Neonatal Pneumonia

General Data
3 day old male
Wt: 2360 g

CC: nanginigtim ang binti
History of Present Illness
3 days PTC:
Patient was born pre-term via SVD, breech
presentation, to a then 20 y/0 primigravid
mother, delivered at home c/o a midwife. On
regular prenatal check-up (2x) at the local
health center, with no exposure to teratogenic
substances or radiation
At birth, patient was noted to have bluish
discoloration of the left upper and lower
extremities and back area.
Patients family was advised to seek consult at
tertiary hospital for further evaluation and
management, hence this consult.
In transit, patient was noted to have increased
breathing rate and retractions.
Review of Systems
(-) fever
(-) change in sensorium
(-) cough
(-) colds
(-) cyanosis
(-) hematuria
(-) seizures

Family Medical History
(+) DM Maternal side of the family
(-) HPN, BA, CA, Congenital Anomalies

Paternal side unknown
Birth and Maternal History
Pre-term, 34 weeks by PA, 38 weeks by LMP,
delivered via SVD, breech presentation, BW
2390 g, AS = ?, NID
Born to a then 20 y/o primigravid, (+) regular
PNCU (2x)
Developmental History
(+) Moro Reflex
(+) Rooting Reflex
(+) Grip Reflex
Course at the ER
Patient was received awake, with spontaneous
movement, and good cry
HR 172 RR 88 T 36.7 fair pulses
PC, AS
SCE, Harsh Breath Sounds, (+) occasional
grunting, (+) subcostal retractions, (+) crackles
AB @ 4
th
ICS, MCL, (-) murmurs
Globular Abdomen, soft, (-) masses
Course at the ER
Grossly male genitalia, (+) bilateral descended
testis
Fair Pulses, CRT < 3 secs
(+) bluish discoloration of Left Upper
Extremity, and Bilateral Lower extremities
Started on Ampicillin (75) and Amikacin (40),
O2 support done -> Ward Admission

Differential Diagnoses
Hyaline Membrane Disease
Rule In: Patient was born preterm (34 weeks)
with persistent cyanosis of extremities, presented
with occasional grunting, subcostal retractions,
crackles, and tachypnea of 88 breaths per minute
on the first hours of life. The patient might also
had perinatal asphyxia due to difficult delivery
secondary to breech presentation.
Rule Out: The incidence of HMD decreases
significantly after 30-32 weeks of gestation. The
patient improved with administration of
antibiotics and oxygen.
Hyaline Membrane Disease
Evaluation: CXR is diagnostic and shows diffuse
atelectasis with an increased density in both
lungs and a fine, granular, ground-glass
appearance of the lungs. The small airways are
filled with air and are clearly surrounded by the
increased density of the pulmonary field, creating
air bronchograms.
Transient Tachypnea of the Newborn
Rule In: Patient presented with tachypnea of 88
breaths per minute during the first 24 hours of life,
associated with grunting, subcostal retractions, and
persistent cyanosis of extremities. Note of minimal
improvement with administration of oxygen support.
Rule Out: Physical examination revealed the presence
of crackles. Tachypnea did not resolve within 24-48
hours of life.
Evaluation: CXR reveals prominent pulmonary vascular
markings, fluid in the intralobar fissures, overaeration,
and flat diaphragms.
Persistent Pulmonary Hypertension of
the Newborn
Rule In: Patient presented with persistent
cyanosis of extremities, associated with
occasional grunting, subcostal retractions, and
tachypnea of 88 breaths per minute. The patient
might also had perinatal asphyxia due to difficult
delivery secondary to breech presentation.
Rule Out: The presence of crackles does not
support the diagnosis of PPHN.
Evaluation: CXR reveals decreased pulmonary
vascular markings.

Neonatal Pneumonia
Rule In: Patient presented with signs of
respiratory distress such as tachypnea,
subcostal retractions, crackles, and cyanosis of
extremities.
Rule Out: Cannot be ruled out.
Diagnostics
Chest X-ray to evaluate the condition of the lungs. Pulmonary
infiltrates suggests pneumonia, diffuse atelectasis supports HMD,
fluids in intralobar fissures points out to a probable TTN, and
decreased lung markings suggests PPHN.
CBC to evaluate if there is an increase in WBC count that supports
the presence of probable infection. It would also show probable
derangement in RBC and hemoglobin that decrease the oxygen-
carrying capacity.
ABG to assess the peripheral oxygen saturation of arterial blood
and probable acidosis/alkalosis of the patient.
Bloo CS to document the presence of infection, know the culprit
organism and test its sensitivity t particular antibiotics.
Hyperoxia test to differentiate if the disease is secondary to a
pulmonary condition or due to a presence of AV shunt.
Serum electrolytes
Laboratory Results
CBC
WBC 7.67
HGB 159
HCT 0.464
PC 222
Neut 0.53
Lymph 0.31
Electrolytes
Calcium 1.94 2.07
Sodium 140 139
Potassium 3.8 4.8
Chloride 111 107
Physical Examination
HR 150 RR 40 T 36.8
o
C GP
PC, AS
ECE, CBS, (-) retractions
DHS, NRRR, (-) m2
Globular, soft, (-) masses
FEP, PNB, CRTs < 2s
(+) bluish discoloration of bilateral plantar
area
Neonatal Pneumonia
Definition:
Inflammation of the parenchyma of the lungs
Onset may be within hours of birth or after 7
days & confined to the lungs
caused by microorganisms,
noninfectious causes
aspiration of food or gastric acid, foreign
bodies hypersensitivity reactions
Early onset
part of generalized sepsis that presents at or
within hours of birth
Late onset
occurs after 7 days of age
Etioloic agents according to time of acquisition

I. Transplacental- CMV, HSV, M. tb, Rubella virus, T.
pallidum, VZV

II. Perinatal- anaerobic bacteria, Chlamydia, CMV, Enteric
bacteria, GBS, H. influenza, HSV,
L. monocytogenes, Mycoplasma

III. Postnatal- Adenovirus, Candida sp., Coagulase-
negative staph, CMV, Echo virus, Enterics, Influenza
viruses A,B, Parainfluenza, Pseudomonas, RSV, S. aureus

Group B Streptoccocci
- most common cause of fulminant infections

Signs and Symptoms:

Early- nonspecific such as poor feeding,
lethargy, irritability, cyanosis, temp instability,
overall impression that the infant is not well

Respiratory symptoms: grunting, tachypnea,
retractions, alar flaring, apnea, cyanosis,
progressive respiratory failure

Signs of pneumonia on PE such as
dullness to percussion, change in breath
sounds and presence of rales/ rhonchi
are very difficult to appreciate in
neonate.

Prenatal Features Increasing Risk for Neonatal
Pneumonia:

Unexplained preterm labor
PROM
Maternal fever
uterine tenderness
foul-smelling amniotic fluid
infection of maternal GUT
Fetal tachycardia
meconium in the AF
Recurrent maternal UTI

Diagnostics:

The diagnosis of pneumonia in neonates is
usually presumptive
Blood culture - done to isolate etiologic agent
but is usually negative
CXR- presence of pulmonary infiltrates
- Difficult to differentiate from RDS
especially in preterm infents

Treatment

Early Onset infections (1
st
7 days of life):
Ampicillin + Aminoglycosides (Gentamicin)/
Cefotaxime
GBS- Penicillin G
MRSA- Vancomycin
Pseudominas Aminoglycosides +
Ceftazidime/ Piperacillin/ Ticarcillin/
Cabernicillin
C. trachomatis- Erythromycin/ TMP-SX