Paediatrics Marrow Pg 11-20 (Neonatology)

Sepsis Algorithm

• Early Onset Sepsis (Age < 72 hrs):
  • Risk Factors Present: Start antibiotics, blood culture, close monitoring.
  • Symptoms Present (Lumbar Puncture): Perform LP.
  • Symptoms Absent (Lumbar Puncture): No LP.
• Late Onset Sepsis (Age > 72 hrs):
  • Risk Factors Present:
    • Symptoms Present: Close monitoring, antibiotics, blood culture, lumbar puncture.
    • Symptoms Absent: Close monitoring.
  • Risk Factors Absent:
    • Not Sick: Sepsis screen.
    • Sick Baby: Sepsis screen.

Spectrum of neonatal sepsis

• Generalized/Septicemia:
  • Respiratory System: Pneumonia.
  • CNS: Meningitis.
  • Bones & Joints: Osteomyelitis, Arthritis.
• Localized/Specific:
  • Respiratory System: Pneumonia.
  • CNS: Meningitis.
  • Bones & Joints: Osteomyelitis, Arthritis.

Early Onset Sepsis

• Source of Infection: Chorioamnionitis, infection of maternal genitalia (foul-smelling liquor), rupture of membranes over 72 hours (Pneumonia > Sepsis).
• Risk Factors: Unclean hands of health professionals and caregivers, low birth weight (LBW) → reduced immunity, lack of breastfeeding.

Late Onset Sepsis

• Source of Infection: Hospital acquired infection, unclean hands of health professionals and caregivers, low birth weight (LBW) → reduced immunity, lack of breastfeeding.

Organisms Implicated

• India: Klebsiella (most common), Acinetobacter, S.aureus.
• Worldwide: Group B Streptococcus (GBS), E.coli, Listeria.

Symptoms

• Non-specific symptoms: Suspect sepsis in any sick baby due to weak immune response.
• Recognized Symptoms (Early symptoms): Change in feeding pattern, lethargy, hypothermia → fever, pneumonia, respiratory distress.
• Signs Specific to Organ Systems: Meningitis: Fever and irritability (non-specific), seizures.

Management

• Investigations:
  • Blood culture: Gold standard, time-consuming.
  • Sepsis screen: Presence of >2 findings.
  • Lumbar puncture (Indication): Suspicion of meningitis in all symptomatic babies.
• Empirical antibiotics (while awaiting culture reports):

• Duration of treatment:
  • Culture negative: 5-7 days (1 week).
  • Culture positive: 3 weeks.
  • Others: 2 weeks.

Components and Values in Sepsis

• Newest marker for neonatal screening: Increased procalcitonin.

Neonatal Jaundice

• Incidence: Seen in up to 60% of newborns.
• Pathological: 5-10% (require treatment).
• Physiological: Majority (no treatment required).

Bilirubin Metabolism

• Breakdown of RBCs: Haem → Biliverdin → Unconjugated bilirubin (water insoluble)
• Unconjugated bilirubin: Conjugated bilirubin (in liver) (water soluble).
• Conjugated bilirubin: Through bile duct → intestines.
• Stercobilinogen (in colon): 90% Excreted in stools.
• Urobilinogen: 10% Excreted in urine.
• Enterohepatic circulation:

Assessment of Jaundice

• Serum Bilirubin Levels: Best investigation, Bilirubin values: Total serum bilirubin (TSB).
• Screening of Baby: Initial clinical assessment, Kramer method: Visual assessment.

Kramer Zones

Respiratory Distress in Newborn

• Respiratory rate: Increased (>60 breaths/min.), normal newborn respiratory rate: 40-60 breaths/min.
• Chest retraction: Due to involvement of accessory respiratory muscles.
• Severe hypoxia: Seen in severe cases.
  • Manifestations: Central cyanosis (involves mucosa), Grunting (expiration against a partially closed glottis → prevents airway/alveolar collapse).

Monitoring of Respiratory Distress

Scoring Systems

Silverman Anderson Score (Used for Preterm Babies)

Downe's Score (Used for Term & Preterm Babies)

Necrotizing Enterocolitis & Neonatal Sepsis

Features

Imaging

Management

• Triad of lab findings: Seen only after stage II b. Do not have great relevance in diagnosis.
• Until stage III a: Medical management - Nil per oral (NPO), total parenteral nutrition (TPN), IV antibiotics:
  • Penicillin + Aminoglycosides + metronidazole (Gram+ve) (Gram-ve) (Anaerobes).
• Stage III b:
  • Hemodynamically unstable: Peritoneal drainage (Emergency procedure).
  • After stabilization: Laparotomy → Resection & Anastomosis.
• Untreated: m/c cause of neonatal mortality.
• Duration of antibiotics:
  • Stage Ia: 3 days.
  • Stage Ib: 7-10 days.
  • Stage II, III a: 14 days.

Causes of Respiratory Distress

Respiratory Distress (Onset within 6 hours of birth)

• Transient tachypnea of newborn (m/c overall).
• Respiratory distress syndrome.
• Meconium aspiration syndrome.

Transient Tachypnea of Newborn (TTNB): (AKA wet lung syndrome)

• Most common in: Term neonates, neonates delivered by lower segment caesarean section (LSCS).

Pathogenesis

• Inadequate stimulation and compression at birth canal.
• Delayed clearance of lung fluids.

Chest X-ray findings

• Perihilar radio-opaque streaks.
• Fluid in the hilum of the lung moves into bronchovascular structures.
• White streaks on X-ray (AKA sunburst appearance).
• Fluid in the interlobar fissure.

Management

• Supportive management (O2 inhalation) - Sufficient as it is transient.
• Improvement seen in 48-72 hours.

Respiratory Distress Syndrome: (AKA hyaline membrane disease (HMD))

• Most common in: Preterm babies ( # Meconium Aspiration Syndrome (MAS)

Pathogenesis

• Post-term baby (>42 weeks).
• IUGR baby.
• Birth stress.
• Meconium expulsion before birth.
• Aspiration of meconium-stained liquor (MSL).

Consequences of MAS

• Atelectasis: Due to complete airway obstruction.
• Air trapping: Difficulty expiring air due to partial airway obstruction.
• Hyperinflation of lung/obstructive emphysema:
• Chemical pneumonitis: Inflammatory response to meconium.
• Inactivation of surfactant:
• Impaired gas exchange:
• Hypoxia, hypercapnia:
• Chronic pulmonary vasoconstriction:
• Persistent pulmonary hypertension (PPHN):

Chest X-ray findings

• Infiltrates in lung fields, seen in chemical pneumonitis.

Diagnosis

• MAS is diagnosed by exclusion, with a history of meconium-stained liquor.

Management

• Supportive management: Oxygen (O2) inhalation, Continuous Positive Airway Pressure (CPAP).
• Mechanical ventilation (severe cases).
• Inhaled nitric oxide (iNO): Pulmonary vasodilator to treat PPHN.

Congenital Diaphragmatic Hernia (CDH)

Pathogenesis

• Anatomical defect in the diaphragm.

Clinical Features

• Respiratory distress: Lung compression in the uterus due to movement of intestines into the mediastinum.
• Pulmonary hypoplasia.

Types of Diaphragmatic Hernias

• Morgagni: Antero-medial diaphragm.
• Bochdalek (most common): Posterolateral diaphragm.
• (Note: The image description is included here but it was not possible to convert the diagram into a table or format it as intended.)*

Clinical Presentation

• Mediastinal shift: Heart sound heard on the right side.
• Sunken/scaphoid abdomen.

Investigations

• USG (Antenatal):
• Chest X-ray (Postnatal): Intestinal air shadows (air-filled bubble-shaped shadows due to bowel), absent diaphragm shadows on the affected side.

Management

• If the baby does not cry at birth: Resuscitation.
• If the baby cries at birth:
  • Medical management (First 48 hours): Intestinal decompression via NG tube → Lung compression, mechanical ventilation via endotracheal tube → Lung expansion.
  • Surgical management ( >48 hours): Hernia repair.

Contraindications

• Congenital diaphragmatic hernia (CDH): Absolute contraindication for bag and mask ventilation. Cause: Forceful entry of air into the esophagus → Inflation of bowel loops → Further compression of lungs.

Prognostic Factors of CDH

• Antenatal USG:
  • Lung-head ratio (LHR): < 1: Bad prognosis.
• Postnatal:
  • PPNH (most important): Bad prognosis.
  • Onset of respiratory distress < 24 hours: Bad prognosis.
  • Presence of liver in the thorax: Bad prognosis.
  • Unaffected lung to be considered.
• (Note: This document describes congenital diaphragmatic hernia (CDH) in newborns, including its presentation, investigations, management, contraindications, and prognostic factors. A chest X-ray image is part of this assessment.)*

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