Neonatal medicine

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Neonatal medicine

The dramatic reduction in neonatal mortality throughout the developed world has resulted from advances in the management of newborn infants together with improvements in maternal health and obstetric care. Neonatal intensive care became increasingly available in the UK from 1975, and it is since that time that the mortality of very low birthweight (VLBW) infants has fallen (Fig. 10.1).

About 8–10% of babies born in the UK are admitted to a neonatal unit for special medical and nursing care, although whenever possible babies are cared for on postnatal wards to avoid separating mothers from their babies. About 1–3% of babies require intensive care.

In the UK, neonatal units are organised as networks, with units providing either:

Modern technology allows even tiny preterm infants to benefit from the full range of intensive care, anaesthesia and surgery. If it is anticipated during pregnancy that the infant is likely to require long-term intensive care or surgery, it is preferable for the transfer to the tertiary centre to be made in utero. When a baby requires transfer postnatally, transport should be by an experienced team of doctors and nurses. Arrangements should also be made for parents to be close to their infant during this stressful time.

Hypoxic-ischaemic encephalopathy

In perinatal asphyxia, gas exchange, either placental or pulmonary, is compromised or ceases altogether, resulting in cardiorespiratory depression. Hypoxia, hypercarbia and metabolic acidosis follow. Compromised cardiac output diminishes tissue perfusion, causing hypoxic-ischaemic injury to the brain and other organs. The neonatal condition is called hypoxic-ischaemic encephalopathy (HIE). It remains an important cause of brain damage, resulting in disability (Fig. 10.2) or death, and its prevention is one of the key aims of modern obstetric care. In developed countries, approximately 0.5–1/1000 liveborn term infants develop HIE and 0.3/1000 have significant neurologic disability. The incidence is higher in developing countries.

Most cases of hypoxic-ischaemic encephalopathy (HIE) follow a significant hypoxic event immediately before or during labour or delivery. These include:

The clinical manifestations start immediately or up to 48 h after asphyxia, and can be graded:

The neuronal damage may be immediate from primary neuronal death or may be delayed from reperfusion injury causing secondary neuronal death. This delay offers the opportunity for neuroprotection with mild hypothermia.

Management

Skilled resuscitation and stabilisation of sick infants will minimise neuronal damage. Infants with HIE may need:

Recent randomised clinical trials have shown that mild hypothermia (cooling to a rectal temperature of 33–34° C for 72 h by wrapping the infant in a cooling blanket) reduces brain damage if started within 6 h of birth.

Prognosis

When HIE is mild, complete recovery can be expected. Infants with moderate HIE who have recovered fully on clinical neurological examination and are feeding normally by 2 weeks of age have an excellent long-term prognosis, but if clinical abnormalities persist beyond that time, full recovery is unlikely. Severe HIE has a mortality of 30–40%, and, of the survivors, over 80% have neurodevelopmental disabilities, particularly cerebral palsy. If magnetic resonance imaging (MRI) at 4–14 days in a term infant shows significant abnormalities (bilateral abnormalities in the basal ganglia and thalamus and lack of myelin in the posterior limb of the internal capsule), there is a very high risk of later cerebral palsy (Fig. 10.3).

Although hypoxic-ischaemic injury usually occurs antenatally or during labour or delivery, it may occur postnatally or be caused by a neonatal condition (e.g. inborn error of metabolism or kernicterus). The diagnosis ‘birth asphyxia’ has potentially serious medicolegal implications; it has been recommended that infants who have the clinical features of HIE should only be considered to have birth asphyxia if there is:

Birth injuries

Infants may be injured at birth, particularly if they are malpositioned or too large for the pelvic outlet. Injuries may also occur during manual manoeuvres, from forceps blades or at Ventouse deliveries. Fortunately, now that Caesarean section is available in every maternity unit, heroic attempts to achieve a vaginal delivery with resultant severe injuries to the infant have become extremely rare.

Soft tissue injuries

These include:

• Caput succedaneum (Fig. 10.4) – bruising and oedema of the presenting part extending beyond the margins of the skull bones; resolves in a few days

• Cephalhaematoma (Figs 10.4, 10.5) – haematoma from bleeding below the periosteum, confined within the margins of the skull sutures. It usually involves the parietal bone. The centre of the haematoma feels soft. It resolves over several weeks

• Chignon (Fig. 10.6) – oedema and bruising from Ventouse delivery

• Bruising to the face after a face presentation and to the genitalia and buttocks after breech delivery. Preterm infants bruise readily from even mild trauma

• Abrasions to the skin from scalp electrodes applied during labour or from accidental scalpel incision at Caesarean section

• Forceps marks to face from pressure of blades – transient

• Subaponeurotic haemorrhage (Fig. 10.4) (very uncommon) – diffuse, boggy swelling of scalp on examination, blood loss may be severe and lead to hypovolaemic shock and coagulopathy.

Nerve palsies

Brachial nerve palsy results from traction to the brachial plexus nerve roots. They may occur at breech deliveries or with shoulder dystocia. Upper nerve root (C5 and C6) injury results in an Erb palsy (Fig. 10.7). It may be accompanied by phrenic nerve palsy causing an elevated diaphragm. Most palsies resolve completely, but should be referred to an orthopaedic or plastic surgeon if not resolved by 2–3 months. Most recover by 2 years. A facial nerve palsy may result from compression of the facial nerve against the mother’s ischial spine. It is unilateral, and there is facial weakness on crying but the eye remains open. It is usually transient, but methylcellulose drops may be needed for the eye. Rarely, nerve palsies may be from damage to the cervical spine, when there is lack of movement below the level of the lesion.

Stabilising the preterm or sick infant

Preterm infants of <34 weeks’ gestation and newborn infants who become seriously ill require their condition to be stabilised and monitored (Fig. 10.8). Many of them will need respiratory and circulatory support.

Stabilising preterm or sick infants

Venous and arterial lines

The preterm infant

The appearance, the likely clinical course, chances of survival and long-term prognosis depend on the gestational age at birth. The appearance and maturational changes of very preterm infants are described in Table 10.1 and the importance of parental involvement shown in Figures 10.10a and b. The external appearance and neurological findings can be scored to provide an estimate of an infant’s gestational age (see Appendix).

The rate and severity of problems associated with prematurity decline markedly with increasing gestation. Infants born at 23–26 weeks’ gestation encounter many problems (Box 10.1), require many weeks of intensive and special care in hospital and have a high overall mortality. With modern intensive care, the prognosis is excellent after 32 weeks’ gestational age. The severity of an infant’s respiratory disease and of any episodes of infection largely determine the neonatal course and outcome.

Respiratory distress syndrome

In respiratory distress syndrome (RDS), (also called hyaline membrane disease), there is a deficiency of surfactant, which lowers surface tension. Surfactant is a mixture of phospholipids and proteins excreted by the type II pneumocytes of the alveolar epithelium. Surfactant deficiency leads to widespread alveolar collapse and inadequate gas exchange. The more preterm the infant, the higher the incidence of RDS; it is common in infants born before 28 weeks’ gestation and tends to be more severe in boys than girls. Surfactant deficiency is rare at term but may occur in infants of diabetic mothers. The term hyaline membrane disease derives from a proteinaceous exudate seen in the airways on histology. Glucocorticoids, given antenatally to the mother, stimulate fetal surfactant production and are given if preterm delivery is anticipated (see Ch. 9.)

The development of surfactant therapy has been a major advance. The preparations are natural, derived from extracts of calf or pig lung. They are instilled directly into the lung via a tracheal tube. Multinational placebo-controlled trials show that surfactant treatment reduces mortality from RDS by about 40%, without increasing the morbidity rate (Fig. 10.11).

At delivery or within 4 h of birth, babies with RDS develop clinical signs of:

The characteristic chest X-ray appearance is shown in Figure 10.12. Treatment with raised ambient oxygen is required, which may need to be supplemented with continuous positive airway pressure (delivered via nasal cannulae) or artificial ventilation via a tracheal tube. The ventilatory requirements need to be adjusted according to the infant’s oxygenation (which is measured continuously), chest wall movements and blood gas analyses. Mechanical ventilation (with intermittent positive pressure ventilation or high-frequency oscillation) may be required. High-flow humidified oxygen therapy, via nasal cannulae, may be used to wean babies from added oxygen therapy.

The preterm infant: maturational changes in appearance and development

Table 10.1

The preterm infant compared with the term infant

Gestation 23–27 weeks Term (37–42 weeks)
Birthweight (50th centile) At 24 weeks – male 700 g, female 620 g At 40 weeks – male 3.55 kg, female 3.4 kg
Skin Very thin (Fig. 10.9a) Thick skin (Fig. 10.9b)
  Dark red colour all over body Pale pink colour
Ears Pinna soft, no recoil Pinna firm, cartilage to edge, immediate recoil
Breast tissue No breast tissue palpable One or both nodules >1 cm
Genitalia Male – scrotum smooth, no testes in scrotum Male – scrotum has rugae, testes in scrotum
  Female – prominent clitoris, labia majora widely separated, labia minora protruding Female – labia minora and clitoris covered
Breathing Needs respiratory support. Apnoea common Rarely needs respiratory support. Apnoea rare
Sucking and swallowing No coordinated sucking Coordinated (from 34–35 weeks)
Feeding Usually needs TPN (total parenteral nutrition), then tube feeding Cries when hungry. Feeds on demand
Cry Faint Loud
Vision, interaction Eyelids may be fused. Infrequent eye movements. Not available for interaction Makes eye contact, alert wakefulness
Hearing Startles to loud noise Responds to sound
Posture Limbs extended, jerky movements Flexed posture, smooth movements

Pneumothorax

In respiratory distress syndrome, air from the overdistended alveoli may track into the interstitium, resulting in pulmonary interstitial emphysema (PIE). In up to 10% of infants ventilated for RDS, air leaks into the pleural cavity and causes a pneumothorax (Fig. 10.13). When this occurs, the infant’s oxygen requirement usually increases, and the breath sounds and chest movement on the affected side are reduced, although this can be difficult to detect clinically. A pneumothorax may be demonstrated by transillumination with a bright fibreoptic light source applied to the chest wall. A tension pneumothorax is treated by inserting a chest drain. In order to try and prevent pneumothoraces, infants are ventilated with the lowest pressures that provide adequate chest movement and satisfactory blood gases.

Apnoea and bradycardia and desaturation

Episodes of apnoea and bradycardia and desaturation are common in very low birthweight infants until they reach about 32 weeks’ gestational age. Bradycardia may occur either when an infant stops breathing for over 20–30 s or when breathing continues but against a closed glottis. An underlying cause (hypoxia, infection, anaemia, electrolyte disturbance, hypoglycaemia, seizures, heart failure or aspiration due to gastro-oesophageal reflux) needs to be excluded, but in many instances, the cause is immaturity of central respiratory control. Breathing will usually start again after gentle physical stimulation. Treatment with the respiratory stimulant caffeine often helps. Continuous positive airways pressure (CPAP) may be necessary if apnoeic episodes are frequent.