Common Neonatal Problems Dr Marea Murray Staff Neonatologist Blacktown Hospital.
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Transcript of Common Neonatal Problems Dr Marea Murray Staff Neonatologist Blacktown Hospital.
Common Neonatal Problems
Dr Marea Murray
Staff Neonatologist
Blacktown Hospital
Concerning Congenital Heart Disease (CHD)
A. Murmurs noted in the first day are usually pathological
B. The Newborn examination picks up 90% of CHD
C. Neonatal cardiac examination does not need to be repeated in the first week for those babies who are discharged early
D. Reduced femoral pulses suggest coarctation and need urgent investigation
E. Basal crepitations and peripheral oedema are the most reliable signs of CHF in a neonate
Congenital Heart Disease
Remember CHD may not be evident at birth Murmurs on day 1 often reflect the transitional changes
and are not significant Early discharge has meant a higher rate of missed
CHD on the Newborn check and the need to examine the baby again later in the first week of life
Murmurs and other signs of CHD often evolve with age– related to changing fetal communications eg closure of the
ductus arteriosus– Changes in pulmonary vascular resistance
Clues to Significant CHD
Is there a family history of CHD? Is the baby normal or is there a syndrome?
– Eg Downs– Williams– Velocardiofacial (C/S 22 deletion)
Is the patient cyanosed?
Clues to Significant CHD
Are there symptoms / signs of CHF?– Feeding difficulties– Tachypnoea– Tachycardia– Hepatomegaly– Sweating around the head
Other signs to look for:-– Pulses (diminished / increased & distribution)– Blood pressure - Beware false readings on the dynamap– Pericardial over activity / thrill– Murmur
Murmurs
If the only abnormal sign is a murmur it is usually not urgent to refer to a Paediatric Cardiologist – Cardiac murmurs are not synonymous with CHD
Possible to use the local paediatricians to help screen these babies if uncertain
Remember there can be significant CHD and NO murmur
Investigation of CHD - Basic
CXR– Situs– Position– Contour– Size– Pulmonary vascularity– Look for right sided aortic arch
Found in 25% OF Tetralogy of Fallot and 40% of Truncus arteriosus
Investigations - Basic
ECG– In rare situations may be diagnostic eg AV canal Ostium
primum ASD and Tricuspid atresia = superior axis– Look for ventricular hypertrophy– Can be difficult to interpret in the newborn
eg normal to have RAD and RV more dominant
Hb and Film– Can underestimate cyanosis with anaemia– Polycythaemia causes over diagnosis of cyanosis– Look for Howell Jolly Bodies- suggests asplenia, has
association with complex CHD
Investigations - Advanced
Referral to Children’s Hospital for – Paediatric Cardiology assessment– Echocardiography
Concerning Neonatal Jaundice
A. Day 1 jaundice is usually physiological
B. In a term baby on day 5, all SBR levels > 300 should be treated with phototherapy
C. In persistent or late onset jaundice, investigating the underlying cause is more important than the actual level of SBR
D. When breast milk has been found to be the cause of jaundice, breast feeding should be discontinued
E. In the presence of raised conjugated bilirubin, biliary atresia is not an important cause to exclude
Neonatal Jaundice
Caused by accumulation of bilirubin– Usually unconjugated– Tetrapyrrole formed from haeme catabolism– Main factors
Increased haeme production eg haemolysis Decreased hepatic clearance Ductus venosus patency Enterohepatic circulation and slow gut transit time
Pathological Jaundice
Jaundice is– Early– High– Late– Prolonged– Conjugated
The neonate is sick
Case History
Full term 3050g breast fed baby Took early discharge on day1 Noted to be jaundiced on day 3 Jaundiced to below the knees but not the feet
– Which investigations ?
Cephalopedal Progression of Jaundice
Zone Mean SD Range1 101 5.1 74 - 135
2 152 29.1 92 - 209
3 202 30.1 138 - 282
4 256 29.1 190 - 313
5 >256– Kramer LI , Am J Dis Child, 1969 118:454.
Serum Bilirubin >270 - 300
Blood group and DCT FBC and blood film G6PD (depending on ethnic group) Direct SBR
Treatment Guidelines
Birth wt phototherapy exchange<1000g 100 200
1000 - 1499 150 250
1500 - 1999 200 300
2000 - 2499 250 350
>2500 340 450
Treatment Guidelines
Subtract 50 micromol/ L if :-– SBR rising >17 micromol/ L/ hour– Serum albumin <2.5g/ L– Persistent acidaemia– Persistent hypoxaemia– Persistent hypercarbia– Proven sepsis– Hypoglycaemia
Current Controversy
Need for treatment– Based on Hsia’s work in 1952 on Term babies with rhesus
haemolytic disease but can we extrapolate from this?– Association between total SBR and kernicterus
3% babies with peak SBR 103 - 256 18% babies with peak SBR 274 - 513 50% babies with peak SBR > 530
Separation of mother and baby Risk of lactation failure
Use of the Bilibed
Allows for treatment in the Postnatal ward with Mother or even treatment at home!
Advantage of proximity to light source and the right spectrum (blue light).
Only a small exposed surface area. (Back) Should be avoided if Jaundice is early (<36hrs) or
levels are high. In term babies our bilibed ranges are as follows:-
D2 (36-48hrs) D3 D4 D5260-320 290-350 320-380 350-380
Case History
Philipino baby goes home on D1 on DMP Mother brings baby to the surgery on D4 as
baby is not feeding well and very jaundiced SBR is 550 micromol/L Urgent admission arranged Blood Film shows evidence of haemolysis Coombs is negative Diagnosis is G6PD deficiency
G6PD
On further questioning – Family placed baby into clothes they had taken out
of moth balls
High risk for kernicterus Need for follow up hearing assessment Neurodevelopmental follow up
Case History
16 day old term neonate presents with jaundice SBR is 220 Would you perform further investigations?
Prolonged Jaundice
Conjugated (Direct) SBR is normal– Breast milk jaundice– Hypothyroidism– Urinary tract infection– Glucuronosyl transferase deficiency
Crigler-Najjar (type 1 and 2) Gilbert’s syndrome
Prolonged Jaundice
Conjugated (Direct) SBR raised– Well infant
Biliary obstruction– Neonatal hepatitis– Biliary atresia
Alpha1 antitrypsin deficiency Hypothyroidism
– Sick infant Sepsis : E coli UTI Galactosaemia Hypopituitarism
Concerning Neonatal Abstinence Syndrome (opiate withdrawal)
A. Naloxone is contraindicated during resuscitation of the neonate
B. Drug withdrawal can occur in babies up to 10 – 14 days of age
C. It is a serious condition which has resulted in neonatal deaths, particularly if parents try to treat it with their methadone
D. Referral to DoCS is mandatory in all cases of NASE. A, B and C are correct
Opiates – Postnatal Issues
Admission of the baby to the postnatal ward is possible in the stable methadone user.
Midwifery staff must be able to score the baby to detect withdrawal.
Scoring occurs for a minimum of 5 days in hospital. Peak onset of withdrawal is 2-4 days postnatally.
Opiates – Postnatal Issues
Withdrawal occurs up to 10- 14 days of age. Therefore if discharge occurs at 5 to 10 days-.– Warn mother / carer what to look for and provide
contact numbers.– Review soon after discharge.
Neonatal Abstinence Syndrome
Modified Finnegan scoring system used to assess abstinence syndrome. Three scores averaging 8 or greater is the indication for SCN admission and treatment.
Morphine is the treatment of choice for Opiate using mothers.
Addition of Phenobarbitone is indicated to control persistent symptoms in babies where mother has used other drugs in addition to opiates.
Regarding Hepatitis C Virus Infection
A. There is a theoretical risk of transmission of HCV if mother breast feeds with cracked nipples
B. Testing the baby for HCV is best done at birth with HCV ab
C. Breast feeding is contraindicated
D. 5 -10% of Mothers with an IV drug using history are positive for HCV
E. Mother to child transmission occurs in 95% of cases
Opiates – Breast Feeding
Breast feeding may help alleviate neonatal abstinence syndrome, however issues of hepatitis C and HIV must be discussed if relevant
Hepatitis C is not a contra-indication to breast feeding. Transmission of Hepatitis C to baby via breast feeding is not proven. However care should be taken with cracked nipples, as this is a theoretical risk.
Weaning from the breast should be gradual.
Neonatal Abstinence Syndrome
Recently a Department of Health guideline on Neonatal Abstinence Syndrome has been released.
Emphasis on multidisciplinary team approach, beginning during the pregnancy.
Liaison with community emphasized.
Safety Guidelines
– Baby must stay for a minimum of 5 – 7 days.– Mother must room in for a minimum of 48 hours
prior to discharge.– Clinic visits at least weekly.– One week supply of morphine at a time.– Close liaison with social worker.– Involvement of DOCS as appropriate.
Concerning Neonatal Sepsis
A. Pyrexia is usually present in septic neonatesB. The rate of and morbidity from sepsis are reduced by covering all Mothers who are GBS positive on HVS with antibiotics in labourC. Surface skin swabs are helpfulD. All neonates born following PROM need antibiotic coverE. WCC of 15 - 25 is significant
Incidence
1 – 10/1000 live births– Varies within and between nurseries– Reduced by prophylaxis
Early Onset Sepsis
Day 1 – 4 (usually D1) Risk factors (PROM, Prematurity – 30-50%, maternal
fever) 25 – 30% are NOT associated with risk factors Usual Pathogens
– GBS– E-Coli
Present as bacteremia and can be dead within 24 hours
Late Onset (> Day 7)
May present as meningitis May have localised disease More likely to be staph aureus and Staph epi Also can be GBS and E-coli Ex-Prems at increased risk
Clinical Symptoms / Signs
Temp instability (up or down) Respiratory distress Feeding difficulties Irritability Lethargy Apnoea IE Most of Neonatology!
– If in doubt in the community – refer in
Examination
Vital signs– HR, RR, Temp,BP, Blood Glucose
Capillary return >2 secs– Hold thumb down on sternum for 5 secs, release
Other Physical signs– General appearance– Recession– Hepatomegaly
How to avoid aggro
Always collect a blood culture first WCC < 5, especially with neutropenia is
suggestive of sepsis Don’t do surface swabs
– Colonisation does not equate to infection– What do you do with the result– Expensive
Some Hints
Use antibiotics– Where FiO2 >30%– Unexplained asphyxia or prematurity
OK to withhold antibiotics– Well prem of >33 weeks without risk factors
Ampicillin / Gentamicin – advantage of covering Listeria
Or Penicillin / Gentamicin Penicillin / Cefotaxime if meningitis