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Perinatal history, normal newborn

Perinatal history, normal newborn






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    Perinatal history, normal newborn Perinatal history, normal newborn Presentation Transcript

    • Perinatal History Dr Varsha Atul Shah
    • 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
    • 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
    • The Perinatal History General Data: Maternal Obstetrical History Maternal medical History Family History Social History History of labor and delivery
    • 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
    • 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
    • Perinatal History: Maternal Medical HistoryInfection Congenital pneumonia Intra-uterine infectionMedication Congenital malformationThyroid problem Hypo/hyperthyroidismDiabetes Hypoglycemia/Polycythemi aHypertension Premature labor, IUGR
    • Perinatal History: Amount of amniotic fluid Polyhydramnios  premature labor, neuromuscular diseases, gut obstruction, hydrops, CHF oligohydramnios  Renal agenesis, pulmonary hypoplasia
    • Perinatal History:multiple gestation
    • Perinatal History:Family history presence of familial or hereditary diseases
    • Perinatal History:Social History civil status, occupation social habits: smoking/drinking Promiscuity
    • 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,
    • 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
    • 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
    • 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
    • TheNewborn
    • The Physical Examination of the Newborn
    • 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
    • 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
    • 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)
    • 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
    • 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
    • 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
    • Vital signs Heart Rate and pulse rate Respiratory rate Temperature Blood Pressure
    • Heart Rate and Pulse rate Normal:  Rate - 110-165 beats per minute regular rhythm,
    • Respiratory Rate Normal:  Respiratory Rate 40-60 Breath per minute, regular
    • Temperature
    • 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.
    • Anthropometric measurements Head circumference Length Weight Cuff should cover 2/3 of the upper arm BP determination
    • 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
    • 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)
    • SKIN Jaundice  Within 24 hours  hemolytic  2-4rth day  physiologic, level within normal  1 week  breast-milk jaundice
    • NEWBORN PE:SKIN•Epidermis: –(-) excoriations/ sloughing•Hair –Lanugo•Texture –moist and smooth•Vernix caseosa
    • NEWBORN PE:SKIN Cysts: Milia,  pinpoint white papules of keratogenous material usually on nose and forehead Vascular pattern:  harlequin; mottling
    • NEWBORN PE:SKIN Papules: Acne miliaria Desquamation Hemangiomas Hemorrhages Macules (mongolian spots) and pustules (erythema toxicum)
    • NEWBORN PE: HEAD Normal:  Caput succedaneum, molding Check for :  overriding of sutures,  Number and size of fontanelles  abnormal shape of head  encephalocoeles
    • Cephalhematomas vs Cephaledema Cephalhematoma Cephaledema Limited by suture lines Crosses midline May increase in size subsides
    • NEWBORN PE: FaciesNeeds work up: Down’s Syndrome Cornelia Delange
    • Newborn PE: EYES Check for:  colobomas, heterochromia  cloudiness of cornea  conjunctival erythema  exudate, edema, jaundice  hemorrhages
    • 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
    • Nose Check for:  Flaring  hyper/hypotelorism  choanal atresia
    • NEWBORN PE: MOUTHCheck for: High arch palate Cleft/lip palate Macroglossia Micrognathia
    • 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
    • NEWBORN PE: NECK Normal: Check for : Dimple or webbing
    • NEWBORN PE: CHEST Check for: paradoxical, periodic, (+) retractions  Symmetry  Apnea, retractions  (+) grunting, (+) Flaring of alae nasi  bowel sounds  decreased air entry  Paradoxical, preriodic
    • Check for air entryAnterior, mid-axillary, posterior
    • 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
    • Palpating the pulsesPalpate brachial and femoral together: simultaneous arrival orslightly earlier arrival of femoral pulseIn coarctation: brachial stronger than femoral
    • NEWBORN PE:ABDOMEN Normal:  Shape cylindrical,  (+) diastasis recti ,  amniotic or cutaneous navel
    • NEWBORN PE:ABDOMEN Check for:  Distention, scaphoid abdomen, umbilicus granuloma,  hernia, inflammation, less than 3 cord vessels
    • NEWBORN PE:ABDOMEN Check for:  Gastroschisis, omphalitis,  omphalocele
    • NEWBORN PE: LIVER Normal:  Smooth edge  normally palpable 1-2 cm below the costal margin
    • NEWBORN PE: SPLEEN Normal: Nonpalpable
    • NEWBORN PE: KIDNEYS Normal: (Bimanual palpation) - Palpable Check for enlarged kidneys
    • NEWBORN PE: MALE GENITALS Normal:  Edema, hydrocele, phimosis Check for:  Bifid scrotum,  cryptorchidism,  inguinal hernia,  chordee,  hypospadia,  microphalus
    • NEWBORN PE: FEMALE GENITALS Normal:  Mucoid or bloody secretion, edema, gaping labia, hymenal tag Check for  ambiguous,  hydrometrocolpos
    • NEWBORN PE: ANUS Normal:  Perforate Check for  imperforate,  coccygeal dimple,  fistula
    • NEWBORN PE: MUSCULOSKELETAL Normal: fetal posture (flexor position of comfort)
    • NEWBORN PE: MUSCULOSKELETAL Check for:  Cortical thumb,  overlapping fingers,  short incurved little finger,  hip subluxation, decreased range of motion  Polydactyly/syndactyly
    • 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:
    • 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”
    • 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”
    • 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
    • NEWBORN PE: CNS State:  Awake - alert, crying, active  Asleep - indeterminate, quiet 
    • NEWBORN PE: CNS Motor: Posture - Flexor, symmetric  Tone - obtuse popliteal angle  Movement - all extremities, nonrepetitive, random, symmetric
    • NEWBORN PE: CNS Reflexes: Deep tendon, grasp, moro, placing, stepping, sucking, tonic neck, trunk incurvation Sensory: 2-3 seconds pin prick response Cranial nerves
    • 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
    • Lesions that resolve spontaneously Harlequin change Breast enlargement and Witches’ milk Hydrocoele Vaginal discharge Mongolian spots Umbilical hernia
    • The Care of the Newborn PFD. Isleta, M.D. for Level V - UPCM
    • 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
    • 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
    • Cardio-pulmonary adaptation
    • Initial management• ABC,s: Airway, Breathing, Circulation• Temperature control• Cord dressing• Bonding
    • 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
    • Nursery Care Bathing and dressing Umbilical cord care Feeding Voiding and stooling Behavior Color
    • Bathing and dressing
    • Thermoregulation
    • Latching on mother’s milk
    • 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
    • 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
    • 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
    • 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
    • Well Baby AOG 38-42 weeks, AGA delivered vaginally, Apgar score >/= 7
    • Normal Values Anthropometric:  Weight: 2.5-4.00  Length: 45-55  HC: 32.6-37.2  BP: AOG related
    • Normal Values Cardiac system:  Heart rate: 120-160 BPM  Rhythm: regular, sinus  EKG: sinus rhythm, RV dominant
    • 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
    • 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
    • Normal Values Renal:  urine output = 1-2 ml/kg/hour  Sp. Gravity = 1.005-1.015  Passage of urine= 1st 24 hours
    • Normal Values Gastrointestinal:  meconium passage  enzyme
    • Normal Values Metabolic:  electrolytes  calcium  blood 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-up CBC, retic, coomb’s Mother’s and Baby’s Blood Type ABG ECG, 2-D Echo Chest X-Ray Hepa profile
    • ECG
    • Chest XrayCardiac shadowPerfusionAerationAir in bowelBones
    • 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+”
    •  What are the High Risk Factors? What problems are you anticipating
    •  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
    • 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?
    • Discharge planning Normal Vital signs Thermoregulated Feeding well Adequate weight gain Family relationship
    • 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
    • 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.
    • 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
    • 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)
    • 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
    • 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
    • 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
    • Hypothermia: cold injuryTemperature < 35oC or 95oF)
    • HYPOTHERMIAVASOCONSTRICTIONFLEXIONHeat production physical Glycolysis WORK metabolic Lipolysis Oxygen debt Acidosis EXHAUSTION
    • 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.
    • Hypothermia: Pathophysiology hypoglycemia, metabolic acidosis,  and death.
    • 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.
    • 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.
    • 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).
    • Ways by which body heat is lost
    • Hypothermia: Pathophysiology . Prolonged unrecognized cold stress may divert calories to produce heat, impairing growth.
    • 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.
    • 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
    • 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
    • NEONATAL COLD INJURY DIAGNOSTIC WORK-UP  Serum sugar, ABG(metabolic acidosis) TREATMENT: warming, correct electrolyte disturbances
    • 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.
    • 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).
    • 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.
    • External heat sources:Servo Control Radiant WarmerIncubatorPortable MattressHeat Lamps * Maintain with cautious use of heatsource*
    • 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
    •  Even under a radiant warmer heat loss by evaporation may still occur when baby is open to 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 infantdeteriorates during or after rewarming.
    • REMEMBER: * Preventing heat loss is much easierthan overcoming the detrimentaleffects of cold stress once they haveoccurred.*
    • HYPERTHERMIA Transitory Fever or dehydration fever  Birth History: uneventful perinatal events and immediate postnatal course, breast fed
    • 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
    • HYPERTHERMIAPE: Restless, with precipitous drop in weight Fontanelle depressed, skin less elastic, Tachycardic,tachypneic
    • HYPERTHERMIA Diagnostic work-up  Increased serum protein, Na and Hct Treatment  Oral or parenteral fluid  Lower environmental temperature
    • 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
    • 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
    • Changes in Energy requirements Abrupt termination of supply of energy at birth: provision of exogenous nutrients mobilization of endogenous fuel and mineral stores
    • Changes in Energy requirements Impaired energy supply and utilization: hypoglycemia hyperglycemia
    • 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
    • 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
    • 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
    • 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.
    • 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.
    • 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.
    • 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.
    • 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
    • Fluids and Electrolytes Changes in fluid requirements Insensible fluid loss respiratory tract, skin, gastro-intestinal tract Urine loss
    • Fluids and Electrolytes Abnormal Fluid accumulation: edema third spacing
    • 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
    • EDEMA Associated with syndromes  Congenital lymphedema (Milroy’s)  Turner’s syndrome  Congenital nephrosis  Hurler’syndrome
    • Electrolytes: Calcium metabolism Placental active transport Parathyroid hormones and calcitonin do not cross placenta 25-hydroxyvitamin-D passes the placenta
    • 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 `
    • HYPOCALCEMIA(TETANY) Diagnostic work-up Treatment: 2 ml/k of 10% calcium gluconate
    • 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
    • Osteopenia of prematurityTreatment: Immobilization of fractures Administration of calcium, P and Vit D
    • HYPOMAGNESEMIA Definition: Serum Mg levels <1.5 mg/dL or 0.62 mmol/L Normal values
    • HYPOMAGNESEMIA Contributing factors/causes: Associated with hypocalcemia Deficient placental transfer Decreased intestinal absorption Neonatal hypoparathyroidism Hyperphosphatemia Renal loss Impaired homeostasis
    • 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
    • HYPERMAGNESEMIA Definition: serum level > 2.8 mg/dL (1.15) mmol/L) Causes: > Maternal treatment with MgSO4 for preeclampsia, > delayed passage of meconium
    • HYPERMAGNESEMIA PE: > CNS depression:lethargy, flaccidity, hyporeflexia > respiratory depression: hypoventilation > hypotension
    • 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
    • LATE METABOLIC ACIDOSIS Diagnostic work-up  ABG: BD= -10 to –16 mEq/L , PCO2 <40  Due to abnormally high rate of endogenous acid formation
    • LATE METABOLIC ACIDOSIS Treatment:  NaHCO3  Change formula to lower protein content with whey to casein ratio of 60:40
    • SUBSTANCE OF ABUSE ANJD WITHDRAWAL Heroin Methadone Alcohol Phenobarbital Cocaine Fetal alcohol syndrome
    • 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