3/27/2013 Disclosures PROBLEMS of THE NEONATAL PERIOD ∗ “I have nothing to disclose” (financially) Susan Fisher-Owens, MD, MPH ∗ …except appreciation to Colin Partridge, MD, MPH Associate Clinical Professor of Clinical Pediatrics Associate Clinical Professor of Preventive and Restorative Dental Sciences for help with slides University of California, San Francisco San Francisco General Hospital UCSF Family Medicine Board Review: Improving Clinical Care Across the Lifespan San Francisco March 27, 2013 Common Neonatal Problems Hypoglycemia Causes ∗ ∗ Hypoglycemia Inadequate glycogenolysis ∗ ∗ Respiratory conditions cold stress, asphyxia ∗ ∗ Infections Inadequate glycogen stores ∗ ∗ Polycythemia prematurity, postdates, intrauterine growth restriction, small for gestational age (SGA) ∗ Bilirubin metabolism: neonatal jaundice ∗ Increased glucose consumption ∗ Bowel obstruction ∗ asphyxia, sepsis ∗ Birth injuries ∗ ∗ Hyperinsulinism Rashes ∗ Infant of Diabetic Mother (IDM) ∗ Murmurs ∗ Feeding difficulties 1 3/27/2013 Hypoglycemia Treatment Respiratory Distress in the Neonate ∗ ∗ Early feeding when possible (breastfeeding, formula, Pulmonary causes ∗ oral glucose) Respiratory Distress Syndrome: surfactant deficiency ∗ ∗ Depending on severity of hypoglycemia and clinical Transient Tachypnea of the Newborn: retained fetal lung findings, may need to need to give intravenous glucose fluid bolus (D10 @ 2-3 ml/kg) ∗ Meconium Aspiration Syndrome ∗ Following bolus infusion, a continuous intravenous ∗ Congenital pneumonia infusion of D10 is often required to maintain normal ∗ Persistent pulmonary hypertension glucose levels ∗ Space occupying lesions: pneumothorax, chylothorax, pleural effusion, congenital diaphragmatic hernia, CCAM Respiratory Distress Syndrome (RDS) Strategies for Prevention of RDS ∗ Surfactant insufficiency and ∗ Prevention of premature delivery pulmonary immaturity ∗ ∗ Decrease antenatal inflammation/infection 33% in infants between 28-34 wks ∗ ∗ <5% in infants > 34 wks Increased risk for preterm labor ∗ Incidence increased ∗ ∗ Antenatal glucocorticoids male infants ∗ ∗ ↑ Does not prevent all RDS or bronchopulmonary dysplasia 6-fold in infants of diabetic mom (IDM) ∗ ∗ multiple births, second-born twin No increased risk to mother of death, chorioamnionitis, or ∗ Severity of illness improved puerperal sepsis by antenatal steroids & surfactant 2 3/27/2013 Meconium Aspiration Syndrome RDS X-ray Findings ∗ Incidence of meconium staining Hypoexpanded lungs ∗ associated with fetal distress and increasing gestational age ∗ Reticulogranular opacification 20% of all deliveries ∗ 30% in infants > 42 weeks http://newborns.stanford.edu/PhotoGallery/MecStaining1.html ∗ Air bronchograms Hypoxia, acidosis lead to fetal gasping ( aspiration) ∗ Meconium Aspiration Syndrome (MAS) found in 2-20% of white-out lungs infants with meconium-stained fluid ∗ Most common cause of respiratory distress in term newborns, typically presenting in first few hours of life ∗ Disease range: mild to severe disease with air leaks, pulmonary hypertension, respiratory failure, and death (iNO, HFOV, and ECMO improve survival) Meconium Aspiration Syndrome Complications of MAS Air leaks pneumomediastinum pnemothorax pneumopericardium Patchy, streaky infiltrates Hyperexpansion pneumomediastinum pneumothorax 3 3/27/2013 Transient Tachypnea of Newborn (TTN) TTN X-ray Findings Slightly hyperexpanded lungs ∗ Delayed clearance of fetal lung fluid “Sunburst” hilar streaks ∗ Term or near-term infants ∗ Delivered via c-section and/or no/little labor Fluid in minor fissure ∗ Chest Xrays: lung hyperaeration, prominent pulmonary Prominent pulmonary vascular markings vascular markings, interstitial fluid, pleural effusion CXR normalizes in 1st 24 hrs ∗ Transient respiratory symptoms (tachypnea, occasional hypoxia, rare dyspnea) resolve within 2-5 days Extra-Pulmonary Causes of Respiratory Radiologic Finding Distress in the Neonate ∗ Hyperthermia, hypothermia ∗ Polycythemia ∗ Hypovolemia, shock, metabolic acidosis ∗ Cardiac disease ∗ Cyanotic congenital heart disease ∗ Left-sided obstructive lesions (coarctation) ∗ Congestive heart failure ∗ Myocardopathy ∗ Myocarditis ∗ Sepsis http://www.medicine.cmu.ac.th/dept/radiology/pedrad/normal.html 4 3/27/2013 Perinatal Infections Risk Factors for Early-Onset Sepsis ∗ ∗ Bacterial infections TORCH infections: ∗ Prematurity < 37 weeks gestation ∗ Group B Streptococcus Incidence is 0.5-2.5%; ∗ ∗ many infants are Chorioamnionitis E. coli ∗ ∗ Listeria monocytogenes asymptomatic at delivery Prolonged ruptured membranes > 24 hours ∗ Toxoplasma gondii, ∗ ∗ Viral infections GBS positive mother ∗ treponema pallidum Herpes simplex ∗ ∗ Male infant ∗ “Other”: syphilis Hepatitis B and C ∗ Rubella ∗ Cytomegalovirus (most common) ∗ Herpes Neonatal Group B Streptococcus Management of Neonatal Infections ∗ Septic work-up for infection Prevention of GBS neonatal sepsis ∗ CBC with differential including bands and platelets ∗ Routine antenatal cultures at 35-36 weeks ∗ Blood culture ∗ ∗ Treat women +/- C-reactive Protein ∗ ∗ +/- Lumbar Puncture with positive cultures with onset of labor ∗ ∗ Specific workup for viral infection with previously infected infants ∗ Treatment ∗ with GBS UTI ∗ Symptomatic: treat with ampicillin and gentamycin (or ampicillin and 2nd/3rd generation cephalosporin for bacterial meningitis). Acyclovir if concerned for herpes. Strategy misses women who deliver prematurely and ∗ Length of treatment depends on clinical findings, CBC, LP, and culture women with no prenatal care results. ∗ Asymptomatic infant at risk (e.g., a non-reassuring CBC): treat for 48 (-72 hrs) until bacterial cultures negative 5 3/27/2013 Prevention of Transmission of Perinatal Hepatitis C Perinatal Hepatitis B ∗ High-risk mothers screened during pregnancy Hepatitis B vaccine prior to hospital discharge for all ∗ Vertical transmission rate is 5-10% infants (<12 hr if Mom HBsAg positive) ∗ ∗ Hepatitis C antibody titers obtained on infant at 6 and 12 HBIG (hepatitis B immunoglobulin) plus vaccine for infants months (even 18 months), or Hepatitis C PCR at 4 mos born to HBsAg positive mother <12 hours of life ∗ All infants should receive routine Hepatitis B vaccine What about breastfeeding with Hepatitis C+ mother? during infancy (1 month and 6 months) ∗ Variable amounts of virus in milk ∗ Breastfeeding safe with HBsAg positive mother with ∗ Studies have not shown increase risk of transmission of vaccine plus HBIG treatment for the infant Hepatitis C with breastfeeding ∗ Recommend pump/dump if cracked/bleeding nipples Perinatal TORCH Infections— Perinatal TORCH Infections— Non-Specific Findings More Specific Findings ∗ SGA, IUGR, postnatal growth failure ∗ Toxoplasmosis: hydrocephalus, chorioretinitis, ∗ Microcephaly, hydrocephalus, intracranial calcifications generalized intracranial calcifications (random ∗ Hepatosplenomegaly, hepatitis, jaundice (elevated direct component) distribution) ∗ ∗ Anemia (hemolytic), thrombocytopenia Syphilis: osteochondritis, periosteal new bone formation, ∗ Skin rashes, petechiae rash, snuffles ∗ Abnormalities of long bones ∗ Rubella: cataracts, “blueberry muffin” rash, patent ductus ∗ Chorioretinitis, cataracts, glaucoma arteriosus, pulmonary stenosis, deafness ∗ Nonimmune hydrops ∗ Cytomegalovirus: microcephaly, periventricular ∗ Developmental and learning disabilities calcifications, hydrocephalus, chorioretinitis, petechiae, thrombocytopenia, hearing loss (progressive) 6 3/27/2013 “Blueberry muffin” rash (cutaneous hematopoeisis) Ocular Findings chorioretinitis cataracts Neonatal Herpes Simplex Herpes Simplex: Clinical Presentations ∗ HSV-1 (15 to 20%) and HSV-2 (80 to 85%) ∗ Disseminated (systemic) disease: ∗ st Neonatal infections with primary HSV is 35-50% ∗ Early onset (1 week of life), 25% of cases ∗ ∗ Neonatal infections with recurrent HSV is 0-5% Sepsis syndrome, liver dysfunction, pneumonia ∗ ∗ Increased risk of transmission with prolonged rupture of CNS disease: meningoencephalitis nd rd membranes, forceps or vacuum delivery, fetal scalp ∗ 2 -3 week of life, 35% of cases monitoring, preterm infants ∗ Fever, irritability, abnormal CSF, seizures ∗ 75% of cases have no history of maternal infection, nor ∗ Early treatment improves outcome, but 40-50% infants have evidence of skin lesions residual neurodevelopmental disability ∗ One may need to start treatment based on clinical presentation ∗ Localized disease: skin, eyes, mouth, 40% of cases and suspicion of infection 7 3/27/2013 Cutaneous HSV: clustered vesicular eruption ulceration Diagnosis of TORCH Infections ∗ Toxoplasmosis ∗ maternal antibody titer and neonatal IGM antibody ∗ Syphilis ∗ RPR or VDRL positive, obtain titers, order treponemal-specific test (FTA or MHA-TP) ∗ CMV ∗ urine culture ∗ Herpes simplex ∗ Surveillance: conjunctival, nasopharyngeal, and rectal swabs for Direct Fluorescent Antibody (DFA) 24-48 hours after birth if suspect exposure ∗ Culture of vesicle scrapings when lesions are present ∗ DFA of vesicle scrapings ∗ PCR: detect HSV-DNA in CSF Polycythemia Polycythemia--Treatment ∗ Hematocrit > 65% on a spun, central venous blood sample ∗ ∗ Complications associated with hyperviscosity If symptomatic neonate with polycythemia, or an infant with ∗ Plethora, slow capillary fill time excessively high hematocrit (> 70%)--by dilutional exchange, ∗ Respiratory distress correcting Hct to approx 55% obs desired ∗ Hypoglycemia Volume of blood = Wt (kg) X 80 cc/kg X (Hct – Hct ) ∗ Hct obs Irritability, lethargy, poor feeding ∗ ∗ Cyanosis, heart