1/5/2017

Common Neonatal Conditions

SUPPLEMENTARY NOTES

Transient Tachypnoea of the Newborn

• The commonest cause of respiratory distress
(Especially in term newborns).
• Delayed resorption of lung fluid.
• More common after birth by caesarean section.
• Chest X-ray may show fluid in the horizontal
fissure.
• May required supplemental oxygen.
• Self-limited: Usually resolve with the first day but
can take up to 2-5 days to completely resolve.
– best to re-evaluate if prolonged.
2

Meconium Aspiration
• 8-20% babies pass meconium before birth.
• Increasingly greater with the gestational age
(especially post-term); rarely in preterms.
• Inhaled meconium at birth or intrauterine
before delivery, especially in asphyxiated
infants.
• Meconium causes mechanical obstruction and
chemical pneumonitis.

1
 1/5/2017

Meconium Aspiration
• Lungs over-inflated, with areas of collapse-
consolidation.
• High incidence of air leak pneumothorax,
pneumomediastinum.
• Often require ventilation support.
• May be complicated with persistent
pulmonary hypertension of newborn (PPHN).
• High morbidity and mortality in severe cases.
4

Pneumonia
• Infants may be of any gestational age.
• Risk factors: prolonged rupture of
membranes, chorioamnionitis, low birth
weight.
• Require investigations to identify infection.
• Broad-spectrum antibiotics started early until
the results available.

Pneumothorax
• May be spontaneous
• May occur secondary to RDS, meconium
aspiration or as a complication of ventilation
• Breath sounds and chest movement reduce on
the affected side
• May be demonstrated by transillumination
with bright fibreoptic light source
• Tension pneumothorax requires chest drain
insertion
6

2
 1/5/2017

Persistent Pulmonary Hypertension of

Newborn (PPHN)
• High pulmonary vascular resistance, right-to-
left shunting within the lungs and at atrial and
ductal levels.
• Maybe primary disorder.
• Can be associated with meconium aspiration,
septicemia, RDS, birth asphyxia.
• Life- threatening.

Persistent Pulmonary Hypertension of

Newborn (PPHN)
• Cyanosed. Heart murmurs often absent.
• Chest X-ray: may be pulmonary oligaemia with
normal heart size
• Echocardiogram required
• Adequate ventilation and circulatory support,
achieve adequate oxygenation
• Inhaled nitric oxide (potent vasodilator)
maybe beneficial
8

Congenital Diaphragmatic Hernia

• May be diagnosed on antenatal ultrasound
screening or present in newborn period.
• 95% occur through posterior foramen of
Bochdalek. Most involve left-sided herniation
of abdominal contents through the
posterolateral foramen of diaphragm apex
beats & heart sounds displaced to right chest,
poor air entry in left chest.
• Results in pulmonary hypoplasia.

3
 1/5/2017

Congenital Diaphragmatic Hernia

• Maybe complicated with pneumothorax in
vigorous resuscitation.
• Large nasogastric tube is passed and suction is
applied to prevent intrathoracic bowel
distension.
• Surgical repair after stabilization.
• Associated lung hypoplasia & PPHN main
cause of high mortality, up to 60%.

10

Neonatal Jaundice

11

Bilirubin Metabolism
• Enzyme, beta- glucuronidase converts
bilirubin glucuronide into unconjugated
bilirubin which 95% is reabsorbed into the
circulation. (enterohepatic circulation)

• Remaining conjugated bilirubin in the large

intestine is metabolised by colonic bacteria to
form urobilinogen which is further oxidized
to urobilin and stercobilin

12

4
 1/5/2017

Causes of Neonatal Jaundice

• Haemolysis due to ABO or Rh-isoimmunisation, G6PD
deficiency, spherocytosis, drugs.
• Physiological jaundice.
• Cephalhaematoma, subaponeurotic haemorrhage.
• Polycythaemia.
• Infection : septicaemia, meningitis, urinary tract
infection, intra-uterine infection.
• Breastfeeding and breastmilk jaundice.
• Gastrointestinal tract obstruction: increase in
enterohepatic circulation.

13

Physiological Jaundice
• Infants almost always have elevated bilirubin
levels compared to adults
• Pathway for bilirubin conjugation and
excretion can take several days to mature
• Increased enterohepatic circulation

14

Physiological Jaundice
• Shorter red blood cells lifespans than adults
– 120 days in adults
– 70 - 90 days in term, 40 days in preterm
• Higher haematocrits than adults
• Generally between day 2 – 5
• Unconjugated (indirect)
• No neurological sequelae

15

5
 1/5/2017

Breast milk jaundice

• There is evidence that breastfeeding is associated
with an increase incidence and severity of early
neonatal jaundice.
(CPG Management of Neonatal Jaundice (Second edition)

• Exact mechanism unclear

• Postulation:
Increase enterohepatic circulation due to
increased beta-glucuronidase in breast milk
Metabolite of progesterone in breast milk inhibits
bilirubin conjugation
16

Breastfeeding jaundice
• Inadequate intake as a result of poor lactation
support can exacerbate jaundice
• Adequate lactation support should be
provided to all mothers.
• In breast fed babies with jaundice associated
with inadequate intake, excessive weight loss
or dehydration, supplementation with
expressed breast milk or formula may be
considered.
(CPG Management of Neonatal Jaundice (Second edition)

17

Chronic Sequelae of Bilirubin

Encephalopathy
• Motor:
• Choreoathetoid cerebral palsy, motor delay
• Cochlear:
• Sensorineural deafness
• Oculo-motor:
• Gaze abnormalities (upward gaze paresis)
• Intellectual:
• cognitive dysfunction

Dental dysplasia 18

6
 1/5/2017

Kernicterus
• May be seen in babies who survive from acute
bilirubin encephalopathy
• Post mortem icteric (yellow) staining of the
basal ganglia, specifically the globus pallidus is
the hallmark of this condition

19

Investigations
• Total serum bilirubin , conjugated/unconjugated
• G6PD status
• Others as indicated:
• Infant’s blood group, maternal blood group, Direct
Coombs’ test (indicated in Day 1 jaundice and severe
jaundice).
• Full blood count, reticulocyte count, peripheral blood
film
• Blood culture, urine microscopy and culture (if
infection is suspected)
• Renal profile (hypernatremic dehydration- inadequate
feeding)
20

Prolonged Jaundice

• Jaundice lasting > 14 days in babies

gestational age > 37weeks
• Babies born < 37 weeks, jaundice > 21 days
• Need to investigate
• Unconjugated VS Conjugated
hyperbilirubinemia

21

7
 1/5/2017

Causes of prolonged jaundice

• Unconjugated
• Hypothyroidism
• Septicemia
• UTI
• Breast milk jaundice
• Haemolysis eg G6PD
deficiency, spherocytosis
• Galactocemia
• Gilbert syndrome
• Conjugated
• Biliary atresia
• Choledochal cyst
• Alagille syndrome
• Neonatal hepatitis
syndrome
• Septicemia/UTI
• Congenital infection
(TORCHES)
• Metabolic disorders (Citrin
defiency, PFIC..)
• TPN

22

Unconjugated hyperbilirubinaemia
• Important investigations: Thyroid function, urine
FEME and C&S, urine for reducing sugar, FBC,
reticulocyte count, peripheral blood film, G6PD
screening.

• Admit if infant is unwell. Otherwise follow-up.

• Breast milk Jaundice is a diagnosis of exclusion. Infant

must be well, gaining weight appropriately, breast-
feeds well and stool is yellow.

23

Conjugated hyperbilirubinemia
• Serum conjugated bilirubin concerntration
>1mg/dl (17 micomol/L) if TSB <5 mg/dL (85
micomol/L)
Or
• More than 20% of the TSB if TSB is >5 mg/dL
(85 micomol/L)

• There is NO physiologic conjugated

hyperbilirubinemia
24

8
 1/5/2017

Conjugated hyperbilirubinemia
• Investigate for biliary atresia and neonatal
hepatitis syndrome.
• Stool colour : pale biliary atresia is a high
possibility: consider an urgent referral to
Paediatric Surgery.

• Phototherapy 'bronzing' of baby’s skin

• Other tests as indicated : LFT, GGT, coagulation

profile, lipid profile, Hepatitis B and C virus status,
TORCHES, VDRL tests, alpha-1 antitrypsin level,
US liver
25

Neonatal Sepsis

26

Neonatal sepsis
• Remains one of the leading causes of
morbidity and mortality both among term and
preterm infants.
• Advances in neonatal care have improved
survival and reduced complications in preterm
infants, sepsis still contributes significantly to
mortality and morbidity among VLBW infants
in Neonatal Intensive Care Units (NICUs)

27

9
 1/5/2017

Signs and Symptoms

• Nonspecific
• Temperature instability
• Respiratory distress, cyanosis, apnoea
• Feeding difficulties
• Lethargy
• Irritability
• Hypotonia, seizures, bulging fontanelle,
• Poor perfusion
• Bleeding problems
• Abdominal distension, hepatomegaly, jaundice
• “Just not looking right”
28

‘Intrapartum Risk of Sepsis’

• <37 weeks gestation
• Intrapartum temperature > 38°C
• Rupture of membranes for > 18 hours

29

Timing of the infection

• Early onset sepsis (EOS): presents in the first
5-7 days of life

• Late onset sepsis (LOS): may occur as early as

5 days of life

30

10
 1/5/2017

• EOS: mostly due to vertical transmission of

bacteria from mothers to infants during the
intrapartum period, usually multisystem
fulminant illness

• LOS: horizontal transmission of pathogens

acquired postnatally and is often more
insidious in onset but can be fulminant at
times

31

Organisms associated with Neonatal

Sepsis

32

Early Onset Sepsis

• Group B streptococcus (GBS, Streptococcus
agalactiae) is a gram-positive encapsulated
bacterium and remains the leading cause of
neonatal sepsis and meningitis

• E. coli is frequently associated with severe

infections and meningitis and is the leading
cause of sepsis related mortality among VLBW
infants

33

11
 1/5/2017

Early Onset Sepsis

• GBS and E. coli together account for about
70% of cases of EOS in the neonatal period

• Listeria monocytogenes is less common.

Associated with invasive disease in the
newborn, spontaneous abortions or stillbirth
if acquired during pregnancy.

34

Late Onset Sepsis

• With improved survival of preterm infants,
LOS has become an important cause of
morbidity and mortality among LBW infants.

• Mainly associated with the organisms

acquired from the environment after birth.

35

Late Onset Sepsis

• 70% of 1st episode LOS were caused by gram-
positive organisms, with coagulase-negative
staphylococci accounting for 48% of the
infections.

• Death rates were highest for infants infected

with Pseudomonas aeruginosa, Candida
albicans, Serratia marcescens, and E. coli.

36

12
 1/5/2017

Late-onset GBS disease

• The incidence of late-onset GBS disease has
remained unchanged despite intrapartum
antibiotic prophylaxis.

• Meningitis remains a common presentation of

late-onset GBS disease, with serious
neurologic sequelae and permanent
impairment among many survivors.

37

Biomarkers of Neonatal Sepsis

• Isolation of bacteria from blood gold standard
for the diagnosis of sepsis.
• 24–48 h for culture results.

• Sepsis cannot always be excluded even when

blood cultures are found to be negative.
• Conversely, isolation of bacteria in a blood culture
may reflect asymptomatic bacteremia or
contamination.

38

Full blood count

• Low WBC and absolute neutrophil counts, as
well as high immature-to-total neutrophil ratio
(I:T) are associated with an increased risk of
infection

39

13
 1/5/2017

C reactive protein (CRP)

• Acute phase reactant
• Serial determination of CRP 24–48 h after the
onset of symptoms increases its sensitivity
• Serial CRP measurements may be helpful in
monitoring the response to treatment in infected
neonates and may help clinicians guide the
duration of antibiotic therapy
• If the CRP levels remain persistently normal, it
correlates strongly with the absence of infection
thereby guiding safe discontinuation of antibiotic
therapy
40

Management
• Isolation precautions
• GBS prophylaxis- intrapartum antibiotic
prophylaxis
• Initial therapy: treatment is most often begun
before a definite causative agent is identified.
• Penicillin+ aminoglycoside (gentamicin)

41

Management
• In nosocomial sepsis, the flora of the NICU
must be considered
• Monitoring antibiotic toxicity/ levels
• Adequate cardiorespiratory support eg.
Oxygen therapy, ventilation support, volume
expanders, inotropes
• Monitor for and treat hypo/hyperglycemia,
metabolic acidosis, DIVC

42

14
 1/5/2017

Complications of Prematurity

43

Patent Ductus Arteriosus

• Ductus arteriosus remains patent in many
preterm infants Shunting of blood across the
ductus
• Asymptomatic/ symptomatic
• May cause apnoea, bradycardia, increased
oxygen requirement, difficult weaning from
mechanical ventilation
• Bounding pulse, increased pulse pressure,
hyperdynamic precordium, systolic murmur
• Signs of heart failure

44

Patent Ductus Arteriosus

• Echocardiography
• Should the ductus be treated? controversial
Treatment (if required)
• fluid restriction
• Indomethacin/Ibuprofen
• Paracetamol (possible alternative)
• Surgical ligation

45

15
 1/5/2017

Periventricular leucomalacia (PVL)

• Ischemic brain parenchymal lesions may
resolve or progress to cystic lesions
• Multiple widespread cysts associated with
poor neurodevelopmental outcome

46

Periventricular leucomalacia (PVL)

47

Apnoea and Bradycardia

• Apnoea absence of breathing for >20
seconds or a shorted pause associated with
oxygen desaturation or bradycardia
• Central/ Obstructive/ Mixed apnoea
• Possible causes/ associations: hypoxia,
infection, anaemia, electrolytes imbalance,
hypoglycemia, convulsions, heart failure,
aspiration, gastro-oesophageal reflux

48

16
 1/5/2017

Apnoea of prematurity
• Incidence of apnoea of prematurity inversely
correlated with gestational age and birth
weight.
• Respiratory stimulant eg caffeine,
theophylline, aminophylline often help.
• Breathing will usually start again after gentle
physical stimulation.
• Respiratory support with CPAP or mechanical
ventilation may be required.
49

Apnoea monitor

50

Necrotising enterocolitis
• Serious illness mainly affecting preterm infants
--> significant morbidity and mortality
• Bowel wall ischemia, infection from bowel
organisms, may be accelerated by milk feeding
• Feeding intolerance, milk aspirated from
stomach, + vomiting (maybe bile stained),
abdominal distension, stool may be blood stained
• May rapidly develop shock, apnoea or respiratory
failure require ventilatory support

51

17
 1/5/2017

52

Necrotising enterocolitis
• Characteristic abdominal X-ray: distended bowel
loops, thicken bowel wall with intramural air, air
in portal tract.
• May progress to bowel perforation
Treatment:
• stop oral feeding, broad spectrum antibiotics
(cover aerobic and anaerobic)
• Parenteral nutrition
• Ventilation and circulatory support
• Surgery for bowel perforation

53

Necrotising enterocolitis
Complications
• Strictures
• Malabsorption (extensive bowel resection)

54

18
 1/5/2017

Necrotising enterocolitis

55

Thermoregulation
• The skin of preterm infants is thin and poorly
keratinised water and heat loss in the first
week of life.
• Large surface area relative to body weight.
• Unable to shiver, unable to curl up.
• Often nursed without coverings/blankets.

56

Thermoregulation
• Little subcutaneous fat
• Decrease store of brown fat.
• Immature temperature regulation center
• Mechanism of heat loss

57

19
 1/5/2017

Incubator Resuscitaire / Radiant Warmer

58

Fluid and Electrolytes

• Vary with gestational age, clinical condition
and whether nursed in a closed incubator or
under radiant heater
• Fluid requirement is adjusted according to
infant’s plasma electrolytes, urine output,
weight change and clinical condition.

59

Infection
• Preterm infants are at increased risk of
infection
• Decrease immunity, fragile skin, invasive
procedures
• During or shortly after birth from organisms
acquired from the maternal birth canal
• Infection later on are nosocomial and often
associated with indwelling catheters or
mechanical ventilation
60

20
 1/5/2017

Nutrition
• Preterm infants have a higher nutritional
requirement due to rapid growth
• Infants of 35-36 weeks gestation more
mature, able to suck and swallow milk
• Less mature infants need oro- or nasogastric
tube feeding
• Introduce enteral feeds (preferably breast
milk) as soon as possible even in very preterm
infants
61

Nutrition
• Breast milk may need to be supplemented
with human milk fortifier
• Very immature or sick infants often require
parenteral nutrition, usually given through a
central venous catheter

62

Osteopenia of prematurity
• Osteopenia of prematurity poor bone
mineralization
• Prevented by provision of adequate
phosphate, calcium and vitamin D

63

21
 1/5/2017

Anaemia
• Iron is mostly transferred to fetus during the
third trimester Preterm infants have low
iron stores, at risk of iron deficiency
• Blood loss from sampling
• Inadequate erythropoietin response
• Iron and folic acid supplements
• Recombinant human erythropoietin may
reduce transfusion requirements (still
controversial)
64

Bronchopulmonary dysplasia (BPD)

• Chronic lung disease of prematurity.
• Persistent oxygen dependency up to 28 days
of life.
• The severity of BPD is classified at 36 weeks
postmentrual age (PMA) in infants < 32 weeks
gestational age and at 56 days of age in infants
with older gestational age, according to the
type of respiratory support to maintain
normal arterial oxygen saturation.

65

BPD: Risk factors

• Prematurity
• Increase survival of ELBW infants Affects ~30%
of infants birthweight <1000g
• Chorioamnionitis
• Pneumonia/ Sepsis
• Inflammation
• Mechanical ventilation-volutrauma/ barotrauma
• Oxygen exposure
• Symptomatic PDA
• Vitamin A deficiency
66

22
 1/5/2017

Chest X-ray

67

BPD: Outcomes
• Some infants go home while still receiving
supplemental oxygen.
• Infants with very severe disease may die of
intercurrent infection or cor pulmonale

68

Premature Babies :
Problems following discharge

• Children born premature are generally shorter

and thinner than those born at full term

• VLBW infants have increased chance (~4X) of

hospital readmission during the first year of
life.

69

23
 1/5/2017

Problems following discharge

• Infants with BPD are more susceptible to
recurrent wheezing, bronchiolitis and chest
infections
• Respiratory syncytial virus (RSV) commonest
cause of bronchiolitis
• IM Palivizumab (monoclonal antibody to RSV)
reduce hospital admission rate for preterm
infants; high cost limits its use.

70

Problems following discharge

• Inguinal hernias
• Neurodevelopmental problems
• Visual impairment
• Hearing impairment
• Cerebral palsy
• Learning difficulties
• Delayed language development
• Poor attention span
• Difficulty with fine motor skills
• Behavioural problems
71

Problems following discharge

• The risk increases markedly if born at very
early gestational age, gross abnormalities on
cranial ultrasound and abnormal neurological
examination at term increased risk of long-
term disability
• Neurodevelopmental progress should be
monitored for all high risk infants, to allow
early detection and treatment of any
problems

72

24
 1/5/2017

Neonatal Hypoglycemia

73

Challenges of Management
• Treatment decisions depend on the clinical
situation and infant characteristics

• There is not a specific plasma glucose

concentration or duration of hypoglycemia
that can predict permanent neurologic injury
in high risk infants.

74

• Neonatal glucose concentrations decrease

after birth, to as low as 1.7 mmol/L during the
first 1 to 2 hours after birth, and then
increase to higher and relatively more stable
concentrations, generally above 2.5 mmol/L
by 12 hours after birth.

75

25