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Newbornphysiology

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Definition

Gestational age Term newborn (37-41 GW)

Preterm newborn (AGA) (41. GW)

Intrauterin retarded newborn (IUGR,or SGA) (

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Anthropometric characteristics ofterm and preterm infants

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IU

GR

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IU

GR

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Menstruation calendar

Intrauterine anthropometry Semi-objective score system usingphysical examination of the newborn

Estimation of gestational age

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Estimation of the gestational ageaccording to Dubowitz

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Preterm - postterm

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Characteristics of preterm skin.Estimation of the gestational age

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Estimation of the gestational age

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Muscle tone and posture

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Maneuvers for the estimation ofgestational age

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Scarf signs and heel-to ear maneuver

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Basic definitioncharacterizing the quality of pregnancy care,neonatal and pediatric care in a country

Infant mortality rate (6.6 %o)Mortality per mille in a period of 0-365 day Neonatal mortality (3.4 %o)

Mortality between birth and 7th day of life

Perinatal mortality (8.3 %o)Mortality from 24. gest. week until the 7th day of

life

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Infant mortality rate (IMR) and neonatalmortality rate (NMR) in Hungary and in the USA

0

5

10

1520

25

30

35

1970 1975 1980 1990 1995 1999

IMR H

NM H

IMR USA

NMR USA

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Infant mortality rate in different countries

0

2

4

6

8

10

S NC

H D IUK

US A H

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Percentage of premature babies inHungary

=BW

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Main causes of death in developed countries

Adults Infants Children

Malignancies

Cardiovasculardiseases

GI diseases

Accidents,drugs, terror

Perinataldiseases

Malformations

Malignancies

Accidents,drugs, terror

Accidents,drugs, terror

Malignancies

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Physiology oforgan adaptation

after birth

Postnatal adaptation

E l h h

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Early contact to the mother

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Adaptation of vital organs

Cardiac adaptation minutes Pulmonary adaptationminutes

Disturbed adaptation in the function ofthese organs will result in a serious,

life-threatening sequences of event

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Re-organizationof the fetalcirculation

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Fetal circulation

Characterized by thepresence of parallel

circulation, shunts in orderto prevent overperfusion ofnon-used organs i.e. lung.The major shunt is theductus arteriosus Botalli

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Circulation inasphyxiated newborn

Asphyxia causes vaso-constriction in pulmonary

arteries. PDA (L to R shunt) Congestive heart,pulmonary edema

Hypoxia maintains pulm.vasocontriction(vitious circle) Abdominal organs hypoperfused

serious secondary diseases

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Effects ofhypoxia

ondifferent

organ

function inthe

newborn

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Consequences of failure to adapt of thefetal circulation

Persistent fetal circulation Long-lasting hypoxia

Hypo-perfused organs with functional and latermorphological consequences

CNS

Kidney

GI mucosa

Myocardium

Other parenchymal organs

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Characteristics of hemodynamics

Shunts

RV provides 2/3 of thetotal myocardial work

Flow in the pre-ductal

aorta is only 10% of CO Flow in ductus art. is

60% of CO

Lung perfusion 4-7% pO2 in the aorta is low:

20-28 mmHg

Pulm. resistance by80%

TPVR increases

Shunts functionally

close within 10-15 h Fetal circulation shows

the adult pattern

within 2 days

Fetal Newborn

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Characteristics of lung function

Low perfusion

Alveoli filled withliquid:40-60 ml; pH:6.4;

protein : 300 mg/dl Amnion fluid

Respiratory

movements duringREM sleep

First inspiration: 10-70 cmH2O per 0.5 sec

First volume: 50 mlFRC: 20-30 ml

First expiration:20-30 cmH2O

Stimuli for the first

inspiration:chemicaltemperature, tactile,clamping the cord

Fetal Newborn

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Adaptation of other organs

Kidney

Fluid and electrolyte homeostasis

Gastrointestinal (GI) system

Haematology CNS

Disturbed adaptation does not result inan acute life-threatening event

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GFR

Gestational weeks

Nephrogenesis

Functionalmaturation

36

Guignard 1981

Kidney development andmaturation

Nephrogenesisuntil the 36th

gest. week

Functional

maturationpostnatally

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Nephron number and intrauterinedevelopment

Genetic factors

Lower maternal energysupply

Low vitamin A status

Maternal diabetes Hormones

Drugs

=control =IUGR

Hinchliffe SA et al: Brit J Obst Gynec 1992. 99: 296.

Nephron No (thousand)

Gestational age

160

640

1 440

3020 40

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Hypothesis: low birth weight and

premature birth are associated withdecreased renal function later in life

Lower nephronnumber

Lower reservecapacity

Total glomerular volume isnegatively correlated to ageNyengaard JR, Bendtsen TF:

Anat Rec 1992.232.194.

Naturally occurring

decline in nephronstructure startsfrom a lower point

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LBW contributes to the high rates of early-

onset CRF in Southeast, South Carolina(Lackland D et al: Arch Intern Med 2000. 160:1472)

LBW is common in

South Carolina. This region has the

highest rate of ESRD

among young people inthe US.

LBW not directly but by

multiple mechanismscontributes to theearly-onset ESRD inCarolina.

N i i l i d d h d fi it

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Non-invasively induced nephron deficit

in two experimental models(Merlet-Bnichou C et al: Pediatr Nephrol 1994. 8: 175)

Uterine artery ligation(, panel a )

Low protein diet (, panel b).

The nephron No correlatedwith birth weight.

Nephron deficit was

remarkable Factors that regulate fetal

growth also govern nephro-genesis

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IGF-1 in the renal development

(Hammerman M: Nephrol Dial Transplant 1999. 14: 1853.)

IGF-1-/- transgenicmice are 10-20 %smaller than wild type.

Have 60% lower BW.

Appr. 95% of IGF-1-/-die perinatally.

Kidney weights are

smaller, mean glom. No

is 20% less

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Newborn kidney function

The role of fetal urine

Blood perfusion offetal kidney is low

GFR low

RVR high Immature tubular

transport system

High vasoactivehormone activity

Down-regulation oftheir receptors

Some hormones playrole in the nephro- andvasculogenesis (IGF1,

AngII)

First urine passage: 20% in the delivery room; 92% within

24 hours; No urine after 36 hrs means renal disease!

Body water compartments

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Body water compartmentsFriis-Hansen BJ: Pediatrics 1961.

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Changes in Fluid Compartments at the Onset of

Labor: decrease in the production of fetal lung fluid

20% increase in fetal blood pressure

Changes in Fluid Compartments During Labor andDelivery:

14% decrease in circulating blood volume

25% reduction in plasma volume placental transfusion induces a variable increase in

circulating blood volume

Increased Interstitial Fluid Compartment

Changes in Fluid Compartments in theImmediate Perinatal Period (1)

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Changes in Fluid Compartments in theImmediate Perinatal Period (2)

Mechanisms Mediating the Transcapillary Loss of Plasma

Volume:

the increase in fetal blood pressure enhances transcapillary

distribution of fluid (and protein)

mild hypoxia during labor and delivery increases transcapillary

leak

Hormonal Regulation of Transcapillary Loss of Plasma

Volume:

norepinephrine, vasopressin, renin-angiotensin, cortisol(vasoconstriction)

bradykinin, prostaglandins, atrial natriuretic peptide (vasodilation)

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Changes in Fluid Compartments in theImmediate Perinatal Period (3)

Neonatal Weight Loss:

term infants lose 5-10% of their birthweight during the first weekof life

preterm infants lose 10-15% of their birthweight during the firsttwo weeks of life

Fluid Compartments Involved in Neonatal Weight Loss:

the perinatally expanded extracellular (extravascular) fluidcompartment

intracellular fluid compartment (prolactin?)

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Fluid compartments in the postnataladaptation. Summary

Fetal ECV increased (IF). Term newborn looses 5-(10) %, preterm10-15% of their birth weight

It is a result of the isotonic contractionof ECV

Efferent limb is the kidney: Na andwater loss.

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Possible mechanism of isotoniccontraction of the ECV after birth

Pulmonary vascular resistance

Pulmonary blood floow

Right ventricular pressure

ANP secretion

Diuresis&

ntriuresis

Extracellular volumen

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GI system

Fetus swallows fromthe 17th GW: 20ml/h

Motor functions aremature

Transport and

secretory functionsare immature

Air fills smallintestine:2-12 hr.rectum: 24 hr.

First stool < 24 hr(meconium)

Meconium leaves

within 3-4 days

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GI tract The number of

stool loss dependson the frequencyof feeding

Color, consistencerelated to breastor formula feeding

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Newborn hematology

Hb: 170-190 g/L9M % HbF

Ht: 60-65%

Iu. hypoxia

polyglobulia (Ht>70 %) Leukocytes ~10 G/L .Pathological 15 G/L

Thr: ~150 G/L

Newborn jaundice

Physiologic anaemia

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Blood disturbances and clinicalsymptoms

Thrombopenia DIC, isoimmunisation

Neutropenia sepsis, isoimmunisation

Polyglobulia hypoxia, twin-transfusion

Acute anemia blood loss, isoimmunisationtwin-transfusion

Chronic anemia physiologic, infection,

arterficial..

(3 5 10 i )

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Apgar score (3, 5, 10 minutes)

8-10 : normal. 5-7 : observation. 100/min

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Rooting reflex

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Rooting reflex

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Palmar and plantar reflex

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Moro reflex

Pathological signs o n the first day of life

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Respiratory distress

Cyanosis, pallor

Icterus (jaundice) Skin alterations

Pyoderma, cord inflammation

Bleeding Edema

Rectal T: >37.5 ill.,

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Minor trauma

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Minor trauma jelei

Meconium Beech delivery Forceps

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Facial asymmetry

Small deformity Facial paresis

Brachial plexus injury (Klumpke, Erb)

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p j y ( p )

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Acrodysplasies

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Polydactylia

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Informative morphogeneticvariations

Ears are often involved as part of

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different syndromes

Sacral

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alterations

hyperpigmentation hypertrychosis spina bifida

pilonidal sinus

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Ectodermal dysplasia

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Intrauterin amniotic bands

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Hernia umbilicalis

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Scrotal haematoma

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Cheilo-gnato-palatoschisis

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Respiratory distress

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Tachypnoe,

Dyspnoe (nasal, jugular, intercostal,sternal drawings, paradox thoraco-abdominal movements, grunting)

Hypoxia

Cyanosis

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IRDS (hyalin

membrane disease

reticulo-granularinfiltrations

air-bronchogram

Therapy

Oxygen

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Oxygen Resp Tx positive end exp. pressure:

Forms: CPAPPEEP High frequency oscillation

. Indications:PFChernia diaphragmatica Surfactans - i.tracheal

Relaxation Circulatory support

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Atelectasia

Hyperinflation

Honey in the combpattern

N l f

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Normal x-ray ofthe newborn

Cardiac

enlargementPeribronchialedema

Newborn chest X

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Newborn chest X-ray IRDS, HMDII.

Cardiac enlargement

reticulo-granularpattern

pneumomediastinum

Chest X ray

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Chest X-ray

Pneumonia

Infiltration

Hyperinflation

Art. umb.catheter