Neonatal abnormalities to consider

For those of us who rarely see sick neonates, it's all the more important to keep up on our neonatal wisdom. Therefore, I have compiled this list of diseases or special considerations that you might see in OB. By keeping up on our wisdom perhaps we can spot something, or provide some incite, that might save the life of someone's prescous baby.

Congenital Heart anomalies: click here

The following are special considerations to consider:

1. Meconium Aspiration:

• Meconium is basically the baby's first bowel movement. It's poop.
• This is mostly prevalent in post term baby's (40 weeks or greater gestation)
• If the baby is born vigorous (breathing, rapid heart rate greater than 100, and good muscle tone) all you need to do is suction mouth and nose with a bulb syringe
• If baby not vigorous intubate and suction mouth and trachea
• Suction should be set at 100 cwp
• Connect suction tubing to meconium aspirator and connect aspirator to ETT and suction while removing the ETT.
• If Meconium baby not breathing it is important to intubate and look beyond the vocal cords to make sure there is no meconium in lungs.
• Meconium in lungs can become an obstruction and cause air trapping you don't want.
• If you need to put patient on ventilator, make sure you consider air trapping.

2. Choanal Atresia:

• Back of nasal passage is blocked
• Usually baby pink and fine when crying
• but blue and apneic when not crying
• Ventilates fine with PPV but not with spontaneous breaths
• Test by inerting NG through both nares
• If symptomatic insert oral airway or 2.5 ETT but not all the way

3. Pierre Robin Syndrome:

• Small mandible
• Retraction of tongue which can block airway
• Incomplete closure of mouth (cleft palate)
• Baby's often have trouble breathing initially at birth
• Put baby on stomach (prone), or...
• If still symptomatic, insert 2.5 ETT or sx catheter
• VEry hard to intubate orally
• Prone usually works great

4. Pneumothorax (collapsed lung):

• Normal for newborn
• Decreased ability to expand lungs
• Lung sounds dim on side of lung effected
• Lung sounds dim on left side can also mean right mainstem intubation
• Increased respiratory distress (tachypnea, grunting, nasal flaring, retractions, cyanosis
• Irritability, restlessness
  
• Diagnose with x-ray or transillumination or chest asymmetry
• May have poor peripheral pulses and hypotension, and mottled appearance
• Flattened or decreased QRS comles on EKG
  
• Don't wait if suspect
• Insert catheter to withdraw air
• Chest tube

5. Pleural effusion:

• Decreased ability to expand lungs
• Diagnose with x-ray
• inser catheter to withdraw fluid
  
• Chest tube

6. Diaghragmatic hernia:

• Usually diagnosed before birth
• Respiratory distress
• Scaphoid (flat) abdomen
• PPHN and cyanotic
• Pulmonary hypoplasia
• lung cannot expand
• Do not use PPV
• Intubate and insert NG

7. Pulnonary Hypoplasia:

• Incomplete development of lung tissue
• Usually Cardiac problem too
• Respiratory distress
• Usually high PPV pressures required
• High risk of pneumo and death
• Usually develops @ 15-24 weeks gestation when amniotic fluid in trachea has less pressure than lungs causing amniotic fluid to leave alveoli and so they collapse and don't grow right
• Normally pressure in trachea is 2 mmHg higher than lungs to prevent amniotic fluid from leaving alveoli
• May be caused by kidney (agenisis and displasia) problems
• May be caused by diaphragmatic hernia
• Treat the symptoms: Supplemental oxygen, intubation and transfer to neonatal ICU (may need ventilator, high frequency ventilation, ECMO, etc)

8. Transient Tachypnea (TTN):

• 1% of newborns
• Wet lung (type II RDS)
• Results when fluid in lungs clears too slowly
• Diagnose with x-ray
• Can happen to premie and full term
• Hard to inhale air
• Sometimes CPAP needed, vent in some cases
• Risk: C-section, Diabetes, asthma mom, small baby for age

9. Persistent Pulmonary Hypertension:

• Arterioles in lungs remain constricted despite 100% FiO2
• This causes the ductus arteriosis to stay open
• Systemic blood pressure remains relatively low
• Causes continued right to left shunt
• Pre ductal SpO2 will be greater than post ductal
• Pre ductal SpO2 (ABG) should be done on right arm
• Post ductal SpO2 should be done on either leg or umbilica vein
• If you have greater than a 15% disparity in post and pre ductal SpO2 (PO2) consider this

10. Hyline Membrane Disease (also called respiratory distress syndrome or RDS):

• is one of the most common problems of premature babies
• occurs in over half of babies born before 28 weeks gestation, but only in less than one-third of those born between 32 and 36 weeks
• The more premature the baby, the more severe the HMD,
• Other risk factors are c-section, twins, perinatal infection, caucasion, male, diabetic mothers, patent ductus arteriosis
• It can cause babies to need extra oxygen and help breathing.
• Caused due to lack of surfactant, which helps keep the alveolar sac open
• Lack of surfactant causes alveoli to collaps with each breath
• As the alveoli collapse, damaged cells collect in the airways and further affect breathing ability.
• These cells are called hyaline membranes
• The baby works harder and harder at breathing, trying to re-inflate the collapsed airways
• As the baby's lung function decreases, less oxygen is taken in and more carbon dioxide builds up in the blood. This can lead to increased acid in the blood called acidosis
• Intubation with mechanical ventilator is needed to decrease work of breathing
• typically worsens over the first 48 to 72 hours, then improves with treatment.
• respiratory difficulty at birth that gets progressively worse
• Symptoms at birth include: central cyanosis, flaring of the nostrils, tachypnea (rapid breathing), grunting sounds with breathing, chest retractions.

11. Happy cyanosis:

• You have cyanotic baby who appears to be otherwise doing well
• Does not respond to supplemental oxygen
• Congenital Heart Disease
• Rare
• 85% SpO2 acceptable
• Seldom critically ill at birth

12. Bradycardia:

• Despite chest compressions and PPV patient bradycardic
• May be due to brain injury (also limp and blue)
• HIE: Hypoxic ischemic encepalopathy (brain injury due to hypoxia which may lead to developmental delay. Cause is usually unknown)
• Acidosis (give Bicarb)
• Congenital neuromuscular disorder - transfer to neonatal critical care
• Sedation: drug to mom passed through placenta -- give narcan

13. Acidosis:

• Causes pulmonary arteriolse to constrict
• treat accordingly

14. Hypoxic Ischemic Encepalopathy*:

• Anoxic brain injury that can be caused due to prolonged resuscitation or lack of resuscitation such as what occured prior to the 1970s and before programs such as the Neonatal Resuscitaion Program were started (resulted in many law suits back then)
• This is the reason NRP was started in the 1970s to prevent litigation (and save lives)
• Follow necessary steps of NRP as best you can to help prevent this
• Make call to neonatal ICU to determine if qualify for body cooling (new program)
• Studies show body cooling may prevent HIE after NRP done
• Closely monitor temperature every 5 minutes (goal to prevent hyperthermia)
• Goal skin temperatature is 35-36 celcius
• Secure IV access (UAC/UVC or peripheral
• Brain damage rarely occurs before birth, and often appears after resuscitation
• Not diagnosed until baby convulses hours after birth
• Mental and behavioral problems may not surface for years
• NRP -- mainly VENTILATION -- can prevent anoxia and hypoxia
• Baby's organs thrived in hypoxic environment, and baby therefore immune to hypoxia so long as perfusion is adequate (perfusion new key to NRP, not so much as oxygen).
• Diagnosed by assessment of color and breathing effort, x-ray, ABG shows hypoxia and acidosis,
• EKG to rule out heart problems that may result in similar symptoms
• Treatment: intubation, CPAP, ventilator, oxygen

15. Bronchopulmonary dysplasia (chronic lung disease)**:

• A complication that may result from Hyline membrane disease
• Other risk factors: birth prior to 34 weeks gestation, birthweight less than 2 kg, premature birth, pulmonary interstitial emphysema (PIE), male, caucasion, family history of asthma, patent ductus arteriosis, maternal womb infection
• Causes: premature birth, excessive oxygen damaged cells of lungs, surfactant deficiency, damage due to mechanical ventilation and suctioning
• general term for long-term respiratory problems in premature babies
• results from lung injury to newborns who must use a mechanical ventilator and extra oxygen for breathing
• Usually occurs in premature infants due to fragule lungs that are easily damaged
• With injury, the tissues inside the lungs become inflamed and can break down causing scarring.
• This scarring can result in difficulty breathing and increased oxygen needs.
• Not diagnosed at birth. Usually diagnosed by history and x-ray
• An ASD is an opening or hole (defect) in the wall (septum) between the heart’s two upper chambers (atria).
• This is called the ductus arteriosis, and is normal before birth. However, it usually closes on its own within the first few weeks of life.
• If too large, may not close on own. Etiology unknown
• Oxygenated blood travels from left ventricle to the right side of the heart
• Some adults have a patent foramen ovale (PFO)
• If the ASD is large, the extra blood being pumped into the lung arteries makes the heart and lungs work harder and the lung arteries can become gradually damaged.
• If the hole is small, it may not cause symptoms or problems
• large hole may cause murmur

16. Malrotation/ Midgut Volvulus:

• Normally, Between 6-12 weeks gestation the bowel enters the abdomen, and cecum rotates counter clockwise to the right lower quadrant, and intestine fixed to posterior abdominal wall by a wide fan of mesentery
  
• Malrotation is when the mesentery fails to attach to entire posterior abdominal wall
• Instead abnormally attaches in region of duodenum
• Midgut Valvulus, thus, is when the gut is twisted clockwise, or clockwise rotation with strangulation -- blood supply to small intestine is cut off
• Presentation: vomiting green colored (bile stained) emisis
• significant pain, bloody stools due to ischemia
• Make patient NPO (no food), have nurse set up an NG tube and set up to low suction
• Abdominal surgery to correct

17. Pneumopericardium:

• Air in pericardial sac that surrounds the heart
  
• Rarely occurs in absence of mechanical ventilation
• May be acute and life threatening
• Require immediate detection and evacuation.
• Signs: Sudden onset, severe cyanosis, muffled or inaudible heart sounds
• flattened or decreased QRS complex on EKG tracing
• Bradycardia, poor or absent peripheral pulses (brachial or femerol)
• Treatment is pericardiocentesis

18. Tracheosophageal Fistula (TEF) / Esophageal Atresia (EA):

• Esophageal Atresia means there is a blockage in the esophagus so that food cannot travel to the stomach. The most common type is where the top half of the esophagus does not connect to the bottom half.
• Signs of this are cyanosis, coughing, gagging, and choking when feeding. Drooling.
  
• Poor feeding
• Risk of aspiration and pneumonia is high
  
• Tracheosophhageal Fistula means there is a passage between the trachea and the esophagus. This may cause food to cross to the trachea and end up in the stomach.
• If TEF suspected, attempt to pass an NG tube and observe that it is coiled in the esophagus when you take a chest x-ray. If NG passes, check stomach for distension, because there could still be a fistula (see below)
• There are five types of TEF (refer to the picture)
• Type A: does not have a fistula from the esophagus to the trachea (x-ray will show absence of bowel gas)
  
• Type B: there is a fistula connecting the upper esophagus to the trachea, making food enter into the trachea and to the lungs causing aspiration of feedings. (X-ray will show absence of bowel gas)
  
• Type C: There is a fistula from the lower esophagus to the trachea. Air will be able to enter the stomach via the tracheal fistula, but there is no way to place an NG tube to the stomach to remove air that collects. Significant abdominal distension may develop
• Type D: There is a fistula from the upper esophagus to the trachea causing feedings to enter the stomach, and there is a fistula from the lower esophagus to the stomach, causing air from the trachea to enter the stomach. You will be unable to feed baby and unable to pass NG tube, plus severe gastric distension will result.
• Type E: There is a fistula between the trachea and esophagus, although there is no esophageal fistula. This will cause air to enter the stomach, yet an NG tube can be placed. Likewise, feedings may also enter the trachea causing aspiration.
• Do not feed, establish IV access, support with oxygen and ventilation, and insert NG into pouch or stomach.
  
• Place the infant prone with head of bed elevated to reduce reflux from stomach to trachea
• If type B or D is present, then the infant should be positioned with the HOB tipped down 20-30 degrees. This is to prevent oral secretions from draining directly to trachea.

*University of Virginia Health System (hyline membrane disease
**University of Virginia Health System (bronchopulmonary dysplasia)
***Kid's Health (coarctation of the aorta)
S.T.A.B.L.E. Program