Approach to sick neonate

Dr.Ismail Mohamed Elghuwael

MAHSA university/ Paediatrics dept
History
• From hospital or from home.
• Antenatal history:
Maternal age
Pregnancy– Planned or unplanned, spontaneous or induced
Liqour
Follow up
Antenatal scan
Fever and rash
Fetal movement
• Birth history:
Mode of delivery
Term or preterm
SVD or LSCS(Emergency or elective)
Crying and Apgar Score
• Post-natal history:
Feeding
Jaundice
Fever
• Family history
Recurrent abortions
Neonatal or childhood death, cause
Consanguinity(degree)
Chronic disorder with fits or developmental delay
• Main complain:( must do full analysis)
Fever
Vomiting
Irritability
Crying
Poor feeding
Scalp sweating
Difficult breathing and noisy breathing
Diarrhea
Bleeding PR
Abdominal distension
Jaundice
Cough
Runny nose
Failure to thrive
Abnormal movement
Straining and facial congestion
Constipation
Urination (must ask in every baby)
Activity
 Physical examination
General look
Activity
Eye opening
Colour
Crying
Irritability
Abnormal sounds
Anterior fontanelle
Perfusion
Vital signs
Lungs
Abdomen
Genitalia
Anus
Diapers
Keep in mind
• Sick neonate with respiratory distress: Thoracic cavity pathology.
• Sick neonate without respiratory distress:
3 main D/D:
Infection
Metabolic disorder
Intracranial hemorrhage
 Investigations
FBC
Sugar, urea, Na, K, Ca, PO4, Mg
Blood gas
LFT
Blood culture
L.P
Urine culture
CXR
Coagulation profile
Brain imaging
Metabolic screen
 Cases from hospital
• Case-1:
• An urgent call was done to the paediatrician on call to review a term
baby who came out already and noted thick meconium stained
liqour. The baby was seen and found tachypneic with grunting and
subcostal recession.
• What should be done before the baby comes out?
• The pediatrician did suctioning and many meconium stained liqour
came out. SpO2 measured and found 85%
• No improvement with head box Oxygen
• No improvement with CPAP
• Intubated and connected to conventional ventilation
 Under conventional ventilation with high
pressure and FiO2 0.9
• SpO2 pre-ductal(in upper limbs): 92%
• SpO2 post-ductal(in lower limbs):80%
• CVS examination: No murmur
• Bedside echo: No evidence of cyanotic congenital heart disease
Key words
• Term baby
• Thick meconium stained liqour
• Came out already
• Refractory hypoxia
• Difference between preductal and post-ductal SpO2 more than 10
• Normal heart structure.
• Diagnosis: Meconium aspiration syndrome complicated by
Persistent pulmonary hypertension
• Case-2:
• A 30 years old diabetic mother with difficulty to control her Diabetes
durning pregnancy but she did close follow up and antenatal U/S
(showed normal baby ?). When she delivered the baby did not cry
and an urgent call was done to the pediatrician. When the
pediatrician arrived he noticed the baby tachypneic with recession
and prominent hemithorax with decreased air entry and hearing
bowel sounds in chest. The abdomen was noted to be scaphoid
Key words:
• Diabetic mother----- risk of congenital anomalies
• Prominent hemithorax with decreased air entry------- something
wrong in the lung
• Audible bowel sounds in chest
• Scaphoid abdomen
• Likely diagnosis: Congenital diaphragmatic hernia.
• But why antenatal U/S was normal?. Is it always normal?
 Congenital diaphragmatic hernia
• 5o% not diagnosed by antenatal U/S
• 40% have other associated anomalies(Cong heart disease, pulmonary
hypoplasia)

Persistent pulmonaey
• Risk of

hypertension of newborn (PPHN)

• Case-3:
• A term newborn baby was born by elective LSCS. Antenatally the
mother was completely healthy and U/S scan for the baby was
completely normal. Baby cried well and was vigorous and did not
require any form of resuscitation. Few minutes later while going to
send him to mother noted to be tachypneic with grunting and
subcostal recession.
• What is the cause of respiratory distress?
Key words:
• Term------ Not RDS
• Completely healthy mother (no vaginal discharge, no fever)------Not
congenital pneumonia
• Normal Antenatal U/S----- Not congenital diaphragmatic hernia
• LSCS------ Transient tachypnea of newborn - Why?
 Chest Xray •
Standard diagnostic tool in TTN •
prominent perihilar streaking (which correlates with the •
engorgement of the lymphatic system with retained lung fluid, and fluid in the
fissures)
Small pleural effusions may be seen •
• Case-4:
• A term neonate was born by SVD to 29 years old mother who was
febrile and had leaking liqour more than 18 hrs. He was born well
without any complications but after 1 hr while he was beside the
mother noted to be tachypneic with grunting and subcostal recession
Key words:
• Term------ Not RDS
• Leaking liqour more than 18 hrs----- risk of infection
• Maternal fever----- risk of infection
• SVD----- Not Transient tachypnea of newborn
• Diagnosis: Congenital pneumonia
Most common organisms:
• Beta hemolytic streptococci group B (The most common)
• Listeria monocytogenes

• Gram negative bacteria

 RADIOLOGICAL INVESTIGATION

Chest x-ray is difficult to differentiate from RDS

(History and clinical examination are much more
important)
 Cases from home
• Case-1:
• 2 weeks old boy who was previously well presented with history of
fever and irritability for 2 days associated with poor feeding and
reduced activity. O/E the baby looks lethargic with very weak cry,
Anterior fontanelle was not bulging
• The baby was born in the hospital and both parents are healthy and
non-consanguineous and they have other 3 healthy children
Key words:

Previously well
Fever and irritability
Poor feeding
Fontanelle is not bulging
Non-consanguineous parents
- Likely diagnosis is Sepsis
• Case-2:
• One week old boy who was born well at home and was not taken to
hospital. At home the media was clean and the child received breast
feeding and was doing well. On day of presentation he was noted pale
and lethargic and his feeding became less. O/E he looked ill, lethargic
, pale, cold extremities and his anterior fontanelle was bulging
Key words:

• Key words:
Home delivery
Pale
Cold extremities
Bulging fontanelle
Likely diagnosis: Hemorrhagic disease of newborn
• Case-3:
• 3 weeks old girl a product of SVD to healthy parents who are cousins
presented to the emergency department with sudden onset of
seizures followed by un-responsiveness. There was no fever and
feeding was well except on the day of presentation noted slightly less.
The parents have 2 healthy children but they have one child who died
at age of one month after presentation with seizures and required
hospitalization without reaching certain diagnosis
Key words:

Parents are cousins

Seizures and un-responsiveness
One child died at age of one month with similar illness
Likely diagnosis: Metabolic disorder
Management of sick neonate
• NICU or PICU
• Oxygenation and ventilation
• Hydration
• Hemodynamic monitoring(fluid boluses, restriction and inotropes)
• Urine output
• OGT
• Nutrition(Parenteral-enteral) after stabilization
• Monitoring of blood gas, glucose and electrolytes
• Specific treatment:
Antibiotics
Special diet
Specific treatment of metabolic disorder
Alprostadil
Anti-convulsive
Referral (Cardiac, neurosurgical, genetic, others)
•Thank you