Neonatal emergencies. Common neonatal conditions. Neonatal presentations

1. Neonatal Emergencies
and
Common
Neonatal Problems
Dr Raseena .VK
MEM Resident

2. NORMAL NEONATAL VEGETATIVE FUNCTIONS

3. FEEDING PATTERNS
● In first few weeks of life- irregular feeding pattern
● By the end of the 1st month - a regular feeding schedule.
● Bottle-fed infants eat 60–120 mL every 2- 4 hours by the end of the first
week of life
● Breastfed infants —feeding every 1 to 3 hours.

4. ● Intake is adequate if the neonate gains weight appropriately and appears
content between feedings.
● Feedings are progressing well if the infant is no longer losing weight by
5- 7 days of age and is gaining weight by 10 - 14 days of age.

5. WEIGHT GAIN
● Weight neonates completely undressed.
● Normal newborns may lose up to 12% of their birth weight during the first
3 to 7 days of life
● Earlier and slightly more accentuated weight loss in exclusively breast-fed
newborns.

6. ● A weight loss of up to 10% is acceptable if the infant’s examination,
stooling, and voiding frequency and behavior are normal.
● Weight gain:
○ 20 - 30 grams per day in the first 3 months of life
○ 15 and 20 grams per day for the next several months.

7. STOOL PATTERNS
● The number, color, and consistency of bowel movements can vary greatly
in the same infant and between infants
● The median daily stools vary between types of nutrition (breast milk,
formula, or mixed), ranging from 1 to 4.1
“Stooling once a week or eight times per day may be normal if the
clinical history and physical examination are also normal”

8. ● Increased stools may be a result of……
○ Excessive intake
○ Concentrated or high sugar formula
○ Maternal use of laxatives
○ Malabsorption/enteropathy
○ Infection.
● Infrequent stooling may be normal (especially if breastfed) or may be a sign of
constipation

9. “Failure to pass meconium in the first 48 hours of life may suggest
Hirschsprung’s disease or cystic fibrosis.”

10. ● Stool color has no significance unless it is acholic or bloody.
● The first stool, which consists of meconium, is usually passed within the
first 24 hours after birth and is thick, sticky, and black.
● Transitional stools, which are greenish brown, appear after initiation of
milk feeding and are replaced by typical yellow, seedy milk stools 3 to 4
days later.

11. BREATHING PATTERNS
● The normal respiratory rate in neonates is 30 to 60 breaths/min.
● Newborn breathing is almost entirely diaphragmatic, and the soft front of the thorax is
usually drawn inward during inspiration while the abdomen protrudes.
● Count the respiratory rate for a full minute with the infant resting or preferably asleep.
● Neonates increase minute ventilation almost entirely through an increase in respiratory
rate rather than inspiratory volume

12. ● neonate with a resting respiratory rate of >60 breaths/min during periods
of regular, quiet breathing requires evaluation for the causes of tachypnea.
● Indrawing and tachypnea may signify intrathoracic or intra-abdominal
pathology.
● Check the nares and upper airway, as neonates are obligate nose breathers,
and nasal congestion, or choanal stenosis or atresia, can cause respiratory
distress.

13. ● Newborn infants, especially those born prematurely, may exhibit periodic
breathing that is characterized by alternating periods of a normal or fast
rate and periods of a markedly slow rate of respiration, with pauses of 3
to 10 seconds between breaths.
● Irregular respiratory patterns are seen in many premature babies during
sleep, but are less common in term infants.

14. “ Periods of apnea >20 seconds or apnea accompanied by bradycardia,
cyanosis, or a change in muscle tone is abnormal and requires evaluation”

15. SLEEPING PATTERNS
● Newborns awaken every 20 minutes to 6 hours, and sleep periods are
spread evenly across the day and night.
● By 3 months of age, most sleep occurs at night, and by 6 months, most
infants are sleeping through the night.
● When the child cries during the night, parents should make sure that
there is no physical reason for crying.

16. CRYING
● crying or irritability is common yet difficult to treat, even in
the presence of an identifiable cause.
● Total crying time increases after birth, peaking at 3 to 5 months of age.
● Infants who present with an episode of acute, inconsolable crying require
careful evaluation for an underlying cause

17. IRRITABILITY EVALUATION
● Thorough history focusing on symptoms other than crying- changes in
feeding, temperature instability, and vomiting
● Systematic head-to-toe examination.
● Palpate the fontanelles for signs of dehydration (sunken), infection, or
ICH (bulging).
● If corneal abrasion is possible, examine the eyes with fluorescein
staining.

18. ● Inspect the mouth for oral thrush
● Check diaper area and groin for rashes, hair tourniquets (also check
fingers and toes), and hernias or testicular torsion.
● Auscultate the heart to appreciate dysrhythmias or murmurs
● Observe respiratory effort that may point to a pulmonary or metabolic
cause of irritability.

19. Conditions Associated With Inconsolable Crying,
Irritability or Lethargy in Neonates
CNS causes…..
● ICH (neonatal alloimmune thrombocytopenia, birth trauma,
nonaccidental trauma, vitamin K deficiency)
● Meningitis
● Elevated intracranial pressure

20. ENT
● Nasal obstruction (choanal atresia
or stenosis)
● Less serious causes
○ Otitis media
○ Nasal congestion (URTI)
○ Oral thrush
○ Stomatitis
Musculoskeletal
● Hair tourniquet of finger/toe
● Injuries
Metabolic
● Inborn errors of metabolism
● Hypoglycaemia
● Congenital adrenal hyperplasia

21. Pulmonary and cardiac causes
● Pneumonia
● Supraventricular tachycardia
● Heart failure
GU causes
● Testicular torsion
● Urinary tract infection
● Genital hair tourniquets
● Diaper rash
● Paraphimosis
GI causes
● Volvulus
● Gastroesophageal reflux disease
● Intussusception
● Incarcerated hernia
● Gastroenteritis
● Anal fissure
● Colic

22. Infectious
○ Sepsis
○ Upper respiratory infection
○ Pneumonia
○ Meningitis

23. NECROTIZING ENTEROCOLITIS
Necrotizing enterocolitis (typically a disease of prematurity)can present in the
term neonate with……
● Poor feeding
● Abdominal distention tenderness, and discoloration
● Lethargy or irritability
● Vomiting or diarrhea
● Temperature instability
● Apnea
● Circulatory collapse.

24. ▪ inflammation of the intestine 🡪 bacterial 🡪 necrosis of the colon and intestine
▪ Due to 🡪 Inadequate ability of the immature intestine to provide an adequate structural
barrier to bacteria

25. THE CRITICALLY
ILL
NEONATE

26. PRINCIPLES OF CARE
A
B
C
BLS
&
ACLS

27. ● There are more stresses and fewer compensatory
● compliant chest wall and cannot increase inspiratory force
● neonatal airway is small
● functional residual capacity in the lungs is small
● abdominal distention can further impair ventilation.
…………..Consider the early use of positive-pressure ventilation or endotracheal intubation for
respiratory insufficiency and nasogastric tube placement for gastric distention

28. “Bradycardia in the neonate is almost always due to respiratory failure and hypoxia
and usually corrects with restoration of adequate airway and breathing.”

29. ● Cardiorespiratory symptoms in neonates are nonspecific and may be due to cardiovascular
or respiratory failure or to systemic diseases
● Stabilize the cardiac and respiratory systems before, or simultaneously with, further
diagnostic evaluation.
● When a specific cause cannot be identified, initiate a full sepsis evaluation
● Begin broad-spectrum antibiotics, and add IV acyclovir if there are any findings suggestive
of exposure to herpes simplex virus.

30. NEONATAL SEPSIS
● Neonatal sepsis is the most common cause of neonatal
cardiorespiratory distress.
● Fever or hypothermia signals serious infection in the neonate.
● Neonates have about twice the risk of serious bacterial infection as do
infants 4 to 8 weeks of age.

31. ● Fever in the first month of life is a rectal temperature ≥38°C (100.4°F).
● Hypothermia is a rectal temperature <36.5°C (97.7°F).

32. NEONATAL SEPSIS
Early-onset disease
● In the first 7 days of life
● Tends to be fulminant
● Associated with maternal or perinatal
risk factors
○ Maternal Fever
○ Group B Strep +ve vaginal swabs
○ Prolonged rupture of membranes
○ Fetal distress
Septic shock and neutropenia are more
common with early onset syndrome
Late-onset disease
● After 1 week of age
● Develop more gradually,
● Less likely to be associated with risk
factors.
Meningitis is more common in late-onset
disease

33. On Examination….
● Clinical signs of sepsis are not specific.
● Tachypnea and respiratory distress may be a sign of sepsis, meningitis, or
UTI.
● Localizing signs may be absent
Nuchal rigidity and Kernig and Brudzinski signs are present in a small
minority of neonates with meningitis.

34. SIGNS Temperature instability (fever, hypothermia)
OF CNS dysfunction (lethargy, irritability, seizures)
NEONATAL Respiratory Distress (apnea, tachypnea,grunting)
SEPSIS Feeding disturbance (vomiting,poor feeding,gastric
distention,diarrhea)
Jaundice, Rashes

35. MICROBIOLOGY OF NEONATAL SEPSIS
Bacterial causes of neonatal sepsis
reflect organisms that colonize the
female genital tract and nasal
mucosa of caregivers.
gram-positive
cocci, such as β-hemolytic
streptococci,

36. The height of the temperature does not distinguish a viral versus
bacterial cause in neonates.

37. Investigation in Neonatal sepsis
● Threshold for a full sepsis workup, including CSF analyses, is lower.
● Admit all neonates to the hospital, and initiate treatment with empiric IV
antibiotics.

38. Treatment of Neonatal sepsis
● Ampicillin (50 milligrams/kg to cover group B Strep and
Listeria)
● Aminoglycoside (Gentamicin, 2.5 milligrams/kg) to cover
E. coli and other gram-negative organisms

39. ● Avoid ceftriaxone in neonates as it can displace bilirubin
and cause kernicterus.
● When gram-negative meningitis is strongly suspected, replace
gentamicin with cefotaxime or ceftazidime (50 milligrams/kg), which
have better CNS penetration.

40. Add IV acyclovir if:
● A maternal history of herpes
● suspicious CSF findings (predominance of lymphocytes and erythrocytes
in a nontraumatic LP)
● All neonates who are ill appearing.

41. CONGENITAL HEART DISEASE
WHEN TO SUSPECT?
“Well-developed neonate presenting with unexplained cardiorespiratory collapse,
cyanosis, and or tachypnea”
Especially without chest retractions or use of accessory muscles for breathing

42. Time of presentation…
In the first week of life……
● Lesions dependent on pulmonary or systemic blood flow through
the ductus arteriosus (e.g., hypoplastic left heart syndrome, critical
coarctation of the aorta) presents with shock and acidosis as the duct
begins to close.
● This can be mistaken for sepsis.

43. After the 2nd week…..
Lesions that involve left-to-right shunting of blood (VSD and ASD) typically
present with CCF as pulmonary vascular resistance falls(allowing pulmonary
over circulation)

44. NEONATAL PNEUMONIA

45. Common bacterial Chlamydia Bordetella pertussis
Fulminant illness with onset within
48 h of birth (infection in utero)
● Usually occurs after 3 wk
● Respiratory distress
● Unstable temperature
● Irritability Or Lethargy
● Tachycardia
● Poor Feeding
● Conjunctivitis in half
● Often afebrile,
● Tachypnoeic
● Prominent “staccato” cough.
● Wheezing uncommon
● Pneumonia
● Paroxysms of cough ±
cyanosis
● Post tussive emesis
● Otherwise well-looking
infant.
● Characteristic whoop is not
present in neonates.
● Apnea may be the only
symptom.
● Suspect when adult
caregiver also has
persistent cough.

46. Management of pneumonia
● Full evaluation for sepsis (blood and urine cultures, chest radiographs,and CBC).
● Blood culture results are typically negative
● LP, Hospitalization and supportive care (oxygen)
● Parenteral antibiotics (ampicillin and gentamicin)
● Nasopharyngeal swab for PCR or cultures- Bordetella or Chlamydia

47. CHLAMYDIA PNEUMONIA
● CXR may show hyperinflation with
interstitial infiltrates.
● Definitive diagnosis by nasopharyngeal
swab for PCR or cultures.
● Eosinophilia may be seen in peripheral
blood count
● Treatment: macrolide (Erythromycin,
Clarithromycin, Or Azithromycin).
Bordetella Pertussis PNEUMONIA
● Lymphocytosis in peripheral blood
count is nonspecific but supports the
diagnosis.
● Macrolides are effective against
Bordetella (not approved by FDA for
infants <6 mo.)
● Neonates should be admitted during
treatment and monitored for adverse
effects.

49. NEONATAL PNEUMONIA….
ETIOLOGY:Mycobacterium tuberculosis
PRESENTATION:
● Half of infants born to actively infected mothers
develop TB if not immunized or treated.
● Acquired by transplacental means, or postnatal
airborne transmission.
● Nonspecific systemic symptoms with multiorgan
involvement (fever, failure to thrive, respiratory
distress, organomegaly).
MANAGEMENT:
● Sepsis evaluation as for bacterial
pneumonia.
● CXR, culture of urine, gastric and
tracheal aspirates.
● Skin testing not sensitive in neonates.
● Routine anti-TB treatment.
● Supportive treatment as needed.

50. NEONATAL PNEUMONIA….
ETIOLOGY: Viral pneumonia
PRESENTATION:
● Initial upper respiratory illness
progressing to respiratory distress and
feeding difficulty.
● Hypoxia, apnea, and bradycardia (with
HSV) may be present.
● Often indistinguishable from
bronchiolitis.
MANAGEMENT:
● Sepsis evaluation as indicated
● IV acyclovir if HSV is suspected.
● Viral testing (direct antigen
detection/PCR/cultures) of nasopharyngeal
washings (swab).
● Rate of concurrent bacterial infections in
confirmed viral infection is low.
● CXR for significant respiratory distress.
● Supportive therapy; monitoring for apnea in
young and premature infants.

51. BRONCHIOLITIS
● Neonates are at particularly high risk for
complications from bronchiolitis,
● Factors that predispose to complications
● Prematurity
● underlying pulmonary or congenital heart disease
● Initial Oxygen saturation <92%
● Bronchiolitis caused by respiratory syncytial virus.

52. Acute bronchiolitis is a clinical diagnosis
Presentation:
● Nasal discharge and sneezing
● Followed by diminished appetite, difficulty with feeds
● Cough, dyspnea, irritability,
● Occasionally, periods of apnea.
● Hypoxia, wheezing, retractions, and possibly palpable liver and spleen due to pulmonary
hyperinflation

53. BRONCHIOLITIS Mx
● a urinalysis should be obtained in febrile neonates (temperature >38.0°C
[100.4°F]), as up to 4% of febrile infants with bronchiolitis have concomitant
urinary tract infection.
● Full sepsis evaluation is not needed unless the neonate appears ill.
● There is no role for antibiotics, inhaled corticosteroids, or β-adrenergic bronchodilators.

54. AIR LEAK SYNDROMES
● Pneumothorax and Pneumomediastinum
● Occur in neonates who have previously had mechanical ventilation
● May also occur spontaneously/ after aspiration/ associated with pneumonia or
other underlying lung disease (including congenital anatomic lesions).
● Management is generally conservative
● May require drainage with needle decompression or chest tube

55. ANATOMIC AIRWAY LESIONS
Anomalies of the upper respiratory tract:
● Choanal atresia
● Laryngomalacia
● Tracheomalacia
● Micrognathia,
● Macroglossia
● Tracheoesophageal fistula
● Vascular slings

56. Anomalies of the lower respiratory tract:
● Congenital lobar emphysema
● Sequestration
● Congenital pulmonary airway
malformation
● Congenital diaphragmatic hernia
● Most of these anomalies are identified in the newborn nursery, but in ED, these diagnoses should
be considered in any infant with respiratory distress.
● Admission is needed for diagnosis.

57. NEUROMUSCULAR DISORDERS
May be associated with shallow breathing and a compensatory
increase in respiratory rate.

58. INFANTILE BOTULISM
● Acquired cause
● Usually preceded by constipation
● Weak cry and feeding difficulties.
● Ocular palsies
● Apnea, weakness or hypotonia, and lethargy are
late symptoms of botulism

59. Other causes of hypotonia that may cause respiratory
symptoms include……..
● Trisomy 21
● Hypoxic-ischemic encephalopathy
● Myelomeningocele
● Spinal muscular atrophy
● Myasthenia gravis
● Metabolic disorders
● Myotonic dystrophy.

60. INBORN ERRORS OF METABOLISM
● May manifest as lethargy or respiratory and/or cardiovascular collapse in the
neonate.
● ED evaluation necessitates only a few tests( bedside glucose, electrolytes, ABG,
serum ammonia, and urine for ketones.
● Follow up on newborn screening if available.
● More specific testing can wait until after resuscitation.

61. ● Administer dextrose-containing IV fluids for suspected metabolic disease
until specialty consultation can be obtained.
● In cases of neurologic signs and hyperammonemia, consider sodium
benzoate and sodium phenylacetate because neurologic outcomes
correlate with the duration of hyperammonemia

62. CONGENITAL ADRENAL HYPERPLASIA
● Acute life-threatening endocrine emergency that present in the neonatal
period
● Infants may present in shock before screening results are known, typically
in the first or second week of life.

64. ● Virilization, ambiguous genitalia, and hyperpigmentation.
● Hyponatremia and hyperkalemia occur in the salt-wasting form of
congenital adrenal hyperplasia.
● Administer hydrocortisone (12.5 to 25.0 milligrams IV/IM/IO) promptly,
while undertaking other resuscitative measures.
● Treat hyperkalemia with standard measurements only if associated with
ECG change

65. INTRACRANIAL HEMORRHAGE
● Birth trauma or non accidental trauma
● Risk factors:
○ Home delivery without administration of vitamin K (associated with
hemorrhagic disease of the newborn)
○ Traumatic vaginal delivery.
○ Consider head CT after initial resuscitation if a diagnosis is not apparent
or intracranial pathology is suspected

66. ABDOMINAL CATASTROPHE
● Consider abdominal catastrophe in a critically ill neonate with
abdominal symptoms.
● Congenital malrotation can
lead to midgut volvulus and intestinal
infarction, with bilious vomiting, a
distended rigid abdomen, sepsis, and
circulatory collapse.

67. INTESTINAL COLIC
● Colic is a symptom complex consisting of the sudden onset of paroxysmal
crying, a flushed face, circumoral pallor, tense abdomen, drawn up legs,
cold feet, and clenched fists.
● The cause is not known.
“Colic is defined as a paroxysm of crying for ≥3 hours per day for ≥3 days
per week over a 3-week period”

68. ● May begin as early as the first week of life but seldom lasts beyond 3 to 4
months of age.
● Diagnosis of exclusion
● Physical examination is normal, and laboratory tests are not required
● There is no specific treatment for colic.

69. MANAGEMENT OF COLIC
● Altering feeding practices (smaller volumes, slower feeds with burping,
dairy/soy restriction, alternate formula) may decrease symptoms.
● If symptoms do not resolve, restrictive diets are not recommended.
● Administration of drugs or sedatives is contraindicated.

70. COUGH AND NASAL CONGESTION
● Cough associated with sneezing and nasal congestion is usually due to
viral URTI.
● Neonates with underlying pulmonary or heart disease may develop
respiratory failure with even mild upper respiratory infections.
● Relation between respiratory symptoms and feeding is imp- might
suggest reflux and aspiration, or even congenital tracheoesophageal
fistula, as a cause.

71. ● Respiratory difficulty when quiet and improvement during crying suggest
choanal atresia.
● Treat the underlying condition
● Do not give cough suppressants to neonates.
● Over-the-counter cold medications are not effective, may be dangerous in
infants, and are contraindicated for children <6 years old.
● Treat nasal congestion with saline drops and bulb suctioning.

72. Feeding Difficulties
Anatomic abnormalities may cause difficulty in feeding and swallowing. -
started at birth, malnourished and dehydrated.
● upper GI abnormalities (e.g., stenoses, strictures, laryngeal clefts, or cleft
palate)
● Compression of the esophagus or trachea by a double aortic arch.
Infants with a recent decrease in intake usually have acute illness, most often
infectious, and should be evaluated urgently.

73. Vomiting
● Vomiting beginning at birth is most likely due to an anatomic abnormality
○ Tracheoesophageal fistula (with esophageal atresia),
○ Upper GI Obstruction - duodenal atresia
○ Midgut malrotation.
● May be unrelated to the GI tract, such as increased ICT, metabolic
disorders, or infections - sepsis, UTI , and gastroenteritis).

74. PYLORIC STENOSIS
● Projectile vomiting at the end of feeding
● Presents between 6 weeks and 6 months of age
● MC surgically correctable cause of vomiting in newborns.
● Typically the infant appears well with an increased appetite.

75. ● Prominent gastric waves progressing from left to right.
● Firm olive-shaped mass under the liver edge.
● Definitive diagnosis – USG
● The well-appearing infant without dehydration, malnutrition, or electrolyte
abnormalities can be discharged with a plan for outpatient surgical correction.
● Admit ill-appearing or dehydrated infants.

76. Blood in the Diaper
● Is it blood? test with a guaiac card
● Origin?
Anal:
● Anal fissure
● Maternal blood swallowed during delivery (Kleihauer-Betke or Apt-Downey test)
Vaginal
● due to withdrawal from placental estrogen

77. ● Presentation after first few days- idiopathic, but consider coagulopathies,
necrotizing enterocolitis, allergic or infectious colitis, and congenital
defects.
● Cow’s milk allergy
● For unresponsive or severe cases, endoscopy and biopsy may be needed
for diagnosis

78. Constipation
● Can go without a bowel movement for 5 to 7 days and then pass a normal
stool.
● if the neonate has never passed stools, especially if there has not been a
stool in the first 48 hours of life, consider…..
○ intestinal stenosis
○ Hirschsprung’s disease
○ Meconium ileus associated with cystic fibrosis.

79. Constipation occurring after birth but within the first month of
life suggests - Hirschsprung’s disease, hypothyroidism, anal
stenosis, or an anteriorly displaced anus.

80. HYPOTHYROIDISM
● Infants with hypothyroidism present with constipation
feeding problems, a weak or hoarse cry, a large anterior
fontanelle, hypothermia, hypotonia, and peripheral edema.
● Early treatment of neonatal hypothyroidism is critical to prevent
permanent neurodevelopmental delay

81. JAUNDICE
Physiologic or pathologic ?
“Physiologic jaundice is characterized by a slow rise in bilirubin (<5 milligrams/dL per 24
hours), with a peak of 5 to 6 milligrams/dL during 2nd to 4th days of life and a decrease to <2
milligrams/dL by 5- 7 days ”

82. UNCONJUGATED HYPERBILIRUBINEMIA
• More common
• Presents earlier
• Related to breakdown of hemoglobin
CONJUGATED
HYPERBILIRUBINEMIA
• Always pathologic
• primary hepatic or biliary disease such as
biliary atresia or hepatitis
• Presents later
• jaundice, acholic stools, and dark urine.

85. ● Bilirubin levels that are significantly higher than 6 milligrams/dL 🡪 can lead to permanent
brain injury—kernicterus.

86. Evaluation of jaundice- Thorough history
● Maternal blood type and RhoGAM® administration
● Term or preterm
● Feeding patterns, including formula or breast milk, frequency, duration, and whether
maternal milk supply is adequate and latching successful
● Stool history, including timing of first stool and transitional stools, color (yellow, acholic),
and frequency
● Regurgitation or vomiting; urine output; and documented fever.
● family history of hemolytic anemia or prior neonatal jaundice (inherited disorder)
● Review maternal and fetal medications.
● infant’s blood type and maternal antibody screen.

87. Scleral icterus is typically noted with serum bilirubin >5 milligrams/dL.

88. Evaluation of jaundice
● Evaluation should be determined by the differential diagnosis
● CBC for anaemia and red cell indices
● blood smear for haemolysis, reticulocyte count,
● LFT, TFT.
● When infection is a concern, obtain appropriate cultures and Gram stains (urine,
cerebrospinal fluid).
Breast milk jaundice is unlikely to cause kernicterus and usually can be treated with
phototherapy, when necessary.

89. Treatment of neonatal jaundice
● Treating cause
● Phototherapy
● Extreme levels of hyperbilirubinemia are treated emergently with exchange
transfusion and require admission to hospital

90. THANK YOU