Category Archives: Diseases Of The Baby First Month
Neonatal Sepsis (Sepsis In Newborn)
Neonatal Sepsis is a life threatening illness caused by bacterial infections occurring in the blood or elsewhere in the body.
- Poor feeding, lower than normal body temperature, and lethargy are the usual symptoms of sepsis.
- The typical symptoms may indicate the condition, but a blood test which detects the bacterial infection in the blood confirms the diagnosis.
- Infants with sepsis may recover completely with appropriate treatment, and usually suffer no lasting consequences.
- Antibiotic therapy and fluid supplementation are intravenously administered. Drugs may be required to maintain blood pressure, and ventilator support may be necessary to aid breathing.
Infants born prematurely are at a higher risk of developing neonatal sepsis than those who are born on completing full term. One reason is that the immune system of the premature babies is not yet fully mature. The other reason is that premature babies lack antibodies which would protect them from various infective organisms, because the mother’s antibodies usually pass through the placenta into the fetus only towards the end of pregnancy.
Sepsis in newborn is differentiated into early-onset and late-onset sepsis based on the time of occurrence of this condition. When the symptoms develop in the very first week of life, it is termed early–onset sepsis and when they appear later than seven days, it is considered as late-onset sepsis. The treatment for both the categories is same, but the causes differ.
Early-Onset Neonatal Sepsis:
The sepsis developing in newborns in the first week usually have the following risk-factors:
- Infections present in the mother affecting the fetus prior to birth or at the time of birth.
- Early rupture of the amniotic sac that encloses the fetus, resulting in prolonged exposure to infective organisms.
- The mother having Group B Streptococcus infection.
Infections of the uterine lining and the urinary tract of the mother may get passed on to the fetus. When the fluid-filled amniotic sac which protects the fetus ruptures much before the onset of labor, the fetus gets exposed to various microorganisms which can cause infections that may lead to sepsis. Escherichia coli and Group B Streptococcus (GBS) are the two usual infective agents causing sepsis in newborns when they are present in the mother. In fact, GBS infection contracted by newborns used to be the major cause of early-onset sepsis till routine screening of the mother for the presence of GBS infection became common. An infected mother is treated with antibiotics at the time of labor, and the infant is also given antibiotic therapy if it has a vaginal delivery.
Late-Onset Neonatal Sepsis:
The infant may develop sepsis seven days or more after birth due to the following reasons:
- Hospitalization of the infant for prolonged periods.
- Catheters inserted into the arteries and veins for various treatment procedures.
- Using endotracheal tube introduced through the mouth or nose of the infant to provide ventilator support.
Exposure to various microorganisms in the hospital, and direct introduction of infections through catheterization and intubation for treatment procedures, and handling the infant with unclean hands, increase the likelihood of the newborn developing sepsis.
Symptoms and Diagnosis
When infants have sepsis, they become lethargic, and usually have a lower body temperature known as hypothermia. Sometimes fever may be present. Feeding becomes poor. Diarrhea and vomiting may be present along with abdominal distension. The skin may be yellowish due to jaundice, or pale because of poor circulation. The extremities feel cold to touch too. Breathing problems such as short breaks in breathing called apnea, and seizures may occur. When the symptoms are present, a blood test to determine the blood count may confirm sepsis, but a culture result identifying the causative agent is a more definitive test.
Meningitis or the infections affecting the membranes enclosing the brain is an extremely dangerous complication precipitated by sepsis. Extreme lethargy, seizures and coma are the usual symptoms of meningitis. The fontanelle or soft spot on the top of the head in infants usually bulges out. When meningitis is suspected, a lumbar puncture is done to draw out a sample of the cerebrospinal fluid for culture study.
Prognosis and Treatment
Premature infants are more prone to neonatal sepsis than term babies and this illness kills more premature babies entering the second week of their life than any other disorder. Most infants who survive the illness recover completely without any long term ill effects. However, infants who had meningitis may have certain lasting consequences like hearing loss, developmental delay, seizures or even cerebral palsy.
The blood is cultured to identify the exact organism that is causing the sepsis so that specific antibiotics against it can be used to treat the infection. However, the doctors usually start antibiotic therapy with wide-spectrum antibiotics even before the results arrive, as any delay can be dangerous. Once the culture report comes, the medications are adjusted accordingly. Fluids are also given intravenously. Infants requiring assistance with breathing are given ventilator support. They are given drugs to keep the blood pressure steady, if required.
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Neonatal Thyroid diseases (Hyperthyroidism and Hypothyroidism)
Newborns may have thyroid disorders such as hypothyroidism; when thyroid gland does not produce adequate amounts of the thyroid hormones, or hyperthyroidism; when there is an overproduction of the same hormones.
Neonatal Hypothyroidism
Underdeveloped thyroid gland, or its absence, is the usual reason for neonatal hypothyroidism. Occasionally, the thyroid gland which is present may not be producing adequate amounts of the hormones, resulting in hyperthyroidism.
Symptoms and Treatment
Hypothyroidism may not produce any symptoms in the beginning. But later on, many symptoms such as lethargy, and lack of muscle tone, may develop. The affected infant may have constipation and decreased appetite. Hoarseness of voice while crying, and bulging of the belly button due to the development of umbilical hernia are the other symptoms. Developmental delays, poor intellectual growth, and stunted physical growth, are the usual outcomes if hypothyroidism is not treated properly. Enlargement of the tongue, and rough facial features, are also characteristics of untreated congenital hypothyroidism.
The prognosis of neonatal hypothyroidism is good if it is detected early, and a simple treatment regimen is followed. In most of the developed countries, a routine blood test is done to assess the thyroid function of all infants. Hypothyroidism is indicated by low levels of the thyroid hormones and higher than normal levels of another hormone called thyroid stimulating hormone. An endocrinologist specializing in the thyroid disorders of infants may prescribe the correct dosage of the thyroid hormone thyroxin, which is given orally. Intellectual disabilities and physical deformities can be prevented by administering the thyroid hormone on a daily basis. Hypothyroidism in infants may require treatment throughout life.
Neonatal Hyperthyroidism
Hyperthyroidism, which is very rare in newborn babies, is known as neonatal Graves’ disease. Graves’ disease in the mother, either during pregnancy, or prior to it, raises the risk of the infant developing this condition. The thyroid stimulating antibodies produced in the mother induce her glands to produce more thyroid hormones. These antibodies, when they cross over to the infant through the placenta, stimulate the infant’s thyroid glands in the same way, resulting in excess production of the hormones.
Symptoms and Treatment
The usual symptoms displayed by the newborn with hyperthyroidism are rapid breathing, abnormally fast heart rate, and elevated metabolic rate. The infant may have excessive appetite, but it may not gain weight properly. A condition called exophthalmos, characterized by the bulging of eyes, may be present in both the infant and its mother. Goiter, or enlargement of the thyroid gland, if present, may cause difficulty in breathing in the newborn due to the pressure it exerts on the windpipe. Abnormally high heart rate may result in heart failure. Neonatal Graves’ disease is a life threatening situation which can result in death, if not detected early and treated appropriately.
The typical symptoms of hyperthyroidism alert the doctors to the possibility of the disorder in the newborn. High thyroid hormone levels in the infant’s blood help in diagnosis. High levels of thyroid stimulating antibodies from the mother’s blood also may be detected in the infant. Since hyperthyroidism is dangerous in infants, a routine thyroid function test in newborns may be a life-saving measure.
Hyperthyroidism in newborns is treated using drugs which retard the thyroid hormone production. Propylthiouracil is such a drug used to slow down the thyroid gland. After the first few months, the treatment can be discontinued, as the antibodies which crossed over from the mother’s bloodstream into the infant through the placenta gradually wear off.
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Neonatal Polycythemia (Polycythemia in Newborn)
Neonatal Polycythemia is the abnormal condition of having too many red blood cells in circulation.
- Post maturity, and low blood levels of oxygen in the fetus are the usual reasons for polycythemia in newborns. If the mother is diabetic, the infant has a higher risk of developing this condition.
- When the number of red blood cells in a given volume of blood is higher, it increases the viscosity of the blood. The thicker blood, or the hyperviscosity of the blood, slows down its flow through the smaller vessels.
- The infants with polycythemia may not exhibit any symptoms, but they may look reddish or dusky. Lethargy, poor feeding may develop due to this condition. Seizures too may occur, but it is very rare.
- A blood test to assess the red blood cell content helps in diagnosing polycythemia.
- When symptoms are absent, mild polycythemia is treated with the administration of adequate amounts of fluids.
- When symptoms are present, exchange transfusion of blood help reduce hyperviscosity, as well as the symptoms associated with polycythemia.
When the blood is too thick due to very high concentration of the RBCs, the blood flow in the capillaries becomes very slow. It may compromise the oxygen supply to the various tissues of the body. The reasons for polycythemia in infants are many. It is very common in postmature infants who are born one or two weeks after the completion of the normal gestational period. Infants born to mothers who have high blood pressure or diabetes, and those from high altitude areas also can have this condition. Smoking during pregnancy is another reason that puts the infants at high risk.
A fetus that had hypoxia or low blood levels of oxygen and which suffered intra uterine growth retardation are prone to developing neonatal polycythemia at birth. When a newborn has received large amounts of blood, either from the placenta before the umbilical cord is severed, or from its twin via twin-to twin blood transfusion, it may result in excess amount of blood in the baby.
When polycythemia is severe, the newborn may have a reddish complexion or may look dusky. Lethargy and poor feeding may be indications of neonatal polycythemia. Very rarely, seizures too occur. A test of hematocrit is often done to assess the red blood count. If the hematocrit is very high or if the symptoms are present, the infant’s blood is diluted by partial exchange transfusion. In this procedure, a small amount of the infant’s blood is drawn out with a syringe first, and then the same quantity of saline is injected back into the vein, thus bringing down the RBC concentration in the blood.
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Neonatal Anemia (Anemia in the Newborn)
Neonatal Anemia is a blood disorder characterized by the abnormal decrease of the red blood cells in the blood.
- Excessive breakdown of the red blood cells, severe blood loss, and nonproduction of red blood cells by the bone marrow, are the usual reasons of anemia in the newborn.
- When the anemia is due to excessive break down of red blood cells, yellowish discoloration of the skin as well as the whites of the infant’s eyes are the usual symptoms resulting from the high bilirubin levels in the blood.
- When severe blood loss is causing the anemia, symptoms of shock such as abnormally fast heart rate, very low blood pressure, fast but shallow breathing, and paleness are usually present.
- Intravenous administration of fluids and exchange blood transfusion are the treatments for anemia in the newborn.
The red blood cell production by the bone marrow temporarily stops for a period of 3 to 4 weeks following birth. It results in a condition called physiologic anemia lasting for about 2 or 3 months after birth. It is quite normal and usually mild, requiring no special treatment. In extremely premature infants the initial reduction of RBCs may be higher than it is in term babies. Neonatal anemia may be much more severe in certain situations which include rapid destruction of RBCs, severe blood loss during birth, and nonproduction of RBCs by the bone marrow. When the infant’s blood is drawn repeatedly for various tests in the initial days after birth, it may lead to anemia, especially in premature infants. Several of the above mentioned situations may occur together causing severe anemia.
Excessive breakdown of red blood cells raises the bilirubin levels in the blood resulting in a condition called hyperbilirubinemia. RBCs may be destroyed excessively and rapidly by the hemolytic disease occurring in the newborn infants. Certain hereditary disorders, if present, may lead to rapid destruction of red blood cells. For example, there is a blood disorder called hereditary spherocytosis characterized by an abnormal spherical shape of the red blood cells. A red blood cell enzyme called glucose-6-phosphate dehydrogenase [G6PD]) may be absent in some babies, though it is quite rare. When the mother uses certain medications such as sulfa drugs or aniline dyes it may affect the fetus and result in rapid destruction of RBCs in the newborn infant.
Many infections passed on to the fetus from the mother such as, syphilis, rubella, toxoplasmosis, herpes simplex and cytomegalovirus infections can be the reason for the destruction of RBCs in newborns. Bacterial infections contracted during birth, or afterwards, also may be responsible.
Severe blood loss resulting from fetal–maternal transfusion can result in neonatal anemia. This occurs towards the end of pregnancy and the beginning of labor. The fetal blood gets transfused into the maternal circulation through the placenta. Sometimes large amounts of blood may remain in the placenta at the time of delivery resulting in less blood in the infant. This may happen when the baby is held up to clamp and cut the umbilical cord, draining blood into the placenta. When twins have shared circulation, twin-to-twin transfusion may take place leaving one baby anemic, and the other with a condition called polycythemia or excess blood. Placental separation from the uterine wall during labor can result in severe fetal blood loss leading to anemia in the newborn.
In rare cases, the bone marrow of the fetus fails to produce red blood cells, causing anemia in infants. A genetic problem which cause anemia due to nonproduction of RBCs is called Diamond-Blackfan anemia. Fanconi’s anemia is another example. Certain infections, including syphilis, HIV and cytomegalovirus infection can prevent the production of RBCs by the bone marrow.
Symptoms and Diagnosis
Mild neonatal anemia is usually asymptomatic. If anemia is moderate, the infant may become lethargic. Poor feeding is another usual symptom of anemia. Some infants may not show any symptoms at all. Severe blood loss during labor, or at the time of delivery, may cause shock in the newborn. Abnormally fast heart rate, extremely low blood pressure, and fast but shallow breathing, are the usual symptoms of shock. The infant may look very pale too. Anemia can be caused when a large number of red blood cells breakdown. In such cases, the excess bilirubin released into the blood may make the skin as well as the whites of the infant’s eyes yellow. The typical symptoms often indicate anemia in infants, but blood tests are necessary to confirm the diagnosis.
Treatment
A mild form of neonatal anemia, which is usually present in most babies, does not need any specific treatment.
If heavy blood loss has been suffered by the infant, either during labor or at the time of delivery, fluids are administered intravenously and if necessary, blood transfusion is also done. Hemolytic disease is another condition which makes the infant extremely anemic and necessitates blood transfusion. Exchange blood transfusion is the preferred procedure for infants, as it serves the dual purpose of increasing the hemoglobin content and red blood cells, while decreasing the blood levels of bilirubin. In this procedure, one syringe of the infant’s blood is drawn out first and then the same amount of fresh blood from the blood bank is injected into the infant in exchange
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Jaundice In Newborn (Neonatal Hyperbilirubinemia)
Neonatal Hyperbilirubinemia or jaundice in newborn is characterized by the presence of excess amounts of bilirubin in the blood, resulting from the breakdown of red blood cells.
- Hyperbilirubinemia in infants is often the result of feeding problems encountered in newborns, as well as the breakdown of large amounts of red blood cells. Infection of the blood, termed sepsis, also may cause this condition.
- Typical symptoms of jaundice, such as the yellowing of the skin and the white part of the eyes, are caused by excess of bilirubin in the blood.
- The symptoms of jaundice indicate hyperbilirubinemia which is confirmed by the bilirubin levels measured by a blood test.
- Infants discharged within a day of birth need to have their blood levels of bilirubin checked by a medical professional at home, or at their doctor’s office, at least once within the next week.
- Phototherapy is used to treat infants with jaundice. Exchange blood transfusion may be necessary in some cases when the blood levels of bilirubin are very high.
When red blood cells in the blood age, they are destroyed in the spleen, and the oxygen carrying compound hemoglobin from the broken down WBCs is recycled. The yellow-colored bilirubin is produced from the heme part in the hemoglobin. When blood reaches the liver, it alters the bilirubin chemically, and incorporates it into bile, which is then poured into the intestines with other digestive secretions. The bilirubin gets eliminated from the body through bowel movements.
An increase in the bilirubin levels in the newborn’s blood is usual in the first few days following birth, but it is considered to be normal. The presence of excess bilirubin in the blood may cause yellowing of the skin, which is called jaundice. The whites of the eyes also may take on a yellowish color. If the infants are not fed well soon after birth, due to illnesses, or disorders of the digestive system, the bilirubin does not get eliminated from the body through bowel movements. It results in the elevation of bilirubin levels in the blood. Breastfeeding infants usually have higher levels of bilirubin in the blood in the first week after birth, but it does not affect them adversely. Eventually, as the breastfeeding improves, the blood levels of bilirubin become normal, as frequent feedings leads to more frequent bowel movements through which the bilirubin is eliminated.
When infants have other serious disorders such as infections or sepsis, it may result in severe neonatal hyperbilirubinemia. Blood group incompatibility (ABO incompatibility, Rh incompatibility) is another significant cause of hyperbilirubinemia as the consequent hemolysis or rapid destruction of red blood cells causes abnormally high levels of bilirubin in the blood.
Moderate to moderately high levels of bilirubin does not cause any serious problems in the infant and it usually resolves on its own or with phototherapy. However, very high levels can lead to brain damage in the infants. Kernicterus is the term used to refer to brain damage resulting from severe hyperbilirubinemia. Extremely premature babies, and those with serious illnesses at birth, are more prone to developing this condition. Intensive treatment helps avoid kernicterus in susceptible infants. Breastfeeding infants who are premature by only a few weeks, and infants discharged within one or two days of birth, should be carefully monitored for signs of jaundice in the following one week or two, as they are at risk of developing kernicterus if their blood levels of bilirubin become elevated unnoticed. Slightly premature babies may not be able to feed as well as babies born at term, which makes them more prone to developing hyperbilirubinemia. Another reason is that the milk production in the mother may be limited in the first few weeks when the baby is born early, and insufficient feedings result in fewer bowel movements.
Symptoms and Diagnosis
Neonatal hyperbilirubinemia is easier to spot in light-skinned infants, as the discoloration usually starts appearing on the face of the infant, and progresses towards the chest and abdomen with the increase in the blood levels of bilirubin, finally reaching the feet. The whites of the eye also may be discolored. But the presence of jaundice alone cannot determine the severity of hyperbilirubinemia. A blood test helps determine the exact amount of bilirubin in the infant’s blood. Very high levels of bilirubin may lead to kernicterus.
Kernicterus has symptoms which include poor feeding and extreme lethargy in the infants. When babies who already have jaundice develop the symptoms characteristic of kernicterus, immediate medical attention should be sought. As kernicterus progresses, more symptoms such as stiffening of muscles, irritability, and arching of the back, may develop. Seizures also may occur. These symptoms may be accompanied by fever too.
All the infants should be monitored for signs of jaundice in the first few days of life. When it is detected, tests should be performed to determine the blood bilirubin levels. In many hospitals, bilirubin levels are routinely checked before the infant is discharged. Sometimes, the jaundice may be very mild in the beginning, but it increases several days after discharge. In such cases the infants should be either checked by a doctor or a qualified medical professional visiting at home, or they should be brought in for a post natal assessment. If the infant is discharged within one day of birth also, it is essential to visit the doctor at least once within the next week. Careful monitoring and testing for bilirubin levels is very important for breastfeeding infants who are born prematurely.
After examining the infants under bright light, the bilirubin level is checked using an equipment called transcutaneous bilirubinometer, which is held close to the infant’s skin. A more accurate method is testing a blood sample taken from the infant.
Treatment
When Neonatal hyperbilirubinemia is mild, it need not be treated. Frequent feedings increase bowel movements through which most of the bilirubin can be excreted, lowering its levels in the blood. When the contents of the intestines remain longer in the body, bilirubin is reabsorbed. Breastfed babies have to be fed as often as possible as they tend to develop jaundice due to poor feeding.
When hyperbilirubinemia is moderate, the infants are treated by phototherapy. Infant’s entire body is exposed to special white or blue lights called bilirubin lights. The light changes bilirubin into another compound which is easily removed by the liver and excreted by the kidneys. To avoid damage to the eyes by the lights, a blindfold is placed over the infant’s eyes. A special fiber-optic blanket which emits bilirubin lights can be used to cover the infant at home. Infants undergoing phototherapy should be tested frequently to ensure that the bilirubin level in the blood is decreasing. There is a possibility that bilirubin levels may remain high even when the outward symptoms of jaundice have disappeared.
Occasionally, mothers are asked to stop breast feeding the infant for one or two days, and to give formula feed instead. Unlike in breastfeeding, it is possible to check the amount of bottle feed the infant is receiving, so that inadequate feeding, if present, can be detected. Once the bilirubin levels start showing a decreasing trend, then breastfeeding can be resumed.
Moderate cases of neonatal hyperbilirubinemia usually respond to phototherapy and get resolved in a few days. But if bilirubin levels do not come down with phototherapy, or when the levels are dangerously high, an exchange blood transfusion can be done for the rapid lowering of bilirubin levels. The transfusion takes place through the infant’s umbilical vein. A catheter is inserted into the vein in the umbilical cord stump and blood is drawn out with the help of a syringe. After the removal of one syringe of jaundiced blood, fresh, healthy blood from the blood bank is injected into the vein in equal amounts. The exchange transfusion helps keep the bilirubin levels low.
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Apnea of Prematurity
Apnea of prematurity is defined as a brief pause in breathing occurring in premature infants, usually lasting for over 20 seconds.
- Episodes of apnea usually occur when the respiratory center in the infant’s brain has not become sufficiently mature due to prematurity.
- Apnea often results in a bluish discoloration of the skin in the infant due to the poor oxygen content in the blood; it may slow down the heart rate too.
- Apnea may be detected on close observation of the infant, or when alerted by a monitor with an alarm attached to the infant.
- Episodes of apnea occur less frequently as the infant’s respiratory center in the brain gradually becomes mature, finally stopping completely.
- When the infant having an episode of apnea does not start breathing when prodded gently, artificial respiration should be given immediately.
- Caffeine is given to infants with severe apnea to stimulate their breathing.
Premature infants, especially those who are born prior to completing 34 weeks of gestation, are prone to apnea of prematurity. The severity, as well as the frequency, of the episodes is dependent on the gestational age of the premature infant. The respiratory center in the infant’s brain which controls breathing may not have become fully developed to regulate the breathing. Due to this, the infant may have intermittent periods of regular breathing punctuated by short pauses, during which the oxygen levels of the blood may get significantly lowered. Apnea in premature infants may be the result of an obstruction of the pharynx too. Obstructive apnea is more common in extremely premature infants, and it occurs due to their poor muscle tone, or because of the neck bending forward and creating a temporary block.
Gradually, as the muscle tone of the infant improves, and the respiratory center in the brain becomes mature, the severity, as well as the frequency, of the episodes will reduce, till they stop completely.
Symptoms and Diagnosis
When infants are born prematurely, they are monitored closely to detect any signs of distress which may require immediate medical attention. They are placed on an apnea monitor which beeps an alarm whenever the breathing of the infant pauses for over 20 seconds. Low heart rate also triggers the alarm. When the episodes of apnea are longer, it may result in low levels of oxygen in the infant’s blood. The infant may have bluish skin and lips, a condition termed cyanosis. Low oxygenation of blood often leads to bradycardia or the slowing down of the heart also.
Apnea in premature infants most commonly occur due to the immaturity of their brain. However, in some cases, it may be the symptom of other disorders like hypoglycemia, which is an abnormally low level of blood glucose. An infection of the blood termed sepsis can also lead to apnea. Hypothermia, or abnormally low body temperature, is another condition in premature infants that may cause apnea. When the episodes of apnea suddenly increase in an infant, doctors investigate all possible reasons for the condition. Samples of urine, blood and cerebrospinal fluid are collected and tested for infections. The blood glucose levels are also tested to detect hypoglycemia.
Treatment
When pauses in breathing are observed either directly, or with the help of the alarm sounded by the apnea monitor, a gentle prod or touch will usually restore normal breathing in the infant. Depending on what caused the apnea, different treatments are given. If an obstruction of the infant’s pharynx is causing the apnea, keeping the infant on its back, with the head positioned centrally with supports, usually help reduce the occurrence. Making the infant lie on its side, with adequate support to the head, also helps.
The stimulating effect of caffeine is used to activate the respiratory center of the brain, if episodes of apnea occur very frequently. Drug treatment with stimulants like coffee is often given to infants who are prone to developing cyanosis with the episodes of apnea. If drug therapy does not yield the desired results, and severe apnea continues to occur frequently, a technique called continuous positive airway pressure or CPAP may be used. Oxygen under slight pressure is delivered to the infants via nose prongs to assist their normal breathing. In very severe cases, ventilator support may be inevitable.
Almost all the premature infants who have episodes of apnea due to prematurity eventually stop having them, even weeks before they complete full term.
Sudden infant death syndrome, or SIDS for short, is more common in premature babies, but there is no direct relation between apnea of prematurity and the risk of sudden infant death later on. Babies who have apnea of prematurity are often discharged from the hospital with an apnea monitor, to detect pauses in the breathing and to alert the parents when they occur. However, the risk of death from SIDS is not in any way reduced by the use of an apnea monitor.
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Neonatal Necrotizing Enterocolitis
Neonatal necrotizing enterocolitis is intestinal damage occurring in premature infants, resulting in the death or necrosis of parts of the intestine.
- Bloody stools, distension of the abdomen, and sluggishness in the infant, are the usual symptoms. Vomiting of a yellowish, rust- colored, or greenish fluid may be present.
- An x-ray of the abdomen helps confirm the condition.
- As part of treatment, feeding is completely stopped and the abdomen is emptied. A suction tube is introduced to reduce pressure in the stomach. Intravenous administration of fluids and antibiotics are started.
- The portions of the intestine which have become damaged due to lack of blood supply are surgically removed. In case surgery is not possible due to the infant’s unstable condition, the abdominal cavity is drained with a tube.
- The rate of survival of infants with necrotizing enterocolitis is around 60 to 80%.
Neonatal Necrotizing enterocolitis (NEC) is primarily a condition affecting infants born prematurely, with low birth weight pre-term infants accounting for almost 85% of the cases. The exact cause of this condition is not known, even though immature blood circulation is thought to be the underlying reason. Limited blood supply to the intestinal tissues due to immature capillary growth may result in the damage of the inner walls of intestines. Bacteria abundant in the gastrointestinal tract may cause infections in the damaged wall of the intestine. When the whole thickness of the wall of the intestine is infected, it may develop perforations on the wall. The stool and other contents of the intestine leaking into the peritoneal cavity may cause peritonitis, or widespread infection and inflammation of the peritoneal membrane as well as other tissues and organs in the abdomen. When the infection enters the blood, it causes sepsis.
Symptoms and Diagnosis
Abdominal distension, or swelling up of the abdomen, is one of the first symptoms to appear. Bloody stools are another indication. Infants with NEC may vomit a greenish yellow or rust- colored fluid. Infants become sluggish and look extremely sick. Frequent disruptions in breathing called apnea and low temperature are other signs.
An x-ray of the abdomen may show a condition called pneumatosis intestinalis characterized by gas collection in wall of the intestine. If there are perforations in the intestinal wall, the presence of free air may be seen in the peritoneal cavity. A blood test may detect bacterial infections or sepsis, if present.
Prognosis
With emergency medical treatment with appropriate drugs, and surgery, the prognosis of premature infants with necrotizing enterocolitis has improved considerably. Survival rates between 60%-80% have been achieved.
Prevention and Treatment
When extremely premature babies are fed expressed milk from their mother, the incidence of necrotizing enterocolitis has been found to be much lower than it is in infants fed formula milk. The protective effect of the mother’s milk can be utilized to prevent the disease by introducing small amounts of it as soon as possible after birth.
When neonatal necrotizing enterocolitis is detected, gastrointestinal nutrition is stopped completely. The pressure in the intestine is relieved by introducing a suction tube into the stomach. Antibiotic therapy is started immediately and fluids as well as drugs are given intravenously.
Majority of infants with necrotizing enterocolitis do not require surgery. But in around 30% of cases, surgery is necessitated by intestinal perforations which leak intestinal matter into the peritoneal cavity, resulting in peritonitis. When the disease progresses without responding to other treatments too, surgery may be the only option. The portions of the intestine which have become irreparably damaged, or which contain dead tissue, are removed. The remaining intestine is rerouted to an opening created on the abdominal wall through which stool is eliminated. This is a temporary measure, and the cut ends of the intestine are reconnected later, once the infant overcomes the disease.
Many infants, particularly the smaller and sicker among the premature infants, may not be strong enough to withstand an abdominal surgery. In such cases, the abdominal cavity is drained by introducing peritoneal drains into the lower part of the abdomen on both sides. The intestinal content leaking into the peritoneal cavity as well as the peritoneal fluid is drained out through these tubes. When combined with antibiotic treatment, this procedure often helps reduce symptoms and stabilizes the infants till they are ready to undergo a major abdominal surgery. Some infants may even get better with this procedure alone, and may not require surgical intervention.
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Retinopathy of Prematurity (ROP)
Retinopathy of prematurity is an eye disease caused by the abnormal growth of the blood vessels in the retina; it has the potential to lead to blindness.
- Premature birth is the single largest cause of retinopathy in infants, with the greatest incidence found in those who are born around 26 weeks of pregnancy or earlier.
- In some cases of retinopathy, the rapid, disorganized growth of the small blood vessels in the retina may result in their bleeding, often causing extensive scarring of the infant’s retina, which may lead to blindness.
- Retinopathy of prematurity is asymptomatic, and is detected when the newborn’s eyes are examined by an ophthalmologist.
- Retinopathy of prematurity often resolves on its own, without any treatment, especially in mild cases. However, frequent eye examinations are required to monitor the progress of the blood vessel development till they are completely developed.
- Laser treatment is used to treat severe cases of retinopathy to prevent blindness.
The development of blood vessels in the retinal wall may be arrested for an initial period, in infants born extremely premature. Later on, the blood vessel growth starts again, but they may grow in a rapid, irregular, and disorganized way. It may cause bleeding of these small vessels, often resulting in scarring. The retina may get detached from the eye wall at the back, leading to blindness. Oxygen toxicity, which results from the active treatment of respiratory distress in premature infants, is found to be a reason for the development of retinopathy.
Retinopathy of prematurity is asymptomatic in infants who develop this condition. Unless an ophthalmologist examines the back of the premature infant’s eyes, it may remain undiagnosed till it progresses to loss of vision.
Prevention and Treatment
Premature infants with a birth weight of 3 pounds or less (1,500 grams or less) should be examined by an ophthalmologist to detect abnormalities in the growth of the retinal blood vessels. Weekly eye examinations are necessary till the blood vessel growth is completed. Yearly eye examinations are recommended for those who have severe retinopathy as infants. When abnormal blood vessel growth is detected, it can be treated to prevent the detachment of the retina and vision loss.
When supplemental oxygen is given to premature infants to reduce respiratory distress, care should be taken to keep the oxygen concentration to the minimum required. Blood oxygen levels should be checked frequently to ensure the lowest necessary level. A pulse oximeter connected to a finger or a toe can continuously measure oxygen levels in the blood.
Retinopathy of prematurity often disappears on its own, especially in mild cases. Laser treatment is an option if retinopathy is very severe. The outer layers of the retina is treated with lasers, which often prevents abnormal blood vessel growth and reduces the possibility of the retina becoming detached and causing blindness.
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Bronchopulmonary Dysplasia
Bronchopulmonary dysplasia is a type of chronic disorder of the lung resulting from repeated injury to the lung tissue.
- Extremely premature infants, those who suffer from lung disease, infants who were on a ventilator for prolonged periods, and babies with insufficiently developed lung tissue, are prone to bronchopulmonary dysplasia.
- Rapid or labored breathing is a symptom of bronchopulmonary dysplasia. Cyanosis, characterized by the bluish discoloration of the skin and the lips, also may be present.
- The usual symptoms of respiratory distress, low blood oxygen levels, and an x-ray of the chest, usually lead to the diagnosis of d bronchopulmonary dysplasia.
- Infants having bronchopulmonary dysplasia have a high rate of survival.
- Exposure to smoke and fumes from cigarettes, space heaters, fireplaces or wood burning stoves should be strictly avoided even after getting discharged from the hospital.
- A specific anti-viral antibody called palivizumab should be injected monthly during the winter as well as fall seasons to prevent respiratory syncytial virus (RSV) infection.
- Good nutritional support, as well as the required respiratory support with supplemental oxygen whenever necessary, either with or without a ventilator, is essential.
This chronic disorder of the lung commonly occurs in extremely premature infants who had severe respiratory distress syndrome or other such serious lung problems at birth. Those who had been on ventilator support for prolonged periods are especially prone to developing bronchopulmonary dysplasia. This is because of the repeated injury caused to the delicate lung tissue when the constant pressure from the ventilator results in the over-expansion of the air-sacs. Over-exposure to high concentration of oxygen also may have caused some damage. The injuries suffered by the lung tissue cause it to become inflamed and the inflamed tissue retains fluid. Infants who have bronchopulmonary dysplasia may fail to develop sufficient air sacs in the lungs.
Babies born at term also develop this condition if they have pneumonia or other such lung problems. It has been found that bronchopulmonary dysplasia can occasionally occur in premature infants who never had respiratory distress or ventilator support.
Symptoms and Diagnosis
Rapid breathing and other such symptoms of respiratory distress are usually present in infants with bronchopulmonary dysplasia. The breathing is labored and the area of chest below the breastbone is drawn in while inhaling each breath. Cyanosis, characterized by bluish skin and lips, develops due to low oxygen content of the blood. In severe cases, the air taken into the lungs takes longer periods to come out of the lungs while exhaling. The air staying longer in the lungs may cause some air to get trapped there, resulting in the over-expansion of the lungs.
Bronchopulmonary dysplasia is suspected in premature babies who had been given ventilator support for prolonged periods extending over many weeks or even months. Infants who require supplemental oxygen for a longer period due to continuing respiratory distress are also suspected to have developed bronchopulmonary dysplasia, especially if they still have low oxygen levels in the blood. An x-ray of the chest can help diagnose the condition.
Prognosis
Prognosis is good for infants with bronchopulmonary dysplasia receiving good medical care and nutritional support, as most babies get better eventually. However, a few babies succumb to the condition even after several months of special care. The survivors have a good chance of leading a normal life as the lungs keep growing more and more healthy tissue and the proportion of the damaged tissue in comparison becomes less. Nevertheless, these survivors are always at a higher risk of contracting respiratory infections, including viral pneumonia due to RSV infection, during the winter season. They are more prone to asthma too.
Prevention and Treatment
Special care should be taken in sheltering the infant having bronchopulmonary dysplasia from further lung injury after getting discharged from the hospital. Any exposure to fumes or smoke, including the smoke from cigarettes, wood-burning fireplaces and stoves may affect the lungs adversely. Even the fumes from space heaters should be avoided. They should be shielded from people with cough, cold and such other infections of the upper respiratory tract also. To prevent the infection of the common respiratory syncytial virus (RSV), a specific antiviral antibody called palivizumab should be injected every month during the main seasons of widespread RSV infections like the winter as well as the fall.
Occasionally, ventilators may have to be used to aid respiration, but care is taken to use them on a very low setting to prevent further injury to the tissues of the lung. Newborns on ventilator support are always taken off the machine as early as possible.
When infants have respiratory distress due to bronchopulmonary dysplasia, oxygen may have to be provided via a tube placed in the nostrils to prevent cyanosis. In some cases, they may require supplemental oxygen for prolonged periods, often extending to several months.
An infant with bronchopulmonary dysplasia should be given good nutritional support to help the lungs develop well and to keep the new tissue in good health. When the new growth increases, the proportion of the damaged tissue in relation to the total lung area becomes less. Also, the new healthy portions can take over the lung function, improving it considerably.
Fluid consumption may have to be restricted in infants with bronchopulmonary dysplasia as there is a tendency for fluid accumulation in the inflamed tissues of the lung. Sometimes diuretics are prescribed to help the excess fluid to be excreted in the urine.
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Pneumothorax In Newborns
Pneumothorax in Newborns is an abnormal condition in which air gets collected in the space between the lung and pleural membrane that surrounds it when the lung ruptures or leaks air.
- Pneumothorax usually develops in infants who have prolonged respiratory distress due to disorders of the lung or because of meconium aspiration syndrome. Infants hooked on to a ventilator, and those who are undergoing continuous positive airway pressure (CPAP) treatment for respiratory distress, are also prone to pneumothorax.
- Difficulty in breathing, lowering of blood pressure, and lung collapse, are the symptoms of pneumothorax.
- The symptoms, and an x-ray of the chest showing the air collection, help diagnose the condition.
- When pneumothorax is detected, the infant is given supplemental oxygen, or kept in an oxygen-rich environment, and the accumulated air is drawn out from the pleural space with the help of a syringe and needle.
Infants who have stiff lungs, particularly those with respiratory distress syndrome, and those who have meconium aspiration syndrome, are at greater risk of developing pneumothorax. Occasionally, infants who are receiving respiratory support through CPAP or continuous positive airway pressure technique, which allows them to breathe normally while oxygen under slight pressure is delivered to them via nose prongs, develop pneumothorax. Infants on ventilator support also tend to develop this condition. When pneumothorax has developed due to continuous positive airway pressure or due to the pressure exerted by the ventilator, the infant’s lungs may collapse, resulting in increased difficulty in breathing. If pneumothorax develops from pressure due to the ventilator or CPAP, it can cause compression to the veins which are carrying blood to the infant’s heart, resulting in inadequate amount of blood in the heart. Consequently, less blood gets pumped out of the heart, leading to low blood pressure and associated complications.
Sometimes, the air leaking from the lungs enters the tissues in the center of the infant’s chest cavity, resulting in a condition called pneumomediastinum. This condition has no negative effect on breathing and usually resolves on its own.
Diagnosis and Treatment
The infants who have respiratory distress may be on ventilator support or undergoing continuous positive airway pressure treatment. Pneumothorax in infants is indicated when the existing breathing difficulties suddenly worsen or when the blood pressure drops. On physical examination, a reduction in the sounds usually produced when air enters and leaves the lung is noticed on the side of the chest where pneumothorax has occurred. The sounds are dampened by the accumulated air in the chest cavity. Positive transillumination is a technique that can be used to detect accumulation of air in the pleural cavity in premature babies. This procedure is conducted inside a dark room with a fiber-optic light used to illuminate the side of the chest where pneumothorax has occurred. An x-ray of the chest can show the air accumulation and confirm the diagnosis.
The treatment depends on the symptoms displayed by the infant with pneumothorax. If the condition is mild, and the infant is not showing any symptoms, no special treatment is necessary. An oxygen-rich environment may be created for a term baby, by keeping it in a tent which has oxygen pumped in for maintaining a higher oxygen level than normal air.
If the breathing difficulty is severe, with outward symptoms of labored breathing such as flaring of nostrils, or if the blood oxygen levels become low, the accumulated air has to be removed immediately. Low blood pressure, which develops due to impaired blood circulation as the veins entering the heart gets compressed, is another situation requiring immediate intervention. The accumulated air is drawn out with a syringe and needle. If this procedure needs to be repeated frequently, a plastic tube is inserted into the pleural cavity to suction out the air continuously. Babies on ventilator support, and those being treated with continuous positive airway pressure, need continuous removal of accumulated air through the suction tube. The arrangement may have to be left in place for several days till the pneumothorax is resolved.
Pneumomediastinum also may be detected in a chest x-ray, but it usually resolves without any treatment.