Chapter 67. Common Neonatal Problems

In general, the signs and symptoms of illness are vague and nonspecific in neonates making the identification of specific diagnoses challenging (Table 67-1). The survival of premature infants has produced a population of children whose corrected gestational age (chronological age since birth in weeks minus the number of weeks of prematurity) makes them, in some ways, similar to neonates. Neonates present to the emergency department with a range of conditions that span from normal to critical.

Bottle-fed infants generally take 6 to 9 feedings (2 to 4 oz) in a 24-hours period, with a relatively stable pattern developing by the end of the first month of life. Breast-fed infants generally prefer feedings every 1 to 3 hours. Infants typically lose up to 12% of their birth weight during the first 3 to 7 days of life. After this time, infants are expected to gain about 1 oz/d (20 to 30 grams) during the first 3 months of life. The number, color, and consistency of stool in the same infant changes from day to day and differs among infants. Normal breast-fed infants may go 5 to 7 days without stooling or have 6 to 7 stools per day. Color has no significance unless blood is present or the stool is acholic (ie, white).

A normal respiratory rate for a neonate is from 30 to 60 breaths/min. Periodic breathing (alternating episodes of rapid breathing with brief (< 5 to 10 seconds) pauses in respiration) is usually normal. Normal newborns awaken at variable intervals that can range from about 20 minutes to 6 hours. Neonates and young infants tend to have no differentiation between day and night until approximately 3 months of age.

There are benign to life-threatening causes of prolonged crying in infants (Table 67-2). True inconsolability represents a serious condition in most infants and requires investigation for injury (accidental or inflicted), infection, supraventricular tachycardia (SVT), corneal abrasion, hair tourniquet, hernia or testicular torsion, or abdominal emergency. If, after a thorough emergency department evaluation, a cause for excessive crying has not been identified and the child continues to be inconsolable, admission to the hospital is warranted.

Intestinal colic is the most common cause of excessive (but not inconsolable) crying. The cause is unknown. The incidence is about 13% of all neonates. The formal definition includes crying for at least 3 hours per day for at least 3 days per week over a 3-week period. Intestinal colic seldom lasts beyond age 3 months. No effective treatment has been identified. In general, the initial diagnosis of colic is not made in the emergency department and it is a diagnosis of exclusion.

A battered child may present with unexplained bruises at different ages, skull fractures, intracranial injuries identifiable on computed tomography of the head, extremity fractures, cigarette burns, retinal hemorrhages, unexplained irritability, lethargy, or coma. See Chapter 187 for further discussion of child abuse.

Fever in the neonate (age 28 days or younger) is defined as the history of documented fever by a parent or presence of a rectal temperature of 38°C (100.4°F) or higher in the ED. Fever in the neonate must be taken seriously, and at this point in time the proper management includes a complete septic work-up, administration of parenteral antibiotics, and admission. See Chapter 66 for appropriate ED therapy of the febrile neonate.

Surgical Lesions

Surgically correctable abdominal emergencies in neonates are uncommon, may present with nonspecific symptomatology, and, when suspected, require prompt consultation with an experienced pediatric surgeon. Chapter 74 discusses the most important abdominal emergencies in children. Common signs and symptoms include irritability and crying, poor feeding, vomiting, constipation, and abdominal distention. Bilious vomiting is suggestive of malrotation with midgut volvulus or intussusception and requires emergent surgical consultation and radiologic evaluation (upper GI for malrotation, air-contrast enema for intussusception). Projectile vomiting following feeds suggests pyloric stenosis, which is evaluated with ultrasound. A groin mass may represent an incarcerated hernia; inguinal hernias are common among premature infants.

Feeding Difficulties

Parental perception that an infant's food intake is inadequate may prompt an ED visit. If the patient's weight gain is adequate (see Normal Vegetative Functions above) and the infant appears satisfied after feeding, parental reassurance is appropriate. A successful trial of feeding in the emergency department can reassure parents, emergency department nurses, and physicians alike. When there is an underlying anatomic abnormality interfering with feeding or swallowing (eg, esophageal stenosis, esophageal stricture, laryngeal cleft, or compression of the esophagus or trachea by a double aortic arch), the infant typically has had trouble feeding from birth and usually presents malnourished and dehydrated.

Regurgitation

Regurgitation is due to reduced lower esophageal sphincter tone and relatively increased intragastric pressure in neonates and is ubiquitous in young infants. Gastric contents are effortlessly expelled, typically within 30 min of feeding, and, though potentially large in volume, are never projectile or bilious.

Gastroesophageal reflux (GERD) is typically a self-limited condition and, if an infant is thriving and gaining weight appropriately, reassurance is appropriate.

Vomiting

Vomiting is differentiated from regurgitation by forceful contraction of the diaphragm and abdominal muscles. Vomiting has a variety of causes and is rarely an isolated symptom. Vomiting from birth is usually due to an anatomic anomaly and is often diagnosed in the newborn nursery. Vomiting is a nonspecific but serious symptom in neonates. Etiologies are diverse and include increased intracranial pressure (eg, shaken-baby syndrome), infections (eg, urinary tract infections, sepsis, or gastroenteritis), hepatobiliary disease (usually accompanied by jaundice), and inborn errors of metabolism (usually accompanied by hypoglycemia and metabolic acidosis). Bilious vomiting in a neonate or infant should be considered a surgical emergency (malrotation in the neonate or infant, intussusception in the older infant).

Diarrhea

Although bacterial infection may cause bloody diarrhea, this is rare in neonates. The most common causes of blood in the stool in infants younger than 6 months are cow's milk intolerance and anal fissures. Breast-fed infants may have heme-positive stool from swallowed maternal blood due to bleeding nipples. Necrotizing enterocolitis may present as bloody diarrhea and usually presents with other signs of sepsis (eg, jaundice, lethargy, fever, poor feeding, or abdominal distention). Abdominal radiography may demonstrate pneumatosis intestinalis or free air. Dehydrated neonates (and neonates with impending dehydration from rotavirus) should be admitted for parenteral rehydration.

Abdominal Distention

Abdominal distention can be normal in the neonate and is usually due to lax abdominal muscles, relatively large intraabdominal organs, and swallowed air. In general, if the neonate appears comfortable, is feeding well, and the abdomen is soft, there is no need for concern.

Constipation

Infrequent bowel movements in neonates do not necessarily mean that the infant is constipated. Stool patterns can be quite variable and breast-fed infants may go 1 week without passing stool and then pass a normal stool. Inquire about the passage of meconium in the first 24 to 48 hours of life; infants without normal stooling in the first 2 days of life may have anatomic anomalies (eg, intestinal stenosis or atresias), cystic fibrosis, Hirschsprung disease, or meconium ileus or plug. Constipation that develops later in the first month of life suggests Hirschsprung disease, hypothyroidism, anal stenosis, or anterior anus. Rarely, botulism can present with constipation that precedes neurologic symptoms (cranial nerve deficits, hypotonia, weak cry). Laxatives and enemas are contraindicated in neonates.

Noisy Breathing and Stridor

Noisy breathing in a neonate is usually benign. Infectious causes of stridor seen commonly in older infants and young children (eg, croup) are rare in neonates. Stridor in a neonate is often due to a congenital anomaly, most commonly, laryngomalacia. Other causes include webs, cysts, atresias, stenoses, clefts, and airway hemangiomas. Chapter 69 reviews upper airway emergencies in infants and children.

Nasal congestion from a mild upper respiratory tract infection may cause significant respiratory problems in a neonate. Neonates are obligate nasal breathers and feed for relatively prolonged periods while breathing only through their noses. The use of saline drops and nasal suctioning is typically effective.

Apnea and Periodic Breathing

Periodic breathing may be normal in neonates. Apnea is formally defined as a cessation of respiration for longer than 10 to 20 seconds with or without accompanying bradycardia and cyanosis. Apnea generally signifies critical illness including infection, CNS injury, and metabolic disease, and prompt investigation and admission for monitoring and treatment should be initiated. Apnea may be the first sign of bronchiolitis with respiratory syncytial virus in neonates and can occur before wheezing. Chlamydia and pertussis can also cause apnea in the young infant.

Cyanosis and Blue Spells

Many disorders can present with cyanosis, and differentiating among them can be a diagnostic challenge. However, symptom patterns may help differentiate various causes and assist in suggesting the correct diagnosis and course of action. Rapid, unlabored respirations and cyanosis suggest cyanotic heart disease with right-to-left shunting (see Chapter 72). Irregular or shallow breathing and cyanosis suggest sepsis, CNS disease, or metabolic disorders (see Chapter 79). Labored breathing with grunting and retractions is suggestive of pulmonary disease such as pneumonia or bronchiolitis (see Chapter 70). All cyanotic neonates should be admitted to the hospital for monitoring, therapy, and further investigation.

There are multiple causes of jaundice, and the likelihood of any specific cause is based on the age of onset. Jaundice that occurs within the first 24 hours of life tends to be serious in nature and usually is addressed while the patient is in the newborn nursery. Jaundice that develops during the second or third day of life is usually physiologic; if the neonate is gaining weight, feeding and stooling well, is not anemic, does not have an elevated direct (conjugated) bilirubin level, and does not have a total bilirubin level indicating the need for phototherapy (see parent chapter of Tintinalli's Emergency Medicine, or http://www.aappolicy.aappublications.org/cgi/content/full/pediatrics;114/1/297.full), reassurance and close follow-up are appropriate. Jaundice that develops after the third day of life is generally serious. Causes include sepsis, UTI, congenital TORCH infections, hemolytic anemia, biliary atresia, breast milk jaundice, and hypothyroidism. Workup of these infants usually includes a complete septic evaluation, including a lumbar puncture, a peripheral blood smear, complete blood count, total and direct bilirubin levels, liver function tests, reticulocyte count, and a Coombs test. Empiric antibiotics (see Chapter 66) are generally administered when sepsis is suspected.

Intraoral lesions due to Candida are typically white and pasty and cover the tongue, lips, gingiva, and buccal mucosa. The presence of oral thrush may prompt a visit to the emergency department because the parent notices “something white” in the mouth or because the discomfort of extensive lesions may interfere with feeding. Treatment consists of topical application of oral nystatin suspension 4 times a day.

Two main types of diaper rash are common in neonates: contact dermatitis and candidal diaper dermatitis. Contact dermatitis is macular, erythematous, and has sharply demarcated edges. Treatment consists of frequent diaper changes, air drying, and application of a barrier cream such as zinc oxide. Candidal dermatitis presents with erythematous plaques with a scalloped border and satellite lesions. Treatment consists of frequent diaper changes and application of nystatin cream 4 times a day.

An apparent life-threatening event (ALTE) is defined as an episode that is frightening to the observer and involves a period of apnea, transient color change (usually pale or cyanotic), and a transient change in tone (limp or stiff). According to the conventional use of ALTE, these infants appear well on presentation to the emergency department. Once it is determined that an ALTE has occurred, the workup typically includes a thorough history and physical exam; vital signs including temperature, HR, RR, and pulse oximetry; and a bedside glucose. Additional laboratory investigations are rarely helpful in the ED and should be directed by the initial history and vital signs but may include: a complete blood count; electrolytes, calcium, phosphorous, magnesium, and ammonia levels; urine toxicological screen; chest radiograph; electrocardiogram; and a septic workup, including blood, urine, and cerebrospinal fluid. Unless the history clearly suggests a benign etiology such as reflux, infants with ALTE are typically admitted to the hospital for further workup and apnea monitoring. The utility of apnea monitoring (particularly in the home) has been recently questioned. At the conclusion of hospitalization, diagnoses of infants with ALTE often remain elusive. When identified, etiologies range from GERD to seizures, inborn errors of metabolism, lower respiratory tract infection, pertussis, gastroenteritis, asthma, head injury, feeding difficulties, and urinary tract infections. There is no relation between ALTEs and sudden infant death syndrome which are now considered distinct entities.