Hyporesponsive newborn

Introduction Decreased responsiveness is a group of clinical symptoms that include a certain degree of dysfunction, decreased muscle tone, decreased limb activity, weak crying and sucking weakness. Neonates not only show low response in central nervous system diseases, but also other severe infections such as shock dehydration, acidosis metabolic disorders, anemia, hypothermia and respiratory failure, etc., all of which can show low response. Clinically low response is often used to determine various A manifestation of the severity of the disease. Strengthening pregnancy and maternal health care is of great significance in preventing this disease.

Cause

1. Hypoxic ischemic encephalopathy Hypoxic ischemic encephalopathy after perinatal asphyxia is the most common cause of early neonatal low response.

2. Sepsis: Infection can occur during intrauterine or postpartum.

3. Respiratory failure: When the newborn is hypoxic, it will soon enter the inhibition state, and the reaction will be low.

4. Hypothermia: It is generally considered that the reaction is slow when the body temperature is below 35 °C, and it is semi-conscious after 33 °C.

5. Hypoglycemia: When hypoglycemia occurs in gestational age infants and premature infants, it is often the first symptom that the response is low and sometimes the response is low.

6. Central nervous system infection: premature babies can only show low response, and full-term infants have a low response in purulent meningitis, suggesting that the disease is weight gain.

7. Drugs: Before the mother gave birth to antihypertensive drugs or anesthetics, such as pregnancy-induced hypertension mothers before delivery, intravenous infusion of a large amount of magnesium sulfate can cause hypermagnesemia and low response, and even respiratory inhibition; Anesthetics such as pethidine within 2 hours before delivery of the mother not only make newborns prone to primary asphyxia, but also show low response after birth.

8. Others: Many diseases in the neonatal period, such as dehydration acidosis, cardiac dysfunction, anemia, intracranial hemorrhage, 21-trisomy syndrome, and acute renal failure, can all show low response.

Pathogenesis:

1. Examination of neonatal arousal state: The neonatal nervous system is immature and the central nervous system is imperfect. It is very different from adult. The neurological function test method commonly used in children and adults is not suitable for newborns. When examining neonatal reflexes for newborns, it must be noted that infants of different gestational ages may have very different responses to external stimuli. Clinically used neurological reactions and neuroreflexes are one of the methods for gestational age assessment.

In the first few days after birth, the newborn is sleeping for about 20 hours every day. When the newborn is doing a neurological reaction check, the most common method for awakening the baby to awaken the newborn is to gently shake the baby's chest with the index finger and thumb and the sole of the foot. It can also be used to wake up the baby. The so-called awakening refers to the opening of the eyes, the movement of the head and limbs, the facial expression movements or crying should pay attention to the physical activity of the limbs is not equal to the cerebral cortical reaction, such as giving a painful stimulation to the soles of the feet, the lower limbs can be flexed and recovered, this is only the spinal cord. Reflexes The so-called cerebral cortex awakening should include facial expressions and/or systemic movements. Premature infants with gestational age below 28 weeks had no arousal reaction, and the limbs had almost no tension; 28 to 30 weeks premature infants had awakening reaction, but the limb tension was poor. The shorter the gestational age, the shorter the duration of the awakening state. The above physiological characteristics must be paid attention to when the neonatal, especially premature infants, check the reaction state.

2. Assessing the infant's response level: The awakening state of the newborn is closely related to the assessment of the infant's response level. Brazelton divides the awakening state of the newborn's physiological condition into the following six states according to the behavioral performance.

(1) Deep sleep: Close your eyes, breathing regularly, no movements in your limbs and trunk, and it will not be easy to change to another state when you give strong stimulation.

(2) light sleep (rapid eye movement sleep): the eyelid closes the eyeball to rotate rapidly, the breathing is irregular, and the strong stimulus is easy to wake up and easily transition to another state.

(3) Drowsiness: The eyes are opened or closed, and the limbs and trunks are less and short-lived.

(4) Quiet awakening: the eyes are open, and the eyeball responds to external stimuli with less physical activity.

(5) Activity awakening: the eyes open and the limbs are active and powerful.

(6) crying: the power of crying is not easy to stop crying.

In different awakening states, the level of response of the newborn is also different when the newborn is doing a neural response test, preferably in a state of quiet or active awakening. Gently swing the baby during the examination or shake the chest with your fingers to wake up the baby to maintain the most appropriate awakening state. If you are in a deep sleep state, you will mistakenly judge that there is no response or activity is weakened. The ambient temperature should be maintained at 27 to 30 °C during inspection to prevent excessive temperature or cold stimulation from affecting the inspection results.

an examination

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If the newborn has a low response, first determine the degree of low response, and then check the accompanying symptoms to do the necessary auxiliary examination to determine the primary disease as soon as possible. The following items can be used as a reference.

1. Consciousness disorder: The method of examining neonatal disturbance of consciousness is to stimulate the newborn, including pain stimulation to observe the response and the degree of response. The method can be used to gently shake the chest, or use the finger to rub the sole of the foot. If there is no reaction, acupuncture can be used. Make painful stimulation. Fenichel divides neonatal disturbances into four states:

(1) Drowsiness: It is easy to wake up, but it is not easy to maintain an awake state.

(2) retarded: non-painful stimuli can wake up but wake up very late, and not fully awake, can not maintain awakening state.

(3) Light coma (sleeping): Only painful stimulation can wake up.

(4) Coma: pain stimulation can not wake up.

2. Muscle tone loss: Neonatal muscle tone loss can be a symptom of nervous system or muscle disease, and also a manifestation of central nervous system depression in many severe systemic diseases. Muscle hypotonia is manifested as double lower extremity abduction, double The arm is soft, the range of motion of the elbow and knee joint is increased, and there is no resistance when the limb is passively moving. When pulling the reaction, pull the baby's hands from the supine position to the sitting position and hang down, not in line with the torso. When standing upright for a few seconds, the head can't be vertical, the limbs are soft and shaken; when the level is raised, the head and limbs are weak and weak. Neonatal muscle tone is often accompanied by weak crying and weak suction, difficulty in swallowing, and significant reduction in voluntary movement

3. Physical examination: focus on the ability to maintain life and accompanying symptoms, vital signs such as body temperature, heart rate, respiration and blood pressure should be recorded in time for neurological examination, including head and canal pressure, convulsions, rhythm, eye movement, pupil size and light The reaction, as well as the original reflex, should be examined in detail to check the fundus if necessary to observe the presence or absence of optic disc edema and fundus hemorrhage. The examination of children with low response should focus on respiratory failure, circulatory failure, shock, high fever and hypothermia, and Nervous system examination

Laboratory inspection:

Neonatal sepsis peripheral blood leukocytosis or decrease, rod-shaped nucleus increased, platelet count decreased C-reactive protein significantly increased bilirubin, blood culture positive for diagnosis; respiratory failure, hypoxic ischemic encephalopathy in children with blood gas analysis Have hypoxemia, hypercapnia, respiratory or metabolic acidosis, severe type II respiratory failure, PaCO2 up to 9.3kPa (70mmHg); blood glucose monitoring helps in the diagnosis of hypoglycemia; central nervous system infections such as Purulent meningitis lumbar puncture can be diagnosed; mother with magnesium sulfate to hypermagnesemia in infants with magnesium >1.75mmol / L (3.5mEq / L); acute renal failure in the presence of urine routine and blood biochemical health search A series of changes; and so on.

Other auxiliary inspections:

Electroencephalogram of hypoxic-ischemic encephalopathy often has abnormal changes. Brain CT and brain B-ultrasound can detect cerebral edema subarachnoid hemorrhage or intraparenchymal hemorrhage. If necessary, X-ray examination, electroencephalography, brain imaging techniques such as magnetic resonance imaging (MRI), camphor scan, CT, Doppler intracranial ultrasound, and brainstem evoked potentials should be selected as needed.

Differential diagnosis

In the neonatal period, various diseases progress to a certain extent, and almost all of them will have a low response. The medical history should be consulted in detail, combined with clinical symptoms and signs and corresponding laboratory-assisted examinations to confirm the diagnosis and differential diagnosis.

Central nervous system disease

(1) central nervous system infection: neonatal suppurative meningitis has a low response, suggesting that the condition is weight gain. Often accompanied by convulsions before sputum tension and other infection symptoms, lumbar puncture can be diagnosed.

(2) Hypoxic ischemic encephalopathy: Most of the full-term children have a history of intrauterine distress and severe asphyxia; the first manifestation of irritability after the emergence of low response, physiological reflexes weakened or disappeared often accompanied by convulsions and increased intracranial pressure EEG Brain CT and brain B-ultrasound can help differential diagnosis.

2. Identification of hypothermia: due to insufficient stimulation of cold stimulation, the body temperature is lowered and the child's response is low. After rewarming treatment, with the recovery of body temperature, the response is better; if the child is caused by low body temperature caused by the severity of the primary disease Low, common severe primary conditions and complications. For example, neonatal infectious diseases often show low response with the development of the disease.

(1) Neonatal scleredema: refers to the hardening of the skin and subcutaneous fat caused by various reasons in the neonatal period, accompanied by clinical syndrome of edema and hypothermia, which is also called cold injury caused by cold alone. Signs, severe cases combined with multiple organ dysfunction, clinical features of body temperature does not rise skin hard swelling and multi-system function damage.

(2) Neonatal sepsis: the biggest clinical feature is the lack of characteristic features, often low response, refusal of milk as the first symptom, plus history of intrauterine infection, intrapartum infection or postpartum infection, laboratory blood test positive Peripheral blood leukopenia, platelet count decreased, C-reactive protein increased significantly, which is helpful for diagnosis.

(3) neonatal pneumonia: poor general condition, low response, crying power, refusal to milk, milk and mouth vomiting, shallow breathing irregularities, etc., rapid changes in the condition of respiratory failure heart failure and life-threatening.

3. Hypoglycemia: hypoglycemia caused by various causes (see neonatal hypoglycemia), when hypoglycemia occurs in small for gestational age and premature infants, the first response is low, and sometimes the response is low. Combined with medical history, there is a history of insufficient eating or asphyxia within 3 days after birth, and clinical manifestations and blood glucose monitoring can be diagnosed.

4. Drug-induced: the mother used antihypertensive drugs before delivery, the baby's low response after birth, combined with the baby's blood magnesium>1.75mmol / L (3.5mEq / L) can be diagnosed; mother with petrolidine within 2h before delivery The anesthetic can be diagnosed when there is suffocation at the time of birth and low postnatal response.

Many diseases in the neonatal period such as dehydration acidosis, cardiac dysfunction shock anemia, intracranial hemorrhage 21-trisomy syndrome and acute renal failure can be combined with clinical features and laboratory tests to confirm the diagnosis.

If the newborn has a low response, first determine the degree of low response, and then check the accompanying symptoms to do the necessary auxiliary examination to determine the primary disease as soon as possible. The following items can be used as reference

1. Consciousness disorder: The method of detecting neonatal disturbance of consciousness is to stimulate the newborn, including pain stimulation to observe whether there is reaction and the degree of reaction. The stimulation method can be used to gently shake the chest, or use the finger to rub the sole of the foot. If there is no reaction, acupuncture can be used. Painful stimulation. Fenichel divides neonatal disturbances into four states:

(1) Drowsiness: It is easy to wake up, but it is not easy to maintain an awake state.

(2) retarded: non-painful stimuli can wake up but wake up very late, and not fully awake, can not maintain awakening state.

(3) Light coma (sleeping): Only painful stimulation can wake up.

(4) Coma: pain stimulation can not wake up.

2. Muscle tone loss: Neonatal muscle tone loss can be a symptom of nervous system or muscle disease, and also a manifestation of central nervous system depression in many severe systemic diseases. Muscle hypotonia is manifested as double lower extremity abduction, double The arms are soft, and the range of motion of the elbow and knee joints is increased without passive resistance. When pulling the reaction, pull the baby's hands from the supine position to the sitting position and hang down. When you can't hold the torso with the torso for a few seconds, the head can't be vertical, the limbs are soft and shaken; the head and limbs are raised horizontally. Weak and weak. Neonatal muscle tone is often accompanied by weak crying and weak suction, difficulty in swallowing, and autonomous movement is significantly reduced.

3. Physical examination: focus on the ability to maintain life and accompanying symptoms, vital signs such as body temperature, respiratory rate and blood pressure should be recorded in a timely manner, neurological examination including head and canal pressure, convulsions, respiratory rhythm, eye movement pupil size and Both the photoreaction and the original reflection should be examined in detail. If necessary, check the fundus for disc edema and fundus hemorrhage. The examination of children with low response should focus on respiratory failure, circulatory failure, shock, high fever and hypothermia, and neurological examination.

Laboratory inspection:

Neonatal sepsis peripheral blood leukocytosis or decrease, rod-shaped nucleus increased, platelet count decreased C-reactive protein significantly increased bilirubin, blood culture positive for diagnosis; respiratory failure, hypoxic ischemic encephalopathy in children with blood gas analysis Have hypoxemia, hypercapnia, respiratory or metabolic acidosis, severe type II respiratory failure, PaCO2 up to 9.3kPa (70mmHg); blood glucose monitoring helps in the diagnosis of hypoglycemia; central nervous system infections such as Purulent meningitis lumbar puncture can be diagnosed; mother with magnesium sulfate to hypermagnesemia in infants with magnesium >1.75mmol / L (3.5mEq / L); acute renal failure in the presence of urine routine and blood biochemical health search A series of changes; and so on.

Other auxiliary inspections:

Electroencephalogram of hypoxic-ischemic encephalopathy often has abnormal changes. Brain CT and brain B-ultrasound can detect cerebral edema subarachnoid hemorrhage or intraparenchymal hemorrhage. If necessary, X-ray examination, electroencephalography, brain imaging techniques such as magnetic resonance imaging (MRI), camphor scan, CT, Doppler intracranial ultrasound, and brainstem evoked potentials should be selected as needed.

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