Common Newborn Problems (2) C1

Management of common problems in
the newborn
NEONATAL ADAPTATION
• It is the process by which one adjusts and becomes
more tuned to the environment.
• Neonatal adaptation :
- Functional adjustment from
intrauterine to extra uterine life
Ability to adjust  HOMEOSTASIS :
– the physiological process by which the internal
systems of the body are maintained
ADAPTATION depends on
1. MATURATION - Related to GA
2. NUTRITIONAL STATUS - Related to birth weight
3. TOLERANCE - The ability to overcome the

new environment
4. ADAPTIVE CAPACITY - the potential or ability
of a system to adapt to the effects of
change
Adaptation involves multi-organ function
 Cardio-circulatory system
 Respiratory system
 Intestinal tract
 Metabolism
 Central nervous system

Adaptation in Cardiovascular system
NEONATAL
FETAL CIRCULATION
CIRCULATION
Adaptation in Respiratory system
Asphyxia
Insult to the fetus / Newborn
Lack of oxygen (Hypoxia)
Lack of perfusion (Ischemia)
AAP Definition of Perinatal Asphyxia

• Metabolic or mixed acidemia with PH <7.2
• APGAR score of <3 for > 10 minutes
• Neurologic sequelae: ( seizures, hypotonia, coma)
• Multiorgan dysfunction
PATHOPHYSIOLOGY
.
Acute asphyxia
Diving reflex
Shunting of blood to Away from

brain adrenals & lungs, kidney
heart gut & skin
NONE BRAIN ORGAN

CEREBRAL CORTICAL LESIONS DAMAGE
PATHOLOGY
• Target Organs of perinatal asphyxia
– Kidneys 50%
– Brain 28%
– Heart 25%
– Lung 23%
– Liver, Bowel, Bone marrow < 5%
Management of HIE
• Perinatal management of high risk pregnancies .
• Early detection of fetal hypoxia during labor and delivery
• Neonatal resuscitation
• Maintain O2 and CO2 in normal ranges

( SaO - 90 % – 95 %).
• Monitor arterial blood pressure
• Administer volume slowly: overall fluid restriction

Causes of respiratory distresses
1. Meconium aspiration syndrome
2. RDS Hyaline Membrane Disease
3. Congenital pneumonia
4. Apnea
5. TTN
Body Temperature
37.5 C
Normal range
36.5 C
Mild hypothermia
36.0 C
Moderate hypothermia
32.0 C
Severe hypothermia
Cold injury
TEMPERATURE ADAPTATION
• FETUS
Intrauterine temperature - (0.7 o Celsius above
mothers temperature)
• NEWBORN
• Extra uterine condition  Hypothermia
large surface area;
poor thermal insulation;
low ability to conserve heat.
Mechanisms of heat lose
Federal Democratic Republic of Ethiopia 14

Mechanism of heat loss
1- CONDUCTION -Dry and wrap the baby Place on a
warm mattress
2. CONVECTION - Wrap the baby and control room

temperature
3. EVAPORATION - Dry the baby and Control humidity

and room temperature
4. RADIATION - Radiant heater and control room

temperature
Clinical manifestation of Hypothermia
1. Peripheral vasoconstriction
- Acrocyanosis, decreased peripheral perfusion
2. CNS depression
- Lethargy, poor feeding, apnea and bradycardia
3. Increased metabolism
- Hypoglycemia, hypoxia, metabolic acidosis
4. Increased pulmonary arterial pressure
- Tachypnea, respiratory distress
5.Depressed Immunologic system
- develop septicemia, sclerema, DIC
Infection
Early Onset neonatal sepsis (<7 days)
Late Onset neonatal sepsis (> 7 days)
• Bacterial meningitis
• Congenital pneumonia
• Neonatal Sepsis
Causative organisms
• Primary sepsis
– Group B streptococcus
– Gram-negative enterics (esp. E. coli)
– Listeria monocytogenes, Staphylococcus, other
streptococci (entercocci), anaerobes, H. flu
• Nosocomial sepsis
– Varies by nursery
– Staphylococcus epidermidis, Pseudomonas, Klebsiella,
Serratia, Proteus, and yeast are most common
Clinical presentation
• Temperature irregularity (high or low)
• Change in behavior
• Lethargy, irritability, changes in tone
• Skin changes
• Poor perfusion, mottling, cyanosis, pallor, petechiae, rashes,
jaundice
• Feeding problems
• Intolerance, vomiting, diarrhea, abdominal distension
• Cardiopulmonary
• Tachypnea, grunting, flaring, retractions, apnea, tachycardia,
hypotension
• Metabolic
• Hypo or hyperglycemia, metabolic acidosis
Management
• Antibiotics
– Primary sepsis: Ampicillin and Gentamicin
– Nosocomial sepsis: Vancomycin and Gentamicin or
cefotaxime
– Change based on culture sensitivities
Prevention
Infection prevention
Hand washing and use of disinfection
Sterility technique during procedures
Supportive therapy
• Respiratory
• Oxygen and ventilation as necessary
• Cardiovascular
• Support blood pressure with volume expanders and/or pressors
• Hematologic
• Treat DIC with FFP and/or cryo
• CNS
• Treat seizures with phenobarbital
• Watch for signs of SIADH (decreased UOP, hyponatremia)
and treat with fluid restriction
• Metabolic
• Treat hypoglycemia/hyperglycemia and metabolic acidosis
GBS Prophylaxis
• GBS is the most common cause of early-onset
sepsis.
– Fatality rate of 5-15%
• 10-30% of women are colonized in the vaginal and

rectal areas.
• Most mothers are screened at 35-37 weeks

gestation.
Neonatal jaundice
• is a yellowish discoloration of the skin and or

sclera due to bilirubin deposition.
• In NB jaundice appears when TB > 7 mg /dl

and almost 97 % healthy full term babies have
biochemical hyperbilirubinemia.
• It could be physiologic or pathologic

Causes of Jaundice
• Isoimmunization
– RH and ABO incompatibility,
– Other blood group incompatibility
• Infection
– Bacterial, viral, protozoal
• Sequestered blood
– Subgalial hemorrhage, cephal hematoma
• Erythrocyte biochemical defect

– G6PD deficiency, Hexokinase deficiency
Causes of Jaundice…cont
• Structural abnormalities of erythrocytes:
– Hereditary spherocytosis, eliptocytosis
• Disorder of hepatic uptake:

– Gilbert syndrome
• Disorder of conjugation:
– Crigler – Najar syndrome (absence of UGT activity)
• Disorder of enterohepatic circulation

– Breast feeding Jaundice
– Hypothyroidism:
Principles of treatment
• Phototherapy
• Exchange transfusion
• Other medical managements
• Note: Use Butanic curve for choosing the management

options.
Nutrition
• .
Proper positioning of babies
– Infants whole body supported
– Infants head, neck and body should be straight
– Infant facing mother
– Infants body close to mother

Proper positioning of babies
• Positioning of baby and mother need to
include
– Infants whole body supported

– Infants head, neck and body should be
straight
– Infant facing mother
– Infants body close to mother

Proper attachment of babies
– Mouth wide open
– Lower lip turned outward
– More areola visible on above than below
– Chin touching the breast

Clues for adequate breast feeding
– At least 3-5 strong suckling before pausing for breath or rest
– Dimpling of cheeks may be seen while suckling
– Hearing of swallowing gurgle
– Milk may be seen around the mouth leaking out when it is

excess

Well and adequately fed baby will be satisfied
and
– Go asleep for 2- 4 hours between each

feedings
– Will have frequent wet diapers (> 6 times)
– Increase weight daily after 7 postnatal days

(20 – 30 gm/kg/day).

Preterm feeding and
it’s challenges
Sever malnutrition
Neurocognitive
defect
Low IQ !!!!!!!
Death
Is there
any
solution
????
Signs of feeding intolerance
– Residual > 1/3 during the next feed
– Vomiting
– Abdominal distension (decreased bowel
sounds)
– Blood in stools or diarrheal stools
– Temperature instability
– Presence of apnea or respiratory distress
– Hyperglycemia or metabolic acidosis
If any of this signs are present stop feeding and put on

iv fluid, rule out NEC and start TPN
Feeding sick babies
• Surgical patient on the GI system
- TEF, duodenal atresia, imperforate anus
• Babies with necrotizing enterocolities (NEC)
• Asphyxiated babies
• Mx – Total parenteral Nutrition

Table1: volume of feeding for preterm neonate & advancement of feed
full feedings” = Volume: up to 180 ml/kg/d
Gestational age Weight(grams) Initial feeds Progression of

feeds/advance as
tolerated
<28 weeks <1000 10 -20ml/kg/day 10-20 ml/kg/day
28 – 32weeks 1000– 1500 20-30 ml/Kg /day Increase by 20-30

ml/kg/day
32- 34 weeks 1500 – 1800 30/kg/day by NG/CUP Increase by 30

ml/kg/day
> 34 weeks >1800 30-60ml/kg/day Increase by 35 ml/kg/day

–to attain full feeds
Table 1: Estimated Maintenance Fluid Requirements based on Weight and
Postnatal Age
Fluid Rate (ml/kg/day)

Birth Weight
Postnatal Age
Day 1 Day 2 Day 3-6 ≥ Day 7
<750 gm 100-140 120-160 140-200 140-160
750-1,000 gm 100-120 120-140 130-180 140-160
1,000 - 1,500 80-100 100-120 120-160 150

gm
1,500 - <2,500 60-80 80-100 120-160 150
gm
>2,500 gm 60-80 80-100 90-150
T
H
A
N
K
Y
O
U

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Management of common problems in

2. NUTRITIONAL STATUS - Related to birth weight

3. TOLERANCE - The ability to overcome the

 Central nervous system

AAP Definition of Perinatal Asphyxia

Shunting of blood to Away from

NONE BRAIN ORGAN

• Maintain O2 and CO2 in normal ranges

• Monitor arterial blood pressure

• Administer volume slowly: overall fluid restriction

2. RDS Hyaline Membrane Disease

Federal Democratic Republic of Ethiopia 14

2. CONVECTION - Wrap the baby and control room

3. EVAPORATION - Dry the baby and Control humidity

4. RADIATION - Radiant heater and control room

• 10-30% of women are colonized in the vaginal and

• Most mothers are screened at 35-37 weeks

• is a yellowish discoloration of the skin and or

• In NB jaundice appears when TB > 7 mg /dl

• It could be physiologic or pathologic

• Erythrocyte biochemical defect

• Disorder of hepatic uptake:

• Disorder of enterohepatic circulation

• Other medical managements

• Note: Use Butanic curve for choosing the management

– Infants whole body supported

– Infants head, neck and body should be straight

– Infant facing mother

– Infants body close to mother

Federal Democratic Republic of Ethiopia 28

– Infants whole body supported

Federal Democratic Republic of Ethiopia 29

– Mouth wide open

– Lower lip turned outward

– More areola visible on above than below

– Chin touching the breast

Federal Democratic Republic of Ethiopia 30

– At least 3-5 strong suckling before pausing for breath or rest

– Dimpling of cheeks may be seen while suckling

– Hearing of swallowing gurgle

– Milk may be seen around the mouth leaking out when it is

Federal Democratic Republic of Ethiopia 32

– Go asleep for 2- 4 hours between each

– Will have frequent wet diapers (> 6 times)

– Increase weight daily after 7 postnatal days

Federal Democratic Republic of Ethiopia 33

If any of this signs are present stop feeding and put on

• Babies with necrotizing enterocolities (NEC)

• Mx – Total parenteral Nutrition

full feedings” = Volume: up to 180 ml/kg/d

Gestational age Weight(grams) Initial feeds Progression of

<28 weeks <1000 10 -20ml/kg/day 10-20 ml/kg/day

28 – 32weeks 1000– 1500 20-30 ml/Kg /day Increase by 20-30

32- 34 weeks 1500 – 1800 30/kg/day by NG/CUP Increase by 30

> 34 weeks >1800 30-60ml/kg/day Increase by 35 ml/kg/day

Fluid Rate (ml/kg/day)

Day 1 Day 2 Day 3-6 ≥ Day 7

<750 gm 100-140 120-160 140-200 140-160

750-1,000 gm 100-120 120-140 130-180 140-160

1,000 - 1,500 80-100 100-120 120-160 150