Signs and Symptoms Cyanosis: Chapter 21 Fever: Chapter 31 Respiratory Distress: Chapter 71 Septic-Appearing Infant: Chapter 73 Tachycardia: Chapter 77 Medical, Surgical, and Trauma Emergencies Cardiac Emergencies: Chapter 86 Pulmonary Emergencies: Chapter 99 The Children’s Hospital of Philadelphia Clinical Pathways ED Pathway for Evaluation/Treatment of Neonates Hyperbilirubinemia/Jaundice URL: https://www.chop.edu/clinical-pathway/hyperbilirubinemiajaundice-neonatal-clinical-pathway Authors: D Aronson, MD; J Lavelle, MD; C Jacobstein, MD; N Boorstein, RN Posted: October 2009, last revised January 2018 With ED Clinical Pathway for Evaluation/Treatment of Febrile Young Infants (0–56 Days Old) URL: https://www.chop.edu/clinical-pathway/febrile-infant-emergentevaluation-clinical-pathway Authors: R Scarfone, MD; P Gala, MD; A Murray, MD; M.K Funari, RN; J Lavelle, MD; L Bell, MD; C Jacobstein, MD Posted: August 2010, last revised August 2019 Current Evidence Evaluation of the newborn poses many unique challenges to clinicians The perinatal transition from fetal to extrauterine life requires a number of critical, coordinated changes in cardiopulmonary physiology that can take several hours to several days to be completed Many neonatal conditions are detected within the first few days of life; however, neonates often present to the emergency department (ED) with critical conditions that manifest at home after routine discharge For example, certain congenital anomalies may be life threatening, and yet may not present until after this transition has been completed and the newborn has been discharged home Other perinatally acquired conditions may not present until days later due to their insidious onset Additional challenges include subtle neonatal presentations and more severe symptoms in response to pathogens because of immature immune function and lack of energy stores The immune system is entirely dependent on passive immunity provided from the mother during pregnancy, leaving the neonate immunocompromised and susceptible to life-threatening infections Furthermore, infants have very little in terms of cardiopulmonary reserve, so that the sick infant can go from well appearing to critically ill and cardiopulmonary arrest in a short period of time Finally, pathogens to which neonates are likely to be exposed during birth include aggressive bacteria and viruses, including Group B streptococcus (GBS), gramnegatives, and herpes simplex Regardless of the etiology of injury or illness, neonates have a very limited ability to communicate critical changes in health Infants cannot express subjective data, and often new parents are unable to identify critical changes in infant behavior As such, it is important for the caregiver to gather and interpret subtle changes in vital signs and the physical examination to avoid catastrophic injury to the ill newborn In this chapter, we will highlight the major differences between neonatal anatomy and physiology compared to that of older children We will also provide clinicians with a concise synopsis of common neonatal disorders that may be encountered in the ED Goals of Treatment Given the unique challenges of neonatal care, the primary goals of treatment are twofold: (1) to distinguish early signs of a sick infant from normal newborn behaviors and (2) to provide timely intervention to prevent permanent injury or death in the case of an ill neonate Clinical Considerations Clinical Recognition To assist in the clinical recognition of a sick infant, close attention must be paid to the vital signs obtained in triage Subtle changes in vital signs can often be the only indication of serious illness, and the early detection of these changes can alert the clinician to intervene prior to the loss of physiologic reserve and cardiopulmonary collapse Weight Each newborn encounter should include a weight check This should be compared to weight at birth The Centers for Disease Control (CDC) growth charts provide normative values for weight and length in boys and girls Birth weight below the 10th percentile identifies the small for gestational age (SGA) and that above the 90th percentile identifies the large for gestational age (LGA) infant Both SGA and LGA infants are at risk for physiologic disturbances SGA infants have decreased fat stores, which can leave the infant more susceptible to hypoglycemia and electrolyte disturbances Additionally, SGA infants are much more sensitive to environmental changes and cannot thermoregulate as well as older infants Hypothermia in the SGA infant can depress the autonomic nervous system, which may result in bradycardia and hypotension The LGA infant is commonly born to a diabetic mother The high levels of growth hormone and insulin and lack of sufficient postnatal glucose delivery result in hypoglycemia and electrolyte disturbances, such as hypocalcemia LGA infants are also at risk for polycythemia Severe polycythemia can compromise cardiovascular function, as well as increase the risk of hyperbilirubinemia Normal weight patterns include a brief period of weight loss in the immediate postnatal period, followed by regular, consistent weight gain for the first few months of life Weight loss is the most sensitive sign for dehydration in the newborn, particularly as other common signs, such as decreased urine output or skin turgor are not reliable findings in this group A loss of more than 10% of birth weight in the first week of life is cause for concern, and should be evaluated, particularly for dehydration, hypoglycemia, and electrolyte disturbances Neonates that have not regained birth weight by 14 days of life should also be evaluated thoroughly Most commonly, slow weight gain is due to decreased milk transfer in breast-fed infants, but can also signify increased caloric and metabolic demands due to underlying congenital anomalies of the cardiovascular, respiratory, gastrointestinal, or renal systems Neurologic diseases, particularly those with decreased tone and motor strength, may also present with weight loss or poor weight gain if the infants not have the strength to adequately suck and swallow A basic metabolic panel (BMP) should be checked for signs of hypernatremia or other electrolyte disturbances Neonates who are receiving suboptimal feeds due to inadequate supply may need to be supplemented with formula Referral of the infant to the pediatrician for serial follow-up is recommended Alternately, those requiring assistance with poor breast-feeding technique may be supplemented with expressed breast milk or formula and referred to a lactation consultant Heart Rate Normal resting heart rate for a neonate can range between 80 and 180 beats/min Over the first few weeks of life heart rate will decrease to 80 to 140 beats/min During rest and deep sleep, the heart rate will typically be in the lower range, and in the higher range with activity or agitation A healthy infant will show variability in heart rate with subtle changes during inspiration and exhalation and when alternating between sleep and alert states Loss of heart rate variability has been associated with systemic illnesses, such as shock and infection Bradycardia can be defined as either a 20 to 30 beat decrease below the infant’s baseline or below 80 beats/min at rest Neonates respond to poor cardiac output by increasing their heart rate because stroke volume cannot increase acutely Therefore, bradycardia is often a late sign of cardiac failure after the normal compensatory mechanisms have collapsed Sinus bradycardia may also occur with hypothermia, hypothyroidism, malnutrition, or electrolyte disturbances Premature infants may also present with recurrent bradycardic events, particularly during episodes of increased vagal tone due to gastrointestinal reflux, emesis, or in association with hypoxemia due to apnea A 12-lead electrocardiogram can help distinguish sinus bradycardia from conduction abnormalities and heart disease Some full-term infants have a low resting heart rate that may reach 80 to 90 beats/min Any infant with bradycardia who shows other signs of cardiovascular instability, such as hypotension and poor capillary refill, or systemic signs of lethargy or poor feeding, should be treated and stabilized immediately Neonatal tachycardia can be defined as a heart rate >190 beat/min Sinus tachycardia may occur in the setting of shock, dehydration, or hypovolemia, as a mechanism to increase cardiac output Neonatal tachycardia can also occur with fever, hyperthyroidism, severe anemia, hypoglycemia, or electrolyte disturbances, such as hypocalcemia The most common conduction abnormality that results in tachycardia in the neonate is supraventricular tachycardia (SVT), which can lead to cardiac failure and shock if sustained For more details on clinical considerations and management of heart rate anomalies in the neonate, see Section: Neonatal Cardiac Emergencies Respiratory Rate The normal respiratory rate of a newborn is between 30 and 60 breaths/min Periodic breathing is a normal finding that presents with pauses between breaths that can last up to 10 seconds Most commonly, the infant will have to pauses close together, followed by a series of short, shallow breaths With periodic ... due to inadequate supply may need to be supplemented with formula Referral of the infant to the pediatrician for serial follow-up is recommended Alternately, those requiring assistance with poor