Introduction Neonatal emergencies are not uncommonproblems. They appear either at the time ofbirth, during the in-hospital post-birth period, orat home within several weeks of discharge. Inall instances they present significant diagnosticand treatment challenges to the clinician, andmust be taken seriously.
DefinitionNeonate: of, relating to, or affecting the newbornand especially the human infant during the firstmonth after birthThe neonatal period commences at birth and ends28 completed days after birth.
Etiology - Retrospective analysis of neonatal deaths and stillbirths infive hospitals in Guyana, December 2007 “This study was conducted in five hospitals: Georgetown Public Hospital Corporation(GPHC) and the four Regional Hospitals: New Amsterdam, West Demerara, Suddie and Linden McKenzie.” “These health facilities offer basic and comprehensive obstetric care to mothers. The results of this study served to inform the Maternal and Child Health Department on the issues related to the causative factors on neonatal deaths and the implications of service recommendations for the health sector.”
Etiology The five leading causes of neonatal deaths from the hospitals were: •Acute respiratory distress, •Bacterial sepsis of the newborn, •Birth asphyxia, •Prematurity and •Brain haemorrhage: subarachnoid haemorrhage due to the injuries of the head of the fetus. Birth injuries to the liver and brain damage occurred in eleven cases. These issues point to quality of care during intranatal care.
Mortality Rate• In 2004, the Neonatal Mortality Rate (NMR) was 20.4.• That is an average of 20.4 children who died not long after birth for every 1,000 who were born alive.• This means that at least 334 of the children recorded in 16,391 live birth figures for 2004 are not alive today.• In 2000, NMR = 54.0• In 2006, NMR = 37.0
Assesssment of Newborn• Apgar scoring• Birth weight and measurements• Physical examination• Gestational assessment• Physical maturity• Neuromuscular maturity
Apgar Scoring Sign Score = 0 Score = 1 Score = 2 Below 100 per Above 100 perHeart Rate Absent minute minute Weak, irregular, orRespiratory Effort Absent Good, crying gasping Well flexed, or active Some flexion ofMuscle Tone Flaccid movements of arms and legs extremitiesReflex/Irritability No response Grimace or weak cry Good cry Body pink, handsColour Blue all over or pale Pink all over and feet blue
Signs & symptoms• The clinical symptoms may be nonspecific.• The history may reveal only a change in feeding pattern or subtle behavioral changes.
Differential Diagnosis• A useful mnemonic to recall the broad differential diagnosis of a neonate with altered mental status: ‘‘THE MISFITS’’
THE MISFITS T-Trauma (non-accidental and accidental) H-Heart disease/Hypovolemia/Hypoxia E-Endocrine (congenital adrenal hyperplasia, thyrotoxicosis) M-Metabolic (electrolyte imbalance) I-Inborn errors of metabolism (metabolic emergencies) S-Sepsis (meningitis, pneumonia, urinary tract infection) F-Formula mishaps (under or over dilution) I-Intestinal conditions (volvulus, intussusception, necrotizing enterocolitis) T-Toxins/Poisons S-Seizures
Trauma• Classified as Accidental or Non-accidental• Non-accidental head trauma may only have subtle historical findings and no physical exam findings• Presenting symptoms may be nonspecific• Early diagnosis of an occult head injury may prevent significant long-term morbidity
Trauma -Accidental• Most head injuries occur secondary to motor vehicle accidents, falls, assaults, recreational activities, and child abuse.• Mechanical or anoxic trauma incurred by the neonate during labor or delivery include:• Head and scalp injuries• Cephalhematoma• Subgaleal Hematoma• Caput Succedameum• Vacuum Caput
Trauma- Accidental Orthopedic Injuries and Fractures Clavile Fracture from Birth Trauma Skull Fracture from Birth Trauma Sternocleidomastoid Hematoma (Torticollis) Peripheral Nerve Injuries Facial Nerve Injury from Birth Trauma Brachial Plexus from Birth Trauma Duchenne-Erb Paralysis Klumpke‟s Paralysis Phrenic Nerve Injury from Birth Trauma Recurrent Laryngeal Nerve Injury from trauma
Shaken Baby Syndrome-Nonaccidental• Shaken baby syndrome is a severe form of child abuse caused by violently shaking an infant or child.• The brain bounces back and forth against the skull.• Causes bruising of the brain (cerebral contusion), swelling, pressure, and bleeding in the brain.• The large veins along the outside of the brain may tear, leading to further bleeding, swelling, and increased pressure.• This can easily cause permanent brain damage or death.
Subdural Hematoma (Arrow) – Bleeding between thedura mater and the brain, commonly occurs in SBS.
Signs & SymptomsVary from mild to severe:• Convulsions (seizures)• Decreased alertness• Extreme irritability or other changes in behavior• Lethargy, sleepiness, not smiling• Loss of consciousness• Loss of vision• No breathing• Pale or bluish skin• Poor feeding, lack of appetite• Vomiting
TreatmentTreatment involves:• Monitoring of intracranial pressure (the pressure within the skull),• Draining of fluid from the cerebral ventricles,• Draining of intracranial hematoma if present.
Prevention •NEVER shake a baby or child in play or in anger. Even gentle shaking can become violent shaking when you are angry. •Do not hold your baby during an argument. •If you find yourself becoming annoyed or angry with your baby, put him in the crib and leave the room. Try to calm down. Call someone for support. •Call a friend or relative to come and stay with the child if you feel out of control. •Contact a local crisis hotline or child abuse hotline for help and guidance. •Seek the help of a counselor and attend parenting classes. •Do not ignore the signs if you suspect child abuse in your home or in the home of someone you know.
Heart Disease• Congenital heart diseases (CHD) encompass a spectrum of structural abnormalities of the heart or intra-thoracic vessels.• Commonly presents in the newborn with central cyanosis, heart failure, sudden collapse or heart murmur.• Classified as Cyanotic or Acyanotic
Cyanotic Heart Disease• Cyanosis is a pathologic process caused by deoxygenated blood in the capillary vessels.• Cyanotic heart defects are not detected in the newborn nursery, presents during the first 2 to 3 weeks of life when the Ductus Arteriosus closes .• There is still adequate oxygenated blood to the systemic circulation through a patent DA.
Terrible T‟sThe congenital heart defects that classically presentwith cyanosis, commonly referred to as the „„TerribleTs”1. Transposition of the great vessels2. Total anomalous pulmonary venous return3. Tetralogy of Fallot4. Truncus arteriosus5. Tricuspid atresia
Acyanotic Heart Disease• Acyanotic heart diseases may also be a result of closure of the ductus arteriosus (DA).• The onset of symptoms typically is gradual, with the onset of congestive heart failure.• Different degrees of obstruction to the left ventricular outflow tract are present that result in an increase in pulmonary blood flow and a gradual development of heart failure.
Signs & Symptoms•Tachypnea• Tachycardia•Hepatomegaly•History of poor feeding•Sweating or color change with feedings•Poor weight gain• Lower extremity edema and jugular venousdistention are unlikely findings at this age
Common Causes•Anemia •Endocardial cushion defect•Aortic atresia •Hypoplastic left heart•Aortic stenosis •Interrupted aortic arch•Arteriovenous malformation •Mitral valve atresia•Coarctation of the Aorta •Patent ductus arteriosus•Complete arteriovenous •Truncus arteriosuscanal•Cor pulmonale caused by •Ventricular septal defectbronchopulmonary dysplasia
Management - Classic Hyperoxia Test•Differentiate between cardiac and noncardiac causes•Provide 100% oxygen•Observe the oxygen saturation on pulse oximetry foran increase of 10% in pulmonary causes (PaO2should increase by 30 mm Hg)•If the neonate‟s oxygen saturation or PaO2 fail toimprove, cyanotic heart disease is suspected.
Management• Administration of prostaglandin E1 (PGE1) as a bolus of 0.05 mcg/kg IV• Success is less likely because the development of heart failure is gradual and the DA may already have been closed for several days to weeks.• First line -Furosemide, 1 mg/kg IVOther adjuvants include dopamine, dobutamine, and digoxin.• Pediatric cardiology consultation
Endocrine• Congenital adrenal hyperplasia - Congenital adrenal hyperplasia refers to a group of inherited disorders of the adrenal gland.• Thyrotoxicosis (Hyperthyroidism) - Thyroid gland makes too much thyroid hormone. The condition is often referred to as an "overactive thyroid."
Congenital adrenal hyperplasiaCaused by a deficiency in the 21-hydroxylaseenzyme - needed for biosynthesis of the steroidhormones aldosterone and cortisol.Patient may present in the first few weeks of life withsymptoms:•Vomiting• hypoglycemia• or even shock.
ThyrotoxicosisInfants born to mothers with Graves‟ disease may developthyrotoxicosis and present with delayed symptoms to the ED.Symptoms may include:•Poor feeding, irritability, tachycardia, respiratory distress,hyperthermia, or congestive heart failure.Treatment:•Propranolol,0.25 mg/kg IV- to control tachycardia.•In addition, propylthiouracil, 1.25 mg/kg IV,•followed by Lugol‟s solution (1–5 drops orally)- to control thehypermetabolic state and hormone release
Metabolic• Genetic disorders in which the body cannot properly turn food into energy.• Usually caused by defects in specific proteins (enzymes) that help break down (metabolize) parts of food.• Problems arise due to accumulation of substances which are toxic or interfere with normal function.
Inborn Errors of metabolism• Nonspecific symptoms: poor feeding, vomiting, failure to thrive, tachycardia, tachypnea, or irritability.• Occasionally the diagnosis may be more apparent and include symptoms of seizures, lethargy, hypoglycemia, apnea, temperature instability, and acidosis.• Physical exam findings are usually normal.
Diagnostic pathway with a normal and an elevated serum ammonia
Sepsis• Neonatal sepsis is a blood infection that occurs in an infant younger than 90 days old.• Early-onset sepsis is seen in the first week of life.• Late-onset sepsis occurs between days 8 and 89.
CausesA number of different bacteria, including :• Escherichia coli ( E. coli),• Listeria• Certain strains of streptococcus• Early-onset neonatal sepsis-appears within 24 hours of birth.
CausesThe following increases an infants risk of early-onsetsepsis:•Group B streptococcus infection during pregnancy•Preterm delivery•Water breaking (rupture of membranes) that lastslonger than 24 hours before birth•Infection of the placenta tissues and amniotic fluid(chorioamnionitis)
Signs & Symptoms•Body temperature changes•Breathing problems•Diarrhea•Low blood sugar•Reduced movements•Reduced sucking•Seizures•Slow heart rate•Swollen belly area•Vomiting•Yellow skin and whites of the eyes (jaundice)
TreatmentRecommended Antibiotics and Dosages for Neonatal Sepsis:• Ampicillin 50-100 mg/kg IV• Gentamicin 2 mg/kg IV• Cefotaxime 50-100 mg/kg IV• Acyclovir 20 mg/kg IV
Formula Mishaps• The inappropriate mixing of water, powdered formula or overdilution of concentrated liquid or premixed formula may result in life-threatening electrolyte disturbances or failure to thrive.• Hyponatremia may present as seizures and requires recognition of an electrolyte abnormality and immediate correction to stop the seizure
Toxins/ Poisons• Toxic ingestions are uncommon in this age group, but occasionally result from a maternal ingestion in a breastfeeding mother, homeopathic remedies, or overuse of accepted medications.
Seizures•Seizures occurring during the neonatal period areoften difficult to recognize.•The cortical development is not complete, and as aresult, generalized motor activity is less common.•Subtle seizures in the term neonate can includeabnormal eye movements (usuallyhorizontal, sustained eye deviation), lipsmacking, abnormaltongue movements, pedaling, or apnea.
ClassificationsClonic seizuresThese movements most commonly are associatedwith electrographic seizures.They often involve 1 extremity or 1 side of the body.The rhythm of the clonic movements is usuallyslow, at 1-3 movements per second.
Classification•Tonic seizures•These may involve 1 extremity or the whole body. Focal tonicseizures involving 1 extremity often are associated withelectrographic seizures.•Generalized tonic seizures often manifest with tonic extensionof the upper and lower limbs and also may involve the axialmusculature in an opisthotonic fashion.•Generalized tonic seizures mimic decorticate posturing; themajority are not associated with electrographic seizures.
ClassificationMyoclonic seizures•These may occur focally in 1 extremity or in severalbody parts (in which case they are described asmultifocal myoclonic seizures).•Focal and multifocal myoclonic seizures typically arenot associated with electrographic correlates.•Generalized myoclonic jerks are possibly the clinicalequivalent of infantile spasms.
Acute Management of Neonatal SeizuresAfter each step, evaluate the infant for ongoing seizures. If seizures persist,advance to next stepStep 1. Stabilize vital functionsStep 2. Correct transient metabolic disturbancesA. Hypoglycemia (target blood sugar 70-120 mg/dL)10% dextrose water IV bolus dose 2 mL/kg followed by a continuousinfusion at 8 mg/kg/minB. Hypocalcemia 5% calcium gluconate IV at 4 mL/kg (need cardiacmonitoring)C. Hypomagnesemia 50% magnesium sulfate IM at 0.2 mL/kg
Acute Management of Neonatal SeizuresStep 3. Phenobarbital 20 mg/kg IV loadCardiorespiratory monitoring5 mg/kg IV (may repeat to total dose of 40 mg/kg)Consider continuous EEG monitoringConsider intubation/ventilationStep 4. Lorazepam 0.05 mg/kg IV (may repeat tototal dose of 0.1 mg/kg)
Acute Management of Neonatal SeizuresStep 5. Phenytoin (fosphenytoin)20 mg/kg slow IV load5 mg/kg slow IV (may repeat to total dose of 30mg/kg)Step 6. Pyridoxine 50-100 mg/kg IV (with *EEGmonitoring)*EEG = electroencephalogram.
Nursing considerations for Management of Neonatal Seizures???
Procedural Algorithm for Neonatal Resuscitation
Recommendations-Postnatal and New Born careEssential newborn care for all newborns should ensure:• Birth in a safe environment with access to complete obstetric and neonatal care.• Avoid unjustified separation from the mother.• Early and exclusive breastfeeding: early suckling, positioning and attaching thebaby to the breast; rooming-in and unrestricted feeding; ten steps to successfulbreastfeeding; safe human milk banking.• Warmth provision and avoidance of bathing during first 24 hours.• Infection control, including cord care and hygiene.• Postpartum vitamin A provided to mother.• Eye prophylaxis to prevent gonococcal opthalmia.• Information and counseling for home care and emergency preparedness.
RecommendationsExtra care for small babies• Extra home visits; support for breastfeeding, thermal care, and hygieniccord care.• Extra attention to warmth, feeding support, and early identification andmanagement of complications.• Skin to skin thermal care (kangaroo mother care).• Vitamin K administration at birth.• Facility-based clinical care of ill newborn babies, particularly those withinfections, prematurity, and birth asphyxia. Short and long term follow up.• Early neurodevelopment stimulation.
RecommendationsPre-discharge package (at facility level or before birth attendant leaves themother in the case of a home delivery)• Careful assessment of high risk factors/danger signs (for both mother andnewborn).• Counseling for mother and family in preventive care, recognition of danger signs,provision of care (what to do and where to go).• Promotion and referral for early postnatal care.• Follow-up care for birth spacing, immunization, nutrition (breastfeeding), growthmonitoring and development of baby.
RecommendationsAssure appropriate care in the home for the mother and newborn• Effective empowerment, participation and communication strategiesincluding community involvement in planning MNCH programs.• Community mobilization and engagement, and antenatal and post nataldomiciliary behaviour change communications to promote:1. evidence-based care practices (breastfeeding, thermal care, and clean cord care),2. care seeking, and3. demand for quality clinical care.
References•Merriam-Webster‟s Learner‟s Dictionaryhttp://www.learnersdictionary.com/search/neonatal•The Maternal and Child Health DepartmentMinistry of Health, Brickdam, GeorgetownRetrospective analysis of neonatal deaths and stillbirths in five hospitals inGuyana,December 2007•Bureau of Statistics57 High Street, Kingston, Georgetown - Multiple Indicator Cluster SurveySummary Report 2006http://www.statisticsguyana.gov.gy/pubs/Guyana_MICS_Summary_Report_2006.pdf