Mohamed Khashaba, MD

Professor of Pediatrics /Neonatology

Director of NICU

Mansoura University
 )Case )1
A 38-week gestation baby with a birth
weight of 3.2 kg developed cyanosis and
respiratory distress at 15 min of life.
He was ventilated and put on IV
dextrose infusion and was pink and stable
on ventilator.

M.Khashaba,MD professor of Pediatrics,Mansoura

 Ventilator settings – pressure 20/3
 Inspiratory time- 0.4 sec
 Ventilatory rate – 40/min

M.Khashaba,MD professor of Pediatrics,Mansoura

 ABG was done about 20
minutes after ventilation
showed:
pH – 7.3

PO2 – 60 mm Hg (7.8 k Pa)

PCO2M.Khashaba,MD
– 35 mmprofessor
Hg (3.9 k Pa)
of Pediatrics,Mansoura
 The baby was pink, but at 10
hours of life the baby suddenly
became blue and limp. Management
was instituted and within 5 minutes
he was back to his activity again.

M.Khashaba,MD professor of Pediatrics,Mansoura

 Give 4 possible causes for the
sudden deterioration of the infant.

M.Khashaba,MD professor of Pediatrics,Mansoura

 DOPE
 D-dislodged tube
 O-Obstructed tube
 P-Pneumothorax
 E-Equipment malfunction

M.Khashaba,MD professor of Pediatrics,Mansoura

 )Case )2

A 4-day-old, exclusively breast fed

baby was noted to be pale, with heart rate
of 180 with gallop rhythm, palpable liver
of 2 cm and black sticky stools.

M.Khashaba,MD professor of Pediatrics,Mansoura

 Baby was born in an ambulance, from
where she was transferred to post-natal
ward.
Pregnancy was uneventful, but
delivery was quick. This was mother’s
fourth child.
Baby was discharged home after 24
hours
M.Khashaba,MD professor of Pediatrics,Mansoura
A. What 2 investigations would you do
to establish your suspected diagnosis?
B. What is the first therapeutic
intervention would you undertake ?
C. What is the diagnosis ?

M.Khashaba,MD professor of Pediatrics,Mansoura

A. CBS, Coagulation study.
B. Blood transfusion,Fresh
frozen plasma.
C. Hemorrhagic Disease of
Newborn.

Clue: exclusive breast fed

baby.
Fresh frozen plasma and not
vitamin K is effective to stop
M.Khashaba,MD professor of Pediatrics,Mansoura
 )Case )3
A 6-month-old girl presents with
two-month history of failure to
gain weight and dehydration.
 Sodium – 128
 Potassium – 3.2
 Urea – 7
 Bicarbonate – 11
Which single investigation is
urgently needed?
M.Khashaba,MD professor of Pediatrics,Mansoura
 Serum 17-
hydoxyprogesterone assay
 Salt losing crisis with
acidosis is a common feature
of Congenital Adrenal
hyperplasia.
M.Khashaba,MD professor of Pediatrics,Mansoura
 )Case )4
A 1 1/2 -year-old child presents with
mild diarrhea and not putting on
weight.
 Na – 128
 K – 3.5
 Cl – 98
 HCO3 – 11
 Urea – 24
 Serum osmolality – 330
What other biochemical investigations
M.Khashaba,MD professor of Pediatrics,Mansoura
you need urgently?
Blood sugar
Diabetic ketoacidosis is
the likely diagnosis.

M.Khashaba,MD professor of Pediatrics,Mansoura

Serum osmolality in mOsm/kg =
[Serum Na+ (mEq/L) + K + (mEq/L) χ 2] +
Glucose mg/dL BUN mg/ dL
+
18 3

M.Khashaba,MD professor of Pediatrics,Mansoura

 )Case )5

M.Khashaba,MD professor of Pediatrics,Mansoura

 Nevus flammus in the region of 1st
branch of Trigeminal nerve is usually
associated with cortical brain lesion
(ophthalmic area).
Brain imaging & eyes evaluation are
required.

Sturge Weber
syndrome
M.Khashaba,MD professor of Pediatrics,Mansoura
 )Case )6

M.Khashaba,MD professor of Pediatrics,Mansoura

 Pilonidal dimple &
sinus
Dimple: Depression in the skin.
Sinus: Connected to deeper structures in
sacral area.
Cyst: Forms at puberty when hair grows in
the depth of the sinus occasionally gets
infected & needs excision.
M.Khashaba,MD professor of Pediatrics,Mansoura
 )Case )7

M.Khashaba,MD professor of Pediatrics,Mansoura

Preauricular Sinus &
tag
Remnant of the first
branchial cleft.
In the most anterior upper
portion of the tragus of
external ear.
An isolated anomaly , may be
bilateral.
No treatment except
M.Khashaba,MD professor if
of Pediatrics,Mansoura
infected
 )Case )8

M.Khashaba,MD professor of Pediatrics,Mansoura

 Sucking blisters
 Present at birth
 Usually on a hand or wrist
 Prenatal U/S: fetus sucks in
utero any part that comes easily
to his mouth

M.Khashaba,MD professor of Pediatrics,Mansoura

 )Case )9

M.Khashaba,MD professor of Pediatrics,Mansoura

 Subcutaneous Fat
Necrosis
 More common in Asphyxiated
babies
 Multiple firm non-tender
subcutaneous nodules or large
plaques that appear one to four
weeks after birth.
 Commonly affect the cheeks,
buttocks, back, and limbs.
 It often occurs over bony
M.Khashaba,MD professor of Pediatrics,Mansoura
prominences. The anterior trunk
 Subcutaneous Fat
Necrosis
 The overlying skin may be
erythematous.
 Lesions may become fluctuant
as fat liquefies; some become
calcified.
 It usually resolves completely
within 1-2 months, although it
M.Khashaba,MD professor of Pediatrics,Mansoura
may persist up to 6 months,
)Case )10
 Fever in a 1 month
aged baby
A 1- month- old infant was
brought to the physician by his
parents because of a fever 38c
)taken rectally) earlier that
morning. He had no associated
symptoms of cough, runny nose,
vomiting, diarrhea, or unusual
fussiness. He was bottle-fed ,
and his mother had noticed that
he was taking a little less than
M.Khashaba,MD professor of Pediatrics,Mansoura
usual. His urination had
 The obstetrical and birth
histories were unremarkable,
and infant had been well until
now. The parents had been
about to leave town to visit
relatives for their summer
vacation but changed their
plans.
M.Khashaba,MD professor of Pediatrics,Mansoura
1. Are there any other questions
the physician should ask the
parents while taking the
history?
 Exposure to illness in the family
and other contacts.

M.Khashaba,MD professor of Pediatrics,Mansoura

1. What should be the physician’s
issue of concern?
 Whether the infant may have a
serious bacterial infection,
particularly bacteremia or
meningitis.
 How to proceed with the
patient’s management while
attempting to exclude
M.Khashaba,MD professor serious
of Pediatrics,Mansoura
Physical Examination
The infant’s rectal
temperature in the office was 38
c. Other vital signs were normal.
He was slightly fussy on
examination. His color was good,
and he did not seem to be in
severe distress. The anterior
fontanelle was soft. Tone, cry,
and suck were normal, and
Moro’s reflex professor
M.Khashaba,MD was intact.
of Pediatrics,Mansoura
Physical Examination

The rest of the examination,

including head, eyes, ears, nose,
throat )HEENT), neck, heart,
lungs, abdomen, extremities,
skin, and external genitalia,
were unremarkable.

M.Khashaba,MD professor of Pediatrics,Mansoura

1) What are your management
options?
 Admit the patient, perform a septic
workup, and initate antibiotic
therapy pending the results of the
septic workup.
 Admit the patient, perform a septic
workup, and observe the infant in
the hospital.
 The M.Khashaba,MD
parents may observe
professor the infant
of Pediatrics,Mansoura
at home with close follow-up.
1. What laboratory tests or studies
should be ordered to exclude a
serious bacterial infection, including
bacteremia and meningitis?
 A complete blood count, urinalysis,
urine culture, blood culture, lumbar
puncture, and chest x-ray included
if the infant has respiratory
symptoms and signs.
M.Khashaba,MD professor of Pediatrics,Mansoura
1. What bacterial pathogens are likely
to be encountered in a 1-month-old
infant with sepsis or bacterial
meningitis or both?
 Group B streptococci, listeria
monocytogenes, and Ecoli are the
pathogens most often encountered
in neonates.

M.Khashaba,MD professor of Pediatrics,Mansoura

1. Which antibiotic should be chosen
for initial coverage and why?
 Intravenous ampicillin and
gentamicin

M.Khashaba,MD professor of Pediatrics,Mansoura

 Low risk criteria
 Absence of infection in the
Bone,joint
 No major respiratory or
cardiovascular problems.
 WBC 5000-15000/mm3.
 Band count < 1500/mm3
 Normal urine analysis.

M.Khashaba,MD professor of Pediatrics,Mansoura

 )Case )11
A male baby was born as
preterm. He was delivered
vaginally. The birth weight of
the baby was 1.4kg.
Gestational age corresponded
to 32 weeks. The Apgar score
was 4 at one minute and 6 at
five M.Khashaba,MD
minutes.professor of Pediatrics,Mansoura
 He developed RD and was
referred to neonatal
intensive care unit . He
started improving without
assisted ventilation.
Standard low birth weight
formula feed was given on
third day of life.

M.Khashaba,MD professor of Pediatrics,Mansoura

 On the eighth day, distension of
the abdomen was noted. Abdomen
was painful on palpation. Feeding
chart showed the presence of 5 ml
of residual milk from the last
feeding.

Nurse in charge noticed that

higher incubator temperature was
required to maintain body
temperature.
M.Khashaba,MD professor of Pediatrics,Mansoura
 A low birth weight baby was
lying sick in the incubator.

Features of IUGR were present.

There was distension of the
abdomen. Anthropometric
measurements included the length
45 cm (3rd centile), the weight 1.3
kg, and the head circumference
was 32 cm.
M.Khashaba,MD professor of Pediatrics,Mansoura
 Activity of the baby was not
satisfactory. He was a febrile.
The heart rate was 130 per
minute. The respiratory rate was
40 per minute. The blood
pressure recorded was 50/40
mm Hg.

M.Khashaba,MD professor of Pediatrics,Mansoura

 Abdomen examination
revealed mild distension and
mild tenderness. Bowel sounds
were sluggish. No organomegaly.
Other system examination were
normal.

M.Khashaba,MD professor of Pediatrics,Mansoura

Hemoglobin : 14g/dl
TLC : 20.000 cells/cu mm
DLC : P88 L28 E2 M2 B0
Blood c/s : Sterile
Urine c/s : Sterile
Stool c/s : Sterile
BT : 6 min (1-6 min)
CT : 5 min (4-8 min)
Platelet count : 4.00.000 cell/cu m
Peripheral blood smear: normal picture with
leucocytosis
M.Khashaba,MD professor of Pediatrics,Mansoura
Serum electrolytes: Na: 120 mEq/L
K: 4 mEq/L
Cl: 98 mEq/L
Arterial blood gases: PH: 7.1
PaO2: 45 mm of Hg
PaCO2: 35 mm of Hg
HCO3: 16 mEq/L
Erect abdomen X-ray: Shows
pneumatosis
intestinalis
M.Khashaba,MD professor of Pediatrics,Mansoura
 Up to 12% of VLBWt babies are
afflicted with definite NEC
 Significant morbidity
 Financial impact
 Important cause of death in preterms
beyond 1st week.

M.Khashaba,MD professor of Pediatrics,Mansoura

 Typical Presentation

Preterm in the 2nd – 3rd week of

life & began feeding

M.Khashaba,MD professor of Pediatrics,Mansoura

 Factors Implicated in
NEC

A. Mucosal Injury
B. Formula feeding
C. Infection

M.Khashaba,MD professor of Pediatrics,Mansoura

 Mucosal Injury
1. Ischemic Damage
• Fetal distress
• Perinatal asphyxia
• RDS
• Hypothermia
• Vascular spasm
• Exchange transfusion
M.Khashaba,MD professor of Pediatrics,Mansoura
 Bowel Ischemia

May be an end result of injury

rather than the initiating factor.

M.Khashaba,MD professor of Pediatrics,Mansoura

 Feeding
Factors involved include:
1. Timing of initiation
2. Rapidity of advancement
3. Type of milk (breast versus
formula)

M.Khashaba,MD professor of Pediatrics,Mansoura

 Infection

• E Coli
• Klebsiella
• Pseudomonas
• Salmonella
• Clostridium
 Risk Factors

Preterm birth is the over-

whelming risk factor

M.Khashaba,MD professor of Pediatrics,Mansoura

 Why in Preterms
1. Decreased gastric acid secretion
2. Immaturity of digestive enzymes.
3. Decreased mobility & incomplete
innervation
4. Immature epithelial barrier
5. Immature immune function

M.Khashaba,MD professor of Pediatrics,Mansoura

 Clinical features
 Onset usually in 1-2 days
 Main features
 Unstable temperature
 Abdominal distension

 Abdominal tenderness

 Low blood pressure

 Bradycardia

 Disseminated intravascular
coagulation
M.Khashaba,MD professor of Pediatrics,Mansoura
 Abdominal Radiographs
 Dilated loops
 Pneumatosis intestinalis
 Portal venous gas
 Perforation

M.Khashaba,MD professor of Pediatrics,Mansoura

 Lab- Studies
 May be normal
 May show abnormal neutrophil
count, thrombocytopenia or acidosis

M.Khashaba,MD professor of Pediatrics,Mansoura

 Differential Diagnosis
 Septicemia
 Meconium plug syndrome
 Malrotation
 Hirschsprung disease

M.Khashaba,MD professor of Pediatrics,Mansoura

M.Khashaba,MD professor of Pediatrics,Mansoura
M.Khashaba,MD professor of Pediatrics,Mansoura
M.Khashaba,MD professor of Pediatrics,Mansoura
M.Khashaba,MD professor of Pediatrics,Mansoura
 Management
 All oral feeds should be stopped.
 Relief gastric distension
 Total parentral nutrition started
 Control of electrolyte & acid-base
balance
 Management of hemodynamic
disturbances
 Plasma or platelet transfusion as
needed
 Combination Antibiotics
M.Khashaba,MD professor of Pediatrics,Mansoura

1. Gastro Intestinal perforation
 Occur in 20-30% of babies
 Onset early 10-48 hrs after onset
2. Peritonitis
 Ascites
 Abdominal mass
 Abdominal wall erythema
 Induration

M.Khashaba,MD professor of Pediatrics,Mansoura