Common Neonatal Problems

Common Neonatal Problems Mohamed Khashaba, MD Professor of Pediatrics/ Neonatology Head of NICU Mansoura University

Key elements to prevent severe hyperbilirubinemia .Promote and support breast feeding- 1 Measure total bilirubin for infants jaundiced in- 2 .the first 24 hour .Interpret level according to age in hours- 3 Provide parents with written and oral- 4 informations, stress paid to ABO .incompatibility .Appropriate follow up- 5

Respiratory Distress (.Tachypnea (RR >60/min • .Flaring, grunting and retractions •

Fractured Clavicle

Abdominal distension, visible loops

What is the most frequent cause of 1st visit ?to the clinic during the first 3 months

Case 1 A 15 month aged infant presented with delayed .motor milestones of development The baby was 36 week gestation, born by C/S and presented 3 days after birth with jaundice. TSB was 29.9 mg/dl, no neurologic signs .were noted DVET was done using O blood, PETSB was19 . mg/dl .The baby was discharged home after PEPTh

Throughout the 1st year, the infant received multiple doses of vitamin D, cerebral stimulants!! For delayed motor ..development

Case 2 Maisels et al, NEJM 358:920-928 A male infant weighing 3400 g was born at 37 weeks' gestation after an uncomplicated pregnancy. The mother is a 24-year-old primipara who has type A Rh-positive blood. The infant's course in the hospital nursery was uncomplicated. Although his mother needed considerable help in establishing effective breast-feeding, he was exclusively breast-fed.

• Jaundice was noted at the age of 34 hours. The total serum bilirubin level was 7.5 mg per deciliter (128 µmol per liter). The infant was discharged at the age of 40 hours and is seen in the pediatrician's office 2 days later, now with marked jaundice. The results of his physical examination are otherwise normal, but his weight, at 3020 g, is 11% below his birth weight.

• His total serum bilirubin level is 19.5 mg /dl. (333 µmol /l), conjugated bilirubin level 0.6 mg /dl (10 µmol /l). • CBC and peripheral-blood smear are normal. • The infant has type A Rh-positive blood. • The pediatrician consults a neonatologist regarding the need for phototherapy.

Case 3 .Male infant born 2/2/2009 to a G1P2 lady by SVD Pregnancy was uneventful apart from PPROM for which she received macrolide prophylaxis, .delivery at 35 weeks The baby needed facial O2, Apgar 5 (1min.) and 8 .(.(5 min In the delivery room, he was given vit. K, started .eye prophylaxis

At 2 hours of age, examination revealed a 2.4 kg, male baby. Vital signs and the rest of .examination were reassuring CRP and CBC were normal At 4 hours of age, both baby and mom were .discharged home in good status

At Day 4 OL Baby presented to OC with jaundice, visual evaluation revealed mild jaundice, the baby was discharged .home with the instructions frequent breast feeding At day 5 OL Mom noticed abnormal movements, duskiness and .weak suckling

.Physical examination at discharge.1 .Accurate gestational age estimation. 2 .No discharge before 48 hrs.3 .Normal vital signs for 12 hrs preceding discharge. 4 .At least 1 stool passed spontaneously. 5 .Twenty four hours of successful feeding. 6

Weight loss >7% during birth hospitalization. 7 . should be assessed for dehydration . Blood glucose screening.8 .Risk assessment for jaundice.9 .Metabolic screening performed.10 Family,enviromental and social risk factors.11 .assessed

Common Clinical Risk Factors for Severe Hyperbilirubinemia Jaundice in the first 24 h Visible jaundice before discharge Previous jaundiced sibling Gestational Age 35-38 ws. Exclusive breast feeding. Bruesing and cephalhematoma. Male gender. PEDIATRICS Vol. 108 No. 3 September 2001, pp. 763-765

(Late preterms (34 - <37 ws Approximately 500 000 born prematures in USA/year (12.5 % of live birth) More than 70% are late preterms (350 000)

frequency % frequency %PEDIATRICS

Vol. 108 No. 3 September 2001, pp. 763-765

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AAP Guidelines Any infant who is jaundiced before 24 hours requires a measurement of the serum bilirubin level and, if it is elevated, the infant should be evaluated for possible hemolytic disease. Follow-up should be provided within 2 to 3 days of discharge to all neonates discharged at <48 hours after birth.

.(AAP Guidelines ( cont Early follow-up is particularly important for infants <38 weeks' gestation. The timing of follow-up depends on the age of discharge and the presence of risk factors. In some cases, follow-up within 24 hours is necessary PEDIATRICS Vol. 108 No. 3 September 2001, pp. 763-765

Every pregnant lady should have her ABO .blood group known before delivery In case of O group, ABO group of the .husband should be determined ,In case of ABO incompatibility The newborn baby should be considered at .risk of early jaundice and kernicterus

Irradiance Spectral irradiance is the irradiance delivered in certain wave length to the surface of the .infant Measured with Radiometer as µW/ cm2/nm. Standard PT deliver 10 µW / cm2/nm. Intensive PT delive 30 µW / cm2/nm.

Factors affecting PT efficacy 1. Infant's distance from the light . 2. Infant's eyes protected with opaque eye patches. 3. Area of skin exposed (hence the need for a light source beneath the infant for intensive phototherapy). 4. If the total serum bilirubin level continues to rise despite treatment, the diaper should be removed. 5. Aluminum foil or white cloth placed on either side of the infant to reflect light .

.(Factors affecting PT efficacy (cont 6.Blue light is most effective for phototherapy, best wavelengths to use are probably in the range of 460 to 490 nm. 7.Light rays should be perpendicular to the surface of the incubator in order to minimize loss of efficacy due to reflectance. 8.Term and near-term infants are treated in a bassinet, to allow the light source to be brought to 10 to 15 cm of the infant .

Sunlight Will lower the serum bilirubin level. Practical difficulties preclude the use of sunlight.

Key elements to prevent severe hyperbilirubinemia .Promote and support breast feeding- 1 Measure total bilirubin for infants jaundiced in- 2 .the first 24 hour .Interpret level according to age in hours- 3 Provide parents with written and oral- 4 informations, stress paid to ABO .incompatibility .Appropriate follow up- 5