmental problemscause of later neurodevelopmental problems
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 common anomalies noted on initial exam
Most frequent birth injuriesMost frequent birth injuries 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
Differentiating Scalp InjuriesDifferentiating Scalp Injuries
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, bradycardia, cyanosis (peripheral)Apnea, bradycardia, cyanosis (peripheral) Tachypnea, gruntingTachypnea, grunting Absent or decreased femoral pulsesAbsent or decreased femoral pulses Heart murmur, cyanosis (central)Heart murmur, cyanosis (central) HypotoniaHypotonia 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 belowSmall for gestational age: <2SD below
Large for gestational age: >2SD aboveLarge for gestational age: >2SD above
Prematurity: <37 weeks gestationPrematurity: <37 weeks gestation
Postmaturity: >42 weeks gestationPostmaturity: >42 weeks gestation
Birth Weight Birth Weight Matters …Matters …
Small for gestational age: Small for gestational age: EtiologiesEtiologies
ConstitutionalConstitutional
MaternalMaternal Illness, Rx/EtOH/drugs/cigs, nutritionIllness, Rx/EtOH/drugs/cigs, nutrition
PlacentalPlacental
FetalFetal Genetic disorder, infections (TORCH)Genetic disorder, infections (TORCH)
Small for gestational age: Small for gestational age: complicationscomplications
AsphyxiaAsphyxia Meconium aspirationMeconium aspiration Congenital malformationsCongenital malformations HypoglycemiaHypoglycemia HypothermiaHypothermia HypocalcemiaHypocalcemia Polycythemia-hyperviscosityPolycythemia-hyperviscosity Increased neonatal mortality (OR 2.77)Increased neonatal mortality (OR 2.77) Long term morbidity …Long term morbidity …
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
Disorders of gestation Disorders of gestation length or of growthlength or of growth
Small for gestational age: <2SD belowSmall for gestational age: <2SD below
Large for gestational age: >2SD aboveLarge for gestational age: >2SD above
Prematurity: <37 weeks gestationPrematurity: <37 weeks gestation
Postmaturity: >42 weeks gestationPostmaturity: >42 weeks gestation
Large for gestational age: Large for gestational age: EtiologiesEtiologies
ConstitutionalConstitutional
Abnormal maternal glucose toleranceAbnormal maternal glucose tolerance
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
Disorders of gestation Disorders of gestation length or of growthlength or of growth
Small for gestational age: <2SD belowSmall for gestational age: <2SD below
Large for gestational age: >2SD aboveLarge for gestational age: >2SD above
Prematurity: <37 weeks gestationPrematurity: <37 weeks gestation
Postmaturity: >42 weeks gestationPostmaturity: >42 weeks gestation
Causes/Risks for Causes/Risks for PrematurityPrematurity Fetal:Fetal:
Multiple gestation Fetal hydrops (immune and non-immune) Congenital/Genetic anomalies
Placental:Placental: Placenta praevia Abruptio placenta Placental insufficiency
Uterine:Uterine: Incompetent cervix Excessive enlargement (hydramnios) Malformations (leiomyomas, septate)
Maternal:Maternal: Previous history of premature delivery Pre-eclampsia Premature rupture of membranes Smoking, substance abuse Chronic medical illnesses, low weight, ‘extremes’ of age Infections (urinary, cervical, amniotic)-group B streptococcus, herpes,
TORCH, etc. Iatrogenic (indicated induction of labor)Iatrogenic (indicated induction of labor)
And then there was a baby And then there was a baby …… Transfer to a level 2 nursery if:Transfer to a level 2 nursery if:
< 36 weeks GA< 36 weeks GA < 2 kg< 2 kg
Transfer to a level 3 nursery if:Transfer to a level 3 nursery if: < 32 weeks GA< 32 weeks GA Respiratory support requiredRespiratory support required
Need for special care due to:Need for special care due to: Risk of complicationsRisk of complications Nutritional needsNutritional needs
Transfer Mom prior to birth if at all possibleTransfer Mom prior to birth if at all possible
Prematurity: ComplicationsPrematurity: Complications 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 Increased interstitial and alveolar lung fluidlung fluid
Surfactant deficiencySurfactant deficiency
Courtesy of Professor Louis De Voshttp://www.ulb.ac.be/sciences/biodic/index.html
17Weeks
Courtesy of Professor Louis De Voshttp://www.ulb.ac.be/sciences/biodic/index.html
22Weeks
Courtesy of Professor Louis De Voshttp://www.ulb.ac.be/sciences/biodic/index.html
25Weeks
CXR: poor aeration, ground-glass CXR: poor aeration, ground-glass appearance, homogenous, air appearance, homogenous, air
bronchogramsbronchograms
Respiratory Distress Respiratory Distress SyndromeSyndrome
Management:Management: Prevention - antenatal steroidsPrevention - antenatal steroids
Positive pressure ventilationPositive pressure ventilation
OxygenOxygen
+/- Surfactant (requires intubation)+/- Surfactant (requires intubation)
Pressure (cmHPressure (cmH220)0)
Vol
um
e (m
l)V
olu
me
(ml)
Bronchopulmonary Bronchopulmonary DysplasiaDysplasia Respiratory symptoms, x-ray Respiratory symptoms, x-ray
abnormalities, and O2 req’t for > 28 d and abnormalities, and O2 req’t for > 28 d and persisting at 36 wks corrected GApersisting at 36 wks corrected GA
Pathophysiology: Disturbed alveolarization with increased
alveolar-to-capillary distance and decreased alveolar-to-capillary ration
Secondary to:• Lung inflammation• Mucociliary dysfunction• Airway narrowing• Hypertrophied airway smooth muscle• Alveolar collapse• Constriction of pulmonary vascular bed
Bronchopulmonary Bronchopulmonary DysplasiaDysplasia
Management:Management: Prevention: IM Vitamin A, CaffeinePrevention: IM Vitamin A, Caffeine NUTRITIONNUTRITION Oxygen +/- ventilationOxygen +/- ventilation +/- Diuretics+/- Diuretics +/- Steroids: systemic, inhaled+/- Steroids: systemic, inhaled +/- Bronchodilators+/- Bronchodilators
Prognosis:Prognosis: Increased respiratory illnesses in childhoodIncreased respiratory illnesses in childhood Decreased long-term lung functionDecreased long-term lung function BUT, fine in the playground by pre-school age (usually BUT, fine in the playground by pre-school age (usually
…)…)
Apnea of PrematurityApnea of Prematurity
Central, obstructive, or mixed **Central, obstructive, or mixed ** Majority of <32 weeksMajority of <32 weeks Treat with:Treat with:
Adequate positioningAdequate positioning OxygenOxygen Methylxanthines (i.e. Caffeine)Methylxanthines (i.e. Caffeine) CPAPCPAP Ventilation if necessaryVentilation if necessary
Patent ductus arteriosusPatent ductus arteriosus Seen in >60% of <1000 g babiesSeen in >60% of <1000 g babies Management strategies:Management strategies:
Preload/afterload reductionPreload/afterload reduction Adequate oxygenationAdequate oxygenation Optimize pHOptimize pH Indomethacin/IbuprofenIndomethacin/Ibuprofen Surgery (PDA ligation)Surgery (PDA ligation) Conservative managementConservative management
Prognosis:Prognosis: Multiple associations (NEC, CLD, etc …) but no Multiple associations (NEC, CLD, etc …) but no
proven causationproven causation
Metabolic Problems of Metabolic Problems of PrematurityPrematurity
HypoglycemiaHypoglycemia
Fluid/electrolyte imbalanceFluid/electrolyte imbalance
Hypocalcemia/hypomagnesemiaHypocalcemia/hypomagnesemia
HyperbilirubinemiaHyperbilirubinemia
HypothermiaHypothermia
Intraventricular hemorrhageIntraventricular hemorrhage 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 cerebral autoregulationabnormal cerebral autoregulation
Prognosis:Prognosis: GoodGood - small amounts of bleeding in the - small amounts of bleeding in the
ventriclesventricles PoorerPoorer - large amount intraparenchymally or if - large amount intraparenchymally or if
post-hemorrhagic hydrocephaluspost-hemorrhagic hydrocephalus
Periventricular leukomalaciaPeriventricular leukomalacia
Pathophysiology:Pathophysiology: 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
Prognosis:Prognosis: Correlated with cerebral palsyCorrelated with cerebral palsy
Necrotizing EnterocolitisNecrotizing Enterocolitis 1-5% NICU admissions1-5% NICU admissions Multi-factorial etiology:Multi-factorial etiology:
Feeds, Prematurity, Ischemia, InfectionFeeds, Prematurity, Ischemia, Infection Diagnosis:Diagnosis: clinical and radiologic clinical and radiologic Treatment:Treatment:
Decompression (NPO, NG tube)Decompression (NPO, NG tube) AntibioticsAntibiotics Surgery prnSurgery prn
Prognosis:Prognosis: 30% mortality if <1500 g30% mortality if <1500 g
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 premsNosocomial sepsis common in prems Most common = coagulase negative Most common = coagulase negative
staphylococcusstaphylococcus Fungi can also be problematic in > 1 week of lifeFungi can also be problematic in > 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 PrematurityRetinopathy of Prematurity
40-70% NICU survivors < 1000 g40-70% NICU survivors < 1000 g
Etiology:Etiology: vasoconstriction leading to abnormal vasoconstriction leading to abnormal
vascular proliferationvascular proliferation
Diagnosis:Diagnosis: ScreeningScreening
Treatment:Treatment: Close monitoring, laser if necessaryClose monitoring, laser if necessary
Long Term Outcomes – 24 Long Term Outcomes – 24 weeksweeks
Local survival (2006-2008) ~ 60%
Risk of severe disability: very low IQ, unable to walk, blindness and/or deafness
~ 15-20% of survivors
Risk of moderate disability: low IQ, walk with aid, impaired vision and/or correctable hearing loss
~ 20-30% of survivors
Deafness ~ 2% of survivors
Blindness 1-10% of survivors
Overall, chance of being ‘normal’ or mildly impaired
~ 50-65% of survivors
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
PostmaturityPostmaturity
Labour tends to be induced to avoid Labour tends to be induced to avoid problems of postmaturity, however if problems of postmaturity, however if dates not accurate may still occurdates not accurate may still 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
RespiratoryRespiratory CardiacCardiac InfectiousInfectious NeurologicNeurologic MetabolicMetabolic GastrointestinalGastrointestinal HematologicalHematological MusculoskeletalMusculoskeletal
Respiratory Problems in the Respiratory Problems in the Term NewbornTerm Newborn
Transient tachypnea of the newbornTransient tachypnea of the newborn Meconium aspirationMeconium aspiration Persistent pulmonary hypertensionPersistent pulmonary hypertension Pulmonary air leaks/PneumothoraxPulmonary air leaks/Pneumothorax Congenital malformationsCongenital malformations Pulmonary hemorrhagePulmonary hemorrhage PneumoniaPneumonia
Transient Tachypnea of the Transient Tachypnea of the NewbornNewborn
Failure to clear lung fluidFailure to clear lung fluid Associated with:Associated with:
Absent labour (planned C/S or C/S Absent labour (planned C/S or C/S without labour) or;without labour) or;
Short labour or;Short labour or; Initial weak or absent respirationsInitial weak or absent respirations
Improves with timeImproves with time
PneumoniaPneumonia
Can initially be difficult to distinguish Can initially be difficult to distinguish from TTN/RDSfrom TTN/RDS
Group B Strep #1Group B Strep #1
Consolidation may appear after a few Consolidation may appear after a few daysdays
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 airways:Anomalies anywhere along airways: Nose to alveoliNose to alveoli Extrinsic or intrinsicExtrinsic or intrinsic
AtresiasAtresias CystsCysts Diaphragmatic herniaDiaphragmatic hernia
Persistent Pulmonary Persistent Pulmonary HypertensionHypertension
Associated with:Associated with: AsphyxiaAsphyxia Meconium aspirationMeconium aspiration SepsisSepsis
Right to left shunting through PDA (i.e. Right to left shunting through PDA (i.e. persistent fetal circulationpersistent fetal circulation))
Treatment:Treatment: Oxygenation, ventilationOxygenation, ventilation Maintain blood pressureMaintain blood pressure Pulmonary vasodilatorsPulmonary vasodilators
Congenital Heart Disease: Congenital Heart Disease: PresentationsPresentations
Cyanosis
Congestive heart failureCongestive heart failure
MurmursMurmurs
DysrhytmiasDysrhytmias
Sepsis: Risk factorsSepsis: Risk factors
Preterm rupture of membranesPreterm rupture of membranes e.g. weekse.g. weeks
Prolonged rupture of membranesProlonged rupture of membranes >18 hours>18 hours
Maternal group B strep carriageMaternal group B strep carriage Maternal GBS bacteriuriaMaternal GBS bacteriuria Previous infant with GBS infectionPrevious infant with GBS infection 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 Infections **Congenital 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, chorioretinitisHydrocephalus, cranial calcifications, chorioretinitis
SyphilisSyphilis:: 0.1/1,0000.1/1,000 Snuffles, osteochondritis/periostitis, rashSnuffles, osteochondritis/periostitis, rash
Herpes Simplex VirusHerpes Simplex Virus:: Vesicles, keratoconjuntivitis, CNS findingsVesicles, keratoconjuntivitis, CNS findings ‘‘Viral’ sepsisViral’ sepsis
Congenital syphilisCongenital syphilis
Treat mother no matter what stage of Treat mother no matter what stage of pregnancypregnancy
If adequate maternal treatment and no If adequate maternal treatment and no signs of infection in newborn, give one signs of infection in newborn, give one dose IM penicillindose IM penicillin
If inadequate maternal treatment, give If inadequate maternal treatment, give 10 days of IV penicillin10 days of IV penicillin
Neonatal herpes simplexNeonatal herpes simplex
Only about 1/3 mothers have overt signsOnly about 1/3 mothers have overt signs
Infection can be disseminated or localInfection can be disseminated or local
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 carrierMaternal hepatitis B carrier
Give baby hepatitis vaccine as soon Give baby hepatitis vaccine as soon as possible after birth (first 12 hours)as possible after birth (first 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/C)Look for other infections (HepB/C) No breastfeeding in developed worldNo breastfeeding in developed world
Vomiting in the NewbornVomiting in the Newborn Not uncommon for some vomiting in 1st Not uncommon for some vomiting in 1st
few hours and days after birthfew hours and days after birth Overfeeding, poor burpingOverfeeding, poor burping
DDx:DDx: GI: obstruction, reflux, milk allergy, NECGI: obstruction, reflux, milk allergy, NEC Infection: Sepsis, Meningitis, UTIInfection: Sepsis, Meningitis, UTI Endocrine: Adrenal hyperplasiaEndocrine: Adrenal hyperplasia CNS: Increased ICPCNS: Increased ICP DrugsDrugs
Bilious vomiting is a medical emergency!Bilious vomiting is a medical emergency!
Upper GI problems Upper GI problems vomitingvomiting
EsophagealEsophageal:: first feed, soon after feedfirst feed, soon after feed excessive droolingexcessive drooling if T-E fistula, risk of aspirationif T-E fistula, risk of aspiration
Small bowel atresiasSmall bowel atresias
Malrotation and volvulusMalrotation and volvulus
AchalasiaAchalasia Chalasia/GERChalasia/GER Pyloric stenosisPyloric stenosis
} Need to r/o
Lower GI ObstructionLower GI Obstruction
Presents with:Presents with: DistentionDistention Failure to pass meconiumFailure to pass meconium Vomiting is a later signVomiting is a later sign
Extrinsic vs intrinsic obstructionExtrinsic vs intrinsic obstruction DDx: Imperforate anus, Hirschprung, DDx: Imperforate anus, Hirschprung,
meconium ileus, meconium plug, meconium ileus, meconium plug, ileal atresia, colonic atresiaileal atresia, colonic atresia
ConstipationConstipation > 90% pass meconium in first 24 h> 90% pass meconium in first 24 h
If ‘constipation’ is present from birth:If ‘constipation’ is present from birth: Consider causes of GI obstructionConsider causes of GI obstruction
If present after birth:If present after birth: Consider Hirschprungs, hypothyroidism, anal Consider Hirschprungs, hypothyroidism, anal
stenosisstenosis
NB:NB: Some breastfed babies normally stool only once Some breastfed babies normally stool only once
every 5-7 daysevery 5-7 days Premature infants often have delayed meconium Premature infants often have delayed meconium
passagepassage
JaundiceJaundice First 24 h or conjugated at ANY time = ALWAYS abNFirst 24 h or conjugated at ANY time = ALWAYS abN Etiology: Etiology: UnconjugatedUnconjugated
1. 1. RBC destruction/hemolyticRBC destruction/hemolytic : : IsoimmuneIsoimmune, RBC membrane, enzymes, , RBC membrane, enzymes,
hgbinopathieshgbinopathies HematomaHematoma SepsisSepsis (mixed hemolytic and hepatocellular (mixed hemolytic and hepatocellular
damage)damage) HypoxiaHypoxia2. 2. Conjugation AbnormalitiesConjugation Abnormalities:: Breast Milk JaundiceBreast Milk Jaundice Metabolic/Genetic: Gilbert, Crigler-Najjar, Metabolic/Genetic: Gilbert, Crigler-Najjar,
HypothyroidismHypothyroidism3. 3. Increased Enterohepatic CirculationIncreased Enterohepatic Circulation:: GI dysmotility or obstructionGI dysmotility or obstruction Breast feeding jaundiceBreast feeding jaundice
Later onset: Conjugated1. 1. Hepatocellular damageHepatocellular damage: : • ViralViral• BacterialBacterial• Metabolic: TPN, CF, tyrosinemia, otherMetabolic: TPN, CF, tyrosinemia, other
2. 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 +/- Abdominal Ultrasound+/- Abdominal Ultrasound +/- Metabolic, Viral workup+/- Metabolic, Viral 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 PrematurityPrematurity
Treatment:Treatment: Transfuse if necessaryTransfuse if necessary
Endocrine Issues - Endocrine Issues - HypothyroidismHypothyroidism
Screen because too late for Screen because too late for proper neurodevelopment if waitproper neurodevelopment if wait
Signs:Signs: Poor feedingPoor feeding ConstipationConstipation Prolonged jaundiceProlonged jaundice Large fontanellesLarge fontanelles Umbilical herniaUmbilical hernia Dry skinDry skin
Endocrine Issues – Endocrine Issues – Ambiguous GenitaliaAmbiguous Genitalia
Congenital adrenal hyperplasiaCongenital adrenal hyperplasia 21-hydroxylase deficiency = most 21-hydroxylase deficiency = most
common enzyme abNcommon enzyme abN Signs = vomiting, diarrhea, Signs = vomiting, diarrhea,
dehydration, shock, convulsions, dehydration, shock, convulsions, clitoris or phallic enlargementclitoris or phallic enlargement
Watch for electrolyte imbalancesWatch for electrolyte imbalances If suspect, send lab tests and treat If suspect, send lab tests and treat
with steroidswith steroids
Endocrine Issues – Infant of Endocrine Issues – Infant of a Mom with Diabetesa Mom with Diabetes
Increased Risk of:Increased Risk of: Congenital malformationsCongenital malformations
• Increased incidence with poor glycemic controlIncreased incidence with poor glycemic control Growth disturbancesGrowth disturbances Metabolic disturbancesMetabolic disturbances
• Hypoglycemia, hypocalcemiaHypoglycemia, hypocalcemia Respiratory:Respiratory:
• RDS, TTNRDS, TTN Hematologic:Hematologic:
• Polycythemia Polycythemia Hyperbilirubinemia Hyperbilirubinemia Cardiovascular problems:Cardiovascular problems:
• Hypertrophic cardiomyopathyHypertrophic cardiomyopathy
HypoglycemiaHypoglycemia
Definition:Definition: 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
Pathophysiology:Pathophysiology: 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 by supplying glucose needs:Treat by supplying glucose needs: Term: supply minimum of 4-6 Term: supply minimum of 4-6
mg/kg/minmg/kg/min Preterm: supply minimum of 6-8 Preterm: supply minimum of 6-8
mg/kg/minmg/kg/min
Look for cause … if severe or persists Look for cause … if severe or persists beyond 48-72h of lifebeyond 48-72h of life ‘‘Critical Sample’ of blood and urineCritical Sample’ of blood and urine
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%
Neonatal seizures: EtiologyNeonatal seizures: Etiology
Thank you! Questions? [email protected]
N.B.
These slides are all based on the LMCC website areas that related to my expertise and wasn’t 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