lmcc review course: “neonatology”

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? gmoore@cheo.on.ca

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