Neonatal Issues

Nutrition

Hyperbilirubinemia (Jaundice)

• 3 Causes:
  • 1. Prehepatic: hemolysis
    
  • 2. Intrahepatic: metabolic
    
  • 3. Posthepatic: biliary obstruction
• Types of bilirubin:
  •  Conjugated/direct
    • cannot cross the blood-brain barrier
      
    • – instead, it is secreted in urine.
      
    • – it can’t cause brain damage but it is always pathologic as it is indicative of problems w biliary excretion
  • Unconjugated/direct
• Presentation:
  • feeding
  • voiding
  • stooling
  • mental status
• History Questions:
  • Breastfed? going well?
  • milk?
  • latching?
  • Number of feeds in the last 24 hours?
  • Length of feeds?
  • Any formula?
  • Number of wet diapers in last 24 hours?
  • Number of stools in the last 24 hours?
  • Stools – meconium or yellow and seedy?
  • Waking to feed?
  • Hungry?
  • Gestational age?
  • Pregnancy complications?
  • Sibling needing phototherapy?
  • Family history of RBC disorders (G6PD)?
  • East Asian ancestry?
  • Ask for newborn screen
    • hypothyroidism and galactosemia are 2 uncommon causes of hyperbilirubinemia screened for in US
• Physical Exam:
  • weight: % changed from birth weight
  • general appearance
    • well appearing and vigorous
    • wake appropriately with exam
    • skin
    • sclera – icterus 
    • skull – cephalohematoma or caput
    • abdomen – organomegaly
    • neurologic – suck and tone
• Diagnostic testing:
  • Total and direct serum bilirubin level
  • DAT ( aka Coombs) in ABO incompatibility
  • For others such as:
    • Severe hyperbilirubinemia
    • Early onset of hyperbilirubinemia (within first 24 hours of life)
    • Rapid rate of bilirubin use (> 0.5 mg/dL per hour)
    • Failure to respond appropriately to phototherapy
    • Persistent hemolysis
      • CBC
      • Reticulocyte count
      • G6PD activity
      • Peripheral smear
      • Type and screen
• Workup:
  • Transcutaneous sensor!
    
  • But the most important thing to do is draw a bilirubin level.
  • Indirect hyperbilirubinemia can cause kernicterus.
  • If a baby has hyperbilirubinemia:
    • If Conjugated (direct):
      • direct bilirubin > 20% of total or > 1mg/dL
      • – sepsis eval: WBC, blood cultures
        
      • – obstruction: HIDA scan
        
      • – Hepatic US
      • – metabolic disease: Crigler-Najjar, Rotor, Dubin-Johnson
    • If Unconjugated (Indirect):
      • 1. Increased hemolysis
        • 1. Coombs test (isoimmunization)
          
          • + = Isoimmunization
            • Rh Disease
            • ABO / Rh Incompatibility
        • 2. Polycythemia
          • MC in infants with diabetic mothers
        • 3. Hgb (CBC)
          
          • • + = Blood transfusion
              • twin-twin transfusion
              • maternal baby
              • delayed cord clamping
        • 4. Extravasted blood
          • E.g. cephalohematoma
        • 5. Reticulocyte count
          
          • + = Hemolysis
            • Spherocytosis
            • G6PD disease
            • Pyruvate Kinase Def
          • + = Hemorrhage
            • Hematoma
            • Bleed
      • 2. Increased enterohepatic circulation
        • 1. Breastfeeding jaundice
        • 2. Breast milk jaundice
• Management:
  • 1. placement under a blue light lamp = phototherapy (only for INDIRECT)
    • – converts indirect bili (which is not water-soluble) to water-soluble metabolites that can be excreted in the urine
    • ==> treatment of direct hyperbilirubinemia w phototherapy would turn the child bronze and would not help at all.
    • Phototherapy:
      • use bilirubin app to calculate risk for phototherapy by using hours from birth and amount of bilirubin
      • delivered overhead in a closed crib
      • bili blanket
      • response is dose-dependent: maximal skin surface area is exposed and that interruptions are minimized
  • 2. Children w extremely high bili or w sx of kernicterus require exchange transfusion
  • 3. Infant fed 2-3 hours
  • 4. offer lactation consultant
  • 5. Offering formula after attempted to breastfeed
    • can help decrease bilirubin levels
    • considered on case by case basis 
  • 6. IV not routinely indicated, but considered in newborns who unable to maintain adequate hydration orally or when approaching the transfusion threshold
  • 7. Total serum bilirubin should be re-measured at 4-12 hour intervals
    • it should drop after phototherapy
    • If it does NOT, more extensive dx testing and NICU consult for potential exchange transfusion may be considered
  • 8. if total serum bilirubin level has dropped below the phototherapy threshold and newborn demonstrating good feeding = discharge with next day followup with a pediatrician.
• Rebound bilirubin Testing considered in:
  • Neonates born at gestational age < 38 weeks
  • Phototherapy initiation at < 72 hours of life
  • if there is clinical concern for ongoing hemolysis

Physiologic Jaundice

• Etiology:
  • jaundice of newborn = onset after 72 hours resolves in less than a week.
  • peaks around day 5
  • Increased is unconj. bili and rise is generally less than 5 points/day.
• Management:
  • phototherapy/exchange

Pathologic Jaundice

• Etiology:
  • jaundice = onsent <24 hrs resolves >2 weeks.
  • Increased bili is conjugated and rise is greater than 5 points/day

Crigler-Najar (Gilberts)

1. Path:

• • genetic intrahepatic conditions leading to increased unconjugated bili
    
  • deficient UDP-glucoronyl transferase

Dubin-Johnson (black liver)Rotors

• Path:
  • genetic intrahepatic conditions leading to decreased excretion of bili (increased conjugated bili)

Breast Feeding Jaundice

• Etiology:
  • day 1-7
  • failure to establish adequate breastfeeding / decreased quantity of breast milk
    
    • Reasons:
      • poor milk supply
      • poor latch
      • cracked / painful nipples
      • poor positioning
• Path:
  • Inadequate feeding -> dehydration and inadequate stooling -> decreased clearance of bilirubin via stool
• Management:
  • feed more

Breast Milk Jaundice

• Etiology:
  • -occurs > 7 day old (often 2-4 weeks of life)
• Path:
  • due to B-glucuronidase in breast milk -> promotes enterohepatic circulation
  • decreased breast quality (milk inhibits conjugation)
    
  • -increased unconjugated bili
    
  • (- breast milk inhibits glucuronyl transferase (the conjugation enzyme). This typically does not cause kernicterus. Formula can be temporarily substituted for breast feeding (preferred) or used to supplement breast feeding. == > both are exaggerations of physiologic jaundice! If direct bili is elevated, alternative explanations need to be explored.)
• Management:
  • hydrolyzed formula

Acute Bilirubin Encephalopathy

• Presentation:
  • lethargy
  • hypotonia
  • poor suck
  • irritability
  • high-pitched cry
  • hypertonia
  • fever
  • seizures

Kernicterus

• Etiology:
  • Chronic and permanent sequelae of BIND
• Presentation:
  • Choreoathtoid cerebral palsy
  • hearing loss
  • gaze abnormalities
  • dental enamel dysplasia

Hypoglycemia

• Etiology:
  • Blood sugar concentration that is inadequate to support neurological organ and tissue functions
  • Usually transient (occurs and resolves within 48-72 hrs of birth)
  • Onset within the 1st six hours of life especially if mom had diabetes, long labor, pushing long time
  • GDM may occur later, preterm may be asymptomatic
  • Blood glucose level >40 1st 4 hours of life and <45 hours 4-24
  • Target glucose >/= 45
  • Babies born to diabetic moms have surfactant deficiency
  • First 6hrs after baby is born is all about transition (have to manage temp and blood sugar on own)
    • – High risk time
  • PROLONGED HYPOGLYCEMIA = NEURO DAMAGE
• Presentation:
  • Jittery (tremor, can look like a seizure)
    
  • Irritability
    
  • High-pitched or weak cry
    
  • Poor feeding, poor suck or coordination (automatic lactation nurse)
    
  • Lethargy, hypotonia (floppy rag doll)
    
  • Hypothermia, tachypnea, cyanosis, apnea, seizures
    
  • Maybe asymptomatic (need to check)
• Jitters vs Seizures:
  • Jitters are fine/tremulousness induced by a stimulus that can be stopped with flexion of the extremity
  • Seizures are not stimulus produces, cannot be stopped, may be associated with abnormal gaze or eye movements
  • Jittery part and put hand and stops then that is diagnostic of jitter (can interrupt jitter)
  • Jittering part and put hand and does not stop then seizure (cannot interrupt seizure)
  • Bicycling of legs is sign of seizure
• Risk Factors for Delivery events:
  • Apgar score <5 (distress/problem with apgar score)
    
    • – Low apgar score, baby tends to go through glucose stores faster
      
  • Hypoxic events
    
  • True knots in cord (changes in O2 and ability to get nutrients from mom)
    
  • Nuchal cord (cord wrapped around neck)
    
  • Meconium aspiration
    
  • Antenatal administration of IV Glucose for mom (baby goes into sugar high and crash)
• Risk Factors:
  • Preterm
    
  • LBW
    
  • Infant of diabetic mother
    
  • SGA/LGA
    
  • Sepsis (ill)
    
  • Hypothermia (cold)
    
  • ROUTINELY TEST, CHECK BLOOD SUGAR EVEN IF NOT SHOWING SIGNS AND SYMPTOMS
    
    • – Term babies we do not routinely test
• Late preterm and Hypoglycemia:
  • Late preterm babies do have decrease glycogen stores and lack hepatic enzymes to take care of gluconeogenesis (not able to make glucose well or convert) b/c of immaturity they have challenges of hormonal regulation and insulin secretion and puts them at increased risk for cold stress and eating difficulties
  • COLD STRESS IS CRITICAL TO MANAGE AND AVOID
• Management:
  • IV glucose
    • – A bolus of 2-4ml/kg of D10W
    • – Continuous infusion 80 mL/kg/day
    • – Will quickly rectify the problem but will also have to wean baby off glucose to make sure they can tolerate and take in feedings and can maintain glucose without IV supplementation
    • – Any baby who needs IV glucose goes to NICU b/c high risk and stays in NICU until able to feed well, stabilize blood sugar and temperature
    • – Recheck screen 15-30 min of IV treatment (if greater than 50 continue to evaluate every 30-60 min until stable x2 screens, follow trend)
  • Continue oral feeding
• Current State:
  • Reasonable/arbitrary cut off 40 mg/dL in 1st 4 hours of life
  • 45 mg/dL in hours 4-24
    • – Baby is stabilizing and doing well
  • Feed at-risk infants by the first hour of age
  • Screen 30 min after feeding
  • Continue screening until 12 hrs of age if IDDM (infant of diabetic mother) or LGA
  • Late preterm or SGA at risk for 24 hrs
  • Breastfed infants may tolerate lower glucose w/o negative sequelae
• Preventions:
  • Prevention is best
  • Assess for risk factors
    • – Screen at-risk babies after first feeding and before every feeding after
    • – needs to be >/= 45
  • Maintain temperature (skin to skin)
    • – Hypoglycemia and hypothermia go hand in hand
  • Feed early and often
    • – All infants should be fed within first hour of life (breast or bottle) and feed every 2-3 hrs
• Colostrum vs. Formula:
  • First ingredient in formula is sugar and can create problems with blood sugar stabilization
    
  • Colostrum has protein and sugar and allows for better blood sugar stabilization

Neonatal fever

• Def:
  • centrally mediated rise in body temperature above the normal daily variation
• Path:
  • pathogen makes host cells release endogenous pyrogens that enter circulation and go to the hypothalamus and make it trigger sympathetic chain to vasoconstrict, contract muscles and decrease sweating– all of these things increase body temperature
    when body temp gets too high cytokines stop getting released and the hypothalamus resets and causes vasodilation and sweating which cools the body
• Fever in neonates (0-30 days)
  • >100.4 (38 C)
• Fever in older children
  • >101.1 (38.4 C)
• body temperature throughout the day
  • higher in the late afternoon lower when sleeping
• “normal” temp taken rectally or in-ear: 99.5
• “normal” temp taken orally: 98.2
• “normal” temp taking under armpit: 97.7
• what causes the majority of fevers in children
  • self-limiting viruses
• serious bacterial illnesses we worry about in infants
  • septicemia
    
  • meningitis
    
  • pneumonia
    
  • enteritis
    
  • septic arthritis
    
  • osteomyelitis
    
  • UTI:
• labs that should be done in all neonates (0-30 days) with fever:
  • CBC
    
  • blood culture
    
  • UA, microscopy
    
  • urine culture
    
  • LP
• Management:
  • neonates (0-30 days):
    • ill-appearing infants, well-appearing infants with abnormal labs, immunocompromised
    • Empiric antibiotics: ampicillin and gentamicin (or amp + cefotaxime)
  • 31+ days old:
    • Empiric antibiotics: ceftriaxone +/- vancomycin
  • Antipyretics to give to infants to reduce fever:
    • acetaminophen and ibuprofen
  • Antipyretic can only be given to kids over 6 months:
    • ibuprofen

Routine newborn care

Fluid and electrolyte disorders

High Risk Newborns