Case
A male infant is born at 36 weeks gestation to a
mother who tested (+) for GBS (Group B
Streptococcus) one week prior to delivery.
She came to the ER with contractions and leaking of
fluid for ~15 hours. By the time she delivered vaginally,
she had been ruptured for >24 hours.
She also had a low grade fever just before delivery, but
was otherwise well.
Case
After birth the baby is not as active as expected. He
has moments when he stops breathing briefly. At
times his breathing is fast & labored with both nasal
flaring and intercostal retractions. He is also noted to
be “moaning” on examination.
He is administered oxygen and admitted in the NICU
for more evaluation.
There is no improvement and oxygen saturations are
<85%. Infant is intubated, placed on a ventilator and a
CXR is taken.
Case
Neonatal Pneumonia
Neonatal Pneumonia
Presentation of bacterial sepsis & concurrent pneumonia
Common cause of significant neonatal morbidity &
mortality
Transmission
Predominantly ascending infection from GU tract
Trans-placental infection or blood borne
Risk factors
PROM > 12 Hr
Maternal chorioamnionitis
Prematurity
Neonatal Pneumonia
Pathogens
Group-B Streptococci or GBS, common (1-4/1000 births)
E.coli, Klebsiella, Listeria monocytogenes,
Pneumococci,
H. influenza, Staph. Aureus, Pseudomonas, Staph-Epi.,
Chlamydia, Viral and Fungal pneumonias
Neonatal Pneumonia
Clinical Features
Tachypnea, Grunting, Flaring & Retractions
Cyanosis, Apnea, Lethargy, CVS instability
Diagnosis
Clinical, blood count, CXR, blood cultures
Laboratory findings
↑ WBC, ↑ band count, thrombocytopenia
Abnormal CXR & +ve blood / tracheal culture
Neonatal Pneumonia
Chest X-ray
Lobar streaky densities (focal or multi-focal)
Basal confluent opacities (unilateral or bilateral)
Differential Dx
RDS, edema or aspiration syndromes
Neonatal Pneumonia
Can present with either diffuse reticulonodular
densities similar to respiratory distress syndrome
or with patchy, asymmetric infiltrates with
hyperaeration similar to meconium aspiration.
The presence of a small pleural effusion is a useful
distinguishing feature as it is a common finding in
neonatal pneumonia (up to 2/3 thirds) and is
uncommon in respiratory distress syndrome.
Neonatal Pneumonia
Treatment
Supportive, NPO, IVF, O2 & Antibiotics
Ventilation & Surfactant needed sometimes
Neonatal Pneumonia
Complications
The neonatologist must maintain a balance between the
ventilatory needs of the infant and the complications
that can result from positive pressure ventilation.
The lung volumes on the daily neonatal CXR are used as
a guide to determine the ventilator settings.
If the compliance of the lungs is too low, or the mean
airway pressure is too high, barotrauma will result.
Pulmonary interstitial emphysema (PIE)
Pneumothorax
Neonatal Pneumonia
Pulmonary interstitial emphysema (PIE) results from
rupture of the alveoli with air accumulating in the
peribronchial and perivascular spaces.
Linear lucencies radiating from the hilum
Can also be cystic in appearance, which can be
difficult to distinguish from chronic lung disease.
Occurs early and is associated with high ventilatory
settings
Chronic lung disease occurs later in the hospital
course with lower ventilatory settings
Neonatal Pneumonia
PIE is an ominous sign because it indicates the
poor compliance of the lungs and is frequently
followed by a pneumothorax.
In addition to adjusting the ventilatory settings as
much as tolerated, it is helpful to put the most
affected side down.
Example of unilateral PIE with a pneumothorax
Close up of left lung
demonstrating the
streaky lucencies of the
air in the interstitium
(red arrows)
Complicated by a
pneumothorax (yellow
arrow).
This patient was treated
with a chest tube and by
placing the left side
down. The PIE resolved
after 2 days.
