Premature Infant

Pt born at < 32 WGA with h/o chronic lung disease presents to establish care. Pt is breastfed. Weight < 10th percentile corrected for age with < 20g/kg/day weight gain per day s/p discharge; concern for neurodevelopmental delay on exam.

• Preventative care

  • Administer palivizumab, Rotavirus vaccine at 2 months

  • Anemia: Start iron supplementation and obtain CBC at 4 and 8 months

  • Refer to ophtho to r/o retinopathy of prematurity

• GERD: Recommend positioning, smaller/more frequent feeds, and thickened feeds as initial management.

  • Place infant in L lateral or prone position s/p feeds

  • Counseled against use of xanthan gum (SimplyThick) due to necrotizing enterocolitis risk

• Failure to gain weight: Start nutrient fortification of breast milk

• Refer to developmental pediatrics if neurodevelopmental delay persists

Neonatal Hypoglycemia

[SGA or LGA] infant > 4 hours of life with maternal h/o GDM and poor feeding presents with whole blood glucose (WBG) < 45 mg/dL. Hypothermia, decreased respiratory rate, abnormal cry, irritability/jitteriness, hypotonia on exam.

• Symptomatic infant:

  • Administer 2 mg/kg D10 IV bolus followed by 6 mg/kg/min D10 IV infusion

  • Monitor WBG q2h until > 45 mg/dL

  • For WBG < 45 mg/dL, increase D10 infusion by 2 mg/kg/min to maximum of 12 mg/kg/min

  • Parents informed that aggressive management is necessary as neonatal hypoglycemia may result in brain injury

• Asymptomatic patient:

  • Implement q2h feeds and measure WBG 20 minutes after each feed

  • Repeat WBG measurement until values > 45 mg/dL x 4

Notes

• Monitor whole blood glucose (WGB) as compared to fingerstick glucose

• For infants < 4 hours of life, target WBG is > 25 mg/dL

Congenital Hypothyroidism

Pt age < 1 month with uncomplicated perinatal history presents with poor feeding. Newborn screen shows elevated TSH, decreased T4. Hypothermia, jaundice on exam.

• Confirm TSH, T4

• Refer for thyroid U/S

• Start levothyroxine immediately and refer to endocrinology

• Parents advised that prognosis is excellent with treatment but that failure to f/u could result in permanent neurologic deficits

Neonatal Jaundice

Non-white M infant born at < 38 WGA via assisted vaginal delivery with h/o sepsis, cephalohematoma, and significant bruising presenting with neonatal jaundice. Infant exclusively breastfed. Maternal h/o GDM; familial h/o hemolytic anemia and neonatal jaundice. Birth weight > 3.5 kg; scleral icterus and yellow skin tone on exam.

• Obtain neonatal blood type (ABO incompatibility), direct antibody titer or Coombs test, CBC/smear, bilirubin levels

• Treatment

  • Start phototherapy pending labs

  • Exchange transfusion if bilirubin > 25 mg/dL

• Discuss adequacy of breasting feeding

  • Increase feedings to 12x per day

  • Provide reassurance to promote continued breastfeeding

Infant GERD

Four month old infant with h/o congenital diaphragmatic hernia, suspected neurodevelopmental disorder, and prematurity presents with regular spitting up and vomiting after meals. Infant sometimes refuses feeds and is fussy/irritable while spitting up; back arching often noted s/p feeds. Parents report recent hospital admission for pneumonia. Failure to gain weight, no palpable abdominal olive on exam.

• Treatment

  • Two week trial of maintaining infant upright during day, reducing feeding volumes while increasing frequency, and use of thickening agents, e.g. 1 tablespoon rice cereal per ounce of formula

  • Failure of conservative therapy: Trial of ranitidine 5 mg/kg/day divided every 12 hours for 4 weeks

  • No response to ranitidine: Refer to pediatric gastroenterology

• Parents counseled that GERD generally resolves by 1 year of age

• Parents encouraged to contact provider if fever, apnea, or persistent vomiting/constipation develops

Notes

• Differential diagnosis

  • Gastroesophageal reflux, i.e. “happy spitters”

    • Similar to GERD, but non-pathologic

    • Occurs in all infants to varying degrees

    • Normal weight gain and little difficulty with feeding

  • Infant colic

  • Hiatal hernia

  • Acute gastroenteritis

• Risk factors for infant GERD

  • Congenital abnormalities

    • Esophageal disorders

    • Diaphragmatic hernia

    • Neurodevelopmental disorders

  • Prematurity

  • Cystic fibrosis

Cryptorchidism

Male infant with h/o prematurity presents with congenital undescended testical on exam. One palpable testicle present.

• Parents counseled that testicles generally descend spontaneously by 4 months of age

• Testicle is undescended by 6 months of age:

  • Refer child to pediatric urologist for surgical evaluation

  • Parents counseled that testicular atrophy and increased risk for testicular cancer may persist despite surgery

Notes

• Spontaneous descend after 6 months of age is rare

• Surgical fixation

  • Reduces risk for testicular torsion

  • Reduces, but does not eliminate, risk for testicular cancer

  • Helps preserve fertility if performed before 1 year of age

Erb's Palsy

Developmental Hip Dysplasia

6 week old F with h/o oligohydramnios, breech position, torticollis presents for well child check. Patient is her mother's first child and was large for gestational age. Clinical notes indicate concern for possible hip dysplasia during previous visits. Clunk felt with Ortolani and Barlow's maneuver on exam.

• Obtain hip ultrasound if not resolved by age 2 months

• Positive hip ultrasound: Refer to pediatric orthopedics for Pavlik harness fitting

• Parents reassured that condition is treatable

Notes

• Ortolani and Barlow maneuvers

  • Screening maneuvers rated “I” by USPSTF and AAFP

  • Only diagnostic in patients < 3 months old

  • A "click" is not a positive sign

  • A "clunk" indicates dislocation or relocation of femoral head

• Prognosis

  • 90% of cases observed in newborns resolve spontaneously

  • Refer at 2 months if issue does not resolve spontaneously

Neonatal Bacterial Meningitis

Pt < 1 m/o born at < 37 WGA with birthweight < 2,500 g to GBS+ mother presents with fever. Intrapartum complications included PPROM, chorioamnionitis, suboptimal APGAR scores. Parents report irritability, poor feeding. [Hypo/hyper]thermia, bulging fontanelle, nuchal rigidity exam.

• Labs

  • Perform LP and send for analysis/culture

  • CSF demonstrates one of the following:

    • > 500 WBCs, > 80% neutrophils, protein > 50 g/L, glucose < 60

    • L. monocytogenes suspected due to CSF with > 100 WBCs, > 50% neutrophils, protein > 50 g/L, glucose < 60

• Treatment

  • Start q 2 hour neurologic exams

  • Start ampicillin, gentamicin, cefotaxime (see notes)

    • Narrow antibiotics based on culture results

    • Repeat LP if no clinical improvement 24 to 48 hours after starting antibiotic therapy

• Counseling

  • Parents advised that mortality rate is approximately 15%

  • Parents informed there is high risk for long-term neurologic impairment

Notes

• Most common pathogens in neonates are Group B strep and E. Coli

• Antibiotic dosing dependent upon weight and postnatal age

Suspected Neonatal Sepsis

Male infant with h/o prematurity, perinatal asphyxia presents with respiratory distress and seizures s/p cyanotic episode. Demonstrated poor feeding prior to symptom onset. Maternal h/o UTI, GBS+, prolonged ROM, chorioamnionitis during pregnancy/delivery. Temperature and blood pressure instability, poor perfusion, petechiae, and lethargy on exam.

• Obtain blood culture, CSF culture

• 3 or more risk factors as mentioned above: Empiric ampicillin/gentamicin x 72 hours while awaiting blood culture results

• Continue antibiotics x 14 days if blood cultures positive

• NICU alerted and will accept transfer of care

Note: Most common causes of neonatal sepsis (in order of prevalence) include

• Group B strep

• E. coli

• Listeria