more knackered neonates…

Respiratory distress in a newborn.

Right sided pneumothorax with mediastinal shift to the left.

Management.

• Supplemental O2
• IV access
• Analgesia
• Insertion of intercostal catheter.
  • 4th-5th intercostal space. Anterior axillary line.
  • SIZES:
    • 8-12F [Newborn]
    • 12-16F [Infant]

** ICC sizes taken from Clinical Practice Guideline “Chest Drain” – The Royal Children’s Hospital Melbourne. 

4 week old male with vomiting & dehydration…

Pyloric Stenosis.

The most common cause of infantile gastrointestinal obstruction beyond the first month of life.

• 1 in every 250 live births.
• Etiology unclear.
• Boys:Girls (4:1)
• Familial.

Clinical Features.

• 2-6 weeks of age
• Gradually progressive vomiting –> then projectile (non-bilious).
• Child appears well with increased appetite.
• Later: visible peristalsis with firm olive-shaped mass palpable in RUQ.

Differential Dx.

• Gastro-oesophageal reflux
• Malrotation-Volvulus
• Non-GIT causes
  • (eg. Head trauma, sepsis, meningitis, drugs or metabolic disorders)

Investigations.

• Observation of child feeding is helpful (confirming true projectile emesis)
• Ultrasound:
  • Pyloric length & diameter
• Barium study
  • Characteristic “string sign,” reflecting passage of contrast material through the narrowed pylorus.
• AXR
  • Gaseous insufflation can resemble ‘double-bubble’ (as above).
  • In late presentations shows enlarged body of stomach.

Management.

• Fluid resuscitation
• Correction of electrolyte abnormalities
  • Recall hypokalaemic, hypochloraemic metabolic alkalosis.
• Surgical consultation –> Pyloromyotomy

4 week old female breathless child with evidence of a recent left thoracotomy.

Diaphragmatic Hernia.

• The initial congenital form can be diagnosed antenatally.
• Results in intraabdominal contents entering the chest during the 2nd trimester.
  • Leads to pulmonary hypoplasia.
• The ultimate determinant of morbidity/mortality is the degree of hypoplasia of the contralateral lung (& whether the liver is located in the thorax).
  • Lung volumes of > 45% of normal predicts survival.

Clinical features.

• Persistent respiratory distress at birth w/ seesawing, side-to-side respirations.
• Cyanosis is common.
• Scaphoid abdomen, with bowel sounds heard in the chest.

Treatment.

• Intubation (and avoidance of gastric insufflation).
• Aim for PCO2 30-35mmHg to reduce pulmonary vascular resistance.
• Placement of an orogastric tube.
• Referral to Tertiary Paediatric Centre & Surgeon for operative repair.

Here is the repeat x-ray of our little fella just prior to transfer…

Newborn infant with tachypnoea & increased work of breathing…

Transient Tachypnoea of the Newborn (TTN)

• One of the most common causes of newborn tachypnoea.
• A failure to cease production of foetal lung fluid after onset of labour.
• Incidence increases significantly if child delivered via caesarian section (before 39 weeks)

Clinical Features.

• Tachypnoea, cyanosis, increased work of breathing.
• Often a diagnosis of exclusion.
• DDx include sepsis, congenital heart disease & respiratory distress syndrome.

CXR.

• Interstitial & alveolar oedema (symmetrical)

Treatment.

• Supplemental oxygen.
  • CPAP
  • some patients require intubation…
• Empiric ABx to cover for sepsis
• Symptoms & CXR clears by 2-3 days.

Image for this case taken from learningradiology.com with thanks…

1. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
2. Rosenʼs Emergency Medicine. Concepts and Clinical Approach. 7th Edition.
3. Current Diagnosis & Treatment: Obstetrics & Gynecology. 11th Edition.