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LMCC Review Course

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Title: LMCC Review Course


1
LMCC Review CourseNeonatology
  • Brigitte Lemyre, MD, FRCPC

2
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

3
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
4
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


5
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

13
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

14
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

16
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

17
The depressed newborn
  • Asphyxia
  • Respiratory condition
  • Hypovolemia/shock
  • Drugs
  • CNS Trauma
  • Congenital malformations

18
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

19
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

20
Physical Examination
  • Vital signs
  • Measurements plot on curves
  • Gestational age assessment
  • Overall appearance
  • System by system

21
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)

41
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

42
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)

46
Small for gestational age complications
  • Asphyxia
  • Meconium aspiration
  • Congenital malformations
  • Hypoglycemia
  • Hypothermia
  • Hypocalcemia
  • Polycythemia-hyperviscosity

47
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

51
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

56
Risk Factors for Prematurity
  • cigarette smoking
  • high perceived stress
  • bacterial vaginoses
  • cocaine use
  • urinary tract infection
  • asymptomatic bacteriuria

57
Prematurity Complications
  • Respiratory distress syndrome
  • Bronchopulmonary dysplasia
  • Apnea of prematurity
  • Patent ductus arteriosus
  • Intraventricular hemorrhage
  • Periventricular leukomalacia
  • Necrotizing enterocolitis
  • Sepsis
  • Anemia
  • Retinopathy of prematurity

58
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

73
Patent ductus arteriosus
  • Up to 42 of lt 1500 g babies
  • Management strategies
  • -preload/afterload reduction
  • -Adequate oxygenation
  • -Optimize pH
  • -indomethacin
  • -surgery
  • -conservative management

74
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
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