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An Atlas of

NEONATOLOGY
Medical care should be humane, and painless;
ideally promotive, preferably preventive, desirably
curative, at times rehabilitative and always
reassuring and consoling
ML Kulkarni

An Atlas of
NEONATOLOGY

ML Kulkarni
MD (Ped), FIAP, FAMS, FIMSA, FRCPCH (UK), FCPCC (LON),
FICP (USA), PhD (Gen. Anthr.), MNAS (NY)

Professor and Head


Department of Pediatrics
JJM Medical College
Devangere, Karnataka
Editorial Assistants
KS Keshavamurthy
P Rajappan Pillai
Preethi M Kulkarni

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An Atlas of Neonatology
2005, ML Kulkarni
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted
in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior
written permission of the author and the publisher.
This book has been published in good faith that the material provided by author is original. Every effort is made
to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any
inadvertent error(s). In case of any dispute, all legal matters to be settled under Delhi jurisdiction only.
First Edition: 2005
ISBN

81-8061-518-9

Typeset at JPBMP typesetting unit


Printed at Ajanta Offset

Dedicated to
My parents
Late Sri Laxmanrao B Kulkarni
and
Late Smt Sharadabai L Kulkarni
who are with God

Preface
The value of a picture cannot be underestimated. The popular sayings like a picture is worth thousand words
and seeing is believing are the testimony for it. Unlike in textual material, the pictures in an atlas hardly need
updating. Older the picture, more value it has like an old wine and an old friendship. Further, very old pictures
may even attain antique values and deserve to be only preserved and protected.
At one end, a collection of only pictures makes an attractive album. Whereas, at the other extreme, a long
text results in monotonous monogram. In an atlas, a blend of believing beauty of a picture and authentic
account of the text give it a unique place in educational tools. It is the general tendency of an average student
to skip reading of pictures and tables, when reading a textbook not realizing their importance. In an atlas, the
very name invites or may even compel the student to read the picture. This we feel is a special advantage of
possessing and reading an atlas, especially in a subject like neonatology, where few atlases are available.
Neonatology is a speciality with a large visual content in it. Some topics like congenital malformation,
dysmorphic syndromes, birth injuries, normal variants in newborn, physical characters of preterm and small for
date babies are largely visual. Whereas, topics like neonatal sepsis, congenital heart diseases etc have less visual
content. To overcome this problem we have incorporated few line diagrams, flow charts and tables to emphasize
the content. More than one photograph of the same condition (of course from different patients) is given in
chapters on congenital malformations and genetic syndromes to help the reader to develop better mental picture.
ML Kulkarni

Acknowledgements
Several postgraduates who have intellectually-interacted with me over the last 29 years need special
acknowledgement. Shri JP Vij, Chairman and Managing Director of Jaypee Brothers Medical Publishers (P) Ltd,
New Delhi who mooted the idea of producing the Atlas of Neonatology and his team for the excellent work.
I also thank the following postgraduate students who helped in the preparation of this book.
(Drs) Sarfraz Navaz, Anuj Sehegal, Prem Alva, Abdul Manaf, AS Savadi, Chidanada, Apporva, Mayi Gowda,
Ram Gopal Shastri, Shankar, Zaheerudin Mohamed, Anant Gupta, Thippeswamy, Nagendra, Naveen, Jaggannath,
Girish Hadli, Anoop Damodar, Vani, Praveen Prabhu and Sredhar.

Contents
1. Nomenclature ....................................................................................................................... 1
2. Labor Room Procedures ....................................................................................................... 4
3. NALS .................................................................................................................................... 8
4. Routine Care of the Newborn ............................................................................................. 16
5. Neonatal Immunization ....................................................................................................... 22
6. Traditional Practices .......................................................................................................... 27
7. Physical Examination of the Newborn ................................................................................ 31
8. Normal Variants ................................................................................................................. 43
9. Stool Cycle in Newborn ..................................................................................................... 52
10. Neonatal Reflexes .............................................................................................................. 54
11. Gestational Age Assessment .............................................................................................. 59
12. Anthropometry .................................................................................................................... 67
13. Classification of Newborns and Problems of Low Birth Weight ........................................ 80
14. Clinical Assessment of Nutrition Status (CANS) at Birth .................................................. 84
15. Feeding of Newborns.......................................................................................................... 89
16. Neonatal Jaundice ............................................................................................................ 102
17. Birth Injuries .................................................................................................................... 114
18. Neonatal Sepsis ............................................................................................................... 125
19. Common Neonatal Infections ........................................................................................... 128
20. Intrauterine Infections ...................................................................................................... 135
21. Perinatal HIV Infection ..................................................................................................... 140
22. Hypoxic Ischemic Encephalopathy ................................................................................... 148

xii

An Atlas of Neonatology

23. Problems of Temperature Regulation ............................................................................... 150


24. Neonatal Convulsions ....................................................................................................... 155
25. Bleeding Neonate ............................................................................................................. 160
26. Infants of Diabetic Mothers .............................................................................................. 163
27. Neonatal Anemia .............................................................................................................. 166
28. Respiratory Distress ......................................................................................................... 171
29. Congenital Heart Disease ................................................................................................ 176
30. Twins ................................................................................................................................ 182
31. Examination of Placenta ................................................................................................... 191
32. Congenital Malformations ................................................................................................ 200
33. Genetic Syndromes .......................................................................................................... 266
Appendices ....................................................................................................................... 351

Index .................................................................................................................................................... 385

Nomenclature

Understanding of proper, and uniform nomenclature


is important in classifying newborns, in anticipating
problems, for demographic purpose, and interpersonal
communication. Below we describe commonly used
terms in neonatal/perinatal practice.
Live Birth
Live birth is complete expulsion or extraction of products
of conception from its mother irrespective of duration
of pregnancy, which after such separation, breathes or
shows any other evidence of life, such as beating of heart,
pulsation of the umbilical cord, definite movement of
voluntary muscles, whether or not the umbilical cord
has been cut or the placenta is attached.
Fetal Death
Early fetal death (abortion): Death of a fetus having
birth weight of less than 500 g, or gestation of less than
22 weeks, or crown-heel length less than 25 cm.
Intermediate fetal death (abortion): Death of fetus
having birth weight between 501 and 1000 g, or
gestation between 22 and 28 weeks, or crown-heel
length between 25 and 35 cm.
Stillbirth (late fetal death): Death of a fetus having birth
weight of 1000 g, gestation of more than 28 weeks,
or crown-heel length of more than 35 cm.
The terms birth weight and gestation are defined
later.
Perinatal period: The perinatal period is most often
defined as a period from 28 weeks of gestation through

the 7th day after birthWHO. Other additional


definitions include:
1. 20 weeks of gestation to 7 days after birth,
2. 20 weeks of gestation to 28 days of life.
Neonatal period: The neonatal period is defined as
less than 28 days of life and it may be subdivided into
period 1 (Birth to <24 hours), period 2 (24 hours to
<7 days), and period 3 (7 to 28 days).
Birth Weight Groups
Low birth weight (LBW)birth weight less than
2500 g.
High-risk low birth weight (HRLBW)birth weight
less than 2000 g.
Very low birth weight (VLBW)birth weight less
than 1500 g.
Extremely low birth weight (ELBW)less than 1000 g.
Gestational Age
The duration of gestation is measured from the first day
of the last menstrual period (LMP). Gestational age is
expressed in completed days or completed weeks.
Gestational Groups
Pretermless than 37 completed weeks or less than
259 days.
Termfrom 37 completed weeks to less than
42 completed weeks or 259 to 294 days.
Posttermmore than 42 completed weeks or more
than 295 days.

An Atlas of Neonatology

Birth Weight/Gestational Age Group


Small-for-gestational age (SGA)Babies with a
birth weight of less than 10th percentile for that period
of gestation.

Table 1.2: Categories of causes of perinatal death


Maternal

Fetal

Maternal age
<18> 35 yrs

Prematurity Birth injuries

Large-for-gestational age (LGA)Babies with a


birth weight greater than 90th percentile for that period
of gestation.

High parity

SGA

Asphyxia

Maternal anemia

Twins

Infections including tetanus

Toxemia

Congenital malformations

Adequate-for-gestational age (AGA)Babies with


a birth weight between 10th and 90th percentile for
that period of gestation.

Poor spacing

Hypothermia

Perinatal Period
From 28 weeks of gestation to first 7 completed days
(168 hours) of life.
Neonatal Period
First 28 days of life. Early neonatal period refers to the
first 7 days (168 hours) of life, while late neonatal
period signifies the period from more than 7 days to
28 days of life.
Perinatal Mortality Rate (PMR)
Perinatal mortality rate (PMR) is defined as late fetal plus
early neonatal (first week) deaths of babies weighing
more than 1000 g (or 28th weeks of gestation or more)
at birth per 1000 total births weighing over 1000 g.
Important causes are listed in Table 1.1.
Stillbirths (>1000 g) + early
neonatal deaths (>1000 g)
Perinatal = 1000
mortality rate Total births weighing >1000 g
Table 1.1: Causes of perinatal mortality and their
percentage
Causes of death
Asphyxia
Prematurity, low birth weight
Congenital malformations
Septicemia
Respiratory distress syndrome
Anemia
Birth trauma
Multiple factors
Undetermined

Percentage
41.6
17.9
6.7
2.4
2.2
1.5
1.2
11.0
15.5

Source: Ministry of Health and Family Welfare, Govt. of India,


1983.

Infants

Prediabetes or
diabetes
Present perinatal mortality is 44.3 per 1000 births (1993)
(Shanti Ghosh) and is 3-4 times more in LBW babies.

Extended Perinatal Mortality Rate


Extended PMR is defined as late fetal plus early
neonatal deaths weighing more than 500 g at birth per
1000 total births weighing over 500 g
Stillbirths (>500 g) + early neonatal
death (>500 g)
Extended = 1000
perinatal
Total births weighing >500 g
mortality rate

Neonatal Mortality Rate (NMR)


Neonatal mortality rate (NMR) is defined as neonatal
deaths of babies weighing more than 1000 g at birth
per 1000 live born infants weighing over 1000 g.
Importance of NMR is that it accounts for 60 percent
of infant mortality (Table 1.3).
Neonatal deaths weighing
>1000 g at birth
Neonatal = 1000
mortality rate Live born infants weighing
>1000 g
(Present status, 1991, NMR: 51.1)
Table 1.3: Causes of neonatal mortality

Immaturity
Birth asphyxia
Infections
Congenital malformations
Others like birth trauma

Extended Neonatal Mortality Rate


The extended neonatal mortality rate can be calculated
by including babies weighing up to 500 g or more at

Nomenclature

birth per 1000 live born infants weighing 500 g or


more.
Neonatal deaths weighing
>500 g at birth
Extended = 1000
neonatal
Live born infants weighing
mortality rate
>500 g

Infant Mortality Rate (IMR)


Infant mortality rate is the ratio of deaths under 1 year
of age in a given year to the total number of live births
in the same year, usually expressed as a rate per 1000
live births. Present rate is 74/1000.
No. of children dying under
1 year of age
Infant =
1000
mortality rate
Total No. of live births
(Source: 1994 Sample Registration System, Registrar General,
Govt. of India).

Causes

Fig. 1.1: Graphical representation of neonatal terminologies

1.
2.
3.
4.

ARI.
Diarrhea.
Under nutrition.
Infections.

An Atlas of Neonatology

Labor Room Procedures

Transition from fetal physiology to a neonatal one is


an important event that determines well-being of a
newborn infant. Most babies have this transition
without any problem. Some unfortunate ones may
have difficulty in needing assistance for intact survival.
In some other, immediate attention may contribute for
better survival. The initial assessment includes helping
the baby to adjust to new environment after proper
assessment. The following description is confined to
normal term baby with vertex presentation. Further
related information is given in Chapters 3 and 4.

STEPS
1. Head is the first part to be delivered in vertex
presentation. Immediately after head is born,
finger should be slipped in to detect presence of
cord round the neck. If a loop of cord is found
it should be either slipped over the head or cut
between clamps (Figs 2.1a to c).

Fig. 2.1a: Head delivery in vertex presentation

Fig. 2.1b: Cord round the neck. Note three loops of cord
around the neck. Twisted cord is also seen

Fig. 2.1c: Loop of cord around neck, slipped over the head

Labor Room Procedures 5

Fig. 2.2: Suctioning of the mouth after delivery

2. Suctioning: To minimize the risk of aspiration of


amniotic fluid, meconium or blood, nose and
mouth should be suctioned immediately after the
delivery of head before the baby takes its first
birth. This step is extremely important in preventing aspiration of meconium and its complications.
Care should be taken to clear mouth first followed
by nose. This is because if nose is suctioned first
suctioning acts as a strong stimulus to initiate
breathing and results in aspiration of throat
secretions (This can be remembered as M comes
before N in alphabets) (Fig. 2.2).
3. Cutting the cord: The umbilical cord is cut between
2 clamps placed 4 or 5 cm from the babys
abdomen. After this the baby is handed over to
the neonatologist (Fig. 2.3).

Fig. 2.3: Cutting the cord. Note cord being cut in between
the clamps

Fig. 2.4: Drying the baby under 200 watt bulb

4. Initial steps of resuscitation: Immediately after


receiving, the baby should be dried using prewarmed clothes under a radiant warmer. After
this, baby is assessed for respiration, heart rate and
other vital signs. If found stable it is proceeded
further or else it should be resuscitated. Further
details about this are given in Chapter 3 (Fig. 2.4).
5. Clamping the cord: Clamp is applied 2 or 3 cm
from the babys abdomen. Usually a plastic clamps
with double grip is used, other methods of clamping
are using thread or rubber band (Fig. 2.5).
6. Tying the identif y band: This is an equally
important step. As soon as the baby is stabilized,
name band containing mothers name, time and
date of birth should be tied to the wrist or ankle
(Fig. 2.6).
7. Eye care: Eye should be wiped using sterile wet
swabs. Care should be taken to use separate swab
for each eye. Some centres follow prophylactic
instillation of antibiotic preparation routinely (Fig.
2.7).
8. Weighing the baby: Babies should be weighed as
soon as convenient and weight should be properly
recorded, excessive chilling should be avoided
while weighing (Fig. 2.8).
9. Vitamin K injection: Though controversial, Vitamin
K. injection is routinely administered to all babies
to prevent hemorrhagic disease of newborn. Site
of injection is anterolateral part of thigh into the
vastus lateralis muscle (Fig. 2.9).

An Atlas of Neonatology

Fig. 2.8: Weighing the baby


Fig. 2.5: Clamping the cord. Note plastic clamp applied
2-3 cm from umbilicus

10. Rooming in: As soon as mothers condition


permits baby should be roomed in. This has a
great value in developing bonding and promoting
breastfeeding, and avoids problems related to
breastfeeding (Fig. 2.10).
Apgar Score
Apgar score is a scoring system providing a gross,
quantitative expression of the babys condition at birth.

Fig. 2.6: Tying the identity

Fig. 2.9: Administration of vitamin K. Note injection being


given to anterolateral thigh (vastus lateralis)

Fig. 2.7: Wiping of the eye

This scoring system was introduced by the anesthetist


Virginea Apgar in 1953.
Apgar scores are taken at 1 minute and 5 minutes.
One minute Apgar score indicates cardiorespiratory
adjustments to extrauterine life, and 5 minute Apgar

Labor Room Procedures 7


Based on the 1 minute Apgar score, babies are
categorized as:
Score of 0-3Severe birth asphyxia
Score of 4-6Moderate birth asphyxia
Score of 7-10No birth asphyxia
2. Babies with moderate birth asphyxia may be shifted
to mother and observed there.
3. Babies with severe asphyxia need care in NICU
(neonatal intensive care unit).
Limitations

Fig. 2.10: Bedding in

score indicates possible prognosis. However, the


extended Apgar score recorded 20 minutes after birth
has much better specificity for the prediction of both
early death and disability (Table 2.1).

INTERPRETATION
1. Apgar scores are used to assess the severity of birth
asphyxia at birth. It helps in planning management
after the resuscitation is accomplished.

1. Apgar scores have no utility in deciding steps of


resuscitation in the labor room.
2. They do not give any clue for future neurological
outcome, which limits their usefulness for epidemiological studies.
Causes other than Birth Asphyxia for
a Low Apgar Score
1. Healthy premature infants, due to immature
nervous system.
2. Nasopharyngeal suction.
3. Maternal drugs.
4. Anesthesia.
5. Sepsis.

Table 2.1: Apgars evaluation of newborn


Sign

Heart rate
Respiratory effort
Muscle tone
Respons to catheter in
nostril
Color

Absent
Absent
Limp
No response

Below 100
Slow, irregular
Some flexion of extremities
Grimace

Over 100
Good crying
Active motion
Cough or sneeze

Blue pale

Body pink, blue extremities

Completely pink

A total score of 10 indicates that an infant is in the best possible condition. An infant with a score of 0 to 3 requires immediate
resuscitation.

An Atlas of Neonatology

NALS

Immediately after birth the transition from fetal to


neonatal physiology occurs smoothly in most of the
newborns. However, in 6 to 10 percent of infants, a
number of adverse fetal and maternal conditions
interfere in this smooth transition. These infants require
resuscitative efforts in the delivery room which when
correctly carried out, are very effective and have a high
success rate. Newborn resuscitation follows the basic
principle of ABC, i.e. airway patency, breathing, and
maintaining circulation. The ten steps involved in it are

listed inside the inverted pyramid to emphasize that the


number of babies requiring each subsequent step goes
on decreasing (Fig. 3.1).

BEING PREPARED FOR RESUSCITATION


ANTICIPATION
Anticipation
Though it is not possible to predict neonatal asphyxia
in all babies, certain antepartum and intrapartum

Fig. 3.1: Steps in neonatal advanced life-support inverted pyramid concept

NALS
factors are well known to be associated with it.
The attending pediatrician should carefully review
antepartum and intrapartum history before hand.
Preparation for high-risk delivery is often the key to a
successful outcome. Co-operation between the obstetric
staff and pediatric staff is important.
The problem can be anticipated before birth in the
following situations.

5. IUGR (intrauterine growth retardation).


6. Fetal distress.
Signs of Antenatal Fetal Distress
1.
2.
3.
4.

Abnormal variations in fetal heart rate or rhythm.


Passage of meconium into liquor amnii.
ECG changes in fetal monitoring records.
Changes in fetal blood pH and gases on fetal blood
samples.

Maternal Factors
1. Maternal age <16 years or >30 years.
2. Maternal illnesses like preeclamptic toxemia (PET),
rheumatic heart disease (RHD), diabetes mellitus,
renal diseases, maternal hypotension, antepartum
hemorrhage (APH), severe anemia and infections.
3. Sedatives, analgesics or general anesthesia given to
mother in the preceding few hours.
4. Maternal drug/alcohol abuse.
5. Placental insufficiencytoxemia, postmaturity.
6. Obstetric disorders like Rh disease, antepartum
hemorrhage (APH), polyhydramnios, oligohydramnios and PET.
7. Abnormal presentations, cord prolapse, prolonged
rupture of membranes.
8. Precipitate labor.
9. Obstetric procedures like lower-segment cesarean
section (LSCS), forceps delivery.
Fetal Factors
1.
2.
3.
4.

Preterm birth.
LBW babies.
Multiple pregnancy.
Ultrasound evidence of fetal anomalies.

Equipment (Table 3.2)


All the equipment listed below should be readily
available in the delivery room. They should be tested
before each delivery.

PREVENTION OF HEAT LOSS (Fig. 3.3)


Newborn infants do not tolerate cold environment,
especially those depressed at birth. This cold stress
increases oxygen requirement and acidosis. This can be
prevented by:
Placing the infant under preheated warmer.
If warmer is not available, 200 Watt bulbs can be
used.
When bulbs are used, they should be kept on 20
minutes before.
Rapid drying with preheated clothes.
Removing wet linens after drying.
Wrapping the baby with fresh warm sheets.

POSITIONING (Fig. 3.4)


As soon as the infant is dried, position the baby supine
with neck slightly extended by keeping a rolled towel

Table 3.1: Some high-risk situations for which resuscitation may be anticipated
High-risk situation

Primary intervention

Preterm delivery
Thick meconium
Maternal hemorrhage
Use of narcotics in labor
Hydrops fetalis
Polyhydramnios,gastrointestinal obstruction
Oligohydramnios, pulmonary hypoplasia
Maternal infection
Maternal diabetes

Intubation, lung expansion


Endotracheal suction
Volume expansion
Administration of naloxone
Intubation,paracentesis, or thoracocentesis
Nasogastric suction
Intubation: careful lung expansion
Administration of antibiotics
Early glucose administration

10

An Atlas of Neonatology
Table 3.2: Equipments for neonatal resuscitation

Suction equipment:
Bulb syringe
Mechanical suction
Suction catheters (5 or 6), 8, 10 Fr.
8 Fr feeding tube and 20 cc syringe.
Meconium aspirator
Bag and Mask Equipment (Fig. 3.2a)
Laryngoscope with straight blades (Fig. 3.2b)
No. 0 and No. 1
Extra bulbs and batteries for layngoscope
Endotracheal tubessizes 2.5, 3, 3.5, 4 mm (Fig 3.2c)
Stylet
Scissors
Gloves
Medications
Epinephrine 1:10,000
Naloxone
Volume expander:
Normal saline,
Ringer lactate,
5% Albumin solution
Sodium bicarbonate
10% dextrose
Radiant warmer
Stethoscope
Syringes
Adhesive tapes
Umbilical catheters 3, 5 Fr
Needles 25, 21, 18 G

Fig. 3.2b: Laryngoscope with straight blades

Modified and adapted from the American Heart Association/


American Academy of Pediatrics. Textbook of Neonatal
Resuscitation Dallas 1994.

Fig. 3.2c: Endotracheal tubes

SUCTIONING THE AIRWAY (Figs 3.5a and b)

Fig. 3.2a: Bag and mask equipment

under the shoulders in sniffing position Avoid hyperextension and hyperflexion.

Clear the airway off any secretion by suctioning mouth


first, and then, nose using a bulb syringe or suction
catheter. Negative pressure used to suction should not
exceed100 mm Hg. Recent NALS does not recommend routine suctioning in healthy and vigorously
crying babies. However,in preterms,LBW, born by
cesarean section, asphyxiated it is indicated.
Remember in English alphabet, M comes before N.

NALS

11

Fig. 3.5a: Suctioning the mouth first

Fig. 3.3: Drying the baby

Fig. 3.4: Positioning the baby with neck in slight extension

TACTILE STIMULATION (Fig. 3.6)


For most newborns, drying and suctioning are enough
to act as stimulation to initiate respiration. If not, tactile
stimulation should be given by either flicking the soles
or rubbing the back. The whole process of drying,

Fig. 3.5b: Suctioning the nose next

positioning, suctioning, and giving tactile stimulation


should not take more than 20-30 seconds.

OXYGEN
After the 5th step, evaluate the infants respiration and
heart rate if ventilation is adequate and the heart rate
is above 100 beats/min, but there is central cyanosis,
give 100 percent free flow oxygen by tube or mask.

BAG AND MASK VENTILATION (Fig. 3.7)

Fig. 3.6: Giving tactile stimulation by flicking the sole

Positive pressure ventilation (PPV) using bag and mask


is indicated if there is failure to establish spontaneous
breathing or heart rate is less than 100 beats/min. A selfinflating bag must be used with an oxygen source and
reservoir to deliver a high concentration of oxygen.
Adequacy of ventilation by bag and mask must be
checked by noting effective chest expansion and
improvement in color and heart rate.

12

An Atlas of Neonatology
seconds) is less than 60 beats/min or between 60 and
80 beats/min and not increasing. Since bradycardia is
usually a result of hypoxemia, chest compressions
should always be performed in conjunction with PPV
at a ratio of 3:1 with 120 compressions and 40 breaths/
min. Two techniques are used to give chest compressions: two fingers technique and two thumb technique
as shown in the figure.

ENDOTRACHEAL INTUBATION (Fig. 3.9)


Fig. 3.7: Bag and mask ventilation

Remember: IndicationsNo spontaneous breathing,


Heart rate <100.
Contraindications: Thick meconium, congenital
diaphragmatic hernia.

Endotracheal intubation is indicated when prolonged


PPV is required, or bag and mask ventilation is not
effective. Apart from these, there are certain situations
where intubation should not be done with bag and
mask ventilation. They are thick meconium stained
infants, and congenital diaphragmatic hernia.

CHEST COMPRESSION (Figs 3.8a and b)


Chest compression should be given following 30
seconds of PPV if the heart rate (by auscultation for 6

Fig. 3.9: Endotracheal intubation

Choice of ET Tube
Based on the weight of the infant the ET tube is selected
as follows.
Fig. 3.8a: Giving chest compression

Weight

Tube size

<1000 gm

2.5

1000-2000 gm

3.0

2000-3000 gm

3.5

>3000 gm

4.0

Rough guide for selection of ET tube-Size of infants little


finger.

Choice of Laryngoscope Straight Blade


Fig. 3.8b: Two techniques of giving chest compression

No. 0 for preterm infants


No. 1 for term infants.

NALS

13

Table 3.3: Medications used in NALS


Drug

Indication

Dosage

Route

Epinephrine (1:10,000)
Volume expander
(Normal saline or Ringer lactate)
Sodium bicarbonate
10% dextrose
Naloxone

H.R. <60 bpm or asystole


Evidence of blood loss

0.1 ml-0.3 ml/kg


10 ml/kg

IV or ET
IV

Documented acidosis
Documented hypoglycemia
Maternal narcotic analgesia

2 mEq/kg
2 ml/kg
0.1 mg/Kg

IV
IV
IV, ET, IM, SC

Note: IVIntravenous, ETEndotracheal tube, IMIntramuscular, SCSubcutaneous

Medications
Administration of medications is rarely needed in
neonatal resuscitation. Indications for use of medication
is heart rate remaining less than 60 beats/min, despite
adequate ventilation with 100 percent oxygen and chest
compression.
The list of medications, dosage, route and indications
are given in Table 3.3.

RESUSCITATION IN SPECIAL
SITUATIONS
Meconium Stained Amniotic Fluid (MSAF)
It is a commonly encountered problem in both term
and preterm babies, which if not handled carefully may
lead to severe asphyxia aspiration pneumonia,
pneumothorax and pulmonary hypertension. The
obstetrician attending the labor should suction oral
cavity and throat once the babys head is delivered to
prevent aspiration into the lungs with the onset of first
cry. Meconium stained amniotic fluid is seen in about
10 to 15 percent of all deliveries. Infants born with

MSAF are 100 fold more likely to develop respiratory


distress than those born through clear liquor (Fig. 3.10).
Resuscitation of Meconium Stained Newborn
1. If a infant is vigorous crying there is no need to do
any special methods
2. If the infant is depressed at birth and meconium is
thick tracheal suctioning using endotracheal tube
with a negative pressure of 100 mgHg should be
done immediately.
3. If infant requires positive pressure ventilation, it
should be given by bag and tube, not by bag and
mask
Congenital Diaphragmatic Hernia
The neonate is usually born with distress or develops
shortly after birth. The distress is due to two reasons:
1) Pulmonary hypoplasia, which is irreversible and 2)
pulmonary hypertension which is reversible. Usually
babies with CDH have scaphoid abdomen and it
should be remembered that the only other cause of
respiratory distress in a neonate with a scaphoid
abdomen is isolated esophageal atresia following
aspiration.
The initial steps in resuscitation an infant with CDH
include, elective endotracheal intubation to minimize
gastric distention resulting from bag and mask, and
continuous gastric decompression, avoiding acidosis and
systemic hypotension.
Abnormal Baby

Fig. 3.10: Problem of MSAF

If lethal abnormalities are seen, avoid resuscitation, but


it is not always possible to decide. Also ethical issues

14

An Atlas of Neonatology

Fig. 3.11: Overview of neonatal resuscitation


Table 3.4: Identifiable disorders or specific structural
defects incompatible with life

Hydranencephaly
Anencephaly
Holoprosencephaly
13 Trisomy syndrome
18 Trisomy syndrome
Triploidy
Renal agenesis
Sirenomelia
Short limb dwarfism syndromes
Achondrogenesis types 1a and 1b
Type II achondrogenesis hypochondrogenesis
Fibrochondrogenesis
Atelosteogenesis
Short-rib polydactyly syndrome, Saldino Noonan type
Thanatophoric dysplasia
Osteogenesis imperfecta type II
Miscellaneous Syndromes
Lethal multiple pterygium syndrome
Neu-laxova syndrome
Meckel-Gruber syndrome
Goldsmith JP, Ginsberg HG, McGettiigan MC. Ethical decisions
in the delivery room. Clin Perinatol 1996;23:529-550.

have to be considered before taking such decisions.


Table 3.4 gives some lethal abnormalities that are
incompatible with life.
Hydrops fetalis should be anticipated if mother has
diabetes mellitus, polyhydramnios, anemia or toxemia.
Diagnosis can be made antenatally by ultrasound
examination and two mode echocardiography. Skilled
resuscitation and anticipation of selective systemic
complications may prevent early neonatal death. The
measures include:
Antenatally digoxin and propranolol are given if fetal
tachyarrhythmias are seen.
Give vitamin K prophylaxis for high-risk mothers.
Prevent overhydration.
If shock is present give blood or plasma.
If edema is seen give furosemide and salt-free
albumin.
If Hb is <10 gm percent do exchange transfusion
(single volume).

NALS
Central venous catheterizationfluid and electrolyte
monitoring.
If there is massive pleural effusion leading to
respiratory distress, pleural tapping is done.

15

Positive pressure mechanical ventilation if pulmonary


edema is present.
Therapeutic paracentesis or thoracocentesis is done
if massive ascites or pleural effusion is present.

16

An Atlas of Neonatology

Routine Care
of the Newborn

A proper care during early neonatal period prevents


many serious consequences. It involves the basic
principles of providing warmth feed, keeping the baby
clean and early picking up of danger signs. Participation
of the whole family in the care should be encouraged.
At the same time, person suffering from contagious
diseases like common cold, cough, skin infections should
not be allowed to handle the infant.
Prevention of Hypothermia
Prevention of hypothermia is perhaps the most essential
need of any infant. The thermoregulatory mechanism
in infants is less efficient making them prone for
hypothermia and its ill effects. Methods available to
prevent hypothermia are summarized below. Also see
Chapter 22.
Ensure that room is warm (ideal temperature 2425.5C, humidity 40-50%).
Keep the baby completely covered including head
(Figs 4.1a and b).
Use radiant room heaters if necessary.
Keep the baby close to mother, allow skin-to-skin
contact and kangaroo mother care.
Avoid giving bath, if insisted; use proper precautions
as described below.
Record temperature regularly and when in doubt,
use a low reading thermometer (Fig. 4.1c).
Bathing
It is better to postpone bathing in the immediate
neonatal period during infants stay in maternity hospital.

Fig: 4.1a: Keeping the baby warm

Fig. 4.1b: Keeping the baby warm by proper warm clothing

But cultural practices in most areas demand bathing to


remove vernix, meconium, blood staining for aesthetic
purposes in such situations proper precautions should
be taken as bathing can cause hypothermia and crying,
both of which increase oxygen consumption.

Routine Care of the Newborn

17

Cord Care (Fig. 4.1d)

Fig. 4.1c: Checking axillary temperature

The precautions to be taken are:


Give bath only to stable babies.
Water should be sterilized before hand by boiling.
Avoid immersion baths for preterms.
Temperature of bath water should not exceed 37C.
Use soaps with neutral pH.
Soaping should be followed by thorough rinsing:
remember all soaps are potential irritants including
baby soaps.
The whole process should not last for more than
5 minutes.
Completely dry the infant after bath.
Take special precaution to dry up skin folds.
Wrap the baby completely after drying.
Avoid rubbing and scrubbing.

Cord is cut and clamped after birth. The stump


becomes shrivelled in 2 to 3 days after which clamp
may be removed within 5 to 10 days cord stump falls
off. Cord care practices vary widely. Some recommend
no interference while others recommend application of
various types of antiseptics to prevent colonization and
secondary bacterial infections. The commonly used
antiseptics are chlorhexidine, 70 percent isopropyl
alcohol, povidone-iodine, Gentian violet, hexachlorophene etc. whether antiseptics are used or not the most
important thing in cord care is daily observation for features
of infection like periumbilical erythema, induration,
purulent, foul smelling discharge from the stump.
Eye Care
Immediately after birth of head, eyes should be cleaned
with sterile swabs taking care to use different swab for
each eye. Some recommend universal prophylaxis with
silver nitrate solution for prevention of ophthalmia
neonatorum but it can cause chemical conjunctivitis,
prompting others not to use it routinely. In either situation
eyes should be carefully watched. Watery or mucoid
discharge can be physiological but purulent one with
associated congestion of conjunctiva should always be
investigated with Gram stain and culture and managed
accordingly. Further details are given in Chapter 19.
Recording Daily Weight (Fig. 4.2)
The baby should be weighed in the labor room immediately after initial stabilization and this should be taken
as birth weight. Thereafter it is recommended to weigh
at least once a day in case of normal infants. Babies
should be weighed naked using electronic scales.
Weighing should be done just before a feed and at the
same time of the day to know any gain or loss. Normal
infants loose weight during first four days of life due
to loss of extracellular fluid. Lost weight will be regained
back by 7th to 10th day of life.
Watching for Danger Signs (Fig. 4.3a)

Fig. 4.1d: Cord care looking for discharge

Apparently healthy infants should be carefully watched


for following dangerous signs and early intervention
should be done.

18

An Atlas of Neonatology

Fig. 4.2: Recording daily weight

Fig. 4.3b: Jaundiced neonate after pressing the


tip of the nose

Fig. 4.3a: Watch for danger sign (abdominal distention)

Lethargy or excessive crying.


No stool in first 24 hours.
No urine in first 72 hours.
Choking after feeding.
Jaundice before 24 hours or persisting beyond one
week (Fig. 4.3b).
Hurried breathing and apnea (Fig. 4.3c).

Fig. 4.3c: Respiratory distress

Routine Care of the Newborn

Refusal of feeds.
Central cyanosis (Fig. 4.3d).
Distention of abdomen (Fig. 4.3a).
Convulsions.
Vomiting/diarrhea.
Bleeding (Fig. 4.3e).
Hypotonia.
Sudden fall or rise of temperature.

Fig. 4.3d: Central cyanosis

Fig. 4.3e: Umbilical bleed

19

Screening for Congenital Disorders (Table 4.1)


Screening in the newborn period plays an important
role in disorders which are difficult to detect clinically,
but early intervention yields dramatic benefits. Phenylketonuria (PKU) and congenital hypothyroidism are the
two commonest disorders for which screening in the
newborn period is done routinely in most western
countries. In India there is no routine newborn
screening program. Whether to screen for a disorder
is determined by certain characteristics they are:
Disorders with high incidence rate.
Disorders where early treatment of asymptomatic
infants decreases morbidity and mortality.
Cost should be low so that mass screening will be
cost effective.
The following screening tests have been recommended by American Academy of Pediatrics:
1. Congenital hypothyroidism.
2. Phenylketonuria.
3. Congenital adrenal hyperplasia.
4. Galactosemia.
5. Cystic fibrosis.
6. Sickle cell disease.
7. Biotidinase deficiency.
8. Maple syrup urine disease.
9. Homocystineuria.
10. Tyrosinemia.
11. Toxoplasmosis.
Technique of Obtaining Blood Specimen for
Screening Tests (Figs 4.4a and b)
Capillary blood obtained by heel puncture is sent
for screening tests.
Warm heel to 40C by wrapping with a warm towel
for 5 minutes.
Select puncture site; lateral and medial sites (seeshaded area in the figure)
Cleans with alcohol; allow to dry
Apply a thin layer of petroleum jelly
Grasp heel firmly; puncture heel with one continuous deliberate movement with a lancet.
Wipe off first drop of blood
Collect blood as necessary by intermittently
squeezing the heel (Table 4.1).

20

An Atlas of Neonatology
Table 4.1: Newborn screening program

Name of the disease/


prevalence

Sample/Test for Screening

Intervention

Remarks

PKU 1:10,000 to 1:25,000


In Asians 1:60,000

Dried blood spot on filter


paper collected by heel
prick on day 3 (after feed),
but not beyond day 7
Guthries test for PA levels
(>4 moles/dl)

Low PA diet before 4 wks


of age, preferably at the
earliest. Maintain serum
PA<6mg/dl. Low PA diets
are commercially available.
Defect of BH4 pathway
does not respond

False positive (1:3300)


benign hyperphenylalaninemia, physiological
mainly with prematurity.
False negative before
12-24 hrs. child refusing
feeds or having persistent
vomiting.

Congenital hypothyroidism
1:3600-5000 multiple
causes

Dried blood spot


radioimmunoassay of T4,
TSH or both, radioisotope
scanning

Thyroxine supplementation

Excellent response to
replacement therapy soft
signs prolonged jaundice,
constipation, umbilical
hernia

Sickle cell disease (SS, SC,


S-thal very high prevalence
in certain geoethnic
groups)

Quantitation of HbS (A&F)


by automated HPLC using
dried blood spot (or in
capillary tubes) from cord
blood, heel prick/
isoelectrofocussing, cellogel
electrophoresis

Penicillin prophylaxis and


immunization against S.
pneumoniae, H. influenzae
& N. meningitides may be
beneficial in reducing
fulminant sepsis. Other
benefits not established

False negative rate not


known False positive very
low. May be checked by
repeat test

MSUD 1:170,000 to
1:400,000

Bacterial inhibition assay


for leucine using a dried
blood spot (Guthries test)

High levels by 14 hours


irrespective of protein
intake. Results must be
available within 2 weeks

False negative rates


extremely low. Specificity
99.9%

Galactosemia 1:60,0001:80,000 (3 different


defects.

Dried blood spot. Microbiologic assay of blood


galactose after ingestion of
milk. >8-10 mg/dl Beutler
spot test for GALT

Galactose free diet as soon


as possible. Rapid turnaround for testing and
reporting needed because
of early onset of symptoms

Enzyme assay may be


negative after blood
transfusion up to 2-3
months. Partial deficiency
may be missed by
screening test. False
positive test likely during
hot humid summer months
because of degradation of
enzyme by heat.

Routine Care of the Newborn

Fig. 4.4a: Routine screening. Sample collection instructions

21

Fig. 4.4b: Heel prick to collect blood for screening tests

BIBLIOGRAPHY
1. Brown ER. Metabolic screening. Clin Perinatl 1998;25:
371-388.

2. Morelli JC, Weston WL. Soaps and shampoos in pediatric


practice. Pediatrics 1987.

22

An Atlas of Neonatology

Neonatal Immunization

It is important to protect children as early as possible


by immunization as vaccine preventable diseases occur
early in childhood. BCG and first doses of OPV and
hepatitis B are recommended to be given in the
neonatal period (Figs 5.1a and b).

Fig 5.1b: Mothers waiting for immunization

Fig. 5.1a

BCG Vaccine
It is recommended to give BCG vaccine at birth for all
institutional deliveries. It is given intradermally over left
upper arm over deltoid insertion using tuberculin
syringe. If BCG is given subcutaneously instead of
intradermally, the complications are more likely to occur

and immunity is going to be inadequate. Hence this


technique is important because loaded syringe and
needle are held almost parallel with the skin with bevel
up. Then the skin is barely pinched up with the needle
tip and advanced slowly till the needle tip has fully
entered the skin. Steadily, 0.1 ml of BCG is injected
over 3 to 5 seconds and needle is withdrawn. A true
intradermal injection will produce a bleb or wheal. The
wheal disappears after one hour. Further progress is as
follows (Figs 5.2a to 5.2g):
Immediate response is wheal formation: subsides
within 6 to 8 hours.
Induration: within 2 weeks: measures 5 to 10 mm.
Pustule formation: after 4 to 6 weeks.
Scab formation: by about 6 to 8 weeks.
Scar or nodule: by 10 to 12 weeks.

Neonatal Immunization

23

Fig. 5.2e: Well-formed bleb


Fig. 5.2a: BCG vaccine vial

Fig. 5.2b: Tuberculin syringe

Fig 5.2f: Well-formed BCG scar


Fig. 5.2c: Technique of giving BCG

Fig. 5.2d: Administering BCG intradermally

Fig. 5.2g: BCG adenitis. Note regional suppurative adenitis

24

An Atlas of Neonatology

Complications of BCG
The local complications that may follow BCG vaccination are ulcer, abscess, regional suppurative lymphadenitis and Kochs phenomenon.
BCG Adenitis (Fig. 5.2g)
The incidence of this complication is estimated to be
1 to 3 percent; usually, only axillary nodes are involved.
This complication occurs within 4 to 6 weeks of
vaccination Initially, lymph nodes are firm in consistency
but may become soft and form abscess later. The
infection may spread to supraclavicular, and cervical
nodes. This condition needs to be treated and the drug
used is isoniazid for 3 months.

Fig. 5.3a: Hepatitis vaccine

Reference: Udhani PM. Textbook of Pediatrics. First


Edn, Jaypee Brothers, New Delhi.

ORAL POLIO VACCINE


In 1989 Ministry of Health, Government of India
recommended one extra dose of OPV at birth for all
hospital deliveries (zero dose) it should be given within
24 hours. If any child fails to receive this dose it can
be given up to 2 weeks (see also cold chain).
Hepatitis B Vaccine
Hepatitis B vaccine should be started soon after birth
during first clinic visit as recommended by IAP. For
babies born to HBsAg-positive mothers, along with the
vaccine, hepatitis B immunoglobulin should be given.
The dosage schedule is given below. See also preterm
immunization (Figs 5.3a to c).
a. Babies of HBsAg negative mothers:
1st dose: at birth or during first clinic visit along with
DPT
2nd dose: 4 weeks after 1st dose
3rd dose: 4-6 months after 1st dose
b. Babies of HBsAg +ve mothers:
1st dose: at birth along with hepatitis immunoglobulin within 12 hours.
If there is delay of more than 12 hours, no need
to give HBIg.

Fig. 5.3b: Hepatitis B immunoglobulin

Fig. 5.3c: Cite of injectionvastus lateralis

Neonatal Immunization

25

Some Practical Tips


Do not give hepatitis vaccine to gluteal region; give
to anterolateral thigh.
When giving hepatitis B vaccine and immunoglobulin simultaneously, use separate syringe, needle
and sites of injections.
Do not freeze hepatitis B vaccination; it looses its
potency.
Reference: Update immunization policies, Guidelines
and Recommendation. Indian pediatr 1999; 36: 567568.
Preterm Immunization
Immunological response of preterm babies is appropriate when immunized with OPV, DPT or Hib. at
appropriate chronological age. Same is true for hepatitis
B vaccine, for whom following strategy is recommended: (1) Preterm babies born to HBsAg +ve mothers,
give heapatitis B vaccine with immunoglobulin within
12 hours, (2) preterm babies born to HBsAg-negative
mothers. Wait till 2 months of age or till discharge
provided babys weight is at least 2 kg at that time for
BCG, babies born >34 weeks of gestation (1.8 kg) can
be vaccinated within days. For babies born with
gestational age <34 weeks wait till they reach postconceptional age of 34 weeks.
BCG, OPV
>34 weeks (1.8 kg): vaccinate
<34 weeks (1.8 kg): Wait till they reach postconceptional age of 34 weeks.
DPTAs per regular schedule.
Hepatitis B
Born to HBsAg-positive mother
Vaccinate + Give immunoglobulin within 12
hours.
Born to HBsAg-negative mother
Wait till baby reaches 2 kg or 2 months of age.
Reference: Thayyil Sudhas S, Kumar A, Singh M, et al.
Safety and efficacy of BCG vaccination in preterm
babies. Arch Dis Child 1999; 81: F64-F66.
Immunization of Babies Born to HIVPositive Mothers
For babies born to HIV-positive mothers, Hepatitis B

Fig. 5.4a: Oral polio vaccine

Fig. 5.4b: Administering OPV

and DPT vaccines can be given safely as per the regular


schedule. Live vaccines that is BCG and OPV, can be
safely given to asymptomatic babies but better avoided
in symptomatic ones.
Cold Chain
Vaccines are known to lose their potency if not stored
and transported at recommended low temperatures.
The cold chain is a system of storage and transport
of vaccines at low temperature from the manufacturer
to the actual vaccination site. OPV is the most sensitive
vaccine to heat requiring storage at 20C. Among
vaccines used in newborn period, OPV should be stored
in first compartment and BCG also in the first
compartment.

26

An Atlas of Neonatology

Fig. 5.5a: Vaccine carrier

Fig. 5.5c: Rightice-lined refrigerator for vaccine storage


Leftdeep fridge for preparing ice packs

Fig. 5.5b: Vaccines inside the carrier

Fig. 5.5d: Ice pack containing OPV and DPT

Vaccine Carriers
These are used to carry small quantities of vaccines (1620 vials).
These carriers are made of special material which
do not allow heat to pass through it. Four fully frozen

ice packs are used for lining the sides and lid should
be closed tightly. Deep fridge (Fig. 5.5c; left) is used
to prepare ice packs and ice-lined refrigerator (Fig. 5.5c;
right) is used for vaccine storage. At vaccination center,
vaccines are kept in slots of ice packs (Fig. 5.5d).

Traditional Practices

27

Traditional Practices

Traditional practices in India vary from region to region.


A few of them are beneficial to the child, but quite a
lot of them are harmful. A doctor taking care of
newborns should be aware of all the types of practices
in the community, he is working in. He must encourage
the good practices, discourage harmful once and be
indifferent to those which do not fall in either category.
A few traditional practices are outlined below.
Beneficial Practices
1. Pregnant woman staying at her mothers house
during pregnancy and delivery.
2. Instillation of colostrum to eyes.
3. Warming up babys clothes on heated tawa to
maintain warm chain.
4. Use of fire with incense to warm up after bath
(Figs 6.1a and b).
5. Traditional clothes and baby in a cradle/hammock
(Figs 6.2a to c).
6. Traditional toys tied to cradle.
7. Isolation of mother and baby for 2 months in a
warm environment.
8. Oil massage to baby before bath (Fig. 6.3).

Fig. 6.1a: Exposing the baby to fumes of incense powder

Harmful Practices
1. Food fads and taboos to pregnant women.
2. Prelacteal feeds for newborns (Figs 6.4 and 6.5a
and b)
a. Discarding colostrum.
b. Rooming in a mother and baby in a dark room
with dirty clothes.

Fig. 6.1b: Garlic and incense powder

28

An Atlas of Neonatology

Fig. 6.2a: Baby sleeping in the hammock

Fig. 6.3: Oil massage

Fig. 6.4: Offering prelacteal feeds

Fig. 6.2b: Traditional hammock

Fig. 6.2c: Traditional hammock

3. Instillation of oil drops in nose and ear.


4. Branding of newborn for prevention of illness (Fig
6.6).
5. Applying kajal and surma to eyes (Fig. 6.7).
6. Janam gutti to baby.
7. Nose ring for prevention of evil eyes (Fig. 6.8).
8. Piercing ears and nose by professional quacks (Fig.
6.9).
9. Application to cord-cow dung, oil, kumkum, ash,
turmeric etc.
10. During resuscitation-slapping, anal dilatation
blowing in ear, throwing hot or cold water.
11. Expressing witchs milk.
12. Bathing for a long time (Fig. 6.10).

Traditional Practices

29

Fig. 6.5a: Giving these is harmful to newborns

Fig. 6.7: Applying kajal to eyes may cause infections

Fig. 6.5b: Offering honey can cause neonatal botulinism

Fig. 6.8: Nose ring. Note surrounding inflammation

Indifferent Practices

Fig. 6.6: Branding note, branded marks at the areas of


chest retraction in a baby with pneumonia

Waist bands, wrist bands, neck band to avoid evil


eyes (Figs 6.11a and b).
Applying oil over anterior fontanel.
Talisman.

30

An Atlas of Neonatology

Fig. 6.9: Ear ring

Fig. 6.11b: Wrist bands and ankle bands to ward off evil eyes

Fig. 6.10: Bathing the baby for a long time. Note


traditional knee bath

Fig. 6.11a: Tying charm round the neck

Fig. 6.12: Guddaluthough the concept of isolating parturant


mother and her baby from rest of the unhygienicallymaintained house is good, the confinement in such a
congested, contaminated special hut (Guddalu) will defeat
the very purpose of good intention

Physical Examination of the Newborn

31

Physical Examination
of the Newborn

The physical examination of the newborn is a special


responsibility as a new individual is being evaluated for
the first time, and very simple things of great importance
may be missed if the approach is not organized and
methodical. The examination is done in three stages
with different objectives in each of them. First examination is done immediately after initial resuscitation
in the labor room to detect life-threatening anomalies
incompatible with life if left unattended. List of
common life-threatening anomalies is given in Table 7.1.
The subsequent examinations depend on the baseline
established during first examination. A detailed second

examination is carried out within 24 hours to detect any


deviation from the baseline. At the time of discharge,
a third examination is done to detect any abnormality
missed earlier or which might have appeared later. The
important points to remember during a neonatal
examination are given below.
Identify the neonate correctly.
Assemble all records and cleaned equipment.
Wash hands thoroughly.
Examine in a warm environment under good light.
Examine preferably in the presence of mother.
Examination should be gentle and methodical.

Table 7.1: Common life-threatening congenital anomalies


Name

Manifestations

Choanal atresia

Respiratory distress in delivery room, apnea, unable to pass nasogastric tube


through nares. Suspect CHARGE syndrome

Pierre Robbin syndrome

Micrognathia, cleft palate, airway obstruction

Diaphragmatic hernia

Scaphoid abdomen, bowel sounds present in chest, respiratory distress

Tracheoesophageal fistula

Polyhydramnios, aspiration pneumonia, excessive salivation, unable to place


nasogastric tube in stomach. Suspect VATER syndrome

Intestinal obstruction:
Volvolus, duodenal atresia,
Ileal atresia

Polyhydramnios, bile-stained emesis, abdominal distention. Suspect trisomy 21,


cystic fibrosis, cocaine abuse by mother

Gastroschisis, omphalocele

Polyhydramnios, intestinal obstruction

Renal agenesis, Potter syndrome

Oligohydramnios, anuria, pulmonary hypoplasia, pneumothorax

Neural tube defects


Anencephalus, meningomyelocele

Polyhydramnios, elevated -fetoprotein, decreased fetal activity.

Ductal-dependent congenital heart disease

Cyanosis, hypotension, murmur

From Stall BJ, Keligman RM in Behrman RE, Kligman RM, Jenson HB Eds Nelson Textobook of Pediatrics 17th edn. Saunders
Philadelphia.

32

An Atlas of Neonatology

Examine those systems first, which require a quiet


infant. e.g. auscultation of lungs, palpation of abdomen,
etc.

WASHING HANDS
Handwashing is the simplest and most cost-effective
way to prevent skin colonization and interrupt
nosocomial transmission. Following guidelines are
recommended.
Use a mild, alkaline to neutral pH, nonantimicrobial
skin cleanser for soiled hands, although routine use
of plain soap may result in dispersal of bacterial
colonies and increase the risk for transmission.
Handwashing after each patient contact is
recommended, even when wearing examination
gloves, because of frequent hand contamination by
undetected leaks in the gloves.
Chlorhexidine and a waterless, alcohol-based
product are agents of choice for hand decontamination of bacteria. In situations in which candida
infection is problematic, 10% povidone-iodine may
be preferable.
Surgical scrubbing may increase skin shedding of
bacteria and is not recommended.
General Examination
Before disturbing a sleeping or a quiet infant, spend
some time to assess his general appearance. Assess his
state of arousal, cry, activity and color. This simple
exercise gives invaluable amount of information about
infants well being (Fig. 7.1).
Vital Signs (Figs 7.2a to d)
Temperature, heart rate, respiratory rate, pulse, blood
pressure and capillary filling time [CFT] will confirm the
general impression had from preliminary inspection.
Temperature can be measured at several sites; oral
cavity rectum, axilla, tympanic membrane or skin.
Rectal temperatures are 1F higher than oral where as
axillary temperatures are 1F lower. Temperature should
be checked at least twice a day. Applying pressure and
noting the time taken for blanching to disappear, check
CFT. Normally it should be less than 3 sec. Heart rate
is counted by auscultation. Normal heart rate is between

Fig. 7.1: Baby in radiant warmer

110 and 160. Pulses are checked for their presence and
volume. Blood pressure is checked in special situations
only.
Anthropometry: Routinely weight, length, head
circumference, chest circumference and mid-arm
circumference are measured. Special measurements are
taken in the presence of any dysmorphic features. The
details are described in chapter 33.
Assessment of gestational age: Using a combination
of neuromuscular and physical criteria gestational age
can be estimated. This is usually done by scoring system
described by Dubowitz with later modification by
Ballard. Further details are described in chapter 11.
Head to Foot Examination
Posture (Figs 7.3a and b): Posture reflects general
neurological status and degree of maturity. Normal
posture of a healthy neonate is that of universal flexion

Physical Examination of the Newborn

Fig. 7.2a: checking axillary temperature

Fig. 7.2b: Checking for femoral pulse

Fig. 7.2c: Checking for dorsalis pedis pulse

Fig. 7.2d: Checking for capillary refill time

Fig. 7.3a: Posture in a normal


term baby

Fig. 7.3b: Posture in prone position. Note buttocks being lifted and weight
borne by the knees compare with that of a preterm baby

33

34

An Atlas of Neonatology

Normal variants
Birth marks
Rashes
Abrasions, ecchymosis
Tache cerebrale may indicate autonomic disturbance
of cutaneous vasculature (Fig. 7.4b).

Edema: Edema can be local or generalized. The


important causes are given in the Table 7.2.
Physiological edema is commonly seen in preterm
babies. It appears by second day of life and disappear
by end of first week (Fig. 7.6).
Table 7.2: Causes of edema
Local

Fig. 7.4a: Normal pink looking baby

General

Caput
Fracture sites
Superior vena cava syndrome
Turner syndrome
Vit E deficiency
Congenital lymphedema

Physiologic
Anemia
Rh isoimmunization
Cardiac failure
Intrauterine infection
Congenital nephrosis
Over-hydration
SIADH
Renal causes
Respiratory distress
syndrome

Head: The important points that should be noted in


the examination of head are given in the Table 7.3.
Table 7.3: Examination of head

Fig. 7.4b: Tache cerebrale

with head usually turned a little towards one side. When


put to prone position, this universal flexion becomes
more obvious so that buttocks are raised and weight
is borne by knees. The head is again kept turned to
one side.
Skin (Figs 7.4a and b): Newborn skin presents wide
range of normal variants and causes undue anxiety in
parents. Normal term newborns have firm and pink
looking skin with the possible exception of palms, soles
and circumoral areas (acrocyanosis) which may be
considered as normal in the first 48 hours. Following
points should be noted in the examination of skin.
Color: pink, pale, ruddy, jaundiced
Texture: firm, loose, thickened (sclerema)

Superficial injuries
Scalp, defects, hair, whorl pattern
Size
Shape
Localized swelling
Skull fractures
Sutures
Fontanellae
Craniotabes
Transillumination

Sutures and fontanellae: The names of 6 sutures


and fontanellae are shown in the figure. Normally, only
anterior and posterior fontanellae are open at birth.
Note the number, size and surface (depressed, flat,
bulged). The variation in the size and number fontanellae may give clue to the underlying conditions which

Physical Examination of the Newborn

35

Fig. 7.6: Local edema over feet in a case of Turner


syndrome

Fig. 7.5a: Major sutures and fontanels in a newborn skull

Craniosynostosis
Microcephaly
Third fontanel:
Down syndrome
Hypothyroidism
(From Avery)
Sutures should be examined for the gap between
them. Separation upto 1cm may be considered as
normal. Premature closure also termed as craniosynostosis can impart various abnormal shapes to the skull
depending on the suture affected. It should be
differentiated from overriding, a normal finding in first
48 hours. This is done by noting ridging at suture lines
in craniosynostosis and step up feel in overriding.

Fig. 7.5b: Checking anterior fontanel

are listed below. Only 3% of newborns have posterior


fontanel greater than 0.5 cm (Figs 7.5a and b).
Too large:
Skeletal disorders (hypophosphatasia, OI etc.)
Chromosome abnormalities
Hypothyroidism
Raised ICT or hydrocephalus
Too small:
Hyperthyroidism

Craniotabes: It is softening of skull bones, which is


demonstrated as ping-pong feel when pressure is
exerted by a fingertip near suture lines. It is a normal
finding when localized. Whereas generalized,
craniotabes may be a sign of defective calcification likeOI, rickets, cleidocranial dysostosis, Down syndrome.
Transillumination of skull: Transillumination of skull
is done when a neurological disorder is considered.
This is carried out in a dark room (after the examiner
gets adapted) using fiberoptic light source being applied
to various parts and taking precautions to avoid
lightleaks. Abnormal transillumination occurs when
transmission is altered by intracranial factors.

36

An Atlas of Neonatology

Face: Facial features reflect those of parents and ethnic


group. Before labeling any subtle abnormality, the
examiner should have a look at the parents and
siblings. Various abnormal facies are given in
Chapter 33.
Eye: Newborn eye examination is difficult.
An attempt to separate the lids should not be made
as it is very difficult due to strong orbicularis. The best
time to examine is when they are spontaneously open.
Holding the baby up and moving gently forward and
backward can sometimes help. Routine ophthalmoscopic examination is not recommended and should be
done when underlying abnormality is suspected. The
feature to look for in eye examination are listed below
(Figs 7.7a to f).

Fig. 7.7a: Examination of the fundus

Table 7.4: Eye examination

Edema of lids
Slant abnormality
Buphthalmos
Proptosis
Subconjunctival hemorrhage
Conjunctivitis
Cataracts
Corneal opacities
Colobomas
White pupil
Blue sclera

Ophthalmoscopic Examination
Ophthalmoscopic examination provides useful information. Inspection of retina requires a dilated pupil. By
direct ophthalmoscopy, two important abnormalities
should be looked for: pre-retinal hemorrhages and
chorioretinitis. The former is associated with intracranial
hemorrhage and the latter suggests intracranial
infection.
The infant is placed supine and to examine the right
eye head is turned with left side of the face resting on
the surface the examiner without touching the baby
should bend over and use the right eye to look at the
childs right eye, similarly the process is repeated with
the left eye.
Ears: General shape, size, position and setting of the
ears should be noted. Presence of accessory ears, tags,

Fig. 7.7b: Indirect ophthalmoscopy to check for red reflex

Fig. 7.7c: White reflex

Physical Examination of the Newborn

37

sinuses may be part of a syndrome complex. Further


details are given in Chapter 33.
Nose: Neonates are obligatory nose breathers.
Checking for patency should be part of routine
examination and can be done by passing a polythene
tube. General shape, size should be inspected.
Mouth: Mouth should be looked for size and
symmetry. Inspection of inside of mouth is best done
when child is crying. Pressing down on the chin can
sometimes help. Mouth holds various normal variants
and should be looked for. Use of tongue depressor is
not recommended (Fig. 7.8).
Fig. 7.7d: Moving the baby to open the eyes

Neck: Neck in neonates is usually short, but full range


of movements is possible. It should be examined for
presence of swelling, webbing, absence of clavicle, and
clavicular fractures.

Fig. 7.7e: Moving the baby to open the eyes

Fig. 7.7f: Edema of the eyelid

Fig. 7.8: Pressing down on chin to open the mouth

38

An Atlas of Neonatology

Chest and heart: Look for the following features while


examining the chest and heart.
Shape
Bilateral expansion
Respiratory rate
Presence of retraction
Percuss for note
Heart rate
Murmurs
Femoral and brachial pulses
Blood pressure
Radiographic examination.
Abdomen: Normally abdomen in newborn period
appears protuberant. Conditions altering the shape of
abdomen are listed in Table 7.5. Relaxed and quiet
infant, and warm hands of examiner are the essential
prerequisites for good abdominal palpation. Liver (up
to 2cm) kidneys (lower lobes), spleen (tip), and
distended bladder are the normally palpable structures.
Unidigital palpation is the preferred method.
Table 7.5: Abnormal shapes of abdomen
Scaphoid:
Distended:

Diaphragmatic hernia tracheoesophageal fistula


Ascites
Intestinal obstruction
Meconium ileus
Paralytic ileus
Hydronephrosis
Diastasis of recti

For palpating kidney, unimanual method is advocated. Presence of any abnormally palpable mass
should prompt further investigation. List of common
congenital abdomen masses is given in Table 7.6 (Figs
7.9a and b).
Genitalia: Look for the following features in males
Length of penis
Position of urethral opening
Urinary stream
Rugosity of scrotum
Feel for both testes
Benign conditions causing parental anxiety are
phimosis, apparently small penis, hydrocele and
retractile testes.

Table 7.6: Abnormal abdominal masses


Renal (55% of total abdominal masses)
Hydronephrosis
Multicystic kidneys
Renal malformations
Renal vein thrombosis
Renal neoplasms
Genital (15%)
Hydrometrocolpos
Ovarian cyst
Gastrointestinal (15%)
Obstructions
Cysts or tumors
Duplications
Retroperitoneal (5%)
Solid tumors
Anterior meningomyelocele
Liver and biliary (5%)
Cysts
Tumors
Adrenal (5%)
Hemorrhage
Neuroblastoma
From: Averys Diseases of the Newborn, 7th edn, Pg: 346

In term female babies labia majora completely cover


the minora. Mucoid discharge, vaginal bleeding, hymenael tags are common and require reassurance. Special
care should be taken to rule out imperforate hymen.
Limbs: Limbs should be examined for the shape,
posture, symmetry and movements. Intrauterine
position has greater influence on these parameters.
Congenital anomalies involving limbs are described in
Chapter 32. Routinely congenital talipes equinovarus
(CTEV) and congenital dislocation of hip (Fig. 7.10b)
should be ruled out. Touching the dorsal surface of foot
to the anterior surface of the leg rules out CTEV (Fig.
7.10a).
Spine: With the baby prone look for any midline
abnormality such as swelling, dimple, tuft of hair,
naevus or sinus. Any of these may be indicative of
underlying abnormality of the vertebral column or
spinal cord and should be investigated.
Neurologic examination: Much information can be
obtained by watching, handling and listening to the
baby throughout the examination than by formally
testing. It should be remembered that gestational age
and degree of arousal influence the physical finding.

Physical Examination of the Newborn

39

Fig. 7.9a: Unidigital palpation of liver

Fig. 7.10a: Test to rule out talipes equinovarus

Fig. 7.9b: Unimanual palpation of kidney

Fig. 7.10b: Checking congenital dislocation of hip

Following points should be looked for in neurological


examination in the newborn.

of head to that of the body and flexion of all limbs


including at the elbow. In hypotonia head lags behind
and there is flexion response of limbs.

Resting posture: Normal posture as described earlier


is that of universal flexion. Decreased tone produces
frog leg position in which thighs are fully abducted so
that the lateral surfaces rest on supporting surface and
arms are flexed at elbow and dorsum of hands rest on
the surface.
Methods for assessing tone: There are 3 tests for
assessing tone. The traction response, vertical suspension
and horizontal suspension (Figs 7.11a to i).
Traction response: Baby is held at wrist and pulled
to sitting posture. Normal response is almost parallel lift

Vertical suspension: Vertical suspension is tested by


lifting the baby by placing both hands in the axillae.
Normally head is maintained in the midline for few
seconds and there is flexion against gravity in all limbs
which is not seen in hypotonia.
Horizontal suspension: This is tested by lifting the
baby horizontally by placing the hands around thorax.
In normal term newborns initial attempts to lift the head
are made and trunk is held straight with flexion of all
limbs. This is not seen in hypotonia.

40

An Atlas of Neonatology

Fig. 7.11a: Vertical suspension in a normal term baby.


Note flexion of limbs

Fig. 7.11b: Vertical suspension in a hypotonic term baby.


Note flexion of limbs

Fig. 7.11c: Traction response in a normal term baby

Fig. 7.11d: Traction response in a hypotonic baby

Physical Examination of the Newborn

Fig. 7.11e: Horizontal suspension in a normal term baby

Fig. 7.11f: Horizontal suspension in a hypotonic baby

Fig. 7.11g: Decorticate posturing

41

42

An Atlas of Neonatology

Fig. 7.11h: Decerebrate posturing

(b)

(a)

(c)
Fig. 7.11i: (a) Opisthotonus, (b) Decerebrate, (c) Decorticate

Normal Variants

43

Normal Variants

The knowledge of normal should precede the


knowledge of abnormal RS Illingworth. Newborns
present with a wide range of normal variants, which
though benign in nature, cause apprehension equally
among parents and ill informed physicians. The
common variants are listed in the Table 8.1.

of these macules is due to the presence of melanin


containing spindle-shaped melanocytes in dermis, which
are presumed to have been arrested during migration
from neural crest to epidermis.

Table 8.1: Normal variants in newborn

Mongolian spots
Erythema toxicum
Epstein pearls
Milia
Hemangiomas of skin
Peeling of skin
Harlequin color changes
Cutis marmorata
Sucking blisters
Sebaceous gland hyperplasia
Transient pustular melanosis
Miliaria rubra/crystallina
Subconjunctival hemorrhage
Breast engorgement
Vaginal bleed
Vaginal mucous discharge
Hymenal tags
Non-retractile prepuce
Hydrocele
Neonatal teeth
Phimosis
Accessory nipple
Prominent xiphisternum
Frontal baldness

Mongolian Spots (Fig. 8.1)


Mongolian spots are blue black or deep brown to slate
gray macular lesions of varying size. The peculiar hue

Fig. 8.1: Mongolian spot

Other features are:


Most common pigmentry lesion
Predominantly seen in lumbosacral area
Occasionally in back of thigh, legs, shoulder
Most of them fade within one or two years
Some persist into adulthood.

Some Interesting Points about Mongolian Spots


These are almost universal in colored races, common
in Eskimos. In China almost all babies have mongolian
spots and is considered by them as a Kick by God
for start of life. In Japan it was thought to be made by

44

An Atlas of Neonatology

God, Kani-sama who precedes over child birth or else


due to the back of the fetus rubbing against the
placenta. In Iraqi villages it is considered as a sign
of Allahs favor. Iranins believe that it occurs when
mother has intercourse during pregnancy. Sometimes
Mongolian spots are confused for bruises and battering
of baby.

No systemic effect
Lesions disappear spontaneously within 3 days.
Differential diagnosis:
Milia rubra
Transient pustular melanosis
Herpes simplex
Bacterial folliculitis.

Erythema Toxicum (Figs 8.2a and b)

Milia (Figs 8.3a to c)

It is a misnomer as the condition is absolutely nontoxic.


Incidence increases with weight and gestational age.
Most common transient rash in healthy neonates
Rarely present at birth
Usually occur in first 2 days of life
Though commonly seen on trunk and face, can
occur anywhere except on palms and soles.

Also called milk spots, present approximately in 35%


of full term infants in India. Appear as multiple yellow,
pearly-white, 1-2 mm papules scattered over the
cheeks, forehead, nose, nasolabial folds and rarely on
the penis. These lesions develop due to blockage of the
pilosebaceus glands of vellus hair. Spontaneous
exfoliation within first few weeks is the rule. Persistence

Fig. 8.2a: Erythema toxicum

Fig. 8.3a: Milia alba (Milk spot)

Fig. 8.2b: Erythema toxicum (Close up view)

Fig. 8.3b: Milia rubra

Normal Variants

45

When they occur on alveolar margins, they are


called Bohns cysts. They resolve spontaneously but may
take several months to do so.
Sucking Blisters (Figs 8.5a and b)
Sucking blisters are seen in about 0.5% of normal
newborns as 0.5-2.0 cm oval bullae or erosions over
lips, thumb and other acral areas. These lesions are
presumed to arise as a result of vigorous sucking inutero; hence the term sucking blisters. They are present
at birth disappear spontaneously in few months . They
should be differentiated from other blistering diseases
of newborn period.
Fig. 8.3c: Milia over penis

of milia or unusually wide spread distribution may be


a manifestation of Basexs syndrome, orofacial digital
syndrome, and Marie-Unnahypotrichosis. When they
are lying in the deeper layers they look red and are
called Milia Rubra.
Epstein Pearls (Palatal cyst) (Fig. 8.4)
Epstein pearls is the name given to milia that occur in
the oral mucosa. The incidence is said to be 88% in
Indian infants. They are found along the median raphe
on the hard palate and at the junction of hard and soft
palate. They appear as 1-2 mm, opaque-white, firm
movable lesionson microscopy they show nests of
epithelial cells.

Fig. 8.5a: Sucking blister

Fig. 8.5b: Sucking blister

Harlequin Color Change (Fig. 8.6)


Fig. 8.4: Epstein pearl (palatal cyst)

Harlequin color change is a very benign condition and


should not be confused with Harlequin fetus, a severe

46

An Atlas of Neonatology

Fig. 8.6: Harlequin color change

form of lamellar icthyosis with grave prognosis. It is a


condition due to disturbed nervous control of
vasomotor tone in which there is reddening of the half
of the body and simultaneous blanching of the other
half. A sharp line of demarcation runs from the center
of forehead down the face and trunk nearly in midline.
It is commonly seen in LBW babies and 10% of full
terms. It is transitory in nature with each episode lasting
from half a minute to 20 minutes with variable number
of episodes in a day. Turning the infant on the other
side may induce blanching of the red side and
reddening of the pale side.

Fig. 8.7a: Cutis marmorata

Cutis Marmorata (Figs 8.7a and b)


It is a reticulate bluish mottling of the skin on the trunk
and the extremities. It is thought to be due to the result
of poor autonomic nervous system control of cutaneous blood vessels and inappropriate shunting of
blood from superficial to deep plexus in certain skin
segments. It may be accentuated in certain disorder like
Down syndrome. It should be differentiated from cutis
marmorata telangiectasia congenita which gives rise to
more intense and often irregular mottling and sometimes thinning of the skin. Other differential diagnosis
is diffuse phlebactasia due to grossly dilated large veins.
Neonatal Teeth (Figs 8.8a and b)
Approximately 1 in 2000 children are born with a tooth
and familial occurrence is well known probably as an
autosomal dominant trait.

Fig. 8.7b: Cutis marmorata

Great people like Julius Caesar, Nepolean and king


Louis XIV were supposed to be born with teeth. In
Poland, China and India such babies are viewed with
fear and superstition and in some parts of Africa they
may even be killed!

Normal Variants

47

Fig. 8.9: Apparent phimosis

may be seen in syndromes like Ellis van Creveld


syndrome, Hallerman Streif syndrome, Sotos syndrome, pachyonychia congenital syndrome, and rarely
in Meckel-Gruber syndrome, Pallister Hall syndrome,
restrictive dermopathy and short rib polydactyly
type I.
Apparent Phimosis in Newborn (Fig. 8.9)
Prepuce in the neonatal period is nonretractile in 95%
of infants and gives an apparent impression of phimosis.
It is still in the process of separation from glans penis
and may take 2-3 years. If the stream of urine is good,
one needs not worry about it.
Figs 8.8a and b: Neonatal tooth in a normal baby

Transient Pustular Melanosis (Fig. 8.10)


Usually they are lower central incisors and it is
unnecessary to remove them. Aspiration and injury to
mothers breast are erroneous fears. They appear yellow
because of deficiency of enamel. They only represent
prematurely erupted deciduous teeth. Neonatal teeth

It is characterized by pustules present at birth, which


later leave macular pigmentation. This eruption is always
present at birth. It is considered to be closely related
to erythema toxicum neonatorum. The differentiating
points are given in the Table 8.2.

Table 8.2: Differences between erythema toxicum and transient pustular melanosis
Incidence
Age of onset
Type of lesion
Contents on microscopy

Erythema toxicum

Transient pustular melanosis

Very common
After 2 days
Vesico-papule or pustule
with surrounding erythema
Eosinophils predominate

Relatively rare
Present at birth
Vesico-pustule with no surrounding
erythema
Neutrophils predominate

48

An Atlas of Neonatology
the extremities during first week of life. In extreme cases,
a congenital ichthyosis has to be considered. But
absence of ectropion, eclobian and gloved appearance
helps in differentiation. Another condition that should
be differentiated is X-linked recessive hypohidrotic
dysplasia.

Fig. 8.10: Transient pustular melanosis

Peeling of skin (Figs 8.11a and b): Excessive


peeling of skin is commonly seen in post term and
growth retarded babies. It is commonly observed over

Subconjunctival hemorrhage (Fig. 8.12): The


semilunar arc of subconjunctival hemorrhage is a
common finding in normal babies. It is most commonly
located at the limbus and brought to the notice by the
observant mother. It is the result of rupture of capillaries
in the sclera from pressure on the fetal head during
delivery. The blood gets reabsorbed after a few days
without leaving any pigmentation.

Fig. 8.12: Subconjunctival hemorrhage

Normal Manifestations due to Maternal


Hormones (Figs 8.13a to d)
Fig. 8.11a: Peeling of skin

Three normal variants are seen in the newborn period


under the influence of maternal hormones which cross
placenta. These are gynecomastia (Fig. 8.13a), vaginal
mucoid discharge (Fig. 8.13c) and bleeding from
vagina (Fig. 8.13b). All these are benign and selflimiting but cause great concern in parents.
Gynecomastia (Fig. 8.13a)

Fig. 8.11b: Peeling of skin

Seen in 30-40% of babies


Seen in both sexes
May be able to express witchs milk
Should be differentiated from mastitis by absence
of erythema and purulent discharge.
Advice not to squeeze and express milk.

Normal Variants

Fig. 8.13a: Bilateral breast engorgement

Fig. 8.13c: Vaginal mucoid discharge

Fig. 8.13b: Vaginal bleed

Fig. 8.13d: Witchs milk

49

Vaginal bleeding occurs due to hyperplasia and


shedding of endometrium, reaching its maximum
between 3rd and 5th day and stopping usually during
2nd week.
Hymenal tags (Fig. 8.14): Tags may project from the
hymen and cause anxiety in the mother. They have no
significance and shrivel and disappear spontaneously
within few day of life.
Hydrocele (Figs 8.15a and b)
The transient hydrocele is due to the presence of a
patent processes vaginalis.
Vaginalis is an outpouching of peritonium drawn
down by the descent of testis, its distal portion persists
as the tunica vaginalis, but the intervening communication with peritoneal cavity is normally obliterated.

Fig. 8.14: Hymenal tag

If the mouth of processus vaginalis is wide it produces


hernia. If the mouth is narrow it produces hydrocele.

50

An Atlas of Neonatology

Fig. 8.16: Supernumerary nipples


Fig. 8.15a: Hydrocele. Note obliteration of normal rugae

Fig. 8.15b: Hydrocele Note obliteration of normal rugae

Treatment: Majority of them resolve spontaneously


prior to 1 year. Surgical intervention is required if the
hydrocele persists beyond 1 year of age.
Supernumerary Nipples (Fig. 8.16)
These occur in about 1.5% of normal newborns and
is more common in colored races. These are seen
anywhere in the milk line that runs from axilla to the
grain on either side. They are insignificant, even though
there is some suggestion that they may be associated
with urinary tract abnormalities.

Fig. 8.17: Prominent xiphisternum

Prominent Xiphisternum (Fig. 8.17)


May protrude anteriorly underneath the skin and may
cause anxiety in mother which needs to be allayed
Hemangiomas of Skin (Stork bites)
(Figs 8.18a and b)
Small capillary hemangiomas are common in the
newborn period. They usually occur over the eyelids
and the nape of the neck, when they are called salmon
patch and stork bites respectively.

Normal Variants

51

Fig. 8.18a: Salmon patch

Fig. 8.19: Frontal baldness

Frontal Baldness (Fig. 8.19)


This is common at the age of 4 weeks and need to be
recognized as a normal variants.

BIBLIOGRAPHY

Fig. 8.18b: Stork bites

1. Berg F, Solomon L. Erythema toxicum neonatorum. Arch


Dis Child 1987;62: 327-328.
2. Jorgenson RJ et al. Intraoral findings and anomalies in
neonates. Pediatrics 1982;69: 577-582.
3. Kulkarni ML, Singh R. Normal variants of skin in neonates.
Ind J Dermat Venerol Leprol 1996;62: 83-86.
4. Varsano IB et al. Urinary tract abnormalities in children
with supernumerary nipples. Pediatrics 1984;73:102.

52

An Atlas of Neonatology

Stool Cycle in Newborn

The features of stools passed in the first few days of


life show definite changing pattern. This can cause
anxiety in parents and treating clinician should be aware
of this changing pattern.
Meconium Stool (Fig. 9.1)
It is the first stool passed by the infant. Ninety-four
percent of infants pass meconium within 24 hrs of birth.
It may continue to be passed for 3-4 days. It is a thick
black, material that collects in the distal portion of small
intestine and colon of the fetus. It consists of bile,
intestinal secretion, desquamated cellular debris and
amniotic fluid.
Fig. 9.2: Transitional stool

Fig. 9.1: Meconium stool

Transitional Stool (Fig. 9.2)


When milk feeding is established, meconium stools give
way to frothy, lighter transitional stool. It is green or

Fig. 9.3: Milk stool

Stool Cycle in Newborn 53


yellow in color and may contain curds (Fig 9.2). It is
passed more frequently and mistaken for diarrhea and
unnecessary antibiotics are used.
Milk Stool (Fig. 9.3)
It follows 3-4 days of breastfeeding. Stools are soft in
consistency and yellowish in color with a sour smell.
Absence of milk stools even by 5th day is indicative of
inadequate breastfeeding.
Stool in Artificially-fed Babies (Fig. 9.4)

Fig. 9.4: Stool of an artificially-fed baby

The stool is pale, firm or dry and foul smelling. Usually


the bulk is more. The pH of the stool ranges from 5.5
to 7.5.

54

An Atlas of Neonatology

10

Neonatal Reflexes

Several transitory reflexes unique to the newborn


period have been described and are exploited to
examine the functional integrity and degree of maturity
of the nervous system. Ten of these reflexes are
routinely tested in clinical examination and are described
below. The age of appearance and disappearance of
these reflexes are shown (Fig. 10.1).

Moros Reflex (Figs 10.2a and b)


Method of Elicitation
Elicited by raising the head of supine infant and allowing
it to drop gently by 10 on to the examiners
supporting hand.

(a)

Fig. 10.1: Age of appearance and disappearance of reflexes


(Adapted from Fletcher MA (ed). Physical Diagnosis in
Neonatology, Lippincott-Raven Philadelphia)

(b)
Figs 10.2a and b: Moros reflex

Neonatal Reflexes
Normal Response

Suckling Reflexes (Fig. 10.4)

Abduction and extension of arm with opening of fingers


followed by adduction and anterior flexion of arm and
clenching of fists followed by crying. The responses are
better seen in upper limbs than in lower.

Method of Eliciting

55

Elicited by introducing clean finger into the mouth or


better by putting the baby to breast.
Normal Response

Abnormal Response
Incomplete: Prematurity (only abduction and
extension)
Less prominent: Asphyxia, meningitis, hypothermia,
kernicterus.
Asymmetrical: Erbs palsy, fracture of clavicle or
humerus, hemiplegia.
Exaggerated: Hypoxic ischemic encephalopathy

Normal response is vigorous sucking. It is present from


28 weeks of gestation and disappears by 4 months.
Abnormal Response
Absence of sucking at birth or persistence beyond
7 months indicates developmental defect.

Rooting Reflex (Fig. 10.3)


Method of Eliciting
By touching the corner of mouth lightly with finger tip.
Response
Bottom lip is lowered on the same side and tongue
moves towards the point of stimulating as finger slides
away, head turns to follow it. It is present from 28 weeks
but well elicited after 32 weeks. Sometimes it may not
be elicited immediately after feeding. Disappears by 4
months in awake state.

Swallowing Reflex (Fig. 10.4)

Abnormal Response

Method

Absence at birth or persistence beyond 7 months


indicates developmental defect.

Fig. 10.4: Suckling and swallowing

It is elicited by putting the baby to breast.


Normal Response
Rhythmical swallowing movements will be felt and seen
at neck. It is present at birth and disappears by 6-9
months.
Abnormal Response
Decreased or absent in general neurological depression,
hypotonia, immaturity and bulbar palsy.
Palmar Grasp (Figs 10.5a and b)
Method

Fig. 10.3: Rooting reflex

Elicited by applying pressure with index finger over


ulnar aspect of palm.

56

An Atlas of Neonatology

Fig. 10.5a: Palmar grasp

Fig. 10.6: Plantar grasp

Plantar Grasp (Fig. 10.6)


Method
It is elicited by pressing a finger against balls of the
infants foot.
Normal Response
Plantar flexion of toes. It is present at birth and
disappears by 6-9 months.
Abnormal Response
Fig. 10.5b: Palmar grasp
Note the reflex strong enough to lift the baby off the bed

Absent in spinal cord defects and asymmetrical in CNS


defects.
Placing Reflex (Fig. 10.7)

Normal Response

Method

Infant grasps finger tightly. It is present at 28 weeks,


but becomes strong by 32 weeks. At 37 weeks it
becomes so strong, the infant can be lifted off the bed.

It is elicited by holding the infant upright so that


dorsum of one foot touches the under surface of table
edge.

Abnormal Response

Normal Response

Exaggerated following severe bilateral cerebral


injury.

Infant lifts the stimulated leg and places over the


table.

Neonatal Reflexes

57

Normal Response
Is automatic walking. It is present at birth in full term
babies and disappears by 6 weeks.
Tonic Neck Reflex (Fig. 10.9)
This reflex differs from others in being less prominent
in the newborn period but becomes marked at a few
weeks of age

Fig. 10.7: Placing reflex

Abnormal
Absent in depressed and anencephalic babies.
Stepping (Fig. 10.8)
Fig. 10.9: Asymmetric tonic neck reflex

Method
Elicited by holding the baby upright with forward
inclination and bringing the feet in contact with the
surface.

Method
Elicited by rotating the head slowly from midline
position towards one side.
Normal Response
Consists of extension of upper limb on the side to which
the face is rotated and flexion of the limb on the other
side. Similar but variable of response is seen in lower
limbs.
Abnormal
The TNR is an important indicator of neurological
abnormality if the responses are excessive and
obligatory. When unilateral, it indicates brain damage
in the hemisphere opposite to the extended limbs.
Gallants Reflex (Fig. 10.10)
Method

Fig. 10.8: Stepping reflex

Elicited by ventrally suspending the baby and stroking


with finger tip down the paravertebral area.

58

An Atlas of Neonatology

Fig. 10.10: Trunk incurvation reflex

Normal Response

Abnormal Response

It is swinging of pelvis towards the stimulated


side.

This response may be useful as an aid in the localization


of spinal cord lesions.

Gestational Age Assessment

11

59

Gestational Age Assessment

Determination of gestational age of a newborn infant


is important in classifying the infant, anticipating complications, and in predicting the outcome. Gestational age
is routinely estimated by calculation from date of last
menstrual period (LMP), antenatal ultrasound scanning
or by clinical examination of the infant after birth. In
many instances, exact date of LMP or records of
ultrasound examination may not be available or
reliable. In such circumstances clinical assessment
alone will be helpful. Clinical assessment is based on

changes in physical and neurologic characters with


gestational age based on these changes many scoring
systems have been described. One such system which
is most widely used is New Ballard Scoring System
which is described below. This system is reliable for the
entire infant population (from extremely premature to
post mature) and is least influenced by clinical
conditions of the baby or neurologic abnormality. There
are 6 neurologic and 6 physical parameters which are
shown below:

PHYSICAL PARAMETERS
1. Skin (Figs 11.1a and b)
Look for translucency over the abdominal wall and score
1

Sticky
Friable
Transparent

Gelatinous
Red
Translucent

Smooth
Pink
Visible veins

Superficial
peeling
and/or rash
Few veins

Cracking
Pale areas
Rare veins

Parchment
Deep crack
No veins

Lethargy
Cracked
Wrinkled

Fig. 11.1a: Preterm


baby skin

Fig. 11.1b: Term baby skin

60

An Atlas of Neonatology

2. Lanugo (Fig. 11.2)


Look for lanugo over the back and score
1

None

Sparse

Abundant

Thinning

Bald areas

Mostly bald

Gestational Age Assessment

61

Fig. 11.2: Lanugo.


Note abundant lanugo in a preterm

3. Plantar Surface (Figs 11.3a and b)


Measure foot length from tip of great toe to back of heal
Look for deep cracks and score
1

Heal-toe
40-50 mm: 1
<40 mm: 2

>50 mm
No crease

Faint red marks

Anterior transverse
crease only

Creases anterior
2/3

Creases over
entire sole

Fig. 11.3a: Preterm baby-sole

Fig. 11.3b: Term sole

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An Atlas of Neonatology

4. Breast (Figs 11.4a and b)


Pickup between finger and thumb, and assess
The development does not depend on the nutrition or sex
1

Imperceptible

Barely perceptible

Flat areola
No bud

Stippled areola
1-2 mm bud

Raised areola
3-4 mm bud

Full areola
5-10 mm bud

Fig. 11.4a: Preterm baby-breast. Note barely visible nipple

Fig. 11.4b: Term baby-breast. Note well-formed breast

5. Eye/Ear (Figs 11.5a and b)


Test for lid fusion by trying to separate the lids by gentle traction; they are inseparable if tightly fused.
a. Inspect upper pinna above meatus
b. For firmness, palpate and fold upper pinna and observe recoil
1

Lids fused
loosely (1)
Tightly (2)

Lids open,
pinna flat, stays
folded

Slightly curved
pinna, soft,
slow recoil

Well-curved
pinna, soft
but ready recoil

Formed and firm,


instant recoil

Thick
cartilage, ear
stiff

Fig. 11.5a: Preterm-ear

Fig. 11.5b: Term-ear

Gestational Age Assessment

63

6a. GenitalsMale (Figs 11.6a and b)


Examine the level of testis
Examine rugosity of scrotal skin
1

Scrotum flat,
smooth

Scrotum empty,
faint rugae

Testes in upper
canal, rare rugae

Testes descending,
few rugae

Testes descending, Testes


few rugae
pendulous,
deep rugae

Fig. 11.6b: Preterm babyMale genitalia

Fig. 11.6a: Term babyMale genitalia

6b. GenitalsFemales (Figs 11.6c and d)


Labia minora and clitoris look prominent in preterms, gradually labia majora grow and completely cover minora
in term infants.
1

Clitoris prominent,
labia flat

Prominent clitoris,
small labia minora

Prominent clitoris,
enlarging minora

Majora and minora


equally prominent

Majora large,
minora small

Majora cover
clitoris and
minora

Fig. 11.6c: TermFemale genitalia

Fig. 11.6d: PretermFemale genitalia

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An Atlas of Neonatology

NEUROLOGICAL PARAMETERS
Posture (Figs 11.7a and b)
Infant should be quiet and lie supine.

Fig. 11.7a: Term babyposture

Fig. 11.7b: Preterm babyposture

Square Window (Wrist) (Figs 11.8a and b)


Flex hand on forearm
Estimate angle between forearm and hypothenar eminence

Fig. 11.8a: Term square window

Fig. 11.8b: Preterm square window

Gestational Age Assessment


Arm Recoil (Figs 11.9a and b)

Infant supine
Take both hands
Flex forearms
Extend parallel to the body and release
Observe recoil at elbow.

Fig. 11.9a: TermArm recoil

Fig. 11.9b: PretermArm recoil

Popliteal Angle (Figs 11.10a and b)

Infant supine
Approximate knee and thigh to abdomen
Extend leg by gentle pressure with index finger behind ankle
Estimate the angle.

Fig. 11.10a: Term babyPopliteal angle

Fig. 11.10b: Preterm babyPopliteal angle

65

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An Atlas of Neonatology

Scarf Sign (Figs 11.11a and b)


Infant supine
Pull arm to try to wrap it around the opposite: note elbow position and score.

Fig. 11.11a: Term babyScarf sign

Fig. 11.11b: Preterm babyScarf sign

Heel to Ear (Figs 11.12a and b)


Infant supine
Draw foot towards head leave knee free
Observe distance between foot and head and score.

Fig. 11.12a: Term babyHeel to ear

Fig. 11.12b: Preterm babyHeel to ear

DECIDING THE GESTATIONAL AGE


After obtaining the total score gestational age is assessed
with the help of maturity rating chart given on the right

side of figure. For example, score of 25 suggest a


gestational age of 34 weeks and so on.

Anthropometry

12

67

Anthropometry

Anthropometry is concerned with the measurement of


physical dimensions of the body. Selected body
measurements can give valuable information regarding
certain types of abnormalities. The period from 24 to
44 weeks after conception is characterized by remarkable growth. The body composition changes
dramatically as the infant accretes muscle, fat and bony
tissues. The interruption of these growth processes by
various factors like genetic or environmental will result

in abnormal morphology of an infant. The body


measurements commonly employed in anthropometry
include length, weight, skin fold thickness, head
circumference, and chest circumference.
There is another related subject called Morphometry
where special measurements are taken whenever one
comes across a dysmorphic infant. These special
measurements may be a characteristic abnormality of
a syndrome and help in syndrome delineation.

BIRTH WEIGHT (Figs 12.1a to h)


Birth weight is one that is recorded within an hour of
birth. Either a good spring weighing scale (Fig. 12.1c)
or preferably beam balance scale (Figs 12.1a and b)
is used for the purpose. The best available scale is
electronic scale (Fig. 12.1d). It shows a reading that is
correct up to one Gm. All the scales should be adjusted
to zero before using. For weighing newborns in villages

Fig. 12.1a: Weighing using a beam balance

Fig. 12.1b: Beam balance

68

An Atlas of Neonatology

Fig. 12.1c: Spring balance

Fig. 12.1f: Maternal height corresponds to


babys birth weight

Fig. 12.1d: Electronic weighing scale

Fig. 12.1g: Salter scale (Spring type scale)

Fig. 12.1e: Maternal mid-arm circumference.


Corresponds to babys birth weight

Fig. 12.1h: Bar scale

Anthropometry
or homes, in clinics and hospitals, small weighing scale
with a dial gives fairly good reading. Such a scale can
be hung from a hook (Figs 12.1g and h) Use a sling
made from cloth or nylon to hold the child. Fix the
scale at eye level for correct reading.
The beam balance scale is used in permanent clinics.
It is accurate, must be kept clean and correctly
adjusted. The other precautions to be taken while
weighing children include:
i. Naked baby should be kept on a clean towel or
paper on the scale pan.
ii. The sick or premature infant can sometimes be
weighed in an incubator using a spring balance.
iii. In home delivery, weight should be taken by
placing the baby in a sling using a simple spring
balance.
Other scales used in the community (color-coded
weighing scale): It is a simple instrument to find out birth
weight. It is a cylindrical instrument with a hook at lower
end and a bar to hold the scale at the upper end. The
weights are marked up to 5 kg with 100 gm divisions.
A newborn weighing less than 2.5 kg is low birth weight
(LBW) and hence the scale is colored yellow and red
to indicate LBW.
Before using the scale, ensure that the pointer is at
zero if possible check against known weights. Fold the
corners of a clean piece of cloth into a hammock.
Place the baby in the hammock, keeping your left
hand underneath if baby slips. Hold the weighing scale
by the right hand with the help of the bar. Check the
weight by the color now visible on the color-coded scale.
If the weight falls in red or yellow color zone, the baby
is of LBW and should be at your special attention.
Always keep the scale at eye level while measuring the
weight. Never hang weights heavier than 5kg.
An important point to be remembered is that birth
weight falls in the first five days (not >10% of birth
weight) and is regained on the 10th day. Subsequently,
in a term baby daily weight gain is around 25 to
30 g.
Other uses of recording weight in newborn are:
i. Monitoring of weight is a sensitive parameter for
assessment of nutrition status and its progress.

69

ii. To assess fluid balance.


iii. To assess cardiopulmonary status.
iv. To assess renal status and to assess response to
therapy.
One should know that maternal mid-arm circumference (Fig. 12.1e) and maternal height (Fig. 12.1f)
have significant influence on her childs birth weight.
Length (Figs 12.2a to c)
Length can be taken most accurately with a measuring
table or a board with a fixed head piece on which the
infant lies supine with his or her legs fully extended. It
is necessary to press the knees lightly back to ensure

Fig. 12.2a: Infantometer

Fig. 12.2b: InfantometerMat type

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An Atlas of Neonatology

Fig. 12.2c: Measuring length using infantometer

maximum length. The feet should be pressed against


the movable foot piece with the ankles fixed to 90.
The length is recorded on a scale (infantometer). Two
persons are needed to hold the baby correctly
(preferably not the mother) and take the measurement.
This type of board is difficult to use in an incubator,
so the length is measured with ruler or a tape. A
specially designed measuring mat type infantometer
may be used in peripheral setting.
Note: The length need not be taken immediately if
the babys condition gives rise to anxiety but should
be recorded certainly in the first 3 days.

occipitofrontal diameter. Other type of tapes may


stretch after repeated measures and may also carry
infection between infants; hence, the tapes should be
frequently reversed or sterilized with antiseptic lotion,
e.g. Savlon, chlorhexidine. Dettol is not satisfactory as
it is a weak antiseptic agent.
Normally head circumference is 33 cm in a term
baby. Head circumferences are usually 2-3 cm larger
than the chest circumference. A head circumference is
less than 10th percentile or more than 90th centile
(NCHS charts) is abnormal.
Chest Circumference (Figs 12.4a and b)
Chest circumference is measured at nipple line in midexpiration using nonstretchable fiberglass tape. Normal
chest circumference is 30-33 cm.

Head Circumferences (Fig. 12.3)


Head circumference measurement may change slightly
during the first 3 days owing to molding during labor,
scalp edema or bruising and cephalhematoma. It is
taken with a nonstretchable fiberglass tape at the

Fig. 12.3: Head circumference

Figs 12.4a and b: Chest circumference

Anthropometry
Mid-arm Circumference (MAC) (Fig. 12.5)

Long Anteroposterior Diameter of the Head

Studies have shown that the MAC values can be used


as a surrogator for birth weight, because weighing
children in remote places is difficult. A MAC of less than
8.5 cm is associated with increased risk of morbidity and
mortality. It is measured using a nonstretchable fiberglass
tape, conventionally on left arm, between the acromion
and the olecranon process, when the arm is kept by
the side of the trunk. A mid-arm circumference of less
than 8.7 cm is indicative of low birth weight (<2.5 kg).

Overgrowth
Cerebral gigantism (Sotos syndrome)
Marshall syndrome

71

Skeletal
Pyknodysostosis
Achondroplasis
Facial genital defects
G syndrome (Opitz-Frias)
Smith-Lemli-Opitz syndrome
Others
X-linked hydrocephalus
Oto-palato-digital syndrome (Taybi)
Marfan syndrome
Short Biparietal Diameter
Sagittal craniosynostosis
Wide Biparietal Diameter

Fig. 12.5: Mid-arm circumference

SPECIAL MORPHOMETRY
Head
The measurements of the neonatal head are useful to
diagnose syndromes, which include short anteroposterior diameter, long anteroposterior diameter, short
biparietal diameter, wide biparietal diameter, microcephaly, and macrocephaly. Some of the common
syndromes associated are listed below.
Short Anteroposterior Diameter of the Head
Craniosynostosis
Acrocephalosyndactyly type I (Apert syndrome)
Acrocephalosyndactyly type III (Saethre-Chotzen
syndrome)
Cranio-oculo-dental syndrome
Craniofacial dysostosis (Crouzon syndrome)
Chromosomal syndromestrisomy 21
Syndromes9q+

Craniosynostosis
Craniofacial dysostosis (Crouzon syndrome)
Cranio-oculodental syndrome
Others
X-linked hydrocephalus
Thanatophoric dwarfism
HallermannStreiff syndrome
KBG syndrome
Eyes
Eye measurements in the newborn are useful in
determining hypotelorism, hypertelorism, dystopia
canthorum (increased distance between outer canthi),
and short and long palpebral fissures. Common
conditions associated with abnormalities of these
measurements are listed below.
Inner Canthal Distance (Fig. 12.6)
The distance between the medial canthi of the left and
right eye is measured. The measurement is taken by
placing the Vernier calipers edges one on either side of
the medial canthi. It should be taken when the child
is relaxed.

72

An Atlas of Neonatology

Fig. 12.6: Inner canthal distance

Fig. 12.8: Interpupillary distance

Outer Canthal Distance (Fig. 12.7)

Interpupillary Distance (Fig. 12.8)

This is the distance between the outer canthi of right


and left eye. It is measured by placing the two tips of
the calipers on the lateral canthi. This is again measured
when the neonate fully is relaxed. Care should be taken
not to apply any pressure, as this would cause reflex
contraction of the orbicularis oculi muscle thus
shortening the distance.

The interpupillary distance is measured by joining the


central points of the pupils of both eyes when the
neonate is in the third state of wakefulness. This
measurement takes considerable time. One has to take
utmost care to avoid injury to the eye. Interpupillary
distance is better derived by the formula
Interpupillary distance (IPD) = 0.7 + 0.59 Inner
canthal distance + 0.41 Outer canthal distance
Hypertelorism is said to be present when IPD is
more than 2 SD and hypotelorism is said to be presnt
when IPD is less than 2 SD (Ref Merlab et al).
Palpebral Fissure Size
This is the distance between the two canthi of the eyes
measured by placing the edges of calipers at the two
canthi of an eye.

Fig. 12.7: Outer canthal distance

Syndromes associated with ocular hypertelorism


Aarskog
Hypochondroplasia
Apert
Kniest
Basal cell nevus
Chromosome 5pCraniocarpotarsal dysplasia Chromosome 13 pCrouzon
Chromosome 13 ring
Fetal hydantoin
Chromosome 18 pFocal dermal hypopalsia
Chromosome 18 p-

Anthropometry
GMl gangliosidosis, type 1
Larsen
Meckel
Median cleft face
Mucopolysaccharidosis 1-H
Noonan
Multiple cartilaginous
exostosis
Oculodentosseous dysplasis
Potter
Robinow

Duplication
Duplication
Duplication
Duplication
Duplication
Duplication
Duplication

Duplication
Duplication
Duplication
14 q
Saethre-Chotzen
Duplication
15p
Stickler
Trisomy 9
Craniometaphyseal dysplasia XXY

2q3q
3q
4q
7q
10q
9p
11p
11q
of proximal

Eyes

Others

of proximal

Syndromes associated with ocular hypotelorism


Baler-Gerold
Chromosome 13 q
Holoprosencephaly
Chromosome 13 ring
Meckel
Duplication of proximal
14 q
Apert
Duplication 6q
Goldenhar
Duplication 11p
Kleeblattschadel anomaly
Duplication of proximal
15 q
Otopalatodigital
Duplication 20 p
Rubinstein-Taybi
Xo (Turner)
Treacher Collins

9q +
10q +
18q+
14 q proximal partial
trisomy
Blepharophimosis
syndrome
Ankyloblepharon
Fetal alcohol
syndrome
Dubowitz syndrome
Williams syndrome
G syndrome (OpitzFrias)

Syndromes associated with long palpebral fissure


Multiple congenital malformations pattern
Ears
The measurements of the external ear (pinna) are useful
for the diagnosis of:
Small ears (microtia)
Large or long ears (macrotia)
Low-set ears
Ear Length (Fig. 12.9a)
Measurements are made by placing the caliper
along the greatest vertical axis of the ear, including the
lobe.

Syndromes associated with dystopia canthorum


Waardenburg syndrome
Orofaciodigital syndrome II (Mohr)
Acrocephalopolysyndactyly type II (Carpenter
syndrome)
Frontonasal dysplasia
Orofaciodigital syndrome I
Basal cell nevus syndrome (occasional)
Oculo-dento-digital syndrome I (occasional)
Blepharophimosis syndrome
Syndromes associated with short palpebral fissure
Chromosomal syndromes
- trisomy 18
- 7q+

73

Fig. 12.9a: Ear length

74

An Atlas of Neonatology

Fig. 12.9b: Ear breadth

Ear Breadth (Fig. 12.9b)


Two rulers should be used, one placed on the anterior
most limit of the tragus and the other on the posterior
most point of the helix, and the distance between them
measured. Care should be taken to maintain the rulers
parallel to each other.
Ear above Eyeline and Percent Ear above
Eyeline (Fig. 12.10)
Ear above eyeline is calculated by measuring the
distance from the superior aspect of the ear to the line
at the inner canthi level. Percent of ear above eyeline
is then determined by
Ear above eyeline

Total ear length


The above three values are used to knowEar
length, ear above eyeline percent of ear above eyeline.
The associated conditions of abnormalities of these
measurements are given below. Ears are said to be low
set if the ear above eyeline is less than 15% of total
ear length.

Fig. 12.10: Ear setting

Acrocephalosyndactyly type I (Apert syndrome)


Cranio-oculo-dental syndrome
Facial defects
Mandibulofacial dysostosis (Treacher Collins
syndrome)
Bixler syndrome (Hypertelorism, microtia, facial
clefting)
Hemifacial microsomia
Moebius syndrome
Facial-limb defects
Craniosynostosis-radial aplasia syndrome
Ear defects
Auditory canal atresia
Deafness and ear pits
Lop ear

Small Ears

Skeletal
Auriculo-osteodysplasia
Klippel-Feil syndrome
Cleidocranial dysplasia (dysostosis)
Fanconi anemia

Craniofacial defects
Craniofacial dysostosis (Crouzon syndrome)

Chromosomal syndromes
Trisomy 21

Anthropometry
Trisomy 13
18pDrugs
Thalidomide syndrome
Infections
Rubella syndrome
Others
C syndrome
Renal, genital, and middle ear anomalies
Congenital heart disease (transposition of the great
vessels and hydroureter)
Long Ears
Chromosomal syndrome
XXY syndrome
Monosomy G
Trisomy 18
Trisomy 13

Leprechaunism
Potter sequence
Deafness, peripheral pulmonary stenoses and
brachytelephalangy
Marfan syndrome
Low-set ears
Craniofacial defects
Acrocephalosyndactyly type II (carpenter syndrome)
(occasional)
Cranio-oculo-dental syndrome
Facial defects
Mandibulofacial dysostosis (Treacher Collins
syndrome)
Oculo-auriculo-vertebral dysplasia (Goldenhar
syndrome)
Frontonasal dysplasia (occasional)
Drugs
Fetal hydantoin syndrome
Fetal aminopterin syndrome

Tricho-rhino-phalangeal syndrome, type II (LangerGiedion syndrome)


Cerebro-oculo-facio-skeletal syndrome (COFS)

Chromosomal syndromes
Trisomy 8+
4p 4p+
5p 7q+
8+
9+
10q+
trisomy 13
13q+
14q+
15q+
18+
18p 18q 21q 22+
22q Penta X
XXXXY

Others
Osteodysplasty (Melnick-needles syndrome)

Others
Potter sequence

Large Ears (macrotia)


Chromosomal syndromes
Trisomy 8+
9+
13q+
13q 13 (q32-13q)
18p 21q 22+
22qEar defects
Lop ears
Arteriovenous fistula of ear
Auditory canal atresia
Facial-skeletal defects

75

76

An Atlas of Neonatology

Camptomelic dwarfism
Iris coloboma and anal atresia syndrome
(occasional)
Cutis laxa-growth deficiency (occasional)
Leprechaunism
Philtrum (Fig. 12.11)
This is the nasolabial groove above the upper lip. The
upper limit is the groove where it joins the tip of the
nose, and the lower limit, were it joins the lip.

Fig. 12.12: Mouth width

Fig. 12.11: Philtrum length

Long philtrum is seen in 4p+, 9p-, 10+, 12p+,


22q- chromosomal syndromes, femoral hypoplasia
unusual facies syndrome, Freeman-Sheldon syndrome,
Trichorhinophalyngeal syndrome (Type I and II),
Blepharonasofacial syndrome, acrodysostosis, Tel
Hashomer camptodactyly syndrome, Robinow
syndrome, deLange syndrome, Williams syndromes,
generalized gangliosidosis, C-syndrome and Marden
Walker syndrome.
Short Philtrum is seen in 4p-, 5p-, 9p+ chromosomal syndromes, oro-facio-digital syndromes type I,
cleft palate lateral synechia syndrome, DiGeorge
sequence and Cohens syndrome.
Mouth Width (Fig. 12.12)
This is the distance between the two lateral angles of
the mouth. This measurement was taken without
touching any part of the face, because even a light
touch over the skin of any region around the mouth
provoked the rooting or sucking reflexes.

Large mouth or macrostomia is seen in Goldenhar


syndrome, Hemifacial microsomia, Treacher Collins
syndrome, Facial cleft, 18p-syndrome, 18q-syndrome,
Beckwith-Wiedemann syndrome, Morquios syndrome,
Scheie syndrome, Kniest dysplasia, Robinow syndrome,
Williams syndrome, C- syndrome, Opitz-Kaveggia FG
syndrome and Coffin-Lowry syndrome.
Small mouth or microstomia is seen in Trisomy 18
syndrome, Treacher Collins syndrome, Bixler
syndrome, Hallermann Streiff syndrome, Otopalatodigital syndrome, Freeman-Sheldon syndrome,
Hypoglossia hypodactylia syndrome and Marden
Walker syndrome.
Palm Length and Palm Breadth
(Figs 12.13a and b)
These measurements are used to determine the size of
the hand. Palm length is obtained by measuring the
distance between the distal flexion crease at the wrist
to the proximal flexion crease of the third (middle)
finger. This is the most simple of the measurements
since one can apply the caliper firmly and without fear
of injury.

Anthropometry

Fig. 12.13a: Palm length

77

Fig. 12.14: Middle finger length

Syndromes Associated with Short Hands


Aarskog
Cerebrohepatorenal
Coffin-sinis
De lange
Fanconi anemia

Fig. 12.13b: Palm breadth

Middle Finger Length (Fig. 12.14)


The length of the middle finger is obtained by
measuring the distance between the proximal flexion
crease of the middle finger to the tip. The length of the
middle finger as percentage of the total hand length
size remains fairly constant from newborn period to age
fourteen (42-43%).
Total Hand Length
Total hand length is obtained by adding the palm length
to the finger length. It must be noted that in some
conditions the total hand length may be normal but
the ratio of finger to palm length may be abnormal.

Prader-Willi
Robinow
Smith-Lemli-Opitz
Achondroplasia
Asphyxiating thoracic
dysplasia
Fetal hydantoin
Ellis-Van Creveld
Fetal warfarin
Cranioectodermal dysplasia
Focal dermal hypoplasia Diastrophic dysplasia
GMI gangliosidosis type 1
Hypoglosis-hypodactylia Pseudoachondroplasia
Mucolipidosis II
Thanatophoric dysplasia
Mucopolysaccharidosis,
1H, I-S, II, III
Duplication 2q
Orofaciodigial 1
Duplication 8 mosaicism
Otopalatodigital
Trisomy 21
Pfieffer
Internipple Distance (Fig. 12.15)
The distance between the two nipples is taken using the
medial side of the nipples as end points.
Widely spaced nipples are noted in Turners,
Noonans, 4 p+, 18 p -, 18 q-, fetal hydantoin, Trisomy
18 and Fraser syndromes, whereas narrowly spaced
nipples are seen in asphyxiating thoracic dystrophy.
Penile Length (Fig. 12.16)
Penile length in the newborn infant is determined from
the pubic ramus to the tip of the glans penis. The

78

An Atlas of Neonatology

Fig. 12.15: Internipple distance

Fig. 12.17a: Foot length

Fig. 12.16: Penile length

Fig. 12.17b: Toe length

location of the tip of the glans penis is determined by


palpation. The stretched penile length was obtained.
This correlates closely with erect penile length.
Micropenis is a feature of many syndromes. A few
of the examples include anencephaly sequence,
Carpenter syndrome, CHARGE association, Meckel
Gruber syndrome, Noonan syndrome, Prader-Willi
syndrome, Robinow syndrome, Triploidy syndrome,
XXXXY syndrome and XXY syndrome.
Foot Length (Figs 12.17a and 17b)
First the distance between proximal flexion crease of
the sole at the base of 2nd toe to the tip of the sole
is measured. Then the distance from the proximal

Fig. 12.17c: Foot breadth

Anthropometry
crease to the top of the 2nd toe is measured. These
are added to get total foot length. Foot breadth is
sometimes measured to determine small or large feet
along with other measurements (Fig. 12.17c).
Foot length measurements are useful in evaluation
of skeletal dysplasia as well as nonskeletal syndromes.
A large foot is seen in cerebral gigantism, Cockayne
syndrome and leprechaunism. Long metatarsals,
resulting in long feet are seen in Marden-Walker
syndrome and Trevor disease. Short feet are seen in
Prader-Willi syndrome, 15q+ syndrome, various types
of brachydactyly and other syndromes with short
metatarsals like Cohens syndrome, Coffin-Siris
syndrome, Roberts syndrome, Weaver syndrome, etc.

BIBLIOGRAPHY
1. Feingold M, Bossert WH. Normal values for selected
physical parameters; An aid for syndrome delineation.

2.
3.
4.
5.

6.
7.

8.

9.

79

New York: The national; foundation March of Dimes


BD:OAS X(13), 1974
Kulkarni ML, Rehman M. Neonatal assessment beyond
birth weight. Indian Pediatr 1991; 28:922-31.
Kulkarni ML, Rajendran NK. Normal values for penile
standards in newborn. Indian Pediatr 1991;28:1341-43.
Kulkarni ML, Rajendran NK. Internipple distance in the
newborn. Indian Pediatr 1992; 29:619-20.
Kulkarni ML, Rajendran NK, Sangam DK. Intercanthal,
outer canthal and interpupillary distances in newborn,
Indian Pediatr 1992; 29: 759-63
Kulkarni ML, Rajendran NK. Values for foot length in
newborn. Indian Pediatrc 1992;29:507-09.
Kulkarni ML, Rajendran NK. Values for mouth and ear
measurements in newborn. Indian Pediatr 1992;29: 35760.
Kulkarni ML, Rajendran NK. Values for total hand length
in newborn from 24-42 weeks gestation. Indian Pediatr
1992; 29:917-19.
Merlob P, Sivan Y, Reisner SH March Of Dimes birth
defects foundation. Birth defects original article series , Vol
20 1984 White Plains New York.

80

An Atlas of Neonatology

13

Classification of
Newborns and Problems of
Low Birth Weight

Classification of newborn infants is important to


anticipate problems in the immediate neonatal period
and to decide on the level of care to be given. It is also
one of the important determinants of long-term
outcome. Newborns are classified based on different
parameters like birth weight, gestational age and a
combination of both.

Classification Based on Gestational Age


(Figs 13.2a and b)
1. Preterm: Babies born before the gestational age of
completed 37 weeks.

Classification Based on Weight (Fig. 13.1)


1. Low birth weight (LBW): Babies with birth weight
less than 2500 gm
2. Very low birth weight (VLBW): Babies with birth
weight less than 1500 gm
3. Extremely low birth weight: Babies with birth weight
less than 1000 gm

Fig. 13.2a: Preterm baby

Fig. 13.1: Babies of different weight groups

Fig. 13.2b: Postterm baby

Classification of Newborns and Problems of Low Birth Weight

Fig. 13.3a: Reference curve for weight for gestational


age for Indian babies developed at AIIMS New Delhi

Fig. 13.3b: Reference curve for weight for gestational age


(Lubchenco or International Curve)

2. Term: Babies born between 37 and 42 weeks of


gestational age.
3. Postterm: Babies born after 42 weeks of gestational
age.
Classification Based on Birth Weight for
Gestational Age (Figs 13.3a and b)
Taking these two parameters into consideration, infants
have been classified based on established population
norms. Reference curves of weight for gestational ages
have been established. Commonly used curve is
Lubchenco curve established for North American
population. Similar curve for Indian population has also
been established. Both these curves are given below.
1. Small for gestational age (SGA) (Fig. 13.4a): Less
than 10th centile on reference curve.
2. Appropriate for gestational age (AGA): Between
10th and 90th centile on reference curve.
3. Large for gestational age (LGA) (Fig. 13.4b): above
90th centile on reference curve.

81

Fig. 13.4a: Small for gestational age IUGR baby

82

An Atlas of Neonatology
b. AGA
c. LGA
III. Postterm
a. SGA
b. AGA
c. LGA
Low Birth Weight Babies
The term low birth weight (LBW) baby refers to any
infant born with a weight of less than 2500 g irrespective
of his gestational age. Low birth weight could be due
to prematurity or growth retardation (IUGR), or a
combination of both. In developing countries growth
retardation accounts for a larger proportion of LBW.
One-third of the babies born in India are LBW and
among them one-third are preterm and two-third are
growth retarded. The problems of both types of LBW
babies are listed in the following table, separately,
though overlapping is common (Table 13.1).

Fig. 13.4b: Large for gestational age baby

Classification Based on Weight for


Gestational Age
Thus we have 9 categories of babies which allow
clinicians to anticipate problems in the immediate
neonatal period and long-term outcome.
I. Preterm
a. SGA
b. AGA
c. LGA
II. Term
a. SGA

IUGR Babies (Fig. 13.4a)


IUGR is not synonymous with SGA. Infants with IUGR
may or may not be SGA. IUGR is deviation of birth
weight from predetermined genetic potential. Two types
of IUGR have been recognized: symmetric and
asymmetric. They are summarized in Table 13.2.

Table 13.1: Common problems of LBW babies


IUGR

Intrauterine fetal demise


Prenatal asphyxia
Meconium aspiration syndrome
Hypoglycemia
Polycythemia-hyperviscosity
Reduced oxygen consumption
Hypothermia
Dysmorphology

Preterm

Hyaline membrane disease


Chronic lung disease
Recurrent apnea
Patent ductus arteriosus
Bradycardia
Hyperbilirunemia
Internal organ hemorrhage
Poor GI motility
Hypocalcemia
Hyperglycemia
Hypothermia
Intraventricular hemorrhage
Kernicterus
Electrolyte disturbances
Infections

Modified and adapted from Behrman RE, Kleigman RM, Jenson HB eds. Nelson
Textbook of Pediatrics, 16th edn, 479, W.B. Saunders company Philadelphia.

Classification of Newborns and Problems of Low Birth Weight


Table 13.2: Showing differences between symmetric and asymmetric IUGR

Age of onset
Pattern of retardation
Head size
Ponderal index
Catch up growth
Genetic growth potential
Causes

Symmetric

Asymmetric

Early
Symmetric
Decreased
Normal
Less
Not attainable
Congenital viral infections
Chromosomal disorders
Single gene deletions and
other genetic disorder
Anomalad syndromes

Late
Asymmetric
Normal
Decreased
More
Attainable
Chronic fetal distress
Pre- eclampsia
Chronic hypertension
Diabetes mellitus
Poor maternal nutrition

Table 13.3: Etiology of intrauterine growth retardation


Intrinsic

Extrinsic

Constitutional

Maternal systemic disease (cardiac, renal, respiratory,


collagen disorders, proteinuric hypertension)
Maternal starvation and chronic malnutrition
Alcohol, substance abuse and smoking
High altitude
Placental vascular anomalies
Maternal diabetes mellitus

Chromosomal disorders
Congenital anomalies
Fetal infections
Teratogenic drugs/chemicals
Ionizing radiation

Typical Features of IUGR Babies


Relatively large head
Scaphoid abdomen
Rough, dry and parchment like skin which
desquamates easily
Long fingernails
Relatively large hands and feet
Wise old person like face
Wide or overriding sutures
Large anterior fontanel
Thin umbilical cord.
IUGR babies can develop later complications like
diabetes mellitus, hypertension and glomerulosclerosis
(Barkers hypothesis). The pathogenesis of this
interesting phenomenon is given in Figure 13.5.

Fig. 13.5: Pathogenesis of fetal injury by maternal


dietary protein deprivation

83

84

An Atlas of Neonatology

14

Clinical Assessment of
Nutrition Status (CANS)
at Birth

The terms fetal malnutrition (FM), intrauterine growth


retardation (IUGR) and small for gestational age (SGA)
are not synonyms; one may occur without the other.
Correct meanings of these terms should be understood
to classify an infant.
SGA: An infant is called small, based on weight cutoff
(for ex <10th percentile) derived from population
norms.
IUGR: This means deviation of fetal growth from a
predetermined genetic potential due to adverse effects
in the intrauterine period.
FM: It is a clinical diagnosis and indicates malnourished
clinical state of infant of any birth weight (SGA, AGA,
LGA.

CANSCORE
A scoring system has been devised by Metcoff to
clinically assess the nutritional status of a newborn infant.
The system has nine components with each component
rated from 4 (best) to 1 (worst). The sum of rating of
each of the nine CANS signs is the CANSCORE. This
can range from 9 (lowest) to 36 (highest). After studying
1382 singleton term babies, scores less than or equal
to 24 were taken as clinical evidence of malnutrition.
Significance: About half of SGA and 5% of AGA
babies have been shown to be malnourished and about
40% of fetally malnourished infants will develop
neurologic and intellectual handicaps later in life. Thus,
assessment of nutritional status is more important than

SGA and IUGR alone in prognosticating long-term


outcome.

CANS
Nine signs for assessing nutritional status in
newborn term-infants: Each of the signs is rated from
4 (best) or 1 (worst). The CANSCORE is the sum of
nine CANS signs (Fig. 14.1).
Hair (Figs 14.1a and b): Large amount, smooth,
silky, easily groomed (4 points); thinner, some straight
staring hair (3 points); still thinner, more straight, with
depigmented hair that does not respond to brushing
(2 points); and straight staring hair with depigmented
stripe (flag sign).
Cheeks (Figs 14.2a and b): Progression from full
buccal pads and round face (4 points); to significantly
reduced buccal fat with narrow, flat face (1 point).
Neck and chin (Figs 14.3a and b): Double or triple
chin fat folds, neck not evident (4 points); to thin chin,
no fat folds, neck with loose, wrinkled skin very evident
(1 point).
Arms (Figs 14.4a and b): Full, round, cannot elicit
accordion folds or lift folds of skin from elbow or
triceps area (4 points); to striking accordion folding of
lower arm elicited when examiners thumb and fingers
of the left hand grasp the arm just below the elbow
of the baby and thumb and fingers of the examiners
right hand circling the wrist of the baby are moved
toward each other; skin is loose and easily grasped and
pulled away from the elbow (1 point).

Clinical Assessment of Nutrition Status (CANS) at Birth

85

Fig. 14.1a: Hair large amount smooth and silky

Fig. 14.1b: Hair thin straight and depigmented

Back (Figs 14.5a and b): Difficult to grasp and lift


skin in the interscapular area (4 points); to skin loose,
easily lifted in a thin fold from the interscapular area
(1 point).
Buttocks (Figs 14.6a and b): Full, round gluteal fat
pads (4 points); to virtually no evident gluteal fat and
skin of the buttocks and upper, posterior thigh loose
and deeply wrinkled (1 point).
Legs (Figs 14.7a and b): Like arms.

Fig. 14.1: Signs for assessing nutritional status

Chest (Figs 14.8a and b): Full; round ribs not seen
(4 points), to progressive prominence of the ribs with
obvious loss of intercostal tissue (1 point).

86

An Atlas of Neonatology

Fig. 14.2a: Full buccal pad, round face

Fig. 14.2b: Reduced buccal pad and flat face

Fig. 14.3a: Double chin fat fold with not so evident chin

Fig. 14.3b: Thin chin with no fat fold

Fig. 14.4a: Full round arms

Fig. 14.4b: Arm with loose skin

Clinical Assessment of Nutrition Status (CANS) at Birth

87

Fig. 14.5a: Difficult to grasp and lift skin in the


interscapular area score 3

Fig. 14.5b: Easily-lifted interscapular skin

Fig. 14.6a: Full round gluteal fat pads

Fig. 14.6b: No evident gluteal fat with loose, wrinkled skin

Fig. 14.7a: Absent accordion

Fig. 14.7b: Accordion in legs

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An Atlas of Neonatology

Fig. 14.8a: Full round chest and ribs not visible

Fig. 14.8b: Loss of intercostal tissue and prominent ribs

Fig. 14.9a: Full round no loose skin

Fig. 14.9b: Abdomen with loose and wrinkled skin

Abdomen (Figs 14.9a and b): Full, round, no loose


skin (4 points) to distended or scaphoid, but with very
loose skin, easily lifted, wrinkled, and accordion folds
demonstrable (1 point).

BIBLIOGRAPHY
1. Metcoff J. Clinical assessment of nutritional status at birth.
Pediatr Clin North Am 1994;41:875.

Feeding of Newborns

15

Feeding of Newborns

BREASTFEEDING
Devine blessing
Oh! Lucky woman,
Let all the four oceans,
Through your breast milk,
Impart strength to your child
Just like God became immortal
By drinking Amrutha, let your
Child become healthy and
strong by drinking nectar (Amrutha) of your breast milk!
Kashyap Samhita
3000 years ago
Breastfeeding is encouraged in Indian culture from
time immemorial and people have accepted it as a
natural way of infant feeding. But, there are still a large
proportion of babies who are not exclusively breastfed
in the first six months and practices like discarding
colostrum, offering prelacteal feeds continue to cause
great morbidity and mortality. It is the responsibility of
all health care providers to make everyone understand
that human milk is for human infants.

BENEFITS OF BREASTFEEDING
Benefits to the Baby

Complete food
Species specific
Individual specific
Easily digested
Well absorbed

89

Enhances brain growth


Better bioavailability of Fe and Ca
Helps emotional bonding
Low solute load on kidneys
Anti-infective property
Prevents allergy
Decreases the risk of later development of diabetes
mellitus, heart disease, cancer
Better IQ in later life
Benefits to the Mother
Quick involution of uterus
Promotes bonding
Exclusive breastfeeding acts as a contraception for
first 6 months
Less work for mother
Prevents ovarian/breast cancer in later life
Benefits to Family
Monetary benefit
Family planning benefit
Better child survival
Benefits to the Nation
Saves huge foreign exchange (see below)
Contributes to child survival
Decreases healthcare costs

BREAST MILK A NATIONAL WEALTH!


Annual births in India: 24.38 million

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An Atlas of Neonatology

After correcting for IMR (73 per 1000): 22.6 million


These 22.6 million lactating mothers produce 8093
million liters of milk
At the present cost of cows milk (Rs 15/L) it would
be: 6000 crores !!
(Source: C Gopalan, NIN)
Cost of Artificial Feed

Rs 6000 in the first 6 months


40% of income of skilled worker
25% income of class IV
12% of income of a graduate teacher

TYPES OF BREASTFEEDING
This is depicted in the following Flow chart 15.1.

Table 15.1: Immunologic factors in human milk


Secretory IgA
Bile salt stimulated lipase: inactivates Giardia lamblia and
Entamoeba histolytica
Bifidis factor: promotes the growth of lactobacilli in the
gut
Cells: active mononuclear and polymorphonuclear
Complement components: opsonic and bacteriolytic activity
Lactoferrin: binds iron and inhibits some bacteria, fungi
Lactoperoxidase: oxidation of bacteria
Lipids: inactivate lipid enveloped viruses
Lysozyme: antibacterial
Nonantibody proteins: inhibit bacterial adherence
Gangliosides: interfere with attachment of enterotoxin
Nonlactose carbohydrate factors: prevent action of toxins
Other macromolecules: inhibit viral attachment, penetration,
or activity
Trypsin-inhibitors: inhibits rotavirus
Adapted from Goldfarb J. Clin Perinatal 1993 ; 20: 225-243.

ANATOMY OF THE BREAST (Fig. 15.1)


Breast is an exocrine gland which consists of 15-20
lactiferous glands. Each lactiferous gland consists of a
bunch of alveoli lined by milk secreting alveolar cells.
Surrounding alveoli are myoepithelial cells which, on
contraction cause expulsion of milk. All the alveoli drain
into small ducts and each duct has a dilated sinus
(lactiferous sinus) at the subareolar area where milk
collects. All ducts open on to the nipple.

PHYSIOLOGY OF LACTATION
Lactation is the physiologic completion of the
reproductive cycle. Many hormones interplay in the
physiology of lactation, and are described as four
hormonal reflexes below.Three more neonatal reflexes
that are involved in breastfeeding are shown in the
picture (Fig. 15.2a)

Flow chart 15.1: Types of breastfeeding. (Scheme for breastfeeding definition from
Ruth A. Lawrence Breastfeeding 4th edition Mosby yearbook inc).

Feeding of Newborns

Fig. 15.1: Anatomy of breast. Milk is made in the alveoli, It


is ejected from lactiferous sinuses (Action of myoepithelial
cells)

91

Fig. 15.2a: Neonatal reflexes. Three reflexes of the babies


that help successful feeding are rooting sucking and
swallowing reflexes a well coordinated sequence of the three
reflexes is needed for successful feeding

Prolactin Reflex (Fig. 15.2b)


The Reflex
Suckling by baby

Stimulation of nerve ending in nipple and areola

Message is carried to hypothalamus via vagus

Stimulation of anterior pituitary to secrete prolactin into


circulation

Prolactin in breast stimulates


epithelial cells to produce milk
Factors promoting
Early suckling
Frequent suckling
Prolonged suckling
Strong and good attachment.
Factors inhibiting
Prelacteal feeds
Incorrect positioning
Painful breast conditions.

Fig. 15.2b: Prolactin reflex (milk making reflex). Anterior pituitary


gets stimulated by vagus when the baby feeds at breast
releasing prolactin that synthesizes milk in the alveoli of breast

Oxytocin or Let Down Reflex (Fig. 15.3)


The Reflex
Suckling by baby

Stimulation of nerve ending in nipple and areola

Message is carried to posterior pituitary via vagus

Release of oxytocin

Oxytocin stimulates myoepithelial cells to contract and


cause ejection

92

An Atlas of Neonatology

Fig. 15.3: Oxytocin reflex is strongly controlled by emotions


positive thoughts help and negative thoughts suppress this
psychosomatic reflex

Factors promoting
Sound and sight of baby
Mothers confidence
Pleasant thought and sensation in mother
Factors inhibiting
Worry
Feeling of embarrassment
Lack of confidence
Stress
Two Intramammary Reflexes (Fig. 15.4)

Fig. 15.4: Intra-mammary reflexes. A substance that


accumulates when there is accumulation of milk in the
breast inhibits secretion of milk. Thus engorged breast
secretes less milk

Let the mother and baby stay together after delivery


Give the baby colostrum, its first immunization.
Nurse the baby on demand, day and night
Ensure that babys mouth completely encloses the
nipple and areola for effective emptying (Figs 15.6a
to f).
Both breasts should be used
Advise to completely empty one breast and then put
to other one
Burp to prevent regurgitation
Feeding Problems
Inverted/flat Nipple (Figs 15.7a to c)

Guidelines for Successful Breastfeeding


Care for the breasts and nipples during pregnancy
Encourage and Support Breastfeeding
(Figs 15.5a to f)
Put the baby to breast as soon as possible after
delivery

Suckling at breast is the most important stimulus for


initiating and maintaining lactation. Babies find difficulty
to suckle if the nipples are flat or inverted, truly inverted
or retracted nipples can cause serious difficulties but are
very rare. Most of these are just flat and could be pulled
out. This should be done ideally in the last trimester
of pregnancy by massaging and pulling for several
minutes each day. Truly retracted nipple are difficult to
manage, but can be helped to a great extent by using
nipple shield or syringe in method, which is commonly
practiced in our part. In this technique plunger is
withdrawn and the other end is cut. The withdrawn

Feeding of Newborns

Fig. 15 .5a: Mother helped in breastfeeding 4 hrs after LSCS.


Grandmothers helping hand comes as a big support to
young and inexperienced mothers in the sacred duty of
breastfeeding their babies.

Fig. 15.5d: Nurses help in breastfeeding

Fig 15.5b: In the hospital paramedicals assisting a group


of young mothers to breastfeed like a role of multiple
grandmothers

Fig. 15.5e: Nurses help a mother to breastfeed

Fig. 15.5c: Early initiation of breastfeeding. Assistance from


nurses, and ayas in the labor room itself for initiation of
breastfeeding

93

Fig. 15.5f: Traditional hammock- comfort both to mother and


baby and grandmother! Traditional hammock a cradle made
of cloth is comfortable and soothing to the baby and gives
some rest to the mother. when the baby is asleep

94

An Atlas of Neonatology

Fig. 15.6c: Good and comfortable position


Fig. 15.6a: Good and bad suckling position. Goodmouth
wide open, whole areola inside the mouth,chin touching
the breast, lower lip everted (Areolar-feeding). Badnipple
feeding

Fig. 15.6d: Note the correct position with wide-open mouth


with large amount of breast tissue in the mouth

Fig. 15.6b: Good and comfortable positon

Fig. 15.6e: Mother comfortably sitting and breastfeeding.


Immediately after delivery nearly after 1/2 hr there is a adrenal
surge making him or her alert and mother is relaxed after
disappearance of labor pains and ecstasy of having a baby
both conducive for successful lactation

Feeding of Newborns

Fig. 15.6f: Good and comfortable position

95

Fig. 15.7a: Bilateral flat nipple

Fig. 15.7b: Retracted nipple before and after syringing

Reference: Kesaree N. Treatment of inverted nipple


using disposable syringe. Indian Pediatr 1993 ; 30: 429430.
Engorgement of Breast (Figs 15.8a and b):

Fig. 15.7c: Retracted nipple by protractility test

plunger is inserted through the cut end. Negative


suction is then applied keeping the new open end over
the nipple and adjacent areola. Nipple will protrude into
the syringe then negative pressure is released after
sometime. This is repeated several times a day for
3-5 days. Usually by 3-7 days nipples will protrude.

Engorgement of breast is due to two elements: 1)


congestion and increased vascularity, which is
physiologic and 2) accumulation of milk which is due
to delayed and infrequent breastfeeding. The best
management of engorgement is prevention. This can
be done by allowing baby to suckle as often and soon
as possible after birth. Once engorgement develops,
mother can be helped by analgesia, applying warm
packs, and manually expressing milk.
Sore Nipple
Causes:
1. Incorrect attachment, nipple suckling
2. Frequent use of soap and water
3. Candida infection

96

An Atlas of Neonatology
Breast Abscess
It occurs as a complication of mastitis. Clinical features
are fever, pain and fluctuant mass in affected breast.
The milk remains clean unless the abscess ruptures into
the ductal system. Usually it drains to outside. Nursing
can be continued if the abscess opening is far from
areola. A true abscess always requires surgical drainage
along with antibiotics. Analgesics, rest, warm soaks and
frequent emptying are helpful. Baby should be carefully
watched for systemic illness when fed from the affected
breast.
Fig. 15.8a: Engorged breast with dilated veins and
inverted nipple

Fig. 15.8b: Breast engorgement with chaffing

4. Rarely, very vigorously suckling baby; barracuda


baby.
Management:
1. Examine the breast, nipple and nursing seen, and
advice good position.
2. Recommend manual expression before feeding
3. Suggest nursing on unaffected breast first, with
affected side exposed to air
4. Apply expressed breast milk on nipple and areola
and allow to dry.
5. Expose nipple to air between feeds.
6. Recommend appropriate ointment
7. Rarely, stop nursing on affected side and replace it
with manual expression or pumping for few days.
8. Use analgesics if required.

Relactation by Drop-drip Method


(Figs 15.9a and b)
This is useful in certain circumstances as listed below
Some babies do not suck for no apparent reason

Fig. 15.9a: Drop-drip method. In the event of decreased milk


secretion few drops of expressed milk dropped onto the
nipple to stimulate suckling reflex in the baby

Fig. 15.9b: The success of drip drop

Feeding of Newborns

97

Decreased flow of milk during first few days.


Babies with some defects like cleft palate/lip are facial
palsy, Pierre Robin sequence need to be taught by
this method.
Technique
Express breast milk
Drop milk over the breast in drops using a spoon
Position the baby to suckle nipple
Babies start suckling
Continue at every feed for 3-4 days.
Babies will learn to suckle at breast.
Reference: Kesaree N. Drop and drip method. Indian
Pediatr 1993; 30: 277-278.

Fig. 15.10b: One can create an exhibition of varities of bottles


used for infant feeding. They vary from penicillin vials to beer
bottles! Glass to gold!

Artificial Feeding (Figs 15.10a to e)


Artificial feeding has been described as worlds largest
experiment without controls. It is important for every
one to understand that unarguably human milk is for
human infants. The hazards of artificial feeding are listed
below.
Diarrheamarasmus syndrome
Aminoacidemia in preterms, acrodermatitis enteropathica due to zinc deficiency.
Deficiency of calcium, iron, vit.B6, essential fatty
acids and vit. E
SIDS, emotional problems, otitis media and
mechanical injury to gums.

Fig. 15.10a: Dangers of artificial feeding are too many


feeding bottle is considered a baby killer !!

Fig. 15.10c: Marasmic baby bottle fed. Bottle feeding and


marasmus are part of vicious cycle. The bottle invariably
contains dirty dilute formula

98

An Atlas of Neonatology

Fig. 15.11: Manual expression of breast milk proper technique


and hygenic principle are important in manual expression
of milk. Expressed milk may be required for spoon-feeding
gavage-feeding and in situation when mother is away from
home for work

Manual Expression of Milk (Fig. 15.11)

Fig. 15.10d: Compare breastfed baby (up) with bottle-fed


baby (down) at 4 months

Indications: sick mothers or babies, preterm babies,


working mothers
For breast conditions like engorgement, sore nipple
etc.
Technique: Wash hands and collecting cups, massage
the breast gentlylean over and shake the breast
place thumb behind areola and fingers oppositepress
towards the chest wallroll fingers towards nipple
moving them with skin. Repeat moving hand around
the breast to clear all the ductsrigid adherence may
be counter productive as every mother develops her
own pattern.
Paladay and Cup Spoon-feeding
(Figs 15.12a and b)

Fig. 15.10e: Breastfed healthy triplets

These alternative feeding techniques are relatively safe


when performed properly. They are used commonly
for babies with gestational age between 30-32 weeks
based on the observation that these babies have well
developed swallowing despite the absence of good
sucking or coordinated sucking and swallowing. The
procedure is as followsuse expressed breast milk
support the baby in upright position.
Wrap the baby so that his movements will not
interfere in feeding

Feeding of Newborns

99

Fig. 15.13a: NG tube insertion


Fig. 15.12a: Spoon-feeding. When sucking is poor and
swallowing is good, preferred method is spoon or paladayfeeding

Fig. 15.13b: NG tube insertion

Fig. 15.12b: Paladay-feeding

For cup and spoon-feeding, small quantities should


be poured directly over the tongue
For paladay-feeding pour through the angle of
mouth in small quantities at a time
Do not feed crying babies.
Gavage-feeding (Figs 15.13a to f)
Babies born before 30 weeks have poor suckle and
swallow and, hence need to be fed through a tube

Fig. 15.13c: NG tube insertion

passed into stomach through nose or mouth. The


feeding tube is measured from the external nares to
the tragus of the ear and from their to the ansiform
cartilage and marked. This length of tube should be

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An Atlas of Neonatology
inserted through the nose. During insertion the head
is slightly raised and a wet tube is gently pushed into
the stomach. Correct position of tube is checked by
either auscultating bubbling of injected air over the
epigastrium or by aspirating the stomach contents. Milk
is taken in a 20 ml syringe attached to the end of tube
and allowed to trickle by gravity. Baby should be placed
in the right lateral position for 15-20 minutes to avoid
regurgitation.

TYPES OF BREAST MILK (Figs 15.14,


15.15a and b)
Fig. 15.13d: NG tube insertion

Colostrum
It is the milk secreted in the first week after delivery.
It is yellow, thick and contains more antibodies and
WBCs. Owing to its antiinfective property, giving
colostrum to the baby has been often called first
immunization of the baby. It has many important
functions apart from nutrition. Which are summarized
in the following Table.
Antibody richProtects against infection and allergy
WBCsAntiinfective (Fig. 15.14)
PurgativeClears meconium helps to prevent jaundice
Growth factorsHelp intestine to mature, prevents allergy,
intolerance.
Vit A richReduces severity of infection prevention eye
disease

Fig. 15.13e: Checking for proper placement of NG tube

Fig. 15.13f: Gavage-feeding. Babies who cannot suckle or


swallow need to be helped by gavage-feeding with
expressed breast milk. Very preterm and sick babies require
this kind of feeding

Fig. 15.14: Colostrum under microscope after Leishman


stain. Note plenty of lymphocytes, fat globules and macrophages.The lymphocyte counts of colostrum is 2000 cells/
cclCell mediated defence

Feeding of Newborns

101

Fig. 15.15b: Mature milk, foremilk and hind milk. Fore milk
has more lactose acts as an appetizer and quenches thirst!
Hind milk has high fat and gives satity at the end of each
feed-like a dessert after a meal!

Fig. 15.15a: Difference between preterm and full term milk.


Preterm milk has double the quantity of protein compared
to mature milk obviously to nurse preterm baby who has high
growth potential

Transitional milk: Milk secreted during the 2nd and


3rd weeks after delivery. Concentrations of fat and
sugar are high and that of proteins low.
Mature milk: This follows transitional milk. It is
thinner, watery and contains all the nutrients essential
for optimal growth of the baby.
Fore milk: It is secreted at the start of a feed. It is
watery, rich in proteins, sugar, vitamins, minerals and
water; satisfies babys thirst.

Hind milk: Follows foremilk; it is richer in fat and


satisfies babys hunger. This is the reason why one
breast should be completely emptied before putting to
the other.
Preterm milk: Secreted by a mother who has
delivered a preterm baby. It contains more protein
vitamins, minerals, sodium, iron, immunoglobulins and
calories. Thus, breast milk is not only species specific,
but also individual specific.

BIBLIOGRAPHY
1. Ruth A. Lawrence Breastfeeding 4th edition Mosby Year-cbook
Inc.

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An Atlas of Neonatology

16

Neonatal Jaundice

Jaundice is the visible manifestation of elevated serum


concentration of bilirubin in skin and sclera. It is the
most common abnormal physical finding in neonatal
period and is an important sign of disease, or functional
disorder affecting hepatic, biliary or hematological
system. Jaundice in adults becomes visible when serum
bilirubin concentration is more than 2 mg/dl, whereas
in newborns it is visible when the level crosses 5 mg/
dl. Sixty percent of term babies and 80% of preterm
babies will have jaundice.

Krammers Method of Assessing the Severity


(Figs 16.2a and b)
Jaundice in newborn infants progresses in a cephalocaudal direction. Therefore the extent of yellowness of
skin is useful to assess the serum level of bilirubin.
Krammer divided body into different zones. Depending
on the involvement of these zones, serum bilirubin level
can be estimated approximately as shown below.

Method of Detecting Jaundice in Newborns


(Fig. 16.1)
Blanching the skin over bony prominences in good
sunlight does this. There should not be yellow clothes
or curtains in the background, which can lead to error
of over estimation. Once Phototherapy is started for
jaundice, this method becomes unreliable.

Fig. 16.1: Method of detecting jaundice

Fig. 16.2a: Krammers body zones for


assessing the severity of jaundice

Neonatal Jaundice

103

Causes

Increased bilirubin load


Defective uptake from plasma
Defective conjugation
Decreased excretion
Increased enterohepatic circulation

Pathological Jaundice
Features

Fig. 16.2b: Jaundiced-sole of a newborn


Face
Chest
Lower abdomen and thighs
Soles and palms

5-7 mg/dl
10 mg/dl
12 mg/dl
>15 mg/dl

Appears in the first 24 hours


Rise of total serum level by more than 5 mg/dl/day
Serum level >15 mg/dl
Direct serum bilirubin more than 2 mg/dl
Clinical jaundice persisting for more than 1 week in
a full term or 2 weeks in premature infant
Clay colored stool with yellow staining by urine.
Causes

MINOLTA TRANSCUTANEOUS
BILIRUBINOMETER
This instrument estimates serum bilirubin concentration
with the help of a photoprobe. The probe is pressed
against forehead or sternum. The light passes through
in built fiber optics and reflectometre and is analyzed
by computerized spectrophotometer to provide digital
display of total bilirubin immediately.
Classification (Tables 16.1 and 16.2)
Jaundice in newborns can be physiological and
pathologic. They are summarized below.
Physiologic Jaundice
Features
Appears after 24 hours
Maximum level by 4th or 5th day in term and 7th
day in preterms
Serum level <15 mg/dl
Disappears before 14 days
Disappears without treatment
Appears late and persists little longer in preterms.

Etiologically, pathological jaundice may be of


unconjugated type or conjugated type. Neonatal
jaundice can also be classified depending on the age
of onset which is clinically more useful. This classification
is also given in Table 16.1.
Table 16.1: Causes of jaundice on the basis of
age of onset
<24 hrs :

1)
2)
3)
4)
24-72 hrs : 1)
2)
3)
4)
>72 hrs :
1)
2)
3)
4)
5)

Hemolytic disease
Intrauterine infections
Crigler-Najjar syndrome
LuceyDriscoll syndrome
Physiological
Sepsis
Polycythemia
Concealed hemorrhage
Septicemia
Neonatal hepatitis syndrome
Breast milk jaundice
Metabolic diseases
Bowel obstructions

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An Atlas of Neonatology
Table 16.2: Etiological classification of jaundice in newborns
Conjugated:
I. Obstruction to biliary flow
Ex: Biliary atresias
Choledochal cyst etc.
II. Hepatic cell injury
Infections: bacterial, viral, parasitic
Idiopathic neonatal hepatitis syndrome
Toxic
Bacterial sepsis
Metabolic
Galactosemia
Fructosemia
Tyrosinemia
Alpha -1-antitrypsin deficiency
Infantile Gauchers disease
Wolman disease
Glycogenosis IV
Neimann-Pick disease
Zellweger syndrome
Byler disease
Immunologic
Lupus erythematosus
Chromosomal disorders
Trisomy 17-18
Trisomy 21

Unconjugated type:
Excessive production of bilirubin
Hemolytic diseases
Extravasation of blood
Polycythema
Swallowed maternal blood
Impaired conjugation or excretion
Hypothyroidism
Hypopituitarism
Crigler-Najjar syndrome I and II
Gilberts disease
Lucey-Driscoll syndrome
Enhanced entero-hepatic circulation
Various types of gut obstructions
I. Chronic bilirubin overload
Erythroblastosis fetalis
Erythrocyte enzyme defects
Congenital erythropoietic porphyria
Spherocytosis elliptocytosis
Pyknocytosis

Approach to a jaundiced neonate: Following maternal and perinatal history is helpful in the evaluation (Tables
16.3 to 16.5).
Table 16.3: Maternal and perinatal history in evaluation of jaundice
Previous sibling with neonatal jaundice
Family history of jaundice, splenectomy,
Mothers blood group information
Maternal illness with fever and rash during pregnancy
Probably history of malaria
Labor and delivery (traumatic delivery)
Delayed cord clamping
PROM, oxytocin, delayed feeding
Delayed passage of meconium and delayed breastfeeding
Maternal drugs
Liver diseases in family

Rh and ABO incompatibility


G6PD, spherocytosis
HDN
UTI
Malaria
Asphyxia, trauma
Polycythemia
Infection
Increased enterohepatic circulation
Sulfa drugs, vitamin K, nitrofurantoin, antimalarials
Galactosemia, alpha-1-antitrypsin deficiency

Table 16.4: Physical examination in evaluation of jaundice


SFD- polycythemia
Microcephalus, hydrocephalus
Pallor
Bruise
Petechiae
Omphalitis
Chorioretinitis
Urine staining clothes yellow

IUI (intrauterine infections)


IUI
Hemolytic anemia, extravasation of blood
Cephalhematoma
IUI, sepsis, HDN
Sepsis
IUI
Cholestasis

Neonatal Jaundice

105

Flow chart 16.1: Diagnostic approach to a neonate with jaundice

Treatment of Hyperbilirubinemia

Kernicterus (Fig. 16.3)

Excessive serum concentration of conjugated bilirubin


results in the deposition of this substance in the CNS
and causes neuronal injury. Two terms are used to
describe the effect of bilirubin toxicity affecting nervous
system: kernicterus and bilirubin encephalopathy, which
represent pathological and clinical observation

Hydration
Phototherapy
Exchange transfusion
Drugs to increase conjugation
Inhibiting reabsorption in the gut
Inhibiting bilirubin production.

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An Atlas of Neonatology
Table 16.5: Investigation for specific cause of jaundice in infants

Toxoplasma, rubella, parvo-B19, CMV


IgM specific antibody
Herpes simplex, VZV, HHV-6
Serology/viral culture of vesicles/EM
HBV
HBs Ag, Anti HBc (IgM),HBV DNA
HCV
HCV RNA by RT-PCR
HIV
Anti HIV, Ig, CD4, PCR
Syphilis
STS, VDRL, FTA-ABS, long bone film
Enterovirus
Serology, CSF for viral culture
Hypopituitarism
Low cortisol, TSH, T4
Hypothyroidism
High TSH, low T3T4
EHBA
Delayed excretion isotope scan, liver biopsy
Inspissate bile
Coombs, haemolysis, dilated bile duct
Sclerosing cholangitis, hair like bile duct, choledochal cyst, carolicyst Ultrasound, cholangiogram
Alagille
Echo, posterior embryotoxin, butterfly vertebrae
Non-syndromic duct paucity
Bile duct paucity on history
Serum AAT, P1 type
A1 ATD
Cystic fibrosis
Sweat chloride, IRT, DNA mutation
Galactosemia
Gal-1-6-phosphate uridyl transferase
Tyrosinemia
Serum tyrosin, methionine, AFP, urine succinale acetone
Hereditary fructosemia
Liver biopsy, EM, ductal biopsy
Wolman
Adrenal calcification
Primary disorders of bile acid synthesis
Urinary bile acids intermediates by FABMS
Byler disease
GGT, genetic testing
Zellweger syndrome
Very long chain fatty acid study
Neonatal lupus erythematous
Anti Ro-antibody (in mother and child)
Neonatal hepatitis with autoimmune hemolytic anemia
Coombs test, giant cell hepatitis
Adapted from Roberts EV, Kelly (Ed). Diseases of the Liver and Biliary System in Children.

had variably raised unconjugated serum bilirubin levels.


In full term infants the basal ganglia are preferentially
stained whereas in preterms the cranial nerve nuclei
and thalamus are affected. Bilirubin encephalopathy
present in two forms: acute and chronic which are
summarized in Table 16.6.
Phototherapy (Fig. 16.4a)

Fig. 16.3: Kernicterus. Note arching of body due


to bilirubin encephalopathy

respectively. Kernicterus refers to the yellow staining of


parts of the brain found at postmortem in infants who

It is the most commonly used method of treatment for


unconjugated hyperbilirubinemia. It has been in use for
the last 45 years and has reduced the incidence of
bilirubin toxicity and need for exchange transfusion.
It involves exposure of the skin of the jaundiced
baby to blue light of wavelength 425-475 mm. On
exposure, bilirubin bound to the skin gets converted
into photoproducts, which are water soluble, nontoxic
and get excreted in urine and stool. Three types of
mechanisms are involved in this conversion viz.
configurational isomerization, structural isomerization,
and photoxidation.

Neonatal Jaundice
Table 16.6: Kernicterus
Acute form
Phase I
(First 1-2 days)

Phase II
(Middle of I week)

Phase III
Chronic form
Ist year

After 1 year

Decreased activity
Lethargy
Poor suckling
Hypotonia
Change in infants cry

Hypertonia
Fever
High pitched cry
Opisthotonus
Seizures
Spasticity is decreased

Hypotonia
Active DTR
Obligatory TNR
Delayed motor skills
Movement disorder
Fixed upward gaze
High frequency hearing loss
Mental retardation

Give frequent extra-feeding every 2 hrs, turn baby


after each feed
Monitor temperature, weight and serum bilirubin
concentration.
Side Effects

Increased insensible water loss


Loose stool
Skin rashes
Bronze baby syndrome
Hyperthermia

Exchange Transfusion (Figs 16.4b to f)

DTR-deep tendon reflexes,TNR-tonic neck reflex.

Indications
1. Hydrops
2. History of previous sibling requiring exchange
transfusion because of Rh-isoimmunization in a
baby for with pallor hepatosplenomegaly and
positive direct Coombs test.
3. Cord Hb <11 gm/dl
4. Cord total serum bilirubin(TSB) >5 mg/dl
5. Rise of TSB >1 mg/dl/hr despite phototherapy
6. Rate of rise of TSB >0.5 mg/dl/hr despite phototherapy, if Hb is between 11-13 gm/dl
7. Any TSB >12 mg/dl in first 24 hrs and any TSB
>20 gm/dl in neonatal periods.

Fig. 16.4a: Phototherapy. Note baby under high intensity


phototherapy

Technique

107

Perform handwashing
Place the baby naked
Fix eye shields
Keep baby at 45 cm from the source
Start phototherapy

Fig. 16.4b: Exchange transfusion.


Note Instruments needed

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An Atlas of Neonatology

Fig. 16.4c: Exchange transfusion.


Note inserting the catheter

Fig. 16.4f: Exchange transfusion technique

Choice of Blood for Exchange Transfusion


1. In ABO incompatibility: Use O-positive blood; ideal
is to have O-positive cells suspended in AB plasma.
2. In Rh-immunization:In an emergency, use
O-negative blood. Ideal is O-negative cells
suspended in AB-plasma or babys blood group but
Rh negative.
3. Other situations: Babys blood group.
Fig. 16.4d: Exchange transfusion. Note exploring for
umbilical vein in a shriveled cord

Fig. 16.4e: Exchange transfusion underway

Technique
1. Scrub and put on a sterile gown and gloves.
2. Place the infant in the supine position and evacuate
the stomach.
3. Perform the umbilical vein catheterization. Prepare
the area. Put sterile drapes on, leaving the umbilical
area exposed. Cut off the excess umbilical cord with
a scalpel, leaving a stump of about 0.5-1cm. Identify
the umbilical vein. The umbilical vein is thin walled,
larger than the 2 arteries and is close to the
periphery of the stump. Take the curved hemostat
and grasp the end of the umbilicus to hold it upright
and steady. Use the forceps to open and dilate the
umbilical vein. Once the vein is sufficiently dilated,
insert the catheter (Figs 16.4c and d).

Neonatal Jaundice

109

4. Attach the bag of blood to the tubing and stopcocks.


5. Establish the volume of each aliquot as given in Table
16.7.
Table 16.7: Aliquots usually used in neonatal exchange
transfusion
Infant weight

Aliquot (ml)

More than 3 kg
2-3 kg
1-2 kg
850 g-1kg
Less than 850 g

20
15
10
5
1-3
Fig. 16.5a: Anti-D immunoglobulin

6. The procedure should not be too fast or slow.


7. The blood should be shaken gently after every 100
ml of exchange because the RBCs will settle rapidly.
8. The total time taken for a double volume exchange
should be one hour.
Rh-incompatibility (Figs 16.5a and b)
When an Rh-negative mother carries Rh-positive fetus,
her immune system gets exposed to fetal Rh-positive
cells resulting in production of anti-D antibodies which
can cross placenta and cause immune-mediated
destruction of fetal RBCs. However during first
exposure the amount of antibodies may not be
sufficient to cause severe problems in the fetus. But the
subsequent pregnancies may result in severe
consequences, which can be graded as mild, moderate
and severe as shown in the Table 16.8.
Table 16.8
Mild: Indirect hyperbilirubinemia not exceeding 16-20 mg/dl
No anemia, no treatment.
Moderate: Moderate anemia severe jaundice with risk of
kernicterus unless treated
No hydrops
Severe: Fetal hydrops in utero
Modified and adapted from Nathan and Oskis Hematology
of Infancy and Childhood, 5th edn.

Following the delivery of a baby to an Rh-negative


mother cord blood should be collected for following
investigations.
Blood grouping and typing
Direct Coombs test

Fig. 16.5b: Collection of cord blood

Maternal antibodies
Hemoglobin level
Serum bilirubin estimation
Hydrops Fetalis (Figs 16.6a to c)
This is the most severe form of Rh-incompatibility.
As a result of destruction of red cells extramedullary
erythropoiesis takes place resulting in hepatosplenomegaly. But worsening of anemia causes hypoxic
damage to liver leading to hypoproteinemia, which
causes severe anasarca and other features.
The typical blown-up appearance of hydrops fetalis
is unmistakable in the postnatal period. The important
features in postnatal period include subcutaneous

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An Atlas of Neonatology

Fig. 16.6a: Hydrops fetalis. Note typical


blown up appearance

Fig. 16.6b: Hydrops fetalis. Note generalized anasarca

edema, ascites, respiratory distress, pallor, excessive


weight, cardiac arrhythmias, hepatosplenomegaly and
placental edema.
It is important that hydrops fetus is diagnosed
antenatally for proper management.

Fig. 16.6c: Hydrops fetalis. Note blown up appearance

Many of the maternal conditions are associated with


increased risk of hydrops fetalis, that include abnormal
uterine enlargement, polyhydramnios, isoimmune
hemolytic disease, positive antibodies, history of
diabetes, pregnancy induced hypertension (PIH),
diminished fetal activity, fetal cardiac arrhythmia and
anemia of unknown origin.
Ultrasound examination remains the best modality
for detection of hydrops fetalis. The features include
pericardial effusion, placentomegaly, dilated umbilical
vein, scalp and body edema, pleural effusion, ascites
and polyhydramnios.
Prevention (Fig.16.5)
Rh-isoimmunization can be prevented by giving Rhantiimmunoglobulin (IgG) to Rh-negative mother
following childbirth or abortion.

Neonatal Jaundice
Dosage
At 28 weeks: 300 mg of Rh-immunoglobulin and
repeat same dose after delivery.
After C.V.S.: the dosage is 50 mg
In large placental hemorrhage and mismatched
transfusion the dosage is more than 300 mg.
Causes of Nonimmune Hydrops
Causes prolonged unconjugated jaundice
Crigler-Najjar syndrome
Breast milk jaundice
Hypothyroidism
Pylroric stenosis
Ongoing hemolysis
Malaria

111

Table 16.9: Features of chronic cholestasis


Bilirubin excretionjaundice
Bile acid excretionpruritis
Fat absorptionsteotorrhoea
Absorption of fatty acidspeeling of skin rashes
Absorption of vit Axerophthalmia
Absorption of vit Eataxia, hemolysis, ophthalmoplegia
and neuropathy
Absorption of vit Drickets, osteopenia
Absorption of vit Kbruising, epistasis, coagulopathy
hypercholesterolemiaxanthoma
Protein catabolismPEM

Neonatal Hepatitis Syndrome (Figs 16.8a and b)


Nonspecific hepatic inflammation due to several
etiologic agents including intrauterine infections, inborn
errors of metabolism, and endocrine disorders are

Conjugated Jaundice (Fig. 16.7)


Features
Conjugated hyperbilirubinemia is characterized clinically
by jaundice with bile in the urine. Jaundice may appear
late in neonatal period or may fail to subside after 1
wk unlike physiological jaundice. The stools may be pale
brown or even chalky white in color. The direct bilirubin
generally exceeds 15% of the total.

Fig. 16.8a: Neonatal hepatitis syndrome. Note marasmic


child lemon yellow hue of jaundice. Compare with Biliary
atresia

Fig. 16.7: Conjugated hyperbilirubinemia. Note pale stool,


high colored urine suggestive of biliary artesia

Etiology
Listed earlier in the Table 16.2.
All conditions causing conjugated hyperbilirubinemia
are pathologic and have a component of cholestasis.
The features of chronic cholestasis are given in the Table
16.9.

Fig. 16.8b: Neonatal hepatitis syndrome. Note marasmic


child lemon yellow hue of jaundice. Compare with biliary
atresia

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An Atlas of Neonatology

Table 16.10: Difference between neonatal hepatitis syndrome and extrahepatic biliary atresia (Figs 16.9a and b)
Neonatal hepatitis syndrome

Extrahepatic biliary atresia

Familial incidence is approximately 20%


More commonly occurs in premature or small for gestational
age infants
Stools are pigmented and persistently pigmented
Associated anomalies are nil

Familial incidence is unlikely


Can occur in any age group
Stools are persistently acholic
Associated anomalies like polysplenia syndrome with
abdominal heterotaxias, malrotation, levocardia,
intraabdominal vascular anomalies
Palpation of liver may find an abnormal size and consistency

Palpation of liver may find hepatomegaly but not


abnormal consistency
Hepatobiliary scintigraphy: Uptake of dye is sluggish, but
excretion into the biliary tract and intestine eventually occurs

Hepatobiliary scintigraphy: Hepatic function is intact and


uptake of the agent is unimpaired but excretion into the
intestine is absent
Liver biopsy: Bile ductal proliferation with presence of bile
plugs, portal or perilobular edema and fibrosis with the basic
hepatolobular architecture intact

Liver biopsy: Distortion of lobular architecture with marked


infiltration with inflammatory cells and total hepatocellular
necrosis. The bile ductules show little alteration. Giant cell
formation is found in either conditions

Fig. 16.9b: Biliary atresia. Note well grown baby with


deep yellow jaundice

Clinical Features

Fig. 16.9a: Biliary atresia. Note well grown baby with


deep yellow jaundice

responsible for this condition. It has to be differentiated


from biliary atresia.The differentiating features are listed
in Table 16.10.

Deep jaundice
Dark urine
Pale stools
Growth retardation
Failure to thrive poor-feeding
Dysmorphic features (trisomy 21, 18, Alagille,
Zellweger, IUI)
Hepatosplenomegaly
Ascites
Cardiac murmur, neurological abnormality
Bleeding (vit K deficiency, platelet deficiency)
Cholestatic features

Neonatal Jaundice

113

Laboratory Findings

Conjugated hyperbilirubinemia
ALT, AST
Alkaline phosphatase later
GGT may
Hypoglycemia
Serum albumin usually normal
Prothrombin time increased
Ultrasoundgallbladder present
Isotope scans
Liver biopsy
Giant cells
Paucity of bile ducts
Bile plugs
Mononuclear cell infiltration

Choledochal Cyst (Fig. 16.10)


Results from cystic dilatation of common bile duct (due
to congenital defect of the duct wall or a mucosal valve,
or abnormal course of the duct through the duodenal
wall). This expanding cyst blocks the entry of bile into

Fig. 16.10: Types choledochal cyst. These cyst can


cause obstructive jaundice

duodenum and causes obstructive jaundice. In older


children, the clinical triad of the cyst is jaundice, pain
abdomen and abdominal mass. In neonates jaundice
with acholic stool, high coloured urine is commonly
seen. Mass may or may not be palpable. Diagnosis can
be established by cholecystography.

114

An Atlas of Neonatology

17

Birth Injuries

Birth injuries are those sustained during the birth


process, which includes labor and delivery. Such injuries
may be avoidable or unavoidable. Majority of these are
mild and have a favorable outcome. Severe injuries can
cause permanent handicap or even death. The
mortality from birth injury in developed countries is
estimated to be 3.7 per 100,000 live births. Birth
injuries are caused by mechanical forces during passage
of the baby through the birth canal either naturally or
by traction or instrumental intervention. Various types
of injuries commonly encountered are listed below:
Skin and soft tissue injury
Erythema
Abrasions
Petechiae
Ecchymosis
Subcutaneous fat necrosis
Lacerations.
Injuries to the head
Scalp lesions due to forceps or electrodes or vacuum
extraction
Moulding
Caput succedaneum
Cephal hematoma
Subgaleal hemorrhage
Skull fractures
Intracranial hemorrhages
Facial injuries
Nasal injuries
Ocular injuries
Ear injuries.

Bony and musculoskeletal injuries


Fracture of clavicle
Fracture of long bonesfemur humerus
Dislocations of joints
Sternomastoid tumor.
Peripheral nerve injuries
Facial nerve
Brachial plexus
Erbs palsy
Klumpkes palsy,
Diaphragmatic paralysis
Internal organ injuries
Intraabdominal organ injuries
Scrotal hematoma.
Skin and Superficial Injuries (Figs 17.1a to d)
The common injuries are abrasions, erythema, blisters,
petechiae, bruising, ecchymosis and are most often
overlooked. Most of these heal without consequences.These superficial injuries are commonly seen
in babies delivered by forceps application. In presence
of extensive petechiae, watch for other sites of bleed
to rule out bleeding disorder. Hemoglobin and serum
bilirubin should be carefully monitored in presence of
large ecchymosis.
Subcutaneous Fat Necrosis
These are well circumscribed indurated lesions that
follow difficult delivery. The features are summarized
below.

Birth Injuries

115

Fig. 17.1a: Face presentation a liability for superficial injuries


Fig. 17.1d: Facial injury following forceps delivery

Appear as irregular indurated nodules


Non-tender
No local rise of temperature
Overlying skin may have altered colour
Usually appear between 6 and 10 days
Require only observation
May take several months to regress completely
Symptomatic hypercalcemia at 3-4 weeks of age is
a known complication.

Scalp Injuries (Figs 17.2a to i)


Fig. 17.1b: Blisters and erythema following face
presentation

Layers of scalp: Scalp has 5 layers as shown in the


Figure 17.2. Collection of blood or fluid in between
these layers produces characteristic physical changes.
These are described below.
Caput Succedaneum (Figs 17.2b and e)
It is probably the most commonly observed lesion that
is characterized by vaguely demarcated area of edema
over that portion of the scalp that was the presenting
part during a vertex delivery. Here serum or blood
accumulates above the layer of periosteum. The
swelling has many characteristic features. It is present
at birth pits on pressure, crosses suture lines and
resolves in few days.
Cephal Hematoma (Figs 17.2c and d)

Fig. 17.1c: Facial bruise after face presentation

Cephal hematoma is a subperiosteal bleed, hence


always limited to the surface of one cranial bone often

116

An Atlas of Neonatology

Fig. 17.2a: Layers of scalp

Fig. 17.2e: Caput succedaneum

Fig. 17.2b: Caput succedaneum

Fig. 17.2c: Cephal hematoma


Fig. 17.2f: Subgaleal hemorrhage

Fig. 17.2d: Cephal hematoma

Fig. 17.2g: Subgaleal hemorrhage

Birth Injuries

117

rubinemia may sometimes be seen and may require


phototherapy. Some cephal hematomas calcify few
months later producing bony bumps over scalp. The
differential diagnoses include caput succedaneum,
cranial meningocele and cranium bifidum. Differences
between cephal hematoma and caput succedaneum are
summarized in the Table 17.1.
Subgaleal Hemorrhage (Figs 17.2f and 17.2g)

Fig. 17.2h: Chignon

Here the blood collects in the soft tissue space between


galea aponeurotica and the periosteum that extends
from the orbital ridges to the occiput and laterally to
the ears. Vacuum extraction is a predisposing factor. The
soft tissue can accumulate as much as 260 ml of blood.
Clinical features are pallor, diffuse swelling of the scalp
progressively involving whole calvarium and features of
cerebral irritation. The blood loss may result in
hypovolemia and shock. Treatment includes restoration
of blood volume and, in deteriorating cases surgical
cauterization of bleeding points. The mortality is 25%.
Vacuum Extraction Injuries
(Figs 17.2h and 17.2i)

Fig. 17.2i: Vacuum extraction

in parietal region, rarely over occipital area. It results


due to rupture blood vessels that traverse from skull
to periosteum. Because subperiosteal bleeding is slow,
the swelling may not be apparent for several hours or
days. An underlying skull fracture may be associated
in some cases. Most cephal hematomas resolve by
themselves in 2 wks to 3 months. Marked hyperbili-

Various types of birth trauma have been associated with


vacuum extraction. These include, superficial scalp
injuries, cephal hematoma, subgaleal hemorrhage,
intracranial hemorrhage, subconjunctival hemorrhage,
clavicular fracture, nerve injuries, and retinal
hemorrhage Chignon is the term used to refer to
artificial caput that is produced beneath the vacuum
cup.

SKULL FRACTURES
Fractures of the skull during labor are relatively
uncommon as the bones are less mineralized and, the
membranous sutures that separate individual bones

Table 17.1: Differences between caput and cephal hematoma


Caput succedaneum

Cephal hematoma

Seen at birth
Crosses sutures and midline
Discoloration of overlying skin
Resolves early
Not associated with fracture

Appears after several hours or days


Sharp periosteal limitations to one bone
No discoloration
Resolves in 2 wks
May be associated with fracture

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An Atlas of Neonatology

permit alteration in the contour of the head. But


fractures do occur in prolonged and difficult labor and
forceps deliveries. Three types of fractures have been
described viz. linear, depressed and occipital
osteodiastosis. Of these, linear fractures are commonly
seen and have good prognosis.
Intracranial Hemorrhage (Figs 17.3a to c)
This can occur due to birth trauma or spontaneously.
the details are summarized in the Table 17.2.

Fig. 17.3c: Subdural hemorrhage

Other Injuries in Head (Fig. 17.4)


Eyes, facial skin, ears are susceptible for injuries during
instrumental deliveries as they are commonly in the
presenting part. Sometimes during cesarean section
they may be inadvertently damaged while putting
incisions. One such example of ear cut is shown in the
picture. Most of these injuries heal well.
Sternomastoid Tumor (Fig. 17.5)

Fig. 17.3a: Subarachnoid hemorrhage

The exact origin of this tumor is controversial. One of


the proposed mechanisms is birth trauma, during difficult
labor involving over stretching of the muscle. This results
in formation hematoma into the muscle, which is replaced
by scarring resulting in shortening of the muscle and
torticollis. Other features are summarized below.
Mass in the midportion of the muscle
Usually noted 10-14 days after birth
Hard, immobile, well circumscribed, measures
1-2 cm
No signs of inflammations
Most resolve by 5-8 months
Conservative therapy of stretching to over correct
position for 6 months
Surgery if persists beyond 1 year

BONE FRACTURES
Fig. 17.3b: Intraventricular bleed

Any bone in the body may be fractured during birth


trauma. But clavicle, humerus and femur are commonly

Birth Injuries

119

Table 17.2: Types of intracranial hemorrhages in newborn and their features


Types of hemorrhage

Predisposing factors

Manifestations

1. Subdural

Acute syndrome: nuchal rigidity, retrocollis,


opisthotonus, signs of midbrain, upper pons
compression, stupor, deviation of eyes,
bradycardia, fatal within min to hours.
Subacute syndrome: onset days after birth
irritability, stupor, irregular respiration, full AF
followed by brainstem compression.
Focal cerebral syndrome: focal seizures, focal
hemiparesis, deviation of eyes to side of lesion
a. Manifestations are variable, some babies may
be asymptomatic
b. Others have a catastrophic onset with severe
pallor, irregular respiration and death, some
babies present with seizures on second day,
baby in interictal period appears normal
c. Apneic spells in preterms
Catastrophic onset: evolution within min-hrs,
stupor, coma, apnea, tonic seizures, decerebrate
postures, fixed dilated pupils, flaccid quadriparesis,
associated bulging AF following increased ICT,
bradycardia, hypotension, hypothermia
Salutatory syndrome: stuttering evolution, hrsdays, altered sensorium, decreased spontaneous
activity, hypotonia, abnormal eye-movements.
Apnea, bradycardia, falling hematocrit, catastrophic
deterioration-diagnosis usually postmortem

Difficult labor especially breech,


brow, face presentations
Full-term infants
CPD
Rigid birth canal, primi
Precipitate deliveries

2. Subarachnoid

a. More in preterms following hypoxic event


b. In full terms following trauma

3. Periventricular
and intraventricular

More in preterms
a. <32 wks GA
b. <1500 g birth weight
c. With H/O birth asphyxia

4. Intracerebral

Prematurity
<32 wks. GA
<1500 g, birth weight, birth trauma

Fig. 17.4: Sutured ear accidentally-cut during


cesarean section

Fig. 17.5: Sternomastoid tumor

120

An Atlas of Neonatology

involved. Multiple fractures are encountered in


conditions with increased fragility of bones like
osteogenesis inperfecta, osteopetrosis congenita,
idiopathic hyperphosphatasia etc. Important bone
fractures commonly seen in birth trauma are
summarized below.

should make one suspect a fracture. Careful examination may reveal swelling and pain on passive
movement. They are treated by splinting, the limb.
Closed reduction and casting is needed only when bony
fragments are displaced. Radial nerve injury may occur
in fracture of humerus. Sometimes multiple fractures
may be feature of Battered baby syndrome.

Fracture of Clavicle (Fig. 17.6a)


Long Bone Fractures (Fig. 17.6b)

Brachial Plexus Injuries (Figs 17.7a to c)

Usually humerus and femur are common long bones


that are fractured. Loss of spontaneous limb movement

Incidence is estimated to be 4 per 1000 live births.


Brachial plexus paralysis refers to weakness or total
paralysis of muscles innervated by nerve roots that

Fig. 17.6a: Fracture of clavicle (right)

Fig. 17.7a: Erbs palsy. Note the peculiar tip hand


position of the arm

Fig. 17.6b: Fracture of femur

Fig. 17.7b: Note unilateral Moros reflex in the same baby

Birth Injuries

121

sometimes associated with injuries to phrenic nerve (C3,


C4) causing unilateral diaphragmatic palsy.
Treatment: Immobilize by fixing upper arm to the
thorax followed by gentle physiotherapy to prevent
contracture.
Prognosis: Carries good prognosis.
Klumpkes Palsy
It is an extremely rare injury in which the roots C8, T1
are affected. The injury results in weakness or paralysis
of the intrinsic muscles of hand and may cause
Horners syndrome.
Facial Nerve Palsy (Figs 17.8a and b)
Site of injury: stylomastoid foramen or ramus of
mandible, rarely in temporal bone fracture on the
contralateral side and three fourth occur on the left side

Fig. 17.7c: Erbs palsy (diaphragmatic palsy) (Left side)

supply the brachial plexus, i.e. C5-C 8 and T1. The


predisposing factors are listed in the table. The clinical
picture varies according to the nerve roots involved.
Differential diagnosis includes fracture clavicle or
humerus which can even coexist.

Clinical features:
Paralysis apparent on 1st or 2nd day
When complete, entire side of face affected
Obliteration of nasolabial fold
Drooping of corner of mouth

Risk Factors for Brachial Plexus Injury


-Shoulder dystocia
-Macrosomia
-Instrumental vaginal delivery
-Gestational diabetes
-History of affected previous infant
Erbs Palsy (Figs 17.7a to c)
This accounts for 90% of brachial plexus injuries.
Roots involved: C5,C6
Clinical features: Peculiar tip hand position; arm is
adducted and internally rotated, forearm is extended
and supinated wrist is flexed. Moros, brachial and radial
reflexes are absent but grasp reflex is intact. It may be

Fig. 17.8a: Right facial nerve palsy

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An Atlas of Neonatology

Fig. 17.8b: Right facial nerve palsy

Drawing of angle of mouth to other side on crying.


Facial palsy secondary to birth trauma(peripheral)
can be differentiated from that of central cause, by
noting involvement of both upper and lower parts
of one half of face and absence of other features
of CNS involvement and by presence of hemotympanium, periaural echymosis and swelling.

Fig. 17.9: Intra-abdominal injury with scrotal hematoma

Treatment:
Protect the eye
Observe, as 90% will resolve spontaneously
Surgical intervention after 1 year
Differentiate from CNS causes, nuclear agenesis, and
congenital hypoplasia of depressor muscle of angle
of mouth.
Internal Organ Injury (17.9)
Rupture of the liver, suprarenal gland, spleen and
kidney occurs in that order of frequency. Important
features are given below.
Scrotal Injury (Fig. 17.10)
Soft tissue injury involving scrotum occurs after breech
deliveries and in large babies. Edema, ecchymosis and

Fig. 17.10: Scrotal injury

hematomas can occur. The degree of swelling and


discoloration can be severe due to laxity of the tissues
and causes considerable concern. However, spontaneous resolution of edema occurs in 1 or 2 days and
discoloration disappears in 4 or 5 days. No treatment
is needed. It has to be differentiated from scrotal

Birth Injuries
hematoma secondary to intraperitoneal hemorrhage
due to rupture of solid organs, which requires urgent
attention.
Breech Deformation (Fig. 17.11)
Approximately 3% of babies are born by breech
presentation. Babies born by breech are at increased
risk of developing asphyxia, traumatic birth injuries, soft
tissue injuries, ecchymosis and subcutaneous fat
necrosis. A common deformation seen in newborn of
complete breech includes lower limbs kept flexed at hip
and extended at knee joint that usually resolves after
a few days. Fractures of clavicle and femur are not
uncommon. Brachial palsy, sternomastoid tumors are
common due to difficulties in delivering the aftercoming
head. Major visceral damage like spleen, liver, kidney
rupture can occur during breech extraction and so also
traumatic intracranial hemorrhages. Many fetal and
maternal factors predispose to breech presentation.
Large fetal head, congenital hip dislocation (CHD),
neuromuscular dysfunction (Down syndrome, PraderWilli, Zellweger, Trisomy 13-18. Smith Lemli-Opitz,
Fetal alcohol syndrome, Werdnig-Hoffmann syndrome,

123

myotonic dystrophy are some of the important


fetal factors, whereas uterine abnormalities, abnormal
placental implantation, oligohydramnios, polyhydramnios, twin pregnancy and low birth weight (LBW) are
maternal factors that predispose to breech delivery.
Child Maltreatment or Battered Baby
Syndrome (Figs 17.12a to c)
This group of injuries closely mimics birth trauma and
needs to be recognized in order to prevent further
adverse consequences. Child maltreatment includes a

Fig. 17.12a: Battered baby syndrome. Note facial


abrasions

Fig. 17.11: Breech deformity

Fig. 17.12b: Battered baby syndrome. Note strangulation


marks and facial abrasion

124

An Atlas of Neonatology
wide spectrum of acts of commission or omission by
the care gives that results in morbidity or death. The
acts can be physical or psychological. The former
category includes acts of omission like not providing
adequate food, clothing, safety, medical care and
schooling and acts of commission like burns, bruises,
and fractures. The psychological maltreatment
encompasses lack of support, love and recognition
insulting, comparing and terrorizing. These abuses have
short and long-term psychological consequences.

BIBLIOGRAPHY

Fig. 17.12c: Battered baby

1. Harpold TL et al. Neonatal neurological trauma. Neurosurg


Clin N Am. 1998; 9: 141-154.
2. Pollock RN.Clinical Obstetrics and Gynecology 2000;
43:236-246.

Neonatal Sepsis

18

Neonatal Sepsis

Neonatal sepsis is a clinical syndrome of multiplying


bacteria in the blood with systemic signs and symptoms
of inflammation. Meanings of other related terms are
summarized in Table 18.1.
Table 18.1: Meanings of common terms used in
neonatal sepsis
Infection: The invasion of normally sterile tissues by microorganism or their products.
Bacteremia: The presence of bacteria in the blood.
Sepsis: The systemic inflammatory response to infection.
Severe sepsis : A systemic inflammatory response that is
associated with organ dysfunction.
Septic shock: A systemic inflammatory response associated
with cardiovascular collapse refractory to fluid replacement.
Multiple organ dysfunction syndrome: A clinical syndrome
characterized by the development of acute, potentially
reversible dysfunction of organs or organ systems not directly
involved in the primary disease process.
Adapted from Marshall JC, Taneja R. in Deitch EA, Vincent
JL, Windsor A (eds). Sepsis and Multiple Organ Dysfunction.
WB Saunders 2002.

Table 18.3: Clinical features of neonatal sepsis

Escherichia coli
Staphylococcus aureus
Klebsiella pneumoniae
Group B streptococci
Table 18.2: Risk factors for neonatal sepsis

Neonatal

Maternal

Low birth weight


Male gender
Invasive procedures
Galactosemia
Asphyxia
Hypoxia, acidosis

Prolonged rupture of membranes


Premature rupture of membrane
Peripartum fever
Foul smelling liquor
Procedures on fetus
Maternal UTI

Hyperthermia
Hypothermia
Lethargy
Irritability
Respiratory distress
Apnea
Cyanosis
Jaundice
Hepatomegaly
Anorexia
Vomiting
Abdominal distention (Fig. 18.1)
Diarrhea

From Klein Jo, Mercy SM. Bacterial sepsis and meningitis. In


Remington JS, Klein Jo (eds). Infectious Diseases of the Fetus
and Newborn Infant, edn 4. Philadelphia: WB Saunders,
1999.

Laboratory Studies
Table 18.4: Laboratory evidence
of sepsis

Common Etiologic Agents

125

Direct evidence

Indirect evidence

Neutropenia (Fig. 18.4)


CRP(Fig. 18.5)
Micro ESR
Leukopenia
Ratio of immature to mature
neutrophils.
Nucleated RBC
(Fig. 18.6)

Blood culture (Fig. 18.2)


CSF culture
Urine culture (Fig. 18.3)
Other fluid analysis
pleural peritoneal etc
Antigen detection
Gram stain examination
of fluids

Reference value for neutrophilic cells in the newborn infants


Copy from Manroe B.L, Weinberg AG, Rosenfeld CR, et al.
The neonatal blood count in health and disease I. Reference
values for neutrophilic cells. J Pediatr 1979 ; 95:89.

126

An Atlas of Neonatology

Fig. 18.3: Method of collecting urine in a


female baby for sepsis screening
Fig. 18.1: Septicemia baby. Note abdominal
distentiona non-specific sign

Fig. 18.2: Blood culture bottle

Fig. 18.4: Septicemia normal total neutrophil count after


correction for nucleated RBCs in neonates from birth to 700
hrs of age (adapted from Manroe BL et al J Pediatr 1979:
95:89)

Neonatal Sepsis

Fig. 18.5: CRP kit

Fig. 18.6: Nucleated RBC

127

128

An Atlas of Neonatology

19

Common Neonatal Infections

Newborn infants are at a higher risk of contracting


various infections. Common etiologic agents and
reasons for increased susceptibility are given below.

3.

Etiology
Common Bacteria in Neonatal Infection
1. Early-onset sepsis (in the first 48 hours after birth)
Group B Streptococcus
Listeria monocytogenes
Gram-negative bacilli
Streptococcus pneumoniae
Haemophilus influenzae
Anaerobes
Staphylococcus epidermidis
2. Late-onset sepsis (after 48 hours of age)
Staphylococcus epidermidis
Enterococci Klebsiella pneumoniae
Pseudomonas aeruginosa
Escherichia coli
Other Gram-negative bacilli
Staphylococcus aureus
Anaerobes

4.

5.

6.

Ascending infection via amniotic fluid


Transplacental hematogenous spread.
Exposure to viruses from mother without antibody
Antenatal, e.g. rubella, CMV, HIV
Viremic spread, e.g. chickenpox virus
Perinatal, e.g. herpes simplex virus, hepatitis B
virus
Peripartum factors
Trauma to skin, vessels, etc., during parturition
Scalp electrodes and other invasive obsteric
procedures
Portals of colonization and subsequent invasion
Umbilicus
Mucosal surfaces
Eye
Skin
Exposure to organisms postnatally
Exposure in neonatal unit or lying-in wards, to
organisms from other babies
Overcrowding
Understaffing

Reasons for Increased Susceptibility to


Infection in the Neonatal Period (Term Infants)

Reasons for Greater Susceptibility to


Infection of Preterm Infants

1. Immaturity of the immune system


Poor humoral response to organisms (IgG, IgM
and IgA)
Relatively poor neutrophil function
2. Exposure to micro-organisms from the maternal
genital tract.

1. Immunological
Reduced transplacental transfer of maternal IgG
Relative immaturity of all immune mechanisms
2. Exposure to micro-organisms from maternal genital
tract. Preterm labor may be precipitated by infection
(choriamnionitis).

Common Neonatal Infections


3. Invasive procedures
Endotracheal tubes
Intravascular catheters
Chest drains
Cerebrospinal fluid shunts
4. Increased postnatal exposure
Organisms from other babies on neonatal unit
Overcrowding and understaffing.
5. Poor surface defenses
Skin thin, easily traumatized
6. Increased risk of conditions predisposing to sepsis
Prolonged artificial ventilation
Intravenous feeding.
7. Antibiotic pressures
Resistant organisms
Fungal infection

129

Fig. 19.1: Meningitis. Note cloudy CSF

Meningitis (Fig. 19.1)


About one-third of babies with sepsis will have
meningitis. The clinical manifestations are frequently
indistinguishable from those of septicemia. These two
facts emphasize the importance of CSF analysis in all
cases of septicemia. The features of bacterial meningitis
in newborns are listed in Table 19.1. The common
etiologic agents are also listed.
Table 19.1: Features of bacterial meningitis

Lethargy
Poor feeds
Altered temperature
Seizures
Vomiting
Abdominal distention
Respiratory distress
Bulging fontanel

Ophthalmia Neonatorum (Fig. 19.2)


It is one of the common infections encountered in the
neonatal period. Most of these infections are acquired
from maternal genital tract during delivery. It presents
as erythema and edema of palpebral conjunctiva and
eyelids with purulent discharge. Different types of
ophthalmia neonatorum include chemical conjunctivitis,
bacterial conjunctivitis, chlamydial conjunctivitis,and viral
conjunctivitis. The traditional method of differentiating

Fig. 19.2: Ophthalmia neonatorum

ophthalmias by age at presentation is unreliable except


for chemical conjunctivitis which presents within first 24
hrs. The important features of 4 groups of ophthalmia
are summarized in Table 19.2.

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An Atlas of Neonatology
Table 19.2: Ophthalmia neonatorum
Causative agent

Diagnosis

Treatment

Chemical

Silver nitrate

Absence of bacteria on Gram stain

Bacterial

Staph.aureus, N.gonorrhoeae, Presence of bacteria on Gram stain


pneumococci, Pseudomonas Isolation by culture

Gram-positive-erythromycin oint.
Gram-negative gentamicin
N. gonorrhoeaeIV Penicillin G

Chlamydial

Chlamydia trachomatis

Basophilic intracytoplasmic inclusion


in epithelial cells on Giemsa staining
Isolation by culture (McCoy)

Oral erythromycin topical


tetracycline or sulfacetamide

Viral

Herpes mainly type II

Maternal history viral culture antigen


detection tests

I.V. acyclovir and topical tri


fluoridine

None

Adapted from O Hara MA: Ophthalmia neonatorum. Pediatr Clin North Am 40:715, 1993.

Tetanus (Figs 19.3a to c)


Neonatal tetanus is a totally preventable condition.
Source of toxin in almost all cases is cord contamination
by unsterile technique during delivery or application of
substances like cowdung to cord stump that is practiced
in many parts. The incubation period varies from
3-14 days. The illness starts with nonspecific symptoms
of irritability, refusal to feed followed by lock jaw,
choking, risus, sardonicus, breathing difficulty, generalized rigidity, and opisthotonos. Management is by
neutralization of toxin, control of spasms, use of muscle
relaxants, and general supportive care. Neonatal tetanus
can be prevented by immunizing mother during
pregnancy by two doses of tetanus toxoid and by sterile
delivery practices.

Fig. 19.3b: Neonatal tetanus. Note relaxed body after


sedation in the same baby

Fig. 19.3c: Neonatal tetanus.


Note risus sardonicus

Omphalitis or Umbilical Cord Stump Infection


(Figs 19.4a and b)
Fig: 19.3a: Neonatal tetanus. Note arched
body due to spasm

Umbilical cord stump infection and umbilical sepsis


usually do not occur if proper clean techniques are

Common Neonatal Infections

131

smelling or there is surrounding periumbilical erythema


or induration. The complications include spread of
infection to abdominal wall, or to the umbilical or portal
vessels, the liver,and the peritoneum:often resulting in
sepsis. Omphalitis usually responds to frequent cleaning
with spirit swabs and application of topical antibiotic
powder. Chronic omphalitis with delayed fall of cord
is seen characteristically in a rare neutrophil function
disorder, leukocyte adhesion deficiency.
Umbilical granuloma develops due to infection, or
due to practice of applying talcum powder to umbilicus.
They can be treated with silver nitrate or copper
sulphate or by dessicating using common salt. Rarely,
surgery may be needed.
Staphylococcal Scalded Skin Syndrome
(SSSS) (Figs 19.5a and b)
It is a generalized manifestation of epidermolytic toxin
produced by Staphylococcus aureus. The toxin splits

Fig. 19.4a: Umbilical granuloma

Fig. 19.4b: Umbilical granuloma

followed during delivery. Interventions like umbilical


catheterization and exchange transfusion increase the
risk. Discharge from umbilicus is common during
neonatal period and a diagnosis of omphalitis, should
not be made unless, the discharge is purulent or foul

Fig. 19.5a: Staphylococcal


scalded skin syndrome

132

An Atlas of Neonatology

Fig. 19.5b: Staphylococcal scalded scale syndrome.


Note digit amputation by incidental ABS

the granular layer of skin and induces proteolysis leaving


extensive areas of denuded skin. The site of primary
infection is often subclinical. The illness starts with
erythema of face, which becomes generalized. This is
followed by eruption of flaccid bullae, and exfoliation
leaving a red moist surface. The lesions are more
pronounced in the extremities. Fluid and electrolyte
imbalance can complicate, if the involvement is more.
Management is by appropriate antibiotics for Staphylococcus and correction of fluid and electrolyte imbalance.
Differential diagnoses include toxic epidermal necrosis,
epidermolysis bullosa, burns, erythema multiforme and
Listeria infection.

Figs 19.6a and b: Bullous impetigo

Scabies (Figs 19.7a and b)


Bullous Impetigo (Figs 19.6a and b)
This condition is caused S. aureus and presents as
bullae of more than 1cm with little or no surrounding
erythema. The same organism also causes SSSS (see
above), but here the toxin is produced locally, and acts
locally. Usually it occurs in the second week of life and
may occur early in the event of prolonged rupture of
membranes.
The bullae are initially filled with clear serous fluid,
which becomes purulent later. Soon, the roof breaks
revealing an erythematous base that quickly dries. The
condition is painless, and the infant remains free of
systemic toxicity.

Scabies in the newborn period is relatively rare. It takes


2-8 weeks to manifest clinically after infestation. Papular
eruption of scabies in neonatal period is seen over the
face, scalp, palms and soles, unlike the intertriginous
localization seen in older children. They are most often
secondarily infected. Other clinical features include
irritability and failure to thrive. Mother and other family
members are often infested. Treatment of choice is 5%
permithrine cream.
Oral Thrush (Fig. 19.8)
Oral thrush is due to mucosal candidial infection,
appearing as plaques of white friable material over

Common Neonatal Infections

133

Fig. 19.8: Oral thrush

topical application of nystatin 1-2 lakh units 4 times


daily for 2 weeks.
Septic Arthritis (Figs 19.9a to d)
Septic arthritis refers to microbial invasion of synovial
space. In neonates it usually occurs in association with

Fig. 19.7a: Scabies

Fig. 19.7b: Scabies. Note the involvement of whole


bodya peculiar feature in infancy

tongue palate, gingivae and buccal mucosa. If the white


plaque is scraped, erythematous raw surface is seen. It
may interfere with normal feeding. Diagnosis is
confirmed by microscopic examination of the KOH
preparation of the scrapings. It is usually treated by

Fig. 19.9a: Septic arthritis. Note swollen,


red right knee

134

An Atlas of Neonatology

Fig. 19.9b: Septic arthritis.


Note arthrotomy wound

Fig. 19.9c: Septic arthritis of both knee joints. Note soft tissue
swelling of both knees. Periosteal reaction along shaft of
right tibia and left femur. Note erosion of upper tibia and
lower end of femur on right side

Fig. 19.9d: Septic arthritis. X-ray right knee showing soft tissue swelling and widening of
joint space suggestive of joint effusion

osteomyelitis. Common causative organisms are


Staphylococcus aureus Gram-negative bacilli, N. gonorrhoeae etc. Clinical features are listed below.
Management depends on drainage of pus and appropriate parenteral antibiotics for at least 3 weeks.
Initial nonspecific features
Normal temperature/fever
Irritability
Local swelling, redness
Paucity of movement of involved limb
Pain on passive movement
Iatrogenic Thrombophlebitis (Fig. 19.10)
This is probably the commonest superficial infection

Fig. 19.10: Iatrogenic thrombophlebitis

occurring whenever there is a breach in aseptic


precautions. Certain commonly used medications can
also cause this complication like calcium gluconate,
dextrose of high concentration.

Intrauterine Infections

20

135

Intrauterine Infections

Certain infections occurring in a pregnant woman


sometimes can result in infection of the fetus in utero
through transplacental transmission. The maternal
infection may be symptomatic or asymptomatic. Fetal
infection will have variable manifestations. It can be
asymptomatic or can cause effects like abortion, stillbirth, congenital malformations, growth retardation,
premature birth etc. Acronym TORCH has been widely
used to focus attention on similarities of clinical
presentation of fetal infection caused by Toxoplasma
gondii, Rubella virus, Cytomegalovirus, Herpes virus
and others (syphilis). The incidence of intrauterine
infection is estimated to be 0.5-2.5%.
Clinical Manifestations
There are certain common clinical manifestations (Table
20.1) associated with TORCH infection. Diagnostic
evaluation for TORCH should be considered in an
infant with any of these presenting features.
Although clinical features overlap, certain features
are more specific for a particular infection and help in

Table 20.1: Common neonatal clinical features


associated with TORCH agents

Growth retardation
Hepatosplenomegaly
Jaundice
Hemolytic anemia
Petechiae/ecchymoses
Microcephaly/hydrocephaly
Intracranial calcification
Pneumonitis
Myocarditis
Cardiac abnormalities
Choreoretinitis
Keratoconjunctivitis
Cataracts
Glaucoma
Non-immune hydrops

Adapted from: Kinney JS, Kumar ML. Should we expand the


TORCH complex? Clin Perinatol 1988:15(4);727.

the diagnostic work up. They are given below. Clinical


history relevant in evaluation is given in Table 20.2.
Flow chart 20.1 describes serological and viral
approach in a suspected case of intrauterine infection.

Table 20.2: Clinical history


Previous obstetric conditions Relevant history to be elicited
Syphilis
Toxoplasmosis
Rubella
Hep-B infection
Herpes viral infection

Genital sore, partner with sexual transmitted disease, previous history of II trimester abortion, stillbirth, affected child.
Contact with cats, eating raw meat, flu-like illness, titer values if available.
Fever with or without rash, often asymptomatic, vaccination status for rubella. (MMR, or rubella
alone), Rubella serum titer values if available
Jaundice in mother, HBsAg carrier status
Genital sores, serum titer values if available

Flow chart 20.1: Serological and viral approach in suspected intrauterine infections

136
An Atlas of Neonatology

Intrauterine Infections

137

Fig. 20.1a: CT scan of congenital toxoplasmosis

Fig. 20.2: Bilateral cataract in rubella

Heart defects like PDA, pulmonary artery stenosis,


and septal defects.
Cytomegalovirus (Figs 20.3a and b)

Fig. 20.1b: CT showing hydrocephalus in toxoplasmosis

Toxoplasmosis: Triad of
Hydrocephalus
Stippled intracranial calcification (Figs 20.1a and b)
Chorioretinitis
Rubella
Bilateral central cataract (Fig. 20.2), glaucoma,
pigmented retina.
Blue berry Muffin syndrome
Bones showing vertical striatia

Microcephaly with periventricular calcification


Inguinal hernias in males
Petechiae with thrombocytopenia
Preterm birth, severe IUGR.

Herpes
Vesicular skin lesions and scarring
Curvilinear intracranial calcification
Seizures
Syphilis

Joint swellings
Snuffles
Hepatosplenomegaly
Skin rash (Figs 20.4a and b)
Jaundice, anemia
Metaphyseal osteochondritis, periostitis (Figs 20.4c
to e): VDRL, FTB-ABS, TPI

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Fig. 20.3a: CT scan. Periventricular calcification in CMV

Fig. 20.4a: Skin rash in syphilis

Fig. 20.3b: Microcephaly in CMV

Fig. 20.4b: Skin rash in syphilis

Intrauterine Infections

Fig. 20.4c: Metaphyseal osteochondritis


in syphilis

Fig. 20.4d: Metaphyseal


osteochondritis in syphilis

Fig. 20.4e: Metaphyseal


osteochondritis in syphilis

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21

Perinatal HIV Infection

Virtually all HIV infections in children are the result of


vertical transmission from an HIV infected mother. The
problem is gigantic, especially so in a developing
country like India. The World Health Organization
estimated that more than 40 million persons worldwide
were living with HIV infection at the end of 2001 ; 2.7
million of these were children below 15 years of age
and more than 90% of HIV infected individuals live in
developing countries. The availability of potent
antiretroviral drugs has dramatically decreased perinatal
transmission of HIV.

Intrapartum Transmission

Timing and Mechanism of Transmission

HIV is secreted in the breast milk of infected women.


Infants of HIV infected mothers, who escape infection
during gestation and delivery may still become infected
through breastfeeding. The mechanism of transmission
through breastfeeding is most likely the frequent and
prolonged exposure of infants oral and gastrointestinal
tract to breast milk. This mode of transmission, accounts
for 12-14% of total transmission.

Mother-infant HIV transmission can occur during


pregnancy (in utero), during labor (intrapartum), or
during postpartum period through breast milk. This
type of categorization is important because, the
magnitude of risk, nature of risk factors, opportunities
for prevention, and prognosis for disease progression
are different in each category. In the absence of any
intervention, the overall rate of transmission is
approximately 25%. The factors determining the
transmission are listed in the following Table 21.1.
In Utero Transmission
This occurs through the placenta. An infant is presumed
to have acquired in utero transmission if a specimen
taken in the first 48 hrs after birth tests positive by
culture or polymerase chain reaction for viral DNA. This
mode of transmission accounts for 25-40% of total
transmission.

This type accounts for greater proportion of total


transmission. It occurs through maternofetal transfusion
of blood during labor or contact of infants skin or
mucous membranes with infected blood or other
maternal secretions during delivery. An infant is
presumed to have acquired HIV infection by this mode,
if a specimen taken in the first week of life tests negative
but becomes positive later.
Postpartum Transmission Through
Breastfeeding

Diagnosis of HIV Infection in Neonatal Period


(Fig. 21.1)
The demonstration of HIV IgG antibodies by ELISA,
followed by a positive confirmatory test such as western
blot or immunofluorescence assay, confirms the
diagnosis of HIV infection in older children and adults.
But this is not possible in neonates and infants because
of transplacentally-transmitted. maternal IgG antibodies
are detectable upto 18 month of age and their detection
by ELISA does not indicate infection of the infant. Thus,

Perinatal HIV Infection

141

Table 21.1: Determinants of mother to child transmission of HIV


A. Maternal
Viral load
Biological prototype of virus
Unprotected sex during pregnancy
Smoking and illicit drug use in mother
Maternal level of CD4 and lymphocyte count
Low maternal vitamin A Level
Time of rupture of membranes and chorioamnionitits
Episiotomy and operative vaginal delivery
Presence and amount of virus in genital tract
B. Fetal
Fetus can ingest the virus
Fetal scalp electrode, scalp blood sampling and umbilical blood sampling
Duration of exposure to maternal secretions (first twin)
Via breast milk depending on the immune response and in the newborn period of breastfeeding and infectivity of mother

Fig. 21.1: Three positive tests using three different kits of different manufacturers is considered confirmatory evidence
for HIV-positivity western blot test which is a confirmatory test is not available easily and is expensive and as per the new
guidelines not necessary for confirmation. DNA, RNA, PCRs and viral cultures are other confirmatory tests used commonly
in developed world

detection of infection in infants relies exclusively on


virologic assays. In the absence of breastfeeding, HIV
exposed infants can be accurately diagnosed by 3 to
6 months of age, and in most cases as early as 6 week
of age.
Following are important points (Flow Chart 21.1) to
remember:
An infant of HIV-positive mother is considered to
be infected if two positive results are obtained for
HIV virologic tests from the infants blood at two
different times. These virologic tests include two HIV
cultures or two HIV DNA PCR assays, or two HIV
RNA PCR or a combination of two of the 3 methods.

An infant of HIV-positive mother is considered


uninfected if these virologic tests are persistently
negative until more than 4 months of age in absence
of breastfeeding.
In the absence of hypogammaglobulinemia, two or
more negative HIV-specific IgG antibody tests
performed beyond 6 months of age with an interval
of at least 1 month between assays also reasonably
rules out HIV infection in infants with no clinical
evidence of HIV disease.
Reference: Fowler MG, Simonds RJ, Roongpisuthipong A.
Update on perinatal HIV transmission. Pediatr Clin North Am
2000 ; 47 (1): 21-38.

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An Atlas of Neonatology
Flow chart 21.1: Diagnostic algorithm

* Need to repeat DNA PCR/culture to rule out false positive.


**If child breast-fed, still at risk and will need DNA PCR < 18 months or ELISA AB > 18 months.
From: Nielson K, Bryson YJ. Diagnosis of HIV infection in children. Pediatr Clin North Am 2000 ; 47 (1): 39-63.

Table 21.2: Treatment regimens for HIV-positive pregnant woman (Fig. 21.2)
Pregnant woman
with no prior ART

Mother presenting in labor

Mother who has already


delivered (with no ART in
pregnancy)

Antepartum

ZDV 300 mg BD starting at


34 weeks of pregnancy

Intrapartum

ZDV 300 mg every 3 hours


through labor

NVP 200 mg stat

Postpartum to newborn

+ ZDV 4mg/kg BD 6 weeks.

NVP 2 mg/kg single dose


within 72 hrs.

NVP 2mg/kg single dose


within 72 hrs.

Infant-feeding

Mother will choose either


feeding or any feeding

Informed to exclusive breastfeeding or safe alternative

Exclusive breastfeeding.

Treatment regimes for HIV-positive pregnant women:


Different treatment regimes are available to reduce the

rate of transmission of HIV from mother to child. These


are listed in the Table 21.2.

Perinatal HIV Infection

Fig. 21.2: In the prevention of parent to child transmission


at the time of delivery a single dose of this drug to mother
in the labor room and to baby within 72 hours of birth has
played a big role especially in developing countries

ANTIRETROVIRAL THERAPY (ART)


Counseling
Counseling is a dialog, which aims to enable an
individual to take decision and find realistic way to
coping. (Dialog-discussion directed towards exploration
of a subject or resolution of a problemOxford
Dictionary).
In the context of PPTCT, counseling gives following
benefits:
Gives informationhelps in decision on voluntary
counseling and tests of mother and father
Weighs up the risk and advantage of pregnancy.
Male choice about contraception.
Male choice about preventing future HIV infection
including condom use.
Explains steps to minimize the transmission to the
baby.

143

Fig. 21.3: In PPTCT program all mothers attending antenatal


clinic counseling regarding parent to child transmission of
HIV before mothers subject themselves for voluntary testing
of their HIV status

3. Implication of positive and negative test results.


4. Informing about benefits and possible disadvantage
of testing.
5. If the test comes positive for a pregnant woman,
then its implications to the unborn child, interventions available to reduce the transmission to child
should be explained.
Post-test Counseling (Fig. 21.4)
The result of the test must be told, at a time and date
chosen by the patient. If admitted during labor as an
emergency, counseling and testing will have to be done
then and there. It should be told to the patients that

Group Counseling (Fig. 21.3)


This is done before a person is tested for HIV status.
Counseling is given to a group of 10-15 members at
a time. The salient components of group counseling are.
1. Providing basic information about HIV, AIDS,
Methods of transmission, tests available to detect.
2. Reason for HIV tests.

Fig. 21.4: After voluntary counseling and testing if the mother


is found to be positive for HIV. She is offered one-to-one
counseling maintaining strict confidentiality

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An Atlas of Neonatology

whatever may be the result, it will be kept confidential.


The positivity of result should be told gently, clearly and
as humanely as possible. The counselor must deal with
the feeling arising form a positive result and must give
emotional support. Wherever possible, refer to
community support organization. About breastfeeding,
the decision should be left to the mother after
explaining the pros and cons of stopping breastfeeding
(see below) decision about antiretroviral treatment and
the advantages and disadvantages of it.
Universal Work Precautions
Wash hands before and after all patient or specimen
contact (Fig. 21.5).

Handle the blood of all patients as potentially


infectious (Fig. 21.6).
Wear gloves for potential contact with blood and
body fluids.
Place used syringes immediately in nearby impermeable container; do not recap or manipulate
needle in any way.
Wear protective eye-wear and mask if splatter with
blood or body fluids is possible (e.g. Bronchoscopy,
oral surgery, etc)
Wear gowns when splash with blood or body fluids
is anticipated.
Handle all linen soiled with blood and/or body
secretions as partially infectious.
Process all laboratory specimens as potentially
infectious.
Wear mask for TB and other respiratory organisms
(HIV is not air borne).
Postexposure Prophylaxis
Health care workers are normally at a very low risk of
acquiring HIV infection during management of patients.
The risk is estimated to 0.3%per exposure.
Steps to be taken in case of accidental exposure are
given below.

Fig. 21.5: Proper hand-washing technique

Fig. 21.6: Waste should be disposed off in appropriate containers. Blue bin: Syringes, IV dripsets, catheters, Ryles tube
and other plastic wastes. White bin: Sharp objects like blades,
needle, and glass pieces. Yellow bin: Body fluids, dressing
material like gauze pieces contaminated with blood, or pus

Immediate steps: Needle sticks and cuts should be


washed with soap and water.
Splashes to the nose, mouth or skin, should be
flushed with water.
Eyes should be irrigated with clean water saline, or
sterile irrigants.
Even though, no scientific evidence exists as to the
fact that the squeezing and encouraging bleeding
and local application of antiseptics reduce the risk
of infection, these measures should always be done.
Immediately after an accidental exposure report to
the appropriate authority and the condition should
be treated as an emergency.
Postexposure prophylactic (PEP) should be started
depending on the three determinants.
Degree of exposure to HIV (determined by the
exposure code) (Flow chart 21.2)
HIV status of the source from whom exposure/
infection has occurred (Flow chart 21.3)
PEP recommendations (Table 21.3)

Perinatal HIV Infection

145

Flow chart 21.2: Determination of the exposure code (EC)

The decision to start PEP should be made as soon


as possible (within hours). Sooner it is started,
greater the benefit. Initiating treatment after 72 hrs
is not recommended as a prophylactic measure but
may still be useful as early treatment of HIV
infection, in case infection has occurred.
Breastfeeding and HIV (Fig. 21.7)
Clear advice and support of feeding options should be
given to HIV-positive women. This will need appropriate
training of the counselors and health care workers.
Training will include breastfeeding counseling,
complementary feeding, infant feeding in MTCT, and

replacement feeding options. The aim of such a


counseling should be not just the giving of information,
but to empower the mother to assess the appropriateness of the alternatives to her specific situation. Every
effort should be made to promote exclusive
breastfeeding up to four months in HIV positive
mothers followed by weaning and complete stoppage
of breastfeeding at 6 months in order to restrict
transmission through breastfeeding. However, such
mothers will be informed about risk of transmission of
HIV through breast milk and its consequences and
would be helped for making informed choice regarding
infant-feeding.

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An Atlas of Neonatology

Fig. 21.7: Counseling of HIV-positive mothers for breastfeeding is a big dilemma.


Breastfeeding is an independent risk for transmission (17%)
Flow chart 21.3: Determination of the HIV status code (HIV SC)

Basic regimen: Four weeks (28 days) of both Zidovudine 600 mg/day in
2-3 divided doses and Lamivudine 150 mg twice a day.
Expanded regimen: Basic regimen plus either Indinavir 800 mg every 8 hrs or
Nelfinavir 750 mg three times a day.
Indinavir should be taken on empty stomach (i.e. without food or with a light meal)
and with increased fluid consumption.
Nelfinavir should be taken with meals.

Perinatal HIV Infection

147

Table 21.3: Determination of PEP recommendation


EC

HIV SC

1
1

1
2

1 or 2
UNKNOWN

PEP recommendation
PEP may not be warranted
Consider basic regimen.
Exposure type poses a negligible risk for HIV transmission
Recommended basic regimen
Most HIV exposures are in this category ; no increased risk for HIV
transmission has been observed but use of PEP is appropriate
Recommended expanded regimen.
Exposure type represents an increased HIV transmission risk.
Recommended expanded regimen.
Exposure type represents an increased HIV transmission risk.
If the source (in the case of an unknown source), the setting where the
exposure occurred suggests a possible risk for HIV exposure and the EC
is 2 or 3, consider PEP basic regimen.

BIBLIOGRAPHY
1. Diagnosis of HIV infection in children. Pediatr Clin N Am
2000: 47:39-63.

2. Fowler MG et al. Update on perinatal HIV transmission.


Pediatr Clin N Am 2000; 47:21-38.

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An Atlas of Neonatology

22

Hypoxic Ischemic
Encephalopathy

Hypoxic ischemic encephalopathy (HIE) is one of the


consequences of perinatal asphyxia. This is commonly
seen in term babies with asphyxia. Clinically, HIE can
be mild, moderate and severe. These are summarized
in Tables 22.1 and 22.3. Apart from HIE, perinatal
asphyxia can cause abnormalities in other organs also
(Table 22.2). They are summarized below. The CT
features are shown in the Figures 22.1 and 22.2.
Table 22.1: Clinical features of HIE
Stage 1:

Stage 2:

Stage 3:

Hyper-alert
Normal muscle tone
Weak suck
Low threshold Moro
Mydriasis
No seizures
Lethargic or obtunded
Mild hypotonia
Weak or absent suck
Weak Moro
Miosis
Focal or multifocal seizures
Stuporous, responds to strong stimuli only
Flaccid
Intermittent decerebration
Absent suck
Poor pupillary light response

Adapted from: Sarnat HB, Surnat MS. Neonatal encephalopathy following fetal distress. Arch Neurol 1976; 33:696.

Table 22.2: Other complications of perinatal asphyxia

Acute tubular necrosis


Hepatic necrosis
Cardiomyopathy
Necrotizing enterocolitis
Meconium aspiration syndrome
Persistent pulmonary hypertension
Syndrome of inappropriate secretion of ADH
Adrenal insufficiency
Table 22.3: Hypoxic ischemic encephalopathies
another grading

Mild:
Consciousness:
Tone:
Seizures:
Time course:
Prognosis:
Moderate:
Consciousness:
Tone:
Seizures:
Time course:
Prognosis:
Severe:
Consciousness:
Tone:
Seizures:
Time course:
Prognosis:

Transitory lethargy followed by jitteriness


Mild head lag on traction
None
Symptoms maximal in first 24 hours
Good
Obtundation, may progress to coma
Hypotonic posture at least, poor traction
response
May or may not be present
Symptoms maximal at 48 to 72 hours
Guarded
Stupor and coma
Severe hypotonia at rest and in traction
A constant feature (EEG if not clinical)
Symptoms maximal from birth to 72 hours
Usually poor

Adapted from: Fenichel GM (ed). Neonatal Neurology 3 rd


edn. Churchil Livingstone INC: New York, 1990.

Hypoxic Ischemic Encephalopathy

Fig. 22.1a: Normal CT scan. Compare with


CT scan showing cerebral edema

Fig. 22.1b: CT scan showing cerebral edema

Fig. 22.2: CT scan showing HIE cystic changes

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An Atlas of Neonatology

23

Problems of
Temperature Regulation

Providing warmth is one of the basic needs of a


newborn infant. Maintaining euthermia is important for
optimal growth. There are certain factors that make a
newborn infant susceptible to loose heat like large
surface area, large head in proportion to body, and little
subcutaneous fat. All these factors get exaggerated in
low birth weight babies.
When exposed to cold environment, unlike adults
newborn infants do not shiver in order to produce heat.
Nevertheless, they maintain body temperature by
burning brown fat that makes up about 2-6% of their
total body weight. But this is not true in very premature
babies who have less amount of brown fat and
increased evaporative water loss. Thus, they are more
susceptible for hypothermia and its consequences.
Modes of Loosing Heat
There are four ways by which body can loose heat (Fig.
23.1).
1. Conductive loss: This occurs due to differences
in temperatures between the baby and the surface
on which he lies.
2. Convective loss: This occurs due to air currents
around the baby.
3. Evaporative loss: This occurs due to latent heat
of evaporation and depends on how wet the baby
is, the thickness of the skin, and humidity of
environment.
4. Radiation loss: This is due to temperature
gradient between 2 objects facing each other.

Fig. 23.1: Modes of loss of heat

THERMONEUTRAL TEMPERATURE
For a particular gestational and postnatal age, there is
a narrow range of temperatures in which oxygen
requirement by the baby is at the lowest. This narrow
range is termed as thermoneutral temperature. If the
ambient temperature fall above or below this, metabolic
rate increases interfering with growth.

NONSHIVERING THERMOGENESIS
As said above, newborn do not shiver and produce
heat. Instead heat is produced by the breakdown
of metabolically-active adipose tissue called brown
fat. Blood gets warmed as it passes through brown fat
and rewarms rest of the body. The distribution of brown
fat is shown in the Figure 23.2 and important
differentiating features form ordinary fat are shown
in Table 23.1.

Problems of Temperature Regulation

151

Flow chart 23.1: Vicious circle of neonatal hypothermia

Fig. 23.2: Distribution of brown fat


Table 23.1: Difference between brown fat and white fat
Brown fat

Many vacuoles per cell


Good vascularity
High innervation
Many mitochondria
Cold stimulates activity
For heat production

White fat

One vacuole per cell


Poor
Low
Few
Starvation stimulate breakdown
For nutrition

Table 23.2: Predisposing factors for hypothermia


in preterms

Thin skin
Increased body surface area to weight ratio
Decreased subcutaneous fat
Decreased amount of brown fat
Extended posture, which exposes more skin surface
Under developed autonomic regulation of cutaneous
vasculature

Neonatal Cold Injury


As said above the predisposing factors for neonatal cold
injury are prematurity (Table 23.2) and in term infants,
intracerebral hemorrhage and CNS malformations. The
vicious circle of cold injury is given in Flow chart 23.1.
Grading Temperatures
Core Body temperature should be taken by checking
rectal temperature with the help of a low reading
thermometer. Normal temperature of a newborn baby
is 36.5-37.5C. The newborn with a temperature of
36.0-36.4C (96.8-97.5F) is under cold stress and
immediate measures to warm the baby may be
rewarding. A newborn with the temperature of 32.035.9C (89.6-96.6F) has moderate hypothermia, while
a temperature less than 32C (89.6F) is severe
hypothermia (Fig. 23.3). Both later situations may lead
to serious morbidity and mortality.

Fig. 23.3: Grades of temperatures

Clinical Features

Lethargy, sluggishness, poor feeding.


Slow, shallow, irregular respiration
Bradycardia
Feels cold to touch
Bright red color of face due to poor dissociation of
oxyhemoglobin at low temperatures giving false
impression of well-being.
Edema and sclerema of skin
Pulmonary hemorrhage
DIC
Metabolic derangements

Management
Rewarming: slow rewarming by keeping the ambient
temperature 1.5C higher than skin temperature is
recommended.

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An Atlas of Neonatology

Administer oxygen
Monitor blood glucose
Correct metabolic acidosis by sodium bicarbonate.
Prevention of Hypothermia in Newborn
In Delivery Room
Use prewarmed sheets to receive the baby
Dry the baby well, with warm towels with special
attention to dry up the scalp
Remove moist, soiled linen and wrap the baby in
fresh, warm sheets
Practice kangaroo care as soon as feasible.
In the Nursery
Incubator (Fig. 23.4a): It is a closed system of maintaining euthermia. When a baby is kept inside an
incubator, convective heat losses are reduced by
reducing air currents. Radiation losses are controlled by
hood or canopy (single or double walled). Conductive
losses are also reduced by maintaining a warm
microenvironment. In India most intensive care units
have single walled incubators. If the room temperature
is low the infant looses heat to cold incubator wall.
Thus, double walled incubators in which the
temperature of the inner wall is not affected by a cooler
room temperature should be preferred.
Main parts of an incubator:
Humidity tank
Hood or canopy
A servo control system for automatic adjustment in
the ambient temperature. This has two types of
control systems: air mode (Fig. 23.4b) and baby
mode (Fig. 23.4c) as shown in the picture.
Advantages: (Table 23.3)
Good thermal regulation
Use is preferred in extremely small or sick babies.
Readily cleanable.
Disadvantages: Access to infants difficult
Not suitable for undertaking prolonged procedures
like exchange transfusion
Increased risk of infection
Costly.

Fig. 23.4a: Baby kept in an incubator

Fig. 23.4b: Air mode of servo control

Fig. 23.4c: Baby mode of servo control

Radiant Warmers (Fig. 23.5)


It creates a warm microenvironment by providing heat
energy by radiation. It is also called open care system,
as it gives easy access to the baby.
Parts:
Basinet for placing the baby
Over head heater
Servo control system

Problems of Temperature Regulation

153

Fig. 23.6: Room heater

Disadvantages:
Not preferable in extremely small or gravelly sick
neonates
Temperature control less optimal due to heat loss
Room Heaters (Fig. 23.6)

Fig. 23.5: Baby kept under radiant warmer

Increasing the room temperature to 30-32C using


room heaters is a cheaper alternative measure to
prevent neonatal hypothermia. But, these are uncomfortable for nursing staff.

Skin sensor
Control panel
Temperature display
Alarms for safety.

Advantages: (Table 23.3)


Easy access to the infant
Less chances of nosocomial infection
Most suitable for undertaking prolonged procedures
like exchange transfusion
Less expensive

Use of Caps and Warm Clothes (Fig. 23.7)


Growing and stable babies should be covered fully .The
relative large size of head (12% of body weight
compared to 2% in the adult) can lose greater
proportion of body heat. Double-layered caps can
significantly reduce the loss.

Table 23.3: Major differences between radiant warmers and incubators


Radiant warmer

Incubator

Open care system hence easy accessibility


Over head heater with reflector with reflector to
focus radiant heat
Easy to clean and maintain
Lower risk of infection unless infant excessively
handled
Cheaper

Closed system hence less accessibility


Under dark heater and fan to circulate warm
filtered air
Difficult to clean and maintain
Risk of infection increases, if not adequately cleaned
and disinfected
Expensive

Modified and adapted from: Deodari AK, Paul VK. Neonatal equipment 2001, 2nd edn Sagar Publications: New Delhi.

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An Atlas of Neonatology
If baby is in incubator or on ventilator care, start
with short duration and extend progressively.
Infants should be naked except for diaper and cap
Put the infant with flexed limb on mothers bare
chest, between her breasts and inside her clothing.
Extend babies neck to prevent obstructive apnea.
Monitor vital signs including temperature

Fig. 23.7: Baby wrapped in warm clothes and covered


with caps

Fig. 23.8: Kangaroo mother care

Kangaroo Mother Care (Fig. 23.8)


Kangaroo care is defined as skin-to-skin contact between
a mother and her low birth weight infant in a hospital
setting. This term was later changed to kangaroo mother
care (KMC) to emphasize the importance of mother and
mothers milk. The guidelines for KMC are as follows.
Initiate kangaroo care as early as possible

Benefits of KMC:
Has popular appeal
Promotes breastfeeding
Babies remain physiologically more stable including
thermally.
Boosts maternal confidence and bonding.
Decreases risk of infection
Cheaper and safer than any other warming device
Warm chain:
The warm chain is a concept introduced to describe a
set of interlinked procedures, which will minimize the
likelihood of development of hypothermia. Any breach
in the chain of procedures increases the risk of
hypothermia. The links of warm chain are given in the
information box:
1. Training all persons involved in the birth and
subsequent care of the baby.
2. Preparing the place of delivery by ensuring a warm,
draught free room.
3. Immediate drying of the newborn baby.
4. Wrapping the baby and giving it to the mother
quickly after birth.
5. Putting the baby to the mothers breast
6. Putting a warm cap on the babys head
7. Ensuring a warm, safe transport if necessary.

BIBLIOGRAPHY
1. Klaus MH, Fannroff AA. In Klaus MH, Fanaroff AA (eds).
Care of the High Risk Neonate. 5th edn W.B. Saunders
Company 2001.
2. Kirsten GF et al. Kangaroo mother care in the nursery.
Pediatr Clin N Am 2001; 48; 443-445.

Neonatal Convulsions

24

Neonatal Convulsions

Convulsions in the newborn period are one of the most


frequently encountered clinical problems. Approximately 0.5% of term babies and 21% of preterm babies
develop this problem, well-organized tonic-clonic type
of seizure that is common in the older children is not
seen in neonates owing to the immaturity of the
newborn brain their clinical expression at this age is
quiet variable subtle and often poorly organized. It is
critical to recognize seizure activity as they indicate
significant underlying abnormality and if unattended,
can cause permanent neurological damage. The clinical
types, classification, etiology and other related factors
are dealth with in Tables 24.1 to 24.6).
Table 24.1: Types of seizures in neonates

Fig: 24.1a: Staring look

Subtle or fragmentary seizures


Clonic seizures
Tonic seizures
Myoclonic seizures
Table 24.2: Close mimics of convulsions

Jitteriness (Table 24.3)


Benign neonatal sleep myoclonus
Stimulus evoked myoclonus

Subtle Convulsions (Fig. 24.1a)


Subtle convulsions comprise 50% of all neonatal
seizures. The clinical forms include staring look, eye
fluttering, lip smacking, drooling and other orobuccolingual movements, rowing, pedaling, apneic spells.
Thus one has to be aware of subtle but important
manifestation of seizure activity in neonates.

Fig. 24.1b: CT scan showing features of HIE

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An Atlas of Neonatology
Table 24.3: Differences between seizure and jitteriness
Features

Seizure

Jitteriness

Eye deviation or other ocular manifestations


Stimulus sensitive
Dominant movement
Movement ceases with gentle passive flexion
EEG

Present
No
Clonic jerking
No
Abnormal

Absent
Yes
Tremor
Yes
No change

Table 24.4: Etiological classification of seizures


Metabolic
Hypoxic ischemia (Fig. 24.1b)
Hypoglycemia (Fig. 24.2)
Hypocalcemia
Other electrolyte imbalances
Pyridoxine dependent
Cerebrovascular lesion
Infarction (Fig. 24.3)
Cortical vein thrombosis
Trauma
Subarachnoid hemorrhage (Fig. 24.4a)
Intracerebral hemorrhage (Fig. 24.4b)
Subdural hemorrhage (Fig. 24.4c)
Intraventricular hemorrhage (Fig. 24.4b)
Infection
Brain anomalies (Figs 24.5a and b)
Hypertensive encephalopathy
Amino acid metabolism defects
Familial seizures
Neurocutaneous syndromes (Fig. 24.6)
Tuberous sclerosis
Incontinentia pigmenti
Selected genetic syndromes
Zellwegers (Fig. 24.7)
Neonatal adrenoleukodystrophy
Smith-Lemli-Opitz syndrome (Fig. 24.8)

Fig. 24.2: Glucometer

Table 24.5: Investigations following neonatal seizures


First line
Pulse oximetry
Glucose
Packed cell volume
Sr. calcium, sodium, magnesium
Arterial pH
Lumbar puncture, blood cultures
Cranial ultrasound
EEG (Figs 24.9a and c)
Second line
CT
Specimens for detecting congenital infections
Serum ammonia, amino acids
Urinary amino acids and organic acids
Therapeutic trial of pyridoxine
Modified and adapted from: Evans D, Levene M. Neonatal
seizures. Arch Dis Child Fetal Neonatal Ed 1998;78: F70-F75.

Fig. 24.3: Infarction

Neonatal Convulsions

Fig. 24.4a: Subarachnoid hemorrhage

Fig. 24.4b: Intraventricular bleed with cerebral extension

Fig. 24.4c: Subdural hemorrhage with


parenchymal extension
Table 24.6: Causes of seizures according to age
Common
1st day
2nd day
3rd day
4-7 days
5th day

157

Uncommon

Anoxia, IVH
Hypernatremia, hyponatremia, hypomagnesemia
hypocalcemia, anomalies CNS infection, accidental injection of local anesthetic
Birth trauma
Sepsis, TORCH
Hypoglycemia, sepsis
Drug withdrawal e.g., (pyridoxine)
Sepsis or meningitis, hypocalcemia, Kernicterus
Zinc deficiency

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An Atlas of Neonatology

Fig. 24.5a: Lobar holoprosencephaly

Fig. 24.7: Zellwegers syndrome

Fig. 24.5b: Porencephaly

Fig. 24.6: Neurofibromatosis. Note caf au lait spots in


the baby and neurofibroma in the mother

Fig. 24.8: Smith-Lemli-Opitz syndrome

Neonatal Convulsions

Fig. 24.9a: Hypsarrhythmia in infantile spasms or West


syndrome

159

Fig. 24.9b: Hypsarrhythmia in infantile spasms or West


syndrome

Fig. 24.9c: Hypsarrhythmia in infantile spasms or West


syndrome

160

An Atlas of Neonatology

25

Bleeding Neonate

Bleeding during neonatal period can occur due to a


wide range of hereditary and acquired causes. The
newborn infant is particularly susceptible due to a
variety of reasons such as physiologic deficiencies of
coagulation factors, prenatal influences like maternal
diseases or drugs, immaturity of blood vessels,
vulnerability to birth trauma, and other conditions
associated with bleeding such as sepsis and asphyxia.

Clinical Presentation

Approach to a Bleeding Neonate

Always ask family history of bleeding disorders


Ask maternal history of condition predisposing, e.g.
SLE, ITP, drug intake, etc.
Enquire about administration of vit K
Type of bleed

Oozing from umbilicus (Figs 25.1a and b)


Bleeding into the scalp
Large cephalohematomas
Bleeding after ritual circumcision
Bleeding from venepuncture sites (Fig. 25.1e)

Mucosal bleedinggastric, rectal (Fig. 25.1c)


Intracranial hemorrhage (Fig. 25.1d)
Petechiae, ecchymosis
Hematoma over skin (Fig. 25.1f)

Etiology
The causes are listed in the Table 25.1.

Table 25.1: Causes of bleeding in the newborn


Impaired vascular function: acidosis, hypoxia, prematurity, etc.
Platelet disorders: Qualitative
- Glanzmanns disease
- BernardSoulier syndrome
Quantitative
- Isoimmune thrombocytopenia
- Maternal ITP/SLE
- Maternal drug intake
- Infection/sepsis and DIC
- Inherited thrombocytopenia
- Giant hemangiomas
- Hyper-viscosity syndromes
Coagulation defects:
Transitory deficiency of vit K-depended factors
Disturbance of clotting in systemic illness like NEC, shock, anoxia, liver disease.
Inherited deficiency of clotting factors.

Bleeding Neonate

Fig. 25.1d: Subdural hemorrhage

Figs 25.1a and b: Umbilical bleed. This is how this baby who
was brought to the hospital. A diagnosis of Factor 13
deficiency was made by family history, bleeding despite
receiving vit K, and urea dissolution test

Fig. 25.1c: Rectal bleed

Fig. 25.1e: Bleeding into venipuncture site

Fig. 25.1f: Hematomas over the skin

161

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An Atlas of Neonatology

Small petechiae or mucosal bleed usually suggestive


of platelet disorder.
Enlarge spleen, large bruisesclotting factor
deficiency, DIC
Enlarged liverIUI
Jaundiceinfection or liver disease
Healthy infantsimmune thrombocytopenia, vit K
deficiency, congenital coagulation factor deficiency
Sick infantsDIC, infection, liver disease
Laboratory studies which help in diagnosing are
given in Table 25.2.
Vit K Deficiency Bleeding (VKDB) (Fig. 25.2)
This disorder should be considered in a bleeding but
otherwise healthy neonate. It presents in 3 forms, which
are summarized along with etiology and treatment in
the Table 25.3.

Fig. 25.2: Vitamin K injection

Table 25.2: Laboratory findings which help in arriving at a diagnosis


General
condition
Sick

Well

Platelets

PT

APTT

N
N

N
N
N

N
N

N
N

N
N

Diagnosis
DIC
Platelet consumption
Liver disease
Vascular hypoxia, acidosis, prematurity
Immune thrombocytopenia marrow aplasia
HDN
Inherited coagulopathy
Trauma factor XIII deficiency Glanzmanns syndrome

Table 25.3: Hemorrhagic disease of the newborn


Early

Classical

Late

Age

<24 hr

2-7 days

2-8 wks

Causes/risk factors

Medications during
pregnancy-INH, RMP
Anticonvulsants

V K content in breast
milk, sterile gut

Disorders interfering with vit. K


absorption, vit K in breast milk

Treatment

Discontinue offending
agent, maternal vit K
prophylaxis

Adequate vit K supply,


vit K prophylaxis

Adequate vit K supply, vit K prophylaxis

Manifestations

Cephal hematoma
Subgaleal hemorrhage
Intracranial hemorrhage
Gastrointestinal
Umbilicus
Intra-abdominal

Gastrointestinal
ENT bleed
Intracranial
Circumcision
Cutaneous
Gastrointestinal
Injection site

Intracranial
Gastrointestinal
Cutaneous
ENT Bleed
Injection site
Thoracic

Infants of Diabetic Mothers 163

26

Infants of Diabetic Mothers

Poorly-controlled diabetes during pregnancy affects


multiple organ systems of the growing fetus resulting
in high morbidity and mortality. The abnormalities
seen in the newborn can grouped into two categories:
embryopathy and fetopathy (Table 26.2). Embryopathy includes the congenital malformations, which arise
as result of the insult occurring in the embryonic period
i.e. at the time of organogenesis which occurs between
3rd and 7th weeks of gestation (Table 26.3). Fetopathy
occurs after 10th week and includes macrosomia and
other postnatal complications but is not associated with
malformations. Common problems arising from poorlycontrolled maternal DM are listed in Table 26.1. The
pathogenesis of some morbid features of IDM is shown
in Flow chart 26.1. The exact pathogenesis of these ill
effects are not known. Some of the probable teratogens
have been thought to be responsible which are listed
in Table 26.4.

Table 26.2: Diabetic fetopathy


Macrosomia
Intrapartum shoulder dystocia
Clavicular fracture
Cranial nerve palsies
Brachial plexopathy (palsy)
Hypoglycemia
Polycythemia
Hypomagnesemia
Hyperbilirubinemia
Hypocalcemia
Cardiomyopathy (thickened interventricular septum)
Renal vein thrombosis

Table 26.1: Problems of infants of diabetic mothers

Macrosomia
Congenital anomalies
Hypoglycemia
Hypocalcemia/hypomagnesemia
Polycythemia/hyperbilirubinemia
Respiratory distress syndrome
Transient tachypnea of the newborn
Hypertrophic cardiomyopathy
Small left colon (Fig. 26.1)
Renal vein thrombosis

Fig. 26.1: Hypoplastic left colon

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An Atlas of Neonatology
Table 26.3: Diabetic embryopathy

Location

Malformations

CNS

Open neural tube defects, holoprosencephaly absent corpus callosum, Arnold-Chiari anomaly,
schizencephaly, microcephaly, macrocephaly, agenesis of olfactory tracts, hydrocephaly, bizarre
undergrowth or overgrowth of brain
Transposition of great vessels, VSD, ASD, TOF, CoA, SUA, hypoplastic left heart, cardiomegaly
Pyloric stenosis, duodenal atresia, microcolon, anorectal atresia, omphalo-enteric cyst/fistula, hernias
Renal agenesis, renal cysts, hydronephrosis, duplication of ureter, ureterocele, uterine agenesis, hypoplastic
vagina, micropenis, hypospadias, cryptorchidism, hypoplastic testes, ambiguous genitals
Caudal dysgenesis/deficiency (Fig. 26.2), craniosynostosis, costovertebral anomalies, limb reduction, cleft
palate, club foot, contractures, polysyndactyly
Situs inversus, microphthalmia, colobomas of iris or chorioretina, anterior chamber dysgenesis,
diaphragmatic hernia, bronchial arch anomalies, choanal atresia, aplasia cutis, cutaneous vascular dysplasia

Cardiovascular
Gastrointestinal
Urogenital
Musculoskeletal
Others

Table 26.4: Putative teratogens in diabetic embryopathy


Metabolism

Results

Carbohydrate

Hyperglycemia
Hyperglycemia in rats>humans
Lipid metabolism
Protein metabolism
Trace metals metabolism

Sorbitol
Nonenzymatic glycosylation of proteins
Radical O2 species
Collagen
Uptake of myoinositol
Arachidonic acid
Uptake of vitamin C
Prostaglandins
Superoxide dismutase
Ketones (hydroxybutyrate and keto-isocaproic acid)
Somatomedin inhibitors
Insulin
Zinc

Decreased level, increased level


Flow chart 26.1: From Schwaartz R. et al; J Pediatr
Endocrinol 1992; 5; 197

Fig. 26.2: Caudal regression syndrome

Infants of Diabetic Mothers 165


Macrosomia (Figs 26.3a to d)
An infant is termed macrosomic if his birth weight is
more than 4000 g or weighs above 90th centile for the
gestational age. The classic appearance of an IDM is that
of a large, ruddy, puffy, fat and often limp infant with

Fig. 26.3a: Infant of diabetic mother. Note macrosomia

Fig. 26.3b: Macrosmia baby. Note peculiar facies

Fig. 26.3c: Infant of diabetic mother. Note macrosomia. Also note characteristic hairy pinna

Fig. 26.3d: Infant of diabetic mother. Chest


X-ray showing cardiomegaly.

legs held in a flexed and abducted position. There is


associated visceromegaly except for brain and kidney.
The pathogenesis is depicted in the Flow chart 26.1.
The common problems of macrosomic infants are
increased risk of birth injury, fetal distress, birth
asphyxia, etc. Differential diagnosis includes Beckwith-Wiedemann syndrome. Other maternal risk factors
for macrosomia include multiparity, weight more than
70 kgs, prolonged pregnancy and previous history of
macrosomic infant.

166

An Atlas of Neonatology

27

Neonatal Anemia

Anemia in newborn period is defined as packed cell


volume of <40%. It is broadly classified into three
categories based on the etiology: blood loss anemia,
hemolytic anemia and anemia as a result of decreased
production. Causes of anemia in the neonatal period
are given in Table 27.1. A diagnostic approach to
anemia in newborns is also given in Table 27.2 and
Flow chart 27.1.

Pallor
Pallor is the external manifestation of severe anemia,
but pallor may be seen in other condition like shock,
asphyxia, and hypothermia etc. Preterm babies may
not look pale despite anemia due to presence of thin
skin.

Table 27.1: Causes of anemia in the neonatal period


Blood loss
a. Occult hemorrhage prior to birth
Example: Amniocentesis in third
trimester, abdominal trauma,
twin transfusion syndrome
b. Obstetric accidents, malformation
of the placenta and cord
Example: Abruptio placenta,
hematoma of cord or placenta.
Rupture of anomalous vessels
(Fig. 27.1)
c. Internal hemorrhage (Figs 27.2a
to c)
Intracranial
Giant cephal hematoma
Caput succedaneum
d. Intra-abdominal organ rupture
by birth trauma (Fig. 27.3)
e. Iatrogenic due to repeated
sampling

Hemolysis
1. Immune
Rh/blood group incompatibility
maternal autoimmune hemolytic
anemia
2. Infection
Bacterial sepsis
Congenital infection including
malaria
3. DIC
4. Macro or micro-angiopathic
anemia
5. Red cell membrane disorders
6. Red cell enzyme deficiencies
7. Thalassemias - and
8. Structural abnormality of and
chains
9. Galactosemia
10. Pyknocytosis
11. Prolonged acidosis

Decreased production
1. Diamond-Blackfan syndrome
2. Pearsons syndrome
3. Congenital infections
Human parvovirus
Adenovirus
CMV
Rubella
Hemangiomas (Fig. 27.4)
Congenital Leukemia
(Fig. 27.5)
4. Down syndrome
5. Osteoporosis

Modified and adapted from: Nathan and Oskis Hematology of Infancy and Childhood 5th edn. W.B. Saunders Company.

Neonatal Anemia

Fig. 27.1: Accessory lobe of placenta the interconnecting


vessels (arrow) are more prone to get ruptured
Fig. 27.2b: Subgaleal bleed

Fig. 27.2a: Cephal hematoma

Fig. 27.2c: Subdural bleed

167

168

An Atlas of Neonatology

Fig. 27.3: Intra-abdominal injury with scrotal hematoma

Fig. 27.5: Congenital CML

Fig. 27.4: Hemangioma

Neonatal Anemia
Flow chart 27.1: Algorithm for lab evaluation of neonatal anemia

169

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An Atlas of Neonatology
Table 27.2: Clinical evaluation of anemia in newborn

1. Family history (esp. Sibs)


Relevant cause
Anemia
Hemolytic, e.g. hemoglobinopathies, immune mediated,
Jaundice
hereditary spherocytosis
Splenectomy
G6PD deficiency, immune-mediated
Gallstones
Hereditary spherocytosis, hemoglobinopathies
2. Obstetric history
Traumatic/instrumental delivery
ICH, cephal hematoma, rupture spleen/liver
APH
Fetoplacental bleed, fetomaternal bleed
Twins
Twin-to-twin transfusion
Drugs (e.g. anticonvulsants, antitubercular drugs) Early HDN
Cesarean section- incision of placenta
Fetoplacental bleed
3. Neonatal
Vitamin K administration
Relevance -HDN
Evidence for sepsis
Septicemia, DIC
GIT bleed
NEC, sepsis, HDN
Jaundice
Hemolysis
Physical examination
1. Acute blood loss
Shock, mild cyanosis, poor perfusion
2. Chronic blood loss
Pallor
3. Hemolysis (chronic)
Pallor, jaundice, hepatosplenomegaly

Respiratory Distress

28

171

Respiratory Distress

Respiratory distress is a major cause for significant


mortality and morbidity. It occurs in 4-6% of newborns.
Many of these are preventable. An infant is said to be
in respiratory distress if he has
Respiratory rate >60 breath/min
Subcostal and intercostal retractions (Fig. 28.1)
Expiratory grunt
Use of accessory muscles (nasal flaring)
Respiratory distress can be of pulmonary or
nonpulmonary in origin. Common conditions causing
respiratory distress are listed in Table 28.1.
Table 28.1: Causes of respiratory distress in neonates
Pulmonary disorders:
Respiratory distress syndrome (RDS)
Transient tachypnea of the newborn (TTNB)
Meconium aspiration syndrome (MAS)
Pneumonia
Air leak syndromes
Pulmonary hypoplasia
Systemic disorders:
Hypothermia
Metabolic acidosis
Anemia/polycythemia
Hypoglycemia
Pulmonary hypertension
Congenital heart disease
Anatomic problems compromising respiratory system:
Upper airway obstruction
Airway malformations
Space occupying lesions
Ribcage anomalies
Phrenic nerve palsy
Neuromuscular disease
From: Martin RJ, Sosenko I, Bancalari E. In Klaus MH, Fanaroff
AA (eds). Care of the High-risk Neonate. 5th edn W.B.
Saunders Company 2001.

Fig. 28.1: Respiratory distress

From clinical point of view respiratory distress can


also be classified as medical and surgical. Which are listed
below.
Medical

Meconium aspiration syndrome


Transient tachypnea of the newborn
Respiratory distress syndrome
Pneumonia, acidosis, asphyxia
Hypothermia, anemia/polycythemia
Hypoglycemia, congenital heart disease

Surgical

Pneumothorax and other air leaks


Tracheoesophageal fistula
Diaphragmatic hernia (Fig. 28.6)
Rib cage anomalies

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An Atlas of Neonatology

The conditions causing respiratory distress differ in


preterm and term babies as well though overlapping
can occur. Some of the conditions which are common
in each category of babies are listed below.
Preterms

Terms

RDS
Pneumonia
Asphyxia
TTNB

MAS
Pneumonia
TTNB
Malformations
Acidosis
Others

Assessment of respiratory distress: Respiratory distress


in the newborn period is usually assessed by a Downes
scoring system which is given below.
Score

Respiratory rate/min < 60


Cyanosis
None
Retractions
Grunting
Air entry

None
None
Good

60-80
None with
40% FiO2
Mild
Minimal
Decreased

>80
Needs > 40%
FiO2
Severe
Obvious
Very poor

Fig. 28.2b: HMD. Note air bronchogram

Score >6 indicates severe distress

Hyaline Membrane Disease or Respiratory


Distress Syndrome (Figs 28.2a to d)
Insufficiency of pulmonary surfactant system results in
hyaline membrane disease also referred to as respiratory distress syndrome. Prematurity is the commonest
predisposing factor. Other factors are given in
Fig. 28.2c: HMD. White out

Fig. 28.2a: Hyaline membrane disease. Note diffuse


reticulo-granular pattern with air bronchogram

Fig. 28.2d: HMD histology. Note alveoli surrounded


by poink membrane

Respiratory Distress
Flow chart 28.1: Pathophysiology of HMD

173

Table 28.3: Clinical features of RDS

Onset within 4 hrs of birth


Respiratory rate>60 breath/min
Recessions with use of accessory muscles of respiration
Expiratory grunt
Cyanosis (may or may not be present)
Fine respiratory crepitation
Peripheral edema
Pulmonary edema
Chest X-ray; reticulogranular pattern, air bronchogram
White out appearance

Meconium Aspiration Syndrome (MAS)


(Figs 28.3a to c and Flow chart 28.2)
Acute or chronic hypoxia of fetus may result in the
passage of meconium in utero. Aspiration of this
material before or during birth may result in MAS. The
pathophysiology is depicted in the flow chart.
From: Martin RJ, Sosenko I, Bancalari E.
In Klaus MH, Fanaroff AA (Eds). Care of the High Risk Neonate, 5th
edn, WB. Saunders Company 2001.

Table 28.2. Clinical features and evaluation of RDS are


listed below (Tables 28.3 and 28.4) followed by Flow
chart 28.1 depicting pathophysiology.

Clinical Features

Infants at risk; Term, post-term and SGA babies.


Meconium stained amniotic fluid
Staining of cord and nails on examination
Distress develops after establishment of respiration
Emphysematous chest

Table 28.2: Predisposing and protective factors for RDS

Radiologic Features

Predisposing

Prematurity

Protective
Cesarean section
Asphyxia
Maternal diabetes

PROM
IUGR
Steroid
TRH

Hyperinflation
Patchy atelectasis
Air leaks:
Pulmonary interstitial emphysema
Pneumothorax (Fig. 28.3d)

Table 28.4: Clinical evaluation of respiratory distress in newborn

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Relevant maternal history

Risk in the baby

Fever in third trimester, PROM, infection


Hydramnios
Oligohydramnios
Post-term, meconium-stained liquor
Toxemia
Diabetes
Sedation during labor
Reserpine to mother
Preterm delivery
Forceful resuscitation

Pneumonia
Tracheo-esophageal fistula
Pulmonary hypoplasia
MAS, TTNB
Polycythemia, asphyxia
HMD, polycythemia, CHD, hypoglycemia
TTNB
Nasal stuffiness
HMD
Pneumothorax

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An Atlas of Neonatology

Fig. 28.3a: Meconium aspiration


syndrome. Air leak syndrome
pneumoperitoneum

Fig. 28.3d: Pneumothorax

Fig. 28.3b: Meconium aspiration


syndrome. Note pachy atelectasis
and hyperinflation

Fig. 28.3e: MAS with pneumopericardium

Pneumomediastinum
Pneumopericardium (Figs 28.3e and f)
Pneumoperitonium
Subcutaneous emphysema

Transient Tachypnea of the Newborn


(Fig. 28.4)
This is a self-limiting condition mainly affecting term

Fig. 28.3c: Meconium aspiration


syndrome

Fig. 28.3f: MAS with pneumopericardium

infants following in uneventful delivery. Infants born by


elective cesarean section and infants of diabetic mothers
are at increased risk. The condition is thought to be due
to delayed clearance of lung fluid resulting in decreased
lung compliance the presentation includes tachypnea,
retractions and nasal flaring. These infants rarely
required more than 40% oxygen to remain pink. Xray shows hyperinflation, perihilar streaking, fluid in

Respiratory Distress

175

Flow Chart 28.2: MAS

Fig. 28.5: Congenital pneumonia with mild-pneumothorax

interlobar fissure and mild-cardiomegaly. The condition


usually resolves in 2-5 days.
Congenital Pneumonia (Fig. 28.5)
Pneumonias in the neonatal period can be acquired
from mother, nosocomial or due to aspiration. They
are listed below.
1. Acquired from the mother
Congenital:
Transplacental pneumonia
Postamnionitis pneumonia
Transnatal (during delivery) (Fig. 28.6)

Fig. 28.6: Congenital diaphragmatic herniaa common


surgical condition causing respiratory distress immediately
after birth

Fig. 28.4: TTNB. Note hyperlucence. Other features include


perihilar streaking fluid in fissures and mild-cardiomegaly

2. Nosocomial pneumonia
3. Aspiration pneumonia
Diffuse involvement on X-ray is suggestive of
congenital pneumonia. Where as bronchopneumonic
pattern is suggestive of transnatally-acquired infections.
Aspiration pneumonias as in esophageal artesia usually
involve right upper, lower lobes of lungs.

176

An Atlas of Neonatology

29

Congenital Heart Diseases

Congenital heart diseases are found in 8 to 12


newborns per 1000 births. However, most of them are
detected in the postneonatal life for various reasons.
The classic presentation of heart dysfunction may not
be seen in the neonatal period. Thus it is very
important to have high degree of suspicion to pick
them up early.
Neonatal Presentation of Congenital Heart
Disease
Central cyanosis (Fig. 29.1a)
Signs of heart failure (distress, failure to gain weight,
feeding difficulties, diaphoresis, hepatomegaly,
periorbital edema, low BP)
Arrhythmias
Asymptomatic heart murmur
Shock
X-ray evidence of cardiomegaly
Abnormal ECG
Incidental detection.

Fig. 29.1a: Central cyanosis

Cyanosis
Cyanosis is the external manifestation of presence of
excessive deoxygenated hemoglobin, which is clinically
detected by blue mucous membranes, nailbeds and
skin. It becomes clinically apparent when the absolute
concentration of deoxygenated hemoglobin exceeds
5 g/dl. Cyanosis due to hypoxemia i.e. central cyanosis
(Fig. 29.1a) should not be confused with acrocyanosis
(Fig. 29.1b), which is blueness of the extremities and
perioral region. This is caused by peripheral

Fig. 29.1b: Acrocyanosis

Congenital Heart Diseases


vasoconstriction and is a normal finding in the first 48
hours of life. Apart from cardiovascular disorders,
cyanosis can be caused by variety of conditions. These
are listed below (Table 29.1).
Table 29.1: Causes of cyanosis in the newborn
Cardiovascular

Pulmonary

Neurologic

Hematologic

Ductal dependent mixing lesions, e.g.


truncus arteriosus.
Lesions with ductal dependent pulmonary blood flow, e.g. TOF, Ebsteins
anomaly
Lesions with ductal dependent systemic
blood flow, e.g. hypoplastic left heart
syndrome, critical CoA
Primary lung disease, e.g. RDS,
pneumonia, etc.
Airway obstruction, e.g. choanal atresia,
macroglossia
Extrinsic compression of lungs, e.g.
pneumothorax, pleural effusion
Central nervous system dysfunctions, e.g.
hypoglycemia, postasphyxial, cerebral
dysfunction
Respiratory neuromuscular dysfunction,
e.g. phrenic nerve palsy, botulism
Methemoglobinemia
Polycythemia

Modified and adapted from: Marino BS, Bird GL, Wernovsky


G. Diagnosis and management of newborn infant with
suspected congenital heart disease. Clin Perinatol 2001, 28:
91-136.

Pulse Oximeter (Fig. 29.2)


It provides a simple, non-invasive, portable and inexpensive method of continuously monitoring oxygen
saturation, and heart rate. The probe of pulse-oximeter

177

consists of a light emitting diode (LED) and a detector.


The LEDs send pulses of light of two different wavelengths through tissue containing a peripheral artery.
The emitted light with two different wavelengths in
variable absorbed by reduced and oxygenated hemoglobins. Based on this difference, the proportion of
oxygenated hemoglobin is estimated and displayed.
Advantages
Non-invasive, provides continuous monitoring and not
affected by skin thickness.
Disadvantages
Not reliable in low perfusion states
Movement of the part interferes with the value.
Less accurate below the saturation of less than 80%.
Abnormal Chest X-ray
Abnormal heart size (Fig. 29.3a): Unlike in older
children, cardiomegaly is not a reliable indicator of heart
disease in newborns. The normal cardiothoracic ratio
is usually more than 0.5 and is influenced by many
variables. Some of the conditions associated with
unequivocal cardiomegaly are listed in Table 29.2.
Table 29.2: Common causes of cardiomegaly

Congenital heart defects


VSD
PDA
TGA
HLHS
Ebsteins anomaly
Cardiomyopathy or myocarditis
Pericardial effusion
Metabolic disturbances
Hypoglycemia
Hypoxemia
Acidosis
Over-hydration

VSDventricular septal defect; PDApatent ductus


arteriosus; TGAtransposition of great arterior, HLHS
hypoplastic left heart syndrome

Abnormal Heart Shapes (Fig. 29.3b)


Fig. 29.2: Pulseoximeter

Some classic abnormal shapes may help in identifying


specific defects. They are:

178

An Atlas of Neonatology

Fig. 29.3a: Abnormal shapes of heart. Abnormal cardiac


silhouette. (A) Boot-shaped heart seen in cyanotic TOF or
Tricuspid atresia. (B) Egg-shaped heart seen in TGA.
(C) Snowman sign seen in TAPVR

Fig. 29.3d: Globular heart in Ebsteins anomaly

Fig. 29.3b: TOF. Note narrow base, upturned apex and


pulmonary oligemia

Fig. 29.3e: TAPVR Snowman configuration. Note plethoric


lung fields, prominent RA

Boot-shapedtetralogy of Fallot, tricuspid atresia


(Fig. 29.3b)
Egg-shapedtransposition of great vessels (Fig.
29.3c)
GlobularEbsteins Anomaly (Fig. 29.3d)
Fig. 29.3c: Transposition of great vessels egg and
end appearance

Snowman configuration: Total anomalous pulmonary


venous connection (TAPVC) (Fig. 29.3e)

Congenital Heart Diseases

179

Table 29.2: Congenital heart disease and chromosomal abnormality


Chromosomal abnormality

Incidence of CHD (%)

Typical lesions

50
99
90
50
67
40
>50
35
20
40
25
>50
<50
14
-

VSD, CAVC
VSD, CAVC, DORV
VSD
VSD
ASD
TAPVR
VSD
COA, Bicuspid aortic valve
VSD
ASD
VSD
PDA
VSD
PDA
VSD

Trisomy 21
Trisomy 18
Trisomy 13
Trisomy 8
Trisomy 22
Trisomy 22 (partial)
Trisomy 9
45 x (Turner)
5 P (Cri du chat)
4 P (Wolf)
13 q
Partial trisomy 14 q
18 q
XXXXY
Triploidy

Modified and adapted from: Copel JA, et al. Congenital heart disease and extra cardiac anomalies:
Associations and indications for fetal echocardiography. Am J Obstet Gynecol 1986; 154: 11211132
VSDventricular septal defect; CAVCcomplete atrioventricular canal; DORVdouble outlet right
ventricle; ASDatrial septal defect; TAPVRtotal anomalous pulmonary venous return; COA
coarctation of aorta
Flow chart 29.1: Differentiation of cardiac and
noncardiac cyanosis

Congenital Heart Disease and Chromosomal


Abnormalities
Various chromosomal abnormalities are known to be
associated with different types of CHD. Infact, in some
of these, they are responsible for significant morbidity
and mortality. Table 29.2 and 29.3 give some more
information. Flow chart 29.1 reflects prenatal diagnostic
method to confirm CHD of cardiac and non-cardiac
origins.
Congenital heart disease and systemic malformation various systemic malformations have been
associated with congenital heart diseases. Identifying
them should make one suspect the presence of associated CHD. The following table gives useful information
(Table 29.4).
Syndromes Associated with Congenital
Heart Disease (Table 29.5)
Certain syndromes are associated with congenital heart
diseases in fact as said above; in most of the cases they
are responsible for morbidity and mortality. A list of
commonly associated syndromes is given below. One
such example is shown in the Figure 29.4.
Myocardial Disorders
That present in the neonatal period include myocarditis,
transient myocardial ischemia, endocardial fibroelastosis,
Pompes disease and anomalous origin of the left
coronary artery from pulmonary artery.

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An Atlas of Neonatology
Table 29.3: Recurrence risks after an isolated defect

Congenital heart defect

Population incidence
10,000

Sibs

Recurrence % Offspring

Ventricular septal defect


Persistent ductus arteriosus
Pulmonary stenosis
Atrial septal defect
Transposition of great vessels
Aortic stenosis
Coarctation of aorta
Tetralogy of Fallot
AV defect (other than with trisomy 21)
Truncus arteriosus
Ebsteins anomaly
Hypoplastic left heart
Tricuspid atresia
Primary endocardial fibroelastosis
Pulmonary atresia

21
7
5.5
5
4
3.5
3.5
3
4
1.5
1.2
2
1.5
1.7
2

3
2.3
2.2
1.4
1.7
3.1
1.5
2
1.7-8 (?3)
1
1
1
1
5
1

1.9-3
2.5
3
2.3
?
3.9
2.7
4
5-10

Table 29.4: Congenital heart disease and systemic malformation


System

Abnormality

% of associated CHD

CNS

Hydrocephalus
Dandy-Walker malformation
Agenesis of corpus callosum
Meckel-Gruber syndrome
Neural tube defects
Microcephaly
Holoprosencephaly

5-15
2-4
15
14
-

GIT

Tracheoesophageal fistula (TEF)


Esophageal atresia with TEF
Duodenal atresia
Jejunal atresia
Anorectal anomalies
Imperforate anus
Omphalocele
Gastroschisis
Diaphragmatic hernia

34
15-40
17
5
22
12
20-32
8
10-22

Genitourinary

Bilateral renal agenesis


Unilateral renal agenesis
Horse shoe kidney
Renal dysplasia
Ureteral obstruction

43
17
39
5
2

Modified and adapted from:


Copel JA, et al. Congenital heart disease and extracardiac anomalies: Associations and indications for fetal echocardiography.
Am J Obstet Gynecol 1986; 154: 1121-1132
Final step is to evaluate features of various syndromes associated with cardiac lesions

Congenital Heart Diseases


Table 29.5: Syndromes associated with congenital heart disease

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.

Syndromes

Features

21 Trisomy (Down syndrome)


Fragile X syndrome
18 Trisomy
13 Trisomy
Noonans syndrome
Turners syndrome
Marfans syndrome
Holt-Oram
Rubinstein Taybi
William syndrome
Congenital rubella
Foetal hydantoin syndrome
Foetal alcohol syndrome
Kawasaki disease
Vater association
Leopard (lentiginosis)
Friedreichs ataxia

Endocardial cushion defect, VSD, TOF and PDA


MVP, aortic root dilatation
VSD, ASD, PDA
VSD, ASD, PDA
Pulmonary valves stenosis, obstruction cardiomyopathy
Coarctation of the aorta, AS, VSD
MVP, MR, aortic root dilatation, aortic dissection
ASD, VSD, first degree heart block
PDA, VSD
Supraventricular aortic stenosis peripheral pulmonic stenosis
PDA, peripheral pulmonary stenosis
Pulmonary and aortic stenosis, coarctation of aorta, PDA
ASD, VSD
Coronary artery aneurysms, MR, arrhythmias, myocardial infarction
VSD, TOF, ASD, PDA
Pulmonic stenosis, hypertrophic cardiomyopathy, myxomas
Cardiomyopathy, dysarrhythmias

Fig. 29.4: ASD in Ellis-van Creveld syndrome

181

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An Atlas of Neonatology

30
Twins are always viewed with interest and sometimes
in the past with superstition. Some such superstitions
are given below.
Twins were believed to have magical power over
nature.
In South-East Asian countries, the mother of twins
was considered impure.
Some Indian tribes believed that twins were derived
from fish and hence were not allowed to go near
water.
In some African and South American countries, a
woman consuming two bananas growing from a
single head or double grain of millet was believed
to give birth to twins.
Siamese Twins
Chang (meaning left) and Eng (meaning right) were
born as conjoined twins in Siam (now Thailand). They
learnt to stand at 12 years and were taken to USA at
17 years. Chang and Eng married two sisters. Chang
had ten children and Eng had nine. Both died at the
age of 63 within a few hours of each other.

Twins

the incidence has been revised to one in hundred


instead of one in eighty. Fertility drugs tend to increase
the incidence. Incidence varies among different human
races. Thirty percent of twins are monozygotic,
remaining 70% dizygotic.
Problems Associated with Twins
Increased incidence of congenital malformations
Perinatal mortality is four times higher than
singletons.
Prematurity (40-55%)
Low birth weight (50-60%)
Intrauterine growth retardation
Twin to twin transfusion syndrome
Hyaline membrane disease
Retinopathy of prematurity
Necrotizing enterocolitis.
Causes of Twin Perinatal Loss
Prematurity, IUGR.

Incidence of Twins

Structural defects: In monochorionic twins: Twin-to-twin


transfusion (TTS), twin reversed arterial perfusion
(TRAP).

Incidence of multiple gestation is given below:


Twins1 in 80 live births
Triplets1 in 802 live births
Quadruplets1 in 803 live births
However, in western world secular trend with
declining incidence of twinning has been observed, and

In monochorionic and monoamniotic twins: Cord


knots, locking of twins at delivery may occur in
monozygotic twins: TTS, TES, TRAP, conjoined twins,
NTD, holoprocencephaly, VACTERL, congenital hip
dislocation, cloacal exstrophy, sirenomelia and gonadal
dysgenesis.

Twins

183

Zygosity of Twinning (Figs 30.2a to c)


Monozygotic or identical twins are derived from single
fertilized ovum. They are of same sex and have identical
genome. Dizygotic or fraternal twins arise from
2 different ova fertilized by two different sperms. They
are like sibs when it comes to sex and sharing of genes.
MZ twinning occurs after fertilization.
1. If separation occurs at 2 cell stageit results in
dichorionic, diamniotic twins.
2. Separation occurring between 3-8 days after
fertilizationmonochorionic diamniotic twins.

Fig. 30.1a: Different positions of breastfeeding of twins

Fig. 30.2a: Mechanism of twinning

Fig. 30.1b: Breastfeeding. The twins simultaneously in


football holding position

Feeding of Twins (Figs 30.1a and b)


The easiest and quickest way to feed twins is put to
breast simultaneously, one on each breast. The position
usually advocated is to keep babies legs behind the
mother, support each head with a pillow and put to
breast. This position is like holding a football, hence also
called football position.

Fig. 30.2b: Monozygotic twins

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An Atlas of Neonatology

Fig. 30.3a: Twin-to-twin transfusion syndrome. Note the


striking difference between weights
Fig. 30.2c: Dizygotic twins

3. Separation between 8-10 days result in monochorionic twins


4. Late separation results in conjoined twins
Zygosity is determined by: (1) sex of the twins
(2) study of a section of the dividing membranes at the
placental insertion, known as T-zone. (3) Blood group
studies (4) DNA finger printing, which is highly reliable.
There are some anomalies peculiar to twins viz TRAP
sequence, conjoined twins, twin-to-twin transfusion.
Some anomalies occur more often in twins, which
include hydrocephalus, CHD, single umbilical artery,
and neural tube defects. Mechanical factors in twins
produce talipes, skull asymmetry and congenital
dislocation of hip often.
Twin-to-twin Transfusion Syndrome
(Figs 30.3a and b)
This commonly occurs in monozygotic twins when
vascular anastomosis develops between two placentas.
The anastomosis may be from artery-to-artery (most
common), from vein-to-vein, or from artery-to-vein.
The last type is more dangerous. The adverse effect
depends on the duration also.
Clinically suspect twin-to-twin transfusion if one twin
is plethoric and other pale
Diagnosis is made if hemoglobin difference is more
than 5 g/dl
Suspect acute form if birth weight difference is less
than 300 g.
Suspect chronic form if birth weight difference is
more than 300 g.

Fig. 30.3b: Twin-to-twin transfusion syndrome. Note the


striking difference between weights

But recently the definition has been changed based


on antenatal sonographic criteria and is defined as the
combined presence of polyhydramnios in one sac and
oligohydramnios in the other sac in a monochorionic
diamniotic pregnancy. Polyhydramnios is defined as a
maximal vertical pocket (MVP) greater than 8 cm and
oligohydramnios is defined as an MVP less than 2 cm
(poly 8- oligo 2).
Twin Reversed Arterial Perfusion (TRAP)
Sequence (Figs 30.4a to c and 30.5a and b)
TRAP sequence is a specific anomaly of multiple
gestation characterized by: 1) vascular communication
between fetuses, 2)a total or partial absence of the
heart and 3)a spectrum of malformations and reduction
anomalies that may affect all tissue.
The perfused twin exhibits a wide range of
abnormalities, while the pump fetus is morphologically
normal. The Figures show the various types of TRAP

Twins

185

Fig. 30.4a: TRAP sequence

Fig. 30.5a: Acardiacus

Fig. 30.4b: TRAP-Twin reversed arterial perfusion


sequence

Fig. 30.5b: Acardiacus radiograph

Fig. 30.4c: Spectrum of TRAP. Note graded loss of normal


form with relative sparing of lower portion of body

sequences (Fig. 30.4a). They may include, absence of


cranial vault, holoprosencephaly, anencephaly, absent
facial features,anophthalmia, microphthalmia, cleft lip/
palate, absent or rudimentary limbs, absent thorax,
diaphragmatic defects, absent lung and heart,
esophageal atresia, short intestine, omphalocele,
gastroschisis, ascites, absent liver, gallbladder, pancreas,
extrophy of cloaca, edematous skin and single umbilical
artery etc. Fifty percent of them have chromosomal

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An Atlas of Neonatology

Fig. 30.6c: conjoined twinsAsymmetric form

Fig. 30.6a: Different types of conjoined twins

Fig. 30.6b: Conjoined twinsThoracopagus type

Fig. 30.6d: Conjoined twinsAsymmetric form

Fig. 30.6e: Conjoined twinsAsymmetric form

Twins

187

Fig. 30.6h: Conjoined twinsAsymmetric

Fig. 30.6f: Conjoined twinsAsymmetric form (Parasitic)

Fig. 30.6i: Conjoined twinsIschiopagus type

abnormalities. Mortality for perfused twin is 100% and


50% for pump twin. Causes of death are intrauterine
heart failure and prematurity.
Conjoined Twins (Figs 30.6a to m)

Fig. 30.6g: Conjoined twinsAsymmetric form

When monozygotic twinning occurs later in the second


week after conception, incomplete division of the
embryos may occur, resulting in conjoined twins.
Conjoined twins are always monoamniotic and monochorionic.

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An Atlas of Neonatology

Fig. 30.6l: Conjoined twins. Barium meal follow through


showing continuity of GIT

Fig. 30.6j: Infantogram of conjoined twins


of ischiopagus type

Fig. 30.6m: Conjoined twins in a bull

Incidence
1% of monozygotic twins
70% of affected pairs are females
Classification
Fig. 30.6k: Infantogram of conjoined twins
thoracopagus type

Conjoined twins are classified according to the parts of


the bodies which are joined or shared.

Twins
1. Thoracopagus including xiphopagusjoined at
chest
2. Omphalopagusanterior abdominal wall
3. Pygopagusat the buttocks
4. Ischiopagusat the ischium
5. Craniopagusat the head
6. Heteropagus or asymmetricalthis can be:
An externally-attached parasitic twin
An enclosed fetus in fetus
An internal teratoma
An acardia connected via the placenta.
Antenatal diagnosis is possible by ultrasonography. Most of these twins are still born. In live
borns, prognosis depends on the extent of
shared organs.

5. Acardiacus myelocephalus: Slight development of


one or more limbs.
The Vanishing Twin Syndrome
Studies have demonstrated that many of the early twin
gestations result in a loss of one of the gestations, and
are converted to singleton pregnancies. The lost product
of conception is reabsorbed partially or completely, and
this phenomenon has been termed the Vanishing twin
syndrome. If not for this phenomenon, the real
incidence of twinning would have been 2-4%.
Fetus Papyraceous (Figs 30.7a and b)
As said above, many twin pregnancies may result in
death of one fetus. The fate of dead fetus depends on
the time of death and length of intrauterine retention.

Acardia (Figs 30.4a, 30.4c, 30.5a and b)


This is seen in twin pregnancies. An acardius is a bizarre
and grossly malformed fetus with no heart, and
circulation is accomplished entirely by the co-twin. This
is similar to TRAP sequence.
This condition almost always occurs in
monochorionic twins. It is characterized by the absence
of heart in the affected fetus which depends on the cotwin for circulation. An acardius fetus looks bizarre and
grossly malformed (monstrous). It is attached to the
placenta by an umbilical cord usually containing one
artery and one vein.
Blood flows from the normal twin to the acardius
through a large artery-to-artery anastomosis. It
circulates through the acardius in reverse course and
returns to the pump twin via a large vein-to-vein
anastomosis. Acardiac fetuses differ greatly in their gross
appearance. Various forms have been recognized which
are listed below. The pump twin is at increased risk of
cardiovascular overload.
1. Acardiacus omphalus: Trunk and limbs are present,
head is absent.
2. Acardiacus acormus: Only head is developed.
3. Acardiacus amorphous: No external form, appears
as an irregular mass covered by skin.
4. Acardiacus anceps: Head is small and poorlydeveloped

189

Fig. 30.7a: Fetus papyraceous

Fig. 30.7b: Fetus papyraceous

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An Atlas of Neonatology

If the death occurs in the first trimester, a flattened mass


of sclerotic placenta with a collapsed membranous sac
may be the only residue. Intrauterine death in the
second trimester results in fetus papyraceous which
appears as an amorphous necrotic mass due to
shrinkage and flattening against the membranes.
Death in the third trimester causes maceration of the
fetus.

BIBLIOGRAPHY
1. Bryan EM. The nature and nurture of twins. Bailliere
Tindall. Am J Obstet Gynecol 1973; 116: 358-365.
2. Kulkarni ML et al. Conjoined twins. Indian Pediatrics 1994,
31: 1017-1024.
3. Kulkarni ML et al. Hetrophagus conjoined twins: Pediatrics
Today 2003: VI, 259-267.
4. Spellacy WN. Antepartum complications in twin
pregnancies. Clin Perinatol 1988; 15: 79-86.
5. Quintero RA. Twin-Twin transfusion syndrome. Clin
Perinatol 2003; 30: 591-600.

Examination of Placenta

31

Examination of Placenta

It is a common tendency of pediatricians to overlook


examination of placenta in the evaluation of a newborn
infant forgetting that it may reveal abnormalities that
are extremely helpful in the diagnosis of many neonatal
conditions.

IMPORTANCE OF PLACENTAL
EXAMINATION

Information of Medicolegal Value may be


Obtained

Causes of Fetal Death, Fetal Distress, and


Neonatal Morbidity may be Documented

Abruptio placentae
Placental infarction
Decidual vascular lesions
Umbilical and chorionic vascular lesions
Infections
Tumors and hamartomas
Amniotic disruption syndrome.

Unsuspected Disorders may be Disclosed

Maternal vascular disease


Abnormal maternal coagulative states
Fetal anomalies
Fetal anemia
Possible immune interactions, gravida fetus
Primary or metastatic neoplasms

Abnormalities of Uncertain, Unknown,


Dubious, or Controversial Significance may
be Recognized
Chronic villitis
Chronic deciduitis

191

Pigmented membrane macrophages


Increased syncytial knots
Increased fibrin deposits
Decidual necrosis
Villous edema.

Explanatory
Mitigating
Disputative.
Miscellaneous Fetal/Neonatal Disorders in
which Placental Study may be Informative
Congenital infection (chorioamnionitis, villitis, villous
edema)
Hematologic disorders
Hemolytic disease of newborn (increased weight,
villous edema, fetal erythroblastemia and
normoblastemia, intravillous hematopoiesis)
-thalassemia (increased weight, villous edema, fetal
erythroblastemia and normoblastemia, intravillous
hematopoiesis)
Congenital leukemia (fetal leukocytosis, intravillous
hematopoiesis)
Congenital nephrosis (increased weight, villous
edema)
Congenital neuroblastoma (villous intravascular
tumor cells)
Triploidy (partial hydatidiform mole)

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An Atlas of Neonatology

Autosomal trisomy (decreased weight, single


umbilical artery, focal villous hydrops)
Storage diseases (deposits of abnormal substance in
villi).
The Indications for Placental Examination
Maternal

Diabetes mellitus
Pregnancy-induced hypertension
Premature rupture of membranes
Preterm delivery (before 36 weeks)
Post-term delivery ( 42 weeks)
Unexplained fever
Poor previous obstetrical history
History of drug abuse, including cocaine

Fetus/Newborn

Stillborn
Neonatal death
Multiple gestation
Prematurity
Intrauterine growth retardation
Congenital anomalies
Erythroblastosis fetalis
Transfer to neonatal intensive care unit
Ominous fetal heart tracing
Presence of meconium
Apgar score below 5 at 1 minute or below 7 at 5
minutes.

Placental/Umbilical Cord

Infarcts
Abruptio placenta
Vasa praevia
Placenta previa
Abnormal calcification
Abnormal appearance of placenta or cord.

Normal Gross Features of Placenta


Shape: Round or oval discoid.
Size: Approximately 20 15 cm.
Thickness: 1.5 2.5 cm at the center thins off
toward periphery.

Fig. 31.1: Fetal surface

Weight: Correlates with birth weight and depends


on gestational age (Normal fetoplacental ratio is
1:4 at 24 weeks, gradually increases to 1:7 at
term)
Fetal surface (Fig. 31.1): Covered by smooth
glistening amnion, which can be peeled off from the
underlying adherent chorion except at the cord
insertion
Maternal surface (Fig. 31.2): Rough, spongy and
reddish-blue in color. It has 15-20 lobes or cotyledons.
Cord insertion: Cord is normally inserted near
center, sometimes eccentrically.
Abnormalities of Placental Weight
Feto-placental weight ratios have been established for
various gestational ages. At term the ratio is 1:7.
Conditions associated with abnormal placental weight
are listed below:
Small placentas
Chronic maternal infections.
Preeclampsia.

Examination of Placenta

Fig. 31.3a: Accessory lobe

Fig. 31.2: Maternal surface

Large placentas

Severe maternal anemia.


Fetal anemia.
Syphilis
Large intervillus thrombi
Maternal diabetes
Congenital fetal nephrosis
Toxoplasmosis
Idiopathic fetal hydrops.

Fig. 31.3b: Circumvallate placenta

Abnormal Placentation (Figs 31.3a to d)


This group includes placenta previa, extrachorial
placenta, membranous placenta, and ring-shaped
placenta. These types of placentas may cause maternal
hemorrhage with secondary effects on the fetus. There
are some other conditions, which can cause
hemorrhage from the fetal vessels like lobar placenta,
multi-lobar placenta placentas with accessory lobes and
bipartite placenta (Fig. 3.3d). In these conditions, the
vessels, which traverse between lobes, do not contain
protective Whartons jelly and are prone to get ruptured
resulting in fetal anemia. The examination for presence
of these abnormalities gives clues to the etiology of
anemia in the newborn.

Fig. 31.3c: Succenturiate placenta

193

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An Atlas of Neonatology
Fenestrated Placenta
In this abnormality the central portion of the placenta
is missing, and some times there may an hole in the
placenta. The clinical significance of this is that it may
be mistaken for missing lobe of placenta after its
extraction.
Marginal Insertion (Fig. 31.3e)
Here the cord is inserted at the placental margin, it is
sometimes referred to as a battledore placenta. It is
found in 7% of term placentas. The rare significance
of this is that sometimes cord may be pulled off from
the placenta.
Circumvallate Placenta (Fig. 31.3b)
Fig. 31.3d: Bipartite placenta

Here the membranes of chorion leave insert with a


typical folding at some inward distance from the margin
of the placenta, toward the cord this type of
placentation is associated with pre-natal bleeding and
premature labor.
Lesions Indicative of Vascular Insufficiency
Maternal utero-placetal insufficiency is known to be
associated with growth retardation, fetal hypoxia, and
perinatal death. Most evident indicators of this condition
on gross examination are retroplacental hematoma and
infarcts (Figs 31.4 and 31.5).

Fig. 31.3e: Battledore

Fig. 31.4: Retroplacental clot

Examination of Placenta

195

Fig. 31.5: Placental infarct

Fresh infarcts appear as dark red, firm, granular


areas. Old ones appear white, and feel hard. Infarcts
are more significant when they are central and greater
than 3 cm in greatest dimension.
Retroplacental hematoma is the pathologic correlate
of clinical entity, abruptio placentae. This condition is
associated with fetal hypoxia resulting from placental
separation and preterm delivery. There is increased risk
of perinatal death. However, sometimes it is not possible
to say whether it is true retroplacental hematoma or
just physiologic retention of blood during 3rd stage of
labor. In such situations, correlation with maternal
history often helps to resolve the problem.

Fig. 31.6: Meconium stained membranes

Abnormalities of Placental Membranes


Chorioamnionitis: Acute chorioamnionitis may be
recognized on gross examination by opaque yellow
malodorous membranes.

Fig. 31.7: Amnion nodosum

Meconium stain (Fig. 31.6): Passage of meconium


in utero can be determined by observing greenish or
greenish-brown staining of membranes. The chronisity
of passage of meconium correlates with hues of staining.
Meconium passed shortly before delivery imparts bluishgreen color, whereas, with longer exposure, the
membranes look muddy brown.

to white, small nodules on the fetal surface measuring


0.05-0.5 cm and contain fetal epidermal cells and hair.
Their presence is indicative of urinary tract abnormalities
and pulmonary hypoplasia, which occurs in long
standing oligohydramnios (Potters sequence). Thus, a
newborn infant with unknown cause of respiratory
distress can be diagnosed if the physician appreciates
amnion nodosum.

Amnion nodosum (Fig. 31.7): This condition is


known to occur in long standing oligohydramnios,
which can be secondary to congenital urinary tract
abnormalities or amniotic fluid loss following prolonged
rupture of membranes. These lesions appear as yellow

Placenta in amniotic band syndrome (ABS) (Fig.


31.8): The term ABS refers to a spectrum of fetal
anomalies that result from mechanical effects of
amniotic bands or sheets on the developing embryo
or fetus. Any congenital anomaly, found in the newborn

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An Atlas of Neonatology

Fig. 31.9: Single umbilical artery


Fig. 31.8: Amniotic membrane in limb body wall complex

or the abortus, which raises the suspicion of ABS,


should prompt the physician to look for any
abnormality in the membranes like bands of amnion
or amnion defect of the fetal surface. Such identification
helps in counseling parents about non-recurrence
nature of the condition. Further details are given in
chapter 33.
Cord Abnormalities
Single umbilical artery (Fig. 31.9): Normally
umbilical cord contains 3 vessels; two arteries and one
vein surrounded by Whartons jelly. Single umbilical
artery (SUA) occurs in 1% of deliveries and it may be
due to agenesis or atresia or due to persistence of
original single allantoid artery of the body stalk. Infants
with SUA have higher prevalence of congenital
anomalies, prematurity, and higher perinatal deaths.
Congenital anomalies occur in nearly 30%, and include
CVS, CNS, genitourinary and digital anomalies. SUA
may also be associated with marginal and velamentous
insertion of the umbilical cord.

Fig. 31.10a: Long cord

Ref: Perspectives in Pediatric Pathology 1984; 8: 345.

Umbilical cord length abnormalities (Figs


31.10a and b): At term the mean length of umbilical
cord is 55 cm. A cord is termed short when the length
is less than 35 cm and long, when it is more than 80
cms. A long cord increases the risk of true knots, cord
compression from fetal entanglement, nuchal cord (Fig.
31.10c), and cord prolapse. A short cord can cause

Fig. 31.10b: Cord round the neck

Examination of Placenta

197

Fig. 31.11a: True knot

Fig. 31.10c: Cord round the neck

cord rupture and delay in the 2nd stage of labor. Rarely


cord may totally be absent. Care should be taken to
measure all segments of cord, before drawing any
conclusion.
Hematoma of the umbilical cord: Results from
extravasation of blood into Whartons jelly. Trauma and
prenatal invasive techniques like cordocentesis, fetoscopy
may be responsible in some cases. Umbilical vein is
involved in most cases. The common site is near the
fetal insertion end. Complications include exsanguination in to amniotic fluid. Perinatal mortality is very
high if there is significant hemorrhage.
True knots of the umbilical cord (Figs 31.11a
and b): True knots form when the fetus passes through
a loop of umbilical cord. These occur specially in
monoamniotic twins, long cord, and polyhydramnios.
They can be single or multiple. They have associated
anomalies. False knots consist of dilatation of the
umbilical vessels and have no significance.
Ref.: Am J Obstet Gynecol 1977; 117: 425.

Fig. 31.11b: True knot

Velamentous insertion: (Fig. 31.12): This means


attachment of the cord to the membranes rather than
to the placental mass. Marginal insertion means
implantation of the cord into the edge of the placenta.
Infants with velamentous insertion or at increased risk
for IUGR, preterm birth and congenital anomalies.

Fig. 31.12: Different types of insertion of cord. From left


to rightNormal, Marginal, Furcate, Velamentous

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An Atlas of Neonatology

Placentas of multiple gestation: Placentas of


multiple gestation offer special opportunities as well as
special problems. These are listed below. See also
chapter 30.
Important Points to Note in Placentas of
Multiple Gestations
Lesions may be present in only 1 fetus/infant
placentas or cords should be labeled to indicate
assignment to individual fetuses/infants.
Interactions with co-twins may be mediated or
expressed in the placenta(s)
Monozygosity is often diagnosable on placental
examination
Gross observations are key to the most important
information
Microscopy is confirmatory and for the record

Placental configuration, composition of septa, and


vascular communications should be recorded
consistently, diagrams and photographs are helpful.
Each report should include a statement regarding
zygosity.
Proforma for Examination of Placenta
(Table 31.1)
1.
2.
3.
4.

Patients identification
Date and time of delivery
Date and time of examination
Maternal information:
a. Diabetes mellitus
b. Hypertension
c. Bleeding (all trimesters)
d. Infection
e. Any other history or finding that is deemed
significant

Table 31.1: Overview of significance of placental examination


Abnormality

Incidence (%)

Significance

Abnormal placental shape


Extrachorial (complete, partial, combined)
Circummarginate
Circumvallate

5-20
0.5-2

None
Ab, IUGR, CA. Premature labor, fetal malformation

Membranous (diffuse)

Rare

AP and PP hemorrhage, Ab, premature labor,


IUGR, adherence

Annular (ring-shaped; girdle; collar)


Fenestrate
Accessory (succenturiate) lobe
Bilobate (bipartite; duplex)
Multilobate

Rare
Rare
5-8
0.04-4.2
Rare

AP and PP hemorrhage, IUGR


None
Fetal hemorrhage, retention
First trimester hemorrhage, adherence
Fetal hemorrhage

Abnormal placental invasiveness/adherence


Accreta, percreta, increta (total, partial, focal)

0.04

Retroplacental hematoma (abruptio placentae)


Abnormal placental location
Previa

AP and PP hemorrhage, uterine rupture, 10% fetal


and maternal mortality
4.5
AP hemorrhage, IUGR; includes 1/3 of cases of
clinical abruption; 1/3 will have clinical abruption
5-28
AP hemorrhage, abruption, IUGR, 10% perinatal
(second trimester) mortality
0.3-0.7

(live births)

Ababortion; APantepartum; CAchorioamnionitis; IUGRintrauterine growth retardation; PPpostpartum.

Examination of Placenta
5.

6.

7.
8.

9.

f. Antenatal scanning report


Labor information
a. Peripartal fever, PROM
b. Type of delivery
c. Liquor: oligo, polyhydramnios, foul smelling,
meconium stained
Neonatal information
a. Apgar score
b. Gestational age and birth weight
c. Any neonatal abnormality
Placental weight and ratio of weight of placenta
and infant
Cord:
a. Length
b. Insertion
c. Number of vessels
d. Abnormality
Membranes and fetal surface
a. Color
b. Opacity
c. Insertion: Marginal
Circumvallate
Circummarginate

10.

11.
12.

13.

199

d. Amnion nodosum
e. Subamniotic hemorrhage
f. Subchronichematoma, cyst
g. Any other abnormality (specify)
Maternal surface
a. Color: pale, plethnic, normal
b. Infarction: site, percentage
c. Thrombus: fresh/old
Hemorrhage
Dimensions:
Lengthlargest diameter
Widthsmallest diameter
Thickness
Any other gross abnormality

BIBLIOGRAPHY
1. Benirschke K. Examination of the placenta. 1961; 18: 309.
2. College of American Pathologist Conference XIX on the
examination of placenta. Arch Pathol Lab Med 1991; 115:
660-721.
3. Lewis SH, Gilbert-Barness E. The placenta and its
significance in neonatal outcome. Advances in Pediatrics
Mosby Inc 1998;45:223-42.
4. Naeye RL. Umbilical cord length: Clinical significance. J
Pediatr 1985; 107: 278-81.

200

An Atlas of Neonatology

32

Congenital Malformations

A study of congenital malformations in infants and


stillborn babies is of paramount importance in reducing
the number of perinatal deaths. About 20% of deaths
in the last trimester of gestation and 15% of those in
the neonatal period are attributed to congenital
malformations. This chapter deals with some of the
commonly encountered congenital malformations and
abnormalities.
Terminology
Congenital malformation: An anatomical defect that is
present at birth is called as congenital malformation.
Major congenital malformation: When congenital
malformation has a major impact on health, function,
survival, and cosmetic aspects, it is called major
congenital malformation.
Minor congenital malformation: When congenital
malformation has no impact on health, function,
survival and cosmetic aspects, it is called minor
congenital malformation.
Malformation syndrome: When multiple anomalies,
which are pathogenetically-related, occur in a single
baby it is said to be a malformation syndrome.
Deformation: An abnormal form, shape, or position of
a part of the body caused by mechanical forces is called
a deformation, e.g: TEV (Talipes equinovarus),
oligohydramnios sequence, breech deformation, etc.

Disruption: If there is a morphologic defect of an


organ, part of an organ or region of body resulting
from an extrinsic breakdown or an interference
with an originally-normal developmental process, it is
called as disruption, e.g. radiation, amniotic bands,
infection.
Dysplasias: When a malformation results from an
abnormal organization of cells in tissues it is called
dysplasia, e.g. many chondrodysplasias.
Sequence: When a pattern of multiple anomalies is
derived from single known or presumed prior anomaly,
or mechanical factor, it is called as sequence, e.g.
Pierre-Robin sequence, Potter sequence.
Association: It is defined as non-random occurrence in
two or more individual of multiple anomalies not known
to be polytopic field defect sequence or syndrome, e.g.
VATER association (Vertebral anomaly, Anal atresia,
Tracheoesophageal fistula, Radial/renal dysplasia),
CHARGE (Coloboma, Heart defect, Atresia choana,
Retarded growth, Genital abnormality, Ear anomaly)
association.
Incidence
Three percent of newborn children have major
malformation. Commonly seen malformations, their
causes and other concerned factors are enlisted in Table
32.1 to 32.5.

Congenital Malformations
Table 32.1: Birth defects monitored by the metropolitan Atlanta congenital defects program
and the birth defects monitoring program, 1991
CNS defects

Orofacial defects

Anencephaly
Spina bifida
Encephalocele
Hydrocephalus
Microcephaly
Anophthalmia and microphthalmia
Congenital cataract
Coloboma of the eye
Aniridia
Cardiovascular defects
Tetralogy of Fallot
Atrial septal defect
Endocardial cushion defect
Pulmonary valve stenosis and atresia
Tricuspid valve stenosis and atresia
Aortic valve stenosis
Hypoplastic left heart syndrome
Patent ductus arteriosus
Coarctation of the aorta
Pulmonary artery stenosis
Lung agenesis and hypoplasia

Cleft palate
Total cleft lip
Gastrointestinal defects
Tracheoesophageal anomalies
Rectal and intestinal atresia eye defects
Genitourinary defects
Renal agenesis and dysgenesis
Bladder exstrophy
Musculoskeletal defects
Transposition of the great vessels
Limb reduction defects
Arthrogryposis
Omphalocele
Gastroschisis
Chromosomal defects
Down syndrome
Trisomy 13
Trisomy 18

Table 32.2: Examples of common minor malformations


Skull
Parietal foramina
Parietal bossing
Prominent forehead
Ears
Preauricular pits
Preauricular tags
Anomalies of auricular cartilage
Eyes
Heterochromia of the iris
Coloboma of the iris
Nose
Short columella
Bulbousnasal tip
Perioral zone
Smooth philtrum
Narrow vermilion
Angular lip pits
Mouth
Palatal pits
Torus palatinus
Hypoplastic lateral incisors
Short lingual frenulum
Neck
Branchial arch remnants
Chest
Supernumerary nipples
Abdomen
Single umbilical artery
Umbilical hernia

Genitalia
Labial adhesions
Hydrocele
Mild hypospadias
Undescended testis
Anus and perineum
Anal tags
Anal stenosis
Back
Sacral dimples
Skin
Isolated pigmented nevi
Small vascular nevi
Skin dimples overlying bony prominences
Hair
Upswept posterior hairline
Supernumerary scalp hair whorl
White forelock
Nails
Spooned nail
Nail grooves
Infantile bowleg
Camptodactyly of fifth fingers
Hands
Clinodactyly of fifth fingers
Potters thumb
Feet
Syndactyly of second and third toes
Short fourth metatarsal.

201

202

An Atlas of Neonatology
Table 32.3: Causes of congenital malformations
Twinning
Conjoined twins, intestinal atresia, porencephaly

Monogenic (7.5% of Serious Anomalies)


X-linked hydrocephalus
Achondroplasia
Ectodermal dysplasia
Apert disease
Treacher Collins syndrome
Chromosomal (6% of Serious Anomalies)
Trisomies 21, 18, 13
XO, XXY
Deletions 4p, 5p, 7q,13q, 18q, 22q
Prader-Willi syndrome (50% have deletion of chromosome
15)
Maternal Illness (2% of Serious Anomalies)
Intrauterine infections (e.g., herpes simplex, CMV, varicellazoster, rubella, and toxoplasmosis)
Maternal Illness (3.5% of Serious Anomalies)
Diabetes mellitus
Phenylketonuria
Hyperthermia
Uterine Environment (% Unknown)
Deformation
Uterine pressure, oligohydramnios, clubfoot, torticollis,
congenital hip dislocation, pulmonary hypoplasia, 7th nerve
palsy
Disruption
Amniotic bands, congenital amputations, gastroschisis,
porencephaly, intestinal atresia

Environmental agents (% Unknown)


Polychlorinated biphenyls
Herbicides
Mercury
Alcohol
Medications (% Unknown)
Thalidomide
Diethylstilbestrol
Phenytoin
Warfarin
Cytotoxic drugs
Isotretinoin (vitamin A)
D-Penicillamine
Valproic acid
Unknown Etoplogies
Polygenetic
Anencephaly/spina bifida
Cleft lip/palate
Pyloric stenosis
Congenital heart disease
Sporadic Syndrome Complexes (Anomalads)
CHARGE syndrome
VATER syndrome
Pierre Robin syndrome
Prune-belly syndrome
Nutritional
Low folic acid-neural tube defects

Table 32.4: List of teratogens


Drug

Effect on fetus

Accutane (isotretinoin)
Alcohol

Facial ear anomalies, heart disease


Congenital cardiac, CNS, limb anomalies; IUGR; developmental delay; attention
deficits; autism
Abortion, malformations
Congenital heart disease, IUGR, withdrawal
Abortion
Stunted growth; corneal opacities; cleft palate; hypoplasia of ovaries, thyroid and
parathyroids
Spina bifida, possible neurodevelopment delay
Cerebral atrophy, microcephaly, seizures
Deafness
Probably no effect, possibly limb reduction
Low birth weight for gestational age
Microcephaly, LBW, IUGR, behavioral disturbances
Multiple malformations
Virilization
Masculinization of female fetus
Spina bifida
Ebsteins anomaly, macrosomia
Abortion
Minamata disease, microcephaly, deafness, blindness, mental retardation
Masculinization of female fetus
Arthrogryposis, cranial neuropathies (Mobius syndrome), equino varus

Aminopterin
Amphetamines
Azathioprine
Busulfan (Myleran)
Carbamazepine
Carbon monoxide
Chloroquine
Chorionic villus sampling
Cigarette smoking
Cocaine/crack
Cyclophosphamide
Danazol
17-ethynyl testosterone (Progestoral)
Hyperthermia
Lithium
6-Mercaptopurine
Methyl mercury
Methyltestosterone
Misoprostol

Contd...

Congenital Malformations

203

Contd...
Norethindrone
Penicillamine
Phenytoin
Polychlorinated biphenyls
Prednisone
Progesterone
Quinine
Stilbestrol (diethylstilbestrol [DES])
Streptomycin
Tetracycline
Thalidomide
Toluene (solvent abuse)
Trimethadione and paramethadione
Valproate
Vitamin D
Warfarin (Coumadin)

Masculinization of female fetus


Cutis laxa syndrome
Congenital anomalies, IUGR, neuroblastoma, bleeding (vitamin K deficiency)
Skin discoloration thickening, desquamation, LBW, acne, developmental delay
Oral clefts
Masculinization of female fetus
Abortion, thrombocytopenia, deafness
Vaginal adenocarcinoma in adolescence
Deafness
Retarded skeletal growth, pigmentation of teeth, hypoplasia of enamel, cataract, limb
malformations
Phocomelia, deafness, other malformations
Craniofacial abnormalities, prematurity, withdrawal syndromes, hypertonia
Abortion, multiple malformations, mental retardation
Spina bifida, impaired neurologic function
Supravalvular aortic stenosis, hypercalcemia
Fetal bleeding and death, hypoplastic nasal structures

CNS central nervous system; IUGR- intrauterine growth restriction; LBWlow birth weight
Adapted from: Stoll BJ, Kliegman RN. In Behrman RE, Kliegman RM, Jenson HB (Eds): Nelson Textbook of Pediatrics 17th edition, W.B.
Saunders Company: Philadelphia.

Table 32.5: Definitions of common clinical signs


Brachycephaly
Brachydactyly
Brushifield spots
Camptodactyly
Clinodactyly
Hypoplastic nail
Low-set ears
Melia
Ocular hypertelorism
Plagiocephaly
Posterior parietal
hair whorl
Preaxial polydactyly
Postaxial polydactyly
Prominent lateral
palatine ridges
Scaphocephaly
Shawl scrotum
Short palpebral fissures
Syndactyly
Synophrys
Telecanthus
Widows peak

A condition in which head shape is shortened from front to back along the sagittal plane; the skull
is rounder than normal
A condition of having short digits
Speckled white rings about two thirds of the distance to the periphery of the iris of the eye
Permanent flexion of one or more fingers associated with missing inner phalangeal creases indicating
lack of finger movement from before 8 wk gestation
A medical or lateral curving of the fingers and usually refers to incurving of the 5th finger
An unusually small nail on a digit
This designation is made when the helix meets the cranium at a level below a horizontal plane that
is an extension of a line through both inner canthi
A suffix meaning limb (e.g. Amelia-missing limb; brachymelia-short limb)
Increased distance between the pupils of the two eyes
A condition in which head shape is asymmetric in the sagittal or coronal planes; can result from
asymmetry in suture closure or from asymmetry of brain growth
A single whorl occurs to the right or left of midline and within 2 cm anterior to the posterior fontanel
in 95% of cases. The whorl represents the focal point from which the posterior scalp skin was under
growth tension during brain growth between the 10th and 16th wk of fetal development. Aberrant
position of the whorl reflects an early defect in brain development
Extra finger or toe present on the medial side of the hand or foot
Extra finger or toe present on the lateral side of the hand or foot
Relative overgrowth of the lateral palatine ridges secondary to a deficit of tongue thrust into the hard
palate
A condition in which the head is elongated from front to back in the sagittal plane; most normal skulls
are scaphocephalic
The scrotal skin joins around the superior aspect of the penis and represents a mild deficit in full
migration of the labila-scrotal folds
Decreased horizontal distance of the eye based on measurement from the inner to the outer canthus
Incomplete separation of the fingers. It most commonly occurs between the 3rd and 4th fingers and
between the 2nd and 3rd toes
Eyebrows that meet in the midline
Lateral displacement of the inner canthi. The inner canthal distance is increased, but the inner papillary
distance is normal
V-shaped midline, downward projection of the scalp hair in the frontal region. It represents an upper
forehead intersection of the bilateral fields of periocular hair growth suppression. It usually occurs
because of the fields are widely spaced, as in ocular hypertelorism.

Adapted from: Stoll BJ, Kliegman RN. In Behrman RE, Kliegman RM, Jenson HB (Eds): Nelson Textbook of Pediatrics 17th edition, W.B.
Saunders Company: Philadelphia.

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An Atlas of Neonatology

CNS MALFORMATIONS
Overview of Brain Development
Among congenital malformations, anomalies of CNS
rank the most frequent and the most tragic of all which
afflict man.Accurate diagnosis is important in the
prevention of CNS malformations through genetic
counselling and prenatal diagnosis. Also several
correctable defects can be repaired.
The formation of central nervous system begins in
embryonic stage and continues throughout gestation.
Any disruptive factor occurring at any time during
pregnancy is capable of disturbing the process. The first,
and to a lesser extent, second trimesters are more
vulnerable periods. For simplicity cerebral development
can broadly be divided into two periods: external
cerebral formation and internal cerebral formation.
External cerebral formation occurs in first 6 weeks of
life and its disruption results in gross and easily
observable malformation. Internal cerebral formation,
takes place after first 6 weeks, and its disruption usually
causes subtle but equally important dysgenesis.
External Cerebral Formation
This takes place in two phases: Dorsal and ventral
induction. Dorsal induction begins with the formation
of the neural plate and ends with closure of the posterior
neuropore. Ventral induction results in differentiation
and cleavage of forebrain to form face and cerebral
hemispheres. The anatomical malformations produced
during external cerebral formation are given in Table
32.6.

Internal Cerebral Formation


This phase begins after 6 weeks post-conception age
and continues upto about 20 years of age. It involves
four processes: neuronal proliferation, neuronal
migration, neuronal organization, and neuronal
myelination. The abnormalities produced during this
phase are given in Table 32.7.
Proliferation: This occurs during 2-4 months of postconception age. In this process, proliferation of
neuroblasts, glia, and vasculature takes place in the
periventricular zone. These cells form the future
neocortex.
Migration: The peak timing of migration is 3 to 5
months post-conception. In this phase migration of
neuroblasts from the periventricular area to the
surface takes place with the help of radial fibres of the
glial cells.
Organization: In this phase, the neuroblasts on the
surface which arrive from the periventricular area, get
organized. This process involves proliferation of
dendrites and axons, formation of synapses, and
selective neuronal death. Glial cells differentiate into
oligodendrocytes and astrocytes. This phase begins
around 6 months of post-conception and continues up
to several years postnatally.
Myelination: This phase begins around 6 months of
gestation and continues up to 20 years postnatally.
Myelination in the CNS is done by oligodendrocytes
and peripherally by Schawann cells.

Table 32.6: External cerebral formation


Timing (postconception)

Embryonal derangement

Disorders

Dorsal induction (3-4 weeks)

Neural tube formation

Craniorhachischisis totalis Exposed rudimentary brain


and spinal cord.
Anencephaly
Exposed rudimentary brain.
Encephalocele
Occipital or frontal sac with
brain.
Myeloschisis or
Exposed rudimentary spinal
myelomeningocele
cord with variable spinal cord
exposure

Anterior neuropore closure


Posterior neuropore closure

Ventral induction (3-6 weeks)

Interaction between
mesoderm and forebrain

Holoprosencephalies

Anatomical abnormality

Single cerebral hemisphere


with microcephaly.

Congenital Malformations

205

Table 32.7: Internal cerebral formation after 6 weeks


Timing
Postconception

Embryonal derangement

Disorder

Anatomical abnormality

Proliferation
(2-4 months)

Neuronal and glial


Proliferation in the
periventricular zone

Microcephaly vera

Well formed but small brain

Macrocephaly

Well formed but large brain

Migration
(3-5 months)

Disordered migration from the


periventricular zone to grey
matter and corpus callosum

Schizencephaly

Clefts in the lateral cerebral wall

Lissencephaly
Pachygyria
Polymicrogyria
Heterotopias

Smooth cerebrum with 3 layer cortex


Few and broad gyri
Multiple small gyri
Neuronal islands in the white matter

Organization
(6 months to
several years)

Dendritic, synaptic and axonal


arborization selective neuronal
death and glial differentiation

Mental retardation
seizure,
Down syndrome

Poor dendritic and synaptic formation

Myelination
(6 months-20 yrs)

Oligodendroglia proliferation

De/Dys myelination
syndromes
Lysosomal disorders
Peroxisomal disorders,
storage disorders,
Canavan and
Alexander disorder

White matter hypoplasia

From: Schaefer GB, Sheth RD, Bodensteiner JB. Cerebral dysgenesis: An overview. Neurologic Clinics. 1994: 12 (4); 773-788.

Neural Tube Defects (NTD)


These are midline defects of the vertebrae resulting in
exposure of the contents of the neural canal. NTDs are
the most common malformation of CNS and the
incidence varies widely in different parts of the world.
By the end of the fourth week, i.e. in dorsal
induction phase(see above), CNS forms a closed
tubular structure detached from the overlying
ectoderm. Occasionally however the neural groove fails
to close, either because of faulty induction by the
underlying mesodermal structure or because of the
action of environmental teratogenic factors on the
neuroepithelial cells. The neural tissue then remains
exposed to the surface. Such a defect may extend the
total length of the embryo or may be restricted to small
area only (complete or parital rechischisis). When
located in the region of spinal cord it is called spina
bifida, while a failure of closure in cephalic region is
known as anencephalus. Different types of neural tube
defects are listed in Table 32.8.

The etiology is multifcatorial and most are inherited


with a multifactorial pattern. Recognised cause of NTD
are given below:
Multifactorial inheritanceanencephaly, meningomyelocele, meningocele, and encephalocele.
Single mutant genes
Meckel syndromeautosomal recessive (phenotype includes occipital encephalocele and rarely
anencephaly)
Mediancleft face syndromepossible autosomal dominant (phenotype includes anterior
encephalocele)
Robert syndromeautosomal recessive (phenotype includes anterior encephalocele)
Syndrome of anterior sacral meningomyelocele
and anal stenosis, either autosomal or X-linked.
Jarcho-Levin syndromeautosomal recessive
(phenotype includes meningomylocele)
HARDE syndromeautosomal recessive (phenotype includes encephalocele)

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An Atlas of Neonatology

Chromosome abnormalities
13 trisomy
18 trisomy
Triploidy
Other abnormalities, such as unbalanced
translocation and ring chromosome.
Probably hereditary, but mode of transmission not
established
Syndrome of occipital encephalocele, myopia,
and retinal dysplasia
Anterior encephalocele among Bantus and Thais.
Teratogenes
Valproic acid (phenotype includes spina bifida)
Aminopterin/amethopterin (phenotype includes
anencephaly and encephalocele)
Thalidomide (phenotype includes, rarely,
anencephaly and meningomyelocele)
Maternal predisposing factors
Diabetes mellitus (anencephaly more frequent
than spina bifida)
Specific phenotypes, but without known cause
Syndrome of craniofacial and limb defects
secondary to aberrant tissue bands (phenotype
includes multiple encephaloceles)
Cloacal extrophy (phenotype includes myelocystocele)
Sacrococcygeal teratoma (phenotype includes
meningomyelocele)
Syndromes and Conditions Associated with NTD
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

ABS
Caudal regression syndrome
Sirenomelia
Cloacal extrophy
Hydrolethalus
Jarcho-Levin syndrome
Meckel-Gruber syndrome (encephalocele)
Median cleft face
OFDSorofaciodigital syndrome
Pentalogy of Cantrell
Renal agenesis
Roberts syndrome (encephalocele)
Walker-Warburg syndrome (encephalocele)
VATER

15.
16.
17.
18.

Trisomy 13 and 18
Trisomy 9
Triploidy
Teratogenes (aminopterin, tegretol, clomiphene,
valproic acid, methotrexate, progestin, dextroamphetamine, caumadin, cytrabine, hyperthermia
and radiation, diabetes).
Table 32.8: Classification of NTD

I. ANENCEPHALUS & SIMILAR ANOMALIES


a. Acephalus
b. Anencephalus
- Incomplete
- Complete
- Craniorhachischisis
c. Iniencephalus
II. SPINA BIFIDA
a. Spina bifida occulta
b. Occult spinal dysraphism
c. Spina bifida cystica - Meningocele, meningomyelocele
III. OTHER ANOMALIES
a. Cranial meningocele, cranium bifidum, and cranial
cephaloceles
b. Encephalocele
IV. ASSOCIATED ANOMALIES
a. Congenital hydrocephalus
b. Arnold-Chiari malformation
c. Dandy-Walker malformation

Holoprosencephaly (Figs 32.1a to f and


32.2a and b)
Failure of embryonic forebrain to cleave sagittally into
cerebral hemispheres, transversely into telencephalon
and diencephalons and horizontally into olfactory and
optic bulbs results in a sequence known as Holoprosencephaly. The degree of failure and the level of failure
of cleavage varies and hence its clinical presentation.
Holoprosencephaly is almost always associated with
mid facial anomalies, the spectrum of which varies
greatly a) Cyclopia: (Fig. 32.2): Single median eye
globe synophthalmia or anophthalmia, proboscis (fused
olfactory placodes forming single tube like structure
above the eye); the brain defect includes alobar
holoprosencephaly. b) Ethmocephaly: The facial
characters include ocular hypotelorism with proboscis
and the associated brain defect is alobar holoprosencephaly. c) Cebocephaly: The facial features are
ocular hypotelorism and blind end of single nostril nose,

Congenital Malformations

207

Fig. 32.1a: Single incisor indicative of a mid-line defect

Fig. 32.1d: Lobar holoprosencephaly picture

Fig. 32.1b: Holoprosencephaly

Fig. 32.1e: Spectrum of facial dysmorphism in Holoprosencephaly. (A) Cyclopia (single median eye) (B) Cyclopia
with single median eye and various degree of doubling of
ocular structures. (C) Cyclopia with proboscis (D) Ethmocephaly (ocular hypotelorism) and proboscis between eyes.
(E) Cebocephaly (ocular hypotelorism and single nostrial
nose) (F) Median clefting and ocular hypotelorism

Fig. 32.1c: Holoprosencephaly

and brain defect is usually alobar holoprosencephaly.


d) Median cleft lip: Ocular hypotelorism, flat nose and
median cleft lip are facial features where as alobar
holoprosencephaly is the brain defect. e) Less severe
facial dysmorphism: include ocular hypotelorism, flat
nose, unilateral or bilateral cleft lip, iris coloboma or

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An Atlas of Neonatology

Fig. 32.1f: Schematic drawing of the neonatal brain seen from above.
(a) Normal both cerebral hemispheres and lateral ventricles are
completely separated. (b) Alobar holoprosencephaly with absence
of division of the cerebral hemispheres and single primitive
ventricular cavity. (c) Semilobar holoprosencephaly with incipent
separation of the hemispheres in the occipital area and partial
development of occipital and temporal horns of the ventricle (d) Lobar
holoprosencephaly almost completely separated cerebral
hemispheres ventricles are almost separated except for frontal
region and are mildly-dilated

Fig. 32.2a: Holoprosencephaly with cyclopia. Single central proboscis, synophthalmia


and single nostril (cebocephaly)

Fig. 32.2b: Holoprosencephaly with cyclopia. Single central


proboscis, synophthalmia and single nostril (cebocephaly)

Congenital Malformations
other anomalies. Absence of nasal septum and single
midline incisor may be the only facial features in
autosomal dominant holoprosencephaly.
All malformations encountered in holoprosencephaly originate from a single primary defect in
morphogenesis thought to be in the prechordal
mesoderm interposed between the roof of the mouth
and the prosencephalon that takes place around third
week of embryonic period. Prechordal mesoderm is
also responsible for the normal development of the
midian facial structure.
The etiology of holoprosencephaly is heterogenous,
and has been described in i) Chromosomal abnormalities: Trisomy 13, Trisomy 18, del 13q del 18 p,
Triploidy, del 2p dup 3p, del 7, and other rarer
chromosomal abnormalities. ii) Monogenic disorders:
Meckel-Gruber syndrome, Autosomal recessive and
dominant X-linked holoprosencephaly, velocardiofacial
syndrome, Marfan syndrome, campomelic dysplasia,
etc.
In addition to heterogenicity of its origin, holoprosencephaly is associated in few cases of neural tube
defects, frontonasal dysplasia, Goldenhar syndrome,
and CHARGE association. In Trisomy-13 syndrome
holoprosencephaly is present in about 70% of cases,

209

whereas in diabetic embryopathy in 1-2%. In the


autosomal dominant variety the gene HPE3 is located
at chromosome 7q36. The reported incidence of
Cyclopia is 1: 40,000 births and that of cebocephaly
and median cleftlip is 1: 16,000 births, probably the
rate is higher in abortuses.
Iniencephaly (Figs 32.3a to c)
It is an extremely rare (1 in 65,000) complex
abnormality characterized by exaggerated lordosis of
spine, imperfect formation of base of skull, rachischisis.
The spine is short and grossly abnormal. Most of these
cases have associated anomalies: midline defects, CVS
anomalies diaphragmatic hernia and renal and skeletal
anomalies. This condition is invariably fatal. It has to
be differentiated from anencephaly and Klippel-Feil
syndrome.
Anencephaly (Figs 32.4a to e)
It is a type of neural tube defect characterized by the
absence of cerebral hemispheres and cranial vault. It
results from failure of closure of anterior end of neural
tube. Most often it is due to multifactorial in inheritance.
The defect is more common in females. It is commonly
associated with polyhydramnios, spina bifida, cleftlip

Fig. 32.3a: Iniencephaly. Note absence of neck with severe retroflexion


of head due to gross disruption of vertebral column

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An Atlas of Neonatology

Fig. 32.4b: Anencephaly. Note absence of cranium and


exposure of brain also note frog-like eyes

Fig. 32.4c: Anencephaly. Note absence of cranium and


exposure of brain. Also note frog-like eyes

Fig. 32.3b: Iniencephaly. Note incidental


exampholos
(Red arrow)

Fig. 32.4d: Anencephaly with rachischisis side view

Fig. 32.3c: Iniencephaly. Extreme retroflexion

Fig. 32.4a: Anencephaly. Note absence of cranium and


exposure of brain

Fig. 32.4e: Anencephaly with myelorachischisis

Congenital Malformations
or palate, club feet and omphalocele. Most cranial vault
is absent; frontal bone above supraorbital region and
parietal bone and squamous part of occipital bone are
absent. The crown of head is covered by a vascular
membrane known as area cerebrovasculosa. Beneath
the mass, few remnants of cerebral hemisphere are
found. Diencephalic and mesencephalic structures are
either completely or partly destroyed. Pituitary and
posterior fossa structures are often preserved. Buling
eyes (frog eyes), large tongue, and very short neck with
absence of cranial vault give anencephalic characteristic
appearance.
Prenatal diagnosis is easily made by elevated AFP
and by ultrasonogram as early as 12-13 wks of
gestation. The condition is immediately fatal. About
30% are born alive, but die soon after. These babies
are a potential source of organs for transplantation.
Polyhydramnios and excessive fetal activity are
common. Breech presentation, premature birth, still
birth are common and when cephalic presentations
present in late pregnancy ultrasound identification may
be difficult.
Encephaloceles (Figs 32.5a to d)
These are a group of neural tube defects. Protrusion
of brain tissue through a bony defect in the skull is
termed as encephalocele. When only meningeal tissue
or meninges plus glial tissue protrude through the
defect, it is termed cranial meningocele.
Occipital encephaloceles are the most common type
(60-80%). Other less common sites are parietal,
frontonasal, intranasal, and nasopharyngeal regions.
These is associated hydrocephalus in about half of cases.
These defects are more common in girls. Other NTDs,
cleft lip/palate, absent corpus callosum, Dandy-Walker
malformation occur as associated features.
Amniotic band syndrome, cryptophthalmus syndrome, Walker-Warburg syndrome, frontonasal dysplasia, Meckel syndrome (AR), and Warfarin syndrome
are often associated with occipital encephaloceles.
Frontonasal encephaloceles must be differentiated
from other cystic lesions occurring at the same region.
These include, nasal gliomas, dermoids and teratomas.
Because frontonasal encephaloceles communicate with

211

Fig. 32.5a: Occipital encephalocele due


to amniotic bands

Fig. 32.5b: Occipital encephalocele in a Albin

subarachnoid space, they pulsate or bulge when both


jugular veins are compressed. This fact helps in
differentiating.
Anterior Encephalocele (Figs 32.6a and b)
Most cases are sporadic; differential diagnosis include
hemangiomas, nasal gliomas, and dermoid cysts.

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An Atlas of Neonatology

Fig. 32.5c: Occipital encephalocele

Fig. 32.6b: Frontal encephalocele

Fig. 32.5d: Occipital encephalocele

Hydrocephalus, hydranencephaly, porencephaly,


arachnoid cysts, hypertelorism anophthalmia, microphthalmia, and small teeth may be associated.
Spina Bifida Occulta (Figs 32.7a to c)

Fig. 32.6a: Frontal encephalocele in a case of


limb body wall complex

When there is defect in the vertebral arch but no


external herniation through the defect, it is termed as
spina bifida occulta. This defect occurs in about 5% of
normal population. Common defects revealed by
radiography include widening of spinal canal, fusion of
vertebral bodies, fused and malformed laminae, spina
bifida and a midline body mass within the spinal canal.
When there is herniation of the meninges or the
meninges and spinal cord through the spinal defect, the
lesion is referred to as spina bifida cystica. In spina bifida
occulta, there is usually no neurologic deficit in the early
part of life but may develop later on. The defect
commonly occurs in L5 or S1 vertebra. There may be
overlying cutaneous lesions indicating occult defect.

Congenital Malformations

213

These lesions are listed in Table 32.9. Presence of any


of these should prompt one to investigate further.
Table 32.9: Cutaneous lesions associated with
spinal dysraphism

Fig. 32.7a: Occult spina bifida with overlying tuft of hair


and rectal prolapse

High index of suspicion

Low index of suspicion

Hypertrichosis
Dimples
Acrochordons/pseudo
tails, true tails
Lipomas
Hemangiomas
Aplasia cutis or scar
Dermoid cyst or sinus

Telangiectasia
Capillary malformation
Hyperpigmentation
Melanocystic nevi
Teratomas

From: Drolet B. Birth marks to worry about. Dermatol


Clin 1998: 16 (3); 447-453.

Meningoceles

Fig. 32.7b: Spina bifida occulta with overlying hirsute skin

In this NTD, there is herniation of only meninges


through the defect. It accounts for 20% of spina bifida
cystica. The lesion appears as a sac covered by a
membrane or by skin which contains only CSF and
transilluminates brilliantly. Common sites are lumbosacral or upper thoracic and cervical regions. There is
associated hydrocephalus in 10% cases. Antenatal
diagnosis by measuring serum AFP level is not possible
because AFP levels are not raised. A meningocele must
be differentiated from meningomyelocele because the
prognoses are vastly different. An infant with meningocele has little or no associated CNS abnormality,
rarely develops hydrocephalus and usually has a normal
neurologic examination.
Meningomyeloceles (Figs 32.8a to h)

Fig. 32.7c: Occult spina bifida with overlying tuft of


hair in an older child

This is the most common type of NTD where there is


herniation of meninges and part of spinal cord through
the defect. The lesion most commonly affects
lumbosacral region. The skeletal defect may involve one
or two vertebrae or may extend the whole length of
the spine. The lesion may appear as a sac of thin
transparent membrane, or as a round bright-red area
resembling granulation tissue and sometimes the spinal
cord may be flattened and exposed, and surrounded
by a thin rim of membranes. Other clinical features
associated with meningomyelocele are listed below.

214

An Atlas of Neonatology

Fig. 32.8a: Lumbosacral meningomyelocele


with hydrocephalus

Fig. 32.8d: Skin covered myelomeningocele

Fig. 32.8b: Cervical myelomeningocele

Fig. 32.8e: Ruptured meningomyelocele

Fig. 32.8c: Ruptured meningomyelocele

Fig. 32.8f: Ruptured meningomyelocele with anal and


urinary incontinence

Congenital Malformations

215

Fig. 32.8g: Lumbosacral meningomyelocele with


hydrocephalus

Fig. 32.9a: Hydrocephaluscerebral aqueductal stenosis.


Note relatively large head size, prominent veins, sunset sign
and relatively small face

Fig. 32.9b: Hydrocephalus Dandy-Walker malformation.


Note large cranium, sunset sign and occipital protuberance
(Right)

Fig. 32.8h: Thoracic myelomeningocele a


relatively rare occurrence

Motor disturbances of skeletal muscles


Sensory disturbances
Sphincter disturbances of bladder and anus
Hydrocephalus

Fig. 32.9c: Hydrocephalusaqueductal stenosis. Note large


head prominent veins, sunset sign and relatively small face

Hydrocephalus (Figs 32.9a to d)


Hydrocephalus is commonly defined as a pathologic
increase in the cerebral ventricular volume. Congenital
hydrocephalus commonly results from obstruction to
normal flow of CSF (Obstructive hydrocephalus).
Aqueductal stenosis is the most common cause for
congenital obstructive hydrocephalus. The obstruction

results from inflammatory gliosis, forming, narrowing


or due to a transverse septum. In aqueductal stenosis,
third and lateral ventricular are dilated. Sometimes
obstruction may be at the exit foramina of fourth
ventricle, foramen of Monro, or within a ventricle or
in a cysterns or at the places of absorption in the

216

An Atlas of Neonatology
Table 32.10: Syndrome associated with hydrocephalus

Hydrolethalus
Osteopetrosis: autosomal recessive lethal
Triploidy syndrome
Walker-Warburg syndrome
X-linked hydrocephalus spectrum

X-linked Hydrocephalus Spectrum (Fig. 32.10)


MASA syndromeacronym for mental retardation,
adducted thumbs, shuffling gait, and aphasia. Bilateral
thumb deformities of flexion and adduction occur in
20% of XLR hydrocephalus due to aqueductal stenosis.

Fig. 32.9d: CT hydrocephalus

arachnoid villi. The term non-communicating hydrocephaly is used when the obstructive site is within the
ventricular system. When the obstruction occurs distal
to the fourth ventricle foramina, i.e. in the cisterns or
cerebral subarachnoid space, the term communicating
hydrocephalus is used. Causes of communicating
hydrocephalus include obliteration of superior sagittal
sinus, absence of arachnoid granuloma, subarachnoid
hemorrhage, etc. Hydrocephalus can rarely be caused
by excessive production of CSF due to choroid plexus
papillomas.
Congenital hydrocephalus may be evident at birth
or may develop soon after. The diagnosis is almost
certain at birth if the head circumference exceeds 97th
centile. In many cases head circumference may be
normal at birth, but head grows excessively in few days.
This fact emphasizes the importance of routinely
measuring head circumference at birth. Apart from
increased head circumference, other features seen are
large, bulging anterior fontanel open posterior fontanel,
widely separated cranial sutures, and dilated scalp veins.
In some cases setting sun sign is observed due to
pressure exerted by suprapineal recess of third ventricle
on the mesencephalic tectum, causing impairment of
ventricle gaze centers (Table 32.10).

Fig. 32.10: XLR Hydrocephalus. Note large cranium, frontal


bossing, short thumb flexed over palms. Also known as
MASA syndromeMental retardation, adducted thumb,
shuffling gait and aphasia

Dandy-Walker Malformation (DWM) (Figs 32.11a


to c)
It is characterized by, 1) hydrocephalus of variable degree,
2) a cyst in posterior fossa, and 3) a defect in the cerebellar
vermis through which the cyst communicates with 4th
ventricle. Other associated anomalies include agenesis
of corpus-callosum, aqueductal stenosis, occipital
encephalocele, polymicrogyria, syringomyelia, heterotopias, facial angiomas, midline cleft palate, cardiovascular
malformations, and polycystic kidneys. The etiologies
of DWM is unknown and may be associated with Meckel
syndrome, Warburg syndrome, Turner syndrome,
maternal diabetes and alcoholism and intrauterine
infections. It may also occur as an isolated AR trait.

Congenital Malformations

217

Fig. 32.11a: Dandy-Walker cyst with dilated third


ventricle and lateral ventricle
Fig. 32.11c: CT Dandy-Walker malformation

Congenital Scalp Defect (Fig. 32.12)

Fig. 32.11b: Dandy-Walker antenatal scan. Note dilated


cyst and associated ventricular enlargement

Also called aplasia cutis congenita. It is characterized


by congenital absence of skin, that can occur any where
in the body, though scalp lesions are more common.
Most lesions of the scalp are at or near the vertex. It
can occur in isolation or may be associated with cerebral
or extra cerebral abnormalities. Eighty percent of cases
are sporadic and remaining are inherited as AR or AD.
Malformation syndromes associated with scalp defects
are Johanson Blizzard syndrome, amniotic band
syndrome, ectodermal dysplasias, trisomy 13, deletion
of short arm of chromosome 4. Most scalp defects pose
only a cosmetic concern if the underlying bone is intact.

Fig. 32.12: Congenital scalp defect may be isolated or associated with syndromes like trisomy 13

218

An Atlas of Neonatology

In approximately 20% of cases, there is an underlying


defect of the skull and dura, leaving the brain exposed
at the base. This poses a risk of meningitis, hemorrhage
or thrombosis involving exposed cortical veins. This
type of lesions should be managed surgically.
Microcephaly (Figs 32.13a to h)
It is a clinical syndrome characterized by head circumference 5th centile below the normal range. The term
micrencephaly is used when smallness of brain or of
the cerebral hemispheres is the only lesion. Microcephaly
may be caused by micrencephaly or by acquired atrophic
lesions. Micrencephaly may be caused by chromosomal
abberations, many single gene disorders, TORCH and
other teratogens, many dysmophic syndromes.
Micrencephalies can also occur as an isolated feature
inherited as an autosomal recessive and XLR trait (Table
32.11).

Fig. 32.13a: Tower-shaped skull or acrocephaly due to


premature fusion of coronal sutures

Table 32.11: Conditions causing microcephaly


Congenital developmental anomalies
Holoprosencephaly
Lissencephaly
Polymicrogyria
Schizencephaly
Chromosomal anomalies
Trisomy 13, 18, and 21
Deletion syndromes
Systemic syndromes
Cat cry syndrome
Cockayne syndrome
Fetal alcohol syndrome
Hallermann-Streiff syndrome
Fetal hydantoin syndrome
Smith-Lemli-Opitz syndrome
Rubinstein-Taybi syndrome
Prader-Willi syndrome
Congenital viral infections
TORCH
Biochemical disorders
Maternal DM
Maternal uremia
Maternal phenylketonuria
Congenital hypothyroidism
Primary familial microcephaly (AD or AR)
Destructive lesions
Cerebral hypoxia
Intraventricular hemorrhage
Modified and adapted from: Vannucci RC, Fanaroff AA, Martin
RJ (eds). Neonatal Perinatal Medicine 6th edition. 1977
Mosby-Year Book Inc.

Fig. 32.13b: Brachycephaly. Note anteroposterior flattening

Fig. 32.13c: Trigonocephaly-Deletion 9 p syndrome. Craniostenosis involving metopic sutures lead to trigonocephaly.
This was a case of 9 p minus syndrome. It can also be seen
in 11q minus and 13q minus syndromes

Congenital Malformations

219

Fig. 32.13g: Mechanism of formation of


abnormal shapes of skull

Fig. 32.13d: Microcephaly

Fig. 32.13e: Clover leaf skull deformity.


X-ray of skull, APLateral

Fig. 32.13h: Tower-shaped skull due to


premature closure of coronal sutures

Fig. 32.13f: Clover leaf skull deformity

Macrencephaly
The term macrencephaly denotes large brain.
Macrocephaly is the term used to denote large head,

with head circumference above 90th centile.


Macrencephaly results from excessive amounts of
normal brain constituents, cellular proliferation or by
storage of metabolites. Macrencephaly can occur in
association with many syndromes viz. BeckwithWiedemann syndrome, cerebral gigantism, achondroplasia, fragile X syndrome, Klinefelter syndrome. It
can also occur as a familial trait (AD or AR).

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An Atlas of Neonatology

Abnormal Shapes of Head (Figs 32.13e to h)


Misshapen heads usually result from premature closure
of one or more cranial sutures, which is termed as
craniosynostosis. It can be simple when only one suture
is fused or compound when two or more sutures are
affected. The sagittal suture is the most commonly affected suture (50%) followed by single coronal, both
coronals, metopic and lambdoid. Premature closure of
a suture produces a combination of primary and secondary cranial deformities due to limitations of brain
growth along the length of the suture and compensatory over growth parallel to the line of fusion. Various
names given to the deformities and their mechanism
are depicted below. Craniostenosis can occur as an
isolated phenomenon or as a part of a dysmorphic
syndrome like Crounzon, Pfeiffer, Apert, Jachson, Weiss,
etc.

Fig. 32.14b: Otocephaly. Note agnathia frontal view


showing synotia

It is an extremely rare anomaly resulting from failure


of development of the mandible, that leads to an
abnormal position of the ears, which are horizontal with
lobules located close to the midline. It may be
associated with other malformations like holoprosencephalies, NTDs, cephaloceles, midline proboscis,
hypoplastic tongue, TEF, congenital heart disease and
adrenal hypoplasia.
Arnold-Chiari Malformations (Fig. 32.15)

Otocephaly (Figs 32.14a and b)


It is a grotesque anomaly characterized by absence or
hypoplasia of the mandible, proximity of the temporal
bones, and abnormal horizontal position of the ears.

Fig. 32.14a: Otocephaly. Note agnathia side view


showing towering skull, proboscis and agnathia

These malformations are characterized by cerebellar


elongation and protrusion through the foramen
magnum into the cervical spinal cord. Four types have
been described.

Fig. 32.15: Arnold-Chiari malformation

Congenital Malformations
Type I: In this type, the medulla is displaced caudally
into the spinal canal, and the inferior pole of the
cerebellar hemisphere is herniated through the foramen
magnum.
Type II: Any feature of type I plus displacement of
medulla, cerebellum and either part or whole fourth
ventricle in the spinal canal. It is usually associated with
non communicating hydrocephalus and lumbosacral
spina bifida.

221

ANOMALIES OF THE FACE REGION


Pierre Robin Sequence (Figs 32.17a to d)
This sequence consists of micrognathia, glossoptosis, and
posterior U-shaped cleft palate. The primary disorder
is early hypoplasia of mandible that results in secondary
posterior placement of tongue and tertiary prevention
of the normal closure of the posterior palatine processes.
In 25% of cases, a known syndrome is associated, some
of which are listed below.

Type III: Any combination of features of type I or II with


herniation of entire cerebellum through the foramen
magnum with a cervical spina bifida cystica.
Type IV: This is characterized by hypoplasia of
cerebellum. It was included by Chiari. It bears no
relation to other Chiari malformation.
Porencephalic Cysts (Fig. 32.16)
It is an intraparenchymal cyst that may or may not
communicate with ventricular cavity. This lesion is
usually limited to cerebral hemisphere. This correlates
clinically by spastic hemiplegia, hemisensory deficits, and
hemianopia. It results from the dissolution of necrotic
regions of brain, with cavitation and cyst formation
within the parenchyma of the cerebral hemisphere.
Necrosis results from vascular or infectious insults in late
fetal or early neonatal period.

Fig. 32.16: Porencephalic cyst

Fig. 32.17a: Pierre Robin sequence. Note


micrognathia crumpled helix

Fig. 32.17b: Pierre Robin sequence. Note cleft palate


and post placed tongue

222

An Atlas of Neonatology
Median Cleft Lip (Fig. 32.18)
A quadrangular or triangular median defect of upper
lip possibly extending posteriorly to the nose. There is
a close relationship between development of the
midline facial structures and the differentiation process
of forebrain. Therefore, cerebral anomalies like
holoprosencephaly are commonly often with defect.
Cleft Lip and Palate (Fig. 32.18)

Fig. 32.17c: Pierre Robin sequence.


Note severe micrognathia

This term refers to a wide spectrum of lateral clefting


defects usually involving upper lip, the palate or both.
Median cleft lip and palate is a different entity. Vast
majority of CL/CP are due to multifactorial etiology.
Many malformation syndromes may be associated with
cleft lip/palate. Few examples are given below: Risk of
recurrence in siblings and offsprings has been determined and is given on page 224.

Fig. 32.17d: Pierre Robin sequence. Note micrognathia,


U-shaped cleft palate and glossoptosis

Upper airway obstruction, suffocation, feeding


difficulties, failure to thrive and occasional sudden deaths
are the common complications. With proper management complications can be avoided.

Fig. 32.18a: Unilateral cleft lip and palate (severe)

Common Associates of Pierre Robin Sequence

Diastrophic dysplasia
Stickler syndrome
Spondyloepiphyseal dysplasia
Beckwith-Wiedemann syndrome
Myotonic dystrophy
Camptomelic syndrome
Trisomy 11q +
Fetal alcohol syndrome
Trimethadione syndrome

Fig. 32.18b: Cleft lip and palate bilateral

Congenital Malformations

223

Fig. 32.18e: Cleft palate in a case of Pierre Robin


sequence. Note micrognathia and glossoptosis

Fig. 32.18c: Cleft lip and palate bilateral


in a case of EEC syndrome

Fig. 32.18f: Cleft palate in a case of Pierre Robin


sequence. Note micrognathia and glossoptosis

Fig 32.18d: Bilateral cleft lip and plalate

Fig. 32.18g: Cleft lip and palate unilateral

224

An Atlas of Neonatology

Fig. 32.18h: Median cleft in a case of holoprosencephaly

Fig. 32.18j: Median cleft in a case of


short rib polydactyly (Majewski type)

Meckel syndrome
ABS syndrome
Multiple pterygium syndrome
Klippel-Feil syndrome
Chromosomal
Roberts syndrome
Trisomy 13 and others
Chondrodysplasia punctata
Isolated cleft palate
Risk to sibs and offspring of a single case
Cleft lip and palate
Risk to sibs or offspring of a unilateral case
Risk to sibs or offspring of a bilateral case

2%
4%
5.5%

Fig. 32.18i: Median cleft in a case of trisomy 13

Epignathus (Fig. 32.19)


AD
Van der Woude syndrome
AR
Larsen syndrome
SLO syndrome

XL
OPD syndrome
OFD syndrome
Others
Robin sequence
de Lange syndrome

It is a teratoma that originates from the soft or hard


palate in the region of Rathkes pouch. It presents as
a mass that protrudes from the mouth. In the fetal
period it can interfere with swallowing and can lead to
polyhydramnios. Though these tumors are benign,
recurrence rate is high after surgical excesion.

Congenital Malformations

225

Fig. 32.20b: Microphthalmos. Note medial epicanthic folds

Fig. 32.19: Epignathus. Protruding teratomatous mass


from palate derived from Rathkes pouch

Eye Anomalies
Cryptophthalmos/Anophthalmos /Microphthalmos
(Figs 32.20a to h)
Cryptophthalmos is a condition that occurs when the
lid folds fails to develop. The skin over the globe passes
continuously from the forehead to the cheek.
Anophthalmos is the absence of an eye. It is a rare
isolated ocular abnormality caused by failure of
formation of optic vesicle during embryonic period.

Fig. 32.20a: Nonsyndromic cryptophthalmos


AR inheritance

Fig. 32.20c: Anophthalmia. Absent eyes small orbits note


smooth philtrum flat nose AR inheritance. Anophthalmia can
be part of chromosomal syndrome, e.g. trisomy 13

Fig. 32.20d: Bilateral cryptophthalmos.


Nonsyndromic AR inheritance

226

An Atlas of Neonatology

Fig. 32.20e: Cryptophthalmos: Two sibs with


Cryptophthalmos parents normal AR inheritance

Fig. 32.20g: Anophthalmos. Microcornea right,


anophthalmos left and abnormal pinna

Fig. 32.20h: Microphthalmos with hemifacial atrophy

gens, and in many genetic syndromes like CHARGE


association, frontonasal dysplasia, Fraser syndrome,
Goldenhar syndrome, Lenz syndrome, Goltz syndrome,
Hallermann-Streiff syndrome, Oculodentodigital
syndrome, Penashokeir syndrome, and Fanconi
syndrome.
Fig. 32.20f: Cryptophthalmos: unilateral nonsyndromic

Microphthalmos is a relatively common condition


occurring in 1 in 2000 live births. In this condition the
eye is smaller than normal and reduced in volume.
Microphthalmia occurs in various chromosomal
anomalies, TORCH and other environmental terato-

Neonatal Cataracts (Fig. 32.21)


When dealing with a newborn with lens opacity it is
important to note whether involvement is unilateral or
bilateral. Bilateral cataracts usually indicate systemic
diseases or heritable conditions. While most unilateral
cataracts are due to local causes. Important causes of
cataract in the newborn period are given below.

Congenital Malformations

227

Inborn errors of metabolism


Galactosemia
Galactokinase deficiency
Lowe syndrome
Birth trauma
Endocrine
Congenital hypoparathyroidism
Albright hereditary osteodystrophy
SLO (Smith-Lemli-Opitz syndrome)
Miscellaneous
Aniridia
Treacher Collins syndrome
Pierre Robin syndrome
Hallermann-Streiff syndrome
Chromosomal
Trisomy 13,18,21
Turner
From Fanaroff
Neonatal Corneal Opacities (Figs 32.22a to c)
Fig. 32.21a: Note large central cataract. Can be part of distinct
syndrome. 10% are hereditary. Bilaterality usually indicate
systemic diseases or heritable condition. Some times type
of cataract can give a clue to pattern of inheritance

Fig. 32.21b: Cataract in a case of Down syndrome

Genetic

- Dominant
- Recessive
- X-linked recessive
Congenital viral infection
TORCH

The ophthalmologist examining an uncooperative infant


with cloudy corneas often feels stumped. This feeling
provides the acronym STUMPED for differential
diagnosis of cloudy corneas.
SSclerocornea
TTears in Descemets membrane
Infantile glaucoma
Trauma
UUlcer
Herpes simplex
MMetabolic
Mucopolysaccharidosis
Mucolipidosis.
Tyrosinosis.
PPosterior corneal defect
Posterior keratoconus
Peters anomaly
Staphyloma.
EEndothelial dystrophy
DDermoid central
Modified and adapted from:
Leibowitz HM, Waring III GO, Corneal Disorders, 2nd edn.
1998 W.B. Saunders Company: Philadelphia.

228

An Atlas of Neonatology
External Ear Malformations (Figs 32.23a to d)

Fig. 32.22a: Corneal dystrophy

The external and middle ears are derived from first and
second bronchial arches, and grooves during first half
of gestation and continue to grow till puberty.
Malformed external and middle ears may be associated
with serious renal anomalies, mandibulofacial dysostosis,
hemifacial microsomia, and other craniofacial
malformations. Other associations include abnormalities
of facial nerve, inner ear malformation and hearing loss
(both conductive and sensory neural). Pinna
malformation mainly include (1) Pit-like depression in
front of helix and above the tragus. It may represent
a cyst or an epidermis lined fistula. Its incidence is 8
per 1000. (2) Accessory skin tags: Incidence is 1-2 per
1000 births. They often contain a core cartilage appear
to represent accessory hillock of His, the hillocks that
normally developed in the recess of the mandibular and
hyoid arches and coalesce to form the auricle.(3) Lop
ears. This results from lack of bending of the cartilage
that forms the antihelix. (4) Microtia-includes subtle
abnormalities of the size, shape, and location of pinna.
Facial nerve may be abnormal. (5) Low set ears: This
designation is made when the helix meet the cranium
at a level below that of horizontal plane which may be
an extension of a line through both inner canthi.

Fig. 32.22b: Corneal dystrophy. Uniformly opaque cornea.


Corneal dystrophy can be part of many syndromes it can be
AD or AR. Any of the five layers of cornea may be involved
in genetic syndromes

Fig. 32.22c: Corneal dystrophy. Seen along with limb


body wall complex

Fig. 32.23a: Ear anomalies. Note cleft-like extension of


angle of mouth right sideGoldenhar syndrome

Congenital Malformations

229

Fig. 32.23b: Ear tag

Fig. 32.23d: Lop ear

Fig. 32.23c: Skin tags in front of right ear and cheek

Cystic Hygroma (Figs 32.24a to c)


The term Hygroma means moist tumor. They are
single or multiple cystic anomalies of the lymphatics
within the soft tissues, usually involving the neck. It
occurs in 1 in 200 spontaneous abortuses.
In the embryo the lymphatic system drains into the
jugular lymphatic sac. A communication between this
primitive structure and jugular vein is formed around
40 days of gestation. Failure of development of this
communication results in lymphatic stasis, lymphatic
dilation, formation of cystic hygroma and sometimes
hydrops and intrauterine death, causing jugular
lymphatic obstruction sequence.

Fig. 32.24a: Cystic hygroma

Cystic hygromas when occur in the lateral and posterior region of neck are often associated with chromosomal anomalies and hydrops (Trisomy 21, 18 and/Turner
syndrome). When they occur elsewhere (skin, chest,
abdomen, limbs, retroperitoneal) associated lesions, they
are not associated with chromosomal anomalies.

230

An Atlas of Neonatology

Fig. 32.24b: Infantogram showing bilateral cystic hygroma


in an abortus with Turner syndrome

examination. Nuchal lucencies are seen in achondrogenesis, Apert syndrome, EEC syndrome, Fryn
syndrome, Joubert syndrome, Multiple Pterygium
syndrome, Noonans syndrome and Smith-Lemli-Opitz
syndrome. Nuchal cystic hygroma can be diagnosed in
the first trimester of pregnancy and some of these
improve. When they are associated with septa or
hydrops, resolution is unlikely.
Nuchal lucencies often resolve whether associated
with abnormal karyotype or not. But totally normal
outcome of the fetus cannot be predicted, as it may
be associated with several syndromes.
Most fetuses with the full XO syndrome are miscarried in the first trimester, prior to prenatal diagnosis
or have large cystic hygromata with severe lymphoedema, leading to death later in gestation. Those who
survive have regression of the cystic hygromata,
resulting in webbing of the neck.
The size of cysts varies and has internal septa giving
honeycomb appearance in US examination.
When detected, fetal karyotyping by cordocentesis
or CVB is indicated. Large cystic hygromas with septa
within, are associated with hydrops and have almost
100% mortality.
Diaphragmatic Hernia (Figs 32.25a to h)

Fig. 32.24c: Bilateral cystic hygroma

Nuchal lucency and cystic hygromata seen in


ultrasound examination are the spectrum of the same
condition. Cystic hygromata are seen in the 2nd
trimester of pregnancy.
Amniotic band syndrome, encephalocele, cervical
meningocele, neck tumors, subcutaneous edema are
often confused with cystic hygromata during ultrasound

Diaphragmatic hernia consists of protrusion of the


abdominal organs into the thoracic cavity through a
diaphragmatic defect. It include
a. Posterolateral diaphragmatic herniaBochdalek
hernia (90%)
b. Retrosternal diaphragmatic herniaMorgagni
hernia (1-2%)
c. Eventration of diaphragm (5%)an upward
displacement of abdominal contents into thorax due
to weak aponeurotic diaphragm.
The incidence varies from 0.03 to 0.05% births. It
can be sporadic and familial. It may be associated with
Beckwith-Wiedemann syndrome, Pierre Robin
syndrome and congenital choanal atresia and
chromosomal abnormalities.
Prognosis is generally bad with 1/3 being dead born
and may have associated serious CNS and cardiac
defects. Those who manifest respiratory disorder and
failure immediately after birth, and those detected in
utero have poor prognosis.

Congenital Malformations

231

Fig. 32.25a: Congenital diaphragmatic hernia of


Morgagnian type
Fig. 32.25c: CDH at autopsy showing coils of
intestine in the thorax

Fig. 32.25b: Antenatal ultrasound demonstrating CDH. Note


heart and stomach bubble lying side-by-side in the thorax

Fig. 32.25d: Morgagnian type of CDH with barium


contrast study

232

An Atlas of Neonatology

Fig. 32.25e: X-ray of CDH showing coils of intestine in


the left hemithorax
Fig. 32.25g: Eventration of diaphragm

Fig. 32.25f: Eventration of diaphragm with barium in the


intrathoracic intestinal lumen

Fig. 32.25h: Eventration of diaphragm showing


sternal recession

Congenital Malformations

233

Polyhydramnios and altered position of heart in


thorax usually by the side of diaphragm are features
to detect CDH by ultrasound antenatally.
Those who present in newborn, present with
respiratory distress, cyanosis, apparent dextrocardia
scaphoid abdomen and bowel sound in left
hemithorax.
Predictors of Mortality in CDH
1. Position of stomach: Presence of stomach in thorax
indicates poor prognosis and its presence in abdomen carries better prognosis.
2. Lung size: Severe hypoplasia of lung which is
determined by comparing in utero lung area with
thoracic area, is indicative of poor prognosis.
3. Cardiac anomalies: CDH with associated cardiac
structural anomalies carries poor prognosis.
4. Chromosomal anomalies: Hernias in associating with
chromosomal abnormalities carry poor prognosis.
Prenatal diagnosis: The gold standard for antenatal
diagnosis is by ultrasound examination. The features
suggestive are:
a. Polyhydramnios
b. Absent or intrathoracic stomach bubble
c. Mediastinal and cardiac shift
d. Fetal hydrops in extreme cases.
Umbilical Hernia (Fig. 32.26)
Umbilical hernia (often associated with diastasis recti)
is due to an imperfect closure or weakness of the
umbilical ring especially in LBW babies. The lesions are
found in 30% of Black infants and 4% of White infants
under 6 weeks.
It appears as a soft swelling covered by skin that
protrudes during crying, coughing, and straining, and
can be easily reduced. The size of the defect varies from
less than 1 cm in diameter to as much as 5 cm.
Strangulation is rare.
Most umbilical hernias will disappear spontaneously
by 1 year of age. Even large hernias have been known
to disappear spontaneously by 5 to 6 years of age. If
hernia persists beyond three years of age causing
symptoms, or gets strangulated or becomes

Fig. 32.26: Umbilical hernia

progressively larger after the age of 1-2 years then


surgery should be considered.
Omphalocele (Figs 32.27a to c)
Omphalocele is a ventral wall defect characterized by
herniation of the intra-abdominal contents into the base
of the umbilical cord, with a covering amnioperitoneal
membrane.
Pentalogy of Cantrell is associated with 5 anomalies,
(1) Midline supraumbilical abdominal defect. (2) Defect
of lower sternum. (3) Deficiency of diaphragmatic
pericardium. (4) Deficiency of anterior diaphragm and
(5) Intracardiac abnormalities.
Beckwith-Wiedemann syndrome is characterized by
the association of macroglossia, visceromegaly and

Fig. 32.27a: Omphalocele

234

An Atlas of Neonatology
Gastroschisis (Figs 32.28a to b)
It is a paraumbilical defect of the anterior abdominal
wall associated with evisceration of abdominal organs
and most cases are sporadic.
The defect is usually located in the right paraumbilical area, the umbilical cord is normally connected
to the abdominal wall and the herniated organs are not
covered by a membrane. In omphalocele, it is central
surrounded by a membrane on which umbilical cord
is inserted.

Fig. 32.27b: Omphalocele

Fig. 32.28a: Gastroschisis

Fig. 32.27c: Antenatally-diagnosed omphalocele. Note


coils of intestine lying outside abdominal wall

omphalocele. Omphalocele may be sporadic or may


be associated with trisomy 13 and 18. Cardiac anomalies and neural tube defects are common associations.
Differential diagnosis is shown in the list below.

Fig. 32.28b: Gastroschisis. Note edematous coils of


intestine

Ectopia Cordis (Fig. 32.29)


Associated Anomalies in Omphalocele

Beckwith Wiedemann
Conjoined twins
Imperforate anus
Trisomy 18
Ileal atresia
Meningocele
Absence of limb
Cardiac anomalies (20%).

In this condition heart is displaced out of the thoracic


cavity. In more than 60% of cases displacement occurs
through a defect in the sternum and in 30% heart gets
displaced into the abdominal cavity through a defect
in the diaphragm. In about 7% of cases thoracoabdominal defect is seen which also forms a component
in the Pentalogy of Cantrell. In the remaining 3% there
is cervical displacement. Associated malformations
include, intracardiac, facial, CNS and skeletal. It can

Congenital Malformations

235

Fig. 32.29: Ectopia cordis

result from amniotic bands. Most babies are dead and


die soon after birth.
Body Stalk Anomaly (Figs 32.30a and b)
This is a severe form of abdominal wall defect due to
failure of formation of the body stalk and is characterized by absence of the umbilicus and umbilical cord.
Most cases are sporadic. The fetus is attached to the
placenta and uterine wall and a large defect of
the anterior abdominal wall allows protrusion of the
viscera.
NTD, GIT, genitourinary and skeletal cardiac, lung
anomalies are common. One umbilical artery is usually
absent.
Prune Belly Syndrome (Eagle-Barrett
Syndrome) (Figs 32.31a to d)
The term prune belly syndrome describes triad of
deficiency of abdominal muscles, dilatation of urinary
tract, and failure of testicular descent. This term should
not be confused with prune belly which denotes lax and
wrinkled abdomen It results from early fetal urethral
obstruction. The pathogenesis is believed to be
secondary to abdominal stretching and distention
during fetal development.
It is usually associated with urinary tract abnormalities such as a grossly dilated bladder, hydronephrosis,

b
Figs 32.30a and b: Body stalk anomaly.Note placenta
attached directly

and hydroureter. Primary urethral obstruction may


explain male predominance and a primary defects in
the mesoderm with secondary renal abnormalities is
also suggested. A milder form partial or incomplete
syndrome includes cryptorchidism, mild urinary tract
abnormalities, mild or unilateral abdominal musculature, and deficient abdominal musculature but with
normal genitourinary system. Persistent urachus and
lower limb shortening are often associated. The
wrinkled abdominal wall gives it the descriptive term
prune belly syndrome.
Chronic abdominal distention in fetus may produce
similar syndrome. Asymmetric lower limbs reduction

236

An Atlas of Neonatology

Fig. 32.31a: Prune belly syndrome

Fig. 32.31c: Distended abdomen on X-ray

Fig. 32.31b: Distended abdomen (X-ray)

Fig. 32.31d

deformities of legs with or without digits have been


described.

membrane invades the entire cloacal membrane except


at the urogenital floor, where the genital tubercles fuse.
Failure of the infraumbilical membrane to invade the
cloacal membrane results in vesicle exstrophy alone,
representing an intermediate spectral deficiency in its
lining. If it occurs before the formation of the urorectal
septum, the more severe cloacal exstrophy results. If
it occurs still later, only epispadiasis results.
The anatomic defects include an absent umbilicus,
protrusion of an exposed posterior bladder wall

Exstrophy of the Bladder or Ectopia Vesicae


(Fig. 32.32)
This anomaly occurs once in 30,000 births. Exstrophic
anomalies include bladder exstrophy, epispadiasis, and
cloacal exstrophy. These conditions result from a
premature breakdown of the infraumbilical membrane
(mesoderm) to varying degrees. Normally, this

Congenital Malformations

237

Table 32.12: Abdominal wall defects


Gastroschisis

Omphalocele

LBWC

Cloacal extrophy

Site

Rt. paraumbilical

Lateral

Below umbilicus

Membrane
CVS anomalies
Other anomalies
Chromosomal anomalies

__
Rare
Rare
__

Midline cord insertion


site
+
Common
Common
Common

+
Common
Always (Spine, limb.
__

Variable
10-15%
Always (Spine, GU)
__

LBWC - Limb body wall complex; GU Genitourinary

2. Isolated esophageal atresia without tracheoesophageal fistula (3-5%).

Fig. 32.32: Exstrophy of bladder

mucosal surface with its striking cherry-red color, the


ureteral orifices spurting urinary effluxes, and sharp
demarcation between the exposed bladder mucosa and
the surrounding skin. There is gap in pelvic symphysis
dorsally tethered incomplete penis, ventrally incomplete
prepuce, broadly splayed glans, short urethral mucosal
strip between the bladder and the glans, but a normally
descended testis, and an underdeveloped scrotum. In
females, divergent labia and mons, bifid clitoris, and
large external urinary meatus occurs (Table 32.12).

Fig. 32.33a: Esophageal atresia with blind pouch in


barium contrast study

Esophageal Atresia (Fig. 32.33)


It occurs in between 1 in 3000 to 1 in 4500 live births.
The exact etiology is not known. Associated anomalies
are seen in more than 50% of cases.
There are five major anatomic types
1. Esophageal atresia with distal tracheoesophageal
fistula(commonest, 85%.): In this type, the
proximal esophagus ends at about T3 vertebra, and
the distal segment of esophagus communicates
through fistula with lower end of trachea.

Fig. 32.33b: Bubbly baby in esophageal atresia

238

An Atlas of Neonatology
CHARGEColobomata, Heart disease, atresia, Mental
Retardation, Genital hypoplasia, and Ear anomalies
and Deafness.
Other associated anomalies include: Rib anomalies,
vertebral abnormalities, duodenal atresia, hydrocephalus, intestinal malrotation.

Fig. 32.33c: Coiled infant feeding tube in a case of


esophageal atresia

Diagnosis: Infants are unable to swallow saliva and


have excessive secretions requiring frequent suctioning.
If the infant is fed he regurgitates immediately with
choking and coughing.
Inability to pass the nasogastric tube beyond 9-13
cm from alveolar ridge should raise suspicion and
diagnosis can be confirmed by radiograph of chest,
neck, and abdomen. Air in the abdomen confirms the
presence of distal TEF. A gasless abdomen is suggestive
of pure atresia.
Prenatal diagnosis is sometimes possible by
demonstrating polyhydramnios with absence of stomach
gas bubble. But this is not a specific finding.
Duodenal Atresia (Fig. 32.34)
It occurs once in 10,000 live births and almost 1/3
cases have associated Down syndrome (Table 32.13).

Fig. 32.33d: Esophageal atresia antenatally-diagnosed


showing blind pouch

3. Isolated tracheoesophageal fistula without atresia


(3-6%).
4. Esophageal atresia with proximal fistula (2%).
5. Esophageal atresia with fistulas to the upper and
lower esophageal segments (3-5%).
Esophageal atresia are associated with part ofVATERVertebral and Vascular, Anal, Tracheal,
Esophageal, Radial and Renal.
VACTERLVertebral, Anal, Cardiac, Tracheal,
Esophageal, Renal and Limb.

Fig. 32.34a: Erect abdomen radiograph in duodenal


atresia showing classical double bubble

Congenital Malformations

239

Depending on the degree of obstruction, the proximal


duodenum and stomach dilate to several times their
normal size with collapsed distal bowel loops. About half
of cases will have polyhydramnios.
Antenatal diagnosis is possible by detecting dilated
stomach and proximal duodenum. The symptoms
include biliary or non-biliary vomiting, abdominal
distention, continuous nasogastric tube aspiration and
X-ray demonstration of double bubble appearance.
Congenital Hypertrophic Pyloric Stenosis
(Figs 32.35a to e)

Fig. 32.34b: Antenatal scan in a duodenal atresia


showing dilated stomach and proximal duodenum

It is one of the commonest surgical conditions presenting in the later part of neonatal period occurring
more commonly in males. The clinical features include
persisting projectile nonbilious vomiting in a healthy
hungry baby.
Examination reveals visible gastric peristalsis and
pyloric mass. The technique of palpating the mass is
very important. The first requisite should be relaxed
baby , mother and the physician. Baby should be put
to left breast and physician should palpate the mass
with his left hand standing on the left side by using three
fingers: ring, middle and index fingers.
The index finger lifts the liver up and ring finger
pushes the coils of intestine down and middle finger
palpates the mass with a kneading movement which is
felt as the tip of nose.

Table 32.13: Duodenal atresia associated anomalies


Down syndrome (30%)
Congenital heart disease (20%)
Other GI anomalies (26%)
- Malrotation
- Esophageal atresia
- Imperforate anus
- Ileal atresia
- Transposed liver
- Duodenal duplication
Vertebral anomalies
- Abnormal number of ribs
- Sacral agenesis
- Hemivertebral bodies
- Cervical ribs
Renal anomalies
Fig. 32.35a: CHPS being operated

240

An Atlas of Neonatology

Fig. 32.35d: CHPS-visible gastric peristalsis


Fig. 32.35b: CHPSbarium study showing the
umbrella sign

Fig. 32.35e: Visible gastric peristalsis in CHPS


Fig. 32.35c: Method of palpating for pyloric mass in
CHPS

Ileojejunal Atresias (Fig. 32.36)


It is important to differentiate these from more common
duodenal atresia, because the latter is associated with
high incidence of other anomalies unlike these conditions. Site of atresia is equally distributed from Treitz
ligament to ileocecal valve. As said above only about
10% cases have associated anomalies. These babies
present with polyhydramnios when in utero. After birth
biliary vomiting (more proximal) and abdominal
distention (less proximal). Diagnosis is made by
radiographic examination. Features of bowel atresia are
summarized in the Table 32.14.

Fig. 32.36a: Multiple fluid levels indicative of lower


intestinal obstruction

Congenital Malformations

241

Fig. 32.36b: Ileal atresia showing atretic ileal


segment on table

Fig. 32.36d: Jejunal atresia at autopsy

Fig. 32.36c: Barium meal study in jejunal atresia

Fig. 32.36e: Jejunal atresia erect abdomen showing


triple bubble appearance

242

An Atlas of Neonatology
Table 32.14: Clinical features of bowel atresia

Polyhydramniosmore common in proximal obstruction


Distended abdomen
Bile stained amniotic fluid due to antenatal vomiting
(common in duodenal atresia)
Gastric aspiration of large volume (>25 ml)
Biliary aspirate
Vomiting in the immediate neonatal period
Indirect hyperbilirubinemia

Hirschsprungs Disease (Figs 32.37a and b)


It occurs approximately 1 in 5000 births and is a
common cause of intestinal obstruction in the neonatal
period. The basic defect lies in the congenital absence
of ganglia in the affected segment of bowel. This
aganglionic segment does not propagate the peristaltic
wave, thus causing a functional bowel obstruction. Distal
part of the colon is commonly affected. Clinically these

Fig. 32.37b: Colostomy done in a case of


Hirschsprungs disease

neonates present with abdominal distention, biliary


vomiting, and failure to pass stool. It is worth remembering that 94% of normal term newborns pass
meconium in the first 24 hrs whereas 94% of infants
with Hirschsprungs disease do not pass stool in the first
24 hrs. The recurrence risk for sibs is given in Table
32.15.
Table 32.15: Hirschsprungs disease
recurrence risk for sibs
Index case
Short segment
Male
Female
Long segment
Male
Female

Male sib

Female sib

4.7
8.1

0.6
2.9

16.1
18.2

11.1
9.1

Imperforate Anus (Figs 32.38a to c)


Definition
Imperforate anus is the lack of an anal opening at
proper location or of proper size. It may be a part of
syndromes that are listed below (Table 32.16):
Types
Fig. 32.37a: Hirschsprungs disease.
Note distended abdomen

1. High imperforate anus: The rectum ends above the


pubo-rectalis sling, the main muscle responsible for
maintaining fecal continence.

Congenital Malformations

243

Fig. 32.38c: Imperforate anus

Fig. 32.38a: Imperforate anus

2. Low imperforate anus: The rectum has traversed the


pubo-rectalis sling in correct position. Variants
include anal stenosis, imperforate anus with perineal
fistula and imperforate anus without fistula.
Diagnosis
1. By inspection and calibration of any perineal
opening.
2. In low imperforate anus meconium may be passed
into the vagina or it may be found in the rugal folds
of the scrotum.
3. In high imperforate anus, the meconium particles
may be present in the urine or in the vagina.
Investigations

Fig. 32.38b: Invertogram for imperforate anus

1. Vaginal examination with a nasal speculum or


cystoscope
2. Ultrasound

Table 32.16: Syndrome featuring anal atresia


Syndrome

Features

Cause

VATER

Vertebral anomalies, T-E fistula, renal and radial defects

Sporadic

G-syndrome (Opitz-Frias)

Hypertelorism, laryngeal cleft and hypospadias

? X-linked recessive

Kaufman-McKusick

Hydrometrocolpos, polydactyly and congenital heart defect

Autosomal recessive

Johanson-Blizzard

Hypoplastic alae nasae, scalp defects, malabsorption, and


hypothyroidism

Autosomal recessive

Asymmetric crying facies

Congenital heart disease

Mostly sporadic

Cat-eye syndrome

Coloboma, congenital heart defect and mental retardation

Partial trisomy 22

244

An Atlas of Neonatology

Management
1. Colostomy for high anomalies.
2. Perineal anoplasty or dilation of fistula for low lesion.
If the level is not known, colostomy is preferable to
blind exploration of the perineum.

HYDROCELE (FIG. 32.39)


This condition in the neonatal period is usually due to
persistent patency of the processus vaginalis which
allows peritoneal fluid to enter an accumulate within
the tunica vaginalis. Spontaneous obliteration of the
processus vaginalis occurs in more than 95% of cases
within first year of life and the surgical treatment needs
to be undertaken only when the hydrocele is
exceptionally large.

Fig. 32.40a: Ambiguous genitalia

Fig. 32.40b: Ambiguous genitalia

Fig. 32.39: Hydrocele

Ambiguous Genitalia (Figs 32.40a to g)


Definition
Ambiguous genitalia is present: (i) when the sex of an
infant is not readily apparent after examination of the
external genitalia or (ii) when a gender role cannot be
assigned on the basis of the appearance of the external
genitalia alone (e.g. microphallus in an apparent male,

Fig. 32.40c: Ambiguous genitalia

Congenital Malformations

245

Fig. 32.40d: Over-masculinisation in a male child with CAH


Fig. 32.40g: Ambiguous genitalia in male-pseudohermaphroditism

labial gonads in an apparent female or bifid penis and


scrotum associated with exstrophy of the bladder.
Etiology

Fig. 32.40e: Ambiguous genitalia in male-pseudohermaphroditism

The ambially of sex is the consequence of either excessive


exposure to androgens in a female fetus (female
pseudohermaphroditism) or inadequate androgenic
action in a male fetus (male pseudohermaphroditism).
Rarely it can result from dysgenetic gonads or true
hermaphroditism in which both testicular and ovarian
tissue are present along with germ cells of both sexes.
This is shown in the following table (Table 32.17).
Table 32.17: Etiology and types of ambiguous genitalia
Female pseudohermaphroditism:
Androgen exposure from fetal source, example: congenital
adrenal hyperplasia, etc.
Androgen exposure from maternal source, example:
virilizing ovarian tumors.
Undetermined origin of androgens
Male pseudohermaphroditism:
Defects in testicular differentiation
Deficiency of testicular hormones
Defects in androgen action
- True hermaphroditism
XX
XY
XX/XY chimeras

Fig. 32.40f: Ambiguous genitalia in male-pseudohermaphroditism

Modified and adapted from Rapaport R. Disorders of the


gonads. Behrman RE, Kliegman RM, Jenson HB (eds).
Nelson Textbook of Pediatrics 16th edn. W.B. Saunders
Company : Philadelphia.

246

An Atlas of Neonatology

Assignment of Sex
It constitutes a medical emergency in the labor room.
This has to be made with meticulous care and with prior
knowledge of karyotypic sex, gonadal sex, hormonal
milieu to which the fetus was exposed in utero, and
postability of surgical correction. One such initial
approach is given below:

Fig. 32.41b: Hypospadiasis

to a fibrous band called chordee, which extends from


the urinary meatus to the tip of the penis.

RECTOVESICAL FISTULA (FIG. 32.42)


Hypospadiasis (Figs 32.41a and b)
Is a common anomaly that occurs one in 300 newborn
males. There is an abnormal location of the external
urinary meatus on the ventral surface of the penis.
Depending on the location of external meatus,
hypospadiasis is classified as: (1) glandular (glans),
(2) coronal (shaft), (3) penile (4) peno scrotal and
(5) perineal. The prepuce is hooded and is present on
the dorsal side. The penis is usually curved ventrally due

Rectovesical fistula is usually associated with severe


urinary tract anomalies and predisposes for hazards of
urinary tract infections.

Fig. 32.42: Rectovesicular fistula presenting with


passage of meconium through the urethra

CONGENITAL VAGINAL OCCLUSION


(FIG. 32.43)

Fig. 32.41a: Hypospadiasis

This condition usually presents in adolescence with


primary amenorrhea. Less commonly it can present in
neonatal period when secretions by the foetal cervical

Congenital Malformations

Fig. 32.43: Vaginal atresia

247

Fig. 32.44a: Bifid scrotum. Note also imperforate anus

and vaginal mucosal glands stimulated by maternal


oestrogens leads to development of hydrocolpos.

MISCELLANEOUS ANOMALIES OF
EXTERNAL GENITALIA (Figs 32.44 a and b)
Some of the rare congenital malformations like accessory testis and bifid scrotum are shown in the pictures.

TERATOMAS (Figs 32.45a to g)


These are the most frequent perinatal neoplasms, that
contain more than one of the three germ layers and
tissue elements that are foreign to the site of origin.
About 50% of teratomas occurring in infancy and
childhood present in the neonatal period. Among these,
40-50% occur in the sacrococcygeal region. Other sites
of occurrence are, head and neck, brain, mediastinum,
retroperitoneum, abdomen and spinal cord.
Sacrococcygeal Teratoma

Fig. 32.44b: Accessory testesa rare anomaly

Occurs once in 40,000 births, mostly in females (80%).


It is a tumor arising from primitive knot or Hansens
node, an aggregation of totipotent cells.

3. Predominant sacral component and external


extension
4. Presacral tumour with no external component

Four Types (Fig. 32.45d)

Type I and II Account for 80%

1. Protruding from perineal region covered by skin


with minimal presacral component
2. Predominant external tumor with a significant
presacral component

Histologically they may be


1. Mature or benign (55-75%) mostly cystic 72%.
2. Immature teratoma 11-28% mostly cystic 62%
3. Malignant teratoma 7-15% mostly solid

248

An Atlas of Neonatology

Fig. 32.45a: Teratoma cheek

Fig. 32.45d: Sacrococcygeal teratoma


anatomic classification

Fig. 32.45b: Teratoma X-ray. Retroperitoneal mass


displacing hydronephrotic right kidney

Fig. 32.45e: Sacrococcygeal teratoma

Bilateral Renal Agenesis (BRA)/ Dysplastic


Kidney (Fig. 32.46)

Fig. 32.45c: Teratoma. 20-day-old baby with right


retroperitoneal teratoma

Occurs 0.1-0.3 per 1000 births. Often it is an isolated


condition but less frequently may be a part of genetic
syndrome like chromosomal disorders (cat eye
syndrome, 4p- syndrome), autosomal recessive
disorders (Fraser syndrome, cerebrooculofacio-skeletal
syndrome, and associated mandibular syndrome)
autosomal dominant syndrome (broncho-otorenal

Congenital Malformations

Fig. 32.45f: Sacrococcygeal teratoma

Fig. 32.45g: Sacrococcygeal teratoma

syndrome, Mullerian duct anomalies and renal


agenesis).
Non-mendalian disorders like TEF, VATER
association, congenital cystic adenomatus malformation
may be associated. Non-syndromic bilateral renal

249

Fig. 32.46: Dysplastic kidneys

agenesis can occur as AR, AD, XLR and multifactorial


disorders.
BRA is associated with Potter sequence, (Potter
syndrome or oligohydramnios sequence) which include:
1. Pulmonary hypoplasia
2. Typical facelow set ears, redundant skin, prominent fold arising at inner canthus of each eye,
parrot beak nose and receeding chin
3. Abberant hand and foot positioning, bowed legs,
clubbed feet and hip dislocation.
Severe oligohydramnios is thought to be responsible
for this phenotype.
Associated anomalies may involve adjacent genital
malformation to sirenomelia and multiple unrelated
anomalies involving heart, CNS, face, etc.
Antenatal diagnosis rests on absence of fetal bladder,
bilateral absence of the fetal kidneys and oligohydramnios.

250

An Atlas of Neonatology

Renal Cystic Diseases (Figs 32.47a to i)


This entity includes autosomal dominant and autosomal
recessive polycystic kidney diseases, and is characterized
by presence of cysts in both kidneys, no evidence of
dysplasia, and continuity of lumen of nephron from the
uriniferoces space to the urinary bladder.

(c)

Fig. 32.47a: Infantile polycystic kidney disease. Grossly


bilaterally enlarged kidney and liver. Inheritance is AR. This
has to be differentiated from cystic dysplastic kidneys and
adult AD polycystic kidney disease with early onset by detailed
histological and DNA studies

(d)
Figs 32.47c and d: Infantile polycystic kidney disease
antenatal scan

Fig. 32.47b: Infantile polycystic kidney disease. Note cystic


liver (vertically-placed arrow and enlarged cystic kidneys on
both side (horizontal arrows)

Fig. 32.47e: Infantile polycystic kidney disease. Histology of


bilateral polycystic kidney showing multiple cystic areas with
glomeruli

Congenital Malformations

251

Fig. 32.47f: Infantile polycystic kidney disease

Fig. 32.47h: Infantile polycystic kidney diseaseUSG.


Note hyperechoic kidneys

Fig. 32.47g: Infantile polycystic kidney disease

Fig. 32.47i: Infantile polycystic kidney diseasepostmortem specimen

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An Atlas of Neonatology

Autosomal recessive (infantile) polycystic kidney


disease. ARPKD is the most common renal cystic
disease seen in children with a frequency of 1.41 per
100,000 live births. The clinical features are listed in
the box. ARPKD has been shown to be due mutations
in both copies of short arm of chromosome 6.
Autosomal dominant polycystic kidney disease presents
later in life.
Oligohydramnios and its sequelae (Potter)
Large bilateral renal masses
Difficult delivery due to enlarged abdomen
Hypertension
Pneumothorax and pulmonary hypoplasia are usual
complications
Renal failure is rare in newborn period
Mild hepatomegaly due to fibrosis.
Renal ultrasound: Large kidneys with increased
echogenicity and multiple cysts. However, this cannot
differentiate from other renal cystic masses. But the
demonstration of liver cysts and/or periportal fibrosis is
highly suggestive. Prenatal diagnosis is possible by 24
weeks of gestation but cannot differentiate from other
simulating conditions.
Abdominal Mass in the Newborn Period
A differential diagnosis of abdominal mass is given in
Table 32.18.
Table 32.18: Causes of mass per abdomen
Cystic

Solid

Hydronephrosis
Multicystic dysplastic kidney
Adrenal hemorrhage
Pancreatic cyst, duplication
Choledochal cyst
Hydrometrocolpos
Ovarian cyst
Mesenteric / omental cyst
Intestinal duplication

Neuroblastoma
Teratoma
Mesoblastic nephroma
Wilms tumor
Hepatoblastoma
Hemangioma (liver)
Hamartoma (liver penc)
Infantile polycystic kidney

Obstetric history for polyhadramniosintestinal


duplication (due to some degree of obstruction)
Potters faciesurinary tract obstruction
Retinal angiomasvon Hippel-Lindau causing
pancreatic and renal cysts.
Subcutaneous massesneuroblastoma
Cutaneous hemangiomahepatic vasicular lesions

HYDRONEPHROSIS (Figs 32.48a to d)


Hydronephrosis is an abnormal dilatation of pelvicalyceal, usually resulting from obstruction at various
levels (obstructive uropathies). Obstruction could be
due to posterior urethral valves, uretero-pelvic junction
obstruction, uretero-vesicular junction obstruction.
Occasionally hydronephrosis can result from vesicoureteric reflux, megacystic-megaureteric syndrome,
cloacal or bladder exstrophy, ectopic ureterocele and
intra-abdominal masses causing compression.
Wilms Tumor (Figs 32.49a to d)
This tumor arises from pluripotent embryonic renal
precursor cells. This tumor is rare in newborns; a renal
mass in a neonate is more likely a congenital
mesoblastic nephroma or a malignant rhabdoid tumor.
The peak age at diagnosis is 2-3yrs. But, rarely they
are present before birth causing dystocia. The main
presenting features in the neonatal period are mass per
abdomen and hematuria (micro/macroscopic).

History and Examination: Important Points


Always ask family historyfor infantile polycystic
kidney
Obstetric history for oligohydramniosurinary tract
obstruction

Fig. 32.48a: Hydronephrosis USG. Bilateral


hydronephrosis due to PUV (posterior urethral valves)

Congenital Malformations

(b)

Fig. 32.49a: Wilms tumor

(c)

(d)
Figs 32.48b to d: Antenatal scan hydronephrosis. Stomach
(s), kidney (k), pelvis (p), calyces(c), right kidney (rk)

Fig. 32.49b: Wilms tumorgross appearance

253

254

An Atlas of Neonatology
Hypertension is rarely observed unlike in older
children. Most of these tumors are sporadic with only
1% being familial.
Neuroblastoma (Fig. 32.50)

Fig. 32.49c: Wilms tumor


Cut section: Hemorrhage necrosis and fleshy appearance
Wilms tumor can be associated with hemi hypertrophy and
aniridia. In bilateral case there is a strong genetic basis.
Small deletions of the short arm of chromosome 11 can
produce. WAGR (Aniridia, Wilms tumor, genital anomalies
and mental retardation)

It is the most common malignant tumor in infants. This


tumor arises from neural crest cells and can originate
anywhere along the sympathetic chain or the adrenal
medulla. In the newborn period adrenal gland is the
commonest (47%). The clinical manifestation depends
on the site of primary tumor and the extent of
dissemination. Its presentation is different in the
neonatal period. Hepatomegaly (64%) and subcutaneous nodules (32%) form the commonest mode of
presentation and biochemical tests include measurement off catecholamine metabolites in urine which has
been proposed as a newborn screening method as well.
The majority of neonates have metastasis at the time
of diagnosis however, the sites of metastasis are different
compared to older children (Table 32.19).

Fig. 32.50: Neuroblastoma


Table 32.19: Incidence of metastases
Liver65%
Subcutaneous32%
Bone marrow10%
Lung6%
Spleen6%
Kidney6%
Pancreas6%
Fig. 32.49d: Wilms tumor: Soft tissue shadow on the
right pushing intestine to left

Modified and adapted from: Scheider KM, Becker JM, Krasna


IH. Neonatal neuroblastoma. Pediatrics 1965; 36: 259-366.

Congenital Malformations

255

Fig. 32.51: Chronic myeloid leukaemia (CML)

Miscellaneous Abdominal Tumor (Fig. 32.51)


Some are neoplastic masses can present in the neonatal
period. One such example of CML is shown in the
picture with large spleen.
Anomalies of Extremities
Polydactyly (Figs 32.52a to d)
Polydactyly denotes presence of extra digits. It can be
inherited as an isolated malformation (AD) or as part
of a recognized syndrome. The list of some of the
syndromes associated with polydactyly is given below
Three terms are commonly used in association with
polydactyly.
Radial polydactylyduplication of the thumb
Central polydactylyduplication of the index,
middle and ring fingers
Ulnar polydactylyduplication of little finger
Postaxialsame as ulnar polydactyly
Preaxialduplication of thumb and central digits.
Common

Figs 32.52a and b: Polydactyly. Post-axial polydactyly of


hands and feet with associated skin tag

Uncommon

Carpenter syndrome
Blooms syndrome
Ellis-van Creveld syndrome
Goltz syndrome
Meckel-Gruber syndrome
Conradi-Hnermann syndrome
Trisomy 13
OFD syndrome
Short rib polydactyly syndrome Rubinstein-Taybi syndrome
Polysyndactyly syndrome
SLO syndrome
Partial trisomy 10q syndrome
Trisomy 4 p syndrome
Laurence-Moon-Biedl syndrome
KTW syndrome

Fig. 32.52c: Polydactyly. Note preaxial polydactyly

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An Atlas of Neonatology

Fig. 32.52d: Polydactyly. Note preaxial polydactyly and


associated radial dysplasia

Syndactyly (Figs 32.53a and b)


It is a term used to denote webbing of fingers. Its
incidence is stated to be 1 in 2000. In about half of
the cases, it is bilateral. Twenty percent are familial,
remaining sporadic. In the hand syndactyly between
middle and ring fingers is the commonest type. In the
feet, it commonly involves 2nd and 3rd toes. The
syndromes and other associated anomalies with
syndactyly are given below.
Some terms associated with syndactyly:
1. Incomplete syndactyly: The interconnection does
not extend till the tips.

Fig. 32.53b: Syndactyly. Note associated hypoplastic nails

2. Complete syndactyly: The interconnection extends


till the tips.
3. Simple syndactyly: Only skin and fibrous tissues form
the interconnection
4. Complex syndactyly: Presence of bony union
anywhere between digits
5. Complicated syndactyly: Syndactylies with
disorganized and abnormal neural, muscular,
vascular and bony elements.
6. Acrosyndactyly: Fusion of distal parts of digits with
free proximal parts
7. Polysyndactyly: Polydactyly + syndactyly.
Common syndromes:
Polands syndrome
Apert syndrome

Anomalies associated
CHD
Ectodermal dysplasia
Orodigital anomalies
Oculodigital dysplasia
Skeletal disorders

Congenital Talipes Equinovarus (CTEV)


(Figs 32.54a to d)

Fig. 32.53a: Polysyndactyly

Has five elements (a) Equinus at the ankle (plantar


flexion), (b) Varus of the sub-talar joint (medial
rotation) (c) Adduction of the fore feet (d) Cavus
deformity with heightened arch, and (e) in some cases
internal rotation of the tibia. It may be unilateral or
bilateral. In bilateral cases spine must be examined
for meningocele. CTEV can occur as an isolated

Congenital Malformations

257

Fig. 32.54c: Congenital talipes equinovarus in a case of


whistling face syndrome

Fig. 32.54a: Congenital talipes equinovarus

Fig. 32.54b: Congenital talipes equinovarus in a case of


Larsen syndrome

Fig. 32.54d: Congenital talipes equinovarus in a case of


Schwartz-Jampel syndrome. Note inguinal hernias, bilateral
equinovarus, micropenis and narrow palpebral fissures

258

An Atlas of Neonatology

deformation due to uterine constraints in oligohydramnios or may be a part of various sequences and
syndromes like meningomyelocele, Pena-Shokeir
syndrome, arthrogryposis multiplexa congenita (Table
32.20).
Incidence
1. One case per 1000 live births.
2. More common in males (2:1 is the male: female
ratio).
3. 50% of cases will have bilateral involvement.
Risk for next sibling is 3%

Fig. 32.56: Hammer toe

Table 32.20: Syndromes featuring CTEV


Amyoplasia congenita disruptiva sequence,
Diastrophic dwarfism,
Distal arthrogryposis,
Escobar syndrome,
Femoral hypoplasia, unusual facies syndrome,
Freeman Sheldon syndrome,
Larsen syndrome,
Meckel Gruber syndrome,
Triploidy syndrome,
Pena Shokeir syndrome,
Zellweger syndrome,
4p, 9p, 13q, 18q delition syndromes.

Rocker Bottom Foot (Fig. 32.55)


This defect is characterised by a prominent heel with
a convex sole seen in trisomy 18, 18q- syndrome and
COFS syndrome. It is due to a prominent calceneus.

HAMMER TOE (Fig. 32.56)


Hammer toe results from flexion deformity at the
proximal interphalangeal joint and extension at
metatarsophalangeal joint. It is usually bilaterally
symmetrical and most commonly involves 2nd toe.
Arthrogryposis Multiplexa Congenita (AMC)
(Figs 32.57a to c)
In this condition multiple joint contractures are present
at birth. It is the consequence of neurologic, muscular
contraction and skeletal abnormalities or due to
intrauterine crowding (Table 32.21).
Table 32.21: Conditions that cause AMC
Congenital myasthenia gravis
Congenital neuropathy
Amyoplasia
Congenital muscular dystrophy
Congenital myotonic dystrophy
Various congenital myopathies
Disorder of brain development
Disorder of development
Disorders of developing medulla

Developmental Dysplasia of Hip (Fig. 32.58)

Fig. 32.55: Rocker bottom foot seen in Trisomy 18 and


other syndromes

This condition describes abnormal relationship between


femoral hand and acetabulum. It includes dislocation,
partial dislocation, instability and many radiographic
abnormalities of development of acetabulum. It is very
important to detect a dislocated hip early in life as the
treatment is more simple and effective.

Congenital Malformations

259

Fig. 32.57c: Distal arthrogryposis

Fig. 32.57a: Distal arthrogryposis distal congenital contractures clenched hands with medial; overlapping of fingers
at birth

Fig. 32.58: Congenital dislocation of hip

Examination to Detect Hip Instability

Fig. 32.57b: Arthrogryposis multiplex congenita

The newborn should be relaxed and must be placed


on a firm surface. Inspect for limb length discrepancy,
asymmetrical thigh or gluteal folds and restricted
movements.
The Ortolani test: this detects the sensation of
dislocated hip reducing
Newborn supine
Examiners index and middle fingers along greater
trochanter and thumb, along inner thigh.

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An Atlas of Neonatology
Table 32.22: Types of albinism

Type

Other features

Inheritance

Tyrosinase negative oculocutaneous


Tyrosinase positive oculocutaneous
Yellow mutant
Ocular
Hermansky-Pudlak syndrome
Chdiak-Higashi syndrome
Cross syndrome

Bleeding diathesis
Neutropenia, increased infections
Ocular anomalies, spasticity and retardation

A.R.
A.R.
A.R.
X.L.R.
A.R.
A.R.
A.R.

Flex hip to 90o


Abduct the hip while lifting the bone anteriorly
Clunk is felt if dislocated head reduces into the
acetabulum.
The Barlows test: This detects whether hip is dislocatable
or not.
Newborn supine, hip flexed to 90o
Abduct the leg, while exerting posteriorly directed
pressure on knee
A palpable clunk is felt if femoral head dislocates.
Albinism (Figs 32.59a to e)
Albinism is a condition comprising a variety of clinical
syndromes with a hereditary defect in the metabolism
of melanin that results in congenital hypopigmentation
of the skin, hair and eyes (oculocutaneous albinism) or
primarily limited to the eyes (ocular albinism). All forms
of albinism will have ocular abnormalities which include
foveal hypoplasia, nystagmus, and decreased visual
acuity. The different types and their inheritance are
summarized in Table 32.22.

Fig. 32.59a: Oculocutaneous albinism in a newborn

Fig. 32.59b: Brown albin

Fig. 32.59c: Oculocutaneous albinism

Congenital Malformations

261

Fig. 32.60: Harlequin baby with its twin

Harlequin Syndrome (Fig. 32.60)


Fig. 32.59d: Albin mother and her child

Fig. 32.59e: Albin children with normal parents

Harlequin syndrome is a lethal form of congenital


icthyosis inherited as an autosomal recessive trait,
characterized by massive over-growth of keratin layers
of skin resulting in parchment like skin and clown-like
appearance (hence the name Harlequin fetus).
The mouth has severe eclabion with a fixed O
shaped fish mouth deformity. The nose is tiny, eyes
protuberant and micrognathia.
Extremities show fixed flexion deformities with
shorten hands and feet. Intrauterine diagnosis is done
by fetal skin biopsy and fetoembryoscopy. In few
instances, midtrimester ultrasound diagnosis has been
made by noting flexion contractures of limb and limited
movements. Fixed open mouth micrognathia and
IUGR and snow flake appearance of amniotic fluid are
prenatal, US findings.
After birth, affected neonates die of respiratory
difficulty, poor suking and skin infection.
The basic defect is an abnormality of lamellar
granules, which have an important role in
desquamation. This syndrome represents several
genotypes with similar clinical manifestations and one
type has the gene on chromosome 11.
Most affected newborns are still born or die in days
or weeks but occasional survival beyond infancy is

262

An Atlas of Neonatology

reported, where skin lesions become less prominent and


are converted to ichthysioform erythroderma.
Collodion Baby (Figs 32.61a and b)
The term Collodion baby designates a rare
dermatologic abnormality of the newborn in which the
body appears to be covered with generalized glistening,
taut, yellowish film termed collodion membrane. This
condition is not a separate disease entity in itself, but
represents a precursor of a disorder of epidermal
development in the majority of cases. These babies look
alike at birth, but later take different clinical courses.
The membrane distorts their facial features and causes
pseudocontracture of the digits. Most of them evolve
into different types of congenital ichthyosis, but about
10% heal spontaneously within the first few weeks, in
which case the term self-healing collodion baby is used.
But it is usually not possible clinically to establish the
diagnosis in the immediate neonatal period and predict
the outcome. In general, the collodion membrane

dessicates, fissures around the joints and is usually shed


within 1-4 weeks. Thus ,clinically only observation over
few weeks will reveal the ultimate fate of the skin.
The collodion membrane is associated with impaired
epidermal barrier function resulting in increased
transepidermal heat and water loss. As a result,
hypothermia, dehydration, hypernatremia, renal failure
are consequent problems. Hyperpyrexia can also
develop if ambient temperature is high. Eroded and
fissured membrane is more prone for infection and
bacterial sepsis is a constant threat. Renal failure and
sepsis are two common causes of death in the neonatal
period. Thus good supportive management till the
condition takes its final shape assumes greater
importance in the neonatal period. Babies should be
nursed in humidified incubators to maintain euthermia
and hydration. Electrolyte levels should be monitored
regularly, specifically looking for hypernatremia. Skin
care includes aseptic handling and application of
emollient like soft paraffin. The long term out look
depends on which types of ichthyosis develops.
Milroy Disease (Fig. 32.62)
It is an autosomal dominant disorder characterized by
lymphatic edema over dorsum of feet and extending

Fig. 32.61a: Collodion baby

Fig. 32.61b: Collodion baby. Note Collodion like skin


abnormal skin usually peels off to give good recovery limited
joint movement

Fig. 32.62: Milroys disease with Lymphedema


extending to genitalia

Congenital Malformations
upto knee. Occasionally seen in upper limbs and over
genitalia as in the figure. Initially it may be slightly
pitting but later it hardens.
Lymphatic edema may be seen over lower limbs in
Turners syndrome, Noonan syndrome and in
congenital lymphangiectasis. In congenital lymphangiectasis these may be lymphangiectasis in intestine causing
protein lossing enteropathy, in renal system causing
chyluria and in lungs causing chylothorax, etc.

263

Fig. 32.64a: Hypothyroidism. A neonate with


hypothyroidism same child after treatment

HAMARTOMATUS NEVI (FIG. 32.63)


The term hamartoma refers to an excessive but focal
overgrowth of cells and tissues native to the organ in
which it occurs. The cells are mature in nature. They
can occur in any tissue, anywhere in the body. They
can be thought of as a link between malformations and
neoplasms. But they are always benign.

Fig. 32.64b: Hypothyroidism

Fig. 32.63: Nevus hamartomatus

Those hamartomas arising from the skin are


responsible for hamartomus nevi and contains blood
vessels, lymphatics and skin cells that are native to the
organ. They are more common in infancy probably
representing developmental aberration.
Hypothyroidism (Figs 32.64a to c)
Classic clinical features of congenital hypothyroidism are
usually absent at birth and appear gradually over first
few weeks, with most features becoming apparent at
about 6 weeks. Nevertheless presence of these features
in the neonatal period should alert the physician to

Fig. 32.64c: Hypothyroidism. Note absence of upper tibial


and lower femoral ossification center

264

An Atlas of Neonatology

suspect hypothyroid state, especially in our country


where routine screening is not in practice. Other classic
features develop in the following weeks. Also given
below are the features and causes (Table 32.23).
Macrosomia (>4 kg)
Wide anterior and posterior fontanels (> 0.5 cm)
Prolonged physiologic jaundice
Feeding difficulties
Hypoactivity
Hypotonia
Hypothermia with mottle skin in the extremities
Respiratory distress
Periorbital cyanosis
Somnolence

Fig. 32.65: Epidermolysis bullosa litialis in an older child

Table 32.23: Etiology of congenital hypothyroidism


Permanent hypothyroidism
Due to thyroid abnormalities (primary hypothyroidism)
Developmental defects
Thyroid agenesis/dysgenesis
Thyroid hypoplasia
Ectopic thyroid
Dyshormonogenesis (inborn errors of thyroid
hormone biosynthesis)
Due to extrathyroidal abnormalities
Hypothalamopituitary abnormalities (secondary or
tertiary hypothyroidism)
Peripheral resistance to thyroid hormones
General
Isolated pituitary
Extrapituitary
Transient neonatal hypothyroidism
Transient hypothyroxinemia
Transient primary hypothyroidism
Transient hyperthyrotropinemia
Low T3 syndrome
Iodine deficiency
Adapted from: Dattani M et al. Current Opinion in Pediatrics
1996;8:389-393
Fig. 32.66: Congenital absence of ribs

Epidermolysis Bullosa (Fig. 32.65)


This is a heterogenous group of heritable blistering
conditions. The various forms are shown in the text box.

CONGENITAL ABSENCE OF RIBS


(FIG. 32.66)
Congenital absence of ribs results due to an arrest of
normal development. It may occur as an isolated

Nonscarring
- EB simplex (AD inheritance)
- Junctional EB (AR inheritance)
Scarring
- Dominant dystrophic EB (AD inheritance)
- Recessive dystrophic EB (AR inheritance)

Congenital Malformations
anomaly or may be associated with the following
syndromes:
Ring chromosome-13
Tetrasomy-9P
Monosomy-20P
Deletion of long arm of chromosome-1
Congenital CMV infection
Cleidocranial dysostosis
Acrofacial dysostosis.

BIBLIOGRAPHY
1. American Academy of Pediatrics Committee on quality
improvement. Clinical practice guideline: Early detection
of developmental dysplasia of the nip pediatrics 2000 ;
105: 986.
2. Cancer 1981; 48: 217.
3. Frieden IJ. Aplasia cutis congenita: A clinical review and
proposal for classification. J Am Acad Dermatol 1986; 14:
646-60.
4. Golden CB, Feusner JH. Malignant abdominal masses in
children: Quick guide to evaluation and diagnosis. Pediatr
Clin N Am 2002; 49: 1369-92.
5. J Pediatr Surge 1974; 9: 391.
6. Kays DW. Surgical condition of the neonatal intestinal tract.
Clin Perinatol 1996; 23: 353-75.
7. Kulkarni ML, Mathew A. Neural tube closure. Indian
Pediatr 1996; 33: 872-74.
8. Kulkarni ML, et al. Limb body wall complexia case report
and review of literature. Perinatology 2003; 5: 91-94.
9. Kulkarni ML, Mathew Kurian. Consanguinity and its effect
on foetal growth and development. J Med Genet 1990;
27: 348-52.

265

10. Kulkarni ML, Mathew MA, Ramachandran B. High


incidence of neural tube defects in South India. Lancet
1987; 1: 1-60.
11. Kulkarni ML, Mathew MA, Reddy V. The range of neural
tube defects in Southern India. Arch Dis Child 1989; 61:
201-04.
12. Kulkarni ML, Naseer A. Otocephaly. Annals of Dentistry
1995; 54 (1-2): 50-52.
13. Kulkarni ML, Singh R. Normal variants of skin in neonates.
Ind J Dermat Venerol Leprol 1996; 62: 83-86
14. Kulkarni ML, Sureshkumar C. Prenatal diagnosis of NTD.
Indian Practitioner 1992 XIV (12): 1033-36.
15. Kulkarni ML, Sureshkumar C. Prenatal diagnosis of NTD.
Pediatric Clinics of India 1993; 28 (4).
16. Kulkarni ML, Venkataramana V, Sureshkumar C.
Syndromic and isolated cryptophthalmos. Indian Pediatr
1995; 32: 1112-15
17. Kulkarni ML. Congenital malformations. The Indian
Practitioner 1994; XLVIII: 137-42.
18. Kulkarni ML. Congenital malformations. Editorial Indian
Pediatr 1989; 26:5-10.
19. Meller JL, Reyes HM, Loeff DS. Gastroschisis and
omphalocele. Clin Perinatol 1989 ; 16: 113-22.
20. Nakayama DK, et al. The pathogenesis of prune belly. Am
J Dis Child 1984; 138: 834-36.
21. Scheider KM, Becker JM, Krasna IH. Neonatal neuroblastoma. Pediatrics 1965; 36: 259-66.
22. Tapper D, Lack EE. Teratomas in infancy and childhood.
A 54 years experience at the childrens hospital medical
center. Ann Surge 1983; 198: 398-409.
23. Wilcox DT et al. Prenatal diagnosis of congenital
diaphragmatic hernia with predictors of mortality. Clin
Perinatol 1996; 23: 701-09.

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33

Genetic Syndromes

INTRODUCTION
Approximately 1% newborns have multiple anomalies
or syndrome. Only 40% of them have recognizable
syndrome and remaining need further evaluation. The
word syndrome means, running together (Greek) and
clinically indicates a constellation of malformations
thought to be pathogenetically related (Tables 33.1 to
33.6).
Table 33.1: Malformation syndromes following
autosomal recessive inheritance
Bardet-Biedl syndrome
Camptomelic dysplasia
Cerebrooculofacio-skeletal (Pena-Shokeir) syndrome (some
families)
Chondrodysplasia punctata (rhizomelic type)
Cockayne syndrome
Cohen syndrome
Cryptophthalmos (Fraser) syndrome
Dubowitz syndrome
Ellis-van Creveld syndrome
Fryns syndrome
Holoprosencephaly (some families)
Hydrolethalus syndrome
Johanson-Blizzard syndrome
Leprechaunism
Marden-Walker syndrome
Meckel syndrome
Mohr syndrome (orofaciodigital syndrome type II)
Multiple pterygium syndrome
Neu-Laxova syndrome
Popliteal pterygium syndrome (lethal)
Roberts syndrome
Seckel syndrome (bird-headed dwarfism)
Smith-Lemli-Opitz syndrome
Werner syndrome

Clinical Approach to a Dysmorphic Child


The clinical approach begins with a careful history. A
proper pedigree chart of at least three generations
should be constructed. Maternal and antenatal histories
must be carefully reviewed. Following tables give a
deeper and a better understanding of the importance
of these aspects.
Table 33.2: Malformation syndromes following
autosomal dominant inheritance

Beckwith-Wiedemann syndrome (some families)


EEC syndrome (ectodactyly-ectodermal dysplasia-clefting)
Freeman-Sheldon (whistling face) syndrome
Holt-Oram syndrome
Leopard syndrome
Mandibulofacial dysostosis (Treacher Collins syndrome)
Melnick-Needles syndrome (osteodysplasty)
Nail-patella syndrome
Noonan syndrome (some families)
Robinows (fetal face) syndrome
Stickler syndrome

Table 33.3: Malformation syndromes following


X-linked inheritance
Aarskog syndrome (faciogenital dysplasia)
Coffin-Lowry syndrome
Corpus callosum agenesis with retinal defects (Aicardi
syndrome) (dominant, lethal in male)
Ectodemral dysplasia, hypohidrotic
FG syndrome
Focal dermal hypoplasia (dominant, lethal in male)
Lenz microphthalmos syndrome
Orofaciodigital syndrome, type I
Otopalatodigital syndrome

Genetic Syndromes 267


Table 33.4: Malformation syndromes in which
recurrence in sibs is rare

Amniotic bands syndrome


Goldenhar syndrome
Hemifacial microsomia
Klippel-Feil syndrome
Klippel-Trenaunay-Weber syndrome
McCune-Albright (fibrous dysplasia) syndrome
Polands syndrome
Rubinstein-Taybi syndrome
Russell-Silver syndrome
Sacral agenesis (caudal regression syndrome)
Sturge-Weber syndrome
Weaver syndrome

Table 33.5: Importance of maternal and antenatal history


Elderly motherchromosomal aneuploidy, e.g. Down
syndrome
Elderly fathernew autosomal dominant mutation, e.g.
achondroplasia, Marfans syndrome
Maternal diabetescaudal regression syndrome
Maternal drugsfetal alcohol, valproate, and hydantion
syndromes
Parental consanguinityautosomal recessive disorders
Racial origine.g. Ellis-van Creveld syndrome in the Anish
Familial occurrencesingle gene, polygenic, and
chromosomal disorders
Early rupture of membranefetal deformation and
disruption
OligohydramniosRenal agenesis, outflow obstruction
Polyhydramniosesophageal atresia, anencephaly, and
neuromuscular disorders.
Poor fetal movementsfetal compression, neuromuscular
disorder
Breech presentationneuromuscular disorder

Physical Recognition of Syndromes


After meticulously reviewing the history, syndrome
delineation is usually attempted by two means:
a. Gestalt recognitionHere the individual syndrome
can be easily organized into a meaningful problem
without consciously analysis the individual
abnormalities, e.g. Down syndrome.
b. By identifying suitable handles: When immediate
recognition is not possible, it is necessary to identify
one or more features (handles) which might lead
to syndrome diagnosis. Certain useful handles are
shown below.
Mental retardation, simian crease, clinodactyly are
nonspecific and are poor handles. Once suitable handles
are identified, syndrome delineation can be attempted
by using monograms on syndromes, e.g. KL Jones,
1997 Smiths recognizable patterns of Malformation
W.B Saunders, Philadelphia; or computer databases,
e.g. London Dysmorphology Database and London
Neurogenetic Database published by Oxford University
Press, Walton street. Oxford Ox2 6DP UK; or Possum
syndrome and skeletal dysplasia database. Murdoch
Institute, Royal Children Hospital. Flemington Road,
Parkville Victoria 3053, Australia.

FURTHER READING
1. The London Dysmorphology Database.
2. Birth Defects Information Services.
3. POSSUMAn Illustrated Database with Clinical
Photographs on Videodisk.

Table 33.6: Useful handles for syndrome identification


Head
Abnormal hair patter
Scalp defects
Craniosynostosis
Encephalocele

Mouth
Cleft lip/palate
Teeth abnormalities

Eyes

Genitalia
Micropenis

Coloboma
Small/absent eyes
Cataract

Digits
Syn/polydactyly
Arachnodactyly
Brachydactyly

Skin
White patch
Pigmented patch

Limbs
Absence
Webbing
Dwarf

Ears
Deafness
Malformed
Preauricular tag

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CHROMOSOMAL ABNORMALITY
Trisomy 21 (Downs syndrome) (Figs 33.1a1-9)
It is the commonest chromosomal disorder occurring
once in 700 births, characterized mainly by mental
retardation and characteristic facial and other abnormalities. Characteristic facial features viz. microbrachycephaly, upslanting palpebral fissures, small malformed
ears, lax skin at neck, alopecia, small hands and fingers,
clinodactyly of little fingers, simian crease, wide gap
between first and second toes and plantar crease
between first and second toes, cardiac defect in 40%
(endocardial cushion defects), relatively small penis in
boys and bulbous vulva in females, cataract, duodenal
atresia and anal atresia, hyperbilirubinemia, transient
leukemoid reaction and leukemia are some of the
features in newborns (Tables 33.7 to 33.9).
Identification of Downs syndrome in neonatal
period is rather difficult but following features help in
recognizing the syndrome: 1) hypotonia 2) poor Moros
reflex 3) hyperflexibility of joints 4) excess skin over
back of neck 5) flat facial profile 6) slanted palpebral

Fig. 33.1a(2): Downs syndrome

Fig. 33.1a(3): Downs syndrome. Downs syndrome in newborn brachymicrocephaly, flat face, upslant eyes, protruding
tongue, thin sparse hair

Fig. 33.1a(1): Downs syndrome. Note brachycephaly


upslanting eyes, narrow palpebral fissure, small nose, small
ears and cutis marmorata

Fig. 33.1a(4): Downs syndrome. Flat facial


profile, frontal alopecia

Genetic Syndromes 269

Fig. 33.1a(5): Downs syndrome. Flat facial profile depressed


nasal bridge-small mouth, protruding tongue and cutis
marmorata loose fold of skin in the neck, medial epicanthal
fold is obvious

Fig. 33.1a(6): Downs syndrome: Note big space


between 1st and 2nd toes

Fig. 33.1a(7): Downs syndrome protruding tongue


showing glossitis

Fig. 33.1a(8): Downs syndrome. Elderly


mother with a newborn baby

Fig. 33.1a(9): Downs syndrome. Loose skin fold

fissures 7) anomalous auricles 8) dysplasia of pelvis


9) dysplasia of middle phalanx of fifth finger and simian
crease.
Downs syndrome occurs once in 700 births and is
due to trisomy of 21 in 95% of cases and due to
translocation between chromosome 21 and 14 in 4%
of cases and due to mosaicism in 1% (i.e. body is a
mixture of normal and 21 trisomic cells) the risk of
Downs syndrome goes on increasing with increasing
maternal age from 1:1500 at 15-30 years to 1: 270
at 35-40 years. Other risk figures are listed below.
Prenatal screening is done by maternal serum triple test
and is confirmed by CVS at 8-11 weeks of gestation.

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An Atlas of Neonatology
Table 33.7: Risk figures in Downs syndrome
Risk

After one trisomic child (mother


aged under 37 years)
If mother aged over 37 years

1%
Double maternal
age risk
Mother is a 14/21 translocation carrier
10%
Father is 14/21 translocation carrier
2%
One parent a 21/21 translocation carrier 100%
Table 33.8: Surveillance for early detection
of problems in Downs syndrome children

At birth

Within
first year
Every year

Clinical examination and if necessary investigations for tracheo-oesophageal fistula,


duodenal obstruction and anal atresia.
Eye examination for cataract.
Chromosomal analysis
If translocation trisomy 21 is found, chromosome analysis of parents.
Thyroid stimulating hormone
Echocardiogram (within first week) clinical
examination and if necessary, investigations for
tracheo-oesophageal fistula, duodenal obstruction and anal atresia
Thyroid function tests (TSH1 T4)
Haemoglobin, serum iron
Hearing evaluation
Eye examination for squint, refraction, cataract
Haemoglobin, serum iron
Thyroid function test
Non-fasting lipids
Auditory assessment
Eye examination
Development assessment, physiotherapy and
if needed speech therapy

Fig. 33.1b(1): Trisomy-13 low hair line, overlapping fingers,


polydactyly, abnormal ears, mental retardation in survivors

Table 33.9: Recurrence risk for translocation Downs


syndrome
Type
of
translocation

Risk of recurrence
Carrier mother
Carrier father

14q;21q
21q;22q
21q;21q

15%
15%
100%

5%
5%
100%

Trisomy 13 (Patau syndrome) (Figs 33.1b1-8)


Trisomy 13 occurs 1 in 20,000 births. The clinical
features include midline cleft lip/palate, polydactyly,
narrow hyper convex finger nails, broad flat nose,
malformed ears, small head, abnormal brain

Fig. 33.1b(2): Trisomy 13. Note scalp defect

(holoprosencephaly like defects), Microphthalmia,


congenital heart diseases, genitourinary anomalies,
hemangiomas over forehead, and scalp defects. The
condition is lethal in first few months of life.

Genetic Syndromes 271

Fig. 33.1b(3): Trisomy 13. Note midline cleft palate


Fig. 33.1b(6): Trisomy 13. With midline cleft lip and
palate with genital abnormality cryptorchidism

Fig. 33.1b(4): Trisomy 13. Note polydactyly with


overlapping fingers

Fig. 33.1b(7): Trisomy 13. Narrow palpebral fissure,


long philtrum, thin upper lip

Fig. 33.1b(5): Trisomy 13. Note scalp defects

Fig. 33.1b(8): Trisomy 13. Narrow palpebral fissure, thin


upper lip, long philtrum

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An Atlas of Neonatology

Trisomy 18 (Edwards syndrome) (Figs 33.1c1-6)


This occurs once in 8,000 births and is characterized
by growth retardation, prominent occiput, clenched
hands (overlapping of index finger over 3rd, and 5th
finger over 4th), small pelvis with limited abduction of
hips, rocker bottom feet, microcephaly, micrognathia,
short sternum, cardiac defects (PDA, VSD and PS),
renal malformations, severe mental retardation, and is
mostly lethal in first year of life.

Fig. 33.1c(3): Edwards syndrome. Prominent occiput,


low set ears, small chin

Fig. 33.1c(1): Edwards syndrome.


Note rocker bottom foot

Fig. 33.1c(4): Edwards syndrome. Note small chin, low


set ears, short palpebral fissure

Fig. 33.1c(2): Edwards syndrome. Small chin low set ears,


prominent occiput, short palpebral fissure, short sternum
narrow pelvis, overlapping fingers, baby had congenital heart
disease, note growth retardation, note contractures at
multiple joints especially at hips

Fig. 33.1c(5): Edwards syndrome. Showing characteristic


clenched hand with overlapping of ring finger by little finger
and middle finger by index finger

Genetic Syndromes 273

Fig. 33.1d(2): Turners syndrome. With fluid collection in


neck in fetus

Fig. 33.1c (6): Edwards syndrome. Small chin, low set ears,
short palpebral fissure, short-sternum overlapping fingers.
Other features include cardia, renal, cryptorchidism and
severe MR

Turners Syndrome (Figs 33.1d1-6)


This is a syndrome of short stature and gonadal
dysgenesis in a phenotypic female due to either absence
of one X-chromosome (50%) or due to structural
abnormality of one of the X-chromosomes (50%). The
Fig. 33.1d(3): Turners syndrome. With congenital
lymphedema, hypoplastic nails. Other features include short
stature, shield chest, COA, horse-shoe kidney, low hair line,
webbing of neck

Fig. 33.1d(1): Turners syndrome.


Note bilateral cystic hygromas in a fetus

Fig. 33.1d(4): Turners syndrome. Loose skin over neck


(webbing)

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An Atlas of Neonatology

Fig. 33.1d(5): Turners syndrome. Short stature,


congenital lymphedema

Fig. 33.1e(1): Wilms tumor gross appearance

Fig. 33.1d(6): Another case of Turners syndrome,


congenital lymphedema of dorsum of feet

incidence is one in 2,000 live females. The presentation


in neonatal period include small size, lymphedema over
hands and feet, cystic hygroma or, lax skin at the neck
(web), short neck, posterior hair line, broad chest with
widely-placed nipples, prominent ears, horse-shoe
kidneys, cardiac defects (bicuspid aortic valve, COA) etc.
Congenital edema disappears in infancy.
Aniridia Wilms (WAGR syndrome) Wilms
Tumor, Aniridia, Genital Abnormalities,
Retardation Mental (Figs 33.1e1-5)
There is an association between aniridia and Wilms
tumor. About 80% of Wilms tumor will have aniridia

Fig. 33.1e(2): Wilms tumor. Soft tissue shadow on the


right pushing intestine to left

and 20% of children with aniridia will develop Wilms


tumor (Friedman 1980). Anterior cataract is common
in aniridia. All children with aniridia should have abdominal palpation by mother and ultrasound examination
frequently till 5 yrs of age and less frequently later.
Interstitial chromosomal deletion involving band 11 p
13 is responsible for this syndrome. WAGR syndrome
includes ambiguous genitalia and mental retardation in
addition to aniridia and Wilms tumor. The disorder is
due to microdeletion of chromosome 11 and the gene
involved is PAX6WT1. Other related syndromes are
listed in Table 33.10.

Genetic Syndromes 275


Table 33.10: Syndromes related to the WT1 and WT2 loci
Syndrome

Locus

Genetic lesion

Phenotype

Wilms tumor risk

WAGR

11p13

Deletion of WT1 gene

Aniridia, genitourinary anomalies,


delayed-onset renal failure

30%

Denys-Drash

11p13

Point mutation in zincfinger region of WT1 gene

Ambiguous genitalia, diffuse


mesangial sclerosis

90%

Fraser

11p13

Point mutation in WT1


intro 9 donor splice site

Ambiguous genitalia, streak gonads,


focal segmental glomerulosclerosis

Low, but several


cases reported

BeckwithWiedemann

11p15

Precise genetic lesion unclear;


loss of imprinting of several
genes including IGF2, H19m
and p57kip2 implicated

Organomegaly, large birth weight,


macroglossia, omphalocele,
hemihypertophy, ear pits and
creases, neonatal hypoglycemia

5%

Fig. 33.1e(4): Wilms tumor cut section hemorrhage necrosis


and fleshy appearance Wilms tumor can be associated with
hemihypertrophy and aniridia. In bilateral case there is a
strong genetic basis. Small deletions of the short arm of
chromosome level can produce WAGR (aniridia, Wilms
tumor, genital anomalies and mental retardation)

Fig. 33.1e(3): Wilms tumor child

Cat Cry Syndrome/Cri du Chat Syndrome


(Fig. 33.1f)
It is a syndrome that results from deletion of tip of the
short arm of chromosome 5. The characteristic features
include primordial growth deficiency, cat like cry in early
infancy, microcephaly, with round flat face. The
characteristic high-toned, weak cry is found in 100%
of cases, and is due to abnormal laryngeal development. The cat like cry becomes less evident with age.

Fig. 33.1e(5): Beckwith-Wiedemann syndrome. Examphalos


upper abdominal distention due to liver enlargement ear
grooves

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An Atlas of Neonatology

Fig. 33.1f: Cat cry syndrome. Mental retardation, cats like cry evident in infancy disappears in older child.
Note round flat face, hypertelorism

Deletion 9P Syndrome (Figs 33.1g1 and 2)


This syndrome results due to deletion of the distal
portion of the short arm of chromosome 9. The
characteristic shape of head results from premature
closure of metopic suture causing trigonocephaly. Other
features include, upslanting of palpebral fissure,
epicanthal folds, prominent eyes, arched eyebrows,
midfacial hypoplasia, short nose with anteverted nares
and long philtrum.

Fig. 33.1g(2): Deletion 9P syndrome. Craniostenosis


involving metopic sutures lead to trigonocephaly this was a
case of 9 p minus syndrome. It can also be seen in 11q
minus and 13 q minus syndromes

Duplication 10 q Syndrome (Figs 33.1h,i)

Fig. 33.1g(1): Deletion 9P syndrome. Note Trigonocephaly


due to premature fusion of metopic suture

Ptosis and short palpebral fissures, camptodactyly and


severe mental retardation are the important features of
this syndrome. It results from Trisomy of distal segment
of the long arm of chromosome 10 (10q 24 q ter).

Genetic Syndromes 277

Fig. 33.1h: Duplication 10 q syndrome. Note ptosis and short


palpebral fissures. Other features include camptodactyly and
severe mental retardation

Fig. 33.2a: Brachmann-de Lange syndrome. Note hairy


forehead, hairy ears, micrognathia, short and anteverted
nostrils, long and thin upper lips

from proximally placed thumb to absence and


ectrodactyly. Inguinal and umbilical hernias and
diaphragmatic hernia are common.
Gastrointestinal, renal, and genitourinary malformations occur more frequently. Inheritance is uncertain
probable location is 3q 26; 17q 23. Prenatal diagnosis
is possible by ultrasound demonstration of micromelia
commonly associated with diaphragmatic hernia and
reduced levels of PAPA in mothers serum in second
trimester. Neonates may have puffy eyes that disappear
after 1 week and eye features become prominent in
early childhood.
Russell-Silver Syndromes (Fig. 33.2b)

Fig. 33.1i: Normal karyogram

GROWTH RESTRICTION
Brachmann-de Lange Syndrome (Fig. 33.2a)
The characteristic features of this syndrome include
mental retardation, low birth weight, microcephaly,
short stature, generalized hirsutism, resulting in
synophrys, microphthalmia, a hairy forehead, hairy
ears, marked hair whorls on posterior trunk and arm
and micrognathia. The nose is short, nostrils anteverted
and flares, philtrum is long and upper lip is thin with
a midline breach. Feeding difficulties, irritability, a deep
horse cry and increased tone in limbs are early
problems. Upper limb defects are common and vary

Typical facies, short stature at birth, and asymmetry of


the limbs are main features of this syndrome. Head is
relatively big (pseudohydrocephalus). Face is small and
triangular with frontal bossing. Mouth is small with thin
lips and down turned corners, Prominent ears, simian
crease, clinodactyly wide anterior fontanelle, caf au lait
spots and teeth anomalies are other features. Excessive
sweating, syndactyly between the second and third toe,
hypoglycemia, delayed bone age, genital abnormalities
are minor anomalies associated. In most cases
intelligence is normal. Most cases are sporadic: however,
autosomal dominant inheritance, chromosomal
anomalies and uniparental disomy have been
suggested.

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An Atlas of Neonatology

Fig. 33.2c(1): Johnson-Blizzard syndrome.


Note multiple caf au lait spots

Fig. 33.2c(2): Johnson-Blizzard syndrome. Note mildmicrocephaly, hypoplastic alae nasi, scalp defect, sparse hair,
frontal upsweep. Other features include hypothyroidism
pancreatic insufficiency and deafness, inherited as AR trait

Fig. 33.2b: Russell-Silver syndrome. Relatively-large head,


frontal bossing, triangular face, thin upper lip, sharp corners
of mouth, simian crease and clinodactyly, growth restriction
at birth skeletal asymmetry, syndactyly of second and third toes

Johnson-Blizzard Syndrome (Figs 33.2c1-2)


The prominent features are short stature of prenatal
onset, microcephaly, hypoplastic alae nasi and mid-line
scalp defects. The hair growth is unusual and is often

spiky. Mental retardation is a usual feature but often


mild. Thyroid deficiency, sensorineural deafness and
exocrine pancreatic deficiency lead to physical and
mental slowness. Congenital heart defects and genitourinary abnormalities may be associated. Antimongoloid
slant and caf au lait spots are other abnormalities.
Hallermann-Streiff Syndrome (Fig. 33.2d)
Frontal prominence thin pointed nose, small chin are
suggestive of this syndrome especially in presence of
microphthalmia and cataract. Nose and chin problems
can cause respiratory and feeding problems in neonatal

Genetic Syndromes 279

Fig. 33.2e(2): Smith-Lemli-Optiz syndrome. Note Microcephaly


with narrow frontal area, broad nasal root, long philtrum, and
low set ears, beaky nose
Fig. 33.2d: Hallemann-Streiff syndrome

period. Sparse eyelashes, dental anomalies, hypotrichosis, skin atrophy, short stature and occasional
congenital heart disease are other features.
Poor ossification of skull with the wormian bones,
large fontanelle, thin ribs, long bones and metaphyseal
widening may be seen in neonatal period. Neonatal
teeth may be seen. Small penis, cryptorchidism are
other features. Inheritance is uncertain.
Smith-Lemli-Optiz (SLO) Syndrome Type I
(Figs 33.2e1-5)
Facial features include microcephaly, bitemporal
narrowing with ptosis, anteverted nostril, a broad nasal

Fig. 33.2e(3): Smith-Lemli-Optiz syndrome. Note male


genital abnormality-hypoplastic penis, and scrotum

Fig. 33.2e(1): Smith-Lemli-Optiz syndrome.


Note strabismus

Fig. 33.2e(4): Smith-Lemli-Optiz syndrome.


Note hypoplastic genitals

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An Atlas of Neonatology

Fig. 33.2e(5): Smith-Lemli-Optiz syndrome. Note microcephaly, ptosis, beaky nose, clenched hand, undescended
testis and mild talipes, longish philtrum. Inheritance is
autosomal recessive

tip, and micrognathia. In the hands, index finger


overlaps middle finger and the thumb can be short with
a short first metacarpal. Dorsiflexed big toes, and
syndactyly between second and third toes are common.
In males micropenis and hypoplastic scrotum are seen.
Short thumb, hypotonia, brain defects, seizures and
EEG abnormalities may be evident in newborn.
Inheritance is autosomal recessive.
Prenatal diagnosis is possible by measuring
dehydrocholesterol in amniotic fluids and chorionic
villus sample. Mutation in 7-dehydrocholesterol
reductase gene that converts 7- dehydrocholesterol into
cholesterol is responsible for the defect. The levels of
7-dehydrocholesterol will be high and that of
cholesterol will be low in patients with SLO
syndrome,and in amniotic fluid and CVS of pregnancy
with SLO syndrome.
There is another SLO type which is lethal in
newborns with similar features. Ambiguous genitalia,
postaxial polydactyly in hands, valgus deformity of feet
with syndactyly of several toes is characteristic.

Fig. 33.2f(1): Robinows syndrome. Note frontal bossing


hypertelorism. Prominent eyes long philtrum, small upturned
nose, triangular mouth with down turned angles and
micrognathia. Note gingival hypertrophy

Robinows Syndrome (Figs 33.2f1-6)


Facial features resemble that of fetus with prominent
forehead, hypertelorism, wide mouth, small nose with

Fig. 33.2f(2): Robinows syndrome.


Note mesomelic shortening

Genetic Syndromes 281

Fig. 33.2f(5): Robinows syndrome.


Note hypoplastic nails in toes

Fig. 33.2f(3): Robinows syndrome. Mesomelic shortening

Fig. 33.2f(6): Robinows syndrome. Note gingival


hypertrophy, mesomelic shortening

Fig. 33.2f(4): Robinows syndrome. Note mesomelia of upper


limbs, short and stubby hand, broad thumbs, clinodactyly

anteverted nostril, small chin,and philtrum. They may


have gum hypertrophy, delayed closure of fontanelle.
Mesomelic shortening is usual.
Micropenis, cleft lip/palate, renal anomalies,
hemivertebrae, congenital heart disease, and finger toe
anomalies are the other anomalies commonly noted.
The gene ROPZ is located on long arm of chromosome
9 (9q 22). The inheritance is either autosomal recessive
or autosomal dominant.

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An Atlas of Neonatology

Noonan Syndrome
It is also called Turner like syndrome. The incidence has
been estimated to be between 1 in 1000 and 1 in 2500
live birth. It is characterized by short stature, short neck
lymphedema of neck and feet, pulmonary stenosis,
ASD, micropenis, cryptorchidism, hemivertebra. A
peculiar chest deformity with pectus carinatum
superiorly and pectus excavatum inferiorly is present.
It has to be differentiated from intrauterine exposure
to primidone, fetal alcohol syndrome, Aarskog
syndrome, cardiofacio-cutaneous syndrome, Williams
syndrome, and Costello syndrome. Transmission is
sporadic in majority of cases and occasionally autosomal
dominant.
Seckels Syndrome (Fig. 33.2g)
It is an AR syndrome characterized by growth
deficiency of prenatal onset, microcephaly, receding

forehead, prominent nose, micrognathia, and low set


malformed ears. Males usually have cryptorchidism.
Though these patients survive into adulthood they
suffer from severe mental deficiency.

FETAL OVERGROWTH
Beckwith-Wiedemann Syndrome (Fig. 33.3a)
It is an autosomal dominant metabolic dysplasia
syndrome with variable degree of expression. The main
features are congenital and/or postnatal gigantism,
muscular macroglossia, visceromegaly. Peculiar facies
(mild exophthalmos with relatively small head,
protruding occiput and telangiectatic nevi over the
upper half), and grooved ears. Sometimes omphalocele
or simple umbilical hernia may be observed.
Hemihypertrophy of the body may also be seen in
some. These infants develop problems like
hypoglycemia, polycythemia, feeding and respiratory
problems in the immediate post-natal period. They are
more prone to develop neoplastic tumors later in life.
Development is normal if hypoglycemia is properly
managed in the neonatal period. Differential diagnosis
include IDM, hypothyroidism.
Ref: Wiedemann HR. In Wiedemann HR Kunzej (eds) Clinical
Syndromes, 3rd edn Mosby-Wolfe.

Fig. 33.2g: Seckels syndrome (Bird-headed dwarfism).


Note microcephaly, prominent nose

Fig. 33.3a: Beckwith-Wiedemann. Examphalos, upper


abdominal distention due to liver enlargement, ear grooves

Genetic Syndromes 283


Infant of Diabetic Mother (Figs 33.3b1-5)
Please see chapter 26.

Fig. 33.3b(3): Macrosomia

Fig. 33.3b(1): Macrosomia baby note peculiar facies

Fig. 33.3b(4): Hairy pinna

Fig. 33.3b(2) Infant of diabetic mother. Note macrosomia

Fig. 33.3b(5): Infant of diabetic mother. Note macrosomia.


Also note characteristic hairy pinna

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PRIMARY BRAIN DEFECT


NEUROMUSCULAR
ABNORMALITY
Walker-Warburg Syndrome (Fig. 33.4a)

Menkes Syndrome (Fig. 33.4b)


It is an X-linked recessive neurodegenerative and
connective tissue disorder that results from systemic
copper deficiency as a result of traping of copper in
intestinal mucosa and kidneys. The incidence is

It is a lethal autosomal recessively inherited syndrome


of abnormal development of brain. It is characterized
by Hydrocephalus, Agyria, Retenial displasia. Fifty
percent of cases have associated occipital Encephalocele.
The early death is the rule. Prenatal diagnosis at
20 weeks of gestation can be made based on the
presence of hydrocephalus and encephalocele.

Fig. 33.4a: Walker-Warburg syndrome. Hydrocephalus, agyria


retinal dysplasia with encephalocele, also known HARD
+/- E syndrome acronym stands for Hydrocephalus, Agyria.
RD Retinal dysplasia, E encephalocele

Fig. 33.4b: Menkes syndrome. Sparse stubby (kinky) hair


other features include cerebral degeneration, seizures
tortousity of artery low serum copper, coarse trabeculation
and fragmentation of metaphysis, hairs appear twisted and
fragile when looked under microscope (see above 3
pictures)

Genetic Syndromes 285


estimated to be 1 in 90,000 to about 1 in 2.5 lakhs
live births. The condition presents in the newborn
period or in early infancy. The presentation includes
lethargy, poor feeding, failure to thrive, twitching,
myoclonic seizures and hypothermia. The hair is twisted
and fractured, giving it the name kinky hair disease.
Progressive neurodegeneration occurs in infancy and
death occurs usually by 3 years.
Pena-Shokeir Syndrome (Fig. 33.4c)
Like the term arthrogryposis, Pena-Shokeir syndrome
represents a number of conditions with same phenotype. Multiple ankylosis, pulmonary hypoplasia, facial
anomalies, and polyhydramnios are the common
features. Severe brain spinal cord and muscle abnormalities are noted in this syndrome. Pena-Shokeir with
multiple ankylosis and pulmonary hypoplasia is an
autosomal recessive disorder.
Microcephaly, low birth weight, short stature,
dysplastic ears, hypertelorism, high nasal bridge,
microphthalmia, short neck, kyphosis, camptodactyly,
limited movements at major joints, rocker bottom feet
and lung hypoplasia are usual features.

COFS (Cerebro-oculofacio-skeletal syndrome)


(Fig. 33.4d)
Microcephaly, cataract and joint contractures should
make one think of this syndrome. Many cases die early
and those who survive fail to thrive. Facial appearance
is characteristic, i.e. nasal root is prominent and
forehead slopes sharply backward. Both eyes and jaws
are small. The condition is probably heterogenous.
Intracranial calcification, camptodactyly, rocker bottom
feet, arthrogryposis, hypotonia, mental retardation are
other important features. Some cases of Cockayne
syndrome are wrongly labeled as COFS syndrome.

Fig. 33.4d: COFS (cerebro-oculofacio-skeletal syndrome)

XLRAqueductal Stenosis (Fig. 33.4e)


Fig. 33.4c: Pena-Shokeir syndrome

The features observed in this condition are aqueductal


stenosis, cerebellar abnormalities, absence or hypoplasia

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An Atlas of Neonatology
exophthalmos and syndactyly with subcutaneous
oedema.
Prenatal growth deficiency, absence of corpus
callosum, hypoplastic cerebrum and cerebellum, sloping
forehead, ocular hypertelorism, absent eyelids, flat
nose, micrognathia, large ears and short neck, short
limbs, flexion contractures of limbs are other important
features.
Meckel-Gruber Syndrome (Figs 33.4g1-6)

Fig. 33.4e: XLR aqueductal stenosis. Large cranium, frontal


bossing note short thumb flexed over palms also known as
MASA syndrome (Mental retardation, Adducted thumb,
Shuffling gait and Aphasia)

of corpus callosum, hydrocephalus, Hirschsprungs


disease, absent or hypoplastic thumbs, adducted thumbs
(50%), mental retardation, developmental delay,
spasticity and brisk deep tendon reflexes. The gene has
been identified as L1CAM.

It is an autosomal recessive disorder lethal in neonatal


period characterised by occipital encephalocele associated with microcephaly, hydrocephaly or anencephaly,
anophthalmia or microphthalmia, polymicrogyria, cleft
lip/palate, polycystic kidneys, hepatic fibrosis and cysts,
ambiguous genitalia, congenital heart diseases and post
axial polydactyly. Hepatic and renal disorders are
consistent. Variability in clinical spectrum occurs.
Prenatal diagnosis is possible by ultrasound examination
and by raised serum AFP levels.
Reference: Salnen et al. J Med Genet 1998; 35: 497-501.

Neu-Laxova Syndrome (Fig. 33.4f)


It is an autosomal recessive lethal disorder characterized
by microcephaly, lissencephaly, canine facies with

Fig. 33.4f: Neu-Laxova syndrome

Fig. 33.4g(1): Meckel-Gruber syndrome.


Occipital encephalocele

Genetic Syndromes 287

Fig. 33.4g(4): Meckel-Gruber syndrome-radiograph

Fig. 33.4g(2): Meckel-Gruber syndrome.


Proboscis, cyclopia, abdominal distention

Fig. 33.4g(5): Meckel-Gruber syndrome. Occipital encephalocele with midline cleft, note polydactyly in right hand (pre
axial) other features include cystic kidneys, eye defects,
talipes and inherited as autosomal recessive

Fig. 33.4g(3): Meckel-Gruber syndrome. Note occipital


encephalocele polydactyly and cystic kidneys removed and
placed beside the still polydactyly born baby

Fig. 33.4g(6): Meckel-Gruber syndrome. Note polydactyly,


abdominal distention due to cystic kidneys, facial defects,
talipes (bilateral)

288

An Atlas of Neonatology

Zellweger (Cerebro-hepato-renal) Syndrome


(Figs 33.4h1-3)
Zellwegers syndrome is transmitted as an autosomal
recessive disorder. The typical facial features include
macrocephaly, flat occiput, flat face, high forehead with

Fig. 33.4h(3): Zellwegers syndrome. Note high forehead


expressionless face, micrognathia, shallow supraorbital
ridge other features include hypotonia, hepatomegaly, renal
cyst AR inheritance wide ant fontanel, note sometimes
syndrome mistaken for Downs syndrome

Fig. 33.4h(1): Zellwegers syndrome. Zellweger syndrome


high forehead, expressionless face, micrognathia shallow
supraorbital ridge, other features include hypotonia
hepatomegaly, renal cyst AR inheritance wide ant fontanel,
baby had PDA

large fontanelles, hypertelorism, epicanthal folds,


upward slanting of palpebral fissures, nystagmus,
posteriorly rotated ears with abnormal helices,
anteverted nares, protruding tongue, high arched
palate, and redundant skin folds of neck. Other
features include bell-shaped chest, hepatomegaly,
hydronephrosis, cryptorchidism, and hypospadiasis in
males, clitromegaly in females. Neurological
abnormalities often seen in this syndrome are mental
retardation, hypotonia, seizures and hyporeflexia or
areflexia. They may also have cardiovascular anomalies
like VSD and PDA. It has an apparent resemblance to
Downs syndrome and is often mistaken for it. Diagnosis
is confirmed by evidence of elevated levels of long
chain fatty acids and pipecolic acid in the blood.
Kulkarni ML. Zellweger syndrome. Indian Pediatrics 2003;
40: 682.

Schwartz-Jumpel Syndrome (Figs 33.4i1-3)

Fig. 33.4h(2): Zellwegers syndrome. Zellweger facial


features expressionless face, high forehead, shallow supraorbital ridge, micrognathia

Schwartz-Jumpel syndrome is a rare AR disorder


characterized by muscle stiffness, mild weakness and a
number of minor dysmorphic features. Though AR
pattern is seen in majority of cases, genetic heterogenity

Genetic Syndromes 289

Fig. 33.4i(1): Schwartz-Jumpel syndrome. Note low hair line,


sad face, pursed lips, and narrow palpebral fissures

Fig. 33.4i(3): Schwartz-Jumpel syndrome. Noteinguinal


hernias, bilateral equinovarus, micropenis

The characteristic features of the syndrome include


short stature, flat face with sad fixed appearance, full
cheeks, and low hair line. Eyes have narrow palpebral
fissure,blepharophimosis and long irregular eyelashes.
Mouth is small with pursed lips, short neck, pectus
carinatum, umbilical hernia, inguinal hernia, small testes
are other features.
Skeletal features are prominent and include small
mandible, spinal anomalies, hip contracture,
fragmenting of femoral epiphysis, widened metaphysis,
joint contractures, osteoporosis and delayed bone age.
Muscles have characteristic myotonic features with
weakness and wasting.
Freeman Sheldon Syndrome (whistling face
syndrome) (Fig. 33.4j)

Fig. 33.4i(2): Schwartz-Jumpel syndrome. Noteinguinal


hernias, bilateral equinovarus,micropenis and narrow
palpebral fissures

like AD inheritance, pseudodominance and uniparental


disomy have been suggested.

It is also called whistling face syndrome. Most of the


features are secondary to increased muscle tone. The
characteristic features include sloping forehead, small
nose, long philtrum, pursed lips (These features give
rise to whistling appearance), contractures at joints,
ulnar deviation of hand, flextion contractures of fingers
and kyphoscoliosis. Inheritance is AD.

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An Atlas of Neonatology

Fig. 33.5a(1): Fraser syndrome. Showing cryptophthalmos,


genitourinary abnormalities, band of hair extending from
temporal area to eye and syndactyly

Fig. 33.4j: Whistling face syndrome (Freeman Sheldon


syndrome). Note characteristic whistling face and bilateral
talipes equinovarus (see both figures above)
Fig. 33.5a(2): Fraser syndrome. Note syndactyly

PRIMARY FACIAL ANOMALIES


Fraser Syndrome (Figs 33.5a1-2)
The main features include hidden eye (cryptophthalmos), syndactyly and abnormal genitalia. It is a
variable syndrome and even cryptophthalmos may not
be present. Cryptophthalmia may be unilateral,
bilateral or asymmetrical. Globe is usually present below
formed eyelids. Absence of eyebrows and eyelashes,
and eye covering skin can extend from the forehead

to the cheeks. A band of hair can extend from the


anterior hairline to the anterior margin of the orbit. The
nose is broad with flat bridge and may have groove
at tip or coloboma of nares. External ears are abnormal
and may have ear canal stenosis. Syndactyly involving
only skin, laryngeal stenosis, renal agenesis, genital
abnormalities are common. Mental retardation occurs
in majority of survivors.

Genetic Syndromes 291

Fig. 33.5b: Treacher Collins syndrome. Note


antimongoloid slant, micrognathia, microtia, beaky nose

Treacher Collins Syndrome (Fig. 33.5b)


It is a disorder of craniofacial development. The
features include antimongoloid slant of the eyes,
coloboma of the lid, micrognathia, microtia and other
deformities of the ears, hypoplastic zygomatic arches,
and macrosomia. Conductive hearing loss and cleft
palate are often present. It is an autosomal dominant
disorder with variable expression. It is caused by
mutation in the treacle gene (TCOF1) situated on the
long arm of chromosome 5. Treacher Collins syndrome
should not be confused with similar entities such as
oculoauriculo vertebral dysplasia, or Goldenhar
syndrome. Coloboma is present in lower eyelid in
Treacher Collins syndrome, whereas in upper eyelid in
Goldenhar syndrome.
Blepharophimosis (Fig. 33.5c)
This is an autosomal dominant disorder characterized
by inner canthal folds, lateral displacement of inner
canthi,short palpebral fissure, and ptosis.There are two
types:type1and 2. Type 1 is characterized by infertility,
menstrual irregularities, and amenorrhea; otherwise two
types are indistinguishable. Minor anomalies may be
associated.

Fig. 33.5c: Blepharophimosis. Inheritance


is autosomal dominant (see both pictures above)

Cleft Lip Sequence (Fig. 33.5d)


Lip is usually formed by 35 days of intrauterine life.
Failure of lip closure results in secondary failure of
closure of the palatal shelves, which close around 8-9
weeks. The other secondary anomalies include defects
of tooth development in the area of cleft lip, and
incomplete development of alae nasi on the side of the
cleft. There may be mild ocular hypertelorism.Tertiary
changes include poor speech, recurrent otitis and
conductive hearing loss. More severe ones, bilateral

292

An Atlas of Neonatology

Fig. 33.5d: Unilateral cleft lip and palate

ones, and familial cases have increased risk of


recurrence in subsequent pregnancy.
Goldenhar Syndrome (Oculoauriculovertebral
spectrum) (Figs 33.5e1-3)
This syndrome results from abnormal morphogenesis
of first and second branchial arches, sometimes
accompanied by vertebral and ocular anomalies. The
disorder occurs once in 3000 to 5000 births with male
predominance. The occurrence of epibulbar dermoid
and vertebral anomaly is called Goldenhar syndrome,
whereas predominantly unilateral occurrence is
designated as hemifacial microsomia. But these two are
different spectrum of same morphogenic abnormality.
The abnormalities include epibulbar dermoids in the
eyes, microtia, accessory ear tags or pits, middle ear
anomalies, macrostomia with cleft like extension at the
corners, hemivertebrae, hypoplasia of vertebrae mainly
in cervical region. Hypoplasia of malar, maxillary and
mandibular bones, facial muscles (especially depressor
anguli oris) occur in association. Cleft lip/palate, cardiac
anomalies, genitourinary abnormalities occasionally
occur.

Fig. 33.5e(1): Goldenhar syndrome (oculoauriculovertebral


spectrum). Note hemi facial atrophy on right Microphthalmia
on the left, cleft like extension of the corner of the mouth,
mostly sporadic. Also known as facio-oculo-auriculovertebral dysostosis (see both pictures above)

Van der Woude Syndrome (Fig. 33.5f)


This syndrome is characterized by lower lip pit (s), with
or without cleft. These pits occur in 80% of cases and
are found in the vermilion border of the lower lip about

Genetic Syndromes 293

Fig. 33.5e(2): Goldenhar syndrome (oculoauriculovertebral


spectrum. Note severe hyperplasia of ramus of mandible

Fig. 33.5f: van der Woude syndrome

cm from the mid line. The pits run through


orbicularis oris muscle and may contain heterotopic
salivary gland, which may produce watery mucoid
secretion. The condition is inherited in an autosomal
dominant fashion and the gene has been mapped to
the long arm of chromosome 1 at q 32-41.
Orofaciodigital Syndrome (OFD) (Figs 33.5g1-8)
It is a heterogeneous group of disorders characterized
by the association of facial anomalies, oral manifestations like high arched palate, cleft lip, cleft palate,
oral frenulae, cleft or lobulated tongue and finger anomalies like polydactyly, syndactyly, brachydactyly and

Fig. 33.5e(3): Goldenhar syndrome (oculoauriculovertebral


spectrum). Note microtia, macrostomia, cleft like extension
of corner of mouth. Malar hypoplasia

Fig. 33.5g(1): Orofaciodigital syndrome (OFD) Type 2


Polydactyly and multiple fatty tumors of tongue. Autosomal
recessive inheritance

294

An Atlas of Neonatology
Table 33.11: Clinical features of various types of OFDs

OFD-Clinical Features

II

III

IV

VI

VII

VIII

High arched palate


Cleft palate
Tongue cleft
Tongue nodule
Oral frenula
Dental anomalies

+
+
+
+
+
+

=
=

+
+
+
+
+
+

=
=
=
=

+
+

+
+

Hypertelorism
Medial cleft lip
Facial asymmetry
Nose anomalies
Micrognathia
Hand
Clinodactyly
Brachydactyly
Syndactyly
Polydactyly - Preaxial
- Postaxial
Foot polydactyly - Pre
- Post
Brain
Cerebral anomalies
Cerebellar anomalies
Porencephaly
Hypothalamic hematoma
Mental retardation
Minor feature- Nystagmus
Skeletal changes
Renal anomalies
Mode of inheritance

+
+
+
+
+

+
+

+
+

+
+
+
+
+

+
+

+
+
+

+
+
+

+
+
+
+
+
+

+
+
+

+
+
+
+
+
+
+

+
+

+
+
+
+
+
+

+
+

+
+
+

+
+

+
+
M

+
+
X-D

AR

S
+
+

AR

M
+
+

AR

AR

+
+

+
S

AR

AD/XD

+
+
XR

Oral

Face

M- Mild, S-Severe, N-Normal, XD-X-linked dominant, AR-Autosomal recessive, AD-Autosomal dominant

Fig. 33.5g(2): Orofaciodigital syndrome (OFD). Note


midline cleft, multiple fatty tumor of tongue

Fig. 33.5g(3): Orofaciodigital syndrome (OFD). Showing


multiple lobulation of tongue, facial dysmorphism and
polydactyly

Genetic Syndromes 295

Fig. 33.5g(4): Orofaciodigital syndrome (OFD).


Note polydactyly of hands and feet
Fig. 33.5g(7): Orofaciodigital syndrome (OFD).
Note polydactyly of hands

Fig. 33.5g(5): Orofaciodigital syndrome (OFD).


Note polydactyly of hands and feet

Fig. 33.5g(8): Orofaciodigital syndrome (OFD).


Note polydactyly of hands

clinodactyly OFDs are classified into eight types based


on phenotypic differences and mode of inheritance.
They are given in the Table 33.11.
Frontonasal Dysplasia (Figs 33.5h1-6)

Fig. 33.5g(6): Orofaciodigital syndrome (OFD)


Note polydactyly of feet

This is a disorder of unknown primary defect in midface


development with incomplete anterior apposition
alignment of eyes, broad notched nasal tip to bifid
nostrils, median cleft lip, broad nasal bridge,
telecanthus, ocular hypertelorism,and widows peak.
These midline deficits of frontal bones are the resultant
abnormalities of unknown midfacial primary defect. This
syndrome is also called the median cleft face syndrome.

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An Atlas of Neonatology

Fig. 33.5h(1): Frontonasal dysplasia

Fig. 33.5h(4): Frontonasal dysplasia

Fig. 33.5h(2): Frontonasal dysplasia.


Note associated imperforate anus

Fig. 33.5h(5): Frontonasal dysplasia. Frontal cleft midline split


of the nose, cleft palate and lip, lax skin, low set ears

The main features are marked hypertelorism, sometimes


with narrowing of the palpebral fissure inconjunction
with broad nasal tip, which is frequently cleft. Notching
of alae nasi might be a feature. The occurrence of
widows peak and an occasional anterior encephalocele
indicates that it may be a midline defect. Intelligence
is normal in majority of cases.
Waardenburgs Syndrome (Figs 33.5i1-4)
Fig. 33.5h(3): Frontonasal dysplasia

White forelock, pigmentery abnormalities of iris


(heterochromia), sensory neural deafness, broad nasal
root, synophrys, and an important finding of lateral

Genetic Syndromes 297

Fig. 33.5h(6): Frontonasal dysplasia. Shown in this photograph are the mother and elder sib of the newborn shown
in previous picture (Figs 33.5h1-5)

Fig. 33.5i(2): Waardenburgs syndrome

Fig. 33.5i(1): Waardenburgs syndrome. Note white forelock of hair. Baby had total aganglionosis of intestine

Fig. 33.5i(3): Waardenburgs syndrome

298

An Atlas of Neonatology
greying of hair, true hypertelorism, cleft lip and palate,
Hirschsprungs disease and congenital heart disease, i.e.
VSD. Type II has no dystropia canthorum and other
features are similar and results from PAX 3 gene
mutation on chromosome 3q. Type III is also AD
disorder due to PAX 3 gene mutation. The features are
similar to type I but upper limb deformation of variable
degrees distinguish this from others. Facial abnormalities
are almost similar to Type I but Cupid bow shape of
upper lip and large nasal root and hypoplastic alae nasi
are more pronounced. Type IV is associated with
Hirschsprungs disease and may be AD or AR.
Reference: Kulkarni ML, et al. J Med Genet 1989; 26: 411-412.

Robin Sequence
Please see chapter 32.
Cataract
Please see chapter 32.
Median Cleft Face Syndrome
Please see chapter 32.
Microphthalmia/Anophthalmia
Fig. 33.5i(4): Waardenburgs syndrome. Note white forelock
and associated Ileal atresia. Long segment Hirschsprungs
disease is a common associated finding in this type of
Waardenburgs syndrome

displacement of inner canthi with short palpebral fissure.


Type I has lateral displacement of medial canthi
(dystopia canthorum) whereas type II has no such
finding. Type III has limb hypoplasia, flexion contractures
and syndactyly in addition to wind features of type I.
Waardenburg syndrome that is characterized by
ocular, auditory, and pigmentary abnormalities of
Type I.
Type I is due to PAX 3 gene mutation situated on
chromosome 2q and is inherited as AD disorder. The
characters include a white forelock, sometimes extensive
depigmentation of skin, sensory neural deafness,
dystopia canthorum, heterochromia irides, synophrys
and a high nasal bridge. Some patients have premature

Please see chapter 32.

FACIAL LIMB DEFECTS


OPD: Otopalato-digital Syndrome II (Figs 33.6a1-2)
An X-linked recessive disorder present at birth with
hypertelorism, anti-mongoloid eye slant, micrognathia,
posteriorly rotated ears, prominent forehead, microstomia and cleft palate, in the limbs, sometimes
dislocation of hips, flexed overlapping fingers,
syndactyly, notched or bifid terminal phalanges, post
axial polydactyly and short halluces and thumbs are
noted.
Langer-Giedion Syndrome (Fig. 33.6b)
An AD disorder due to microdeletion at chromosome
8q having a close similarity to trichorhinophalangeal
(TRP) syndrome. There is mild short stature, mild-

Genetic Syndromes 299

Fig. 33.6a(1): Otopalatodigital syndrome. Note antimongoloid


slant micrognathia, posteriorly rotated ears, prominent
forehead and microstomia

Fig. 33.6b: Langer-Giedion syndrome. Note Microcephaly,


bulbous nose, thickened and notched alae nasi and long
simple philtrum, absent hair, loose skin, prominent ears

Stickler Syndrome (Figs 33.6c1-13)


Stickler syndrome is an autosomal dominant connective
tissue disorder. The characteristic features include eye
manifestations like myopia, vitreoretinal degeneration,
cataracts and retinal detachment, facial features; midface
hypoplasia broad nasal bridge, Pierre Robin sequence,
and skeletal features like epiphyseal dysplasia and
premature degenerative joint diseases.
The disorder may have variability in expression.
Pierre Robin sequence, buphthalmos and arachnodactyly are usual presentation in the neonatal period.
20 to 30% of patients with Pierre Robin sequence have
Stickler syndrome.
Conditions associated with Pierre Robin sequence
include campomelic dysplasia, Marshall syndrome fetal
alcohol syndrome, trimethadone and hydantoin

Fig. 33.6a(2): Otopalatodigital syndrome.


Note notched and bifid toes

microcephaly, bulbous nose, thickened and notched


alae nasi long simple philtrum, sparse hair and
prominent ears. At birth the skin may be very loose
which regresses with age. Radiography reveals cone
shaped epiphysis and poor mineralisation at ends of
the phalanges and exostoses of the long bones. Mild
mental retardation may be present. Langer-Giedion
syndrome (TRP II) and TRP I result from different sized
deletion in 8q and thus may be considered a contiguous
gene syndrome.

Fig. 33.6c(1): Stickler syndrome. Note arachnodactyly

300

An Atlas of Neonatology

Fig. 33.6c(4): Stickler syndrome. Note prominence of


large joints, arachnodactyly

Fig. 33.6c(2): Stickler syndrome and parent. Father enucleated for retinal detachment. Note bilateral buphthalmos and
Pierre Robin sequence in the child

Fig. 33.6c(5): Stickler syndrome. Note small nose with


anteverted nostrils with flat facial profile

Fig. 33.6c(3): Stickler syndrome congenital buphthalmos with


Pierre-Robin sequence. Note flat face and prominent eyes
(see both pictures above)

Fig. 33.6c(6): Stickler syndrome. Note flat facies with depressed nasal bridge and short nose, also seen are prominent
eyes

Genetic Syndromes 301

Fig. 33.6c(7): Stickler syndrome.


Note hypospadiasis

Fig. 33.6c(10): Stickler syndrome. Note


bilateral talipes, prominence of knee joints.
Also seen is bilateral genu valgus

Fig. 33.6c(8): Stickler syndrome

Fig. 33.6c(9): Stickler syndrome.


Note hazy cornea

Fig. 33.6c(11): Stickler syndrome. Side view


showing flat face with short nose

302

An Atlas of Neonatology

Fig. 33.6c(12): Stickler syndrome

Fig. 33.6c(13): Stickler syndrome. Note camptodactylia

Fig. 33.7a(1): Grebe syndrome. Short limbs predominantlyinvolving lower limbs, severity of shortening progress from
proximal to distal limb resulting in grape like fingers and
toes, trunk and head normal, polydactyly may be a feature

syndromes, ABS, CHARGE association, velocardiofacial syndrome, femoral hypoplasia and unusual face
syndrome, Cerebrocostomandibular syndrome
Mobeius sequence, Nager acro-facial dysostosis and
Beckwith-Wiedemann syndrome.
Ref: Kulkarni et al, Annals of Dentistry 1993; 52 (2)

LIMB ABNORMALITIES
Grebe Syndrome (Figs 33.7a1-8)
Grebe syndrome is characterized by short limbs with
progressive shortening of limbs from proximal to distal
ends with predominant involvement of lower limbs with
grape like toes. Bones of the limbs are hypoplastic and
the small bones are usually absent. Postaxial polydactyly
is common. Heterozygotes may have polydactyly,
brachydactyly, hallux valgus, and delayed bone age.

Fig. 33.7a(2): Grebe syndrome in one of the


twins (right)

Genetic Syndromes 303

Fig. 33.7a(3): Grebe syndrome

Fig. 33.7a(6): Grebe syndrome. Severe micromelia


especially in the lower limbs
absent bones/hypoplastic in
the lower limb, shortening
progressively increases
distally. Head and trunk
normal

Fig. 33.7a(4): Bulbous fingers in Grebe syndrome


Fig. 33.7a(7): Grebe syndrome. With very
short lower limb and bulbous toes

Radiographic abnormalities include short long bones


of upper limbs; ulna much shorter than radius,
rudimentary or absent carpal bones and phalanges.
Lower limb long bones are short with short feet in
valgus position with rudimentary or often absent
phalanges.
The gene (CDMD-I) of Grebe syndrome has been
mapped to chromosome 20. Though the inheritance
of this disorder is considered to be autosomal recessive,
data suggests that the gene may have some effect in
the heterozygotes. About 90% of the cases reported are
from consanguineous union.
Fig. 33.7a(5): Grebe syndrome

Reference: Kulkarni ML, et al. Grebe syndrome. J Med


Genet 1995, 32 : 326-327.

304

An Atlas of Neonatology

Fig. 33.7b: Popliteal pterygium syndrome


Fig. 33.7a(8): Grebe syndrome a stillborn. Many patients are
stillborn or die in infancy, survivors are said to be of normal
intelligence, develop normal secondary sexual characteristics and walk without difficulty. Inheritance AR

Popliteal Pterygium Syndrome (Fig. 33.7b)


An AD disorder with wide variability in expression
characterized by popliteal web (90%), cleft palate (90%)
and lower lip pits (50%). Genital anomalies occur in
50% of cases and include hypoplastic labia majora,
scrotal dysplasia and cryptorchidism.
Femoral Hypoplasia, Unusual Facies
Syndrome (Figs 33.7c1-4)
A syndrome of unknown etiology often occurring
sporadically characterized by femoral hypoplasia, short
nose and cleft palate. Maternal diabetes is reported
frequently.
The face has short nose with hypoplastic alae nasi,
long philtrum, thin upper lip, micrognathia and cleft
palate, abnormal ears and upslant of eyes.
Limb shortening may be unilateral or bilateral and
of varying degree. Femora are hypoplastic to absent.

Fig. 33.7c(1): Femoral hypoplasia unusual facies syndrome


short-bowed femora (unilateral or bilateral), vertebral and
sacral anomalies, variable hypoplasia of humeri

Genetic Syndromes 305


Tibia, fibula may be involved in shortening along with
restricted elbow movement with radioulnar synostosis
and limited shoulder movement. Spinal, pelvic and
genitourinary anomalies are common.
Radial Dysplasia (Figs 33.7d1-4)
Radial dysplasias occur in Fanconis pancytopenia, HoltOram syndrome, Roberts-SC phocomelia, VATER
association, Beller Gerold syndrome, and Levy Hollister
syndrome. Rarely seen in trisomy 13 and 18, deLange
Fig. 33.7c(2): Femoral hypoplasia unusual facies
syndrome

Fig. 33.7c(3): Femoral hypoplasia unusual facies syndrome


posterior view showing short femora and short lower trunk

Fig. 33.7d(1): Radial dysplasia in TAR syndrome. Radial


aplasia, purpura other features congenital heart, defects of
lower limb, Inheritance AR

Fig. 33.7c(4): Femoral hypoplasia unusual facies syndrome

Fig. 33.7d(2) Radial dysplasia

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An Atlas of Neonatology

Fig. 33.7d(3): Bilateral radial dysplasia


Fig. 33.7e(1): EEC syndrome-cleft lip palate

Fig. 33.7e(2): EEC syndrome-Ectodactyly

Fig. 33.7d(4): Holt-Oram syndrome.


Note radial dysplasia

syndrome, cat eye syndrome, Nager syndrome and


Seckel syndrome. Holt-Oram syndrome is characterised
by aplasia or hypoplasia of radial structures with ASD
and is inherited as a dominant syndrome. TAR
syndrome consists of thrombocytopenia with usually
bilateral absent radius. It is inherited as an AR disorder.
EEC Syndrome (Figs 33.7e1-5)
The ectrodactyly, ectodermal dysplasia, clefting
syndrome is a multiple congenital anomaly syndrome

Fig. 33.7e(3): EEC syndrome ectodactyly (split hand), missing


digit from middle ray of hand with partially-split palm giving
a lobster claw appearance, usually a AD disorder with
markedly reduced penetrance, occasionally part of
syndrome, e.g. EEC

Genetic Syndromes 307


the findings in some cases and urogenital anomaly is
another hallmark of the syndrome. The anomaly is
thought to be inherited as an autosomal dominant
pattern in some families. However, genetic heterogeneity is also known to exist.
Larsen Syndrome (Figs 33.7f1-14)
Characterized by joint hypermobility, multiple joint
dislocations, especially of knees and talipes equinovarus. The mid face is hypoplastic with depressed nasal

Fig. 33.7e(4): EEC syndrome. Bilateral cleft lip and


palate in a case of EEC syndrome

Fig. 33.7f(1): Larsen syndrome. Flat mid-face, depressed


nasal tip, dislocation of knee and hip, positional deformity
of feet, other features include prominent forehead,
hypertelorism cleftlip and palate, Inheritance AD or AR

Fig. 33.7e(5): EEC syndromeectodactyly, ectodermal


dysplasia and cleft palate

characterized by ectodermal dysplasia, distal limb


anomaly, cleft lip/palate and lacrimal duct anomalies.
Embryologically the EEC syndrome and related disorders represent disorders of ectodermal/mesodermal
interaction. Mental retardation is reported to be among

Fig. 33.7f(2): Larsen syndrome.


Hyperextensibility of knee

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An Atlas of Neonatology

Fig. 33.7f(3): Larsen syndrome. Talipes equinovarus or valgus,


delayed coalescence of the two-calacaneal ossification
centers

Fig. 33.7f(6): Larsen syndrome


Fig. 33.7f(4): Larsen syndrome.
Talipes equinovarus

Fig. 33.7f(5): Larsen syndrome.


Multiple joint dislocations

Fig. 33.7f(7): Larsen syndrome.


Hip and knee dislocation

Genetic Syndromes 309

Fig. 33.7f(8): Larsen syndrome. Hypertelorism, prominent


forehead hypertelorism, depressed nasal tip and flat face

Fig. 33.7f(11): Larsen syndrome


Fig. 33.7f(9): Larsen syndrome. Long non-tapering fingers
with spatulate thumbs, short nail. Short metacarpals and
multiple carpal ossification centers

Fig. 33.7f(10): Larsen syndrome

Fig. 33.7f(12): Larsen syndrome. Note simian crease


micrognathia

310

An Atlas of Neonatology

Fig. 33.7f(13): Larsen syndrome

(1)

Fig. 33.7f(14): Larsen syndrome. Typical posture note


hyperextensibility of knee

bridge. Cleft palate may be present. Radiography


reveals under mineralization and over tubulation of long
bones, a bifid calcaneum and advanced bone age in
carpal or extracarpal bones. Scoliosis and coronal clefts
of vertebrae and subluxation of the vertebrae may be
found. Subglottic stenosis, anal atresia, uterine
malformation, radioulnar synostosis, preaxial
polydactyly are reported in some cases. The disorder
is either autosome recessively or dominantly inherited.
Lethal Multiple Pterygium Syndrome
(Figs 33.7g1-2)
An AR disorder characterised by ankyloblepharon with
corneal ulceration in 50%, epicanthal folds, hyper-

(2)
Fig. 33.7g: (1) Multiple pterygium syndrome. (2) Pterygia
(web) at knees and elbows short neck, hypertelorism
epicanthic, folds flat nose, TEV and foot abnormalities

telorism, down turned eyes, hypoplastic malformed


nose, micrognathia, and cleft palate. Filiform strands
connect upper and lower lips.
Flexion contractures of elbow, shoulder, hips, knees,
ankles, hands and feet are common. Pterygium is
present in chin to sternum, cervical, auxillary, crural,
anticubital, popliteal and ankles. All patients are stillborn
or die in immediate neonatal period.

Genetic Syndromes 311

SKELETAL DYSPLASIAS
Achondrogenesis Types 1 and 2 (Figs 33.8a1-4)
Both are autosomal recessive lethal disorders
characterized by large head, low nasal bridge, very short
limbs, and incomplete ossification of lower spine.
Achondrogenesis type I and II (ParentFraccaro type
and Langer-Saldino type) cannot be distinguished
clinically. Both result in stillbirth and are characterized
by severe micromelia, a relatively large head, a short
neck, a short trunk and protuberant abdomen. Both
have flat nasal bridge, and short nose with short
anteverted nostrils. Radiologically, ossification of skull,
spine and pelvis is more deficient in type I than in type
II. The long bones are more severly micromelic in type
I and there are spiky metaphyseal spurs in both but
more so in type I. Type I has been subdivided into
two types: A (Houston- Harris type) and B (ParentFraccaro type). Type IA cases have multiple rib fractures
and almost complete lack of ossification of spine.
Encephalocele may occur occasionally. The gene

Fig. 33.8a(1): Achondrogenesis Type I. Note large head,


extreme micromelia, all 4 limbs and protuberant abdomen,
note relatively narrow chest

Fig. 33.8a(2): Achondrogenesis Type I. Deficient ossification


of vertebral bodies, pelvis and sacrum, multiple fracture and
under ossification of ribs and severely shortened long bones
with spur formation, AR inheritance

Fig. 33.8a(3): Achondrogenesis Type II. Severe micromelia


abdominal distention, large head, radiological features
differentiate from Type 1a and 1b

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An Atlas of Neonatology

Fig. 33.8a(4): Achondrogenesis Type II. Note complete


absence of spine ossification with relatively normal skull a
differentiating feature from Type 1 achondrogenesis

involved in Type I is DTDST and in Type II, COL2A1and


both are inherited as autosomal recessive disorders.

Fig. 33.8b(1): Short rib polydactyly type I (Saldino Noonan


Type). SRP1 note hydropic appearance, short limbs, narrow
chest, hypoplastic penis, syndactyly, Note incidental cleft lip

Short Rib Polydactyly Types I and II (Saldino


Noonan type and Majewski type) (Figs 33.8b1-7)
Short stature, narrow thorax, short limbs, postaxial
polydactyly of hands and/or feet, short horizontal
ribs,and small iliac bones with horizontal acetabular roof
are characteristic features in both types. Abnormal
genitalia, imperforate anus, cardiac and renal defects
may occur.
Radiographs show short horizontal ribs, metaphyseal
irregularities of long bones with spurs extending from
medial and lateral segments, and triangular ossification
defects above lateral aspect of acetabulum.
Type II or Majewski type is characterized by
disproportionately short, abnormally shaped tibia in
addition to short limbs and short ribs, and postaxial
polydactyly. Cleft lip/palate, general abnormalities, and
renal cysts may occur in type II. Both types are
autosomal recessive disorders with lethality soon after
birth due to pulmonary hypoplasia.

Fig. 33.8b(2): Short rib polydactyly type I (Saldino Noonan


Type). Severely shortened ribs, small pelvis and very short
tubular bone with jagged appearance at the metaphysis,
other features polydactyly, hydrops, early death and aut.
dominant inheritance

Genetic Syndromes 313

Fig. 33.8b(3): Short rib polydactyly type II (Majewski type). Note


midline cleft, narrow thorax, short limbs, short flat nose with
median cleft lip, ambiguous genitalia, slight hydropic
appearance

Fig. 33.8b(6): Short rib polydactyly type II (Majewski type). Note


midline cleft, narrow thorax, short limbs, short flat nose with
median cleft lip, ambiguous genitalia, slight hydropic
appearance

Fig. 33.8b(4): Short rib polydactyly type II (Majewski type).


Narrow thorax, short limbs relatively narrow pelvis, short oval,
tibia polydactyly, short horizontal ribs, inheritance AR

Fig. 33.8b(5): Short rib polydactyly type II (Majewski type).


Note polydactyly in all extremities, also seen is ambiguous
genitalia

Fig. 33.8b(7): Short rib polydactyly type II (Majewski type).


Short horizontal ribs small iliac bones with horizontal acetabular roof, postaxial polydactyly, disproportionately short
oval shaped tibia, short rounded metacarpals and metatarsal

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An Atlas of Neonatology

Thanatophoric Dysplasia (Figs 33.8c1-3)


An autosomal dominant disorder almost always due to
fresh gene mutation (FGFR3) characterized by short
limbs, flat vertebrae, and large cranium with low nasal
bridge. These patients usually die shortly after birth
(thanatophoric means death bringing) due to respiratory insufficiency as a result of narrow thorax.

Fig. 33.8c(1): Thanatophoric dysplasia. Note large head,


frontal bossing, depressed bridge of nose short bowed
limbs, small thorax, mid face hypoplasia with anteverted
nostrils

Fig. 33.8c(3): Thanatophoric dysplasia. Note wrinkled


skin and other features

All long bones are short with wide irregular cupped


metaphysis. Telephone receiver like femora, flat
vertebral bodies, small iliac bones, and a spur at medial
side of acetabulum are characteristic radiologic features.
Prenatal diagnosis by ultrasound is possible and there
is no recurrence in subsequent pregnancies as most
cases are fresh mutations. Type I has bent femora and
flat vertebral bodies, whereas Type II has straight femora
and taller vertebral bodies. Those with cloverleaf skull
always have Type II disease.
Camptomelic Dysplasia (Figs 33.8d1-3)

Fig. 33.8c(2): Thanatophoric dysplasia. Very short tubular


bones with metaphyseal flaring and cupping, short telephone
receiver femora with medial metaphyseal spur, flat vertebral
bodies giving inverted u or h shaped appearance in AP
projection, most cases are sporadic

This disorder is due to an autosomal dominant gene


that is usually lethal characterized by bowed tibia,
hypoplastic scapule, flat face, short and flat vertebrae,
bent bones, slender ribs, kyphoscoliosis, small iliac
wings. Absence of ossification centers of proximal tibial
and distal femoral epiphysis and talus are characteristic
radiologic finding.

Genetic Syndromes 315


Jeune Asphyxiating Thoracic Dystrophy
(Figs 33.8e1-3)

Fig. 33.8d(1): Camptomelic dwarfism. Note bowed legs


Hypertelorism micrognathia, ambiguous genitalia and talipes

An autosomal recessive disorder characterized by small


thorax, short limbs and hypoplastic iliac wings. Fifty
percent of cases have postaxial polydactyly. Face is
normal, limb shortening is rhizomelic. Ribs are short;
ilia are small with irregularity of acetabulum from which
medial bony projection is visible. Premature ossification
of capital femoral epiphysis is typically seen in the
newborn. Most infants die early in life due to hypoplastic
lungs. Those who survive develop renal failure due to
renal cysts nephropathy and cirrhosis due to hepatic
involvement. Biliary atresia, cardiac and renal
anomalies, hydrocephalus, and tracheal/laryngeal
abnormalities have been described. Ultrasound may
reveal renal cysts. Prenatal diagnosis is possible by
ultrasound at about 18-20 weeks by demonstrating
narrow thorax. Norms for thoracic circumference
abdominal ratios have been established which aid in
the diagnosis. Ribcage perimeter and AC (Abdominal/
chest) ratio has shown to be more reliable.

Fig. 33.8d(2): Camptomelic dwarfism: Note bowed femora


and tibia mimicking fracture hypoplastic fibulae, bell-shaped
narrow thorax. Other clinical feature are cleft palate, hypertelorism and occasional cardiac and genital anomalies

Fig. 33.8d(3): Camptomelic dwarfism. Mild bowing of femora,


short fibula, absent ossification center at knee joint

Fig. 33.8e(1): Jeunes thoracic dystrophy. Note narrow


chest with apparent abdominal distention

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An Atlas of Neonatology

(2)
Fig. 33.8f(1): Achondroplasia. Large head with frontal bossing
mild rhizomelia in newborn period abnormal acetabular roof
in newborn period which is an important finding in newborn
period

(3)
Figs 33.8e(2-3): 2. Jeunes thoracic dystrophy. 3.
Note: bell-shaped thorax and hypoplastic lungs

Achondroplasia (Figs 33.8f1-4)


It is an autosomal dominant disorder due to mutation
in the gene encoding fibroblast growth factor receptor
3 (FGFR3) located on chromosome 4. Clinically it is
characterized by rhizomelic short limbs, frontal bossing,
low nasal bridge, mid facial hypoplasia, progressive
narrowing of lumbar interpedicular distance, lumbar
lordosis, short tubular bones with metaphyseal flare,and
small trident hand. When an achondroplasiac marries
another achondroplasiac, there is a 25% risk of
homozygous achondroplasia (which is lethal in neonatal
period) and 50% risk of heterozygous achondroplasia
compatible with almost normal life. Hydrocephalus and
spinal complications can be serious.
Achondroplasia should be diagnosed at birth; but
rhizomelic short limbs and broad prominent forehead

Fig. 33.8f(2): Achondroplasia. An older patient with achondroplasia showing decreasing interpeduncular distance from
thoracic to lumbar spine, short round iliac crest, narrow sacrosciatic notches, horizontal acetabular roof, oval translucency
of proximal femora, note also widened metaphysis of long
bone, AD disorder wherein 80% are new mutations

may not be striking at birth. But pelvis is always


abnormal; the iliac wings are small and squarish, and

Genetic Syndromes 317


acetabular roof is horizontal with narrowing of greater
sciatic notch. From the roof, there is a projecting medial
bony spike. Short long bones and metaphyseal slope
result in a translucent area at the proximal ends of the
femora in the neonatal period. The narrowing of
interpedicular distance becomes evident later. Abnormal
foramen magnum, hydrocephalus, spinal stenosis may
cause neurological problems. Prenatal diagnosis is
possible by combined use of US and molecular
methods (detecting mutation in FGFR3 gene).
Metatropic Dysplasia (Figs 33.8g1-3)

Fig. 33.8f(3): Achondroplasia. Short long bones particularly


proximal ones with widened metaphysis

This is an AR or sporadically inherited, short limbed,


skeletal dysplasia with dumbbell like configuration of
long bones (trumpet shaped metaphyses), a narrow but
normal length thorax and occasionally a coccygeal
appendage similar to a tail (a characteristic finding if
present).Metatrophic means changeable as in this
condition, the proportion of trunk to the limb changes

Fig. 33.8f(4): Achondroplasia. Made for each other. An


achondroplasiac has married an achondroplasiac. In such
a situation there is 50% chance for heterozygous achondroplasia as the baby shown in the figure, however there is 25%
risk of severe homozygous achondroplasia which is often
lethal in neonatal period, note large head, frontal bossing
depressed nasal bridge and mild rhizomelic shortening of
limbs in the baby

Fig. 33.8g(1): Metatrophic dwarfism. Trunk is


relatively long with short limbs

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An Atlas of Neonatology
Ellis-van Creveld Syndrome
(chondroectodermal dysplasia) (Figs 33.8h1-5)
An AR disorder characterized by short distal extremities,
polydactyly and hypoplastic nails. Neonatal teeth,
alveolar ridges, atrial septal defects are often present.
It closely fesembles Jeune thoracic dystrophy; but it can
be differentiated from by the presence of cardiac rather
than renal defects which is seen in the latter condition.

Fig. 33.8g(2): Metatrophic Dwarfism. Short stature, short


limbs prominent joints, severe kyphoscoliosis, narrow chest
relatively long feet. Incidentally note postaxial polydactyly

(1)

Fig. 33.8g(3): Metatrophic Dwarfism. Extreme flaring of


metaphysis (Dumb bell-shaped long bones) in the neonatal
period with platyspondylia. A caudal appendage (tail) is
some times diagnostic

over time. Small thorax, thoracic kyphoscoliosis and


metaphyseal flaring are characteristic findings. There is
genetic heterogeneity in this disorder. The lethal
autosomal recessive form has severe mushrooming and
shortening of tubular bones and severe under
ossification of vertebral bodies. Nonlethal autosomal
dominant and autosomal recessive forms are also
described. Narrow thorax, short ribs, short limbs,
metaphyseal flaring, restricted mobility at joints, square
iliac wings are characteristic features.

(2)
Figs 33.8h(1-2). Ellis-van Creveld syndrome (1). Note short
distal extremities and post-axial polydactyly. Symmetric postaxial polydactyly in all the limbs is differentiating feature from
Jeune thoracic dystrophy (2)

Genetic Syndromes 319


Autosomal Recessive Chondrodysplasia
Punctata (Rhizomelic type) (Figs 33.8i1-2)
An autosomal recessive disorder due to loss of specific
peroxisomal functions characterized by short humeri,
femora, coronal cleft of vertebrae and punctate
epiphyseal mineralization. Mental retardation microcephaly, alopecia, flat feet, cataract, ichthyosis are other
features noted in this disorder. The life span is severely
shortened. An X-link dominant variety (ConradiHnermann) also exists.
Fig. 33.8h(3): Ellis-van Creveld syndrome.
Note Wormian bones

Fig. 33.8i(1): Chondrodysplasia punctata. In an older child


Note alopecia, rhizomelic shortening, low nasal bridge flat
facies, hypoplasia of malar eminence
Fig. 33.8h(4): Ellis-van Creveld syndrome. Trident appearance of acetabular roof, hypoplasia of the upper lateral tibia,
postaxial polydactyly, other feature are short limb, small chest
making trunk appear long and thin, oral frenulae, neonatal
teeth, hypoplastic nail and ASD. Inheritance AR. Note
cardiomegaly due to ASD

Fig. 33.8h(5): Ellis-van Creveld syndrome. Showing ASD in


echo a important differentiating feature from Jeune asphyxiating dystrophy

Fig. 33.8i(2): Chondrodysplasia punctata. Note short limbs


more severe in upper limbs flat mid face, dry skin with some
dimpling, inheritance AR, X-ray shows expanded metaphysis
and epiphysis and extra-cartilaginous stippling and coronal
cleft of lumbar vertebrae

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An Atlas of Neonatology

Hypophosphatasia (Figs 33.8j1-2)

Cleidocranial Dysostosis (Figs 33.8k1-4)

An AR disorder characterized by poorly mineralized


cranium, short ribs, hypoplastic fragile bones and rickets
like changes at metaphysis. Moth eaten appearance of
metaphysis, spurs of ulna, fibula are other features.
Serum alkaline phosphatase is low and urinary
excretion of phosphoethanolamine is increased. Death
results in early infancy due to respiratory insufficiency.
Based on age of onset and clinical findings, there are
four types; perinatal lethal type, infantile type, juvenile
type and an adult type.

An autosomal dominant disorder with wide variability


in expression, characterized by defect of clavicle
(hypoplasia to absence), big head with wide anterior
fontanel and frontal bossing. Absent clavicle occurs in
10%. Narrow thorax, extra ribs, incompletely ossified
sternum, unossified pubic bones, hypoplastic iliac
bones, wide cranial sutures, wormian bones, and
enlarged foramen magnum are other features.
Absent or hypoplastic clavicles can occur in other
disorders like Sprengels deformity, Roberts syndrome,
Holt-Oram syndrome, TAR syndrome, achondrogenesis, osteogenesis imperfecta, and in certain
chromosomal and multiple anomaly syndromes.

Fig. 33.8j(1): Hypophosphatasia. Note features of rickets,


costochondral beading, widening of wrists
Fig. 33.8k(1): Cleidocranial dysostosis. Note absent
clavicles and narrow thorax

Fig. 33.8j(2): Hypophosphatasia. X-ray of the same child taken


later in infancy. Generalized osteoporosis, widened
metaphysis with moth eaten appearance, ricket like changes
at metaphysis

Fig. 33.8k(2): Cleidocranial dysostosis. Note wide sutures


wormian bones poorly mineralized skull, wide anterior
fontanel

Genetic Syndromes 321


and cleft palate are frequent. The disease is usually
recognized at birth. But milder cases are recognised
later. With time infants develop progressive kyphoscoliosis, respiratory compromise, twisted gait, and
inflammation of pinna causing cauliflower ear.
Radiologically there is marked shortening of first
metacarpal, irregular length of metacarpal and
irregularities of metaphyses and epiphysis.
Antenatal diagnosis is possible by ultrasound during
second trimester.
Fig. 33.8k(3): In an older child note widely separated
sutures and widely open anterior fontanel

Fig. 33.8k(4): Cleidocranial dysostosis. In skull and absent


clavicle and narrow thorax in chest X-ray and clinical photo
showing approximation of shoulders

Mesomelic Dysplasia Severe Dominant Form


(Fig. 33.8m)
It is an autosomal dominant disorder with gross
shortening of distal limb bones with partial absence of
fibula. Fore arm and legs show abnormalities fibulae
are partially or completely absent causing disruption at
ankle joint, the ulna is shorter than radius, which is
bowed and radial head is malformed and dislocated.
Note incidental fracture of femora due to breech
delivery.

Diastrophic Dysplasia (Fig. 33.8l)


An AR disorder due to DTDST gene on chromosome
5q characterised by micromelia (mainly rhizomelic) club
foot, hand deformities, short and widely placed fingers
with thumbs in hitchhiker position, multiple joint
contractures and scoliosis. The term diastrophic means
twisted. The head and skull are normal. Micrognathia
Fig. 33.8m: Mesomelic dysplasia (severe dominant form). It
is an autosomal dominant disorder with gross shortening
of distal limb bones with partial absence of fibula. Forearm
and legs show abnormalities, fibulae are partially or
completely absent causing disruption at ankle joint, the ulna
is shorter than radius, which is bowed and radial head is
malformed and dislocated. Note incidental fracture of femora
due to breech delivery

Fibrochondrogenesis (Fig. 33.8n)

Fig. 33.8l: Diastrophic dwarf. Note abducted thumb and


rhizomelic shortening, short stature and joint contractures

A rare autosomal recessive lethal rhizomelic chondrodysplasia which is characterized by distinctive fibrosis of
growth plate cartilage. The clinical characters include
relatively large head with wide anterior fontanelle,

322

An Atlas of Neonatology

Fig. 33.8n: Fibrochondrogenesis. Note relatively large head, short neck and rhizomelic short limbs.
X-rays show dumb-bell shaped long bones, irregular acetabulum, ovoid short fibula

bulging eyes with large cornea, hypoplastic nose, long


philtrum, cleft palate, short neck and low set ears.
Vertebrae are flat, ribs are thin with cupping at both
ends. Limbs are rhizomelically short, long bones are
short, dumb-bell shape with irregular metaphysis,
fibulae are short and ovoid, ilia are irregularly flat and
spiky acetabulum are other features.
Skeletal dysplasia also occur in mammals other than
humans (Fig. 33.8o).

CRANIOSYNOSTOSIS
Craniosynostosis is an abnormal shape or dimension of
skull caused by premature fusion of one or more skull
sutures. It includes scaphocephaly, brachycephaly,
oxycephaly, plagiocephaly, trigonocephaly, turricephaly,
and cloverleaf skull. Craniosynostosis may be an isolated
entity or may be part of other syndromes such as
chromosomal (mainly structural anomalies), metabolic
(idiopathic, hypercalcemia, rickets, hypophosphatasia,
hyperthyroidism, MPS, mucolipidosis), inherited
Mendelian disorder (Apert, Bellar Gerold, Carpenter,
Crouzon, Escobar, Bixler, Lowry, Pfeiffer), teratogenic
(e.g. aminopterin, infection). See also chapter 32.
Aperts Syndrome (Acrocephalosyndactyly)
(Figs 33.9a1-2)

Fig. 33.8o: Skeletal dysplasia in dogs

An autosomal dominant craniosynostosis, occurring


sporadically due to mutation in FGFR 2 gene on
chromosome 10. Most of the cases are due to fresh
mutations. Acrocephaly, brachycephaly, cerebral
atrophy, delayed closure of fontanel, hypertelorism,
proptosis, down slanting of eyes small nose, flat face,
hypoplastic maxilla,cutaneous or osseus syndactyly
(Mitten hand or baseball glove appearance of hand)

Genetic Syndromes 323

Fig. 33.9b: Carpenter syndrome. Note abnormal shape


of skull (craniosynostosis) and polydactyly

Carpenter Syndrome (Fig. 33.9b)


Fig. 33.9a(1): Aperts syndrome. Note high full
forehead, mid-facial hypoplasia, small nose

It is characterized by acrocephaly, polydactyly and


syndactyly of feet, lateral displacement of inner canthi,
CVS anomalies in 50%, genital abnormalities and
variable mental development.
Clover Leaf Skull Deformity (Fig. 33.9c)
Clover leaf skull syndrome is characterized by the
association of premature closure of the coronal,
lambdoid, and sagittal sutures and hydrocephalus. As

Fig. 33.9a(2): Apert syndrome

and other skeletal anomalies are other features.


Deafness, optic atrophy,hydrocephalus, crowding of
teeth develop in later life. PND is possible by US and
molecular means.
At birth all cranial sutures are abnormal apart from
lambdoid and head is tower-shaped, flat from front to
back with prominent forehead.

Fig. 33.9c: Clover leaf skull deformity. Clinical and


radiological findings

324

An Atlas of Neonatology

a result of this a grotesque shaped skull is found, that


shows bulging of 3 bones the temporal, occipital, and
frontal. The term clover leaf refers to these three
leaves. It can occur as an isolated condition or may
be associated with conditions like thanatophoric
dysplasia and campomelic dysplasia.

PRIMARY SOFT TISSUE/


CONNECTIVE TISSUE ANOMALIES
Klippel Trenaunay-Weber Syndrome
(Figs 33.10a1-2)
The cardinal features of this syndrome are capillary or
cavernus cutaneous hemangiomas, vericose veins and
hypertrophy involving one side of the body or a single
limb. Hemangiomas commonly occur in limbs or trunk.
Vericosities may be evident in the newborn period.
Most cases are sporadic.

Fig. 33.10a(1): Klippel-Trenaunay-Weber syndrome.


Asymmetrical hypertrophy of limb associated with vascular
nevi other features include venous malformations of internal
organs, syndactyly or polydactyly, vascular lesions of skin
may be remote from the hypertrophied limb, usually sporadic

Fig. 33.10a(2): Klippel-Trenaunay-Weber syndrome.


Note hypertrophy of the second toe and hemangioma

Osteogenesis Imperfecta Type II Perinatal


Lethal (Figs 33.10b1-8)
These infants are either stillborn or die in infancy. There
are multiple intrauterine fractures of long bones and
ribs. Long bones are bent and rib cage is small causing
respiratory insufficiency. Skull is large and fontanelle are
wide. Sclera is blue.

Fig. 33.10b(1): Osteogenesis imperfecta type I


(Perinatal lethal type)

Genetic Syndromes 325

Fig. 33.10b(2): Osteogenesis imperfecta type II (perinatal


lethal type). Multiple long bone fracture appear bend. Note
rib fracture

Fig. 33.10b(5): Osteogenesis imperfecta type II


(perinatal lethal type)

Fig. 33.10b(6): Osteogenesis imperfecta type II (perinatal


lethal type). Perinatal lethal type showing multiple deformities due to fracture
Fig. 33.10b(3): Osteogenesis imperfecta type II
(perinatal lethal type)

Fig. 33.10b(4): Osteogenesis imperfecta type II


(perinatal lethal type)

Fig. 33.10b(7): Osteogenesis imperfecta type II (Perinatal


lethal type). Multiple fractures of long bones with crumpled
appearance, multiple fractures of ribs appreciated as beading

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An Atlas of Neonatology

Fig. 33.10b(8): Osteogenesis imperfecta type II (Perinatal


lethal type). Multiple fractures of long bones and ribs resulting
in shortening of limbs

Osteogenesis Imperfecta Type III


(progressive deforming) (Figs 33.10c1-3)

Fig. 33.10c(2): OI Type III mild bowing of femora due to


fracture of femoral. Note bowing of legs due to fracture

Babies display shortened, bowed extremities, thoracic


defects and relative macrodactyly intrauterine fractures
are common and postnatal fractures go on occurring

Fig. 33.10c(3): Note blue sclera

with minor trauma and heal with excessive callus and


cause deformities. Sclera may be blue.
Marfans Syndrome (Figs 33.10d1-3)
Fig. 33.10c(1): Osteogenesis imperfecta type III (progressive
deforming type).Note blue sclera mild bowing of femora due
to fracture of note bowing of legs due to fracture

This condition is caused by a mutation of the Fibrillin1 gene (FBN-1) on chromosome 15 and is inherited
as an AD disorder. This disorder is characterized by

Genetic Syndromes 327

Fig. 33.10d(1): Marfans syndrome. Marfan baby with his


mother. Note tall stature of the mother

dolichostenomelia (long tapering limbs), arachnodactyly, pectus deformities of chest, mitral and aortic
regurgitations, upward ectopia lentis, myopia, high
palate, and mild joint laxity. Other connective tissue
features include scoliosis,and skin striae. A dilated aortic
root may be demonstrated even in some neonates and
aneurysm and dissection of aorta is an important cause
for mortality. Dural ectasia is demonstrated in some
cases. Long fingers, thumb sign (flexed and abducted
thumb crosses palm) are other features.
A severe neonatal variety has been described where
in marked Marfanoid features are associated with severe
cardiac valve insufficiency, aortic root dilatation and
early death. Many infants have congenital contractures
of the large joints, hypermobility of the fingers,
micrognathia and anterior chest deformity. The defect
is due to FBN-1 gene and can occur as AD or sporadic
case.
Ehlers-Danlos Syndrome (Fig. 33.10e)
Ehlers-Danlos syndrome is a heterogenous group of
connective tissue disorder characterised by abnormalities of skin, joints and other connective tissues due
to defective synthesis of fibrillar collagen in the
connective tissue. Collagen forms more than half of the
white fibres in the connective tissue including skin,
ligaments, tendons, blood vessels, viscera, bones and

Fig. 33.10d(2): Marfans syndrome. Marfans syndrome in new


born, mother of this child also had Marfans syndrome note
arachnodactyly. Echocardiogram showed aortic root dilatation

Fig. 33.10d(3): Marfans syndrome. Marfans syndrome in the


mother showing arachnodactyly, mother had aortic root
dilatation, MVP and was on beta blockers, she successfully
went through two pregnancies and deliveries

Fig. 33.10e: Ehlers-Danlos syndrome. Note hyperextensible skin. Note long fingers

328

An Atlas of Neonatology

Table 33.12: Classification, clinical features, mode of inheritance and biochemical defects in Ehlers-Danlos syndrome
Old

Classification
Revised

I Gravis

Classical

Soft, velvety
Large++
Hyperextensible+++ Small+++
Scoliosis+
Bruising++
Abnormal
scars

II Mitis

Classical

Soft, velvety
Hyperextensible+
Bruising+
Abnormal scars++

Large++
Small+++
Scoliosis++

III Familial
Hypermobility

Hypermobile

Soft
Hyperextensible+

Large+++
Small++

IV Arterial

Vascular

Thin transparent
Bruising

Large +
Small+

Pinched face, thin nose AD


Arterial/bowel/uterine
Rupture
Thin extremities
Short stature

CQL3A1
Mutations

V X-linked

Removed to
other
category

Soft, velvety
Hyperextensible+
Bruising+
Abnormal scars

Large++
Small++

Intra-muscular
hemorrhage

XLR

Not known

VI Ocular

Ocularscoliotic Soft, velvety


Hyperextensible+
Bruising+
Abnormal scars++

Large++
Small++
Scoliosis++
Dislocation+

Ocular fragility
Vascular fragility
Myopia
Hernia
Brittle cornea
Blue sclera

AR

Lysyl
hydroxylase
deficiency

VII A/B
Arthrochalasis
multiplex
Congenita
mutations

Arthrochalasis

Soft, velvety
Hyperextensible+
Bruising+

Large+++
Small+++
Dislocation
+++

Short stature

AD

COL1A1/
COL1A2

VII C Dermatospraxis

Dermatospraxis

Soft, velvety
Bruising++
Fragility+++

Hernia
Blue sclera
Vascular fragility
Osteopenia

AR

pNPI
Mutations

VIII
Periodontal

Removed to
other
category

Soft, velvety
Hyperextensible++
Bruising++
Abnormal scars++

Large ++
Small++

Periodontitis juvenalis

AD

Not known

IX
X linked cutis
laxa

Removed
from EDS
phenotypes

Soft
Lax
Hyperextensible

Limited
pronation/
supination

Bladder diverticula
Broad clavicles
Occipital horns

XLR

ATP7A
Mutations

X
Fibronectin
defect

Removed to
other
category

Hyperextensible++
Bruising++
Abnormal scars++

Large+
Small++

Petechiae
Striae distensae

AR

Defect in
fibronectin

Skin

Clinical features
Joint
Other connective tissue
hypermobility

Inheritance

Molecular
defect

Premature rupture of
fetal membrane,
varicose veins, hernia,
Abnormal valves

AD

COL5A1,
COL5A2,
COL1A1
Mutations

Varicose veins,
Abnormal valves

AD

COL5A1,
COL5A2,
Mutations
COL1A1
Null alleles

AD

Not known

Genetic Syndromes 329


cartilage. They have distinguishing gene structure,
amino acid sequence, tissue distribution and cells of
origin. Fibrillar collagens are a subset of five (I, II, III,
V and XI) of the nineteen known types of collagen
encoded by nine distinct genes. The ten identified types
of Ehlers-Danlos syndrome result from alterations in
fibrillar collagen structure, expression or posttranslational
processing. Therefore different forms of Ehlers-Danlos
syndrome present with phenotypic variations depending
on the tissue involvement, genetic defects and mode
of inheritance.
The classification of Ehlers-Danlos syndrome
depends on tissue involved, mode of inheritance and
biochemical defect. Of the ten types identified, types
I, II & III, that have autosomal dominant inheritance
accounts for 90% of the cases. New mutations with lack
of family history are reported in more than 50% (Table
33.12).

Prenatal diagnosis is possible by ultrasound


examination, which shows O shaped mouth and
restricted movements, polyhydramnios, etc.
Beals Contractural Arachnodactyly (Figs 33.10g1-3)
The disorder results from mutation of FBN-2 gene on
chromosome 15 and is inherited as an AD disorder. The

Restrictive Dermopathy (Fig. 33.10f)


It is an AR disorder that presents in neonatal period
with aplasia cutis or rigid skin, characteristic face (open
round mouth, hypertelorism, a small nose and mouth,
micrognathia and low set ears, absence of eyelashes and
eyebrows) and multiple joint contractures, death results
from respiratory failure because of rigid thorax, thin,
dysplastic clavicles, ribbon like ribs, poorly mineralized
skull are some of the radiologic features.

Fig. 33.10f: Restrictive dermopathy. Note downward slant of


eyes, hypertelorism, pinched nose, blepharophimosis,
microstomia with trismus, low set ears, micrognathia, and
skin erosion, transparent skin with easily visible blood vessel,
rigid skin, long nails

Fig. 33.10g(1): Beals contractural arachnodactyly.


Note cotractures at ankle joints

Fig. 33.10g(2): Beals contractural arachnodactyly.


Note arachnodactyly

330

An Atlas of Neonatology

Fig. 33.10g(3): Cutis laxa. Loose folds of skin, sagging jowls,


long upper lips. It may be inherited as AR, AD or XLR trait.
This condition has to be differentiated from Ehlers-Danlos
syndrome

disorder is often confused with Marfan syndrome, but


is a separate entity. Joint contractures present at birth
involving fingers, knees, hips and elbows to varying
extent and crumpled helix are characteristic features.
The most serious complication is scoliosis. The
contractures in this syndrome improve with age. Eye
and cardiac manifestations are rarely reported.
A severe congenital variety is reported which, often
as cardiac malformation, restrictive lung disease and
duodenal atresia in addition to the usual features of
arachnodactyly, contractures and crumpled helix.

Fig. 33.11a(1): Incontinentia pigmenti

Harlequin Syndrome
Please see chapter 32.

TUMORS AND HAMARTOMAS


Incontinentia Pigmenti (Figs 33.11a1-3)
Between birth and 6 weeks of age a linear vesicular
eruption appears on the trunk followed within a week
by warty eruption, which might persist up to 1 year of
age. The most serious abnormality is mental retardation
and seizures. Other anomalies are eye anomalies
(anophthalmia, cataract, optic atrophy, detached
retina), vertebral anomalies, and teeth abnormalities.
X-linked dominant inheritance with intrauterine lethality
in males is seen.

Fig. 33.11a(2): Incontinentia pigmenti. multiple small


pigmented bullae, whorled skin pigmentation other features
include seziures, microphthalmia inherited as X linked
dominant. Lethal in male hence only female are born

Sturge-Weber Syndrome
Consists of constellation of symptoms and signs including
a facial nevus (Portwine stain), seizures, hemiparesis,
intracranial calcification and in many cases mental
retardation. The incidence is one in 50,000 births.

Genetic Syndromes 331

Fig. 33.11a(3): Incontinentia pigmenti. Note linear skin


pigmentation in young infant

The facial nevus is present at birth and tends to be


usually unilateral and always involves upper face and
eyelid. Nevus may be seen in other areas as well.
Buphthalmos of the ipsilateral eye can occur. Seizures
develop in the first year and typical railroad calcification
of cerebral vessels is seen along with cortical atrophy
at around 10 years of age.
Neurocutaneous Melanosis Sequence
(Fig. 33.11b)
Neurocutaneous melanosis (NCM) is a sporadic unusual
congenital neurocutaneous syndrome characterized by
the presence of gaint or multiple nevi and extensive
proliferation of melanotic cells in the central nervous
system occurring once in 20,000 live births. Gaint
pigmented nevi are usually seen in bathing trunk area,
less frequently in the occipital region or upper back.

Fig. 33.11b: Melanosis sequence

Some times, small or medium sized congenital


melanocytic nevi are seen on the scalp, face, or neck
in association with the large lesions. The essential
pathologic characteristic of the central nervous system
in NCM is overpopulation of melanotic cells in the
leptomeninges. Central nervous system function may
be normal initially, but seizures and mental deterioration
may begin before 1year of age, apparently related to
progression of the melanoblastic involvement of the
pia-arachnoid, leading to increased intracranial pressure,
spinal cord compression and to diffuse or localized
malignancy that occurs in greater than 50% of patients.
The neurologic complications include, chronic basal
meningitis, seizures, hydrocephalus and rarely subdural
and intracranial hemorrhage. Majority of patients die
before 2years of age and only 10% of the patients are
known to have survived past the age of 25 years.
The syndrome seems to be morphogenesis error of
the embryonic neuroectoderm. The genetic mechanism
underlying these complex birth defects has been
hypothesized to result from the action of lethal
autosomal dominant genes surviving by mosaicism.
Hypomelanosis of Ito (Fig. 33.11c)
An etiologically heterogeneous (chromosomal or genetic
mosaicism) condition characterized by characteristic skin

Fig. 33.11c: Hypomelanosis of Ito in an older child

332

An Atlas of Neonatology

lesions showing streaked, whorled, or mottled areas of


hypopigmentation on limbs and trunk usually evident
in infancy.
Mental retardation, seizures and cerebral atrophy are
common associations.
Tuberous Sclerosis (TS) (Fig. 33.11d)
It is inherited as an AD trait, occurring once in 6000
births. TS gene is located on chromosome 9q (TSC1)
and 16p (TSC2)
Fifty per cent cases occur as inherited cases and
remaining as sporadic cases. The classic triad of TS
includes adenoma sebacium (malar angiofibromas),
mental retardation, and convulsions. But in neonatal
period the manifestation include hypopigmented patches
(ash leaf spots), forehead fibromas, myoclonic jerks.
Investigation may reveal renal cysts (angioleiomyoma),
cardiac rhabdomyoma. Hypopigmented patches are
better seen with Woods lamp. CT features of calcified
tubers in periventricular area develop after 3-4 years.
Shagreen patches develope around 2 years of age and
adenoma sebaceum at around 4 years of age.

Fig. 33.11e(1): Neurofibromatosis Type 1 AD disorder. Note


caf au lait spots over the babies trunk and neurofibromata
over mothers abdomen and right forearm

Fig. 33.11e(2): Neurofibromatosis Type 1 AD. Newborn with


caf au lait spots on mothers forearm and neurofibroma

Fig. 33.11d: Calcification in a case of tuberous sclerosis

Neurofibromatosis (NF) (Figs 33.11e1-2)


An AD disorder that exists in two forms: I and II. NFI occurs once in 400 births and is diagnosed by any
two of the following signs:

1. Six or more caf-au-lait spots over 5mm in prepubertal individuals and over 15mm in post pubertal
individuals. Caf-au-lait spots are present in 100%
cases of NF. They are present at birth but increase
in number and depth of pigmentation with age.
2. Axillary or inguinal freckling
3. Two or more iris Lisch nodules: Hamartomas
located within the iris and seen by slit lamp. They
are present in 75% cases of NF-I but not in NF-II.
They start appearing after 3 years and increase in
number and size with advancing age.
4. Two or more neurofibromas or one plexiform
neurofibroma

Genetic Syndromes 333


5. A distinctive osseous lesion such as sphenoidal
dysplasia (causing pulsations, exophthalmos) or
cortical thinning of long bones with or without
pseudoarthrosis.
6. Optic glioma occurs in 15% of NF-I
7. A first degree relative with NF-I
NF-II accounts for 10% of all cases of NF with an
incidence of 1 in 50,000. It usually presents late in life.
It is diagnosed by:
1. Bilateral VIII nerve masses (acoustic neuroma)
2. A parent, sib or child with NF-II
Hemangiomas (Figs 33.11f1-3)
These lesions result from developmental malformation
of blood vessels of the skin and subcutaneous tissue and
occasionally affecting internal organs like liver, kidney,
meninges, etc.The incidence of hemangiomas in term
infants is 1-2.6%. However 10-12% of children develop
hemangiomas and most of them are noticed at about
1 month of age. There are three types of hemangiomas:
1. Capillary hemangioma: It consists of a number of
inter communicating blood spaces of the size of
capillaries. It may present clinically as strawberry
nevus or as a port-wine stain as in Sturge-Weber
syndrome. Strawberry nevi appear few weeks after
birth and may grow slowly up to three years, but
eventually regress spontaneously around 7-8 years
of age. They rarely need treatment unless they are
in vital areas or rapidly growing, which are treated
by cortisone or laser therapy. Port-wine stain is

Fig. 33.11f(2): Hemangioma. Note hemangioma


over scalp and shoulder

Fig. 33.11f(3): Hemangioma. Nasal hemangiomas may


cause nasal obstruction. Oral steroids may help

Fig. 33.11f(1): Hemangioma. Note periorbital hemangiomas.


Same child after 4 weeks of steroid therapy

reddish discoloration of skin, the size of which may


vary. It is present at birth and remains throughout
life. Facial distribution is associated with vascular
malformation of the cerebral cortex and the
meninges (Sturge-Weber syndrome) and they may
cause seizures, mental retardation and motor deficits.

334

An Atlas of Neonatology

These cerebral vascular malformations may calcify


after 10-12 years and may cause rail road pattern
of calcification seen on skull X-ray.
2. Cavernous hemangioms: When the deeper
vasculature is involved the hemangioma is called
cavernous, which can extend into subcutaneous
tissue and even deeper into the muscles In these
hemangiomas the blood spaces called sinuses are
larger than capillaries and they inter communicate.
3. Plexiform hemangiomas: In these feeding vessels are
arterioles and cause pulsations. They are also called
as cersoid aneurysms.
Hemangiomas have a well-defined course consisting
of an early rapid growth phase, followed by slow
involution in most cases. Most of them regress by 57 years with most of this process occurring in first few
years of life. About 10% develop problems like
ulceration, infection, Kasabach-Merritt syndrome, and
disfigurement from rapid growth, occlusion or
compression of a vital structure or orifice and high
output failure.
Eyelid hemangiomas may cause amblyopia,
astigmatism, strabismus, ptosis, proptosis, exposure
keratitis, etc. The commonly used methods of treatment
include, surgical resection injection of intralesional
steroids, oral steroids, and laser therapy.

Fig. 33.11g(1): Proteus syndrome in a newborn

Fig. 33.11g(2): Proteus syndrome in an older child

Neuroblastoma
Please see chapter 32.
Teratoma
Please see chapter 32.

characteristic features are hemihypertrophy and


macrodactyly.

TERATOGENS

Cystic Hygroma

Congenital Rubella Syndrome

Please see chapter 32.

Congenital Rubella can involve many organs. Common


manifestations include IUGR, cataract, microphthalmia,
myocarditis, PDA, pulmonary artery branch stenosis,
blue berry Muffins skin lesions, sensory neural hearing
loss and meningoencephalitis.
Persistent infection leads to pneumonia, hepatitis,
bone lucencies, thrombocytopenic purpura and later
developmental delay. The triad of cataract, PDA and
sensory neural deafness is referred to as Congenital
Rubella syndrome.

Proteus Syndrome (Figs 33.11g1-2)


Proteus syndrome is a syndrome of unknown etiology
characterized by hemihypertrophy, subcutaneous
tumors and macrodactyly. Overgrowth may be seen all
over the body or may be part of the body, head is
usually big. Hyperpigmented areas (epidermal nevi),
Lipoma, lymphangioma, and hemangioma occur
over thorax and upper abdomen. The most

Genetic Syndromes 335


Specific IgM in neonatal serum or viral culture from
neonatesnasopharynx, or urine or tissues confirm the
diagnosis. Prenatal diagnosis of fetal Rubella can be
made by either isolating the virus from amniotic
fluid or by identification of rubella specific IgM in cord
blood.
First trimester infection causes rubella syndrome in
70% of cases. It is 90% if infection occurs before 11
weeks of pregnancy and is 10-20% by end of first
trimester. See also chapter 20.
Congenital Varicella Syndrome
When pregnant women contracts chicken pox about
25% of the fetus become infected. Two percent of
fetuses whose mother had varicella between 8-20
weeks of gestation show varicella embryopathy; most
features are due to virus induced damage to CNS.
VZV fetopathy includes cicatricial skin lesions
hypopigmentation, microphthalmia, chorioretinitis, optic
atrophy, cataract, microcephaly, hydrocephaly, cerebral
calcification, hypoplasia of an extremity, Horners
syndrome and urinary sphincter disturbances and
absent tendon reflexes.
Viral DNA can be detected in tissue sample by PCR.
See also chapter 20.

Fig. 33.12a(1): Jarcho Levin syndrome. Multiple vertebral


defects consists of hemi-vertebrae abnormal and crowdedribs are the radiological features. Anteverted nostrils, broad
forehead and upslanting eyes, short neck, broad chest are
some of the clinical features condition is inherited as
autosomal recessive trait. See X-ray

CMV
Please see chapter 20.
Toxoplasmosis
Please see chapter 20.

Fig. 33.12a(2): Jarcho Levin syndrome. Multiple vertebral


defects: hemi-vertebrae abnormal and crowded-ribs other
features include anteverted nostril, broad forehead, upslanting eyes, short neck, note abdominal distention. Autosomal
recessive inheritance

Syphilis
Please see chapter 20.

MISCELLANEOUS SYNDROMES
Jarcho Levin Syndrome (Figs 33.12a1-3)
It is an autosomal recessive syndrome characterized by
short neck, costovertebral dysostosis, crab like flaring
of chest or absence of ribs, protuberant abdomen and
abnormal thorax. These infants die early due to
pulmonary complications due to small thorax.

Fig. 33.12a(3): Jarcho


Levin syndrome. Showing
costovertebral dysostosis
crab-like flaring of ribs.
Note short neck, various
spinal abnormalities and
abdominal distention

336

An Atlas of Neonatology

Fig. 33.12b: Leprechaunism. Emaciated appearance


hirsutism, thick lips, wide nostrils, large clitoris, inheritance
AR. Other features include prominent eyes, mental
retardation, low birth weight, hyperinsulinism

Fig. 33.12c: Lipodystrophy. Hirsutism with lipoatrophy


later develop insulin resistance, diabetes mellitus

Leprechaunism (Donohues Syndrome)


(Fig. 33.12b)
An autosomal recessive disorder due to mutation in
INSR (insulin receptor) gene, characterized by growth
retardation, severe failure to thrive, generalized
lipodystrophy, hirsutism, protuberant abdomen,
umbilical and inguinal hernias, large penis or clitoris,
aged face, microcephaly, large low set ears, hypertelorism, large mouth, gum hypertrophy, breast
engorgement, prominent eyes, depressed nasal bridge,
broad nasal tip, thick lips and micrognathia. Relatively
large hands and feet, acanthosis nigricans, hyperplasia
of pancreatic islets and cryptic gonadal changes are seen
at autopsy. The syndrome is characterized by insulin
resistance and prenatal diagnosis is reported by
molecular analysis of the insulin receptor gene.

Fig. 33.12d: Milroys disease

Lipodystrophy (Fig. 33.12c)

Milroys Disease (Fig. 33.12d)

It is a hereditary disorder of generalized deficiency of


adipose tissue which can sometimes present at birth
with hirsutism, coarse skin with hyperpigmentation,
abundant curly scalp hair, generalized lipoatrophy,
macrosomia with increased length.

A disorder with congenital lymphedema.


Please see chapter 32.
Infantile Polycystic Kidney
Please see chapter 32.

Genetic Syndromes 337

SEQUENCES AND ASSOCIATIONS


Amniotic Rupture Sequence (ABS)
(Figs 33.13a1-15)
Early rupture of the amnion results in mesodermic
bands that emanate from the chorionic side of the
amnion and insert in the fetal body, leading to
amputation, constriction and postural deformities
secondary to immobilization.The abnormalities may
sometimes simulate genetic dysmorphic syndromes.But
careful examination of defects and examination of
placenta can aid in making a diagnosis.This is extremely
important in counseling the parents.

Fig. 33.13a(1): Amniotic band sequence. Note constricting


band almost touching bone over right limb

Fig. 33.13a(2) Amniotic band sequence. Note amniotic band


(arrow) placenta ( pl ). Antenatal diagnosis of amniotic band

Fig. 33.13a(3): Amniotic band sequence.


Note amputations of fingers

Fig. 33.13a(4): Amniotic band sequence. Note constricting band


with distal limb edema right foot and left toe amputations

Fig. 33.13a(5): Amniotic band sequence. Note amputations


of left forearm and deformity of lower limbs

338

An Atlas of Neonatology

Fig. 33.13a(6): Amniotic band sequence. Note syndactyly,


brachydactyly due to amniotic bands
Fig. 33.13a(9): Amniotic band sequence. Note constriction
band with talipes and brachysyndactyly

Fig. 33.13a(7): Amniotic band sequence.


Note constriction left leg

Fig. 33.13a(8): Amniotic band sequence.


Note amputation of fingers

Fig. 33.13a(10): Amniotic band sequence. Note amputation


of digits and incidental staphylococcal scalded skin
syndrome

Fig. 33.13a(11): Amniotic band sequence. Amniotic band


causing encephalocele, facial disruption and limb body wall
complex. Note band being lifted

Genetic Syndromes 339

Fig. 33.13a(14): ABS causing transverse limb defect


Fig. 33.13a(12): Amniotic band. Note facial disfigurement
due to amniotic band sequence

Fig. 33.13a(15): Amniotic band sequence


transverse limb defect

Abnormalities include;
Limb defects: Multiple, asymmetric, constriction rings
of limbs and digits, amputation of limb or digits.
Pseudosyndactyly, abnormal dermal ridge pattern,
simian crease and club feet.
Craniofacial defects: Encephalocele, multiple and
asymmetrical anencephaly, facial clefting lip/palate
severe nasal deformities, asymmetrical microphthalmia,
incomplete or absent cranial calcification.
Visceral defects: Gastroschisis, omphalocele
Fig. 33.13a(13): Amniotic band sequence. Occipital
encephalocele due to amniotic bands

Ref. Am J Obstet Gynecol 91; 65, 1965, J Pediatr 95: 544,


1979, Am J Obstet Gynecol 144; 243: 1982.

340

An Atlas of Neonatology

Limb Body Wall Sequence (Figs 33.13b1-7)


Limb body wall complex is a variable set of disruptive
anomalies, including lateral body wall defect involving
thorax, abdomen or both, skeletal abnormalities of the
spine, lower or upper limb reduction anomalies and
failure of umbilical cord development. The incidence
is 1:50,000 births. The defects observed in the limb
body wall complex are incompatible with extrauterine
life. Most infants are stillborn, or succumb in the early
neonatal period due to respiratory insufficiency.
The diagnosis of this entity is based on two of the
three following characteristics.
1. Exencephaly/encephalocele and facial clefts
2. Thoraco and/or abdominoschisis and
3. Limb defects
Associated malformations include central nervous
system lesions (64%), like exencephaly, encephalocele,

Fig. 33.13b(3): Limb body wall complex

Fig. 33.13b(4): Limb body wall complex


Fig. 33.13b(1): Limb body wall complex

Fig. 33.13b(2): Limb body wall complex

Fig. 33.13b(5): Limb body wall complex

Genetic Syndromes 341

Fig. 33.13b(6): Limb body wall complex

ectopia cordis, sternal cleft, cardiac defects and an upper


midline omphalocele (pentalogy of Cantrell). Failure of
closure of the caudal body fold results in exstrophy of
the bladder, imperforate anus, partial colonic agenesis
and agenesis of one umbilical artery together with
hypogastric omphalocele. Aplasia or hypoplasia of the
paraspinous or thoracolumbar musculature is
responsible for severe scoliosis. Insufficiency in both
cephalic and caudal body folding leads to a combination
of the above mentioned features. Differential diagnoses
of limb body wall complex include early amnion
rupture, extra amniotic pregnancy, omphalocele,
pentalogy of Cantrell and gastroschisis.
Prenatal diagnosis of limb-body wall complex is
done by ultrasonography. Ultrasonographic detection
of abdominoschisis, scoliosis, abnormalities of the lower
extremities, a single umbilical artery and a short
umbilical cord is important for the prenatal diagnosis.
Association with very high maternal serum and amniotic
fluid alpha-fetoprotein has been reported.
Sirenomelia (Figs 33.13c1-4)

Fig. 33.13b(7): Limb body wall complex. Note anencephaly,


thoracoabdominal evisceration and limb defects

meningomyelocele and hydrocephalus, midfacial


(defects (40%), absent diaphragm (74%), cardiac
defects (43%), gastrointestinal malformations (100%)
(malrotation, intestinal atresia, anal atresia), renal
abnormalities (65%), genital abnormalities (56%),
amniotic bands (40%) and placental abnormalities.
The body stalk malformation results from a defect
in the germinal disc, leading to an abnormal body
folding, an abnormal amniotic cavity formation and a
failure to obliterate the extraembryonic coelom. This
accounts for the short or absent umbilical cord and the
broad insertion of the amnio-peritoneal membrane
onto the placental chorionic plate. Cephalic body fold
defects lead to an anterior diaphragmatic hernia,

Sirenomelia, is an anomalous development of the


caudal region of the body, with varying degrees of
fusion of lower limbs. It is an exceptionally rare
congenital malformation characterized by a single fused
lower limb. Incidence of this rare anomaly is
approximately 1/1,00,000 births. Various anomalies like
vertebral defects, renal agenesis, imperforate anus,
neural tube defects, etc. occur associated with sirenomelia.
Normally, the umbilical cord contains two arteries
originating from the iliac arteries which return the blood
to the placenta. In many sirenomelia cases, a single
umbilical artery is found originating from the abdominal
aorta. The aorta distal to the origin of this major vessel
is always subordinate and gives no tributaries, especially
renal or inferior mesenteric arteries, before it bifurcates
into iliac arteries. This vascular alteration leads to a
Vitelline artery steal in which blood is diverted from
the caudal structures of the embryo to the placenta.
This is considered responsible for fused limbs, sacral
dysgenesis, vertebral defects, imperforate anus and
absence of rectum, absence of genitalia, and absence

342

An Atlas of Neonatology

Fig. 33.13c(2): Sirenomelia


Fig. 33.13c(1): Sirenomelia

Fig. 33.13c(3): Sirenomelia

Fig. 33.13c(4): Sirenomelia (Radiological spectrum)

Genetic Syndromes 343


of bladder that occurs in sirenomelia. Association of
omphalocele, exomphalos, pentalogy of Cantrell and
limb bodywall complex in sirenomelia cases suggests a
common etiology similar to vascular steal leading to
ventral developmental defects in these conditions.
Caudal regression syndrome comprises developmental anomalies of the caudal vertebrae, neural tube,
urogenital and digestive organs and hind limbs; the
precursors of all of which are derived from the caudal
eminence. This anomaly is encountered in babies of
diabetic mothers. The overlapping of associations in
caudal regression syndrome and sirenomelia, made
researchers consider sirenomelia as a severe manifestation of caudal regressions syndrome.
Association of cranial defects like hydrocephalus,
cebocephaly, holoprosencephaly, anencephaly etc. in
many reported cases of sirenomelia could not be
explained by caudal regression or vascular steal alone.
So also the association of radial dysplasia (a component
of VACTERL anomaly) with sirenomelia is inexplainable
with the above hypothesis. These heterotopic defects
in multiple congenital anomalies can be better understood by the recent concept of primary developmental
defect during blastogenesis. Blastogenesis is the period
in embryonal development extending from time of
fecundation to the end of gastrulation (4th week). It
is during this period that the undifferentiated regions
of embryo (primary field) get differentiated to areas of
specific morphogenetic fates (progenitor fields). A single
hit during this period may produce defects in different
progenitor fields producing polytopic manifestations.
The heterogeneity depends on the timing and intensity
of this hit.

Fig. 33.13d(1): Oligohydramnios sequence. Potters facies

Fig. 33.13d(2): Oligohydramnios sequence. Potters facies

Oligohydramnios Sequence (Figs 33.13d1-4)


Oligohydramnios or decreased amniotic fluid seen in
about 0.5% of pregnancy. Oligohydramnios may be a
direct manifestation of an underlying anomaly like renal
agenesis. The presence of oligohydramnios will have
secondary effects on fetus due to fetal compression and
pulmonary hypoplasia. The typical face is characterized
by flat face, big nose with flat nasal tip, low set ears,
receding chin and prominent skin folds along the cheeks
(Potters face).

Fig. 33.13d(3): Oligohydramnios sequence. Potters facies

344

An Atlas of Neonatology
Table 33.13: Summary of effects of oligohydramnios

Fig. 33.13d(4): Oligohydramnios sequence. Potters facies

Renal agenesis, urethral atresia


Renal dysplasia
IUGR
Postmaturity
Obstructive uropathy
Pulmonary hypoplasia
Potters syndrome
Fetal limb defects
Fetal facial defects
Amnion nodosum
Prune belly syndrome
Club foot
Intestinal pseudoobstruction
Umbilical cord compression during delivery

Fig. 33.13e(1): Early urethral obstruction sequence.


Note huge dilated abdomen

In prolonged pregnancy, chronic amniotic fluid leak


or diminished uterine height should lead to the
suspicion of oligohydramnios. Several ultrasonographs
should be done to monitor fetal growth and amniotic
volumes.
Other adverse effects of oligohydramnios on the
fetus are depicted in Table 33.13.
Early Urethral Obstruction Sequence
(Figs 33.13e 1-3)
Urethral valve, urethral atresia, a bladder neck obstruction or distal urethral obstruction early in embryogenesis
results in bladder distention. It occurs predominantly
in males with male to female ratio of 20:1. The bladder
valve distention causes hydroureter and renal dysplasia
or may cause severe abdominal distention leading to

Fig. 33.13e(2): Early urethral obstruction sequence.


Note hypertrophied bladder and open abdomen

abdominal muscle deficiency and excessive abdominal


skin. Early bladder distention can also lead to persistent

Genetic Syndromes 345

Fig. 33.13e(3): Early urethral obstruction sequence

urethral valves, colonic malrotation, iliac vessel


compression which causes lower limb deficiency and
cryptorchidism. The bladder may rupture. Most babies
die in mid or late pregnancy. The condition can also
occur as a component of VATER association. See prune
belly syndrome in chapter 32.
Exstrophy of the Bladder or Ectopia Vesicae
(Fig. 33.13f)
This anomaly occurs once in 30,000 births. Exstrophic
anomalies include bladder exstrophy, epispadiasis and
cloacal exstrophy. These conditions result from a
premature breakdown of the infraumbilical membrane
(mesoderm) to varying degrees. Normally, this
membrane invades the entire cloacal membrane except
at the urogenital floor, where the genital tubercles fuse.
Failure of the infraumbilical membrane to invade the
cloacal membrane results in vesicle exstrophy alone,
representing an intermediate spectral deficiency in its
lining. If it occurs before the formation of the urorectal
septum, the more severe cloacal exstrophy results. If
it occurs still later epispadiasis results.
The anatomic defects include an absent umbilicus,
protrusion of an exposed posterior bladder wall
mucosal surface with its striking cherri red colour, the

Fig. 33.13f: Exstrophy of baldder (Ectopia vesicae)

ureteral orifices spurting urinary effluxes and sharp


demarcation between the exposed bladder mucosa and
the surrounding skin. There is gap in pelvic symphysis,
dorsally tethered incomplete penis, ventrally incomplete
prepuce, broadly splayed glans, short urethral mucosal
strip between the bladder and the glans, but a normally
descended testis and an underdeveloped scrotum. In
females, divergent labia and mons, bifid clitoris and large
external urinary meatus occurs.
Caudal Dysplasia Sequence (syndrome)
(Fig. 33.13g)
The structural abnormalities include varying degrees of
incomplete development of sacrum, to a less extent,
lumbar vertebrae. Absence of sacrum leads to flat
buttocks, short interglutial cleft, dimpling of buttocks,

346

An Atlas of Neonatology

Fig. 33.13h: Klippel-Feil sequence

Fig. 33.13g: Caudal dysplasia sequence

disruption of distal spinal cord leading to incontinence


of urine and stool.
Severely affected infants have flexion and abduction
of hips, popliteal webs and TEV. Renal agenesis,
imperforate anus, cleft lip/palate, microcephaly, and
meningomyelocele occasionally occur. Maternal
diabetes is associated with this syndrome in 16% of
cases.

Fig. 33.13i(1): VATER association. Note anal atresia

Klippel-Feil Sequence (Fig. 33.13h)


This sequence is characterized by fusion of cervical
vertebrae and short neck, which can cause webbing of
neck and torticollis. It is more common in females and
the incidence is estimated to 1 in 42,000 births. This
sequence can be a part of iniencephaly, cervical
meningomyelocele. Syringomyelia or syringobulbia.
Deafness is found in 30% of cases.
VATER Association (Figs 33.13i1-2)
This association is an acronym for vertebral defects, anal
atresia, tracheoesophageal fistula with esophageal atresia
and radial and renal dysplasia. Single umbilical artery

Fig. 33.13i(2): VATER association. Note genital abnormality,


anal atresia, radial dysplasia, Vertebral anomalies, anal
atresia, cardiac defects tracheoesophageal fistula, radial/
renal, limb defects

Genetic Syndromes 347


and cardiac defects are also associate, and some times,
the association is also called VATERS to include
ventricular septal defect and single umbilical artery. The
exact etiology is unknown; it is sporadic in occurrence.
Arthrogryposis
Please see chapter 32.
Holoprosencephaly Sequence
Please see chapter 32.
Renal Agenesis
Please see chapter 32.

Fig. 33.13j(2): CHARGE association.


Note ear anomalies

Spinal Dysraphism Sequence


Please see chapter 32.
Twin: Conjoined and Acardia
Please see chapter 32.
Hypothyroid Sequence
Please see chapter 32.
CHARGE Association (Figs 33.13j1-9)
CHARGE acronym consists of Coloboma, Heart
disease, Atresia choane, Retarded growth and
development, and or CNS anomalies, Genital
anomalies, and or hypogonadism and, Ear anomalies
and or Deafness.

Fig. 33.13j(1): CHARGE association. Note genital


abnormality

Fig. 33.13j(3): CHARGE association.


Note genital abnormality

Fig. 33.13j(4): CHARGE association

348

An Atlas of Neonatology

Fig. 33.13j(5): CHARGE association. CHARGE acronym


consists of Coloboma, heart disease, atresia choane,
retarded growth and development, and or CNS anomalies
genital anomalies, and or hypogonadism and, ear
anomalies and or deafness

Fig. 33.13j(8): CHARGE association

Fig. 33.13j(6): CHARGE association. Note bony atresia


posterior choane bilateral (arrow)

Fig. 33.13j(9): CHARGE association. MCU showing


vesicoureteric reflux with cystitis

BIBLIOGRAPHY

Fig. 33.13j(7): CHARGE association. Note hydronephrosis

1. Kulkarni ML, Mathew Kurian, Guruprasad G,


Panchakshariah. Genetic heterogenicity in Waardenburg
syndrome. J Med Genet 1989; 26: 411-12.
2. Kulkarni ML, Venugopal P. Amniotic band syndromeA
review. Indian Pediatr 1990; 27: 471-76.
3. Kulkarni ML, Reddy VV, Mehta DS. Amniotic band
syndrome: Report of a case. Annals of Dentistry 1991;
1(1): 30-32
4. Kulkarni ML. Noonan syndrome. Indian Pediatr 2003; 40:
431-32.

Genetic Syndromes 349


5. Kulkarni ML, et al. Robinow syndrome. Indian Pediatr
2004; 41:89.
6. Kulkarni ML, et al. Zellweger syndrome. Indian Pediatr
2003; 40: 682.
7. Kulkarni ML, et al. Sirenomelia. Ind J Ped 2004; 71:447-9.
8. Kulkarni ML, et al. Limb body wall complexA case
report and review of literature. Perinatology 2003; 5: 9194.
9. Kulkarni ML. Grebe syndrome. London dysmorphology
Data Base. Oxford University Press. Walton Street, Oxford,
OX3, 6DP, UK 1995.
10. Kulkarni ML. Waardenburg syndrome. London
Dysmorphology Data Base. Oxford University Press.
Walton Street. Oxford, OX3, 6DP, UK 1995.
11. Kulkarni ML. Grebe Syndrome. Possum/Ossum
Syndromes and Skeletal Dysplasia Data Base. The
Murdoch Institute, Royal Children Hospital, Flemington
Road, Parkville, Victoria 3053, Australia 1995.
12. Kulkarni ML. Waardenburg Syndrome. Possum/Ossum
Syndromes and Skeletal Dysplasia Data Base. The
Murdoch Institute, Royal Children Hospital, Flemington
Road, Parkville, Victoria 3053, Australia 1995.
13. Kulkarni ML, Venkataramana V, Sureshkumar C,
Vijayendra Reddy E. Hypomelanosis of Ito. Indian Pediatr
1996; 33: 243-245.
14. Kulkarni ML, Bhagyavathi M, Nasser A. OFD syndrome.
Annals of Dentistry (Accepted and in press).
15. Kulkarni ML, Sureshkumar C, George VG. Stickler
syndromeReport of 4 cases. Annals of Dentistry. 1993;
52 (2): 20-27.
16. Kulkarni ML, Basavaraj AC, Sureshkumar C, George VG,
Venkataramana V. Conjoined twins. Indian Pediatr 1994;
31: 1017-1024
17. Kulkarni ML, Sureshkumar C, Venkataramana V, Samuel
Koshyt, Bhagyavathi M, Sekhar Reddy G. Thanatophoric
dysplasia. Indian Pediatr 1994; 31: 1405-1410.

18. Kulkarni ML, Sureshkumar C, Venkataramana V, Shabber


HM. Russell-Silver syndromeA study of 3 cases. Annals
of Dentistry 1995; 54 (1-2): 56-60.
19. Kulkarni ML, Bhagyavathi M, Naseer A, Basanthkumar GR,
Kulkarni BM. Grebe syndromeA severely affected case.
J Med Gen 1995; 32 (4): 326-327.
20. Kulkarni ML, Sureshkumar C, Venkataramana V. Samuel
Koshyt, Bhagyavathi M. Congenital contractural
arachnodactyly. Indian Pediatr 1995; 32: 657-65.
21. Kulkarni ML, Kulkarni BM, Abdul Naseer PU. Antenatal
diagnosis of Grebe syndrome in a twins pregnancy by
ultrasound. Indian Pediatr 1995, 32:1007-11
22. Kulkarni ML, Venkateshan G. Grebes Syndrome-a family
study. Indian J Orthopaedics 1991; 25: 39-40.
23. Kulkarni ML. Down syndrome. Indian Practitioner 1991;
XLIV (7): 523-26.
24. Kulkarni ML. Turner syndrome. Indian Practitioner 1991;
XIIV (10): 775-77.
25. Kulkarni ML, Venkataramana V. Anthropometry in clinical
genetics. Pediatrics Clinics of India 1993; 28 (3): 19-32.
26. Kulkarni ML. Chromosomal disorders. The Indian
Practitioner 1993; XLVII: 53-6.
27. Kulkarni ML, Sekhar Reddy G. Skeletal DysplasiaAn
evaluation. The Indian Practitioner 1994; XLVII: 309-16.
28. Kulkarni ML, Srinivasulu B, Kulkarni BM, Kulkarni PM,
Anitha S. Oral Facial Digital Syndrome Type-V (Thurston
Syndrome)-A Family report. J Clinal Genetics and Tribal
Research 1998; 3: 104-10.
29. Kulkarni ML, Srinivasulu B, Woodun R, Kulkarni PM,
Anitha S. Oral facial digital syndromeA case report. J
Clinal Genetics and Tribal Research 1998; 3: 111-18.
30. Kulkarni ML, Kirankumar BV. Holt-Oram syndrome.
Pediatrics Today 2000; 111-239.
31. Kulkarni ML, Kirankumar BV, Ramesh Dasari. Asymmetric
crying face syndrome. Pediatrics Today 2000; 111(7):
507.

APPENDICES
APPENDIX-1
Salient Features of Selected Neonatal Syndromes

For diagnosis of multiple malformation syndromes, developing


a mental picture is of paramount importance. Reading
exhaustive literature may not help in developing one. A brief
and concise synopsis of various syndromes listed below will
help the reader to conceive and comprehend to develop the
most needed mental picture of a syndrome. For better
delineation, the synopsis includes the most glaring and
important features.
SYNDROMES WITH DISORDERED GROWTH
Cornelia de Lange

Growth retardation
Microbrachycephaly
Micrognathia
Bushy eyebrows, synophrys
Micromelia, syndactyly, oligodactyly
Cardiac defects
Genital defect

Russell-Silver Syndrome

Severe growth restriction at birth


Asymmetry
Prominent head large AF
Triangular face thin upper lip, large ears
Clinodactyly, syndactyly of II and III toes

Seckel Syndrome

IUGR
Microcephaly
Micrognathia
Clenched hands syndactyly II III
Valgus feet, polydactyly
Micropenis
Genital abnormality
Renal abnormality

Beckwith-Wiedemann Syndrome

Omphalocele
Macroglossia
Organ hypertrophy especially kidneys

Infant of Diabetic Mother

Macrosomia
Caudal regression syndrome
Congenital heart diseases

Noonan Syndrome

Short stature
Short neck
Lymphedema neck, feet
Pulmonary stenosis ASD
Micropenis
Cryptorchidism
Hemi vertebrae

Johnson-Blizzard Syndrome

Hypoplastic alae nasi


Midline scalp defects
Frontal up sweep
Hypothyroidism
Deafness
Pancreatic insufficiency

Hallermann-Streiff Syndrome

Microphthalmia
Small pinched nose
Hypotrichosis
Neonatal teeth
Cataracts

Robinow Syndrome

Flat face
Frontal bossing
Prominent, down slant eyes
Small upturned nose
Triangular mouth
Micrognathia alveolar ridge
Short forearm
Small hands
Hypogenitalism
Wide anterior fontanel

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An Atlas of Neonatology

SYNDROMES WITH MAJOR FACIAL DEFECTS


Fraser Syndrome

Cryptophthalmos
Ear and nose anomaly
Syndactyly
Genitourinary abnormality
Laryngeal stenosis

Inner canthal fold


Lateral displacement of inner canthi

Waardenburg Syndrome

White forelock
Dystopia canthorum
Deafness
Hirschsprungs disease

Goldenhar Syndrome

Hemifacial atrophy
Ear anomaly with tags
Hypoplastic mandible
Macrostomia
Vertebral anomalies

Oro-Facial-Digital Syndrome

Facial clefts
Broad nasal bridge
Bifid nasal bridge
Bifid nasal tip
Micrognathia
Multiple clefts of tongue
Polysyndactyly, bifid hallux
Clinodactyly of fifth finger

Pierre Robin Syndrome

Micrognathia
Glossoptosis
U-shaped cleft palate

Treacher Collins Syndrome

Micrognathia
Antimongoloid eye slant
Notch in lower eyelid
Abnormal auricles, skin tags
Cleft palate

Medium Cleft Face (Frontonasal Dysplasia)

Hypertelorism
Median cleft lip
Split nose

Van der Woude Syndrome

Lip pit-cleft lip


Lower lip pit (s)
Cleft lip

Blepharophimosis Syndrome

Ptosis

SYNDROMES WITH PRIMARY BRAIN/NEUROMUSCULAR


ABNORMALITY
Meckel Gruber Syndrome

Encephalocele
Polydactyly
Cystic kidneys
Microcephaly
Microphthalmia
Cleft palate
Cryptorchidism
Heart defects
Various brain abnormalities

Neu-Laxova Syndrome

Microcephaly
Hypertelorism
Protruding eyes
Absent lids
Cataract
Microphthalmia
Syndactyly
Ichthyosis
Various brain abnormalities

Walker Warburg Syndrome (Hard E)

Hydrocephalus
Agyria
Retinal dysplasia
With or without encephalocele

X-linked Hydrocephalus

Males
Aqueductal stenosis
Adducted thumbs flexed over palms

Zellweger Syndrome

Hypotonia
High forehead
Flat face
Hepatorenomegaly

Appendices
Menkes Kinky Hair Disease

Twisted fractured hair


Seizures
Progressive CNS deterioration
XLR inheritance

Schwartz Jumpel Syndrome

Myotonia
Blepharophimosis
Joint movement limitation

353

Radial dysplasia
Ulnar and humeral abnormality
ASD /VSD

Larsen Syndrome

Hyperextension of knees
Dislocated elbow, knee, hip
Club feet
Depressed bridge of nose
Cleft palate
Hypertelorism

COFS Syndrome

Neurogenic arthrogryposis
Microcephaly
Micrognathia
Microphthalmia
Cataract
Blepharophimosis
Large ears
Rocker bottom feet

Multiple Pterygium Syndrome (Lethal)

Flexion contractures and pterygia at chin, axilla, elbow,


popliteal, ankle joints
Neck edema (cystic hygroma)
Micrognathia
Cleft palate
Hypertelorism.

Roberts Syndrome
SYNDROMES WITH LIMB ANOMALIES
EEC Syndrome

Cleft lip with or without cleft palate


Ectrodactyly, syndactyly
Ectodermal dysplasia
Various genitourinary abnormalities

Femoral Hypoplasia Unusual Face Syndrome

Cleft palate, micrognathia, large ears


Short, bowed, femora (uni or bilateral)
Vertebral sacral anomaly
Variable hypoplasia of humeri
Urinary tract abnormalities

Severe hypomelia of limbs (mainly upper limb)


Contractures at joint
Oligosyndactyly
Microcephaly
Micrognathia
Hypertelorism
Cleft lip.

TAR Syndrome

Bilateral absence of radius with ulnar hypoplasia


Abnormal humeri
Thumb always present
Abnormal lower extremities
Thrombocytopenia.

Freeman Sheldon Syndrome (Whistling Face Syndrome)

Sloping forehead
Small nose
Long philtrum
Pursed lips
Contractures at joints
Ulnar deviation of hands
Flexion contractures of fingers
Kyphoscoliosis

Holt Oram Syndrome

Phocomelia

Grebe Syndrome

Marked distal limb reduction


Shortening progressing from proximal to distal
Upper limbs more severely involved, grape like fingers
Polydactyly
Normal trunk, face and intelligence.

Popliteal Pterygium Syndrome

Popliteal web
Cleft palate
Lower lip pits

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An Atlas of Neonatology

SYNDROMES WITH FACIAL LIMB MALFORMATION


Otopalatodigital Syndrome II

Prominent forehead
Hypertelorism
Antimongoloid slant
Flat nasal bridge
Micrognathia
Cleft palate
Clenched fingers
Low set and malformed ears

Short trident hand with short fingers


Abnormal acetabular roof in newborn
Exaggerated lumbar lordosis.

Campomelic Dysplasia

Marked bowing of femur and tibia (mimicking fractures)


Hypoplastic fibulae
Bell-shaped narrow thorax
Cleft palate
Hypertelorism.
Occasional cardiac, renal, genital abnormalities.

Stickler Syndrome

Pierre-Robin sequence
Flat face
Buphthalmos
Myopia
Arachnodactyly
Hypotonia.

Langer Giedion Syndrome

Bulbous nose
Loose skin
Multiple exostosis.

Trichorhinophalangeal Syndrome

Bulbous nose
Sparse hair
Epiphyseal coning
Short metacarpals and metatarsals (IV and V).

SYNDROMES OF SKELETAL DYSPLASIAS

Chondrodysplasia Punctata

Rhizomelic shortening
Stippled calcification of epiphysis
Brachycephaly
Hypertelorism
Cataract.

Cleidocranial Dysostosis

Big head
Wide fontanel and sutures
Short or absent clavicle
Hypoplastic iliac bones.

Diastrophic Dysplasia

All bones are very short


Club feet
Kyphoscoliosis
Hitch hiker thumb
Micrognathia
Cleft lip.

Achondrogenesis I and II
Type I
Lethal skeletal dysplasia
Large and poorly ossified skull
Micrognathia, severe shortening of limbs
Narrow chest, short ribs
Poorly ossified iliac bones and spine.
Type II
Relatively normal skull ossification
More variable shortening of limbs
Complete absence of spine, ossification differentiate it from
type one

Ellis-van Creveld Syndrome

Short long bones


Polydactyly
Narrow thorax
Short ribs
Heart defects (ASD).

Hypophosphatasia (Lethal type)

Marked demineralization of skull


Short-bowed and demineralized bones with fractures
Decreased serum alkaline phosphatase
Increased excretion of ethanolaminic acid in urine.

Achondroplasia (Hetero)

Large head with frontal bossing


Depressed nasal bridge
Mild rhizomelia in newborn

Jeune Thoracic Dystrophy

Short long bones


Narrow chest and short ribs causing asphyxia

Appendices

Polydactyly
Renal cysts.

Short Rib Polydactyly II (Majewaski)

Shortening of all bones


Pre/post axial polydactyly of hands/feet.
Short narrow thorax
Cleft palate.

Metatrophic Dysplasia

Big head
Short limbs with relatively big hands/feet
Short femora
Metaphyseal flaring
Narrow long thorax
Platyspondyly
Kyphoscoliosis
Sacral tail (characteristic if present).

Short Rib Polydactyly [Saldinonoonan (I) and Naumoff


(III)]: Two Spectrums

Severe micromelia
Very short ribs
Poorly mineralized vertebrae
Polydactyly
Narrow thorax
Heart defects
Imperforate anus
Intestinal atresia
Hypoplastic/polycystic kidneys
Ambiguous genitalia.

Thanatophoric Dysplasia

Telephone receiver femora


Fibula shorter than tibia
Narrow chest
Flat vertebrae
Big head, frontal bossing
Depressed nasal bridge
II Clover leaf skull with features of type I
Vertebrae are bigger
Femora are straighter

Fibrochondrogenesis

Wide fontanel and sutures


Large eyes and cornea
Short nose
Long philtrum
Cleft palate

355

Rhizomelic short limbs


Long bones: Dumbbell-shaped with irregular metaphysis
Hypoplastic ilia
AR mostly lethal

SYNDROMES WITH CRANIOSYNOSTOSIS


Apert Syndrome

Acrobrachycephaly
Flat face
Hypertelorism
Syndactyly (osseous and cutaneous) of II, III, IV fingers
Broad hallux and thumb.

Carpenter Syndrome

Brachyacrocephaly
Depressed nasal bridge
Micrognathia
Clinodactyly, syn/polydactyly
Heart defects
Omphalocele
Hypogonadism.

MISCELLANEOUS SYNDROMES
Jarcho-Levin Syndrome

Short neck
Costovertebral dysostosis
Crab like flaring or absence of ribs, thoracic abnormality
Protuberant abnormality
Occasional genital and renal abnormalities.

Infantile Polycystic Kidney

Enlarged echogenic kidney with lack of architecture


Micrognathia
Hepatic cysts
Congenital hip dislocation.

Leprechaunism

Prenatal adipose deficiency


Wrinkled loose skin
Full lips
Abdominal distention
Islet cell hyperplasia
Large phallus
Hirsutism
Large hands and feet
Insulin resistance.

Milroys Syndrome

Congenital lymphedema mainly of lower limbs.

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An Atlas of Neonatology

Incontinentia Pigmenti

Caudal Regression Sequence

Irregular pigmented linear skin lesions over limbs and trunk.


Only females are affected
CNS and eye, hair, nail, bone abnormalities.

Hypomelanosis of Ito

Streaked, whorled or mottled areas of hypopigmentation on


limb/ trunk in infancy
Mental retardation, seizures
Macrocephaly
Hypertrichosis
Skeletal anomalies

Flexion contractures of lower limbs


Femoral hypoplasia
Talipes equinovarus
Sacral agenesis
Pelvic deformities

CHARGE Association

Neurocutaneous Melanosis

Holoprosencephaly Sequence

Melanosis of skin and Pia-arachnoid


CNS deterioration

Sturge-Weber Syndrome

Flat facial hemangiomata


Meningeal hemangiomata with seizures.

Lipodystrophy

Lipoatrophy
Phallic hypertrophy
Hepatomegaly
Hyperlipemia
Diabetes mellitus.

SEQUENCES AND ASSOCIATIONS


Amniotic Band Sequence

Encephalocele
Asymmetric anencephaly
Micrognathia
Facial cleft
Constriction and amputation of limbs
Limb body wall complex
Gastroschisis
Syndactyly
Clenched hands

Fixed extremities
Arms flexed
Hyperextended knees
Clubbed feet
Clenched hands

Varying degree of incomplete separation of cerebral


hemispheres (Alobar, semilobar)

Alobar

Absent inner-hemisphere fissure


Single central ventricle
Fused thalami
Absent third-ventricle
Absent olfactory bulb
Cyclopia
Cebocephaly
Median cleft lip/palate
Hypotelorism
Maxillary hypoplasia

Lobar

Some fusion of lateral ventricles and singulate gyrus


Absent cavum septum pellucidum
Separate lateral ventricles except for frontal horns

Semilobar

Arthrogryposis

Choanal atresia
Heart defects
Atresia Ani/esophagus
Retarded growth
Genital abnormality
Ear anomaly

Partially-separated posterior cerebral hemispheres with single


ventricle

Klippel-Feil Sequence

Short neck
Fusion of multiple cervical vertebrae
Low set ears

Appendices
Pena-Shokeir Syndrome

357

Hypothyroid Sequence

Multiple contractures of limbs


Ulnar deviation of hands
Talipes equinovarus
Clenched hand
Hypoplastic lungs
Cryptorchidism
Micrognathia
Depressed nasal bridge
Hypertelorism
TRAP Sequence

Pentalogy of Cantrell
Five components include
Ectopia cordis
Omphalocele
Disruption of distal sternum
Anterior diaphragm
Diaphragmatic pericardium
Prune-belly Syndrome

Prune belly
Distended bladder, ureter
Megalourethra
Cryptorchidism

Conjoined Twins

Absent kidney
Narrow chest
Single umbilical artery
Sirenomelia
Flat squashed face

Vertebral anomalies, VSD


Anal atresia
Tracheoesophageal atresia
Radial or and renal abnormalities

Sirenomelia

Fusion and severe deformities of lower limbs


Bilateral renal agenesis
Absent genitals
Imperforate anus
Abdominal wall defects
Single umbilical artery
Potter face
Heart and lung defects

Oligohydramnios
Bladder distention abdominal distention hydroureter
renal dysplasia
Persistent urachus, colon malrotation, iliac vessel
compression, lower limb deficiency, cryptorchidism

Spinal Dysraphism Sequence

VATER Association

Craniopagus
Thoracopagus
Ischiopagus
Omphalopagus
Partial heteropagus

Early Urethral Obstruction Sequence

Renal Agenesis, Potters Sequence

Variably missing head, heart, upper limbs, lungs, pancreas,


upper intestine in recipient twin.

Defect in closure of neural tube


Defect in closure of anterior neural tube anencephaly
Defect in closure of posterior neural tube
Meningomyelocele hydrocephalus
Spina bifida
Club foot

Exstrophy of Bladder Sequence

Breakdown of cloacal membrane, exposing posterior wall


of bladder
Incomplete fusion of genital tubercles epispadiasis
Separated pubic rami

Oligohydramnios Sequences

Renal agenesis
Amnion nodosum
Pulmonary hypoplasia and death
Fetal compression Potters face, breach, abnormal position
of hands and feet.

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An Atlas of Neonatology

TERATOGENS
Thalidomide

Phocomelia
Heart defect
Microtia
Duodenal atresia
Spinal abnormalities

Cytomegalovirus

Intracranial calcification
Microcephaly
Brain atrophy
Hydrocephalus
Cardiomegaly
IUGR
Hepatosplenomegaly
Thrombocytopenia

Rubella Syndrome

Microcephaly
Cataract
PDA, pulmonary artery branch stenosis
Deafness
Hepatosplenomegaly
IUGR

Syphilis

Osteochondritis
Hepatosplenomegaly
Skin rashes
Mucocutaneous lesions

Toxoplasmosis

Cataract
Microcephaly
Intracranial calcification
Ventriculomegaly
Hepatosplenomegaly
IUGR

Varicella Syndrome

Cicatrizing skin lesions


Club feet
Abnormal position of hands

CHROMOSOMAL ABNORMALITIES
Trisomy 13

Microcephaly

Holoprosencephaly
Midline cleft
Hypotelorism
Cyclopia
Camptodactyly
Polydactyly
Renal anomalies
Cardiac defects

Trisomy 18

Micrognathia
Microphthalmia
Hypertelorism
Clenched hands (with overlapping index finger)
Rocker bottom foot
CHD
Short sternum
Renal/GIT defects
IUGR

Trisomy 21

Microbrachycephaly
Upslant of eyes
Nuchal thickening
Small ears
Clinodactyly
Micropenis
CHD-endocardial cushion defects
Duodenal, anal atresia

Turner Syndrome

Short, webbed neck


Cystic hygroma
Wide chest
Coarctation of aorta
Horse shoe kidney
Lymphatic edema of limbs

FURTHER READING
1. Benacerraf BR (ed). Ultrasound of Fetal Syndrome, ed I
1998, Churchill Livingstone, New York.
2. Jones KL (ed) Smiths Recognizable Patterns of Human
Malformation. 5th edn 1997, WB Saunders Philadelphia.
3. Remero R, Pilu G, Jeanty P, Ghidini A, Hobbing JC (eds).
Prenatal Diagnosis of Congenital Anomalies. Appleton
and Lange, California.
4. Rumack CM, Wilson SR Charboneau JW (Eds). Diagnostic
Ultrasound 2nd edition 1998, Mosby, St. Louis.

Appendices

359

APPENDIX-2
General Information About Medical Genetics in India
Table 1: Genetic centers in India
Center for Genetic Disorders, Department of Human Genetics, Guru Nanak Dev University Amritsar
Department of Human Genetics and Anatomy, St. Johns Medical College
Bangalore
Department of Pediatrics and Hematology, Postgraduate Institute of Medical Education and Research
Chandigarh
Department of Genetics, Institute of Child Health and Institute of Obstetrics Gynecology
Chennai
Department of Genetics, Ramakrishna Mission Hospital
Kolkata
Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences
Lucknow
Department of Pediatrics, KEM Hospital
Mumbai
ICMR Immunohaematology Center, KEM Hospital
Mumbai
ICMR Genetic Research Center, Indian Council of Medical Research, Wadia Hospital for Children
Mumbai
Genetics Unit, Department of Pediatrics, All India Institute of Medical Sciences
New Delhi
Department of Genetic Medicine, Sir Ganga Ram Hospital
New Delhi
Genetics Center, Department of Pediatrics, BJ Medical College
Pune
Department of Zoology, Banaras Hindu University
Varanasi
Department of Pediatrics, JJM Medical College
Davangere
Table 2: Empiric risk of recurrence of isolated malformation
Malformation

Frequency per 1000 births

Anencephaly/Spina bifida
Cardiac malformation
Cleft lip and cleft palate
Cleft palate alone
Pyloric stenosis
Talipes equinovarus
Dislocation of hip
Hirschsprung disease

4-5
6-8
2
0.5
2-3
3-4
3-4
0.1

Recurrence for normal parents of one affected child


5%
3-4%
4-5%
2-6%
3%
2-8%
3-4%
6%

Table 3: Surveillance for early detection of problems in Down syndrome children


At birth

Within first year

Every year

Clinical examination and if necessary investigations for tracheoesophageal fistula, duodenal obstruction
and anal atresia.
Eye examination for cataract.
Chromosomal analysis
If translocation trisomy 21 is found, chromosome analysis of parents.
Thyroid stimulating hormone
Echocardiogram (within first week) clinical examination and if necessary, investigations for tracheoesophageal fistula, duodenal obstruction and anal atresia
Thyroid function tests (TSH1 T4)
Haemoglobin, serum iron
Hearing evaluation
Eye examination for squint, refraction, cataract
Haemoglobin, serum iron
Thyroid function test
Non-fasting lipids
Auditory assessment
Eye examination
Development assessment, physiotherapy and if needed speech therapy

360

An Atlas of Neonatology
Table 4: Causes of perinatal deaths

Genetic

Non-genetic

1. ChromosomalTrisomies, triploidy, tetraploidy, monosomy X, deletion, duplications.


2. Skeletal dysplasiasAchondrogenesis, short rib polydactyly syndromes, thanatophoric dysplasia,
osteogenesis imperfectatype II, etc.
3. Recognizable syndromes: Smith-Lemli-Opitz syndrome, Meckel Gruber syndrome, Walker Warburg
syndrome etc.
4. Alpha thalassemia and some metabolic errors.
5. Congenital malformations
Neural tube defects
Central nervous system abnormalities like holoprosencephaly, hydrocephalus
Renal abnormalitiesAgenesis, cystic and obstructive diseases of kidney.
Cardiac defectsTransposition of great vessels, Hypoplastic left heart
Laryngeal and tracheoesophageal abnormalities
Abdominal wall defects : Omphalocele and gastroschisis
Multiple malformations of unknown etiology
1. Placental
2. Infection
3. Cord problems
4. Obstetric problems
5. Early amnion rupture sequence
6. Maternal illness
7. Twins

List of Books Related to Medical Genetics


Practical Genetic Counseling 5th edition
Peter S. Harper
Butterworth Heinemann
Oxford : Butter Worth 1998, 1999
575.1 Acc No. 15104
Atlas of Skeletal Dysplasias
Wynne Davies
Churchill Livingstone, Edinburgh
1985
Clinical Genetics/Radiology
616.710757 Dav. Acc No. 781
Syndromes of the Head and Neck - 3rd edition
RJ Gorlin,
New York
Oxford University Press
199-977 p.
Clinical Genetics
4757, 617.5 GOK, N90
Birth Defects Encyclopedia
Mary Lovise Boyse, USA
Blackwell Sciences 1990
Clinical Genetics
5657 Acc No. 616.043

Multiple Congenital Anomalies: A Diagnostic Compendium


Robin M. Winter, London
Chapman and Hall, 1991
Clinical Genetics
4173 Acc No. 618 9243
A Color Atlas of Clinical Genetics
Michail Baraitser, Robin Winter
Wolfe Medical Publication, 1983
Clinical Genetics
575.1
Radiology of Syndromes, Metabolic Disorders and
Skeletal Dysplasias 3rd edition
Taybi H, Lachman RS
Chicago, Yearbook Medical Pub. 1990, 933 p.
Mosby
1996
Clinical Genetics/Radiology
616. 07572 Acc No. 12105
Emerys Elements of Medical Genetics 11th edition
Robert F Mueller, Ian D Young
Churchill Livingstone
Edinburgh, 2001
Clinical Genetics
575. 1 MVE Acc No. 16850

Appendices
The Genetics of Neurological Disorders
Michael Baraitser
Oxford Med. Publishers
1997
Clinical Genetics
616. 42 Bar
Smiths Recognizable Pattern of Human Deformations
Smith DW
Philadelphia
WB Saunders
1988-183p.
Clinical Genetics
616. 043 3222
ISBN 07216-2338-7
Ultrasound of Fetal Syndromes
Benacerraff
Churchill Livingstone
Fetal USG
1998
616.07543 Acc No. 14072
Ultrasonography in Obs. & Gyne
Peter W. Callen
W.B. Saunders
1993
USG Obstetrics
Prenatal Diagnosis of Congenital Anomalies
Roberto Romero
Appleton and Lange
1990
USG Fetal
618.22/PRE Acc No. 1637
Pediatric Neurology Principles and Practice - 3rd edition
Swaiman KF, Vol. I and II
CV Mosby
1990
Pediatrics/Neurology
618.92/2635 Acc No. 15378
Catalog of Teratogenic Agents
TS Shepard
John Hopkins University Press
1995
Pharmacology/Teratology
616. 043 SHE

361

List of Journals Related to Medical Genetics


1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.

Acta Cytologica
Acta Oncologica
Acta Pediatrics
American Journal of Hematology
American Journal of Human Genetics
American Journal of Medical Genetics
Annals of Hematology
Blood
British Journal of Hematology
Cell
Clinical Dysmorphology
Clinical Genetics
Cytogenetics and Cell Genetics
Gene
Genetic Testing
Genomics
Human Gene Therapy
Human Genetics
Human Molecular Genetics
Journal of Medical Genetics
Lancet
Nature Genetics
Nuclear Acid Research
Prenatal Diagnosis
Science
Seminars in Perinatology
Trends in Genetics
Transfusion
Tissue Antigens
Bone marrow Transplantation
Proceeding of the National Academy of Sciences of the
United States of America
32. Trends in Biochemical Sciences
33. Genome Human
34. Reviews in Immunogenetics
Clinical Genetic Computer Resources
A. Online Mendelian inheritance in Man (OMIM)
http://www3.ncbi.nlm.nih.gov/Omim/-human genes and genetic
disorders authored and edited by Dr. Victor A. McKusick and
colleagues.
John Hopkins University. Entries include general description,
phenotype, clinical features, biochemistry, and genotype, mode
of inheritance, diagnosis, management, molecular genetics,
references, clinical synopsis, pictures, and date edited.
www3.ncbi.nlm.nih.gov/Omim/ http://www3.ncbi.nlm.nih.gov/
Omim/.

362

An Atlas of Neonatology

Available on CD-ROM, PC-GDB for MS Windown- Ray Duncan,


Cedars-Sinai Medical Center, Los Angeles, CA, distributed by
GDB.

3) Human cytogenetics databases http://www.oup.co.uk/>,


developed by Albert Schinzel, clinical and cytogenetic data
related to 1,200 chromosome aneuploidies, references.

1) London Dysmorphology Database


http://www.oup.co.uk/ep/prodsupp/medical/ldd> (LDDB) ver
2.2, >3,320 nonchromosomal, multiple congenital anomaly
syndromes with references.

4) Dysmorphology Photo Library


http://www.oup.co.uk/ep/prodsupp/medical/omd2_2/> ver 2.2
CD-ROM used with London Dysmorphology database or London
Neurogenetics database. 11,230 clinical photographs illustrate
syndromes in dysmorphology/neurogenetics databases.

2) London Neurogenetics Database


http://www.oup.co.uk/ep/prodsupp/medical/omd2_2/>, >2,950
syndromes involving central and peripheral nervous system,
references. Clinical neurological features, neuroradiology,
neurophysiology, and neuropathology including nerve and
muscle biopsy findings.

C. Possum : http://www.pssum.net.au/> (Pictures of standard


syndromes and undiagnosed malformations) version 5.1, Dr.
Agnes Bankier and John Marquet -$1000, The Murdoch Institute
for Research into Birth Defects, P.O. Box 1100 Parkville 3052
Melbourne, Victoria AUSTRALIA Voice : (613) 8341 6201 Fax:
(613) 348-1391 ACN: (006) 566-972 www.pssum.net.au/
http://www.pssum.net.au/>.

Appendices
APPENDIX-3
Fetal Autopsy Proforma
(ABORTIONS/STILLBIRTHS/NEONATAL DEATH WITH OR WITHOUT CONGENITAL MALFORMATIONS)

1. Name of Mother

______________________________________________________________________

2. Age of Mother

______________________________________________________________________

3. Name of Father

______________________________________________________________________

4. Age of Father

______________________________________________________________________

5. Present Address

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Permanent Address

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

6. C.R. Number

______________________________________________________________________

7. Abortion/Delivery date & time

______________________________________________________________________

8. Date and Time of receipt of fetus :

______________________________________________________________________

9. LMP

______________________________________________________________________

10. Gestational age

______________________________________________________________________

11. Mode of Abortion /Delivery

______________________________________________________________________

12. Name and Address of


referring doctor

______________________________________________________________________

13. Referral Diagnosis

______________________________________________________________________

14. Reason for Referring

______________________________________________________________________

15. Pedigree Chart

______________________________________________________________________

16. OBSTETRIC HISTORY

______________________________________________________________________

Present 0/11
Single/Multiple Pregnancy
H/O Drug Intake
H/O Viral Fever
H/O Radiation
Loss of Fetal Movement (date)
Obstetric U/S Report

363

364

An Atlas of Neonatology

Past H/O

Socio-economic History

Medical History

Surgical History

INVESTIGATIONS

AMNION
Intact/Ruptured/Meconium Staining
Amniotic Fluid
Others
CHORION
1. Membrane
2. Villous
3. Weight
4. Meconium Staining
5. Others
UMBILICAL CORD
1. Length
2. Diameter
3. Normal/Abnormal
a) False Knot/True Knot/Thromeoset/Twisted/Constricted/Cystic Dilatat
b) Long/Short
c) Insertion Central/Paracentral/Marginal/Velamentous
d) Number of Vessels
e) Meconium Staining
f) Hemorrhage
PLACENTA
1. Shape
2. Infarcts
3. Meconium Staining
4. Hemorrhage
Placenta Previa/Accidental HGE (Retroplacental Clot) Subchorionic/Intervillous/Decidual)
5. Type Singleton/Twin/Placenta (Monochorionic Monoamniotic Diamniotic/Dichorionic Diamniotic)
6. Weight
7. Amniotic Bands
8. Intervillous Fibrin Deposition

Appendices

365

FETUS/EMBRYO
A. Fresh/Fixed
B. Autolysed None/Slight/Severe
General Appearance
C. Measurements
a) Length
1. CRL
2. CHL
3. Elbow Wrist Length
4. Hand Length
5. Knee Ankle Length
6. Foot Length
b) Circumference
1. H C
2. C C
3. A C
c) Cranial Distances
1. Inner canthal
2. Outer canthal
d) Nose Tip to Lip Distance
e) Bridge (Nose) Lip Distance
f) Right Ear Length
D. Weight
E. Developmental Age (Wks)
F. Sex
G. Description External Examination
a) General
Habitus - Normal /Thin/Fatty/Hydrops/Dwarf/Asymmetric/Skin-Normal/Ichthyosis/ Loose/Hyper-pigmented/Petechiae/Evidence
of Trauma/Constriction
b) Craniofacial
1. Skull Normal/Abnormal Microcephaly/Macrocephaly/Hydrocephaly/Anencephaly/Encephalocele/Cyclops/
Cebocephaly
2. Face Normal/Large/Small/Midface Hypoplasia
3. Hair Normal/Abnormal/Hypertrichosis/Low Hair Line/Eye Brows Normal/ Not developed
4. Eye Palpebral fissure/Normal/Mongoloid Slant/Antimongoloid
Distance Normal/Hypertelorism/Hypotelorism
Size Normal/Microphthalmos/Anophthalmos Epicanthal Fold
5. Ear Normal/Abnormal Small/Abnormal Shape/Position
6. Nose Bridge Normal/Depressed/Elevated
Length Normal/Short/Long
Nostril Normal/Single
7. Philtrum Prominent/Flat/Absent
8. Lips Normal/Prominent/Cleft
9. Mouth Normal/Large/Small
10. Palate Normal/Cleft/High Arched
11. Tongue Normal/Protruding/Small
12. Upper Jaw Normal/Hypoplastic
13. Lower Jaw Normal/Micrognathia/Retrognathia
14. Neck Normal/Short/Cystic Hygroma/Webbing

366

An Atlas of Neonatology

c) Thorax
1. Chest Normal/Shield/Narrow/Short/Pectus Excavatum/Pectus Carinatum
2. Nipples Normal/Abnormal/Supernumerary
3. Breast Normal/Abnormal/Enlarged
4. Ribs Normal/Abnormal/Missing
5. Vertebrae Normal/Abnormal Hemivertebra/Scoliosis/Kyphosis/Spina Bifida/Bifida Total/Cervical/Thoracic/
Lumbar/Sacral/Meningocele/Myelocele/Cranioschisis
d) Upper Limb
1. Normal/Short/Amputated/Joint Dysplasia/Abnormal Position/Lobster Claw
2. Hand Normal/Short/Long
3. Fingers Normal/Long/Short/Syndactyly/Polydactyly/Amputated/Broad Thumb/Clinodactyly/Brachydactyly
4. Palmer Crease Normal/Abnormal/Simian Crease/Sydney Crease
5. Nails Normal/Hypoplastic
e) Lower Limb
1. Length - Normal/Long/Short/Amputated
2. Position Normal/Talipes Varus Valgus/Genu Varum Valgum
Recurvatum/Jt. Dysplasia Dislocation.
3. Nails Normal/Hypoplastic
4. Toe Syndactyly/Polydactyly/Amputated/Broad Toe/2nd Toe Bigger Than 1st Toe/1st & 2nd Toe Deviated.
5. Foot Normal/Short/Long/Abnormal Crease/Rocker bottom Foot
f) Abdomen
Normal/Short/Narrow
Hepatomegaly/Splenomegaly
Ascites/Prune belly/Omphalocele
Umbilicus Normal/Low Set/High Set/Hernia
g) External Genitalia
Normal Female/Normal Male/Ambiguous/Ambi. Male/Ambi. Female
Penis Normal/Short/Long
Clitoris - Normal/Short/Long
Urethra Normal Hypospadius/Epispadius/Exstrophy
Testis Normal/Undescended Location/Agenesis
h) Anus
Normal Patent/Imperforate
H. Description Internal Examination
a) Thorax
1. Thymus Normal/Enlarged/Small/Absent/Petechiae/SI ; Weight (Size = in all internal organs : Aorta, Big versel,
Pulm. Tr., IVC, SVC)
2. Heart Location Normal/Abnormal
Enlarged Rt. Side/Enlarged Lt. Side
TGV/Coarctation/Stenotic
Petechiae
Pericardial Effusion
Rt. Atrium
Rt. Ventricle
Lt. Atrium
Lt. Ventricle Normal/Hypoplastic
Pulm. Valve cusps Normal/Bicuspid/Dysplastic
Aortic valve cusps Normal Bicuspid/Dysplastic/ASD/VSD/Memb./Muscular
Tricuspid Atresia/Mitral Atresia/Endocardial/Fibroclastosis/Gis/Weight
3. Lungs Normal/Abnormal
(Rt- Lt) Hypoplastic/Congestion/Petechiae/Effusion Trachea Normal/Abnormal/T E Fistula/Weight

Appendices

367

4. Diaphragm
Normal/Abnormal
Hernia/Eventration
5. Esophagus Normal/Abnormal
Stenosis/Atresia/T-E Fistula
b) Abdomen
1. Liver - Normal/Abnormal
Weight
Situs Inversus
Rupture/Necrosis/Cirrhosis
2. Gall Bladder Normal/Abnormal/Atresia
3. Gut Normal/Abnormal/Malrotated/Atresia/Stenosis/Meckels Diverticulum/Volvulous/Megacolon
4. Apendix Location/Normal/Abnormal
5. Spleen Location/Asplenia/Polysplenia/Normal Weight
6. Adrenal Size/Normal/Abnormal/Hypoplastic Weight (RT Lt)
7. Kidney (Rt-Lt) Size/Normal/Abnormal Horse Shoe Shape/Pelvic/Polycystic/Agenesis/Weight
Ureter Normal/Abnormal/Hydroureter/Duplication
Bladder Normal/Abnormal
8. Pancreas Normal/Abnormal/Weight
9. Stomach Location/Normal/Abnormal
10. Gonads (Rt Lt) Ovaries Normal/Abnormal/Streak/Agenesis/Cystic
Uterus Shape/Normal/Abnormal/Bicornuate/Septate
Tube (Rt Lt) Normal/Abnormal
Vagina - Normal/Abnormal
11. Nervous System
1. Brain - Normal/Abnormal/Large/Small
Hemorrhage Subdural/Subarachnoid/Intraventricular Hydranencephaly/Porencephaly/Hydrocephaly/
Holoprosencephaly
2. Weight
3. Spinal Cord Normal/Abnormal
4. Eyes Normal/Abnormal/Large/Small
Lens/Sclera/Iris
(Summary of internal findings)
I.
Sections for H/ P Examination/Naked Eye Exam.
1. Placenta
2. Cord
3. Thymus
4. Heart
5. Lungs
6. Liver
7. Kidney
8. Adrenal
9. Ureter
10. Spleen
11. Pancreas
12. Ileum
13. Colon
14. Gonads
15. Stomach
16. Uterus/Vagina
17. Skin
18. Others
J. Radiological Examination
a) X- rays
Whole Body
AP
Lat.
Skull
AP
Lat.
b) C.T. Head
Sagittal Whole Body
Serology
Toxoplasma/VDRL/Rubella/CMV/Herpes/Parvovirus B

368

An Atlas of Neonatology

K. Microbiology
Chlamydia/Listeria/Mycoplasma/Others
L. Cytogenetics
Karyotype/Tissue Culture/Placenta Culture
M. Photography
N. Others
Sl. No.
Weights
Ratios
I. Organs
a) Brain
b) Thymus
c) Heart
d) Lungs
e) Liver
f) Kidney
g) Adrenal
h) Spleen
i) Pancreas
II. Ratios
Normal Range
a) Lungs/Heart
2/1 to 4/1
b) Brain/Liver
2/1 to 4/1
c) Liver/Heart
4/1 to 7/1
d) Thymus/Spleen/Adrenal 1/1/1

FINAL DIAGNOSIS

SUMMARY

COUNSELING

Sulphate transporter

DTDST
CCA, FBN2

Beal syndrome

EVC
FOP, BMP2A
GBA1
GLB1
TBD, HEXA
GM2 II
MPSIH, IDUA
-L-iduronidase
FGFR3
TNS, ALP
COL2A1

Fibrodysplasia ossificans progressive

Gaucher disease
GM1 gangliosidosis
GM2 gangliosidosis I
GM2 gangliosidosis II

Homocystinuria
Hurler syndrome
Hurler-Scheie syndrome MPSIS, IDUA
Hypochondroplasia

Infantile hypophosphatasia

Kniest dysplasia

5q23 - q31

Type II collagen

12q13 - q14

1p34 - p36.1

21q22.3
4p16.3
MPS Type I S
4p16.3

Cystathionine synthetase
-L-iduronidase
4p16.3
FGFR3
Alkaline phosphatase, liver/bone/kidney

20p12
1q21
3p21.33
15q22-q25
15q13

Bone morphogenic protein 2A

4q12.21
At least 3 foci
5q32 - q33.1
Xp

6p21

17q24 - 17q25

Acid glucocerebrosidase 1
galactosidase
Hexosaminidase A, polypeptide
Hexosaminidase B, polypeptide

4p16

Sulphate transporter
Short stature homeo box gene

DG11
EXT 1, 2, 3
DTDST
SHOX

Dentinogenesis imperfecta
Diaphyseal aclasis
Diastrophic dysplasia
Dyschondrosteosis

Ellis-van-Creveld

HMG-box 9 protein, SRY-related


Xq28
Xp22.32
Peroxisomal abnormality
OBFA1

Campomelic dysplasia
CMD1, SOX9
Chondrodysplasia punctata X-linked dom.
CDPX2
Chondrodysplasia punctata X-linked rec.
CDPX1
Chondrodysplasia punctata (rhizomelic type) CDPR, PEX7
Craniocleidodysostosis
CCD, CBFA1

5q32 - q33.1

12q13 - q14
5q32 - q33.1
4p16.3

Collagen II, -1 polypeptide


Sulphate transporter
Fibroblast growth factor receptor 3

COL2A1
DTDST
ACH. FGFR3

Achondrogenesis and hypochondrogenesis


Achondrogenesis type IB
Achondroplasia
Acrodysostosis
Atelosteogenesis type II
Fibrillin-2

Chromosome location

Defective gene product

Symbol

Disease

Also spondylo-epiphyseal dysplasia congenita


contd...

Impaired mineralisation

Also achondroplasia

Ectopia lentis
MPS Type I H

Also Morquio
Tay Sachs
Sandhoff

Hereditary brown teeth


Genetic heterogeneity
Also achondrogenesis 1B, atelosteogenesis II

Ambiguous genitalia/sex reversal in 46XY patients


Happle, Conradi-Hnermann

Congenital arachnodactyly

Also diastrophic dysplasia


Also hypochondroplasia
Clinical similarities to pseudohypoparathyroidism
Also diastrophic dysplasia

Notes

Gene Locations of the Skeletal Dysplasias (alphabetical order)

Appendices
369

Symbol
LESD
MANB
MFS1, FBN1

GNS, G6S
GUSB
MPS II
ARSB
GNPTA
COMP, COL9A2
NPS1
NF1, VRNF
NF2, ACN
NPD, SMPD1
COL2A2, COL1A1

CALL, CALL
COL2A1
COMP
AHO, GNAS1
PDDR, VDD1
CTSK
ASC 3, SCS
See Hurler-Scheie
NEU
COL2A1
SEDT
COL2A1
TD, FGFR3
TRPS1
TRPS2, LGS

Disease

Letterer-Siwe disease

Mannosidosis
Marfan syndrome
McCune-Albright syndrome

MPS IIID
MPS VII
MPS II
MPS VI
Mucolipidosis II and III
Multiple epiphyseal dysplasia

Nail-patella syndrome
Neurofibromatosis I
Neurofibromatosis II
Niemann-Pick disease

Osteogenesis imperfecta

Osteopetrosis

Polyostotic fibrous dysplasia


Precocious osteoarthritis
Pseudoachondroplasia
Pseudohypoparathyroidism
Pseudo-vitamin D dependency rickets
Pyknodysostosis

Saethre-Chotzen syndrome
Scheie syndrome
Sialidosis
Spondylo-epiphyseal dysplasia congenita
Spondylo-epiphyseal dysplasia tarda
Stickler syndrome

Thanatophoric dysplasia
Trichorhinophalangeal syndrome 1
Trichorhinophalangeal syndrome 2

contd...
Defective gene product

Collagen 1, -2 polypeptides

12q13 - q14

Xp22
Collagen II, -1 polypeptide

8q24, 12

4p 16.3

6p21
12q13 - q14

neuraminidase
Collagen II,-1 polypeptide

FGFR 3
8q24.11 - q24.1
Deletion of EXT and TRP 1

7p21

12q13 - q14
19p13.1
20q
12q14
1q21

TWIST

Cathepsin K

Collagen II, -1 polypeptide


Cartilage, oligomenic matrix protein
GS *a protein

8q22, 1p21

7p22.1, 17q21.31 - q22

Sphingomyelinase

Carbonic anhydrase II

9q34
17q11.2
22q12.2
11p15.4 - p15.1

Neurofibromin

12q14
7q21.11
Xq27 - q28
5q13
4q21 - q23
19p12 - p13.1, 1p32.2 - p33

19p13.2-q12
15q21.1

Chromosome location

N-acetylglucosamine-6-sulfatase
glucuronidase
iduronidase 2 sulfatase
Arylsulfatase B
N-acetylaglucosaminic-1 phosphotransferase
COMP, Type IX collagen

mannosidase
Fibrillin-1

13q14-q31

Notes

Langer-Giedion

Progressive myoclonus and visual loss


Also Kniest
X-linked type
Cartilage collagen

Mosaic phenotype

Collagen of skin, tendon and bone, mutations


cause
sub-types I-IV

Bilateral acoustic neuromata


Sphingomyelin lipidosis

Glomerulonephritis may occur

Hunters syndrome
Maroteaux-Lamy syndrome
I-cell disease (II). pseudo-Hurler (III)
Genetic heterogeneity

polyostotic fibrous dysplasia with precocious


puberty
Sanfilippo D syndrome

Disseminated histiocytosis X

370
An Atlas of Neonatology

Spondylo-Epiphyseal Dysplasias - Congenita - Classical type, others with distal


involvement e.g. brachydactyly
Tarda - autosomal dominant and recessive; X linked recessive

Predominantly Metaphyseal Dysplasias: Metaphyseal Chondrodysplasias (M.C.D)


Types: Schmid, McKusick, Jansen, Pena, with malabsorption and neutropenia, others.
(See also hypophosphatasia, rickets, included with metabolic bone disease (ix).
Spondylo-Metaphyseal Dysplasias - Types Kozlowski, Sutcliffe

Short Limbs/Normal Trunk - Achondroplasia, hypochondroplasia, dyschondrosteosis


Robinow, Werner, acromesomelia, acrodysostosis, others

Short Limbs and Trunk (may or may not be disproportionate) - Pseudoachondroplasia,


diastrophic dysplasia, metatropic dwarfism, kniest, Ellis-van Creveld, Jeune, others.
(See Also storage disorders (viii))

Lethal Forms of Short-Limbed Dwarfism - Thanatophoric, achondrogenesis,


short rib / polydactyly syndromes, campomelic dwarfism, others
(See Also hypophosphatasia (ix) and osteogenesis imperfecta (x))

Increased Limb Length - Marfan, congenital contractural arachnodactyly, homocystinuria

Storage Disorders - Mucopolysaccharide disorders, mucolipidoses,


mannosidosis, sialidoses

Metabolic Bone Disease - Hypo-and hyperphosphatasia, hypophosphataemic rickets,


pseudohypoparathyroidism, others
(See Also metaphyseal disorders, (iii))

Decreased Bone Density - Osteogenesis imperfecta group, idiopathic juvenile osteoporosis,


Hajdu Cheney (osteolysis), others
also membrane bone disorder - cleidocranial dysostosis
Cleidocranial

Increased Bone Density (Sclerosing Bone Dysplasias) - Osteopetrosis, pyknodysostosis,


Pyles craniometaphyseal dysplasia, fronto-metaphyseal dysplasia, osteodysplasty (Melnick-Needles),
Angelmanns, craniodiaphyseal dysplasia, osteopathia striata and osteopoikilosis

Tumour-Like Disorders (Bony Or Fibrous) - Diaphyseal aclasis, Olliers, Maffuccis,


dysplasia epiphysealis hemimelica, myositis ossificans progressive,
polyostotic fibrous dysplasia (including Albright), melorheostosis, neurofibromatosis

(ii)

(iii)

(iv)

(v)

(vi)

(vii)

(viii)

(ix)

(x)

(xi)

(xii)

Skeletal Dysplasia Group- Diagnostic Course April 1998


Increase Specialist scanning required to establish correct diagnosis
* G ** - genetic testing not available except for known familial mutations

Predominantly Epiphyseal Dysplasias Multiple epiphyseal dysplasia, hereditary arthroophthalmopathy. (Stickler), chondrodysplasia punctata (Conradi), severe rhizomelic, milder forms

(i)

Clinical Diagnostic Groups

Achondroplasia G

MCD Jansen
MCD with
neutropenia

SED cong. G**

Conradi B
Stickler G**

Clinical
By Genetic/
Biochemical Testing*
Period/Early
Infancy

Osteopetrosis (20+ weeks)


Pyknodysostosis (20+ weeks)

O.I. type II A, B, C (16+ weeks)


O.I. type III (24+ weeks)

Hypophosphatasia (16+ weeks)

Thanatophoric (16+ weeks)


Achondrogenesis (16+ weeks)
Campomelic (16+ weeks)
Short rib syndromes (16+ weeks)

Neurofibromatosis G**

Osteopetrosis (carbonic anhydrase


deficiency type only)
B, G**

O.I.G**

Hypophosphatasia B.G**

MPS. MLS B

Marfan G**
Homocystinuria B

Thanatophoric G
Achondrogenesis G**
Campomelic G**

Pseudoachon: (20+ weeks)


Pseudoachon: G**
Diastrophic: (16+ weeks)
Diastrophic G**
Kniest: (18+ weeks)
Kniest G**
Metatropic: (18+ weeks)
Ellis-van Creveld: (Jeune) (20+ weeks)

Achondroplasia (20+ weeks)


Acromesomelia

MCD with neutropenia G**


MCD Schmid G**
MCD Jansen G**

SED cong. (18+ weeks)

Conradi (rhizo:) have


stippled epiphyses (18+ weeks)

Pre-Natal Diagnosis
By Ultrasound
Examination+
(G; B.)

Age of Diagnosis and Method of Prenatal Diagnosis


Diagnosis
2 Years+

Mild ost. imp.


Juv. osteoporosis
Hajdu-Cheney
Cleidocranial

Hypophos rickets
Pseudohypo-para:

MPS

Marfan
Homocystinuria

Pseudoaction:

Hypochondroplasia
Dyschondrosteosis
Acrodysostosis

SED tarda

Myositis oss.
Poly. fib. dys.
Melorheostosis
Neurofibromatosis

All others

Severe osteopetrosis All others


Pyknodysostosis
Severe cranio-meta:
Cranio dia:
Severe Melnick Needles

Ost. imp.

Hypophosphatasia

MLS

Marfan (neonatal)
Cong. contractural
arachnodactyly

All

E. van C., Jeune


Diastrophic
Metatropic
Kniest

Achondroplasia

All other MCD


and SMP

SED cong.

Conradi (rhizomelic), Conradi (mild)


Stickler
Stickler (mild)

Clinical
Diagnosis In
Neonatal

Appendices
371

372

An Atlas of Neonatology

Appendices

373

374

An Atlas of Neonatology
APPENDIX-4
Pedigree Symbols

Appendices

Degrees of relationship
Proportion of genes shared
First degree
Sibs
Dizygotic twins
Parents
Children
Second degree
Half sibs
Uncles, aunts
Nephews, nieces
Third degree
First cousins
Half uncles, aunts
Half nephews, nieces

1/2

1/4

1/8

375

376

An Atlas of Neonatology
Patterns of Relationships

(Contd...)

Appendices
(Contd...)

Reference: Practical Genetic Counseling by Peter Harper

377

378

An Atlas of Neonatology
APPENDIX-5
Neonatal Case Record
Chigateri District Hospital, Davangere - 577 004.
Neonatal Case Sheet, Department of Paediatrics

Name B/o
Age
Sex
Address

:
:
:
:

Sl. No
Hospital No
D.O.Birth
D.O. Admission

Father
Street
Town/Village
District
State

:
:
:
:

MATERNAL HISTORY:
I.

Medical History:
Age
Gravida
Parity
Living children
Blood group & Rh.
Consanguinity
- Uncle Niece
- First cousin
- BFC
Pedigree

II. Hypertension
Diabetes
Heart disease
Tuberculosis
Asthma
Epilepsy
Thyroid disease
UTI
Others Smoking
Alcoholic
Narcotics

III. Obstetrics performance:


Pregnancy

Outcome
Date of
delivery

Gestational
age

Sex

B.Wt. N

Abortion/Stillbirth

Neonatal death

I
II
III
IV
V
Present pregnancy
1. LMP
2. EDD
3. ANC
4. USG abdomen
5. X-ray chest
6. NST / OCT
7. Hb%
8. P. smear
9. VDRL
10. HBsAg

a)
b)
c)
d)
e)
f)
g)
h)
i)
j)

Hypertension/PHE/Eclampsia
Anaemia
Diabetes - stage
Jaundice - type
Oligo/polyhydramnios
Vaginal bleeding
Heart disease
PROM
Seizure
Placental insufficiency

Appendices
11.
12.
13.
14.

HIV
TORCH
Urine
Others

Labour events:
1) Spontaneous / Induced
2) Drugs- Oxytocin
Pethidine
Tocolytic agents

3) Duration:

1st stage......hrs
2nd stage........hrs

4) PROM
5) MSAF

Delivery events:
I) Type - Normal vaginal
Instrumental
Caesarean section

II) Presentation
-Vertex
-Breech
-Others

Indication:
Drugs Gen anesthesia
Spinal / Epidural
Others

III) Place
-Hospital
-Home
-PHC
-Other Hospital

Postnatal events:
* Resuscitation methods used
* Drugs used for NALS
* APGAR
1
5
10
Physical examination:
I) -Single/Twin : 1st twin/2nd twin
-Gestational age.......wks (Table-1)
-Sex

-Cry
-Colour
-Activity

-B weight.......kgs (Table-2)
-Length.........cms
-H.C.............cms
-M.A.C........cms

GENERAL PHYSICAL EXAMINATION:


Skin
Craniofacial
CNS
Neonatal Reflexes -Moros reflex
Rooting reflex
Sucking reflex
Grasp reflex

II) -Vital signs

-Plantar

-HR
RR
BP

379

380

An Atlas of Neonatology
Palmar
Neck
Chest
CVS
Lungs
Abdomen
Genitalia
Extremity
External cong. anomalies

IMPRESSION
Course in hospital
Treatment given
Discharge plan
Follow-up
Dysmorphic child

Appendices
(Abortion / Stillbirth / Neonatal death with or without congenital malformation)
Name of Mother ....................................................... Age ...............................................................................................
Name of Father ......................................................... Age ...............................................................................................
Date and time of receiving the neonate / foetus ...........................................................................................................
Pedigree:
Obstetrics:
- Single / Multiple pregnancy
- History of drug intake/Viral Fever/Radiation/Lymphadenopathy/Rashes
- Obstetric USG report
- Medical history
PHYSICAL EXAMINATION:
1) General appearance:
Habits : N/Thin/Fatty/Dwarf/Hydrops/Asymmetrical
Skin : N/lchthyosis/Loose/Hyperpigmented/Petechiae
Evidence of trauma/Constriction
Measurements :

1. Length- Crown rump length


Crown heel length
Elbow wrist L
Hand L
Knee ankle L
Foot L
2. Circumference
- HC....cms
CC.....cms
AC.....cms
3. Distances
- Inner canthal distance
Outer canthal distance
4. Nose tip to lip distances

2) Craniofacial:
Skull

Face
Hair
Eyebrows
Eyes

:
:
:
:

Ear
Nose
Philtrum
Lips
Mouth
Palate
Tongue
Upper jaw

:
:
:
:
:
:
:
:

N/Abnormal / Microcephaly / Macrocephaly / Anencephaly


Encephalocele / Cyclops / Cebocephaly
L / Large / Small / Midface hypoplasia
N / Hypertrichosis / Low hair line
N / Not Delivered
Palpebral fissure - N / Mongoloid / antimongoloid slant
Distance - N / Hypertelorism / Hypotelorism
Size - N / Microphthalmos / Anophthalmos / Epicanthal fold
N / Abnormal - shape, size, position
Bridge - N / Depressed / Elevated
Prominent / Absent
N / Prominent / Absent
N / Large / Small
N / Cleft / High arched
N / Small / Protruded
N / Hypoplastic

381

382

An Atlas of Neonatology

Lower jaw
Neck
3) Thorax:
Chest
Nipple
Breast
Ribs
Vertebrae

:
:

N / Micrognathia / Retrognathia
N / Short / Webbing / Cystic hygroma

:
:
:
:
:

4) Upper limb
Hand
Fingers

:
:
:

Palmar crease
Nails
5) Lower limb:
Length
Position

:
:

N / Narrow / Short / P. excavatum / P. carinatum


N / Supernumerary
N / Enlarged
N / Missing
N / Hemivertebrae / Scoliosis / Kyphosis / Spina bifida
bifida total / Meningocele / Myelocele
N / Short / Amputated / Abnormal position / Long joint dysplasia
N / Short / Long
N / Short / Long / Syndactyly / Polydactyly / Clinodactyly
Brachydactyly / Amputated / Broad thumb
N / Abnormal / Simean / Sydney C
N / Hypoplastic

:
:

Nails
Foots
Toe

:
:
:

6) Abdomen

7) Umbilicus

N / Short / Amputated / Long


N / Talipes - valgus / Varus / Genu varum - Valgum
Recurvant / Jt. Dysplasias / Dislocation
N / Hypoplastic
N / Short / Long / Rocker bottom / Abnormal / Crease
Syndactyly / Polydactyly / Amputated / Broad
2nd toe bigger than 1st toe / deviation of 1st and 2nd toe
N / Short / Narrow / Distended
Organomegaly / Ascitis / Prune belly
Omphalocele / N / Low set / High set
Cord - Length
diameter
Knots
Insertion
No. of vessels

8) External genitalia:
N: Female / N male Ambiguous - Male / Female
Penis
: N / Short / Long
Clitoris
: N / Short / Long
Urethra
: N / Hypospadias / epispadias
Testes
: N / Undescended / Agenesis
9) Anus
: N / Patent / Imperforate
Systemic Examination:
CNS
CVS
RS
PA
Radiological investigations
Microbiological tests
Cytogenetics
Serology
Photography
Signature of Doctor.

Appendices

383

Weight in pounds

Weight in Kgs

384
An Atlas of Neonatology

INDEX
A
Abnormal abdominal masses 38
Abnormal baby 13
Abnormal heart size 177
Abortion 1
Air bronchogram 172
Ambiguous genitalia 244
Anatomy of the breast 90
Anomalies of extremities
polydactyly 255
syndactyly 256
Anomalies of the face region 221
body stalk anomaly 235
cleft lip and palate 222
congenital hypertrophic pyloric stenosis 239
cystic hygroma 229
diaphragmatic hernia 230
duodenal atresia 238
Eagle Barrett syndrome 235
ectopia cordis 234
ectopia vesicae 236
epignathus 224
esophageal atresia 237
external ear malformations 228
eye anomalies
anophthalmos 225
cryptophthalmos 225
microphthalmos 225
gastroschisis 234
Hirschsprungs disease 242
ileojejunal atresias 240
imperforate anus 242
median cleft lip 222
neonatal cataracts 226
neonatal corenal opacities 227
omphalocele 233
Pierre Robin sequence 221
Prune belly syndrome 235
umbilical hernia 233
Antenatal fetal distress 9
Anthropometry 32, 67
birth weight 67
head circumferences 70
length 69
mid-arm circumference 71
special morphometry 71
ears 73
eyes 71
foot length 78
head 71
internipple distance 77
large ears (macrotia) 75
long ears 75

middle finger length 77


mouth width 76
palm length and palm breadth 76
penile length 77
philtrum 76
small ears 74
total hand length 77
Antiretroviral therapy (ART)
counseling 143
group 143
post-test 143
postexposure prophylaxis 144
universal work precautions 144
Apgar score 6
Apgars evaluation of newborn 7
Artificial feeding 97
Assignment of sex 246

B
Battered baby syndrome 123
Beckwith-Wiedemann syndrome 275
Biliary atresia 112
Birth injuries 114
caput succedaneum 115
cephal hematoma 115
scalp injuries 115
skin and superficial injuries 114
subcutaneous fat necrosis 114
subgaleal hemorrhage 117
vacuum extraction injuries 117
Birth weight groups 1
Bleeding neonate
approach to a bleeding neonate 160
clinical presentation 160
etiology 160
vit K deficiency bleeding 162
Bone fractures 118
brachial plexus injuries 120
breech deformation 123
Erbs palsy 121
facial nerve palsy 121
fracture of clavicle 120
internal organ injury 122
Klumpkes palsy 121
long bone fracture 120
scrotal injury 122
Breastfeeding
benefits 89
benefit to the nation 89
benefits to family 89
benefits to the baby 89
benefits to the mother 89
guidelines for successful breastfeeding 92
types 90
Breastfeeding and HIV 145

C
CANS
signs 84
abdomen 88
arms 84
back 85
buttocks 85
cheeks 84
chest 85
hair 84
legs 85
neck and chin 84
Caudal regression syndrome 164
Causes of perinatal death 2
Cephal hematoma 167
Chlorhexidine 32
Choledochal cyst 113
Chromosomal abnormality 268
cat cry syndrome/cri du chat syndrome
275
deletion 9P
syndrome 276
duplication 10 q syndrome 276
trisomy 13 (Patau syndrome) 270
trisomy 18 (Edwards syndrome) 272
trisomy 21 (Downs syndrome) 268
Turners syndrome 273
WAGR syndrome 274
Chronic cholestasis 111
Classification of newborns 80
based on birth weight for gestational age 81
based on gestational age 80
based on weight 80
classification based on weight for
gestational age 82
CNS malformations 204
abnormal shapes of head 220
anencephaly 209
Arnold-Chiari malformations 220
congenital scalp defect 217
Dandy Walker malformation 216
encephaloceles 211
external cerebral formation 204
holoprosencephaly 206
hydrocephalus 215
iniencephaly 209
internal cerebral formation 204
meningoceles 213
meningomyeloceles 213
microcephaly 218
neural tube defects 205
otocephaly 220
overview of brain development 204
porencephalic cysts 221
spina bifida occulta 212
X-linked hydrocephalus spectrum 216

386

An Atlas of Neonatology

Cold chain 25
Common minor malformations 201
Common neonatal infections 128
bullous impetigo 132
common bacteria in neonatal infection
group B Streptococcus 128
Haemophilus influenzae 128
Listeria monocytogenes 128
Staphylococcus epidermidis 128
Streptococcus pneumoniae 128
iatrogenic thrombophlebitis 134
meningitis 129
omphalitis 130
ophthalmia neonatorum 129
oral thrush 132
scabies 132
septic arthritis 133
staphylococcal scalded skin syndrome 131
tetanus 130
Complications of perinatal asphyxia 148
Congenital absence of ribs 264
Congenital CML 168
Congenital diaphragmatic hernia 13
Congenital heart diseases 176
abnormal heart shapes 177
congenital heart disease and chromosomal
abnormalities 179
congenital heart disease and systemic
malformation 179
cyanosis 176
globular heart 178
globular-Ebsteins anomaly 178
myocardial disorders 179
syndromes associated with congenital heart
disease 179
TOF 178
transposition of great vessels 178
Congenital hypothyroidism 264
Congenital malformations 200
causes 202
incidence 200
terminology 200
Congenital pneumonia 175
Congenital talipes equinovarus 256
Congenital vaginal occlusion 246
Craniosynostosis
acrocephalosyndactyly 322
Apert syndrome 322
Carpenter syndrome 323
clover leaf skull deformity 323

D
Diabetic embryopathy 164
Diabetic fetopathy 163
Dysmorphic child 266

E
Epidermolysis bullosa 264
Examination of placenta
importance 191
significance 198
Exchange transfusion 107

Extended neonatal mortality rate 2


Extended perinatal mortality rate 2

F
Facial limb defects
Langer Giedion syndrome 298
otopalatodigital syndrome II 298
Stickler syndrome 299
Features of placenta 192
abnormal placentation 193
abnormalities of placental membranes
amnion nodosum 195
chorioamnionitis 195
meconium stain 195
placenta in amniotic band syndrome
195
abnormalities of placental weight 192
circumvallate palcenata 194
cord abnormalities 196
hematoma of the umbilical cord 197
placentas of multiple gestation 198
single umbilical artery 196
true knots of the umbilical cord 197
umbilical cord length abnormalities 196
velamentous insertion 197
fenestrated placenta 194
Feeding problems 92
breast abscess 96
engorgement of breast 95
inverted/flat nipple 92
sore nipple 95
Female pseudohermaphroditism 245
Fetal death
early 1
intermediate 1
late 1
Fetal injury 83
Fetal overgrowth
Beckwith-Wiedemann syndrome 282
FM 84

plantar surface 61
skin 59
Gestational age group
adequate-for-gestational age 2
large-for-gestational age 2
small-for-gestational age 2
Gestational groups 1
Growth restriction
Brachmann-de Lange syndrome 277
Hallermann Streiff syndrome 278
Johnson Blizzard syndrome 278
Robinows syndrome 280
Russell-Silver syndromes 277
Seckels syndrome 282
Smith-Lemli-Optiz (SLO) syndrome 279

H
Hamartomus nevi 263
Hammer toe 258
albinism 260
arthrogryposis multiplexa congenita 258
Collodion baby 262
developmental dysplasia of hip 258
Harlequin syndrome 261
Milroy disease 262
Handles for syndrome identification 267
Heat loss 9
Hemangioma 168
Hemorrhagic disease of the newborn 162
HIV status code 146
HIV-positive pregnant women 142
Hyaline membrane disease 172
Hydrocele 244
Hydronephrosis 252
Hydrops fetalis 109
Hyperbilirubinemia 105
Hypospadiasis 246
Hypothyroidism 263
Hypoxic ischemic encephalopathy
clinical features 148
Hypsarrhythmia 159

G
Gavage-feeding 99, 100
Gene locations of the skeletal dysplasias
369
Genetic syndromes 266
Gestational age 1
Gestational age assessment 59
neurological parameters 64
arm recoil 65
heel to ear 66
popliteal angle 65
posture 64
scarf sign 66
square window 64
physical parameters 59
breast 62
ear 62
eye 62
genitals-female 63
genitals-male 63
lanugo 60

I
Infant mortality rate 3
Infantometer 69
Information about medical genetics in India
359
Intramammary reflexes 92
Intrauterine infections
clinical manifestations 135
cytomegalovirus 137
herpes 137
rubella 137
syphilis 137
toxoplasmosis 137
IUGR 84
IUGR babies 82

J
Jaundiced neonate 104

Index
K
Kernicterus 105

L
Labor room procedures
steps 4
Life-threatening congenital anomalies 31
Limb abnormalities 302
EEC syndrome 306
femoral hypoplasia 304
Grebe syndrome 302
Larsen syndrome 307
lethal multiple pterygium syndrome 310
popliteal pterygium syndrome 304
radial dysplasia 305
unusual facies syndrome 304
Live birth 1
Lobar holoprosencephaly 158
Low birth weight babies 82

M
Macrosomia 165
Male pseudohermaphroditism 245
Malformation syndromes 266
Maternal hormones 48
Meconium aspiration syndrome 173
Meconium stained amniotic fluid 13
Meconium stained newborn 13
Microcephaly 138
Minolta transcutaneous bilirubinometer 103
Miscellaneous abdominal tumor 255
Miscellaneous anomalies of external genitalia
247
Miscellaneous syndromes 335
infantile polycystic kidney 336
Jarcho Levin syndrome 335
leprechaunism (Donohues syndrome) 336
lipodystrophy 336
Milroys disease 336

N
NALS 8
medications used 13
Neonatal anemia
causes 166
clinical evaluation 170
Neonatal case record 378
Neonatal cold injury 151
Neonatal convulsions
mimics of convulsions 155
subtle convulsions 155
Neonatal hepatitis syndrome 111, 112
Neonatal immunization
BCG vaccine 22
adenitis 24
complications 24
hepatitis B vaccine 24
immunization of babies born to HIVpositive mothers 25
oral polio vaccine 24
preterm immunization 25

Neonatal jaundice 102


classification
conjugated 111
pathologic 103
physiologic 103
evaluation 104
method of detecting jaundice in newborns
102
Neonatal mortality rate 2
Neonatal period 1, 2
Neonatal presentation of congenital heart
disease 176
Neonatal reflexes 54
Gallants reflex 57
Moros reflex 54
palmar grasp 55
placing reflex 56
plantar grasp 56
rooting reflex 55
stepping 57
suckling reflexes 55
swallowing reflex 55
tonic neck reflex 57
Neonatal sepsis
clinical features 125
common etiologic agents
Escherichia coli 125
group B streptococci 125
Klebsiella pneumoniae 125
Staphylococcus aureus 125
laboratory studies 125
Neuroblastoma 254
Neurofibromatosis 158
Newborn maturity rating and classification
383
Newborn Screening Programme 20
Nonshivering thermogenesis 149
Normal variants 43
apparent phimosis in newborn 47
cutis marmorata 46
epstein pearls (palatal cyst) 45
erythema toxicum 44
frontal baldness 51
gynecomastia 48
Harlequin color change 45
hemangiomas of skin 50
hydrocele 49
hymenal tags 49
milia 44
mongolian spots 43
neonatal teeth 46
normal variants in newborn 43
peeling of skin 48
prominent xiphisternum 50
subconjunctival hemorrhage 48
sucking blisters 45
supernumerary nipples 50
transient pustular melanosis 47

O
Oxygen 11
Oxytocin 91

387

P
Paladay and cup spoon-feeding 98
Pallor 166
Pedigree symbols 374
PEP recommendation 147
Perinatal HIV infection
diagnosis of HIV infection in neonatal
period 140
in utero transmission 140
intrapartum transmission 140
postpartum transmission through
breastfeeding 140
timing and mechanism of transmission 140
Perinatal mortality rate 2
Perinatal period 1, 2
Phototherapy 106
Physical examination of the newborn 31
general examination 32
head to foot examination 32
ophthalmoscopic examination 36
washing hands 32
Physical recognition of syndrome 267
Physiology of lactation 90
Porencephaly 158
Prevention of hypothermia in newborn 152
Primary brain defect 284
COFS (cerebrooculofacio-skeletal
syndrome) 285
Freeman Sheldon syndrome 289
Meckel-Gruber syndrome 286
Menkes syndrome 284
Neu-Laxova syndrome 286
Pena-Shokeir syndrome 285
Schwartz-Jumpel syndrome 288
Walker Warburg syndrome 284
XLR-aqueductal stenosis 285
Zellweger (cerebro-hepato-renal) syndrome
288
Primary facial anomalies 290
anophthalmia 298
blepharophimosis 291
cataract 298
cleft lip sequence 291
Fraser syndrome 290
frontonasal dysplasia 295
Goldenhar syndrome 292
median cleft face syndrome 298
microphthalmia 298
orofaciodigital syndrome 293
Robin sequence 298
Treacher Collins syndrome 291
Van der Woude syndrome 292
Waardenburgs syndrome 296
Primary soft tissue/connective tissue anomalies
324
beals contractural arachnodactyly 329
Ehlers-Danlos syndrome 327
Harlequin syndrome 330
Klippel-Trenaunay-Weber syndrome 324
Marfans syndrome 326
osteogenesis imperfecta type II perinatal
lethal 324
osteogenesis imperfecta type III 326
restrictive dermopathy 329

388

An Atlas of Neonatology

Problems of infants of diabetic mothers 163


Problems of temperature regulation
modes of loosing heat 149
conductive loss 149
convective loss 149
evaporative loss 149
radiation loss 149
Pulse oximeter 177
Putative teratogens 164

R
Rectovesical fistula 246
Relactation 96
Renal cystic diseases 250
Respiratory distress 171
assessment of respiratory distress 172
causes
anatomic problems compromising
respiratory system 171
pulmonary disorders 171
systemic disorders 171
clinical evaluation 173
predisposing and protective factors 173
Respiratory distress syndrome 172
Resuscitation 8
Rh-incompatibility 109
Rocker bottom foot 258
Routine care of the newborn
bathing 16
cold care 17
eye care 17
prevention of hypothermia 16
recording daily weight 17
screening for congenital disorders 19
watching for danger signs 17

S
Scrotal hematoma 168
Selected neonatal syndromes 351
miscellaneous syndromes 355
syndromes of skeletal dysplasias 354
syndromes with disordered growth 351
syndromes with facial limb malformation
354
syndromes with limb anomalies 353
syndromes with major facial defects 352
syndromes with primary brain/
neuromuscular abnormality 352
Septic arthritis 134
Septicemia baby 126
Sequence and associations
amniotic rupture sequence 337
arthrogryposis 347
caudal dysplasia sequence 345

CHARGE association 347


exstrophy of the bladder or ectopia vesicae
345
holoprosencephaly sequence 347
hypothyroid sequence 347
Klippel-Feil sequence 346
limb body wall sequence 340
oligohydramnios sequence 343
renal agenesis 347
sirenomelia 341
spinal dysraphism sequence 347
twin: conjoined and acardia 374
urethral obstruction sequence 344
VATER association 346
SGA 84
Skeletal dysplasias
achondrogenesis types 1 and 2 311
achondroplasia 316
autosomal recessive chondrodysplasia
punctata 319
campomelic dysplasia 314
cleidocranial dysostosis 320
diastrophic dysplasia 321
Ellis-van Creveld syndrome 318
fibrochondrogenesis 321
hypophosphatasia 320
intracranial hemorrhage 118
Jeune asphyxiating thoracic dystrophy 315
mesomelic dysplasia severe dominant form
321
metatropic dysplasia 317
other injuries in head 118
short rib polydactyly types I and II 312
Skull fractures 117
sternomastoid tumor 118
thanatophoric dysplasia 314
Smith-Lemli-Opitz syndrome 158
Stool cycle in newborn
meconium stool 52
milk stool 53
stool in artificially-fed babies 53
transitional stool 52

T
Tachyarrhythmias 14
Tactile stimulation 11
Teratogens 202, 334
CMV 335
congenital rubella syndrome 334
congenital varicella syndrome 335
syphilis 335
toxoplasmosis 335
Teratomas
sacrococcygeal teratoma 247
Term infants 128

Thermoneutral temperature 149


Traditional practices
beneficial 27
harmful 27
indifferent 29
Transient tachypnea of the newborn 174
Tumors and hamartomas 330
cystic hygroma 334
hemangiomas 333
hypomelanosis of ito 331
incontinentia pigmenti 330
neuroblastoma 334
neurocutaneous melanosis sequence
331
neurofibromatosis 332
Proteus syndrome 334
Sturge-Weber syndrome 330
teratoma 334
tuberous sclerosis 332
Twins
causes of twin perinatal loss 182
classification 188
acardia 189
fetus papyraceous 189
vanishing twin syndrome 189
conjoined twins 187
feeding of twins 183
incidence of twins 182
problems associated with twins 182
Siamese twins 182
twin reversed arterial perfusion sequence
184
twin-to-twin transfusion syndrome 184
zygosity of twinning 183
Types of breast milk
colostrum 100
fore milk 101
hind milk 101
mature milk 101
preterm milk 101
transitional milk 101
Types of seizures 155
causes of seizures 157
classification of seizures 156

V
Vaccine carriers 26

W
Wilms tumor 252

Z
Zellweger syndrome 158