APPENDICITIS

Definition: Inflammation of the appendix in the large intestine.

Note: Whenever a child complains of severe abdominal pains, it is likely that the parent is concerned that the child may have appendicitis. If abdominal pain develops suddenly and the child continues to complain, the doctor should be contacted. It is impor- tant that the diagnosis of this condition be established early to avoid having the appendix rupture, which causes more serious problems for the child.

1. How did this condition develop in my child?

The appendix is a leftover of development where the small and large bowel are joined in the right lower quadrant of the child’s abdomen. It is hollow, and it opens into the large bowel. The opening is small and susceptible to being clogged by a stool ball (called a fecalith), or it can swell shut when the child has a viral illness somewhere else in the body. The opening of the appendix is surrounded with the same lymphoid tissue that swells in your child’s neck when he or she gets a viral illness. The appendix normally has bacteria in its hollow center that are evacuated with the stool. If the opening is blocked, however, the bacteria continue to grow but cannot escape. Pressure builds up, and the bacteria can invade the wall of the appendix, weakening it. If left untreated, the appendix can “rupture,” spilling the infection into the wider abdomen.

2. Are there further tests to be done to more fully establish the diagnosis?

The most common test is a CT scan of the abdomen and pelvis. Sometimes a sonogram can also identify appendicitis. There is no single test (or combination of tests) that is 100 percent accurate, so the decision to perform an appendectomy is based on a combination of blood and urine tests, radiology images like a CT scan, and examination by an experienced surgeon. Sometimes, if the diagnosis is in doubt, your child may be admitted to the hospital for a period of observation and/or repeat testing.

3. What is the treatment for this condition?

The definitive treatment is to remove the appendix with an operation. This may be done through an incision in the right lower quad- rant of the abdomen or with a laparoscope (which uses three small incisions, one of which is in the belly button). If the appendix has already ruptured and a pus pocket (abscess) has formed around it, the best treatment may be to drain the pus and treat the child with antibiotics first and remove the appendix later (sometimes six weeks later). Many children require intravenous fluids and antibiotics for several hours prior to the operation so they tolerate the anesthesia better.

4. What complications can occur as a result of this condition if left untreated?

The complication that everyone worries about is rupture. If a child has a nonruptured appendix removed, he or she can usually be discharged home without antibiotics in one to two days after the operation. If the appendix has ruptured, however, the child will need five to seven days of intravenous antibiotics after the operation and additional oral antibiotics at home. Even then, children are at much higher risk for abscess formation (usually forms about a week after the appendectomy), which may require drainage with another procedure.

5. What, where, and by whom should the surgery to correct this condition be performed?

The appendectomy is usually performed by a pediatric surgeon in smaller children and by a pediatric or adult general surgeon in teenagers. It must be done in a full service hospital, not a day surgery center.

6. If surgery is necessary, what are the potential complications that can occur?

Local infections in the skin incisions can occur. This appears as bright redness extending more than one-half inch from the edges of the incision or pus draining from the incision. Local infection is treated by removing the outer layer of stitches to allow the area to drain and by antibiotics.

     An abscess (a pus pocket formed deep in the abdomen) can occur about a week after an appendectomy for ruptured appendicitis. Formation of an abscess is rare after an appendectomy for nonruptured appendicitis. The abscess is almost always discovered prior to the child going home. If the child still has fever, severe pain, and/or persistently abnormal blood tests greater than one week after the operation, a repeat CT scan of the abdomen and pelvis may be done to check for an abscess. If one is found, one of three treatments will likely be recommended: continued IV antibiotics (for smaller abscesses), drainage by the radiologist using a CT scan for guidance (with the child asleep, a small catheter is inserted into the abscess and left in place until it resolves), or (rarely) another operation for drainage of abscesses that cannot be reached safely by the radiologist.

7. When do you wish to see my child again regarding this condition?

If the appendix did not rupture, one visit to the surgeon two to three weeks after discharge home is sufficient. Most children will be allowed to return to sports or physical education classes after this visit. If the appendix ruptured, an additional visit may be necessary after all antibiotics have been completed. 

ANEMIA

Definition: A condition of reduced red blood cells in the circulatory system.

Note: This is always a worrisome condition in childhood. Anemia can make children sluggish and decrease their capacity to perform. There is no reason why the cause of anemia cannot be fully established and appropriate treatment rendered if necessary.

1. What causes this condition to occur in my child?

Anemia occurs when there are not enough red blood cells to meet the needs of the child. Red blood cells carry oxygen to the various parts of the body. There are three reasons why a child may become anemic.

The first cause is bleeding. If the child is losing red blood cells from the body, whether it is from chronic nosebleeds or from bleeding in the gastrointestinal tract, eventually the red blood cell count will go down, and the child could become anemic.

     The second reason why a child may become anemic is if the body is unable to produce sufficient amounts of red blood cells. The most common reason in childhood is a lack of sufficient iron in the diet. This occurs most frequently in children between the ages of one and two who have had a diet made up primarily of cow’s whole milk. If the child is not getting sufficient iron in the diet, then the child is not able to make sufficient red blood cells. This can result in severe anemia. 

     The third reason why a child may become anemic would be if the red blood cells that the child produced do not survive in the body for a normal period of time. Normally, once red blood cells are made, the red blood cells will last in the body for approximately three months. There are a number of conditions that could cause the red blood cells to break down earlier than normal. In general, these are called hemolytic anemias. There are many different types of hemolytic anemia. Some types are inherited and are not correctable. Some types occur after certain viral illnesses and will eventually get better.

2. What tests are needed to better define the condition?

The first step is to measure the amount of hemoglobin and red cells in the body. Then, the physician or the laboratory technician will look at the red blood cells under the microscope. This will often give the physician a clue as to what is causing the anemia.

     The physician then might order a number of different tests to deter- mine the diagnosis. For instance, if the physician feels that the child may be losing blood, the physician may order special tests on the stool to look for any signs of blood. The physician also might want to measure the amount of iron in your child’s body. There are many tests that can better define the reasons for anemia.

3. How is it treated, and is it correctable?

The treatment for anemia depends on its cause. If the anemia is due to bleeding, then the cause for the bleeding must be determined, and corrective action will be taken. If the anemia is due to an insufficient amount of iron in the diet, then the patient will be placed on supple- mental iron, and often a change in diet is warranted. Some types of anemia are not correctable, though the most common forms of anemia are easily correctable.

4. Are there any potential side effects of the treatment?

There is always the possibility of side effects with any treatment, but in general, the treatment of anemia is well tolerated. Certain oral iron preparations may cause some temporary discoloration of the teeth or some belly pains or some constipation. Often, the physician can change the type of iron supplementation to meet your child’s needs.

5. What symptoms will my child have as a result of the condition?

In general, the symptoms of anemia are not seen in childhood until the anemia is fairly severe. The signs of anemia generally include fatigue and lack of energy.

6. Do we need to consult a hematologist (blood disorder specialist)?

Most pediatricians are able to diagnose and treat the more common causes of anemia in childhood. Sometimes the pediatrician will request a consultation from a pediatric hematologist for advice in treating anemia.

7. How often will my child need to be tested in the future to see if the condition is improving?

This depends on the cause of the anemia. If the anemia is due to iron deficiency, then the child will be tested several times in the first year or two to make sure that the condition is improving. In other cases of anemia, the scheduling for repeat testing will depend on the cause of the anemia.

8. When do you wish to see my child again regarding this disorder?

The frequency of visits to the doctor for the treatment of anemia will depend upon the cause of the anemia. In general, several trips to the doctor will be required in the first six months to a year if the anemia is due to iron deficiency. 

ACNE

Definition: A chronic inflammatory disease of the sebaceous (oil) glands characterized by pimples and pustules occurring primarily on the face, back, and chest.

Note: There is no need for a teenager to grow up with severe scarring due to acne. Today there are good treatments that can minimize the long-term cosmetic ill effects caused by this condition.

1. What causes this condition to occur in my child?

Acne is triggered by hormone changes in adolescence. Children with acne have oil (sebaceous) glands that tend to produce more sebum (oil). They also have pores that tend to plug more easily. These plugs are made of sebum and dead skin cells. When the pore becomes plugged, bacteria are trapped in the pore, and the pore becomes inflamed, resulting in a pimple. Genetics also plays a role, and some families are more prone to develop acne than others. Unlike what many people think, acne is not due to dirt or not washing your face enough.

2. Is there any way to predict how bad it will get?

Signs that a child may develop more severe acne include earlier age of onset, family history, and being male. As a general rule, males tend to have more severe acne than females. The earlier acne starts (i.e., before age thirteen), the more severe it may be. Children prone to develop bad acne often have family members who had severe or scar- ring acne. The presence of deeper, tender, cyst-type acne lesions or scarring is a sign of more severe acne, and children with these signs should seek treatment early.

3. What can I do to prevent it from getting worse?

Face washing is not enough. The best thing you can do is to start treatment early. In general, it takes eight weeks for any acne treatment to start working, so if you do not see any improvement from your child’s over-the-counter acne treatment after eight weeks, you may need to consider prescription treatment. Your child should avoid squeezing pimples; this makes the pore more inflamed and increases the risk of scarring. Children should also not scrub their faces harshly or use abrasive cleansers, since this can inflame the skin more. Things that touch or fit tightly against the skin can plug pores, so your child should keep his or her hair, hands, head- bands, caps, hair products (gels, hair sprays, etc.), and sports gear off of the face, forehead, shoulders, and back as much as possible.

Products (moisturizers, sunscreens, cosmetics) used on the face and body should be oil free and noncomedogenic (proven not to cause acne). If possible, teens should avoid jobs in places such as fast food restaurants or auto shops, where the skin will be in contact with oil or grease that can aggravate acne.

4. Does diet affect acne?

This is an area of much debate. In general, there are no specific foods that are proven to worsen acne. It is always a good idea to limit junk food as much as possible, but this may not have any bearing on your child’s acne. If there is one particular food that consistently seems to worsen your child’s acne, then avoiding that food may help.

5. What skin cleanser should be used?

A mild, nonabrasive, nondrying cleanser applied with clean hands or a clean washcloth and warm (not hot) water once or twice daily is recommended. For acne, medicated cleansers containing either benzoyl peroxide or salicylic acid can be used, but they may cause skin irritation or dryness, especially if used in combination with prescription acne medications. Astringents are usually not needed, but may be helpful for teenagers with very oily skin.

6. What about Retin A, benzoyl peroxide, and topical antibiotics?

Retinoids (Tretinoin [Retin A, Renova, or Avita], adapalene [Differin], and tazarotene [Tazorac]) are vitamin A–derived medica- tions and are some of the most effective acne medications that we have. They come in cream or gel forms. Retinoids gently exfoliate the dead skin cells and prevent the first step of acne formation, which is the plugging of the pores. By keeping the pores open, pimple formation is prevented. Retinoids are effective for all types of acne lesions. Like most acne medications, they are best used on a consistent basis on the entire acne-prone area (rather than spot-treating individual pimples only). Using the medication on all acne-prone areas helps to prevent future pimples from forming. Retinoids work well alone or in combination with other therapies but should be applied sparingly and no more than once daily to limit dryness and irritation, which are common side effects. Because they can make the skin more sensitive to the sun, sunscreens and sun protection should be used. They should not be used by teens who are pregnant.

     Benzoyl peroxide is another standard acne therapy. Like the retinoids, it is effective for all types of acne lesions and may be used alone or in combination with other therapies. It has antibacterial as well as antiplugging effects. Benzoyl peroxide is available as a wash or as a leave-on topical (a cream or gel applied to the skin). Dryness is a common side effect and can usually be prevented by applying a gentle moisturizer and stopping the medication for a few days. Some individuals may develop a skin allergy to this medication, so if severe redness or irritation develop, you should consult your child’s doctor. Benzoyl peroxide may bleach clothing, towels, or bedding.

     Topical antibiotics decrease the acne-causing bacteria (Propionibacterium acnes) on the skin but have no effect on plugging of the pores. They work best for inflammatory acne (red bumps, pus bumps, and cysts). It is best not to use topical antibiotics alone as a single therapy. Using topical antibiotics in combination with a retinoid or benzoyl peroxide improves the effectiveness of the medications and makes it less likely that the acne bacteria will develop resist- ance to the antibiotic over time.

7. What about oral antibiotics?

For teenagers with severe inflammatory acne that does not respond to topical therapy alone, oral antibiotics can be very helpful. As with topical antibiotics, oral antibiotics do not prevent plugging of the pores, so they are not helpful for non inflamed acne lesions, such as black- heads, and are best used in combination with a retinoid or benzoyl peroxide. They should not be used alone as the only acne therapy.

     The most commonly used oral antibiotic is the tetracycline family (tetracycline, doxycycline, or minocycline). In general, oral antibiotics are used for a period of several months until the acne is improved and can be controlled with topical medications alone, but use for longer periods of time may be required for some individuals. Courses of less than one month are generally not effective.

      These medications are usually well tolerated but can cause nausea if taken on an empty stomach. They can also cause sun sensitivity, so sun protection and sunscreen use is important when taking these medications. For females, taking any oral antibiotic can increase the likelihood of developing a vaginal yeast infection; signs of this include vaginal itching or irritation and a whitish discharge. Oral tetracyclines should not be taken if your child is pregnant. It is common for teenagers to prefer the convenience of oral antibiotics, so they may be tempted to stop their topical medications. For best results, it is very important that they continue using their other medications as prescribed.

8. What about Accutane (oral isotretinoin)?

Oral isotretinoin (Accutane) is the most potent medication currently available for acne. Because this medication can cause birth defects if taken by a pregnant female and because laboratory monitoring is required, this medication should be reserved for severe acne only. It is most effective for severe cystic or scarring acne that has failed to respond to at least three months of maximal combination therapy (oral antibiotic plus a topical retinoid and another topical medication). All patients must be entered into a registry by a physician registered to use this medication, and females must use two methods of birth control to prevent pregnancy. It is not effective for females with hormonal types of acne, such as acne related to polycystic ovary syndrome.

9. When should we consider a dermatologist?

If your child’s acne has not responded to over-the-counter therapy or to the medications prescribed by his or her primary care physician, consultation with a dermatologist would be recommended. If your child has severe or scarring acne, if severe acne runs in your family, or if your child develops significant acne at a very young age, you may want to consider seeing a dermatologist sooner.

10. When do you want to see my child again regarding this condition?

Because most acne therapies require a minimum of eight weeks to start working, follow-up two to three months after starting therapy is generally recommended. Earlier follow-up may be needed if prob- lems, such as irritation or other medication side effects, develop. A temporary worsening of the acne four to six weeks after starting treatment is not uncommon and is considered normal; medications should be continued, and the acne typically gets better over the next several weeks. 

UNDESCENDED TESTICLE(S)

Definition: When one or both testicles do not descend completely into the scrotum.

1. What caused this condition?

There are many theories as to what causes an undescended testis. Some include decreased intraabdominal pressure during the third trimester of pregnancy to push the testis from the abdominal cavity to the scrotum. Some feel that there may be a decreased amount of male hormone such as testosterone during the descent of the testis. However, there is no unifying theory or answer to the cause of undescended testes.

2. Is there a danger of sterility or any other problem as a result of this condition?

If the testicle is undescended only on one side, the fertility rate is the same as a normal population. If there is an undescended testis on both sides, the most current data suggests that fertility is only approximately 65 percent to 70 percent. Testis cancer risk is elevated in adult men who have a history of an undescended testis.

3. Will an operation be necessary to correct this condition and, if so, when?

If the testicle is not in the scrotum by approximately nine months of age, then an operation is necessary to position the testicle in the scrotum where it will grow and develop normally. If the testicle is nonpalpable (cannot be felt on examination of the body), then the operation is usually performed at approximately six months of age.

4. When do we need to consult a surgeon?

Generally if a child has an undescended testis, we would like to see the child at a time convenient for the family. Any time between two and six months of age is a good time to have a surgeon initially evaluate the situation.

5. Are there any medicines that can be used to help bring down the testicle(s)?

No.

6. Are there any danger signs that I should look for?

Yes. Most boys who have an undescended testis have a small hernia that coexists with the undescended testis. If there appears to be swelling or tenderness in the groin area suggestive of a bulge or hernia, then this would suggest that the surgery should be done immediately, as this type of hernia can potentially damage or cause loss of the testicle. Rarely an undescended testis can twist (testis torsion) and cause swelling and pain.

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

After discharge, we would like to re-examine the baby in two to three months. 

SEIZURES - NEONATAL

Definition: Convulsive fits or spasms during the first month of life.

1. What is a seizure?

A seizure is a clinical event (episode) that is the result of excessive activity of a group of nerve cells (neurons) in the brain. There are many different types of seizures (staring, turning the body to one side, jerking of the arms and legs, etc.). The type of seizure a baby has depends upon the baby’s age and the part of the brain that the seizure is coming from. Also, the cause of the seizure may determine the type of seizure a baby has.

2. What causes seizures in babies?

Anything that can cause the brain not to work normally can cause a seizure. Common causes in babies include not getting enough blood and oxygen to the brain, bleeding in the brain, infections of the brain, strokes (when the blood flow to a part of the brain is cut off), metabolic problems (such as low blood sugar or calcium), abnormalities in how the brain is formed, inherited problems, or drug withdrawal (such as if the mother used certain drugs or alcohol during the pregnancy especially on a regular basis). There are other less common causes as well.

3. How are seizures treated, and how effective is the treatment?

Treatment depends upon the cause of the seizure. For example, if the blood sugar is too low, giving sugar typically solves the problem. Sometimes it is necessary to give medication to stop the seizures. The more commonly used medications include diazepam (Valium), lorazepam (Ativan), phenobarbital, and phenytoin (Dilantin). The effectiveness of these medicines at stopping seizures is mainly dependent upon the cause of the seizures. Similarly, how long the baby will need to stay on the medication(s) is often dependent on the cause of the seizures.

4. Are there any side effects to the medicines used in the treatment?

Like any medication, there is always the possibility of side effects. In general, these medications are quite safe. The most common side effect is sleepiness (sedation). This will usually go away once the baby gets used to the medication (typically in three to seven days).

5. What potential harm can the seizures have, and can they cause brain damage?

Many times, it is the presence of brain damage (such as stroke, infection, bleeding in the brain, trauma, and malformations of the brain) that cause the seizures. In these cases, it is the underlying problem that causes brain damage, not the seizure. In some instances, however, especially if the seizures are very long (greater than fifteen to thirty minutes), or they are very frequent, they may cause brain damage.

6. What tests do we need to do to establish any possible underlying cause?

What testing your baby may need will be determined by the circumstances around your baby’s seizures. It is likely that your baby will have some blood and urine tests. If it is found that your baby has low blood sugar and giving your baby some sugar solves the problem, then no other testing may be needed. If the doctor is worried about infection, it is likely that he or she will do a spinal tap. If the blood tests are normal and there is not an obvious cause for the seizure, it is likely that your doctor will want to look at your baby’s brain, either with a CT or MRI head scan. Your doctor may also want to get a brain wave test (electroencephalogram or EEG).

7. Do you think that the seizures will recur, and what are the possibilities that my baby will outgrow them? 

Whether or not the seizures will recur is in large part due to the cause of the seizures. Babies that have had lack of blood or oxygen to brain, strokes, trauma, and conditions where the brain did not form normally tend to have seizures that can be hard to stop and often come back later in life. Babies that are normal except for a family history of seizures in early life or that have had low blood sugar or calcium as the cause of their seizures often do very well, and the seizures typically do not come back.

8. Do we need to consult with a neurologist?

This depends on the cause for the seizures. Babies that have low blood sugar or low calcium as the cause for their seizures do not typically need to be seen by a neurologist. When more serious conditions like stroke, trauma, abnormalities in brain formation, or lack of oxygen occur, follow-up with a neurologist is a good idea.

9. Are there any precautions we need to take when we go home, such as connecting my baby to an apnea monitor?

In most cases, unless there are complicating problems (breathing problems, swallowing problems, etc.), there is no need for special monitoring or precautions. Typically, treating your baby as you would any other newborn is all that is needed.

10. When do you wish to see my child again regarding this condition following discharge?

When your baby needs to return for follow-up will be dependent on the cause of your baby’s seizures. Normally, we will see your baby two weeks after discharge from the hospital. If you see a neurologist in the hospital, he or she will arrange for follow-up if needed. Many times, if follow-up is required, he or she will ask to see your baby one to three months after discharge, but again, this will be determined in large part by the cause of your baby’s seizures. 

RAPID BREATHING (Respiratory Distress Syndrome/Transient Tachypnea)

Definition: Rapid breathing in the early days of life due to immaturity of the lungs or

decreased absorption of fetal lung fluid.

1. What caused this condition?

Rapid breathing (tachypnea) is a sign of an abnormality in the lungs. Causes for the rapid breathing can be lung fluid that did not clear quickly (transient tachypnea of newborn), inadequate levels of a substance (surfactant) in the lungs that prevents them from collapsing (respiratory distress syndrome), or infection (pneumonia).

2. What is actually taking place in the lungs?

The lungs are stiffer than normal and have a decreased ability to get oxygen into the bloodstream and carbon dioxide out. In some cases, there may be gradual collapsing of the small air sacs that, as it progresses, makes the condition worse.

3. How does it differ from pneumonia?

Pneumonia is caused by an infection. This condition is caused by either too much fluid in the lungs after delivery or decreased amounts of a chemical that stops the air sacs in the lungs from collapsing.

4. What tests are needed to further define this condition?

Chest X rays are the main test, but many of these conditions can appear the same on chest X ray. Often the way the baby acts after several hours will determine whether there is just fluid or if there is collapse occurring. Since infection is always a concern, a blood count and blood culture are also almost always done. A blood gas to deter- mine how well the lungs are functioning is also frequently performed.

5. How dangerous is this condition, and can we expect a complete recovery?

If there is extra fluid only, the condition is mild, and the baby gener- ally starts to get better several hours after treatment. If there are decreased amounts of surfactant present, then the baby will most likely need some type of breathing support. Decreased surfactant is a more significant condition with potentially more complications and a longer need for treatment. In both conditions the affected newborn generally makes a complete recovery.

6. What kind of treatment will be needed, and are there any potential negative side effects from the treatment? 

In most cases either additional oxygen support and/or breathing support with a machine will be needed. An artificial form of the chemical to prevent lung collapse, surfactant, will be given to babies meeting levels of support to warrant its use. If artificial surfactant replacement is needed, then a breathing tube will be placed into the baby’s airway (trachea), and the chemical will be given directly into the lungs. The breathing tube may then be removed or kept in place and a form of breathing support will be started. This breathing support can either be through prongs that go in the baby’s nose or by a breathing machine (ventilator) attached to the breathing tube.

     As with any abnormality in the lungs and need for breathing assis- tance, a hole can develop in the lung(s) that allows air to escape from the lung into the chest cavity (pneumothorax). As this air accumulates, it may compress the lungs and cause further worsening of the breathing condition. Many of these leaks require a drainage tube (chest tube) placed into the chest to remove this trapped air. Occasionally, these leaks can also occur within the lungs (pulmonary interstitial emphysema), under the skin, or around the heart. These may require different drainage tubes or special ventilators to treat.

7. How long will my baby need to stay in the hospital?

Depending on the severity and whether it is excess fluid or low levels of surfactant, the baby may stay in the hospital from three days to several weeks. Infants with excess fluid and mild surfactant shortage respond quickly and will have shorter stays. In all cases, the breathing concerns have to be resolved and the baby feeding by mouth prior to going home.

8. Will the treatment or the disorder weaken the lungs in the future and predispose my baby to future respiratory tract problems?

In most babies that are close to their due date or at their due date there are minimal long-term effects on the lungs. The majority of these babies will have no further respiratory concerns.

9. Will I be able to stay in the hospital until my baby is fully recovered?

The usual hospital stay for a mother is two to four days, depending on the type of delivery. Babies with excess fluid have a better chance of being able to be discharged with the mother. Mothers of infants with surfactant immaturity will most likely be discharged prior to the baby’s recovery.

10. Will any treatment be needed at home following discharge, and, if so, who will help me administer it?

It is unusual for babies that are not very premature to require any treatments after discharge. More premature babies may require supplemental oxygen, intermittent breathing treatments, or rarely, additional breathing support. Parents of babies with these needs will be trained prior to discharge and often spend one to two days and nights in the hospital with their baby prior to discharge. Sometimes a home nurse may assist or check in regarding the care of the baby after discharge.

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

Most babies with breathing issues that require them to be transferred to the neonatal intensive care unit will be cared for by a neonatologist. Pulmonary specialists are generally consulted near discharge if the baby is going to require breathing support at home.

12. Is this hospital capable of dealing with this disorder, or does my baby need to be transferred to another hospital that is more capable of dealing with difficult illnesses?

This depends on each hospital’s capabilities and pediatrician’s comfort level in treating sick newborns. Many smaller hospitals will attempt to take care of babies with excess fluid that just need additional oxygen and are stable or improving. If the baby’s condition is getting worse and breathing support is needed, that is generally done at larger hospitals that have special areas called neonatal intensive care units (NICUs) and neonatologists (newborn specialists).

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

This is dependent on the age of the baby at birth. If the baby was near its expected birth date, then usually care with the pediatrician is needed. The more premature the baby was will increase the potential need for pulmonology and developmental specialty care. 

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. 

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. 

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. 

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. 

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.