LMCC Review Course:LMCC Review Course:“Neonatology”“Neonatology”

Gregory Moore, MD, FRCPCGregory Moore, MD, FRCPC

Division of NeonatologyDivision of Neonatology

April 2010April 2010

OutlineOutline1.1. Resuscitation principlesResuscitation principles

1.1. Transition to ex-utero lifeTransition to ex-utero life

2.2. Normal newborn care and assessmentNormal newborn care and assessment

3.3. Small and Large-for-Gestational Age Small and Large-for-Gestational Age neonates and their problemsneonates and their problems

4.4. Prematurity and its complicationsPrematurity and its complications

5.5. Problems of the term infantProblems of the term infant

For Starters …For Starters …

Infant (< 1 yr old) mortality: 5 deaths per 1000 live births (Canada) Due to congenital anomalies, prematurity,

asphyxia, infections, SIDS

Normal vitals for a baby at term: HR: 120-160/min * RR: 40-60/min * BP: 50-80/30-40 mmHg Sats: >95% by ~1 hr of age *

For Starters …For Starters …

Gestation (wks)Gestation (wks) Birth Weight (kg)Birth Weight (kg)

2727 1.01.0

3030 1.51.5

3333 2.02.0

3535 2.32.3

37-4037-40 3.5 (2.5 – 4.5)3.5 (2.5 – 4.5)

Newborn ResuscitationNewborn Resuscitation Initial steps: warm, dry, ‘stimulate’Initial steps: warm, dry, ‘stimulate’ Evaluate respirationsEvaluate respirations Evaluate heart rateEvaluate heart rate Evaluate toneEvaluate tone Evaluate colorEvaluate color

RememberRemember - the key to a baby’s - the key to a baby’s transition to the real world is transition to the real world is ‘‘openingopening’ the lungs: ’ the lungs: VENTILATION VENTILATION OxygenationOxygenation

1. ‘Red’ blood from placenta

2. ‘Less red’ blood from right to left atrium via patent

foramen ovale

3. Small amount of‘pink’ blood

going to lungs

In-uteroIn-utero

4. Pink blood goes from the

pulmonary artery to aorta via

ductus arteriosus …

produces mixing of

pink and blue blood

1. Cord is clamped

Increases SVR

2. Foramen ovale functionally closes

3. Pulmonary arteries

vasodilate to increase blood

flow to the lungs

Ex-uteroEx-utero

4. Ductus arteriosus closes

Fluid-filled alveoli in utero

Diminished blood flow in-utero through fetal lungs

Importance of first breath

The End ProductThe End Product

Neonatal Resuscitation Neonatal Resuscitation ProgramProgram

90% of babies

9% of babies

0.9% of babies

0.1% of babies

Newborn ResuscitationNewborn Resuscitation A: AirwayA: Airway B: BreathingB: Breathing C: CirculationC: Circulation D: DrugsD: Drugs E: EnvironmentE: Environment F: FluidsF: Fluids G: GlucoseG: Glucose

““IV, O2, Monitor” … if distressedIV, O2, Monitor” … if distressed

NB. Newborn ResuscitationNB. Newborn Resuscitation

MECONIUMMECONIUM in the amniotic fluid AND in the amniotic fluid AND depressed newborn (not crying, limp):depressed newborn (not crying, limp): Intubate and suction below cords FIRSTIntubate and suction below cords FIRST

Suspect Suspect diaphragmatic herniadiaphragmatic hernia:: Intubate ASAPIntubate ASAP

Pink when crying … blue when not:Pink when crying … blue when not: Suspect Suspect choanal atresiachoanal atresia and try an oral and try an oral

airwayairway

The Apgar ScoreThe Apgar Score

Feature 0 points 1 point 2 points Heart rate

0

< 100

> 100

Respiratory Effort

Apnea Irregular, gasping

Regular, crying

Color Pale, blue Pale or blue extremities

Pink

Muscle tone Absent Weak, passive tone

Active movement

Reflex irritability

Absent Grimace Active avoidance

Ensure warmth and early nutrient Ensure warmth and early nutrient intakeintake

Support breastfeedingSupport breastfeeding

Monitor weight and hydration statusMonitor weight and hydration status

Educate about infant care **Educate about infant care **

Anticipatory guidance **Anticipatory guidance **

Principles of Routine CarePrinciples of Routine Care

Principles of Routine CarePrinciples of Routine Care Prophylaxis for common problemsProphylaxis for common problems

Eye care: erythromycin ointmentEye care: erythromycin ointment Vitamin K: 1 mg IMVitamin K: 1 mg IM

Screening for disease: >24hScreening for disease: >24h Newborn screen (24-72 hr)Newborn screen (24-72 hr)

• PKU (1/15,000)PKU (1/15,000)• Hypothyroidism (1/4000)Hypothyroidism (1/4000)• 24 other diseases (OA/AA/FA disorders, SCA, 24 other diseases (OA/AA/FA disorders, SCA,

Hgb’pathies’, CAH, galactosemia, endocrinopathies)Hgb’pathies’, CAH, galactosemia, endocrinopathies) Neurosensory hearing loss (pre-d/c)Neurosensory hearing loss (pre-d/c) Hyperbilirubinemia (pre-d/c)Hyperbilirubinemia (pre-d/c)

Blood group and Coombs if mother Rh negativeBlood group and Coombs if mother Rh negative

The Newborn HistoryThe Newborn History IdentificationIdentification Maternal History:Maternal History:

• AgeAge• Past medical/surgicalPast medical/surgical• Medications, Drugs/Smoking/EtOHMedications, Drugs/Smoking/EtOH• Past pregnancy(ies) (GTPAL)Past pregnancy(ies) (GTPAL)• Current pregnancy (including screening test results, Current pregnancy (including screening test results,

antenatal steroid use)antenatal steroid use) Family HistoryFamily History Social HistorySocial History Labour and Delivery HistoryLabour and Delivery History Resuscitation HistoryResuscitation History Early Postnatal CourseEarly Postnatal Course

Physical ExaminationPhysical Examination Vital signsVital signs

Measurements Measurements plot! plot!

Gestational age assessmentGestational age assessment

Overall appearance (well/unwell)Overall appearance (well/unwell)

System by system (or head to toe) **System by system (or head to toe) **

The depressed newbornThe depressed newborn Neurological:Neurological:

Asphyxia, CNS TraumaAsphyxia, CNS Trauma

Respiratory:Respiratory: Apnea (secondary)Apnea (secondary)

Cardiovascular:Cardiovascular: Hypovolemia/shock/hydropsHypovolemia/shock/hydrops

Congenital:Congenital: MalformationsMalformations

DrugsDrugs

The Basic TestsThe Basic Tests Blood gas (arterial or capillary) Glucose Electrolytes Complete Blood Count + differential Blood culture Chest X-ray

Consider: Lactate, CRP, echocardiogram, abdominal x-ray Full septic workup if > 72 hours old

Perinatal AsphyxiaPerinatal Asphyxia- Must be documented by cordocentesis, fetal - Must be documented by cordocentesis, fetal

scalp blood sampling, cord blood samplingscalp blood sampling, cord blood sampling pH pH << 7.00, base deficit 7.00, base deficit >> 15 mEq/L 15 mEq/L Apgar less than 5 at 5 minutesApgar less than 5 at 5 minutes EncephalopathyEncephalopathy Multiorgan involvement (heart, kidneys, Multiorgan involvement (heart, kidneys,

marrow, liver)marrow, liver)

- Neonatal encephalopathy must be - Neonatal encephalopathy must be documented for perinatal asphyxia to be documented for perinatal asphyxia to be considered as a cause of later considered as a cause of later neurodevelopmental problemsneurodevelopmental problems

Skin tags 10-15/1000Polydactyly 10-15/1000

Cleft lip or palate 1-4/1000Congenital heart defect 1-4/1000

Congenital hip dysplasia 1-4/1000

Down Syndrome 1-4/1000

Talipes equinovarus 1-4/1000

Spina bifida 1-4/10,000

Most common anomalies noted on initial exam