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10-The ill Newborn (sepsis,seizure and birth injuries)-F-SC-Med07.pdf

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    The Newborn II

    Dr : Maha Bamehriz

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    Neonatal Sepsis

    • Definition :Neonatal sepsis is a clinical syndrome of systemic

    illness accompanied by bacteremia occurring in the first

    month of life.

    • Incidence. The incidence of primary sepsis is 1-8 per 1000 live

    births and as high as 13-27 per 1000 for infants weighing

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    Neonatal Sepsis Classification:

    1. Early onset sepsis

    first 72hrs after birth( 1st 3 days). (5-7 d)

    It is associated with acquisition of microorganisms

    from the mother (the intrapartum period from the

    maternal genital tract).

    It is usually a multisystem fulminant illness with

    prominent respiratory symptoms.

    Causative organisms:

    - Bacterial

    - Viral

    - Fungal

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    Neonatal Sepsis

    The microorganisms most commonly associated

    with early-onset infection include:

    - Group B Streptococcus (GBS)( most common)

    - Escherichia coli- Listeria monocytogenes

    - Coagulase-negative Staphylococcus

    - Haemophilus influenzae

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    Neonatal Sepsis

    2. Late onset sepsis:

    It occurs at 4 - 90 days of life(from 4th day to the 3rd month oflife) .

    It is acquired from the care giving environment.

    These infants usually have an identifiable focus, mostoften meningitis in addition to sepsis.

    The most common causative organisms are:

    - Coagulase-negative staphylococci ,Staphylococcus aureus ,GBS

    - E coli,Klebsiella, Pseudomonas,Enterobacter 

    - Serratia , Acinetobacter ,Anaerobes.

    - Candida

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    Neonatal Sepsis

    • Risk Factors:

    Maternal :

    1. Premature or prolonged (>18 h) rupture of

    membranes.

    2. Maternal peripartum fever (38 °C/100.4 °F) or

    infection( Chorioamnionitis( inflammation of the fetal

    membranes{amnion and chorion }due to bacterial

    infect.), UTI, vaginal colonization with GBS, previous

    delivery of a neonate with GBS disease, perinealcolonization with E. coli ).

    3. Meconium-stained or foul-smelling amniotic fluid.

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    Neonatal Sepsis

    • Risk factors:

    fetal and Neonatal :

    1. Prematurity and low birth weight .

    2. Resuscitation at birth.

    3. Multiple gestation.

    4. Invasive procedures.

    5. Males / Black.

    6. Metabolic disorder.7. Congenital anomaly

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    Neonatal Sepsis

    • Clinical features :

    Clinical signs and symptoms of sepsis are nonspecific.

    - Temperature irregularity.

    - Change in behaviour.( crying and irritability)- Skin changes, (rash )

    - Feeding problems.

    - Cardiopulmonary.

    - Metabolic disturbances

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    Neonatal Sepsis

    • Diagnosis :

    • CBC (↓ platelets usually) & Differential.

    • Acute-phase reactants(CRP).

    Cultures.• Radiologic studies ( CXR, Urinary tract imaging.)

    • Other studies (Examination of the placenta and fetal

    membranes) if U think in congenital infection

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    Neonatal Sepsis

    • Deferential Diagnosis :

    • Respiratory distress syndrome (RDS)

    • Metabolic diseases

    Hematologic disease• CNS disease

    • Cardiac disease ( cyanotic congenital heart disease)

    • Other infectious processes (ie, TORCH infections)

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    Neonatal Sepsis

    • Management :

    • 1- ABC

    • 2- IV fluid

    3- Initial therapy : Immediately start Antibiotic

    - Treatment is most often begun before a definite causativeagent is identified.

    - It consists of a penicillin, usually Ampicillin, plus anaminoglycoside such as Gentamicin .

    - In nosocomial sepsis, the flora of the NICU must beconsidered, generally, staphylococcal coverage withVancomycin plus either an aminoglycoside or a third-generation cephalosporin is usually begun.

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    Neonatal Sepsis

    • Management :

    Continuing therapy :

    - Based on culture and sensitivity results, clinical course, and

    other serial lab studies (CRP).

    Complications and supportive therapy.

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    NEONATAL SEIZURE

    seizure is defined clinically as a paroxysmal alteration in

    neurologic function (ie, behavioral, motor, or autonomic

    function) (Volpe, 2001).

    In the neonatal brain, glial proliferation, neuronal migration,

    establishment of axonal and dendritic contacts, and myelin

    deposition are incomplete.

    seizures in the neonate are different from those seen in older

    children.

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    NEONATAL SEIZURE

    Clinical types:

    - based on clinical presentation, Four types of seizures, are

    recognized:

    1. subtle

    2. clonic

    3. tonic

    4. Myoclonic

    * Nerver come tonic clonic together as in adult .

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    NEONATAL SEIZURE

    Clinical types:

    1. Subtle seizures:

    - These seizures are not clearly clonic, tonic, or myoclonic .

    - More common in premature than in full-term infants.

    - They consist of tonic horizontal deviation of the eyes with

    or without jerking; eyelid blinking or fluttering; sucking,

    smacking, or drooling ,"swimming," "rowing," or "pedaling"

    movements ,and apneic spells

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    NEONATAL SEIZURE

    2. Clonic seizures:- More common in full-term infants than in premature

    infants .

    - Focal seizures and Multifocal seizures.

    3. Tonic seizures- Occur primarily in premature infants.

    - Focal seizures and Generalized seizures

    4. Myoclonic seizures

    - Seen in both full-term and premature infants and are

    characterized by single or multiple synchronous jerks.

    - Focal , Multifocal , Generalized

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    NEONATAL SEIZURE

    Is it seizure or jitteriness ?

    • It is important to distinguish jitteriness from seizures.

    • Jitteriness is not accompanied by abnormal eye movements,

    and movements cease on application of passive flexion.

    • In jitteriness , movements are stimulus sensitive and are not

     jerky.

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    JitterinessSEIZURE

    Normal phenomenapathological

    will STOP once you holdit 

    If you try to control it :It will NOT stop

    ( rhythmic , continuous )

    start if you stimulatehim ( eg : change his

    clothes …. )

    Start without anystimulation ..

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    Etiology of Neonatal seizure

    • Perinatal asphyxia

    • Intracranial hemorrhage

    • Metabolic abnormalities

    Hypoglycemia ,Hypocalcaemia

    • Electrolyte disturbances:Hypo- and Hypernatremia

    • Amino acid disorders

    • Congenital malformations

    • Infections

    • Inherited seizure disorders

    • Benign familial epilepsy

    • Tuberous sclerosis

    • Zellweger syndrome

    • Pyridoxine dependency

    • Drug withdrawal

    • Toxin exposure (particular

    local anesthetics

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    NEONATAL SEIZURE

    Management:

    • Because repeated seizures may lead to brain injury, urgent

    treatment is indicated.

    • The method of treatment depends on the cause.• Anticonvulsant therapy:

    Conventional anticonvulsant treatment is used when no

    underlying metabolic cause is found.

    Loading doses of phenobarbital and phenytoin control 70% ofneonatal seizures.

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    NEONATAL SEIZURE

    Anticonvulsant therapy:

    1. Phenobarbital is usually given first .

    2. Phenytoin (Dilantin).

    3. Midazolam.4. Diazepam (Valium) and Lorazepam (Ativan)

    5. Paraldehyde.

    6. Pyridoxine. ( in pyridoxine deficiency cases)

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    NEONATAL SEIZURE

    Prognosis :

    • the prognosis varies with the cause .• Infants with hypocalcemic convulsions have an excellent

    prognosis.

    • seizures secondary to congenital malformations have a

    poor prognosis.• Symptomatic hypoglycemia has a 50% risk of death or

    complications.

    • CNS infection carries a risk of 70%.

    • Asphyxiated infants with seizures have a 50% chance ofa poor outcome ( CP ).

    • 17% of patients with neonatal seizures have recurrentseizures later in life.

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    Birth Injuries

    Cephalohematoma :

    - It is a subperiosteal hemorrhage ( due tear in blood vessels)

    that never extends across the suture line.

    - It can be secondary to a traumatic or forceps delivery.- Most cephalohematomas resolve in 2-3 weeks ( so Don’t

    touch it ... Rarely : may need interference )

    - Aspiration of the hematoma is rarely necessary.

    Caput succedaneum: the bleeding is

    - Diffused . - cross the suture .

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    Birth Injuries

    cephalhaematoma

    Caput

    succedaneum

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    Birth Injuries

    Erb-Duchenne paralysis: ( waiter’s tip position)

    - Involves injury to the fifth and sixth cervical nerves.- There is adduction and internal rotation of the arm. The

    forearm is in pronation ,the power of extension is

    retained ,The wrist is flexed.

    - This condition can be associated with diaphragmparalysis( phrenic nerve palsy )

    - prognosis : resolve completely , if Not resolved by 6

    weeks should be referred to orthopaedic surgeon

    Klumpke’s palsy : less often .

    lower root of brachial plexus are injured , lead to hand

    drop

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    Birth InjuriesErb’s palsy

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    Birth Injuries

    Clavicular fracture:

    - Most common newborn orthopaedic injury.

    - Signs

     – Pain with movement and Moro reflex .

     – Pseudoparalysis of extremity on Fracture side.

     – Sternocleidomastoid muscle spasm on affected side .

     – Crepitus at Fracture site.

     – Palpable bony irregularity at Fracture site .

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    Birth Injuries

    - Prognosis

     – Excellent, even for displaced Fractures .

     – Palpable callus formation in 7 to 10 days

     – Fracture heals in 4 to 6 weeks ,

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    Birth Injuries

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    Reviewed by: Amal Alsomairi