2. COMMON NEONATAL
PROBLEMS
Dr Ab.Ghaffar Lattifi
First year paediatric resident
FMIC-Kabul
Ab.ghaffar.latiffi@gmail.com

3. The
1st 24 hours
of Life
The first 24 hours of life is a
very significant and a highly
vulnerable time due to critical
transition from intrauterine to
extrauterine life

4. Overview




The transition from intrauterine to extrauterine life is a
complex process involving virtually every organ system in
the body.
The most dramatic changes are seen in the lung and the
cardiovascular system.
Failure to adequately make this transition can be lifethreatening and these infants often require supportive care.
In order to select the optimal intervention, it is essential to
understand the normal physiology of respiratory and
cardiovascular transition.

5. General Appearance

5
Full term:
– Look dark purple or red in color
– Symmetric
– vigorously crying with accompanying activity
of the arms and legs
resting posture of a breech baby
– Lying with the extremities motionless,
to conserve energy for diff breathing.
– Flexed extremities(sign of good muscle tone)
– Hands tightly fisted with thumb covered by the fingers.

6. NORMAL VITAL SIGNS

7. MINOR PROBLEMS IN
NORMAL NEWBORN




Many of these problems are transient and benign in nature.
detailed history , thorough evaluation and complete physical
examination are vital for early differentiation from abnormal findings.
Proper advice, guidance and assurance to the family is cornerstone.
Breast feeding and early physical contact should be encouraged.

8. VERNIX CASEOSA








Whitish adherent cheesy-like covering on newborn skin.
Produced by epithelial cell breakdown.
Vernix facilitates passage through birth canal,
Prevents transepidermal water loss, maintain body temperature
Protects the delecate skin from amniotic fluid and a barrier to
bacteria.
Absent in post term infants
Will fall off in 1 to 2 weeks
Removing vernix for cosmetic reasons is not recommended.

9. ERYTHEMA NEONATRUM



Overall blush to reddish color.
Usually appears in the transition period
and can occur when the infant has been
stimulated ,over oxygenated or overheated.
This is a normal phenomenon and lasts only several hours.
Differential diagnosis:

plethora

10. ACROCYANOSIS






Bluish discoloration of hands, feet
and perioral area
Particularly the palms and soles are blue.
The skin and mucosa are spared.
Due to immature peripheral circulation.
Exacerbated by cold temperatures.
Disappearing over the next few hours.(not present after 1 st 24 h)
Differential diagnosis:


hemodynamic instability
Central cyanosis

11. Breast Engorgement





Bilateral fullness of both breasts.
Overlying skin shows no signs of redness, warmth or tenderness
The condition resolves spontaneously and no intervention is
required.
Results by high levels of maternal hormones.
Massage or squeezing the breasts or nipples is not
recommended

12. Erb’s Palsy








(brachial plexus palsy)
Injury to the 5th and 6th cervical nerves
associated with a difficult delivery frequently in babies weighing
in excess of 4 kg.
No spontaneous arm movement on one side
Forearm is extended and pronated.
DTR are absent. wrist are spared and there is normal grasp.
These improve in 90% of cases.
If there is no recovery after 3 months ,surgical exploration and
nerve grafts should be contemplated within the first year of life.
If movement of the arm is still limited at one year of age,
permanent paralysis is likely

13. PHYSIOLOGIC JAUNDICES







Common neonatal problem, approx 60% of
term and 80% of preterm infants develop
Total Bilirubin raise by less than 5 mg/dl per day.
Appear after 24 hrs of age, Peaks by 3 to 5 days of age .
Visual inspection is not a reliable indicator to estimate the extent of
jaundice.
Resolve by 1 week in term and by 2 weeks in preterm.
Mechanisms:




Increased bilirubin production.(high RBC mass)
Defective uptake and conjugation and excretion of bilirubin
Managed by frequent feedings and phototheraphy in severe cases.
Placing in front of a window for sun or giving vitamin C is ineffective .

14. WEIGHT LOSS IN FIRST WEEK




Normally babies lose 8-10% of birth weight in the first
week of life
Because of passage of meconium, urine and reduction of
extracellular fluid volume.
Weight is regained by 10-14 days age.
Subsequently there should be gain of 20-40gr/day.

15. PERIODIC BREATHING

Normal maturative process (immaturity of respiratory center)
breaths very rapidly for a few seconds, then pauses and then
resumes normal rhythmic breathing
Brief pauses should be <10 sec
Normal breathing between episodes
Not associated with bradycardia
Most common in preterm infants.

Differential diagnosis:








Apnea of prematurity
TTN
RDS

16. Transient Tachypnea of the
Newborn (TTN)






A benign self-limited respiratory disorder characterized
Mild respiratory distress immediately after birth
Usually full-term and well looking
Common in those delivered C-section, precipitous labor , IDM
Fetal distress ,Delayed cord clamping and Maternal sedation
Results from slow absorption of lung fluid
Peaks at about 36 hours of life
Resolution within 24–72 hrs
Differential diagnosis:



SEPSIS
Neonatal pneumonia
Meconium aspiration syndrome

17. VOMITTING

Gastric irritation by amniotic fluid:
On day

one, non-bilious, no abdominal distension, responds to stomach wash
Gastric irritation by swallowed maternal blood :
- Cracked and bleeding nipple
- Antepartum hemorrage
- Baby may pass malaena stools, rather than meconium.

Gastro esophageal reflux:
-Overfeeding and Improper feeding
- effortless, after feed and on lying flat
Differential diagnosis:


GI obstruction, raised ICP ,CNS infection
Birth asphyxia, Sepsis,IEM

18. FAILURE TO PASS URINE






Fetus voids urine regularly in –utero after 12 weeks of gestataion.
After birth most babies void on the first but all babies must pass
urine by 48 hours of age.
Babies with delayed passage of urine should investigated for
obstructive uropathy and renal agenesia.
Normal babies void 6-12 times/day.
Some babies cry before passing urine due to discomfort of full
bladder.
starts crying again after having passed urine due to wet napkins.

19. FAILURE TO PASS MECONIUM
Passage of some amount of meconium usually occurs within the first 12
hours of life,
 99% of term infants and 95% of preterm infants passing meconium within
the first 48 hours of life.
 followed by yellow and seedy stools (transitional stools) for next 1-2 days.
 Failure to pass Meconium by 24 hours of age is an indication
for doing appropriate investigation to exclude any pathology
 Failure to pass Meconium can occur as a result of imperforate anus,
functional intestinal obstruction (i.e., Hirschsprung disease), illness, or
hypotonia.
 Ninety percent of patients with meconium ileum will have cystic fibrosis
and thus should be tested for CF.


20. Bowel Pattern and Constipation





Frequency of stooling in breast fed can vary from every feeding
initially to every several days (after each feeding to one every 1 to 7
days)
Gastro colic reflex( After every feed, normal activity, good feeding)
which may persist for weeks.
Formula-fed baby has a bowel movement every 1 to 3 days.
True Constipation is uncommon in newborns and requires evaluation
If the infant develops abdominal distention, vomiting, refusal to eat,
bloody stools, or extremely hard stools.
Rx
Maximize fluid intake(milk), Adding of sugar in milk
Laxatives should be avoided.

21. Dehydration fever




Some healthy babies may develop fever on the 2nd or 3rd
day of life
Due to poor heat dissipation mechanisms ,higher rate of
insensible losses ,inadequate intake of breast milk during
the phase of physiologic lactational inadequacy.
The baby remains active, alert and cries for feeds.
The baby should be dressed with light and loose cotton
clothes and his environment kept cool in summer.

22. Jitteriness




A tremor that is stimulus sensitive and can be stopped by
passively flexing the affected limb.
Jitteriness is not accompanied by autonomic changes or
ocular signs
Benign neonatal sleep myoclonus occurs only during
sleep.
should be evaluated for hypoglycemia ,hypocalcemia,
electrolyte abnormalities.
DDX with


Seizures
CNS Infection and Sepsis

23. conjunctivitis

Gonorrhoea
–
–
–
–
–
–

Must be ruled out in every case of conjunctivitis within 1st wk of life
Usually presents at 2–5 days (may be earlier w/PROM or later w/ failed prophylaxis)
Bilateral; clear watery discharge progressing to tense palpebral edema,
w/ copious, thick purulent exudates.
Culture positive for gonococcus
Ceftriaxone single dose IM
Staphylococcus aureus:
–
–
–
–
–
–
onset day 3 or later
One eye involved
Moderate amount of pus
Culture positive for staphylococcus
Apply 1% tetracycline ointment to the affected (4 time/day)
There is no need for systemic antibiotics.

24. Conjunctivitis


Chlamydia
– Time of onset day 5 -7 or later(can present up to 21 days)
– First watery discharge progressing to mucopurulent
– Both eyes involved
– Culture negative
–
Mother is Positive for STD
– Treat with Oral Erythromycin for 14 days + 1% tetracycline ointment
– Use of erythromycin is associated with Hypertrophic pyloric stenosis but
still recommend by AAP.
Chemical irritation
– Usage of silver nitrate in eyes after birth.
– Redness , swellings and small amount of pus present
– Both eyes involved
– Culture negative
–
Resolves spontaneously.

25. NASOLACRIMAL DUCT OBSTRUCTION
In approximately 6% of newborns, one or both of the
lacrimal ducts is blocked, preventing drainage of tears.
 Affected children appear to have excessive tearing.
 90% blocked ducts open spontaneously by 6 mo of age.
 Obstruction beyond 6 to 12 months of age should be
evaluated by an ophthalmologist
 warm compress or massage from outer to inner canthal
folds ‘‘milk the duct’’ results in resolution of majority of
cases.
 if secondarily infected may need topical antibiotics.


26. UMBLICAL SEPSIS





Umbilical cord normally falls off in 7-10 days and the wound heals
in about 15 days.
Redness and swelling around the umbilicus or pus drainage.
If the area of redness extends to < 1cm of surrounding area and no
other sign of sepsis is present , local cleaning with antiseptic solution
till redness subsides usually suffices.
If redness in surrounding area is >1cm or there are signs of sepsis,
then in addition to local therapy, systemic antibiotic should be started
as management of septicemia.
Complication
Sepsis,CNS infection, Cellulitis,Necrotizing
fasciitis

27. Excessive Crying

Common causes of cry in a neonate are:
•
•
•
•
•
•
•
•
Hunger and thirst
Nasal block.
Pain and discomfort
Full bladder
Painful evacuation of hard stool
Wet napkins
Intestinal colic
May need cuddle
hypertention(Hypoxia)
D
D
X
- Insect bites
- Otitis media
- Intussuception ,volvulus
- Bone and joint sepsis
- Unapparent trauma
- Incarcerated hernia
- Pul

28. EVENING COLIC






Crying associated with flexion of thighs and flushing of face with
frowning occur at a precise time in the evening and last for a couple
of minutes or hours.
Starting in the 2nd wks, peaking at 6 weeks, and often resolving by 4
months of age
Excessive crying initiating a vicious cycle of colic-crying-colic.
Holding the baby against skin, rocking, cuddling, provide relief.
Administration of antispasmodic drops 30min before the anticipated
time of colic .
Hypoallergenic formula or elimination diet for breastfeeding mothers
DDX with
GERD : accompanied by emesis and occur soon after feeding.
Milk protein intolerance: accompanied by diarrhea or hematochezia.

29. VAGINAL BLEEDING
Menstrual like vaginal bleeding may due to withdrawal of maternal
estrogen.
 occur in about ¼ female babies after 3-5 days of birth.
 The bleeding is mild and lasts for 2-4 days.
 The local aseptic cleaning of genitals is advised .
 If bleeding seems excessive, vitamin K deficient bleeding
or other coagulopathy should be considered.
MUCOID VAGINAL SECRETION
Most female babies have thin grayish white mucoid vaginal
secretions. These should not be mistaken for purulent discharge.


30. Urate Crystals in Urine
(Pink Diaper Syndrome)





Often mistaken for blood in the urine,
Urate crystals are a frequent intermittent finding in the first week.
The characteristic appearance of pink-orange material is sufficient to
make the diagnosis.
Easily distinguished from blood on the basis of appearance, but
occult blood testing can also be performed.
Urate crystals are typically found in the setting of concentrated urine
and may indicate dehydration

31. SUBCONJUNCTIVAL
HEMORRHAGE




Newborns often have small, bilateral hemorrhages,
presumably from the pressure of uterine contractions
But is more common after a traumatic delivery.
This condition is seen in 5% of newborn infants.
The blood gets reabsorbed after a few days without
leaving any pigmentation.

32. Umbilical hernia






Imperfect closure or weakness
of the umbilical ring
LBW, female
Disappear spontaneously by 1 yr
Strangulation rare
Surgery if persisting to age 3-4 yr, symptomatic, strangulated, larger
Application of coin and bandage over the hernia is not recommended

33. Umbilical Granuloma




Well-circumscribed ,friable, moist, pinkish tissue
at the base of the umbilicus
Without treatment, it could ooze and become an irritation for
several months.
Small umbilical granuloma usually respond to application of
crystal salt or silver nitrate.
Large one need surgical excision.
DDX with

Umbilical polyp (retained intestinal or gastric mucosa)


Brighter red than granuloma
Does not respond to silver nitrate cauterization

34. Caput Succedaneum and Cephalhematoma
Indicators
Caput succedaneum
Cephalhematoma
Location
Presenting part of the head
Periosteum of skull bone
Character
soft, puffy, scalp swelling
firm, scalp swelling with
clear edges
Time of Onset
present at birth
Appears after 24 to 48 hours
of birth
Extent of
Involvement
both hemispheres; crosses
the suture lines
individual bone; does not
cross the suture lines
Period of
Absorption
3 to 4 days
Few weeks to months
Treatment
None
Supportive

36. Normal Peeling





Term but most commonly post term infants can exhibit
excessive peeling of skin.
Usually occurs after 24-36 hours
Some time a few erythema toxicum are seen with feeling.
Will resolve spontaneously and does not need any creams, oil,
ointment or lotions.
Excessive peeling is seen in pathological conditions like
placental dysfunction, congenital syphilis and candidiasis.
4S syndrome

37. Normal peeling Versus
4S
•Diffuse erythema of the
skin develops abruptly
• Marked skin
tenderness and fever
•Blisters and bullae
rupture
•Diffuse erosion with
epidermal separation
•Typically perioral and
flexural area

38. CUTIS MARMORATA







Bluish mottling of skin in response to chilling,
stress or overstimulation.
Resolves quickly with warming.
Onset during first 2 to 4 weeks of life;
Due to immaturity of the autonomic nervous
system of newborns.
If persists after the infant is warmed implies an
obstruction to blood flow such as hyperviscosity or
vasculitis.
Persistence beyond neonatal period is a possible
marker for trisomy 18, Down syndrome,
hypothyroidism
DDX from sepsis and hypovolemia.

39. Harlequin color change


Transient hemi color change with erythema
on one half of the and pallor on the other.
It present in the first 2-5 days of life

Common in LBW, hypoxia ,intracranial injury
and prematurity(prematurity of hypothalamic center.

It may persist for 30 sec to 20 min and has no long
term sequelae .
Resolve with supine position ,increased muscle
activity and crying


40. Seborrheic Dermatitis (Cradle cap)






Greasy ,yellow plaques on the scalp with some
degree of hair loss.
Pruritus is infrequent unlike atopic dermatitis
highly prevalent during the first 4 weeks of life
Primarily affect head and intertriginous areas.
Treatment options include gentle scrubbing,applying vaseline and
using soft brush to remove scales
Occasionally topical mild corticosteriod or antifungal is indicated

41. ACNE NEONATORUM



Multiple discrete Erythematouse papules
develop between 2 and 4 weeks of life.
transient increases in circulatory androgens contribute.

Usually resolves within four months without
scarring.

In severe cases, 2.5% benzoyl peroxide lotion
can be used to hasten resolution.
DDX with
 Erythema toxicum
 candidiasis
 staphylococcal infection


42. Milia





Multiple 1- to 2-mm yellowish white cystic lesions
Affect 40% of newborns
found most commonly over the cheeks ,forehead, nose, and
nasolabial folds due to blocked sebaceous glands
Known as Epstein’s pearls when they occur in the
oral cavity(palates).
self-limited and are reabsorbed
by 3 months of age

43. M.Rubra
MILIARIA(HEAT RASH)





Small Erythematouse papules and pustules
on the forehead, neck, upper trunk
Usually after first wk of life
Resulting from the occlusion and rupture
of sweat ducts in the skin,
responds to avoidance of overheating,
removal of excess clothing, cool baths,
and air conditioning
topical creams or lotions aggravate the condition.
M.crystalina

44. ERYTHEMA TOXICUM


Very common rash occurs in almost 50%
Small white/yellow papules or pustules
on a red base seen on face, trunk and limbs.

Usually develop 2 – 3 days after birth .

Sparing palms and soles.

Lesions seem to migrate by disappearing
within Hrs and then reappearing elsewhere.

Resolves within 2 weeks
Differential diagnosis:


herpes simplex
staphylococcal disease of the skin
of newborns

45. TRANSIENT NEONATAL
PUSTULAR MELANOSIS





Small superficial white pustules on a
non erythematous base present at the
time of delivery on neck, back, extremities, and palms or soles
New lesions do not usually appear after birth.
The pustules are fragile and rupture quickly.
often resolving within 2–3 days No treatment is necessary. Hyperpigmented
macules may last for several weeks to months.
Gram stain of pustules demonstrates neutrophils, rare eosinophils, and an
absence of bacteria.
 Acne neonatrum
 Herpes simplex (due to serious consequence Every unknown rash in
neonate should be ddx with HSV)
 staphylococcal disease of the skin

46. SUCKING BLISTERS
 Flaccid bullae, 5–15mm
produced by Vigorous sucking by the fetus .
May evolve quickly to erosion
Resolve in days to weeks
Characteristic locations
Radial forearm, wrist, hand ( dorsal thumb, index fingers)
 No need for treatment




Differential diagnosis:
 Bullous impetigo
 Neonatal herpes simplex
 Epidermolysis bullosa

47. ORAL THRUSH







White patches that coat the inside of
the cheeks and tongue
cannot be easily wiped off and may bleed slightly.
Usually develop symptoms during the first weeks of life
The infection most commonly occurs during passage of the
infected birth canal, infected feeding bottles, contaminated
breast nipples and prolonged antibiotic therapy.
Cause irritability and difficulty in feeding
In severe cases spread to esophagus.
May need Nystatin or Fluconazole oral drops.

48. Irritant Diaper Dermatitis
Spares
skin folds




Confluent Erythematouse papules
persisting longer than 2 or 3 days is usually complicated by C. Albicans.
Skin Folds Spared
accentuation on the convex surfaces exposed to urine and stool.
Rx




Keeping the skin as dry as possible with frequent diaper changes
Zinc oxide cream
Rinsing with just warm water
In severe cases 1% hydrocortisone(few days)

49. Candidiasis Diaper rash
–
–
–
–
–
Erythematouse plaques with peripheral
desquamation
Irregular, scaly border
Satellite lesions on diaper region
Inguinal creases commonly involved
topical anticandidal agent

50. Birth marks
 comprise a wide spectrum of common
and uncommon congenital disorders
 recognition is crucial for predicting the
natural course and associated
abnormalities
Birth marks
Occurrence(%)
Salmon patch
40.3
Mongolian spot
23.3
Hemangioma
2.6
Port wine stain
0.3
1.3
Melanocytic nevus

51. angel kisses
SALMON PATCHES (Nevus Simplex)




Reddish or pink patches on the
forehead ,nape of neck eyelids ,nose
and upper lips.
They are sometimes mistaken for
bruising.
Disappear after 2 years of age
They cross the midline, if unilateral
in the distribution of trigeminal nerve
first
branch (cranial nerve V1) ,need MRI
at 6mo of age for RO of Sturge
Weber syndrome.
Storks bite

52. MONGOLIAN SPOTS





Blue to blue-black macules occur anywhere on
the body,mostly on the back and buttocks
Caused by the deposition of normal body
pigment under the skin.
Malignant degeneration does not occur
mistaken for bruising as a sign of child abuse.
Usually disappear within four to five years
occasionally persist into adulthood.
Differential diagnosis:


Bruise
Birth trauma

53. Port-wine stain




Seriouse and Permanent birthmark
that starts out pink, but turns darker
red or purple as a child grows.
Usually unilateral,appears on the
face and neck, but it can affect other
areas of the body
sometimes they occur with KlippelTrenaunay syndrome or SturgeWeber syndrome
Laser therapy is the usual treatment
of choice

54. Congenital Melanocytic nevus







CMN occur in up to 1% of all newborns.
Size vary from few mm to several cm or more in diameter.
Typically appears on the scalp or trunk of the body
CMN may be flat or raised,hairy,pinkish tan to brown or black.
there is increased risk for development of malignant melanoma.
Prophylactic removal of small CMN should be
considered but can be delayed until the end of the first decade
All CMN with atypical features should be excised
regardless of size.
Giant CMN with atypical features,
including a scalloped border,
irregular pigmentation, and
variable thickness.

55. Cafe au lait spot





Light brown and coffee colored permanent birthmarks .
May be present at birth or develop during childhood
Café au lait spots may be found on any part of the body.
One to 3 café-au-lait spots are common in normal children
presence of six or more with a diameter of greater than 0.5 cm
highly suggestive of neurofibromatosis.

56. Disorders with Café-au-Lait Spots








Tuberous sclerosis
Albright syndrome(precocious puberty)
Ataxia-telangiectasia
Bloom syndrome(GENETIC DISORDER WITH PHOTOSENSITIVITY)
Ataxia-telangiectasia
Turner syndrome
Fanconi anemia
Gaucher disease

57. THAN
K