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 Range 1 101 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 D5 260-320 290-350 320-380 350-380
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 NAS E. 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 neonates B. The rate of and morbidity from sepsis are reduced by covering all Mothers who are GBS positive on HVS with antibiotics in labour C. Surface skin swabs are helpful D. All neonates born following PROM need antibiotic cover E. 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