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Neonatal medicine Dr Deborah Davidson Paediatric RegiFellowClinical Education Whittington Hospital February 2024 Objectives: • Understand the approach to neonatal resuscitation • Define Neonatal Sepsis • List Risk Factors for Developing Neonatal Sepsis • Appreciate the signs of neonatal sepsis Neonatal • Know the principles of management of neonatal sepsis Medicine • Assess neonatal jaundice • Differentiate between physiological and pathological neonatal jaundice • Understand the management approach of neonatal jaundice You are the Neonatal SHO on Call… • You are holding the delivery bleep. • The bleep goes off and you are called to a delivery • What information do you want to know from the maternity team? This Photo by Unknown Author is licensed under CC BY-SA-NC • Gestational Age • Indication for attendance Reason for • Meconium • Antepartum Hemorrhage attendance/ • Fetal Distress – tachycardia, bradycardia, CTG Condition of abnormalities Faetus • Prematurity • Assisted Delivery – Forceps, Ventouse • Diabetes, HPT, Pre-eclampsia • Infections • Syphillis, HIV, HIV Maternal • TORCH : Toxoplasmosis, Rubella, CMV, Herpes/Hepatitis/HIV Health • Substance use, Medications • Blood Group • BleedingAntenatal Scans • First Trimester • Screening for T21,T18,T13 • 20 weeks • Anomaly Scan • Third Trimester • Growth • Amniotic Fluid • Congenital Abnormalities • Lie (Cephalic/Breech/Transverse) • Umbilical Artery Dopplers This Photo by Unknown Author is licensed under CC BY-SA • Maternal Infection • Prolonged Rupture of Membranes (PROM) • > 24 Hours in Term Baby • >18 Hours in Preterm Baby Risk Factors For • GBS Sepsis • Spontaneous Preterm Birth https://www.nice.org.uk/guidance/ng195 • GA 38 Weeks • PROM 27 Hours. Mother has received antibiotics • CTG Now showing fetal distress Our Case: • Normal antenatal scans • Maternal Blood Group A- • Maternal Virology NegativeBaby Delivered… 0 1 2 Appearance (colour) Blue Centrally Blue Peripherally Pink Pulse Absent <100 >100 Grimace (response) No response Grimace/Week Response Cry/Cough/Sneeze Activity (tone) Limp Some Tone Flexed , Active Respiration None Irregular Crying or Spontaneous Regular Respiration On Immediate Assessment What is your next action? You attend the delivery of a 37 Week Gestational Age baby. On assessment Immediately after birth the baby has APGARS as follows: 0 1 2 Appearance (colour) 0 Blue Centrally Blue Peripherally Pink Pulse 1 Absent <100 >100 Grimace (response) 0 No response Grimace/Week Cry/Cough/Sneeze Response Activity (tone) 1 Limp Some Tone Flexed , Active Respiration 0 None Irregular Crying or Spontaneous Regular Respiration 2 What is the most appropriate first step to take? A. Immediately start CPR B. Dry, Stimulate and warm the baby and reassess C. Provide 5 Inflation Breaths and Continue Down the NLS Algorithm D. Observe the baby for a minute and repeat APGARS E. Cover the baby in a plastic bag and reassess You attend the delivery of a 37 Week Gestational Age baby. On assessment Immediately after birth the baby has APGARS as follows: What is the most appropriate first step to take? A. Immediately start CPR B. Dry, Stimulate and warm the baby and reassess C. Provide 5 Inflation Breaths and Continue Down the NLS Algorithm D. Observe the baby for a minute and repeat APGARS E. Cover the baby in a plastic bag and reassess Most babies will only require some stimulation and warmth to help them transition to extrauterine life. If further intervention is needed follow the NLS Algorithm.Case Continued • Following drying and stimulation of the baby: • Starts crying and spontaneous respiration • Apgar's at 1 minute of life 8 • Apgars at 5 minutes of life 10 • Give to mother for skin to skin and cuddles This Photo by Unknown Author is licensed under CC BY• Midwife reminds you that the mother is PROM and asks if you want to start antibiotics? According to NICE Guidelines on Early Neonatal Sepsis, in which of these cases would you start antibiotics? Assume that all of the babies have a normal examination. A. Gestational Age 38 Weeks, thick meconium seen at delivery B. Gestational Age 36 Weeks, Maternal Diabetes C. Gestational Age 38 Weeks, Membranes Ruptured 22 Hours, Maternal GBS Colonisation D. Gestational Age 38 Weeks, Membranes ruptured 27 Hours, Maternal GBS Colonisation E. Gestational Age 36 Weeks, Membranes Ruptured 15 hours, thick meconium at deliveryNeonatal Sepsis Early Late < 72 Hours > 72 Hours Birth Canal, Chorioamnionitis Birth Canal, Chorioamnionitis + Hospital Acquired, Community Acquired Common organisms: Common organisms: Group B Streptococcus (GBS) Group B Streptococcus Gram-negative organisms Gram-negative organisms Listeria monocytogenes Coagulase negative staphyloccus Staphylococcus aureus Enterococcus benzylpenicillin and gentamicin Cefotaxime and Amoxicillin https://www.nice.org.uk/guidance/ng51/chapter/Antibiotic- therapy-intravenous-fluid-and-oxygen#newborn-babies-under- 28-daysNeonatal infection: determining the need for antibiotic treatment of babies within 72 hours of birth (pg 1 of 2) Before birth: for women in labour, identify If there are any risk factors for early- If group B streptococcus is first identified in onset neonatal infection (see box 1) or and assess risk factors for early-onset if there are clinical indicators of possible the mother within 72 hours of baby’s birth: neonatal infection (see box 1). Throughout early-onset neonatal infection (see box 2) labour, monitor for any new risk factors. •ask those directly involved in the baby’s perform an immediate clinical assessment. care if they have any concerns in For guidance on managing prelabour relation to clinical indicators (see box 2) rupture of membranes at term, see the Review the maternal and neonatal history NICE guideline on intrapartum care. and carry out a physical examination of the •identify any other risk factors present, and baby, including assessment of vital signs. look for clinical indicators of infection. Any red flag No red flags, but 1 non-red-flag risk factor No red flags, risk factors or OR OR clinical indicators 2 or more non-red-flag risk factors or No red flags, but 1 non-red-flag No laboratory evidence of clinical indicators clinical indicator possible infection Use clinical judgement: Perform investigations and Do not routinely give •Is it safe to withold antibiotics? antibiotic treatment. start antibiotic treatment. •Do the baby’s vital signs and clinical Continue routine care Do not wait for test results (see the NICE guideline on before starting antibiotics. condition need to be monitored? postnatal care). If monitoring, continue for at least 12 hours using a newborn early warning system. YES NO Consider performing Reassure family. When the Any clinical concerns during monitoring? investigations and starting baby is discharged, give antibiotic treatment. advice to parents or carers. Note: The Kaiser Permanente neonatal sepsis calculator can be used as an This is a summary of some of the advice in the NICE guideline on alternative to the NICE red flag framework neonatal infection: antibiotics for prevention and treatment. © NICE 2021. All rights reserved. Subject to Notice of rights.• Midwife reminds you that the mother is PROM and asks if you want to start antibiotics? According to NICE Guidelines on Early Neonatal Sepsis, in which of these cases would you start antibiotics? Assume that all of the babies have a normal examination. A. Gestational Age 38 Weeks, thick meconium seen at delivery B. Gestational Age 36 Weeks, Maternal Diabetes C. Gestational Age 38 Weeks, Membranes Ruptured 22 Hours, Maternal GBS Colonisation D. Gestational Age 38 Weeks, Membranes ruptured 27 Hours, Maternal GBS Colonisation E. Gestational Age 36 Weeks, Membranes Ruptured 15 hours, thick meconium at delivery• Midwife reminds you that the mother is PROM and asks if you want to start antibiotics? According to NICE Guidelines on Early Neonatal Sepsis, in which of these cases would you start antibiotics? Assume that all of the babies have a normal examination. A. Gestational Age 38 Weeks, thick meconium seen at delivery B. Gestational Age 36 Weeks, Maternal Diabetes C. Gestational Age 38 Weeks, Membranes Ruptured 22 Hours, Maternal GBS Colonisation D. Gestational Age 38 Weeks, Membranes ruptured 27 Hours, Maternal GBS Colonisation E. Gestational Age 36 Weeks, Membranes Ruptured 15 hours, thick meconium at delivery12 Hours of The midwife calls you as she is concerned Life about the babies observations. Grunting, no obvious obstruction A Saturations 88% in Airtal recessions. RR 71. B CRT 3 Seconds HR 161 Normal Heart sounds, Examination: C No murmur, femoral pulses palpable bilaterally Fontanelle Soft and non bulging, Flexed limbs, D Primitive reflexes present Temperature 35.9. No rash, no jaundice, no E other abnormalities noted What is the most likely cause of this presentation? What is the most likely cause of this presentation? A term newborn presents with respiratory distress, hypothermia and poor feeding at 12 hours of life. There is a history of PROM. What is the most likely diagnosis? A. This is most likely late neonatal sepsis, take a blood culture and CRP and initiate Cefotaxime within an hour B. This is most likely respiratory distress syndrome, initiate ventilatory support and administer Surfactant C. This is most likely early neonatal sepsis, take a blood culture and CRP and initiate Gentamicin and Benzylpenicillin within an hour D. This is most likely a Ventricular Septal Defect, arrange for an urgent echo and cardiology consult E. This is most likely Transient Tachypnoea of the Newborn, continue to monitor the baby of the postnatal ward What is the most likely cause of this presentation? A term newborn presents with respiratory distress, hypothermia and poor feeding at 8 hours of life. There is a history of PROM. What is the most likely diagnosis? A. This is most likely late neonatal sepsis, take a blood culture and CRP and initiate Cefotaxime within an hour B. This is most likely respiratory distress syndrome, initiate ventilatory support and administer Surfactant C. This is most likely early neonatal sepsis, take a blood culture and CRP and initiate Gentamicin and Benzylpenicillin within an hour D. This is most likely a Ventricular Septal Defect, arrange for an urgent echo and cardiology consult E. This is most likely Transient Tachypnoea of the Newborn, continue to monitor the baby of the postnatal wardManagement: • Call For HELP. Consider 2222 • Stabilize ABCD – Needs Respiratory Support • ALWAYS THINKS SEPSIS!!! • Differentials: Cardiac, Meconium Aspiration, Congenital Pneumonia, RDS in a preterm, TTN, Metabolic (Rare but NB) • Consider CXR and Capillary Blood Gas ThisPhotobyUnknownAuthorislicensed underCCBY-SA • CRP Elevated: 28 • Blood culture negative after 48 hours • CXR changes • Completed Weened to room air by day 2 of Outcome: life • Ready for discharge to the mother on the postnatal ward to complete 5 Days of antibiotics for congenital pneumonia Postnatal Ward: Day 3 of Life The midwife calls you to review the baby as they now appear Jaundiced. She has performed a Transcutaneous Bilirubin Reading, and the result is 300 micromol/l. The baby is 38 Weeks Gestational age and the mother is Rhesus Negative Which of the following are not risk factors for neonatal jaundice? A. Maternal Blood Group A- B. Small for Gestational Age C. Prematurity D. Breast Feeding E. Meconium Aspiration Postnatal Ward: Day 3 of Life The midwife calls you to review the baby as they now appear Jaundiced. She has performed a Transcutaneous Bilirubin Reading, and the result is 300 micromol/l. The baby is 38 Weeks Gestational age and the mother is Rhesus Negative Which of the following are not risk factors for neonatal jaundice? A. Maternal Blood Group A- B. Small for Gestational Age C. Prematurity D. Exclusive Breast Feeding E. Meconium AspirationPostnatal Ward: Day 3 of Life The midwife calls you to review the baby as they now appear Jaundiced. She has performed a Transcutaneous Bilirubin Reading, and the result is 300 micromol/l. The baby was born at 38 Weeks Gestational age and the mother is Rhesus Negative. What is the most correct statement? A. The is physiological jaundice, no further actions need to be taken B. This baby is at risk of Haemolysis due to Rhesus incompatibility. Take a serum bilirubin, blood group and DAT and plot the bilirubin results on a treatment threshold graph. C. This baby baby is at risk of Haemolysis due to Rhesus incompatibility. They will require an urgent Exchange Transfusion. D. This is pathological jaundice, start phototherapy immediately and monitor the levels. E. This baby is at risk of Haemolysis due to Rhesus incompatibility. Administer Anti-D to the baby immediaitely.Postnatal Ward: Day 3 of Life The midwife calls you to review the baby as they now appear Jaundiced. She has performed a Transcutaneous Bilirubin Reading, and the result is 300 micromol/l. The baby was born at 38 Weeks Gestational age and the mother is Rhesus Negative. What is the most correct statement? A. The is physiological jaundice, no further actions need to be taken B. This baby is at risk of Haemolysis due to Rhesus incompatibility. Take a serum bilirubin, blood group and DAT and plot the bilirubin results on a treatment threshold graph. C. This baby baby is at risk of Haemolysis due to Rhesus incompatibility. They will require an urgent Exchange Transfusion. D. This is pathological jaundice, start phototherapy immediately and monitor the levels. E. This baby is at risk of Haemolysis due to Rhesus incompatibility. Administer Anti-D to the baby immediaitely. Approximately 60% of term and 80% of preterm babies develop jaundice in the first week of life, and about 10% of breastfed babies are still jaundiced at 1 month [NICE, 2016]. Neonatal Jaundice • Physiological Jaundice • Increased Red Cell Turnover • Immature hepatic uptake and conjugationFactors associated with significant neonatal hyperbilirubinaemia: • Decreased gestational age/pretermdelivery. • Low infant birth weight. • Development of jaundice within first 24 hours of life. • Male sex. • Visible bruising. • Cephalhaematoma. • Maternal age older than 25 years. • Maternal diabetes mellitus. • Asian, European, or native American ethnicity. • Sibling born with jaundice requiring phototherapy/other treatment. • Dehydration. • Poor caloric intake/increased neonatal weight loss. • Breastfeeding. https://cks.nice.org.uk/topics/jaundice-in-the-newborn/background-information/risk-factors/Differentiate between Physiological Jaundice and Pathological Jaundice Always < 24 Hours Pathological Early Pathological 24 Hours -14 Days Neonatal Jaundice Physiological Pathological Prolonged: > 14 Days (21 in a preterm baby) Breast Milk Jaundice Causes of Pathological Jaundice (This list is not exhaustive) Haemolysis Infection Obstruction • ABO incompatibility • Neonatal Sepsis • Biliary Atresia • Rhesus Incompatibility • Hepatitis • G6PD Deficiency Endocrine/Metabolic Breast Feeding Jaundice • Hypothyroidism • Galactosemia • Poor volume of intake due to supply of feeding difficultiesMeasuring Bilirubin in Neonatal Jaundice • Transcutaneous Bilirubin (TCB) • > 35/40 • >24 Hours of life < 14 days of life • No Previous Phototherapy • Serum Bilirubin • TCB > 250umol/l OR meets threshold for phototherapy • <35/40 • < 24 hours of life • Baby has been on phototherapy • TCB not availableMeasuring Bilirubin in Neonatal Jaundice • Plot Bilirubin on Treatment Threshold Graph • Use correct Graph for Gestational Age • Plot on the exact hour of life • Plot accuratelyPhototherapy: • Use of light waves to bring down bilirubin levels to normal through a process called photo-oxidation. Exposure to green- blue light at a wavelength of 420 - 550nm produces water- soluble isomers of bilirubin . • This allows for improved breakdown and excretion of bilirubinThis Photo by Unknown Author is licensed under CC BY-SA This Photo by Unknown Author is licensed under CC BY-NC This Photo by Unknown Author is licensed under CC BY-NC-ND This Photo by Unknown Author is licensed under CC BY • Rhesus or ABO incompatibility • If severe (above exchange transfusion threshold, rapidly Haemolytic rising) • Intensive phototherapy Jaundice • IV Fluids • IV Immunoglobulins • Prepare for Exchange TransfusionDay 16 of Life The midwife refers the baby for assessment as they are still jaundiced You review a term baby at 16 days of life presenting with Jaundice. The SBR is 300umol/l. Which of the below statements are correct? A. This is physiological jaundice, continue to monitor with a TCB B. This is prolonged neonatal Jaundice, assess for conjungated hyperbilirubinemia by assessing stool colour and measuring conjugated bilirubin C. This is prolonged neonatal Jaundice, Admit for phototherapy D. This could be breast milk Jaundice – Stop breast feeding and switch to Formula E. This is prolonged neonatal Jaundice, advise the parents to expose the baby to the sunDay 16 of Life The midwife refers the baby as they are still jaundiced You review a term baby at 16 days of life presenting with Jaundice. The SBR is 300umol/l. Which of the below statements are correct? A. This is physiological jaundice, continue to monitor with a TCB B. This is prolonged neonatal Jaundice, assess for conjungated hyperbilirubinemia by assessing stool colour and measuring conjugated bilirubin C. This is prolonged neonatal Jaundice, Admit for phototherapy D. This could be breast milk Jaundice – Stop breast feeding and switch to Formula E. This is prolonged neonatal Jaundice, advise the parents to expose the baby to the sunProlonged Neonatal Jaundice • 14 Days in a Term Baby > 21 Days in a preterm baby • Ensure the baby is thriving and no signs of infection • Need to exclude obstructive Jaundiceà Biliary Atresia • Pale Stools , Dark Urine • Conjugated Fraction > 20umol/l OR > 10% if total Bilirubin >200umol/l • Consider Congenital Hypothyroidism ( check if had Guthrie test done) • Co• Perform FBC,Group and DATbility and ongoing haemolysis • Consider G6PD Deficiency in male infants of high-risk ethnic background • Breast fed babies may remain jaundice for 6 weeks. If excluded pathology can reassure- physiological. Do not stop breast feeding. Objectives: • Understand the approach to neonatal resuscitation • Define Neonatal Sepsis • List Risk Factors for Developing Neonatal Sepsis Neonatal • Appreciate the signs of neonatal sepsis • Know the principles of management of neonatal sepsis Medicine • Assess neonatal jaundice • Differentiate between physiological and pathological neonatal jaundice • jaundicend the management approach of neonatalFeedback THANK YOU FOR LISTENING ANY QUESTIONS Please use the QR code to complete the feedback form for this session. Certificates of attendance will be issued once completed! Thank you for listening! BIMA Clinical Specialties Teaching Series