Neonatal Distress Causes

Aka: Neonatal Distress Causes, Neonatal Distress, Crashing Neonate, Crashing Newborn, Newborn Distress, THE MISFITS Mnemonic, SSICCCFIT Mnemonic, TAMM Mnemonic, DATA Mnemonic, Neonatal Distress Risk Factors

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II. Causes: Common

  1. Serious Bacterial Infection (SBI)
    1. See Neonatal Sepsis
    2. Fever (or Hypothermia) is associated with serious Bacterial Infection in 10% of age <2 weeks and 5% of age 2-4 weeks
    3. Start empiric antibiotics for Neonatal Sepsis in undifferentiated Newborn Distress until cause identified
  2. Congenital Heart Disease
    1. Most likely cause in a hemodynamically unstable infant with normal Temperature
    2. Congenital Heart Disease affects up to 0.3% of live births (contrast with 0.001% for neonatal Septic Shock)
    3. Examine for rales, murmurs, Hepatomegaly and obtain Chest XRay
    4. Early Echocardiogram (consider bedside Rapid Ultrasound for Shock and Hypertension)
    5. Distinguish ductal dependent pulmonary Blood Flow from ductal dependent systemic Blood Flow
  3. Inborn Errors of Metabolism
    1. Typically identified on modern Newborn Screening, but manifestations may precede lab results
    2. Initial empiric management includes Intravenous Fluid and dextrose (D10)
    3. Obtain and manage ammonia levels (neurotoxic)
  4. References
    1. Sloas, Checchia and Orman in Majoewsky (2013) EM: Rap 13(9): 8
    2. Claudius and Kallay in Swadron (2023) EM:Rap 23(5): 9-10

III. Causes: Delayed Presentation (e.g. Emergency department)

  1. Mnemonic: THE MISFITS
    1. Tumor, Thermal, Trauma (Non-accidental Trauma)
    2. Heart disease, Hypovolemia, or Hypoxia
    3. Endocrine
      1. Hyperthyroidism
      2. Congenital Adrenal Hyperplasia
    4. Metabolic disease
      1. Electrolyte disturbances
    5. Inborn Errors of Metabolism
    6. Sepsis
    7. Formula or Feeding abnormalities (Too concentrated or dilute)
    8. Intestinal Emergencies
      1. Volvulus
      2. Intussusception
      3. Necrotizing Enterocolitis
      4. Incarcerated Hernia
      5. Diaphragmatic Hernia
    9. Toxins
    10. Seizures
  2. Mnemonic: SSICCCFIT
    1. Sepsis
    2. Seizures
    3. Inborn Errors of Metabolism
    4. Congenital Adrenal Hyperplasia
    5. Congenital Heart Disease
    6. CNS Hemorrhage
    7. Formula
    8. Intestinal
    9. Toxins

IV. Causes: Immediate (follows delivery)

  1. Mnemonic: TAMM
    1. Trauma
    2. Asphyxia
    3. Medications
    4. Malformations
  2. Mnemonic: DATA
    1. Drugs
    2. Asphyxia
    3. Trauma
    4. Anomalies
  3. Specific Causes of peripartum distress
    1. Intrauterine Asphyxia
    2. Depressants and other Medications (maternal)
      1. Opioid Abuse or prescribed Opioids
      2. Barbiturates
      3. Local Anesthesia
      4. Alcohol Abuse
      5. Magnesium
      6. Lithium Carbonate
      7. Beta Blockers
    3. Trauma
      1. Cerebral edema
      2. Cerebral Hemorrhage (rare)
    4. Congenital Anomalies or Malformations
    5. Prematurity
    6. Mechanical airway obstruction
    7. Parenchymal lung disease
    8. Neurologic disorders

V. Risk Factors: Antepartum

  1. See causes as above
  2. Maternal conditions
    1. Diabetes Mellitus (or other maternal serious chronic comorbidity)
    2. Pregnancy Induced Hypertension
    3. Maternal Anemia
    4. Late Pregnancy Bleeding
  3. Other Maternal factors
    1. Maternal age <17 years old or over age 38 years old
    2. Limited or absent Prenatal Care
    3. Maternal Substance Abuse
  4. Fetal Status
    1. Multiple Gestation
    2. Oligohydramnios or polyhydramnios
    3. Small for Gestational Age
    4. Postterm Pregnancy
    5. Preterm Infant (especially if < 1500 g or immature Fetal Lung Maturity)
    6. Decreased fetal activity

VI. Risk Factors: Intrapartum

  1. Maternal factors
    1. Chorioamnionitis (or other serious infection)
    2. Maternal medications (Analgesics, sedation)
    3. Placental Abruption
    4. Cesarean Section
    5. Assisted Delivery (Vacuum Assisted Delivery, Forceps Assisted Delivery)
    6. Prolonged or Arrest of the Second Stage of Labor
    7. Premature Labor
    8. Precipitous Delivery
    9. Meconium stained amniotic fluid
  2. Fetal Status
    1. Fetal Distress
    2. Malpresentation (e.g. Breech)
    3. Prolapsed Cord

VII. References

  1. (2016) CALS Manual, 14th ed, p. I-198
  2. Claudius, Behar, Nichols in Herbert (2015) EM:Rap 15(1): 3-4
  3. Spangler, Claudius, Behar and Nicholas in Herbert (2016) EM:Rap 16(9): 11-3

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