not uncommon and is thought to occur as a result of birth trauma Clinical manifestations depend on the degree of hemorrhage, and typically include signs of anemia, and rarely adrenal insufficiency (poor feeding, vomiting, diarrhea, obstipation, dehydration, irritability, hypoglycemia, uremia, and shock) Treatment is largely supportive, and may include corticosteroids in the setting of adrenal insufficiency Rarely, surgical intervention for vessel ligation or adrenalectomy is warranted Neuroblastomas are the most common cause of neonatal tumors, and occur most commonly in the adrenal gland These can be distinguished from adrenal hemorrhage based on US, and confirmed with urine homovanillic acid (HVA) and vanillylmandelic acid (VMA) levels Pelvic Masses Ovarian cysts can result from maternal hormonal stimulation in utero and often are diagnosed in the fetal period, where the vast majority resolves prior to delivery For those that persist into the neonatal period, expectant management is warranted as again most will resolve spontaneously Large or complex cysts may be at risk for torsion, which should be treated surgically Additional complications are rare but can include rupture with resultant hemoperitoneum or bowel obstruction Smaller cysts will typically resolve with expectant management alone Genitourinary Anomalies Goals of Treatment Most genitourinary anomalies in the newborn are benign lesions or lesions that can be monitored by the pediatrician in an outpatient setting The goal of treatment is to recognize the anomalies that require urgent evaluation and treatment CLINICAL PEARLS AND PITFALLS Vaginal discharge in the female neonate is typically benign, and represents withdrawal of maternal hormones Patients with ambiguous genitalia, particularly infants with masculinization of female-appearing genitalia, should be evaluated for congenital adrenal hyperplasia, which can result in a life-threatening adrenal crisis if untreated Circumcision Complications from circumcision are rare, and in the newborn, typically occur to times per 1,000 procedures Most common complications include bleeding, particularly if there is an underlying coagulopathy For minor bleeding, treatment includes manual pressure and a compression dressing Circumferential dressings need to be monitored for penile ischemia or urinary retention If bleeding continues and a specific bleeding vessel can be identified, treatment includes topical administration of lidocaine with epinephrine and/or sutures If bleeding is generalized and persistent, the infant should be evaluated for a coagulopathy with complete blood count, and coagulation studies Wound infection is another infrequent complication of circumcision It is typically localized, with evidence of local redness, irritation, or drainage If localized, treatment includes topical antibiotic ointment, although caregivers should be educated on generalized symptoms of fever, irritability, or lethargy If present, infants with generalized symptoms should be evaluated for sepsis with blood, urine, and CSF cultures and parenteral antibiotics Surgical complications of the procedure can include injury to the urethra or glans If injury is suspected, urgent pediatric urology consultation should be obtained If the circumcision has not been completed, any prepuce or redundant skin should be left intact as this tissue may be used in the repair Similarly, if there is evidence of hypospadias, circumcision should be deferred and referred to pediatric urology, for repair Urethrocutaneous fistulas can also result from circumcision, although these can be corrected as an outpatient procedure several months after the initial procedures If the glans is injured or amputated during the procedure, the severed tissue should be wrapped in saline-soaked gauze, placed indirectly on ice An emergent pediatric urology consult should be obtained, as there have been reports of successful reattachment if it is performed within an hour of injury Additional glans injury can occur if the Plastibell ring, which normally sits over the glans for several days until the skin sloughs and ring falls off, is displaced If the ring cannot be removed easily, it may need to be removed used ring cutters, particularly in the setting of constriction or ischemia Vaginal Discharge Newborn females may present with either a milky white or blood-tinged vaginal discharge Both can be attributed to withdrawal from maternal hormones, and need nothing more than conservative management, observance, and reassurance to the parents Occasionally, a girl with prolapsed urethra will present with “blood in the diaper.” The prolapsed urethra is recognizable as an annular, beefy red or purple mass between the labia Ambiguous Genitalia A normal genital examination in newborn girls includes a fully opening vagina (without posterior labial fusion), clitoris width of to mm, and absence of gonads in the labia majora or inguinal region In boys, the urethral opening should be at the tip of the glans, with a stretched penile length of 2.5 to cm, and bilateral testes in the scrotal sacs Patients with male-appearing genitalia but micropenis, moderate to severe hypospadias or bilateral cryptorchidism, or patient with female-appearing genitalia but posterior labial fusion, clitoromegaly, or a labial/inguinal mass, require further evaluation for an intersex disorder Diagnostic evaluation includes peripheral blood karyotype, serum testosterone and 17-OH progesterone levels, and pelvic US The most immediate concern is when ambiguous genitalia results from CAH Typically, adrenal insufficiency will present between and 21 days Females with CAH are more easily recognized by abnormal masculinization of the external genitalia Early signs of adrenal insufficiency may include lethargy, decrease oral intake, increased emesis, failure to thrive, and weight loss In severe cases, patients will present with obtundation, hypotension, gray appearance, cardiac arrhythmias (due to hyperkalemia), or seizures (due to hyponatremia or hypoglycemia) For patients with suspected CAH, serum electrolytes and glucose should be checked, and any abnormalities corrected, and cortisol replacement should be instituted In the salt-wasting form of CAH, patients may also require mineralocorticoid replacement and salt supplementation NEONATAL NEUROLOGIC EMERGENCIES Goals of Treatment Neurologic findings in neonates are subtle Seizures are easily missed Irritability or lethargy may be the only signs of systemic infection The goals of treatment are to recognize these subtle findings and to aggressively treat underlying causes, such as hypoglycemia, hyponatremia, and infections RELATED CHAPTERS Signs and Symptoms Apnea: Chapter 14 Medical, Surgical, and Trauma Emergencies Neurologic Emergencies: Chapter 97 Seizures CLINICAL PEARLS AND PITFALLS Clinical seizures in the neonate are very subtle due to incomplete myelination of the motor pathways; infants can present with tongue thrusting, lip smacking, bicycling, or intermittent repetitive motions of a single extremity or trunk; generalized clonic–tonic movements are unlikely manifestations Neonatal seizures can be due to hypoglycemia and/or electrolyte abnormalities, particularly from incorrect formula preparation Neonatal seizures may benefit from pyridoxine Current Evidence Because of rapid, continued development of the neonatal brain, both clinical and electroencephalographic (EEG) seizures of the newborn, vary dramatically from the older child, so that recognizing the seizing infant remains a major challenge to clinicians Therefore, the true incidence of neonatal seizures remains unclear, with reported ranges between 0.5% in term infants and 22% in preterm infants The effect of neonatal seizures on outcome is largely influenced by the underlying disease process However, regardless of etiology, it is believed that seizures in the neonate can disrupt normal biochemical pathways responsible for the development and maturation of the CNS Prolonged neonatal seizures can lower the seizure threshold in later life and are associated with learning and memory impairments in adults with seizure disorders Complicating outcome studies of neonatal seizures is that many antiepileptic medications may contribute to medication-induced brain injury and/or teratogenic effects on the brain development, particularly with prolonged use Goals of Treatment The primary goal of treatment is early recognition of neonatal seizures, identification of the etiology, and control of the seizure as quickly as possible True seizure activity should be distinguished from more benign, nonepileptic behaviors of newborns, such as tremors, jitteriness, or benign sleep myoclonus If the seizure is due to hypoglycemia or electrolyte anomalies, initial treatment should be correction of the underlying metabolic abnormality If antiepileptic medications are used to treat seizures, it is important to also initiate EEG ... complications of the procedure can include injury to the urethra or glans If injury is suspected, urgent pediatric urology consultation should be obtained If the circumcision has not been completed, any... Similarly, if there is evidence of hypospadias, circumcision should be deferred and referred to pediatric urology, for repair Urethrocutaneous fistulas can also result from circumcision, although... the severed tissue should be wrapped in saline-soaked gauze, placed indirectly on ice An emergent pediatric urology consult should be obtained, as there have been reports of successful reattachment