1. Dr. Miada Mahmoud Rady EMS /481 Neonatal emergencies
Neonatal Diseases
Dr. Miada Mahmoud Rady
EMS /481
Neonatal emergencies

2. Lecture Topics Apnea . Hypoglycemia .
Prematurity and low birth weight.
Seizers in newborn.

3. Apnea Definition : respiratory pause of greater than 20 seconds.
Causes :
Hypoxia or hypothermia.
Narcotic or CNS depressants.
Weakness of respiratory muscle.
Septicemia.
Metabolic disorders.
CNS disorders.

4. Sequence of apnea events
Tachypnea
Primary apnea
Reversible with stimulation
Gasping
Secondary apnea
Irreversible with stimulation .
Ventilation is must.
Oxygen deprivation persists

5. Pathophysiology and Types
When deprived of oxygen , either before or after birth , newborn demonstrate specific sequence of event leading to apnea:
Transient period of rapid breathing.
Primary apnea which has the following characteristics :
Associated with mild bradycardia and decrease in neuromuscular tone .
Reversible with simple stimulation and oxygenation.

6. Deep gasping breathing .
Secondary apnea , which has the following criteria :
Associated with sever bradycardia and hypotension and decline in neuromuscular tone .
Does not respond to stimulation .
Spontaneous resumption of breathing will never occur.
Assisted ventilation is must.

7. Assessment and management
Careful history.
Examination with special focus on neurologic signs and signs of infections.
It is difficult clinically to differentiate between primary and secondary apnea so always assume it is secondary and start resuscitation immediately.

8. Neonatal hypoglycemia

9. Introduction
Newborns at significant risk of acute hypoglycemia due to:
Poor glucose stores.
Inability to stimulate the immature neonatal liver to release glucose.
Increased metabolism that uses large quantities of available glucose.

10. Hypoglycemia
Definition : blood glucose level of less than 45 mg/dL in full-term or preterm newborns.
It result from imbalance between glucose supply and utilization due to :
Inadequate intake or storage.
Increased glucose utilization.

11. Etiology Disorders related to decreased glycogen stores:
Small for gestational age
Prematurity
Postmaturity
Increased use of glucose:
Newborn of a diabetic mother:
Large for gestational age
Hypoxia
Hyperthermia
Sepsis

12. Clinical presentation
Most newborns are asymptomatic until glucose level falls below 20 mg/dL., then it may result in seizures.
Any case of seizers in newborn glucose test is crucial.

13. Clinical presentation
Specific:
Vomiting.
Tremers
Tachycardia
Tachypnea
Seizers
Coma
Nonspecific :
Poor sucking .
Irritability
Irregular respiration.
Cyanosis
Apnea

14. Assessment Obtain baseline vital signs and oxygen saturation readings.
Provide as necessary ( Additional oxygen ,Assisted ventilation , Blood pressure support and IV access
If the blood glucose level is less than 40 mg/dL:
An IV bolus of 10% dextrose solution (2 mL/kg) can be given.
Recheck blood glucose level in about 30 minutes.
Dextrose IV administration may need to be followed by a 10% dextrose infusion at 60 to 100 mL/kg/d.

15. Diaphragmatic hernia
Definition : An abnormal opening in the diaphragm that causes herniaition of the abdominal contents into chest cavity.
Mortality may be as high as 50%.
Causes the heart and mediastinum to shift to the contralateral side of the hernia.

16. Signs and Symptoms Respiratory distress.
Heart sounds shifted to the right.
Decreased breath sounds on the left.
Bowel sounds heard in the chest.
Scaphoid abdomen.
Child may be asymptomatic or suffering from sever distress.

17. Assessment and Management
Resuscitate on 100% oxygen.
if PPV is necessary, place an ET tube, and deliver a peak ventilatory pressure of 25 mm Hg or less.
Place an orogastric tube, and provide intermittent suctioning to minimize distention. ( caused by PPV)
Monitor heart rate continuously during transport.
Definitive treatment is surgical correction, so transport to a facility with a neonatal intensive care and pediatric surgery.

18. Premature and low birth weight infants
Premature newborns : newborns delivered before 37 weeks of gestation.
Low birth weight : newborns weighing less than 5½ lb (2,500 g)

19. Causes of prematurity Idiopathic ( commonest ).
maternal conditions associated with preterm labor and delivery as :
Maternal infection (UTI) and Chorioamnionitis .
Placental insufficiency .
Preeclampsia and eclampsia.
Polyhydraminos .

20. Complication of prematurity
Respiratory distress syndrome
Hypothermia
Sepsis
Intraventricular hemorrhage.
Increased mortality

21. Causes and predisposing factors of low birth weight
The most common etiology is prematurity.
Predisposing factors include:
Genetic factors
Infection
Cervical incompetence
Abruption
Multiple gestations (twins, triplets)
Previous delivery of a premature infant

22. Complication
Morbidity and mortality are related to degree of prematurity.
Those who are delivered after 28 weeks of gestation and receive cardiovascular support survive long term.
Those born at 24 weeks of gestation have high morbidity and mortality.

23. Assessment of prematurity

24. The degree of prematurity is determined by :
Physical features:
Maturity of skin
Size of infant
Degree of respiratory distress
Information from family about gestational dating:
Last menstrual period
Estimated due date
Ultrasound dating
Information related to maternal or fetal complications

25. Management
To optimize survival for a newborn delivered prematurely in the field:
Provide Cardiorespiratory support.
Provide a thermoneutral environment.
Use only minimum pressure necessary to move chest when providing PPV because the risk of retinopathy of prematurity, worsened by long-term oxygen exposure.

26. Seizures In The Newborn
Most characteristic sign of neurologic disease in the newborn and is usually related to an underlying abnormality.

27. Causes of seizers in newborn
In the first 3 days of delivery are usually caused by:
Hypoxic ischemic encephalopathy
Hypoglycemia.
Other metabolic disturbances e.g. disturbances in calcium , proteins , ammonia and other electrolytes .

28. Seizures that begin 3 days or longer after birth are likely from :
Intracranial infections (meningitis).
Intracranial hemorrhage.
Development defects.
Epilepsy.

29. Types and signs of seizers
Subtle seizure : (eye deviation , blinking , sucking , pedaling leg movement and apnea).
Tonic seizers : (Tonic limb extension OR arms flexion and leg extension )
Focal colonic seizers : localized jerking
Myoclonic seizers : flexion jerks of upper or lower extremities.

30. Complication of seizers
Seizures may interfere with:
Cardiopulmonary function
Feeding
Metabolic function
Prolonged seizures may cause brain injury.

31. Differential diagnosis
The following are often mistaken for seizures in the newborn:
Normal movements when a newborn is drowsy or asleep
Jitteriness
Gastroesophageal reflux and choking episodes

32. Management Obtain baseline vital signs and oxygen saturation readings.
Provide additional oxygen, assisted ventilation, blood pressure evaluation, and IV access as necessary.
f blood glucose level is less than 40 mg/dL, give an IV bolus of 10% dextrose solution and recheck in 30 minutes.
Monitor respiratory status and oxygen saturation carefully.
Maintain normal body temperature.