Perinatal history, normal newborn

Perinatal Perinatal HistoryHistory

Dr Varsha Atul ShahDr Varsha Atul Shah

Learning Objectives: Learning Objectives: Perinatal HistoryPerinatal History

By the end of the lecture the By the end of the lecture the student should be able to:student should be able to: know the different parts of the know the different parts of the

Perinatal History and the Perinatal History and the contents of eachcontents of each

understand the effect/s of understand the effect/s of intrauterine environment on the intrauterine environment on the the growing fetus the growing fetus

Learning Objectives: Learning Objectives: Perinatal HistoryPerinatal History

By the end of the lecture the By the end of the lecture the student should be able to:student should be able to: Give the different pre and perinatal Give the different pre and perinatal

High Risk Factors which can High Risk Factors which can compromise the well-being of the compromise the well-being of the fetus and/or the newborn infant fetus and/or the newborn infant

anticipate newborn problems based anticipate newborn problems based on High Risk Factorson High Risk Factors

The Perinatal HistoryThe Perinatal History

General Data:General Data: Maternal Obstetrical HistoryMaternal Obstetrical History Maternal medical HistoryMaternal medical History Family HistoryFamily History Social HistorySocial History History of labor and deliveryHistory of labor and delivery

Perinatal History:General DataPerinatal History:General Data

BBX born at the PGH-OBAS after BBX born at the PGH-OBAS after _____ weeks of gestation, to a G-P _____ weeks of gestation, to a G-P (FT-PT-Ab-LC) woman by (FT-PT-Ab-LC) woman by SVD/CBE, OFE, CS, weighing SVD/CBE, OFE, CS, weighing _______ grams and with Apgar _______ grams and with Apgar score of in____ 1 and ____5 score of in____ 1 and ____5 minutesminutes

Perinatal History:Maternal Perinatal History:Maternal past and present obstetrical past and present obstetrical

historyhistory

Age: < 19 or > Age: < 19 or > 3535

IUGR ; bleeding, IUGR ; bleeding, hypertensionhypertension

Gravidity/ParityGravidity/Parity IUGR, IUGR, hypertension;hypertension;

bleedingbleeding

Hx of Hx of FT/PT/Ab/LCFT/PT/Ab/LC

Fetal Fetal wastage/distresswastage/distress

LMP, PNCLMP, PNC Uterine size, Uterine size, nutritionnutrition

Perinatal History:Perinatal History:Maternal Medical HistoryMaternal Medical History

InfectionInfection Congenital Congenital pneumoniapneumonia

Intra-uterine Intra-uterine infectioninfection

MedicationMedication Congenital Congenital malformationmalformation

Thyroid Thyroid problemproblem

Hypo/Hypo/hyperthyroidismhyperthyroidism

DiabetesDiabetes Hypoglycemia/Hypoglycemia/PolycythemiaPolycythemia

HypertensionHypertension Premature labor, Premature labor, IUGRIUGR

Perinatal History: Perinatal History: Amount of amniotic fluidAmount of amniotic fluid

PolyhydramniosPolyhydramnios

oligohydramniooligohydramnioss

premature labor, premature labor, neuromuscular neuromuscular diseases, gut diseases, gut obstruction, hydrops, obstruction, hydrops, CHF CHF

Renal agenesis, Renal agenesis, pulmonary hypoplasiapulmonary hypoplasia

Perinatal History: Perinatal History: multiple gestationmultiple gestation

Perinatal History:Family historyPerinatal History:Family history

presence of familial or presence of familial or hereditary diseaseshereditary diseases

Perinatal History:Social HistoryPerinatal History:Social History

civil status, occupationcivil status, occupation social habits: smoking/drinkingsocial habits: smoking/drinking PromiscuityPromiscuity


SmokingSmoking

•A team of California and Ohio scientists showed that maternal exposure to cigarette smoke is associated with a doubled risk of a rare but "devastating" condition called persistent pulmonary hypertension of the newborn,


AlcoholismAlcoholism high alcohol levels ingested high alcohol levels ingested

during pregnancy damage during pregnancy damage embryonic and fetal developmentembryonic and fetal development alcohol or breakdown product alcohol or breakdown product

impairs placental transfer of amino impairs placental transfer of amino acids and zinc needed for protein acids and zinc needed for protein synthesissynthesis

Perinatal History: LaborPerinatal History: Labor

prolonged and prolonged and difficult labordifficult labor

premature rupture premature rupture of membrane (24 hrs of membrane (24 hrs before deliverybefore delivery

Precipitous deliveryPrecipitous delivery

maternal anestheticsmaternal anesthetics

Vaginal bleed Vaginal bleed

Infection, hypoxiaInfection, hypoxia

infection, amnionitisinfection, amnionitis

IC bleedIC bleed Intrauterine/birth asphyxiaIntrauterine/birth asphyxia

low Apgarlow Apgar

hypovolemia, hypoxia, fetal hypovolemia, hypoxia, fetal anoxia and brain damage anoxia and brain damage

Perinatal History:DeliveryPerinatal History:Delivery

Mode of delivery:Mode of delivery:

Breech, suctionBreech, suction Delay in the delivery Delay in the delivery of the after-coming of the after-coming head, hypoxiahead, hypoxia

CaesarianCaesarian Neonatal depression Neonatal depression due to maternal due to maternal anesthetics; TTNanesthetics; TTN

Cord coil, prolapseCord coil, prolapse HypoxiaHypoxia

Amniotic Fluid:Amniotic Fluid:

Color, smellColor, smellAspirationAspiration

InfectionInfection

Meconium stainingMeconium staining Aspiration, PPHNAspiration, PPHN

Apgar ScoreApgar Score Asphyxia, HIEAsphyxia, HIE

The The NewbornNewborn

The Physical Examination The Physical Examination of the Newbornof the Newborn

Learning Objectives:Learning Objectives:Physical Examination of the Physical Examination of the

NewbornNewborn By the end of the lecture the student By the end of the lecture the student

should be able to:should be able to: take the vital signs of the newborntake the vital signs of the newborn obtain the anthropometric obtain the anthropometric

measurements of the newbornmeasurements of the newborn perform complete physical perform complete physical

examinationexamination elicit primitive reflexes in the newbornelicit primitive reflexes in the newborn

DELIVERY ROOM ASSESSMENT: DELIVERY ROOM ASSESSMENT:

APGAR SCOREAPGAR SCORE Dictates the need to resuscitateDictates the need to resuscitate

BALLARDSBALLARDS Determines the age of gestation (AOG) based on neurological Determines the age of gestation (AOG) based on neurological

and physical scoring and physical scoring <37 weeks - preterms<37 weeks - preterms 38-42 weeks - full terms38-42 weeks - full terms >42 weeks - post-terms>42 weeks - post-terms

DELIVERY ROOM ASSESSMENT: DELIVERY ROOM ASSESSMENT: AOG is plotted vs. weight on the Lubchengco chart to AOG is plotted vs. weight on the Lubchengco chart to

determine the nutritional status of the newborndetermine the nutritional status of the newborn <10<10thth %tile - Small for Gestational Age (SGA) %tile - Small for Gestational Age (SGA) Symmetric: HC=Weight=Length =<10Symmetric: HC=Weight=Length =<10thth %tile %tile Asymmetric: HC=length > Weight (<10Asymmetric: HC=length > Weight (<10thth %tile) %tile) 1010thth-90-90thth %tile - Appropriate for Gestational Age (AGA) %tile - Appropriate for Gestational Age (AGA) >90>90thth %tile - Large for Gestational Age (LGA) %tile - Large for Gestational Age (LGA)

A quick initial PE should be performed at the A quick initial PE should be performed at the DRDR

No major anomaliesNo major anomalies no birth injuriesno birth injuries tongue and body appear pinktongue and body appear pink breathing is normalbreathing is normal if mother has hydramnios, a if mother has hydramnios, a

feeding tube should be passed feeding tube should be passed into the stomach to exclude into the stomach to exclude esophageal atresiaesophageal atresia

Routine detailed PE to be done within Routine detailed PE to be done within 24 hours 24 hours

To detect congenital anomalies not To detect congenital anomalies not identified at birthidentified at birth

to identify common neonatal to identify common neonatal problems and initiate their problems and initiate their management or reassure the parentsmanagement or reassure the parents

check for potential problems arising check for potential problems arising from maternal diseases, familial from maternal diseases, familial disorders or those detected during disorders or those detected during pregnancypregnancy

Order of examinationOrder of examination

Newborn is quiet, in-between Newborn is quiet, in-between feedingfeeding

listen to the heart and lungs first listen to the heart and lungs first and examine the eyes directlyand examine the eyes directly

Exact sequence is not important Exact sequence is not important as long as all aspects are as long as all aspects are examined at some stage and the examined at some stage and the whole of the infant is examinedwhole of the infant is examined

Vital signsVital signs

Heart Rate and pulse rateHeart Rate and pulse rate Respiratory rateRespiratory rate TemperatureTemperature Blood PressureBlood Pressure

Heart Rate and Pulse rateHeart Rate and Pulse rate

Normal:Normal: Rate - 110-165 beats per minute regular Rate - 110-165 beats per minute regular

rhythm, rhythm,

Respiratory RateRespiratory Rate

Normal: Normal: Respiratory Rate 40-60 Breath per minute, Respiratory Rate 40-60 Breath per minute,

regularregular

TemperatureTemperature

Blood PressureBlood Pressure

BP determination

Cuff should cover 2/3 of the upper arm

AOG and weight related

Obtain BP of both upper and lower extremities:

In coarctation, both arms higher than leg pressure if coarc is distal to the origin of the left subclavian a.

Anthropometric measurementsAnthropometric measurements

Head Head circumferencecircumference

LengthLength WeightWeight

BP determination

Cuff should cover 2/3 of the upper arm

GENERAL APPEARANCEGENERAL APPEARANCE

State of alertnessState of alertness lethargic or irritablelethargic or irritable

PosturePosture Full terms: hips abducted and partially flexed; Full terms: hips abducted and partially flexed;

knees flexedknees flexed arms adducted and flexed at elbowsarms adducted and flexed at elbows Fists clenched; four fingers overlapping thumbFists clenched; four fingers overlapping thumb

ToneTone Support chest with one hand, infant Support chest with one hand, infant

should be able to hold head for 3 secondsshould be able to hold head for 3 seconds

SKINSKIN

Color: Color: Acrocyanosis < 24 hoursAcrocyanosis < 24 hours PallorPallor

Low hemoglobinLow hemoglobin CyanosisCyanosis

Central- hypoxemia (due to either intra-Central- hypoxemia (due to either intra-cardiac or intra-pulmonary shuntingcardiac or intra-pulmonary shunting

PlethoraPlethora Polycythemia (Hematocrit > 0.65)Polycythemia (Hematocrit > 0.65)

SKINSKIN

JaundiceJaundice Within 24 hours Within 24 hours

hemolytichemolytic 2-4rth day 2-4rth day

physiologic, physiologic, level within normal level within normal

1 week 1 week breast-milk jaundicebreast-milk jaundice

NEWBORN PE:SKIN

•Epidermis:

–(-) excoriations/ sloughing

•Hair

–Lanugo

•Texture

–moist and smooth

•Vernix caseosa

NEWBORN PE:SKINNEWBORN PE:SKIN

Cysts: Milia,Cysts: Milia, pinpoint white papules of pinpoint white papules of

keratogenous material usually on nose keratogenous material usually on nose and foreheadand forehead

Vascular pattern: Vascular pattern: harlequin; mottling harlequin; mottling

NEWBORN PE:SKINNEWBORN PE:SKIN Papules: AcnePapules: Acne miliariamiliaria DesquamationDesquamation HemangiomasHemangiomas HemorrhagesHemorrhages Macules Macules (mongolian spots) (mongolian spots) and pustulesand pustules

(erythema toxicum) (erythema toxicum)

NEWBORN PE: HEADNEWBORN PE: HEAD

Normal:Normal: Caput succedaneum, moldingCaput succedaneum, molding

Check for :Check for : overriding of sutures, overriding of sutures, Number and size of fontanellesNumber and size of fontanelles abnormal shape of headabnormal shape of head encephalocoelesencephalocoeles

Cephalhematomas vs Cephalhematomas vs CephaledemaCephaledema

Cephalhematoma

Limited by suture lines May increase in size

Cephaledema

Crosses midline subsides

NEWBORN PE: FaciesNEWBORN PE: Facies

Needs work up:

Down’s Syndrome

Cornelia Delange

Newborn PE: EYESNewborn PE: EYES

Check for:Check for: colobomas, heterochromiacolobomas, heterochromia cloudiness of corneacloudiness of cornea conjunctival erythemaconjunctival erythema exudate, edema, jaundiceexudate, edema, jaundice hemorrhageshemorrhages

Newborn PE: EYESNewborn PE: EYES

Pupillary size and reactivity to Pupillary size and reactivity to lightlight

red orange reflex red orange reflex hold the opthalmoscope 6-8” from hold the opthalmoscope 6-8” from

the eyesthe eyes the normal newborn transmits a the normal newborn transmits a

clear red colorclear red color opacities may suggest cataractopacities may suggest cataract

NoseNose

Check for:Check for: FlaringFlaring hyper/hypotelorismhyper/hypotelorism choanal atresiachoanal atresia

NEWBORN PE: MOUTHNEWBORN PE: MOUTH

Check for:

High arch palate

Cleft/lip palate

Macroglossia

Micrognathia

Newborn PE: EARSNewborn PE: EARS

Check for:Check for: Setting Setting

top of pinna falls top of pinna falls above a line drawn above a line drawn from the outer canthus from the outer canthus of the eyes at right of the eyes at right angle to the face angle to the face

Asymmetry, Asymmetry, irregular shapesirregular shapes

auricular auricular or pre-auricular pits, or pre-auricular pits, skin tags, liomas skin tags, liomas

NEWBORN PE: NECKNEWBORN PE: NECK

Normal:Normal: CheckCheck for : Dimple for : Dimple or webbingor webbing

NEWBORN PE: CHESTNEWBORN PE: CHEST

Check for: paradoxical, periodic, Check for: paradoxical, periodic, (+) (+) retractions retractions SymmetrySymmetry Apnea, retractionsApnea, retractions (+) grunting, (+) Flaring of alae nasi (+) grunting, (+) Flaring of alae nasi bowel soundsbowel sounds decreased air entrydecreased air entry Paradoxical, preriodicParadoxical, preriodic

Check for air entryCheck for air entry

Anterior, mid-axillary, posterior

NEWBORN PE: HEARTNEWBORN PE: HEART

Normal:Normal: regular rhythm, systolic murmur regular rhythm, systolic murmur < 24 hrs, splitting of S2 varies with < 24 hrs, splitting of S2 varies with breathingbreathing

Check for:Check for: Decreased pulses, Decreased pulses, bradycardia, bradycardia, S2 widely split, systolic murmur > 24 hrsS2 widely split, systolic murmur > 24 hrs femoral or cardiac-radial lag, femoral or cardiac-radial lag, diastolic murmur diastolic murmur

Palpating the pulsesPalpating the pulses

Palpate brachial and femoral together: simultaneous arrival or slightly earlier arrival of femoral pulse

In coarctation: brachial stronger than femoral

NEWBORN PE:ABDOMENNEWBORN PE:ABDOMEN

Normal: Normal: Shape cylindrical, Shape cylindrical,

(+) diastasis recti , (+) diastasis recti ,

amniotic or cutaneous amniotic or cutaneous

navelnavel


Check for:Check for: Distention, scaphoid Distention, scaphoid

abdomen, umbilicus abdomen, umbilicus granuloma, granuloma,

hernia, inflammation, hernia, inflammation, less than 3 less than 3 cord vesselscord vessels


Check for:Check for: Gastroschisis, omphalitis, Gastroschisis, omphalitis, omphaloceleomphalocele

NEWBORN PE: LIVERNEWBORN PE: LIVER

Normal:Normal: Smooth edgeSmooth edge normally palpable 1-2 cm below the costal marginnormally palpable 1-2 cm below the costal margin

NEWBORN PE: SPLEENNEWBORN PE: SPLEEN

Normal: Normal: NonpalpableNonpalpable

NEWBORN PE: KIDNEYSNEWBORN PE: KIDNEYS

Normal: Normal: (Bimanual palpation) -(Bimanual palpation) -PalpablePalpable

Check for enlarged kidneysCheck for enlarged kidneys

NEWBORN PE: MALE GENITALSNEWBORN PE: MALE GENITALS

Normal: Normal: Edema, hydrocele, Edema, hydrocele,

phimosisphimosis Check for:Check for:

Bifid scrotum, Bifid scrotum, cryptorchidism, cryptorchidism, inguinal hernia, inguinal hernia, chordee, chordee, hypospadia, hypospadia, microphalusmicrophalus

NEWBORN PE: FEMALE GENITALSNEWBORN PE: FEMALE GENITALS

Normal: Normal: Mucoid or bloody Mucoid or bloody

secretion, secretion, edema, edema, gaping labia, gaping labia, hymenal taghymenal tag

Check for Check for ambiguous, ambiguous, hydrometrocolposhydrometrocolpos

NEWBORN PE: ANUSNEWBORN PE: ANUS

Normal: Normal: PerforatePerforate

Check for Check for imperforate, imperforate, coccygeal dimple, coccygeal dimple,

fistula fistula

NEWBORN PE: MUSCULOSKELETALNEWBORN PE: MUSCULOSKELETAL

Normal:Normal: fetal posture fetal posture (flexor position of (flexor position of comfort)comfort)

NEWBORN PE: MUSCULOSKELETALNEWBORN PE: MUSCULOSKELETAL

Check for:Check for: CorticalCortical thumb, thumb, overlapping fingers, overlapping fingers, short incurved little finger, short incurved little finger, hip subluxation, decreased hip subluxation, decreased

range of motionrange of motion Polydactyly/syndactylyPolydactyly/syndactyly

Checking for hip dislocationChecking for hip dislocation

Infant lies supine on flat, firm Infant lies supine on flat, firm surface and be relaxed. Stabilize surface and be relaxed. Stabilize the hip with one hand, and the the hip with one hand, and the middle finger of the other hand middle finger of the other hand placed over the greater trochanter placed over the greater trochanter and the thumb over the lesser and the thumb over the lesser trochanter: trochanter:


1. the hip is flexed and adducted 1. the hip is flexed and adducted and femoral head gently pushed and femoral head gently pushed downward (Barlowe’s) In hip downward (Barlowe’s) In hip dislocation the femoral head will be dislocation the femoral head will be pushed out of the acetabulum and pushed out of the acetabulum and will move with a “clunk”will move with a “clunk”


2. Check if it can be returned 2. Check if it can be returned from a dislocated position back from a dislocated position back into the acetabulum into the acetabulum (Ortolani’s)(Ortolani’s) the hip is abducted, upward the hip is abducted, upward

leverage is appliedleverage is applied a dislocated hip will return with a dislocated hip will return with

a”clunk”a”clunk”

Checking for back, spine and Checking for back, spine and muscle tonemuscle tone

On prone position babies can lift On prone position babies can lift their head to the horizontal and their head to the horizontal and straighten the backstraighten the back

Check : Check : back and spine for back and spine for midline defects and midline defects and any any curvature of the curvature of the spine spine

NEWBORN PE: CNSNEWBORN PE: CNS

State:State: Awake - alert, crying, Awake - alert, crying,

activeactive Asleep - Asleep -

indeterminate, quietindeterminate, quiet


Motor: Motor: Posture - Flexor, symmetric Posture - Flexor, symmetric Tone - obtuse popliteal angleTone - obtuse popliteal angle Movement - all extremities, nonrepetitive, Movement - all extremities, nonrepetitive,

random, symmetricrandom, symmetric


Reflexes: Deep tendon, grasp, moro, Reflexes: Deep tendon, grasp, moro, placing, stepping, sucking, tonic neck, placing, stepping, sucking, tonic neck, trunk incurvation trunk incurvation

Sensory: 2-3 seconds pin prick Sensory: 2-3 seconds pin prick responseresponse

Cranial nervesCranial nerves

Lesions that resolve spontaneouslyLesions that resolve spontaneously Peripheral and traumatic cyanosisPeripheral and traumatic cyanosis Molding, caput, cephalhematomaMolding, caput, cephalhematoma Swollen eyelidsSwollen eyelids Subconjunctival hemorrhagesSubconjunctival hemorrhages Peeling of the skinPeeling of the skin Capillary hemangiomasCapillary hemangiomas Erythema toxicum, miliaErythema toxicum, milia Epstein’s pearls cystsEpstein’s pearls cysts

Lesions that resolve spontaneouslyLesions that resolve spontaneously Harlequin changeHarlequin change Breast enlargement and Witches’ milkBreast enlargement and Witches’ milk HydrocoeleHydrocoele Vaginal dischargeVaginal discharge Mongolian spotsMongolian spots Umbilical herniaUmbilical hernia

The Care of the The Care of the NewbornNewborn

PFD. Isleta, M.D.PFD. Isleta, M.D.

forfor

Level V - UPCMLevel V - UPCM

Learning Objectives: Learning Objectives: Immediate Care of the Immediate Care of the

newbornnewborn By the end of the lecture the By the end of the lecture the

student should be able to:student should be able to: explain the reasons behind the explain the reasons behind the

principles of newborn care at birthprinciples of newborn care at birth identify well, at risk and sick identify well, at risk and sick

neonateneonate Plan for nursery and discharge Plan for nursery and discharge

carecare

Principles of Care at BirthPrinciples of Care at Birth

Establishment of respiration Establishment of respiration Prevention of hypothermiaPrevention of hypothermia Establishment of breast-feedingEstablishment of breast-feeding Prevention of infectionPrevention of infection Prevention of hemorrhagic disease of the Prevention of hemorrhagic disease of the

newbornnewborn Identification of high risk neonatesIdentification of high risk neonates

Cardio-pulmonary adaptationCardio-pulmonary adaptation

Initial management

• ABC,s: Airway, Breathing, Circulation

• Temperature control

• Cord dressing

• Bonding

Plan of action: Routine CarePlan of action: Routine Care Admission procedures:Admission procedures:

Transition and initial Physical Transition and initial Physical AssessmentAssessment

Vit KVit K Eye prophylaxisEye prophylaxis General laboratory evaluationGeneral laboratory evaluation

CBC, Blood type and Coomb’s testCBC, Blood type and Coomb’s test Glucose screeningGlucose screening Newborn screeningNewborn screening

Nursery CareNursery Care

Bathing and dressingBathing and dressing Umbilical cord careUmbilical cord care FeedingFeeding Voiding and stoolingVoiding and stooling BehaviorBehavior ColorColor

Bathing and dressing

ThermoregulationThermoregulation

Latching on mother’s milkLatching on mother’s milk















Well BabyWell Baby

AOG 38-42 AOG 38-42 weeks, weeks,

AGAAGA delivered delivered

vaginally,vaginally, Apgar score Apgar score >/= >/=

77

Normal ValuesNormal Values

Anthropometric:Anthropometric:

Weight: 2.5-4.00Weight: 2.5-4.00 Length: 45-55 Length: 45-55 HC: 32.6-37.2HC: 32.6-37.2 BP: AOG relatedBP: AOG related


Cardiac system:Cardiac system:

Heart rate: 120-160 BPMHeart rate: 120-160 BPM Rhythm: regular, sinusRhythm: regular, sinus EKG: sinus rhythm, RV dominant EKG: sinus rhythm, RV dominant


Respiratory system:Respiratory system:

Respiratory rate: 40-60 BMPRespiratory rate: 40-60 BMP ABG: pH 7.30-7.40 ABG: pH 7.30-7.40

PaC02 : 35-45 PaC02 : 35-45 PaO2: 60-100 PaO2: 60-100 BE/BD: -5- BE/BD: -5-00


Hematologic:Hematologic:

Hgb: 16.5 gms/dLHgb: 16.5 gms/dL Hct: 53.0%Hct: 53.0% NRBC: 500 mm3NRBC: 500 mm3 Retic count: 2-7%Retic count: 2-7% Blood volume: FT = 80 ml/kg ; PT = Blood volume: FT = 80 ml/kg ; PT =

100 ml/kg100 ml/kg


Renal:Renal:

urine output = 1-2 ml/kg/hoururine output = 1-2 ml/kg/hour Sp. Gravity = 1.005-1.015Sp. Gravity = 1.005-1.015 Passage of urine= 1st 24 hoursPassage of urine= 1st 24 hours


Gastrointestinal:Gastrointestinal:

meconium passagemeconium passage enzymeenzyme


Metabolic:Metabolic:

electrolyteselectrolytes calciumcalcium blood sugarblood sugar

High Risk Baby

• AOG <37->42 weeks,

• SGA, LGA• Breech,• Caesarian section,• (+) HRF• Apgar <3 in 1 ; • <6 in 5 min Preterm, 29 weeks by PA, 668 g

SGA, cephalic, SVD, LBG, AS 2,3,7

Sick Baby

• Abnormal VS,

• Congenital anomaly requiring surgery

• IU infection

• Asphyxiated

Diagnostic work-upDiagnostic work-up

CBC, retic, coomb’sCBC, retic, coomb’s Mother’s and Baby’s Blood TypeMother’s and Baby’s Blood Type ABGABG ECG, 2-D EchoECG, 2-D Echo Chest X-RayChest X-Ray Hepa profileHepa profile

ECGECG

Chest XrayChest XrayCardiac shadow

Perfusion

Aeration

Air in bowel

Bones

Case 1: Baby Boy R., 39 weeks gestation Case 1: Baby Boy R., 39 weeks gestation born to a 25-year old G1P0, born to a 25-year old G1P0,

“0“0-”-” pregnant woman, + ROM 12 hours pregnant woman, + ROM 12 hours before delivery; + maternal fever; Apgar before delivery; + maternal fever; Apgar

score 7-9. score 7-9. Baby is “O Baby is “O++””

What are the High Risk Factors?What are the High Risk Factors? What problems are you anticipatingWhat problems are you anticipating

PE: Occipital cephalhematoma and PE: Occipital cephalhematoma and bruises over facebruises over face

Course in the nursery: fed poorly at Course in the nursery: fed poorly at 36 hours of age and appears 36 hours of age and appears somewhat lethargic and icteric.somewhat lethargic and icteric.

Lab: CBC, Blood culture, TB=15 Lab: CBC, Blood culture, TB=15 mg/dl ; + Coombsmg/dl ; + Coombs

Baby S: born by precipitous deliveryBaby S: born by precipitous delivery19 yo G1P0 after 32 weeks gestation19 yo G1P0 after 32 weeks gestation

(-) Prenatal care; Apgar score 5-8(-) Prenatal care; Apgar score 5-8In the Nx: RR=80 BPM;cyanotic,gruntingIn the Nx: RR=80 BPM;cyanotic,grunting

1. Identify the high risk factors 1. Identify the high risk factors 2. What is the most likely diagnosis?2. What is the most likely diagnosis? 3. What other diagnoses should be 3. What other diagnoses should be

considered?considered? 4. What laboratory studies would you 4. What laboratory studies would you

order?order?

Discharge planningDischarge planning

Normal Vital signsNormal Vital signs ThermoregulatedThermoregulated Feeding wellFeeding well Adequate weight gainAdequate weight gain Family relationshipFamily relationship

METABOLIC METABOLIC ADAPTATION IN ADAPTATION IN THE NEWBORNTHE NEWBORN

UPCM LEVEL VUPCM LEVEL V

Learning ObjectivesLearning Objectives

By the end of the lecture the student must By the end of the lecture the student must know and understand the physiologic changes know and understand the physiologic changes that occur during metabolic adaptation at that occur during metabolic adaptation at birth with regards to:birth with regards to:

1. Thermoregulation 1. Thermoregulation 2. Energy requirements 2. Energy requirements

3. Fluid and electrolytes 3. Fluid and electrolytes 4. Acid-base balance 4. Acid-base balance

5. exposure to harmful intrauterine 5. exposure to harmful intrauterine environment: Drugs of abuseenvironment: Drugs of abuse

ThermoregulationThermoregulation

..THE NORMAL BODY TEMPERATURETHE NORMAL BODY TEMPERATURE It is physiologically safe to It is physiologically safe to

maintain the core temperature maintain the core temperature within the normal range for infants within the normal range for infants which is from 36.6 ºC to 37.5 ºC. which is from 36.6 ºC to 37.5 ºC.

Maintaining normal temperature:

Efforts should be made to maintain the axilary and rectal T at 37oC (98.6oF)

Check T q 15 – 30 min until within n range and at least q h until infant is transported to the nursery

Thermoneutral environmentThermoneutral environment

DEFINITI0N:DEFINITI0N: Range of environmental Range of environmental

temperature below and above temperature below and above which oxygen demand and which oxygen demand and metabolism are increased.metabolism are increased.

Range differ for age of gestation Range differ for age of gestation and day of life (based on available and day of life (based on available table)table)

Heat loss and heat productionHeat loss and heat production

Heat production by:Heat production by: mobilization of brown fatsmobilization of brown fats

Heat loss by:Heat loss by: 1.1.1.1. EvaporationEvaporation 1.2.1.2. ConductionConduction 1.3.1.3. ConvectionConvection 1.4.1.4. RadiationRadiation

External source of heat: drop lights, External source of heat: drop lights, phototherapy open warmers, Incubatorsphototherapy open warmers, Incubators

Thermal regulation: Thermal regulation: Heat lossHeat loss

RadiationRadiation Cold windows and wallsCold windows and walls

ConductionConduction Infant scale, wet linen, xray platesInfant scale, wet linen, xray plates

EvaporationEvaporation Amniotiuc fluid, bathingAmniotiuc fluid, bathing

ConvectionConvection 02 free flow, bag/mask, ET,drafts 02 free flow, bag/mask, ET,drafts

Thermal regulation: heat productionThermal regulation: heat production

Heat production by mobilization of Heat production by mobilization of brown fatsbrown fats

resulting to production of free fatty acid resulting to production of free fatty acid which adds to which adds to

metabolic acidosis metabolic acidosis which may which may cause pulmonary cause pulmonary vasoconstriction vasoconstriction leading to persistence of fetal leading to persistence of fetal circulation circulation and and cyanosiscyanosis

Hypothermia: cold injuryHypothermia: cold injury

Temperature < 35oC or 95oF)

HYPOTHERMIA

VASOCONSTRICTION

FLEXION

Heat production

physical

metabolic WORK

Glycolysis

Lipolysis

Oxygen debt

Acidosis

EXHAUSTION

Hypothermia: EtiologyHypothermia: Etiology

•The newborn's thermal environment is affected by: 1. relative humidity 2. air flow, 3. proximity of cold surfaces (to which heat is

lost by radiation),

4. and the ambient air temperature.

Hypothermia: PathophysiologyHypothermia: Pathophysiology

hypoglycemia, metabolic acidosis, and death.


Radiation heat loss occurs rapidly because of a high ratio of surface area to body weight, This is more pronounced in low-birth-weight newborns, making them particularly vulnerable.


. Evaporative heat loss (eg, a newborn wet with amniotic fluid in the delivery room) and conductive and convective heat losses can contribute to large heat losses and lead to hypothermia, even in a reasonably warm room.


. Because the O2 requirement

(metabolic rate) increases with cold stress, hypothermia may also result in tissue hypoxia and neurologic damage in newborns with respiratory insufficiency (eg, the preterm newborn with respiratory distress syndrome).

Ways by which body heat is lostWays by which body heat is lost


. Prolonged unrecognized cold stress may divert calories to produce heat, impairing growth.


. Newborns respond to cooling by sympathetic nerve discharge of norepinephrine in the "brown fat." This specialized tissue of the newborn, located in the nape of the neck, between the scapulae, and around the kidneys and adrenals, responds by lipolysis followed by oxidation or reesterification of the fatty acids that are released. These reactions produce heat locally, and a rich blood supply to the brown fat helps transfer this heat to the rest of the newborn's body. This reaction may increase the metabolic rate and O2 consumption

two- to threefold above baseline.

Three detrimental effects of cooling:

Development of Acidosis 3 Main Causes a. Brown Fat Metabolism b. Vasoconstriction c. Anaerobic metabolismIncreased Metabolic rate and risk of hypoglycemiaIncreased O2 Consumption

NEONATAL COLD INJURYNEONATAL COLD INJURY

Cause: exposure to cold environmentCause: exposure to cold environment Signs and symptoms:Signs and symptoms:

Apathy, refusal to feed, oliguria, coldness Apathy, refusal to feed, oliguria, coldness to touch, edema, temp 29.5-35 Cto touch, edema, temp 29.5-35 C

PE: bradycardia, apnea, hardening of PE: bradycardia, apnea, hardening of extremities should be differenciated extremities should be differenciated from sclerema, maybe complicated from sclerema, maybe complicated with pulm hgewith pulm hge

NEONATAL COLD INJURYNEONATAL COLD INJURY

DIAGNOSTIC WORK-UPDIAGNOSTIC WORK-UP Serum sugar, ABG(metabolic acidosis) Serum sugar, ABG(metabolic acidosis)

TREATMENT: TREATMENT: warming, warming, correct electrolyte correct electrolyte disturbancesdisturbances

ProphylaxisProphylaxis

Hypothermia can be prevented by:• rapidly drying the newborn in the delivery room

(to avoid evaporative heat loss)

•swaddling him (including his head) in a warm blanket.

•If the newborn is exposed for resuscitation, observation, or to provide skin-to-skin contact with the mother, he should be warmed under a radiant warmer.

ProphylaxisProphylaxis

For sick newborns, a neutral thermal environment--the environmental conditions and temperature at which the newborn's metabolic rate is minimized while maintaining a normal core temperature (37° C [98.6° F])--should be maintained.

This can be approximated by setting the incubator temperature according to the newborn's birth weight and postnatal age. Alternatively, heat can be provided using an incubator or radiant warmer with a servomechanism set to maintain the skin temperature at 36.5° C (97.7° F).

TreatmentTreatment

1. Hypothermia is treated by rewarming the newborn in an incubator or under a radiant warmer. 2. The newborn should be monitored for hypoglycemia and apnea. 3. Hypothermia that is not caused by a cooling environment may be due to

pathologic conditions such as sepsis or intracranial hemorrhage and will require specific treatment.

External heat sources:

Servo Control Radiant WarmerIncubatorPortable MattressHeat Lamps * Maintain with cautious use of heat source*

The servo-care incubatorThe servo-care incubator

Indications for use of incubatorIndications for use of incubator When there is a need to measure and When there is a need to measure and

maintain body within normal rangemaintain body within normal range for automated control of environmental for automated control of environmental

temperature temperature

Even under a radiant Even under a radiant warmer heat warmer heat loss by loss by evaporation may still evaporation may still occur occur when baby is when baby is open to open to atmosphere atmosphere

Warming a severely hypothermic( Temperature < 35oC or 95oF):

Incubator – increase the Temp to 1-1.5oC above body TempRadiant Warmer – set servo control To 36.5oC

*Be ready to do CPR if infant deteriorates during or after rewarming.

REMEMBER:

* Preventing heat loss is much easier than overcoming the detrimental effects of cold stress once they have occurred.*

HYPERTHERMIAHYPERTHERMIA

Transitory Fever or dehydration Transitory Fever or dehydration feverfever Birth History: uneventful perinatal Birth History: uneventful perinatal

events and immediate postnatal events and immediate postnatal course, breast fedcourse, breast fed


Diagnosis: Core temperature 38-39Diagnosis: Core temperature 38-39° ° C, on 2C, on 2ndnd-3-3rdrd day of life, exposed to day of life, exposed to high environmental temperatures, high environmental temperatures, low fluid intake, decreased urine low fluid intake, decreased urine output and frequency of urinationoutput and frequency of urination PE: Restless, with precipitous drop in PE: Restless, with precipitous drop in

weightweight Fontanelle depressed, skin less elastic, Fontanelle depressed, skin less elastic,

tachycardic,tachypneictachycardic,tachypneic


PE: PE: Restless, with precipitous drop Restless, with precipitous drop in weight Fontanelle in weight Fontanelle depressed, skin less elastic, depressed, skin less elastic, Tachycardic,tachypneicTachycardic,tachypneic


Diagnostic work-upDiagnostic work-up Increased serum protein, Na and HctIncreased serum protein, Na and Hct

TreatmentTreatment Oral or parenteral fluidOral or parenteral fluid Lower environmental temperatureLower environmental temperature


Severe form:Severe form: Temp as high as 41-44 CTemp as high as 41-44 C Skin hot and dry and infant appears Skin hot and dry and infant appears

apatheticapathetic Stupor, grayish pallor, coma, Stupor, grayish pallor, coma,

convulsions (due to hypernatremia)convulsions (due to hypernatremia) High morbidity and mortality ratesHigh morbidity and mortality rates Death due to hemorrhagic shock and Death due to hemorrhagic shock and

encepalopathy encepalopathy

Changes in Energy Changes in Energy requirementsrequirements

Intra-uterine supply of energy: Intra-uterine supply of energy: In-utero ------In-utero ------ Placenta---- Placenta----Fetus Fetus maternal metabolic homeostasis placental maternal metabolic homeostasis placental exchange fetal regulatory mechanismexchange fetal regulatory mechanism

Continuously provides glucose, calcium, Continuously provides glucose, calcium, magnesium magnesium


Abrupt termination of supply of energy at Abrupt termination of supply of energy at birth: birth:

provision of exogenous nutrients provision of exogenous nutrients mobilization of endogenous fuel mobilization of endogenous fuel and mineral and mineral stores stores


Impaired energy supply and Impaired energy supply and utilization:utilization:

hypoglycemia hypoglycemia hyperglycemia hyperglycemia

Hypoglycemia: definitionHypoglycemia: definition

Any plasma glucose level < 50 mg/dL Any plasma glucose level < 50 mg/dL (2.8 mmol/liter) with symptoms that (2.8 mmol/liter) with symptoms that resolve with glucose treatmentresolve with glucose treatment

Karp, Scardino and Butler, 1995Karp, Scardino and Butler, 1995

Preterm versus term infantsPreterm versus term infants Healthy newborns: slightly lower levels Healthy newborns: slightly lower levels

accepted in 1accepted in 1stst 24 hours – as low as 40 24 hours – as low as 40 mg/dL (2.2 mmol/liter)mg/dL (2.2 mmol/liter)

Cornblath and Schwartz, 1993Cornblath and Schwartz, 1993

Infants at high risk to develop Infants at high risk to develop hypoglycemiahypoglycemia: : > SGA/ LGA infants > SGA/ LGA infants > Infants of Diabetic > Infants of Diabetic mothers (IDM) > Premature mothers (IDM) > Premature infants > infants > Infants with perinatal stress: Infants with perinatal stress: sepsis, shock, asphyxia, sepsis, shock, asphyxia, hypothermiahypothermia

Hypoglycemia: causesHypoglycemia: causes

Symptoms of HypoglycemiaSymptoms of Hypoglycemia

JitterinessJitteriness Hypothermia/Hypothermia/

Temperature Temperature instabilityinstability

LethargyLethargy ApathyApathy HypotoniaHypotonia ApneaApnea

Irregular respirations Poor suck or refusal to

eat Vomiting Cyanosis High-pitched or weak

cry Seizures

Treatment of Hypoglycemia:Treatment of Hypoglycemia:

IV Treatment of Blood Sugar IV Treatment of Blood Sugar << 40 mg/dL 40 mg/dL (2.2 mmol/L)(2.2 mmol/L)

Step 1. Give an IV bolus of DStep 1. Give an IV bolus of D1010W.W.Dose: 2 ml’s per kg IV over several minutes.Dose: 2 ml’s per kg IV over several minutes.

Step 2. Recheck the blood sugar within 15-Step 2. Recheck the blood sugar within 15-30 minutes after any glucose bolus or 30 minutes after any glucose bolus or increase in IV rate.increase in IV rate.

Treatment of Treatment of Hypoglycemia:Hypoglycemia:

Step 3. Immediately following the IV Step 3. Immediately following the IV bolus, if not done already start a bolus, if not done already start a continuous IV infusion of Dcontinuous IV infusion of D1010W at a W at a rate of 80 ml’s per kg per day.rate of 80 ml’s per kg per day.

Step 4. Repeat the IV bolus if the Step 4. Repeat the IV bolus if the blood sugar is again 40 or less.blood sugar is again 40 or less.


Step 5. If the blood sugar does not Step 5. If the blood sugar does not improve and stabilize over 50 after 2 improve and stabilize over 50 after 2 boluses of glucose, repeat the glucose boluses of glucose, repeat the glucose bolus and increase the IV to 100 or 120 bolus and increase the IV to 100 or 120 ml’s per kg per day and/or change the ml’s per kg per day and/or change the IV glucose concentration to DIV glucose concentration to D12.512.5W.W.


Step 6. Evaluate the blood sugar Step 6. Evaluate the blood sugar frequently – every 15-30 minutes until frequently – every 15-30 minutes until stable > 50 on at least 2 consecutive stable > 50 on at least 2 consecutive evaluations.evaluations.

To prevent wide swings in serum To prevent wide swings in serum glucose, do not use 25% or 50% glucose, do not use 25% or 50% glucose boluses.glucose boluses.

Fluids and ElectrolytesFluids and Electrolytes

Changes in fluid compartments ( Changes in fluid compartments ( % TBW)% TBW)

AgeAge ECFECF ICFICF TBFTBF

Fetus,Fetus,

24 wks24 wks65 %65 % 25 %25 % > 90 %> 90 %

NB, NB, FTFT

40 %40 % 35 %35 % 74 %74 %

NB, NB, PTPT

ExpandedExpanded ExcessExcess


Changes in fluid requirements Changes in fluid requirements Insensible fluid Insensible fluid loss loss respiratory tract, respiratory tract, skin, skin, gastro-intestinal gastro-intestinal tract tract

Urine lossUrine loss


Abnormal Fluid accumulation: Abnormal Fluid accumulation: edema edema third spacing third spacing

EDEMAEDEMA

Contributing factors/causes: Contributing factors/causes: IDMIDM Hydrops fetalisHydrops fetalis Prematurity- decreased ability to excrete Prematurity- decreased ability to excrete

water or sodium, low protein, anemia, Vit water or sodium, low protein, anemia, Vit E deifiencyE deifiency

RDSRDS Birth pressuresBirth pressures CHFCHF Concentrated cow’s milk formulaConcentrated cow’s milk formula

EDEMAEDEMA

Associated with syndromes Associated with syndromes Congenital lymphedema (Milroy’s)Congenital lymphedema (Milroy’s) Turner’s syndromeTurner’s syndrome Congenital nephrosisCongenital nephrosis Hurler’syndromeHurler’syndrome

Electrolytes: Calcium Electrolytes: Calcium metabolismmetabolism

Placental active transportPlacental active transport Parathyroid hormones and Parathyroid hormones and

calcitonin do not cross placentacalcitonin do not cross placenta 25-hydroxyvitamin-D passes the 25-hydroxyvitamin-D passes the

placentaplacenta

HYPOCALCEMIA(TETANY)HYPOCALCEMIA(TETANY)

Definition:Definition: Normal calcium level = 8-11 mg/dLNormal calcium level = 8-11 mg/dL

Cause: Transient Cause: Transient hypoparathyroidism in the newborn. hypoparathyroidism in the newborn. Grouped as: Grouped as:

11stst 36 hours of life before 36 hours of life before achieving oral achieving oral intake of intake of milk milk High phosphate load from High phosphate load from cow’s milk cow’s milk occurring on the occurring on the 55thth-10-10thth day of life day of life `̀

HYPOCALCEMIA(TETANY)HYPOCALCEMIA(TETANY)

Diagnostic work-up Diagnostic work-up Treatment:Treatment:

2 ml/k of 10% calcium gluconate2 ml/k of 10% calcium gluconate

Osteopenia of prematurityOsteopenia of prematurity

History: prematurity with chronic illnessHistory: prematurity with chronic illness Definition:Rickets-like syndrome with Definition:Rickets-like syndrome with

pathologic fractures and pathologic fractures and demineralization of bones,demineralization of bones,

May be associated with:May be associated with: cholestasis and Vit D or calcium cholestasis and Vit D or calcium

malabsorptionmalabsorption Urine calcium loss due to diureticsUrine calcium loss due to diuretics Poor calcium, P, or vit D intakePoor calcium, P, or vit D intake

Osteopenia of prematurityOsteopenia of prematurity

Treatment:Treatment:

Immobilization of fracturesImmobilization of fractures

Administration of calcium, P and Vit DAdministration of calcium, P and Vit D

HYPOMAGNESEMIAHYPOMAGNESEMIA

Definition: Definition: Serum Mg levels <1.5 mg/dL or Serum Mg levels <1.5 mg/dL or 0.62 mmol/L0.62 mmol/L

Normal valuesNormal values


Contributing factors/causes: Contributing factors/causes: Associated with hypocalcemia Associated with hypocalcemia Deficient placental transfer Deficient placental transfer Decreased intestinal absorption Decreased intestinal absorption Neonatal hypoparathyroidism Neonatal hypoparathyroidism Hyperphosphatemia Hyperphosphatemia Renal loss Renal loss Impaired homeostasis Impaired homeostasis


PEPE Symptoms usually do not develop until Symptoms usually do not develop until

level falls < 1.2 mg/dLlevel falls < 1.2 mg/dL Diagnostic work-Diagnostic work-

Serum levelsSerum levels TreatmentTreatment

Mg sulfate 0.25 ml/k of a 50% solution Mg sulfate 0.25 ml/k of a 50% solution IMIM

HYPERMAGNESEMIAHYPERMAGNESEMIA

Definition: serum level > 2.8 mg/dL Definition: serum level > 2.8 mg/dL (1.15) mmol/L)(1.15) mmol/L)

Causes: Causes: > Maternal > Maternal treatment with MgSO4 for treatment with MgSO4 for preeclampsia, > delayed passage preeclampsia, > delayed passage of meconiumof meconium

HYPERMAGNESEMIAHYPERMAGNESEMIA

PE: PE: > CNS > CNS depression:lethargy, flaccidity, depression:lethargy, flaccidity, hyporeflexia hyporeflexia > respiratory > respiratory depression: hypoventilation depression: hypoventilation > hypotension > hypotension

LATE METABOLIC ACIDOSISLATE METABOLIC ACIDOSIS

Definition: Usually negative for Definition: Usually negative for asphyxia, respiratory distress; asphyxia, respiratory distress; Onset 2Onset 2ndnd-3-3rdrd week of life, common week of life, common among preterm, LBW (5-10%) among preterm, LBW (5-10%)

Causes:Causes: Fed with formula containing a high Fed with formula containing a high

content of protein shortly after birth, content of protein shortly after birth, delay in start of postnatal weight gaindelay in start of postnatal weight gain

PE:PE: Vigorous, essentially normal PEVigorous, essentially normal PE


Diagnostic work-upDiagnostic work-up ABG: BD= -10 to –16 mEq/L , ABG: BD= -10 to –16 mEq/L ,

PCO2 <40PCO2 <40 Due to abnormally high rate of Due to abnormally high rate of

endogenous acid formationendogenous acid formation


TreatmentTreatment: : NaHCO3NaHCO3 Change formula to lower protein Change formula to lower protein

content with whey to casein ratio content with whey to casein ratio of 60:40of 60:40

SUBSTANCE OF ABUSE ANJD SUBSTANCE OF ABUSE ANJD WITHDRAWALWITHDRAWAL

HeroinHeroin MethadoneMethadone AlcoholAlcohol PhenobarbitalPhenobarbital CocaineCocaine Fetal alcohol syndromeFetal alcohol syndrome

Fetal Alcohol SyndromeFetal Alcohol Syndrome

Cause: impaired transfer of essential Cause: impaired transfer of essential amino acids and zinc, both needed amino acids and zinc, both needed for protein synthesisfor protein synthesis

IUGR for head weight and lengthIUGR for head weight and length Facial abnormalitiesFacial abnormalities Cardiac defectsCardiac defects Minor joint and limb abnormalitiesMinor joint and limb abnormalities Mental retardationMental retardation

Education

Perinatal history, normal newborn