lmcc review course: “neonatology” gregory moore, md, frcpc division of neonatology april 2010
TRANSCRIPT
LMCC Review Course:LMCC Review Course:“Neonatology”“Neonatology”
Gregory Moore, MD, FRCPCGregory Moore, MD, FRCPC
Division of NeonatologyDivision of Neonatology
April 2010April 2010
OutlineOutline1.1. Resuscitation principlesResuscitation principles
1.1. Transition to ex-utero lifeTransition to ex-utero life
2.2. Normal newborn care and assessmentNormal newborn care and assessment
3.3. Small and Large-for-Gestational Age Small and Large-for-Gestational Age neonates and their problemsneonates and their problems
4.4. Prematurity and its complicationsPrematurity and its complications
5.5. Problems of the term infantProblems of the term infant
For Starters …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 *
For Starters …For Starters …
Gestation (wks)Gestation (wks) Birth Weight (kg)Birth Weight (kg)
2727 1.01.0
3030 1.51.5
3333 2.02.0
3535 2.32.3
37-4037-40 3.5 (2.5 – 4.5)3.5 (2.5 – 4.5)
Newborn ResuscitationNewborn Resuscitation Initial steps: warm, dry, ‘stimulate’Initial steps: warm, dry, ‘stimulate’ Evaluate respirationsEvaluate respirations Evaluate heart rateEvaluate heart rate Evaluate toneEvaluate tone Evaluate colorEvaluate color
RememberRemember - the key to a baby’s - the key to a baby’s transition to the real world is transition to the real world is ‘‘openingopening’ the lungs: ’ the lungs: VENTILATION VENTILATION OxygenationOxygenation
1. ‘Red’ blood from placenta
2. ‘Less red’ blood from right to left atrium via patent
foramen ovale
3. Small amount of‘pink’ blood
going to lungs
In-uteroIn-utero
4. Pink blood goes from the
pulmonary artery to aorta via
ductus arteriosus …
produces mixing of
pink and blue blood
1. Cord is clamped
Increases SVR
2. Foramen ovale functionally closes
3. Pulmonary arteries
vasodilate to increase blood
flow to the lungs
Ex-uteroEx-utero
4. Ductus arteriosus closes
Fluid-filled alveoli in utero
Diminished blood flow in-utero through fetal lungs
Importance of first breath
The End ProductThe End Product
Neonatal Resuscitation Neonatal Resuscitation ProgramProgram
90% of babies
9% of babies
0.9% of babies
0.1% of babies
Newborn ResuscitationNewborn Resuscitation A: AirwayA: Airway B: BreathingB: Breathing C: CirculationC: Circulation D: DrugsD: Drugs E: EnvironmentE: Environment F: FluidsF: Fluids G: GlucoseG: Glucose
““IV, O2, Monitor” … if distressedIV, O2, Monitor” … if distressed
NB. Newborn ResuscitationNB. Newborn Resuscitation
MECONIUMMECONIUM in the amniotic fluid AND in the amniotic fluid AND depressed newborn (not crying, limp):depressed newborn (not crying, limp): Intubate and suction below cords FIRSTIntubate and suction below cords FIRST
Suspect Suspect diaphragmatic herniadiaphragmatic hernia:: Intubate ASAPIntubate ASAP
Pink when crying … blue when not:Pink when crying … blue when not: Suspect Suspect choanal atresiachoanal atresia and try an oral and try an oral
airwayairway
The Apgar ScoreThe Apgar Score
Feature 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
Ensure warmth and early nutrient Ensure warmth and early nutrient intakeintake
Support breastfeedingSupport breastfeeding
Monitor weight and hydration statusMonitor weight and hydration status
Educate about infant care **Educate about infant care **
Anticipatory guidance **Anticipatory guidance **
Principles of Routine CarePrinciples of Routine Care
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 Newborn screen (24-72 hr)Newborn screen (24-72 hr)
• PKU (1/15,000)PKU (1/15,000)• Hypothyroidism (1/4000)Hypothyroidism (1/4000)• 24 other diseases (OA/AA/FA disorders, SCA, 24 other diseases (OA/AA/FA disorders, SCA,
Hgb’pathies’, CAH, galactosemia, endocrinopathies)Hgb’pathies’, CAH, galactosemia, endocrinopathies) Neurosensory hearing loss (pre-d/c)Neurosensory hearing loss (pre-d/c) Hyperbilirubinemia (pre-d/c)Hyperbilirubinemia (pre-d/c)
Blood group and Coombs if mother Rh negativeBlood group and Coombs if mother Rh negative
The Newborn HistoryThe Newborn History IdentificationIdentification Maternal History:Maternal History:
• AgeAge• Past medical/surgicalPast medical/surgical• Medications, Drugs/Smoking/EtOHMedications, Drugs/Smoking/EtOH• Past pregnancy(ies) (GTPAL)Past pregnancy(ies) (GTPAL)• Current pregnancy (including screening test results, Current pregnancy (including screening test results,
antenatal steroid use)antenatal steroid use) Family HistoryFamily History Social HistorySocial History Labour and Delivery HistoryLabour and Delivery History Resuscitation HistoryResuscitation History Early Postnatal CourseEarly Postnatal Course
Physical ExaminationPhysical Examination Vital signsVital signs
Measurements Measurements plot! plot!
Gestational age assessmentGestational age assessment
Overall appearance (well/unwell)Overall appearance (well/unwell)
System by system (or head to toe) **System by system (or head to toe) **
The depressed newbornThe depressed newborn Neurological:Neurological:
Asphyxia, CNS TraumaAsphyxia, CNS Trauma
Respiratory:Respiratory: Apnea (secondary)Apnea (secondary)
Cardiovascular:Cardiovascular: Hypovolemia/shock/hydropsHypovolemia/shock/hydrops
Congenital:Congenital: MalformationsMalformations
DrugsDrugs
The Basic TestsThe 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
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 Apgar less than 5 at 5 minutesApgar less than 5 at 5 minutes EncephalopathyEncephalopathy Multiorgan involvement (heart, kidneys, Multiorgan involvement (heart, kidneys,
marrow, liver)marrow, liver)
- Neonatal encephalopathy must be - Neonatal encephalopathy must be documented for perinatal asphyxia to be documented for perinatal asphyxia to be considered as a cause of later considered as a cause of later neurodevelopmental problemsneurodevelopmental problems
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
Most common anomalies noted on initial exam