Perinatal history, normal newborn


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Perinatal history, normal newborn

  1. 1. Perinatal History Dr Varsha Atul Shah
  2. 2. Learning Objectives: Perinatal History By the end of the lecture the student should be able to:  know the different parts of the Perinatal History and the contents of each  understand the effect/s of intrauterine environment on the the growing fetus
  3. 3. Learning Objectives: Perinatal History By the end of the lecture the student should be able to:  Give the different pre and perinatal High Risk Factors which can compromise the well-being of the fetus and/or the newborn infant  anticipate newborn problems based on High Risk Factors
  4. 4. The Perinatal History General Data: Maternal Obstetrical History Maternal medical History Family History Social History History of labor and delivery
  5. 5. Perinatal History:General Data BBX born at the PGH-OBAS after _____ weeks of gestation, to a G-P (FT-PT-Ab-LC) woman by SVD/CBE, OFE, CS, weighing _______ grams and with Apgar score of in____ 1 and ____5 minutes
  6. 6. Perinatal History:Maternal past and present obstetrical historyAge: < 19 or > 35 IUGR ; bleeding, hypertensionGravidity/Parity IUGR, hypertension; bleedingHx of FT/PT/Ab/LC Fetal wastage/distressLMP, PNC Uterine size, nutrition
  7. 7. Perinatal History: Maternal Medical HistoryInfection Congenital pneumonia Intra-uterine infectionMedication Congenital malformationThyroid problem Hypo/hyperthyroidismDiabetes Hypoglycemia/Polycythemi aHypertension Premature labor, IUGR
  8. 8. Perinatal History: Amount of amniotic fluid Polyhydramnios  premature labor, neuromuscular diseases, gut obstruction, hydrops, CHF oligohydramnios  Renal agenesis, pulmonary hypoplasia
  9. 9. Perinatal History:multiple gestation
  10. 10. Perinatal History:Family history presence of familial or hereditary diseases
  11. 11. Perinatal History:Social History civil status, occupation social habits: smoking/drinking Promiscuity
  12. 12. Perinatal History:Social HistorySmoking•A team of California andOhio scientists showedthat maternal exposure tocigarette smoke isassociated with a doubledrisk of a rare but"devastating" conditioncalled persistentpulmonary hypertension ofthe newborn,
  13. 13. Perinatal History:Social HistoryAlcoholism  high alcohol levels ingested during pregnancy damage embryonic and fetal development  alcohol or breakdown product impairs placental transfer of amino acids and zinc needed for protein synthesis
  14. 14. Perinatal History: Labor prolonged and difficult  Infection, hypoxia labor premature rupture of  infection, amnionitis membrane (24 hrs before delivery  IC bleed Precipitous delivery  Intrauterine/birth asphyxia maternal anesthetics  low Apgar Vaginal bleed  hypovolemia, hypoxia, fetal anoxia and brain damage
  15. 15. Perinatal History:DeliveryMode of delivery:Breech, suction Delay in the delivery of the after-coming head, hypoxiaCaesarian Neonatal depression due to maternal anesthetics; TTNCord coil, prolapse HypoxiaAmniotic Fluid: AspirationColor, smell InfectionMeconium staining Aspiration, PPHNApgar Score Asphyxia, HIE
  16. 16. TheNewborn
  17. 17. The Physical Examination of the Newborn
  18. 18. Learning Objectives: Physical Examination of the Newborn By the end of the lecture the student should be able to:  take the vital signs of the newborn  obtain the anthropometric measurements of the newborn  perform complete physical examination  elicit primitive reflexes in the newborn
  19. 19. DELIVERY ROOM ASSESSMENT: APGAR SCORE  Dictates the need to resuscitate BALLARDS  Determines the age of gestation (AOG) based on neurological and physical scoring  <37 weeks - preterms  38-42 weeks - full terms  >42 weeks - post-terms
  20. 20. DELIVERY ROOM ASSESSMENT: AOG is plotted vs. weight on the Lubchengco chart to determine the nutritional status of the newborn  <10th %tile - Small for Gestational Age (SGA)  Symmetric: HC=Weight=Length =<10th %tile  Asymmetric: HC=length > Weight (<10th %tile)  10th-90th %tile - Appropriate for Gestational Age (AGA)  >90th %tile - Large for Gestational Age (LGA)
  21. 21. A quick initial PE should be performed at the DR No major anomalies no birth injuries tongue and body appear pink breathing is normal if mother has hydramnios, a feeding tube should be passed into the stomach to exclude esophageal atresia
  22. 22. Routine detailed PE to be done within 24 hours To detect congenital anomalies not identified at birth to identify common neonatal problems and initiate their management or reassure the parents check for potential problems arising from maternal diseases, familial disorders or those detected during pregnancy
  23. 23. Order of examination Newborn is quiet, in-between feeding listen to the heart and lungs first and examine the eyes directly Exact sequence is not important as long as all aspects are examined at some stage and the whole of the infant is examined
  24. 24. Vital signs Heart Rate and pulse rate Respiratory rate Temperature Blood Pressure
  25. 25. Heart Rate and Pulse rate Normal:  Rate - 110-165 beats per minute regular rhythm,
  26. 26. Respiratory Rate Normal:  Respiratory Rate 40-60 Breath per minute, regular
  27. 27. Temperature
  28. 28. Blood PressureAOG and weightrelatedObtain BP of bothupper and lower Cuffextremities: shouldIn coarctation, cover 2/3both arms higher of thethan leg pressure upper armif coarc is distal to BP determinationthe origin of theleft subclavian a.
  29. 29. Anthropometric measurements Head circumference Length Weight Cuff should cover 2/3 of the upper arm BP determination
  30. 30. GENERAL APPEARANCE State of alertness  lethargic or irritable Posture  Full terms: hips abducted and partially flexed; knees flexed  arms adducted and flexed at elbows  Fists clenched; four fingers overlapping thumb Tone  Support chest with one hand, infant should be able to hold head for 3 seconds
  31. 31. SKIN Color:  Acrocyanosis < 24 hours  Pallor  Low hemoglobin  Cyanosis  Central- hypoxemia (due to either intra- cardiac or intra-pulmonary shunting  Plethora  Polycythemia (Hematocrit > 0.65)
  32. 32. SKIN Jaundice  Within 24 hours  hemolytic  2-4rth day  physiologic, level within normal  1 week  breast-milk jaundice
  33. 33. NEWBORN PE:SKIN•Epidermis: –(-) excoriations/ sloughing•Hair –Lanugo•Texture –moist and smooth•Vernix caseosa
  34. 34. NEWBORN PE:SKIN Cysts: Milia,  pinpoint white papules of keratogenous material usually on nose and forehead Vascular pattern:  harlequin; mottling
  35. 35. NEWBORN PE:SKIN Papules: Acne miliaria Desquamation Hemangiomas Hemorrhages Macules (mongolian spots) and pustules (erythema toxicum)
  36. 36. NEWBORN PE: HEAD Normal:  Caput succedaneum, molding Check for :  overriding of sutures,  Number and size of fontanelles  abnormal shape of head  encephalocoeles
  37. 37. Cephalhematomas vs Cephaledema Cephalhematoma Cephaledema Limited by suture lines Crosses midline May increase in size subsides
  38. 38. NEWBORN PE: FaciesNeeds work up: Down’s Syndrome Cornelia Delange
  39. 39. Newborn PE: EYES Check for:  colobomas, heterochromia  cloudiness of cornea  conjunctival erythema  exudate, edema, jaundice  hemorrhages
  40. 40. Newborn PE: EYES Pupillary size and reactivity to light red orange reflex  hold the opthalmoscope 6-8” from the eyes  the normal newborn transmits a clear red color  opacities may suggest cataract
  41. 41. Nose Check for:  Flaring  hyper/hypotelorism  choanal atresia
  42. 42. NEWBORN PE: MOUTHCheck for: High arch palate Cleft/lip palate Macroglossia Micrognathia
  43. 43. Newborn PE: EARS Check for:  Setting  top of pinna falls above a line drawn from the outer canthus of the eyes at right angle to the face  Asymmetry, irregular shapes
  44. 44. NEWBORN PE: NECK Normal: Check for : Dimple or webbing
  45. 45. NEWBORN PE: CHEST Check for: paradoxical, periodic, (+) retractions  Symmetry  Apnea, retractions  (+) grunting, (+) Flaring of alae nasi  bowel sounds  decreased air entry  Paradoxical, preriodic
  46. 46. Check for air entryAnterior, mid-axillary, posterior
  47. 47. NEWBORN PE: HEART Normal: regular rhythm, systolic murmur < 24 hrs, splitting of S2 varies with breathing Check for:  Decreased pulses,  bradycardia,  S2 widely split, systolic murmur > 24 hrs  femoral or cardiac-radial lag,  diastolic murmur
  48. 48. Palpating the pulsesPalpate brachial and femoral together: simultaneous arrival orslightly earlier arrival of femoral pulseIn coarctation: brachial stronger than femoral
  49. 49. NEWBORN PE:ABDOMEN Normal:  Shape cylindrical,  (+) diastasis recti ,  amniotic or cutaneous navel
  50. 50. NEWBORN PE:ABDOMEN Check for:  Distention, scaphoid abdomen, umbilicus granuloma,  hernia, inflammation, less than 3 cord vessels
  51. 51. NEWBORN PE:ABDOMEN Check for:  Gastroschisis, omphalitis,  omphalocele
  52. 52. NEWBORN PE: LIVER Normal:  Smooth edge  normally palpable 1-2 cm below the costal margin
  53. 53. NEWBORN PE: SPLEEN Normal: Nonpalpable
  54. 54. NEWBORN PE: KIDNEYS Normal: (Bimanual palpation) - Palpable Check for enlarged kidneys
  55. 55. NEWBORN PE: MALE GENITALS Normal:  Edema, hydrocele, phimosis Check for:  Bifid scrotum,  cryptorchidism,  inguinal hernia,  chordee,  hypospadia,  microphalus
  56. 56. NEWBORN PE: FEMALE GENITALS Normal:  Mucoid or bloody secretion, edema, gaping labia, hymenal tag Check for  ambiguous,  hydrometrocolpos
  57. 57. NEWBORN PE: ANUS Normal:  Perforate Check for  imperforate,  coccygeal dimple,  fistula
  58. 58. NEWBORN PE: MUSCULOSKELETAL Normal: fetal posture (flexor position of comfort)
  59. 59. NEWBORN PE: MUSCULOSKELETAL Check for:  Cortical thumb,  overlapping fingers,  short incurved little finger,  hip subluxation, decreased range of motion  Polydactyly/syndactyly
  60. 60. Checking for hip dislocation Infant lies supine on flat, firm surface and be relaxed. Stabilize the hip with one hand, and the middle finger of the other hand placed over the greater trochanter and the thumb over the lesser trochanter:
  61. 61. Checking for hip dislocation 1. the hip is flexed and adducted and femoral head gently pushed downward (Barlowe’s) In hip dislocation the femoral head will be pushed out of the acetabulum and will move with a “clunk”
  62. 62. Checking for hip dislocation 2. Check if it can be returned from a dislocated position back into the acetabulum (Ortolani’s)  the hip is abducted, upward leverage is applied  a dislocated hip will return with a”clunk”
  63. 63. Checking for back, spine and muscle tone  On prone position babies can lift their head to the horizontal and straighten the back  Check : back and spine for midline defects and any curvature of the spine
  64. 64. NEWBORN PE: CNS State:  Awake - alert, crying, active  Asleep - indeterminate, quiet 
  65. 65. NEWBORN PE: CNS Motor: Posture - Flexor, symmetric  Tone - obtuse popliteal angle  Movement - all extremities, nonrepetitive, random, symmetric
  66. 66. NEWBORN PE: CNS Reflexes: Deep tendon, grasp, moro, placing, stepping, sucking, tonic neck, trunk incurvation Sensory: 2-3 seconds pin prick response Cranial nerves
  67. 67. Lesions that resolve spontaneously Peripheral and traumatic cyanosis Molding, caput, cephalhematoma Swollen eyelids Subconjunctival hemorrhages Peeling of the skin Capillary hemangiomas Erythema toxicum, milia Epstein’s pearls cysts
  68. 68. Lesions that resolve spontaneously Harlequin change Breast enlargement and Witches’ milk Hydrocoele Vaginal discharge Mongolian spots Umbilical hernia
  69. 69. The Care of the Newborn PFD. Isleta, M.D. for Level V - UPCM
  70. 70. Learning Objectives: Immediate Care of the newborn  By the end of the lecture the student should be able to:  explain the reasons behind the principles of newborn care at birth  identify well, at risk and sick neonate  Plan for nursery and discharge care
  71. 71. Principles of Care at Birth Establishment of respiration Prevention of hypothermia Establishment of breast-feeding Prevention of infection Prevention of hemorrhagic disease of the newborn Identification of high risk neonates
  72. 72. Cardio-pulmonary adaptation
  73. 73. Initial management• ABC,s: Airway, Breathing, Circulation• Temperature control• Cord dressing• Bonding
  74. 74. Plan of action: Routine Care Admission procedures:  Transition and initial Physical Assessment  Vit K  Eye prophylaxis  General laboratory evaluation  CBC, Blood type and Coomb’s test  Glucose screening  Newborn screening
  75. 75. Nursery Care Bathing and dressing Umbilical cord care Feeding Voiding and stooling Behavior Color
  76. 76. Bathing and dressing
  77. 77. Thermoregulation
  78. 78. Latching on mother’s milk
  79. 79. A quick initial PE should be performed at the DR No major anomalies no birth injuries tongue and body appear pink breathing is normal if mother has hydramnios, a feeding tube should be passed into the stomach to exclude esophageal atresia
  80. 80. Routine detailed PE to be done within 24 hours To detect congenital anomalies not identified at birth to identify common neonatal problems and initiate their management or reassure the parents check for potential problems arising from maternal diseases, familial disorders or those detected during pregnancy
  81. 81. A quick initial PE should be performed at the DR No major anomalies no birth injuries tongue and body appear pink breathing is normal if mother has hydramnios, a feeding tube should be passed into the stomach to exclude esophageal atresia
  82. 82. Routine detailed PE to be done within 24 hours To detect congenital anomalies not identified at birth to identify common neonatal problems and initiate their management or reassure the parents check for potential problems arising from maternal diseases, familial disorders or those detected during pregnancy
  83. 83. Well Baby AOG 38-42 weeks, AGA delivered vaginally, Apgar score >/= 7
  84. 84. Normal Values Anthropometric:  Weight: 2.5-4.00  Length: 45-55  HC: 32.6-37.2  BP: AOG related
  85. 85. Normal Values Cardiac system:  Heart rate: 120-160 BPM  Rhythm: regular, sinus  EKG: sinus rhythm, RV dominant
  86. 86. Normal Values Respiratory system:  Respiratory rate: 40-60 BMP  ABG: pH 7.30-7.40 PaC02 : 35-45 PaO2: 60-100 BE/ BD: -5-0
  87. 87. Normal Values Hematologic:  Hgb: 16.5 gms/dL  Hct: 53.0%  NRBC: 500 mm3  Retic count: 2-7%  Blood volume: FT = 80 ml/kg ; PT = 100 ml/kg
  88. 88. Normal Values Renal:  urine output = 1-2 ml/kg/hour  Sp. Gravity = 1.005-1.015  Passage of urine= 1st 24 hours
  89. 89. Normal Values Gastrointestinal:  meconium passage  enzyme
  90. 90. Normal Values Metabolic:  electrolytes  calcium  blood sugar
  91. 91. 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
  92. 92. Sick Baby• Abnormal VS,• Congenital anomaly requiring surgery• IU infection• Asphyxiated
  93. 93. Diagnostic work-up CBC, retic, coomb’s Mother’s and Baby’s Blood Type ABG ECG, 2-D Echo Chest X-Ray Hepa profile
  94. 94. ECG
  95. 95. Chest XrayCardiac shadowPerfusionAerationAir in bowelBones
  96. 96. Case 1: Baby Boy R., 39 weeks gestation born to a 25-year old G1P0, “0-” pregnant woman, + ROM 12 hours before delivery; + maternal fever; Apgar score 7-9. Baby is “O+”
  97. 97.  What are the High Risk Factors? What problems are you anticipating
  98. 98.  PE: Occipital cephalhematoma and bruises over face Course in the nursery: fed poorly at 36 hours of age and appears somewhat lethargic and icteric. Lab: CBC, Blood culture, TB=15 mg/dl ; + Coombs
  99. 99. Baby S: born by precipitous delivery 19 yo G1P0 after 32 weeks gestation (-) Prenatal care; Apgar score 5-8 In the Nx: RR=80 BPM;cyanotic,grunting 1. Identify the high risk factors 2. What is the most likely diagnosis? 3. What other diagnoses should be considered? 4. What laboratory studies would you order?
  100. 100. Discharge planning Normal Vital signs Thermoregulated Feeding well Adequate weight gain Family relationship
  102. 102. Learning Objectives By the end of the lecture the student must know and understand the physiologic changes that occur during metabolic adaptation at birth with regards to: 1. Thermoregulation 2. Energy requirements 3. Fluid and electrolytes 4. Acid-base balance 5. exposure to harmful intrauterine environment: Drugs of abuse
  103. 103. Thermoregulation.THE NORMAL BODY TEMPERATURE  It is physiologically safe to maintain the core temperature within the normal range for infants which is from 36.6 ºC to 37.5 ºC.
  104. 104. Maintaining normal temperature:Efforts should be made to maintain theaxilary and rectal T at 37oC (98.6oF)Check T q 15 – 30 min until within n rangeand at least q h until infant is transportedto the nursery
  105. 105. Thermoneutral environment DEFINITI0N:  Range of environmental temperature below and above which oxygen demand and metabolism are increased.  Range differ for age of gestation and day of life (based on available table)
  106. 106. Heat loss and heat production  Heat production by:  mobilization of brown fats  Heat loss by:  1.1. Evaporation  1.2. Conduction  1.3. Convection  1.4. Radiation External source of heat: drop lights, phototherapy open warmers, Incubators
  107. 107. Thermal regulation: Heat loss Radiation  Cold windows and walls Conduction  Infant scale, wet linen, xray plates Evaporation  Amniotiuc fluid, bathing Convection  02 free flow, bag/mask, ET,drafts
  108. 108. Thermal regulation: heat production  Heat production by mobilization of brown fats  resulting to production of free fatty acid which adds to metabolic acidosis which may cause pulmonary vasoconstriction leading to persistence of fetal circulation and cyanosis
  109. 109. Hypothermia: cold injuryTemperature < 35oC or 95oF)
  110. 110. HYPOTHERMIAVASOCONSTRICTIONFLEXIONHeat production physical Glycolysis WORK metabolic Lipolysis Oxygen debt Acidosis EXHAUSTION
  111. 111. Hypothermia: Etiology•The newborns 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.
  112. 112. Hypothermia: Pathophysiology hypoglycemia, metabolic acidosis,  and death.
  113. 113. Hypothermia: 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.
  114. 114. Hypothermia: 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.
  115. 115. Hypothermia: 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).
  116. 116. Ways by which body heat is lost
  117. 117. Hypothermia: Pathophysiology . Prolonged unrecognized cold stress may divert calories to produce heat, impairing growth.
  118. 118. Hypothermia: Pathophysiology. Newborns respond to cooling by sympathetic nervedischarge of norepinephrine in the "brown fat." Thisspecialized tissue of the newborn, located in the napeof the neck, between the scapulae, and around thekidneys and adrenals, responds by lipolysis followedby oxidation or reesterification of the fatty acids thatare released. These reactions produce heat locally, anda rich blood supply to the brown fat helps transfer thisheat to the rest of the newborns body. This reactionmay increase the metabolic rate and O2 consumptiontwo- to threefold above baseline.
  119. 119. Three detrimental effects ofcooling: Development of Acidosis 3 Main Causes a. Brown Fat Metabolism b. Vasoconstriction c. Anaerobic metabolism Increased Metabolic rate and risk of hypoglycemia Increased O2 Consumption
  120. 120. NEONATAL COLD INJURY Cause: exposure to cold environment Signs and symptoms:  Apathy, refusal to feed, oliguria, coldness to touch, edema, temp 29.5-35 C PE: bradycardia, apnea, hardening of extremities should be differenciated from sclerema, maybe complicated with pulm hge
  121. 121. NEONATAL COLD INJURY DIAGNOSTIC WORK-UP  Serum sugar, ABG(metabolic acidosis) TREATMENT: warming, correct electrolyte disturbances
  122. 122. ProphylaxisHypothermia can be prevented by:• rapidly drying the newborn in the delivery room (to avoid evaporative heat loss)•swaddling him (including his head) in a warmblanket.•If the newborn is exposed for resuscitation,observation, or to provide skin-to-skin contact withthe mother, he should be warmed under a radiantwarmer.
  123. 123. ProphylaxisFor sick newborns, a neutral thermal environment--the environmental conditions and temperature atwhich the newborns metabolic rate is minimizedwhile maintaining a normal core temperature (37° C[98.6° F])--should be maintained.This can be approximated by setting the incubatortemperature according to the newborns birth weightand postnatal age. Alternatively, heat can beprovided using an incubator or radiant warmer witha servomechanism set to maintain the skintemperature at 36.5° C (97.7° F).
  124. 124. Treatment1. 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.7. 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.
  125. 125. External heat sources:Servo Control Radiant WarmerIncubatorPortable MattressHeat Lamps * Maintain with cautious use of heatsource*
  126. 126. The servo-care incubator Indications for use of incubator  When there is a need to measure and maintain body within normal range  for automated control of environmental temperature
  127. 127.  Even under a radiant warmer heat loss by evaporation may still occur when baby is open to atmosphere
  128. 128. 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 infantdeteriorates during or after rewarming.
  129. 129. REMEMBER: * Preventing heat loss is much easierthan overcoming the detrimentaleffects of cold stress once they haveoccurred.*
  130. 130. HYPERTHERMIA Transitory Fever or dehydration fever  Birth History: uneventful perinatal events and immediate postnatal course, breast fed
  131. 131. HYPERTHERMIADiagnosis: Core temperature 38-39° C, on 2nd-3rd day of life, exposed to high environmental temperatures, low fluid intake, decreased urine output and frequency of urination  PE: Restless, with precipitous drop in weight  Fontanelle depressed, skin less elastic, tachycardic,tachypneic
  132. 132. HYPERTHERMIAPE: Restless, with precipitous drop in weight Fontanelle depressed, skin less elastic, Tachycardic,tachypneic
  133. 133. HYPERTHERMIA Diagnostic work-up  Increased serum protein, Na and Hct Treatment  Oral or parenteral fluid  Lower environmental temperature
  134. 134. HYPERTHERMIA Severe form:  Temp as high as 41-44 C  Skin hot and dry and infant appears apathetic  Stupor, grayish pallor, coma, convulsions (due to hypernatremia)  High morbidity and mortality rates  Death due to hemorrhagic shock and encepalopathy
  135. 135. Changes in Energy requirements Intra-uterine supply of energy: In-utero ------ Placenta---- Fetus maternal metabolic homeostasis placental exchange fetal regulatory mechanismContinuously provides glucose, calcium, magnesium
  136. 136. Changes in Energy requirements Abrupt termination of supply of energy at birth: provision of exogenous nutrients mobilization of endogenous fuel and mineral stores
  137. 137. Changes in Energy requirements Impaired energy supply and utilization: hypoglycemia hyperglycemia
  138. 138. Hypoglycemia: definition Any plasma glucose level < 50 mg/dL (2.8 mmol/liter) with symptoms that resolve with glucose treatment Karp, Scardino and Butler, 1995 Preterm versus term infants Healthy newborns: slightly lower levels accepted in 1st 24 hours – as low as 40 mg/dL (2.2 mmol/liter) Cornblath and Schwartz, 1993
  139. 139. Hypoglycemia: causes Infants at high risk to develop hypoglycemia: > SGA/ LGA infants > Infants of Diabetic mothers (IDM) > Premature infants > Infants with perinatal stress: sepsis, shock, asphyxia, hypothermia
  140. 140. Symptoms of Hypoglycemia Jitteriness  Irregular respirations Hypothermia/  Poor suck or refusal to eat Temperature instability  Vomiting Lethargy  Cyanosis Apathy  High-pitched or weak Hypotonia cry Apnea  Seizures
  141. 141. Treatment of Hypoglycemia: IV Treatment of Blood Sugar < 40 mg/dL (2.2 mmol/L) Step 1. Give an IV bolus of D10W. Dose: 2 ml’s per kg IV over several minutes. Step 2. Recheck the blood sugar within 15-30 minutes after any glucose bolus or increase in IV rate.
  142. 142. Treatment of Hypoglycemia: Step 3. Immediately following the IV bolus, if not done already start a continuous IV infusion of D10W at a rate of 80 ml’s per kg per day. Step 4. Repeat the IV bolus if the blood sugar is again 40 or less.
  143. 143. Treatment of Hypoglycemia: Step 5. If the blood sugar does not improve and stabilize over 50 after 2 boluses of glucose, repeat the glucose bolus and increase the IV to 100 or 120 ml’s per kg per day and/or change the IV glucose concentration to D12.5W.
  144. 144. Treatment of Hypoglycemia: Step 6. Evaluate the blood sugar frequently – every 15-30 minutes until stable > 50 on at least 2 consecutive evaluations. To prevent wide swings in serum glucose, do not use 25% or 50% glucose boluses.
  145. 145. Fluids and Electrolytes Changes in fluid compartments ( % TBW) Age ECF ICF TBF Fetus, 65 % 25 % > 90 % 24 wks NB, FT 40 % 35 % 74 % Expanded Excess NB, PT
  146. 146. Fluids and Electrolytes Changes in fluid requirements Insensible fluid loss respiratory tract, skin, gastro-intestinal tract Urine loss
  147. 147. Fluids and Electrolytes Abnormal Fluid accumulation: edema third spacing
  148. 148. EDEMA Contributing factors/causes:  IDM  Hydrops fetalis  Prematurity- decreased ability to excrete water or sodium, low protein, anemia, Vit E deifiency  RDS  Birth pressures  CHF  Concentrated cow’s milk formula
  149. 149. EDEMA Associated with syndromes  Congenital lymphedema (Milroy’s)  Turner’s syndrome  Congenital nephrosis  Hurler’syndrome
  150. 150. Electrolytes: Calcium metabolism Placental active transport Parathyroid hormones and calcitonin do not cross placenta 25-hydroxyvitamin-D passes the placenta
  151. 151. HYPOCALCEMIA(TETANY) Definition:  Normal calcium level = 8-11 mg/dL Cause: Transient hypoparathyroidism in the newborn. Grouped as: 1st 36 hours of life before achieving oral intake of milk High phosphate load from cow’s milk occurring on the 5th-10th day of life `
  152. 152. HYPOCALCEMIA(TETANY) Diagnostic work-up Treatment: 2 ml/k of 10% calcium gluconate
  153. 153. Osteopenia of prematurity History: prematurity with chronic illness Definition:Rickets-like syndrome with pathologic fractures and demineralization of bones, May be associated with:  cholestasis and Vit D or calcium malabsorption  Urine calcium loss due to diuretics  Poor calcium, P, or vit D intake
  154. 154. Osteopenia of prematurityTreatment: Immobilization of fractures Administration of calcium, P and Vit D
  155. 155. HYPOMAGNESEMIA Definition: Serum Mg levels <1.5 mg/dL or 0.62 mmol/L Normal values
  156. 156. HYPOMAGNESEMIA Contributing factors/causes: Associated with hypocalcemia Deficient placental transfer Decreased intestinal absorption Neonatal hypoparathyroidism Hyperphosphatemia Renal loss Impaired homeostasis
  157. 157. HYPOMAGNESEMIA PE  Symptoms usually do not develop until level falls < 1.2 mg/dL Diagnostic work-  Serum levels Treatment  Mg sulfate 0.25 ml/k of a 50% solution IM
  158. 158. HYPERMAGNESEMIA Definition: serum level > 2.8 mg/dL (1.15) mmol/L) Causes: > Maternal treatment with MgSO4 for preeclampsia, > delayed passage of meconium
  159. 159. HYPERMAGNESEMIA PE: > CNS depression:lethargy, flaccidity, hyporeflexia > respiratory depression: hypoventilation > hypotension
  160. 160. LATE METABOLIC ACIDOSIS Definition: Usually negative for asphyxia, respiratory distress; Onset 2nd-3rd week of life, common among preterm, LBW (5-10%) Causes:  Fed with formula containing a high content of protein shortly after birth, delay in start of postnatal weight gain PE:  Vigorous, essentially normal PE
  161. 161. LATE METABOLIC ACIDOSIS Diagnostic work-up  ABG: BD= -10 to –16 mEq/L , PCO2 <40  Due to abnormally high rate of endogenous acid formation
  162. 162. LATE METABOLIC ACIDOSIS Treatment:  NaHCO3  Change formula to lower protein content with whey to casein ratio of 60:40
  163. 163. SUBSTANCE OF ABUSE ANJD WITHDRAWAL Heroin Methadone Alcohol Phenobarbital Cocaine Fetal alcohol syndrome
  164. 164. Fetal Alcohol Syndrome Cause: impaired transfer of essential amino acids and zinc, both needed for protein synthesis IUGR for head weight and length Facial abnormalities Cardiac defects Minor joint and limb abnormalities Mental retardation