ppt

1. Common Neonatal Problems
Dr Marea Murray
Staff Neonatologist
Blacktown Hospital

2. Concerning Congenital Heart
Disease (CHD)
A. Murmurs noted in the first day are usually pathological
B. The Newborn examination picks up 90% of CHD
C. Neonatal cardiac examination does not need to be
repeated in the first week for those babies who are
discharged early
D. Reduced femoral pulses suggest coarctation and need
urgent investigation
E. Basal crepitations and peripheral oedema are the most
reliable signs of CHF in a neonate

3. Congenital Heart Disease
 Remember CHD may not be evident at birth
 Murmurs on day 1 often reflect the transitional changes
and are not significant
 Early discharge has meant a higher rate of missed
CHD on the Newborn check and the need to examine
the baby again later in the first week of life
 Murmurs and other signs of CHD often evolve with age
– related to changing fetal communications eg closure of the
ductus arteriosus
– Changes in pulmonary vascular resistance

4. Clues to Significant CHD
 Is there a family history of CHD?
 Is the baby normal or is there a syndrome?
– Eg Downs
– Williams
– Velocardiofacial (C/S 22 deletion)
 Is the patient cyanosed?

5. Clues to Significant CHD
 Are there symptoms / signs of CHF?
– Feeding difficulties
– Tachypnoea
– Tachycardia
– Hepatomegaly
– Sweating around the head
 Other signs to look for:-
– Pulses (diminished / increased & distribution)
– Blood pressure - Beware false readings on the dynamap
– Pericardial over activity / thrill
– Murmur

6. Murmurs
 If the only abnormal sign is a murmur it is
usually not urgent to refer to a Paediatric
Cardiologist
– Cardiac murmurs are not synonymous with CHD
 Possible to use the local paediatricians to help
screen these babies if uncertain
 Remember there can be significant CHD and
NO murmur

7. Investigation of CHD - Basic
 CXR
– Situs
– Position
– Contour
– Size
– Pulmonary vascularity
– Look for right sided aortic arch
 Found in 25% OF Tetralogy of Fallot and 40% of Truncus
arteriosus

8. Investigations - Basic
 ECG
– In rare situations may be diagnostic eg AV canal Ostium
primum ASD and Tricuspid atresia = superior axis
– Look for ventricular hypertrophy
– Can be difficult to interpret in the newborn
 eg normal to have RAD and RV more dominant
 Hb and Film
– Can underestimate cyanosis with anaemia
– Polycythaemia causes over diagnosis of cyanosis
– Look for Howell Jolly Bodies- suggests asplenia, has
association with complex CHD

9. Investigations - Advanced
 Referral to Children’s Hospital for
– Paediatric Cardiology assessment
– Echocardiography

10. Concerning Neonatal Jaundice
A. Day 1 jaundice is usually physiological
B. In a term baby on day 5, all SBR levels > 300
should be treated with phototherapy
C. In persistent or late onset jaundice, investigating
the underlying cause is more important than the
actual level of SBR
D. When breast milk has been found to be the cause
of jaundice, breast feeding should be discontinued
E. In the presence of raised conjugated bilirubin,
biliary atresia is not an important cause to exclude

11. Neonatal Jaundice
 Caused by accumulation of bilirubin
– Usually unconjugated
– Tetrapyrrole formed from haeme catabolism
– Main factors
 Increased haeme production eg haemolysis
 Decreased hepatic clearance
 Ductus venosus patency
 Enterohepatic circulation and slow gut transit time

12. Pathological Jaundice
 Jaundice is
– Early
– High
– Late
– Prolonged
– Conjugated
 The neonate is sick

13. Case History
 Full term 3050g breast fed baby
 Took early discharge on day1
 Noted to be jaundiced on day 3
 Jaundiced to below the knees but not the feet
– Which investigations ?

15. Cephalopedal Progression of
Jaundice
 Zone Mean SD Range
1 101 5.1 74 - 135
2 152 29.1 92 - 209
3 202 30.1 138 - 282
4 256 29.1 190 - 313
5 >256
– Kramer LI , Am J Dis Child, 1969 118:454.

16. Serum Bilirubin >270 - 300
 Blood group and DCT
 FBC and blood film
 G6PD (depending on ethnic group)
 Direct SBR

17. Treatment Guidelines
 Birth wt phototherapy exchange
<1000g 100 200
1000 - 1499 150 250
1500 - 1999 200 300
2000 - 2499 250 350
>2500 340 450

18. Treatment Guidelines
 Subtract 50 micromol/ L if :-
– SBR rising >17 micromol/ L/ hour
– Serum albumin <2.5g/ L
– Persistent acidaemia
– Persistent hypoxaemia
– Persistent hypercarbia
– Proven sepsis
– Hypoglycaemia

19. Current Controversy
 Need for treatment
– Based on Hsia’s work in 1952 on Term babies with rhesus
haemolytic disease but can we extrapolate from this?
– Association between total SBR and kernicterus
 3% babies with peak SBR 103 - 256
 18% babies with peak SBR 274 - 513
 50% babies with peak SBR > 530
 Separation of mother and baby
 Risk of lactation failure

20. Use of the Bilibed
 Allows for treatment in the Postnatal ward with
Mother or even treatment at home!
 Advantage of proximity to light source and the
right spectrum (blue light).
 Only a small exposed surface area. (Back)
 Should be avoided if Jaundice is early (<36hrs) or
levels are high.
 In term babies our bilibed ranges are as follows:-
D2 (36-48hrs) D3 D4 D5
260-320 290-350 320-380 350-380

21. Case History
 Philipino baby goes home on D1 on DMP
 Mother brings baby to the surgery on D4 as
baby is not feeding well and very jaundiced
 SBR is 550 micromol/L
 Urgent admission arranged
 Blood Film shows evidence of haemolysis
 Coombs is negative
 Diagnosis is G6PD deficiency

22. G6PD
 On further questioning
– Family placed baby into clothes they had taken out
of moth balls
 High risk for kernicterus
 Need for follow up hearing assessment
 Neurodevelopmental follow up

23. Case History
 16 day old term neonate presents with jaundice
 SBR is 220
 Would you perform further investigations?

24. Prolonged Jaundice
 Conjugated (Direct) SBR is normal
– Breast milk jaundice
– Hypothyroidism
– Urinary tract infection
– Glucuronosyl transferase deficiency
 Crigler-Najjar (type 1 and 2)
 Gilbert’s syndrome

25. Prolonged Jaundice
 Conjugated (Direct) SBR raised
– Well infant
 Biliary obstruction
– Neonatal hepatitis
– Biliary atresia
 Alpha1 antitrypsin deficiency
 Hypothyroidism
– Sick infant
 Sepsis : E coli UTI
 Galactosaemia
 Hypopituitarism

26. Concerning Neonatal Abstinence
Syndrome (opiate withdrawal)
A. Naloxone is contraindicated during
resuscitation of the neonate
B. Drug withdrawal can occur in babies up to
10 – 14 days of age
C. It is a serious condition which has resulted
in neonatal deaths, particularly if parents try to
treat it with their methadone
D. Referral to DoCS is mandatory in all cases
of NAS
E. A, B and C are correct

27. Opiates – Postnatal Issues
 Admission of the baby to the postnatal
ward is possible in the stable methadone
user.
 Midwifery staff must be able to score the
baby to detect withdrawal.
 Scoring occurs for a minimum of 5 days in
hospital. Peak onset of withdrawal is 2-4
days postnatally.

28. Opiates – Postnatal Issues
 Withdrawal occurs up to 10- 14 days of age.
Therefore if discharge occurs at 5 to 10
days-.
– Warn mother / carer what to look for and provide
contact numbers.
– Review soon after discharge.

29. Neonatal Abstinence
Syndrome
 Modified Finnegan scoring system used to assess
abstinence syndrome. Three scores averaging 8 or
greater is the indication for SCN admission and
treatment.
 Morphine is the treatment of choice for Opiate
using mothers.
 Addition of Phenobarbitone is indicated to control
persistent symptoms in babies where mother has
used other drugs in addition to opiates.

30. Regarding Hepatitis C Virus
Infection
A. There is a theoretical risk of transmission of HCV if
mother breast feeds with cracked nipples
B. Testing the baby for HCV is best done at birth with
HCV ab
C. Breast feeding is contraindicated
D. 5 -10% of Mothers with an IV drug using history are
positive for HCV
E. Mother to child transmission occurs in 95% of cases

31. Opiates – Breast Feeding
 Breast feeding may help alleviate neonatal
abstinence syndrome, however issues of hepatitis
C and HIV must be discussed if relevant
 Hepatitis C is not a contra-indication to breast
feeding. Transmission of Hepatitis C to baby via
breast feeding is not proven. However care should
be taken with cracked nipples, as this is a
theoretical risk.
 Weaning from the breast should be gradual.

32. Neonatal Abstinence Syndrome
 Recently a Department of Health guideline
on Neonatal Abstinence Syndrome has
been released.
 Emphasis on multidisciplinary team
approach, beginning during the pregnancy.
 Liaison with community emphasized.

33. Safety Guidelines
– Baby must stay for a minimum of 5 – 7 days.
– Mother must room in for a minimum of 48 hours
prior to discharge.
– Clinic visits at least weekly.
– One week supply of morphine at a time.
– Close liaison with social worker.
– Involvement of DOCS as appropriate.

34. Concerning Neonatal Sepsis
A. Pyrexia is usually present in septic neonates
B. The rate of and morbidity from sepsis are reduced by
covering all Mothers who are GBS positive on HVS with
antibiotics in labour
C. Surface skin swabs are helpful
D. All neonates born following PROM need antibiotic
cover
E. WCC of 15 - 25 is significant

35. Incidence
 1 – 10/1000 live births
– Varies within and between nurseries
– Reduced by prophylaxis

36. Early Onset Sepsis
 Day 1 – 4 (usually D1)
 Risk factors (PROM, Prematurity – 30-50%, maternal
fever)
 25 – 30% are NOT associated with risk factors
 Usual Pathogens
– GBS
– E-Coli
 Present as bacteremia and can be dead within 24
hours

37. Late Onset (> Day 7)
 May present as meningitis
 May have localised disease
 More likely to be staph aureus and Staph epi
 Also can be GBS and E-coli
 Ex-Prems at increased risk

38. Clinical Symptoms / Signs
 Temp instability (up or down)
 Respiratory distress
 Feeding difficulties
 Irritability
 Lethargy
 Apnoea
 IE Most of Neonatology!
– If in doubt in the community – refer in

39. Examination
 Vital signs
– HR, RR, Temp,BP, Blood Glucose
 Capillary return >2 secs
– Hold thumb down on sternum for 5 secs, release
 Other Physical signs
– General appearance
– Recession
– Hepatomegaly

40. How to avoid aggro
 Always collect a blood culture first
 WCC < 5, especially with neutropenia is
suggestive of sepsis
 Don’t do surface swabs
– Colonisation does not equate to infection
– What do you do with the result
– Expensive

41. Some Hints
 Use antibiotics
– Where FiO2 >30%
– Unexplained asphyxia or prematurity
 OK to withhold antibiotics
– Well prem of >33 weeks without risk factors
 Ampicillin / Gentamicin – advantage of covering
Listeria
Or
 Penicillin / Gentamicin
 Penicillin / Cefotaxime if meningitis