1. Neonatal Pneumonia

2. General Data 3 day old male Wt: 2360 g CC: “nanginigtim ang binti”

3. History of Present Illness 3 days PTC: Patient was born pre-term via SVD, breech presentation, to a then 20 y/0 primigravid mother, delivered at home c/o a midwife. On regular prenatal check-up (2x) at the local health center, with no exposure to teratogenic substances or radiation

4. At birth, patient was noted to have bluish discoloration of the left upper and lower extremities and back area. Patient’s family was advised to seek consult at tertiary hospital for further evaluation and management, hence this consult. In transit, patient was noted to have increased breathing rate and retractions.

5. Review of Systems (-) fever (-) change in sensorium (-) cough (-) colds (-) cyanosis (-) hematuria (-) seizures

6. Family Medical History (+) DM – Maternal side of the family (-) HPN, BA, CA, Congenital Anomalies Paternal side unknown

7. Birth and Maternal History Pre-term, 34 weeks by PA, 38 weeks by LMP, delivered via SVD, breech presentation, BW 2390 g, AS = ?, NID Born to a then 20 y/o primigravid, (+) regular PNCU (2x)

8. Developmental History (+) Moro Reflex (+) Rooting Reflex (+) Grip Reflex

9. Course at the ER Patient was received awake, with spontaneous movement, and good cry HR 172 RR 88 T 36.7 fair pulses PC, AS SCE, Harsh Breath Sounds, (+) occasional grunting, (+) subcostal retractions, (+) crackles AB @ 4 th ICS, MCL, (-) murmurs Globular Abdomen, soft, (-) masses

10. Course at the ER Grossly male genitalia, (+) bilateral descended testis Fair Pulses, CRT < 3 secs (+) bluish discoloration of Left Upper Extremity, and Bilateral Lower extremities Started on Ampicillin (75) and Amikacin (40), O2 support done -> Ward Admission

11. Differential Diagnoses

12. Hyaline Membrane Disease Rule In: Patient was born preterm (34 weeks) with persistent cyanosis of extremities, presented with occasional grunting, subcostal retractions, crackles, and tachypnea of 88 breaths per minute on the first hours of life. The patient might also had perinatal asphyxia due to difficult delivery secondary to breech presentation. Rule Out: The incidence of HMD decreases significantly after 30-32 weeks of gestation. The patient improved with administration of antibiotics and oxygen.

13. Hyaline Membrane Disease Evaluation: CXR is diagnostic and shows diffuse atelectasis with an increased density in both lungs and a fine, granular, ground-glass appearance of the lungs. The small airways are filled with air and are clearly surrounded by the increased density of the pulmonary field, creating air bronchograms.

14. Transient Tachypnea of the Newborn Rule In: Patient presented with tachypnea of 88 breaths per minute during the first 24 hours of life, associated with grunting, subcostal retractions, and persistent cyanosis of extremities. Note of minimal improvement with administration of oxygen support. Rule Out: Physical examination revealed the presence of crackles. Tachypnea did not resolve within 24-48 hours of life. Evaluation: CXR reveals prominent pulmonary vascular markings, fluid in the intralobar fissures, overaeration, and flat diaphragms.

15. Persistent Pulmonary Hypertension of the Newborn Rule In: Patient presented with persistent cyanosis of extremities, associated with occasional grunting, subcostal retractions, and tachypnea of 88 breaths per minute. The patient might also had perinatal asphyxia due to difficult delivery secondary to breech presentation. Rule Out: The presence of crackles does not support the diagnosis of PPHN. Evaluation: CXR reveals decreased pulmonary vascular markings.

16. Neonatal Pneumonia Rule In: Patient presented with signs of respiratory distress such as tachypnea, subcostal retractions, crackles, and cyanosis of extremities. Rule Out: Cannot be ruled out.

17. Diagnostics Chest X-ray to evaluate the condition of the lungs. Pulmonary infiltrates suggests pneumonia, diffuse atelectasis supports HMD, fluids in intralobar fissures points out to a probable TTN, and decreased lung markings suggests PPHN. CBC to evaluate if there is an increase in WBC count that supports the presence of probable infection. It would also show probable derangement in RBC and hemoglobin that decrease the oxygen- carrying capacity. ABG to assess the peripheral oxygen saturation of arterial blood and probable acidosis/alkalosis of the patient. Bloo CS to document the presence of infection, know the culprit organism and test its sensitivity t particular antibiotics. Hyperoxia test to differentiate if the disease is secondary to a pulmonary condition or due to a presence of AV shunt. Serum electrolytes

18. Laboratory Results CBC WBC7.67 HGB159 HCT0.464 PC222 Neut0.53 Lymph0.31 Electrolytes Calcium1.942.07 Sodium140139 Potassium3.84.8 Chloride111107

19. Physical Examination HR 150 RR 40 T 36.8 o C GP PC, AS ECE, CBS, (-) retractions DHS, NRRR, (-) m2 Globular, soft, (-) masses FEP, PNB, CRTs < 2s (+) bluish discoloration of bilateral plantar area

20. Neonatal Pneumonia

21. Definition: Inflammation of the parenchyma of the lungs Onset may be within hours of birth or after 7 days & confined to the lungs caused by microorganisms, noninfectious causes aspiration of food or gastric acid, foreign bodies hypersensitivity reactions

22. Early onset part of generalized sepsis that presents at or within hours of birth Late onset occurs after 7 days of age

23. Etioloic agents according to time of acquisition I. Transplacental- CMV, HSV, M. tb, Rubella virus, T. pallidum, VZV II. Perinatal- anaerobic bacteria, Chlamydia, CMV, Enteric bacteria, GBS, H. influenza, HSV, L. monocytogenes, Mycoplasma III. Postnatal- Adenovirus, Candida sp., Coagulase- negative staph, CMV, Echo virus, Enterics, Influenza viruses A,B, Parainfluenza, Pseudomonas, RSV, S. aureus

24. Group B Streptoccocci - most common cause of fulminant infections

25. Signs and Symptoms: Early- nonspecific such as poor feeding, lethargy, irritability, cyanosis, temp instability, overall impression that the infant is not well Respiratory symptoms: grunting, tachypnea, retractions, alar flaring, apnea, cyanosis, progressive respiratory failure

26. Signs of pneumonia on PE such as dullness to percussion, change in breath sounds and presence of rales/ rhonchi are very difficult to appreciate in neonate.

27. Prenatal Features Increasing Risk for Neonatal Pneumonia: Unexplained preterm labor PROM Maternal fever uterine tenderness foul-smelling amniotic fluid infection of maternal GUT Fetal tachycardia meconium in the AF Recurrent maternal UTI

28. Diagnostics: The diagnosis of pneumonia in neonates is usually presumptive Blood culture - done to isolate etiologic agent but is usually negative CXR- presence of pulmonary infiltrates - Difficult to differentiate from RDS especially in preterm infents

29. Treatment Early Onset infections (1 st 7 days of life): Ampicillin + Aminoglycosides (Gentamicin)/ Cefotaxime GBS- Penicillin G MRSA- Vancomycin Pseudominas – Aminoglycosides + Ceftazidime/ Piperacillin/ Ticarcillin/ Cabernicillin C. trachomatis- Erythromycin/ TMP-SX