1. SOME ASPECTS IN Neonatal Management BY: RUBANA BAABBAD MD CONSULTANT NEONATOLOGIST

2. Contents: Resuscitation Resuscitation APGAR Score APGAR Score Management of Premature Infant Management of Premature Infant Management of Infant Diabetic Mother Management of Infant Diabetic Mother Premature vs dysmature Premature vs dysmature

3. Delivery Room Resuscitation ANTICIPATION & RECOGNITION OF NEONATE IN DISTRESS: Primary Apnea: due to brief hypoxia Recovers with stimulation and oxygen supplement. Secondary Apnea:with prolonged hypoxia. Requires assisted ventilation and oxygen. Assume all times that it is secondary and resuscitate immediately.

4. Goals of Resuscitation: 1) Minimizing Immediate Heat Loss 2) Establishing Normal Respiration and Lung Expansion 3) Increasing Arterial PO2 4) Supporting Adequate Cardiac Output

5. STEPS FOR EFFECTIVE RESUSCITATION Preparation:pediatric team should be present Preparation:pediatric team should be present a)identify high risk deliveries : fetal distress,fetal disease or serious conditions like meconium,prematurity,post- maturity abnormal fetal wt.,major anomalies,hydrops,multiple gestation, cord prolapse,abruptio placentae. a)identify high risk deliveries : fetal distress,fetal disease or serious conditions like meconium,prematurity,post- maturity abnormal fetal wt.,major anomalies,hydrops,multiple gestation, cord prolapse,abruptio placentae. Labor &delivery conditions: like Labor &delivery conditions: like APH.,abnormal presentation,difficult labor APH.,abnormal presentation,difficult labor

6. NO PEDIATRIC TEAM REQUIRED:PERSONNEL FOR EVALUATION neonatal conditions :unexpected congenital anomalies,respiatory distress,unanticipated neonatal depression. Maternal conditions: signs of maternal infection maternal illness e.g.DM,isoimmunization,PET,renal, endocrine, pulmonary,or cardiac disease.

7. NESSESARY EQUIPMENT 1. Radiant warmer 2. Oxygen source 3. Self inflating bag with reservoir or anesthesia bag 4. Face mask with appropriate size 5. Suction 6. Stethoscope 7. Emergency box: laryngoscope, batteries ET. Tubes,drugs:epinephrin(1:10000),NaHco3 4.2%, Naloxon, albumin, and NaCL 0.9% 8. Umbilical catheterization tray 9. Syringes, needles, t-connectors, and stopcocks 10. Transport incubator with batteries 11. Pulse oximetry

8. Begin a process of evaluation,decision,and action. decision decision action action evaluation evaluation Place on warm table Place on warm table Dry &discard the wet linens+extra warming Dry &discard the wet linens+extra warming Positioning Positioning Suction the mouth, oropharynx, and nares (avoid deep pharyngeal suction Suction the mouth, oropharynx, and nares (avoid deep pharyngeal suction

9. EVALUATION&ACTION Evaluate for: Evaluate for: color: cyanosed ------oxygen color: cyanosed ------oxygen Respiratory distress: signs? Respiratory distress: signs? Indications of bag and mask ventilation: apnea, HR< 100 Indications of bag and mask ventilation: apnea, HR< 100 Rate, press, technique Rate, press, technique indication for intubation, ET size & suction catheter sizes. indication for intubation, ET size & suction catheter sizes.

10. TUBE SIZE Wt.of infant ETsize Suction catheter size <1000 gm 2.5 5-6 fr 1000 -2000 gm 36 2000 – 3000 gm 3.58 >3000 gm 48

11. CHEST COMPRESSIONS Indications: if after 15-30 sec of +ve press ventilation 100% O2 & HR<60 / 60-80 bpm & not ↑ Indications: if after 15-30 sec of +ve press ventilation 100% O2 & HR<60 / 60-80 bpm & not ↑ Technique : 1 finger breadth below nipple line, using 2 fingers compress 1-2 cm 90\ min ratio 3:1 cc to vent. Technique : 1 finger breadth below nipple line, using 2 fingers compress 1-2 cm 90\ min ratio 3:1 cc to vent.

12. Medications used for resuscitation Indications: Indications: Bradycardia with HR < 80 BPM despite adequate ventilation with 100% O2 and chest compression for mini. Of 30 sec or HR=0 Bradycardia with HR < 80 BPM despite adequate ventilation with 100% O2 and chest compression for mini. Of 30 sec or HR=0 Epinephrine Epinephrine Volume expanders Volume expanders Naloxone hydrochloride Naloxone hydrochloride NaHCO3 NaHCO3

13. Dosage Chart Epinephrine 0.1~0.3 ml/kg 1:10,000 Volume expander 10 ml/kg NS./albumin,RL./BLD NaHCO32mEq/kg 0.5 mEq/ml Naloxone Hydrochlori- de 0.1mg/kg 1mg/ml or 0.4 mg/ml

14. Special resuscitation efforts Meconium present at delivary Meconium present at delivary Diaphragmatic hernia Diaphragmatic hernia

15. APGAR SCORE DEFINITION: an assessment of the newborn’s physical condition immediately after birth ; involve HR,respiratory effort,color, muscle tone & reflex. DEFINITION: an assessment of the newborn’s physical condition immediately after birth ; involve HR,respiratory effort,color, muscle tone & reflex. Devised in 1952 by VERGINIA APGAR the American anasthatologist Devised in 1952 by VERGINIA APGAR the American anasthatologist The score range from 1-10 The score range from 1-10 Calculated at 1&5 min. & if <7 to be repeated every 5 min.up to 20 min. Calculated at 1&5 min. & if <7 to be repeated every 5 min.up to 20 min.

16. Apgar scoring system sign012 HRabsent < 100 bpm > 100bpm Resp.effortabsent Slow/ irregular Good crying Muscle tone limp Some flexion of the extremities Active motion Reflex irritability No response grimace Cough/ sneeze colorBlue/pale Pink body,blue extremities All pink

17. Definition of dysmaturity 1. Characteristic of faulty embryologic development, often leading to structural and/or functional abnormalities. 2. Relating to or characteristic of an infant whose birth weight is inappropriately low for its gestational age

18. Premature vs. Dysmature > 20wks.& 20wks.&< 37 weeks Incomplete organ system development Incomplete organ system development thin shiny skin,extended arms and legs,little subcutanous fat,spase hair few palmar and sole creases,poorly developed ear cartilage,genitalia boys few rugae undescended testicles- girls gaping labia prominent clitoris thin shiny skin,extended arms and legs,little subcutanous fat,spase hair few palmar and sole creases,poorly developed ear cartilage,genitalia boys few rugae undescended testicles- girls gaping labia prominent clitoris postmaturity syndrome: a syndrome due to placental insufficiency that causes chronic stress and hypoxia, seen in fetuses and neonates in postterm pregnancies, characterized by decreased subcutaneous fat, skin desquamation, and long fingernails, often with yellow meconium staining of the nails, skin, and vernix. postmaturity syndrome: a syndrome due to placental insufficiency that causes chronic stress and hypoxia, seen in fetuses and neonates in postterm pregnancies, characterized by decreased subcutaneous fat, skin desquamation, and long fingernails, often with yellow meconium staining of the nails, skin, and vernix.

19. The Premature infant The premature infant is quickly transferred from the warm fluid medium of the liquor amnii with its practically constant temperature to the variable circumstances of an extrauterine life; he/she loses the preparatory transition-time of the third trimester of intrauterine existence. The premature infant is quickly transferred from the warm fluid medium of the liquor amnii with its practically constant temperature to the variable circumstances of an extrauterine life; he/she loses the preparatory transition-time of the third trimester of intrauterine existence.

20. Problems of prematurity Thermoregulation Thermoregulation Respiratory distress Respiratory distress Apnea Apnea Sepsis Sepsis poor sucking& swallowing reflex poor sucking& swallowing reflex Neurologic Neurologic Cvs Cvs Hematologic Hematologic Nutritional Nutritional Gastrointestinal Gastrointestinal Metabolic Metabolic Renal Renal Immunologic Immunologic opthalmologic opthalmologic

21. Management of premature infants Thermal regulation Thermal regulation O2 therapy & assissted ventilation O2 therapy & assissted ventilation PDA PDA Fluid& electrolite management Fluid& electrolite management Nutrition Nutrition Hyperbilirubinemia Hyperbilirubinemia Infection Infection immunization immunization

22. Management of infants of diabetic mothers Evaluation: before delivery : size, pulmonary maturity, obvious anomalies Evaluation: before delivery : size, pulmonary maturity, obvious anomalies After delivery: Apgar score, physical examination for major congenital anomalies After delivery: Apgar score, physical examination for major congenital anomalies In the nursery: continuous evaluation repeat the examination, monitor blood glucose, hematocrit, calcium & bilirubin levels. In the nursery: continuous evaluation repeat the examination, monitor blood glucose, hematocrit, calcium & bilirubin levels.