Neonatal Problems - Part 1

Emergency Department visits in neonates are often due to unclear and nonspecific symptoms. Subtle signs may not point to a specific illness. For instance, Respiratory, Cardiac, Abdominal and Metabolic pathologies can all cause respiratory distress. Many visits just need reassurance and understanding of what constitutes normal for a neonate but the key remains to differentiate benign symptoms from potentially life-threatening underlying disease.

Normal Neonatal Patterns

1. Feeding pattern are quite erratic in the few weeks of life. Breastfed infants take shorter and more frequent feeds (q1-3hrs) as compared to formula fed ones. Adequate Intake is considered if weight gain ranges between 20-30gms/day in the first three months. It is important to remember that neonates loose up to 12% (may be more in exclusively breast fed infants) of their body weight in the first week and are back to their birth weight by 15th day of life. 

2. Just like feeding, bowel movements also varies in number, colour and  consistency. 

Meconium (fist stool) is passed within the first 24 hours after birth. Color changes from black->dark green->yellow seedy by day 4. Failure to pass meconium in the first 48 hours of life may suggest Hirschsprung’s disease or cystic fibrosis.  Breastfed infants may occasionally go 5 to 7 days without a bowel movement. In contrast, overfeeding or use of formula that is too high in sugar content also can produce loose stools.

3. Normal respiratory rate in neonates is 30 to 60 breaths/min. Neonates increase minute ventilation almost entirely through an increase in respiratory rate rather than inspiratory volume. A resting RR >60 breaths/min requires evaluation. Observe respirations to determine if breathing is thoracic or abdominal. Since neonates are obligate nose breathers, even nasal congestion may cause respiratory distress. Periodic breathing (alternating periods of a normal/fast/slow rate with pauses of 3-10 seconds between breaths) is common in pre-term infants. Prolonged Apnea (>20 seconds) or apnea accompanied by bradycardia, cyanosis, or a change in muscle tone is abnormal and requires evaluation. 

4. Infants sleep pattern is fragmented ranging from from 20 minutes to 6 hours cycles spread throughout the day and night. By 6 months, most infants are sleeping through the night. It is important to look for any physical reason of unexplained nighttime cry. Benign causes of cry include Reflux, Wet or Soiled Nappies, Hunger, Too hot or too cold, Teething etc. Carefully look for other pathologies in an episode of acute, inconsolable crying. 

Crying

Inconsolable crying requires a thorough history and head-to-toe examination. Here is a list of illnesses presenting as crying. 

CNS: Intracranial Bleed (NAI, VIt K deficiency), Meningitis and Raised ICP
ENT: Choanal Atresia, Otitis Media, URTI
Eye: Corneal Abrasion, FB eye
CVS: Arrythmias, Heart Failure
RS: Pneumonia
GI: Oral Thrush, Stomatitis, Volvolus, Intussusception, Hernia, Anal Fissure, reflux, UTI, Diaper Rash, Gastroenetritis
GU: Testicular torsion, hair tourniquet, paraphimosis
MSK: NAI, Hair tourniquet 
Metabolic: Inborn errors, hypoglycaemia, Congenital Adrenal Hyperplasia 

If a careful history and complete physical examination does not reveal any source and the infant remains quiet during the ED observation period, reassure and advise follow up with the general practitioner. 

Colic: Unknown pathophysiology. Sudden onset of paroxysmal crying, a flushed face, circumoral pallor, tense abdomen, drawn up legs, cold feet, and clenched fists. Colic is defined as a paroxysm of crying for ≥3 hours per day for ≥3 days per week over a 3-week period. It is a diagnosis of exclusion. Rule out other sinister causes of irritability.

There is no specific treatment for colic and casual administration of drugs or sedatives is contraindicated. Colic creates immense stress among caregivers stress. 

Cough/Cold: Cough/Runny nose and Sneezing are usually due to Viral URTI. Neonates with underlying pulmonary or heart disease may develop respiratory failure with even mild URTIs. Check for ill contacts and perinatal infectious risk factors. Respiratory symptoms related with feeding might suggest reflux and aspiration or congenital tracheoesophageal fistula. Respiratory difficulty when quiet and improvement during crying suggest choanal atresia. Treat the underlying condition. Do not give cough suppressants to neonates. Treat nasal congestion with instillation of saline drops and bulb suctioning.

Abnormal Airway Sounds: May be related to benign problems. Distinguish between:

1.Stertor (snoring sound due to soft tissue vibrations in nasopharynx). Stertor can be a symptom of choanal stenosis which can be confirmed by inability to pass a small nasogastric tube through the affected nostril is diagnostic of this condition. 

2. Stridor (sign of upper airway obstruction, can be inspiratory or expiratory) commonly occurs due to laryngomalacia. Stridor may also be a symptom of congenital anomalies causing a fixed obstruction (webs, cysts, atresia, stenosis, clefts, and hemangiomas) anywhere from the nose to the trachea and bronchi. Stridor from fixed lesions is often biphasic. 

• Stridor worsening with cry: laryngomalacia, tracheomalacia, or subglottic hemangioma 
• Stridor accompanied by feeding difficulties: vascular ring, laryngeal cleft, or tracheoesophageal fistula. 
• Stridor with hoarseness or weak cry suggests vocal cord paralysis.
• Stride post intubation: maybe due to subglottic stenosis 
• Stride with fever: croup, epiglottitis, and abscess 

When the diagnosis is uncertain, admit for observation and evaluation. 

Periodic Breathing: Periodic breathing must be differentiated from apnea. Apnea is cessation of breathing for ≥20 seconds, or cessation of breathing for a period <20 seconds accompanied by bradycardia, cyanosis, or a change in muscle tone. It signifies critical illness and warrants investigation and admission for monitoring and therapy. Apnea usually indicates respiratory muscle fatigue and impending respiratory arrest. Provide airway and ventilatory support, and search for the cause. If no obvious cause is found, presume sepsis, obtain cultures, and initi- ate broad-spectrum antibiotics and acyclovir if there is concern for herpes simplex virus. 

Abnormal Movements: 

1. Benign sleep myoclonus: Rhythmic myoclonic jerks observed when the infant is drowsy or in quiet sleep and can be suppressed upon touching and/or waking the infant

2. Startle Reflex: Single myoclonic jerk with extension of the arms and legs triggered by noise or tactile stimulation.

3. Seizures: Present with subtle manifestations, such as eye deviation, tongue thrusting, eyelid fluttering, apnea, pedaling movements, or arching, rather than generalized activity. Neonatal seizures usually indicate a severe underlying structural or metabolic problem and are rarely idiopathic.

Eye Discharge: Clear eye discharge with crusting over the eyelashes without associated conjunctival redness or irritation, is commonly seen in neonates and infants and results from narrow or obstructed nasolacrimal ducts. This condition usually resolves sponta- neously and requires antibiotics only when complicated conjunctivitis or dacryocystitis. Ophthalmologic consultation in needed if problem persists past 12 months of age or  if associated with recurrent infections. Causes of Red Eye include Corneal Abrasion, Acute Glaucoma, Conjunctivitis (Gonococcal, Chlamydial, Herpes Simplex) 

References;

Tintinalli's Emergency Medicine 8th edition

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic