LeBonheur Seminars:

27 January 2006

Here
Heres Looking at You Kid:
Neonatal Presentations to
the Emergency Department

Neonatal Emergency
Department Visits
Shortened postpartum stay has
decreased the amount of time for
parental instruction
Emergency Department may be only
source for health care
Physicians in the ED must be able to
manage the most serious to the most
common of neonatal presentations

W. Ricks Hanna Jr., MD

Neonatal Emergency
Department Visits
Most Frequent Presenting Complaints
Jaundice
Difficulty breathing
Feeding problems
Irritability
Abnormal bowel movement frequency
Lethargy
Millar KR, Pediatric Emergency Care 2000; 16:145-150.

Neonatal Patient: History

Neonate
Mother
Immediate history
Pregnancy history
Labor and delivery
Family history

Neonatal Emergency
Department Visits
Most Frequent Diagnoses
Normal newborn
Jaundice
Feeding problem
Possible sepsis
Dehydration

Millar KR, Pediatric Emergency Care 2000; 16:145-150.

Neonatal Patient: Vital Signs

Growth
Temperature
100.4o, (38o) considered fever

Heart Rate
120-160 bpm
Tachycardia
Bradycardia < 80 bpm

Neonatal Patient: Vital Signs

Respiratory Rate
40-60 bpm
Periodic breathing of the newborn
Apnea

Blood Pressure
Systolic 60-90 mmHg

Feeding

2-3 oz of formula every 2-3 hours

10 minutes each breast every 2-3 hours
10-12 wet diapers per day
1-3 bowel movements per day
Overfeeding/Underfeeding common
presentations

Sleeping

Infants sleep 18-22 hours per day

Not necessarily at night
Any pattern normal variant
Predictable pattern by 2-3 months
Back to sleep

Colic

Constipation

Defined as paroxysms of crying for

three hours per day or more for three
days per week for a three week period
Typical newborn may cry up to two
hours per day peaks at 6 weeks of age.
Diagnosis of exclusion

Frequency of stools not constipation but

the nature and difficulty passing the
stool
Important to determine timeline
Congenital defects
Botulism
Dehydration

Eyes: General
Newborns are very nearsighted at birth
Eyes closed most of the time
Best way to open eyes is to hold the
infant upright and sway from side to
side or up and down

Eyes: Common Problems

Leukokoria
Conjunctivitis
Dacrostenosis
Scleral and Subconjunctival
Hemorrhages
Strabismus

Eyes: Leukokoria

Red reflex should always be visualized

Leukokoria-white pupillary reflex
Always an abnormal finding
Associated with colobomas,
cataracts,retinal detachment,
retinopathy of prematurity,
retinoblastoma
Ophthalmology referral

Eyes: Conjunctivitis
Chemical
Bacterial
Gonococcal
Chlamydial
Other

Viral
Herpes

Fleisher, Ludwig, Baskin. Atlas of Pediatric Emergency Medicine, 2004.

Eyes: Chemical Conjunctivitis

Eyes: Gonococcal
Conjunctivitis

Most common cause

Presents 12-24 hours after prophylaxis
Resolves by 48 hours
Erythromycin 0.5% or Tetracycline 1%
recommended for prophylaxis

Neisseria Gonorrhoeae
Presents 2-5 days after birth
Marked lid inflammation, chemosis and
copious purulent discharge
Medical emergency

Eyes: Gonococcal
Conjunctivitis

Eyes: Chlamydial
Conjunctivitis

Complete septic work up

Systemic disease: Ceftriaxone 2550mg/kg IV for 7 days
Local eye disease: Ceftriaxone 2550mg/kg IV or IM as a single dose
Treat empirically for chlamydia

Chlamydia trachomatis
Presents 5-14 days
Mild inflammation to severe swelling
with copious discharge
10-15% have pneumonia
Antigen detection
Treatment oral erythromycin
50mg/kg/day divided q6hrs for 14 days

Eyes: Herpes Simplex

Presents 2-16 days of life

Look for skin findings
Flourescein exam shows dendrites on cornea
Complete septic work up
IV Acyclovir 20mg/kg IV
Topical treatment as well Vidarabine ointment
5 times a day for up to 21 days
30-50% will recur within 2 years
Fleisher, Ludwig, Baskin. Atlas of Pediatric Emergency Medicine, 2004.

Eyes: Dacryostenosis

Congenital obstruction of nasolacrimal duct

Usually unilateral
Increased tearing and crusting of the eye
Massage will express tears and purulent
material
Rule out corneal abrasion and glaucoma
Treatment
Massage therapy
Antibiotics if needed
Ophthalmology at one year of age
Bacterial Conjunctivitis in Children: Containing the Infection Infectious Diseases in Children, Jan. 2006.

Fever: General
In the neonate fever >/= 100.40 (380)
rectally
Other symptoms: hypothermia, poor
feeding, decreased activity, apnea,
irritability, rashes, jaundice and seizures
Always have high index of suspicion
Prenatal history important

Fever: Microbiology

Group B strep
E coli
Listeria monocytogenes
Herpes simplex
TORCH infections

Fever: Evaluation
Physical Exam
Laboratory
CBC, Blood Culture
Urinalysis and Culture
Spinal fluid and Culture
+/- Chest x-ray, Metabolic panel, ESR,
CRP

Fever: Management
Antibiotics
Inpatient versus Outpatient

Fleisher, Ludwig, Baskin. Atlas of Pediatric Emergency Medicine, 2004.

Hyperbilirubinemia:
General
Bilirubin formed from the breakdown of
hemoglobin.
Accumulates in the skin when there is
excessive hemolysis, failure of liver
conjugation or inadequate liver excretion
Bilirubin classification
Unconjugated-Indirect-not processed by liver
Conjugated-Direct-processed by liver

Hyperbilirubinemia:
History

When was jaundice noticed?

What are the color of stools and urine?
What type of feedings is the baby getting?
Are the feedings adequate?
Has the infant been vomiting?
Infant and maternal blood types
Is the mother diabetic?
Is there a family history of jaundice?

Hyperbilirubinemia:
Physical Exam
Jaundice usually progress in a caudal
fashion
Scleral icterus is most sensitive
Complete exam including: vitals,
distribution of icterus, presence of
cephalohematoma or organomegaly

Hyperbilirubinemia:
Laboratory
Total serum bilirubin
Complete Blood Count with smear
Coombs test
Reticulocyte count
Urinalysis and culture
Other labs as dictated by history and exam

Not pathologic appears >24 hours

Moderate degree of jaundice
considered normal if labs normal and
exam unremarkable
Follow bilirubin looking for the peak if
getting close to levels requiring therapy

Hyperbilirubinemia:
Breast Milk Jaundice

Hyperbilirubinemia:
Blood Type Incompatibility

Direct and Indirect levels initially

Hyperbilirubinemia:
Physiologic Jaundice

May be early and due to inadequate

calorie intake and dehydration until milk
supply is sufficient
Can have late onset breast milk
jaundice for unknown reasons
Follow levels as needed
Encourage frequent breast feeding

Test mother and infant for ABO type

and Rh factors
Hemoglobin may be low
If incompatibility exists and
phototherapy ineffective may need
exchange transfusion

Hyperbilirubinemia:
Other Causes

Sepsis
Prematurity
G6PD deficiency
Gilberts disease
Crigler-Najjar syndrome

Fleisher GR, Ludwig, S. Textbook of Pediatric Emergency Medicine, 2004.

Cardiovascular:
General
Neonatal cardiovascular system is
dynamic
Moves from low pressure system to
high pressure system
Ductus arteriosus closes functionally
10-14 hours but anatomically at 2-3
weeks
Closure may precipitate crisis

Cardiovascular:
Cyanotic Heart Disease
Present with ductus closure
Hyperoxia test differentiate between cardiac
and noncardiac causes
Etiologies:

Tetralogy of Fallot
Tricuspid Atresia
Total anomalous venous return
Transposition of the great vessels
Truncus arteriosus
Pulmonary stenosis

Cardiovascular:
Acyanotic Heart Disease
Ductus closure may precipitate crisis
Onset usually gradual with CHF present
History may include: poor feeding,
diaphoresis, poor weight gain, color
change with feeding
CHF classic triad: tachypnea,
tachycardia and hepatomegaly

Cardiovascular:
Cyanotic Heart Disease
Management
A,B,Cs
CXR, EKG, Echo if available
Prostaglandin E1 (PGE1)
Bolus 0.05mcg/kg IV
Infusion 0.05-0.1mcg/kg/min IV
Apnea common with PGE1

Wean O2 after PGE1

Cardiovascular surgery consultation after
stabilization

Cardiovascular:
Acyanotic Heart Disease
Etiologies
Hypoplastic left heart
Coarctation of the aorta
Complete AV canal
VSD
ASD
PDA

Cardiovascular:
Acyanotic Heart Disease
Management

A,B,Cs
CXR, EKG, Echo if available, Electrolytes
PGE1 may be needed
Lasix 1mg/kg IV first line therapy for CHF
Dopamine, Dobutamine and Digoxin may be
needed
Pediatric cardiology consultation after stabilization

Cardiovascular:
Dysrhythmias
Supraventricular tachycardia most
common
Heart rate greater than 220
Presentation: poor feeding, irritability,
CHF and shock

Cardiovascular:
Dysrhythmias
SVT management
Stable patient
Vagal maneuvers-ice bag to face
Adenosine 0.1mg/kg (maximum 6mg) rapid IV push
Double adenosine (maximum 12mg)

Unstable patient
Synchronized cardioversion 0.5-1.0 joules/kg

Monitor EKG during conversion

Pediatric cardiology consultation after stabilization

GI: Malrotation of Bowel with

Volvulus
Malrotation occurs in 1/500 live births
Volvulus develops in approximately
50%
Abnormal fixation of the bowel
mesentery
Volvulus and obstruction at points of
abnormal fixation

GI: Malrotation of Bowel with

Volvulus
Presentation
Bilious emesis, altered mental status,
shock
Pain usually constant
Bloody stools
Obstruction is high so may not have
distension

GI: Malrotation of Bowel with

Volvulus
Management
Surgical emergency
Radiographs
KUB-double bubble, bowel loop over liver
Upper GI-coiled spring

A,B,Cs
Fluid resuscitation
Nasogastric tube
Fleisher, Ludwig, Baskin. Atlas of Pediatric Emergency Medicine, 2004.

GI: Pyloric Stenosis

1/250 live births
Male/Female 4:1
Feeds well for first week then begins
vomiting at 2-5 weeks
Vomiting increases until projectile
Secondary to muscle hypertrophy

GI: Pyloric Stenosis

Presentation
History
Olive
Peristaltic waves across abdomen
Infant may appear wasted

Diagnosis
Electrolytes
Ultrasound

GI: Pyloric Stenosis

Management
Admit
Rehydration
Surgery

Fleisher, Ludwig, Baskin. Atlas of Pediatric Emergency Medicine, 2004.

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Fleisher, Ludwig, Baskin. Atlas of Pediatric Emergency Medicine, 2004.

Neonatal Seizures:
Types

Neonatal Seizures
Difficult to recognize clinically
Generalized tonic clonic activity not
common
Subtle signs include lip smacking,
apnea, eye deviations

Subtle-most common
Tonic-sustained posturing of a limb
Clonic-rhythmic jerking of one or more
parts of the body
Myoclonic-repetitive rapid jerks of the
entire body or an extremity

Neonatal Seizures:
Etiology

Perinatal asphyxia
Intraventricular hemorrhage
Metabolic
Infection
Malformation

Neonatal Seizures:
Management

A,B,Cs
Electrolytes include Ca and Mg
Glucose-2-4cc/kg of D10
Sodium-5-7cc/kg of 3% saline
Full septic work up
Head CT
Admission

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Neonatal Seizures:
Pharmocology
Benzodiazepines
Ativan-0.05-0.1mg/kg IV
Valium-0.2-0.3mg/kg IV or 0.5mg/kg rectal
Versed-0.1mg/kg IV or 0.2mg/kg IM

Anticonvulsants
Phenobarbital-20mg/kg IV
Fosphenytoin-15-20mg/kg IV
Pyridoxine-50-100mg IV-(actively seizing)

Antibiotics

End
W. Ricks Hanna Jr. , MD

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