Pediatric emergency medicine trisk 615

Signs and Symptoms
Cyanosis: Chapter 21
Fever: Chapter 31
Respiratory Distress: Chapter 71
Septic-Appearing Infant: Chapter 73
Tachycardia: Chapter 77
Medical, Surgical, and Trauma Emergencies
Cardiac Emergencies: Chapter 86
Pulmonary Emergencies: Chapter 99
The Children’s Hospital of Philadelphia Clinical Pathways
ED Pathway for Evaluation/Treatment of Neonates
Hyperbilirubinemia/Jaundice
URL: />Authors: D. Aronson, MD; J. Lavelle, MD; C. Jacobstein, MD; N.
Boorstein, RN
Posted: October 2009, last revised January 2018

With

ED Clinical Pathway for Evaluation/Treatment of Febrile Young
Infants (0–56 Days Old)
URL: />Authors: R. Scarfone, MD; P. Gala, MD; A. Murray, MD; M.K. Funari,
RN; J. Lavelle, MD; L. Bell, MD; C. Jacobstein, MD
Posted: August 2010, last revised August 2019

Current Evidence
Evaluation of the newborn poses many unique challenges to clinicians. The
perinatal transition from fetal to extrauterine life requires a number of critical,
coordinated changes in cardiopulmonary physiology that can take several hours to
several days to be completed. Many neonatal conditions are detected within the
first few days of life; however, neonates often present to the emergency
department (ED) with critical conditions that manifest at home after routine

discharge. For example, certain congenital anomalies may be life threatening, and
yet may not present until after this transition has been completed and the newborn
has been discharged home. Other perinatally acquired conditions may not present
until days later due to their insidious onset. Additional challenges include subtle
neonatal presentations and more severe symptoms in response to pathogens
because of immature immune function and lack of energy stores. The immune
system is entirely dependent on passive immunity provided from the mother
during pregnancy, leaving the neonate immunocompromised and susceptible to
life-threatening infections. Furthermore, infants have very little in terms of
cardiopulmonary reserve, so that the sick infant can go from well appearing to
critically ill and cardiopulmonary arrest in a short period of time. Finally,
pathogens to which neonates are likely to be exposed during birth include
aggressive bacteria and viruses, including Group B streptococcus (GBS), gramnegatives, and herpes simplex.
Regardless of the etiology of injury or illness, neonates have a very limited
ability to communicate critical changes in health. Infants cannot express
subjective data, and often new parents are unable to identify critical changes in
infant behavior. As such, it is important for the caregiver to gather and interpret
subtle changes in vital signs and the physical examination to avoid catastrophic
injury to the ill newborn.
In this chapter, we will highlight the major differences between neonatal
anatomy and physiology compared to that of older children. We will also provide
clinicians with a concise synopsis of common neonatal disorders that may be
encountered in the ED.

Goals of Treatment
Given the unique challenges of neonatal care, the primary goals of treatment are
twofold: (1) to distinguish early signs of a sick infant from normal newborn
behaviors and (2) to provide timely intervention to prevent permanent injury or

death in the case of an ill neonate.

Clinical Considerations
Clinical Recognition
To assist in the clinical recognition of a sick infant, close attention must be paid to
the vital signs obtained in triage. Subtle changes in vital signs can often be the
only indication of serious illness, and the early detection of these changes can
alert the clinician to intervene prior to the loss of physiologic reserve and
cardiopulmonary collapse.


Weight
Each newborn encounter should include a weight check. This should be compared
to weight at birth. The Centers for Disease Control (CDC) growth charts provide
normative values for weight and length in boys and girls. Birth weight below the
10th percentile identifies the small for gestational age (SGA) and that above the
90th percentile identifies the large for gestational age (LGA) infant. Both SGA
and LGA infants are at risk for physiologic disturbances. SGA infants have
decreased fat stores, which can leave the infant more susceptible to hypoglycemia
and electrolyte disturbances. Additionally, SGA infants are much more sensitive
to environmental changes and cannot thermoregulate as well as older infants.
Hypothermia in the SGA infant can depress the autonomic nervous system, which
may result in bradycardia and hypotension. The LGA infant is commonly born to
a diabetic mother. The high levels of growth hormone and insulin and lack of
sufficient postnatal glucose delivery result in hypoglycemia and electrolyte
disturbances, such as hypocalcemia. LGA infants are also at risk for
polycythemia. Severe polycythemia can compromise cardiovascular function, as
well as increase the risk of hyperbilirubinemia.
Normal weight patterns include a brief period of weight loss in the immediate
postnatal period, followed by regular, consistent weight gain for the first few

months of life. Weight loss is the most sensitive sign for dehydration in the
newborn, particularly as other common signs, such as decreased urine output or
skin turgor are not reliable findings in this group. A loss of more than 10% of
birth weight in the first week of life is cause for concern, and should be evaluated,
particularly for dehydration, hypoglycemia, and electrolyte disturbances.
Neonates that have not regained birth weight by 14 days of life should also be
evaluated thoroughly. Most commonly, slow weight gain is due to decreased milk
transfer in breast-fed infants, but can also signify increased caloric and metabolic
demands due to underlying congenital anomalies of the cardiovascular,
respiratory, gastrointestinal, or renal systems. Neurologic diseases, particularly
those with decreased tone and motor strength, may also present with weight loss
or poor weight gain if the infants do not have the strength to adequately suck and
swallow. A basic metabolic panel (BMP) should be checked for signs of
hypernatremia or other electrolyte disturbances. Neonates who are receiving
suboptimal feeds due to inadequate supply may need to be supplemented with
formula. Referral of the infant to the pediatrician for serial follow-up is
recommended. Alternately, those requiring assistance with poor breast-feeding
technique may be supplemented with expressed breast milk or formula and
referred to a lactation consultant.


Heart Rate
Normal resting heart rate for a neonate can range between 80 and 180 beats/min.
Over the first few weeks of life heart rate will decrease to 80 to 140 beats/min.
During rest and deep sleep, the heart rate will typically be in the lower range, and
in the higher range with activity or agitation. A healthy infant will show
variability in heart rate with subtle changes during inspiration and exhalation and
when alternating between sleep and alert states. Loss of heart rate variability has
been associated with systemic illnesses, such as shock and infection.
Bradycardia can be defined as either a 20 to 30 beat decrease below the

infant’s baseline or below 80 beats/min at rest. Neonates respond to poor cardiac
output by increasing their heart rate because stroke volume cannot increase
acutely. Therefore, bradycardia is often a late sign of cardiac failure after the
normal compensatory mechanisms have collapsed. Sinus bradycardia may also
occur with hypothermia, hypothyroidism, malnutrition, or electrolyte
disturbances. Premature infants may also present with recurrent bradycardic
events, particularly during episodes of increased vagal tone due to gastrointestinal
reflux, emesis, or in association with hypoxemia due to apnea. A 12-lead
electrocardiogram can help distinguish sinus bradycardia from conduction
abnormalities and heart disease. Some full-term infants have a low resting heart
rate that may reach 80 to 90 beats/min. Any infant with bradycardia who shows
other signs of cardiovascular instability, such as hypotension and poor capillary
refill, or systemic signs of lethargy or poor feeding, should be treated and
stabilized immediately.
Neonatal tachycardia can be defined as a heart rate >190 beat/min. Sinus
tachycardia may occur in the setting of shock, dehydration, or hypovolemia, as a
mechanism to increase cardiac output. Neonatal tachycardia can also occur with
fever, hyperthyroidism, severe anemia, hypoglycemia, or electrolyte disturbances,
such as hypocalcemia. The most common conduction abnormality that results in
tachycardia in the neonate is supraventricular tachycardia (SVT), which can lead
to cardiac failure and shock if sustained.
For more details on clinical considerations and management of heart rate
anomalies in the neonate, see Section: Neonatal Cardiac Emergencies.
Respiratory Rate
The normal respiratory rate of a newborn is between 30 and 60 breaths/min.
Periodic breathing is a normal finding that presents with pauses between breaths
that can last up to 10 seconds. Most commonly, the infant will have 2 to 3 pauses
close together, followed by a series of short, shallow breaths. With periodic