1. Adib Mursyidi
A&E Department

2.  5-day-old boy brought to ED for very poor
feeding, lethargy. Full term SVD with
unremarkable prenatal and post natal history
 What is your next step?
 FREAK OUT!!!!

4.  Ill neonate  frightening entity for most
clinicians
 Neonatal = first 28 days of life, but may be
expanded to account for gestational age
 Generally  sign and symptoms are vague
and non-specific, can be fatal!

5.  Fever / hypothermia
 Abnormal tone (limping/stiff)
 Altered mental status (lethargy/irritability)
 Weak suck
 Poor feeding
 Jaundice
 Abnormal respiration
 Cyanosis or mottling
 Vomiting

6. FEEDINGTREND
 In breast feeding : 1 to 3 hourly, bottle : 6 to 9 in
24hr
 Lose up to 12% of birth weight during first 3-
7days
 After this time, gain 20-30g during first 3months
STOOLS
 Normal BF infants may go 5-7days without
stools OR 6-7 stools per day
 Color : no significant unless blood is present OR
acholic (white)

7. RESPIRATORY
 Range 40-60x per min
 Periodic breathing (alternating episodes of
rapid breathing with brief <5-10sec pause) 
usually normal
 Healthy infant sleeps median 16.2hr per day

9.  In non accidental head trauma  subtle
history with no obvious physical finding, non
specific
 Evaluation includingCT Scan, USG, MRI. Skull
X-ray might not helpful because infant can
have significant injury without skull fracture
 X-ray only likely to have positive findings if
the were visible sign of injury
 Child <2 years old might have occult
traumatic head injury and retinal hemorrhage

10.  Evaluation and stabilization of ABC’s
 Bedside glucose
 Temperature regulation
 If bruises or known of ICB
 Lab should include FBC, PT, APTT
 Neuroimaging should be done after stabilization
 Patient should be admitted to respective
team
 Skeletal survey and ophthalmologic exam should
be part of evaluation

12.  Always consider theTerribleT’s
▪ Tetralogy of Fallot (TOF)
▪ Tricuspid atresia (TA)
▪ Transposition of great vessels (TOGV)
▪ Total anomalous pulmonary venous return (TAPVR)
▪ Truncus arteriosus (TA)
 CHD might not detected in newborn nursery 
still adequate oxygenated blood through
systemic circulation via patent ductus arteriosus
(PDA)
 PDA closes by 2 weeks of age (delay in
detecting)

13.  Boot shaped heart
 Elevated cardiac apex

14. “Egg on a string”

15. “Snowman sign”

16.  Providing 100% O2 can help differentiating
between cardiac vs non-cardiac
 Non-cardiac at least have 10% increase in
pulse oximetry value, where in cardiac have
minimal changing in O2 saturation
 Hyperoxia test (ABG in room air, then repeat
ABG after 10min of 100% O2)
 In cardiac  minimal change in PaO2

17.  Examination should include BP in 4 extremities
 Murmur maybe audible, absence does not exclude
cardiac defect
 CXR, ECG and ECHO is diagnostic
 Prostaglandin E1 (PGE1) as bolus of IV 0.05mcg/kg
followed by IV infusion 0.05-0.01mcg/kg/min 
watchout for hypotension, seizure, apnea
 Definitive airway management for transportation

18.  Typically present with symptoms of
congestive heart failure. Causes:
 Acyanotic heart disease (ventricular septal defect,
atrial septal defect, patent ductus arteriosus,
coarctation of the aorta)
 Severe anemia
 Trauma
 Sepsis
 Metabolic abnormalities
 Thyrotoxicosis

19.  Classic symptoms: tachypnea, tachycardia,
hepatomegaly
 History include poor/slow feeding, sweating,
color change with feeding, poor weight gain

20.  Stabilization of ABC’s
 CXR, ECG, FBC, serum electrolyte
 ECHO  diagnostic of heart defect
 IV Furosemide 1mg/kg
 IV Dopamine 5-15mcg/kg/min, IV
Dobutamine 2.5-15mcg/kg/min for CVS
support
 Carefully not to overload this patient
 Cardiology consultation

21.  Mostly cause by RSV, adenovirus, influenza
 Classic symptoms : rhinorrhea, cough,
congestion, apnea, significant respiratory
distress and wheezing

22.  Depending on symptoms
 In severe, prolonged apnea accompanied by
bradycardia, unresponsive to O2 therapy,
may required intubation
 Nebulization with corticosteroid therapy
 Sepsis evaluation should be consider
 Admission in premature and other comorbid
(reactive airway disease)

24.  Present in the 1st week with vomiting,
hypoglycemia or shock
 Common cause in CAH : deficiency in 21
hydroxylase enzyme
 CAH diagnosed at birth by routine newborn
screening, but missed due inadequate blood,
lab error, inability to contact family
 Hypotension that unresponsive to fluids and
inotropes leads to suspicion of CAH

25.  Stabilization of ABC’s
 Bedside glucose, serum electrolytes (usually
had hyponatremia and hyperkalemia)
 IV Hydrocortisone 25-50mg/m2, imperative
to treat hypoglycemia
 HyperK in this patient response to fluids,
however in symptomatic with ECG changes,
calcium chloride, sodium bicarbonate, insulin
and glucose may be needed

26.  Develop in infant born to mother with Grave’s
disease
 Cause by transmission of maternalTS
immunoglobin
 Present with poor feeding, failure to thrive,
tachycardia, irritability, hyperthermia,
vomiting, diarrhea, jaundice,
thrombocytopenia, respiratory distress, heart
failure and shock

27.  Diagnosis is difficult without clear history of
Grave’s disease from mother
 Evaluation should includeThyroid function
test

28.  Stabilization withABC’s
 IV Propranolol 0.25 mg/kg for the tachycardia
 IV Propylthiouracil (PTU) 1.25 mg/kg followed
 Lugol's solution 1-5 drops by mouth
 Given 1 hour after the PTU
 This will help to control the hypermetabolic state
 Admit with endocrine consultation

30.  Delay/unrecognized/uncommon and not part
of routine screening and symptoms
 Non specific symptoms such as poor
feeding, vomiting, failure to thrive,
tachycardia, tachypnea, or irritability
 Occasionally symptoms of seizures, lethargy,
hypoglycemia, apnea, temperature instability,
and acidosis.
 Physical exam findings are usually normal

31.  Stabilization withABC’s
 Bedside glucose
 FBC, serum electrolytes, pH, lactate,
ammonia, LFT, urinalysis for reducing
substances and ketones
 Main goal : stop exposure to protein that
maybe converted to toxic metabolic and clear
the body of toxic byproduct

33.  In any rectal temperature >38 C
 Sign and symptoms : poor feeding, irritability,
apnea, hypothermia, jaundice, rashes,
increased sleeping, seizures, or vomiting
 Maternal and fully physical exam might help

34.  Stabilization withABC’s
 Full septic evaluation : CBC, blood culture,
urinalysis, urine culture, cerebral spinal fluid
[CSF] culture and analysis, and CXR
 To administer broad spectrum antibiotic in
sepsis / life threatening symptoms
 In neonatal herpes  early recognition and
treat with acyclovir may decrease mortality

35.  IVAmpicillin 50-100mg/kg and IV Gentamicin
2mg/kg
OR
 IV Cefotaxime 50-100mg/kg
 IV Acyclovir 20mg/kg

37.  Inappropriate mixing of water and powdered
formula
 Overdilution of concentrated liquid of
premixed formula
 This may result life threatening electrolyte
disturbances or failure to thrive
 Hyponatremia may present as seizures and
immediate correction to stop seizure

38.  Malrotation caused by abnormal rotation of
bowel in utero  result in an unfixed portion
of bowel that may later twist on itself 
resulting volvulus and bowel ischemia/death
 Diagnoses as early in 1st month of life
 Symptoms include bilious emesis and poor
feeding, lethargy and shock in advanced state

39.  Stabilization of ABC’s
 Fluids resuscitation,
NGT placement,
surgical consultation
 AXR might normal,
sign of bowel
obstruction or classic
double bubble sign

40.  Life threatening, might unrecognized
 History of constipation, with additionally
history of unable to pass meconium in 1st
24hours of life
 Poor feeding, vomiting, irritability, abdominal
distention, hematochezia and shock

41.  Stabilization of ABC’s
 Fluid resuscitation
 Administration of broad spectrum antibiotic
 AXR : enlarged or dilated section of colon
 Need surgical consultation

42.  Classical disease of premature neonates
 Similar presentation with Hirschsprung
enterocolitis
 Management includes stabilization of ABC,
fluid resuscitation, NGT placement
 AXR demonstrate pneumatosis intestinalis /
portal air
 Administration of broad spectrum antibiotic
and surgical consultation

43.  Most common, neonate may represent
normal healthy baby
 Evaluation depend on presentation
 ED management include stabilization, lab
evaluation
 Based on hospital protocal

45.  Uncommon in this group, can be result from
maternal ingestion in BF mother,
homeopathic remedies, drug overuse
 Most common “teething gel”
 ED management primarily supportive and
based on clinical presentation
 Hospitalization might required for
observation and monitoring

46.  Neonate suspect with seizure difficult to
diagnose
 History can include their newborn not acting
right or more somnolent
 Neonate had immature cortical development,
seizure activity might not tonic-clonic
 Symptoms include lip-smacking, abnormal
eye or tongue movement, pedaling, apnea

49.  Describing event “frightening to the observer
and is characterized by some combination of
apnea, color change, marked change in muscle
tone, choking, or gagging”
 ED management : depending on historical
information provided by observer and
examination
 Hospitalization maybe appropriate for
observing and monitoring

50.  Common differential diagnosis of ALTE
 Sepsis/Meningitis/Encephalitis
 Pneumonia/RSV
 Hypothermia/hypoglycemia
 Anemia
 ICB
 Acid base disturbance/Electrolyte abnormalities/IEM
 Seizures
 GERD
 Child abuse

51.  Further history
 Feeding well previously, 2oz every 2hours
 Starting to sucking poorly and taking less than
half oz every feeding
 On examination  difficult to arouse, slightly
jaundiced and mottled, other examination
unremarkable
 Temp 35.5, HR 190, RR 50, BP 66/38, CRT
>2sec

52.  IV access obtained via scalp
 FBC :WCC raise, electrolyte normal. UFEME
clear.
 Infant was given IV NS 20ml/kg bolus and
started on maintenance fluids
 IV Ampicillin and IV Gentamicin was initiated
 LP was performed : no evidence of meningitis
 Blood C&S showed Group B Strep

53.  Antibiotic was changed to penicillin in view of
sensitivity and continue for 10days
 Infant was discharge well after 12 days of
hospitalization

54.  Neonatal emergencies may provoke anxiety
in ED clinician
 Mnemonics “THE MISFITS” is a helpful tools
 Infant  rare entity
 Sign and symptoms are non specific
 To treat unstable neonate  narrow down
diagnosis  begin life-sustaining treatment
 ensure safe disposition

55.  References
 Evidence Based Review of Neonatal Emergencies
in Pediatrics, Aug 2010
 Medscape Emergency Medicine : Neonatal
Emergencies
 Pediatric Protocol 3rd edition, 2013