Neonatal Emergencies

and
Common
Dr Raseena
Neonatal .VK
Problems
MEM Resident
NORMAL NEONATAL VEGETATIVE FUNCTIONS
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.

● 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.

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.
● 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.
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”
● 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
“Failure to pass meconium in the first 48 hours of life may suggest
Hirschsprung’s disease or cystic fibrosis.”
● 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.
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
● 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.
● 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.
“ Periods of apnea >20 seconds or apnea accompanied by bradycardia,
cyanosis, or a change in muscle tone is abnormal and requires evaluation”
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.
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
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.

● 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.
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
ENT Musculoskeletal

● Hair tourniquet of finger/toe

● Nasal obstruction (choanal atresia
● Injuries
or stenosis)
● Less serious causes
Metabolic
○ Otitis media
○ Nasal congestion (URTI) ● Inborn errors of metabolism
○ Oral thrush ● Hypoglycaemia
○ Stomatitis ● Congenital adrenal hyperplasia
 GI causes
Pulmonary and cardiac causes
● Volvulus
● Pneumonia
● Gastroesophageal reflux disease
● Supraventricular tachycardia
● Intussusception
● Heart failure
● Incarcerated hernia
● Gastroenteritis
● Anal fissure
GU causes ● Colic

● Testicular torsion
● Urinary tract infection
● Genital hair tourniquets
● Diaper rash
● Paraphimosis
Infectious

○ Sepsis

○ Upper respiratory infection

○ Pneumonia

○ Meningitis
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.
▪ 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
 THE
CRITICALLY
ILL
NEONATE
PRINCIPLES OF CARE

A BLS
B &
C ACLS
● 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
“Bradycardia in the neonate is almost always due to respiratory failure and hypoxia
and usually corrects with restoration of adequate airway and breathing.”
● 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.
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.
● 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).

 NEONATAL SEPSIS
Early-onset disease Late-onset disease
● In the first 7 days of life
● Tends to be fulminant
● Associated with maternal or perinatal ● After 1 week of age
risk factors ● Develop more gradually,
○ Maternal Fever ● Less likely to be associated with risk
○ Group B Strep +ve vaginal swabs factors.
○ Prolonged rupture of membranes
○ Fetal distress
Meningitis is more common in late-onset
Septic shock and neutropenia are more
disease
common with early onset syndrome
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.
 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
MICROBIOLOGY OF NEONATAL SEPSIS
gram-positive
Bacterial causes of neonatal sepsis cocci, such as β-hemolytic
streptococci,
reflect organisms that colonize the
female genital tract and nasal
mucosa of caregivers.
BACTERIA
Listeria- Enteric organism
sepsis and
meningitis
The height of the temperature does not distinguish a viral versus
bacterial cause in neonates.
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.
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
● 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.
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.
 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

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.

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)
NEONATAL PNEUMONIA
 Common bacterial Chlamydia Bordetella pertussis

Fulminant illness with onset within ● Usually occurs after 3 wk

48 h of birth (infection in utero)

● Respiratory distress ● Conjunctivitis in half ● Pneumonia

● Unstable temperature ● Often afebrile, ● Paroxysms of cough ±
● Irritability Or Lethargy ● Tachypnoeic cyanosis
● Tachycardia ● Prominent “staccato” cough. ● Post tussive emesis
● Poor Feeding ● Wheezing uncommon ● 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.
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

CHLAMYDIA PNEUMONIA
Bordetella Pertussis PNEUMONIA

● CXR may show hyperinflation with

● Lymphocytosis in peripheral blood
interstitial infiltrates.
count is nonspecific but supports the
diagnosis.
● Definitive diagnosis by nasopharyngeal
swab for PCR or cultures. ● Macrolides are effective against
Bordetella (not approved by FDA for
● Eosinophilia may be seen in peripheral infants <6 mo.)
blood count

● Neonates should be admitted during

● Treatment: macrolide (Erythromycin,
treatment and monitored for adverse
Clarithromycin, Or Azithromycin).
effects.
 NEONATAL PNEUMONIA….
ETIOLOGY:Mycobacterium tuberculosis

MANAGEMENT:
PRESENTATION:
● Half of infants born to actively infected ● Sepsis evaluation as for bacterial

mothers develop TB if not immunized or pneumonia.

● CXR, culture of urine, gastric and
treated.
tracheal aspirates.
● Acquired by transplacental means, or ● Skin testing not sensitive in neonates.
postnatal airborne transmission. ● Routine anti-TB treatment.
● Nonspecific systemic symptoms with ● Supportive treatment as needed.

multiorgan involvement (fever, failure to

thrive, respiratory distress, organomegaly).
NEONATAL PNEUMONIA….

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

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
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.
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
ANATOMIC AIRWAY LESIONS
Anomalies of the upper respiratory tract:

● Choanal atresia
● Laryngomalacia
● Tracheomalacia
● Micrognathia,
● Macroglossia
● Tracheoesophageal fistula
● Vascular slings
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.

NEUROMUSCULAR DISORDERS

May be associated with shallow breathing and a compensatory

increase in respiratory rate.
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

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.
 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.

● 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
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.
● 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
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
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.
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”
● 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.

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.

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.
● 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.

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.
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).
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.

● 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.

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

● 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
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.
Constipation occurring after birth but within the first month of
life suggests - Hirschsprung’s disease, hypothyroidism, anal
stenosis, or an anteriorly displaced anus.
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
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 2 nd to 4th days of life and a decrease
to <2 milligrams/dL by 5- 7 days ”
 UNCONJUGATED HYPERBILIRUBINEMIA CONJUGATED
• More common HYPERBILIRUBINEMIA
• Presents earlier • Always pathologic
• Related to breakdown of hemoglobin • primary hepatic or biliary disease
such as biliary atresia or hepatitis
• Presents later
• jaundice, acholic stools, and dark
urine.
● Bilirubin levels that are significantly higher than 6 milligrams/dL 🡪 can lead to
permanent brain injury—kernicterus.
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.
Scleral icterus is typically noted with serum bilirubin >5 milligrams/dL.
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.
Treatment of neonatal jaundice
● Treating cause

● Phototherapy

● Extreme levels of hyperbilirubinemia are treated emergently with exchange

transfusion and require admission to hospital
THANK YOU