Neonatal Cold Injury Syndrome (sclerema neonatorum)

Objectives

What will I learn?

Etiologies and pathophysiology

Symptoms

Diagnosis

Treatment

Definition

-- mainly caused by cold stress

--the clinical features are low body

temperature and scleredema

--serious one may appear multiple organ

dysfunction.

Scleredema --- hardening of the skin and subcutaneous tissue

Etiology and pathophysiology

Characteristics of temperature regulation

and subcutaneous fatty composition in

newborn

● immaturity of temperature regulation

center

● relative large surface area and rich

blood flow cause poor thermal insulation

● limited storage of energy, heat production

mainly by brown fatty metabolism,

lacking shivery thermogenesis

● more quantity of saturated fatty acid with

higher melting point

Imbalance between heat production and loss

Distribution of neonatal brown fat

Cold injury

● Cold environment increase heat loss, low body

temperature causes constriction of peripheral

blood vessels, dysfunction of microcirculation

● Low body temperature and cold environment

cause anoxia, metabolic disturbance and

acidosis even multiple organ dysfunction (MOD)

Other Factors

● severe infection,

● premature,

● asphyxia, ICH,

● erythroblastosis

Imbalance between heat production and loss

Heat production Heat production Heat production Heat production

cold

√

asphyxiaNon-enough Non-enough intakeintake

√

infection

√ √

Imbalance between heat production and loss

Heat loss Heat loss Heat loss Heat loss

cold

√

relative larger surface

√

coldcold

√

immature of temperature

center

immature of temperature center

relative larger surface cold 、 non-enough intake

infection 、 asphyxia

heat production

of brown fat↓

anoxia, acidosis

higher saturated fatty acid

higher melt point

body temperature ↓

coagulation of subcutaneous fat

Pathogenesis of Neonatal Scleredema

Anoxia, acidosis coagulation of subcutaneous fat

constriction of skin vessels

anoxia of tissue

hardening of skin

Slowly blood flow

disturbance of microcirculation

capillary permeability ↑

edema circulating volume↓

shock

multiple organs dysfunction

DIC

● usually occur in cold season

● during first 3 days or any time in preterm infants

● Low body temperature

● Scleredema

● MOD in severe case

Clinical Manifestations

● feature: skin and subcutaneous tissue

become indurated, woody, non-pitting,

cold to touch, involved area may with

edema, redness, cyanosis; symmetrical

● Sequence: calves→thighs→low

extremities→buttock→cheeks→upper

extremities→whole body

Scleredema

Neonatal scleredema

multiple organ dysfunction

● bradycardia, dyspnea,

● microcirculation disturbance,

● shock, DIC,

● acute renal failure,

● pulmonary hemorrhage

Evaluation of body surface area

Head and neck 20%

Upper limbs 18%

Anterior part of trunk 14%

Posterior part of trunk 14%

Buttock 8%

Lower limbs 26%

20%

9% 9%14% 14%

8%

13% 13%

Degrees of NCIS

Body temperature( ) involved area change of ℃organic

anus T axil – anus T (% 、 color) function

I0 ≥ 35 positive < 20 no change

(mild) pale

II0 < 35 0 or positive 20 ～ 50 poor reaction

(moderate) dark red bradycardia

III0 < 35 negative > 50 shock 、 DIC 、

(severe) or < 30 cyanotic PH or ARF

nonspecific examination for diagnosis.

blood gas analysis, CT, PT,

blood glucose level, platelet,

electrolytes, BUN,

fibrogen, etc.

EKG, X - ray

Laboratory Examination

Differential diagnosis

Neonatal edema● Localized edema

● Premature infant edema

--hypoalbuminemia, hyponatremia

● Hemolytic disease of newborns

- anemia, splenohepatomegaly or Jaundice

● Congenital nephrosis

-abnormal in urine

Neonatal edema

Differential diagnosis

Subcutaneous gangrene - staphylococcus aureus

-compressive site or impaired site

-swelling, blush, hard

-darkening, bleed, ulcer

-obscure boundary

Neonatal Subcutaneous Gangrene

treatment

Heat loss

Heat production

Correction of organ dysfunction

normal body temperature organs function

Treatment

● Restoration of body temperature

● Energy supply and fluid infusion

● Correction of organ dysfunction

· correction of acidosis and volume expansion

· treatment of pulmonary hemorrhage

· arrangement of ARF and DIC

● Others: antibiotics, symtomatic therapy

Treatment

Rewarming

● TR >30 , TA-R≥0℃

--Placed in a neutral thermal

environment

--Returned to normal temperature

during 6~12 hours

Treatment

● TR < 30 , ℃ TA-R<0

• Placed in a incubator where environmental

temperature higher 1~2 than body ℃

temperature( 0.5-1 /h℃ )

• Kept in a neutral thermal environment when

TR ≥ 35 ℃

• Returned to normal temperature during

12~24 hours

Treatment

Ways of re-warming

● Incubator

● Open radiant warmer bed

● Others

water bath, electric blanket ,

Kangaroo Care, etc

Incubator

Open radiant warmer bed

Huge omphalocele( 巨大脐膨出）

Prevention

● Neonatal care:

warm environment, enough clothes

● Encourage early breast feeding

● Prevent high risk factors:

premature, infection, asphyxia

Conclusion and Review

● How to diagnose neonatal sepsis?

● Which marker can indicate neonatal

infection?

● How many factors can cause NCIS?

● Which complication is caused by NCIS?

● State the clinic S/S and degrees of NCIS.

Mini case discussion

Clinical case presentation

• Patient1:10.09.06

• Sex: male

• GA:32+2W

• BW:1240g

• Vaginal delivery Apgar:8-10-10

• Umbilical pH:7.22

PROM of 2days

intrapartum ampicillin because of PROM(pre-

rupture of membrane ） and maternal elevation of

CRP

Admitted to NICU duo to prematurity

General condition is unstable

• Frequent apnea 2 hrs after birth,

aminophyllin and CPAP （ continuous positive airway

pressure ） was given for 3 days and apnea

disappeared.

• Because of VLBW, umbilical venous

catheterization was performed on D1 and the

catheter was removed on D7. PICC （ peri-

intravenous central-line catheterization ） was inserted

on D7.

• The general condition was stable after D3

except poor enteral feeding.

• On postnatal D13, he was getting worse :

tachypnea, tachycardia, pale, grunting ,

abdominal distention, cyanosis, low BP

and hypothemia.

--antibiotics , IVIG, CPAP was given.

23/4/8 49

Questions

• What kinds of diseases did the baby

suffer? Predisposing factor?

• What kinds of Lab tests would you

order?

• How can you save his life?

• How about his prognosis?

Septic work-ups

• Complete Blood Count

• Blood & Urine cultures

• Lumbar Puncture

• Chest X-Ray

• Line cultures

< 2 abnormal values & culture negative

Treat for 48 hours,(regardless of maternaltreatment) & dischargehome when appropriate

Culture + orLP abnormal

Culture - &LP normal

Treat for 7-10 daysfor bacteremia &14-21 days for

meningitis

Treat for 48 hrs. iflow suspicion of

sepsis & nopretreatment

Begin antibiotics

Evaluation of Symptomatic Infants for Neonatal Sepsis

> 2 abnormal values

= ~12hrs**WBC/Diff & CRP

Blood cultureChest x-ray

lumbarpuncture

Treat for 7-10 daysif high suspicion ofsepsis or mother

pretreated

Infant appears well & symptoms resolve

Treat for 7-10 days ifhigh suspicion of

sepsis