SHANZ – PEDIA 1.

04 NEONATOLOGY II
SEPSIS
SEPSIS NEONATORUM GBS SEPSIS
DEFINITION • Sepsis: clinical syndrome + organism ID
• Bacteremia: clinical symptom without organism isolation
EPID Mortality ▪ 13-69% worldwide < PH • NOT IN PH, COMMON IN US
▪ 13-15% all neonatal death (US) < PH • 10-30% women of child-bearing age
Meningitis ▪ 0.4-2.8 in 1000 livebirth > US • NOT STD
▪ CNS involvement (higher morbidity risk)
Sepsis ▪ 1-21 in 1000 livebirth worldwide (1-8 in US)
▪ Culture proven 2 in 1000
▪ premature <1kg = 26 in 1000, 1-2kg = 8-9
▪ baby has not reached 3rd trimester (no IgG
transfer, immature immunity, infection risk)
• Overall SEPSIS rate: 8 in 1000
• maternal fever rate: 4 in 1000
• PROM rate: 10-13 in 1000
• Fever + PROM rate: 87 in 1000
ETIO-PATHO GENERAL HOST FACTORS: • Gestational age
• Prematurity • maternal well being
• Black race (for GBS), MALE • ruptured membranes > 18 hr
• normal flora in mom: E.coli (PH), S.epidermidis • delivery location
• birth asphyxia, meconium staining, stress • infant/fetal symptomatology
• skin & mucous membrane integrity breakage
• procedures (lines, ET tubes)
• Low APGAR score
MATERNAL/OB FACTORS
• General: SES, Poor prenatal care, vaginal flora, PREMATURITY, substance abuse, twins
• Maternal infection: CHORIOAMNIONITIS (10%), fever > 38, tachycardia, venereal
disease, UTI//bacteriuria (3rd trimester), foul smelling lochia, GBS (+)
• OB manipulation (amniocentesis, amnioinfusion, prolonged labor, fetal monitoring,
digital exam, previa/ abruption)
• premature + PROM, preterm labor
S/S PROM (Premature Rupture of Membrane) • Screening indication:
• prematurity 15-25% due to maternal infection o maternal chorioamnionitis
• term > 18-24 hr, preterm > 12-18 hr o Previous GBS (+) baby
• bacterial infection → INC PG synthesis (stimulated by TNF/IL) → cytokine release → o Current GBS (+) w/inadequate Tx (<4hr)
release of collagenase & elastase → ROM o GBS-UTI
• (+) Amniotic fluid cultures 15% (with intact membrane) o <37 AOG, ROM ≥ 18 hr (cut off INC risk),
SEPSIS S/S o Maternal temp ≥38C
Meningitis S/S o prolonged labor >20hr
o home/contaminated delivery
o amniotic fluid smell/color chocolate
o persistent fetal tachycardia
PROGNOSIS • Fatal: 2-4x in LBW (<2.5kg)
• overall mortality 15-40%
• survival unlikely if granulocytopenic (I/T > 0.8)
DIAGNOSIS • CBC: WBC < 5.0, ANC < 1.750, bands >2, I/T >0.2, Plt <100k • (+) Anti-GBS IgG
• CXR: infiltrate, KUB: Ileus, Periosteal elevation • Culture 35-37 weeks AOG (rectal, vaginal)
• CSF WBC >20 (+) = IV antibiotics during labor & delivery
• CRP > 1.0 mg/dl (best for NPV, screen only) • CBC + differential + platelet count
o PPV: obtained at 24 hr (>4-10 mg/dL) • blood culture x 1
• High NPV (truly negative) • CXR, LP for symptomatic
• Low PPV (abnormal not due to infection)
TREATMENT • I/T < 0.3 + ANC > 1500 = Normal
• I/T > 0.3 + ANC < 1500 = Antibiotic, at risk!
• ANTIBIOTICS:
o Ampicillin 100mg/kg/dose IV q12hr
o Gentamicin 3.5mg/kg/dose IVq24 or IM for asymptomatic
o Ampicillin 200-300mg/kg/day (MENINGITIS)
• Symptomatic: respiratory, CVS, fluid support
• specific: antimicrobial, immune globulin
• non specific: IVIG
PREVENTION • vaccine, GBS prophylaxis, handwashing !!

INFECTION
ORGANISM
• GBS (G+) 50%, E.coli (G-) 50%,
L.monocytogenes, S.epidermidis,
Candida, nosocomial
KEYS:
• transient tachypnea
• early onset: 1st 24 hr (85%)
respiratory = tachypnea, normal
flora organisms
• late onset: 7-90 days
CNS (meningitis)
HC associated
INFECTION IN SEPSIS
TRANSPLACENTAL/ HEMATOGENOUS ASCENDING/ BIRTH CANAL NOSOCOMIAL
• anytime during gestation • when membranes rupture • direct contact w/ hospital personnel,
• 1st trimester: alter embryogenesis • during passage @birth canal mom, family, breast milk (CMV, HIV),
(congenital malformation) TORCH • colonization of aerobic & contaminated equipment
• 3rd trimester: active infection @ anaerobic organism • Most common: hand contamination
delivery (TORCHS) • ascending amniotic from HC personnel
• Delay until after birth (TORCHS) infection/colonization
• TORCHS • E.coli • Staph coagulase (-) (most common)
• Acute viruses • GBS • MRSA, fungi
• parvovirus • Herpes • Klebsiella, c.dificile
• herpes • HIV • pseudomonas, rotavirus

SEPSIS SYMPTOMS
SEPSIS MENINGITIS DEFINITIONS
• 90% RDS (INC PR, Apnea 55% > 20sec, hypoxia 36%, flaring/ grunting) • Irritable • Grunting (forced expiration against closed glottis
• bradycardia • lethargy to distend alveoli & increase oxygenation)
• temp instability • changes in muscle tone • Mottled (temp instability, skin is trying to contract
• feeding problem • poorly responsive & preserve heat)
• lethargy, irritable 23% • Apnea: shift (aerobic → anaerobic) kreb, accum.
• jaundice, pallor, mottling of lactate = CHERRY RED LIPS
• hypo/hyper Glycemia
• CVS: Hypotension, hypoperfusion, tachycardia
• metabolic acidosis

TETANUS NEONATORUM
ETIO-PATHO S/S WHO
• tetanus toxin/ tetanoplasmin • tetanic seizure (painful, powerful bursts of • 6 DOSES
• tetanolysin muscle contraction) Never • 2 TTCV (Td) min 4 wk interval
• unhealed umbilical stump (unsterile • muscle spasm – (larynx/chest wall)→ received • 2nd dose: min 2wk before birth
instrument) asphyxiation, stiff jaw, stiff abdomen, stiff back • 5 yr protection: 3rd dose: min 6 mo later
• no passive immunity (mom is not muscle, contraction of facial muscles • lifelong: 4th & 5th dose in min 1 yr interval
immune) • fast pulse, fever sweating Had 3 TTCV • 2 doses ASAP @ pregnancy
• inability to suck starting 3rd-10th days of age, @childhood • min 4 wk interval
dysphagia • 2nd dose: min 2wk before birth
• complication: Bronchopneumonia (aspiration) • lifelong: 6th dose min 1 yr after 5th
→ death Had 4 TTCV • 1 booster ASAP
@childhood • Lifelong:6th dose min 1 yr after 5th

TOXOPLASMOSIS
NOTE • T.gondii (cat feces, undercooked meat)
• acute maternal infection
• • significant risk @ 1 time
st
1 tri = spontaneous abortion
• 2nd tri = fetal death, newborn dse
• 3rd tri = subclinical, no ADR
• 2nd-6th mo GA → fetal damage
S/S • 70-90% asymptomatic/undiagnosed
• CNS & EYES
• IUGR/SGA, Jaundice, HSM
• Maculopapular rash
• hydrocephalus (severe)
• microcephaly
• seizure (severe)
• cataracts
• chorioretinitis, visual impairment
• thrombocytopenia
DX • blood/CSF culture (ELISA)
toxoplasmosis IgM & IgG
• MRI: diffuse intracranial calcification
• ophtha exam: chorioretinitis
TX • Pyrimethamine
• Sulfadiazine + leucoverin
• Prev @ high risk: spiramycin
PROG • Abnormal IQ, Seizure, microcephalic
• hydrocephalus (need shunting)
• visual defect if w/chorioretinitis
CHLAMYDIA
NOTE • C.trachomatis
S/S • Less dramatic conjunctivitis (Hyperemia)
• Pneumonia (wheezing & staccato cough)
• no fever
DX • CXR: Hyperinflated, minimal infiltrate
• RADT on nasopharyngeal secretion
TX • Oral erythromycin for 2 weeks
• for mom: azithromycin
CONGENITAL INFECTIONS
RUBELLA
• mom contracts virus @1st trimester
• IUGR/SGA, HSM, jaundice
• popular rash (blueberry muffin rash)
• cataracts, retinopathy
• CHD, PDA (machinery like murmur)
• sensorineural deafness
• adult: rash, arthritis, adenopathy,
fever
• Rubella titer: mom’s immune status
• ECG
• Ophtha exam
• supportive (none)
GONORRHEA
• N. gonorrhea
• Purulent & copious conjunctivitis
(ophthalmia neonatorum)
• Sepsis, arthritis, meningitis
• RADT
• Cefotaxime
• for mom: ceftriaxone + AZ
CMV HSV SYPHILLIS
• highest risk: 1st half of • very contagious (skin-skin) • T.pallidum @ neonate/ pregnancy
pregnancy • RED FLAG: mom’s 1st HSV outbreak • untreated maternal syphilis
• CS indication:
st
infection o active HSV infection
o past HSV infection
o suspicious HSV genital lesion
• ill @birth • genital herpes in mother • EARLY: Jaundice, HSM, Coomb’s
• IUGR/SGA, HSM, jaundice NEG HA, Snuffles (high load),
• Microcephaly, CUTANEOUS 40% mucocutaneous lesion of palms &
• petechiae, rash • 1st week soles, periostitis, persistent
• sensorineural deafness • localized lesion: eye, mouth, skin rhinorrhea, lymphadenopathy
• chorioretinitis CNS 30% • LATE: > 2 years old: hutchinson’s
• long term sequels (disabilities, • 1st month teeth, saddle nose, frontal bossing,
MR) • herpes encephalitis, apnea, seizure knee synovial seems, interstitial
DISSEMINATED 25% keratitis, deafness, mulberry molars,
• after birth rhagades, hydrocephalus, mental
• multiorgan disease, septic retardation
• most consistent: periostitis,
osteochondritis
• Urine: CMV • HSV PCR (Serum, CSF) • VDRL, RPR (Serum + CSF)
• MRI: Periventricular Repeat serum VDRL 3,6,12 mo
calcification Repeat CSF VDRL q6mo – 3yo
• (+) bone XRAY: saber shins
• CSF: mild peocytosis, mod INC prot
• CONFIRM: FTA-ABS
• confirm: placental, umbilical cord
• Gancyclovir (may reduce • Acyclovir (60 MKD) • Penicillin G (Higher dose for CSF +)
progression to deafness in • MOM & BABY
longterm intake) • required for persistent (+) VDRL or
(+) at 6mo
ZIKA SYNDROME
• ss-RNA, Flavivirus,
• Aedes aegypti & albopticus bite, maternal-fetal (periconception, intrauterine, perinatal), sexual, lab exposure
• 5 birth defects: rarely seen during pregnancy
• severe microcephaly → partially collapsed skull [HC < 3rd percentile for GA & SEX]
• decreased brain tissue + brain damage (specific pattern of Ca deposits)
• damage to back of eye (specific scarring pattern)
• incubation period: 3-14 days (viremia: days – 1 week) [SEMEN & URINE > BLOOD]
 FETAL VARICELLA NEONATAL VARICELLA HIV HEPA B
NOTE • Mom contracted VZV @ 7-28 wk AOG • Mom contracted VZV @2wk prior delivery • routine prenatal care • born to mom with heap B
• highest risk: 5days before/2 days after delivery • HIV (+) pregnant mom should take • prenatal screening: HBsAg
S/S • Limb hypoplasia (clavicle, scapula) • progressive vesicular rash Zidovudine at 14wk AOG the latest • 95% cases of transmission = during delivery
• rib anomalies, scoliosis • ill-appearing • Elective CS: reduce transmission (if before
• umbilical hernia • temperature instability ROM)
• microcephaly, cortical atrophy, seizure • absolute contraindication for
• chorioretinitis, optic disc hypoplasia breastfeeding
• microthalia
• circatrical cutaneous scarring
(dermatomal),
DX • (+) titer • clinical • test HIV at 2 mo & 4 mo higher risk of transmission: if MOM:
• negative @ 4 mo = true negative • HBeAg+ & HbeAb –
• high serum HBcAb (core Ab)
• high serum HBV DNA
TX • supportive • VZIG administration • If mom was treated @ pregnancy: • HBV Vaccine & HBIG within 24 hr
• 30% die @ first month • IV acyclovir Zidovudine within 12hr of birth for 6wk • not a contraindication of breastfeeding
• if mom was not treated @ pregnancy:
Zidovudine: double/triple
 DIGESTIVE CONTINUATION
JAUNDICE KERNICTERUS
NOTE • Yellow: unconjugated, nonpolar, lipid soluble bilirubin • bilirubin encephalopathy
• unconjugated bilirubin [indirect, neurotoxic]
o enzymatic (heme-oxygenase, biliverdin reductase)
o nonenzymatic (reticuloendothelial cells reducing agent)
• conjugated bilirubin [direct]: UDP glucoronyl transferase → polar,
water soluble glucuronide of bilirubin [hepatic /systemic illness]
EPID • @1st week of birth: 60% of term, 80% of preterm • deposition of unconjugated bilirubin in BG & Brainstem nuclei
ETIO • Physiologic: INC bilirubin load, defective plasma uptake, defective • BBB passage
conjugation, DEC excretion, INC entero-hepatic circulation • Albumin-bilirubin binding
• unconjugated: Crigler Najjar syndrome, breastmilk jaundice, hypoTH, • neuronal susceptibility to injury
pyloric stenosis, ongoing hemolysis, malaria, non-hemolytic (G6PD • 90%: previously healthy, predominantly breastfed term & near term
def + UDPGT-1 def) • more mature = greater susceptibility
• conjugated: idiopathic neonatal hepatitis, infection (HepB, TORCH,
Sepsis), biliary atresia (>2wk, alcoholic stool, dark urine), choledochal
cyst, metabolic (galactosemia, tyrosinemia, hypoTH, total parenteral
nutrition)
• RISK FACTORS: Jaundice within 1st 24hr, sibling jaundice history,
unrecognized hemolysis, non optimal sucking, G6PD deficiency,
infection, cephalohematoma, east Asian/north Indian
• gene polymorphism: UGT1A1, SLCOB1B1
• Toxic effect: hypoproteinemia, bilirubin displacement, acidosis, INC.
FFA concentration (d/t hypoGlu, starvation, hypothermia)
• Neurotoxic effect: BBB permeability, nerve cell membrane, asphyxia,
prematurity, hyperosmolality, infection
• serum bil: (early-frequent feeding), (breastfeeding, dehydration)
• delay in meconium passage (1 mg bil/dL)
• oxytocin @ mother & phenolic detergent
S/S • visible @ adult sclera > 2 mg/dL, @newborn skin > 5mg/dL • TERM: 2-5 days after birth
• palms soles > arms & LL > thigh > UL > face [cephalocaudal] • PRETERM: 7th day the latest
physiologic Pathologic (Asian) • Early signs: similar to sepsis, asphyxia, hypoglycemia, ICH
• after 24 hr • within 24hr • Common initial sign: lethargy, poor feeding, loss of moro reflex,
• max: 4th-5th day in term • INC bil > 5 mg/dL> day opisthotonos + bulging fontanel, face twitching, shrill high pitched cry
• max: 7th day in preterm • detect bil > 2 mg/dL • advanced: convulsion + spasm, stiff arm extension, inward rotation,
• serum < 15 mg/dL • serum > 15 mg/dL clenched fist
• undetectable after 14days • persist after 14 days • severe neuro signs: die , survivor: 2-3mo few abnormalities
• self-limiting • stool: clay white, urine: yellow • mild: min brain dysFX, partially deaf, neuromuscular incoordination
late 1st opisthotonos, muscle rigidity, irregular movement,
• CONJUGATED HYPERBIL: high colored urine, white/clay stool year convulsion
• kernicterus evidence in deeply jaundiced: lethargy, poor feeding, 2nd year opisthotonos seizures abate, INC: Irregular involuntary
poor/absent moro’s reflex, opisthotonos, convulsions movement, muscle rigidity, hypotonia
3rd year complete neuro symptoms, bilateral choreoathetosis +
involuntary muscle spasm, EPS, seizure, dysarthric speech,
high frequency hearing loss, squinting, defective eye
upward movement, pyramidal sign, hypotonia, ataxia
PROG associated with pyloric stenosis: • overt neuro sign: grave prognosis
• caloric deprivation, UDPGT deficiency, INC enterohepatic circulation (75% die, 80% have bilateral choreoathetosis with involuntary muscle
from ileus spasms)
kernicterus (bilirubin encephalopathy)
neurologic dysfunction (indirect hyperbilirubinemia)
DX • ascertain birthweight, GA, postnatal age • bilirubin > 20 mg/dL
• well/ill clinical condition
• maternal & perinatal history, PE
• LAB: Total Bil, Direct Bil, Blood group, Rh, Hct, Retic, PBS, Sepsis
screen, liver fx, TH fx, TORCH titer, liver scan (conj. hyperbil)
• DiffDx in Direct hyperbil: hepatitis, Congenital bile duct disorder,
cholestasis, inborn error of metabolism, CF, sepsis
TX • reduce serum bilirubin , prevent bilirubin toxicity • GOAL: Prevent neurotoxicity
PHOTOTHERAPY Primary: PHOTOTHERAPY
• 450-460 nm (insoluble native bilirubin → soluble photoisomer) • 6-12hr to have measurable effect
• white light tubes 6-8 (150W halogen bulb) • contraindication: porphyria
• 4 blue light tubes (MOST EFFECTIVE) • close eyes to prevent light exposure and corneal damage (shield from
• cradle/incubator, eye shades bulb breakage)
 • Handwash → baby @ cradle/incubator → 45cm distance from light
• frequent extra breast feeding every 2hr
• record temp every 2-4hr, daily weight, urine freq, bilirubin level
• ADR: INC sensible water loss, loose stool, skin rash, bronze baby
syndrome, hyperthermia, upset maternal-baby interaction, hypoCa
EXCHANGE TRANSFUSION
• ABO incompatibility: O cells in AB plasma/ O same Rh
• Rh Isoimmunization: O cells in AB plasma/ O-neg/baby’s group(-)
DRUGS
PREV • early feeding
• adequate hydration
• Bronze baby syndrome: dark grayish brown skin, elevated B1 and
obstructive liver disease. may continue phototherapy
Secondary: Exchange transfusion
• double volume exchange transfusion
• complication: metab acidosis, NEC, GvHd
• term: at day 1 or 2 (not after day 4)
• preterm: after 7th day
Antibiotic (septicemia)
IVIG
• Adjunct for isoimmune hemolytic disease
METALLOPORPHYRIN: SnMP drug candidate, competitive enzymatic
inhibition, single IM dose on day 1. may cause transient erythema in
concurrent phototherapy treatment
• Don’t discharge early without follow up within 48 hr
• universal screening for hyperBIL after birth (1st 24-48 hr)
• hour specific bilirubin nomorgram, PE

CAUSES OF JAUNDICE
Within 24 hr 24-72 hr After 72 hr
• hemolytic disease of newborn (Rh, ABO) • Physiological, sepsis, polycythemia, concealed • sepsis, cephalohematoma, neonatal hepatitis,
• Infection: TORCH, Malaria, bacterial hemorrhage, IVH, increased enterohepatic circulation extra-hepatic biliary atresia, breastmilk jaundice,
• G6PD Deficiency • familial nonhemolytic iceterus (crigler najjr) metabolic disorders
• early onset breastfeeding jaundice

CAUSES OF JAUNDICE
During 1st day or later After 3rd day, within 1st week After 1st week
• extensive ecchymosis, blood • bacterial sepsis, UTI, infection (TORCH) • breastmilk jaundice, septicemia, congenital atresia, bile duct paucity,
extravasation, polycythemia hepatitis, galactosemia, hypoTH, CF, Congenital hemolytic anemia

MAISEL’S chart
Serum bil (mg/dL) Birth weight Age <24 hr Age 24-48 hr Age 49-72 hr Age > 72 hr
<5 all
5-9 Phototherapy if
10-14 <2.5kg hemolysis Phototherapy if hemolysis
>2.5kg Investigate if bilirubin >12mg%
15-19 <2.5kg Exchange transfusion Consider exchange transfusion
>2.5kg Exchange transfusion phototherapy
>20 all Exchange transfusion

NEWBORN ENDOCRINE DISORDERS

NEONATAL HYPOGLYCEMIA NEONATAL HYPOCALCEMIA
ETIO • at risk: infants of diabetic mother (secondary to hyperinsulinism, LGA, • reduce Ca concentration between 10 days of life
cardiomyopathy, RDS, polycythemia, plethora, microcolon, feeding • early onset (0-2 day): prematurity, IDM, asphyxia
difficulty) • late onset (7-10 days): cow’s milk, hypoPTH (Digeorge), hypoMg, Vit D
• at risk: IUGAR, SDA deficiency
• at risk: beckwith Wiedemann syndrome, nesidioblastosis,GSD,
galactosemia, adrenalin insufficiency, sepsis, hypopituitary, asphyxia
S/S • Lethargy, poor feeding, irritability, tremor, apnea, seizure • CATS: Convulsion, arrhythmia, tetany, stridor, spasm
• high pitched cry
• jitteriness
• tremor, seizure
DX • blood glucose < 40 mg/dL (1st feed – 4 hr of life) • iCa < 4 mg/dL
• blood glucose <45 mg/dL (4 hours of life & 24 hr) • Total Ca < 8 mg/dL (term), < 7 mg/dL (preterm)
• metab profile. liver function test, Serum Mg, PO4, PTH level, vit D level,
urine electrolytes
TX • initial management • IV calcium gluconate
• blood glucose <30 or <40 + symptoms = initial bonus D10W at • ECG for DiGeorge (cardiac defects)
2mL/kg (correct hypoglycemia)
• PO or IV dextrose drip (frequent glucose check)
• unwean after IV for 5days: metabolic cause
COMP • CNS Problem (seizure, intractable) (lubchenco chart)
 CONGENITAL HYPOTHYROIDISM NEONATAL THYROTOXICOSIS CONGENITAL ADRENAL HYPERPLASIA
ETIO • inadequate thyroid hormone production • ASSOC. with uncontrolled/undiagnosed • enzyme deficiency for roger synthesis pathway
in newborn Grave’s • low negative feedback → high ACTH
• 3-7% ASD, VSD • TRab stimulation crosses placenta → stipulate • most common: 21-hydroxylase deficiency
• mostly sporadic fetal thyroid (necessary for cortisol & aldosterone synthesis)
• Malpositioned thyroid > thyroid agenesis • known maternal hyperTH o low cortisol, low ALD, INC ACTH
> dyshormonogenesis > HPT dysfunction o 17-OH progesterone shunted to sex steroid
S/S • reduced activity, hypotonia, large anterior PRENATAL: • FEMALE: Ambiguous genitalia (clitoromegaly,
fontanelle (>3.6cm), poor feeding, poor • fetal tachycardia labia majora fusion, abnormal urethral
growth, jaundice, constipation, hoarse cry • oligohydramnios pathology)
• late: coarse face, macroglossia, umbilical • IUGR • MALE: Normal at birth, INC scrotal pigmentation
hernia, myxedema, pallor, goiter, mottled • Goiter • BOTH SEX: Salt wasting, dehydration (first mon)
cool/dry skin • BABY: Tachycardia, exophthalmos, low Na → irritability, tachycardia, loose stool,
hyperactive, vomiting, CHF, arrythmia, pulmo vomiting, poor feeding, shock, coma
hypertension, poor weight gain
PROG • untreated: cretinism (archaic): severe • routine NBS: Low Na, High K
cognitive impairment, growth defects • elevated 17a-OHprogesterone
DX • TSH & FT4 • INC fetal T3/T4 production • fluid resuscitation
• Diff dx: McCune Albright syndrome (Café au • glucocorticoid (hydrocortisol): BP ,renin monitor
lait spots), TSH-R mutation • consultation
TX • Levothyroxine • Methimazole (reduce thyroid hormone)
• Propanolol (marked cardiac s/s)
• Mom: take PTU during pregnancy

BLEEDING DISORDERS
HEMOPHILIA A & B VITAMIN K DEFICIENCY
ETIO • X-linked recessive • no vit K supplement
• A: factor 8 deficiency, B: factor 9 deficiency • malabsorption (CF, biliary atresia)
• necessary for Factor 2,7,9,10
• site of absorption: terminal ileum (80-85% assisted by normal flora)
S/S • weakness, orthostasis, joint pain, warmth, stiffness, headache, • factor type bleeding (similar to hemophilia)
stiffneck, irritable, meningeal sign, hematemesis, melena, BRPR, • superficial bleeding
epistaxis, prolonged bleeding after circumcision, arthritis in young
boy, purpura, ecchymoses
DX • CBC: IDA • CBC: anemia (blood loss)
• Coag: prolonged PTT, Normal PT, Normal BT • normal BT, Prolonged PT, PTT
• deficiency in factor 8 or 9 • Deficiency in factor 2,7,9,10
TX • uncontrollable bleeding: aggressive hemostasis, immobilization, • prophylactic IM of vit K to all newborns
F8/9 administration • severe bleeding: FFP + oral/parenteral vit K
• outpatient: prophylactic factor replacement • Mild-moderate bleeding: oral/parenteral Vit K only
• malabsorption: water soluble vit K
• breastfed babies: supplement vit K
PREV • avoid high impact contact sports or high risk trauma activity • give vit K prophylaxis at the end of first 24hr of life

DIC
ETIO • widespread clot formation
• factor supply exhaustion
• associated with sepsis 50%
• most common during neonatal period
(infection, asphyxia)
S/S • bleeding (platelet/F type): petechiae,
purpura. low platelet
• acral cyanosis, skin necrosis, gangrene
• renal/hepatic dysfunction
DX • Dfiff dx: HUS. PT, PTT, BT Prolonged,
TX • EMERGENT: maintain fluid status
• active bleeding: FFP, Platelet
• thrombosis predominant:
unfractionated heparin, tPA
THROMBOCYTOPENIA
NAIP (ALLOIMMUNE) WAS
• rarely d/t: Primary disorder of megakaryopoeisis • x-linked disorder
• often due to: systemic illness/ transfer of maternal Ab
against fetal platelet
• associated with TORCH and perinatal G(-) bacteria
• 1 in 4000-5000 livebirths
• generalized petechiae & purpura on first few days • thrombocytopenia (tiny/bizarre
• 30% with ICH (severe NAIP): PRENATAL/ PERINATAL platelet), eczema, recurrent infection
• Low platelet
• MATERNAL Antibodies against father’s platelet
• Prolonged BT, normal PT, PTT • Prolonged BT,
• IVIG prenatally to mother @2nd trimester onward • Nutrition, routine IVIG,
• fetal platelet count monitoring (percutaneous umbilical • serious bleeding: platelet transfusion
cord sampling) • splenectomy + lifelong antibiotic
• CS delivery prophylaxis
• severe thrombocytopenia: 1 unit platelet transfusion • CHOICE: bone marrow/ cord blood
(washed maternal platelet) transplantation
 IDA POLYCYTHEMIA
ETIO • most common cause of anemia • SGA. LGA infants
• 4th month of age • diabetic mothers
• early cord clamping (<30sec) • placental insufficiency, prematurity, postdatism, maternal smoking
• insufficient diet/intake (breast milk is low in iron) during pregnancy
• chronic intestinal blood loss d/t cow’s milk
• lead poisoning
S/S • pallor • plethora, ruddiness
• fatigability • irritability
• irritability • tremors
• feeding difficulty • jitteriness
• failure to thrive • seizure
• priapism
DX • CBC, Anemia, low HRB, Low MCV • CBC: Hct > 65%
• Iron study: low Ferritin, low serum iron • basic metabolic panel: hypoglycemic
• bilirubin: indirect (more turnover)
• serumCa: low (CNS manifestation)
• ABG
TX • Iron supp 1mg/kg + vitamin C (for absorption) • Asymptomatic: observe, serial Hct, glucose level every 6hr, partial
• premature: 2 mg/kg oral supplement exchange transfusion if Hct > 75%
• Symptomatic: manage fluid, electrolyte, glucose, partial exchange
transfusion (remove blood then replace with normal saline)
PREV • delayed (1-3min) Cord clamping
• anemia screening at 1 year
• RDA (7-12mo) = 11 mg/day
• RDA (1-3 yo) = 7 mg/day
• RDA (4-8 yo) = 10 mg/day
• RDA (9-13 yo) = 8 mg/day
• RDA (14-18 yo) = 11 mg boys, 15 mg girls