Paediatrics

1. Neonatal Emergencies
Natangwe Shimhanda
MBChB V
19/07/16

2. Introduction
• A rapid clinical assessment of the seriously ill neonate will
identify if there is potential respiratory, circulatory or
neurological failure. Not to exceed a minute.
• Resuscitation is given immediately, if necessary, followed by
secondary assessment and other emergency treatment.
• The neonate may present with shock, respiratory distress,
as a drowsy/unconscious or fiting child or with a surgical
emergency.
• The key to successful outcome is in the early recognition
and active management of conditions that are life-
threatening and potentially reversible.

4. Vital signs
Heart rate 110 - 150
Respiratory rate <60
SpO2 > 85%
Capillary refill < 2 secs

5. Causes

6. Causes cont..

7. Hypoglycemia
• Blood glucose < 2.6 mmol/L
Management
<72 hours
>72 hours
Milk Feeds (start early and regularly)
[Unless nil per Os], Monitor Glucose
IV glucose infusion
Repeat Blood glucose
>2.6mmol/L
*wean Glucose PRN
*increase feeds
*Repeat Blood glucose (1-
3 hourly)
*Bolus 2ml/kg 10% Dextrose water
as required
*Continuous infusion (Pump) start
6-8mg glucose/kg/min, increase by
2mg/kg/min every 30mins until
blood glucose > 2.5
*Maximum 15mg/kg/min.
*Start glucagon infusion when 10mg
gluscose/kg/min is reached
Repeat Blood glucose
Blood Glucose <2.6mmol/L
Glucagon 1-2mg/kg/24hours IV
continuous
*steroids Hydrocortisone and
Prednisolone
*Persistent Hyperinsulinemia
Diazoside 5-10mg/kg/day or
somatostatin analogue

8. Special Investigations
Symptomatic/ Persistent hypoglycemia
• Insulin, cortisol, Growth
Hormone
• Acid base balance
• Urine reducing
substances, ketones
• Monitor Glucose levels
(every 30 mins until
normal and then 1-3
hourly)
• As for <72 hours
• Lactate, pyruvate
• Amino acids
• others
< 72 hours
> 72 hours

9. Hyperglycemia
• Suspected in Neonates with a blood sugar
levels of >11mmol/L
• Possible causes:
 Iatrogenic, IV glucose infusions, steroid administration,
aminophylline, TPN (lipids)
 Very low birth weight neonate
 Sepsis
 Intra-ventricular Hemorrhage
 Stress: Asphyxia, Respiratory distress, surgery
 Transient neonatal Diabetes mellitus

10. Dangers and Management
• Hyper-osmolarity, osmotic diuresis, dehydration, Intracranial hemorrhage,
death
• Management:
 Confirm with blood glucose test
 Find the cause and correct
 If Administering IV fluids with 10% dextrose (neonatalyte/neolyte) switch
to 5% dextrose with 0.2 NaCl IV solution.
 Repeat blood glucose hourly and aim to keep between 5.5-11mmol/L
 If it remains above 14mmol/L in spite of limiting glucose intake to
4mg/kg/min, consider insulin therapy with consultation w/ the consultant
and preferably in an ICU setting
 Actrapid (short acting), add 1 U(0.01ml) insulin to a syringe containing
10mls 5% dextrose water

11. Shock
• Circulation is inadequate to meet the demands of the tissues.
• Critically ill neonates are often in shock, usually because of hypovolaemia
due to fluid loss or maldistribution of fluid, as occurs in sepsis or intestinal
obstruction
• Children normally require a much higher fluid intake per kilogram of body
weight than adults because they have a higher surface area to volume
ratio and a higher basal metabolic rate.
• Therefore they may become dehydrated if: there is loss of the normal
fluid-retaining mechanisms, e.g. the permeable skin of premature infants,
increased urinary losses or capillary leak, additional fluid losses due to
fever, diarrhoea or increased insensible losses (e.g. increased sweating or
tachypnoea)

12. Clinical signs
• In early, compensated shock, the BP is maintained by increased heart and
respiratory rate, redistribution of blood from venous reserve volume and
diversion of blood flow from non-essential tissues such as the skin in the
peripheries, which become cold, to the vital organs like brain and heart.

13. Management
• Fluid resuscitation - Rapid restoration of the
intravascular circulating volume is the priority.
Deficit: % dehydration *
weight*10
Maintenance:
First 10kg - 4ml/kg
Second 10kg – 2ml/kg
Subsequent – 1ml/kg
Ongoing losses:
5mls/kg Vomiting
10mls/kg loose stool

14. Subsequent management
• If there is no improvement following fluid resuscitation
or there is progression of shock and respiratory failure,
a paediatric intensive care unit should be involved and
transfer arranged as the child may need:
 tracheal intubation and mechanical ventilation
 invasive monitoring of blood pressure
 inotropic support
 correction of haematological, biochemical and
metabolic derangements
 support for renal or liver failure.

15. Septicaemia
• Proliferation/dissemination of bacteria in the
bloodstream, leading to the host response of
inflammatory cytokines release and activation
of endothelial cells, which may lead to septic
shock
• In neonates, the commonest causes of
septicaemia are group B streptococcus or
Gram negative organisms acquired from the
birth canal

16. Clinical features of Septicaemia

17. Management Priorities
• Antibiotics
• Fluids
 Significant hypovolaemia is often present, owing to fluid
maldistribution, which occurs due to the release of vasoactive
mediators by host inflammatory and endothelial cells. There is loss
of intravascular proteins and fluid which may occur due to the
development of ‘capillary leak’ caused by endothelial cell
dysfunction. Circulating plasma volume is lost into the interstitial
fluid
Gram Positive e.g. Group B,
Beta Hemolytic Strept and
Listeria
Gram Negative e.g. E.coli,
klebsiella, Proteus etc
Ampicillin 50-100mg/kg/24hours IV (100-
200mg/kg meningitis)
Gentamycin 5mg/kg IV

18. Management
Circulatory support
• Myocardial dysfunction occurs as inflammatory cytokines and
circulating toxins depress myocardial contractility. Inotropic
support may be required.
Disseminated intravascular coagulation (DIC)
• Abnormal blood clotting causes widespread microvascular
thrombosis and consumption of clotting factors. If bleeding
occurs, clotting derangement should be corrected with fresh
frozen plasma and platelet transfusions.
Steroids
• There is no evidence that steroids are of benefit in septic
shock

19. CNS
Signs and Symptoms
• seizures
• lethargy
• irritability/tremors
• hypotonia
Evaluation
• LP
• EEG
• US
• CT/MRI
Conditions
• Hypoxic-Ischemic
Encephalopathy (HIE)
• Intra-cranial
Hemorrhage
• Drug withdrawal
• Malformations
• Meningitis

20. Seizures
• Seizures occurring during the neonatal period are often
difficult to recognize.
• The cortical development is not complete, and as a
result, generalized motor activity is less common.
• Subtle seizures in the term neonate can include
abnormal eye movements (usually horizontal,
sustained eye deviation), lip smacking, abnormal
• tongue movements, pedaling, or apnea.

21. Classifications
• Clonic seizures
These movements most commonly are associated
with electrographic seizures.
They often involve 1 extremity or 1 side of the
body.
The rhythm of the clonic movements is usually
slow, at 1-3 movements per second.

22. Classifications
• Tonic seizures
 These may involve 1 extremity or the whole body. Focal
tonic seizures involving 1 extremity often are associated
with electrographic seizures.
 Generalized tonic seizures often manifest with tonic
extension of the upper and lower limbs and also may
involve the axial musculature in an opisthotonic fashion.
 Generalized tonic seizures mimic decorticate posturing; the
majority are not associated with electrographic seizures.

23. Classifications
• Myoclonic seizures
 These may occur focally in 1 extremity or in several
body parts (in which case they are described as
multifocal myoclonic seizures).
 Focal and multifocal myoclonic seizures typically are
not associated with electrographic correlates.
 Generalized myoclonic jerks are possibly the clinical
equivalent of infantile spasms.

24. Causes
Within first 24 hours of life
• Hypoxic ischemic encephalopathy
• Meningitis/sepsis
• Subdural/Subarachnoid/
Interventricular hemorrhage
• Intrauterine infection
• Trauma
• Pyridoxine dependency
• Drug effect/withdrawal
24-72 hours
• Meningitis/sepsis
• In premature infants: IVH
• In full-term infants:
infarction, venous
thrombosis
• Cerebral dysgenesis
72 hours to 1 week
• Above causes
• Inborn errors of metabolism
• Hypocalcemia
• Familial neonatal seizures
1 week to 4 weeks
Above causes
HSV

25. Acute Management of Neonatal
Seizures
• ABCDextrose (check HGT)
With hypoglycaemia: Glucose 10% 5ml/kg, 25 % 2-3ml/kg IV
W/out hypoglycaemia
• Phenobarbital: 20mg/kg IV loading dose; additional phenobarbital 5mg/kg IV to a
max of 20mg/kg
• Asphyxiated birth; Phenytoin 20mg/kg IV (1 mg/kg/min), Lorazepam: 0.05-0.10
mg/kg, IV
• If status epilepticus: Anaesthetic drugs and ventilate
• Hypocalcemia: Calcium gluconate, 5 % solution, 4 ml/kg IV
• Hypomagnesemia: Magnesium sulfate, 50% solution, 0.2ml/kg IM
• Pyridoxine deficiency: Pyridoxine 50-100 mg IV
Infections/Sepsis
• Ampicillin 50 mg/kg BD IV
• Gentamicin 5 mg/kg OD IV
• Meningitis- High dose Ampicillin 100mg/kg BD IV

26. Treatment of Electroclinical Seizures
• Phenobarbital 20 mg/kg
10 mg/kg boluses until 40-50 microgm/ml
• Phenytoin 20 mg/kg
• Lorazepam 0.1 mg/kg
• Pyridoxine 50-100 mg IV with EEG

27. Respiratory System
Signs and Symptoms
• tachypnea
• nasal flaring
• grunting
• retractions
• apnea
Conditions – anatomic approach
Alveolar
Hyaline Membrane Disease
(HMD) or Respiratory
Distress Syndrome (RDS)
Pneumonia
Meconium Aspiration
Syndrome (MAS)
Milk aspiration
Parenchymal
Transient Tachypnea of the
Newborn (TTN)
Cystic Adenomatoid
Malformation
Congenital Lobar
Emphysema

28. Space-occupying
Air Leak
Effusion
Congenital Diaphragmatic
Hernia
Airway
Laryngomalacia/tracheom
alacia
Tracheal web
Vocal cord paralysis
Choanal atresia
Extra-pulmonary
Sepsis/meningitis
Congenital Heart
Disease
Hypothermia
Metabolic error
Abdominal distention

29. Hyaline Membrane Disease
Meconium Aspiration Syndrome
Cystic Adenomatoid Malformation

30. Respiratory Distress Syndrome
Pulmonary and Extra-pulmonary Causes
Signs of respiratory distress:
• tachypnoea (>60 breaths/min)
• laboured breathing, with chest wall recession (particularly sternal and subcostal
indrawing) and nasal flaring
• expiratory grunting
• cyanosis if severe.
Affected infants should be admitted to the neonatal
unit for monitoring of heart and respiratory rates, oxygenation
and circulation. A chest X-ray will be required
to help identify the cause, especially those causes
which may need immediate treatment, e.g. pneumothorax
or diaphragmatic hernia. Additional ambient
oxygen, mechanical ventilation and circulatory support
are given as required.

31. Management
• Affected infants should be admitted to the
neonatal unit for monitoring of heart and
respiratory rates, oxygenation and circulation.
• A chest X-ray will be required to help identify the
cause, especially those causes which may need
immediate treatment, e.g. pneumothorax or
diaphragmatic hernia.
• Additional ambient oxygen, mechanical
ventilation and circulatory support are given as
required.

32. Cardiovascular System
• Congenital heart diseases (CHD) encompass a
spectrum of structural abnormalities of the
heart or intra-thoracic vessels.
• Commonly presents in the newborn with
central cyanosis, heart failure, sudden collapse
or heart murmur.
• Cyanotic or Acyanotic

33. Cyanotic Heart Lesions
• Cyanosis is a pathologic process caused by
deoxygenated blood in the capillary vessels.
• Cyanotic heart defects are not detected in the
newborn nursery, presents during the first 2 to 3
weeks of life when the Ductus Arteriosus closes .
• There is still adequate oxygenated blood to the
systemic circulation through a patent DA

34. Terrible Ts
Classically present with cyanosis
1. Transposition of the great vessels
2. Total anomalous pulmonary venous return
3. Tetralogy of Fallot
4. Truncus arteriosus
5. Tricuspid atresia

35. Acyanotic Heart Disease
• Acyanotic heart diseases may also be a result of
closure of the ductus arteriosus (DA).
• The onset of symptoms typically is gradual, with
the onset of congestive heart failure.
• Different degrees of obstruction to the left
ventricular outflow tract are present that result in
an increase in pulmonary blood flow and a
gradual development of heart failure.

36. Signs and Symptoms
• Tachypnea
• Tachycardia
• Hepatomegaly
• History of poor feeding
• Sweating or color change with feedings
• Poor weight gain
• Lower extremity edema and jugular venous
distention are unlikely findings at this age

37. Classic Hyperoxia Test
• Differentiate between cardiac and noncardiac causes
• Provide 100% oxygen
• Observe the oxygen saturation on pulse oximetry for
an increase of 10% in pulmonary causes (PaO2 should
increase by 30 mm Hg)
• If the neonate’s oxygen saturation or PaO2 fail to
improve, cyanotic heart disease is suspected.

38. Management
• Administration of prostaglandin E1 (PGE1) as a bolus of
0.05 mcg/kg IV
• Success is less likely because the development of heart
failure is gradual and the DA may already have been closed
for several days to weeks.
• First line -Furosemide, 1 mg/kg IV
• Other adjuvants include dopamine, dobutamine, and
digoxin.
• Pediatric cardiology consultation

39. HEMATOLOGIC
Signs and Symptoms
• Pallor
• Shock
• Early Jaundice
• Petechiae
Conditions
Acute Blood loss
• Placenta previa
• Abrutio placentae
• Velamentous cord
insertion
• Cord accident
• Organ rupture
Conditions
Chronic Blood loss
• Maternal-fetal
• Twin-twin transfusion
• Hemolytic anemias –
immune, non-immune
Conditions
• Thrombocytopenia
• Polycythemia
• Hemorrhagic Disease
of the Newborn

40. GASTRO-INTESTINAL SYSTEM
Conditions
• Congenital malformations
• Tracheal-Esophageal Fistula
(TEF)
• Duodenal atresia
• Intestinal atresias
• Omphalocele
• Gastroschisis
• Necrotizing Enterocolitis
(NEC)
Signs and Symptoms
• distention
• failure to stool
• vomiting
Evaluation
• Abdominal films
• Contrast studies
• US

41. Tracheal-Esophageal Fistula
Omphalocele
Gastroschisis
NEC - pneumotosis
Pneumotosis intestinalis

43. Double Bubble Sign
Intestinal atresia
Ileal Atresia
Duodenal Atresia

44. Congenital Diaphragmatic Hernia
Classification
Absent diaphragm : rare
Diaphragmatic hernia
• 80% posterolateral L >R
(Bochdalek)
• 2% anterior (Morgagni)
• 15 - 20% paraesophageal
Eventration (15 - 20%)
Classic Triad: Dyspnea, Cyanosis,
Apparent dextrocardia
Immediate management:
Intubation and stomach
decompression

45. The End

46. References
• Lissauer T, Clayden G, 2012. Illustrated
Textbook Of Paediatrics. Fourth edition. ©
2012 Elsevier Ltd
• Wittenberg D.F. (2009), Coovadia’s Paediatrics
and Child Health. Oxford University Press
Southern Africa (pty) Ltd
• Philip Henning, 2012. Neonatology, A Guide
For Doctors. Tygerberg Children’s Hospital,
Stellenbosch University. South Africa