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. 

INTESTINAL INFLAMMATION (Necrotizing Enterocolitis)

Definition: An acute inflammation of the inner lining of the bowel with the presence of

membrane-like areas and superficial ulcerations. Also called NEC.

1. What caused this condition?

In most cases, the baby was born early or premature and has been given some type of feeding. The lining or barrier of the intestinal tract has been injured, and this injury has allowed bacteria to get into the wall of the intestine. The bacteria cause an infection, injury, or weakness to the intestinal wall and an inflammatory reaction in those areas.

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

The confirmatory signs of necrotizing enterocolitis (NEC) are seen on X rays of the abdomen. When NEC is suspected, a culture (test for bacteria in the bloodstream), a complete blood count (CBC), and a test to determine the level of inflammation (CRP) may also be performed on the infant’s blood. A series of X rays of the abdomen and blood are done for several days to monitor this condition. A consultation with a pediatric surgeon may also be requested.

3. What potential dangers does NEC pose?

NEC is a serious concern and will cause some setback in the baby’s condition. There are “mild” causes of NEC involving a limited portion of the intestine that improve in twenty-four to forty-eight hours of starting treatment. There are other cases of NEC that involve extensive areas or all of the intestine and are progressive. These cases require surgery with possible removal of intestine and are life threatening. When all of the intestine is involved, there may be no treat- ment possible, and it is then a fatal condition.

4. What is the treatment for NEC, and how long will it take for my baby to recover?

The treatment for NEC is stopping any feedings, starting antibiotic therapy, administering medications to stabilize the blood pressure and blood components (e.g., platelets and plasma) to prevent bleeding, and supporting breathing. Often a pediatric surgeon will be requested to evaluate the baby. Monitoring with repeat X rays of the abdomen, blood testing, and physical examinations are performed, often as frequently as every six hours. A surgery is needed if a hole (perforation) occurs in the intestine or if the baby is not getting better. If surgery is performed, frequently a section or sections of intestine may be removed and the ends of the intestine brought up to and through the abdominal wall. The surgeon may decide to place a piece of rubber drain in the abdominal space if the infant is unstable and will not tolerate a major operation. The length of recovery may vary from ten to fourteen days in the cases that respond to medicines, to a prolonged (years long) dependence on IV fluids in cases where there has been extensive involve- ment or removal of intestine.

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

There are many side effects that are related to the infection and inflammation from the NEC. Several of the antibiotics used to treat the infection require blood levels to be monitored and may result in some hearing loss if too high (due to toxic effects of the antibiotics on the nerve function within the inner ear). Breathing failure, kidney failure, low blood pressure, and bleeding problems are common issues that occur with NEC. When needed, surgery may be performed in a less than stable situation. Blood and fluid losses due to bleeding abnormalities and inflammation may further worsen the situation. Decreased blood pressure and flow could also cause injury to the brain. The baby may need prolonged IV nutrition, which could lead to liver injury, a need for stable IV access, and subsequent infections of the bloodstream. A complication that may occur four to six weeks after the infant recovers is a narrowing in the intestine that requires surgery to correct.

6. Is it possible that this condition could get worse?

When NEC is first suspected or diagnosed, it is difficult to predict if it will respond or progress despite adequate treatment. Close observation of the baby is needed in the first twenty-four to forty-eight hours after beginning treatment. Often the condition does get more serious before improving.

7. Do we need to consult a neonatologist (newborn specialist) or gastroenterologist (specialist of the digestive system)?

Neonatologists should be consulted and assist in or assume the care of a baby with NEC or suspected NEC. A pediatric surgeon is often consulted as well. A gastroenterologist is generally not required during the critical period and may become involved after recovery if the baby is not able to grow on feedings or if concerns of liver injury from long- term IV nutritional support is present.

8. Will I be able to breastfeed my baby during this illness?

No. The stoppage of any feeding, breast or formula, takes place when NEC is suspected or confirmed. Resting of the intestinal tract and antibiotics are the main therapies for NEC. The baby may not be able to feed for a minimum of seven days in suspected NEC. If NEC is confirmed, a minimum of ten to fourteen days is required.

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

If a narrowing in the intestinal tract is suspected or if there is evidence of an intestinal blockage, an X ray test with dye and consultation with a surgeon will be necessary. If there are continued issues regarding how well the infant is able to digest and absorb feedings or if the infant is sent home on IV nutrition, then a gastroenterologist may be necessary. Attention to developmental issues is also important. 

HYPOSPADIAS

Definition: When the opening normally at the end of the penis is located on the undersurface of the penis.

1. What caused this condition to occur?

There are multiple possible causes with genetic, environmental, and hormonal factors influencing development of the penis. No one is certain as to the exact cause of this condition. The incidence of hypospadias has been increasing worldwide over the past few decades. The incidence is approaching 1 percent of newborns.

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

Typically, the diagnosis is made on physical examination of the newborn. The majority of boys with hypospadias will need no further evaluation to help plan a treatment course. If your child has an undescended testicle along with hypospadias, blood testing to evaluate for an endocrine problem or other developmental conditions should be performed. Some cases of severe hypospadias may also require such testing. It is not recommended to perform newborn circumcision in patients with hypospadias as the foreskin may be useful in reconstruction at a later date.

3. What kind of symptoms or problems can occur as a result of the condition?

The penis has basically two functions: urination and sex. Children with uncorrected hypospadias may be impacted in either or both of these categories. Penile curvature (chordee) associated with hypospadias may make penetration painful or difficult to achieve. Depending on the location of the urethral opening, urinating while standing may be impossible to perform without significant spraying and deflection of the urine stream. If the hypospadia is corrected, there should be no future problems in either area.

4. Will it need to be corrected? If so, when and how?

Almost all cases of hypospadias require surgical treatment, although some of the most minor hypospadias may not require any intervention. Many pediatric urologists will recommend surgery to be performed after four months of age. There are over two hundred described techniques that are used for hypospadia repairs. Your physician will discuss the technique that will be best suited for your son’s particular anatomy. There has been much advancement in technique over the past years, and now hypospadia repair is almost always done as a day surgery on an outpatient basis.

5. Do we need to see a urologist and, if so, when?

The timing of urologic consultation is up to you and your pediatrician. Hospital consultation may be warranted if there are concerns or uncertainty about the diagnosis. Otherwise, outpatient consultation is completely appropriate and can be performed anytime between zero and two months of age.

6. Is there a possibility that there will be a problem later on in sexual or urinary function?

As discussed above in question #3, there can be impact on both sexual or urinary function in patients with hypospadias. If the problem is corrected early in life, it is unlikely that there will be any future issues in either of these areas.

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

After the initial consultation with your urologist, either scheduling for correction or a follow-up visit for your child at around two months of age may be recommended. This will be influenced by the degree of hypospadias and any other medical issues that your child may have. 

HYPOGLYCEMIA

Definition: Low blood sugar.

1. What caused this condition to occur?

Hypoglycemia occurs when the baby’s blood sugar (glucose) is low, with a measure that is less than 40 mg/dL to 45 mg/dL. Low blood sugar is due to a disruption or abnormality in the baby’s blood sugar regulatory system and is most common in the first two hours after birth. Much of the time, it is corrected with early feeding and continued monitoring for the first twenty-four hours. Babies born to mothers with diabetes or babies that are large for their age may have a more significant decrease in the blood sugar levels and need monitoring of the blood sugar level for several days. In rare cases, severe and quite prolonged low–blood sugar levels may require surgery, special diet, and/or medication.

2. Is hypoglycemia dangerous, and will it have any permanent impact on my baby’s health?

In the majority of cases, when brief and treated promptly, there are no permanent effects of low blood sugar on the baby. However, untreated or prolonged blood sugar levels may lead to brain injury.

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

In most cases, a simple measurement of the blood sugar level by a machine at the bedside is all that is necessary. Sometimes a confirmation of the low measurement by the bedside machine will need to be performed. This is done by collecting a small amount of blood from the baby and sending it to the laboratory. In the rarer cases of severe and prolonged low blood sugar, blood levels of various hormones may be needed and may take several days to return.

4. How are we going to treat it, and are there any side effects that might occur from the treatments?

In most cases, the low blood sugar level is treated with either feedings alone or in combination with intravenous (IV) sugar solutions. Infrequently in more severe cases, medications may be also given either as an IV or by mouth. There are generally no side effects.

5. How long will the condition take to correct?

In infants that are born to mothers without diabetes and are normal size for their age, normal blood sugar levels will generally be obtained within three to six hours of birth and monitoring may continue for up to twenty-four hours. In infants that are born to mothers with diabetes or are large for their age, the ability to maintain normal blood sugar levels without treatment and monitoring may take three to five days or longer.

6. Is there a chance the condition might come back following discharge from the hospital, and is there any special need for follow-up?

As long as the baby is feeding normally, the vast majority of babies will not have any recurrence of low blood sugar, and no special follow- up is needed. In the rare cases of severe and prolonged low blood sugars where surgery, medications, and/or a special diet has been required, those infants will need continued monitoring at home and follow-up with pediatric endocrinologists, doctors that specialize in disorders of hormone levels or metabolism.

7. Does hypoglycemia predispose my baby to developing diabetes or any other sugar metabolism disorder later in life?

Infants born to long-standing diabetic mothers may have a genetic predisposition to developing diabetes. Infants born to mothers with high blood sugars during the pregnancy or mothers with later onset diabetes are not at an increased risk for developing diabetes later in life, but may be at higher risk to be obese in the preteen and teenage years.

8. Will future babies that I might have be more inclined to have hypoglycemia? Is there any precaution that I can take to prevent it from happening again?

Mothers that have high blood sugars or diabetes, either when not pregnant or just when pregnant, will continue to have infants that are at higher risk for low blood sugars after birth. Monitoring of blood sugars during pregnancy as needed and maintaining good control of the blood sugar levels prior to and during the pregnancy will decrease the risk of the infant.

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

In the large majority of babies, there is no need for special follow-up. Babies should have demonstrated that they can maintain normal blood sugar levels for a period of time prior to discharge and are expected to continue to do so. 

HEART DISEASE - CONGENITAL

Definition: Abnormalities of the heart or conduction system that occur at birth.

1. What is wrong with my baby’s heart, and what problems does the defect cause?

A congenital heart defect is a birth defect of the heart. Many different types of defects exist. The most common type of defect is a hole in either the upper or lower wall of the heart. Both of these defects result in an excess amount of blood flow to the lungs. Other defects include abnormalities with the heart valves, resulting in the heart muscle having to work harder than normal to pump blood to the lungs or body.

2. Is the condition potentially dangerous?

Many congenital heart defects are minor and present no significant risk whatsoever to the child. However, some types of defects can be dangerous or even life threatening.

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

The most common test is an echocardiogram. This test uses sound waves to visualize the structures of the heart. In almost all cases, a clear diagnosis can be made based on the findings of an echocardiogram. Other tests that are often performed include pulse oximetry (checking the oxygen level in the blood), electrocardiography (assessing the heart’s electricity), and a chest X ray to visualize both the heart and lungs.

4. Will my baby need surgery, and is the condition correctable?

The majority of congenital heart defects are minor in nature and require no specific treatment whatsoever. More serious defects may require surgery. Fortunately, in this day and age almost all congenital heart defects are correctable with surgery and have excellent outcomes.

5. Will any heart medicines be needed to treat this problem?

Most minor congenital heart defects do not require any medications whatsoever. More significant defects may require medications. Typically, medicine is used either to improve the pumping function of the heart or to relieve the lungs of any excess fluid.

6. Do we need to see a pediatric cardiologist and, if so, when?

Your pediatrician will determine whether it is necessary to see a pediatric cardiologist. Some types of minor congenital heart disease may not require a referral to a specialist. However, if a more significant heart defect is suspected, usually a referral is made at that time.

7. Will my baby become blue (cyanotic) from this condition?

Certain types of heart defects result in a blue appearance to the skin, termed cyanosis. This blue appearance results from an inadequate amount of oxygen in the blood, usually due to the blood failing to pass from the heart to the lungs. Blood with a normal amount of oxygen has a red or pink appearance to it, but blood lacking oxygen is blue. In general, heart defects resulting in cyanosis are fairly unusual and are usually noticed at or shortly after birth.

8. After I leave the hospital, what danger signs do I look for that would indicate that my baby is having a problem related to this condition?

Rapid breathing is one sign that might indicate a potential heart problem in a baby. This is usually caused by excessive blood flow to the lungs, although occasionally it may be due to a lower than normal oxygen level in the bloodstream. Other signs that might indicate a potential heart problem in a baby would include unusual color changes, such as a bluish or pale appearance to the skin, poor appetite, or unusual irritability.

9. Do I need to limit my baby’s activities in any way after we go home?

Most babies diagnosed with heart problems do not need any limitation on their activities whatsoever. However, check with your doctor as the recommendation may vary based on the seriousness of your child’s heart condition.

10. After discharge from the hospital, when do you wish to see my baby again concerning this condition?

Usually, follow-up will be determined by the type of heart condition that your baby has been diagnosed with. Minor heart defects may only require reassessment at routine visits. More significant heart conditions may require more frequent checkups. 

CLUBFOOT

Definition: A type of structural deformity of the foot present at birth.

1. What caused this condition to occur?

“Clubfoot” is a term that describes a complex, abnormal structural alignment of the bones and joints of the foot and ankle. It most likely represents abnormal development of many tissue types below the knee. The exact cause of clubfoot is still debated. It is likely caused by multiple factors, including genetic and environmental factors. Proposed theories of the cause of clubfoot include molding of the foot while still in the womb (in utero molding), primary muscle problems, primary bone deformity, primary blood vessel lesion, intrauterine viral infection, primary nerve lesion, and abnormal stiffening of the tissues. The actual cause is likely a combination of these factors.

2. What exactly is structurally wrong with the foot?

The appearance of clubfeet are created by both the malalignment of the bones at the joints and the altered shape of the bones. In addition, the muscles, ligaments, tendons, and connective tissue (fascia) of the foot and ankle are contracted, or shortened. The result is a rigid foot that is turned downward and inward.

3. How is it treated, and how successful is the treatment?

The goal of treatment is a painless, flexible foot that strikes the ground in proper position when walking. Regardless of the severity or rigidity, the initial treatment is nonoperative, using repeated sequen- tial castings, also called “serial castings.” The goal of this kind of treat- ment is to limit the amount of surgery required.

Nonoperative treatment involves weekly serial castings to promote gradual correction of the foot over six to eight weeks. Following this casting regimen, nearly all children require a short outpatient surgical procedure to fully correct the foot. Then a special brace is worn full time for eight to nine months and part time for two to three years. The ability to completely correct the clubfoot deformity depends on each child’s unique initial severity and rigidity, the age at which treat- ment is started, the skill of the orthopedic surgeon, and the definition of complete correction. Although the position of the foot may be dramatically improved with treatment, nearly all patients with clubfoot have a difference in calf size, foot size, and possibly overall limb length compared to unaffected limbs. Eighty percent of children have a pain- less functional foot following serial manipulation and casting.

4. Will my child be able to walk and exercise normally following treatment?

Most children who undergo successful nonoperative treatment are able to walk normally. Because this is an abnormality of most of the tissues below the knee, some difference between normal limbs will always be observed. In a fully corrected foot, light exercise is generally well tolerated.

5. Do you think that there will be any limitations or disadvantages athletically because of this condition? Again, the goal of nonoperative treatment is a painless, supple, prop- erly positioned foot. Generally, there is some residual stiffness and weakness compared to normal limbs. Depending on the initial severity and degree of correction achieved and maintained, there will likely be some degree of limitation athletically.

6. When do we need to see an orthopedic surgeon?

Consultation with a pediatric orthopedic surgeon should take place when the diagnosis is made. Serial manipulation and casting should be initiated as early as possible, preferably within the first week of life.

7. After discharge from the hospital, what kind of follow-up will be needed for this condition?

If consultation with your pediatric orthopedic surgeon did not occur prior to discharge from the hospital, your child should be seen in the office in the first week of life. Weekly follow-up visits for manipulation and casting will be necessary for the first six to eight weeks. Periodic follow-up will be necessary throughout childhood.