PNEUMONIA - NEONATAL

Definition: Infection of the lungs in the newborn period.

1. What caused this condition?

In the majority of cases, bacteria has gotten into the lungs causing an infection. This can be the only site of the infection, or pneumonia can be present when there is a generalized infection of the blood- stream also.

The bacteria can get into the baby’s lungs from the placenta, during the delivery process, or after birth. Occasionally, the pneumonia may be caused by viruses or other infectious agents such as chlamydia, a sexually transmitted infection.

2. How dangerous is this condition, and what complications can occur?

All infections in newborns can be serious and potentially life threatening. Depending on the severity of the pneumonia, the baby may only have fast breathing with need for additional oxygen or could require support with a breathing machine and high levels of additional oxygen.

3. What is the proposed treatment?

As with all bacterial infections, antibiotics need to be started as soon as any infection might be suspected. The antibiotics will ultimately cure the infection. As pneumonia can cause the lungs to not function normally, the baby may need additional oxygen or support with a breathing tube and breathing machine. The length of antibiotic treatment in the hospital is at least seven days and may be more.

4. What potential side effects can occur from the treatment?

Most antibiotics have little to no side effects. Some antibiotics may require blood levels performed to make certain they are in a range to treat the infection, but not cause side effects. If some type of breathing support is needed, holes in the lungs (pneumothorax), or injury to the lungs can occur.

5. How long will it take for my baby to improve once the treatment has begun?

Generally, the newborn will begin to get better twenty-four to forty- eight hours after the antibiotics have been given.

6. What additional diagnostic tests should my baby have?

A chest X ray, blood count, and blood culture are done on babies with suspected pneumonia. Other blood tests that may be done are a measurement of inflammation, c-reactive protein, and a blood gas, which determines how well the lungs are functioning. If a breathing tube is required, a sample of the secretions from the airways may be sent to determine if bacteria are present or not.

7. After the condition is resolved, will my baby be more prone to respiratory tract infections in the future?

No.

8. Do we need to consult with a neonatologist (newborn specialist) or a pulmonologist (lung specialist)?

If the baby requires additional oxygen or breathing support, a neonatologist is consulted. Some babies that have very mild cases or “suspected” pneumonia may stay in the regular newborn nursery under the pediatrician’s care.

9. What kind of follow-up will be needed with you in the future?

For mild to moderate cases of pneumonia, routine follow-up with the pediatrician is all that is necessary. In severe cases, a developmental specialist may also monitor your child’s progress. 

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MECONIUM ASPIRATION

Definition: When the newborn or fetus inhales meconium (first stool) into the lower

respiratory tract.

1. What caused this condition?

The baby had a bowel movement while still inside the mother’s uterus. Meconium is the name for the first stools that a baby passes. The meconium gets into the fluid surrounding the baby and can be swallowed into the lungs or breathing passageways prior to or at the time of birth. Babies that are under stress or go beyond their expected due date have a higher incidence of passing meconium while still in the uterus. Generally, meconium aspiration is seen in babies that are not premature.

2. Is this condition dangerous, and what kind of damage can it cause?

If the meconium gets into the airways leading to the lungs, it causes a blockage of the passageways. This stops or impedes the flow of air into and out of portions of the lungs. This can lead to low oxygen levels or a buildup of carbon dioxide.

     If significant, this disruption in the functioning of the lungs can lead to a continued high blood pressure in the blood vessels leading to the lungs. When this occurs, there is further inability of the lungs to get oxygen into the bloodstream and to remove carbon dioxide due to blood bypassing the lungs.

     Another common complication of meconium aspiration is the development of a hole in the lung(s). This is called a pneumothorax. Air escapes from the lung into the chest cavity and is trapped between the chest wall and lung. As the air builds up, it compresses the lung and again disrupts normal lung function.

3. What tests are needed to further define the condition?

The presence of meconium is noted when the water is broken either naturally or by the obstetrician. The fluid will have a greenish discoloration. The thickness and degree of discoloration indicates the amount of meconium present. After the baby is born chest X rays will confirm the findings of meconium aspiration if present. A sample of blood called a blood gas along with oxygen-level monitoring (pulse oximeter) will show low oxygen levels and disturbances in lung functioning.

4. What is the treatment?

Prevention is the main treatment. If meconium stained fluid is noted, the obstetrician may infuse sterile salt water into the uterus to dilute the meconium. At the time of delivery, the obstetrician will attempt to clean out the nose and mouth prior to the delivery of the rest of the baby. The baby may then have a breathing tube passed into the trachea, the main passage to the lungs, and suction applied while it is removed.

     If the baby has further or continued problems, then additional oxygen and/or a breathing machine may be needed. If a breathing tube is needed, the instillation of a medication called surfactant may be given through it to help break up the meconium and improve the function of the lungs. If the baby has significant breathing concerns, a ventilator called an oscillator may be used.

     If the baby develops a pneumothorax, or hole in the lung(s), a drainage tube may be needed. This drainage tube is called a chest tube, and it is placed between the ribs on the side of the air leak to prevent the lung from collapsing.

5. What side effects can occur from the treatment?

The most common early side effect is a hole in the lung(s) from air being trapped by the meconium or from the degree of ventilator support required to get acceptable oxygen and carbon dioxide levels. It is treated as mentioned above.

     The lungs can be injured from being on the ventilator. They may develop an inflammatory reaction to the irritation of the meconium and being on the ventilator and high oxygen concentrations. If this occurs, it may delay coming off of the ventilator and additional oxygen. This inflammatory response can occasionally lead to the baby having feeding problems due to increased work of breathing and needing extra oxygen at the time of discharge.

     Infrequently, a baby may have severe meconium aspiration along with severe elevations in the blood pressure in the blood vessels leading to the lungs. This may require treatment with a heart-lung bypass (ECMO).

6. How long will it take for my baby to show improvement?

Most babies get better in seven to ten days. A baby with severe meconium aspiration may require a longer hospital stay, potentially up to a month, to be well enough to be discharged.

7. What complications can develop?

The more frequent complications are the same as the side effects from being treated. Holes in the lung (pneumothoraces) or the failure of the blood pressure to lower in the lungs after birth (pulmonary hyper- tension) may be present and complicate the meconium aspiration. Occasionally, babies may have some inflammation in their lungs that delays their improvement.

8. Can pneumonia develop?

Pneumonia caused by bacteria is not associated with the meconium aspiration itself. Infection may occur in any patient that has a breathing tube in place and receives ventilatory support for a period of time, especially longer than fourteen days.

9. Will this condition weaken my baby’s lungs for the future?

Both the presence of meconium and being on a breathing machine with exposure to high concentrations of oxygen can cause an inflammatory response in the lungs. In some cases this can lead to delayed recovery and some lung abnormalities for the first several months of life. Most babies with mild-to-moderate meconium aspiration will not have any long-lasting lung problems.

10. After discharge from the hospital, what kind of follow-up will be needed?

In most cases, your child’s pediatrician will be all that is necessary. In severe cases of meconium aspiration, the baby may be at more risk for developmental delays and a developmental specialist may be required. 

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LUNG RUPTURE (Pneumothorax or Pneumomediastinum)

Definition: Free air in the chest cavity.

1. What has caused this condition?

There was a tear or rupture in the air sacs (alveoli) in the lungs. This tear allowed air to escape out of the lung and into either the space between the lung and the chest wall (pneumothorax) or into the tissues along the blood vessels (pneumomediastinum). Pneumothorax is relatively common in newborn babies, occurring in approximately 1 percent of all newborns. Many babies have no symptoms. Others have symptoms related to the compression of the lung(s) by the leaked air and need treatment and/or supplemental oxygen. Babies that have other breathing prob- lems and require breath assistance from a breathing machine are at potentially higher risks to develop air leaks in their lungs.

2. How is it treated?

In a lot of cases when the baby is otherwise healthy and without symp- toms, observation is all that is needed and the tear will heal itself and the air be reabsorbed. In cases where the air leak is larger and the baby is having symptoms, the air may need to be pulled out (aspirated) by putting a needle in the baby’s chest wall. After the air in the chest cavity is pulled out, the needle is removed, and the baby is monitored for recurrence. If the leak continues or if the baby is on a breathing machine for support, a drainage tube (chest tube) is placed in the chest wall to continuously drain the air until the leak heals. Many babies that have symptoms due to the free air will also require extra oxygen to keep their oxygen levels in an acceptable range. During this time, your baby may be breathing faster than normal or harder than normal and not be able to feed by mouth. This may require feedings via a tube, or the feedings withheld and IV fluids started. 

3. How long will it take to correct itself?

This depends on the size of the leak. Many babies with small leaks that seal over rapidly are better in twelve to twenty-four hours, sometimes without symptoms. Babies that require needle aspiration or drainage tube placement may require two to three days or more to close the tear and allow the lungs to heal.

4. Do we need to consult with a neonatologist (newborn specialist) or a pediatric surgeon?

If the baby has symptoms or requires aspiration, drainage tube place- ment, or extra oxygen, a neonatologist is often involved in the care. Babies that are just breathing a bit fast or have no symptoms are often watched in newborn nursery by the pediatrician. It is rare that a surgeon or surgery is needed.

5. What tests need to be done to further define the condition?

An X ray of the chest is the test that absolutely confirms that a pneumothorax or pneumomediastinum is present. It can also provide some information as to how much air and compression on the lungs has occurred. Prior to the chest X ray, you may be able to suspect an air leak by listening to the chest and hearing decreased breath sounds on the side with the leak. You can also place a light on the front of the chest (transillumination), which may indicate air has leaked out of the lung and accumulated in the chest.

6. What kind of future complications can we anticipate as a result of this illness?

The majority of babies will have no long-term effects from the air leak itself. The rupture or hole will heal by itself. Any future complications are most likely to occur if the baby is premature or there was another lung problem that required treatment.

7. Are the lungs left weakened from this condition and, if so, in what way?

No, the lungs will heal the tear and recover in almost all cases. If there were other lung problems that were also present, some breathing abnormalities could persist until the lungs are healed from those conditions.

8. After discharge from the hospital, what kind of follow-up will be needed?

As the rupture or tear in the lung is healed at the time of discharge, just routine follow-up with the pediatrician is necessary. 

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KIDNEY ENLARGEMENT (Hydronephrosis)

Definition: Swelling of the kidney as a result of obstruction to the flow of urine.

1. What caused this condition?

Hydronephrosis in most babies is a minor condition that goes away on its own. It likely represents increased urine production by the fetus prior to delivery that goes away with time. Occasionally, hydronephrosis may be due to an obstruction that is caused by abnormal development of the ureter (the tube that carries the urine from the kidney to the bladder). Hydronephrosis may also represent the backwash of urine from the bladder to the kidney known as vesicoureteral reflux.

2. What tests are needed to further define the disorder?

In most cases, ultrasound imaging is used to discover kidneys that are hydronephrotic. Once a kidney has been determined to be hydronephrotic, depending on the age and gender of the baby, a bladder X ray should be performed to look for backwash of urine up to the kidney (vesicoureteral reflux) or blockage in the urethra if the child is male. In other instances where the condition is quite severe, a nuclear medi- cine renal scan should be performed to rule out obstruction of the kidney. An obstruction might require surgical intervention to preserve the kidney. If the hydronephrosis involves both kidneys, then further evaluation with a standard blood test should be performed in the hospital or office to make sure that kidney function is normal.

3. Is this condition causing my baby any pain or discomfort?

If the kidney is significantly swollen (dilated) or it is obstructed, the baby may have pain, nausea or vomiting, or even blood in the urine. However, most degrees of hydronephrosis do not cause any pain or discomfort.

4. Is it correctable, and will surgery be necessary?

Most hydronephrosis is minor and will resolve or improve on its own as the baby gets bigger. However, if the dilation is significant or severe, then this may represent an obstruction of the kidney that will require surgery to resolve the obstruction. If the dilation of the kidney is related to vesicoureteral reflux, and if the reflux does not resolve as the baby gets older, then correction of the reflux may be necessary. Blockage of the male urethra must be corrected with surgery.

5. Will it predispose my baby to kidney disease or infection in the future?

Most hydronephrosis does not predispose the kidney to disease or infection; however, if the dilation is related to vesicoureteral reflux, reflux is a risk factor for developing both bladder and kidney infections. If the dilation is severe and involves both kidneys, then kidney disease is a possibility.

6. Do we need to consult a urologist and, if so, when?

Once the diagnosis of hydronephrosis is made, the urologist should be consulted to review the X rays, perform a complete history and physical examination of the baby and then determine if any other further studies are necessary. While this is generally not an urgent condition, if the child is having pain, significant infections, or it involves both kidneys, then the urologist should see the child immediately.

7. How will the condition be monitored following discharge from the hospital, and what tests will need to be done?

An ultrasound and further studies are usually recommended approximately four to six weeks following discharge. Depending on whether or not the hydronephrosis is severe, a renal scan may need to be performed. If the hydronephrosis involves both kidneys, then a stan- dard blood test would need to be performed to determine kidney function. If the child has not had an evaluation for vesicoureteral reflux, then a bladder X ray test would be necessary.

8. What danger signs should we look for after leaving the hospital that would indicate that the kidney problem might be getting worse?

The most common symptoms associated with severe hydronephrosis or an obstructed kidney is abdominal, side, or back pain and vomiting. Fever may represent a urinary infection.

9. After discharge from the hospital, when do you wish to see my baby again?

After the child is discharged, we will normally see the child back in our office for an ultrasound and further studies approximately four to six weeks later. See question #7 for details. 

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JAUNDICE

Definition: Yellow appearance of the skin caused by bile pigment deposits in the skin.

1. What is jaundice, and what caused it to appear in my baby?

Jaundice is a common condition occurring in newborn babies. It is a yellowish skin discoloration caused by a waste product in the body called bilirubin. Bilirubin is produced when certain proteins and red blood cells are destroyed, which is a normal process that happens early on after birth. Newborns are more likely to be jaundiced due to increased destruction of red blood cells and the body’s slow processing of bilirubin due to an immature functioning liver.

2. Is jaundice dangerous?

In the majority of cases, jaundice is not a life-threatening or serious condition. The bilirubin levels can get high enough that treatment is needed. In most cases the treatment is relatively simple with special lights (see question #5). If the bilirubin level gets to a serious level, then an exchange of the baby’s blood (exchange transfusion) may be necessary. Fortunately, this is a rare occurrence.

3. What tests are needed to further define the condition?

Most of the time, a meter will first be placed to the baby’s forehead as a screening test. If the meter level is elevated, then it will be necessary to do a blood test to measure the bilirubin level. A test for the blood type of the infant is generally necessary to determine if it is compatible with the mother’s blood type, but most of the time this is done on blood from the umbilical cord at the time of delivery. If there is a concern about rapid destruction of the red blood cells, a blood count may be necessary.

4. What is considered to be a danger point for the bilirubin level?

The actual level that treatment is started is dependent on the baby’s age at birth, the number of days since birth, and whether or not there are conditions causing increased and more rapid red blood cell destruction. If the bilirubin level is rising quickly or approaching 20 mg/dL or more, therapy is generally started. Levels above 25 mg/dL have been associated with deposits of bilirubin (staining) on portions of the brain in some babies. This staining can lead to brain damage and lifelong injury.

5. If my baby’s bilirubin level exceeds the danger point, what kind of therapy will be given and will it correct the problem?

The main therapy is phototherapy. The baby is given eye protection and is placed with minimal clothing under special blue lights. These lights help in the removal of bilirubin. Phototherapy usually lasts from two to five days. If the baby is dehydrated, IV fluids may be started to correct the dehydration. Sometimes, breast-feeding and breast milk may not be given while the baby is under treatment for the jaundice.

6. Is phototherapy safe, and will there be any bad consequences afterward?

Phototherapy with appropriate eye protection has no serious side effects. Sometimes babies pass more stools while under phototherapy. Also since they are uncovered, some will require a heating source to prevent them from getting cold.

7. How often do we follow the bilirubin level, and will we continue to follow the level at home following discharge from the hospital?

If there are concerns, the bilirubin level is generally followed daily. This continues until the bilirubin level stabilizes or starts to drop. There may be a need for ongoing blood levels after discharge as the jaundice can persist for the first several weeks.

8. Can my baby become anemic from this disorder?

No, not from the jaundice itself. Jaundice is more severe in babies when there is a process that causes rapid or increased destruction of the red blood cells. There may be an incompatibility between the blood types of mother and baby, a defect in the red blood cells, or excessive bleeding or bruising that could cause the anemia and also make the baby more likely to have jaundice that requires treatment.

9. Is there anything else we need to know concerning this condition and its management?

Bilirubin is mainly passed from the body in the stool. Good feedings and ensuring good hydration in the first two to four days of life can decrease the risk of significant jaundice.

Very high levels of jaundice can lead to a condition called kernicterus. This is when parts of the brain are stained by the bilirubin. Kernicterus leads to cerebral palsy and lifelong abnormalities of the nervous system.

10. After discharge from the hospital, what kind of follow-up will be needed?

As discussed earlier, some babies require continued monitoring of the blood levels after discharge. This may be daily for several days. Some babies may require readmission to the hospital for treatment with phototherapy. Your pediatrician will instruct you on the frequency for the blood tests on discharge from the hospital. 

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