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LMCC Review Course: “Neonatology”

LMCC Review Course: “Neonatology”. Gregory Moore, MD, FRCPC Division of Neonatology March 2012. Outline. Resuscitation principles Transition to ex-utero life Normal newborn care and assessment Small and Large-for-Gestational Age neonates and their problems

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LMCC Review Course: “Neonatology”

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  1. LMCC Review Course:“Neonatology” Gregory Moore, MD, FRCPC Division of Neonatology March 2012

  2. Outline • Resuscitation principles • Transition to ex-utero life • Normal newborn care and assessment • Small and Large-for-Gestational Age neonates and their problems • Prematurity and its complications • Problems of the term infant

  3. For Starters … Infant (< 1 yr old) mortality: 5 deaths per 1000 live births (Canada) Due to congenital anomalies, prematurity, asphyxia, infections, SIDS Normal vitals for a baby at term: HR: 120-160/min * RR: 40-60/min * BP: 50-80/30-40 mmHg Sats: >95% by ~1 hr of age *

  4. For Starters …

  5. Newborn Resuscitation • Initial steps: warm, dry, ‘stimulate’ • Evaluate respirations • Evaluate heart rate • Evaluate tone • Evaluate color • Remember - the key to a baby’s transition to the real world is ‘opening’ the lungs: VENTILATION  Oxygenation

  6. 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 ductus arteriosus … produces mixing of pink and less red blood 1. ‘Red’ blood from placenta In-utero

  7. 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

  8. Fluid-filled alveoli in utero Diminished blood flow in-utero through fetal lungs

  9. Importance of first breath

  10. The End Product

  11. Neonatal Resuscitation Program

  12. 90% of babies

  13. 9% of babies

  14. 0.9% of babies

  15. 0.1% of babies

  16. Newborn Resuscitation • A: Airway • B: Breathing • C: Circulation • D: Drugs • E: Environment • F: Fluids • G: Glucose • “IV, O2, Monitor” … if distressed

  17. NB. Newborn Resuscitation • MECONIUM in the amniotic fluid AND depressed newborn (limp, not crying): • Intubate and suction below cords FIRST • Suspect diaphragmatic hernia: • Intubate ASAP • Pink when crying … blue when not: • Suspect choanal atresia and try an oral airway

  18. The Apgar Score

  19. Principles of Routine Care • Ensure warmth and early nutrient intake • Support breastfeeding • Monitor weight and hydration status • Educate about infant care ** • Anticipatory guidance **

  20. Principles of Routine Care • Prophylaxis for common problems • Eye care: erythromycin ointment • Vitamin K: 1 mg IM • Screening for disease: >24h • Newborn screen (24-72 hr) • PKU (1/15,000) • Hypothyroidism (1/4000) • 24 other diseases (OA/AA/FA disorders, SCA, Hgb’pathies’, CAH, galactosemia, endocrinopathies) • Neurosensory hearing loss (pre-d/c) • Hyperbilirubinemia (pre-d/c) • Blood group and Coombs if mother Rh negative

  21. The Newborn History • Identification • Maternal History: • Age • Past medical/surgical • Medications, Drugs/Smoking/EtOH • Past pregnancy(ies) (GTPAL) • Current pregnancy (including screening test results, antenatal steroid use) • Family History • Social History • Labour and Delivery History • Resuscitation History • Early Postnatal Course

  22. Physical Examination • Vital signs • Measurements  plot! • Gestational age assessment • Overall appearance (well/unwell) • System by system (or head to toe) **

  23. The depressed newborn • Neurological: • Asphyxia, CNS Trauma • Respiratory: • Apnea (secondary) • Cardiovascular: • Hypovolemia/shock/hydrops • Congenital: • Malformations • Drugs

  24. The Basic Tests • Blood gas (arterial or capillary) • Glucose • Electrolytes • Complete Blood Count + differential • Blood culture • Chest X-ray • Consider: • Lactate, CRP, echocardiogram, abdominal x-ray • Full septic workup if > 72 hours old

  25. Perinatal Asphyxia - Must be documented by cordocentesis, fetal scalp blood sampling, cord blood sampling • pH < 7.00, base deficit > 15 mEq/L • Apgar less than 5 at 5 minutes • Encephalopathy • Multiorgan involvement (heart, kidneys, marrow, liver) - Neonatal encephalopathy must be documented for perinatal asphyxia to be considered as a cause of later neurodevelopmental problems

  26. Most common anomalies noted on initial exam

  27. Most frequent birth injuries • Asphyxia • Broken clavicle • Facial palsy • Brachial plexus injury • Fractures of humerus or skull • Lacerations or scalp injuries • Ruptured internal organs • Testicular trauma • Fat necrosis

  28. Differentiating Scalp Injuries

  29. Commonest Congenital Abdominal Masses • Renal (55%) • Genital (15%) • Gastrointestinal (15%) • Liver and Biliary (5%) • Retroperitoneal (5%) • Adrenal (5%)

  30. Common physical findings of clinical significance • Apnea, bradycardia, cyanosis (peripheral) • Tachypnea, grunting • Absent or decreased femoral pulses • Heart murmur, cyanosis (central) • Hypotonia • Organomegaly • Absent red reflex • Jaundice • Plethora or pallor or diffuse petechiae

  31. Disorders of gestation length or of growth • Small for gestational age: <2SD below • Large for gestational age: >2SD above • Prematurity: <37 weeks gestation • Postmaturity: >42 weeks gestation

  32. Birth Weight Matters …

  33. Small for gestational age: Etiologies • Constitutional • Maternal • Illness, Rx/EtOH/drugs/cigs, nutrition • Placental • Fetal • Genetic disorder, infections (TORCH)

  34. Small for gestational age: complications • Asphyxia • Meconium aspiration • Congenital malformations • Hypoglycemia • Hypothermia • Hypocalcemia • Polycythemia-hyperviscosity • Increased neonatal mortality (OR 2.77) • Long term morbidity …

  35. Small for gestational age: Management • Optimal resuscitation • Maintenance of body temperature • Early feeds or administration of glucose • Meticulous history and physical examination, including placenta • Work-up for etiology

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