common neonatal problems
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The 1st 24 hours of Life
The first 24 hours of life is a very significant and a highly vulnerable time due to critical transition from intrauterine to extrauterine life
Overview
The transition from intrauterine to extrauterine life is a complex process involving virtually every organ system in the body.
The most dramatic changes are seen in the lung and the cardiovascular system.
Failure to adequately make this transition can be life-threatening and these infants often require supportive care.
In order to select the optimal intervention, it is essential to understand the normal physiology of respiratory and cardiovascular transition.
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General Appearance
Full term:– Look dark purple or red in color– Symmetric– vigorously crying with accompanying activity
of the arms and legs– Lying with the extremities motionless,
to conserve energy for diff breathing.– Flexed extremities(sign of good muscle tone)– Hands tightly fisted with thumb covered by the fingers.
resting posture of a breech baby
NORMAL VITAL SIGNS
MINOR PROBLEMS IN NORMAL NEWBORN
Many of these problems are transient and benign in nature. detailed history , thorough evaluation and complete physical
examination are vital for early differentiation from abnormal findings. Proper advice, guidance and assurance to the family is cornerstone. Breast feeding and early physical contact should be encouraged.
VERNIX CASEOSA
Whitish adherent cheesy-like covering on newborn skin. Produced by epithelial cell breakdown. Vernix facilitates passage through birth canal, Prevents transepidermal water loss, maintain body temperature Protects the delecate skin from amniotic fluid and a barrier to
bacteria. Absent in post term infants Will fall off in 1 to 2 weeks Removing vernix for cosmetic reasons is not recommended.
ERYTHEMA NEONATRUM
Overall blush to reddish color. Usually appears in the transition period
and can occur when the infant has been
stimulated ,over oxygenated or overheated. This is a normal phenomenon and lasts only several hours.
Differential diagnosis: plethora
Bluish discoloration of hands, feet
and perioral area Particularly the palms and soles are blue. The skin and mucosa are spared. Due to immature peripheral circulation. Exacerbated by cold temperatures. Disappearing over the next few hours.(not present after 1st 24 h)
Differential diagnosis: hemodynamic instability Central cyanosis
ACROCYANOSIS
Bilateral fullness of both breasts. Overlying skin shows no signs of redness, warmth or tenderness The condition resolves spontaneously and no intervention is
required. Results by high levels of maternal hormones.
Massage or squeezing the breasts or nipples is not recommended
Breast Engorgement
Erb’s Palsy (brachial plexus palsy)
Injury to the 5th and 6th cervical nerves associated with a difficult delivery frequently in babies weighing in excess of 4
kg. No spontaneous arm movement on one side Forearm is extended and pronated. DTR are absent. wrist are spared and there is normal grasp. These improve in 90% of cases. If there is no recovery after 3 months ,surgical exploration and
nerve grafts should be contemplated within the first year of life. If movement of the arm is still limited at one year of age, permanent paralysis
is likely
PHYSIOLOGIC JAUNDICES
Common neonatal problem, approx 60% of
term and 80% of preterm infants develop Total Bilirubin raise by less than 5 mg/dl per day. Appear after 24 hrs of age, Peaks by 3 to 5 days of age . Visual inspection is not a reliable indicator to estimate the extent of jaundice. Resolve by 1 week in term and by 2 weeks in preterm. Mechanisms:
Increased bilirubin production.(high RBC mass) Defective uptake and conjugation and excretion of bilirubin
Managed by frequent feedings and phototheraphy in severe cases. Placing in front of a window for sun or giving vitamin C is ineffective .
WEIGHT LOSS IN FIRST WEEK
Normally babies lose 8-10% of birth weight in the first week of life
Because of passage of meconium, urine and reduction of extracellular fluid volume.
Weight is regained by 10-14 days age. Subsequently there should be gain of 20-40gr/day.
PERIODIC BREATHING
Normal maturative process (immaturity of respiratory center) breaths very rapidly for a few seconds, then pauses and then
resumes normal rhythmic breathing Brief pauses should be <10 sec Normal breathing between episodes Not associated with bradycardia Most common in preterm infants. Differential diagnosis:
Apnea of prematurity TTN RDS
Transient Tachypnea of the Newborn (TTN)
A benign self-limited respiratory disorder characterized
Mild respiratory distress immediately after birth Usually full-term and well looking Common in those delivered C-section, precipitous labor , IDM
Fetal distress ,Delayed cord clamping and Maternal sedation Results from slow absorption of lung fluid Peaks at about 36 hours of life Resolution within 24–72 hrs Differential diagnosis:
SEPSIS
Neonatal pneumonia Meconium aspiration syndrome
VOMITTING
Gastric irritation by amniotic fluid: On day one, non-bilious, no abdominal distension, responds to stomach wash
Gastric irritation by swallowed maternal blood : - Cracked and bleeding nipple
- Antepartum hemorrage
- Baby may pass malaena stools, rather than meconium.
Gastro esophageal reflux: -Overfeeding and Improper feeding
- effortless, after feed and on lying flat
Differential diagnosis: GI obstruction, raised ICP ,CNS infection Birth asphyxia, Sepsis,IEM
FAILURE TO PASS URINE
Fetus voids urine regularly in –utero after 12 weeks of gestataion. After birth most babies void on the first but all babies must pass
urine by 48 hours of age. Babies with delayed passage of urine should investigated for
obstructive uropathy and renal agenesia. Normal babies void 6-12 times/day. Some babies cry before passing urine due to discomfort of full
bladder. starts crying again after having passed urine due to wet napkins.
FAILURE TO PASS MECONIUM
Passage of some amount of meconium usually occurs within the first 12 hours of life,
99% of term infants and 95% of preterm infants passing meconium within the first 48 hours of life.
followed by yellow and seedy stools (transitional stools) for next 1-2 days. Failure to pass Meconium by 24 hours of age is an indication
for doing appropriate investigation to exclude any pathology Failure to pass Meconium can occur as a result of imperforate anus, functional
intestinal obstruction (i.e., Hirschsprung disease), illness, or hypotonia. Ninety percent of patients with meconium ileum will have cystic fibrosis and
thus should be tested for CF.
Bowel Pattern and Constipation
Frequency of stooling in breast fed can vary from every feeding initially to every several days (after each feeding to one every 1 to 7 days)
Gastro colic reflex( After every feed, normal activity, good feeding) which may persist for weeks.
Formula-fed baby has a bowel movement every 1 to 3 days. True Constipation is uncommon in newborns and requires evaluation If the infant develops abdominal distention, vomiting, refusal to eat,
bloody stools, or extremely hard stools.
Rx Maximize fluid intake(milk), Adding of sugar in milk
Laxatives should be avoided.
Dehydration fever
Some healthy babies may develop fever on the 2nd or 3rd day of life
Due to poor heat dissipation mechanisms ,higher rate of insensible losses ,inadequate intake of breast milk during the phase of physiologic lactational inadequacy.
The baby remains active, alert and cries for feeds. The baby should be dressed with light and loose cotton
clothes and his environment kept cool in summer.
Jitteriness
A tremor that is stimulus sensitive and can be stopped by passively flexing the affected limb.
Jitteriness is not accompanied by autonomic changes or ocular signs
Benign neonatal sleep myoclonus occurs only during sleep.
should be evaluated for hypoglycemia ,hypocalcemia, electrolyte abnormalities.
DDX with Seizures CNS Infection and Sepsis
conjunctivitis
Gonorrhoea– Must be ruled out in every case of conjunctivitis within 1st wk of life– Usually presents at 2–5 days (may be earlier w/PROM or later w/ failed prophylaxis) – Bilateral; clear watery discharge progressing to tense palpebral edema, – w/ copious, thick purulent exudates.– Culture positive for gonococcus– Ceftriaxone single dose IM
Staphylococcus aureus: – onset day 3 or later– One eye involved– Moderate amount of pus– Culture positive for staphylococcus– Apply 1% tetracycline ointment to the affected (4 time/day)– There is no need for systemic antibiotics.
Conjunctivitis
Chlamydia– Time of onset day 5 -7 or later(can present up to 21 days)– First watery discharge progressing to mucopurulent– Both eyes involved– Culture negative– Mother is Positive for STD – Treat with Oral Erythromycin for 14 days + 1% tetracycline ointment – Use of erythromycin is associated with Hypertrophic pyloric stenosis but still recommend
by AAP. Chemical irritation
– Usage of silver nitrate in eyes after birth.– Redness , swellings and small amount of pus present– Both eyes involved– Culture negative– Resolves spontaneously.
NASOLACRIMAL DUCT OBSTRUCTION
In approximately 6% of newborns, one or both of the lacrimal ducts is blocked, preventing drainage of tears.
Affected children appear to have excessive tearing. 90% blocked ducts open spontaneously by 6 mo of age. Obstruction beyond 6 to 12 months of age should be
evaluated by an ophthalmologist warm compress or massage from outer to inner canthal folds
‘‘milk the duct’’ results in resolution of majority of cases. if secondarily infected may need topical antibiotics.
UMBLICAL SEPSIS
Umbilical cord normally falls off in 7-10 days and the wound heals
in about 15 days. Redness and swelling around the umbilicus or pus drainage. If the area of redness extends to < 1cm of surrounding area and no
other sign of sepsis is present , local cleaning with antiseptic solution till redness subsides usually suffices.
If redness in surrounding area is >1cm or there are signs of sepsis, then in addition to local therapy, systemic antibiotic should be started as management of septicemia.
Complication Sepsis,CNS infection, Cellulitis,Necrotizing fasciitis
Excessive Crying
Common causes of cry in a neonate are:
• Hunger and thirst• Nasal block. - Insect bites • Pain and discomfort - Otitis media• Full bladder - Intussuception ,volvulus• Painful evacuation of hard stool - Bone and joint sepsis• Wet napkins - Unapparent trauma • Intestinal colic - Incarcerated hernia • May need cuddle - Pul hypertention(Hypoxia)
D D X
EVENING COLIC
Crying associated with flexion of thighs and flushing of face with frowning occur at a precise time in the evening and last for a couple of minutes or hours.
Starting in the 2nd wks, peaking at 6 weeks, and often resolving by 4 months of age
Excessive crying initiating a vicious cycle of colic-crying-colic. Holding the baby against skin, rocking, cuddling, provide relief. Administration of antispasmodic drops 30min before the anticipated
time of colic . Hypoallergenic formula or elimination diet for breastfeeding mothers DDX with GERD : accompanied by emesis and occur soon after feeding. Milk protein intolerance: accompanied by diarrhea or hematochezia.
VAGINAL BLEEDING
Menstrual like vaginal bleeding may due to withdrawal of maternal estrogen.
occur in about ¼ female babies after 3-5 days of birth. The bleeding is mild and lasts for 2-4 days. The local aseptic cleaning of genitals is advised . If bleeding seems excessive, vitamin K deficient bleeding
or other coagulopathy should be considered.
MUCOID VAGINAL SECRETION
Most female babies have thin grayish white mucoid vaginal
secretions. These should not be mistaken for purulent discharge.
Urate Crystals in Urine (Pink Diaper Syndrome)
Often mistaken for blood in the urine, Urate crystals are a frequent intermittent finding in the first week. The characteristic appearance of pink-orange material is sufficient to
make the diagnosis. Easily distinguished from blood on the basis of appearance, but
occult blood testing can also be performed. Urate crystals are typically found in the setting of concentrated urine
and may indicate dehydration
SUBCONJUNCTIVAL HEMORRHAGE
Newborns often have small, bilateral hemorrhages, presumably from the pressure of uterine contractions
But is more common after a traumatic delivery. This condition is seen in 5% of newborn infants. The blood gets reabsorbed after a few days without
leaving any pigmentation.
Umbilical hernia
Imperfect closure or weakness of the umbilical ring
LBW, female Disappear spontaneously by 1 yr
Strangulation rare Surgery if persisting to age 3-4 yr, symptomatic, strangulated, larger Application of coin and bandage over the hernia is not recommended
Umbilical Granuloma
Well-circumscribed ,friable, moist, pinkish tissue
at the base of the umbilicus Without treatment, it could ooze and become an irritation for several
months. Small umbilical granuloma usually respond to application of
crystal salt or silver nitrate. Large one need surgical excision.
DDX with Umbilical polyp (retained intestinal or gastric mucosa)
Brighter red than granuloma Does not respond to silver nitrate cauterization
Caput Succedaneum and Cephalhematoma
Indicators Caput succedaneum Cephalhematoma
Location Presenting part of the head Periosteum of skull bone
Character soft, puffy, scalp swelling firm, scalp swelling withclear edges
Time of Onset present at birth Appears after 24 to 48 hours of birth
Extent of Involvement
both hemispheres; crosses the suture lines
individual bone; does not cross the suture lines
Period of Absorption
3 to 4 days Few weeks to months
Treatment None Supportive
Normal Peeling
Term but most commonly post term infants can exhibit excessive peeling of skin.
Usually occurs after 24-36 hours Some time a few erythema toxicum are seen with feeling. Will resolve spontaneously and does not need any creams, oil,
ointment or lotions. Excessive peeling is seen in pathological conditions like
placental dysfunction, congenital syphilis and candidiasis.
4S syndrome
•Diffuse erythema of the skin develops abruptly• Marked skin tenderness and fever •Blisters and bullae rupture •Diffuse erosion with epidermal separation•Typically perioral and flexural area
Normal peeling Versus 4S
CUTIS MARMORATA
Bluish mottling of skin in response to chilling, stress or overstimulation.
Resolves quickly with warming. Onset during first 2 to 4 weeks of life; Due to immaturity of the autonomic nervous
system of newborns. If persists after the infant is warmed implies an
obstruction to blood flow such as hyperviscosity or vasculitis.
Persistence beyond neonatal period is a possible marker for trisomy 18, Down syndrome, hypothyroidism
DDX from sepsis and hypovolemia.
Harlequin color change
Transient hemi color change with erythema
on one half of the and pallor on the other. It present in the first 2-5 days of life Common in LBW, hypoxia ,intracranial injury
and prematurity(prematurity of hypothalamic center.
It may persist for 30 sec to 20 min and has no long
term sequelae . Resolve with supine position ,increased muscle
activity and crying
Seborrheic Dermatitis (Cradle cap)
Greasy ,yellow plaques on the scalp with some
degree of hair loss. Pruritus is infrequent unlike atopic dermatitis highly prevalent during the first 4 weeks of life Primarily affect head and intertriginous areas. Treatment options include gentle scrubbing,applying vaseline and
using soft brush to remove scales Occasionally topical mild corticosteriod or antifungal is indicated
ACNE NEONATORUM
Usually resolves within four months without scarring.
In severe cases, 2.5% benzoyl peroxide lotion can be used to hasten resolution.
DDX with Erythema toxicum candidiasis staphylococcal infection
transient increases in circulatory androgens contribute.
Multiple discrete Erythematouse papules develop between 2 and 4 weeks of life.
Milia
Multiple 1- to 2-mm yellowish white cystic lesions Affect 40% of newborns found most commonly over the cheeks ,forehead, nose, and
nasolabial folds due to blocked sebaceous glands Known as Epstein’s pearls when they occur in the
oral cavity(palates). self-limited and are reabsorbed
by 3 months of age
MILIARIA(HEAT RASH)
Small Erythematouse papules and pustules
on the forehead, neck, upper trunk Usually after first wk of life Resulting from the occlusion and rupture
of sweat ducts in the skin, responds to avoidance of overheating,
removal of excess clothing, cool baths,
and air conditioning topical creams or lotions aggravate the condition.
M.Rubra
M.crystalina
ERYTHEMA TOXICUM
Very common rash occurs in almost 50% of newborns Small white/yellow papules or pustules
on a red base seen on face, trunk and limbs. Usually develop 2 – 3 days after birth . Sparing palms and soles. Lesions seem to migrate by disappearing
within Hrs and then reappearing elsewhere. Resolves within 2 weeks
Differential diagnosis: herpes simplex staphylococcal disease of the skin
TRANSIENT NEONATAL PUSTULAR MELANOSIS
Small superficial white pustules on a
non erythematous base present at the
time of delivery on neck, back, extremities, and palms or soles New lesions do not usually appear after birth. The pustules are fragile and rupture quickly. often resolving within 2–3 days No treatment is necessary. Hyperpigmented
macules may last for several weeks to months. Gram stain of pustules demonstrates neutrophils, rare eosinophils, and an
absence of bacteria. Acne neonatrum Herpes simplex (due to serious consequence Every unknown rash in
neonate should be ddx with HSV) staphylococcal disease of the skin
SUCKING BLISTERS
Flaccid bullae, 5–15mm produced by Vigorous sucking by the fetus . May evolve quickly to erosion Resolve in days to weeks Characteristic locations Radial forearm, wrist, hand ( dorsal thumb, index fingers) No need for treatment
Differential diagnosis: Bullous impetigo Neonatal herpes simplex Epidermolysis bullosa
ORAL THRUSH
White patches that coat the inside of
the cheeks and tongue cannot be easily wiped off and may bleed slightly. Usually develop symptoms during the first weeks of life The infection most commonly occurs during passage of the
infected birth canal, infected feeding bottles, contaminated breast nipples and prolonged antibiotic therapy. Cause irritability and difficulty in feeding In severe cases spread to esophagus. May need Nystatin or Fluconazole oral drops.
Irritant Diaper DermatitisSpares skin folds
Confluent Erythematouse papules persisting longer than 2 or 3 days is usually complicated by C. Albicans. Skin Folds Spared accentuation on the convex surfaces exposed to urine and stool.
Keeping the skin as dry as possible with frequent diaper changes Zinc oxide cream Rinsing with just warm water In severe cases 1% hydrocortisone(few days)
Rx
Candidiasis Diaper rash
– Erythematouse plaques with peripheral desquamation
– Irregular, scaly border– Satellite lesions on diaper region– Inguinal creases commonly involved – topical anticandidal agent
Birth marks
Birth marks
comprise a wide spectrum of common and uncommon congenital disorders recognition is crucial for predicting the natural course and associated abnormalities
Occurrence(%)
Salmon patch
Hemangioma
40.3
Port wine stain
Mongolian spot
Melanocytic nevus
2.6
0.3
23.3
1.3
SALMON PATCHES (Nevus Simplex)
Reddish or pink patches on the forehead ,nape of neck eyelids ,nose and upper lips.
They are sometimes mistaken for bruising.
Disappear after 2 years of age They cross the midline, if unilateral
in the distribution of trigeminal nerve first
branch (cranial nerve V1) ,need MRI at 6mo of age for R\O of Sturge Weber syndrome.
angel kisses
Storks bite
MONGOLIAN SPOTS
Blue to blue-black macules occur anywhere on the body,mostly on the back and buttocks
Caused by the deposition of normal body pigment under the skin.
Malignant degeneration does not occur mistaken for bruising as a sign of child abuse. Usually disappear within four to five years occasionally persist
into adulthood.
Differential diagnosis: Bruise Birth trauma
Port-wine stain
Seriouse and Permanent birthmark that starts out pink, but turns darker red or purple as a child grows.
Usually unilateral,appears on the face and neck, but it can affect other areas of the body
sometimes they occur with Klippel-Trenaunay syndrome or Sturge-Weber syndrome
Laser therapy is the usual treatment of choice
Congenital Melanocytic nevus
CMN occur in up to 1% of all newborns. Size vary from few mm to several cm or more in diameter. Typically appears on the scalp or trunk of the body CMN may be flat or raised,hairy,pinkish tan to brown or black. there is increased risk for development of malignant melanoma. Prophylactic removal of small CMN should be
considered but can be delayed until the end of the first decade All CMN with atypical features should be excised
regardless of size.
Giant CMN with atypical features, including a scalloped border, irregular pigmentation, and variable thickness.
Cafe au lait spot
Light brown and coffee colored permanent birthmarks . May be present at birth or develop during childhood Café au lait spots may be found on any part of the body. One to 3 café-au-lait spots are common in normal children presence of six or more with a diameter of greater than 0.5 cm
highly suggestive of neurofibromatosis.
Disorders with Café-au-Lait Spots
Tuberous sclerosis Albright syndrome(precocious puberty) Ataxia-telangiectasia Bloom syndrome(GENETIC DISORDER WITH PHOTOSENSITIVITY)
Ataxia-telangiectasia Turner syndrome Fanconi anemia Gaucher disease
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