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Perinatal History

 Dr Varsha Atul Shah
Learning Objectives:
               Perinatal History
   By the end of the lecture the student
    should be able to:
   ...
Learning Objectives:
                 Perinatal History
   By the end of the lecture the student should
    be able to:
 ...
The Perinatal History

   General Data:
   Maternal Obstetrical History
   Maternal medical History
   Family History
...
Perinatal History:General Data


   BBX born at the PGH-OBAS after _____
    weeks of gestation, to a G-P (FT-PT-Ab-LC)
 ...
Perinatal History:Maternal past and
      present obstetrical history

Age: < 19 or > 35 IUGR ; bleeding,
                ...
Perinatal History:
            Maternal Medical History

Infection            Congenital pneumonia
                     In...
Perinatal History:
          Amount of amniotic fluid


   Polyhydramnios       premature labor,
                       ...
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 History

Smoking
•A team of California and
Ohio scientists showed
that maternal exposure to
cigar...
Perinatal History:Social History


Alcoholism
     high alcohol levels ingested during
      pregnancy damage embryonic a...
Perinatal History: Labor
   prolonged and difficult      Infection, hypoxia
    labor
   premature rupture of         ...
Perinatal History:Delivery
Mode of delivery:
Breech, suction            Delay in the delivery of the
                     ...
The
Newborn
The Physical Examination of the
           Newborn
Learning Objectives:
      Physical Examination of the Newborn
   By the end of the lecture the student should be
    abl...
DELIVERY ROOM ASSESSMENT:
   APGAR SCORE
       Dictates the need to resuscitate


   BALLARDS
            Determines ...
DELIVERY ROOM ASSESSMENT:
   AOG is plotted vs. weight on the Lubchengco chart to
    determine the nutritional status of...
A quick initial PE should be performed at the
                      DR
   No major anomalies
   no birth injuries
    t...
Routine detailed PE to be done within
              24 hours
   To detect congenital anomalies not
    identified at birt...
Order of examination
   Newborn is quiet, in-between feeding
   listen to the heart and lungs first and
    examine the ...
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 Pressure

AOG and weight
related
Obtain BP of both
upper and lower
                                       Cuff
extre...
Anthropometric measurements
   Head                  circumference
   Length
   Weight
                                ...
GENERAL APPEARANCE
   State of alertness
       lethargic or irritable
   Posture
       Full terms: hips abducted and...
SKIN
   Color:
     Acrocyanosis < 24 hours
     Pallor

        Low hemoglobin

     Cyanosis

        Central- hyp...
SKIN

   Jaundice
       Within 24 hours
            hemolytic
       2-4rth day
             physiologic,
          ...
NEWBORN PE:SKIN

•Epidermis:
   –(-) excoriations/
        sloughing
•Hair
   –Lanugo
•Texture
   –moist and
         smoo...
NEWBORN PE:SKIN
   Cysts: Milia,
        pinpoint white papules of keratogenous
        material usually on nose    and ...
NEWBORN PE:SKIN
   Papules: Acne
   miliaria
   Desquamation
   Hemangiomas
   Hemorrhages
   Macules
   (mongolian...
NEWBORN PE: HEAD
   Normal:
       Caput succedaneum, molding
   Check for :
     overriding of sutures,
     Number ...
Cephalhematomas vs Cephaledema




 Cephalhematoma            Cephaledema

 Limited by suture lines   Crosses midline
 May...
NEWBORN PE: Facies

Needs work up:

    Down’s Syndrome

    Cornelia Delange
Newborn PE: EYES

   Check for:
     colobomas, heterochromia
     cloudiness of cornea

     conjunctival erythema

 ...
Newborn PE: EYES

   Pupillary size and reactivity to light
   red orange reflex
     hold the opthalmoscope 6-8” from ...
Nose
   Check for:
     Flaring
     hyper/hypotelorism

     choanal atresia
NEWBORN PE: MOUTH


Check for:
     High arch palate
     Cleft/lip palate
     Macroglossia
     Micrognathia
Newborn PE: EARS

   Check for:
       Setting
            top of pinna falls

                     above a line
      ...
NEWBORN PE: NECK

   Normal:
   Check for : Dimple or webbing
NEWBORN PE: CHEST

   Check for: paradoxical, periodic,
                      (+) retractions
     Symmetry
     Apnea,...
Check for air entry




Anterior, mid-axillary, posterior
NEWBORN PE: HEART
   Normal: regular rhythm, systolic murmur < 24 hrs,
    splitting of S2 varies with breathing
   Chec...
Palpating the pulses




Palpate brachial and femoral together: simultaneous arrival or
slightly earlier arrival of femora...
NEWBORN PE:ABDOMEN

   Normal:
     Shape cylindrical,


       (+) diastasis recti ,

       amniotic or cutaneous
  ...
NEWBORN PE:ABDOMEN
   Check for:
     Distention, scaphoid abdomen,
      umbilicus granuloma,
     hernia, inflammatio...
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,
       c...
NEWBORN PE: FEMALE GENITALS

   Normal:
       Mucoid or bloody
        secretion, edema,
        gaping labia,
        ...
NEWBORN PE: ANUS

   Normal:
       Perforate
   Check for
     imperforate,
     coccygeal        dimple,

       f...
NEWBORN PE: MUSCULOSKELETAL
   Normal:      fetal posture
    (flexor position of comfort)
NEWBORN PE: MUSCULOSKELETAL
   Check for:
       Cortical thumb,
       overlapping fingers,
       short incurved lit...
Checking for hip dislocation

   Infant lies supine on flat, firm surface and be
    relaxed. Stabilize the hip with one ...
Checking for hip dislocation

   1. the hip is flexed and adducted and femoral
    head gently pushed downward (Barlowe’s...
Checking for hip dislocation

   2. Check if it can be returned from a
    dislocated position back into the
    acetabul...
Checking for back, spine and muscle tone

  On prone position babies can lift their head
   to the horizontal and straigh...
NEWBORN PE: CNS

   State:
       Awake - alert, crying,
        active
       Asleep -
        indeterminate, quiet

 ...
NEWBORN PE: CNS

   Motor:
    Posture - Flexor, symmetric
     Tone - obtuse popliteal angle

     Movement - all ext...
NEWBORN PE: CNS
   Reflexes: Deep tendon, grasp, moro,
    placing, stepping, sucking, tonic neck,
    trunk incurvation
...
Lesions that resolve spontaneously
   Peripheral and traumatic cyanosis
   Molding, caput, cephalhematoma
   Swollen ey...
Lesions that resolve spontaneously
   Harlequin change
   Breast enlargement and Witches’ milk
   Hydrocoele
   Vagina...
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 a...
Principles of Care at Birth
   Establishment of respiration
   Prevention of hypothermia
   Establishment of breast-fee...
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
...
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
    t...
Routine detailed PE to be done within
              24 hours
   To detect congenital anomalies not
    identified at birt...
A quick initial PE should be performed at the
                      DR
   No major anomalies
   no birth injuries
    t...
Routine detailed PE to be done within
              24 hours
   To detect congenital anomalies not
    identified at birt...
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...
Normal Values
   Respiratory system:

     Respiratory rate: 40-60 BMP
     ABG: pH 7.30-7.40
      PaC02 : 35-45
     ...
Normal Values
   Hematologic:

     Hgb: 16.5 gms/dL
     Hct: 53.0%

     NRBC: 500 mm3

     Retic count: 2-7%

   ...
Normal Values
   Renal:

     urine output = 1-2 ml/kg/hour
     Sp. Gravity = 1.005-1.015

     Passage of urine= 1st...
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 ...
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
 ...
ECG
Chest Xray
Cardiac shadow
Perfusion


Aeration
Air in bowel
Bones
Case 1: Baby Boy R., 39 weeks gestation
        born to a 25-year old G1P0,
  “0-” pregnant woman, + ROM 12 hours
 before ...
   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 an...
Baby S: born by precipitous delivery
       19 yo G1P0 after 32 weeks gestation
          (-) Prenatal care; Apgar score 5...
Discharge planning

   Normal Vital signs
   Thermoregulated
   Feeding well
   Adequate weight gain
   Family relati...
METABOLIC
ADAPTATION IN THE
    NEWBORN
     UPCM LEVEL V
Learning Objectives
   By the end of the lecture the student must know and
    understand the physiologic changes that oc...
Thermoregulation


.THE NORMAL BODY TEMPERATURE
    It is physiologically safe to
     maintain the core temperature
    ...
Maintaining normal temperature:

Efforts should be made to maintain the
axilary and rectal T at 37oC (98.6oF)

Check T q 1...
Thermoneutral environment

 DEFINITI0N:

   Range  of environmental
    temperature below and above
    which oxygen dem...
Heat loss and heat production

        Heat   production by:
             mobilization of brown fats
        Heat   los...
Thermal regulation: Heat loss
   Radiation
       Cold windows and walls
   Conduction
       Infant scale, wet linen,...
Thermal regulation: heat production

  Heat
      production by mobilization of
  brown fats
      resulting to producti...
Hypothermia: cold injury



Temperature < 35oC or 95oF)
HYPOTHERMIA


VASOCONSTRICTION
FLEXION



Heat production
       physical                  Glycolysis
                    ...
Hypothermia: Etiology
•The newborn's thermal environment is affected by:
       1. relative humidity
       2. air flow,
 ...
Hypothermia: Pathophysiology

 hypoglycemia,
 metabolic acidosis,
  and death.
Hypothermia: Pathophysiology

 Radiation heat loss occurs rapidly
 because of a high ratio of surface area
 to body weigh...
Hypothermia: Pathophysiology

 . Evaporative heat loss (eg, a
 newborn wet with amniotic fluid in the
 delivery room) and...
Hypothermia: Pathophysiology

 . Because the O2 requirement
 (metabolic rate) increases with cold
 stress, hypothermia ma...
Ways by which body heat is lost
Hypothermia: Pathophysiology

 . Prolonged unrecognized cold stress
 may divert calories to produce heat,
 impairing grow...
Hypothermia: Pathophysiology

. Newborns respond to cooling by sympathetic nerve
discharge of norepinephrine in the "brow...
Three detrimental effects of
cooling:
 Development of Acidosis
     3 Main Causes
      a. Brown Fat Metabolism
      b. V...
NEONATAL COLD INJURY

   Cause: exposure to cold environment
   Signs and symptoms:
       Apathy, refusal to feed, oli...
NEONATAL COLD INJURY

   DIAGNOSTIC WORK-UP
       Serum sugar, ABG(metabolic acidosis)

   TREATMENT:
    warming,
   ...
Prophylaxis

Hypothermia can be prevented by:
• rapidly drying the newborn in the delivery room
       (to avoid evaporati...
Prophylaxis

For sick newborns, a neutral thermal environment--
the environmental conditions and temperature at
which the ...
Treatment

1. Hypothermia is treated by rewarming the
    newborn in an incubator or under a
    radiant warmer.
2. The ne...
External heat sources:

Servo Control Radiant Warmer
Incubator
Portable Mattress
Heat Lamps
 * Maintain with cautious use ...
The servo-care incubator

 Indications   for use of incubator
   When there is a need to measure and
    maintain body w...
 Even under a radiant
            warmer
 heat loss by
 evaporation may still
                 occur
 when baby is
      ...
Warming a severely hypothermic
( Temperature < 35oC or 95oF):

Incubator – increase the Temp to 1-1.5oC

             abov...
REMEMBER:

 * Preventing heat loss is much easier
than overcoming the detrimental
effects of cold stress once they have
oc...
HYPERTHERMIA

   Transitory Fever or dehydration fever
       Birth History: uneventful perinatal events and
        imm...
HYPERTHERMIA

Diagnosis: Core temperature 38-39° C, on
 2nd-3rd day of life, exposed to high
 environmental temperatures, ...
HYPERTHERMIA

PE:                                  Restless,
 with precipitous drop in weight
 Fontanelle depressed, skin ...
HYPERTHERMIA

   Diagnostic work-up
        Increased serum protein, Na and Hct

   Treatment
      Oral or parenteral...
HYPERTHERMIA
   Severe form:
      Temp as high as 41-44 C

      Skin hot and dry and infant appears apathetic

     ...
Changes in Energy requirements

   Intra-uterine supply of energy:

          In-utero ------ Placenta---- Fetus       ...
Changes in Energy requirements
   Abrupt termination of supply of energy at birth:


             provision of exogenous ...
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
    ...
Hypoglycemia: causes
   Infants at high risk to develop
    hypoglycemia:
    > SGA/ LGA infants
    > Infants of Diabeti...
Symptoms of Hypoglycemia

   Jitteriness       Irregular respirations

   Hypothermia/  Poor suck or refusal to
      ...
Treatment of Hypoglycemia:

   IV Treatment of Blood Sugar < 40 mg/dL (2.2
    mmol/L)
   Step 1. Give an IV bolus of D1...
Treatment of Hypoglycemia:

   Step 3. Immediately following the IV bolus, if not
    done already start a continuous IV ...
Treatment of Hypoglycemia:

   Step 5. If the blood sugar does not improve and
    stabilize over 50 after 2 boluses of g...
Treatment of Hypoglycemia:

   Step 6. Evaluate the blood sugar frequently – every
    15-30 minutes until stable > 50 on...
Fluids and Electrolytes
   Changes in fluid compartments ( % TBW)

             Age      ECF        ICF    TBF

         ...
Fluids and Electrolytes
   Changes in fluid requirements
                                 Insensible
    fluid loss
    r...
Fluids and Electrolytes
   Abnormal Fluid accumulation:       edema
                                   third
    spacing
EDEMA
   Contributing factors/causes:
       IDM
       Hydrops fetalis
       Prematurity- decreased ability to excre...
EDEMA
   Associated with syndromes
     Congenital lymphedema (Milroy’s)
     Turner’s syndrome

     Congenital nephr...
Electrolytes: Calcium metabolism
   Placental active transport
   Parathyroid hormones and calcitonin do not
    cross p...
HYPOCALCEMIA(TETANY)
   Definition:
       Normal calcium level = 8-11 mg/dL
   Cause: Transient hypoparathyroidism in ...
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
    path...
Osteopenia of prematurity
Treatment:
  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 trans...
HYPOMAGNESEMIA

   PE
       Symptoms usually do not develop until level falls <
        1.2 mg/dL
   Diagnostic work-
...
HYPERMAGNESEMIA

   Definition: serum level > 2.8 mg/dL (1.15)
    mmol/L)
   Causes:
         > Maternal treatment with...
HYPERMAGNESEMIA

   PE:
        > CNS depression:lethargy, flaccidity,
    hyporeflexia
        > respiratory depression:...
LATE METABOLIC ACIDOSIS

   Definition: Usually negative for asphyxia,
    respiratory distress; Onset 2nd-3rd week of li...
LATE METABOLIC ACIDOSIS

   Diagnostic work-up
     ABG: BD= -10 to –16 mEq/L , PCO2 <40
     Due to abnormally high ra...
LATE METABOLIC ACIDOSIS

   Treatment:
     NaHCO3
     Change formula to lower protein content with
      whey to case...
SUBSTANCE OF ABUSE ANJD
             WITHDRAWAL
   Heroin
   Methadone
   Alcohol
   Phenobarbital
   Cocaine
   Fet...
Fetal Alcohol Syndrome
   Cause: impaired transfer of essential amino acids
    and zinc, both needed for protein synthes...
Perinatal history, normal newborn
Perinatal history, normal newborn
Perinatal history, normal newborn
Perinatal history, normal newborn
Perinatal history, normal newborn
Perinatal history, normal newborn
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Perinatal history, normal newborn

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Perinatal history, normal newborn

  1. 1. Perinatal History Dr Varsha Atul Shah
  2. 2. 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
  3. 3. 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
  4. 4. The Perinatal History  General Data:  Maternal Obstetrical History  Maternal medical History  Family History  Social History  History of labor and delivery
  5. 5. 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
  6. 6. Perinatal History:Maternal past and present obstetrical history Age: < 19 or > 35 IUGR ; bleeding, hypertension Gravidity/Parity IUGR, hypertension; bleeding Hx of FT/PT/Ab/LC Fetal wastage/distress LMP, PNC Uterine size, nutrition
  7. 7. Perinatal History: Maternal Medical History Infection Congenital pneumonia Intra-uterine infection Medication Congenital malformation Thyroid problem Hypo/hyperthyroidism Diabetes Hypoglycemia/Polycythemi a Hypertension Premature labor, IUGR
  8. 8. Perinatal History: Amount of amniotic fluid  Polyhydramnios  premature labor, neuromuscular diseases, gut obstruction, hydrops, CHF  oligohydramnios  Renal agenesis, pulmonary hypoplasia
  9. 9. Perinatal History: multiple gestation
  10. 10. Perinatal History:Family history  presence of familial or hereditary diseases
  11. 11. Perinatal History:Social History  civil status, occupation  social habits: smoking/drinking  Promiscuity
  12. 12. Perinatal History:Social History Smoking •A team of California and Ohio scientists showed that maternal exposure to cigarette smoke is associated with a doubled risk of a rare but "devastating" condition called persistent pulmonary hypertension of the newborn,
  13. 13. Perinatal History:Social History Alcoholism  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
  14. 14. 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
  15. 15. Perinatal History:Delivery Mode of delivery: Breech, suction Delay in the delivery of the after-coming head, hypoxia Caesarian Neonatal depression due to maternal anesthetics; TTN Cord coil, prolapse Hypoxia Amniotic Fluid: Aspiration Color, smell Infection Meconium staining Aspiration, PPHN Apgar Score Asphyxia, HIE
  16. 16. The Newborn
  17. 17. The Physical Examination of the Newborn
  18. 18. 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
  19. 19. 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
  20. 20. 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)
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. Vital signs  Heart Rate and pulse rate  Respiratory rate  Temperature  Blood Pressure
  25. 25. Heart Rate and Pulse rate  Normal:  Rate - 110-165 beats per minute regular rhythm,
  26. 26. Respiratory Rate  Normal:  Respiratory Rate 40-60 Breath per minute, regular
  27. 27. Temperature
  28. 28. Blood Pressure AOG and weight related Obtain BP of both upper and lower Cuff extremities: should In coarctation, cover 2/3 both arms higher of the than leg pressure upper arm if coarc is distal to BP determination the origin of the left subclavian a.
  29. 29. Anthropometric measurements  Head circumference  Length  Weight Cuff should cover 2/3 of the upper arm BP determination
  30. 30. 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
  31. 31. 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) 
  32. 32. SKIN  Jaundice  Within 24 hours  hemolytic  2-4rth day  physiologic, level within normal  1 week  breast-milk jaundice
  33. 33. NEWBORN PE:SKIN •Epidermis: –(-) excoriations/ sloughing •Hair –Lanugo •Texture –moist and smooth •Vernix caseosa
  34. 34. NEWBORN PE:SKIN  Cysts: Milia,  pinpoint white papules of keratogenous material usually on nose and forehead  Vascular pattern:  harlequin; mottling
  35. 35. NEWBORN PE:SKIN  Papules: Acne  miliaria  Desquamation  Hemangiomas  Hemorrhages  Macules  (mongolian spots)  and pustules (erythema toxicum)
  36. 36. NEWBORN PE: HEAD  Normal:  Caput succedaneum, molding  Check for :  overriding of sutures,  Number and size of fontanelles  abnormal shape of head  encephalocoeles
  37. 37. Cephalhematomas vs Cephaledema Cephalhematoma Cephaledema Limited by suture lines Crosses midline May increase in size subsides
  38. 38. NEWBORN PE: Facies Needs work up: Down’s Syndrome Cornelia Delange
  39. 39. Newborn PE: EYES  Check for:  colobomas, heterochromia  cloudiness of cornea  conjunctival erythema  exudate, edema, jaundice  hemorrhages
  40. 40. 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
  41. 41. Nose  Check for:  Flaring  hyper/hypotelorism  choanal atresia
  42. 42. NEWBORN PE: MOUTH Check for: High arch palate Cleft/lip palate Macroglossia Micrognathia
  43. 43. 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
  44. 44. NEWBORN PE: NECK  Normal:  Check for : Dimple or webbing
  45. 45. NEWBORN PE: CHEST  Check for: paradoxical, periodic, (+) retractions  Symmetry  Apnea, retractions  (+) grunting, (+) Flaring of alae nasi  bowel sounds  decreased air entry  Paradoxical, preriodic
  46. 46. Check for air entry Anterior, mid-axillary, posterior
  47. 47. 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
  48. 48. Palpating the pulses Palpate brachial and femoral together: simultaneous arrival or slightly earlier arrival of femoral pulse In coarctation: brachial stronger than femoral
  49. 49. NEWBORN PE:ABDOMEN  Normal:  Shape cylindrical,  (+) diastasis recti ,  amniotic or cutaneous navel
  50. 50. NEWBORN PE:ABDOMEN  Check for:  Distention, scaphoid abdomen, umbilicus granuloma,  hernia, inflammation, less than 3 cord vessels
  51. 51. NEWBORN PE:ABDOMEN  Check for:  Gastroschisis, omphalitis,  omphalocele
  52. 52. NEWBORN PE: LIVER  Normal:  Smooth edge  normally palpable 1-2 cm below the costal margin
  53. 53. NEWBORN PE: SPLEEN  Normal: Nonpalpable
  54. 54. NEWBORN PE: KIDNEYS  Normal: (Bimanual palpation) - Palpable  Check for enlarged kidneys
  55. 55. NEWBORN PE: MALE GENITALS  Normal:  Edema, hydrocele, phimosis  Check for:  Bifid scrotum,  cryptorchidism,  inguinal hernia,  chordee,  hypospadia,  microphalus
  56. 56. NEWBORN PE: FEMALE GENITALS  Normal:  Mucoid or bloody secretion, edema, gaping labia, hymenal tag  Check for  ambiguous,  hydrometrocolpos
  57. 57. NEWBORN PE: ANUS  Normal:  Perforate  Check for  imperforate,  coccygeal dimple,  fistula
  58. 58. NEWBORN PE: MUSCULOSKELETAL  Normal: fetal posture (flexor position of comfort)
  59. 59. NEWBORN PE: MUSCULOSKELETAL  Check for:  Cortical thumb,  overlapping fingers,  short incurved little finger,  hip subluxation, decreased range of motion  Polydactyly/syndactyly
  60. 60. 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:
  61. 61. 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”
  62. 62. 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”
  63. 63. 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
  64. 64. NEWBORN PE: CNS  State:  Awake - alert, crying, active  Asleep - indeterminate, quiet 
  65. 65. NEWBORN PE: CNS  Motor: Posture - Flexor, symmetric  Tone - obtuse popliteal angle  Movement - all extremities, nonrepetitive, random, symmetric
  66. 66. NEWBORN PE: CNS  Reflexes: Deep tendon, grasp, moro, placing, stepping, sucking, tonic neck, trunk incurvation  Sensory: 2-3 seconds pin prick response  Cranial nerves
  67. 67. 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
  68. 68. Lesions that resolve spontaneously  Harlequin change  Breast enlargement and Witches’ milk  Hydrocoele  Vaginal discharge  Mongolian spots  Umbilical hernia
  69. 69. The Care of the Newborn PFD. Isleta, M.D. for Level V - UPCM
  70. 70. 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
  71. 71. 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
  72. 72. Cardio-pulmonary adaptation
  73. 73. Initial management • ABC,s: Airway, Breathing, Circulation • Temperature control • Cord dressing • Bonding
  74. 74. 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
  75. 75. Nursery Care  Bathing and dressing  Umbilical cord care  Feeding  Voiding and stooling  Behavior  Color
  76. 76. Bathing and dressing
  77. 77. Thermoregulation
  78. 78. Latching on mother’s milk
  79. 79. 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
  80. 80. 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
  81. 81. 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
  82. 82. 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
  83. 83. Well Baby  AOG 38-42 weeks,  AGA  delivered vaginally,  Apgar score >/= 7
  84. 84. Normal Values  Anthropometric:  Weight: 2.5-4.00  Length: 45-55  HC: 32.6-37.2  BP: AOG related
  85. 85. Normal Values  Cardiac system:  Heart rate: 120-160 BPM  Rhythm: regular, sinus  EKG: sinus rhythm, RV dominant
  86. 86. 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
  87. 87. 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
  88. 88. Normal Values  Renal:  urine output = 1-2 ml/kg/hour  Sp. Gravity = 1.005-1.015  Passage of urine= 1st 24 hours
  89. 89. Normal Values  Gastrointestinal:  meconium passage  enzyme
  90. 90. Normal Values  Metabolic:  electrolytes  calcium  blood sugar
  91. 91. 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
  92. 92. Sick Baby • Abnormal VS, • Congenital anomaly requiring surgery • IU infection • Asphyxiated
  93. 93. Diagnostic work-up  CBC, retic, coomb’s  Mother’s and Baby’s Blood Type  ABG  ECG, 2-D Echo  Chest X-Ray  Hepa profile
  94. 94. ECG
  95. 95. Chest Xray Cardiac shadow Perfusion Aeration Air in bowel Bones
  96. 96. 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+”
  97. 97.  What are the High Risk Factors?  What problems are you anticipating
  98. 98.  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
  99. 99. 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?
  100. 100. Discharge planning  Normal Vital signs  Thermoregulated  Feeding well  Adequate weight gain  Family relationship
  101. 101. METABOLIC ADAPTATION IN THE NEWBORN UPCM LEVEL V
  102. 102. 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
  103. 103. 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.
  104. 104. Maintaining normal temperature: Efforts should be made to maintain the axilary and rectal T at 37oC (98.6oF) Check T q 15 – 30 min until within n range and at least q h until infant is transported to the nursery
  105. 105. 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)
  106. 106. 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
  107. 107. 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
  108. 108. 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
  109. 109. Hypothermia: cold injury Temperature < 35oC or 95oF)
  110. 110. HYPOTHERMIA VASOCONSTRICTION FLEXION Heat production physical Glycolysis WORK metabolic Lipolysis Oxygen debt Acidosis EXHAUSTION
  111. 111. Hypothermia: Etiology •The newborn's 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.
  112. 112. Hypothermia: Pathophysiology hypoglycemia, metabolic acidosis,  and death.
  113. 113. 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.
  114. 114. 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.
  115. 115. 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).
  116. 116. Ways by which body heat is lost
  117. 117. Hypothermia: Pathophysiology . Prolonged unrecognized cold stress may divert calories to produce heat, impairing growth.
  118. 118. Hypothermia: Pathophysiology . Newborns respond to cooling by sympathetic nerve discharge of norepinephrine in the "brown fat." This specialized tissue of the newborn, located in the nape of the neck, between the scapulae, and around the kidneys and adrenals, responds by lipolysis followed by oxidation or reesterification of the fatty acids that are released. These reactions produce heat locally, and a rich blood supply to the brown fat helps transfer this heat to the rest of the newborn's body. This reaction may increase the metabolic rate and O2 consumption two- to threefold above baseline.
  119. 119. Three detrimental effects of cooling: 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
  120. 120. 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
  121. 121. NEONATAL COLD INJURY  DIAGNOSTIC WORK-UP  Serum sugar, ABG(metabolic acidosis)  TREATMENT: warming, correct electrolyte disturbances
  122. 122. Prophylaxis Hypothermia can be prevented by: • rapidly drying the newborn in the delivery room (to avoid evaporative heat loss) •swaddling him (including his head) in a warm blanket. •If the newborn is exposed for resuscitation, observation, or to provide skin-to-skin contact with the mother, he should be warmed under a radiant warmer.
  123. 123. Prophylaxis For sick newborns, a neutral thermal environment-- the environmental conditions and temperature at which the newborn's metabolic rate is minimized while maintaining a normal core temperature (37° C [98.6° F])--should be maintained. This can be approximated by setting the incubator temperature according to the newborn's birth weight and postnatal age. Alternatively, heat can be provided using an incubator or radiant warmer with a servomechanism set to maintain the skin temperature at 36.5° C (97.7° F).
  124. 124. Treatment 1. 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.
  125. 125. External heat sources: Servo Control Radiant Warmer Incubator Portable Mattress Heat Lamps * Maintain with cautious use of heat source*
  126. 126. 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
  127. 127.  Even under a radiant warmer heat loss by evaporation may still occur when baby is open to atmosphere
  128. 128. Warming a severely hypothermic ( Temperature < 35oC or 95oF): Incubator – increase the Temp to 1-1.5oC above body Temp Radiant Warmer – set servo control To 36.5oC *Be ready to do CPR if infant deteriorates during or after rewarming.
  129. 129. REMEMBER: * Preventing heat loss is much easier than overcoming the detrimental effects of cold stress once they have occurred.*
  130. 130. HYPERTHERMIA  Transitory Fever or dehydration fever  Birth History: uneventful perinatal events and immediate postnatal course, breast fed
  131. 131. HYPERTHERMIA Diagnosis: 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
  132. 132. HYPERTHERMIA PE: Restless, with precipitous drop in weight Fontanelle depressed, skin less elastic, Tachycardic,tachypneic
  133. 133. HYPERTHERMIA  Diagnostic work-up  Increased serum protein, Na and Hct  Treatment  Oral or parenteral fluid  Lower environmental temperature
  134. 134. 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
  135. 135. Changes in Energy requirements  Intra-uterine supply of energy: In-utero ------ Placenta---- Fetus maternal metabolic homeostasis placental exchange fetal regulatory mechanism Continuously provides glucose, calcium, magnesium
  136. 136. Changes in Energy requirements  Abrupt termination of supply of energy at birth: provision of exogenous nutrients mobilization of endogenous fuel and mineral stores
  137. 137. Changes in Energy requirements  Impaired energy supply and utilization: hypoglycemia hyperglycemia
  138. 138. 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
  139. 139. 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
  140. 140. 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
  141. 141. 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.
  142. 142. 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.
  143. 143. 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.
  144. 144. 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.
  145. 145. 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
  146. 146. Fluids and Electrolytes  Changes in fluid requirements Insensible fluid loss respiratory tract, skin, gastro-intestinal tract Urine loss
  147. 147. Fluids and Electrolytes  Abnormal Fluid accumulation: edema third spacing
  148. 148. 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
  149. 149. EDEMA  Associated with syndromes  Congenital lymphedema (Milroy’s)  Turner’s syndrome  Congenital nephrosis  Hurler’syndrome
  150. 150. Electrolytes: Calcium metabolism  Placental active transport  Parathyroid hormones and calcitonin do not cross placenta  25-hydroxyvitamin-D passes the placenta
  151. 151. 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 `
  152. 152. HYPOCALCEMIA(TETANY)  Diagnostic work-up  Treatment: 2 ml/k of 10% calcium gluconate
  153. 153. 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
  154. 154. Osteopenia of prematurity Treatment: Immobilization of fractures Administration of calcium, P and Vit D
  155. 155. HYPOMAGNESEMIA  Definition: Serum Mg levels <1.5 mg/dL or 0.62 mmol/L  Normal values
  156. 156. HYPOMAGNESEMIA  Contributing factors/causes: Associated with hypocalcemia Deficient placental transfer Decreased intestinal absorption Neonatal hypoparathyroidism Hyperphosphatemia Renal loss Impaired homeostasis
  157. 157. 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
  158. 158. HYPERMAGNESEMIA  Definition: serum level > 2.8 mg/dL (1.15) mmol/L)  Causes: > Maternal treatment with MgSO4 for preeclampsia, > delayed passage of meconium
  159. 159. HYPERMAGNESEMIA  PE: > CNS depression:lethargy, flaccidity, hyporeflexia > respiratory depression: hypoventilation > hypotension
  160. 160. 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
  161. 161. LATE METABOLIC ACIDOSIS  Diagnostic work-up  ABG: BD= -10 to –16 mEq/L , PCO2 <40  Due to abnormally high rate of endogenous acid formation
  162. 162. LATE METABOLIC ACIDOSIS  Treatment:  NaHCO3  Change formula to lower protein content with whey to casein ratio of 60:40
  163. 163. SUBSTANCE OF ABUSE ANJD WITHDRAWAL  Heroin  Methadone  Alcohol  Phenobarbital  Cocaine  Fetal alcohol syndrome
  164. 164. 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
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