Newborn & neonatology

Jaundice, RDS, NEC, HIE, meconium aspiration, neonatal sepsis, transient tachypnea, newborn screening.

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◆Neonatal jaundice

•Physiologic (24 hr – 1 wk): unconjugated; supportive; phototherapy if approaching threshold
•Pathologic (<24 hr of life OR >2 wk OR very high) — workup
•Breastfeeding jaundice: dehydration in first week — more feeds
•Breast milk jaundice: starts later (week 2), benign β-glucuronidase effect — continue breastfeeding
•Hemolytic (ABO, Rh, hereditary spherocytosis, G6PD): rapid rise → consider exchange
•Conjugated jaundice (direct bili >2 or >20%): ALWAYS pathologic — biliary atresia (Kasai by 2 months), CF, neonatal hepatitis
•Kernicterus: bilirubin-induced encephalopathy — preventable cause of CP; thresholds vary by hours of life + risk factors

•Surfactant deficiency (RDS): preterm, ground-glass CXR, air bronchograms; CPAP, exogenous surfactant; betamethasone if anticipated preterm delivery
•Transient tachypnea of newborn (TTN): term, often post-C-section; fluid in fissure on CXR; resolves 24–72 hr
•Meconium aspiration: post-term + meconium-stained fluid; chemical pneumonitis + risk of pulmonary HTN
•Pneumonia (GBS, gram-negs): respiratory distress + sepsis features
•Persistent pulmonary hypertension of newborn (PPHN): cyanosis + pre/post-ductal sat difference; iNO, ECMO
•Diaphragmatic hernia: scaphoid abdomen + bowel sounds in chest + respiratory distress; do NOT bag-mask (worsens), intubate

•Early-onset (<7 days): GBS, E. coli, Listeria — empiric ampicillin + gentamicin
•Late-onset (>7 days): coag-negative Staph, S. aureus, gram-negatives — empiric vancomycin + cefotaxime or gentamicin
•Always check + treat for meningitis if sepsis (LP, add appropriate coverage)
•Maternal GBS+ → intrapartum penicillin or clindamycin if allergic
•Risk factors: prematurity, prolonged ROM (>18 hr), maternal chorio, GBS positive without prophylaxis

•Preterm + first weeks of life; rare in term newborns
•Abdominal distention, bloody stools, feeding intolerance, sepsis features
•X-ray: pneumatosis intestinalis (air in bowel wall) — pathognomonic; portal venous gas; pneumoperitoneum if perforated
•Treatment: NPO, NG decompression, IV antibiotics (ampicillin + gentamicin + metronidazole or clindamycin), TPN; surgery if perforation/clinical deterioration
•Breast milk PROTECTS against NEC

•Hypoxic-ischemic encephalopathy (HIE): perinatal hypoxia → seizures, encephalopathy, multi-organ dysfunction
•Therapeutic hypothermia (33.5°C × 72 hr) within 6 hr of birth — neuroprotection
•Brachial plexus injuries: Erb (C5–C6) 'waiter's tip' from shoulder dystocia; Klumpke (C8–T1) claw hand
•Caput succedaneum: crosses suture lines (soft tissue), resolves days
•Cephalohematoma: subperiosteal, does NOT cross sutures, weeks to resolve, watch for jaundice
•Subgaleal hemorrhage: under aponeurosis, can be massive (life-threatening blood loss)

•Heel-stick blood spot: PKU, congenital hypothyroidism, CF, sickle cell, biotinidase, galactosemia, MCAD, etc.
•Hearing screen (otoacoustic emissions or ABR) all newborns
•Critical CHD screen with pulse oximetry (pre + post-ductal sats)
•Bilirubin screening (transcutaneous or serum) before discharge
•Hep B vaccine (and HBIG if mom HBsAg+)

◆Conjugated hyperbilirubinemia in a newborn is ALWAYS pathologic — biliary atresia until proven otherwise (Kasai before 60 days)
◆Pneumatosis intestinalis on abdominal X-ray = NEC
◆GBS+ mother → intrapartum penicillin (clindamycin if penicillin-allergic with documented susceptibility)
◆Therapeutic hypothermia for HIE within 6 hours of birth — every hour matters
◆Diaphragmatic hernia: do NOT bag-mask (distends bowel in chest) — INTUBATE
◆Cephalohematoma respects suture lines; subgaleal does not and can exsanguinate
◆Caput succedaneum is SOFT TISSUE → crosses sutures (vs cephalohematoma which is subperiosteal)

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