Newborn Emergencies



Newborn Emergencies


Suzan Schneeweiss



Introduction



  • Need to distinguish between benign conditions/normal variants and critical neonatal illness


  • Signs and symptoms of critical neonatal illness often nonspecific



    • Red flags: poor feeding, vomiting, lethargy, cyanosis, apnea, seizures, hypo/hyperthermia, excessive weight loss








Table 11.1 Normal Variants















Uric acid crystals in diaper


  • Appearance: red brick dust



  • Differentiate from blood: negative urine dipstick or guaiac test


Harlequin sign


  • 5% of newborns; upper half of body appears pale and dependent half turns deep red



  • Transient phenomenon lasting seconds to minutes and is altered by changing position of baby



  • If episodes beyond 4 wks, consider CV abnormalities


Transient cutis marmorata


  • Mottling or marbling of skin accompanies acrocyanosis and occurs when infant is cold


Breast tissue hypertrophy


  • May be seen in both males and females during first postnatal week; may remain enlarged well into first year



  • Do not squeeze as this often leads to abscess formation











Table 11.2 Benign Conditions


















Cephalohematoma


  • Becomes more apparent and increases in size several days after birth; resolves spontaneously


Nasal congestion or stuffiness


  • Mucous membrane swelling from repetitive suctioning of nose



  • Unilateral usually associated with deformity of nose which resolves spontaneously



  • Consider an acute viral infection and congenital syphilis: “snuffles”


Fractured clavicle


  • Superficial swelling and loss of normal distinct edge of clavicle


Torticollis


  • Fibrotic shortening of sternocleidomastoid muscle resulting from hemorrhage within muscle belly at time of birth



  • Infant holds head to one side; 1-3 cm swelling on contralateral side of neck



  • Treatment: range of motion exercises


Umbilical granulomas


  • Hypertrophic granulation tissue at base of stump



  • May have serosanguinous drainage



  • Differential diagnosis: umbilical polyp (urachal or omphalomesenteric duct anomaly)



  • Treat with cauterization with silver nitrate stick or double ligature technique to surgically remove









Table 11.3 Transient Benign Cutaneous Lesions





















Milia


  • Common; due to retention of keratin and sebaceous material in pilosebaceous unit



  • 1-3 mm whitish papules on nose, cheeks, upper lip, and forehead; disappear spontaneously in first month of life


Sucking blisters


  • Bullae found on thumb, index finger, dorsum of hand or wrist; secondary to continued sucking in utero


Neonatal acne


  • 20% of infants; appears after 1-2 weeks, resolves spontaneously within 6 months



  • Inflammatory papules and pustules


Erythema toxicum neonatorum


  • 20-60% newborns; onset 24-72 hours of life



  • Erythematous macules, papules, wheals, vesicles, and pustules; evanescent waxing and waning appearance; disappear within 2 weeks


Transient neonatal pustular melanosis


  • Vesiculopustular lesions that rupture in a few days leaving well demarcated 2-3 mm hyperpigmented lesions with a collarette of scale that fades to hyperpigmented macules; disappear within weeks to months



  • More common in African-American newborns (2-5%)



  • No treatment required


Miliaria


  • Due to obstruction of sweat glands



  • Miliaria crystalline: 1-2 mm grouped flaccid vesicular lesions with no associated erythema



  • Miliaria rubra (prickly heat): confluent tiny, scaly, erythematous papules or papulovesicular lesions



  • Avoid excessive heat, occlusive clothing or devices




Cutaneous Lesions Requiring Treatment


Staphylococcal pyoderma



  • Due to Staphylococcus aureus colonization in first few weeks of life


  • Vesicles, pustules, and bullae arising on normal or slightly erythematous skin; bullae rupture easily to leave superficial erosion with a collarette of scale


  • Common sites: periumbilical region, neck folds, axillae, and diaper area


  • Diagnosis: Gram stain and culture of contents of bullae or pustule


  • Treatment: topical antibiotic ointment if localized, but most infants require oral therapy with cloxacillin or a cephalosporin


Staphylococcal Scalded Skin Syndrome



  • Due to endotoxin from certain Staphylococcus aureus strains


  • Onset between 3-7 days with fever, irritability, cutaneous tenderness and erythema; flaccid bullae that rapidly denude on erythematous base


  • Nikolsky sign: rubbing of skin causes skin separation


  • Treatment: intravenous cloxacillin


Neonatal Candidiasis



  • Due to C. albicans often in first weeks of life; often involves diaper area and oral mucosa (thrush)


  • Erythematous scaly patches with characteristic satellite papules and pustules


  • Topical therapy with an imidazole cream for skin rash


Herpes Neonatorum



  • HSV 1 or 2; 80% due to HSV 2—poorer prognosis


  • Route of transmission usually occurs during delivery (85%), but may occur in utero (5%) or postnatally (10%)


  • Highest risk of transmission in pregnant women with primary infection in third trimester (50%)



  • May occur in absence of skin lesions; need high index of suspicion


  • 60-80% of infected infants born to mothers with no history of genital herpes


Clinical Manifestations


SEM: skin, eye, mouth



  • Presents at ˜ day 10-11


  • Discrete vesicles and keratoconjunctivitis


  • Risk of neurologic impairment 30-40% if do not receive antiviral therapy


  • 75% progress to either CNS or disseminated disease without antiviral treatment; therefore, all require aggressive treatment


CNS disease (encephalitis)



  • May present with seizures (50%), lethargy, irritability, tremors, poor feeding, temperature instability, bulging fontanelle, and pyramidal tract signs


  • CSF culture positive in 25-40%; generally have proteinosis and pleocytosis (50-100 WBC/mm3) with predominantly mononuclear cells


  • 40% do not have cutaneous vesicles at presentation


  • High incidence of morbidity and mortality despite treatment


Disseminated disease



  • Present generally at day 9-11 of life


  • Multiple organ involvement and signs: irritability, seizures, respiratory distress, jaundice, bleeding diatheses, shock, and often vesicular rash


  • 22% of HSV-infected neonates


  • 70% survival with treatment; 15% neurologic abnormalities


Investigations



  • Look for disseminated infection (visceral) and CNS disease



    • CBC, LFTs, LP with CSF (including PCR), CXR (respiratory symptoms)



    • Viral culture from skin, conjunctiva, mouth and throat, rectum, urine


    • PCR assays more sensitive than culture for neurologic infection


Treatment



  • Intravenous acyclovir for 14-21 days (21 days if CNS involvement or disseminated disease)


  • Monitor neutrophil count if receiving IV acyclovir (neutropenia)


Infantile seborrheic dermatitis



  • Self-limited inflammatory condition, usually appears within 3-8 weeks of life


  • Well-demarcated areas of erythema covered by greasy scale over scalp (cradle cap), face, diaper area, trunk, and proximal flexures


  • Treatment: olive oil to loosen scales on scalp and mild topical hydrocortisone cream or ointment to involved areas


Jaundice



  • Imbalance between production and elimination of bilirubin


  • Occurs in 60-70% of term infants and most premature infants


  • Visual estimation of degree of jaundice poor


  • Severe jaundice and kernicterus can occur in full-term healthy newborns with no apparent hemolysis or any cause other than breastfeeding


  • Increased risk of kernicterus with G6PD deficiency


Clinical Evaluation



  • Assess adequacy of breastfeeding



    • Weight loss (average 6.1% by day 3)


    • Urine output (4-6 wet diapers) and 3-4 stools/day


  • Acute bilirubin encephalopathy



    • Clinical neurologic findings caused by bilirubin toxicity



    • Early phase: lethargy, hypotonia, poor feeding


    • Intermediate phase: stupor, irritability, and hypertonia; fever, high-pitched cry; may alternate with drowsiness and hypotonia


    • Late phase: pronounced retrocollis-opisthotonos, shrill cry, no feeding, apnea, fever, deep stupor to coma, seizures → death


Major Risk Factors for Jaundice

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Jun 22, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Newborn Emergencies

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