The NEWBORN infant

PHYSIOLOGIC CHANGES IN THE NEWBORN 1. Physiologic weight loss (during 1 10 days term; 2 weeks for preterm) a. due to contraction of extracellular fluid within 72 hrs b. Passage of Meconium c. Urination within 24 hours d. Vernix casseosa removal (cheesy material covering the baby) 2. Physiologic Jaundice - due to increase in hemolysis - fetal RBC life= 90 days due to HgF, as compared to adults 120 days 3. Vasomotor Instability a. mottling of skin (like marble floor) - symphysis pubis down is pink; above is blue due to vasomotor insufficiency) b. acrocyanosis (of extremities) c. Harlequin color change 4. Genital crisis -pseudomenses occurs in FEMALE babies during 1st week 5. Witch milk - milk from babys breast, gynecomastia in BOTH male and female - due to maternal hormonal withdrawal (progesterone) 6. Transitional stools - black greenish yellow (due to breast milk) 7. Inanition fever/ dehydration fever (3rd day) - due to inadequate caloric intake 8. Physiologic desquamation of skin (1st week) 9. Falling off of umbilical cord - 10 to 14 days for term; 2 weeks to a month for preterm due to decreased immune response 10. Physiologic Anemia - 1st 4 months of life - < 10g/ dl due to rapid destruction of RBC - due to decreased capacity of kidneys to do erythropoietic activities - increased hemolysis due to shorter lifespan of RBC Some Important Integrated and Protective Reflexes
Reflex Ons et Diaspp ears Absent Young prematures, severe systemic dis, General depression, Kernicterus Assymetric Brachial plexus injury, clavicular &/or humeral fracture, congenital hemiplegia Persisten t CP, neurodegenerativ e disease
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CLASSIFICATION OF THE NEWBORN INFANT Early 20th century - debate whether prematurity should be defined by AOG or BW 1935- AAP defined prematurity as a live born infant w/ a BW of 2,500g 1960s- not all neonates weighing less than 2500g at birth are preterm - routinely classify newborn on AOG and BW Common Clinical Problems in the Newborn 1. Aberration in the uterine growth SGA, LGA 2. Feeding Difficulties - babies may still vomit due to amniotic fluid - babies with so much saliva (mother with hx of polyhydramnios) 3. Respiratory distress/apnea - pre-term, due to lack of surfactant 4. Cyanosis - pulmo, neuro and metab prob 5. Vomiting/diarrhea/Abdominal Distension -may be seen in infection - differentiate abd distention from globular abd.: a. percussion b. veins seen c. glistening 6. Jaundice - physiologic - breast feeding jaundice (decrease caloric intake in breast milk) - breast milk jaundice ( substance in milk-FAcompete with albumin binding site) 7. Abnormal Secretions / discharges - yellow: fr upper GI due to atresia - white: pyloric stenosis 8. Bleeding - esp in preterm due to lack of clotting factors 9. Pallor 10. Jitteriness / seizures (myelination is not yet complete) - jitteriness will stop when baby is held, seizure wont 11. Meconium Staining- due to hypoxia 12. Temperature instability INTRAUTERINE GROWTH RETARDATION IUGR a deviation from or a reduction in an expected fetal growth pattern and is caused by multiple adverse effects on the fetus SGA weight is lower than population norms or lower than a pre-determined cut-off weight (-250, 5th percentile, 10th percentile) - May be pathologic / non- pathologic Infant Classification by Gestational Age Pre-term < 37 weeks AOG Term 37 42 weeks AOG Post-term > 42 weeks AOG Infant Classification by weight at birth NBW 2500 3999 g VLBW - < 1500 g LBW - < 2500 g ELBW - < 1000 g *SGA should be delivered in a tertiary hospital

Moro (startle reflex) Grasp Palmar & Plantar Rooting and Sucking Tonic Neck Parachute: (note: this is a protective reflex which manifests later w/ cerebral palsy

Birth

5 mo

Birth Birth Birth

6 mo 910mo 3 mo 5-6 mo

8-9 mo

Persist s

Assymetric / Symetric IUGR based on HC Evaluation and Management for complications of IUGR / SGA 1. Hypoxia, acidosis congenital anomalies 2. Infection perinatal discharge 3. Meconium aspiration 4. Pulmonary hemorrhage 5. PPHN 6. Hypothermia 7. Hypoglycemia 8. Hypocalcemia 9. Hyponatremia 10. Polycythemia HIGH RISK INFANTS ( page 547 of Nelsons Pedia ) neonatologists [specialist for high risk infants] - infants who should be under close observation by experienced physicians and nurses - 9% of all births require special or neonatal intensive care

- Cesarean section - Forcepts delivery - Apgar scores < 4 at 1 min Neonate: - Birthweight <2500 or >4000 g - Birth before 37 or after 42 weeks of gestation - SGA, LGA growth status - Tachypnea, cyanosis - Congenital malformation - Pallor, Plethora, Petechiae (usually have cytomegalovirus infection) MULTIPLE PREGNANCIES: Incidence: Black and East Indians > whites > Asians

1. Identical twins (mononuclear twin) - 1 ova fertilized by 1 sperm 2. Fraternal twins (polyovular/dizygotic) 2 eggs and 2 sperm 3. > 2 (triplets, etc) quad, quin, setuplets Demographic Social factors: 4. Conjoined twins (Siamese twins 1:50,000) - Maternal age < 16 or > 40 yrs old - late monouvular separation - Illicit drug, alcohol, cigarette use - 2 separate embryo in one amniotic sac - Poverty a. Thoracoomphalagus (25%) thorax - Unmarried and abdomen fused - Emotional or physical stress b. Thoracopagus (18%) fused thorax c. Omphalagus (10%) abdomen Past Medical History d. Craniopagus (6%) head - Genetic Disorders e. Incomplete duplication (10%) - DM 5. Superfecundation 2 ova fertilized different age of - Hypertension gestation - Asymptomatic Bacteriuria 6. Superfetation another ovum is fertilized when theres - Rheumatologic illness (SLE): baby, congenital heart block already a fetus in the uterus - long-term medication (different AOG; when born,, 1 is preterm, the other could be term) Previous Pregnancy - Intrauterine fetal demise Prenatal Diagnosis of Multiple Pregnancies - Neonatal Death 1. Uterine size >AOG - Prematurity 2. Auscultation of 2 fetal heart tones - IUGR 3. Increased levels of maternal serum of fete protein and - Congenital malformation HOG - Incompetent Cervix 4. Ultrasound - Blood group sensitization, neonatal jaundice - Neonatal thrombocytopenia Classification - Hydrops fetalis LBW < 2500 g - Inborn errors of metabolism VLB < 1500 g ELBW < 1000 g Present Pregnancy -Vaginal bleeding (abruption placentas, placenta previa) Pre-term completed < 37 weeks of gestation - STD (colonization; herpes simplex, group B Term 37 42 weeks streptococcus), Chlamydia, syphilis, hepatitis B, HIV Post term - >42 weeks -Multiple gestation - Preeclampsia ( BP in mother) Characteristic changes in Monochorionic twins w/ - Premature rupture of membrane uncompensated Placental Arteriovenous shunts: (page 543 - Short interpregnancy time of Nelsons Pedia) - Poly-oligohydramnios - Acute medical or surgical illness Twin on - Inadequate prenatal care (minimum of 4 visits to OB before delivery) Arterial Side (Donor) Venous Side (Recipient) - Familial or acquired hypercoagulable states - Prematurity - Prematurity 0 Treatment of infertility (result into multiple gestation due - Oligohydramnios - Polyhydramnios to infertility treatment) - Small premature - Hydrops Labor and Delivery - Malnourished - Large premature - Premature labor (<37 weeks) - Pale - Well Nourished - Post dates (>42 weeks) - Anemic - Plethoric - Fetal Distress - Hypovolemia - Polycythemia - Immature LS ration; absent phosphatidylglycerol (detects - Microcardia - Hypovolemic whether lungs of baby are - Glomeruli small/normal - Cardiac hypertrophy mature enough for external environment) - Arterioles thin- walled - Myocaridal dysfunction - Breech presentation - Tricuspid valve regurgitation - Meconium-stained fluid - Right ventricle outflow - Nuchal cord obstruction

- Glomeruli large - Arterioles thick walled - donor edematous due to congestion of the heart - Recipient smaller FACTORS OFTEN ASSOCIATED WITH IUGR (Nelsons pedia page 551) Fetal: - Chromosomal disorders (eg., autosomal trisomies) - Chronic fetal infections (eg., cytomegalic inclusion disease, congenital rubella, syphilis) - Congenital anomalies syndrome compleses - Irradiation - Multiple gestation - Pancreatic hypoplasia - Insulin Deficiency - Insulin like growth factor type 1 deficiency Placental - Decreased placental weight or cellularity, or both - Decrease in surface area - Villous placentitis (bacterial, viral, parasitic) - Infarction - Tumor (chorioangloma, hydatidiform mole) - Placental separation - Twin transfusion syndrome Maternal: - Toxemia - Hypertension or renal disease, or both - Hypoxemia (high altitude, cyanotic cardiac or pulmonary disease) - Malnutrition or chronic illness - Sickle cell anemia - Drugs (narcotics, alcohol, cigarettes, cocaine, antimetabolites) * Assymetric IUGR - Head, normal circumference - 1st trimester of pregnancy * Symetric IUGR - Head, leg, weight fall on the same range - Last trimester of pregnancy

Gabaldon, June Joanbelle USTmedB2007