perinatal history, normal newborn
TRANSCRIPT
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
Perinatal History:Social HistoryPerinatal History:Social History
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,
Perinatal History:Social HistoryPerinatal History:Social History
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
NEWBORN PE:ABDOMENNEWBORN PE:ABDOMEN
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
NEWBORN PE:ABDOMENNEWBORN PE:ABDOMEN
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:
Checking for hip dislocationChecking for hip dislocation
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”
Checking for hip dislocationChecking for hip dislocation
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
NEWBORN PE: CNSNEWBORN PE: CNS
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
NEWBORN PE: CNSNEWBORN PE: CNS
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
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
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
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
Normal ValuesNormal Values
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
Normal ValuesNormal Values
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
Normal ValuesNormal Values
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
Normal ValuesNormal Values
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
Normal ValuesNormal Values
Gastrointestinal:Gastrointestinal:
meconium passagemeconium passage enzymeenzyme
Normal ValuesNormal Values
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.
Hypothermia: PathophysiologyHypothermia: Pathophysiology
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.
Hypothermia: PathophysiologyHypothermia: Pathophysiology
. 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.
Hypothermia: PathophysiologyHypothermia: Pathophysiology
. 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
Hypothermia: PathophysiologyHypothermia: Pathophysiology
. Prolonged unrecognized cold stress may divert calories to produce heat, impairing growth.
Hypothermia: PathophysiologyHypothermia: Pathophysiology
. 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
HYPERTHERMIAHYPERTHERMIA
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
HYPERTHERMIAHYPERTHERMIA
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
HYPERTHERMIAHYPERTHERMIA
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
HYPERTHERMIAHYPERTHERMIA
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
Changes in Energy Changes in Energy requirementsrequirements
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
Changes in Energy Changes in Energy requirementsrequirements
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.
Treatment of Treatment of Hypoglycemia:Hypoglycemia:
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.
Treatment of Treatment of Hypoglycemia:Hypoglycemia:
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
Fluids and ElectrolytesFluids and Electrolytes
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
Fluids and ElectrolytesFluids and Electrolytes
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
HYPOMAGNESEMIAHYPOMAGNESEMIA
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
HYPOMAGNESEMIAHYPOMAGNESEMIA
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
LATE METABOLIC ACIDOSISLATE METABOLIC ACIDOSIS
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
LATE METABOLIC ACIDOSISLATE METABOLIC ACIDOSIS
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