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