lmcc review course “neonatology” lmcc review course “neonatology” brigitte lemyre, md, frcpc
TRANSCRIPT
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LMCC Review CourseLMCC Review Course“Neonatology”“Neonatology”
Brigitte Lemyre, MD, FRCPCBrigitte Lemyre, MD, FRCPC
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OutlineOutline
Resuscitation principles, transition Resuscitation principles, transition to lifeto life
Normal newborn care and Normal newborn care and assessmentassessment
IUGR and LGA and their problemsIUGR and LGA and their problems Prematurity and its complicationsPrematurity and its complications Problems of the term infantProblems of the term infant
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Infant mortality:
9-10: 1000 birthsDue to congenital anomalies, prematurity, asphyxia, infections, SIDS
Normal baby at term:
HR: 120-160/minRR: 40-60/minWeight: 2.5-4.5 kgBP: 50-80/30-40 mmHg
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Gestational age and sizeGestational age and size
GestationGestation SizeSize
28 weeks28 weeks 1.0 kg1.0 kg
30 weeks30 weeks 1.5 kg1.5 kg
33 weeks33 weeks 2.0 kg2.0 kg
35 weeks35 weeks 2.3 kg2.3 kg
37-40 weeks37-40 weeks 2.5 – 4.5 kg2.5 – 4.5 kg
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Newborn ResuscitationNewborn Resuscitation
Initial stepsInitial steps Evaluate respirationEvaluate respiration Evaluate heart rateEvaluate heart rate Evaluate colorEvaluate color
Remember - the usual problem Remember - the usual problem in the neonate is the lungs: in the neonate is the lungs: VENTILATION!VENTILATION!
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Fluid filled alveoli in utero
Diminished blood flow through fetal lungs
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Importance of first breath
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Newborn ResuscitationNewborn Resuscitation
A: AirwayA: Airway B: BreathingB: Breathing C: CirculationC: Circulation D: DrugsD: Drugs E: EnvironmentE: Environment F: FluidsF: Fluids G: GlucoseG: Glucose
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Special Circumstances in Special Circumstances in Newborn ResuscitationNewborn Resuscitation
Meconium in amniotic fluid AND Meconium in amniotic fluid AND depressed newborn (not crying, depressed newborn (not crying, limp): limp): Intubate and suction Intubate and suction below cordsbelow cords
Suspect diaphragmatic hernia: Suspect diaphragmatic hernia: IntubateIntubate
Pink when crying, blue when not: Pink when crying, blue when not: Suspect Suspect choanal atresiachoanal atresia and try and try an oral airwayan oral airway
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The Apgar ScoreThe Apgar ScoreFeature 0 points 1 point 2 points Heart rate
0
< 100
> 100
Respiratory Effort
Apnea Irregular, gasping
Regular, crying
Color Pale, blue Pale or blue extremities
Pink
Muscle tone Absent Weak, passive tone
Active movement
Reflex irritability
Absent Grimace Active avoidance
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Ensure warmth and adequate Ensure warmth and adequate nutrient intakenutrient intake
Monitor weight, hydration statusMonitor weight, hydration status Support breastfeedingSupport breastfeeding Educate about infant careEducate about infant care Anticipatory guidanceAnticipatory guidance
Principles of Routine CarePrinciples of Routine Care
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Principles of Routine CarePrinciples of Routine Care Prophylaxis for common problemsProphylaxis for common problems
– Eye care: erythromycin ointmentEye care: erythromycin ointment– Vitamin K: 1 mg IMVitamin K: 1 mg IM
Screening for disease: >24hScreening for disease: >24h– PKU (1/15,000)PKU (1/15,000)– Hypothyroidism (1/4000)Hypothyroidism (1/4000)– Neurosensory hearing lossNeurosensory hearing loss– 24 other metabolic diseases (organic acid 24 other metabolic diseases (organic acid
disorders, FAOD, aminoacid disorders, sickle cell disorders, FAOD, aminoacid disorders, sickle cell and hemoglobinopathies, CAH, galactosemia, and hemoglobinopathies, CAH, galactosemia, endocrinopathies)endocrinopathies)
Blood group and Coombs if mother rH negBlood group and Coombs if mother rH neg
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The depressed newbornThe depressed newborn
AsphyxiaAsphyxia Respiratory conditionRespiratory condition Hypovolemia/shockHypovolemia/shock DrugsDrugs CNS TraumaCNS Trauma Congenital malformationsCongenital malformations
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Perinatal AsphyxiaPerinatal Asphyxia
Must be documented by cordocentesis, fetal Must be documented by cordocentesis, fetal scalp blood sampling, cord blood samplingscalp blood sampling, cord blood sampling
pH pH << 7.00, base deficit 7.00, base deficit >> 15 mEq/L 15 mEq/L EncephalopathyEncephalopathy Multiorgan involvement (heart, kidneys, Multiorgan involvement (heart, kidneys,
marrow, liver)marrow, liver)
For perinatal asphyxia to have been cause ofFor perinatal asphyxia to have been cause oflater neurodevelopmental problem, mustlater neurodevelopmental problem, mustdocument neonatal encephalopathydocument neonatal encephalopathy
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The Newborn HistoryThe Newborn History
The baby’s history is:The baby’s history is:– the family historythe family history– the mother’s past medical historythe mother’s past medical history– the mother’s pregnancy history the mother’s pregnancy history
(including any information about (including any information about screening tests, amniotic fluid)screening tests, amniotic fluid)
– the labor and delivery history (including the labor and delivery history (including the placenta and umbilical cord)the placenta and umbilical cord)
– the resuscitation historythe resuscitation history
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Physical ExaminationPhysical Examination
Vital signsVital signs Measurements: plot on curvesMeasurements: plot on curves Gestational age assessmentGestational age assessment Overall appearanceOverall appearance System by systemSystem by system
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Most common anomalies Most common anomalies noted on initial examnoted on initial exam
Skin tags 10-15/1000Polydactyly 10-15/1000
Cleft lip or palate 1-4/1000Congenital heart defect 1-4/1000
Congenital hip dysplasia 1-4/1000
Down Syndrome 1-4/1000
Talipes equinovarus 1-4/1000
Spina bifida 1-4/10,000
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Most frequent birth Most frequent birth injuriesinjuries
AsphyxiaAsphyxia Broken clavicleBroken clavicle Facial palsyFacial palsy Brachial plexus injuryBrachial plexus injury Fractures of humerus or skullFractures of humerus or skull Lacerations or scalp injuriesLacerations or scalp injuries Ruptured internal organsRuptured internal organs Testicular traumaTesticular trauma Fat necrosisFat necrosis
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Commonest Congenital Commonest Congenital Abdominal MassesAbdominal Masses
Renal (55%)Renal (55%) Genital (15%)Genital (15%) Gastrointestinal (15%)Gastrointestinal (15%) Liver and Biliary (5%)Liver and Biliary (5%) Retroperitoneal (5%)Retroperitoneal (5%) Adrenal (5%)Adrenal (5%)
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Common physical findings Common physical findings of clinical significanceof clinical significance
Apnea, tachypnea, gruntingApnea, tachypnea, grunting Bradycardia, cyanosisBradycardia, cyanosis HypotoniaHypotonia Absent or decreased femoral pulsesAbsent or decreased femoral pulses Heart murmurHeart murmur OrganomegalyOrganomegaly Absent red reflexAbsent red reflex JaundiceJaundice Plethora or pallor or diffuse petechiaePlethora or pallor or diffuse petechiae
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Disorders of gestation Disorders of gestation length or of growthlength or of growth
Small for gestational age: <2SD Small for gestational age: <2SD belowbelow
Large for gestational age: >2SD Large for gestational age: >2SD aboveabove
Prematurity: <37 weeks gestationPrematurity: <37 weeks gestation Postmaturity: >42 weeks gestationPostmaturity: >42 weeks gestation
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Small for gestational age: Small for gestational age: etiologiesetiologies
Constitutional: ethnicityConstitutional: ethnicity Maternal: illness, Rx/R-OH/drugs,Maternal: illness, Rx/R-OH/drugs,
nutritionnutrition PlacentalPlacental Fetal: genetic disorder, infections Fetal: genetic disorder, infections
(TORCH)(TORCH)
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Small for gestational age: Small for gestational age: complicationscomplications
AsphyxiaAsphyxia Meconium aspirationMeconium aspiration Congenital malformationsCongenital malformations HypoglycemiaHypoglycemia HypothermiaHypothermia HypocalcemiaHypocalcemia Polycythemia-hyperviscosityPolycythemia-hyperviscosity
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Small for gestational age: Small for gestational age: ManagementManagement
Optimal resuscitationOptimal resuscitation Maintenance of body temperatureMaintenance of body temperature Early feeds or administration of Early feeds or administration of
glucoseglucose Meticulous history and physical Meticulous history and physical
examination, including placentaexamination, including placenta Work-up for etiologyWork-up for etiology
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Disorders of gestation Disorders of gestation length or of growthlength or of growth
Small for gestational age: <2SD Small for gestational age: <2SD belowbelow
Large for gestational age: >2SD Large for gestational age: >2SD aboveabove
Prematurity: <37 weeks gestationPrematurity: <37 weeks gestation Postmaturity: >42 weeks gestationPostmaturity: >42 weeks gestation
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Large for gestational age: Large for gestational age: EtiologiesEtiologies
ConstitutionalConstitutional Abnormal maternal glucose Abnormal maternal glucose
tolerancetolerance Syndromes: Beckwith-WiedemannSyndromes: Beckwith-Wiedemann
SotosSotos
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Large for gestational age: Large for gestational age: ComplicationsComplications
AsphyxiaAsphyxia Birth traumaBirth trauma HypoglycemiaHypoglycemia
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Large for gestational age: Large for gestational age: ManagementManagement
Optimal resuscitationOptimal resuscitation Early feeds or administration of Early feeds or administration of
glucoseglucose
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Disorders of gestation Disorders of gestation length or of growthlength or of growth
Small for gestational age: <2SD Small for gestational age: <2SD belowbelow
Large for gestational age: >2SD Large for gestational age: >2SD aboveabove
Prematurity: <37 weeks Prematurity: <37 weeks gestationgestation
Postmaturity: >42 weeks gestationPostmaturity: >42 weeks gestation
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Risk Factors for PrematurityRisk Factors for Prematurity
-previous preterm birth/labour-previous preterm birth/labour-cervical/placental anomalies-cervical/placental anomalies-chorioamnionitis-chorioamnionitis-uterine distention-uterine distention-twins/multiple pregnancy -twins/multiple pregnancy -maternal medical conditions -maternal medical conditions -low pre-pregnancy weight-low pre-pregnancy weight-maternal age-maternal age
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–cigarette smoking–high perceived stress –bacterial vaginoses–cocaine use –urinary tract infection–asymptomatic bacteriuria
Risk Factors for Risk Factors for PrematurityPrematurity
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Prematurity: Prematurity: ComplicationsComplications
Respiratory distress syndromeRespiratory distress syndrome Bronchopulmonary dysplasiaBronchopulmonary dysplasia Apnea of prematurityApnea of prematurity Patent ductus arteriosusPatent ductus arteriosus Intraventricular hemorrhageIntraventricular hemorrhage Periventricular leukomalaciaPeriventricular leukomalacia Necrotizing enterocolitisNecrotizing enterocolitis SepsisSepsis AnemiaAnemia Retinopathy of prematurityRetinopathy of prematurity
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Respiratory Distress Respiratory Distress SyndromeSyndrome
EtiologyEtiology– Anatomic immaturity of the lungAnatomic immaturity of the lung– Increased interstitial and alveolar lung Increased interstitial and alveolar lung
fluidfluid– Surfactant deficiencySurfactant deficiency
ManagementManagement– Prevention: antenatal steroidsPrevention: antenatal steroids– OxygenOxygen– Positive pressurePositive pressure– SurfactantSurfactant
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Courtesy of Professor Louis De Voshttp://www.ulb.ac.be/sciences/biodic/index.html
17Weeks
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Courtesy of Professor Louis De Voshttp://www.ulb.ac.be/sciences/biodic/index.html
22Weeks
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Courtesy of Professor Louis De Voshttp://www.ulb.ac.be/sciences/biodic/index.html
25Weeks
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Bronchopulmonary Bronchopulmonary DysplasiaDysplasia
Respiratory symptoms, oxygen Respiratory symptoms, oxygen requirement for at least 28 days, and X-requirement for at least 28 days, and X-ray abnormalities at 36 wks ray abnormalities at 36 wks postconceptional agepostconceptional age
Pathophysiology: disturbed alveolarization
-Lung inflammation -Mucociliary dysfunction
-Airway narrowing-Hypertrophied airway smooth muscle-Alveolar collapse-Constriction of pulmonary vascular bed
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Management:Management:
–PreventionPrevention
–NutritionNutrition
–Oxygen +/- ventilationOxygen +/- ventilation
–BronchodilatorsBronchodilators
–DiureticsDiuretics
–Steroids: inhaled vs systemicSteroids: inhaled vs systemic
Bronchopulmonary Bronchopulmonary DysplasiaDysplasia
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Apnea of PrematurityApnea of Prematurity
Central, obstructive, or mixedCentral, obstructive, or mixed Majority of <32 weeksMajority of <32 weeks Treat withTreat with
– Adequate positioningAdequate positioning– OxygenOxygen– MethylxanthinesMethylxanthines– CPAPCPAP– Ventilation if necessaryVentilation if necessary
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Patent ductus arteriosusPatent ductus arteriosus
Up to 42% of < 1500 g babiesUp to 42% of < 1500 g babies Management strategies:Management strategies:
-preload/afterload reduction-preload/afterload reduction
-Adequate oxygenation-Adequate oxygenation
-Optimize pH-Optimize pH
-indomethacin -indomethacin
-surgery-surgery
-conservative management-conservative management
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Metabolic Problems of Metabolic Problems of PrematurityPrematurity
HypoglycemiaHypoglycemia Fluid/electrolyte imbalanceFluid/electrolyte imbalance Hypocalcemia/hypomagnesemiaHypocalcemia/hypomagnesemia HyperbilirubinemiaHyperbilirubinemia HypothermiaHypothermia
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Intraventricular Intraventricular hemorrhagehemorrhage
Common in < 1500 gm babiesCommon in < 1500 gm babies Usually evident in 1st week of lifeUsually evident in 1st week of life Reasons:Reasons:
– highly vascularized germinal matrixhighly vascularized germinal matrix– less basement membrane to capillariesless basement membrane to capillaries– abnormal autoregulationabnormal autoregulation
Prognosis good for small amount bleeding Prognosis good for small amount bleeding in ventricles but poorer if large amount in ventricles but poorer if large amount intraparenchymally or if posthemorrhagic intraparenchymally or if posthemorrhagic hydrocephalushydrocephalus
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Periventricular Periventricular leukomalacialeukomalacia
Ischemic lesion to watershed area Ischemic lesion to watershed area around ventricles in premature infantsaround ventricles in premature infants
Link to inflammation?Link to inflammation? Most often shows up 3-4 wks after Most often shows up 3-4 wks after
deliverydelivery Correlated with cerebral palsyCorrelated with cerebral palsy
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Necrotizing EnterocolitisNecrotizing Enterocolitis
1-5% NICU admissions1-5% NICU admissions Multifactorial etiologyMultifactorial etiology
feeds, prematurity, ischemia, infectionfeeds, prematurity, ischemia, infection Diagnosis: clinical and radiologicDiagnosis: clinical and radiologic Treatment:Treatment:
– Decompression (NPO, NG tube)Decompression (NPO, NG tube)– antibioticsantibiotics– surgery if necessarysurgery if necessary
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SepsisSepsis Suboptimal immune function in preemies Suboptimal immune function in preemies
plus poor skin barrier, indwelling cathetersplus poor skin barrier, indwelling catheters GBS and coliforms cause early onset sepsisGBS and coliforms cause early onset sepsis
< 5-7 days of life< 5-7 days of life Nosocomial sepsis common in prems with Nosocomial sepsis common in prems with
most common organism = coagulase most common organism = coagulase negative staphylococcus; fungi can also be negative staphylococcus; fungi can also be problematic problematic
in > 1 week of lifein > 1 week of life
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Anemia of PrematurityAnemia of Prematurity Reasons:Reasons:
– decreased hemoglobin at deliverydecreased hemoglobin at delivery– decreased RBC survivaldecreased RBC survival– blunted erythropoietin responseblunted erythropoietin response– IATROGENICIATROGENIC
Treatment:Treatment:– preventionprevention– iron supplementationiron supplementation– transfusiontransfusion– EPOEPO
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Retinopathy of Retinopathy of PrematurityPrematurity
40-70% NICU survivors < 1000 g40-70% NICU survivors < 1000 g Etiology: vasoconstriction leading to Etiology: vasoconstriction leading to
abnormal vascular proliferationabnormal vascular proliferation Diagnosis: screeningDiagnosis: screening Treatment: close monitoring, laser if Treatment: close monitoring, laser if
necessarynecessary
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Disorders of gestation Disorders of gestation length or of growthlength or of growth
Small for gestational age: <2SD Small for gestational age: <2SD belowbelow
Large for gestational age: >2SD Large for gestational age: >2SD aboveabove
Prematurity: <37 weeks gestationPrematurity: <37 weeks gestation Postmaturity: >42 weeks gestationPostmaturity: >42 weeks gestation
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PostmaturityPostmaturity
Labour tends to be induced to Labour tends to be induced to avoid problems of postmaturity, avoid problems of postmaturity, however if dates not accurate may however if dates not accurate may still occurstill occur
Possible complicationsPossible complications– growth disturbancesgrowth disturbances– asphyxiaasphyxia– meconium aspiration syndromemeconium aspiration syndrome
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Problems of the Term Problems of the Term NewbornNewborn
RespiratoryRespiratory CardiacCardiac SepsisSepsis DigestiveDigestive JaundiceJaundice Anemia, polycythemia, hemorrhageAnemia, polycythemia, hemorrhage RenalRenal EndocrineEndocrine NeurologicNeurologic
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Respiratory Distress in the Respiratory Distress in the NewbornNewborn
Respiratory systemRespiratory system CardiacCardiac InfectiousInfectious NeurologicNeurologic MetabolicMetabolic Upper airwayUpper airway Maternal RxMaternal Rx MusculoskeletalMusculoskeletal
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Respiratory Problems in Respiratory Problems in the Term Newbornthe Term Newborn
Transient tachypnea of the newbornTransient tachypnea of the newborn PneumoniaPneumonia Meconium aspirationMeconium aspiration Pulmonary air leaksPulmonary air leaks Congenital malformationsCongenital malformations Persistent pulmonary hypertensionPersistent pulmonary hypertension Pulmonary hemorrhagePulmonary hemorrhage
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Transient Tachypnea of Transient Tachypnea of the Newbornthe Newborn
Failure to clear lung fluidFailure to clear lung fluid Associated with absent or short Associated with absent or short
labour or initial weak or absent labour or initial weak or absent respirationsrespirations
Improves with timeImproves with time
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PneumoniaPneumonia
Can initially be difficult to Can initially be difficult to distinguish from TTN/RDSdistinguish from TTN/RDS
Group B Strep #1Group B Strep #1 Consolidation may appear after a Consolidation may appear after a
few daysfew days
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Meconium Aspiration Meconium Aspiration SyndromeSyndrome
Meconium-stained amniotic fluid Meconium-stained amniotic fluid Intrauterine insult may lead to gaspingIntrauterine insult may lead to gasping Meconium aspiratedMeconium aspirated
– PneumonitisPneumonitis– Airway occlusionAirway occlusion– Pulmonary air leak syndromePulmonary air leak syndrome
May lead to persistent pulmonary May lead to persistent pulmonary hypertensionhypertension
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Congenital MalformationsCongenital Malformations
Anomalies anywhere along Anomalies anywhere along airways, extrinsic or intrinsicairways, extrinsic or intrinsic
AtresiasAtresias CystsCysts Diaphragmatic herniaDiaphragmatic hernia
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Persistent Pulmonary Persistent Pulmonary HypertensionHypertension
Associated withAssociated with– asphyxiaasphyxia– meconium aspirationmeconium aspiration– sepsissepsis
Right to left shunting, Right to left shunting, persistent fetal persistent fetal circulationcirculation
Treatment:Treatment:– oxygenation, ventilationoxygenation, ventilation– maintain blood pressuremaintain blood pressure– pulmonary vasodilatorspulmonary vasodilators
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Congenital Heart Disease: Congenital Heart Disease: presentationspresentations
Cyanosis– presents earlypresents early– defects with right to left shuntsdefects with right to left shunts– TOF, tricuspic atresia, TGA, TAPVR, truncus TOF, tricuspic atresia, TGA, TAPVR, truncus
arteriosus, pulm. atresiaarteriosus, pulm. atresia Congestive heart failureCongestive heart failure
– fewer compensatory mechanisms so fewer compensatory mechanisms so common and can occur very quicklycommon and can occur very quickly
– tachycardia, tachypnea, hepatomegaly, tachycardia, tachypnea, hepatomegaly, feeding difficulty, cardiomegaly, diaphoresisfeeding difficulty, cardiomegaly, diaphoresis
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MurmursMurmurs
DysrhythmiasDysrhythmias
Presentations of Presentations of Congenital Heart DiseaseCongenital Heart Disease
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Congenital heart disease: Congenital heart disease: Most commonly diagnosedMost commonly diagnosed
Ventricular Septal DefectVentricular Septal Defect Transposition of the Great VesselsTransposition of the Great Vessels Tetralogy of FallotTetralogy of Fallot Coarctation of the AortaCoarctation of the Aorta Patent Ductus ArteriosusPatent Ductus Arteriosus Endocardial Cushion DefectEndocardial Cushion Defect Hypoplastic Left HeartHypoplastic Left Heart
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Sepsis: risk factorsSepsis: risk factors
Preterm rupture of membranesPreterm rupture of membranes Prolonged rupture of membranesProlonged rupture of membranes Maternal group B strep carriageMaternal group B strep carriage ChorioamnionitisChorioamnionitis
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Neonatal SepsisNeonatal Sepsis THINK OF IT!THINK OF IT!
– Signs may be subtle, non-specificSigns may be subtle, non-specific– Incidence bacterial sepsis = 1-5/1000 live birthsIncidence bacterial sepsis = 1-5/1000 live births– Commonest organisms:Commonest organisms:
group B streptococcusgroup B streptococcus gram negatives (gram negatives (E coliE coli, Klebsiella), Klebsiella) enterococcus, H flu, staph speciesenterococcus, H flu, staph species listerialisteria
Work up and treatWork up and treat if suspect sepsis if suspect sepsis– Use broad spectrum antibioticsUse broad spectrum antibiotics
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Ophthalmia neonatorum Ophthalmia neonatorum 1st days - differentiate chemical vs infected1st days - differentiate chemical vs infected 2nd-3rd wk - viral or bacterial2nd-3rd wk - viral or bacterial Gonococcal:Gonococcal:
– within 5 days of birthwithin 5 days of birth– gram negative intracellular diplococcigram negative intracellular diplococci– if suspect, Penicillin asapif suspect, Penicillin asap– highly contagioushighly contagious
Chlamydia:Chlamydia:– 5-14 days5-14 days– conjunctival scrapingconjunctival scraping– topical antibioticstopical antibiotics
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Congenital InfectionsCongenital Infections CMV:
– 5-25/1,000 live births5-25/1,000 live births– asymptomatic vs severe symptomsasymptomatic vs severe symptoms– microcephaly, thrombocytopenia, microcephaly, thrombocytopenia,
hepatosplenomegaly, chorioretinitishepatosplenomegaly, chorioretinitis– sequelae of hearing loss and developmental sequelae of hearing loss and developmental
delaydelay RubellaRubella
– 0.5/1,0000.5/1,000– cataracts, rash, congenital heart disease, cataracts, rash, congenital heart disease,
developmental delaydevelopmental delay
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Congenital InfectionsCongenital Infections ToxoplasmosisToxoplasmosis::
– 0.5-1.0/1,0000.5-1.0/1,000– hydrocephalus, cranial calcifications, hydrocephalus, cranial calcifications,
chorioretinitischorioretinitis SyphilisSyphilis::
– 0.1/1,0000.1/1,000– snuffles, osteochondritis/periostitis, rashsnuffles, osteochondritis/periostitis, rash
HerpesHerpes::– vesicles, keratoconjuntivitis, CNS vesicles, keratoconjuntivitis, CNS
findingsfindings
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Congenital syphilisCongenital syphilis
Treat mother no matter what stage Treat mother no matter what stage of pregnancyof pregnancy
If adequate maternal treatment If adequate maternal treatment and no signs of infection in and no signs of infection in newborn, give one dose IM newborn, give one dose IM penicillinpenicillin
If inadequate maternal treatment, If inadequate maternal treatment, give 10 days of IV penicillingive 10 days of IV penicillin
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Neonatal herpes simplexNeonatal herpes simplex
Only about 1/3 mothers have overt Only about 1/3 mothers have overt signssigns
Infection can be disseminated or Infection can be disseminated or locallocal
Usually present at 5-10 days of ageUsually present at 5-10 days of age If suspect:If suspect:
– Cultures, PCRCultures, PCR– Treat with acylovirTreat with acylovir
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Maternal hepatitis B Maternal hepatitis B carriercarrier
Give baby hepatitis vaccine as Give baby hepatitis vaccine as soon as possible after birth (first soon as possible after birth (first 12 hours)12 hours)
BathBath Universal precautionsUniversal precautions Immune globulin in first 7 daysImmune globulin in first 7 days
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HIVHIV Virus can be transmitted Virus can be transmitted
transplacentally, transplacentally, intrapartumintrapartum, or , or postpartumpostpartum
Screen mothersScreen mothers Treat mothers with antiretrovirals Treat mothers with antiretrovirals Treat babies with AZT for 6 wksTreat babies with AZT for 6 wks Universal precautionsUniversal precautions Look for other infections (HepB, HepC)Look for other infections (HepB, HepC)
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Digestive DisordersDigestive Disorders
VomitingVomiting DiarrheaDiarrhea ConstipationConstipation
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Vomiting in the NewbornVomiting in the Newborn
Not uncommon for some vomiting in Not uncommon for some vomiting in 1st few hours after birth1st few hours after birth
Overfeeding, poor burpingOverfeeding, poor burping DDx: Gastrointestinal obstructionDDx: Gastrointestinal obstruction
Increased intracranial Increased intracranial pressurepressure
Bilious vomiting is a medical Bilious vomiting is a medical emergency!emergency!
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Upper G-I problems Upper G-I problems causing vomitingcausing vomiting
EsophagealEsophageal::– first feed, soon after feedfirst feed, soon after feed– excessive droolingexcessive drooling– if T-E fistula, risk aspirationif T-E fistula, risk aspiration
Small bowel atresiasSmall bowel atresias Malrotation and volvulusMalrotation and volvulus AchalasiaAchalasia Chalasia/GERChalasia/GER Pyloric stenosisPyloric stenosis
}Need to r/o
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Non-GI causes of vomitingNon-GI causes of vomiting
SepsisSepsis Adrenal hyperplasiaAdrenal hyperplasia MeningitisMeningitis UTIUTI Milk allergyMilk allergy
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Lower GI ObstructionLower GI Obstruction
Initially, distention, failure to pass Initially, distention, failure to pass meconium… vomiting is later signmeconium… vomiting is later sign
Extrinsic vs intrinsic obstructionExtrinsic vs intrinsic obstruction DDx: Imperforate anus, DDx: Imperforate anus,
Hirschprung, meconium ileus, Hirschprung, meconium ileus, meconium plugs, ileal atresia, meconium plugs, ileal atresia, colonic atresiacolonic atresia
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ConstipationConstipation
> 90% pass meconium in first 24 h> 90% pass meconium in first 24 h Present at birth, consider causes of Present at birth, consider causes of
GI obstructionGI obstruction Present after birth, consider Present after birth, consider
Hirschprung, hypothyroidism, anal Hirschprung, hypothyroidism, anal stenosisstenosis
NB some breastfed babies normally NB some breastfed babies normally stool only once every 5-7 daysstool only once every 5-7 days
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DiarrheaDiarrhea
InfectionInfection– E coli, salmonella, echovirus, E coli, salmonella, echovirus,
rotavirus, adenovirusrotavirus, adenovirus Watch for fluid and electrolyte Watch for fluid and electrolyte
imbalanceimbalance
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JaundiceJaundice First 24 h, always abnormalFirst 24 h, always abnormal Etiology: Etiology: unconjugatedunconjugated
1. 1. RBC destruction/hemolyticRBC destruction/hemolytic : :– isoimmune, RBC membrane, enzymes, isoimmune, RBC membrane, enzymes,
hemoglobinopathieshemoglobinopathies– HematomaHematoma– Sepsis (mixed hemolytic and hepatocellular damageSepsis (mixed hemolytic and hepatocellular damage– HypoxiaHypoxia2. 2. Congenital/metabolicCongenital/metabolic::– Criggler-NajarCriggler-Najar– Hypothyroidism, galactosemiaHypothyroidism, galactosemia
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Later onset: conjugated1.1. Hepatocellular damageHepatocellular damage: : • ViralViral• bacterialbacterial• Metabolic: CF, tyrosinemiaMetabolic: CF, tyrosinemia2. 2. Post hepaticPost hepatic: : • biliary atresiabiliary atresia• choledochal cystcholedochal cyst
JaundiceJaundice
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Jaundice - Work-UpJaundice - Work-Up
History and physical examinationHistory and physical examination Bilirubin - total and directBilirubin - total and direct Blood type and Coomb’sBlood type and Coomb’s HemoglobinHemoglobin Reticulocyte countReticulocyte count SmearSmear Septic workupSeptic workup
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Risk factors for kernicterusRisk factors for kernicterus
PrematurityPrematurity HemolysisHemolysis AsphyxiaAsphyxia AcidosisAcidosis InfectionInfection Cold stressCold stress HypoglycemiaHypoglycemia
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Treatment of JaundiceTreatment of Jaundice
Nutrition/hydrationNutrition/hydration PhototherapyPhototherapy Exchange transfusionExchange transfusion
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AnemiaAnemia
HemorrhageHemorrhage– feto-maternalfeto-maternal– feto-placentalfeto-placental– feto-fetalfeto-fetal– intracranial or extracranialintracranial or extracranial– rupture of internal organsrupture of internal organs
HemolysisHemolysis Treatment:Treatment:
– Transfuse if necessaryTransfuse if necessary
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Polycythemia-Polycythemia-Hyperviscosity SyndromeHyperviscosity Syndrome
Hematocrit > 65 or 70%Hematocrit > 65 or 70% ““Sludging” of blood in organSludging” of blood in organ May present with:May present with:
– respiratory symptomsrespiratory symptoms– CNS symptomsCNS symptoms– thrombocytopeniathrombocytopenia
Treat by partial exchange transfusionTreat by partial exchange transfusion
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Bleeding in the NewbornBleeding in the Newborn
Hemorrhagic disease of the newbornHemorrhagic disease of the newborn ThrombocytopeniaThrombocytopenia
– immuneimmune– infection relatedinfection related– congenitalcongenital
Disseminated intravascular Disseminated intravascular coagulationcoagulation
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Renal issues in the Renal issues in the NewbornNewborn
Most common site of congenital Most common site of congenital malformations and hence abdominal massesmalformations and hence abdominal masses
Renal vein thrombosis: complication of infant Renal vein thrombosis: complication of infant of diabetic mother or polycythemiaof diabetic mother or polycythemia
Increased risk of UTI’s in uncircumcised Increased risk of UTI’s in uncircumcised males (but still not as high as infant females) males (but still not as high as infant females)
All newborns have poor concentrating ability; All newborns have poor concentrating ability; small prematures at high risk for small prematures at high risk for fluid/electrolyte imbalancefluid/electrolyte imbalance
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Endocrine issues in the Endocrine issues in the NewbornNewborn
Congenital hypothyroidismCongenital hypothyroidism– Screen because too late if waitScreen because too late if wait– Signs = poor feeding, constipation, Signs = poor feeding, constipation,
prolonged jaundice, large fontanelles, prolonged jaundice, large fontanelles, umbilical hernia, dry skinumbilical hernia, dry skin
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Endocrine Issues in the Endocrine Issues in the NewbornNewborn
Congenital adrenal hyperplasiaCongenital adrenal hyperplasia– 21-hydroxylase deficiency most 21-hydroxylase deficiency most
commoncommon– Signs = vomiting, diarrhea, Signs = vomiting, diarrhea,
dehydration, shock, convulsions, dehydration, shock, convulsions, clitoris or phallic enlargementclitoris or phallic enlargement
– Watch for electrolyte imbalanceWatch for electrolyte imbalance– If suspect, send lab tests and treatIf suspect, send lab tests and treat
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Endocrine issues in the Endocrine issues in the NewbornNewborn
Infant of diabetic motherInfant of diabetic mother– Congenital malformations (especially Congenital malformations (especially
important to have good control preconception)important to have good control preconception)– Growth disturbancesGrowth disturbances– Metabolic disturbances: glucose, CaMetabolic disturbances: glucose, Ca+ +
– Respiratory distress syndrome and transient Respiratory distress syndrome and transient tachypnea of the newborn: more pronetachypnea of the newborn: more prone
– Polycythemia: jaundicePolycythemia: jaundice– Cardiovascular problems: hypertrophic Cardiovascular problems: hypertrophic
cardiomyopathycardiomyopathy
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HypoglycemiaHypoglycemia
BS <2.6 prem and bottle fed termBS <2.6 prem and bottle fed term
BS <2.0 breastfedBS <2.0 breastfed
** No clear safe cutoff for all** No clear safe cutoff for all Lack of supplyLack of supply Lack of reserve (low glycogen): IUGRLack of reserve (low glycogen): IUGR Inability to use/produce: metabolicInability to use/produce: metabolic Increased utilization: sepsisIncreased utilization: sepsis Increased insulin productionIncreased insulin production
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HypoglycemiaHypoglycemia
Treat: supply 4-6 mg/kg/min termTreat: supply 4-6 mg/kg/min term
6-8 mg/kg/min prem6-8 mg/kg/min prem Look for cause, especially if severe Look for cause, especially if severe
oror
persists beyond 48-72h of lifepersists beyond 48-72h of life
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Neonatal seizures: Neonatal seizures: etiologyetiology
Asphyxia 46%Infection 17%Intracranial hemorrhage 7%Intraventricular hemorrhage 6%Infarction 6%Hypoglycemia 5%Congenital anomaly of CNS 4%Inborn errors of metabolism 4%Subarachnoid hemorrhage 2%
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The Hypotonic Infant: The Hypotonic Infant: EtiologiesEtiologies
Central nervous system diseaseCentral nervous system disease Spinal cord diseasesSpinal cord diseases Diseases of the peripheral nerveDiseases of the peripheral nerve Diseases of the neuromuscular Diseases of the neuromuscular
junctionjunction Muscle DiseasesMuscle Diseases Systemic diseasesSystemic diseases Metabolic diseasesMetabolic diseases
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Work-up of Hypotonic Work-up of Hypotonic InfantInfant
Exhaustive history Exhaustive history Complete physical examinationComplete physical examination Imaging: CXR, U/S, CT, MRIImaging: CXR, U/S, CT, MRI Nerve conduction velocity, electromyographyNerve conduction velocity, electromyography Serum CPK, AST, CSF proteinSerum CPK, AST, CSF protein Muscle biopsy, nerve biopsyMuscle biopsy, nerve biopsy Molecular genetics (myotonic dystrophy, Molecular genetics (myotonic dystrophy,
Prader-Willi)Prader-Willi) OtherOther