Neonatal emergencies guidelines

NEONATAL EMERGENCIES
GUIDELINES
Dr. sayed ismail
Professor of pediatrics
Head of pediatric department, ASH
sayedahmed1900@gmail.com
+971-0551256783

Objectives
• To know the common causes of neonatal emergencies
• How to diagnose the neonatal emergencies ?
• How to the mange neonatal emergencies ?

Emergency problems
1. Respiratory
2. Cardiac
3. Shock
4. CNS

• Airway and Breathing
• Effort of breathing
• Respiratory rate
• Stridor/wheeze
• Auscultation
• Skin colour
• Circulation
• Heart rate
• Pulse volume
• BP
• Capillary refill
• Skin temperature
Disability
• Conscious level
• Pupils
• blood glucose
Exposure
• Skin
• Temperature
The whole P. assessment should take less than a minute.
4
The primary assessment of an infant or child = ABCDE

Secondary Assessment
1- History / SAMPLE S For Signs And Symptoms
A – Allergy to foods or drugs
M - Medication
P - Past History
L - Last Meal
E Event Result To The Problem
2- Clinical Examination Head To Toe Examination
Clue
3- ongoing assessment of vital signs 5

Diagnostic tests
Blood gases ,
CBC ,WBC ,Hb concentration
Pulse oximetry , continuous monitoring
CXR
Blood chemistry ,
prothrombin time and a partial thromboplastin time
Echocardiography
Brain imaging
6

Initial management
Primary assessment of circulation as before
1. Oxygenation : to any child with respiratory difficulty or hypoxia.
• Give high‐flow oxygen to keep spo2 more than 94%
2. Ventilation
• In the child with inadequate respiratory effort, this should be supported
either with bag–valve–mask ventilation or intubation and intermittent
positive pressure ventilation.
3. Support circulation in shock
• Provide IV or intraosseous access should be gained
• immediate infusion of crystalloid (10- 20 ml/kg) given. In shock
• Vasoactive drugs 7

8
Initial management of decreased conscious level or convulsions
● Consider intubation to stabilize the airway in any child with a conscious level
recorded as P or U (only responding to painful stimuli or unresponsive).
●Treat hypoglycaemia with a bolus of glucose (2 ml/kg of 10% glucose) followed
by an IV infusion of glucose
● Intravenous lorazepam, buccal midazolam or rectal diazepam should be given
for prolonged or recurrent fits .
● Manage raised intracranial pressure if present

Last film for Marilyn Monroe -1961

The common neonatal emergencies. The mnemonic "THE MISFITS"
is helpful to quickly memorize these critical diagnoses
T-Trauma
H-Heart disease
E-Endocrine
M-Metabolic (electrolyte imbalance)
I-Inborn errors of metabolism
S-Sepsis
F-Formula mishaps
I-Intestinal catastrophes
T-Toxins/poisons
S-Seizures

(Accidental and Nonaccidental)
• Nonaccidental head trauma may have non specific
S/S. , bulging fontanel
• Neuroimaging for any suspected injury , which may
include a computed tomography (CT) scan,
ultrasound, or magnetic resonance imaging (MRI).
ED management :
• Stabilization of the ABCDE,
• Laboratory Tests , (PT), (PTT).
• Neuroimaging after stabilization.
• The patient should be admitted and the injury
reported to the appropriate state department
for abuse.
• A skeletal survey
• Ophthalmologic exam
Trauma
ICH

Heart Disease and Hypoxia
• the DD of cyanosis includes respiratory causes, cardiac causes,
• Cyanotic Heart Disease : terrible T's :
• Tetralogy of Fallot (TOF)
• Tricuspid atresia (TA)
• Transposition of the great vessels (TOGV)
• Total anomalous pulmonary venous return (TAPVR)
• Truncus arteriosus (TA)

Is this cyanosis secondary to pulmonary or cardiac etiology?
Pulmonary cyanosisCardiac cyanosis
Respiratory distressComfortable at rest
ImproveWorsens with crying
Normal cardiac examinationMurmur ± hyperdynamic heart
ImproveNo response to 100% O2
Normal heartCardiomegaly on X-ray
NormalAbnormal ECG
CO2 retentionNormal pCO2
Treatment of lung diseasesProstaglandin 0.1μg/kg/min, cardiac
consultation

Test Cardiac noncardiac
the pulse oximetry after Providing
100% oxygen
minimal change least a 10% increase
Blood gases after hyperoxia test =
initial arterial blood gas (ABG) on room air and
then a repeat ABG after 10 minutes of 100%
oxygen
minimal change Marked increase of po2
Differentiating between cardiac and noncardiac causes of cyanosis

• Assessment of cyanotic cardiac case should include
• blood pressures in all 4 extremities and
• a careful cardiac exam. Although a murmur may be audible, the absence does not exclude a cardiac
defect.
• A chest radiograph (CXR)
• Electrocardiogram (ECG)
• Echocardiogram is diagnostic.
Management
• General management + specific management
• Prostaglandin E1 (PGE1) as a bolus of 0.05 mcg/kg IV, followed by an infusion of 0.05-0.01 mcg/kg/min IV.
• Pediatric cardiac consultation

Acyanotic Heart Disease
• Presents with congestive heart failure. Has a more gradual clinical decompensation
when compared with the cyanotic heart defects and it may not present until after the
first 2-3 weeks of age.
• Causes of heart failure
• Acyanotic heart disease
• Ventricular septal defect,
• Atrial septal defect,
• Patent ductus arteriosus,
• Coarctation of the aorta)
• Supraventricular tachycardia
• Systemic lupus erythematosus
• Thyrotoxicosis

• C/P : symptoms : poor feeding, sweating or color change with feeding, poor weight gain.
• The classic signs for congestive heart failure include:
• Tachypnea ,
• Tachycardia,
• Gallop
• Hepatomegaly.
• Initial management
• Stabilization of the ABCDE
• a CXR, ECG, and laboratory evaluation including a CBC and serum electrolytes.
• An echocardiogram is diagnostic of the heart defect
• Management :
• Furosemide (1.0 mg/kg IV),
• plus dopamine or dobutamine for cardiovascular support.
• Pediatric cardiology should be consulted.

Supraventricular Tachycardia
• (SVT) is the most common neonatal
dysrhythmia.
• C/P range from tachycardia to poor
feeding, irritability, heart failure,
and shock.
Diagnosis
• The heart rate at ≥ 220 beats
• Narrow QRS < 0.08 seconds.

• ED management is dependent on the patient stability :
• In a stable patient
• Vagal maneuvers ( icing the face,).
• If unsuccessful, IV adenosine 0.1 mg/kg IV push followed immediately by flush should be administered (maximum of 6 mg/kg). If SVT persists then a
second dose of adenosine 0.2 mg/kg IV (maximum of 12 mg/kg) may be administered.
• An unstable patient
• Without IV access should be treated with synchronized cardioversion (0.5-1.0 J/kg).
• If there is established IV access and adenosine is readily available, then the initial cardioversion may be attempted
pharmacologically.
• If the SVT is unresponsive to adenosine or synchronized cardioversion or if a wide QRS is suspected
• Amiodarone 5 mg/kg IV over 20-60 minutes .
• Alternatively, procainamide 15 mg/kg IV over 30-60 minutes may be administered.
• Amiodarone and procainamide should not be administered together because the combination can lead to hypotension and
widening of the QRS complex.
• Lidocaine (1 mg/kg IV) is a final option for a wide QRS and should only be used in consultation with a pediatric
cardiologist.

Apnea (Apparent Life-Threatening Event, or ALTE)
• Apnea is defined as a cessation of respiration for 20
seconds or more and is associated with color
change (cyanosis or pallor) or bradycardia.
•
• An ALTE is used to describe any event that is
"frightening to the observer and is characterized by
some combination of apnea, color change, marked
change in muscle tone, choking, or gagging.
• Hospitalization may be appropriate for
observation and monitoring.
Common Differential
Diagnosis of Apnea
Sepsis
Pneumonia
RSV
Hypothermia
Anemia
Botulism
Dysrhythmias
Acid/base disturbance
Intracranial hemorrhage
Meningitis/encephalitis
Pertussis
Hypoglycemia
Seizures
Gastroesophageal reflux
Child abuse
Inborn errors of metabolism

Bronchiolitis
• Bronchiolitis is more common in the winter and spring seasons.
• These patients may present with more classic symptoms that include rhinorrhea, cough,
congestion, or significant respiratory distress and wheezing.
• Apnea also may be the only initial symptom in an infant with no other respiratory
symptoms
• Management is dependent on the presenting symptoms.
• Infants with severe, prolonged apnea accompanied by bradycardia and who are unresponsive to
oxygen therapy and stimulation may require intubation.
• Nebulized racemic epinephrine or a beta-agonist. Nebulized racemic epinephrine has demonstrated
better results on respiratory distress than a beta-agonist

Endocrine Emergencies: Congenital Adrenal Hyperplasia
• often diagnosed at birth by routine newborn screening, but diagnosis may be
missed
• S/S in the first few weeks of life: vomiting, hypoglycemia, or even
shock.
Management
• Lab : hyponatremia , hypoglycemia ,hypocalcemia and
hyperkalemia.
• if Hypotension is unresponsive to fluids or inotropes you should
suspect CAH.
• Start hydrocortisone IV.
• Treat the hypoglycemia.
• Often hyperkalemia in these patients will respond to fluid therapy;
• But if the patient is symptomatic or has ECG changes, then calcium chloride,
sodium bicarbonate, insulin and glucose, and sodium polystyrene sulfonate
(Kayexalate) may be necessary.
• These patients require pediatric critical care management and
endocrine consultation.

Thyrotoxicosis
• Neonatal thyrotoxicosis may develop in infants born to mothers
with Graves disease. It is caused by transmission of maternal
thyroid-stimulating immunoglobulin.
• The presentation is often delayed and may present to the ED with
symptoms such as poor feeding, failure to thrive, tachycardia,
irritability, hyperthermia, vomiting, diarrhea, jaundice,
thrombocytopenia, respiratory distress, heart failure and shock.
• Initial diagnosis may be difficult without a clear history of
Graves disease from the mother. Evaluation should include thyroid
functions tests.
• Treatment after stabilization will include propranolol for the
tachycardia, and propylthiouracilIV followed by Lugol's solution .
• The Lugol's solution ( decrease the amount of thyroid hormones)should be
given 1 hour after the PTU. This will help to control the
hypermetabolic state.
• Endocrine consultation and admission to a pediatric hospital is
recommended.

Inborn Errors of Metabolism: Metabolic Emergencies
• Newborn screening may be helpful for recognizing some of the IEM, but there
are over 400 causes that have been identified and it is not possible to routinely
screen for all of them
• Presenting symptoms
• Nonspecific symptoms include poor feeding, vomiting, failure to thrive,
tachycardia, tachypnea, or irritability
• Occasionally Suspected symptoms : seizures, lethargy, hypoglycemia, and
acidosis.
• Physical exam findings are usually normal.

Initial management
• Stabilization of the ABCDE and a bedside blood glucose evaluation.
• Laboratory : CBC, serum electrolytes, pH, lactate, ammonia, liver function tests, and urinalysis
for reducing substances and ketones.
• The complete evaluation should also include blood and urine for organic and amino acids.
• Sodium bicarbonate (starting dose of 1 meq/kg) can be life-saving for patients who are
severely acidotic due to organic acidemias.
• Fluid resuscitation, IV dextrose to prevent further catabolism, and admission to a
pediatric hospital with a genetics consultation.

Diagnostic pathway for inborn errors of metabolism with normal and elevated serum
ammonia levels.

Neonatal emergencies guidelines

Sepsis
• It is standard of care to complete a full sepsis evaluation (CBC, blood culture,
urinalysis, urine culture, cerebral spinal fluid [CSF] culture and analysis, and
CXR) in any neonate with a rectal temperature of ≥ 100.4° F. = 38 C
• The symptoms are nonspecific : poor feeding, irritability, apnea, hypothermia, jaundice,
rashes, increased sleeping, seizures, or vomiting.
• A thorough maternal history and physical examination may be helpful.
• Initial laboratory :.
• WBC COUNT is not helpful to differentiate febrile neonates with a more serious bacterial
infection from those without a serious bacterial infection.
• One study demonstrated that a low WBC count increased the odds of bacterial
meningitis.
• In addition, the urinalysis may also be unremarkable in those neonates with a culture
positive UTI.
• 14% of febrile neonates will be diagnosed with a UTI

• Ampicillin 50-100 mg/kg IV and
• Gentamicin 2 mg/kg IV or
• Cefotaxime 50-100 mg/kg IV
• Acyclovir 20 mg/kg IV
Management :
it is standard of care to administer broad-spectrum antibiotics (Table ) to all neonates who
1- undergo a sepsis evaluation
2- or present with life-threatening symptoms that do not have another readily apparent cause.
Recommended Antibiotics and Dosages for Neonatal Sepsis

Neonatal herpes
• No maternal history in 60% to 80% of women with an unrecognized infection.
• Early recognition and treatment with acyclovir significantly decrease the mortality from
90% to 31%.
• Start treatment in any neonate with high fever, CSF with a lymphocytosis or numerous
red blood cells in an atraumatic spinal tap, seizures, or a known maternal history of
herpes infection.
• The CSF analysis should include a herpes polymerase chain reaction (PCR) and herpes
culture.
• These neonates typically require a higher level of care in a pediatric ICU

• Cutaneous cellulitis should broaden the antibiotic coverage to include
an antistaphylococcal agent such as clindamycin 10 mg/kg IV.
• Omphalitis, a periumbilical infection, often requires fluid
resuscitation and prompt surgical intervention because of the
possible extension to the peritoneum.
• These patients should also undergo a full sepsis work-up.

Formula Mishaps
• The inappropriate mixing of water and powdered formula or
overdilution of formula may result in life-threatening electrolyte
disturbances or failure to thrive.
• Hyponatremia may present as seizures and requires immediate
correction to stop the seizure

Intestinal Catastrophes
• Vomiting
• It may be difficult to differentiate a life-threatening cause from a
mild viral gastroenteritis or even severe gastroesophageal reflux.
• Bilious emesis is always concerning and should always initiate a
pediatric surgery consultation.

Malrotation With Midgut Volvulus
• Malrotation is caused by an abnormal rotation of bowel on itself, resulting in volvulus and bowel ischemia or
death.
• Malrotation occurs in 1 / 5000 live births and is usually diagnosed in the 1st month of life.
• The presenting symptoms : include bilious emesis and poor feeding, or lethargy and shock
• Abdominal radiographs may be normal, have signs of small bowel obstruction, or the classic
"double bubble" sign may be present.
• An upper gastrointestinal (GI) study with contrast is the gold standard for diagnosis, but an
abdominal ultrasound may also be helpful in an experienced technician's hands.
• Confirmation radiographic studies should never delay surgical consultation or transfer to an
appropriate pediatric facility
• Initial management includes stabilization of the ABCDE, fluid resuscitation, a nasogastric tube
placement, and pediatric surgical consultation

Malrotation With Midgut Volvulus

Toxic Megacolon
• Toxic megacolon or enterocolitis is a life-threatening presentation of a patient with
Hirschsprung disease.
• Hirschsprung disease occurs in 1 out of 5000 live births.
• History of failure to pass meconium in the first 24 hours of life, should increase
suspicion of Hirschsprung disease.
• Presenting symptoms may include poor feeding, vomiting, irritability, abdominal
distention, and hematochezia and shock as the condition progresses to
enterocolitis.
• An abdominal radiograph may reveal an enlarged or dilated section of colon.
• Initial management should include stabilization of the ABCDE, fluid resuscitation,
and administration of broad-spectrum antibiotics.
• Surgical consultation and pediatric critical care management is necessary in the
presence of enterocolitis.

Hypertrophic Pyloric Stenosis
• Infants with projectile nonbilious vomiting should be evaluated for hypertrophic pyloric stenosis (HPS).
• Is common and occurs in 1 out of 250 live births with a male:female ratio of 4:1.
• An increased incidence of HPS in neonates who have had an early exposure to oral erythromycin.
• The classic physical exam findings of a palpable "olive" structure in the right upper quadrant and visible
peristaltic waves may be present.
• The classic electrolyte disturbance of hypochloremic, hypokalemic metabolic alkalosis is now an uncommon
finding because HPS is often diagnosed before these electrolyte abnormalities develop.
• Diagnosis is confirmed with an ultrasound
• If an upper GI study is performed, a "string sign" will be visible.
• ED management includes stabilization and IV access to replace fluid and electrolytes. Laboratory evaluation
should include serum electrolytes.
• Although surgical management is the standard, reports of pharmacologic management with IV atropine
followed by oral atropine show satisfactory results.

Hyperbilirubinemia (Jaundice)
• Jaundice in the neonate may physiological or pathological or life-threatening illness.
• Initial evaluation will be dependent on the clinical presentation but should include laboratory evaluation for
conjugated (direct) and unconjugated (indirect) bilirubin, hematocrit, reticulocyte count, and Coombs test.
• Direct hyperbilirubinemia is always pathologic and include biliary atresia, alpha-1 anti-trypsin deficiency,
and hepatitis.
• Indirect hyperbilirubinemia is usually due to breastfeeding or normal physiologic causes, but the more
concerning causes include ABO incompatibility, sepsis, glucose-6-phosphate deficiency, spherocytosis, Gilbert's
disease, or Crigler-Najjar syndrome.
• ED management should include stabilization of the ABCDE, and laboratory evaluation
• Initiation of phototherapy , IV immunoglbin -- or exchange transfusion -- is dependent on the neonate's
gestational age and total serum bilirubin.
• Consultation with a pediatric gastroenterologist,

• American Academy of Pediatrics
Recommendations for Phototherapy and
Exchange Transfusion in the Healthy Term (> 38
Weeks) Neonate
Age Phototherapy Exchange
24 hours 12 g/dL 19 g/dL
> 96 hours 20 g/dL 25 g/dL

Toxins
• Toxic ingestions are uncommon in this age group, but occasionally result from a maternal
ingestion in a breastfeeding mother, homeopathic remedies, or overuse of accepted medications.
• Teething gels may be used as an attempt to relieve distress for both parents and neonates. Note
that teething gels often contain benzocaine which may cause methemoglobinemia with overuse.
• Star anise tea ‫يانسون‬ is a homeopathic remedy also used for infantile colic. A recent study
in Pediatrics described 7 cases of neurotoxicity due to neonatal consumption of star anise tea,
• ED management is primarily supportive.
• Hospitalization for monitoring and observation is recommended. Finally,

Seizures
• Neonates have immature cortical development, and seizure activity may not be generalized or tonic-
clonic.
• Symptoms that should be taken seriously include lip-smacking, abnormal eye or tongue movements,
pedaling, or apnea.
• Common Causes of Neonatal Seizures:
1. Anoxia/hypoxia
2. Trauma , Intracranial hemorrhage
3. Congenital anomalies of brain
4. Infection
5. Metabolic :Hypoglycemia/hyperglycemia, Hypocalcemia,
Hyponatremia/hypernatremia ,Hyperphosphatemia
1. Drugs or Drug withdrawal
2. Benign idiopathic neonatal seizures , Benign familial neonatal seizures

• Initial management includes
• bedside blood glucose level, and serum electrolytes.
• fImmediate correction of hypoglycemia (< 40 mg/dL) with 2-4 ml/kg of a 10% dextrose
solution may be necessary.
• Other laboratory tests should include a CBC, blood culture, and liver function tests. Because
5% to 10% of all neonatal seizures are of infectious etiology, a full sepsis evaluation should
be completed when patient stability permits.
• The first-line pharmacologic management for convulsions is lorazepam IV. This may be
repeated 2 or 3 times before moving to the second-line treatment, phenobarbital.
• The third-line treatment would be phenytoin or fosphenytoin IV..

Pharmaceutical Management of Neonatal Seizures
Benzodiazepines
Lorazepam 0.05-0.1 mg/kg IV
Diazepam 0.2-0.3 mg/kg IV or 0.5 mg/kg rectal
Midazolam 0.1 mg/kg IV or 0.2 mg/kg IM
Phenobarbital 20 mg/kg IV initially then repeat 10
mg/kg IV q 10 minutes (maximum of 50-
60 mg/kg)
Phenytoin/fosphenytoin 15-20 mg/kg IV
Table : provides the step-wise pharmacologic treatment and doses for neonatal seizures Table 8 provides the
step-wise pharmacologic treatment and doses for neonatal seizures

The more common electrolyte abnormalities include hyponatremia (< 125 mg/kg) and
hypocalcemia (< 7 mg/dL).
• Hyponatremia is corrected with 5-10 cc/kg IV of 3% saline
• hypocalcemia with 100-300 mg/kg IV of calcium gluconate solution.
• The administration of broad-spectrum antibiotics and acyclovir should not be
delayed until the completion of a sepsis evaluation.
• Once stabilized, neuroimaging should be completed.
• These patients should be admitted to a pediatric ICU for close monitoring.

Summary
• The mnemonic "THE MISFITS" is helpful to recall the common neonatal
emergencies
• Most of neonatal emergencies have non specific S/S
• Sepsis should be suspected in any critically ill neonate
• Initial management includes Stabilization of the ABCDE

• Shane SA, Fuchs SM. Skull fractures in infants and predictors of associated intracranial injury. Pediatr Emerg Care. 1997;13:198-203. Abstract
• Rubin DM, Christian CW, Bilaniuk LT, et al. Occult head injury in high-risk abused children. Pediatrics. 2003;111:1382-1386. Abstract
• Brousseau T, Sharieff GQ. Improving neonatal emergency care: critical concepts. Pediatr Emerg Med Rep. 2005;10:49-60.
• Boyce T. Rates of hospitalizations for respiratory syncytial virus among Medicaid. J Pediatr. 2000;137:865-870. Abstract
• Wainwright C, Altamirano L, Cheney J, et al. A multicenter, randomized, double-blind, controlled trial of nebulized epinephrine in infants with acute bronchiolitis.
N Engl J Med. 2003;349:27-35. Abstract
• Kabbani MD. Congenital adrenal hyperplasia: epidemiology, management and practical drug treatment. Pediatr Drugs. 2001;3:599-611.
• Ellaway CJ, Wilcken B, Chistodoulou J. Neonatology for the generalist: clinical approach to inborn errors of metabolism presenting in the newborn period. J
Pediatr Child Health. 2002;38:511-517.
• Bonsu BK, Harper MB. A low peripheral blood white blood cell count in infants younger then 90 days increases the odds of acute bacterial meningitis relative to
bacteremia. Acad Emerg Med. 2004;11:1297-1301. Abstract
• Lin D, Huang S, Lin C, et al. Urinary tract infection in febrile infants younger than eight weeks of age. Pediatrics. 2000;105(2):E20.
• Diamond C, Mohan K, Frenkel L, Corey L. Viremia in neonatal herpes simplex virus infections. Pediatr Infect Dis J. 1999;18:487-489. Abstract
• Kimberlin DW, Lin CY, Jacobs RF, et al. Safety and efficacy of high dose intravenous acyclovir in the management of neonatal herpes simplex virus infections.
Pediatrics. 2001;108:230-238. Abstract
• Irish MS, Pearl RH, Caty MG, et al. The approach to common abdominal diagnosis in infants and children. Pediatr Clin North Am. 1998;45: 729-772. Abstract
• Swenson O. Hirschsprung disease: a review. Pediatrics. 2002;109:914-917. Abstract
• Kawahara H, Imura K, Nishikawa M, et al. Intravenous atropine treatment in infantile hypertrophic pyloric stenosis. Arch Dis Child. 2002;87:71-74. Abstract
• Ize-Ludlow D, Ragone S, Bruck IS, et al. Neurotoxicities in infants seen with the consumption of star anise tea. Pediatrics. 2004;114(5):e653-e656.
• Nicholas MH, Watson S, Gonzalez del Rey J, et al. Baking soda: a potentially fatal home remedy. Pediatr Emerg Care. 1995;11:109-111. Abstract
• Volpe JJ. Neonatal seizures: Current concepts and revised classification. Pediatrics. 1989;84:422-428. Abstract
References

Questions
1. Cyanotic Heart Disease include all of these disease except:
1. Tetralogy of Fallot (TOF)
2. Patent ductus arteriosus
3. Tricuspid atresia
4. Transposition of the great vessels (TOGV)
2. Thyrotoxicosis diagnosis depends on :
1. Typical s/s tachycardia, irritability, hyperthermia, vomiting, diarrhea
2. a clear history of Graves disease from the mother.
3. Presence of goiter
3. Sepsis
1. The symptoms are nonspecific
2. a full sepsis evaluation is a recommended standard of care
3. Oral antibiotic should be given early
4. IV broad-spectrum antibiotics is administered as soon as possible
Choose the right answer

4. Bilious emesis in neonate should suspects :
1. Viral gastroenteritis
2. Malrotation
3. severe gastroesophageal reflux.
5. Common Causes of Neonatal Seizures are except :
1. Intracranial hemorrhage
2. Congenital anomalies of brain
3. Infection
4. Hypoglycemia
5. fever

Key answer
1- 2
2- 2
3- 3
4-2
5- 5

Neonatal emergencies guidelines

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