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45 Cards in this Set
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Neonatology defn |
Definition: A subspecialty of Paediatrics that consists of the medical care of newborn infants, especially the ill or premature. |
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Essentials for resuscitation of the new born(9) |
RESUSCITATION IN THE DELIVERY ROOM: ESSENTIALS: ♣Place newborn under a radiant warmer Suction, if necessary Dry thoroughly. Remove wet linen Position – on back, neck neutral position Provide tactile stimulation (optional) Skin to skin contact with mumNB: The cord should be cut at 2cm from base, and maintained clean by cleaning with chlorhexidine.NB: Clean delivery kits. Aseptic ligation of umbilical cord.Trained attendants. |
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Important observations at birth (5) |
Apgar score. Birth WeightDanger signs: cyanosis, pallor , bleeding, jaundice , convulsionsGross problems: congenital defects, any emergency problems: e.g. intestinal obstruction, etc,Ensure vitamin K administration
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Clinical history of a newborn (13) |
• Biodata. •Observed complaints / problems •HPI: Onset & progression •PMH: Interventions since birth •FH:Birth order, family size, inheritance •SH:- Locality, parental Hx, occupations, economic status •Danger signs—Not able to breastfeed, skin pustules, floppy or stiff, pallour, Difficulty in breathing, Convulsions, or hypothermia, Cord—red, draining pus, or bleeding. • Birth Hx: ANC: Attendance, any antenatal corticosteroids given, ARTs on mum, maternal problems Natal - mode of delivery. Institutions, duration of labour Postnatal: – Apgar score, quality of cry after birth •Nutrition /Dietary Hx---Breastfeeding, Intravenous, cup & spoon, N/G •Immunization •Growth and development • Systemic Inquiry---brief and relevant
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Physical exam(6) |
Head to Toe or by systemsGeneral –GC, jaundice, pallor, tachypnoea, adenopathy, oedema, cyanosis, fever, nutritional status , clubbingR.S - Respiratory distress--RR>60/min – tachypnoea, flaring of alae naesi, recessions, stridor, grunting , cyanosis, check added soundsCVS—Cyanosis, tachycardia (N= 120 -160), oedema, hepatomegaly, Shock (capillary refill >3 sec).P.A—Movements, Distension, Ascites, Spleen and liver enlargement, any abdominal masses.CNS—consciousness(AVPU), reflexes, Neurological deficit●Other systems-as necessary, eg. GUS
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Main kinds of care (4) |
Supportive Rehabilitative Specific Preventive |
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Supportive care of the newborn (7) |
Supportive•Rooming in – Babies stay with their mothers 24hrs•Keep warm– Incubator•Ambient temperature > 280c.•Bathe baby-After 6hours.•Umbilical care – clean with chlorhexidine•Feeding-Promote early and friendly breastfeeding , within 30 minutes•Exclusive breastfeeding for 6/12-Avoid bottle feeding and formula milk.
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Preventive care (5) |
♣Preventive Hand washing of staff and caretakersVit K administration at birthINH ( If mum has open PTB)PMTCT if mum is seropositiveTetracycline eye oint 1% both eyes stat
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Growth Development (5) |
♣Growth-Increase in size of the whole body or any of its parts.Results from multiplication of cells or enlargement of the already existing cells.Measured by wt, ht, circumference, muscle size, etc. ♣Development --Acquisition of skills Motor – gross Manipulations (fine) Speech Emotional or social
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Patterns of growth: Genital, suprarenal, general, neural, lymphoid |
♣GENITAL:Minimal growth until adolescence, when growth starts and continues after other systems stop. ♣SUPRARENAL GROWTH: Enlarges enormously during foetal life, atrophies at birth, then rises at adolescence. ♣GENERAL PATTERN:Early rapid growth, slows down at 4yrs, and rapid growth at adolescence. ♣NEURAL GROWTH:Grows ahead of other patterns. At birth,it is ¼ of adult brain; at 6/12, it is 1/2 adult brain, 2yrs – 4/5, 5 years 90%, and 10 yrs-95%. Growth is rapid during first years of life. ♣LYMPHOID PATTERN 1st decade:200% adult, then atrophies (Large tonsils and lymph nodes, adenoids) 2nd decade:-Atrophy to adult size.
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Prenatal periods Embryo, Foetus, premature birth, full term, Neonate, infancy |
PRENATAL PERIOD: 0-280 days =40 weeks Embryo=0-12 weeks Foetus=12 weeks – birth. Premature=Birth between 28 -37 wks of gestation Full term delivery=40 weeks Neonate=0-28 days. Infancy=First year. |
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Indicators of growth |
● WEIGHT • Average wt = 2.7 – 3.2 KgAfter birth, first 3-5 days, 5-10% wt is lost due to emission of meconium, urine, insensible perspiration and inadequate fluid input.Regain B.W at 10-14th day.1st 5 months – 20g/day gain.Rest of 1st year- 15g/ day Double weight = 5 months.Treble wt = 1 year = 10 Kgs
●HEIGHT: At birth 50cm, 1yr =75 cm, 2yr= 85cm ●HEAD CIRCUMFERENCEAt birth 35cm,1yr= 45 cm, 2 yr = 47cm, 3yr= 50 cmPosterior fontanelle closes at 4/12 Anterior fontanelle closes at 9-18/12 ●BONE DEVELOPMENT: Ossification centres at birth (Femoral, tibia, calcaneus, etc) ●DENTITIONOne tooth at 6/12 ( lower , central incisor)First dentition completed by end of 2nd year
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Reasons for weight loss after birth |
After birth, first 3-5 days, 5-10% wt is lost due to emission of meconium, urine, insensible perspiration Inadequate fluid input.Regain B.W at 10-14th day. |
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Indicators of development (5) |
Acquisition of skills •Reflexes •Moros (Startled), Sucking, Rooting, Stepping (Walking) Placing, Grasp, and Asymmetrical tonic neck reflex{When the face is turned to one side, the arm and leg on that side extend, while on the opposite side they flex.} •Gross motor development Head control at 3/12, Sitting at 6/12, Crawling at 9/12, Walking at 15/12 • Manipulation Active grasp at 3/12, Reaches objects at 6/12 • Speech •social development
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Factors influencing growth(3) |
•Chromosomal and genetic factors •Environmental factors Social environment Maternal nutrition Medical problems in mother (Hypertension, diabetes, renal disease) •Hormones Insulin – IDM. Term baby birth weight > 4 Kg Corticosteroids- Stunted growth
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Factors influencing placental nutrition |
Circulatory diseases e.g. Heart disease , Hypertension Inflammatory disease Hormonal disorders e.g. diabetes mellitus |
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Proteins(4) |
Few intact proteins cross The foetus mainly synthesizes its own proteins using amino acids. e.g. Thyroxine from Tyrosine Concentration of essential aa is higher in the placenta than either foetal or maternal. They are transferred by an active mechanism. Early in intrauterine life, all proteins synthesized are structural, but turn to functional proteins as organogenesis gets completed |
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Fats(4) |
● There is considerable rise in lipoproteins in pregnancy especially the triglycerides •Placenta is relatively impermeable to lipid because of the large molecular weight. •Almost all the lipids needed by the foetus are synthesized by itself from glucose and acetates. •The foetal thyroid is thought to be important in regulation of foetal metabolism of cholesterol.
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Carbohydrates(5) |
■Foetus derives all its energy from carbohydrates. Glucose crosses placenta barrier by an active transport mechanism.■Glycogen: Stores in the foetus are abundant. After 8th wk, placenta glycogen starts to fall.♣Liver: At birth has twice as much glycogen per unit wt as the adult.♣Heart: Foetal heart has high glycogen content Rapidly depleted by perinatal anoxia♣Skeletal muscle: Glycogen stores are also high. |
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Minerals (3) and Vitamins (2) |
MINERALS Iron is actively transported from maternal stores. Early in embryonic life, Iron is used for formation of RBCs Calcium deposition rises to over 10 times after 38 weeks. VITAMINS Water soluble vitamins readily cross the placenta Fat soluble vitamins do not readily cross the placenta. |
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Antenatal diagnosis(5) |
● Clinical: Serial bimanual and abdominal examination ● 24 hour urine Oestriol. ● X-rays ■Ultrasound ▪Amniotic fluid studies |
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Info from an X ray(5) |
▪Abnormalities-Anencephaly, Spina Bifida, Hydrocephalus ▪Ossification in epiphysis Lower end of femur 36/40 Upper end of tibia 38/40 Cuboid-----40/40 ▪Risks of irradiation to foetus and mother real, hence not repeatable. |
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Parts of an ultrasound(8) and benefits(3) |
●Ultrasound benefits (Non- invasive, safe, can be repeated)
•Crown–rump length (head to the buttocks). This matches well with the GA. (First 12 wks of gestation.) •Biparietal diameter – Predicts IUGR (12-18 wks) •Head circumference •Abdominal circumference ( Indicates IUGR)•Foetal movements •Fetal heart movements : Basis of cardio tocography- Absence of movements in foetal death. •Congenital abnormalities: Anencephaly,Hydrocephaly, Spina Bifida, Exomphalos, Heart defects – Septal defects and chamber enlargement •BPP-NST+Movs+Tone+Amniotic Fluid+Breathing
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Which are high risk neonates?(14) |
■ Premature babies: Risk of CP and mental retardation. ■ Postmature babies: Risk of MAS, hypoglycaemia, skin sepsis ■ Low birth weight <2.5 Kg ■ L.GA – IDM: Risk of hypoglycaemia, birth injury ■ Baby of Mum with BOH. ■ Severe asphyxia neonatorum- Risk of developmental disability due to birth injury. ■ HDN – Risk of Kernicterus ■Baby with IUGR – Hypothermia , hypoglycaemia ■NNS: Risk of CP, sensory & learning deficits ■ Congenital defects e.g. spina Bifida, diaphragmatic hernia, hydramnios. ■ Maternal problems • Infection • PROM • PIH • Diabetes Mellitus • Severe social problems, Drug addiction, Prolonged infertility, Elderly primigravida ■ Anaemia ■ Hypoglycaemia ■ Stress in pregnancy- Hyperemesis gravidarum, accident
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Characteristics of care of High risk neonates(3) |
CHARACTERISTICS Close observation First few days or weeks of life are critical Skilled personnel essential.
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Interventions for High Risk Neonates (7) |
•Neonatal intensive care •Diagnose and treat medical complications. •Effective follow up clinic •To identify developmental disability. •To provide parental counseling – Positioning, handling and feeding. •Physiotherapy and occupational therapy. •Co-operation with other medical disciplines. |
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Follow up parameters for High risk Neonates (7) |
FOLLOW UP PARAMETERS• Growth-Length, wt, head circumference •Breathing disorders: Apnoea •Hearing •Vision- ROP •Language •Motor skills •Neurological developments: Hypotonia, hypertonia, seizure, feeding problems.
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Prematurity defn and causes(3) |
PREMATURITY Defn: Born before 37 wks of pregnancy Causes: •Maternal factors •Pregnancy related factors •Foetal related factors
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Maternal factors (10) |
♣Maternal factors • Pre- eclampsia (PIH) • Chronic heart or kidney disease. • Diabetes • Hypertension •Drug use, including alcohol • Cervical incompetence • Smoking • Infections – UTI , GBS, Transplacental, malaria •Abnormal uterus, fibroids • Maternal malnutrition, anaemia
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Pregnancy related factors(5) |
♣ Pregnancy Related Factors •Placenta praevia • Abruptio placenta • Premature rupture of membrane (PROM) • Polyhydramnios • Oligohydramnios
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Foetal related factors (5) |
♣Foetal Related Factors • Mutiple pregnancy • Infections – CMV, Rubella, syphilis • Birth defects – CHD, diaphragmatic hernia , TOF • Blood group incompatibility • Chromosomal abnormality – Trisomy 21
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Risks in Premature infants(9) |
▪ LBW – Morbidity and mortality rising with decreasing BW ▪ Hypothermia-Nurse baby in a thermoneutral environment ▪ Anaemia ▪ Neonatal Jaundice. ▪ Metabolic – Hypocalcaemia, Hypoglycaemia etc. ▪ Feeding challenges, NEC. ▪ CNS –Birth injury, Neonatal seizures, ROP, IVH and PVL. ▪ Neonatal sepsis ▪ RDS
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Clinical features of premature infants(12) |
CLINICAL FEATURES ● LBW ● Skin thin , shiny, pink or red with visible veins, with little subcutaneous fat. ● Scalp hair scanty, with lots of body lanugo. ● Weak cry and body tone. ● Genitals small and underdeveloped –(male scrotum small with few or no rugae, testes may be undescended. In the female, labia majora not covering labia minora, clitoris prominent. ● Large head relative to rest of body. ● Few creases on soles of feet. ● Soft ears with little cartilage. ● Undeveloped breast tissue. ● Sleeps most of time, with reduced physical activity when awake. ●Rapid breathing with periodic breathing or gets apnoea. ●Weak, poorly co-ordinated sucking and swallowing reflexes.
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Management of a premature infant (8) |
MANAGEMENT. •Hx-Antenatally –APH,HT, Infections, blood gp Natal – PROM, premature labour, Narcotics Postnatal- APGAR score- Resuscitation, MOD • P/E: B.W, Reflexes, malformations, RDS, Sepsis. • Investigations: Haemogram, BGA, U/E, cranial u/s, X- rays , septic screen, Dubowitz,V/E, L.S. ratio, ophthalmology review at one month for ROP in VLBWs. • Supportive:- warmth, feeds / fluids , oxygen. • Preventive-Prenatal steroids, Iron, calcium, handwashing. • Specific – If relevant and treat complications. • Rehabilitative – Anaemia, rickets, CP, hydrocephalus, Seizures.
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Prognosis depends on (3) |
• Prognosis - Depends on (a) B.W, (b) GA, and ©Quality of care after birth. |
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Classification of premature infants (3) |
▪LBW classification ▪SGA ▪LGA |
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LBW Classification |
♣ LBW: <2500g at birth.(WHO) ♣ VLBW:<1500g ♣ ELBW: < 1000g LBWs - about 20 times more likely to die than heavier babies, more so in developing than developed countries.
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SGA Defn ,Characteristics(4), Complications (7) |
SGA(Intrauterine Growth Restriction, Dysmaturity) (Small for Gestational Age) Weights are less than tenth percentile for gestational age. Important characteristics ▪Marked loss of subcutaneous fat. ▪ If postmature, skin is dry , cracked, wrinkled, peeling and may be meconium stained with absence of vernix caseosa. ▪ Usually hungry and feed well.
▪ Appearance of unusual alertness or a wide eyed look. Common Complications ■ Hypoglycaemia – due to lack of glycogen stores. ■ Hypothermia. ■ Massive pulmonary haemorrhage. ■ Skin infections. ■ Meconium aspiration ( usually in postmature infants). ■ Perinatal asphyxia ( Usually in full term) ■ Polycythaemia – Due to chronic mild hypoxia caused by placental insufficiency – erythropoietin released increases leading to an increased erythrocyte production. |
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LGA Defn, predisposing factors (8)
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LGA—LARGE FOR GESTATIONAL AGE Defn- Babies with BW above the 90th percentile for GAMacrosomia--Wt is above 4000g – Due to anabolic effects of high foetal insulin levels.
Predisposing Factors ● Poorly controlled gestational/ pre-existing diabetes ● Gestational age > 40 weeks. ● M> F ● Genetic: Tall and obese mother. ● Excessive maternal weight gain . ● Multipara 2-3 x more than primiparas. ● Congenital anomalies – TGA ● Erythroblastosis foetalis.
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Signs and symptoms(6), Diagnosis, Management(2) |
Symptoms and signs ▪ Large , obese, plethora ▪ Listless and limp and may feed poorly ▪ Delivery complics – Birth injury (shoulder dystocia, fracture of the clavicle). ▪ Metabolic complications – Hypoglycaemia. ▪ Resp complics(RDS) Surfactant production is delayed ▪Hyperbillirubinaemia – Polycythaemia; Intolerance to oral feedings(increases entero-hepatic circulation of bilirubin) Diagnosis – Ultrasound Management ■Early feeding essential to prevent hypoglycaemia. ■C/S for safe delivery and avoid birth canal lacerations. |
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Feeding problems(10) |
• VLBW babies cannot breastfeed or be fed by cup and spoon because they have no sucking and swallowing reflexes. ♣Feeding Problems ▪ Aspiration pneumonia-Babies with cleft lip and palate or who vomit feeds, those with RDS or tachypnoea ▪Vomiting ▪Overfeeding-Obesity ▪Dehydration
▪ Underfeeding – Failure to thrive. ▪ Hypoxia during feeds ( in Prematures). May need oxygen. ▪ Milk allergy in infants. ▪ Constipation ▪ Spitting up (regurgitation )-May result in GOR
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Bubbling the baby (5) |
Bubbling the Newborn (a)Place baby on shoulder. (b) Hold baby upright leaning slightly forward . (c) Hold baby across the lap . Then rub or gently pat the back until air is expelled. When no belch occurs , position the baby on his right side of abdomen . |
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Maternal problems with feeding(5) |
▪ Breast engorgement- 3rd postpartum day. Breast feed frequently and express milk. Apply warm compresses. ▪ Leaking breasts-occurs when mum sees or hears a baby. Fold arm across the breast and press firmly. Place absorbent pads. ▪ Maternal anxiety. – Decreases milk production. ▪ Sore, cracked or fissured nipples-Due to nipple and areola not properly in mouth, friction of gums on the nipple, sucking on empty breast, or failure to break suction before removing the infant from the breast. ▪ Delayed milk production – Caused by failure to breastfeed baby shortly after birth, or not fed frequently enough.
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Feeding the newborn Type of feed(4) Mode of Administration (4) Frequency of feeding Quantifying feed (3) |
Choice of type of feed ■ Breast milk. ■ cow’s milk. ■ IV fluids (N/saline , 5 % dextrose, 10% dextrose) ■ IV hyperalimentation. Choice of mode of administration ■ Breast feeding – within the first 30 minutes of life. ■ Cup and spoon ■ Naso-gastric feeding. ■ IV. Mode of feeding is dictated by the BW and the clinical state. Frequency of feeds: 3 hourly. Quantifying feeds:Dependent upon age,wt, and clinical state of baby. |
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Contents of Breast milk(6) |
● Macrophages and Neutrophils phagocytose bacteria ● Secretary IgA & Interferon – Anti-infective agents produced by lymphocytes. ● Immunoglobulins – IgA, IgG, IgM, IgD. ● Lysozyme – 5000X more in human milk than cow’s milk (anti-infective) ● Lactoferrin- Plenty in human milk , absent in cow’s milk. Binds Fe preventing pathogenic E. coli from obtaining the Fe they need for survival. ● Lactobacillus – Discourages multiplication of pathogens particularly gram positive bacilli . Babies fed on cow’s milk have gram NEGATIVE bacilli in their gut flora. |
