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An Overview of Neonatal

Kamlah olaimat


Objectives:

1. To discuss Thermoregulation.

2. To discuss Low birth weight and jaundice.


Thermoregulation• Is a balance between heat loss and heat gain .

– The main goal is to control the neonates environment in order to maintain a neutral thermal environment .

• Normal temperature of the neonate 36.5 c-37.5c (auxiliary may be .5-1 c lower )

• Hypothermia : temp<36.5c• Hyperthermia: temp>37.5c


Mechanism of thermogulation

• Heat production result from the release of norepinephrine resulting in the metabolism of brown fat store and the consumption of oxygen and glucose.

• At birth , an immediate fall in body temperature and cold stress occurs .

• Preterm neonate do not have the ability to increase their body temperature by increase metabolic rate and they have much smaller store of brown fat than term neonate .

Miss : Kamlah Olaimat 6 6

Newborn lose heat by four mechanisms:

1- convection: heat flow from newborn to cooler air. 2- radiation: transfer heat from body to cold solid object not in contact with the body. 3- evaporation: conversion of liquid to vapor. 4- conduction: transfer heat from body to cold solid object in contact with the body.

Insulation is not efficient because little fat available.** How newborn conserve heat?From the brown fat that available in the

intrascapular, thorax and perineal area. It found in the mature newborn and produce heat by increasing metabolism.

Temperature

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Conduction

Evaporation

Convection

Radiation


Heat ProductionThe human body responds to cold in three ways:

1.Voluntary muscular activity (vasoconstriction and increased movement)

2.Shivering (inefficient in the term newborn)

3.Chemical or nonshivering thermogenesis (brown-fat metabolism for several hours after birth)


Hypothermia

• Condition associated with hypothermia:-

C old environment

Incorrect care of the neonate immediately after birth .

Inadequate drying

Insufficient clothing

Separation from mother

Inadequate warming procedure ( before and during transport)

Diseased and stressed infant


Hypothermia

• Symptoms and signs :-

Measuring the neonate temperature may not detect early changes of cold stress as the neonate will initially use energy store to maintain central temperature


Hypothermia

• Initial signs that may be present include:-

o Feet are cold to touch

o Week sucking ability or inability

o Lethargy and week cry.

o Skin color changes from pale and cyanosis to peripheral mottling or plethora

o Tachypnea and tachycardia.


Later signs

• Lethargy

• Apnea and bradycardia.

• There is a high risk for hypoglycaemia , metabolic acidosis


HYPERTHERMIA

• Condition associated with :-

o High temperature environment

o Intracranial hemorrhage

o Infection

• Signs and symptoms:

• Warm skin ( flushed and pink initially and pale later )

• Tachycardia and tachypnea

• Dehydratin increase , heat stroke and death .


Management

1. Temperature control:-

In the delivery room :-

- Provide warm environment

- Dry neonate immediately

- Direct skin – to – skin contact with mother

- Use radiant warmers at birth

- Cover the neonates head with a cap


Low Birth WIEGHT

• Alow birth weight ( LBW ) neonate is one whose birth weight is less than 2.500 gm .

• Very low birth weight ( VLBW ) <1.500gm

• Extremely very low birth weight ( ELBW) < 1.000gm.

• Causes of LBW:-

• 1. Prematurety ( gestational age < 37gw)

• 2. Growth restriction ( below 10th percentile )

• 3. Both .


Preterm infant

• A preterm neonate is one whose birth occurs before the end of the last day of thirty seventh week following the onset of last menstrual period

• Prematurety with its complication is the leading cause of neonatal mortality in Jordan ( 35%)

Causes of preterm birth :-

• 1. Fetal

- Fetal distress

- Multiple gestation


Preterm infant• 2. Placental

- Placenta previa

- Abruptio placenta

3. Maternal

- Pre – eclampsia

- Chronic medical illness ( e.g. heart disease )

- Infection( UTI)

- Drug abuse

4. Other :-

- Premature rupture of membrane

- Polyhydramnios


Complication of Prematurety• 1. Difficulty in maintain body temperature due to • Increased heat loss• Reduced subcutaneous fat • Large surface area – to body weight ratio• Reduced heat production because inadequate

brown fat and inability to shiver .• 2. Respiratory difficulties:-• Deficiency of pulmonary surfactant • Risk of aspiration due to poor gag and cough

reflexes , uncoordinated sucking and swallowing• Week respiratory muscles• Periodic breathing Apnea


Complication of Prematurety

• 3. Gastrointestinal and nutritional problem:-• Poor sucking reflexes especially before 34 gw

• Decreased intestinal motility

• Delayed gastric emptying


Complication of Prematurety

• 4. Hepatic immaturity:-• Impaired conjugation and excretion of bilriubin

• Deficincy of vitamin k – depending clotting factors

• 5. Renal immaturity:-

• Renal elimination of drug may be diminished

• Electrolyte implance

• Immunologic immaturity :-• High risk for infection

• Lack transplacental transfers of maternal IgG during third trimester

• Impaired phagocytosis


Management

• 1. In delivery room :-

• Resuscitation immediately

• Adequate oxygenation

• Maintenance of temperature

• 2. Neonatal management :-

• Thermal regulation

• Oxygen therapy

• Fluid and electrolyte therapy

• Nutrition( gavages feeding or parenteral)

• Monitor of billirubin( phototherapy, bld exchange )

X

Hyperbilirubinemia

Its refer to an exaccessive level of billirubin in the blood>2mg\dl.

Its represent in tow form :

1. Conjugated hyperbilirubinemia

2. Un Conjugated hyperbilirubinemia

Both form characterized by “yellowish”

Discoloration of skin , sclera ,and mucous

Membrane.

Serum billirubin level between 5-7mg\dl


Hyperbilirubinemia

• Incidence:-

60%in full term .

80% of preterm neonate

Source of billirubin :-

75% from break down of hemoglobin

25% comes from breakdown of non Hb – protein and ineffective erythropoisis .

Notes:- neonate produce about twice as much bilirubin daily (6-8 mg\kg\daily) than adult (3-4 mg \kg\daily) .


Bilirubin

turnover in

Newborn

Hb Haem + Globin

Other sourcesBILIRUBIN

UCB binds to S albumin

Dissociates from albumin

UDPG - T

Bil monoglucoronide +

Bil Diglucoronide

Water sol Bil

Binds to cytoplasmic

Ligandin (Y protein)

Excreted into bile canaliculi

Enters Gut

Excreted in stool

Biliverdin + CO + FeBilirubin Reductase

Haem oxygenase

Beta Glucoronidase

UCB

Production

transport

uptakeUptake

Excretion

Conjugation


Bilirubin load causing jaundice in

Newborn>ed RBC vol & <ed RBC survival

>ed Bil monoglucoronide

<ed Bil Diglucoronide

UCB

Pro

du

cti

on

Tra

nsp

ort

Uptake

Excretion

Conjugation

>ed Ineffective erythropoiesis & >ed Heam

turnover

Non availability of Albumin

binding sites

Defective conjugation

<ed LIigandin

Decreased excretion

<ed gut motility

Poor evacuation

>>ed beta glucoronidase, <ed

intestinal bacteria

>ed BILIRUBIN load

Defective uptake from plasma

>ed Entero-hepatic circulation


Hyperbilirubinemia

• Classification of Hyperbilirubinemia :

• 1. Unconjugated ( indirect)

physiological jaundice.

Breast milk jaundice

-Early onset jaundice

- Late onset jaundice

Hemolytic jaundice ( most common)


Nursing assessment and intervention

• Be alert for signs and symptoms of jaundice:-

o Sclera appear yellow before skin yellow

o Skin appear light to bright yellow

o Lethargy

o dark amber, concentrated urine

o Poor feeding

o Color and amount of stool

o Support breast feeding


Investigation for all neonate with jaundice

• Total serum billirubin ( direct and indirect)

• CBC

• Blood group for both mother and baby

• Blood film

• Direct Coombs test


Management

• PhototherapyLight therapy provides energy to exposed skin in order to

convert Unconjugated billirubin to water soluble form to enhance its excretion .

• Technique:-o Blue light with wave length 425-475nmo Plastic covero White linens in cot to reflect lighto Baby undressed o Cover eye and genital area o Lamp should be 5-8 cm over incubator and 45-50cm above

baby


Management

1. Phototherapy

o Neutral thermal environment

o Monitor wight daily

o Monetored fluied balance

o Bilirubin level should be followed after 24 hours after stop phototherapy

o Skin color assessment not affective during phototherapy


Complication of phototherapy

• Loose stools

• Skin rashes

• Overheating

• Dehydration

• Eye injury

• Bronze baby syndrome


Babies under phototherapy

Baby under conventional

phototherapyBaby under triple unit intense

phototherapy


2. Exchange transfusion

• This procedure to remove billirubin and hemolytic antibodies and correct anemia

• Why to start Exchange transfusion:-

o Sick or well neonate

o Birth weight

o Gestational age

o Cases of hemolysis( as Rh or ABO incompatibility , or G6PD)


Exchange transfusion

• Monitor billirubin level 4-6 hours after exchange

• If billirubin level persist a second exchange considered

• Continue phototherapy before and after exchange


Complication of exchange

• Vascular( thrombosis)• Cardiac( overload)• Electrolyte disturbance• InfectionNursing care after exchange:-o Neonate isolatedo Observe color and toneo Monitor site for bleeding and infectiono V\S q 1\2 hour for sex hourso Girth measurement and bowel sound


Exchange transfusion


2. kernicterus

• It deposit of Unconjugated billirubin in the

basal ganglia of the brain .

• Cell injury , yellow staining , neural loss

• In preterm infant even billirubin level in low range may cause kernicterus .


kernicterus

• Clinical presentation :-Through 4 stages :-1. General neurological depression , poor motor

reflex , poor feeding , vomiting , high pitch cry, lethargy

2. Seizures , fever , paralysis mortality high 3. After one week spasticity decrease and may

disappear4. After the period of neonatal and reflect the

damage happened as spasticity, deafness , mental retardation


kernicterus

• The level at which kernicterus can occur variable and no specific billirubin level safe or toxic .

• Management :-

• Phototherapy and exchange immediately


Kernicterus


3. Conjugated hyperbilirubinemia :-

Conjugated hyperbilirubinemia :-Increased level of direct billirubin >20% of

total serum Its signs of hepatobiliary dysfunction

• Etiology:-• Extra hepatic biliary obstruction• Biliary atresia• External compression • Infection



• Clinical manifestation:-• Signs of sepses • Abdominal distention• Vomiting• Clay-colored stool• Dark urineInvestigation:-Liver function testAbdominal ultrasoundLiver biopsy



• Management:-

• Key is to identify the underlying cause

• Phototherapy should not use

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