LMCC Review Course: “Neonatology” Gregory Moore, MD, FRCPC Division of Neonatology April 2010

Outline 1. Resuscitation principles 1. Transition to ex-utero life 2. Normal newborn care and assessment 3. Small and Large-for-Gestational Age neonates and their problems 4. Prematurity and its complications 5. Problems of the term infant

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: /min * RR: 40-60/min * BP: 50-80/30-40 mmHg Sats: >95% by ~1 hr of age *

For Starters … Gestation (wks) Birth Weight (kg) (2.5 – 4.5)

Newborn Resuscitation  Initial steps: warm, dry, ‘stimulate’  Evaluate respirations  Evaluate heart rate  Evaluate tone  Evaluate color  Remember - the key to a baby’s transition to the real world is ‘opening’ the lungs: VENTILATION  Oxygenation

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-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-utero 4. Ductus arteriosus closes

Fluid-filled alveoli in utero Diminished blood flow in-utero through fetal lungs

Importance of first breath

The End Product

Neonatal Resuscitation Program

90% of babies

9% of babies

0.9% of babies

0.1% of babies

Newborn Resuscitation  A: Airway  B: Breathing  C: Circulation  D: Drugs  E: Environment  F: Fluids  G: Glucose  “IV, O2, Monitor” … if distressed

NB. Newborn Resuscitation  MECONIUM in the amniotic fluid AND depressed newborn (not crying, limp): Intubate and suction below cords FIRST Intubate and suction below cords FIRST  Suspect diaphragmatic hernia: Intubate ASAP Intubate ASAP  Pink when crying … blue when not: Suspect choanal atresia and try an oral airway Suspect choanal atresia and try an oral airway

The Apgar Score

 Ensure warmth and early nutrient intake  Support breastfeeding  Monitor weight and hydration status  Educate about infant care **  Anticipatory guidance ** Principles of Routine Care

 Prophylaxis for common problems Eye care: erythromycin ointment Eye care: erythromycin ointment Vitamin K: 1 mg IM Vitamin K: 1 mg IM  Screening 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, Hgb’pathies’, CAH, galactosemia, endocrinopathies)24 other diseases (OA/AA/FA disorders, SCA, 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 negative

The Newborn History Identification Identification 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, antenatal steroid use)Current pregnancy (including screening test results, antenatal steroid use) Family History Family History Social History Social History Labour and Delivery History Labour and Delivery History Resuscitation History Resuscitation History Early Postnatal Course Early Postnatal Course

Physical Examination  Vital signs  Measurements  plot!  Gestational age assessment  Overall appearance (well/unwell)  System by system (or head to toe) **

The depressed newborn  Neurological: Asphyxia, CNS Trauma Asphyxia, CNS Trauma  Respiratory: Apnea (secondary) Apnea (secondary)  Cardiovascular: Hypovolemia/shock/hydrops Hypovolemia/shock/hydrops  Congenital: Malformations Malformations  Drugs

The 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 Asphyxia - Must be documented by cordocentesis, fetal scalp blood sampling, cord blood sampling  pH 15 mEq/L  Apgar less than 5 at 5 minutes  Encephalopathy  Multiorgan involvement (heart, kidneys, marrow, liver) - Neonatal encephalopathy must be documented for perinatal asphyxia to be considered as a cause of later neurodevelopmental problems

Most common anomalies noted on initial exam