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  • Because of a neonate's limited number of activities, presenting symptoms are rather limited.
  • Every sick neonate must have a bedside blood sugar checked as soon as possible and hypoglycemia treated immediately.
  • Children with both pulmonary and cardiac defects can appear normal initially because of the existence of the foramen ovale and the ductus arteriosus, with symptoms appearing days after discharge when the right and left sides of the heart become completely isolated.
  • Inborn errors of metabolism associated with well-defined clinical syndromes are generally identified early. In contrast, those conditions associated with a single hormone or enzyme defect may go undetected until a toxic metabolite accumulates or an electrolyte or endocrine catastrophe occurs.
  • An ominous sign in any newborn is bilious emesis.


The first 30 days of the life of a child can be a very revealing time in the life of a child both for parents and for medical personnel. In utero, the fetus is protected from metabolic and anatomic anomalies by its relationship with the placenta and maternal circulation. Once delivery occurs, the child must be self-sustaining; and if a congenital problem exists, maternal compensatory effects are no longer available.


Aside from the expansion of the lungs, most of the physiologic changes associated with birth occur gradually. As such, many congenital problems will not become clinically evident until hours to weeks after birth and may not occur until after discharge from the nursery.


Because of a neonate's limited number of activities, presenting symptoms are rather limited. Changes in level of consciousness, respiratory distress, feeding or stooling difficulties, or abnormal motor activities are complaints that lead a parent to bring their infant to the emergency department (ED). Unfortunately, the specific cause of the presenting symptoms may have nothing to do with the origin of the child's pathology, and it is the emergency physicians' responsibility to discover the underlying cause of the concerning behavior. This chapter will discuss the ED presentation and management of these neonatal emergencies.


Because of the limited history and physical findings in this age group, much of the evaluation of ill-appearing neonates is protocol driven. All sick neonates should have a capillary glucose determination and pulse oximetry as part of their initial assessment on arrival to the ED. Other studies that should be included as part of the ED evaluation are complete blood count, electrolyte panel with sodium, potassium, bicarbonate, calcium, glucose, BUN and creatinine, blood cultures, urinalysis, urine culture, and chest x-ray. Lumbar punctures, electrocardiograms, electroencephalograms, and diagnoses-specific studies may also be ordered as the clinical scenario dictates. Sepsis is the primary cause of an ill-appearing neonate and is discussed at length in Chapter 2.


In utero, all oxygen requirements are handled through the placenta. Anatomic problems in the lungs and heart are masked because in effect the fetus requires only a single heart chamber to circulate oxygenated blood. In addition, because of multiple internal shunts within ...

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