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Neonatology: Treatment, symptoms, advice and help

 

Neonatology is not a big part of the undergraduate paediatric curriculum. What appears below should give you and idea of the conditions involved and allow you to 'bluff your way'.


A neonate is a baby less than 28 days old.


Respiratory


A number of different pathologies can cause respiratory distress in the newborn. Features of this distress include:


  • tachypnoea (>60 breaths/minute)
  • subcostal and sternal recession (the soft bones of the newborn's ribcage are deformed with increased work of breathing) and tracheal tug
  • grunting (attempt to maintain Positive End Expiratory Pressure [PEEP] and thereby prevent lung collapse at expiration)
  • nasal flaring
  • low saturations
  • apnoea (immature brain control of respiration)


Hyaline Membrane Disease (HMD) is the pathological finding in the lungs of newborn premature babies. The clinical picture it produces is called 'Respiratory Distress Syndrome' (RDS).


The condition is caused by immaturity of the lungs, especially lack of surfactant production. The absence of surfactant, which normally reduces the surface tension in the lungs, leads to collapse. It can occur in term infants, especially infants of diabetic mothers, though this is rare. As well as lacking surfactant the lungs of premature babies are underdeveloped. Alveoli only start to form at about 24 weeks' gestation and at this stage are thick walled and poorly adapted for gas exchange. As the baby matures so do the lungs with increased numbers and maturity of the alveoli. (This development actually continues until the child is about seven years old).


It is lung maturity that usually limits resuscitation of very premature infants. Steroids given to mother up to 48 hours before delivery help to mature the lungs by 'switching on' surfactant production. After delivery surfactant can be given to babies with RDS.


Bronchopulmonary Dysplasia (BPD) is the sequel of hyaline membrane disease. It is defined as an oxygen requirement beyond 36 weeks gestation (previously an oxygen requirement at 28 days of age). It results from damage to the developing lung caused by HMD and ventilation. Babies with BPD can require oxygen for well over a year after delivery. Failure to provide adequate oxygen can lead to pulmonary hypertension and death. Steroids are sometimes used to ameliorate the condition.


Transient Tachypnoea of the Newborn (TTN) is caused by retained lung fluid after delivery. During a normal delivery the fluid in a baby's lungs is squeezed out through the mouth and reabsorbed into the lungs. If this fails to happen (e.g. if the baby is delivered by routine caesarean section) the lung fluid can be retained and can cause respiratory distress. Treatment is rarely required but the importance of TTN lies in its differential diagnoses (i.e. sepsis, RDS, pneumothorax, lung malformation).


Meconium Aspiration can occur if a baby has a bowel action (passes meconium) as a result of stress during delivery. Foetal breathing movement then draw the meconium into the lungs where it can cause a inflammation (pneumonitis). Babies with meconium aspiration syndrome can be very ill though much of this may be due to the distress which caused the passage of meconium during labour. Despite this aspiration of meconium in its own right can result in significant morbidity.


Pneumothorax can occur spontaneously after delivery (possibly in up to 5% of deliveries) or be caused by too high an inflation pressure being used to expand the lungs if resuscitation is required.


Lung Malformations (diaphragmatic hernia, sequestrated lobe) congenital heart disease (CHD) are rare but important causes of respira