Neonatal NightmaresDr Mary McCaskill

Paediatric Emergency Physician

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

Signs and symptoms• Less specific

– Changes to feeding, vomiting– Behaviour, tone– Urine and stool output– Colour, perfusion– Breathing, apnoea

Potential deterioration• Rapid• Apnoea• Bradycardia• Arrest

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

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

Sepsis• Why?

– Temperature – hypothermic presentation– Deterioration in condition

• Source? – Urinary tract infection –most likely– Meningitis possible– Group B Strep infection

Treatment• IV cannula• Fluids -resuscitate

– then glucose containing fluids• IV antibiotics

– Gentamicin– Ampicillin– Cefotaxime

Next steps• Consider Acyclovir –if seizures,

vesicles, maternal herpes• Inotropes if minimal improvement• Source investigations

– Urine specimen– Lumbar puncture– Chest radiograph

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

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

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

Hyperkalaemia

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

Hypoglycaemia• Blood and urine for

– hormonal levels– amino acids– long chain fatty acid deficiency

• Treat with 10% Dextrose as before

Diagnosis• Congenital Adrenal Hypoplasia

– hyperkalaemia, hyponatraemia– Hypoglycaemia– Treat with hydrocortisone

• Renal disease -Posterior urethral valves– hyperkalaemia, hyponatraemia– raised creatinine

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

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

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

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

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

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

Treatment• Sepsis treated• Rehydration• Surgical cause likely

– Duodenal web, hernia or other obstruction– Necrotising enterocolitis– Volvulus

Nightmares• Consider

– Sepsis– Cardiac cause– Endocrine or metabolic– Surgical cause

• Treat neonates with great caution

Questions?