respiratory distress in newborn

[raj887]

I had a question about some lab values that were taken of my newborn in hospital.  He was born at 39 weeks with no fetal distress in utero or during labor.  He had APGAr scores of 6 at 1 minute and 7 at 5 minutes.  He had a loose nuchal cord around neck.  He had respiratory distress at birth and was dx with aspiration of amniotic fluid with respiratory symptoms and a small right sided pneumothorax that did not require a chest tube and hypovolemia.  My question is about his ABG's.  The umbilical artery abg was ph 7.27 and base excess -5.8.  17 minutes after birth his ABG was taken with ph of 7.11 and base excess of -13.7.  He received oxygen and sodium bicarb and was out of NICU in two days on room air.  With the ph and base excess values I have typed, what is the likelihood that he would have any neurological damage?  We had one neonatologist say it was extremely unlikely, and another that said he would likely have renal damage before neurological damage, and that no neurological damage is seen until base excess is >20 and ph <6.9.  Just wanted to know your thoughts on his risk for neurological issues later in life including ADD and if it is significant that base excess and ph dropped so much in first 17 minutes of life.  Thanks for your help.  I am a physician and just want to better understand the ABG values and risk to him in future since there was some discrepancy in what our neonatologists said.

[raj887]

Thank you for the help.  The only thing I wanted to tell you was that the neonatologists said the mixed acidemia was due to hypoxia from the aspiration and moderate sized pneumothorax.  None of them thought it was due to metabolic defect.  We think that it probably was worse also because of the delay in time it took NICU to respond.  At 12 minutes of life, when he got to the nicu, his pulse ox was 83 % on room air.  Thanks again for everything.

[Santosh Kondekar, MD]

Dear raj887,

Thanks for reverting.

From the description provided, it is obvious that the problem lasted for a short while, but we do not know its cause yet.

I understand your concern about the neurological sequelae but it is important to note that the history of this episode may be important for some minor issues like say delayed grasp power, memory or some minor learning disability later in life. So it is important to note that there has been an episode of acidosis (the reasons for which are currently unknown) which can occur again under periods of stress (like metabolic defects which present with acidosis and get precipitated with stress).

I would like to reassure you that there is nothing to worry about currently as there is no evidence to suggest any neurological damage at present.

I would suggest that the baby should be assessed by the early intervention team twice in first 6 months, and then thrice in next 6 months.

I wish you and your child all the best.

Best Regards
Dr. Santosh Kondekar.

[raj887]

Sorry, his weight currently is 9 pounds at two weeks of age.  He was 8 lb 9 oz at birth and was 21 1/2 inches in length.  He never had any seizures, etc in hospital.  When he was first delivered he cried out and then became hypoxic.  The labor and delivery nurses tried to stimulate him and suction him and then gave him oxygen.  Our anesthesiologist helped with giving him some breaths by bag mask within two or three minutes while waiting on the NICU that came between 5 and 10 minutes.  He did begin to pink up some with bag mask and had APGAR of 7 within 5 minutes.  The neonatologists said that if he had been severely acidotic they would have put a cool cap on him which they said he did not come close to needing and that he would most likely be neurologically normal because of short duration of hypoxia and levels of ph and base excess.

[raj887]

He is only two weeks old now with intact neurological state breastfeeding well.  He was immediately placed on oxygen and acidosis and hypovolemia were corrected within one hour of birth if not sooner.  The two neonatologists he saw in the hospital just recommended normal follow up.  They said that he was at no greater risk for neurological impairment than a normal term newborn since his issues were corrected fast and the ph and base excess did not drop to serious acidosis levels.  What do you think of this?  With the values I gave you, was he ever in severe metabolic acidosis or just mild to moderate?  Should we follow up differently than suggested?  thanks for the information.

[Santosh Kondekar, MD]

Dear raj887,

I am sorry for what your baby had to go through. The most important thing here is to realize that there is no direct cause and effect relationship between episodes of hypoxia, acidosis, respiratory distress, pneumothorax (though all these are interrelated and can be following each other) and the neurological outcome. As you too may be aware, severe hypoxia and severe acidosis can surely cause multisystem failure, but there is no defined sequence for it. According to literature, only 10 to 20 % cases of cerebral palsy are due to neonatal hypoxia.

So as such the values don’t matter and the ABGs might be normal even in serious neurological damage or renal damage too. ABG values can often be temporarily deranged and may get corrected soon with therapy, so a single or sequential ABG reading cannot be used to predict the neurological prognosis. What matters more is how long did the acidosis last. A pH closer to 7 lasting more than 6 hours can cause serious hyperventilation, loss of CO2 (PCO2 below 15) and "acidosis related" intracranial damage (bleed). It is important to note that this is not the scenario with every case. A sudden drop in pH and base excess doesn’t predict any neurological sequelae.

Apart from acidosis, hypoglycemia, hypoxia, shock (hypovolemia) are more serious and easily correlatable markers of neurological damage.
What is important is to know that whatever might have happened, he is a newborn who was at risk for neurological damage. Whatever may be the risk, the further management and follow up should be done seriously and meticulously even though all issues appear normal at some stage.

These infants need a close watch on milestones, early intervention and stimulation techniques so that possible sequelae can be avoided or modified.

I would also like to know his current age, weight and milestones achieved.

Hope that this information helps and hope that you will get better soon.

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Best Regards,
Dr. Santosh Kondekar