Common Neonatal Problems

Dr Marea Murray
Staff Neonatologist
Blacktown Hospital

Concerning Congenital Heart

Disease (CHD)
A. Murmurs noted in the first day are usually pathological
B. The Newborn examination picks up 90% of CHD
C. Neonatal cardiac examination does not need to be
repeated in the first week for those babies who are
discharged early
D. Reduced femoral pulses suggest coarctation and need
urgent investigation
E. Basal crepitations and peripheral oedema are the most
reliable signs of CHF in a neonate

Congenital Heart Disease

Remember CHD may not be evident at birth

Murmurs on day 1 often reflect the transitional changes
and are not significant
Early discharge has meant a higher rate of missed
CHD on the Newborn check and the need to examine
the baby again later in the first week of life
Murmurs and other signs of CHD often evolve with age

related to changing fetal communications eg closure of the

ductus arteriosus
Changes in pulmonary vascular resistance

Clues to Significant CHD

Is

there a family history of CHD?

Is the baby normal or is there a syndrome?

Is

Eg Downs
Williams
Velocardiofacial (C/S 22 deletion)

the patient cyanosed?

Clues to Significant CHD

Are there symptoms / signs of CHF?

Feeding difficulties
Tachypnoea
Tachycardia
Hepatomegaly
Sweating around the head

Other signs to look for:

Pulses (diminished / increased & distribution)

Blood pressure - Beware false readings on the dynamap
Pericardial over activity / thrill
Murmur

Murmurs
If

the only abnormal sign is a murmur it is

usually not urgent to refer to a Paediatric
Cardiologist

Cardiac murmurs are not synonymous with CHD

Possible

to use the local paediatricians to help

screen these babies if uncertain
Remember there can be significant CHD and
NO murmur

Investigation of CHD - Basic

CXR

Situs
Position
Contour
Size
Pulmonary vascularity
Look for right sided aortic arch
Found

in 25% OF Tetralogy of Fallot and 40% of Truncus

arteriosus

Investigations - Basic

ECG

In rare situations may be diagnostic eg AV canal Ostium

primum ASD and Tricuspid atresia = superior axis
Look for ventricular hypertrophy
Can be difficult to interpret in the newborn

eg normal to have RAD and RV more dominant

Hb and Film

Can underestimate cyanosis with anaemia

Polycythaemia causes over diagnosis of cyanosis
Look for Howell Jolly Bodies- suggests asplenia, has
association with complex CHD

Investigations - Advanced
Referral

to Childrens Hospital for

Paediatric Cardiology assessment

Echocardiography

Concerning Neonatal Jaundice

A. Day 1 jaundice is usually physiological
B. In a term baby on day 5, all SBR levels > 300
should be treated with phototherapy
C. In persistent or late onset jaundice, investigating
the underlying cause is more important than the
actual level of SBR
D. When breast milk has been found to be the cause
of jaundice, breast feeding should be discontinued
E. In the presence of raised conjugated bilirubin,
biliary atresia is not an important cause to exclude

Neonatal Jaundice
Caused

by accumulation of bilirubin

Usually unconjugated
Tetrapyrrole formed from haeme catabolism
Main factors
Increased

haeme production eg haemolysis

Decreased hepatic clearance
Ductus venosus patency
Enterohepatic circulation and slow gut transit time

Pathological Jaundice
Jaundice

is

Early
High
Late
Prolonged
Conjugated

The

neonate is sick

Case History
Full

term 3050g breast fed baby

Took early discharge on day1
Noted to be jaundiced on day 3
Jaundiced to below the knees but not the feet

Which investigations ?

Cephalopedal Progression of
Jaundice
Zone

Mean

SD

Range

1
2
3
4
5

101
152
202
256
>256

5.1
29.1
30.1
29.1

74 - 135
92 - 209
138 - 282
190 - 313

Kramer LI , Am J Dis Child, 1969 118:454.

Serum Bilirubin >270 - 300

Blood

group and DCT

FBC and blood film
G6PD (depending on ethnic group)
Direct SBR

Treatment Guidelines
Birth

wt

<1000g
1000 - 1499
1500 - 1999
2000 - 2499
>2500

phototherapy
100
150
200
250
340

exchange
200
250
300
350
450

Treatment Guidelines
Subtract

50 micromol/ L if :-

SBR rising >17 micromol/ L/ hour

Serum albumin <2.5g/ L
Persistent acidaemia
Persistent hypoxaemia
Persistent hypercarbia
Proven sepsis
Hypoglycaemia

Current Controversy

Need for treatment

Based on Hsias work in 1952 on Term babies with rhesus

haemolytic disease but can we extrapolate from this?
Association between total SBR and kernicterus
3% babies with peak SBR 103 - 256
18% babies with peak SBR 274 - 513
50% babies with peak SBR > 530

Separation of mother and baby

Risk of lactation failure

Use of the Bilibed

Allows for treatment in the Postnatal ward with

Mother or even treatment at home!
Advantage of proximity to light source and the right
spectrum (blue light).
Only a small exposed surface area. (Back)
Should be avoided if Jaundice is early (<36hrs) or
levels are high.
In term babies our bilibed ranges are as follows:D2 (36-48hrs)
D3
260-320
290-350

D4
D5
320-380

350-380

Case History
Philipino

baby goes home on D1 on DMP

Mother brings baby to the surgery on D4 as
baby is not feeding well and very jaundiced
SBR is 550 micromol/L
Urgent admission arranged
Blood Film shows evidence of haemolysis
Coombs is negative
Diagnosis is G6PD deficiency

G6PD
On

further questioning

Family placed baby into clothes they had taken out

of moth balls

High

risk for kernicterus

Need for follow up hearing assessment
Neurodevelopmental follow up

Case History
16

day old term neonate presents with jaundice

SBR is 220
Would you perform further investigations?

Prolonged Jaundice
Conjugated

(Direct) SBR is normal

Breast milk jaundice

Hypothyroidism
Urinary tract infection
Glucuronosyl transferase deficiency
Crigler-Najjar

(type 1 and 2)
Gilberts syndrome

Prolonged Jaundice

Conjugated (Direct) SBR raised

Well infant

Biliary obstruction

Neonatal hepatitis
Biliary atresia

Alpha1 antitrypsin deficiency

Hypothyroidism

Sick infant

Sepsis : E coli UTI

Galactosaemia
Hypopituitarism

Concerning Neonatal Abstinence

Syndrome (opiate withdrawal)
A. Naloxone is contraindicated during
resuscitation of the neonate
B. Drug withdrawal can occur in babies up to
10 14 days of age
C. It is a serious condition which has resulted
in neonatal deaths, particularly if parents try to
treat it with their methadone
D. Referral to DoCS is mandatory in all cases
of NAS
E. A, B and C are correct

Opiates Postnatal Issues

Admission

of the baby to the postnatal

ward is possible in the stable methadone
user.
Midwifery staff must be able to score the
baby to detect withdrawal.
Scoring occurs for a minimum of 5 days in
hospital. Peak onset of withdrawal is 2-4
days postnatally.

Opiates Postnatal Issues

Withdrawal

occurs up to 10- 14 days of age.

Therefore if discharge occurs at 5 to 10
days-.

Warn mother / carer what to look for and provide

contact numbers.
Review soon after discharge.

Neonatal Abstinence
Syndrome

Modified Finnegan scoring system used to assess

abstinence syndrome. Three scores averaging 8 or
greater is the indication for SCN admission and
treatment.
Morphine is the treatment of choice for Opiate
using mothers.
Addition of Phenobarbitone is indicated to control
persistent symptoms in babies where mother has
used other drugs in addition to opiates.

Regarding Hepatitis C Virus

Infection
A. There is a theoretical risk of transmission of HCV if
mother breast feeds with cracked nipples
B. Testing the baby for HCV is best done at birth with HCV
ab
C. Breast feeding is contraindicated
D. 5 -10% of Mothers with an IV drug using history are
positive for HCV
E. Mother to child transmission occurs in 95% of cases

Opiates Breast Feeding

Breast feeding may help alleviate neonatal

abstinence syndrome, however issues of hepatitis
C and HIV must be discussed if relevant
Hepatitis C is not a contra-indication to breast
feeding. Transmission of Hepatitis C to baby via
breast feeding is not proven. However care should
be taken with cracked nipples, as this is a
theoretical risk.
Weaning from the breast should be gradual.

Neonatal Abstinence Syndrome

Recently

a Department of Health guideline

on Neonatal Abstinence Syndrome has
been released.
Emphasis on multidisciplinary team
approach, beginning during the pregnancy.
Liaison with community emphasized.

Safety Guidelines

Baby must stay for a minimum of 5 7 days.

Mother must room in for a minimum of 48 hours
prior to discharge.
Clinic visits at least weekly.
One week supply of morphine at a time.
Close liaison with social worker.
Involvement of DOCS as appropriate.

Concerning Neonatal Sepsis

A. Pyrexia is usually present in septic neonates
B. The rate of and morbidity from sepsis are reduced by
covering all Mothers who are GBS positive on HVS with
antibiotics in labour
C. Surface skin swabs are helpful
D. All neonates born following PROM need antibiotic
cover
E. WCC of 15 - 25 is significant

Incidence
1

10/1000 live births

Varies within and between nurseries
Reduced by prophylaxis

Early Onset Sepsis

Day 1 4 (usually D1)

Risk factors (PROM, Prematurity 30-50%, maternal
fever)
25 30% are NOT associated with risk factors
Usual Pathogens

GBS
E-Coli

Present as bacteremia and can be dead within 24

hours

Late Onset (> Day 7)

May

present as meningitis
May have localised disease
More likely to be staph aureus and Staph epi
Also can be GBS and E-coli
Ex-Prems at increased risk

Clinical Symptoms / Signs

Temp

instability (up or down)

Respiratory distress
Feeding difficulties
Irritability
Lethargy
Apnoea
IE Most of Neonatology!

If in doubt in the community refer in

Examination
Vital

signs

HR, RR, Temp,BP, Blood Glucose

Capillary

Hold thumb down on sternum for 5 secs, release

Other

return >2 secs

Physical signs

General appearance
Recession
Hepatomegaly

How to avoid aggro

Always

collect a blood culture first

WCC < 5, especially with neutropenia is
suggestive of sepsis
Dont do surface swabs

Colonisation does not equate to infection

What do you do with the result
Expensive

Some Hints

Use antibiotics

OK to withhold antibiotics

Where FiO2 >30%

Unexplained asphyxia or prematurity
Well prem of >33 weeks without risk factors

Ampicillin / Gentamicin advantage of covering Listeria

Or

Penicillin / Gentamicin
Penicillin / Cefotaxime if meningitis