Paediatrics: Neonatology

• The healthy newborn: Newborn Life Support | The Newborn Examination (NIPE) | Newborn Screening | Normal Findings That Worry Parents | Feeding, Weight and Vitamins | Safe Sleep and SUDI
• Common problems: Neonatal Jaundice | Prolonged Jaundice | Breathing Problems in the Newborn | Neonatal Infection | Neonatal Hypoglycaemia | Neonatal Abstinence Syndrome
• Prematurity and birth problems: Problems of Prematurity | Necrotising Enterocolitis | Hypoxic-ischaemic Encephalopathy | Birth Injuries
• Congenital problems: Developmental Dysplasia of the Hip | Cleft Lip and Palate | Abdominal Wall and Gut Anomalies | The Blue or Collapsing Newborn
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

👶 Neonatology covers the first 28 days of life. Most babies are healthy, and much of the work is reassurance — explaining normal findings and supporting feeding. But newborns show illness in vague ways (poor feeding, lethargy, temperature instability, jaundice), and infection, hypoglycaemia and heart disease can deteriorate fast. The newborn examination and screening programmes pick up hidden problems early.
Your four questions for every baby: Was the baby born at term, and were there risk factors (prolonged rupture of membranes, maternal fever, GBS, diabetes)? Is the baby feeding, alert and warm? Are there red flags — jaundice in the first 24 hours, breathing difficulty, cyanosis, bilious vomiting, collapse? Has the newborn examination and screening been done?

Newborn Life Support

• Most babies need only drying and warmth; about 1 in 10 need some help to start breathing.
• Before birth — check equipment; warm environment; ask about gestation, meconium, and risk factors.
• Deferred cord clamping — at least 60 seconds for well babies (and preterm babies if possible).
• Steps (Resuscitation Council UK):
  • Dry and wrap the baby (term), stimulate; keep warm. Preterm under 32 weeks — place in a plastic bag without drying, under a radiant heater, with a hat.
  • Assess — tone, breathing, heart rate (stethoscope; ECG leads or oximetry help).
  • Airway — head in the neutral position (a towel under the shoulders can help); jaw thrust.
  • If not breathing — give 5 inflation breaths (each 2–3 seconds) with a face mask — air for term babies (21–30% oxygen for preterm babies).
  • Reassess heart rate — if rising, continue ventilation breaths (about 30 a minute) until breathing well.
  • If heart rate stays under 60/min after 30 seconds of effective ventilation — start chest compressions at a ratio of 3 compressions to 1 breath (encircling technique, lower third of sternum), and increase oxygen to 100%.
  • Drugs (via umbilical venous catheter) — adrenaline; glucose; volume (saline or O-negative blood) if blood loss.
• Apgar score at 1, 5 and 10 minutes:

• A score of 7–10 is normal; low scores at 5 minutes and beyond suggest the need for continued resuscitation.
• Meconium-stained liquor — don't routinely suction; if the baby is not breathing, start inflation breaths (inspect and clear the airway under direct vision if obstructed).

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The Newborn Examination (NIPE)

• NHS Newborn and Infant Physical Examination (NIPE) — a full top-to-toe check within 72 hours of birth, and again at 6–8 weeks (GP).
• The four NIPE screening areas:
  • Eyes — red reflex: absent or abnormal suggests congenital cataract or retinoblastoma — refer urgently.
  • Heart — murmurs, heart rate, femoral pulses (coarctation), cyanosis.
  • Hips — Barlow and Ortolani tests for developmental dysplasia of the hip.
  • Testes (boys) — both descended? Undescended testes at 6–8 weeks need referral (bilateral undescended testes at birth — urgent review for disorders of sex development).
• Also check:
  • Weight, length, head circumference (plotted on the growth chart).
  • Head — fontanelles (bulging or sunken), sutures, shape, caput, cephalhaematoma.
  • Face — dysmorphic features, palate (look and feel — a cleft of the soft palate can be missed).
  • Skin — jaundice, birthmarks, pallor, bruising.
  • Chest — breathing rate and effort.
  • Abdomen — masses, organomegaly, umbilical cord, anus (patent and in the right place), genitalia (hypospadias, ambiguous genitalia).
  • Spine — midline swellings, sacral dimples, hair tufts (spina bifida occulta).
  • Limbs — digits, talipes, brachial plexus injury, clavicles.
  • Neurology — tone, posture, cry, Moro and sucking reflexes.
  • Passing urine and meconium within 24 hours (delayed meconium — Hirschsprung's disease, cystic fibrosis).

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Newborn Screening

• Newborn blood spot test ("heel prick") — at about day 5 (between day 5 and 8). Screens for:
  • Sickle cell disease.
  • Cystic fibrosis (immunoreactive trypsinogen).
  • Congenital hypothyroidism (TSH).
  • Inherited metabolic diseases — phenylketonuria (PKU), MCADD (medium-chain acyl-CoA dehydrogenase deficiency), maple syrup urine disease, isovaleric acidaemia, glutaric aciduria type 1, homocystinuria.
  • (Screening for severe combined immunodeficiency has also been evaluated in parts of England.)
• Newborn hearing screening — automated otoacoustic emissions (before discharge or in the first weeks); if no clear response, automated auditory brainstem response; then audiology. Early diagnosis improves speech and language.
• NIPE — eyes, heart, hips, testes (above).
• Antenatal results to check — maternal infections (HIV, hepatitis B, syphilis), blood group and antibodies, GBS, anomaly scan findings.

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Normal Findings That Worry Parents

• Skin:
  • Erythema toxicum — blotchy red patches with white or yellow centres in the first days; harmless, moves around, settles in a week.
  • Milia — tiny white spots on the nose (blocked sebaceous glands).
  • Congenital dermal melanocytosis ("Mongolian blue spots") — blue-grey patches, often on the lower back and buttocks, in babies with darker skin. Document them at the newborn check so they aren't mistaken for bruises.
  • Stork marks (salmon patches) — pink marks on the eyelids, forehead and back of the neck; fade (the neck may persist).
  • Peripheral cyanosis (blue hands and feet — acrocyanosis) in the first days.
• Head:
  • Caput succedaneum — soft swelling of the scalp over the presenting part, crosses suture lines, settles in days.
  • Moulding of the skull bones.
• Breast swelling (both sexes) and small vaginal bleeds in girls — from maternal hormones.
• Umbilical hernia — common (especially in Black babies); most close by 3–5 years.
• Sticky eyes — blocked tear duct (clean with cooled boiled water).
• Hiccups, sneezing, irregular breathing during sleep (periodic breathing).
• Weight loss of up to 10% in the first days (see Feeding).
• Physiological jaundice — after day 1, settling within 2 weeks.
• Positional talipes — foot can be moved fully to the normal position (corrects itself), unlike structural talipes (see the Neurology and MSK chapter).

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Feeding, Weight and Vitamins

• Weight — babies normally lose up to 10% of birth weight in the first few days and regain it by 2 weeks.
  • Weight loss over 10% — assess feeding (often breastfeeding difficulty), check for hypernatraemic dehydration (sodium, jaundice), infection.
• Feeding — breastfeeding support (see the Labour, Birth and Postnatal Care chapter); term babies feed 8–12 times in 24 hours; formula about 150 mL/kg/day once established.
• Signs of good feeding — 6 or more wet nappies a day after day 5, yellow stools, alert, regaining weight.
• Vitamin K — offered to all newborns (1 mg IM at birth, or an oral regimen) to prevent vitamin K deficiency bleeding (haemorrhagic disease of the newborn) — can cause brain bleeds, especially in exclusively breastfed babies.
• Vitamin D — breastfed babies should have vitamin D drops (8.5–10 micrograms a day) from birth; formula-fed babies need it only if having under 500 mL of formula a day.
• Healthy Start vitamins for eligible families.

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Safe Sleep and SUDI

• Sudden unexpected death in infancy (SUDI) — most often in the first 6 months; sudden infant death syndrome (SIDS) when no cause is found.
• Safe sleep advice (Lullaby Trust):
  • On the back for every sleep ("back to sleep").
  • Feet to foot of the cot; firm, flat, waterproof mattress; no pillows, bumpers or soft toys.
  • Room-share (in a cot in the parents' room) for the first 6 months.
  • Smoke-free — in pregnancy and around the baby (the biggest modifiable risk).
  • Don't co-sleep on a sofa or armchair, or in a bed if a parent has drunk alcohol, taken drugs or sedating medicines, smokes, or if the baby was preterm or low birth weight.
  • Avoid overheating; no hats indoors.
  • Breastfeeding and using a dummy at sleep times may reduce risk.
• After a sudden infant death — joint agency response (police, paediatrician, social care); child death review; bereavement support.

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Neonatal Jaundice

• Very common — about 60% of term and 80% of preterm babies.
• Why — high red cell mass with shorter red cell life, immature liver conjugation, increased gut reabsorption.
• Types and causes:

• Assessment (NICE CG98):
  • Look for jaundice in good natural light (blanch the skin; check the gums and sclerae in darker skin).
  • Don't rely on visual inspection to estimate the level — measure.
  • Transcutaneous bilirubinometer in babies over 35 weeks and over 24 hours old; serum bilirubin if within 24 hours, under 35 weeks, or high readings.
  • Plot on a gestation-specific treatment threshold chart.
  • Risk factors for significant jaundice — gestation under 38 weeks, a sibling who needed phototherapy, exclusive breastfeeding, visible jaundice in the first 24 hours.
• Tests (if significant or early) — FBC, blood film, blood group (baby and mother), direct antiglobulin test (Coombs — haemolytic disease), G6PD (by ethnicity), infection screen; conjugated bilirubin if prolonged.
• Treatment:
  • Phototherapy — blue light converts bilirubin to a water-soluble form; based on the threshold chart. Keep feeding; cover eyes; monitor temperature and hydration.
  • Exchange transfusion — very high levels or signs of bilirubin encephalopathy.
  • IVIG — rhesus or ABO haemolytic disease with rapidly rising bilirubin.
• Kernicterus (bilirubin encephalopathy) — unconjugated bilirubin crosses into the brain: lethargy, poor feeding, high-pitched cry, hypertonia, arching (opisthotonus), seizures; long term — cerebral palsy (dyskinetic), deafness, learning disability.

⚠️ Safety Pearl: Jaundice in the first 24 hours of life is always abnormal — measure bilirubin urgently (within 2 hours) and look for haemolysis or sepsis.

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Prolonged Jaundice

• Definition — jaundice lasting over 14 days in term babies (over 21 days in preterm).
• Prolonged jaundice screen:
  • Total and conjugated (direct) bilirubin — the key test.
  • FBC, blood group and DAT.
  • TFTs (if newborn screening not done or abnormal).
  • Urine culture (UTI).
  • Urine for reducing substances (galactosaemia), LFTs.
  • Ask about stool and urine colour.
• Unconjugated — usually breast milk jaundice (well baby, gaining weight — continue breastfeeding); also hypothyroidism, haemolysis, infection, Gilbert's or Crigler–Najjar syndrome.
• Conjugated hyperbilirubinaemia (conjugated over 25 µmol/L, or over 20% of total) — always pathological, needs urgent assessment:
  • Biliary atresia — pale (chalky) stools, dark urine, enlarged liver; progressive destruction of the bile ducts. Kasai portoenterostomy works best before 6–8 weeks; many later need a liver transplant. Use a stool colour chart.
  • Neonatal hepatitis (infections — CMV, TORCH), alpha-1 antitrypsin deficiency, Alagille syndrome, choledochal cyst, cystic fibrosis, parenteral nutrition, galactosaemia.

💡 Clinical Pearl: A jaundiced baby over 2 weeks old with pale stools and dark urine has biliary atresia until proven otherwise. Check the conjugated bilirubin — early surgery saves livers.

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Breathing Problems in the Newborn

• Signs of respiratory distress — fast breathing (over 60/min), grunting, nasal flaring, recession (subcostal, intercostal), head bobbing, cyanosis, apnoea.
• Transient tachypnoea of the newborn (TTN):
  • Delayed clearance of lung fluid — the commonest cause; after caesarean (especially without labour) or fast births.
  • Fast breathing in the first hours; chest X-ray — fluid in the fissures.
  • Supportive (oxygen if needed); settles within 24–48 hours. Exclude infection.
• Respiratory distress syndrome (surfactant deficiency):
  • Preterm babies (especially under 32 weeks); also babies of diabetic mothers.
  • Worsening distress from birth; chest X-ray — "ground glass" with air bronchograms.
  • Prevention — antenatal steroids.
  • Treatment — CPAP; surfactant via the trachea (LISA or intubation); ventilation if needed.
• Meconium aspiration syndrome — post-term or distressed babies inhale meconium: chemical pneumonitis, airway blockage, pulmonary hypertension. Supportive care, ventilation, surfactant.
• Congenital pneumonia and sepsis (GBS) — always consider; antibiotics.
• Pneumothorax — sudden deterioration (especially on ventilation); transillumination; chest drain.
• Persistent pulmonary hypertension of the newborn — high lung blood pressure after birth, shunting through the duct and foramen ovale: severe hypoxia. Ventilation, nitric oxide, ECMO.
• Congenital diaphragmatic hernia — bowel in the chest (usually left): scaphoid abdomen, bowel sounds in the chest, displaced heart sounds. Often diagnosed antenatally. Don't use bag-and-mask ventilation (inflates the bowel) — intubate, NG tube; surgery after stabilisation.
• Choanal atresia — cyanosis when feeding that improves when crying.

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Neonatal Infection

• Early-onset infection (within 72 hours) — from the mother around birth:
  • Group B streptococcus (the commonest), E. coli, Listeria.
  • Risk factors — maternal GBS colonisation or previous GBS baby, prelabour rupture of membranes over 18–24 hours, preterm birth, maternal fever or chorioamnionitis, maternal sepsis, infection in a twin.
• Late-onset infection (after 72 hours) — often from the environment: coagulase-negative staphylococci (central lines in preterm babies), Staph aureus, E. coli, GBS, Klebsiella.
• Signs — often subtle:
  • Poor feeding, lethargy, irritability.
  • Temperature instability (fever or low temperature).
  • Breathing difficulty, apnoea, grunting.
  • Tachycardia or bradycardia; poor perfusion; mottled skin.
  • Jaundice in the first 24 hours; hypoglycaemia; seizures; bulging fontanelle (meningitis).
• Management (NICE NG195):
  • Use a risk assessment (red flags and other indicators; the Kaiser Permanente sepsis calculator is used in many UK units).
  • Red flags (any one = treat) — suspected or confirmed infection in another baby (twin), parenteral antibiotics for confirmed maternal sepsis in labour, respiratory distress starting over 4 hours after birth, seizures, need for mechanical ventilation in a term baby, signs of shock.
  • Blood culture, FBC, CRP (at baseline and at 18–24 hours); lumbar puncture if strong suspicion or signs of meningitis.
  • Early-onset — IV benzylpenicillin with gentamicin, within 1 hour of the decision.
  • Meningitis — cefotaxime (or ceftriaxone after the first days) plus amoxicillin (Listeria).
  • Late-onset (in the community) — e.g. cefotaxime plus amoxicillin; on neonatal units per local policy.
  • Stop antibiotics at 36 hours if cultures are negative, CRP is low and the baby is well.
• Other important neonatal infections — herpes simplex (vesicles, seizures, liver failure — IV aciclovir), congenital CMV, toxoplasmosis, syphilis, HIV and hepatitis B exposure (see the Medical Problems in Pregnancy chapter), conjunctivitis (gonococcal, chlamydial).
• Fever in any baby under 3 months — see the Paediatric Infections chapter (high risk).

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Neonatal Hypoglycaemia

• Glucose normally dips in the first hours after birth; healthy term babies use other fuels (ketones). Routine glucose checks in healthy term babies are not needed.
• At-risk babies (check glucose before the second feed, about 2–4 hours after birth):
  • Infant of a diabetic mother (high insulin).
  • Small for gestational age or growth-restricted (low stores).
  • Preterm (under 37 weeks).
  • Hypothermia; sepsis; perinatal asphyxia.
  • Mother on beta-blockers (labetalol) in late pregnancy.
  • Rare — congenital hyperinsulinism, Beckwith–Wiedemann syndrome, inborn errors of metabolism, hypopituitarism.
• Definition (BAPM) — glucose under 2.0 mmol/L in at-risk babies requires action (or under 2.6 with symptoms); local thresholds vary.
• Signs — jitteriness, poor feeding, drowsiness, floppiness, apnoea, hypothermia, seizures — or none.
• Management:
  • Feed early (within the first hour) and often; skin-to-skin; keep warm.
  • Buccal dextrose gel 40% (200 mg/kg) massaged into the cheek, plus a feed.
  • IV 10% glucose — bolus of 2 mL/kg then infusion if severe, symptomatic, or not responding.
  • Persistent or recurrent — investigate (insulin, cortisol, growth hormone, ketones, metabolic tests at the time of hypoglycaemia).
• Untreated severe hypoglycaemia causes brain injury.

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Neonatal Abstinence Syndrome

• What it is: Withdrawal in a baby exposed in the womb to opioids (heroin, methadone, buprenorphine), benzodiazepines, or other drugs.
• Onset — usually within 1–3 days (later with methadone, up to 7 days).
• Features:
  • Irritability, high-pitched cry, tremors, increased tone, poor sleep.
  • Poor feeding, vomiting, diarrhoea, poor weight gain.
  • Sweating, sneezing, yawning, fast breathing, fever.
  • Seizures (severe).
• Management:
  • Observe for at least 3–5 days with a scoring tool (e.g. modified Finnegan).
  • Supportive — skin-to-skin, swaddling, low-stimulation environment, small frequent feeds; breastfeeding is encouraged if the mother is stable on substitution therapy and HIV-negative.
  • Oral morphine for opioid withdrawal if scores are high; phenobarbital for polydrug use.
  • Safeguarding assessment and support for the family.
• SSRIs in late pregnancy — "neonatal adaptation syndrome": jitteriness, poor feeding, breathing problems; usually mild and short-lived.
• Fetal alcohol spectrum disorder — smooth philtrum, thin upper lip, short palpebral fissures, small head, growth restriction, learning and behaviour problems.

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Problems of Prematurity

• Preterm — born before 37 weeks; extremely preterm under 28 weeks. Survival at 24 weeks is now around 60–70% in UK neonatal units, with high rates of disability.
• Corrected age — use the age from the due date when assessing growth and development, until about 2 years.
• Problems:
  • Breathing — respiratory distress syndrome; apnoea of prematurity (treated with caffeine); bronchopulmonary dysplasia (chronic lung disease — oxygen need at 36 weeks corrected).
  • Brain — intraventricular haemorrhage (first days, most under 32 weeks; screened with cranial ultrasound); periventricular leukomalacia (white matter damage — spastic diplegia); hydrocephalus.
  • Gut — necrotising enterocolitis; feeding intolerance.
  • Heart — patent ductus arteriosus (bounding pulses, murmur; ibuprofen or paracetamol to close it, or surgery).
  • Eyes — retinopathy of prematurity (screen under 31 weeks or under 1,501 g).
  • Infection — immature immunity, lines.
  • Temperature — hypothermia (thin skin, little fat).
  • Metabolic — hypoglycaemia; jaundice; anaemia of prematurity; metabolic bone disease.
• Long-term — cerebral palsy, learning difficulties, ADHD and autism (more common), visual and hearing impairment, chronic lung disease, poor growth. Neurodevelopmental follow-up to 2 years corrected.
• Breast milk (mother's own or donor) reduces NEC and infection.

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Necrotising Enterocolitis

• What it is: Inflammation and death of the bowel wall — mainly in preterm babies, usually in the first 2 weeks after feeds begin.
• Risk factors — prematurity, low birth weight, formula feeding, growth restriction, perinatal asphyxia, congenital heart disease, sepsis.
• Features:
  • Feed intolerance, bilious (green) aspirates or vomiting.
  • Abdominal distension and tenderness; discoloured abdominal wall.
  • Blood in the stools.
  • Signs of sepsis — apnoea, temperature instability, shock.
• Abdominal X-ray:
  • Dilated bowel loops, thickened bowel walls.
  • Pneumatosis intestinalis (gas in the bowel wall) — diagnostic.
  • Portal venous gas.
  • Pneumoperitoneum (perforation) — e.g. the "football sign".
• Management:
  • Stop feeds (nil by mouth), NG tube on free drainage.
  • IV broad-spectrum antibiotics; IV fluids; parenteral nutrition.
  • Surgical review — laparotomy for perforation or deterioration (bowel resection, stoma).
• Complications — strictures, short bowel syndrome, death.

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Hypoxic-ischaemic Encephalopathy

• What it is: Brain injury from lack of oxygen or blood flow around birth (e.g. abruption, cord prolapse, uterine rupture, prolonged difficult birth).
• Signs — low Apgar scores, need for resuscitation, metabolic acidosis on cord gases, then encephalopathy:
  • Mild — irritability, jitteriness, hyperalert.
  • Moderate — lethargy, low tone, poor feeding, seizures.
  • Severe — coma, floppiness, absent reflexes, prolonged seizures, multi-organ failure.
• Management:
  • Therapeutic hypothermia (cooling to 33–34 °C for 72 hours, started within 6 hours of birth) for term or near-term babies with moderate to severe HIE — reduces death and disability.
  • Supportive care — breathing, BP, glucose, fluids (kidney injury), treat seizures; cerebral function monitoring (aEEG); MRI brain.
• Outcomes — mild usually good; moderate to severe — risk of cerebral palsy (often dyskinetic or quadriplegic), learning disability, epilepsy, death.

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Birth Injuries

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Developmental Dysplasia of the Hip

• What it is: An abnormally formed hip joint — from a shallow socket to a dislocated hip. More common in girls and the left hip.
• Risk factors (NIPE):
  • First-degree family history of hip problems in early life.
  • Breech presentation at or after 36 weeks (or at birth if earlier), whatever the method of birth; breech in a twin.
  • Also — first baby, oligohydramnios, high birth weight, tight swaddling.
• Examination (newborn and 6–8 weeks):
  • Barlow test — dislocates an unstable hip by pushing the flexed thigh backwards.
  • Ortolani test — relocates a dislocated hip by abducting the flexed thigh (a "clunk").
  • Later signs (older babies) — limited abduction, leg length difference, asymmetrical thigh creases, limp or waddling gait when walking.
• Imaging:
  • Hip ultrasound by 6 weeks for babies with risk factors (and within 2 weeks if an abnormal examination).
  • X-ray after about 4–6 months (when the femoral head ossifies).
• Treatment:
  • Pavlik harness (holds hips flexed and abducted) — under 6 months; for 6–12 weeks or more.
  • Older babies or failed harness — closed or open reduction under anaesthetic and a spica cast; osteotomy later.
• Untreated — limp, early arthritis, leg length difference.

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Cleft Lip and Palate

• What it is: Failure of the lip and/or palate to fuse during early pregnancy. About 1 in 700 babies.
• Associations — family history, maternal smoking, antiepileptics (valproate, phenytoin), folate deficiency; syndromes (22q11 deletion, Pierre Robin sequence — small jaw, cleft palate, breathing problems).
• Diagnosis — cleft lip is often seen on the 20-week scan; cleft palate may be missed — look and feel the palate at the newborn examination.
• Problems:
  • Feeding — difficulty sucking; special bottles and teats; cleft nurse specialist.
  • Hearing — glue ear (Eustachian tube dysfunction).
  • Speech — nasal speech.
  • Dental problems.
• Treatment (regional cleft team):
  • Lip repair at about 3 months.
  • Palate repair at about 6–12 months.
  • Speech and language therapy, hearing checks, orthodontics, later surgery (bone graft).

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Abdominal Wall and Gut Anomalies

• Gastroschisis:
  • Bowel protrudes through a defect beside the umbilicus (usually right), without a covering sac.
  • Linked to young mothers, smoking and drug use; rarely associated with other anomalies.
  • Cover the bowel in cling film, keep warm, NG tube, fluids; surgery soon after birth (good outcome).
• Exomphalos (omphalocele):
  • Abdominal contents protrude through the umbilicus, covered by a sac.
  • Associated with chromosomal abnormalities (trisomy 13, 18), Beckwith–Wiedemann syndrome, and heart defects.
• Oesophageal atresia (usually with a tracheo-oesophageal fistula):
  • Polyhydramnios in pregnancy; frothy saliva, choking and cyanosis with the first feed.
  • An NG tube can't be passed (coils in the upper pouch on X-ray).
  • Nil by mouth, suction the pouch (Replogle tube), surgery.
  • VACTERL associations — Vertebral, Anorectal, Cardiac, Tracheo-oEsophageal, Renal, Limb anomalies.
• Duodenal atresia — bilious vomiting from the first day; "double bubble" on X-ray; linked to Down syndrome.
• Malrotation with volvulus, Hirschsprung's disease, meconium ileus (cystic fibrosis), anorectal malformations — see the Paediatric Gastroenterology and Surgery chapter.
• Bilious (green) vomiting in a newborn is a surgical emergency until proven otherwise.

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The Blue or Collapsing Newborn

• Central cyanosis (blue tongue and lips) is always abnormal.
• Causes:
  • Respiratory — RDS, pneumonia, meconium, pneumothorax, diaphragmatic hernia, PPHN.
  • Cyanotic congenital heart disease — transposition of the great arteries (the commonest presenting in the first days), tetralogy of Fallot, tricuspid atresia, total anomalous pulmonary venous drainage, hypoplastic left heart syndrome.
  • Sepsis; methaemoglobinaemia; polycythaemia.
• Hyperoxia (nitrogen washout) test — giving 100% oxygen improves oxygen levels in lung disease but not much in cyanotic heart disease.
• Duct-dependent heart lesions:
  • Some babies need the ductus arteriosus to stay open — e.g. transposition, pulmonary atresia (cyanosis), and left heart obstruction — coarctation, hypoplastic left heart, critical aortic stenosis (collapse, shock, weak or absent femoral pulses).
  • They often deteriorate at 2–3 days as the duct closes — collapse, cyanosis, shock, acidosis (may be mistaken for sepsis).
  • Treatment — prostaglandin E (alprostadil or dinoprostone) infusion to reopen the duct (side effect — apnoea); urgent transfer to a cardiac centre.
• Pulse oximetry (pre- and post-ductal — right hand and a foot) helps detect critical heart disease.
• Collapsing newborn — differentials: sepsis, duct-dependent heart disease, inborn errors of metabolism (vomiting, acidosis, high ammonia), congenital adrenal hyperplasia (salt-losing crisis in boys at 1–2 weeks — low sodium, high potassium), non-accidental injury, hypoglycaemia.
• See the Paediatric Respiratory and Cardiac chapter.

⚠️ Safety Pearl: A baby who becomes grey, floppy and shocked at 2–3 days old may have a duct-dependent heart lesion. Feel the femoral pulses, give antibiotics for possible sepsis — and start a prostaglandin infusion if a heart cause is suspected.

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Drug Reference Table

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Spot the Diagnosis