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Distressed Newborn

Distressed Newborn. Jemy Joseph Group D - Peds PAL April 22 2014 Tutor and acknowledgement: Dr. Joanna Seliga- Siwecka , Neonatologist. Disclaimer. Week 1-Day 2 in Pediatrics block Minimal experience with newborns What comes to mind when you think newborn?. Source: Google Search.

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Distressed Newborn

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  1. Distressed Newborn Jemy Joseph Group D - Peds PAL April 22 2014 Tutor and acknowledgement: Dr. Joanna Seliga-Siwecka, Neonatologist

  2. Disclaimer • Week 1-Day 2 in Pediatrics block • Minimal experience with newborns What comes to mind when you think newborn?

  3. Source: Google Search

  4. Distressed Newborn? • What comes to your mind?

  5. Objectives • To review the basic principles of newborn care and neonatal resuscitation and discuss the use and significance of Apgar scores. • To understand the fetal circulation and the changes that occur at birth. • To review lung development in utero, the pathophysiology of respiratory distress syndrome and its management. • To explore the most common causes of distress in the newborn and its management. • To describe the 3 commonly measured growth parameters and understand the concepts of low birth weight, prematurity, psychosocial issues and their implications/significance.

  6. Case • A female infant is born to a community hospital by assisted breech delivery at 34 weeks to a sixteen-year-old single primigravida. There has been no antenatal care. Her birth weight is 1.8kg, Apgar scores 51 95. Half an hour later the baby’s breathing is laboured and there is apparent cyanosis. What is your approach to this problem?

  7. Review the basic principles of newborn care and neonatal resuscitation and discuss the use and significance of Apgar scores. OBJECTIVE #1

  8. Basic principles of newborn care • Warmth: Keep newborn dry and warm to avoid hypothermia; radiant heat or skin-to-skin, heater • Airway + Breathing: Resuscitate and maintain an airway (stimulation, suction) • Circulation: HR, BP, O2 Sats, Temp, (Colour) • Global: congenital anomalies, malformations, birth trauma, umbilical vessels • Hygiene: Maintain hygiene during delivery and cord cutting; treat infections promptly • Love/bonding: Ensure the newborn infant stays close to its mother, and mothers have open access to their newborn infant if he or she requires special care • Food: Encourage early breastfeeding, and feed high-risk newborns more frequently • Medications: Routine – Vitamin K, erythromycin; (+/- Heb B vaccine +/- Hep B Ig if high risk)

  9. Neonatal resuscitation • ~ 10% of newborns need some assistance to begin breathing at birth; <1% require extensive resuscitation • Initial rapid assessment: 3 characteristics: • (i) Term gestation? • (ii) Crying / breathing? • (iii) Good muscle tone? • If the answer to any of the above is no, ≥ 1 of the following actions in sequence: • (next slide)

  10. Neonatal resuscitation • VENTILATION!! • VENTILATION!! • VENTILATION!!

  11. Neonatal resuscitation • Initial stabilization (provide warmth, clear airway if necessary, dry, stimulate) • Ventilation: O2, PPV (CPAP, PEEP), LMA, ETT • PPV = positive pressure ventilation • CPAP= continuous positive airway pressure • PEEP = positive end-expiratory pressure • Chest compressions if HR <60: 3:1 (15:1 if cardiac etiology) • Administration of epinephrine and/or volume expansion • Epi 0.01-0.03 mg/kg • Volume: isotonic crystalloid solution 10 mL/kg

  12. Neonatal resuscitation • Tips: • Titrate SpO2 - insufficient or excessive oxygenation can be harmful • Measure of adequate initial ventilation is prompt improvement in HR • Assisted ventilation @ 40-60 breaths/min to achieve / maintain HR > 100 bpm • Even after newborn resuscitated, close monitoring and anticipatory care required • NEONATE RESUS FLOWCHART

  13. APGAR SCORES • Rapid + standardized assessment of infants after delivery and their response to resuscitation. • 5 components each with a score of 0, 1 or 2. Score reported at 1 and 5 minutes after birth. • Low score may be due to a number of factors including fetal distress & resuscitation, prematurity, maternal medications, cardiorespiratory or neurologicconditions; Low scores could be associated with neonatal mortality, cerebal palsy. • NO predictive value for long-term outcome

  14. Apgar Scores 7-10 Normal 4-6 Low <3 Neonatal resuscitation

  15. Understand the fetal circulation and the changes that occur at birth OBJECTIVE #2

  16. 3. Small amount of ‘pink’ blood going to lungs 2. ‘Less red’ blood from right to left atrium via patent foramen ovale 4. Pink blood goes from the pulmonary artery to aorta via ductusarteriosus … produces mixing of pink and less red blood 1. ‘Red’ blood from placenta In-utero

  17. 3. Pulmonary arteries vasodilate to increase blood flow to the lungs 2. Foramen ovale functionally closes 4. Ductus arteriosus closes 1. Cord is clamped  Increases SVR Ex-utero

  18. Video link • Video • http://www.embryology.ch/anglais/pcardio/umstellung01.html

  19. Fetal circulation • 1 Umbilical vein: O2 blood to fetus • 2 umbilical arteries: DeO2 blood away fetus • Placenta breathes for fetus; Blood is directed away from lungs via PFO and DA • PFO: Blood shunt R to L atrium • DA: Blood shunt pulmonary artery to aorta PVR = pulmonary vascular resistance; SVR = systemic vascular resistance; PFO = patent foramen ovale; DA = ductusarteriosus; L = left; R = right

  20. Circulation at birth • Fetus: Lungs filled w fluid;  PVR; L R shunt • 1st breath  lung expansion + O2pulm resistance (surfactant) pulm blood flow • Cord clamped  SVR • Shunt from pulmonary  systemic closed PVR = pulmonary vascular resistance; SVR = systemic vascular resistance; PFO = patent foramen ovale; DA = ductusarteriosus; L = left; R = right

  21. Review lung development in utero, the pathophysiology of respiratory distress syndrome and its management OBJECTIVE #3

  22. Adult lung anatomy

  23. Adult lung anatomy

  24. Early Embryonic Stage (3-7 wks) • Formation of lung buds (major conducting airways)

  25. No air spaces = no ability to exchange gas • Lung tissue issolid

  26. Pseudo-glandular Stage (5-17 wks) (Acinar tubules becomes acina  alveoli) RAPID airway branching • Bronchial tree + acinar tubules develop 16-25 divisions • Period of rapidbranching of the airway

  27. Blood vesselsgrowparallel to bronchi but are far fromairspaces • Very few terminal buds (= ‘future airspaces’) are present

  28. Terminal bud Acinar tubule 17 Weeks Respiratory bronchiole Terminal bronchiole http://www.ulb.ac.be/sciences/biodic/index.html

  29. Canalicular Stage (16-26w) The major events in this period: • Segmentation of bronchi is complete • Mesenchyme becomes veryvascular • Period of early acinar development • Thinning of epithelial cells lining airways and acini: air-blood barrier • Differentiation: type I, type II Area for gas exchange is limited

  30. (Type II) (Type I) 4 ( acini  alveoli) 2 4 1 3 5 5 1 3 2 • More air spaces are present • Capillaries are approximated (gettingcloser) to air spaces • By end of period, terminal sacs can exchange gas.

  31. - Interface of pulmonary vasculature with terminal buds 22 Weeks http://www.ulb.ac.be/sciences/biodic/index.html

  32. - Note the dramatic increase in the amount of vascularization as we move through the canalicular stage 25 Weeks http://www.ulb.ac.be/sciences/biodic/index.html

  33. Canalicular Stage (16-26 w) • By the end of this period, enough gas exchange may be present to support life. • No true alveoli exist. • Diffusion is hampered. • Deficit in gas exchange. • Survival is possible

  34. Terminal Sac Stage (24-36w) • Major event: development of airspace. • Air spaces are much larger • Thin walled air spaces • Capillaries are approximated to the air spaces • Babies born near the end of the period are well equipped for extra-uterine breathing. • Babies born early in this period usually need some form of assistance to breathe. Survival is probable # of alveoli: 29 wks GA 29 million Term 55-150 m

  35. Alveolar Stage (36w-8 yrs) • Formation of secondary alveolar septa to create true alveolar ducts + alveoli • Adult: 300-400 million alveoli

  36. ….pathophysiology of Respiratory Distress Syndrome (RDS) and its management OBJECTIVE #3

  37. Lung physiology • In neonatal lung: • Physics: Higher the surface tension (ST), the more a sphere will tend to collapse • Surfactant = substance that  ST  takes  pressure to open a sphere (alveoli) What is respiratory distress? Some signs and symptoms?

  38. Explore the most common causes of distress in the newborn and its management OBJECTIVE #4

  39. Respiratory distress in the newborn CLINICAL PRESENTATION: • Tachypnea • Use of accessory muscles, indrawing • Desaturation • Grunting • Apnea

  40. Causes of respiratory distress • Upper airway obstruction • Pulmonary • Cardiac • Thoracic • Metabolic: hypoglycemia, urea cycle defects • Diaphragmatic • Neuromuscular • Infection • Hematologic • Other: asphyxia, acidosis, hypothermia

  41. Respiratory Distress Syndrome (RDS) • Disease of the premature infant • Rarelyterm infant: maternal type 1 DM • Caused by surfactant deficiency • Poor lungcompliance, decrease in FRC (FunctionalResidualCapacity)

  42. RDS clinical features • Tachypnea • Use of accessory muscles, indrawing • Hypoxia • Cyanosis • Grunting • Apnea [Unit name – Lecture title – Prof name]

  43. RDS Management • Resuscitation, O2, ventilation, • Surfactant • prenatal corticosteroids if risk of preterm delivery ( 24-34 wks gestation) [Unit name – Lecture title – Prof name]

  44. Transienttachypnea of the newborn (TTN) • Disease of the latepre-termor near-term infant • Pathophysiology: • Delay in reabsorption of pulmonaryfluid • Risk factor: • Absence of labor (ex C-section) • Rapid labour & delivery • Presents right afterbirth

  45. TTN – Presentation and Rx • Clinical features • Tachypnea • Often no hypoxia or cyanosis • Treatment • Supportive • O2 if hypoxic • Full recovery 2-5 days [Unit name – Lecture title – Prof name]

  46. Infection / Sepsis • Common organisms: Group B Step, S. aureus, S. pneumoniae • GBS is a (most common) colonizer of vaginal tract; transmitted vertically to 1% infants in colonized mothers • Risk factors: • Prolonged ROM (rupture of membrane) • Premature • Maternal fever [Unit name – Lecture title – Prof name]

  47. Bronchopulmonary Dysplasia (BPD) • Respiratorydiseasewhichmanifests as a result of an acute pulmonarydiseasewithin the first 2 weeks of life in preterm infants • Def’n: • need for oxygenat 36 weekscorrected GA • afterhavingneededoxygen for at least 28 days • + CXR compatible • Important anomalies clinically, radiologically and on gases

  48. Other respiratory diseases • Meconium Aspiration Syndrome (MAS) • Bronchopulmonary Dysplasia (BPD) • Persistent Pulmonary Hypertension (PPH) • Pneumothorax • (Handout will have details of these) [Unit name – Lecture title – Prof name]

  49. Management of the newborn in respiratory distress • Airway, Breathing, Circulation • Provide oxygen to ensure adequate Sa02 • IV fluids and glucose, maintain temperature stability, do not feed • CXR, monitor blood gases, serum glucose • Do CBC, blood culture, start antibiotics for possible neonatal sepsis • Ventilatory support if needed to maintain oxygenation, correct respiratory acidosis

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