1. Neonatal Nightmares
Dr Mary McCaskill
Paediatric Emergency
Physician

2. Neonates
•
Major adjustments in physiology
•
First signs of congenital problems
•
At risk of serious bacterial infection
•
No baseline for normal state
•
Inexperience of parent –infant
interaction

3. Signs and symptoms
•
Less specific
– Changes to feeding, vomiting
– Behaviour, tone
– Urine and stool output
– Colour, perfusion
– Breathing, apnoea

4. Potential deterioration
•
Rapid
•
Apnoea
•
Bradycardia
•
Arrest

5. Catherine
•
10 days old, born at term, normal
delivery, first child, breast fed, had
regained birth weight
•
2 days ‘off colour’, shorter feeds
•
24 hours vomiting small amounts at end
of feed
•
Fever to 38.3oC overnight

6. Examination
•
Airway patent
•
No respiratory distress, chest clear
•
Pale, tachycardic 180, perfusion
reduced
•
Poorly responsive to mother, floppy
•
Apnoea noted responding to stimulation
•
Bedside blood sugar 4.3

7. Sepsis
•
Why?
– Temperature – hypothermic presentation
– Deterioration in condition
•
Source?
– Urinary tract infection –most likely
– Meningitis possible
– Group B Strep infection

8. Treatment
•
IV cannula
•
Fluids -resuscitate
– then glucose containing fluids
•
IV antibiotics
– Gentamicin
– Ampicillin
– Cefotaxime

9. Next steps
•
Consider Acyclovir –if seizures,
vesicles, maternal herpes
•
Inotropes if minimal improvement
•
Source investigations
– Urine specimen
– Lumbar puncture
– Chest radiograph

10. James
•
9 days old, born at term, normal
delivery, second child, breast fed, had
regained birth weight
•
2 days ‘off colour’, shorter feeds
•
24 hours vomiting small amounts at end
of feed
•
No fever

11. Examination
•
Airway patent
•
No respiratory distress, chest clear
•
Pink, bradycardic 80, perfusion reduced
•
Quiet, reduced response, normal tone
•
Apnoea noted responding to stimulation
•
Sepsis treatment started

12. Electrolytes
•
Na 123, K 10.33
•
Glucose 2.8
•
Lactate 3.4
•
ECG –runs of ventricular tachycardia
•
Lab results –Creatinine 133

14. Hyperkalaemia
•
Salbutamol
•
Calcium gluconate
•
Dextrose 2ml/kg of 10%
•
Bicarbonate
•
Resonium rectally
•
Pads on chest, amiodarone prepared

15. Hypoglycaemia
•
Blood and urine for
– hormonal levels
– amino acids
– long chain fatty acid deficiency
•
Treat with 10% Dextrose as before

16. Diagnosis
•
Congenital Adrenal Hypoplasia
– hyperkalaemia, hyponatraemia
– Hypoglycaemia
– Treat with hydrocortisone
•
Renal disease -Posterior urethral valves
– hyperkalaemia, hyponatraemia
– raised creatinine

17. Sam
•
7 days old, born at term, normal
delivery, second child, bottle fed, still
below birth weight
•
Fussy feeder, breaks off during feed
•
24 hours vomiting small amounts at end
of feed
•
No fever

18. Examination
•
Airway patent
•
Grunting, tachypnoeic, chest clear
•
Pale, tachycardic 188, perfusion
reduced, skin mottled and grey legs
•
Poorly responsive to mother, floppy
•
Apnoea noted responding to stimulation
•
Bedside blood sugar 4.6

19. Cardiac examination
•
Femoral pulses impalpable
•
BP normal in both arms and unable to
record in legs
•
No murmurs heard
•
Diagnosis of Coarctation of the aorta
•
Shock following closure of ductus
arteriosus

20. Treatment
•
Treat for sepsis
•
Fluid to support preload
•
Prostaglandin infusion to open duct
•
Intubation to avoid apnoea
•
Consider fentanyl for sedation

21. Jasmine
•
9 days old, born at term, normal
delivery, second child, bottle fed, still
below birth weight
•
Difficulty feeding
•
48 hours green vomits after each feed
•
No fever

22. Examination
•
Airway patent
•
Grunting, chest clear
•
Pale, tachycardic 190, perfusion
reduced, eyes sunken
•
Poorly responsive to mother, floppy
•
Distended abdomen, soft non tender
•
Bedside blood sugar 3.2

23. Treatment
•
Sepsis treated
•
Rehydration
•
Surgical cause likely
– Duodenal web, hernia or other obstruction
– Necrotising enterocolitis
– Volvulus

24. Nightmares
•
Consider
– Sepsis
– Cardiac cause
– Endocrine or metabolic
– Surgical cause
•
Treat neonates with great caution

25. Questions?