Neonatal Collapse
Last updated 4th May 2020 - Tom Heaton
The collapsed neonate is a presentation that may require urgent intervention outside specialist centres.
This can be considered as the sudden deterioration, including arrest, of a child that was apparently healthy at birth.
The presentation is usually in the first 7 days.
This is a good overview video: https://www.youtube.com/watch?v=4qLLdFZKHAs
The key differentials include:
There are some additional diagnoses that are important:
This can be considered as the sudden deterioration, including arrest, of a child that was apparently healthy at birth.
The presentation is usually in the first 7 days.
This is a good overview video: https://www.youtube.com/watch?v=4qLLdFZKHAs
The key differentials include:
- Sepsis
- Congenital heart disease (CHD)
- Metabolic disorders
- Non accidental injury
There are some additional diagnoses that are important:
- Abdominal/surgical
- Myocarditis
- Endocrine: Adrenal insufficiency. Hypothyroidism
- Respiratory tract infection
- Toxins
Sepsis
Sepsis within the first week of life is a serious condition with high risk of morbidity and mortality.
Some key pathogens include:
As is the case in many age groups, but even more so here, the presentation is often non specific.
Key features that may suggest this as a diagnosis include:
Some key pathogens include:
- Bacterial
- Group B strep
- Listeria
- E. coli
- Staph
- Group B strep
- Viral
- HSV
- Enteroviruses
- HSV
- Fungal
- Candida
- Candida
As is the case in many age groups, but even more so here, the presentation is often non specific.
Key features that may suggest this as a diagnosis include:
- Temperature change - >38.5 or <36
- Heart rate change - >180 or <100
- Tachypnoea - >50 bpm
- Leukocytosis - > 34x10^9/L
Congenital Heart Disease
This is an important potential pathology and is considered in more detail elsewhere.
Key features that may support this as a diagnosis include:
The major CHD phenotype that is of concern in the collapsed neonate is ‘duct-dependent’ CHD.
Here, the patent ductus arteriosus had been masking whatever serious underlying CHD lesion the child had, by allowing mixing across the sides of the circulation, and as it closes, the problems can suddenly manifest themselves.
Key features that may support this as a diagnosis include:
- Cyanosis - refractory to oxygen
- Tachypnoea - especially in the absence of lung pathology
- Murmur
- Absent femoral pulses
- Hepatomegaly
- Lactic acidosis unresponsive to initial resuscitation
- CXR changes - Cardiomegaly and pulmonary oedema
The major CHD phenotype that is of concern in the collapsed neonate is ‘duct-dependent’ CHD.
Here, the patent ductus arteriosus had been masking whatever serious underlying CHD lesion the child had, by allowing mixing across the sides of the circulation, and as it closes, the problems can suddenly manifest themselves.
Metabolic
There are a wide range of metabolic disorders that can affect neonates, and thus a wide range of presentations.
Some key ones to consider include:
Key features that may suggest this as a cause of neonatal collapse are generally those of a multi systemic nature, including:
Despite the extensive number of potential causes, establishing the ammonia level in a potentially metabolic cause of collapse is essential.
This is because of the notable toxicity of it to the developing brain, which is related to both the degree and duration of the elevation.
Lowering this is therefore a time-critical management task.
Some key ones to consider include:
- Hypoglycaemia
- Inborn errors of metabolism
- Hyperinsulinemia
- Fatty acid oxidation defects
- Inborn errors of metabolism
- Congenital adrenal hyperplasia
- Maternal thyrotoxicosis
- Congenital hypothyroidism
- Urea cycle defects
- Glycogen storage disorders
- Organic acidemias
- Mitochondrial disorders
Key features that may suggest this as a cause of neonatal collapse are generally those of a multi systemic nature, including:
- Hypoglycemia
- Lactic acidemia
- Hyperammonemia
- Notable smell
- Ambiguous genitalia
- Lethargy
- Vomiting
- Seizures
- Abnormal tone
Despite the extensive number of potential causes, establishing the ammonia level in a potentially metabolic cause of collapse is essential.
This is because of the notable toxicity of it to the developing brain, which is related to both the degree and duration of the elevation.
Lowering this is therefore a time-critical management task.
NAI
This remains a clear consideration for all pediatric presentations.
This is discussed in more detail elsewhere.
A clear exploration of the history and careful examination of the child is essential here.
Essentially any injury in a neonate is going to be caused by someone else, because of their development level.
Injuries can very rapidly lead to compromise in these children because of the
Consider exploring the history of administration of vitamin K at birth, as hemorrhagic disease of the newborn is a parallel consideration in some presentations.
This is discussed in more detail elsewhere.
A clear exploration of the history and careful examination of the child is essential here.
Essentially any injury in a neonate is going to be caused by someone else, because of their development level.
Injuries can very rapidly lead to compromise in these children because of the
Consider exploring the history of administration of vitamin K at birth, as hemorrhagic disease of the newborn is a parallel consideration in some presentations.
Presentation
Certain factors in the history can provide useful information on the underlying cause.
Features to consider exploring include:
PC
PMH
Family/Social History
Features to consider exploring include:
PC
- Respiratory history
- Feeding
- Appearance
- Neurological status
PMH
- Known diagnoses
- Antenatal history
- Appropriate scans
- Growth
- Pathogens in mother - Group B strep, HSV
- Appropriate scans
- Delivery history
- Gestation at delivery
- Mode of delivery
- Perinatal complications
- Risk factors for sepsis
- Gestation at delivery
- Neonatal exam
Family/Social History
- Any hereditary disorders
- CHD
- Metabolic disorder
- Sudden infant death
- CHD
- Consanguinity
- Other illness at home
- Foreign travel
Assessment
These patients can often present in extremis.
A systematic approach is therefore advocated, as usual, generally an A to E approach, treating life-threatening issues as they are encountered.
Airway
Airway support may be needed.
This may be due to the presentation or treatment e.g. prostaglandin infusion can lead to apnoeas, so I&V should be considered in this group (>15mcg/kg/min).
Intubation should be undertaken by an appropriately skilled operator in a safe environment.
Resuscitation of the patient should be optimised prior to induction of anaesthesia for intubation.
There should also be anticipation of possible CVS instability, with preparation for this, with emergency drugs available.
Breathing
The respiratory status of the patient should be considered.
This will include standard features of assessment:
In cases of PDA dependent heart disease, there may remain hypoxia resistant to oxygenation, and indeed, oxygen is a potent trigger for duct closure.
Target oxygenation in these patients is usually 75-85% to reduce the impact of oxygen on duct closure.
Insertion of a gastric tube may allow decompression of the stomach to aid ventilation.
A CXR should be performed to provide information on lung fields, heart size and OETT position.
Circulation
Fluid resuscitation (initially 10ml/kg crystalloid) is usually appropriate in most of these presentations.
The addition of pharmacological support of the circulation with adrenaline infusion may be considered.
Central access may be considered in sick patients, although this may remain a specialist skill, outside of the scope of non-paediatric specialists.
Peripheral lines (and indeed IO access) can be used for most infusions in the interim.
Consider insertion of an arterial line if the skills are available.
Similarly, if there are skills available locally to perform an echocardiogram, this can provide very useful information.
Good rule of thumb values for the neonate are 60/30 (40) mmHg.
Disability
Sedation will need to be commenced to tolerate IMV if this has been needed, and will usually entail morphine and midazolam (although midaz may not be needed).
Pupils and glucose levels should be measured regularly.
Phenobarbitone (20mg/kg) is the anticonvulsant of choice in this age group.
The collapsed state is a contraindication to performing a lumbar puncture so suspected meningitis is treated clinically.
Hypoglycaemia can be corrected with 10% glucose 2ml/kg.
Exposure
Patients can get cold very quickly and temperature should be maintained, either through caring for them in a resuscitaire or maintaining covering.
Despite this, a thorough examination is still important.
The assessment of the metabolic patient can include a number of investigations.
Hypoglycaemia screen (best taken when hypoglycaemic):
Fluid therapy will be commenced, with a max of 100ml/kg/day recommended because of the SIADH risk.
This inclusion of glucose in this is important.
A systematic approach is therefore advocated, as usual, generally an A to E approach, treating life-threatening issues as they are encountered.
Airway
Airway support may be needed.
This may be due to the presentation or treatment e.g. prostaglandin infusion can lead to apnoeas, so I&V should be considered in this group (>15mcg/kg/min).
Intubation should be undertaken by an appropriately skilled operator in a safe environment.
Resuscitation of the patient should be optimised prior to induction of anaesthesia for intubation.
There should also be anticipation of possible CVS instability, with preparation for this, with emergency drugs available.
Breathing
The respiratory status of the patient should be considered.
This will include standard features of assessment:
- SpO2 - pre and postductal
- Respiratory rate
- Work of breathing
- Lung field auscultation
- Blood gas analysis
In cases of PDA dependent heart disease, there may remain hypoxia resistant to oxygenation, and indeed, oxygen is a potent trigger for duct closure.
Target oxygenation in these patients is usually 75-85% to reduce the impact of oxygen on duct closure.
Insertion of a gastric tube may allow decompression of the stomach to aid ventilation.
A CXR should be performed to provide information on lung fields, heart size and OETT position.
Circulation
- Colour
- Cap refill
- Heart rate
- Blood pressure
- Pulses - comparing at different sites
- Heart sounds
Fluid resuscitation (initially 10ml/kg crystalloid) is usually appropriate in most of these presentations.
The addition of pharmacological support of the circulation with adrenaline infusion may be considered.
Central access may be considered in sick patients, although this may remain a specialist skill, outside of the scope of non-paediatric specialists.
Peripheral lines (and indeed IO access) can be used for most infusions in the interim.
Consider insertion of an arterial line if the skills are available.
Similarly, if there are skills available locally to perform an echocardiogram, this can provide very useful information.
Good rule of thumb values for the neonate are 60/30 (40) mmHg.
Disability
- Conscious level
- Pupils
- Glucose
- Fontanelles
Sedation will need to be commenced to tolerate IMV if this has been needed, and will usually entail morphine and midazolam (although midaz may not be needed).
Pupils and glucose levels should be measured regularly.
Phenobarbitone (20mg/kg) is the anticonvulsant of choice in this age group.
The collapsed state is a contraindication to performing a lumbar puncture so suspected meningitis is treated clinically.
Hypoglycaemia can be corrected with 10% glucose 2ml/kg.
Exposure
- Temperature
- Rash
- Abdominal exam
- Liver margin?
- Bloods
- FBC
- U&E
- Bone profile
- LFTs
- Ammonia
- Inflammatory markers - may not be elevated in neonatal sepsis
- Blood cultures
- Meningococcal and HSV PCR
Patients can get cold very quickly and temperature should be maintained, either through caring for them in a resuscitaire or maintaining covering.
Despite this, a thorough examination is still important.
The assessment of the metabolic patient can include a number of investigations.
Hypoglycaemia screen (best taken when hypoglycaemic):
- Lab glucose
- Lactate
- Ketones
- Insulin
- Cortisol
- Growth hormone
- Urine: ketones, inorganic acids
- Ammonia
- Lab glucose
- Plasma amino acids
- Lactate
- GAL-1-PUT
- Urine: ketones, organic and amino acids, orotic acid.
Fluid therapy will be commenced, with a max of 100ml/kg/day recommended because of the SIADH risk.
This inclusion of glucose in this is important.
Management
Part of the management will follow the above systematic review.
The involvement of the appropriate specialist teams can be very helpful in these situations.
There is a network of critical care retrieval teams in the UK that can be an excellent source of advice here.
Antibiotics
The challenge of diagnosing sepsis and the significant impact of it mean that there is a very low threshold for giving antibiotics in a collapsed neonate.
There is little that can provide good positive or negative predictive value, and so ‘cover’ is usually given.
This will tend to be cefotaxime and amoxicillin IV.
This may need alteration if there is an increased likelihood of nosocomial pathogens.
Strong consideration should also be given to IV acyclovir to cover for HSV infection, for much the same reasons.
Duct-Dependent CHD
The specific goal in these patients is to reopen the ductus arteriosus, and return the child back to the circulation that it had before, where it was apparently fairly stable.
This is of course a temporising measure, but can allow time for specialist input.
This will usually entail a prostaglandin infusion.
There are differing doses for ‘opening’ and ‘maintaining’ duct patency, and in the collapsed neonate, it is the opening that is required.
This needs a higher dose: starting at 20ng/kg/min, and titrating up rapidly if needed (can go to 50 and then even 100 if needed).
It is important to note that these are not the only potential CHD lesions in the collapsed neonate, and so specialist input is essential.
Some patients require urgent surgical intervention, and will derive little benefit, or even adverse effects, from such supportive measures.
Ammonia
Establishing the ammonia level in a potentially metabolic cause of collapse is essential.
This is because of the notable toxicity of it to the developing brain, which is related to both the degree and duration of the elevation.
Lowering this is therefore a time-critical management task.
Initial management involves cessation of all protein intake and administration of IV glucose and intralipid.
There are a range of specific treatment options for these patients, which is best guided by a specialist.
The British Inherited Metabolic Disease Group have some useful emergency guidance. http://www.bimdg.org.uk/site/index.asp
Options may include:
The involvement of the appropriate specialist teams can be very helpful in these situations.
There is a network of critical care retrieval teams in the UK that can be an excellent source of advice here.
Antibiotics
The challenge of diagnosing sepsis and the significant impact of it mean that there is a very low threshold for giving antibiotics in a collapsed neonate.
There is little that can provide good positive or negative predictive value, and so ‘cover’ is usually given.
This will tend to be cefotaxime and amoxicillin IV.
This may need alteration if there is an increased likelihood of nosocomial pathogens.
Strong consideration should also be given to IV acyclovir to cover for HSV infection, for much the same reasons.
Duct-Dependent CHD
The specific goal in these patients is to reopen the ductus arteriosus, and return the child back to the circulation that it had before, where it was apparently fairly stable.
This is of course a temporising measure, but can allow time for specialist input.
This will usually entail a prostaglandin infusion.
There are differing doses for ‘opening’ and ‘maintaining’ duct patency, and in the collapsed neonate, it is the opening that is required.
This needs a higher dose: starting at 20ng/kg/min, and titrating up rapidly if needed (can go to 50 and then even 100 if needed).
It is important to note that these are not the only potential CHD lesions in the collapsed neonate, and so specialist input is essential.
Some patients require urgent surgical intervention, and will derive little benefit, or even adverse effects, from such supportive measures.
Ammonia
Establishing the ammonia level in a potentially metabolic cause of collapse is essential.
This is because of the notable toxicity of it to the developing brain, which is related to both the degree and duration of the elevation.
Lowering this is therefore a time-critical management task.
Initial management involves cessation of all protein intake and administration of IV glucose and intralipid.
There are a range of specific treatment options for these patients, which is best guided by a specialist.
The British Inherited Metabolic Disease Group have some useful emergency guidance. http://www.bimdg.org.uk/site/index.asp
Options may include:
- Ammonia scavengers: sodium benzoate, arginine
- RRT
Links & References
- Lal, N. Varshney, T. The collapsed neonate in the emergency department. BJA Education. 2018. 18(8):254-8. https://bjaed.org/article/S2058-5349(18)30062-3/abstract
- Flannigan, C. Collapsed neonate. 2016. Paediatric Emergencies. https://www.paediatricemergencies.com/collapsed-neonate/
- Paediatric Emergencies. Collapsed Neonate. Youtube. 2016. https://www.youtube.com/watch?v=4qLLdFZKHAs
- Crashcall. Drug calculator. https://www.nwts.nhs.uk/documentation/crashcall
- British Inherited Metabolic Disease Group. http://www.bimdg.org.uk/site/index.asp
