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A male infant is born at 38 weeks, 4 days of gestation via spontaneous vaginal delivery to a 20-year-old gravida 4, para 2-0-2-2 woman. The maternal history is significant for substance abuse of cocaine, inadequate prenatal care, iron-deficiency anemia, and newly diagnosed and untreated human immunodeficiency virus (HIV) infection with a viral load of 658 copies/mL. Her medical history includes a repaired congenital ventricular septal defect at the age of 4 years. The infant is vigorous at birth and admitted to the NICU for HIV antiretroviral drug therapy because of the untreated maternal HIV infection. The infant is hemodynamically stable during the first 72 hours after birth and starts having tachypnea on day 3, with respiratory rates ranging from 70 to 90 breaths/min; all his other vital signs are within normal limits. Physical examination findings are unremarkable, with no retractions, no adventitious lung sounds, or cardiac murmurs. The infant requires no respiratory support. Initial chest radiography shows diffuse perihilar interstitial markings and mild ground glass appearance (Fig 1). Because of persistent tachypnea, 2-dimensional (2D) transthoracic echocardiography (Echo) and electrocardiography (EKG) are performed on day 4. EKG shows normal sinus rhythm with rightward axis deviation (normal for age) and no ST/T wave changes. The 2D Echo is significant for the left anterior descending (LAD) coronary artery draining into right ventricle and significantly dilated left main and left anterior coronary arteries (Figs 2, 3, and 4). Follow-up Echo shows worsening of the condition, for which serial cardiac troponins levels are measured. The troponin level is initially normal and then starts to increase as follows: …

A female neonate born at 39 weeks of gestation is transferred from the well newborn nursery 7 hours after birth because of apnea and cyanosis. The infant is born via elective repeat cesarean section. The pregnancy had been complicated by chronic hypertension and gestational diabetes mellitus. Maternal medications during pregnancy were labetalol and metformin. The maternal perinatal screening results were unremarkable. Membranes ruptured at the time of delivery. Apgar scores are 9 and 9 at 1 and 5 minutes, respectively. Arterial cord pH is 7.29, with a base deficit of −4.3. The infant appears well after delivery, and hence is transferred to the newborn nursery to remain with the mother. Around 7 hours after birth, the infant is cold, and her temperature is

A 28-day-old male infant born at 36 weeks’ gestation is admitted to the hospital for the second time with rhythmic movements. The infant is a monochorionic diamniotic twin born to a healthy primigravida with normal prenatal screens. The maternal medications were iron, folic acid, and a multivitamin. The prenatal course was significant for twin-to-twin transfusion syndrome resulting in intrauterine death of the second twin at 24 weeks’ gestation. This twin was the recipient twin. Follow-up fetal ultrasonography showed that this twin had moderate oligohydramnios, appropriate fetal growth, and normal Doppler studies without evidence of uteroplacental flow insufficiency. The infant was born at 36 weeks’ gestation because of unstoppable preterm labor. He emerged vigorous and had Apgar scores of 7 and 8 at 1 and 5 minutes of age, respectively. His birthweight was 2,600 g (39th percentile). He remained in the hospital for 2 days, and was discharged exclusively breastfeeding and receiving vitamin D supplementation. At 13 days of age, his parents brought him to the local hospital because of frequent abnormal jerky movements of his right arm lasting for 25 to 30 seconds. He was admitted to the NICU for evaluation. The parents reported that he had otherwise been doing well at home except for some intermittent brief jerky movements of his arms and legs lasting 10 to 15 seconds occurring a few times per day since the second day after birth. The infant’s physical examination findings were normal except for bradycardia (heart rate 66 beats/min) and mild tachypnea (respiratory rate 62 breaths/min). During the hospitalization, the infant had 3 episodes of myoclonic jerks of the right upper and lower limbs lasting for approximately 30 seconds, with an associated increase in heart rate. These movements were consistent with seizure activity and thus, phenobarbital was started. The infant had a normal …

A preterm male neonate is born at 31 weeks of gestation via cesarean section for a category 2 fetal heart tracing. The prenatal history is significant for maternal autosomal dominant polycystic kidney disease (ADPKD). The pregnancy had been complicated by maternal chronic hypertension, preeclampsia with severe features, and significant enlargement with increased echogenicity of fetal kidneys on ultrasonography. Maternal laboratory findings are reassuring and antenatal steroids complete before delivery. At delivery, the neonate has poor respiratory effort, requiring continuous positive airway pressure and is transferred to the NICU. On arrival, he is noted to be in respiratory distress with coarse breath sounds bilaterally, grunting, and significant retractions. Evaluation for infection is initiated and antibiotics started. A chest radiograph is significant for hyperexpansion with bilateral diffuse alveolar and interstitial opacities. He undergoes intubation and receives surfactant twice. Following surfactant administration, he continues to receive mechanical ventilation. He undergoes extubation on day 7 after birth and receives 6 L/min high-flow nasal cannula. He is unable to wean further because of intermittent tachypnea, desaturations, and worsened retractions with weaning. Chest radiography consistently shows diffuse alveolar and interstitial opacities, and the infant has no clinical improvement despite several trials of furosemide, albuterol, budesonide, and fluid restriction (Fig 1). By day 23 after birth, a 3-day course of dexamethasone is tried, which leads to some improvement, allowing the infant to …

A 10-day-old male neonate is referred in view of inability to wean off respiratory support. The infant is born through assisted breech delivery with a birthweight of 2.75 kg to a gravida 2 woman. Antenatal history is not significant. However, there is meconium staining of the amniotic fluid. The infant did not cry after birth and his Apgar scores are 3 and 6 at 1 minute and 5 minutes, respectively. He has cyanosis and tachypnea soon after birth requiring intubation. Vital signs at admission include a temperature of 97.7°F (36.5°C), heart rate of 155 beats/min, capillary refill time of 2 seconds, and saturation of 94% on ventilator. The infant’s activity is diminished, with poor tone in all 4 limbs. The possibilities considered at this stage are perinatal asphyxia, meconium aspiration syndrome, congenital pneumonia, congenital heart disease, sepsis, and persistent pulmonary hypertension of the newborn. Initial investigations indicate negative sepsis screen (total white blood cell count 20,000/μL [20×109/L], C-reactive protein

A 935-g girl with intrauterine growth restriction is born at 29 weeks and 5 days of gestation to a 26-year-old gravida 6, para 2 woman. The pregnancy is significant for chronic hypertension treated with hydralazine, and labor is induced for preeclampsia which is diagnosed on the day of delivery. Intrapartum magnesium and betamethasone are administered and cesarean section is performed for nonreassuring fetal heart tones. The neonate’s Apgar scores are 5 and 8 at 1 and 5 minutes, respectively, and she requires continuous positive airway pressure for tachypnea, retractions, and desaturations. Her clinical condition improves in the NICU and she is weaned to room air by day 8 after birth. She tolerates fortified nasogastric feeds well until 6 weeks after birth when she is found to have repeated choking and gagging episodes with copious oral and nasal secretions. Omeprazole and glycopyrrolate are started on days 54 and 59 after birth, respectively, with no significant improvement. Serial head ultrasonography scans are normal and a brain magnetic resonance imaging (MRI) scan shows an asymmetric maxilla but normal brain structure. She is transferred to our institution on day 66 after birth for further evaluation …

A male infant is born at 37 weeks’ gestation, with a birthweight of 2,915 g (∼6th percentile on the World Health Organization growth curve, Z score = −1.53) to a 22-year-old gravida 5, para 1 woman, who has a history of 4 spontaneous abortions. After an uneventful prenatal course, the neonate is brought to our NICU 16 days after birth because of concern about dysmorphic features, poor feeding tolerance, and respiratory distress. At the transferring institution, he had received nasogastric tube feedings because of intermittent hypoglycemia and desaturations, with episodes of tachypnea during oral feeding attempts. He had been placed on nasal cannula at 13 days after birth because of his worsening respiratory condition. At the time of transfer, his oxygen saturation is good on high-flow nasal cannula and he is tolerating full enteral nasogastric feeds. Shortly after transfer, the infant’s respiratory requirements escalate, including the need for ventilator support for suspected pulmonary hypertension, which improves after …

A term male neonate is delivered by a 23-year-old primigravida woman at 40 weeks of gestation via normal vaginal delivery. The antenatal and intrapartum periods are uneventful, except for prolonged rupture of membranes of 20 hours. The neonate is placed on skin-to-skin contact with the mother and breastfeeding is initiated. At 36 hours after birth, the neonate is noted to have tachypnea, periumbilical erythema, and purulent conjunctivitis. He is transferred to the NICU with a provisional diagnosis of early-onset neonatal sepsis. Empirical antibiotics are initiated after sepsis screening and blood culture specimens are obtained and skin and conjunctival swabs performed. The neonate is noted to have oxygen saturation on pulse oximetry of 89% to 91%, improving marginally to 92% to 93% on heated humidified high-flow nasal cannula (HHFNC) with fraction of inspired oxygen (Fio2) of 0.4. There is no appreciable murmur and bilateral femoral pulses are palpable. ### Progression Over the next 24 hours the neonate developed tachycardia, with a heart rate of 168 beats/min, palpable soft hepatomegaly of 3 cm, cold peripheries, core-peripheral temperature difference of 2°C (35.6°F), and inability to oxygenate on HHFNC with Fio2 of 0.8. Chest radiography showed gross cardiomegaly (Fig 1). The peripheral pulses were bounding and noninvasive blood pressure was 52/22 mm Hg, with a …

A male neonate is born at 36 2/7 weeks via vaginal delivery at a level 2 nursery. The mother is a 34-year-old, gravida 8, para 4, aborta 3 woman. The maternal history is remarkable for chronic hypertension that was treated with labetalol and amlodipine; hypothyroidism that was treated with levothyroxine; and obesity and gestational diabetes that were controlled with diet. Maternal laboratory findings are as follows: human immunodeficiency virus, negative; rapid plasma reagin, nonreactive; hepatitis B, negative; group B Streptococcus, negative; blood type, O positive; and antibodies, negative. The mother has not received any medication at the time of delivery. The neonate is born via cesarean section for nonreassuring fetal heart tracing and clear amniotic fluids. Anthropometric measurements at birth are as follows: weight, 2,740 g (45th percentile); head circumference, 34 cm (77th percentile); length, 45.5 cm (20th percentile); growth status: appropriate for gestational age; Apgar scores, 7 and 8 at 1 and 5 minutes, respectively. The neonate requires positive pressure ventilation for 1 minute after delivery. On admission to the nursery, the neonate exhibits signs of mild respiratory distress and tachypnea, and is placed on continuous positive airway pressure (CPAP) of 6 cm H2O with a fraction of inspired oxygen (Fio2) of 50%; chest radiograph (Fig 1) shows mild ground glass appearance. Because of his worsening respiratory status, the neonate undergoes intubation and is administered surfactant. A few minutes after surfactant administration, the infant’s condition suddenly deteriorates, requiring an increase in Fio2 to 100%. Although the neonate receives maximal ventilator and oxygen support, his oxygen saturation remains under 80%. The presence of a pneumothorax prompts the placement of a left chest tube. He is transferred to a …

A male infant born via vaginal delivery presents with biphasic stridor, cyanosis, tachypnea, chest retractions, and copious secretions since birth. ### Prenatal and Birth Histories ### Presentation After birth, the infant was noted to have increased work of breathing, severe biphasic stridor, and cyanosis. He was briefly given positive pressure ventilation for apnea, and was then administered CPAP with a fraction of inspired oxygen (Fio2) of 100%. Multiple attempts at intubation were unsuccessful; a laryngeal mask airway placement was not attempted. The infant was subsequently given high-flow nasal cannula at 3 L/min with an Fio2 of 1 and transported to the NICU at a tertiary hospital. The infant continued to have stridor with significant increased work of breathing, but saturations remained 85% or greater on 3 L/min and an Fio2 of 1. Before transport, a capillary blood gas showed a pH of 7.08 and Pco2 of 89 mm Hg (12 kPa); a chest radiograph was concerning for bibasilar pneumothoraces. ### Vital Signs ### Physical Examination (4 Hours after Birth)

A 38-1/7-week-gestation girl is born to a 21-year-old gravida 2, para 1 woman via normal spontaneous vaginal delivery. The woman had prenatal care with negative serologic findings. The infant is vigorous at birth with Apgar scores of 9 and 9 at 1 and 5 minutes, respectively. At approximately 30 hours after birth, she is hypothermic to 34.4°C with poor oral feeding, hypotonia, and tachypnea. Her glucose level is 32 mg/dL (1.78 mmol/L). A sepsis evaluation is performed, and ampicillin and gentamicin are started empirically. She is placed on high-flow nasal cannula for respiratory support and transferrend to a nearby hospital for a higher level of care. At approximately 34 hours after birth, the infant is noted to have coffee ground emesis, and she is in a clinical state of decompensation. She develops hepatomegaly, severe metabolic acidosis (base deficit −16), hyperkalemia (7.3 mEq/L [7.3 mmol/L]), and elevated creatinine concentration (1.52 mg/dL [134.4 μmol/L]). At approximately 45 hours, she develops bradycardia requiring intubation, chest compressions, and vasopressor support with 2 doses of epinephrine and initiation of a dopamine infusion. She is transferred to a tertiary referral center for further evaluation and management, given her continued clinical decline and severe metabolic derangements. At approximately 49 hours after birth, she is noted to have hepatomegaly palpable to the level of the pelvis, …

A 2-day-old term male infant presents with a lesion located on the ventral surface of the neck. ### Prenatal and Birth Histories ### Presentation The infant developed respiratory distress at 2 hours of age with tachypnea and retractions. He was initially treated with continuous positive airway pressure (CPAP) and heated humidified high-flow nasal cannula. He was noted to have a lesion located on the ventral surface of the neck. He was transported to our facility at 2 days of age for further management. Vital signs included the following. ### Physical Examination

A 2,340-g male infant is born vaginally at 34 weeks of gestation to a mother with a history of asthma and hyperthyroidism. The pregnancy is overall uncomplicated except for preterm labor, and the delivery is notable for meconium-stained amniotic fluid and unknown group B Streptococcus status treated with 2 doses of penicillin. The infant does well initially with Apgar scores of 8 and 9, but soon develops tachycardia, tachypnea, and hypoxemia; radiography demonstrates respiratory distress syndrome with a small pneumothorax. Nasal cannula is needed to maintain normal oxygen saturations, and septic evaluation result is negative. Examination is notable for the vital signs described before, a barrel-shaped chest, and hyperreflexia. He is started on gavage feeds and treated with phototherapy for hyperbilirubinemia. On day 7 after birth, he suddenly develops worsening tachycardia to the 200s, tachypnea with respiratory distress, and decreased perfusion with mottling. Echocardiography reveals severe cardiac dysfunction, prompting transfer to the cardiac intensive …

A 39-3/7 weeks’ gestation male infant is born to a 29-year-old gravida 1 para 0 woman via urgent cesarean delivery due to failed induction. Prenatal laboratory tests yielded unremarkable results. Rupture of membranes is for 7 days. Apgar scores are 3, 6, and 8 at 1, 5, and 10 minutes, respectively. In the delivery room, the baby requires positive pressure ventilation for respiratory distress. Initial chest radiography reveals a possible diaphragmatic hernia (Fig 1). The patient is intubated for respiratory distress and placed on a conventional ventilator. After placement of umbilical catheters, the infant is transferred to the NICU for further care. Repeat chest radiography reveals bowel-containing diaphragmatic hernia, stomach visible below the diaphragm, and a crescent opacity in the left upper lung field suggestive of a herniated spleen. Initial echocardiography on postnatal day 2 reveals abnormal ventricular septal motion but no significant tricuspid regurgitation consistent with pulmonary hypertension. The patient is taken to the operating room for repair, reduction, and primary closure of the hernia (Fig 2). Following surgery, the patient is weaned to continuous positive airway pressure on postnatal day 4 and subsequently weaned to room air on postnatal day 6. Figure 1. Chest radiograph revealing a possible diaphragmatic hernia, with the stomach visible below the diaphragm. Figure 2. Chest radiograph status post repair of the left diaphragmatic hernia. Seven days after birth, the patient develops tachypnea during feeding without retractions or desaturations, prompting another chest radiograph. ### Diagnosis The chest radiograph revealed retrocardiac opacity suspicious for a pulmonary sequestration. Chest ultrasonography followed by magnetic resonance imaging/magnetic resonance angiography confirmed the diagnosis of pulmonary sequestration (Figs 3 and 4). The size of the pulmonary sequestration was 4.5 cm anteroposterior × 2.8 cm transverse × 3.6 cm craniocaudal. Figure 3. Magnetic resonance imaging showing …

A male newborn is delivered at 35 -6/7 weeks’ gestational age with a birthweight of 2,700 g (50th percentile) to a gravida 3, para 2, 33-year old mother by elective lower segment cesarean section for prolonged rupture of membranes. Fetal ultrasound is unremarkable; a complete course of antenatal steroids and 2 doses of benzylpenicillin are administered. Apgar scores are 7 and 9 at 1 and 5 minutes, respectively. Maternal history is unremarkable except for a treated urinary tract infection at 33 weeks. Group B streptococcal screening is negative. Umbilical arterial blood gas shows a pH of 7.30; base deficit of 1.5 mmol/L; and lactate of 3.6 mmol/L. At 1 hour of age, the infant is noted to have cyanosis and tachypnea, with respiratory rates of 80 to 90 breaths per minute, requiring 50% of incubator oxygen and subsequently nasal continuous positive airway pressure to maintain oxygen saturation of 91% to 95%. There is no pre- and postductal saturation gradient, and thoracic transillumation excludes a significant pneumothorax. On examination, the precordial impulse and femoral pulses are normal, heart sounds are dual, and a 1/6 systolic murmur at the lower left sternal edge is heard. There is no hepatosplenomegaly. Capillary blood gas shows the following: pH, 7.26; partial pressure of carbon dioxide, 62 mm Hg (8.2 kPa); partial pressure of oxygen (Pao2), 34 mm Hg (4.5 kPa); base excess, –1.8; plasma lactate, 30.6 mg/dL (3.4 mmol/L); and serum glucose, 45 mg/dL (2.5 mmol/L). Intravenous access is obtained with a full blood count and blood culture, and benzylpenicillin and gentamicin are administered. Arterial blood sampling from the right radial artery demonstrates Pao2 of 49 mm Hg (6.5 kPa) in 50% inspired oxygen (Fio2), which does not increase in 90% Fio2. An echocardiogram at 5 …

A 38-week, 2,800-g male neonate is born to a gravida 2, para 1 mother with an uneventful antenatal period; the neonate is born via normal vaginal delivery. After a normal transition, he is transferred to the mother’s room and begins exclusive breastfeeding. Around 24 hours after birth, in the postnatal ward, the neonate is noted to have tachypnea with poor peripheral pulses and prolonged capillary refill time. Considering the possibility of early-onset sepsis with shock, a 10 mL/kg normal saline bolus is given over 30 minutes and the neonate is transferred to the NICU. Further evaluation shows a respiratory rate of 72 breaths/min, mild intercostal retractions, and heart rate of 150 beats/min, with feeble peripheral pulses and a capillary refill time of 4 seconds. No pallor, icterus, or petechiae are noted, and the cry, tone, and activity of the neonate are normal. The neonate is given oxygen by hood at 3 L/min, intravenous fluids, and intravenous antibiotics. ### Progression/Diagnosis Cardiac examination reveals normal first and second heart sounds with a grade 3/6 systolic murmur in the aortic area. Chest radiography (Fig 1) reveals a normal heart size, …

A late preterm neonate presents with irregularly irregular heart rate, tachycardia, and respiratory distress soon after birth. ### Prenatal and Birth Histories ### Presentation (Day 1) Immediately after birth, the neonate was noted to have tachypnea and tachycardia. The neonate was transferred to the neonatal intensive care unit and was given oxygen by head box with a 3-L/min flow and intravenous 10% dextrose at 60 mL/kg/d. Bedside electrocardiography revealed atrial flutter with absent P wave (Fig 1). Figure 1. Atrial flutter apparent on bedside electrocardiogram. Chest radiography revealed cardiomegaly. Bedside echocardiography revealed a right atrial mass that measured 27 × 27 mm along with multiple small masses along both sides of interventricular septum and left ventricular posterior wall (Fig 2). Figure 2. Two-dimensional echocardiogram showing a 27 × 27-mm mass in the right atrium. Multiple small masses are apparent on the interventricular septum. ### Vital Signs ### Physical Examination (Day 1)

A 3,886-g term male infant is born to a 34-year-old gravida 8, para 5025 mother who received regular prenatal care. The pregnancy was complicated by maternal morbid obesity and fetal macrosomia at 38 weeks’ gestation. The mother’s blood type is O Rh positive. She is rubella immune and tests negative for syphilis, hepatitis B, human immunodeficiency virus, group B Streptococcus , gonorrhea, and Chlamydia . She presented in labor with spontaneous rupture of membranes for 22 hours and has meconium-stained amniotic fluid. The labor was augmented with oxytocin and further complicated by maternal chorioamnionitis. The mother received intrapartum treatment with intravenous ampicillin and gentamicin. The vaginal delivery is complicated by shoulder dystocia requiring lateral flexion of the head and neck and passage of terminal meconium. The infant cries spontaneously after delivery and has a good heart rate of greater than 100 beats per minute. Apgar scores are 7 and 8 at 1 and 5 minutes, respectively. The cord blood gas (arterial) reveals: pH 7.30, Pco2 39 mm Hg (5.19 kPa), Po2 27 mm Hg (3.59 kPa), bicarbonate 19 mEq/L (19 mmol/L), and base excess -7 mEq/L (-7 mmol/L). Shortly after delivery, the infant develops tachypnea and retractions and requires continuous positive airway pressure (CPAP) of 6 cm H2O and about 30% oxygen. The physical examination reveals a large for gestational age male infant who has tachypnea and mild-to-moderate retractions on CPAP. His growth parameters are as follows: weight 3.89 kg (above the 90th percentile), length 51 cm (between the 50th and 90th percentiles), and head circumference 35.5 cm (between the 50th and 90th percentiles). He is poorly perfused, with delayed capillary refill of less than 3 seconds and a large caput succedaneum. He has weakness of the left upper arm, which is pronated and …

A premature infant (twin 2) presents with a palpable, protruding bulge in the chest wall at age 19 days (Fig 1; Video). Video: Please click here or on video to view premature infant with chest wall bulge. Figure 1. Premature infant with chest wall bulge. ### Prenatal and Birth Histories ### Presentation Twin 2 was diagnosed postnatally with a coarctation of the aorta and underwent repair of this coarctation and a patent ductus arteriosus ligation at age 11 days. Postoperatively, he required a left chest tube, which was removed on postoperative day 1. He was recovering well at 18 days of age, receiving 3 L oxygen via high-flow nasal cannula, with a fraction of inspired oxygen (Fio2) of 0.25, and intermittent tachypnea. His inotropic support had been discontinued and he was tolerating trophic feedings. However, on examination, a well-demarcated bulge overlying the fourth intercostal space of the left upper anterior hemithorax was detected. ### Vital Signs

A newborn male infant is delivered by a gravida 2 woman at 36 weeks of gestation via emergency cesarean section because of decreased fetal movements. The antenatal period was uneventful. The woman had a low-grade fever (100°F [37.8°C]) before delivery, which eventually subsided within 24 hours. The neonate did not require any resuscitation and had normal Apgar scores. He developed tachypnea immediately after birth and remained at the birth center NICU. His breathing normalized in a few hours, and he was moved to be with his mother and started breastfeeding. On the second day, the mother noticed that the infant was lethargic and not feeding well. She also noticed an increased respiratory rate. The infant was moved to our center for further management. At admission, the neonate was 41 hours old; had tachypnea (respiratory rate of 77 breaths per minute); was grunting; and had a heart rate of 161 beats per minute, capillary refill time of 4 seconds, cold peripheries, pallor, and low-volume pulse. His noninvasive blood pressure was 54/30 mm Hg. Oxygen saturation in room air was 85%. Systemic examination revealed normal breath …

A male appropriate-for-gestational age infant is born at 39 6/7 weeks to a 25-year-old gravida 1, para 0, group B Streptococcus− negative woman at a community hospital via unremarkable spontaneous vaginal delivery. The prenatal history is significant only for a transient rash on the mother’s palms 1 to 2 weeks before delivery, which was associated with nausea and vomiting. All prenatal laboratory values are normal, and membranes rupture 5 hours before delivery, with clear fluid. The infant is born floppy and cyanotic, with no respiratory effort. He is dried and stimulated, and shows some improvement. His Apgar scores are 7 and 8 at 1 and 5 minutes, respectively. The pediatrics team is called shortly after delivery for persistent cyanosis, tachypnea, and grunting. The infant’s condition quickly progresses to apnea and bradycardia, which requires a prolonged resuscitation including intubation, chest compressions, and 2 doses of epinephrine. At 30 minutes, bright red blood is noted to be coming from the endotracheal tube. After stabilization, the infant is urgently transported to a tertiary care center for further management. On admission to the tertiary care center, physical examination reveals a pale, hypotonic, hypotensive infant with coarse breath sounds and minimal spontaneous movements. No organomegaly, skin lesions, or dysmorphic features are noted. Initial laboratory studies indicate that the …

A term male infant is born to a consanguineous couple by emergency cesarean section for nonprogressive labor. The mother’s antenatal period was uncomplicated. Her first pregnancy resulted in an abortion in the second month of gestation. The newborn’s Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. The infant appears normal soon after birth and formula feeding is started. On the second day, he is noted to have fast breathing for which he is admitted to a local hospital and receives intravenous fluids, antibiotics, and oxygen. However, in view of worsening respiratory distress, the infant is referred to our center on the third day after birth. On admission to our NICU, the infant’s temperature is 97.2oF (36.2oC), he has tachypnea, with a respiratory rate of 90 breaths per minute and minimal intercostal recessions, oxygen saturation is 94% on room air, heart rate is 160 beats per minute, peripheral extremities are warm, capillary refill time is less than 3 seconds, and blood pressure in the right upper limb is 62/29 mm Hg (mean arterial pressure, 40 mm Hg). There is no dysmorphism, weight is 2.7 kg, and head circumference is 36 cm (90th percentile). On systemic examination, the liver edge is felt 3 cm below the right costal margin, and auscultatory …

A 2,280-g, term, female infant is born to a 26-year-old, gravida 3, para 2012 mother who received regular prenatal care. The pregnancy was complicated by fetal growth restriction. The mother’s blood type is A Rh negative, she is rubella immune, and she tests negative for human immunodeficiency virus, hepatitis B, and syphilis but positive for group B streptococcus. She presents in labor with spontaneous rupture of membranes for 13 hours and has meconium-stained amniotic fluid. The mother receives intrapartum prophylaxis with 2 doses of intravenous penicillin. The labor is augmented with oxytocin. The infant is delivered by normal spontaneous vaginal delivery. Apgar scores are 8 and 8 at 1 and 5 minutes, respectively. Soon after delivery, the infant is noted to be pale and to have intermittent tachypnea. Clinical examination reveals a term female infant who has tachypnea and is severely growth restricted. Her growth parameters are as follows: weight, 2,280 kg (below the third percentile); length, 45 cm (below the third percentile); and head circumference, 30 cm (below the third percentile). She is also noted to have exophthalmos with downward slanting palpebral fissures, low-set ears, micrognathia with cleft palate and bifid uvula, a grade 2 to 3/6 systolic murmur at the upper left sternal border and normal femoral pulses, small fifth digits of hands, and partial syndactyly of the second and third toes. The rest of the examination findings are normal. Initial pulse oximetry measurement on the right hand reveals 68% saturation in room air. The infant is transferred to the neonatal …

A male newborn is transferred to the neonatal intensive care unit (NICU) for management of respiratory distress and in utero illicit drug exposure. The mother is gravida 3, para 2002 whose previous child was conceived by a different father. Family medical history is not significant. The pregnancy was complicated by limited prenatal care, maternal incarceration, Escherichia coli urinary tract infection, and use of amphetamines, opiates, and tobacco. The infant was delivered at 37 weeks’ gestation in an ambulance en route to the hospital. Resuscitation at birth included chest compressions and positive pressure ventilation. His course in the NICU is remarkable for persistent mild tachypnea necessitating positive pressure ventilation via nasal cannula until age 14 days. The cause of his respiratory distress is unknown, although he has a narrow thorax apparent on physical examination and radiography (Figure 1). Figure 1. Chest radiograph of the patient at age 3 days reveals a narrow thorax. An initial sepsis evaluation revealed thrombocytopenia (platelet count, 60 × 103/μL [60 × 109/L]), leukopenia (white blood cell count, 3,700/μL [3.7 60 × 109/L]), and neutropenia (absolute neutrophil count [ANC], 703/μL [0.7 × 109/L]). The thrombocytopenia responds to platelet transfusion with subsequent normalization throughout the hospital stay. The neutropenia, however, persists. The patient has variable and usually nonsustained response to administrations of granulocyte colony-stimulating factor …

Children’s interstitial lung disease is a group of relatively rare pulmonary disorders that can present in the neonatal or early infancy periods. A classification scheme was developed in 2007 to aid clinicians and researchers in more accurate recognition and diagnosis. Infants who present with a prolonged oxygen requirement and/or persistent tachypnea may suffer from one of these conditions. Although more widely described afflictions, such as pulmonary hypoplasia or genetic errors of surfactant metabolism, may be considered in the differential diagnosis of these symptoms, a few of the remaining disorders have been only recently described, making them important entities to become familiar with in contemporary medical practice. This article describes the lesser-known conditions that have the potential to cause significant pulmonary disease in infancy.

On day 2 after birth, a term male infant began having episodes of tachypnea and oxygen desaturation to 60% to 70% during feeding, which self-resolved after removing the nipple. A chest radiograph showed a hazy opacity in the right lower lung field. Physical examination revealed an unlabored breathing pattern with equal air entry in all lung fields. (Figure 1). Figure 1. Figure 2. Right lung multicystic lesion. Figure 3. Right lung cystic lesion, with possible feeding vessel (anterior view). Figure 4. MRI repeated at 34 weeks’ gestation showed minimal regression of the mass, with continued multicystic appearance but no definitive mass effect (posterior view). ### Prenatal and Birth Histories The patient was not to have anything by mouth, but he continued to have frequent oxygen desaturation episodes without associated respiratory distress.

A 2½-day-old full term infant born by induced vaginal delivery to a 33-year-old G1P1 female with an uncomplicated pregnancy presents to the emergency department because of feeding refusal and severe apnea. She is found to have severe hypoglycemia and dehydration, but despite resuscitative efforts dies. Before presentation, at home the infant spit up yellow mucus-like material and had several episodes described as “lethargy” with stiffening of the legs. Appropriately vigorous at birth (Apgar scores of 9 at both 1 and 5 minutes), the infant received an initial feeding at the breast at 1 to 2 hours after birth. However, during the mother and infant's hospital stay, subsequent feedings were erratic with markedly decreased interest in feeding and decreased vigor noted in the nursery. A sepsis evaluation in the nursery was negative. Tests including a second newborn screen and urine organic acids were sent to the lab and the infant went home with results pending. A 39-week, 4.4-kg, male infant born to a 29-year-old primigravida woman with unremarkable serologies is admitted to the special care nursery due to tachypnea and persistent hypoglycemia. The pregnancy was complicated by fetal macrosomia, although the mother had a normal 1-hour glucose tolerance test. Delivery was complicated by fetal macrosomia requiring primary C-section and thick meconium at the time of artificial rupture of membranes. The patient cried at the abdomen and did not require further resuscitation. Blood sugar checked at 15 minutes after birth due to macrosomia was 43 and a repeat at 30 minutes after birth was 33. The patient was given oral formula with repeat dextrostix of 30 at 1 hour of age, prompting admission to nursery for intravenous dextrose administration and further evaluation. Admission weight is 4,470 g (>90%), length 56 cm (>90%), and head circumference 38 cm (>90%). Examination showed tachypnea with …

A 3,050-g term infant is born via spontaneous vaginal delivery to a 23-year-old now G1P1 woman. The pregnancy was complicated by oligohydramnios (diagnosed at 20 weeks' gestation). Maternal hepatitis surface antigen, human immunodeficiency virus, rapid plasma reagin, and group B streptococci test results were negative. Membranes ruptured spontaneously approximately 6 hours before delivery, and Apgar scores are 9 and 9 at 1 and 5 minutes, respectively. The infant is admitted to the neonatal intensive care unit at 19 hours of age for tachypnea and oxygen desaturations to 68% on room air associated with bottle feeding. He is started on 100% oxygen at 1 L/min by nasal cannula, which improves his respiratory status. On a repeat attempt at oral feeding, the infant has copious secretions, coughing, and “gurgling” sounds. “Nothing by mouth” is ordered while further evaluation is initiated. The initial complete blood count shows a white blood cell count of 16.1×103/μL (16.1×109/L) with 12% segmented neutrophils, 54% bands, 19% lymphocytes, and 10% monocytes; hemoglobin of 18.4 g/dL (184 g/L); hematocrit of 51.3% (0.513); and platelet count of 265×103/μL (265×109/L). A nasogastric tube is placed without difficulty. Chest radiograph findings are unremarkable (Fig. 1). Blood is drawn and antibiotics initiated until blood culture is negative at 48 hours. Figure 1. Anteroposterior chest radiograph shows clear lungs and a normal heart. The bulge on the right is due to a normal thymus gland. On physical examination, the infant has a temperature of 37.6°C, heart rate of 160 beats/min, respiratory rate of 64 breaths/min, and blood pressure of 65/35 mm Hg. Oxygen saturation is 90% on 1 L/min of room air by nasal cannula. Head examination reveals a soft anterior fontanelle and patent nares bilaterally with nasal cannula in place. Ear-nose-throat examination shows no anatomic abnormality. The …

A female infant born at 36 weeks to a 25-year-old G2P2 mother by normal spontaneous vaginal delivery after an uncomplicated pregnancy, presents with respiratory distress and shock at 1 month of age. She has had 2 days of increased work of breathing with tachypnea and tracheal tugging; 2 weeks of cough, rhinorrhea, and nasal congestion; and currently an episode of cyanosis lasting 2 minutes. Weight gain has been appropriate since birth. On physical examination, rectal temperature is 34°C, heart rate is 126 beats per minute, blood pressure is 58/31 mm Hg, and oxygen saturation is 40% in room air. The patient has prolonged capillary refill indicative of poor peripheral perfusion, coarse breath sounds with rhonchi bilaterally, and hepatosplenomegaly. A chest radiograph shows diffuse coarse bilateral interstitial opacities with lucency over the right middle lobe (Fig 1). Figure 1. Chest radiograph demonstrating bilateral diffuse coarse interstitial markings with subsegmental left lower lobe opacity, right mid-lobe lucency, and small right-sided pleural effusion. Initial laboratory studies include an arterial blood gas with pH of 7.03, a Pco2 of 70 mm Hg, calculated bicarbonate of 18 mEq/L, and a base excess of –13; the patient’s serum lactate level was 6.7 mmol/L. The white blood cell count is 25.6 × 103/μL (25.6 × 109/L) with 41% neutrophils and 38% band forms. The C-reactive protein level is 107 mg/L. The serum total bilirubin is 1.3 mg/dL, alanine aminotransferase is 22 U/L, and aspartate aminotransferase is 88 U/L. Her prothrombin time (PT) is 31.9 seconds (international normalized ratio: 3.1), and activated partial thromboplastin time (aPTT) is 51.9 seconds. The cerebrospinal fluid cell count (CSF) cell count, differential, protein, and glucose are normal. Samples of blood, urine, CSF, and endotracheal tube aspirate were sent for viral and bacterial culture and polymerase chain reaction assays. Quantitative …

A male infant is born via cesarean section due to fetal distress and bradycardia at 33 weeks' gestation. The G5P1, now P2, mother had three previous spontaneous abortions of unknown cause. Her prenatal course was otherwise uneventful, with serology results within normal parameters. Membranes are ruptured at the time of delivery, and Apgar scores of 7 and 9 are assigned at 1 and 5 minutes, respectively. The neonate is admitted directly to the neonatal intensive care unit (NICU) for preterm management and diagnostic evaluation. On admission, physical examination reveals a crying neonate who is difficult to console. Biometric measurements correspond to the 50th to 75th percentiles for head circumference, length, and weight. Vital signs are within normal range for gestation, and oxygen saturations are appropriate at room air. The remainder of the physical examination reveals no dysmorphic features, nonbulging fontanelle, equal red reflexes bilaterally, soft abdomen without masses, and no skin lesions. A peripheral intravenous line is placed without difficulty and blood is drawn for evaluation, including blood culture. Antibiotics are initiated until the cultures are negative at 48 hours. White blood cell count and hematocrit, including differential count, are appropriate for gestational age, but the platelet count is 51×103/mcL (51×109/L). Bottle feedings are initiated, but the infant continues to be inconsolable. Head ultrasonography reveals bilateral grade III intraventricular hemorrhages without progression on subsequent studies. During the infant's 5-week admission, serial blood studies show consistently low platelet values, ranging from 60 to 75×103/mcL (60 to 75×109/L). Pathologic evaluation of the peripheral smears reveal macrothrombocytopenia and blue-gray, spindle-shaped inclusion bodies within white blood cells. Further testing confirms the diagnosis. A nurse in the NICU reports that a 5-week-old male infant has tachypnea. He has had acute episodes of irritability while being fed formula …

A 26-year-old healthy gravida 3 woman (with history of two spontaneous pregnancy losses) delivers at term a 2,730-g female infant by normal spontaneous vaginal delivery. The second trimester maternal serum alpha-fetoprotein was elevated, and amniocentesis revealed normal female karyotype. The pregnancy was complicated by oligohydramnios (diagnosed at 20 weeks' gestation) that progressed to anhydramnios by 29 weeks' gestation. Fetal ultrasonography showed bilaterally enlarged echogenic kidneys (Fig. 1) and signs suggestive of a Dandy-Walker variant. Figure 1. Fetal ultrasonography at 20 weeks' gestation showing increased renal echogenicity. At delivery, the Apgar scores are 9 and 9 at 1 and 5 minutes, respectively. The baby develops tachypnea and is transferred to the neonatal intensive care unit on nasal continuous positive airway pressure. Initial physical examination reveals asymmetry of the head and face (right ear pinna “crumpled” and left ear pinna flattened), multiple positional contractures that are predominantly in the upper extremities, and clenched fists. Abdominal ultrasonography shows bilateral echogenic kidneys with small cysts predominantly at the periphery (Fig. 2). Figure 2. Renal ultrasonography showing mildly enlarged, echogenic kidneys with multiple small cysts, predominantly at the periphery. Neurosonography shows bilateral subependymal hemorrhages with small intraventricular hemorrhage and signs suggestive of lissencephaly. Magnetic resonance imaging of the brain confirms these findings. A 4-week-old male neonate presents to the clinic with a history of “noisy breathing since birth.” His mother reports that the noise is unaffected by crying, feeding, agitation, or position. She denies any history of fever, cyanosis, vomiting, choking, diaphoresis, murmur, or seizures. The infant was born at term, weighing 3,600 g, to a primigravida mother via normal vaginal delivery, and there were no perinatal complications. There are no findings of note on family history. The child is gaining weight satisfactorily on formula feedings. On physical examination, the well-nourished infant appears in no apparent distress. His …

A 2.9-kg female infant is born at 35 weeks' gestation to a 33-year-old G4P3 woman via cesarean section due to chronic hypertension complicated by superimposed preeclampsia. The mother's blood type is A-negative; the antibody screen is positive for anti-D, anti-C, and anti-G antibodies; she has no prior history of sensitization; and her serologies are negative. The Apgar scores are 7 and 9 at 1 and 5 minutes, respectively. At birth, the infant appears pale and exhibits tachycardia, moderate hepatosplenomegaly, tachypnea, and mild respiratory distress requiring supplemental oxygen. Complete blood count and blood cultures are obtained, and ampicillin and gentamicin are started. The admission hematocrit is 21% (0.21), with a reticulocyte count of 64%. An umbilical venous catheter is placed for intravenous (IV) access. The infant receives a transfusion of packed red blood cells for significant anemia associated with tachycardia. Prophylactic phototherapy is started because of Rh sensitization. The cord blood bilirubin measures 11.4 mg/dL (195 mcmol/L). The infant's blood type is A-negative, and the antibody screen is positive for anti-D and anti-C antibodies, with a positive direct Coombs test. The red blood cell phenotype reveals the presence of “C” antigen. This is a very uncommon antigen in an Rh-negative infant, but the antigen had stimulated the anti-C antibodies that traversed the placenta and caused severe hemolysis of the newborn. At 7 hours of age, the infant's bilirubin is 16 mg/dL (273.6 mcmol/L). She is given two doses of intravenous immune globulin, and phototherapy is intensified. After 24 hours of intensive phototherapy, the infant develops a large reddish-purple discoloration on her abdomen that resembles a severe burn (Fig. 1). The well-demarcated, erythematous, purpuric rash is present over the areas closely exposed to the phototherapy lights and does not blanch with diascopy. No vesiculobullous eruptions, edema, or tenderness is noted. The unexposed …

A 2,435-g male infant is born at 38 weeks gestational age to a 22-year-old G2P1001 woman who is blood group O+ and negative for group B Streptococcus. Labor had been induced for intrauterine growth restriction. Rupture of membranes with clear fluid occurred 3 hours before delivery, and the baby is delivered by emergency cesarean section for fetal bradycardia. Apgar scores are 8 at 1 minute and 8 at 5 minutes. The baby is suctioned by bulb and nasogastric tube. At 8 minutes of age, the baby's lungs sound wet, with a pulse oximetry reading of 68%, and 40% blow-by oxygen is started. By 15 minutes of age, he is breathing room air with a pulse oximetry reading of 98%. Physical examination in the newborn nursery yields normal results, with a Ballard score of 39 weeks, weight between the 10th and 25th percentiles, length at the 75th percentile, and head circumference at the 25th percentile. He has one low temperature of 35.4°C initially, but the capillary blood glucose measurements are 59 mg/dL (3.3 mmol/L) or more. He does well on formula feedings, with a weight loss of 15 g at 12 hours and 40 g at 36 hours. At 45 hours of age, after an uneventful hospital stay, the baby develops tachypnea and moderate intercostal and subcostal retractions. His pulse oximetry reading is 85% to 89%. He is placed on oxygen by nasal cannula, and an evaluation is undertaken that reveals the source of his respiratory distress. A 23-day-old male infant presents to the clinic because of persistent crying. Yesterday, he was seen in the emergency department, where colic was diagnosed. Today, his mother appears overwhelmed, stating that the baby cries throughout the day and night. She is concerned that the infant has abdominal pain or pain in his left …

A newborn boy is admitted to the neonatal intensive care unit (NICU) because of pallor and respiratory distress. His mother is a 32-year-old primigravida, who has type 2 diabetes mellitus and whose pre-pregnancy treatment with metformin was changed to insulin early in the pregnancy. In the first trimester, the mother had a throat infection that was treated with clarithromycin. Results of routine antenatal serologic screening, ultrasonography, and fetal echocardiography were normal. The mother presented to hospital with decreased fetal movements at 36 weeks and 3 days of gestation. Electronic fetal heart rate monitoring (EFM) was performed (Fig. 1) and she returned home. Several hours later, after review of the EFM record, she was recalled but could not be reached until the next morning, when EFM was repeated (Fig. 2). Figure 1. Initial electronic fetal heart rate monitoring strip. Figure 2. Second electronic fetal heart monitoring strip. A pale and nonvigorous male baby, who had a heart rate of 80 beats/min, was delivered by urgent cesarean section. He was resuscitated with bag-and-mask ventilation for 60 seconds followed by 100% free-flow oxygen; oxygen saturation was 75% at 3 minutes. His birthweight was 2.6 kg, his Apgar scores were 5 at 1 minute and 6 at 5 minutes, and his umbilical venous pH was 7.20. On admission to the NICU, the infant's physical examination shows extreme pallor, tachypnea, mild-to-moderate subcostal retractions, nasal flaring, and intermittent grunting. His oxygen saturation is 92% on nasal continuous positive airway pressure of 5 cm H2O and Fio2 of 0.35. Pulmonary and cardiac auscultation yield normal results. His pulse is weak and capillary refill time is 4 seconds. His heart rate is 200 beats/min and oscillometric blood pressure cannot be obtained. His liver and spleen are not palpably enlarged. Neurologically, he is alert but irritable, he has …

A 2.6-kg infant was born at 38 weeks’ gestation to a 16-year-old G1P0 woman. The prenatal history included maternal Chlamydia infection. The baby was delivered via emergent cesarian section because of nonreassuring fetal heart tones. His Apgar scores were 7 and 9 at 1 and 5 minutes, respectively. He exhibited tachypnea and hypoxia at birth, with a respiratory rate of 80 to 100 breaths/min, grunting, chest retractions, and coarse breath sounds. Other than a mild systolic ejection murmur, the remainder of the physical examination findings were normal. The baby's A-a gradient (a measure of the difference in the partial pressure of oxygen in the alveolar spaces and the arterial blood) was elevated, initially 473 mm Hg on 100% Fio2. Chest radiographs showed no signs of acute air space disease for the first several postnatal weeks. Over the next several months, the infant continues to have a respiratory rate of 60 to 90 breaths/min, with increased work of breathing, gradually requiring increases in supplemental oxygen to achieve an Spo2 in the mid-90s. Chest computed tomography (CT) scan performed at 2 weeks of age showed attenuation of the pulmonary vasculature and hyperinflation of the lungs. Although motion artifact limited the evaluation, the chest CT showed no focal lung opacities and no other anatomic defects. Repeated echocardiography revealed a small patent foramen ovale (left-to-right shunt) and normal ventricular size and function. Multiple therapies are tried without obvious …

At 4 days of age, an infant was admitted to the county hospital with an elevated temperature and poor feeding. He was treated for 3 days for presumed sepsis. Two days after discharge, he develops tachypnea and jittery movements and is admitted to the university hospital. Upon arrival, he is having a tonic-clonic seizure that lasts for 5 minutes, followed by a hypotonic phase. ### Prenatal History and Birth History: ### Initial Hospital Course: The baby is transferred to the neonatal intensive care unit where physical examination reveals hyperirritability, a bulging fontanel, tachypnea, and mild dehydration. Lumbar puncture reveals 400 cells/mm3, and cefotaxime plus amikacin are administered empirically for meningitis. Computed tomography (CT) scan demonstrates ventricular dilatation and gaping of cranial sutures (Fig. 1). Figure 1. An extraventricular catheter is placed for drainage. During the course of therapy, Escherichia coli is isolated from the cerebrospinal fluid and blood cultures. …

A 4-day-old preterm male infant presents with respiratory failure requiring 100% oxygen on assisted ventilation. ### Prenatal History: ### Birth History and Presentation: The infant was delivered by the vaginal route in vertex presentation. He had initial poor respiratory effort, but responded to warming, stimulation, and blow-by oxygen. Apgar scores were 7 at 1 minute and 8 at 5 minutes. He continued to demonstrate increased work of breathing and was intubated in the delivery room. He was admitted to the neonatal intensive care unit (NICU) for prematurity and respiratory distress. His birthweight was 1,589 g, which was appropriate for gestational age. Thirty minutes after birth, the patient had worsening tachypnea and subcostal retractions; chest radiograph at this time demonstrated diffuse bilateral reticular granular densities and microatelectasis CXR 1 . Oxygen saturation in room air was 78%. When 100% oxygen was administered, the oxygen saturation increased to 92%. Arterial blood gas (ABG) revealed: What is the appropriate treatment of this infant at this time? On arrival to the NICU, the patient was intubated and placed on mechanical ventilation. An echocardiogram revealed normal cardiac structure and function. The blood lactate level was elevated at 225.2 mg/dL (25 mmol/L). Blood ammonia concentration also was elevated at 518 mmol/L. Ketones were noted in the urine. ### Vital Signs Were: ### Physical Examination

After completing this article, readers should be able to: 1. Differentiate between cardiac and respiratory causes of cyanosis. 2. Describe the primary parenchymal diseases that can cause respiratory distress in the neonate. 3. Describe the primary developmental lung abnormalities that can cause respiratory distress in the neonate. One of the most common reasons for admission of term neonates to a neonatal intensive care unit (NICU) is respiratory distress. (1) The cause may be of pulmonary or nonpulmonary origin. The nonpulmonary causes include cardiac, infectious, metabolic, central nervous system, and miscellaneous conditions. This review focuses on the major pulmonary causes for respiratory distress in term infants, in particular, the first two of the four groups that appear in Table 1. (2) | Parenchymal conditions | || | Developmental abnormalities | | Airway abnormalities | | Mechanical abnormalities | Table 1. Potential Pulmonary Causes for Respiratory Distress in Neonates Differentiating cardiac and respiratory causes of cyanosis is a common clinical problem, particularly in cases in which there is little or no tachypnea or respiratory distress. The major signs of neonatal respiratory distress are tachypnea and cyanosis, in which tachypnea is defined as a respiratory rate consistently greater than 60 breaths/min. A hyperoxia test may assist in differentiating between the two. Pulse oximetry may help to decide whether a formal hyperoxic test is useful. A neonate who exhibits cyanosis without marked respiratory distress and has an O2 saturation of less than 85% in both room air and 100% oxygen likely has an intracardiac shunt. If the O2 saturation increases to more than 85% on 100% oxygen, …

At 2 days of age, a term female newborn infant is evaluated for tachypnea. She was born at 40 weeks’ gestation, with birthweight 4.6 kg, to a 34-year-old G2P2 woman via normal spontaneous vaginal delivery. Maternal history is pertinent for well-controlled gestational diabetes mellitus and hypothyroidism treated with levothyroxine. Prenatal laboratories are significant for group B Streptococcus positivity for which the mother was adequately treated. All other prenatal laboratories are unremarkable. The delivery was complicated by a nuchal cord and apnea requiring positive pressure ventilation for 10 seconds. Apgar scores were 6 at 1 minute and 9 at 5 minutes. A review of her vital signs from the newborn nursery reveal the following: heart rate, 128 beats per minute; respiratory rate, 52 breaths per minute; and oxygen saturation, 89% in room air that had improved without supplemental oxygen. Her respiratory rate is 82 breaths per minute, and pre- and postductal oxygen saturations are 97% in room air. On physical examination, she is consistently tachypneic, as noted by multiple caregivers, with minimal subcostal retractions but without grunting or flaring. The remainder of her examination is within normal limits. Basic metabolic panel, capillary blood gas, and complete blood count are all normal. A chest radiograph is read as unremarkable (Fig 1A). Blood cultures are drawn, but given a low risk for sepsis, antibiotics are not started. A cardiologist is consulted for sustained tachypnea and a new grade I/VI systolic murmur in the left lower sternal border. An echocardiogram …

Twins (31 3/7 weeks) were born to a 31-year-old healthy mother with a pregnancy remarkable for an accidental administration of epinephrine at 10 3/7 weeks. The mother was experiencing severe hyperemesis gravidarum for which her physician ordered intravenous (IV) dolasetron mesylate (Anzemet®, sanofi-aventis, Bridgewater, NJ), but the outpatient nurse unintentionally administered epinephrine instead. The nurse gave the mother 1 mL of the 1:1,000 concentration of IV epinephrine. In adults, the dose of epinephrine for anaphylaxis is 1 mL of 1:1,000 solution intramuscularly or subcutaneously, and for cardiac arrest, it is 1 mL of 1:10,000 intravenously. The plaintiff experts pointed out that this mother received a concentration of epinephrine 10-fold higher than that used for cardiac arrest; for the 10-week fetuses, they were likewise exposed to a mega-dose. The mother immediately became pale and dizzy and developed chest pain, shortness of breath, tachycardia, and hypertension. An electrocardiograph showed a subendocardial myocardial infarction. A perinatologist closely observed the twins before and subsequent to this event. The twins were diamniotic monochorionic (DiMo) males as a result of in vitro fertilization (IVF). A week after the epinephrine administration, the mother experienced vaginal bleeding and an ultrasound showed a “possible subchorionic hematoma.” At 14 5/7 weeks’ gestation, 30 days after the epinephrine mishap, discordance was noted in the twin size (121 g and 96 g). The larger twin had polyhydramnios, for which 220 mL of red-brown amniotic fluid was removed. Both bladders were visible. No further amnioreduction was needed for the remainder of the pregnancy. The twin-to-twin transfusion syndrome (TTTS) met the least severe grade of the Quintero grading system (I of V). At 30 4/7 weeks’ gestation, the mother experienced a mild brownish discharge. On external monitoring, regular uterine contractions were occurring. The mother was admitted for IV tocolysis and antenatal steroids, …

A 2-hour-old term female infant presents with respiratory distress and oxygen desaturation requiring 100% oxygen. ### Prenatal history ### Birth history ### Presentation

A 2,816 g female infant is born to a 21-year-old woman pregnant for the first time. Pregnancy is uneventful until she presents with a complaint of decreased fetal movement at 34-weeks’-gestation. Emergency cesarean delivery is performed due to persistent sinusoidal pattern on prolonged fetal heart rate monitoring and an abnormal biophysical profile score of 4 of 10. Cord blood gases are as follows: pH of 7.38; partial pressure of carbon dioxide, arterial, of 40 mm Hg; partial pressure of oxygen, arterial, of 31 mm Hg; and base excess of –1.4 mmol/L. Delivery is attended by the high-risk team, including a neonatologist. Apgar scores are 4 and 8 at 1 and 5 minutes, respectively. The infant required positive pressure ventilation for a brief period of time due to delayed initiation of spontaneous breathing and blow-by oxygen thereafter for mild respiratory distress and generalized pallor. On admission to the NICU, the infant is noted to have continuing respiratory distress, with tachypnea, retractions, and desaturations to the low 80s, which prompts intubation and surfactant administration. Radiograph of the chest shows findings consistent with surfactant deficiency. Despite generalized pallor, the rest of the infant’s vital signs are within normal limits without evidence of hypovolemic shock. Physical examination findings display absence of jaundice, petechaie, purpura, birthmarks, hepatosplenomegaly, dysmorphic features, or birth defects. A stat hematocrit determination reveals a value of 17% with a hemoglobin value of 5 g/dL. An intravenous infusion of D10W is begun at 60 mL/kg per day, and a packed red …

A 2-day-old male infant is transferred urgently from another hospital to the emergency department for sudden onset of cyanosis, tachypnea, retractions, and hypoactivity. Head swelling is noted. The infant was born by cesarean section to a G3P2L2 mother whose pregnancy and delivery were uneventful by report. Prenatal course was unremarkable. Maternal serologies were not available. On arrival, the infant is noted to have generalized severe pallor; he is unconscious and flaccid with extended extremities. His heart rate is 69 beats per minute and falling; his capillary refill is delayed with nonpalpable peripheral pulses. He has no spontaneous movements and is unresponsive to painful stimuli. His pupils are fixed, dilated, and nonreactive to light bilaterally. Head examination reveals open anterior and posterior fontanelles, with a left frontoparietal fluctuant edema extending to the neck. Immediate resuscitation is initiated, including endotracheal intubation, chest compressions, medications (epinephrine), and fluid resuscitation with normal saline then O negative packed red blood cells via an intra-osseous line. Placement of an umbilical venous line is not attempted because of dry umbilical stump. Attempts at obtaining arterial or venous blood gas fail due to poor perfusion. Further details in the history, physical examination, and imaging studies reveal the diagnosis. Further details reveal a history of head trauma 2 hours before presentation. The infant had fallen on the concrete ground during routine bathing care. Immediately after the fall, the infant was reported to be active; however, shortly thereafter, he became less active and cyanotic requiring oxygen support. Upon presentation, detailed examination reveals a boggy fluid collection on the left frontoparietal area extending to the neck with a ballotable fluid wave beneath the scalp. Skull radiograph reveals two comminuted and displaced fractures of the left parietal …

A 3,915-g term infant is born to a 19-year-old primi gravida. The mother has received regular prenatal care and her pregnancy is uneventful. She is negative for HIV, syphilis, and hepatitis B and is Rubella immune. She smoked marijuana during pregnancy, but denies any other substance abuse. She ruptures her membranes 14 hours before the delivery and has clear amniotic fluid. The infant is delivered by normal spontaneous vaginal delivery, which is complicated by shoulder dystocia. Apgar scores are 5, 7, and 9 at 1, 5, and 10 minutes, respectively. Soon after delivery, the infant is noted to have subcostal retractions. Clinical examination reveals an appropriately grown term infant who has tachypnea and subcostal retractions. Her right arm is noted to be extended and internally rotated with pronated forearm. She is also noted to have a large left-sided parieto-occipital scalp swelling. The rest of the examination is normal. Pulse oximetry measurement on the right hand shows 81% to 82% saturations in room air. The infant is transferred to ICU and is started on 40% supplemental oxygen, 2 L per minute by nasal cannula. The oxygen concentration is gradually increased to 100%, but the saturations remain in low 80s. A preductal arterial blood gas on 100% oxygen showed a pH 7.29, PCO2 47, PO2 50, and base excess of −4. In view of the persistent hypoxemia and desaturations, she is endotracheally intubated and mechanically ventilated. Blood is drawn for culture and complete blood cell count and she is commenced on ampicillin and gentamicin. The clinical findings along with the chest radiograph (Fig) suggest the diagnosis. Further investigations confirm the suspicion. Figure. Chest radiograph of the infant prior to intubation. …

A preterm male newborn presents with hypotonicity and respiratory distress that includes tachypnea, intercostal retractions, and cyanosis. ### Prenatal History: ### Birth History: ### Presentation: The baby did not cry at birth and was resuscitated with a bag and mask. Because of bradycardia, tachypnea, and cyanosis, the infant was transferred to the neonatal intensive care unit for ventilatory support. …

A 4-hour-old term female infant presents with respiratory distress that includes tachypnea, grunting, retractions, and cyanosis. ### Prenatal History: ### Birth History: ### Presentation: Four hours after birth, because the patient exhibits tachypnea and appears dusky, she is transferred to the neonatal intensive care unit. She is not breastfeeding. Nasal continuous positive airway pressure (NCPAP) with 5 cm of H2O is administered, but the …

A 45-day-old male baby presents to the neonatology outpatient department with a 4-day history of stridor. The mother reports that he had a sudden onset of tachypnea and feeding difficulty with normal body temperature. The pregnancy was uneventful, and the birth proceeded without complications or active resuscitative measures. The baby was discharged on postnatal day 4 and has been asymptomatic until the recent development of stridor. Physical examination reveals inappropriate tachypnea, inspiratory stridor, and difficulty in feeding. The axillary temperature is normal, and oxygen saturation is 92% in room air. The complete blood count, electrolytes, blood urea nitrogen, serum creatinine, and C-reactive protein values are within normal limits. Chest radiograph appears normal. Neonate presenting with respiratory distress