Neonatal Conditions

Transient Tachypnoea of the New-born (TTN)

This is a condition which is the most common cause of respiratory distress in babies.

– In the fetus, the lungs are filled with fluid, however this normally gets squeezed out during vaginal birth and the remainder gets absorbed shortly after birth into the bloodstream.

– The problem arises when there is a delay in the reabsorption of lung fluid, which “drowns” lungs

– A risk factor is C-section delivery (as fluid is not squeezed out of the lungs)

Symptoms:

– Respiratory distress (tachypnoea, tachycardia, breathlessness)

Diagnosis:

– Diagnosis of exclusion once other more serious conditions have been ruled out

– CXR –> shows hyperinflated lungs with fluid in individual lung lobes

Management:

– Give oxygen to maintain O₂ saturations

– Usually, it is a self-resolving condition as the fluid is absorbed into blood within days

Meconium Aspiration Syndrome

This is a condition which is caused by the foetus aspirating its meconium (first stool that the foetus passes)

– The meconium is a lung irritant and can lead to mechanical obstruction and chemical pneumonitis

Symptoms:

– Respiratory distress (tachypnoea, breathlessness, coughing) and hypoxia

– Risk factor for developing persistent pulmonary hypertension of the Newborn

– May also develop pneumonia and sepsis

Diagnosis:

– Can be diagnosed if you see baby with respiratory distress in infant born in dark meconium stained amnionic fluid

Management:

– Respiratory support (with mechanical ventilation) with anti-inflammatories/pulmonary dilators if pulmonary hypertension

Persistent Pulmonary Hypertension of the New-born (PPHN)

This is a condition which causes pulmonary hypertension in neonates.

– It is caused by failure of the pulmonary circulation to undergo the normal transition after birth

– There is sustained high pulmonary vascular resistance after birth which leads to pulmonary hypertension

– This can cause right-to-left shunting across persistent foetal shunts (PFO, PDA) and thus hypoxia

Causes:

– Primary –> idiopathic

– Secondary –> after birth asphyxia, meconium aspiration, sepsis

Symptoms:

– Gives cyanosis soon after birth

– Can lead to chronic lung disease leading to respiratory distress

– Increased incidence of hospital acquired infections

Test:

– Echocardiogram shows high pulmonary resistance

Management:

– Oxygen therapy (with mechanical ventilation) and pulmonary vasodilators to reduce resistance

Jaundice of the new-born

This refers to yellowing of the skin which occurs in 50% of all new-born infants

– It occurs as there is marked physiological release of Haemoglobin from RBC breakdown because of the high haemoglobin concentration at birth

– In addition, the RBC lifespan of neonates is shorter than that of adults (70d v 120d)

– Also, hepatic bilirubin metabolism is less efficient in the first few days of life

– It is also more common in breastfed-babies

Diagnosis:

– Measure serum bilirubin level (blood test or transcutaneous bilirubinometer)

– The level is then plotted on a chart to see whether need to treat

Management:

Need for treatment and treatment options are determined using charts of the bilirubin level

– If below treatment line –> encourage feeds, avoid dehydration, and give support for breastfeeding

– If above treatment line –> 1st line is phototherapy (makes bilirubin water soluble to stop it crossing BBB)

–> 2nd line is exchange transfusion (removing baby’s blood and replace with donor)

Sudden infant death syndrome (SIDS)

This is the sudden unexplained death of a child <1-year-old, which occurs due to an unknown reason.

– It usually occurs during sleep, between the hours of midnight and 9am and is known as “cot-death”

– Whilst the exact cause is unknown, there are many risk factors which contribute to the syndrome

– In addition, certain factors like sharing the room with the baby and breastfeeding are known to be protective

Risk factors:

These are additive and together can give a much higher risk of death

– Infant –> Low birth weight, prematurity, male sex

– Parents –> Parental smoking, multiple births, maternal drug use, young mother <21 years old

– Environment –> Putting the baby to sleep prone (instead of on back)

– Bed sharing, infant pillow use

– Hyperthermia (over-wrapping) or head covering)

Diagnosis:

– It is a diagnosis of exclusion.

– Can only be diagnosed if the death remains unexplained after an autopsy, finding out the medical history of patient and family and investigation the death scene.

Management:

– After death, families are offering emotional support and grief counselling

Symptoms:

– Pulmonary hypoplasia –> causes respiratory distress (SOB, cyanosis)

– Poor air entry into the left chest

– Raised blood pressure

– Apex beat and heart sounds displaced to right

Diagnosis:

– X-ray chest and abdomen shows loops of bowel in the chest:

Management:

– NG tube (suction of bowel contents) and intubation to secure airway

– Surgical correction is required

Hypoglycaemia

This refers to a low glucose level, generally considered as <2.6mM in the bloodstream

– A transient drop in blood glucose is commonly seen after birth as part of the adaptation to postnatal life

– Even term babies often get hypoglycaemic in the first 24 hours without any complications

– However, severe or prolonged hypoglycaemia may result in long-term neurological damage

Risk factors:

– Prematurity, infection, diabetic mothers, IUGR and macrosomia

Symptoms:

– Can be asymptomatic

– Can cause irritability, lethargy, apnoea, grunting, sweating, seizures

Management:

– If mild –> promote breast or bottle feeding

– If severe –> IV 10% dextrose

Haemorrhagic Disease of the new-born

This is a condition which causes bleeding in the neonate due to vitamin K deficiency.

– Vitamin K is needed as it is a cofactor for the carboxylation and maturation of various clotting factors

– It can lead to a spectrum of disease from minor bruising to large haemorrhages which can be seen up to 8 weeks after birth

Risk factors:

– Liver disease

– Maternal antiepileptic therapy –> these impair synthesis of vitamin K-dependent clotting factors

– Breast fed babies –> the breast milk is a poor source of Vitamin K

Symptoms:

These can occur up to 8 weeks after birth

– Bruising

– Haematemesis and melaena

– Potential intracranial haemorrhage

Management:

– IM Vitamin K and fresh frozen plasma if severe bleeding

Prevention:

– Vitamin K is offered all infants immediately after birth, usually as single IM injection

– Mothers on antiepileptics should receive oral prophylaxis from 36 weeks’ gestation