Adib Mursyidi A&E Department

5-day-old boy brought to ED for very poor feeding, lethargy. Full term SVD with unremarkable prenatal and post natal history

What is your next step?

FREAK OUT!!!!

Ill neonate frightening entity for most clinicians

Neonatal = first 28 days of life, but may be expanded to account for gestational age

Generally sign and symptoms are vague and non-specific, can be fatal!

Fever / hypothermia Abnormal tone (limping/stiff) Altered mental status (lethargy/irritability) Weak suck Poor feeding Jaundice Abnormal respiration Cyanosis or mottling Vomiting

FEEDING TREND In breast feeding : 1 to 3 hourly, bottle : 6 to 9 in

24hr Lose up to 12% of birth weight during first 3-

7days After this time, gain 20-30g during first 3months

STOOLS Normal BF infants may go 5-7days without

stools OR 6-7 stools per day Color : no significant unless blood is present OR

acholic (white)

RESPIRATORY Range 40-60x per min Periodic breathing (alternating episodes of

rapid breathing with brief <5-10sec pause) usually normal

Healthy infant sleeps median 16.2hr per day

In non accidental head trauma subtle history with no obvious physical finding, non specific

Evaluation including CT Scan, USG, MRI. Skull X-ray might not helpful because infant can have significant injury without skull fracture

X-ray only likely to have positive findings if the were visible sign of injury

Child <2 years old might have occult traumatic head injury and retinal hemorrhage

Evaluation and stabilization of ABC’s Bedside glucose Temperature regulation If bruises or known of ICB Lab should include FBC, PT, APTT

Neuroimaging should be done after stabilization Patient should be admitted to respective

team Skeletal survey and ophthalmologic exam should

be part of evaluation

Always consider the Terrible T’s ▪ Tetralogy of Fallot (TOF) ▪ Tricuspid atresia (TA) ▪ Transposition of great vessels (TOGV) ▪ Total anomalous pulmonary venous return (TAPVR) ▪ Truncus arteriosus (TA)

CHD might not detected in newborn nursery still adequate oxygenated blood through systemic circulation via patent ductus arteriosus (PDA)

PDA closes by 2 weeks of age (delay in detecting)

Boot shaped heart Elevated cardiac apex

“Egg on a string”

“Snowman sign”

Providing 100% O2 can help differentiating between cardiac vs non-cardiac

Non-cardiac at least have 10% increase in pulse oximetry value, where in cardiac have minimal changing in O2 saturation

Hyperoxia test (ABG in room air, then repeat ABG after 10min of 100% O2)

In cardiac minimal change in PaO2

Examination should include BP in 4 extremities Murmur maybe audible, absence does not exclude

cardiac defect CXR, ECG and ECHO is diagnostic Prostaglandin E1 (PGE1) as bolus of IV 0.05mcg/kg

followed by IV infusion 0.05-0.01mcg/kg/min watchout for hypotension, seizure, apnea

Definitive airway management for transportation

Typically present with symptoms of congestive heart failure. Causes: Acyanotic heart disease (ventricular septal defect,

atrial septal defect, patent ductus arteriosus, coarctation of the aorta)

Severe anemia

Trauma

Sepsis

Metabolic abnormalities

Thyrotoxicosis

Classic symptoms: tachypnea, tachycardia, hepatomegaly

History include poor/slow feeding, sweating, color change with feeding, poor weight gain

Stabilization of ABC’s CXR, ECG, FBC, serum electrolyte ECHO diagnostic of heart defect IV Furosemide 1mg/kg IV Dopamine 5-15mcg/kg/min, IV

Dobutamine 2.5-15mcg/kg/min for CVS support

Carefully not to overload this patient Cardiology consultation

Mostly cause by RSV, adenovirus, influenza Classic symptoms : rhinorrhea, cough,

congestion, apnea, significant respiratory distress and wheezing

Depending on symptoms In severe, prolonged apnea accompanied by

bradycardia, unresponsive to O2 therapy, may required intubation

Nebulization with corticosteroid therapy Sepsis evaluation should be consider Admission in premature and other comorbid

(reactive airway disease)

Present in the 1st week with vomiting, hypoglycemia or shock

Common cause in CAH : deficiency in 21 hydroxylase enzyme

CAH diagnosed at birth by routine newborn screening, but missed due inadequate blood, lab error, inability to contact family

Hypotension that unresponsive to fluids and inotropes leads to suspicion of CAH

Stabilization of ABC’s Bedside glucose, serum electrolytes (usually

had hyponatremia and hyperkalemia) IV Hydrocortisone 25-50mg/m2, imperative

to treat hypoglycemia HyperK in this patient response to fluids,

however in symptomatic with ECG changes, calcium chloride, sodium bicarbonate, insulin and glucose may be needed

Develop in infant born to mother with Grave’s disease

Cause by transmission of maternal TS immunoglobin

Present with poor feeding, failure to thrive, tachycardia, irritability, hyperthermia, vomiting, diarrhea, jaundice, thrombocytopenia, respiratory distress, heart failure and shock

Diagnosis is difficult without clear history of Grave’s disease from mother

Evaluation should include Thyroid function test

Stabilization with ABC’s IV Propranolol 0.25 mg/kg for the tachycardia IV Propylthiouracil (PTU) 1.25 mg/kg followed Lugol's solution 1-5 drops by mouth

Given 1 hour after the PTU

This will help to control the hypermetabolic state

Admit with endocrine consultation

Delay/unrecognized/uncommon and not part of routine screening and symptoms

Non specific symptoms such as poor feeding, vomiting, failure to thrive, tachycardia, tachypnea, or irritability

Occasionally symptoms of seizures, lethargy, hypoglycemia, apnea, temperature instability, and acidosis.

Physical exam findings are usually normal

Stabilization with ABC’s Bedside glucose FBC, serum electrolytes, pH, lactate,

ammonia, LFT, urinalysis for reducing substances and ketones

Main goal : stop exposure to protein that maybe converted to toxic metabolic and clear the body of toxic byproduct

In any rectal temperature >38 C Sign and symptoms : poor feeding, irritability,

apnea, hypothermia, jaundice, rashes, increased sleeping, seizures, or vomiting

Maternal and fully physical exam might help

Stabilization with ABC’s Full septic evaluation : CBC, blood culture,

urinalysis, urine culture, cerebral spinal fluid [CSF] culture and analysis, and CXR

To administer broad spectrum antibiotic in sepsis / life threatening symptoms

In neonatal herpes early recognition and treat with acyclovir may decrease mortality

IV Ampicillin 50-100mg/kg and IV Gentamicin 2mg/kg OR

IV Cefotaxime 50-100mg/kg IV Acyclovir 20mg/kg

Inappropriate mixing of water and powdered formula

Overdilution of concentrated liquid of premixed formula

This may result life threatening electrolyte disturbances or failure to thrive

Hyponatremia may present as seizures and immediate correction to stop seizure

Malrotation caused by abnormal rotation of bowel in utero result in an unfixed portion of bowel that may later twist on itself resulting volvulus and bowel ischemia/death

Diagnoses as early in 1st month of life Symptoms include bilious emesis and poor

feeding, lethargy and shock in advanced state

Stabilization of ABC’s Fluids resuscitation,

NGT placement, surgical consultation

AXR might normal, sign of bowel obstruction or classic double bubble sign

Life threatening, might unrecognized History of constipation, with additionally

history of unable to pass meconium in 1st 24hours of life

Poor feeding, vomiting, irritability, abdominal distention, hematochezia and shock

Stabilization of ABC’s Fluid resuscitation Administration of broad spectrum antibiotic AXR : enlarged or dilated section of colon Need surgical consultation

Classical disease of premature neonates Similar presentation with Hirschsprung

enterocolitis Management includes stabilization of ABC,

fluid resuscitation, NGT placement AXR demonstrate pneumatosis intestinalis /

portal air Administration of broad spectrum antibiotic

and surgical consultation

Most common, neonate may represent normal healthy baby

Evaluation depend on presentation ED management include stabilization, lab

evaluation Based on hospital protocal

Uncommon in this group, can be result from maternal ingestion in BF mother, homeopathic remedies, drug overuse

Most common “teething gel” ED management primarily supportive and

based on clinical presentation Hospitalization might required for

observation and monitoring

Neonate suspect with seizure difficult to diagnose

History can include their newborn not acting right or more somnolent

Neonate had immature cortical development, seizure activity might not tonic-clonic

Symptoms include lip-smacking, abnormal eye or tongue movement, pedaling, apnea

Describing event “frightening to the observer and is characterized by some combination of apnea, color change, marked change in muscle tone, choking, or gagging”

ED management : depending on historical information provided by observer and examination

Hospitalization maybe appropriate for observing and monitoring

Common differential diagnosis of ALTE Sepsis/Meningitis/Encephalitis

Pneumonia/RSV

Hypothermia/hypoglycemia

Anemia

ICB

Acid base disturbance/Electrolyte abnormalities/IEM

Seizures

GERD

Child abuse

Further history

Feeding well previously, 2oz every 2hours

Starting to sucking poorly and taking less than half oz every feeding

On examination difficult to arouse, slightly jaundiced and mottled, other examination unremarkable

Temp 35.5, HR 190, RR 50, BP 66/38, CRT >2sec

IV access obtained via scalp FBC : WCC raise, electrolyte normal. UFEME

clear. Infant was given IV NS 20ml/kg bolus and

started on maintenance fluids IV Ampicillin and IV Gentamicin was initiated LP was performed : no evidence of meningitis Blood C&S showed Group B Strep

Antibiotic was changed to penicillin in view of sensitivity and continue for 10days

Infant was discharge well after 12 days of hospitalization

Neonatal emergencies may provoke anxiety in ED clinician

Mnemonics “THE MISFITS” is a helpful tools Infant rare entity Sign and symptoms are non specific To treat unstable neonate narrow down

diagnosis begin life-sustaining treatment ensure safe disposition

References

Evidence Based Review of Neonatal Emergencies in Pediatrics, Aug 2010

Medscape Emergency Medicine : Neonatal Emergencies

Pediatric Protocol 3rd edition, 2013