1. Perinatal History
Dr Varsha Atul Shah

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. 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. The Perinatal History
 General Data:
 Maternal Obstetrical History
 Maternal medical History
 Family History
 Social History
 History of labor and delivery

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. 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. 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. Perinatal History:
Amount of amniotic fluid
 Polyhydramnios  premature labor,
neuromuscular diseases,
gut obstruction, hydrops,
CHF
 oligohydramnios  Renal agenesis, pulmonary
hypoplasia

9. Perinatal History:
multiple gestation

10. Perinatal History:Family history
 presence of familial or hereditary diseases

11. Perinatal History:Social History
 civil status, occupation
 social habits: smoking/drinking
 Promiscuity

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. 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. 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. 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

17. The
Newborn

18. The Physical Examination of the
Newborn

19. 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

20. 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

21. 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)

22. 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

23. 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

24. 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

25. Vital signs
 Heart Rate and pulse rate
 Respiratory rate
 Temperature
 Blood Pressure

26. Heart Rate and Pulse rate
 Normal:
 Rate - 110-165 beats per minute regular
rhythm,

27. Respiratory Rate
 Normal:
 Respiratory Rate 40-60 Breath per minute,
regular

28. Temperature

29. 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.

30. Anthropometric measurements
 Head circumference
 Length
 Weight
Cuff
should
cover 2/3
of the
upper arm
BP determination

31. 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

32. 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)


33. SKIN
 Jaundice
 Within 24 hours
 hemolytic
 2-4rth day
 physiologic,
level within normal
 1 week
 breast-milk jaundice

34. NEWBORN PE:SKIN
•Epidermis:
–(-) excoriations/
sloughing
•Hair
–Lanugo
•Texture
–moist and
smooth
•Vernix caseosa

35. NEWBORN PE:SKIN
 Cysts: Milia,
 pinpoint white papules of keratogenous
material usually on nose and forehead
 Vascular pattern:
 harlequin; mottling

36. NEWBORN PE:SKIN
 Papules: Acne
 miliaria
 Desquamation
 Hemangiomas
 Hemorrhages
 Macules
 (mongolian spots)
 and pustules
(erythema toxicum)

37. NEWBORN PE: HEAD
 Normal:
 Caput succedaneum, molding
 Check for :
 overriding of sutures,
 Number and size of fontanelles
 abnormal shape of head
 encephalocoeles

38. Cephalhematomas vs Cephaledema
Cephalhematoma Cephaledema
Limited by suture lines Crosses midline
May increase in size subsides

39. NEWBORN PE: Facies
Needs work up:
Down’s Syndrome
Cornelia Delange

40. Newborn PE: EYES
 Check for:
 colobomas, heterochromia
 cloudiness of cornea
 conjunctival erythema
 exudate, edema, jaundice
 hemorrhages

41. 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

42. Nose
 Check for:
 Flaring
 hyper/hypotelorism
 choanal atresia

43. NEWBORN PE: MOUTH
Check for:
High arch palate
Cleft/lip palate
Macroglossia
Micrognathia

44. 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

45. NEWBORN PE: NECK
 Normal:
 Check for : Dimple or webbing

46. NEWBORN PE: CHEST
 Check for: paradoxical, periodic,
(+) retractions
 Symmetry
 Apnea, retractions
 (+) grunting, (+) Flaring of alae nasi
 bowel sounds
 decreased air entry
 Paradoxical, preriodic

47. Check for air entry
Anterior, mid-axillary, posterior

48. 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

49. Palpating the pulses
Palpate brachial and femoral together: simultaneous arrival or
slightly earlier arrival of femoral pulse
In coarctation: brachial stronger than femoral

50. NEWBORN PE:ABDOMEN
 Normal:
 Shape cylindrical,
 (+) diastasis recti ,
 amniotic or cutaneous
navel

51. NEWBORN PE:ABDOMEN
 Check for:
 Distention, scaphoid abdomen,
umbilicus granuloma,
 hernia, inflammation,
less than 3 cord vessels

52. NEWBORN PE:ABDOMEN
 Check for:
 Gastroschisis, omphalitis,
 omphalocele

53. NEWBORN PE: LIVER
 Normal:
 Smooth edge
 normally palpable 1-2 cm below the costal margin

54. NEWBORN PE: SPLEEN
 Normal:
Nonpalpable

55. NEWBORN PE: KIDNEYS
 Normal:
(Bimanual palpation) -
Palpable
 Check for enlarged kidneys

56. NEWBORN PE: MALE GENITALS
 Normal:
 Edema, hydrocele, phimosis
 Check for:
 Bifid scrotum,
 cryptorchidism,
 inguinal hernia,
 chordee,
 hypospadia,
 microphalus

57. NEWBORN PE: FEMALE GENITALS
 Normal:
 Mucoid or bloody
secretion, edema,
gaping labia,
hymenal tag
 Check for
 ambiguous,
 hydrometrocolpos

58. NEWBORN PE: ANUS
 Normal:
 Perforate
 Check for
 imperforate,
 coccygeal dimple,
 fistula

59. NEWBORN PE: MUSCULOSKELETAL
 Normal: fetal posture
(flexor position of comfort)

60. NEWBORN PE: MUSCULOSKELETAL
 Check for:
 Cortical thumb,
 overlapping fingers,
 short incurved little finger,
 hip subluxation, decreased
range of motion
 Polydactyly/syndactyly

61. 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:

62. 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”

63. 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”

64. 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

65. NEWBORN PE: CNS
 State:
 Awake - alert, crying,
active
 Asleep -
indeterminate, quiet


66. NEWBORN PE: CNS
 Motor:
Posture - Flexor, symmetric
 Tone - obtuse popliteal angle
 Movement - all extremities, nonrepetitive,
random, symmetric

67. NEWBORN PE: CNS
 Reflexes: Deep tendon, grasp, moro,
placing, stepping, sucking, tonic neck,
trunk incurvation
 Sensory: 2-3 seconds pin prick
response
 Cranial nerves

68. 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

69. Lesions that resolve spontaneously
 Harlequin change
 Breast enlargement and Witches’ milk
 Hydrocoele
 Vaginal discharge
 Mongolian spots
 Umbilical hernia

70. The Care of the
Newborn
PFD. Isleta, M.D.
for
Level V - UPCM

71. 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

72. 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

73. Cardio-pulmonary adaptation

74. Initial management
• ABC,s: Airway, Breathing, Circulation
• Temperature control
• Cord dressing
• Bonding

75. 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

76. Nursery Care
 Bathing and dressing
 Umbilical cord care
 Feeding
 Voiding and stooling
 Behavior
 Color

77. Bathing and dressing

79. Thermoregulation

80. Latching on mother’s milk

82. 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

83. 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

84. 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

85. 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

86. Well Baby
 AOG 38-42
weeks,
 AGA
 delivered
vaginally,
 Apgar score
>/= 7

87. Normal Values
 Anthropometric:
 Weight: 2.5-4.00
 Length: 45-55
 HC: 32.6-37.2
 BP: AOG related

88. Normal Values
 Cardiac system:
 Heart rate: 120-160 BPM
 Rhythm: regular, sinus
 EKG: sinus rhythm, RV dominant

89. 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

90. 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

91. Normal Values
 Renal:
 urine output = 1-2 ml/kg/hour
 Sp. Gravity = 1.005-1.015
 Passage of urine= 1st 24 hours

92. Normal Values
 Gastrointestinal:
 meconium passage
 enzyme

93. Normal Values
 Metabolic:
 electrolytes
 calcium
 blood sugar

94. 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

95. Sick Baby
• Abnormal VS,
• Congenital
anomaly
requiring
surgery
• IU infection
• Asphyxiated

96. Diagnostic work-up
 CBC, retic, coomb’s
 Mother’s and Baby’s Blood Type
 ABG
 ECG, 2-D Echo
 Chest X-Ray
 Hepa profile

97. ECG

98. Chest Xray
Cardiac shadow
Perfusion
Aeration
Air in bowel
Bones

99. 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+”

100.  What are the High Risk Factors?
 What problems are you anticipating

101.  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

102. 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?

103. Discharge planning
 Normal Vital signs
 Thermoregulated
 Feeding well
 Adequate weight gain
 Family relationship

105. METABOLIC
ADAPTATION IN THE
NEWBORN
UPCM LEVEL V

106. 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

107. 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.

108. 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

109. 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)

110. 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

111. 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

112. 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

113. Hypothermia: cold injury
Temperature < 35oC or 95oF)

114. HYPOTHERMIA
VASOCONSTRICTION
FLEXION
Heat production
physical Glycolysis
WORK
metabolic Lipolysis
Oxygen debt
Acidosis
EXHAUSTION

115. 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.

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

117. 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.

118. 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.

119. 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).

120. Ways by which body heat is lost

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

122. 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.

123. 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

124. 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

125. NEONATAL COLD INJURY
 DIAGNOSTIC WORK-UP
 Serum sugar, ABG(metabolic acidosis)
 TREATMENT:
warming,
correct electrolyte disturbances

126. 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.

127. 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).

128. 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.

129. External heat sources:
Servo Control Radiant Warmer
Incubator
Portable Mattress
Heat Lamps
* Maintain with cautious use of heat
source*

130. 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

131.  Even under a radiant
warmer
heat loss by
evaporation may still
occur
when baby is
open to
atmosphere

132. 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.

133. REMEMBER:
* Preventing heat loss is much easier
than overcoming the detrimental
effects of cold stress once they have
occurred.*

134. HYPERTHERMIA
 Transitory Fever or dehydration fever
 Birth History: uneventful perinatal events and
immediate postnatal course, breast fed

135. 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

136. HYPERTHERMIA
PE: Restless,
with precipitous drop in weight
Fontanelle depressed, skin less elastic,
Tachycardic,tachypneic

137. HYPERTHERMIA
 Diagnostic work-up
 Increased serum protein, Na and Hct
 Treatment
 Oral or parenteral fluid
 Lower environmental temperature

138. 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

139. 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

140. Changes in Energy requirements
 Abrupt termination of supply of energy at birth:
provision of exogenous nutrients
mobilization of endogenous fuel and
mineral stores

141. Changes in Energy requirements
 Impaired energy supply and utilization:
hypoglycemia
hyperglycemia

142. 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

143. 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

144. 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

145. 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.

146. 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.

147. 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.

148. 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.

149. 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

150. Fluids and Electrolytes
 Changes in fluid requirements
Insensible
fluid loss
respiratory tract,
skin,
gastro-intestinal tract
Urine loss

151. Fluids and Electrolytes
 Abnormal Fluid accumulation: edema
third
spacing

152. 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

153. EDEMA
 Associated with syndromes
 Congenital lymphedema (Milroy’s)
 Turner’s syndrome
 Congenital nephrosis
 Hurler’syndrome

154. Electrolytes: Calcium metabolism
 Placental active transport
 Parathyroid hormones and calcitonin do not
cross placenta
 25-hydroxyvitamin-D passes the placenta

155. 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 `

156. HYPOCALCEMIA(TETANY)
 Diagnostic work-up
 Treatment:
2 ml/k of 10% calcium gluconate

157. 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

158. Osteopenia of prematurity
Treatment:
Immobilization of fractures
Administration of calcium, P and Vit D

159. HYPOMAGNESEMIA
 Definition:
Serum Mg levels <1.5 mg/dL or 0.62 mmol/L
 Normal values

160. HYPOMAGNESEMIA
 Contributing factors/causes:
Associated with hypocalcemia Deficient
placental transfer Decreased intestinal
absorption Neonatal
hypoparathyroidism Hyperphosphatemia
Renal loss
Impaired homeostasis

161. 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

162. HYPERMAGNESEMIA
 Definition: serum level > 2.8 mg/dL (1.15)
mmol/L)
 Causes:
> Maternal treatment with MgSO4 for
preeclampsia, > delayed passage of
meconium

163. HYPERMAGNESEMIA
 PE:
> CNS depression:lethargy, flaccidity,
hyporeflexia
> respiratory depression: hypoventilation
> hypotension

164. 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

165. LATE METABOLIC ACIDOSIS
 Diagnostic work-up
 ABG: BD= -10 to –16 mEq/L , PCO2 <40
 Due to abnormally high rate of endogenous
acid formation

166. LATE METABOLIC ACIDOSIS
 Treatment:
 NaHCO3
 Change formula to lower protein content with
whey to casein ratio of 60:40

167. SUBSTANCE OF ABUSE ANJD
WITHDRAWAL
 Heroin
 Methadone
 Alcohol
 Phenobarbital
 Cocaine
 Fetal alcohol syndrome

168. 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