diseases of the newborn belen amparo e. velasco, m.d
TRANSCRIPT
DISEASES OF DISEASES OF THE NEWBORNTHE NEWBORN
Belen Amparo E. Velasco, M.D.
BIRTH INJURIES
INTRACRANIAL INJURIES
SPINAL CORD INJURIES
NERVE INJURIES
INTRACRANIAL INJURIES
Most common site of fatal and disabling injury – intracranial cavity
Preterm – more prone to hypoxic cerebral injury – spontaneous intraventricular hemorrhage
Term infants – more prone to subdural hemorrhages which are traumatic in origin
INTRACRANIAL INJURIES CLINICAL MANIFESTATIONS: Nonspecific Most common:
Respiratory distress Pallor Lethargy/somnolence with poor response to stimuli
Hypo- or hyperreflexiaConvulsionsSigns of ICPUnequal pupilsTachy- or bradycardia
INTRACRANIAL INJURIES DIAGNOSIS: Clinical history/course Spinal taps (done in extreme caution) Cranial ultrasount vs CT scan of the head
TREATMENT: Minimal handling Management of ICP – fluid restriction Furosemide paCO2 25-30 torr Thermoregulation Oxygen and ventilatory support, as warranted Anticonvulsant for siezure Vitamin K for coagulation defect
SPINAL CORD INJURIES
Associated with difficult delivery
Types of injuryComplete transection – permanent paralysisPartial transectionCord compression – transient paralysis
NERVE INJURIES
BRACHIAL PALSY
FACIAL PARALYSIS
DIAPHRAGMATIC PARALYSIS
SCIATIC NERVE INJURY
BRACHIAL PALSY
ERB-DUCHENNE PARALYSISInjury to the 5th-6th crevical rootAbsent Moro on the affected side
KLUMPKE’S PARALYSISInjury to the 7th cervical and 8th thoracic rootLoss of sensory and motor fxn of hand and wrist
BRACHIAL PALSY
DIAPHRAGMATIC PARALYSISInjury to 4th cervical root
HORNER’S SYNDROMEInjury to the sympathetic ganglionCharacterized by ptosis, enophthalmos, miosis, and
anhydrosis of the face on the affected side
OTHER NERVE INJURIES
FACIAL PALSYInjury to the 7th nerve
SCIATIC NERVE INJURY
CLAVICULAR FRACTURE
Associated with difficult delivery esp shoulder dystocia
INTRAABDOMINAL INJURIES
More common in breech deliveries
Commonly ass with liver laceration and intraabdominal bleed
INFECTIONS OF THE NEWBORN
INCIDENCE: 1-5 per 1000 livebirths
PREDISPOSING FACTORSPrematurity
Male genderMaternal infectionDifficult deliveryCongenital anomalies
INFECTIONS OF THE NEWBORN
ROUTES OF ENTRY
Hematogenous spread
Ascending infection
Direct contact along birth canal
Breaks in the skin
INFECTIONS OF THE NEWBORN
CHANGING SPECTRUM OF PREDOMINANT PATHOGENS
EARLY ONSET SEPSIS1930’s Grp A Strep Others:E.coli,Staph
1940’s E.coli Others:Streptococci
1950’s S. aureus Others:E.coli/Pseudo
1960’s E.coli Others:Pseudo/Kleb
1970’s Grp B Strep Others:E.coli/ Listeria
1980’s Grp B Strepup to E.colipresent
LATE-ONSET SEPSIS1970’s S. aureus Others:Grp D Strep1980’s Coagulase(-) Others: G(-) enteric
Staph & Streptococciup to S. aureus Untypable
H.influenzaePresent
LATE LATE-ONSET SEPSIS1990’s Candida sp.
Coagulase (-)Staph
INFECTIONS OF THE NEWBORNEARLY-ONSET VS LATE-ONSET
VS LATE LATE-ONSETEARLY LATE LATE-
LATEOnset <4 days >4 days > 30 daysIncidence 0.1-0.4% 5-25% -Transmission vertical vertical/
postnatal env. postnatal env.
Clinical fulminant insiduous insiduous Sxs pneumonia meningitis
multisystem Morbidity neurologic prolonged prolonged handicap hospitalization
hospitalizationMortality 15-50% 10-15%
INFECTIONS OF THE NEWBORN
DIAGNOSIS OF SEPSIS
Clinical judgment Recovery of the organism from a
meaningful site: Blood culture UA vs UV specimens - The best alternative is
still blood culture from a peripheral vein Volume of blood – 0.5 ml should be
adequate. Larger specimens will often grow faster
Single vs multiple blood cultures- With early onset sepsis, a single culture would suffice. With late-onset sepsis esp with possible CONS, at least two cultures should be obtained.
INFECTIONS OF THE NEWBORNTREATMENT MODALITIES
AGAINST SEPSIS
METHODS GENERALLY USED: Early Detection Fluids, nutrition, antibiotics, ventilatory
support Catecholamines
AGENTS POSTULATED TO IMPROVE OUTCOME OF SEPSIS:
Antiserum to endotoxin Monoclonal antibodies to endotoxin
SPECIFIC INFECTIONS
MENINGITIS
PNEUMONIA
DIARRHEA/NEC
URINARY TRACT INFECTION
ARTHRITIS
CONJUNCTIVITIS
OTHER BACTERIAL INFECTIONS
TETANUS NEONATORUMHistory of unhygienic cord practicesClinical diagnosis characterized by TRISMUSPrevention with tetanus immunization of the
mother
OTHER BACTERIAL INFECTIONS
CONGENITAL TUBERCULOSISGhons complex in the liverDiagnostics include:
AFB smear of gastric aspirateTuberculin testPlacental pathologic exam
OTHER BACTERIAL INFECTIONS
CONGENITAL SYPHILISMay occur with other STDsCharacterized by jaundice, hepatosplenomegaly,
macular rashes with wet desquamating skin teeming with spirochetes
VDRL for screening. Confirmatory test FTA-ABS
NON-BACTERIAL INFECTIONS
TORCHS
TOXOPLASMOSIS
CONGENITAL RUBELLA
CYTOMEGALOVIRUS INFECTION
HERPES SIMPLEX INFECTION
NON-BACTERIAL INFECTIONS
OTHER VIRAL INFECTIONS:
MUMPS
HEPATITIS B
AIDS
TREATMENT OF INFECTION
SPECIFIC THERAPY:
AmpicillinGentamicin3rd generation Cephalosporin:
SUPPORTIVE THERAPY
Fluid resuscitation (crystalloids/colloids)InotropesNutritional supportImmunotherapy
TREATMENT OF INFECTION
SPECIFIC THERAPY:
TETANUS: Penicillin, TIG, AnticonvulsantTUBERCULOSIS: INH, Rifampicin, PZASYPHILIS: PenicillinTOXOPLASMOSIS: SpiramycinCYTOMEGALOVIRUS INFECTION:
GanciclovirHERPES SIMPLEX INFECTION/VARICELLA:
AcyclovirHIV: Zimovudine
JAUNDICE IN THE NEWBORNBILIRUBIN METABOLISM
biliverdinHemoglobin bilirubinHeme oxygenase
C0 Iron
biliverdinreductase
1 mole of Hgb = 1 mole each of C0 & bilirubin
Transport = bilirubin is transported to liver bound to serum albumin
Uptake = nonpolar bilirubin (dissociated from albumin) crosses the hepatocyte plasma membrane,binds to cytoplasmic ligandin (Y protein) fortransport to SER
Note: Phenobarbital increases concentration of ligandin
CONJUGATION
UCBSER
UDPG-T (Pb)
Bil. Monoglucuronide (CB)
Bil. Diglu-curonide
Bile canaliculi
EXCRETION
CB biliary tree
GIT
stool
B-glucuronidaseUCB(liver)
Enterohepatic circ.
BILIRUBIN METABOLISMBILIRUBIN METABOLISM
JAUNDICE
Color is due to accumulation in the skin of unconjugated, nonpolar, lipid-soluble bilirubin (indirect) formed from Hgb by heme oxygenase, biliverdin reductase, and nonenzymatic reducing agents in the RES
RISK FACTORS FOR HYPERBILIRUBINEMIA
History of previous sibling with hyperbilirubinemia
Decreasing gestational age Breastfeeding Large weight loss after birth
CAUSES OF HYPERBILIRUBINEMIA
Enhanced enterohepatic circulation due to: High levels of intestinal B-glucuronidase bilirubin monoglucuronide intestinal bacteria gut motility with poor evacuation of
meconium
CAUSES OF HYPERBILIRUBINEMIA
Defective uptake of bilirubin from plasma ligandinBinding of ligandin by other anions
Defective conjugation due to UDPG-T activity
Decreased hepatic excretion of bilirubin
PHYSIOLOGIC HYPERBILIRUBINEMIA
Onset of jaundice beyond 24 hours of age Rise in TSB less then 0.5 mg/dL/hour or
5mg/dl/day Peaks at 3-5 days Resolves in a week Levels not rising above 12mg/dl No associated illness
NONPHYSIOLOGIC HYPERBILIRUBINEMIA
Onset of jaundice before 24 hours of age Any elevation of TSB that requires
phototherapy Rise in TSB over 0.5 mg/dL/hour Signs of underlying illness eg. vomiting,
lethargy, poor feeding, excessive weight loss, apnea, tachypnea, To instability
Jaundice persisting after 8 days in FT, 14 days in PT
PATHOLOGIC CAUSES OF HYPERBILIRUBINEMIA
PRODUCTION
Isoimmunizatioin: Rh, ABO, minor blood grps
Erythrocyte biochem. Defect: G6PD, pyruvate kinase, hexokinase, porphyria
Structural abnormalities of RBCs: hereditary spherocytosis, eliptocytosis
PATHOLOGIC CAUSES OF HYPERBILIRUBINEMIA
PRODUCTION
Infection: bacterial, viral, protozoal (mixed jaundice)
Sequestered blood: subdural hematoma, cephalhematoma, ecchymoses, hemangiomas
Others: IDM, obstructive jaundice, galactosemia, hemolysis (DIC, vit K deficiency)
UPTAKE
Gilbert’s syndrome hypothyroidism galactosemia
PATHOLOGIC CAUSES OF HYPERBILIRUBINEMIA
CONJUGATION
Crigler-Najjar syndromes (types I, II) Transient familial neonatal
hyperbilirubinemia Galactosemia, hypothyroidism
PATHOLOGIC CAUSES OF HYPERBILIRUBINEMIA
EXCRETION
Idiopathic neonatal hepatitis Biliary atresia
PATHOLOGIC CAUSES OF HYPERBILIRUBINEMIA
ENTEROHEPATIC CIRCULATION
Breastmilk jaundice (early, late onset) Starvation Pyloric stenosis Intestinal obstruction
PATHOLOGIC CAUSES OF HYPERBILIRUBINEMIA
WORK-UP FOR JAUNDICE
Total serum bilirubin, B1, B2 Blood type, Rh, direct Coombs test of
the infant Blood type, Rh, antibody screen of the
mother Peripheral smear and reticulocyte count Hct
WORK-UP FOR JAUNDICE
If direct Coombs + - antibody on infant’s RBC
G6PD screen, congenital hypothyroidism, metabolic defects (urine metabolic screen)
For neonatal cholestasis: Liver function test, TORCH assay, UTZ, liver biopsy
TREATMENT OF HYPERBILIRUBINEMIA
Phototherapy Exchange Transfusion Phenobarbital ? Tin (Sn) protoporyhyrin or tin mesoporphyrin:
inhibits conversion of biliverdin to bilirubin by heme oxgenase Dose: single IM on D1 of life Complications:transient erythema
TREATMENT OF CHOLESTASIS
Ursodeoxycholic acid 10mg/k/day Kasai Procedure for biliary atresia
MANAGEMENT OF HYPERBILIRUBINEMIA IN THE HEALTHY TERM NEWBORN
AGE HOURS
CONSIDER PHOTOTHERAPY
PHOTOTHERAPY EXCHANGE TRANSFUSION, IF INTENSIVE
PHOTOTHERAPY FAILS
EXCHANGE TRANSFUSION &
INTENSIVE PHOTOTHERAPY
<24 … … … …
25-48
>12 >15 >20 >25
49-72
>15 >18 >25 >30
>72 >17 >20 >25 >30
Serum bilirubin = mg/dL
JAUNDICE IN PREMATURE INFANTS
WEIGHT IN GRAMS
PHOTOTHERAPY EXCHANGE TRANSFUSION
< 1000 gms.
Start within 24 hours
10-12 mg/dL
1000-1500 gm
7-9 mg/dL 12-15 mg/dL
2000-2500 gm
13-15 mg/dL 18-20 mg/dL
CLINICAL MANIFESTATIONS OF KERNICTERUS
Onset of symptoms: 2-5 d (FT), 7 d (PT) Early phase: lethargy, poor feeding, loss of
Moro reflex Second phase: prostration, dec. DTRs,
respiratory distress Late phase: opisthotonus, bulging fontanel.
Twitching of face & limbs, high-pitched cry Advanced cases: convulsions, spasm, stiff
extension of arms inward rotation with fists clenched
COMPLICATIONS OF KERNICTERUS
Cerebral palsy Mental retardation Seizure disorder Behavioral problem Dental dysplasia
RESPIRATORY DISTURBANCES
STRIDOR
Harsh sound produced by turbulent flow thru partially obstructed
Ass with upper airway obstruction
RESPIRATORY DISTURBANCES
STRIDOR
CAUSES OF STRIDORChoanal atresiaLaryngomalaciaMacroglossiaSubglottic stenosisNeck masses
RESPIRATORY DISTURBANCES
RESPIRATORY DISTRESS SYNDROME
Basic Pathology:Deficiency of pulmonary surfactant with
subsequent lung collapseImmaturity of the chest wall
RESPIRATORY DISTURBANCES
RESPIRATORY DISTRESS SYNDROME
Clinical Manifestations:Respiratory distressAnemiaHypotensionOliguriaHypotheramia
RESPIRATORY DISTURBANCES
RESPIRATORY DISTRESS SYNDROME
DIAGNOSIS:Chest radiograph
Ground-glass appearanceAir bronchogramLung opacity
Arterial blood gas
RESPIRATORY DISTURBANCES
RESPIRATORY DISTRESS SYNDROME
Treatment:Oxygen therapyCorrection of acidosisSurfactantAntibioticsTreatment of associated
condition/complication
RESPIRATORY DISTURBANCES
TRANSIENT TACHYPNEA OF THE NB
Result of delayed absorption of fetal lung fluid seen during CS deliveries
RESPIRATORY DISTURBANCES
TRANSIENT TACHYPNEA OF THE NB
Characterized by respiratory distress during the first two – three days of life
RESPIRATORY DISTURBANCES
TRANSIENT TACHYPNEA OF THE NB
DIAGNOSIS:Chest radiograph
Effusion along fissure linesWet lung
RESPIRATORY DISTURBANCES
TRANSIENT TACHYPNEA OF THE NB
TREATMENTOxygen therapy
RESPIRATORY DISTURBANCES
APNEA
CAUSES OF APNEA:Central apnea: IVH, sedationObstructive apnea: RDS, pneumonia Mxed type: Sepsis, PDA
RESPIRATORY DISTURBANCES
APNEA
TREATMENT OF APNEA:Treat underlying causePhysical stimulationPositive pressure ventilationAminophylline?
RESPIRATORY DISTURBANCES
NEONATAL PNEUMONIA
MECONIUM ASPIRATION
CARDIOVASCULAR DISTURBANCESCONTROL OF THE HEART RATE
CARDIOVASCULAR DISTURBANCESCONGENITAL HEART DEFECTS
Incidence: About 8 of every 1,000 babies in the U.S. are born with a congenital heart defect
CARDIOVASCULAR DISTURBANCESCONGENITAL HEART DEFECTS
COMMON ACYANOTIC ABNORMALITIES:
Septal defect: Opening between right & left atrium or between right & left ventricle.
CARDIOVASCULAR DISTURBANCESCONGENITAL HEART DEFECTS
COMMON ACYANOTIC ABNORMALITIES:
Patent ductus arteriosus: Fetal blood vessel that usually closes soon after birth remains open with oxygen-rich blood returning from the lungs pumped to the lungs again, placing extra strain on the right ventricle and on the blood vessels leading to and from the lung.
CARDIOVASCULAR DISTURBANCESCONGENITAL HEART DEFECTS
COMMON CYANOTIC ABNORMALITIES:
Transposition of great arteries: exchange of role of the aorta and pulmonary artery
CARDIOVASCULAR DISTURBANCESCONGENITAL HEART DEFECTS
COMMON CYANOTIC ABNORMALITIES:
Coarctation of the aorta: a portion of the aorta is abnormally narrow and unable to carry sufficient blood to the body, placing extra strain on the left ventricle with high blood pressure in the upper body and rupture of blood vessel in the brain
CARDIOVASCULAR DISTURBANCESCONGENITAL HEART DEFECTS
COMMON CYANOTIC ABNORMALITIES:
Tetralogy of Fallot: a combination of four different heart malformations allows mixing of oxygenated and deoxygenated blood pumped by the heart.
CARDIOVASCULAR DISTURBANCESCONGENITAL HEART DEFECTS
Causes of Congenital Heart Defect:
Genetic factors,
Viral infections
Exposure to certain chemicals
CARDIOVASCULAR DISTURBANCESCONGENITAL HEART DEFECTS
Treatment: Surgical correction of the defect
Patch made from pericardium or synthetic fabric for septal defect
Ligation of ductus arteriosus
Snipping out narrowed portion of the aorta while sewing the normal ends togetherin coarctation of the aorta,
Corrective procedure for each part of the defect in Tetralogy of Fallot
Note: Success rates are well above 90 percent, with treated children living healthy, normal lives.
CARDIOVASCULAR DISTURBANCES
SHOCK
HYPERTENSION
RHYTHM DISTURBANCES
GASTROINTESTINAL DISTURBANCES
NECROTISING ENTEROCOLITIES
4 Is:
Ischemia Immaturity Infection Ingestion of milk
GASTROINTESTINAL DISTURBANCES
NECROTISING ENTEROCOLITIS
Clinical Manifestations:Non-specificResidual on feedingAbdominal distentionBlood-streaked stools
GASTROINTESTINAL DISTURBANCES
NECROTISING ENTEROCOLITIS
Diagnosis:Abd xray: Pneumatosis intestinalis
Fixed dilated loopsPortal vein gas
Liver UTZ: Hepatic microbubbles
GASTROINTESTINAL DISTURBANCES
NECROTISING ENTEROCOLITIES
Treatment:NPOTotal Parenteral NutritionGastric decompressionAntibioticsSurgical intervention, if indicated
HEMATOLOGIC DISTURBANCES
ANEMIA
CAUSES OF ANEMIAHemolysisAcute blood lossParenteral nutritional deficiency
HEMATOLOGIC DISTURBANCES
ANEMIA
TREATMENT OF ANEMIAReplacement of blood loss
PRBC transfusion 10cc/kTreatment of underlying cause
Vitamin K of HDNVitamin E and Iron ErythropoietinSpecific factor repolacement for
hemophilia
HEMATOLOGIC DISTURBANCES
POLYCYTHEMIA
CAUSES OF POLYCYTHEMIAPlacental dysfunction (SGA)Late cord clampingFeto-fetal/Maternofetal transfusionAdrenogenital syndromeIDM
HEMATOLOGIC DISTURBANCES
POLYCYTHEMIA
CLINICAL SXS OF POLYCYTHEMIALethargy with poor suckCyanosis
COMPLICATIONSHyperbilirubinemiaVenous thrombosisPPHN
HEMATOLOGIC DISTURBANCES
POLYCYTHEMIA
TREATMENT OF POLYCYTHEMIAPartial exchange transfusion
ENDOCRINE DISORDERS
INFANT OF DIABETIC MOTHER
May be asymptomaticSymptoms of hypoglycemia:
TremorsApneaLimpnessFeeding difficultyHigh-pitched cry
ENDOCRINE DISORDERS
INFANT OF DIABETIC MOTHER
Associated conditions:Hyaline membrane diseaseHypocalcemiaPolycythemiaHyperbilirubinemia
ENDOCRINE DISORDERS
INFANT OF DIABETIC MOTHER
Associated anomalies:Septal hypertrophyMicrocolon
ENDOCRINE DISORDERS
INFANT OF DIABETIC MOTHER
Treatment:2cc/k D10WaterIncrease GIRHydrocortisone
ENDOCRINE DISORDERS
CONGENITAL HYPOTHYROIDISM
Rarely obvious at birthFLK with large anterior fontanel,
low nasal bridge, large tongue, umbilical hernia, and constipation
May present as persistent jaundice
ENDOCRINE DISORDERS
CONGENITAL HYPOTHYROIDISM
Diagnosis:T4 and TSH
Treatment:levo-Thyroxine 5-10mg/k/d
ENDOCRINE DISORDERS
CONGENITAL ADRENAL HYPERPLASIA
Usually present with ambiguous genitalia
75% may go into adrenal crisis – salt-losing type due to 21-hydroxylase deficiency
ENDOCRINE DISORDERS
CONGENITAL ADRENAL HYPERPLASIA
Diagnosis:Serum cortisol, pregnaneloneUrinary 17ketosteroidsKaryotypingPelvic UTZ
Treatment:Hydrocortisone