Vomiting in the NewbornVomiting in the Newborn

Not uncommon for some vomiting in 1st Not uncommon for some vomiting in 1st few hours and days after birthfew hours and days after birth Overfeeding, poor burpingOverfeeding, poor burping

DDx:DDx: GI: obstruction, reflux, milk allergy, NECGI: obstruction, reflux, milk allergy, NEC Infection: Sepsis, Meningitis, UTIInfection: Sepsis, Meningitis, UTI Endocrine: Adrenal hyperplasiaEndocrine: Adrenal hyperplasia CNS: Increased ICPCNS: Increased ICP DrugsDrugs

Bilious vomiting is a medical emergency!Bilious vomiting is a medical emergency!

Upper GI problems Upper GI problems vomitingvomiting

EsophagealEsophageal:: first feed, soon after feedfirst feed, soon after feed excessive droolingexcessive drooling if T-E fistula, risk of aspirationif T-E fistula, risk of aspiration

Small bowel atresiasSmall bowel atresias

Malrotation and volvulusMalrotation and volvulus

AchalasiaAchalasia Chalasia/GERChalasia/GER Pyloric stenosisPyloric stenosis

} Need to r/o

Lower GI ObstructionLower GI Obstruction

Presents with:Presents with: DistentionDistention Failure to pass meconiumFailure to pass meconium Vomiting is a later signVomiting is a later sign

Extrinsic vs intrinsic obstructionExtrinsic vs intrinsic obstruction DDx: Imperforate anus, Hirschprung, DDx: Imperforate anus, Hirschprung,

meconium ileus, meconium plug, meconium ileus, meconium plug, ileal atresia, colonic atresiaileal atresia, colonic atresia

ConstipationConstipation > 90% pass meconium in first 24 h> 90% pass meconium in first 24 h

If ‘constipation’ is present from birth:If ‘constipation’ is present from birth: Consider causes of GI obstructionConsider causes of GI obstruction

If present after birth:If present after birth: Consider Hirschprungs, hypothyroidism, anal Consider Hirschprungs, hypothyroidism, anal

stenosisstenosis

NB:NB: Some breastfed babies normally stool only Some breastfed babies normally stool only

once every 5-7 daysonce every 5-7 days Premature infants often have delayed Premature infants often have delayed

meconium passagemeconium passage

JaundiceJaundice First 24 h or conjugated at ANY time = ALWAYS abNFirst 24 h or conjugated at ANY time = ALWAYS abN Etiology: Etiology: UnconjugatedUnconjugated

1. 1. RBC destruction/hemolyticRBC destruction/hemolytic : : IsoimmuneIsoimmune, RBC membrane, enzymes, , RBC membrane, enzymes,

hgbinopathieshgbinopathies HematomaHematoma SepsisSepsis (mixed hemolytic and hepatocellular (mixed hemolytic and hepatocellular

damage)damage) HypoxiaHypoxia2. 2. Conjugation AbnormalitiesConjugation Abnormalities:: Breast Milk JaundiceBreast Milk Jaundice Metabolic/Genetic: Gilbert, Crigler-Najjar, Metabolic/Genetic: Gilbert, Crigler-Najjar,

HypothyroidismHypothyroidism3. 3. Increased Enterohepatic CirculationIncreased Enterohepatic Circulation:: GI dysmotility or obstructionGI dysmotility or obstruction Breast feeding jaundiceBreast feeding jaundice

Later onset: Conjugated1. 1. Hepatocellular damageHepatocellular damage: : • ViralViral• BacterialBacterial• Metabolic: TPN, CF, tyrosinemia, otherMetabolic: TPN, CF, tyrosinemia, other

2. 2. Post hepaticPost hepatic: : • biliary atresiabiliary atresia• choledochal cystcholedochal cyst

JaundiceJaundice

Jaundice - Work-UpJaundice - Work-Up History and physical examinationHistory and physical examination Bilirubin - total and directBilirubin - total and direct Blood type and Coomb’sBlood type and Coomb’s HemoglobinHemoglobin Reticulocyte countReticulocyte count SmearSmear Septic workupSeptic workup +/- Abdominal Ultrasound+/- Abdominal Ultrasound +/- Metabolic, Viral workup+/- Metabolic, Viral workup

Risk factors for kernicterusRisk factors for kernicterus

PrematurityPrematurity HemolysisHemolysis AsphyxiaAsphyxia AcidosisAcidosis InfectionInfection Cold stressCold stress HypoglycemiaHypoglycemia

Treatment of JaundiceTreatment of Jaundice

Nutrition/hydrationNutrition/hydration

PhototherapyPhototherapy

Exchange transfusionExchange transfusion

AnemiaAnemia HemorrhageHemorrhage

Feto-maternalFeto-maternal Feto-placentalFeto-placental Feto-fetalFeto-fetal Intracranial or extracranialIntracranial or extracranial Rupture of internal organsRupture of internal organs

HemolysisHemolysis PrematurityPrematurity

Treatment:Treatment: Transfuse if necessaryTransfuse if necessary

Endocrine Issues - Endocrine Issues - HypothyroidismHypothyroidism

Screen because too late for Screen because too late for proper neurodevelopment if waitproper neurodevelopment if wait

Signs:Signs: Poor feedingPoor feeding ConstipationConstipation Prolonged jaundiceProlonged jaundice Large fontanellesLarge fontanelles Umbilical herniaUmbilical hernia Dry skinDry skin

Endocrine Issues – Endocrine Issues – Ambiguous GenitaliaAmbiguous Genitalia

Congenital adrenal hyperplasiaCongenital adrenal hyperplasia 21-hydroxylase deficiency = most 21-hydroxylase deficiency = most

common enzyme abNcommon enzyme abN Signs = vomiting, diarrhea, Signs = vomiting, diarrhea,

dehydration, shock, convulsions, dehydration, shock, convulsions, clitoris or phallic enlargementclitoris or phallic enlargement

Watch for electrolyte imbalancesWatch for electrolyte imbalances If suspect, send lab tests and treat If suspect, send lab tests and treat

with steroidswith steroids

Endocrine Issues – Infant of Endocrine Issues – Infant of a Mom with Diabetesa Mom with Diabetes

Increased Risk of:Increased Risk of: Congenital malformationsCongenital malformations

• Increased incidence with poor glycemic controlIncreased incidence with poor glycemic control Growth disturbancesGrowth disturbances Metabolic disturbancesMetabolic disturbances

• Hypoglycemia, hypocalcemiaHypoglycemia, hypocalcemia Respiratory:Respiratory:

• RDS, TTNRDS, TTN Hematologic:Hematologic:

• Polycythemia Polycythemia Hyperbilirubinemia Hyperbilirubinemia Cardiovascular problems:Cardiovascular problems:

• Hypertrophic cardiomyopathyHypertrophic cardiomyopathy

HypoglycemiaHypoglycemia

Definition:Definition: BS <2.6 prem and bottle fed termBS <2.6 prem and bottle fed term BS <2.0 breastfedBS <2.0 breastfed ** No clear safe cutoff for all** No clear safe cutoff for all

Pathophysiology:Pathophysiology: Lack of supplyLack of supply Lack of reserve (low glycogen): IUGRLack of reserve (low glycogen): IUGR Inability to use/produce: metabolicInability to use/produce: metabolic Increased utilization: sepsisIncreased utilization: sepsis Increased insulin productionIncreased insulin production

HypoglycemiaHypoglycemia

Treat by supplying glucose needs:Treat by supplying glucose needs: Term: supply minimum of 4-6 Term: supply minimum of 4-6

mg/kg/minmg/kg/min Preterm: supply minimum of 6-8 Preterm: supply minimum of 6-8

mg/kg/minmg/kg/min

Look for cause … if severe or persists Look for cause … if severe or persists beyond 48-72h of lifebeyond 48-72h of life ‘‘Critical Sample’ of blood and urineCritical Sample’ of blood and urine

Asphyxia 46%Infection 17%Intracranial hemorrhage 7%Intraventricular hemorrhage 6%Infarction 6%Hypoglycemia 5%Congenital anomaly of CNS 4%Inborn errors of metabolism 4%Subarachnoid hemorrhage 2%

Neonatal seizures: EtiologyNeonatal seizures: Etiology

Thank you! Questions?