Neonatal Diseases

Overview

The neonatal period is only the first 28 days of life, but it accounts for 40% of all deaths in children under the age of five. Even within the neonatal period, mortality rates vary greatly, with 75 percent of all neonatal deaths occurring in the first week of life including 25 to 45 % in the first 24 hours after birth.

Neonatal diseases are defined as disruptions in a newborn's normal bodily condition, organs, and improper function. Obstetricians play a critical role in reducing the frequency of newborn illnesses.

Some frequent neonatal illnesses include prematurity, respiratory dysfunction, birth trauma, congenital abnormalities, neonatal infection, and hemolytic disorders of the baby. The most essential factor in minimizing these illnesses is preventive obstetrics.

Neonatal jaundice

Neonatal jaundice is characterized by a yellowish discoloration of the skin, conjunctiva, and sclera caused by elevated serum or plasma bilirubin levels during the newborn period. Jaundice is derived from the French word "jaune," which means "yellow." In most neonates, neonatal jaundice is a minor and transitory condition. It is, nevertheless, critical to detect neonates with jaundice who do not fit this pattern, as failing to do so may result in long-term consequences.

Causes

In newborns, unconjugated hyperbilirubinemia can be caused by either physiologic or pathologic factors. Physiologic factors account for more than 75% of newborn unconjugated hyperbilirubinemia. Physiologic jaundice, also known as non-pathologic jaundice, is mild and temporary. This is due to variations in bilirubin metabolism during the newborn period, which results in a higher bilirubin burden.

The increased bilirubin load in the newborn results from increased bilirubin production due to a higher mass of red blood cells with a shorter neonatal lifespan, decreased bilirubin clearance due to a deficiency of the uridine diphosphate glucuronosyltransferase (UGT) enzyme, which has about 1% of the activity of the adult liver in the newborn, and increased enterohepatic circulation.

The G6PD enzyme, present in red blood cells (RBCs), defends against oxidative stress by converting NADP into NADPH (nicotinamide adenine dinucleotide phosphate hydrogenase) (nicotinamide adenine dinucleotide phosphate). Hemolysis of RBCs occurs when it is deficient and in the presence of oxidant stresses such as disease, some medicines, colors, and foods such as fava beans.

Depending on the GGPD mutation, the clinical presentation varies, and some neonates may appear with neonatal jaundice with severe hyperbilirubinemia or kernicterus. G6PD is an X-linked illness, meaning men are more likely to be afflicted and females are more likely to be asymptomatic carriers.

Clinical presentation

The examination of a neonate with jaundice begins with a complete history, which includes birth history, family history, the beginning of jaundice, and maternal lab tests, which are helpful in distinguishing between unconjugated and conjugated jaundice. If a newborn screen is available, it may provide valuable information.

The American Academy of Pediatrics advises that all neonates be screened for jaundice and risk factors for developing severe hyperbilirubinemia. Pre-discharge bilirubin in the high-risk zone, jaundice observed within the first 24 hours, blood group incompatibility, gestational age 35 to 36 weeks, a previous sibling who received phototherapy, cephalohematoma or significant bruising, exclusive breastfeeding, and east Asian race are all major risk factors in newborns over 35 weeks gestation. Prematurity is also known to increase the likelihood of having severe hyperbilirubinemia.

Minor risk factors include high intermediate-range blood bilirubin, a macrocosmic child born to a diabetic mother, polycythemia, male gender, and maternal age more than 25 years. A thorough examination of the newborn should include the overall look, ocular examination, abdominal examination, neurological exam, and skin rashes, as well as any hepatomegaly, splenomegaly, or ascites.

Management

Severe hyperbilirubinemia is treated with phototherapy, IV immunoglobulin, or exchange transfusion to prevent acute bilirubin encephalopathy and kernicterus. There are nomograms available to assess the bilirubin levels that need phototherapy and exchange transfusion.

Phototherapy is initiated depending on the nomogram's risk factors and blood bilirubin level. Bilirubin absorbs light most efficiently in the blue-green region (460 to 490 nm) and is either photoisomerized and expelled in bile or transformed into lumirubin and secreted in urine. During phototherapy, the newborn's eyes must be covered and the maximum amount of body surface area exposed to light.

Because most bilirubin is eliminated in the urine as lumirubin, it is critical to maintain hydration and urine production. Phototherapy is not recommended in conjugated hyperbilirubinemia because it can cause "bronze baby syndrome," which is characterized by grayish-brown staining of the skin, serum, and urine. When phototherapy is stopped, the total blood bilirubin level rises, a phenomenon known as "rebound bilirubin." The level of "rebound bilirubin" is frequently lower than the level at the start of phototherapy and does not need resumption of phototherapy.

Despite phototherapy, IV immunoglobulin is suggested for increased bilirubin levels caused by iso-immune hemolysis. When the bilirubin level is within 2 to 3 mg/dl of the exchange transfusion level, IV immunoglobin is started.

Complications

When bilirubin breaches the blood-brain barrier, newborns who develop severe hyperbilirubinemia are at risk for bilirubin-induced neurologic dysfunction (BIND). Bilirubin binds to the globus pallidus, as well as the hippocampus, cerebellum, and subthalamic nuclear bodies, producing neurotoxicity via apoptosis and necrosis.

This causes acute bilirubin encephalopathy (ABE), which is characterized by lethargy, hypotonia, and reduced sucking and is reversible. Kernicterus, a persistent condition, may occur as ABE advances. Cerebral palsy, seizures, arching, posturing, and sensorineural hearing loss are all symptoms.

Neonatal Sepsis

Sepsis is a potentially fatal illness caused by the spread of bacteria throughout the body's blood and tissues. Viruses, fungi, parasites, and bacteria can all cause it. Some of these infectious agents are passed on from mother to child, while others are picked up from the environment. Sepsis symptoms, like those of meningitis, are nonspecific and vary from kid to child. A reduced heart rate, breathing difficulties, jaundice, difficulty feeding, a low or unstable body temperature, lethargy, or severe fussiness are all symptoms of infection.

How is it diagnosed and treated?

Doctors sample blood and occasionally check cerebrospinal fluid and other bodily fluids to seek for bacteria or other infections in order to diagnose or rule out sepsis. In most cases, they screen for sepsis and meningitis in the same work-up. If a positive diagnosis is made, the kid will be given antibiotics during his or her hospital stay.

Neonatal Meningitis

Meningitis is an inflammatory condition that affects the membranes that surround the brain and spinal cord. It is caused by viruses, fungi, and bacteria such as Listeria, GBS, and E. coli. Newborns can pick up one of these viruses during delivery or from their environment, especially if their immune systems are underdeveloped, making them more vulnerable.

In babies, symptoms of infection include prolonged crying, irritability, sleeping more than normal, lethargy, refusing to take the breast or bottle, low or fluctuating body temperature, jaundice, pallor, breathing issues, rashes, vomiting, or diarrhea. Fontanels, or soft areas, in newborns may bulge as the condition worsens.

Because of their immature immune systems, neonates are especially vulnerable to this illness. Depending on the child's age, gestational age, and location, different pathogens are responsible. The organism distribution found in newborn meningitis is comparable to that seen in neonatal sepsis. There are two types of Alzheimer's disease: early-onset and late-onset. The disease manifests itself within the first 72 hours of life. Premature infants are more likely to have late-onset disease, and they are infected with a distinct collection of pathogens.

The use of intrapartum medicines to treat Group B streptococcus (GBS) infection has considerably reduced the occurrence of early-onset meningitis. GBS, on the other hand, continues to be the most prevalent cause of meningitis and newborn sepsis, accounting for more than 40% of all early-onset infections. The next most prevalent infection in this group is E. coli, which has emerged as the leading cause of early-onset sepsis and meningitis among very low birth weight (VLBW) newborns (less than 1500 g).

The incidence of late-onset diabetes is closely related to gestational age and birth weight in the late-onset group. Coagulation-negative staphylococci and Staphylococcus aureus are the most prevalent culprits here, followed by E. coli and Klebsiella.

Listeria is another pathogen identified in early-onset meningitis, and drug coverage should take this into account as well. Late-onset disease should include additional nosocomial pathogens, particularly those seen in neonatal critical care units, such as Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus.

Viral infections, such as herpes simplex virus (HSV) infection and enterovirus, should be examined. With a comprehensive maternal history showing HSV infection, antiviral therapy is strongly advised.

Diagnosis of neonatal meningitis

Any infant 28 days or younger who has a fever (100.4 F) should get a septic workup. A complete blood count (CBC) with differential, blood culture, catheterized urine with culture, chest radiograph, and lumbar puncture are all included. Orders for lumbar puncture should include cell count, glucose, protein, gram stain, culture, and, if HSV polymerase chain reaction (PCR) testing is suspected, an HSV polymerase chain reaction (PCR) research.

A lumbar puncture with cell count, protein, gram stain, and culture is required to make this diagnosis. The CSF culture continues to remain the gold standard. WBC counts in CSF for bacterial meningitis typically range from 200 to 100,000 per mL, and 25 to 1000 per mL for viral meningitis.

In the differential, bacterial sickness may have 80 percent to 100 percent neutrophils while viral illness may have fewer than 50 percent neutrophils. According to some sources, the cell count in CSF might be inaccurate. Typically, any WBC count over than 20 per mL should be cause for worry; however, certain studies demonstrate that meningitis can exist even with a normal WBC level.

In the future, PCR may be a more sensitive and real-time method for diagnosing meningitis. When compared to culture, a real-time PCR technique for detecting various infections, including Streptococcus pneumonia, E. coli, GBS, S. aureus, and L. monocytogenes, showed a greater detection rate (72 vs. 48 %). PCR found infections that cultures did not identify even after antibiotics were begun (58 vs. 29 %). More research is required before PCR can be extensively employed.

C-reactive protein (CRP) and procalcitonin are two more tests used to diagnose SBI in babies. CRP research in diagnosis has been encouraging, but its use is limited since it takes 8 to 10 hours to synthesize, therefore its sensitivity varies. Procalcitonin appears to be promising, as it rises within 2 hours after infection. If drawn after the first hours of life, it has a high sensitivity (92.6%) and specificity (97.5%).

Management

Meningitis in newborns has a high morbidity and fatality rate, hence treatment is vigorous. Infants should be hospitalized and cultures should be performed every 72 hours until they are negative. Antibiotics with a broad range of action should be begun as soon as feasible. Toxic patients may need to be treated in a pediatric critical care unit.

Ampicillin and gentamicin or cefotaxime are antibiotic options for newborn meningitis. Ampicillin 150 mg/kg per day split every 8 hours for newborns fewer than 8 days old, adding gentamicin 4 mg/kg daily or cefotaxime 100 to 150 mg/kg per day divided every 8 to 12 hours.

The antibiotics are the same from 8 to 28 days old, although the dose is somewhat altered. The ampicillin dose is 200 mg/kg/day split every 6 to 8 hours, adding the equivalent dose for gentamycin or cefotaxime, which is 150 to 200 mg/kg/day divided every 6 to 8 hours.

If you have a high level of worry about HSV, commencing acyclovir is strongly suggested. The daily dosage is 60 mg/kg, split every 8 hours, for a total of 20 mg/kg each dose. Seizures, skin lesions, and abnormal liver function tests are some of the symptoms that cause this.

Transient Tachypnea of the Newborn (TTN)

TTN (transient tachypnea of the newborn) is a harmless, self-limiting syndrome that can occur in newborns of any gestational age, immediately after birth. It is caused by a delay in the removal of fetal lung fluid upon delivery, resulting in inefficient gas exchange, respiratory discomfort, and tachypnea. It frequently presents a substantial diagnostic quandary in the management of newborn neonates with respiratory distress in the nursery.

The duration of respiratory distress is the most important factor in determining TTN diagnosis. If the pain disappears during the first few hours of delivery, it is referred to as "delayed transition." Six hours is an artificial threshold between "delayed transition" and TTN since at this time, the infant may have feeding difficulties and require additional interventions. TTN is typically an exclusion diagnosis, thus any tachypnea lasting more than 6 hours needs a workup to rule out other causes of respiratory distress.

Given TTN is a self-limited condition, supportive care is the mainstay of treatment.

Rule of 2 hours: If a newborn's health has not improved or has worsened two hours after the beginning of respiratory distress, or if FiO2 needed is greater than 0.4 or a chest x-ray is abnormal, consider moving the infant to a center with a better level of neonatal care.
Routine NICU care should include continuous cardiac monitoring, maintaining a neutral temperature environment, obtaining intravenous (IV) access, doing blood glucose tests, and monitoring for sepsis.

Respiratory

If pulse oximetry or ABG indicate hypoxemia, oxygen supplementation may be necessary.
Although an oxygen hood is the preferable first approach, nasal cannulas and CPAP can also be employed.
The concentration should be adjusted to keep oxygen saturation in the low 90s.
Endotracheal intubation and the need for ECMO assistance are infrequent, although they should always be considered in patients with deteriorating respiratory status.
Arterial blood gas (ABG) analysis should be repeated, and pulse oximetry monitoring should be maintained until indications of respiratory distress have subsided.

Nutrition

The degree of nutritional care necessary in neonates is usually determined by their respiratory state.
Tachypnea of more than 80 breaths per minute, together with the related increased labor of breathing, makes it dangerous for the newborn to take oral meals.
These newborns should be kept nil per oral (NPO), with intravenous (IV) fluids starting at 60 to 80 ml per kg per day.
If the respiratory distress is subsiding, the diagnosis is confirmed, and the respiratory rate is less than 80 breaths per minute, enteral feeding can be initiated.
Enteral feeds should always be begun carefully, with gradual increases in feed volume until the tachypnea has cleared entirely.

Infectious

Because TTN can be difficult to distinguish from early newborn sepsis and pneumonia, empiric antibiotic treatment with ampicillin and gentamicin should be explored at all times.

Medications

In randomized controlled studies comparing the effectiveness of furosemide or racemic epinephrine in TTN, there was no significant difference in the duration of tachypnea or length of hospital stay compared to controls.
Salbutamol (inhaled beta2-agonist) has been demonstrated to reduce symptom duration and hospital stay; however, further evidence-based research is needed to establish its effectiveness and safety.

Neonatal infection

Neonatal infections are infections that occur in the neonate (newborn) during prenatal development or the first four weeks of life (neonatal period). Neonatal infections can be acquired by mother-to-child transmission, in the birth canal during labor, or after birth. Some neonatal infections appear immediately after birth, whereas others may appear later in life. Some prenatal illnesses, such as HIV, hepatitis B, and malaria, do not manifest themselves until much later in life.

Preterm or low birth weight neonates are at an increased risk of infection. Infant respiratory distress syndrome is a disorder that commonly affects preterm newborns and can have long-term harmful repercussions; it can also occur as a result of an infection. In some cases, newborn respiratory tract disorders may predispose to subsequent respiratory infections and inflammatory reactions associated with lung disease.

Antibiotics can be useful in newborn infections, especially if the germ is discovered soon. Pathogen detection has increased significantly with improving technology, rather than depending primarily on culture procedures; nonetheless, neonatal mortality reduction has not kept pace, remaining 20 percent to 50 percent.

While preterm newborns are at a higher risk, any neonate can get infected. Premature rupture of membranes (breakage of the amniotic sac) may also be connected with neonatal infection, increasing the risk of neonatal sepsis by enabling germs to enter the womb before to the infant's birth. Neonatal infection may be upsetting for families and necessitates a concerted effort on the part of professionals to manage it. Research to enhance infection therapy and preventive treatment of the mother to avoid baby infections is ongoing.

Signs to Look for

Many illnesses have symptoms that are identical. If your new infant exhibits any of the following indications of infection, contact your child's doctor or seek immediate medical attention:

Poor feeding
Breathing difficulty
Listlessness
Decreased or elevated temperature
Unusual skin rash or change in skin color
Persistent crying
Unusual irritability

A significant shift in a baby's behavior, such as napping all the time or not sleeping at all, might also be a clue that something is wrong. These symptoms are especially concerning if the kid is less than two months old. If you suspect a problem, have your kid checked by a doctor as soon as possible.

Group B Streptococcal Disease (GBS)

Group B streptococcus is a common bacteria that may cause a number of illnesses in infants. Sepsis, pneumonia, and meningitis are among the most prevalent. Many pregnant women carry these germs in the rectum or vagina, where they can readily transmit to the infant if the mother has not been treated with antibiotics.

Babies with GBS frequently exhibit infection signs during the first week of birth, however others develop symptoms weeks or months later. Symptoms may include difficulty breathing or eating, a high temperature, listlessness, or excessive crankiness, depending on the illness (pneumonia or sepsis, for example).

How is it diagnosed and treated?

Doctors use blood tests and cultures of blood, urine, and, if required, cerebrospinal fluid to hunt for bacteria in order to diagnose GBS. To get a blood sample, doctors use needles, and a spinal needle to perform a lumbar puncture to extract cerebrospinal fluid. A catheter placed into the urethra is often used to retrieve urine. Antibiotics are used to treat GBS infections, as well as cautious care and observation in the hospital.

Listeriosis

Infection with the bacterium Listeria monocytogenes can cause pneumonia, sepsis, and meningitis in babies. Most individuals are exposed to the germs through contaminated food since the bacteria are abundant in soil and water and can wind up on fruits and vegetables as well as animal products such as meat and dairy products. Food that has not been properly washed, pasteurized, or cooked may cause listeriosis.

If a woman has listeriosis while pregnant, her babies may be exposed to microorganisms. Listeriosis can cause preterm birth or even stillbirth in extreme situations. Babies born with listeriosis may exhibit symptoms of illness similar to those seen in GBS patients.

E. Coli Infection

Escherichia coli (E. coli) is another bacterial pathogen that can cause urinary tract infections, sepsis, meningitis, and pneumonia in neonates. Everyone contains E. coli, and newborns can get infected after labor, when they pass through the birth canal, or by coming into touch with the germs in the hospital or at home. Most neonates who develop ill from E. coli infection have extremely weak immune systems, making them especially prone to infection.

The symptoms, like with other bacterial infections, will vary depending on the kind of infection caused by E. coli, although fever, unusual fussiness, listlessness, or lack of interest in eating are frequent. Doctors identify E. coli infection by culture of blood, urine, or cerebrospinal fluid and treat it with antibiotics.

Conclusion

Regular prenatal check-ups, a balanced diet, iron and folic acid supplements, and avoiding multiple pregnancies are among steps that can help prevent preterm. Fetal hypoxia is caused by any of the circumstances that produce maternal hypoxia during pregnancy.

The cornerstones of combating respiratory dysfunction are proper prenatal care and the avoidance of narcotic medicines throughout pregnancy. Obstetricians have an essential role in reducing birth trauma, which is a prime example of neonatal diseases.

Proper prenatal treatment to diagnose any obstetrical defect significantly minimizes delivery stress. In the event of congenital abnormalities, genetic counseling and early abortion in cases of gross congenital aberration are key factors that obstetricians can address. Obstetricians can help reduce neonatal infections by addressing any abnormal vaginal discharge during the prenatal period. Dirty dressings should be avoided during delivery.

Proper immunization of the mother, as well as HIV transmission counseling, is also essential. Adequate Rh and ABO blood groups in the prenatal period, as well as proper care at the moment of birth, can help to prevent infant hemolytic disorders.