LMCC Review Course

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LMCC Review CourseNeonatology

• Brigitte Lemyre, MD, FRCPC

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Outline

• Resuscitation principles, transition to life
• Normal newborn care and assessment
• IUGR and LGA and their problems
• Prematurity and its complications
• Problems of the term infant

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Infant mortality 9-10 1000 births Due to
congenital anomalies, prematurity, asphyxia,
infections, SIDS Normal baby at term HR
120-160/min RR 40-60/min Weight 2.5-4.5
kg BP 50-80/30-40 mmHg
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Gestational age and size
Gestation Size
28 weeks 1.0 kg
30 weeks 1.5 kg
33 weeks 2.0 kg
35 weeks 2.3 kg
37-40 weeks 2.5 4.5 kg


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Newborn Resuscitation

• Initial steps
• Evaluate respiration
• Evaluate heart rate
• Evaluate color
• Remember - the usual problem in the neonate is
  the lungs VENTILATION!

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Fluid filled alveoli in utero
Diminished blood flow through fetal lungs
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Importance of first breath
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Newborn Resuscitation

• A Airway
• B Breathing
• C Circulation
• D Drugs
• E Environment
• F Fluids
• G Glucose

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Special Circumstances in Newborn Resuscitation

• Meconium in amniotic fluid AND depressed newborn
  (not crying, limp) Intubate and suction below
  cords
• Suspect diaphragmatic hernia Intubate
• Pink when crying, blue when not Suspect choanal
  atresia and try an oral airway

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The Apgar Score
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Principles of Routine Care

• Ensure warmth and adequate nutrient intake
• Monitor weight, hydration status
• Support breastfeeding
• Educate about infant care
• Anticipatory guidance

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Principles of Routine Care

• Prophylaxis for common problems
• Eye care erythromycin ointment
• Vitamin K 1 mg IM
• Screening for disease gt24h
• PKU (1/15,000)
• Hypothyroidism (1/4000)
• Neurosensory hearing loss
• 24 other metabolic diseases (organic acid
  disorders, FAOD, aminoacid disorders, sickle cell
  and hemoglobinopathies, CAH, galactosemia,
  endocrinopathies)
• Blood group and Coombs if mother rH neg

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The depressed newborn

• Asphyxia
• Respiratory condition
• Hypovolemia/shock
• Drugs
• CNS Trauma
• Congenital malformations

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Perinatal Asphyxia

• Must be documented by cordocentesis, fetal scalp
  blood sampling, cord blood sampling
• pH lt 7.00, base deficit gt 15 mEq/L
• Encephalopathy
• Multiorgan involvement (heart, kidneys, marrow,
  liver)
• For perinatal asphyxia to have been cause of
• later neurodevelopmental problem, must
• document neonatal encephalopathy

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The Newborn History

• The babys history is
• the family history
• the mothers past medical history
• the mothers pregnancy history (including any
  information about screening tests, amniotic
  fluid)
• the labor and delivery history (including the
  placenta and umbilical cord)
• the resuscitation history

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Physical Examination

• Vital signs
• Measurements plot on curves
• Gestational age assessment
• Overall appearance
• System by system

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Most common anomalies noted on initial exam
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Most frequent birth injuries

• Asphyxia
• Broken clavicle
• Facial palsy
• Brachial plexus injury
• Fractures of humerus or skull
• Lacerations or scalp injuries
• Ruptured internal organs
• Testicular trauma
• Fat necrosis

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Commonest Congenital Abdominal Masses

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

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Common physical findings of clinical significance

• Apnea, tachypnea, grunting
• Bradycardia, cyanosis
• Hypotonia
• Absent or decreased femoral pulses
• Heart murmur
• Organomegaly
• Absent red reflex
• Jaundice
• Plethora or pallor or diffuse petechiae

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Disorders of gestation length or of growth

• Small for gestational age lt2SD below
• Large for gestational age gt2SD above
• Prematurity lt37 weeks gestation
• Postmaturity gt42 weeks gestation

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Small for gestational age etiologies

• Constitutional ethnicity
• Maternal illness, Rx/R-OH/drugs,
• nutrition
• Placental
• Fetal genetic disorder, infections (TORCH)

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Small for gestational age complications

• Asphyxia
• Meconium aspiration
• Congenital malformations
• Hypoglycemia
• Hypothermia
• Hypocalcemia
• Polycythemia-hyperviscosity

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Small for gestational age Management

• Optimal resuscitation
• Maintenance of body temperature
• Early feeds or administration of glucose
• Meticulous history and physical examination,
  including placenta
• Work-up for etiology

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Disorders of gestation length or of growth

• Small for gestational age lt2SD below
• Large for gestational age gt2SD above
• Prematurity lt37 weeks gestation
• Postmaturity gt42 weeks gestation

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Large for gestational age Etiologies

• Constitutional
• Abnormal maternal glucose tolerance
• Syndromes Beckwith-Wiedemann
• Sotos

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Large for gestational age Complications

• Asphyxia
• Birth trauma
• Hypoglycemia

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Large for gestational age Management

• Optimal resuscitation
• Early feeds or administration of glucose

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Disorders of gestation length or of growth

• Small for gestational age lt2SD below
• Large for gestational age gt2SD above
• Prematurity lt37 weeks gestation
• Postmaturity gt42 weeks gestation

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Risk Factors for Prematurity

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

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Risk Factors for Prematurity

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

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Prematurity Complications

• Respiratory distress syndrome
• Bronchopulmonary dysplasia
• Apnea of prematurity
• Patent ductus arteriosus
• Intraventricular hemorrhage
• Periventricular leukomalacia
• Necrotizing enterocolitis
• Sepsis
• Anemia
• Retinopathy of prematurity

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Respiratory Distress Syndrome

• Etiology
• Anatomic immaturity of the lung
• Increased interstitial and alveolar lung fluid
• Surfactant deficiency
• Management
• Prevention antenatal steroids
• Oxygen
• Positive pressure
• Surfactant

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17 Weeks
Courtesy of Professor Louis De Vos http//www.ulb.
ac.be/sciences/biodic/index.html
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22 Weeks
Courtesy of Professor Louis De Vos http//www.ulb.
ac.be/sciences/biodic/index.html
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25 Weeks
Courtesy of Professor Louis De Vos http//www.ulb.
ac.be/sciences/biodic/index.html
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Bronchopulmonary Dysplasia

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

Pathophysiology disturbed alveolarization
-Lung inflammation
-Mucociliary dysfunction
-Airway narrowing -Hypertrophied airway
smooth muscle -Alveolar collapse -Constriction
of pulmonary vascular bed
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Bronchopulmonary Dysplasia

• Management
• Prevention
• Nutrition
• Oxygen /- ventilation
• Bronchodilators
• Diuretics
• Steroids inhaled vs systemic

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Apnea of Prematurity

• Central, obstructive, or mixed
• Majority of lt32 weeks
• Treat with
• Adequate positioning
• Oxygen
• Methylxanthines
• CPAP
• Ventilation if necessary

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Patent ductus arteriosus

• Up to 42 of lt 1500 g babies
• Management strategies
• -preload/afterload reduction
• -Adequate oxygenation
• -Optimize pH
• -indomethacin
• -surgery
• -conservative management

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Metabolic Problems of Prematurity

• Hypoglycemia
• Fluid/electrolyte imbalance
• Hypocalcemia/hypomagnesemia
• Hyperbilirubinemia
• Hypothermia

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Intraventricular hemorrhage

• Common in lt 1500 gm babies
• Usually evident in 1st week of life
• Reasons
• highly vascularized germinal matrix
• less basement membrane to capillaries
• abnormal autoregulation
• Prognosis good for small amount bleeding in
  ventricles but poorer if large amount
  intraparenchymally or if posthemorrhagic
  hydrocephalus

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Periventricular leukomalacia

• Ischemic lesion to watershed area around
  ventricles in premature infants
• Link to inflammation?
• Most often shows up 3-4 wks after delivery
• Correlated with cerebral palsy

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Necrotizing Enterocolitis

• 1-5 NICU admissions
• Multifactorial etiology
• feeds, prematurity, ischemia, infection
• Diagnosis clinical and radiologic
• Treatment
• Decompression (NPO, NG tube)
• antibiotics
• surgery if necessary

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Sepsis

• Suboptimal immune function in preemies plus poor
  skin barrier, indwelling catheters
• GBS and coliforms cause early onset sepsis
• lt 5-7 days of life
• Nosocomial sepsis common in prems with most
  common organism coagulase negative
  staphylococcus fungi can also be problematic
• in gt 1 week of life

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Anemia of Prematurity

• Reasons
• decreased hemoglobin at delivery
• decreased RBC survival
• blunted erythropoietin response
• IATROGENIC
• Treatment
• prevention
• iron supplementation
• transfusion
• EPO

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Retinopathy of Prematurity

• 40-70 NICU survivors lt 1000 g
• Etiology vasoconstriction leading to abnormal
  vascular proliferation
• Diagnosis screening
• Treatment close monitoring, laser if necessary

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Disorders of gestation length or of growth

• Small for gestational age lt2SD below
• Large for gestational age gt2SD above
• Prematurity lt37 weeks gestation
• Postmaturity gt42 weeks gestation

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Postmaturity

• Labour tends to be induced to avoid problems of
  postmaturity, however if dates not accurate may
  still occur
• Possible complications
• growth disturbances
• asphyxia
• meconium aspiration syndrome

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Problems of the Term Newborn

• Respiratory
• Cardiac
• Sepsis
• Digestive
• Jaundice
• Anemia, polycythemia, hemorrhage
• Renal
• Endocrine
• Neurologic

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Respiratory Distress in the Newborn

• Respiratory system
• Cardiac
• Infectious
• Neurologic
• Metabolic
• Upper airway
• Maternal Rx
• Musculoskeletal

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Respiratory Problems in the Term Newborn

• Transient tachypnea of the newborn
• Pneumonia
• Meconium aspiration
• Pulmonary air leaks
• Congenital malformations
• Persistent pulmonary hypertension
• Pulmonary hemorrhage

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Transient Tachypnea of the Newborn

• Failure to clear lung fluid
• Associated with absent or short labour or initial
  weak or absent respirations
• Improves with time

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Pneumonia

• Can initially be difficult to distinguish from
  TTN/RDS
• Group B Strep 1
• Consolidation may appear after a few days

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Meconium Aspiration Syndrome

• Meconium-stained amniotic fluid
• Intrauterine insult may lead to gasping
• Meconium aspirated
• Pneumonitis
• Airway occlusion
• Pulmonary air leak syndrome
• May lead to persistent pulmonary hypertension

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Congenital Malformations

• Anomalies anywhere along airways, extrinsic or
  intrinsic
• Atresias
• Cysts
• Diaphragmatic hernia

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Persistent Pulmonary Hypertension

• Associated with
• asphyxia
• meconium aspiration
• sepsis
• Right to left shunting, persistent fetal
  circulation
• Treatment
• oxygenation, ventilation
• maintain blood pressure
• pulmonary vasodilators

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Congenital Heart Disease presentations

• Cyanosis
• presents early
• defects with right to left shunts
• TOF, tricuspic atresia, TGA, TAPVR, truncus
  arteriosus, pulm. atresia
• Congestive heart failure
• fewer compensatory mechanisms so common and can
  occur very quickly
• tachycardia, tachypnea, hepatomegaly, feeding
  difficulty, cardiomegaly, diaphoresis

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Presentations of Congenital Heart Disease

• Murmurs
• Dysrhythmias

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Congenital heart disease Most commonly diagnosed

• Ventricular Septal Defect
• Transposition of the Great Vessels
• Tetralogy of Fallot
• Coarctation of the Aorta
• Patent Ductus Arteriosus
• Endocardial Cushion Defect
• Hypoplastic Left Heart

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Sepsis risk factors

• Preterm rupture of membranes
• Prolonged rupture of membranes
• Maternal group B strep carriage
• Chorioamnionitis

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Neonatal Sepsis

• THINK OF IT!
• Signs may be subtle, non-specific
• Incidence bacterial sepsis 1-5/1000 live births
• Commonest organisms
• group B streptococcus
• gram negatives (E coli, Klebsiella)
• enterococcus, H flu, staph species
• listeria
• Work up and treat if suspect sepsis
• Use broad spectrum antibiotics

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Ophthalmia neonatorum

• 1st days - differentiate chemical vs infected
• 2nd-3rd wk - viral or bacterial
• Gonococcal
• within 5 days of birth
• gram negative intracellular diplococci
• if suspect, Penicillin asap
• highly contagious
• Chlamydia
• 5-14 days
• conjunctival scraping
• topical antibiotics

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Congenital Infections

• CMV
• 5-25/1,000 live births
• asymptomatic vs severe symptoms
• microcephaly, thrombocytopenia,
  hepatosplenomegaly, chorioretinitis
• sequelae of hearing loss and developmental delay
• Rubella
• 0.5/1,000
• cataracts, rash, congenital heart disease,
  developmental delay

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Congenital Infections

• Toxoplasmosis
• 0.5-1.0/1,000
• hydrocephalus, cranial calcifications,
  chorioretinitis
• Syphilis
• 0.1/1,000
• snuffles, osteochondritis/periostitis, rash
• Herpes
• vesicles, keratoconjuntivitis, CNS findings

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Congenital syphilis

• Treat 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

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Neonatal herpes simplex

• Only about 1/3 mothers have overt signs
• Infection can be disseminated or local
• Usually present at 5-10 days of age
• If suspect
• Cultures, PCR
• Treat with acylovir

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Maternal hepatitis B carrier

• Give baby hepatitis vaccine as soon as possible
  after birth (first 12 hours)
• Bath
• Universal precautions
• Immune globulin in first 7 days

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HIV

• Virus can be transmitted transplacentally,
  intrapartum, or postpartum
• Screen mothers
• Treat mothers with antiretrovirals
• Treat babies with AZT for 6 wks
• Universal precautions
• Look for other infections (HepB, HepC)

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Digestive Disorders

• Vomiting
• Diarrhea
• Constipation

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Vomiting in the Newborn

• Not uncommon for some vomiting in 1st few hours
  after birth
• Overfeeding, poor burping
• DDx Gastrointestinal obstruction
• Increased intracranial pressure
• Bilious vomiting is a medical emergency!

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Upper G-I problems causing vomiting

• Esophageal
• first feed, soon after feed
• excessive drooling
• if T-E fistula, risk aspiration
• Small bowel atresias
• Malrotation and volvulus
• Achalasia
• Chalasia/GER
• Pyloric stenosis

Need to r/o
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Non-GI causes of vomiting

• Sepsis
• Adrenal hyperplasia
• Meningitis
• UTI
• Milk allergy

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Lower GI Obstruction

• Initially, distention, failure to pass meconium
  vomiting is later sign
• Extrinsic vs intrinsic obstruction
• DDx Imperforate anus, Hirschprung, meconium
  ileus, meconium plugs, ileal atresia, colonic
  atresia

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Constipation

• gt 90 pass meconium in first 24 h
• Present at birth, consider causes of GI
  obstruction
• Present after birth, consider Hirschprung,
  hypothyroidism, anal stenosis
• NB some breastfed babies normally stool only once
  every 5-7 days

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Diarrhea

• Infection
• E coli, salmonella, echovirus, rotavirus,
  adenovirus
• Watch for fluid and electrolyte imbalance

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Jaundice

• First 24 h, always abnormal
• Etiology unconjugated
• 1. RBC destruction/hemolytic
• isoimmune, RBC membrane, enzymes,
  hemoglobinopathies
• Hematoma
• Sepsis (mixed hemolytic and hepatocellular damage
• Hypoxia
• 2. Congenital/metabolic
• Criggler-Najar
• Hypothyroidism, galactosemia

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Jaundice

• Later onset conjugated
• Hepatocellular damage
• Viral
• bacterial
• Metabolic CF, tyrosinemia
• 2. Post hepatic
• biliary atresia
• choledochal cyst

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Jaundice - Work-Up

• History and physical examination
• Bilirubin - total and direct
• Blood type and Coombs
• Hemoglobin
• Reticulocyte count
• Smear
• Septic workup

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Risk factors for kernicterus

• Prematurity
• Hemolysis
• Asphyxia
• Acidosis
• Infection
• Cold stress
• Hypoglycemia

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Treatment of Jaundice

• Nutrition/hydration
• Phototherapy
• Exchange transfusion

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Anemia

• Hemorrhage
• feto-maternal
• feto-placental
• feto-fetal
• intracranial or extracranial
• rupture of internal organs
• Hemolysis
• Treatment
• Transfuse if necessary

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Polycythemia-Hyperviscosity Syndrome

• Hematocrit gt 65 or 70
• Sludging of blood in organ
• May present with
• respiratory symptoms
• CNS symptoms
• thrombocytopenia
• Treat by partial exchange transfusion

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Bleeding in the Newborn

• Hemorrhagic disease of the newborn
• Thrombocytopenia
• immune
• infection related
• congenital
• Disseminated intravascular coagulation

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Renal issues in the Newborn

• Most common site of congenital malformations and
  hence abdominal masses
• Renal vein thrombosis complication of infant of
  diabetic mother or polycythemia
• Increased risk of UTIs in uncircumcised males
  (but still not as high as infant females)
• All newborns have poor concentrating ability
  small prematures at high risk for
  fluid/electrolyte imbalance

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Endocrine issues in the Newborn

• Congenital hypothyroidism
• Screen because too late if wait
• Signs poor feeding, constipation, prolonged
  jaundice, large fontanelles, umbilical hernia,
  dry skin

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Endocrine Issues in the Newborn

• Congenital adrenal hyperplasia
• 21-hydroxylase deficiency most common
• Signs vomiting, diarrhea, dehydration, shock,
  convulsions, clitoris or phallic enlargement
• Watch for electrolyte imbalance
• If suspect, send lab tests and treat

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Endocrine issues in the Newborn

• Infant of diabetic mother
• Congenital malformations (especially important to
  have good control preconception)
• Growth disturbances
• Metabolic disturbances glucose, Ca
• Respiratory distress syndrome and transient
  tachypnea of the newborn more prone
• Polycythemia jaundice
• Cardiovascular problems hypertrophic
  cardiomyopathy

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Hypoglycemia

• BS lt2.6 prem and bottle fed term
• BS lt2.0 breastfed
• No clear safe cutoff for all
• Lack of supply
• Lack of reserve (low glycogen) IUGR
• Inability to use/produce metabolic
• Increased utilization sepsis
• Increased insulin production

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Hypoglycemia

• Treat supply 4-6 mg/kg/min term
• 6-8 mg/kg/min prem
• Look for cause, especially if severe or
• persists beyond 48-72h of life

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Neonatal seizures etiology

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The Hypotonic Infant Etiologies

• Central nervous system disease
• Spinal cord diseases
• Diseases of the peripheral nerve
• Diseases of the neuromuscular junction
• Muscle Diseases
• Systemic diseases
• Metabolic diseases

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Work-up of Hypotonic Infant

• Exhaustive history
• Complete physical examination
• Imaging CXR, U/S, CT, MRI
• Nerve conduction velocity, electromyography
• Serum CPK, AST, CSF protein
• Muscle biopsy, nerve biopsy
• Molecular genetics (myotonic dystrophy,
  Prader-Willi)
• Other