Neonatal Readiness Lecture Notes

Instructor Information

  • Kathleen Berg, MD, FAAEM
    • Assistant Professor, UT Dell Medical School
    • Senior Director of Quality, USACS South
    • Assistant Director of Pediatrics, Ascension Seton Hays

Disclosure

  • No relationships with commercial interests.

Overview of Topics

  • Precipitous Delivery
  • The Return Visit

Precipitous Delivery

Clinical Case

  • A 25-year-old female G1P0 presents to a Free-Standing Emergency Department (FSED) in active labor.
    • Limited prenatal care; estimated gestation around 30 weeks.
    • Uncomplicated delivery, but infant exhibits:
    • Gasping respirations
    • Poor tone

Neonatal Resuscitation Program (NRP)

  • Majority of perinatal codes are respiratory.
  • Hyperoxia can be harmful; aim for 21% FiO2.

NRP Review Steps

  1. If infant is term with normal respiratory effort and tone, NRP not needed.
  2. Initial steps: Warm, dry, stimulate, reposition airway, suction if necessary.
  3. If apnea or heart rate (HR) <100: Begin Positive Pressure Ventilation (PPV).
  4. If no improvement within 1 minute of PPV: Consider endotracheal intubation (ETT).
  5. If HR <60: Initiate chest compressions and administer epinephrine.
  6. Increase FiO2 to 100% in such cases.

Resuscitation Targets

  • Target HR: >100
  • Normal respiratory effort with no cyanosis.

Target Oxygen Saturation Table

TimeOxygen Saturation (%)
1 min60%-65%
2 min65%-70%
3 min70%-75%
4 min75%-80%
5 min80%-85%
10 min85%-95%

Initial Oxygen Concentration for PPV

  • ≥35 weeks' GA: 21% oxygen

Key Points about Precipitous Delivery

  • Most perinatal codes respiratory in origin.
  • Chest compressions are warranted if HR <60 despite PPV.
  • NRP target: HR >100 and normal respiratory effort without cyanosis.

The Return Visit

Differential Diagnosis for Return Visit

  • THE MISFITS acronym:
    • T: Trauma
    • H: Heart disease
    • E: Endocrine
    • M: Metabolic
    • I: Inborn errors of metabolism
    • S: Sepsis
    • F: Formula mishaps
    • I: Intestinal catastrophes
    • T: Toxins
    • S: Seizures

Case 1:

  • 10-day-old male with:
    • Poor feeding and fussiness
    • Vomiting after feeds
    • Afebrile, listless, with abdominal distension

Case 1 Progression

  • Continued vomiting while awaiting surgery, now less responsive and has subtle facial twitching.
  • Point of Care (POC) glucose: 29.

Metabolic Emergencies

Hypoglycemia
  • BG <40 in the first 24 hours, <50 thereafter.
  • Symptoms:
    • Hypotonia, lethargy, poor feeding, jitteriness
    • Seizures, congestive heart failure (CHF), apnea, cyanosis, hypothermia
    • Risk of permanent neurologic damage if untreated.
  • Management: Administer 5 ml/kg of D10.

Case 2

  • 10-day-old male with:
    • Poor feeding, fussiness, vomiting after every feed
    • Afebrile but hypotensive and tachycardic
    • Initial labs do not improve blood pressure despite multiple normal saline (NS) boluses.

Endocrine Emergencies

Congenital Adrenal Hyperplasia (CAH)
  • Symptoms: Hyponatremia, hyperkalemia, hypoglycemia, metabolic acidosis.
    • Variable presentation based on sex:
    • Females: early diagnosis, symptoms include virilization and ambiguous genitalia.
    • Males: present later with salt-losing crisis.
  • Management:
    • Airway, Breathing, Circulation checks (ABCs)
    • Blood pressure management and rehydration
    • Electrolyte correction with hydrocortisone (25 mg).

Inborn Errors of Metabolism

  • Characteristics: Metabolic crises triggered by protein, fat, or carbohydrate intake or infection.
  • Management:
    • ABCs, keep patient NPO
    • Fluid resuscitation with D10 + 1/4NS to 1/2NS at 1.5-2 times maintenance
    • Consider bicarbonate if pH <7.1

Case 3

  • 10-day-old male presents similarly to previous cases, with unusual odor reported by the mother.
  • Labs show elevated ammonia levels: 463, abnormal blood gases suggestive of acidosis.

Formula Mishaps

  • Common inappropriate preparations leading to hypo or hypernatremia.
  • Hyponatremia Treatment:
    • Asymptomatic: Free water restriction, normal saline
    • Symptomatic: Administer 3-5 ml/kg of 3% NS over 15-30 min.
  • Hypernatremia Treatment: Normal saline, increase free water intake.

Key Points about Return Visit

  • Always consider sepsis in an ill-appearing neonate; culture everything and administer empiric antibiotics (e.g., Ampicillin + gentamicin or cefotaxime).
  • Bilious emesis indicates a surgical emergency.
  • Patients with CAH need electrolyte repletion, IV fluids, and hydrocortisone.
  • For suspected inborn errors of metabolism, keep patient NPO and provide IV dextrose.

Final Key Points on Precipitous Delivery

  • Most perinatal codes are due to respiratory issues.
  • Initiate chest compressions for HR <60 despite PPV.
  • Ensure targeted resuscitation: HR >100, normal respiratory effort, and no cyanosis.

Contact Information

  • Kathleen Berg's Email: ktberg@ascension.org