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Mohamed Khashaba, MD
Professor of Pediatrics /Neonatology
Director of NICU
Mansoura University
A 38-week gestation baby with a birth A 38-week gestation baby with a birth
weight of 3.2 kg developed cyanosis and weight of 3.2 kg developed cyanosis and
respiratory distress at 15 min of life.respiratory distress at 15 min of life.
He was ventilated and put on IV He was ventilated and put on IV
dextrose infusion and was pink and stable dextrose infusion and was pink and stable
on ventilator.on ventilator.
Case (1)Case (1)
M.Khashaba,MD professor of Pediatrics,Mansoura
Ventilator settings – pressure Ventilator settings – pressure 20/320/3
Inspiratory time- 0.4 secInspiratory time- 0.4 sec Ventilatory rate – 40/minVentilatory rate – 40/min
M.Khashaba,MD professor of Pediatrics,Mansoura
ABG was done about 20 ABG was done about 20
minutes after ventilation minutes after ventilation
showed:showed:
pH – 7.3pH – 7.3
POPO22 – 60 mm Hg (7.8 k Pa) – 60 mm Hg (7.8 k Pa)
PCOPCO22 – 35 mm Hg (3.9 k Pa) – 35 mm Hg (3.9 k Pa)M.Khashaba,MD professor of Pediatrics,Mansoura
The baby was pink, but at 10 The baby was pink, but at 10
hours of life the baby suddenly hours of life the baby suddenly
became blue and limp. Management became blue and limp. Management
was instituted and within 5 minutes was instituted and within 5 minutes
he was back to his activity again.he was back to his activity again.
M.Khashaba,MD professor of Pediatrics,Mansoura
Give 4 possible causes for the Give 4 possible causes for the
sudden deterioration of the infant.sudden deterioration of the infant.
M.Khashaba,MD professor of Pediatrics,Mansoura
DOPEDOPE DD-dislodged tube-dislodged tube
OO-Obstructed tube-Obstructed tube
PP-Pneumothorax-Pneumothorax
EE-Equipment malfunction-Equipment malfunction
M.Khashaba,MD professor of Pediatrics,Mansoura
A 4-day-old, exclusively breast fed A 4-day-old, exclusively breast fed
baby was noted to be pale, with heart rate baby was noted to be pale, with heart rate
of 180 with gallop rhythm, palpable liver of 180 with gallop rhythm, palpable liver
of 2 cm and black sticky stools. of 2 cm and black sticky stools.
Case (2)Case (2)
M.Khashaba,MD professor of Pediatrics,Mansoura
Baby was born in an ambulance, Baby was born in an ambulance,
from where she was transferred to post-from where she was transferred to post-
natal ward. natal ward.
Pregnancy was uneventful, but Pregnancy was uneventful, but
delivery was quick. This was mother’s delivery was quick. This was mother’s
fourth child. fourth child.
Baby was discharged home after 24 Baby was discharged home after 24
hourshoursM.Khashaba,MD professor of Pediatrics,Mansoura
A.A. What 2 investigations would you do What 2 investigations would you do
to establish your suspected diagnosis?to establish your suspected diagnosis?
B.B. What is the first therapeutic What is the first therapeutic
intervention would you undertake ?intervention would you undertake ?
C.C. What is the diagnosis ?What is the diagnosis ?
M.Khashaba,MD professor of Pediatrics,Mansoura
A. CBS, Coagulation study.A. CBS, Coagulation study. B. Blood transfusion,Fresh B. Blood transfusion,Fresh
frozen plasma.frozen plasma. C. Hemorrhagic Disease of C. Hemorrhagic Disease of
Newborn.Newborn.
Clue: exclusive breast fed baby.Clue: exclusive breast fed baby. Fresh frozen plasma and not Fresh frozen plasma and not
vitamin K is effective to stop vitamin K is effective to stop bleeding.bleeding.
M.Khashaba,MD professor of Pediatrics,Mansoura
A 6-month-old girl presents with A 6-month-old girl presents with two-month history of failure to two-month history of failure to gain weight and dehydration.gain weight and dehydration.
Sodium – 128Sodium – 128 Potassium – 3.2Potassium – 3.2 Urea – 7Urea – 7 Bicarbonate – 11Bicarbonate – 11
Which single investigation is Which single investigation is urgently needed?urgently needed?
Case (3)Case (3)
M.Khashaba,MD professor of Pediatrics,Mansoura
Serum 17-Serum 17-
hydoxyprogesterone assayhydoxyprogesterone assay
Salt losing crisis with Salt losing crisis with
acidosis is a common feature acidosis is a common feature
of Congenital Adrenal of Congenital Adrenal
hyperplasia.hyperplasia.M.Khashaba,MD professor of Pediatrics,Mansoura
A 1 1/2 -year-old child presents with A 1 1/2 -year-old child presents with mild diarrhea and not putting on mild diarrhea and not putting on weight.weight.
Na – 128Na – 128 K – 3.5K – 3.5 Cl – 98Cl – 98 HCO3 – 11HCO3 – 11 Urea – 24Urea – 24 Serum osmolality – 330Serum osmolality – 330
What other biochemical investigations What other biochemical investigations you need urgently?you need urgently?
Case (4)Case (4)
M.Khashaba,MD professor of Pediatrics,Mansoura
Blood sugarBlood sugarDiabetic ketoacidosis is Diabetic ketoacidosis is the likely diagnosis.the likely diagnosis.
M.Khashaba,MD professor of Pediatrics,Mansoura
Serum osmolality in mOsm/kg =Serum osmolality in mOsm/kg =
[Serum Na[Serum Na++ (mEq/L) + K (mEq/L) + K + + (mEq/L)(mEq/L) χχ 2] + 2] +
Glucose mg/dLGlucose mg/dL
++BUN mg/ dLBUN mg/ dL
181833
M.Khashaba,MD professor of Pediatrics,Mansoura
Case (5)Case (5)
M.Khashaba,MD professor of Pediatrics,Mansoura
Nevus flammus in the region of 1Nevus flammus in the region of 1stst
branch of Trigeminal nerve is usually branch of Trigeminal nerve is usually
associated with cortical brain lesion associated with cortical brain lesion
(ophthalmic area).(ophthalmic area).
Brain imaging & eyes evaluation are Brain imaging & eyes evaluation are
requiredrequired..
Sturge Weber Sturge Weber syndromesyndrome
M.Khashaba,MD professor of Pediatrics,Mansoura
Case (6)Case (6)
M.Khashaba,MD professor of Pediatrics,Mansoura
Pilonidal dimple & Pilonidal dimple & sinussinus
DimpleDimple:: D Depression in the skin.epression in the skin.
Sinus:Sinus: Connected to deeper structures in Connected to deeper structures in
sacral area.sacral area.
Cyst:Cyst: Forms at puberty when hair grows in Forms at puberty when hair grows in
the depth of the sinus occasionally gets the depth of the sinus occasionally gets
infected & needs excision. infected & needs excision.
M.Khashaba,MD professor of Pediatrics,Mansoura
Case (7)Case (7)
M.Khashaba,MD professor of Pediatrics,Mansoura
Preauricular Sinus Preauricular Sinus & tag& tag
Remnant of the first branchial Remnant of the first branchial cleft.cleft.
In the most anterior upper In the most anterior upper portion of the tragus of portion of the tragus of external ear.external ear.
An isolated anomaly , may be An isolated anomaly , may be bilateral.bilateral.
No treatment except if infectedNo treatment except if infectedM.Khashaba,MD professor of Pediatrics,Mansoura
Case (8)Case (8)
M.Khashaba,MD professor of Pediatrics,Mansoura
Sucking blistersSucking blisters Present at birthPresent at birth
Usually on a hand or wristUsually on a hand or wrist
Prenatal U/S: fetus sucks in Prenatal U/S: fetus sucks in
utero any part that comes easily utero any part that comes easily
to his mouthto his mouth
M.Khashaba,MD professor of Pediatrics,Mansoura
Case (9)Case (9)
M.Khashaba,MD professor of Pediatrics,Mansoura
Subcutaneous Fat Subcutaneous Fat NecrosisNecrosis
More common in Asphyxiated babies Multiple firm non-tender
subcutaneous nodules or large plaques that appear one to four weeks after birth.
Commonly affect the cheeks, buttocks, back, and limbs.
It often occurs over bony prominences. The anterior trunk tends to be spared.
M.Khashaba,MD professor of Pediatrics,Mansoura
Subcutaneous Fat Subcutaneous Fat NecrosisNecrosis
The overlying skin may be erythematous.
Lesions may become fluctuant as fat liquefies; some become calcified.
It usually resolves completely within 1-2 months, although it may persist up to 6 months, especially when lesions are calcifiedM.Khashaba,MD professor of Pediatrics,Mansoura
Case (10)Case (10)
Fever in a 1 month Fever in a 1 month aged babyaged baby
A 1- month- old infant was A 1- month- old infant was brought to the physician by his brought to the physician by his parents because of a fever 38c parents because of a fever 38c (taken rectally) earlier that (taken rectally) earlier that morning. He had no associated morning. He had no associated symptoms of cough, runny nose, symptoms of cough, runny nose, vomiting, diarrhea, or unusual vomiting, diarrhea, or unusual fussiness. He was bottle-fed , and fussiness. He was bottle-fed , and his mother had noticed that he was his mother had noticed that he was taking a little less than usual. His taking a little less than usual. His urination had decreased. urination had decreased. M.Khashaba,MD professor of Pediatrics,Mansoura
The obstetrical and birth histories The obstetrical and birth histories
were unremarkable, and infant had were unremarkable, and infant had
been well until now. The parents had been well until now. The parents had
been about to leave town to visit been about to leave town to visit
relatives for their summer vacation relatives for their summer vacation
but changed their plans. but changed their plans.
M.Khashaba,MD professor of Pediatrics,Mansoura
1.1. Are there any other questions Are there any other questions
the physician should ask the the physician should ask the
parents while taking the parents while taking the
history?history?
Exposure to illness in the family Exposure to illness in the family
and other contacts.and other contacts.
M.Khashaba,MD professor of Pediatrics,Mansoura
2.2. What should be the physician’s What should be the physician’s
issue of concern? issue of concern?
Whether the infant may have a Whether the infant may have a
serious bacterial infection, serious bacterial infection,
particularly bacteremia or particularly bacteremia or
meningitis.meningitis.
How to proceed with the patient’s How to proceed with the patient’s
management while attempting to management while attempting to
exclude serious infections.exclude serious infections.M.Khashaba,MD professor of Pediatrics,Mansoura
Physical ExaminationPhysical Examination
The infant’s rectal The infant’s rectal temperature in the office was 38 c. temperature in the office was 38 c. Other vital signs were normal. He Other vital signs were normal. He was slightly fussy on examination. was slightly fussy on examination. His color was good, and he did not His color was good, and he did not seem to be in severe distress. The seem to be in severe distress. The anterior fontanelle was soft. Tone, anterior fontanelle was soft. Tone, cry, and suck were normal, and cry, and suck were normal, and Moro’s reflex was intact. Moro’s reflex was intact.
M.Khashaba,MD professor of Pediatrics,Mansoura
Physical ExaminationPhysical Examination
The rest of the examination, The rest of the examination, including head, eyes, ears, nose, including head, eyes, ears, nose, throat (HEENT), neck, heart, throat (HEENT), neck, heart, lungs, abdomen, extremities, lungs, abdomen, extremities, skin, and external genitalia, were skin, and external genitalia, were unremarkable.unremarkable.
M.Khashaba,MD professor of Pediatrics,Mansoura
3)3) What are your management options?What are your management options? Admit the patient, perform a septic Admit the patient, perform a septic
workup, and initate antibiotic therapy workup, and initate antibiotic therapy pending the results of the septic pending the results of the septic workup.workup.
Admit the patient, perform a septic Admit the patient, perform a septic workup, and observe the infant in the workup, and observe the infant in the hospital.hospital.
The parents may observe the infant at The parents may observe the infant at home with close follow-up. home with close follow-up.
M.Khashaba,MD professor of Pediatrics,Mansoura
4.4. What laboratory tests or studies What laboratory tests or studies should be ordered to exclude a should be ordered to exclude a serious bacterial infection, including serious bacterial infection, including bacteremia and meningitis?bacteremia and meningitis?
A complete blood count, urinalysis, A complete blood count, urinalysis, urine culture, blood culture, lumbar urine culture, blood culture, lumbar puncture, and chest x-ray included puncture, and chest x-ray included if the infant has respiratory if the infant has respiratory symptoms and signs.symptoms and signs.
M.Khashaba,MD professor of Pediatrics,Mansoura
5.5. What bacterial pathogens are likely What bacterial pathogens are likely to be encountered in a 1-month-old to be encountered in a 1-month-old infant with sepsis or bacterial infant with sepsis or bacterial meningitis or both?meningitis or both?
Group B streptococci, listeria Group B streptococci, listeria monocytogenes, and Ecoli are the monocytogenes, and Ecoli are the pathogens most often encountered pathogens most often encountered in neonates.in neonates.
M.Khashaba,MD professor of Pediatrics,Mansoura
6.6. Which antibiotic should be chosen Which antibiotic should be chosen
for initial coverage and why?for initial coverage and why?
Intravenous ampicillin and Intravenous ampicillin and
gentamicingentamicin
M.Khashaba,MD professor of Pediatrics,Mansoura
Low risk criteriaLow risk criteria
Absence of infection in the Absence of infection in the Bone,joint Bone,joint
No major respiratory or No major respiratory or cardiovascular problems.cardiovascular problems.
WBC 5000-15000/mm3.WBC 5000-15000/mm3. Band count < 1500/mm3Band count < 1500/mm3 Normal urine analysis.Normal urine analysis.
M.Khashaba,MD professor of Pediatrics,Mansoura
A male baby was born as A male baby was born as preterm. He was delivered preterm. He was delivered vaginally. The birth weight of vaginally. The birth weight of the baby was 1.4kg. Gestational the baby was 1.4kg. Gestational age corresponded to 32 weeks. age corresponded to 32 weeks. The Apgar score was 4 at one The Apgar score was 4 at one minute and 6 at five minutes.minute and 6 at five minutes.
Case (11)Case (11)
M.Khashaba,MD professor of Pediatrics,Mansoura
He developed RD and was He developed RD and was referred to neonatal intensive referred to neonatal intensive care unit . He started care unit . He started improving without assisted improving without assisted ventilation. ventilation.
Standard low birth weight Standard low birth weight formula feed was given on formula feed was given on third day of life. third day of life.
M.Khashaba,MD professor of Pediatrics,Mansoura
On the eighth day, distension of On the eighth day, distension of the abdomen was noted. Abdomen the abdomen was noted. Abdomen was painful on palpation. Feeding was painful on palpation. Feeding chart showed the presence of 5 ml chart showed the presence of 5 ml of residual milk from the last of residual milk from the last feeding. feeding.
Nurse in charge noticed that Nurse in charge noticed that higher incubator temperature was higher incubator temperature was required to maintain body required to maintain body temperature.temperature.
M.Khashaba,MD professor of Pediatrics,Mansoura
A low birth weight baby was A low birth weight baby was lying sick in the incubator.lying sick in the incubator.
Features of IUGR were Features of IUGR were present. There was distension of present. There was distension of the abdomen. Anthropometric the abdomen. Anthropometric measurements included the length measurements included the length 45 cm (345 cm (3rdrd centile), the weight 1.3 centile), the weight 1.3 kg, and the head circumference kg, and the head circumference was 32 cm. was 32 cm.
M.Khashaba,MD professor of Pediatrics,Mansoura
Activity of the baby was not Activity of the baby was not
satisfactory. He was a febrile. satisfactory. He was a febrile.
The heart rate was 130 per The heart rate was 130 per
minute. The respiratory rate was minute. The respiratory rate was
40 per minute. The blood 40 per minute. The blood
pressure recorded was 50/40 pressure recorded was 50/40
mm Hg. mm Hg.
M.Khashaba,MD professor of Pediatrics,Mansoura
Abdomen examination Abdomen examination revealed mild distension and revealed mild distension and mild tenderness. Bowel sounds mild tenderness. Bowel sounds were sluggish. No were sluggish. No organomegaly. Other system organomegaly. Other system examination were normal.examination were normal.
M.Khashaba,MD professor of Pediatrics,Mansoura
HemoglobinHemoglobin : 14g/dl : 14g/dl
TLCTLC : 20.000 cells/cu mm : 20.000 cells/cu mm
DLCDLC : P : P8888 L L2828 E E22 M M22 B B00
Blood c/sBlood c/s : Sterile : Sterile
Urine c/sUrine c/s : Sterile : Sterile
Stool c/sStool c/s : Sterile : Sterile
BTBT : 6 min (1-6 min) : 6 min (1-6 min)
CTCT : 5 min (4-8 min) : 5 min (4-8 min)
Platelet countPlatelet count : 4.00.000 cell/cu m : 4.00.000 cell/cu m
Peripheral blood smear: normal picture with Peripheral blood smear: normal picture with leucocytosisleucocytosis
M.Khashaba,MD professor of Pediatrics,Mansoura
Serum electrolytesSerum electrolytes: Na: 120 mEq/L: Na: 120 mEq/L
K: 4 mEq/LK: 4 mEq/L
Cl: 98 mEq/LCl: 98 mEq/L
Arterial blood gasesArterial blood gases: PH: 7.1: PH: 7.1
PPaaOO22: 45 mm of Hg: 45 mm of Hg
PPaaCOCO2: 2: 35 mm of Hg35 mm of Hg
HCOHCO33: 16 mEq/L: 16 mEq/L
Erect abdomen X-ray:Erect abdomen X-ray: Shows Shows pneumatosis pneumatosis
intestinalisintestinalisM.Khashaba,MD professor of Pediatrics,Mansoura
Up to 12% of VLBWt babies are Up to 12% of VLBWt babies are afflicted with definite NECafflicted with definite NEC
Significant morbiditySignificant morbidity Financial impactFinancial impact Important cause of death in Important cause of death in
preterms beyond 1preterms beyond 1stst week. week.
M.Khashaba,MD professor of Pediatrics,Mansoura
Typical PresentationTypical Presentation
Preterm in the 2Preterm in the 2ndnd – 3 – 3rdrd week of week of life & began feedinglife & began feeding
M.Khashaba,MD professor of Pediatrics,Mansoura
Factors Implicated in Factors Implicated in NECNEC
A.A. Mucosal InjuryMucosal Injury
B.B. Formula feedingFormula feeding
C.C. InfectionInfection
M.Khashaba,MD professor of Pediatrics,Mansoura
Mucosal InjuryMucosal Injury
1.1. Ischemic DamageIschemic Damage• Fetal distressFetal distress• Perinatal asphyxiaPerinatal asphyxia• RDSRDS• HypothermiaHypothermia• Vascular spasmVascular spasm• Exchange transfusionExchange transfusion
M.Khashaba,MD professor of Pediatrics,Mansoura
Bowel IschemiaBowel Ischemia
May be an end result of injury May be an end result of injury rather than the initiating factor.rather than the initiating factor.
M.Khashaba,MD professor of Pediatrics,Mansoura
FeedingFeeding
Factors involved include:Factors involved include:1.1. Timing of initiation Timing of initiation
2.2. Rapidity of advancementRapidity of advancement
3.3. Type of milk (breast versus Type of milk (breast versus formula)formula)
M.Khashaba,MD professor of Pediatrics,Mansoura
InfectionInfection
• E ColiE Coli• KlebsiellaKlebsiella• PseudomonasPseudomonas• SalmonellaSalmonella• Clostridium Clostridium
Risk FactorsRisk Factors
Preterm birth is the over- Preterm birth is the over- whelming risk factorwhelming risk factor
M.Khashaba,MD professor of Pediatrics,Mansoura
Why in Preterms Why in Preterms
1.1. Decreased gastric acid secretionDecreased gastric acid secretion
2.2. Immaturity of digestive enzymes.Immaturity of digestive enzymes.
3.3. Decreased mobility & incomplete Decreased mobility & incomplete innervationinnervation
4.4. Immature epithelial barrierImmature epithelial barrier
5.5. Immature immune functionImmature immune function
M.Khashaba,MD professor of Pediatrics,Mansoura
Clinical featuresClinical features Onset usually in 1-2 daysOnset usually in 1-2 days Main featuresMain features
Unstable temperatureUnstable temperature Abdominal distensionAbdominal distension Abdominal tendernessAbdominal tenderness Low blood pressure Low blood pressure BradycardiaBradycardia Disseminated intravascular Disseminated intravascular
coagulation coagulation M.Khashaba,MD professor of Pediatrics,Mansoura
Abdominal RadiographsAbdominal Radiographs
Dilated loops Dilated loops Pneumatosis intestinalisPneumatosis intestinalis Portal venous gasPortal venous gas Perforation Perforation
M.Khashaba,MD professor of Pediatrics,Mansoura
Lab- Studies Lab- Studies
May be normalMay be normal May show abnormal neutrophil May show abnormal neutrophil
count, thrombocytopenia or acidosiscount, thrombocytopenia or acidosis
M.Khashaba,MD professor of Pediatrics,Mansoura
Differential DiagnosisDifferential Diagnosis
SepticemiaSepticemia Meconium plug syndromeMeconium plug syndrome MalrotationMalrotation Hirschsprung diseaseHirschsprung disease
M.Khashaba,MD professor of Pediatrics,Mansoura
M.Khashaba,MD professor of Pediatrics,Mansoura
M.Khashaba,MD professor of Pediatrics,Mansoura
M.Khashaba,MD professor of Pediatrics,Mansoura
M.Khashaba,MD professor of Pediatrics,Mansoura
ManagementManagement All oral feeds should be stopped.All oral feeds should be stopped. Relief gastric distensionRelief gastric distension Total parentral nutrition startedTotal parentral nutrition started Control of electrolyte & acid-base balanceControl of electrolyte & acid-base balance Management of hemodynamic disturbancesManagement of hemodynamic disturbances Plasma or platelet transfusion as neededPlasma or platelet transfusion as needed Combination AntibioticsCombination Antibiotics follow up for possible perforation follow up for possible perforation
M.Khashaba,MD professor of Pediatrics,Mansoura
1.1. Gastro Intestinal perforationGastro Intestinal perforation Occur in 20-30% of babiesOccur in 20-30% of babies Onset early 10-48 hrs after onsetOnset early 10-48 hrs after onset
2.2. Peritonitis Peritonitis AscitesAscites Abdominal massAbdominal mass Abdominal wall erythemaAbdominal wall erythema Induration Induration
M.Khashaba,MD professor of Pediatrics,Mansoura
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