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Mdcu Neonatology Review

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Mdcu Neonatology Review Mdcu Neonatology Review Document Transcript

  • MD Chula 2010 y nl O se U al rn Baby boy born at 38 weeks GA, by C/S , te No ANC Apgar score at 1 and 5 mins. = 4, 5 Grunting at 30 min. after birth In RR 60 /min. PR 150 /min. BT 36.5°c BW 4,200 g Ht 50 cm. HC 34 cm. puffy face, hairy ears ,Suprasternal and subcostal retraction,Lungs: fine crepitations both sides At 2 hours of age, DTX 30 mg/dl, Hct 67%
  • MD Chula 2010 y nl O se U al rn ž No ANC (no GDM screening) te ž Term 38 wk LGA ( but normal Ht, HC) ž Hypoglycemia In Infant of diabetic mother
  • MD Chula 2010 y nl O se U al rn ž Chest x-rayà diffuse reticulogranular te pattern ,hypoaeration ž Dx.. In ž Respiratory distress syndrome
  • MD Chula 2010 y nl O se U al rn ž Respiratory distressà RDS te ž Hypoglycemia ( BS < 40 mg%) ž Polycythemia (Hct > 65%) In ž Infant of diabetic mother (IDM)
  • MD Chula 2010 y nl O se U al rn ž Surfactant deficiency (decreased te production and secretion) is the primary cause In ž Mature levels of pulmonary surfactant are usually present after 35 wk. ž Synthesis of surfactant depends in part on normal pH, temperature, and perfusion
  • MD Chula 2010 Increase Risk Decrease Risk •Prematurity •pregnancy-associated •maternal diabetes hypertension •multiple births •maternal heroin use y •cesarean section •prolonged rupture of •precipitous delivery membranes nl •asphyxia •Antenatal corticosteroid O •cold stress prophylaxis •history of previously affected infants se U al Which of following decrease the risk for this rn condition? ž Cold stress te ž Maternal DM In ž Birth asphyxia ž Cesarean section ž Prolong rupture of membrane
  • MD Chula 2010 y nl O (lecithin) se U al rn ž Alveolar atelectasis, hyaline membrane formation, and interstitial edema make the te lungs less compliant ž Sign of respiratory distress appear within In minutes of birth ž Breath sounds may be normal or diminished , on deep inspiration, fine rales may be heard ž symptoms and signs reach a peak within 3 days, after which improvement is gradual
  • MD Chula 2010 ž blood glucose < 40 mg/dL ž sustained or repetitive hypoglycemia in infants and children can retard brain development and function y ž Long term sequeleà mental retardation, nl seizure disorder O se U al rn ž Limited glycogen supplyà preterm, te perinatal stress ž Diminished glucose productionà SGA In ž HyperinsulinismàIDM, Hydrops fetalis ž Othersàhypothermia, sepsis,polycythemia
  • MD Chula 2010 y nl O se U al rn ž Apnea/ tachypnea te ž Bradycardia/ Tachycardia ž Cyanosis In ž Lethargy ž Poor feeding ž Jitteriness ž Seizure
  • MD Chula 2010 ž asymptomatic infantsà frequent feeding and/or intravenous infusion of glucose ž acute symptomatic infant à 2 mL/kg of D10 W IV push, followed by IV drip glucose at 6–8 mg/kg/min y adjusting the rate to maintain blood nl ž glucose levels in the normal range. O ž If hypoglycemic seizures are present, some recommend a 4 mL/kg bolus of D10 W. se U al rn the most appropriate fluid management..E te ž 10% D/W 2 ml/kg IV push then ž IV drip 85 ml/kg/day à glucose rate 6 In mg/kg/min. (if drip 65 ml/kg/dayà glucose rate 4 mg/kg/min.)
  • MD Chula 2010 y nl O se U al rn ž Due to slow absorption of fetal lung fluid ž early onset of tachypnea, sometimes with te retractions, or expiratory grunting and, occasionally, cyanosis that is relieved by In minimal oxygen (<40%). ž usually recover rapidly within 3 days. The lungs are generally clear without rales or rhonchi ž chest x-ray shows prominent pulmonary vascular markings, fluid in the intralobar fissures, overaeration, flat diaphragms, and, rarely, pleural effusions.
  • In te rn al U MD Chula 2010 se O nl y
  • MD Chula 2010 ž 40 % atrophic or absent testis ž 60% undescended testis ž Between 2 and 5 percent of full-term and 30 percent of premature male y infants are born with an undescended testicle nl ž Most undescended testicles descend O spontaneously before six months of age àthe optimal time for surgical correction ž se no later than 9–15 mo (∵↓ fertility) U al rn may be… te ž genetic female with congenital adrenal hyperplasia(esp.with hypospadias)* In ž disorder of the androgen receptor ž true hermaphrodite ž Anorchia ž bilaterally undescended testis *immediately life-threatening and must be excluded.
  • MD Chula 2010 The initial laboratory evaluation includes ž Karyotype ž ultrasound of the pelvic structures y nl ž 17-hydroxyprogesterone ž measurement of electrolytes and O glucose se U al The following investigations are needed rn except? ž Karyotype te ž Pelvic ultrasound In ž Serum creatinine ž Serum electrolyte ž 17 hydroxyprogesterone
  • MD Chula 2010 At what child age is the appropriate time for surgery? ž 1 - 4 weeks ž 2 – 6 months ž 9– 15 months ž 2 – 3 years y nl ž 3 – 5 years O se U al rn te In
  • MD Chula 2010 ž Depressed infants (those with hypotonia, bradycardia, fetal acidosis, or apnea) should undergo endotracheal intubation, y and suction should be applied nl directly to the endotracheal tube O to remove meconium from the airway. se U al rn ž Routine intrapartum nasopharyngeal te suctioning in pregnancies with meconium-stained amniotic fluid does In not reduce the risk for MAS ž Routine intubation to aspirate the lungs of vigorous infants born through meconium-stained fluid is not recommended
  • MD Chula 2010 y nl O Meconium aspirator se U al ž After resuscitation the baby was sent to rn Nursery . He developed tachypnea RR 70 /min., subcostal retraction, increase te chest AP diameter and diminished breath sound on the right . Oxygen box In was given which achieved O2 saturation of 88%.
  • MD Chula 2010 ž Pneumonia ž Pneumothorax ž Lung atelectasis Congenital Lung cyst y ž Transient tachypnea of the newborn nl ž O se U al rn ž “ball-valve” type of bronchial or te bronchiolar obstruction resulting from meconium aspiration In ž Air leaks occur during the 1st 24– 36 hr
  • MD Chula 2010 y nl O se U al rn What is the most appropriate fluid te management in the first 24 hours? ž 5%D/W rate 8 ml/hr In ž 10%D/W rate 8ml/hr ž 10%D N/5 rate 8ml/hr ž 10%D N/5 +KCl 20 mEq/L rate 8 ml/hr ž Infant formula 20 ml× 8 feeds by OG tube
  • MD Chula 2010 ž Respiratory distress ž Hypoxia àNPO ž Circulatory IV fluid insufficiency y Excessive 10%D/W nl ž secretion O ž Sepsis ž CNS depression se U al rn In the first day of life te ž Neonate s have low GFR à low urine output, Na+, K+ excretion In ž Do not give Na+ and K+ just water ž Why 10% not 5%
  • MD Chula 2010 ml/kg/day Fullterm Preterm Day 1 60- 60-70 70- 70-80 y nl Day 2-3 100- 100 -120 150 O se U al rn ž Fluid requirement 60-70 ml/kg/day (not te 100) ž Glucose requirement 4-8 mg/kg/min. In ž If give 5%D/W at this volume ,glucose rate just 2 mg/kg/min. ž The answer is B(10%D/W rate 8 ml/hr)
  • MD Chula 2010 y nl O se U al rn In most cases, benign peoblem in neonate te However: ž Untreated severe indirect In hyperbillirubinemiaàneurotoxic ž Conjugated hyperbillirubinemiaànot neurotoxic but indicate serious hepatic or systemic illness
  • MD Chula 2010 ž 60% of full-term newborn becomes visibly jaundice on the 2nd–3rd day ž Rising <5 mg/dL/24 hr ž peaking between the 2nd and 4th days y ž bilirubin levels rarely rise above 12 mg/dL nl ž decreasing to below 2 mg/dL between O the 5th and 7th days of life se U al rn result from.. te ž increased bilirubin production from the breakdown of fetal red blood cells (high In Hct, short RBC survival) ž transient limitation in the conjugation of bilirubin by the immature neonatal liver. ž Enterohepatic circulation
  • MD Chula 2010 y nl O se U al rn 5 mg/dl te face à In abdomen à 15 mg/dl sole à 20 mg/dl
  • MD Chula 2010 ž Male ž East Asian race ž Late preterm ž polycythemia ž Cephalhematoma /bruising y ž Blood group incompatibility nl ž Exclusive breast feeding Sibling with neonatal jaundice O ž ž Delayed bowel movement ž Mother with DM, oxytocin Rx se U al rn te In Distribution of maximal bilirubin levels during the 1st wk of life in breast-fed and formula-fed white infants over 2,500 g. (From Maisels J, Gifford K: Normal serum bilirubin levels in the newborn and the effect of breast-feeding. Pediatrics 1986;78:837.)
  • MD Chula 2010 žBreast-feeding jaundice žBreast milk jaundice y nl O se U al rn • in the 1st week of life te • due to decreased milk intake with dehydration and/or reduced caloric intake. In • Rx:Frequent breast-feeding (>10/24 hr), rooming-in with night feeding, discouraging 5% dextrose or water supplementation
  • MD Chula 2010 ž after the 7th day of life ž Peak during the 2nd–3rd week ž gradually decreases but may persist for 3–10 wk y ž may be due to the presence of nl glucuronidase in some breast milk. O se U al rn (1) it appears in the 1st 24–36 hr of life te (2) serum bilirubin is rising at a rate faster than 5 mg/dL/24 hr In (3) serum bilirubin is >12 mg/dL in full-term infants (especially in the absence of risk factors) or 10–14 mg/dL in preterm infants (4) jaundice persists after 10–14 days of life (5) Direct bilirubin is >2 mg/dL at any time.
  • MD Chula 2010 ž A 24-hour-old female infant, term, NL, Apgar score 8,9, Birth weight 2,900 gm. His mother G1P1 had good prenatal care, VDRL-NR, HBsAg+, blood group O-positive , is giving breast feeding. ž PE: Alert, active infant. Jaundice from face to abdomen. Heart& Lungs are within normal limit. Liver 1 cm. below RCM. Hct y 43%, MB 12.5 mg/dl, blood group A-positive. Blood smear show nucleated RBC, nl microspherocyte. O se U al rn ž First born te ž Female gender ž Breast feeding In ž Term gestation ž Mother’s HBV carrier
  • MD Chula 2010 ž G6PD deficiency ž Neonatal hepatitis ž ABO incompatibility Physiologic jaundice y ž Breast feeding jaundice nl ž O se U al rn ž G6PD level te ž Liver function test ž Direct Coombs’ test In ž Indirect Coombs’ test ž No need for investigation
  • MD Chula 2010 Mother blood group O, infant group A or B and ž Positive direct Coombs’ test ž Jaundice appear within 12-24 hours y ž Microspherocyte on blood smear nl O se U al rn ž Phototherapy te ž Exchange transfusion ž Change to formula feeding In ž Blood for liver function test ž Increase frequency of breast feeding
  • MD Chula 2010 ž BCG ž Hepatitis B vaccine(HBV) ž BCG and HBV BCG and Hepatitis B immunoglobulin(HB y ž IG) nl ž BCG, HBV and HBIG O se U al rn ž Hepatitis B within 12 hr. te ž HBIG within 12 hr. ž BCG In
  • MD Chula 2010 y nl O se U al rn 2 wk-term infant with breast feeding te PE: well active, jaundice face to sole TSH screening at 48 hr. of age was 15 mIU/L In TSB 27 mg%, dB 1 mg%, Hct 50% ž What is the most likely diagnosis?
  • MD Chula 2010 ž Hemolysis ž hereditary glucuronyl transferase deficiency y ž breast-milk jaundice nl ž Hypothyroidism O ž intestinal obstruction se U al rn ž Jaundice persisting for more than te 2 wk or associated with acholic stools and dark urine suggests In biliary atresia ž Increase direct bilirubin >20% of total bilirubin
  • MD Chula 2010 ž Because most of these infants are asymptomatic at birth ž all newborns are screen for this serious and treatable disease. y ž In Thailand use TSH for screening nl ž A heel-stick blood sample is taken at O discharge or 3 days of life. se U al rn te In
  • MD Chula 2010 ž Biliary atresia ž Hypothyroidism ž hyperthyroidism Breast milk jaundice y ž Breast feeding jaundice nl ž O se U al rn ž Surgery te ž Antithyroid drug ž Thyroid hormone In ž Exchange transfusion ž Intensive phototherapy
  • MD Chula 2010 exchange transfusion if TSB rise to this level despite intensive phototherapy >6 hours Age(day) TSB (mg/dl) y nl 1 20 2 22 O 3 24 ≥4 se 25 U al rn te In
  • MD Chula 2010 ž 45 xo ž 46 xx ž 47 xxy 47 xx, +18 y ž 47 xx, +21 nl ž O se U al rn te In
  • MD Chula 2010 y nl O se U al rn ž Gasless abdomen te ž Double bubble sign ž Pneumatosis intestinalis In ž Generalized intestinal dilatation ž Dilatation of the stomach with little gas in the small bowel
  • MD Chula 2010 ž Down syndrome occurs in 20–30% of patients with duodenal atresia ž The hallmark of duodenal obstruction is bilious vomiting without abdominal y distention, which is usually noted on the nl 1st day of life The diagnosis is suggested by the O ž presence of a “double-bubble sign” on plain abdominal radiographs se U al rn te In
  • MD Chula 2010 y nl O se U al rn ž Clinical sign Percentage of infants Hyperthermia 51 te Hypothermia 15 Lethargy 25 Irritability 16 In Respiratory distress 33 Apnea 22 Cyanosis 24 Jaundice 35 Hepatomegaly 33 Anorexia 28 Vomiting 25 Abdominal distention 17
  • MD Chula 2010 y nl O se U Neonatal Early onset Late onset sepsis al Onset <3 days 3-28 days rn Mode of Vertical Community infection acquired or •preterm premature nosocomial te Predisposing rupture of •Prematurity factor membranes(15%) •Teenage mother In (incidence • chorioamnionitis(20%) •Hospitalized infant sepsis) •Preterm birth <31 weeks Fulminant Subtle, nonspecific §Group B streptococcus §Community Clinical §E. Coli acquired; as early presentation §H. Influenzae onset plus Bacteriology §Enterococcus species S.pneumoniae, §Listeria monocytogenes N.meningitidis §Hospital acquired; CONS, candida, S.aureus,acinetobac ter,…
  • MD Chula 2010 ž CBC ž Blood culture ž Urine culture (late onset) Lumbar puncture (25% of late onset y ž community acquired sepsis develop nl meningitis without meningeal sign) O se U al rn ž Antibiotic cover gram positive and gram te negative bacteria ž Duration In organism Without With meningitis meningitis Gram 7-10 days 14-21 days positive 10-14 days Gram negative
  • In te rn al U MD Chula 2010 se O nl y