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Micro Machines: Sick Neonates at #RATH2018
- 26. Case courtesy of Radswiki, Radiopaedia.org, rID: 11515 Hypertrophic Pyloric Stenosis
- 36. Case courtesy of ECHOTMTECG (YouTube.com)
- 40. Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 23909
- 43. Case courtesy of Dr Fakhry Mahmoud Ebouda, Radiopaedia.org, rID: 26787
- 48. Image courtesy of Angela Perez, Quizlet.com
Editor's Notes
- If there’s one area in paediatric emergency medicine that seems to scare people more than any other, it’s neonates. It’s hard to fathom how something so small can be so terrifying! But the good news is that there’s very little new stuff happening in neonatal emergency medicine. That’s good for me, because there’s not much I can tell you here that you don’t already know. So instead of bringing you anything really cutting edge, I am going to take this opportunity to give you a refresher of the basics of what makes neonates different from other humans, and what that means for you in looking after the neonates in your department.
- Micro Machines were marketed as "The Original Scale Miniatures", but there are a number of ways Micro Machines aren't quite a scale miniature of a real car. The same can be said of neonates; they aren't quite scale miniatures of adults as there are some things we need to think about a bit differently. Let's consider the similarities between neonates and Micro Machines.
- Precipitous delivery in ED is quite a lot like unboxing something you bought on the internet. You may have had pictures of the outside which give you an idea of what things are going to be like on the inside, but there's always that element of uncertainty that makes us really excited - or terrified - about what might really be about to come out.
- Three possibilities Baby Scenario 1: Vigorous crying, good tone, HR>100, pink/blue. These babies are sometimes a little blue around the edges but with a good cry they pink up very quickly. For these babies, delayed cord clamping should be considered. There are a number of proposed advantages to delayed cord clamping: improvement in iron status for next 3-6/12, reduced transfusion needs in the preterm infant, improved stability of blood pressure and heart rate during the neonatal period, possible reduction in interventricular haemorrhage, periventricular leukomalacia (these things are both potentially BAD) and late onset sepsis HOWEVER babies needing resuscitation have been excluded from all studies on delayed cord clamping so we need to employ a little common sense. If no resuscitation is required, cord clamping can be delayed for 1min (there’s no need to milk the cord). You can dry and wrap the baby, hand him/her to mum for skin-to-skin or breast feeding (assuming that mum is in a fit state to receive her newborn) and remember to keep the baby warm (a clean dry towel may be sufficient).
- Baby Scenario 2: Inadequate breathing/apnoea, normal/reduced tone, HR<100, blue. These babies don’t require “resuscitation” per se but instead something we are now to call “assisted transition” to life outside the uterus. They are usually blue around the edges and may have a low heart rate, but they usually improve rapidly with drying and wrapping followed by mask inflation breaths, although some may require subsequent ventilation breaths too (see below). Don’t delay cord clamping in these babies – get them dry, warm and breathing.
- Baby Scenario 3: Inadequate breathing/apnoea, floppy, low/undetectable HR, pale. Don’t panic. This is actually relatively rare – only around 1-2 per 1000 births requires resuscitation as we are about to describe it. As previously we want to dry and wrap the baby and begin to resuscitate – airway first, then inflation, then ventilation. These babies may also need some chest compressions and a very small number receive drugs. Resuscitation Dry, wrap, start the clock
- Airway opening in neutral position Breathing assessment plus inflation breaths (x 5, lasting 2-3 secs) at 15-30cmH20. If no spontaneous effort, then give 1 second ventilation breaths. Use air at first, and get a helper to put a sats probe on the right hand. SpO2 rises from 60% in utero to around 90% at 10mins of life. Airway again – consider intubation if you are suctioning, or struggling to ventilate. Breathing again – establish ventilation before chest compressions as most babies respond to ventilation. Circulation – start compressions if HR<60/min, ratio 1:3. If you are doing compressions, it’s reasonable to start increasing FiO2 Drugs are rarely needed – maybe adrenaline, UVC simplest (remember – two arteries, one vein). Guidelines state that if no heart rate at any time for ten mins, stopping is appropriate. Less clear guidance if persisting bradycardia despite efforts.
- Airway opening in neutral position Breathing assessment plus inflation breaths (x 5, lasting 2-3 secs) at 15-30cmH20. If no spontaneous effort, then give 1 second ventilation breaths. Use air at first, and get a helper to put a sats probe on the right hand. SpO2 rises from 60% in utero to around 90% at 10mins of life. Airway again – consider intubation if you are suctioning, or struggling to ventilate. Breathing again – establish ventilation before chest compressions as most babies respond to ventilation. Circulation – start compressions if HR<60/min, ratio 1:3. If you are doing compressions, it’s reasonable to start increasing FiO2 Drugs are rarely needed – maybe adrenaline, UVC simplest (remember – two arteries, one vein). Guidelines state that if no heart rate at any time for ten mins, stopping is appropriate. Less clear guidance if persisting bradycardia despite efforts.
- Airway opening in neutral position Breathing assessment plus inflation breaths (x 5, lasting 2-3 secs) at 15-30cmH20. If no spontaneous effort, then give 1 second ventilation breaths. Use air at first, and get a helper to put a sats probe on the right hand. SpO2 rises from 60% in utero to around 90% at 10mins of life. Airway again – consider intubation if you are suctioning, or struggling to ventilate. Breathing again – establish ventilation before chest compressions as most babies respond to ventilation. Circulation – start compressions if HR<60/min, ratio 1:3. If you are doing compressions, it’s reasonable to start increasing FiO2 Drugs are rarely needed – maybe adrenaline, UVC simplest (remember – two arteries, one vein). Guidelines state that if no heart rate at any time for ten mins, stopping is appropriate. Less clear guidance if persisting bradycardia despite efforts.
- Now, let’s take a tour of the micro machine that has been brought into the ED, having been born and at some point made it home from hospital. That’s a key issue here – at some point, they have been deemed well enough to survive outside a NICU, so that’s the starting point you’re going to try to get them back to. We’ll take a whirlwind tour of the micromachine itself, and of the common causes of illness that present in ED.
- In utero, babies are effectively on ECMO and TPN - foetal life is essentially high-level intensive care. We don’t expect adults to do very much when they first come out of ICU, so it’s not surprising that babies don’t do much either
- In utero, babies are effectively on ECMO and TPN - foetal life is essentially high-level intensive care. We don’t expect adults to do very much when they first come out of ICU, so it’s not surprising that babies don’t do much either
- Fuel tanks – everything to do with feeding Babies really don’t do very much. They eat, they sleep, they cry, and they make dirty nappies. So let’s start off with thinking about feeding, since that’s what parents will genuinely be most obsessed with. Poor feeding is a nonspecific but early sign of a number of serious pathologies. Like Micro machines, babies have small fuel tanks, so they need to be filled up regularly.
- The requirement increases from 60ml/kg on day 1 to 150ml/kg on day 7 in divided feeds, usually 3-4 hourly. Babies do not tolerate prolonged starvation as their stores are low, leaving them prone to hypoglycaemia.
- The requirement increases from 60ml/kg on day 1 to 150ml/kg on day 7 in divided feeds, usually 3-4 hourly. Babies do not tolerate prolonged starvation as their stores are low, leaving them prone to hypoglycaemia.
- But those first few weeks of life are often where metabolic disorders present, as Katie has alluded to, so have a low threshold for hypoglycaemia screening (bloods and urine) if the BSL is less than 2.6mmol/L Hypoglycaemia can coexist with a number of other conditions, but its presence can be easily missed – so think about it early.
- Inborn errors of metabolism and endocrine disorders may present in the neonatal period – in the presence of hypoglycaemia with jaundice or high lactate also check ketones and ammonia, then consider NBM and IV fluids to break the cycle of toxic metabolite production.
- Inborn errors of metabolism and endocrine disorders may present in the neonatal period – in the presence of hypoglycaemia with jaundice or high lactate also check ketones and ammonia, then consider NBM and IV fluids to break the cycle of toxic metabolite production.
- Send a split bilirubin as well as a Coombs test and reticulocyte count in jaundiced, sick neonates – breastmilk jaundice (after first 48h) is unconjungated – conjugated >15% of total is always bad. https://www.rch.org.au/clinicalguide/guideline_index/Jaundice_in_early_infancy/
- We also need to ensure the right fuel is going in. Breastfed babies may have issues with latching, with maternal milk production requiring top-up feeds, and this can be a very emotive area that we should explore with sensitivity. It’s worth thinking about what is going in when we are taking a feeding history – that includes any medication mothers are taking and any they have stopped – opioid withdrawal can present as a jittery, irritable infant and a mother may not always disclose that she has been an opioid user, especially if she is bottle-feeding the infant. Consider “home remedies” and topical therapies and ask about them specifically. Formula fed infants are at risk when feeds are inappropriately diluted, so do ask about feed preparation.
- Exhaust – everything to do with the gut
- As well as crying, babies poop a lot. They will establish a pattern of bowel movement that is their “normal” – and there is a whole spectrum of normal. Meconium – that dark green/black stool – should start to be passed in the first 24h. Beyond this, what comes out depends on what is going in. Breastfed babies tend to have yellow, soft poo which may appear to contain seeds or curds. With formula, babies poo seems to smell more although they may go fewer times in a day. Failure to pass that meconium stool should prompt you to consider obstruction, particularly if there is also abdominal distension and bilious vomiting.
- Babies will also vomit; it is usually milky, cream or yellow coloured. Bile-staining of vomiting is a cause for concern, but be sure to elicit exactly what is meant by bile as a common lay interpretation is that bile is stomach contents and that bile is anything yellow/green in colour.
- To be honest, if you’re not at a paediatric surgical centre, bilious vomiting in a neonate should prompt planning to transfer the child at the same time as undertaking further investigations. There are many possible causes such as malrotation and midgut volvulus, but you can’t fix them without a surgeon
- The management of all this stuff is pretty standard – NBM, NGT, IV access for maintenance fluids and analgesia, consider antibiotics and get the baby to a surgeon.
- As far as investigations go, AXR may not be your friend – it can be misleadingly normal or abnormal and is definitely useful in retrospect - but what use is that? Examination is far more useful. Masses may be palpable in the abdomen - you won't find them unless you are gentle and thorough.
- The management of all this stuff is pretty standard – NBM, NGT, IV access for maintenance fluids and analgesia, consider antibiotics and get the baby to a surgeon! Even if the condition can be managed medically it can be hard to tell and that decision is best left in expert hands.
- Engine problems – cardiac presentations
- Cardiac problems present in three ways and may be more common than sepsis. - Shock due to obstruction of systemic circulation (usually duct-dependent lesion) - Cyanosis due to obstruction to pulmonary circulation - Heart failure
- Usually present within the first two weeks, typically around day 5-6 at time of duct closure.
- Start with an ECG as monitors lie and SVT is common and easily treatable (although structural lesions may coexist)
- Be cautious with fluids – 5ml/kg and if no response, hold off
- Right hand is pre-ductal, feet are post-ductal. Difference of 3% or more suggests shunting.
- Prostaglandins E1 (alprostadil) – start at 0.05mcg/kg/min, expect apnoea, be ready to intubate. Increase to 0.1mcg/kg/min after 10mins if no effect observed; reduce to 0.01mcg/kg/min once effect is observed. PGE1 buys you time but can be tricky to get hold of/prepare, so think of it early.
- Correct calcium and glucose Chest XR may help confirm diagnosis and reveal pulmonary oedema Consider furosemide 1mg/kg IV if fluid overloaded.
- Consider lifting the bonnet
- Get specialist help and plan for transfer to a centre with cardiac surgery. NETS will advise on choice of pressor/inotrope if required.
- Soft top – respiratory problems
- Lack of a calcified thoracic cage is at the heart of many respiratory problems in neonates. Muscles fatigue quickly, so apnoeas will happen readily and are easy to miss while you are distracted by other things. Feeding is a double whammy as babies struggle to feed and breathe during viral upper respiratory tract infections with nasal congestion, and a full stomach (either with milk or air from crying) restricts diaphragmatic movement. Considering they didn’t do any actual breathing in utero, babies are trying to make up for it on the outside.
- Pneumothoraces are rare but they do happen and are poorly tolerated. Image (CXR, ultrasound) or transilluminate and consider the need to drain if in respiratory distress/low SpO2, compromised circulation. You can perform needle aspiration with a 24g needle, three-way-tap and a syringe, or NETS carries Safe-T-centesis which is a pigtail intercostal catheter.
- Pneumothoraces are rare but they do happen and are poorly tolerated. Image (CXR, ultrasound) or transilluminate and consider the need to drain if in respiratory distress/low SpO2, compromised circulation. You can perform needle aspiration with a 24g needle, three-way-tap and a syringe, or NETS carries Safe-T-centesis which is a pigtail intercostal catheter.
- Limited momentum (speed/distance) – major trauma Neonates rarely sustain major trauma mechanisms (except NAI) because they are non-mobile and thus unable to generate significant momentum without the help of someone bigger.
- Head injuries are most common particularly in dropped babies – remember that subgaleal haemorrhage can be significant in a child with a small circulating volume (80ml/kg = 320ml for a 4kg baby eg a can of soda) and can cause shock.
- Head injuries are most common particularly in dropped babies – remember that subgaleal haemorrhage can be significant in a child with a small circulating volume (80ml/kg = 320ml for a 4kg baby eg a can of soda) and can cause shock.
- Poorly secured vehicle – sepsis
- Sepsis is often at the forefront of our mind when treating sick neonates. Big bad organisms are GBS, Staph aureus, E Coli and Listeria. Infection may coexist and/or precipitate one of the other pathologies, so many sick babies also get antibiotic cover. Amp and gent or amp and cefotaxime will treat most, gent if G-ve (UTI), Staph coverage for skin source
- Sepsis is often at the forefront of our mind when treating sick neonates. Big bad organisms are GBS, Staph aureus, E Coli and Listeria. Infection may coexist and/or precipitate one of the other pathologies, so many sick babies also get antibiotic cover. Amp and gent or amp and cefotaxime will treat most, gent if G-ve (UTI), Staph coverage for skin source
- Omphalitis – mean day at presentation = 3. Erythema around umbilical stump, extending to abdominal wall – assume badness. Culture swabs, if sick treat as sepsis (often polymicrobial), may lead to necrotising fasciitis (10%), peritonitis, portal vein thrombosis, abscess or spontaneous bowel evisceration.
- Treat with fluid boluses and pressor support with early escalation to paediatric ICU setting if not responding.
- Defective steering – seizures The steering wheel of a micro machine isn't actually connected to the wheels, so movement is not particularly well coordinated
- Babies are prone to seizures but they are rarely a standalone diagnosis, most are associated with hypoxia, hypoglycaemia or intracranial badness (trauma or infection). Consider acyclovir to cover H. simplex encephalitis.
- No air con – hypothermia Without air con it's hard to regulate the temperature of a micro machine - babies have similar issues with thermoregulation.
- Babies are also poorly insulated and prone to getting cold quickly – use a resuscitaire or warming pad to maintain warmth during procedures if possible.
- Babies also have very sensitive and reactive vasomotor tone, meaning they can quickly change their skin perfusion leading to pallor, cyanosis or mottling. This may happen in response to temperature but be wary of overlooking skin perfusion as an important clinical indicator.
- So, how can we put this together, to help us remember the things that are different about neonates?
- You might have heard of THE MISFITS; I also like NEO SECRETS
- You might have heard of THE MISFITS; I also like NEO SECRETS
- You might have heard of THE MISFITS; I also like NEO SECRETS
- You might have heard of THE MISFITS; I also like NEO SECRETS
- And there are really three things we need to do: Key points Good history, particularly of feeding Examination Venous gas and BSL
- And three things to consider
- You can find further reading and some collated foam resources here
- Thanks to
- I’ve been Natalie May