common problems in neonates

7/23/2019 Common Problems in Neonates

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Common Problems In

Neonates



Neonates

• Neonatal period is defned as the period rombirth until 28 days o lie

•

Term: Babies born alive within 3 !ompletedwee"s to #2 !ompleted wee"s$

• Preterm is defned as babies born alive beore 3

wee"s o pre%nan!y are !ompleted$ – e&tremely preterm '(28 wee"s) – very preterm '28 to (32 wee"s) – moderate to late preterm '32 to (3 wee"s)$



Content

Common in all neonates:• *ei%ht and +rowth• ,aundi!e• Cerebral In-ury• .epsis• Con%enital Ine!tions

/ore !ommon in premature neonates:• 0espiratory 1istress .yndrome• Intraventri!ular emorrha%e• Ne!rotiin% 4ntero!olitis



,aundi!ePhysiolo%i!al ,aundi!e

Breast /il" ,aundi!e

5B6 in!ompaitibility0h in!ompatibility

+7P 1ef!ien!y



1efnition

• yperbilirubinemia : .erum bilirubin 9mol; in neonates$

• ,aundi!e is the yellowishdis!olouration o the s"in< mu!ousmembrane and s!lera due todeposition o bilirubin$

• Babies be!ome !lini!ally -aundi!ewhen serum bilirubin levels rea!h 8=>

?2@ 9mol;?m% bilirubin A ?



Bilirubin /etabolism

• 'Indire!t) Unconjugatedbilirubin is lipid soluble andbinds to albumin in the blood$

• I albumin bindin% sites areull< bilirubin !an be displa!ed$

ree un!on-u%ated bilirubin!an !ross blood brain barrier

• n!on-u%ated bilirubin is!onverted to bilirubindi%lu!uronide '!on-u%ated) inthe liver by %lu!uronyltranserase$

• Con-u%ated bilirubin is watersoluble and !an be e&!retedinto the urine



Classif!ation and !auses

• Con-u%ated vs n!on-u%ated• Pre>hepati!< intrahepati!< post

hepati!



Clini!ally

Onset <24 hours(pathological)

Onset >24 hours to 2 weeks Prolon ged Duration over 2weeks

eamolysis :• 0hesus In!ompaitibility•5B6 in!ompatibility•+7P def!ien!y•.phero!ytosis•Pyruvate Dinase•1ru%s• Poly!ythemia

Physiolo%i!al -aundi!e .ur%i!al:• Biliary 5tresia• Choledo!al Cyst

Con%enital Ine!tions:• C/E• T60C4.

Breast /il" ,aundi!e Neonatal hepatitis

Ine!tions:• TI•.epsis• /enin%itis

.ur%i!al:• Biliary atresia•Choledo!al !yst

emolysis Inborn error o metabolism

4nyme def!ien!y• Cri%%ler na--ar•+ilbert syndome

ypothyroidism

.ur%i!al



one

!aundiice "sti#ated$%&

? ead 5nd ne!" 78 F ?3=

2 pper trun" 8= F 2@#

3 ;ower trun" andthi%hs

?37 F 22

# 5rms and below"nee

?8 F 3@7

= ands< eet 3@7



Physiolo%i!al ,aundi!e'ncreased& #ass .horter 0BC

liespan Immaturity o

%lu!uronyltranserase



Physiolo%i!al ,aundi!e

• 1ia%nosis o e&!lusion on!e all other!auses have been ruled out

• owever< it is the most !ommon!ause o -aundi!e in neonates

• 4pidemiolo%y: 6!!urs in 7@G oneonates



Breast /il" ,aundi!e

Possibly due to : – /il" !ontainin% inhibitor o bilirubin !on-u%ation – Breast mil" %lu!uronidase in!reases enterohepati!

re!ir!ulation

• Interruption o o breast eedin% or ?>2 days<may !ause de!line in bilirubin levels< whi!h doesnot in!rease si%nif!antly ater breasteedin%resumes

• /ana%ement: – !ontinue breasteedin% despite this be!ause bilriubin

levels rarely rea!hes more than 3@@ 9mol; '2@m%d;)



Patholo%i!al ,aundi!e:5B6 In!ompatibility

*e#ol+tic disease o,the newborn

• 6!!urs when: –

/other: Blood %roup 6'sensitied to anti%en 5 or B)

– Baby: Blood %roup 5 or B

• I%+ !ross pla!enta bya!tive transport

•

Be!omes less severe withea!h pre%nan!y – Probably due to anti>5 or

anti>B bindin% to nonerythro!yti! !ells that!ontain 5 or B anti%en



0h in!ompaitibility

"r+throblastosis-etalis• 0h Hve '1) anti%ens o the etus

sensities the 0h >ve 'd) mother• 0esults in I%+ antibody

produ!tion• 1ete!ted by Coombs test• ?st baby: /ay maniest anemia

and hyperbilirubinemia• *orsens whith subseuent

pre%nan!ies

• etal ydrops F 5s!ites<pleuralperi!ardial eJusion<anasar!a$ In!reased ris" o etaldeath is hi%h



Preventin% 0h sensitiation

• +ive 0h> mother anti h. i##uneglobulin (ho/01)

• 1one at: – 28 wee"s %estational a%e – *ithin 2 hours ater birth

• ow it wor"s: – Binds to to all possible etal 0hH erythro!ytes

enterin% maternal !ir!ulation – Interers with maternal anti 0hH antibody

produ!tion 'un"nown me!hanism)



+7P 1ef!ien!y

• Common hetero%enous K lin"edre!essive trait

• .!reenin% by !ord blood•

/ana%ement: 5voidan!e o

/lutathion #aintainsintegrit+ o, & andprevents oidant

injur+ to &



Prolon%ed ,aundi!eUnconjugated*+perbilirubine#ia

• .epsis• emolysis• ypothyroidism

onjugated*+perbilirubine#ia

• .ur%i!al !ause – Biliary atresia –

Choledo!al !yst• Neonatal epatitis• Con%enital Ine!tions

'C/E< T60C4.)

• /etaboli! disorders – L> ? antitrypsin

def!ien!y – %las!tosemia



Clini!al /aniestation o Derni!terus

• 4arly: – ;ethar%y< ypotonia< irritability< poor /orro

reMe&< poor eedin%

•

;ate: – Bul%in% ontanelle< opisthotoni! posture<

hypertoni!ity< paralysis o upward %ae< seiures

• Compli!ations: – Nerve deaness< !horeoathetoid !erebral palsy<

mental retardation< dis!olouration o teeth<enamel dysplasia



Derni!terus

• Bilirubin is to&i! to developin% !entralnervous system$ 1isrupts neuronalmetabolism and un!tion< espe!ially

in basal %an%lia• 0emember 'Indire!t)

Unconjugated bilirubin is lipid

soluble and !an !ross blood brainbarrier

• n!on-u%ated bilirubin levels e&!eed

bindin% !apa!ity o albumin and



Treatment o un!on-u%ated hyperbilirubinemia :Phototherapy

nder E li%ht '#2=>#=mm wavelen%th)<photo!hemi!al rea!tion o!!urs< un!on-u%atedbilirubin transormed into water soluble iso#ers<b+pass hepatic conjugation< and is easily

e&!reted

• Term: *hen T.B is =@ umoll below levels orintensive phototherapy

• Preterm: 5t lower levels based on a%e oprematurity – *hy To prevent hi%h levels o bilirubin that may reuire

e&!han%e transusion



rea men o n!on u%a e



rea men o n!on u%a eyperbilirubinemia: 4&!han%e

Transusion• Indi!ations:

– Total bilirubin 3@@ umol; – 4arly onset ,aundi!e 'frst 2# hours) –

0apidly risin% -aundi!e 'more than 8$=umol;hr)• Perormed throu%h umbili!al venous

!atheter enterin% inerior vena !ava< or!onMuen!e o umbili!al vein and portal vein$

• 5mount o blood transused: double bloodvolume$



Compli!ations o treatment

• Phototherapy: – Insensible water loss – 1airrhoea –

1ehydration – /a!ulopapular rash – Potential or retinal dama%e

• 4&!han%e Therapy: – Blood related F transusion rea!tion – Catheter F vessel peroration – Pro!edure F hypotension< N4C



Cerebral In-ury

-

ypo&i! Is!hemi!4n!ephalopaty-Intraventri!ular hemorrha%e



ypo&i! Is!hemi! 4n!ephalopathy'I4)



Pathophysiolo%ytero>pla!entalblood Mow

Perinatal hypo&ia

5naerobi!

o&idation

Eas!ularendothelial

4dema

Intereren!e ospontaneousrespiration

Cerebral Is!hemia;a!ti! 5!idosis

Tissue in-ury

0edu!ed!ardia!output

Term inant :•Cerebral 4dema•!orti!al ne!rosis•basal %an%lia involvement

Preterm inant:•Periventri!ular leu"omala!ia

eper,usion3



Clini!al /aniestation andsta%in%



Pro%nosis

• Cerebral insult: – Corti!al 5trophy

– /ental 0etardation

–

.pasti! diuadriple%ia

• Based on 5p%ar .!ore• 5p%ar @>3

– ?@ mins : /oratlity '2@G)< !erebral palsy '=G)

– 2@ mins : /ortality '7@G)< cerebral pals+(56)



/ana%ement

• .upportive mana%ement – Initial 0esus!itation and stabiliation

– Eentilation support – Perusion and blood pressure mana%ement – luid and ele!trolyte mana%ement – 5void hyperthermia –

ypothermia therapyO – Treat seiures

– Consultation to !are ta"ers$



Neonatal .epsis



4pidemiolo%y



1efnition:

• 5 disease o inants who are less than a monthold and are !lini!ally ill with positive !ultures$

•

4arly onset : a!uired beore or durin% delivery

• ;ate onset : a!uired ater delivery in the!ommunity or the nursery

• Noso!omial sepsis : o!!urs ater 2 hours ohospital stay



i k f f d



Risk Factors of Infants andMother

5ny sta%e

Prematurity< low birth wei%ht$

/ale %ender$

Neutropenia due to other !auses$



4arly 6nset .epsis

• /aternal +B. 'Group B Streptococcus) !arrier 'hi%h va%inalswab QE.R<

urine !ulture< previous pre%nan!y o baby with +B. sepsis)$• Prolon%ed rupture o membranes 'P06/) '?8 hours)$•

Preterm labourPP06/$• /aternal pyre&ia 38S C< maternal peripartum ine!tion<

!lini!al

!horioamnionitis< dis!oloured or oul>smellin% liuor<maternal urinary tra!t ine!tion$

• .epti! or traumati! delivery< etal hypo&ia$• Inant with %ala!tosaemia 'in!reased sus!eptibility to E.

coli)$



;ate 6nset .epsis

ospital a!uired 'noso!omial) sepsis$

> 6ver!rowded nursery$

> Poor hand hy%iene$

> Central lines< peripheral venous !atheters< umbili!al

!atheters$> /e!hani!al ventilation$

> 5sso!iation with indometha!in or !losure o P15< IElipid administration with !oa%ulase>ne%ativeStaphylococcal 'CoN.) ba!teriemia$• Coloniation o patients by !ertain or%anisms$• Ine!tion rom amily members or !onta!ts$• Cultural pra!ti!es< housin% and so!ioe!onomi! status$



Presentation o disease

• +eneral F temperature instability (37! or 3!in thermoneutral environment< poor eedin%

• 0espi F apnoea< ta!hypnoea< %runtin%< !yanosis<in!reasin% 62 reuirement

• CE. F ta!hy!ardia< poor perusion< hypotension• +I F vomitin%< abdominal distension< diarrhoea<

hepatome%aly< splenome%aly< -aundi!e•

CN. F lethar%y< irritability< seiures< bul%in%ontanelle< hypotoni!



• /etaboli! F hyper%ly!aemia< hypo%ly!aemia<metaboli! a!idosis

• ."in F pustules< !ellulitis< omphalitis< pete!hiae<

thrombophleblitis• 4ye F eye dis!har%e• /us!ulos"eletal F septi! arthritis< osteomyelitis<

pseudoparesisU

• 6ther systemi! illness: PPN< N4C< intestinalperoration< I4/

• 0is" o ine!tion: Transient parenteral nutrient< !entralvenous line



Investi%ation

• 4viden!e o inMammation – ;eu"o!ytosis 2@&?@VW; or leu"openia (=&?@VW; – C>rea!tive protein 'raised in 2 samples 2# hours apart) – 1IEC< CK0

• 4viden!e o ine!tion – Positive !ulture rom normally sterile site 'blood< C.< urine)

• 4viden!e o multior%an ailure – /etaboli! a!idosis – Impaired pulmonary un!tion 'hyper!arbiaXhypo&ia) – Impaired renal un!tion 'raised urea and !reatinine) – ;iver dysun!tion 'raised liver enymes< prolon%ed PT) – Bone marrow suppression 'pan!ytopenia)



/ana%ement

4mpiri!al antibioti!s

.tart immediately when dia%nosis issuspe!ted and ater all appropriatespe!imens ta"en$ 1o not wait or!ulture results$

Tra!e !ulture results ater #8 > 2

hours$ 5d-ust antibioti!s a!!ordin% toresults$ .top antibioti!s i !ultures aresterile< ine!tion is !lini!ally unli"ely$



4mpiri!al antibioti! treatment (Early Onset)

• IE C$Peni!illin5mpi!illin and +entami!in• .pe!if! !hoi!e when spe!if! or%anisms

suspe!ted!onfrmed$

• Chan%e antibioti!s a!!ordin% to !ulture and sensitivityresult

4mpiri!al antibioti! treatment F (Late Onset)

•

or !ommunity a!uired ine!tion< start on> Clo&a!illin5mpi!illin and +entami!in or non>CN.ine!tion< and

> C$Peni!illin and Ceota&ime or CN. ine!tion



or hospital a!uired 'noso!omial) sepsis> Choi!e depends on prevalent or%anisms in the

nursery and its sensitivity$

> or nursery where /0CoN. /0.5 are !ommon<

!onsider Ean!omy!inY or non>4.B; %ram ne%ativerods< !onsider !ephalosporinY or 4.B;s !onsider!arbapenamsY or seudo!onas !onsider Cetaidime$

> 5naerobi! ine!tions 'e$%$ Intraabdominal sepsis)<!onsider /etronidaole$

> Consider un%al sepsis i patient not respondin% toantibioti!s espe!ially i preterm E;B* or withindwellin% lon% lines$



1uration o 5ntibioti!s

>?@ days or pneumonia or provenneonatal sepsis

?# days or +B. menin%itis

5t least 2? days or +ram>ne%ativemenin%itis



Consider removin% !entral lines Compli!ations and .upportive Therapy

0espiratory: ensure adeuate o&y%enation '%ive o&y%en<ventilator support)

Cardiovas!ular: support BP and perusion to prevent sho!"$

ematolo%i!al: monitor or 1IEC

CN.: seiure !ontrol and monitor or .I51

/etaboli!: loo" or hypohyper%ly!aemia< ele!trolyte< a!id>base disorder

Therapy with IE immune %lobulin had no eJe!t on the out!omeso

suspe!ted or proven neonatal sepsis$



Prematurity



Classif!ation

&+ Date

• /oderate to ;ate

Preterm A 32>(3*6+

• Eery Preterm A 28>(32 *6+

• 4&treme Preterm A(28 *6+

&+ 7eight

• ;B* A (2$="%• E;B* A (?$="%• 4;B* A (?"%

-acts ,ro# 7*O•4very year< an estimated ?= million babies are born preterm$•Preterm birth !ompli!ations are the leadin% !ause o deathamon% !hildren under = years o a%e< responsible or nearly ?million deaths in 2@?3$



Problems in Prematurity



$e#perature egulation• .us!eptible or hypothermia

– ;ar%e sura!e area to body wei%ht ratio – ;ess sub!utaneous at< brown at and %ly!o%en – Inability to shiver

• Compli!ation – /etaboli! a!idosis dt peripheral vaso!onstri!tion X anaerobi!

metabolism – ypo%ly!emia dt depletion o %ly!o%en stora%e – ypo&aemia – In!reased !alories reuirement – 5pnea – .ho!" with redu!ed !ardia! output – Pulmonary hemorrha%e

• /ana%ement >>> In!ubator 's"in temperature set at 37$=SC)



espirator+

espirator+ Distress %+ndro#e (D%)• dt absen!e or def!ient o sura!tant• ;un% .ura!tant 'le!ithin)

– /ade by type 2 Pneumo!ytes based on etal ree !ortisol levelby 3#>37 wee"s +5 suZ!iently

– ;owers the sura!e tension at low lun% volumes to preventatele!tasis

• 5s a result< neonates lun%s are non>!ompliantstiJ<!ollapsedinadeuate ventilation < whi!h leads to hypo&ia< a!idosis



• /aniestations o 01. – Cyanosis – Ta!hpnoea –

Nasal Marin% – Chest 0e!essions – +runtin% Y !losure o %lottis durin% inspiration to

maintain lun% E< preventin% atele!tasis – 0espiratory distress rom 7hrs o lie< worsens over 2>

3days and improves over ?>2 wee"s• Predisposin% a!tors:

– Prematurity – ypo&ia< a!idosis< sho!"< asphy&ia< hypothermia

•

CK0:?$ ine reti!ular %round %lass appearan!e

2$5ir bron!ho%rams



http:emedi!ine$meds!ape$!omarti!le#@W#@W>overview



• Treatment: – .ura!tant repla!ement admin via 4TT – Eentilatory support as needed – /inimal handlin%

• Compli!ations: – Pneumothora& 'ventilation o stiJ lun%s) – Bron!hopulmonary dysplasia –

IE – P15

• Prevention : /aternal steroids i planneed to deliver early

0



0pnea 1efnition :>

.top breathin% or ?= se!onds

0 (8@min .P62 (8@G

Causes ypo%ly!emia luid X ele!trolyte imbalan!e Temperature Mu!tuation .epsis 5naemia Brain lesion

/& >>> monitor< theophylline X CP5P



ardiovascularPatent Ductus 0rteriosus (PD0)

1ia%nosis :> Clini!al : !ontinuossystoli! murmur in let 2IC.< wide pulse

pressure 2=mm%< in!rease prae!ordial a!tivity< in!reaseventilatory reuirement

CK0 : !ardiome%aly< pulmonary venous !on%estion

Confrmatory : 21 1oppler 4!ho

Compli!ation :> CC IE Pulmonary hemorrha%e

0enal impairment N4C Chroni! lun% disease



/ana%ement :> 1edical

luid restri!tion< avoid dehydration IEoral Indometha!in or Ibuproen CI in :> untreated ine!tion< bleedin% '+I or !ranial)< Platelet

(7@< N4C< du!t dependent C1< impaired renal un!tion ' !r?#@< urea ?#)

%urgical

Primary trans!atheter ballon an%ioplasty .tent .ur%ery



*e#atolog+

0ne#ia o, Pre#aturit+ Causes :>

Phlebotomy 'small total blood volume) 0apid rate o %rowth

Prolon%ed !essation o erythropoietin release until C+5 3#>37 *6+



*+perbilirubinae#ia

Preterm more prone to %et bilirubinen!ephalopathy

?$ ;ow albunin

2$ ypo&ia

3$ 5!idosis#$ 1ru%s

Total Bilirubin 'mi!romol;)

Birth *ei%ht '%) Phototherapy 4T

(?=@@ 8=>?#@ 22@>2=?=@@>?WWW ?#@>2@@ 2=>3@@

2@@@>2#WW ?W@>2#@ 3@@>3#@



/astrointestinal

8ecroti9ing "nterocolitis (8") 5!ute bowel ne!rosis< ass with prematurity andor bowel

is!hemia =>?@G in E;B*< with #@G mortality

Breast mil" >>> prote!tive 0is" a!tor

5PProlon%ed rupture o membrane 37Co!aine abusin% mother

I+0Cyanoti! heart diseasePoly!ythemia Twin

1ia%nosis :>



1ia%nosis : 5bdominal ss

?$ 1istention H Tenderness

2$ Eomit

3$ Bloody stool#$ 5bdominal wall erythemainduration

.ystemi! ss?$ 0espiratory distress

2$ 5pnea3$ Brady!ardia

#$ Temperature instability

=$ Poor eedin%

7$ ypotension

$ 5!idosis

0adiolo%y indin%s:>



0adiolo%y indin%s: .uspi!ious : thi!"en bowel wall< as!ites< f&ed>position loops 1efnitive : intramural %as 'pneumatosis intestinalis)< portal

or hepati! vein %as< pneumoperitoneum



/ana%ement:> .epti! wor" up NP6

Broad .pe!trum antibioti! >>> ampi!ilin and %entami!in TPN .ur%ery

.ta%in% Treatment

': %uspected

>mild si%ns >no blood in stool > 5K0 normalmild ileus

•NP6•5ntibioti! K3

'': De;nite >abdominal erythema

>intramural %as H> portal %as

•NP6•5ntibioti! K >?@

''': 0dvanced >!ompli!ated by a!idosis<sho!"< 1IEC< peritonitis >intramural %as with portal %asH> peroration

•NP6•5ntibioti! K 2=2•Eentilation•luid•Inotropes•.ur%ery



8eurolog+

'ntraventricular *e#orrhage ('*) Bleedin% into the subependymal %erminal matri& o

brain 'hi%hly vas!ular) 0is" a!tor :>

ypertension ypotension ypovolaemia 0apid volume e&pansion : !olloid inusion< 4T ypo&ia< yper!arbia

5!idosis< anaemia

Clini!al presentation :>



C !a p ese a o 6ver minute to hour

.tupor Coma

0espiratory abnormalities .eiure la!!id

6ver hours to days 5ltered level o !ons!iousness 1e!reased movement

ypotonia 5bnormal eye position and movement Ti%ht popliteal an%le

.ilent

1ia%nosis >>> !ranial ultrasound

+radin% :>



% I : (?@G ventri!ular area II : ?@>=@G ventri!ular area III : =@G ventri!ular area< distended

Periventri!ular hemorrha%e 'PE) : periventri!ulare!hodensity

/ana%ement :> /aintain !erebral perusion >>> !ontrol BP

Prevent !erebral hemodynami! disturban!e Prevent post>hemorrha%i! hydro!ephalus

.euele :> /otor def!it Co%nitive def!it Post>hemorrha%i! hydro!ephalus

Periventricular =euko#alacia (P=)



Ne!rosis o white matter 1oral and lateral to e&ternal an%le o lateral ventri!les .ymmetri!al bilateral Clini!al : apnea < seiure Cranial ultrasound :

4!hodense o!i '?!m) by ? wee" 4!holu!ent !yst '3mm) by ?>3 wee"s

Eentri!le enlar%e by ?>3 months .euele : .pasti! diple%ia Co%nitive < intelle!tual X visual def!it .eiure



Ophthal#olog+

etinopath+ o, Pre#aturit+• Caused by eJe!ts o o&y%en to&i!ity on the developin% blood

vessels o prem babies• Patho%enesis:

4&!essive arterial 62 tension !auses vaso!onstri!tion >>>retinal

hypo&ia>>> neovas!ularisation >>> bleedin% >>>>retinal deta!hment• sually both eyes involved but severity may vary• Careul monitorin% o 5B+ Pa62 win =@>@mm%• .!reenin% : '[ # w"s old3#w"s C+5)

– Babies (?=@@% 'E;B*)

– (28wee"s +5• Treatment

– 0eer to ophthalmolo%ist – ;ess severe 06P would resolve spontaneously without visual impairment

Orthopedic



Orthopedic 6steopenia o Prematurity•

5 de!rease in the amount o or%ani! bone matri& !alledosteoid seen in premature inants resultin% in wea" andbrittle bones< hi%h ris" o ra!tures

• Causes – ;ar%e amt o Ca and Phosphate are transerred rom mother to

etus win the last 3 months o %estationY premature inant may

not have re!eived adeuate amounts – In!rease in a!tivity in the womb win last 3 months thou%ht to

have aided bone developmentY premature inants have limitedphysi!al a!tivity

– Preterm inants loses more phosphate in urine than term inants

• Clini!al eatures – 5symptomati! – 0ib ra!tures are not un!ommon in babies with !hroni! lun%

disease – 0edu!ed movement or swellin% o limb – Clini!al ri!"ets is rare



• 1& X I& – ;on% bone K>ray –

.erum Ca !an be normal – .erum Phosphates 'low) – 5l"aline phosphatase 'hi%h)

• Treatment – Cal!iumPhosphate supplements into breast mil"IE Muids – .pe!ial premature ormulas when breast mil" is not

available

common problems in neonates

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