Neonatal Problems ================= þ Neonatal illness - an inborn error of metabolism (IEM) should be considered in a previously normal neonate with acute clinical deterioration. Conversely, the presence of infection does not exclude the possibility of IEMs, because these patients frequently deteriorate and become septic quickly. Standard laboratory values, particularly blood ammonia, electrolytes, and urinalysis can be helpful in further classifying the IEM and tailoring treatment in the emergency department. - Treatment for IEMs consists of general measures as well as specific medications if a probable type of IEM is suspected. Unless the infant has a known IEM and is already on a special formula, all dietary intake should be withheld and feedings reintroduced after consultation with a specialist. Intravenous fluid containing dextrose may be indicated, particularly if a urea cycle defect is suspected, because stimulating endogenous insulin will minimize protein catabolism and ammonia production. After appropriate fluid boluses of normal saline to correct shock, most IEMs can be managed with a standard intravenous fluid consisting of 10% dextrose in one-fourth normal saline at 1.5 times maintenance. Metabolic acidosis unresponsive to intravenous fluids should be treated with sodium bicarbonate boluses of 1 to 2 mEq/kg. Although controversial for other diseases, bicarbonate use for IEMs is indicated, but standard calculations of bicarbonate requirements will underestimate actual needs owing to ongoing production of acidic metabolites [28,30]. Correction of severe acidosis will often require large doses of bicarbonate, up to 20 mEq/kg in some organic acidemias [31]. Liberal use of bicarbonate should be performed in consultation with a metabolic specialist. The rapid removal of toxins may be life-saving in some cases, particularly with severe hyperammonemia. An ammonia level greater than 120 mmol/mL in a newborn is considered neurotoxic. Hemodialysis to remove excessive ammonia is more effective than peritoneal or other extracorporeal routes. [Kwon KT, Tsai VW. Metabolic emergencies. Emergency medicine clinics of North America 2007;25:1041-60, vi.] Neonatal Thyroid Storm: Neonatal hyperthyroidism and thyroid storm have many therapeutic options. Beta-adrenergic blockade can be achieved with propanolol in a 0.01 mg/kg/dose intravenously and titrated to clinical effect; alternative oral dosing is 2 mg/kg/d in three to four divided doses. Thyroid hormone synthesis can be blocked using propylthiouracil, 5 to 10 mg/kg/d, or methimazole, 0.5 to 1 mg/kg/d, both in three divided oral doses. Iodine can be given in the form of Lugol’s solution (8 mg iodine/drop), 1 to 3 drops daily. Iodine should be started at least 1 hour after administering an anti- thyroid drug like propylthiouracil to avoid increasing thyroid gland stores before the anti-thyroid effect occurs. Glucocorticoid treatment with hydrocortisone or prednisone may also be helpful in severe cases, because it inhibits thyroid hormone release and decreases peripheral conversion of T4 to T3. þ Derm/umbilicus þ Cough: - Pertussis + lots of complications + macrolides eliminate carriage, treat whole household + antibiotics don't help cough + if bad, admit infants for apnea monitoring + ^WBC, lymphocytes - Chlamydia pneumonia + 3/4 of afebrile pneumonia under 2 months + most coughing babies with history of conjunctivitis has Chlamydia pneumonia. + CXR shows hyperinflation, fluffy infiltrates + ^WBC, eosinophils þ If not coughing in the ED room, likely from smokers at home. - baby may cough when held against grandma with smoke on clothing.