a 01 NORMAL NEWBORN Definitions 00:00:28, * Newborn period : First 4 weeks after birth, First week > early newborn period, Next 3 weeks — late newborn period. * Average birth weight in India ‘bd hy £45 kg! Low birth weight. <1S kg! Very low birth weight. <1 Kg + Extremely low birth weight. * Big baby/macrosomia ? 4 kg at time oF birth, Birth weight should always be interpreted with gestational age using intrauterine growth chart. Lower reference curve + 1o™ percentile. Upper reference curve + 90" percentile. Baby weight above 90" percentile : Large for Gestational Age Len). Baby weight between 90" percentic and Io" percentile : Appropriate for Gestational Age eA). Baby weight below Io" Percentile : Small for Gestational Age Small for gestational age sienna’ 00:04:25 Types s ’ , i |. Normal variant : Aka. Constitutional SEA (more common). a.1UGR (intrauterine growth restriction/retardation) —> i Always associated with pathology. Paediatrics + v4.5 * Marrow 6.6 + 2023Bee F 01 ‘eoeds ennoy Points to difSerentiate IUGR from constitutional SEA + lueR babies * Have loose skin Folds (atleast 2). * Placento/umbilical cord appears thin. * Head circumference 727 chest circumference Gifference 7 3 em). Note! Normal difference between head and chest circumference ot birth is 3 om. 1 luge? Mokernal cause (more common) |e of utero- placental insufficiency like Gestational HTN. Fetal couse genetic defects, anomalies. Lote (a™ or 3%) trimester. Early O°) trimester. Grain sparing, Head size is Normal § Rest of the body is Small, called Asymmetric WUeR. Note + rain sparing + No brain sparing (because of early onsed). Every part of the body undergoes growth restriction + Symmetrical luge. Lake trimester — placental insufficiency — blood supply 1 nutrient delivery to the baby | — undergoes adaptation ™ Brain sparing @rain development not affected). To distinguish between symmetric § asymmetric IUGR # Ponderal index (pp) - Wear @ _ length Com)? PL? a+ Symmetric luge, Pl < a+ Asymmetric IueR, Paediatr * 100 v4.5 + Marrow 6.6 + 2023,CE EEE O41 NormalNewborn = 3. Large for gestational age 00:12:21 Birth weight > 90" percentile. Causes : 1. Constitutional L@A/ normal variant. a. Infant of Diabetic mother (gestational diabetes). 3. SOTOS syndrome (cerebral gigantism) : * Intellectual disability. * Premoture tooth eruption. * Developmental delay, 4. Beckwith-Wiedemann a tongue Omphalools syndrome. Penny Macroglossia. Tnjonts Antestines ; Uvex er Anterior abdominal defects. like Omphalocele § Umbilical often orgons giiok oukeide of tea, bedly Arocugh tee hernia. E belly button - Hemihypertrophy, i Increased risk for Wilms’s 5 tumor. Seckwith-wiedeman syndrome. Assessment of maturity A (00:16:25 Newborns ore divided into Preterm, Term and Post-term babies according to the gestational age. Gestational Age < 3 weeks + & days : Pre term baby, 37 weeks to 41 Weeks + 6 days + Term baby. 2 42 weeks : Post term baby. Gestational age is calculated From LP. Post notal assessment of Gestational age is done using Expanded New Bollard Score (ENeS). Criteria + 1, Physical maturity, a. Neuromuscular moturity, ‘Active space Range of gestation : 40 weeks 10,44 weeks. Total Score range: -I0 to +50; Recuracy ' +1 week, Paediatrics » v4.5 + Marrow 6.5 + 2023ae 0% Differentiating points based on physical appearance : Preterm Term ' Posture: ‘Extension. Flexion. tone. ood tone. (Attitude of universal Mlexion) Sear? sign Positive (Flexed elbow Negative (Flexed elbow crosses midline): | tone, | does not cross midline) : | 00d tone. | Greost buds/ | Smm | nodule. ‘ | external Serotum: Appears light | Serotum : Pigmented. Genitalia : mole | very less/absent rugae. | Rugae ++. Testis not palpable (as it | Testis palpable. descends by 3 weeks ). External Labia. majora. and Labia majora is Genitalia: minora. are visible. Visible (it covers labia. | Female minora). Eas recoil Slow (elastic cartilage not | Fast (well developed well developed). elastic cartilage). Lonuge hair | Abundant. Sparse/absent. [Getai hair) : Points to identify post term baby : | meconium staining over nails, fingers § body. After 42 weeks, anal sphincter opens in-utero. 8. Overgroun fingernails. 3. skin wrinkles (d/t decrease in amniotic Suid), Paediatrics + v4.5 + Marrow 6.5 » 2023ea ee LL 02 ROUTINE NEWBORN CARE Routine newborn care . 00:00:25 At birth : S cleans. * Clean hands § wear Gloves. * Clean surface (towel used to receive babies should be clean and warm). * Clean scissors/ blade Gor cutting umbilical cord). * Clean cord clamp. * Clean cord (It should be kept dry). Delayed cord clamping + * Delayed clamping by 30-60 seconds after birth. * Advantages * a. f amount oF blood Slowing From mother to baby vio. placenta which | risk of anemia. in'later life. b. In Preterm babies : | risk of intraventricular hemorrhage. fe Prevention of hypothermia # * Delivery room temperature at a5°C. * No free draft of air in the delivery room. * Facilitate skin to skin contact of baby and mother. Breastfeeding : Should be started as early as possible after birth. Rooming-in 3 * To keep the baby and the mother together, Facilitates * Also helps in exclusive breastfeeding, j Prophylaxis at the time of birth + * vitamin 1+ Given Im in anterolateral aspect of thigh. Paediatrics + v4.5 + Marrow 6.5 + 2023,eK lc ie y 02 Dose #1 mg, IF weight <1 kg (LOW) # 0.5 mg, Activates clotting factors a,7,9,0, Prevents hemorrhagic disease of newhorn, Normal observations in newborn 00:05:58 Vital signs : * Temperature ! 305°C to 318°C. * Heart rate + lO-160/min, * Respiratory rate : 40-60/min, * Blood pressure : 60/40 mm ha, CFT Capillary filing time) : Normal: <3 secs, Measure of circulation in the body. Checked over bony Prominence, Preferred site is over sternum, . Normal findings in newborn : Skin and mucosa : Erythema. toxieum Exythema. toxicum is a misnomer. Now called erythema, neonatorum, Erythema toxicum/ | Pustular melanosis neonotorum, (more common) Red populo-pustular Hyperpigmented lesions. Appears after | patches + pustules. a4 hours, Appears within a4 Paediatrics + v4.5 + Marrow 6.5 » 2023— iz" 02 Routine Newborn 7 Care a. eect of maternal estrogen : * white discharge per vagina (mucus From cervin). * Breast engorgement. ® Bleeding per vagina (due to withdrawal of maternal estrogen leading to endometrial sloughing). 3, Epithelial inclusion cyst/Retention cyst tj Appears white : White spots/ milk spots. *® Face § around the nose ! milia. * Gums : Bohn's nodules. * Polote : Epstein pearls. 4. Mongolian spots + * Hyperpigmented macules. * Common in Indian § Asian people. S. Salmon patch/strawherry angioma/ stork bite/nevus Slammeus * * Bright red coloured lesion. * Seen in forehead § nape of neck. Mongolian Phimoala wv ; Tnobility to Subnock tee Ska preckh or Peper) covering tha: huod Cgloni) | te eee Salmon patch Other normal findings + * Small subeonjunctival/retinal hemorrhages. hile passing through birth cana). * Hymenal skin tags in female babies. * Physiological phimosis in male babies. Reassurance is the only treatment required for all normal new born findings. ‘Active space Paediatrics + v4.5 » Marrow 6.5 + 2023— : — 02 Head swellings in newborn Caput | Cephalohematoma. succedaneum (more common) Location | Subcutaneous ‘Sub periosteum plane. Deep swelling, Localised Guperficial swelling | Cimited by sutures). in scalp). m/c location : Parietal Diffuse. bone Reason Prolonged labour—> | instrumental delivery—> Congestion of scalp | Trauma. to skull veins Edema. Appear- | At birth/soon after Slowly increases over a. once birth. period of 1a-a4 hours ofter birth. Disap- a-3 days. 3-6 weeks. [pearance Associa— Negotive S-aS% cases : Linear tions 9” skull Fractures, jaundice é haem break down fet Forming bilirubin) Coput suecedaneum ae Galeal oponeurosis Periosteum Coput succedaneum lea ‘aponeUsOss forces Periosteum Cephabineinatona, Pagdiatrics + v4.5 » Marrow 6.5 * 2023‘a | z= Q2 Routine Newb Care Cephalo-hematoma Subgaleal hemorrhage (most severe) ! * Hemorrhage beneath galea aponeurosis. * Associated with vacuum assisted delivery. * diffuse accumulation of blood * Hypovolemia— shock. * Palior Gue to decreased circulating blood volume). * Jaundice (ysis of RECs). Head swellings summary * [superRei diffuse collection of Syid | Caput succedoneum ‘Superficial, diffuse collection of blood. Subgaleal hemorrhage beep, localized collection of blood Cephalohematoma Active space Paediatrics + v4.5 + Marrow 6.5 + 202302 Neonatal reflexes ee 22 Generally present during the newborn period but with Few exceptions. Also called primitive/immature reflexes (Disappear ofter brain matures). a Reflex Onset Fully Duration | developed | Palmar orasp | a8 weeks | 3 weeks of | a-3 months reflex of gestation. after birth. gestation, Rooting reflex | a8-3a 34-36 weeks | Less prominent weeks of | of gestation. | by | month | gestation. after birth, | Moro reflex | a8-3a 31 weeks of |S-l months — | weeks of | gestation oSter birth. gestotion. | (term). Asymmetric | 3sth week || month 6-7 months tonic neck | of gestation | (Postnatal) | after birth reflex Porochute I-8 months |10-ll months | Persists © reflex onrtad Ahroughout life 4 | | qi Rooting reflex + Palmar grasp retiex, Stimulotion of the baby's mouth causes the mouth to turn in the direction of the stimulus. Helps in ottachment 4 sucking, during initiation of breast feeding Rooting reson. Paediatrics + v4.5 » Manow 6.5 + 2023= -_ =z * O2 RoutineNewborn 11 Care Components of moro reflex + Abduction § extension followed by adduction § Slexion + ory, Complete moro + Seen only in term babies. moro reflex Abnormalities in moro reflex : : * Absent moro reflex! > Baby bern with on underdeveloped basin 4 an Anomalies like anencephaly, | incornplcta. Skull. stage 3 Hypoxic ischemic encephalopathy (Hie). 4 * unilateral moro reMlex Nerve injury (brachial plexus igjury e.g, erb’s palsy). Bony igjury like Fractures /dislocation(Ghoulder dislocation). m/c fracture at time of birth + Fracture clavicle. * Persistent Moro : Persists even ofter lo months + Immaturity oF brain cerebral palsy). Asymmetric tonic neck reslex (ATNR) + if head of the baby is turned to one side, the upper limb on the same side willl extend, while the other upper limb becomes Slexed Asymmetric Tonie Neck Reslex Reflexes appearing after birth/ Infantile reflexes 00:39:56 mnemonic : SPL Gpecial) Parachute reflex + * Protective extension reaction i Sorward, a ¥ i * Prevents head from hitting the i ground while Falling, down. : * Persists throughout life. ‘ Forward Parachute Reflex Paediatrics + v4.5 * Marrow 6.5 * 2023es eonatology 02 Symmetric Tonic Neck Reflex (STNR) # Also called crawling reflex (helps in crawling). * Neck extension — Upper limb extension 4 lower limb Slexion. Neck flexion > Upper limb Slexion § lower limb extension, Appears by 4 - & months after birth. Duration + 8-14 months after birth. ‘Symmetric Tonic Neck Reslex Londou reflex : On horizontal suspension, * Alexion of neck — Slexion of limbs, * Extension of neck — Extension of limbs, Appears : 3 months after birth, Duration + 9 months after birth Paediatrics + v4.5 + Marrow 6.5 » 2023nr i lle 03 Management of LBW Babies MANAGEMENT OF LBW BABIES Care of LBW babies 00:00:30 Reasons for Lew (Low Birth Weighd : 1. Preterm babies (developed countries). a. 1UGR/grousth restriction (developing countries) > SEA babies (Small for Gestational Age). m/c problem of Law babies Hypothermia. Temperature regulation in a. new born # * Normal: 305-375 °C. * Site of measurement : Axilla. For precise recording —> 6ulb of thermometer should be placed over roo? of dry axilla for a minimum oF 3 min, while holding the axilla. close to the babys body, Modes of heat loss in a new born # Conduction heat loss + Baby will lose heat when Placed on a. cold surface. a. Evaporative heat loss + by sweating, 3, Convection heat loss : Air current or air Slow around, the baby, causing heat loss. 4, Radiotion heot loss + Heat From baby radiating +o the roo?/walls of the room. modes of heat loss in a. newborn Most important mechanism of heat loss : Radiation heat loss. most important site of heat loss : Head (larger body surface oreo). Hence, baby's head must be covered to prevent excessive heat loss, ‘Active space Paediatrics + v4.5 * Marrow 6.5 * 2023ee ll y 03 LOW) babies more prone to hypothermia, than normal Weight babies : Greoter surface oreo of head loss Low brown Fot Less body Fat > Less insulation > Heat loss Lew babies (preter ‘extension posture > More eel heat loss). Normal weight babies erin) Lesser surface area of head Flexion posture (protects from More brown Fat more body fot ‘Skin more permeable to heat loss Sources of heat production Skin less permeable 00:06:34 \. Increased physical activity + Crying/movements of limbs > muscle contraction > Increased heat production, @. Symphothetic surge # Cold exposure > Stress > release of sympathetic hormones — Increased heot production via brown Fat. Brown vs white adipose tissue + & e- Uusrte adpooyte ——erounetpoayte one large fat vacuole. _| Small Fok vacuoles Less mitochondria. More mitochondria, Coroun coloured structures) Less vascularity ‘Less nerve innervation More nerve innervation Guympathetic nerves) Grown Fok cells + Specialized structures present in new born Which helps in heat production, ‘cords OnNIOY Location oF brown Sox + * Nope/back side of neck (m/c), Pagdiatrics + v4.5 » Marrow 6.5 + 2023EEE EE EEE” Q3 Managementof 15 LBW Babies * Interscapular region. © Pxilla/groin region. * Peri-renal areas. Non-shivering thermogenesis 00:10:35 Mechanism of generation of heat in a new born, without shivering, with the help of brown Fat tissue. Normally in a fat cell : Oxidation couples with phosphorylation Coupling reaction) to produce ATR. exposure to cold Stress { Sympathetic surge Release of sympathetic hormones (norepinephrine # m/c) uncoupling reaction (oxidation does not end in phosphorylation) Diverts oxidation towards heat generation Hypothermia (< 305°C) : Normal temperature * 30S-37:S°C. Classification Cold stress Doce Severe Ge-20.4°C) hypothermia, hypothermia @a-30°C) OG Ve 28°C) becomes cold Prevention of hypothermia. : i Hemodynamically stable baby * * Gently cover the baby (especially the head), * if LeW/preterm > Kangaroo mother care Paediatrics + v4.5 « Marrow 6.5 + 2023eoeds ennoy to baby > Protects baby from \. Position + Posture of baby Vertical or uprig 3 Early discharge of baby (due to Cause of contact with mother). Duration + Variable (can be upto a4 hrs). Long duration : most preferred, Fi leaagai t . When baby weighs > as kg (Lew). Hemodynomically unstable babies : Monoged in NICU Weonatal cu), Rodiont Warmer @y radiation of Heat generated over the surface > & the boby, & Incubator (By convection of heat excl chamber, Paediatrics «v4.5 » Marrow 6,5 + 2023TC zs 03 Management of LBW Babies Radiant warmer and Incubator Nutrition of LBW babies 00:22:20, It depends on gestational age. < a8 weeks of gestation (extremely premature) : Total parenteral nutrition (TPN) as Iv Sluids, No enteral feeding as gastrointestinal tract is not developed completely, Preferred Iv Suids : * <48 hours : 10% dextrose. * 2 48 hours : Isolyte-P. Amount of IV Suids to be given : Initial dose : /o-80 mi/ko/a4 hours. Increase by 10-20 mi/kg everyday. Maintainence dose + Upto ISO mi/Ko/a4 hours. 88-32 weeks of gestation + * Only suckling burst seen Guckling + swallowing + breathing coordination not completely developed). Expressed Breast milk (6m) given carefully, * Baby may aspirate Nesagactre tube i neuboens 6m if given by mouth directly, Therefore £8M given through nasogastric tube/ orogastric tube. * Length of insertion of NG, tube : Nose to ear lobule to ear lobule to midpoint be- 4ween xiphoid sternum § umbilicus should be measured, marked § then inserted, 7 1 J ‘ Paediatrics + v4.5 « Marrow 6.5 + 2023ee ‘eoeds oAOY 03 3a-34 weeks of gestation + Coordinotion better developed, 28M with a paladai or Katori spoon. 7 34 weeks (completely develo Ne Paladai coordination) * Nutritional supplements 00:31:21 weight ] Supplements All bobies vitamin D (400 Iu/day # Orally For | year). Is- akg Vitamin b + Iron (ama/ka/ day) + From 6-8 weeks after birth till! year (ew babies have inadequate iron stores). 41S kg (ery low birth ron + HMF (Human mills Fortifer). weighd) Nutritional sachets continued till baby, reaches 40 weeks of gestation after birth. Continue Iron + Vitamin © for | year. ron is supplemented additionally as HMF does not contain iron in sufficient quan- ‘ities. Problems faced by L6W babies (preterm/IuGR babies) + Preterm babies luge babies Neonatal asphyxia _| Inereased risks Increased risk. Hypothermia. Increased risk. Increased risk. Low nutrient reserves | Hypoglycemia (ow Hypoglycemia. (ow glyeogen reserves). | glycogen reserves). Kernicterus (orain Increased ris, - due to bilirubin): High levels of bilirubin > easy into brain blood brain barrier is more permeable in | preterm babies), Necrotizing, Increased risk, x enterocolitis (eC) Potent ductus Increased risk, = a Arteriosus (PDA) | Paediatrics » v4.5 » Marrow 6.5 » 2023lL Polyeythemia. luge > Stress > Intrauterine hypoxia. (chronic) > Release of EPO > Increase erythropoiesis > Polyeythemia, Less surfactant Meconium aspiration causing Respiral syndrome (mAs). Distress SOR aa IUGR > Stress > Release of motilin > Increased peristalsis of intestines > Passage of meconium in-utero™ Aspirated by baby during delivery > mAs, (RDS) Problems faced by premature babies due to immaturity oF organ systems L._ Intraventricular haemorrhage (ivi) : < 34 weeks. * Germinal motrix Group oF Fragile blood vessels around the ventricles) undergoes involution 7 34 weeks. * IF baby < 34 weeks > Germinal matrix still present > Prone to bleed > Rupture> Bleeding into the ventricles. & Increased risk of apnoea of premoturity * Absent breathing 7 20 seconds or any duration + bradycardia or cyanosis. Treatment : Coffeine citrate. 2, Inereased risk of developing Sensorineural Hearing Loss Gn): Frequent screening tests done * * Oto-Acoustie Emissions (OnE). * Automated Auditory erainstem Response (ARER) (most preferred. 4, increased risk of developing Retinopathy of Prematurity OP), can lead to blindness : * Que to immoturi ity of retina. * when exposed to high levels of oxygen therapy (huperoxio). * Prevented by limiting 0, exposure + By continuously monitoring Sp, (90-95% maintenance). Paediatrics » v4.5 « Marrow 6.5 » 2023 Q3 Management of 19 LBW Babies ‘Active spacele 04 NEONATAL RESUSCITATION Neonatal resuscitation program 2021 00:00:33, The guidelines Sor neonatal resuscitation are based on NRP (Neonatal Resuscitation Programme) a0al. In newborn babies, the priority is respiration 77 temperature 7 circulation. Resuscitation in newborns is not done under room air, done under warmer air, Initial assessment 4 pre-birth questions before delivery, 1. Term gestation or not. &. Amniotic Muid clear or not. 3, Additional risk Factors. 4, umbilical cord mx plan — Delayed cord clamping by 30-bO seconds, any investigation from cord. Algorithm + Initial steps # x |. Temperoture (maintain warmth : wormen)| Initial assessment | | a. stimulote the baby by gentle tactile noo stimulation : = * Rubbing the back mee ster * Flicking the soles. No 2, Position the airway of the baby by slight eA extension/snif$ing posture (Place a rolled : cotton towel behind the shoulder blades | respiratory effort ||. Head tilts back slightly). & 100/min| OPEonal step + = Suctioning of the secretions (mouth, then Positive pressure || nose) to prevent aspiration (routine Ventilation PPV) _ ||| suctioning not recommended anymore). HR 100/min but inadequate/ HR <100/min § baby is not labored breathing breathing/apnea. J Oxygen Positive pressure ventilation(PPv) supplementation Non-invasive Invasive L L Bag {mask | | endotracheal ventilation tube CPAP : Continuous Positive Airway Pressure . In preterm, deficiency of surfactant > T chances of alveolar collapse. CPAP increases pressure in airway 4 Keep the alveoli open. Chest compressions : ecisharuesy* * a thumb technique (preferred). popes Shera) * Site : Lower 1/3 of sternum. * Avoid xiphisternum (easily injured). * 1/3 of the antero posterior @P) diameter. * Chest compressions + ventilation @otio = 3:1 > 90 compressions + 30 ventilation in | min) * ventilation is given by alternate airway (D. * monitor HR With cardiac monitor. No response to chest compressions (no inerease in HR) > Adrenaline injection (I: 10,000 — strength). Route : Umbilical vein (Wv 27 Interosseous route (10) > ET). Dose + * 0.2 mi/kg or 0.08 mg/kg (iv/i0) Paediatrics » v4.5 + Marrow 6.5 + 2023 Neonatal Resuscitation ‘Active spacea CC! llCSS y 04 * I mi/kg or 01 ma/kg endotracheal route). Adrenaline injection —* No improvement — Consider volume expansion with NS 10 mi/kg (ast effort where definite history of blood loss present). Moximum duration of neonatal resuscitation + 20 minutes —> All steps done — no increase in HR — call off resuscitation. Timelines between + * Initial step to PPV + | minute Golden minute of resuscitation). * PPV § chest compression initiation + 30 seconds. * Chest compression initiation { adrenaline injection : 20 seconds, * Bag & mask ventilation / BMV 00:26:29 volume of bag for resuscitation : 240-750 ml. most sensitive response : Increase in HR 7 100/min. \F no response — ventilation corrective steps (meSOPA) : * mask readjustment. * Reposition head. * Suction. * Open the mouth + provide breathing, Pressure to be increased. * Alternate airway (eT). Correct position of the mask InCorrect InCorrect Incorrect Rote of mv : 40-60/min, Pressure + “eoeds eADy * First breath + 30-40 em H,0, * Subsequent breaths : 1s-a0 cm H.0 (lower pressure prevent trauma to the alveoli). Paediatrics + v4.5 + Martow 6.5ME lle 04 fenesuston Recommended FiO, + * Babies born (late preterm, term) 2 35 weeks : Room air (ai OL. * Babies born (preterm) < 35 weeks ! dI-20% O.. Further titration of oxygen depends on $p0, response. Target SpO,' [min wuss | [amin 75-80% | amin 65-70% 5 min 80-85% | amin 10-18% lo min 85-90% Excessive oxygen can lead to deleterious effects on newborns — Retinopathy OF Prematurity/ROP — Blindness if untreated, pO, is checked using pulse oximeter (right hand). Absolute contraindication : congenital diaphragmatic hernia (intestines are already compressing the lungs). mv = fiir enters into both trachea and oesophagus — Pushes more air in intestines —> more compression of lungs. Endotracheal intubation 00:36:12 Laryngoscopy with a straight blade Size: 0 for preterm 4! for term babies Go visualise glottic region). Type of eT: uncuffed tube will be preferred in new-born (cuSSed eT might couse pressure induced tracheal necrosis). Inner diameter of €T + * <1 kg child + .S mm diameter, * I-A kg + 3 mm. * 7akg + 2.5 mm. Length of insertion = 6 + weight of child (kg). Actwe space Best way to confirm position of €T : End tidal CO, with Copnography, Paediatrics + v4.5 + Marrow 6.5 * 2023eo lh t—“—s—SSS y 05 INFECTIONS IN NEONATES Types of infections 00:00:08, Superficial infections Systemic infections Superficial infections : |. Omphalitis (infection of the umbilical cord) + Redness/induration/pus discharge around umbilicus. Leads to systemic infection Gepsis), if untreated. mx: Size of Evidence of Treatment indurotion/redness | sepsis é1em No Topical 05% gentian violet 4 times 0 day > 10m Yes Wv systemic antibiotics Great like sepsis) 2. Oral thrush + Coused by Candida. species. itis difficult to wipe of, Presence of hemorrhagic spots after forceful removal. Mx? Topical Nystatin or clotrimazole 4 times a doy, till al} the lesions are resolved, 3, Conjunctivitis (ophthalmia neonatorum) : Required during delivery of the baby along the infected birth canal. | teisseria. gonorrhoea Chlamydia trachomatis, 5 Time of Day 3-7 From s™ day of delivery ; presentation | Discharge | Copious and purulent Seanty Treatment WV Ceftriaxone/ Oral Azithromycin For 3 Cefotaxime for 1-10 | days/erythromycin for days 4 days Paediatrics + v4.5 + Marrow 6.5 * 2023,RE ees ig 05 _ Infections in Neonate GonococCal conjunctivitis is treated as an emergency, because blindness and systemic infection can occur, if le untreated. Prophylaxis of ophthaimia neonatorum : 0.8% topical erythromycin. Systemic infections : Neonatal sepsis + a™ m/c cause of neonatal mortality, Diagnosed by presence of clinical features of sepsis along, with bacteremia (presence of bacteria in blood as detected by blood culture) in the I month of life. Causative organisms * India: Klebsiella. 2 Staphylococcus aureus 7 E.coli * worldwide : Group 6 Streptococci (68s). Note : m/c overall cause of neonatal mortality is prematurity. Early onset sepsis, Lote onset sepsis Onset | < 7 hours of life > 7a hours of life Source | From the mother (in the Hospital acquired uterus/passage via. birth infection (nosocomial) Risk * Chorioamnionitis * unclean hands of health factors thigh Fever in mother personnel Gnost @) + Foul smelling liquor) important preventable * Duration of Rom 2a4 hours | couse). @7a hours : very high risk). | * Pretermr/low birth weight * pprom (preterm premature | babies. rupture of membranes of | ® Absence of breast ‘any duration). feeding, * 23unclean vagina! examinations. . Type of | Pneumonia Septicaemia or meningitis. : infection 2 Any sick, baby —> Suspect sepsis —> Start |v antibiotics. Paediatrics + v4.5 » Marrow 6.5 * 2023Me 2 _ -. 05 Manifestations of neonatal sepsis # ° forly features : fitered feeding pattern, lethar ge bok y * Reliable feature + Hypothermia (Hypothermia 7 Sever ir, preterm babies). * Pneumonia: Respiratory distress. * Meningitis + Seizures, No singje Feature 1s diagnostic of neonatal sepsis. Mx of neonatal sepsis * 1. Gold standard : @lood oulture (takes 48-7 hours to get report) — Start empirical ontibiotics (don't wait for reports). &.Sereening for sepsis using S components (Presence of any ais significant) : Rlenoxtrol volue < scoo/tren? (erenoture imecune syste) <1200/ tect * Sepss screening has regstive predictive vole (relgs to rule out infection). * ® screenina ic regotive : Rocence oF diceoce. * @ screening 6 positive : 00 0 blood culture to Neuer F better roreer | | 4-6 hours otter nfecton ean oun | Not routreyusedn | | epee wreenecs HOCLAD ES Tes Ct ert t it, % Femmes «085+ Maem 65 + 004Se EE Q5 Infections in 27 Neonate Other investigations + * Chest x ray (in case of suspected pneumonia). * Lumbar puncture : To r/o meningitis. Done in all Symptomatic babies with suspected/confirmed sepsis. Exception ' Asymptomatic babies —> Presence of only risk factors, but baby is otherwise normal. Lumbar puncture is not required. Rx: Empirical antibiotics + Ampiciliin (Gram positive) + Amikacin/ gentamicin (@ram negotive). No response to treatment by 48 hours/severe infection such aS Meningitis or septic shock. L Add. 3% generation cephalosporin (cettriaxone/Cefotaxime) 4 Add cloxacillin GF suspected Staphylococcus aureus infection) L Add. Vancomycin (in case of mes). Le In NICU with high incidence of resistant strains : (Cefotaxime/ Piperocillin tazobactam/ Ciprofloxacin) + Amikacin. Durotion of antibiotic therapy in neonatal sepsis * Diagnosis Durotion Culture negative sepsis (screening positive and/or S-T days clinical course consistent with sepsis, but negative culture), Blood culture positive without meningitis 4 days Meningitis (CSF culture +ve) 3 weeks Ventrieulitis (Diagnosed using, med 4- weeks Active space Paediatrics * v4.5 » Marrow 6.5 + 2023— 4 a 06 BIRTH ASPHYXIA, HIE AND NEONATAL SEIZURES Perinatal asphyxia Za rrosred 065 excrorae n tre fetus due to cungicotors oF precporess/ yoker uch ods 40+ ° wpono. s wupercorbo. © Lostic anidess | train Seature to dograse oxprnyo. umbice) orterio) biocd pH <7. wre detoten & birth ospriyo.* 4 60 condition trot should be excidered in ory EIKO ureren tre baby 0% to nttiote breathing o 80h obie 6 stan cresting of the tere Acts consequences F orth oxphuyso.: Que to hyporo. Bron + Hupote: tchemie eacegnolgotiny Giz). muti ocgon toiure + Kideey Onl ofter tron) — Foute Tuoior vecroae (GTN) in provsra\ tubule Gnak seccitiie) a teosrcin reo ON ni tees * Lactic acidosis Los. pe. sare 6 KEN 0 bobies vith birth osphyyo.* < Ao. et wes pete: Cecreose3 onuperation to tees + ttrerio.: rodcopste docsy supply to tees. Gppetusion) . werent: ron eysy Lesere use & cecrctel won eipry woriduide. tesraten ohn cisco (4, A reseoto) mortality, ee : ; G4 Wie ae COD Fake (Ene RK ete! BE Oe We Creer! Pots (CD), esrotobe eases, 4410. Pansies + hE Naeem 6EE EEE 06 Sarnat & Sarnat staging eae ne a nae in One ce eae mE mee SENNENENESIITE Features | Stage! Stoge a sone? | Consciousness | Normal/ Lethargic Comotose | hyperalert Ai cae cc nhac Reflexes Easily Stuggish fbsent (moro, elicitable ® i Sucking) (hyperactive) i Seizures Absent 4+ in fieck a4 |Aicenk ro | hours broin | octivty) Autonomic Sympathetic | Para. No activity | involvement overactivity sympothetic overactivity Pupil size mydriasis miosis Uneaual + Poorty/rok reactive to light. Heart Rote Increased, Decreased _| Voriable | Posture. Normal Flexion Decerecrote | 66, Normal Low voltoge | 6urst | complexes. | suppression | Seizure isoelectric 1 spikes seen_| pattern | cuaeon cashours |ashoursto4| Several days | 1é doys | to Weers | Outeome/ 90% + Normol |€O%+Gc0d |SO%: Death | Prognosis outcome. | a> ah = Sequeloe in neurclagiea! | the form oF | Sequeloe. cerecral palsy Child wil not oloys prooress from stage | to other stages. it con present in any stose. Binh Paphyna, HIE and Neonsts Cannes Active apacelogy ‘#5eds enjoy Se rr eC Sarat § Sarnat staging is also indicative of the Prognosis, Hie is the leading cause of neonatal seizures. Normal posture ! universal flexion resisting passive exten Decerebrate posture : All limbs in extension, sion, Neurological sequelae depend on the area. of brain ofSectes by Hig. Factors that determine area affected : |. Glood supply of brain. &. Gestational age. 3. Metabolic demands of different parts of the baby’s brain. Parasagittal infarct 00:13:35 Porasagittel cerebral injury Seeninterm babies. &) Poresaojttel area —> Water shed area supplied between onterior { middle cerebral artery, Motor cortex § subcortical areas are affected, initicliy, Upper limbs are Predominantly affected. R4 lems uitl eventually be affected : Spastic quadriplegia. cerebral palsy (cP), Periventriculor leukemaldcia + * Seen in preterm bobies.(y) * BRRects motor distribution oF both lower limbs : Spastic dipiesia CP Pacdiatrics + v4.5 + Marrow 6.5 +2023Birth As uy HIE anc Seizure Trunks Zone of periventricular ischemia, hemorrhages Intraventricular bleed in gteral ventricle Zone of periventricular hemorrhages Other patterns of ischemic brain injury in term babies : l. Focal ischemic necrosis : Only one part of brain is affected, Associated with focal seizures § hemiparesis (upper § lower limbs on one side are affected). 2. Selective neuronal necrosis + Particular areas of brain are commonly affected. : Deep nuclei of brain: Putamen of basal ganglia (extra pyramidal symptoms), Hippocampus. Purkinje cells of cerebellum — Ataxia, vertigo. HF many areas affected together + CP with low IQ. Neuroimaging 00:19:25 I. Screening test: Neurosonogram. Ultrasonogram through Fontanelles. Only small part oF brain is visualized so it is only a screening test. Its main role is to rule out significant intracranial hemorrhages. 2. Definitive test : MRI of brain. In early stages * Diffusion Weighted Imaging (wD shows abnormality (early changes) within few hours after birth. Active space Treatment of Hie + * No specific cure * Only supportive management (Maintain blood sugar, temperoture and administer adequate Sluids) Paediatrics + v4.5 +» Marrow 6.5 + 2023a ‘eoeds OAR © Seizure management : AEG : Amplitude integrated e€q Sor bedside monitoring of seizure activity in a newborn. 1. Only! - a electrodes used (conventional £€& has t'o electrodes) a. Facilitates continuous monitoring oF seizure activity, 3. Helps in detection of subclinical seizure activity in cu, A, OfEG iS 0 SCrEeNING, test only, Diagnostic test Conventional £69 Rx of seizures? Phenobarbitone (DOC) uv currently Phenytoin most effective Levetiracetam Therapeutic hypothermia 00:23:43 Inducing hypothermia, by placing ice packs or cooling crystals * Around the baby's body + whole body cooling, * Only around the head + Selective head cooling. Preferred: whole body cooling 7 selective head cooling, whole body cooling offers uniform cooling 4 better outcomes Temperoture maintained : 335 °C (23 - 24°C). Mechanism of action + * Decreases neuronal injury by decreasing neuronal propinss. * Decreases production of free radicals § nitric oxide. * Decreases production of excitatory amino acid glutamate: * Decreases incidence of seizures. Criteria for therapeutic hypothermia + * Post menstrual age : 7 4 weeks of gestation. * Birth weight + 2 a ko, * Stage a/Stoge 3 Hie. * Should be started within & hours of birth Duration + ahr Paudiatries + v4.9 + Marrow 6.6» 2023ea ld” Cl eT lO Birth Asphy> 06 HIE and Nec : ; Seizures Types and Etiology of Neonatal Seizures 00:29:48 fe Alencar EO ACA DEIZUEES: . O0BAS Types : |. Subtle seizures : m/c type in children. Minimal manifestations * Ocular movements (Eg : Deviation of eye or continuous blinking of eyes For few seconds) * OroFacial lingual movements (Eg Continuous chewing). * Limbs (€g + cycling movement). Seizure generated impulse is not transmitted rapidly in the immature brain. a. Focal Clonic + Best prognosis. 3. Tonic 4. myoclonic + Worst prognosis. Etiology + L Hie (n/c) + SO to 60% within I* day of lifeGmostiy within 1a hrs). 2. Metabolic causes : * Hypoglycemia. °. Hypocalcemia. * Hypomagnesemia. 3, Infections + ° Sepsis. * TORCH infections. 4. Intracranial hemorrhage + © Preterm : Intraventricular hemorrhage. * Term : Subarachnoid hemorrhage (Good outcome). S. Developmental defects + Congenital anomalies (g anencephaly) ©. Pyridoxine deficiency/ dependent seizures. * Rare cause of neonatal seizures. * Typically manifests as refractory seizures. * | pyridoxine f excitatory glutamate — Active space refractory seizures Paediatrics + v4.5 + Marrow 6.5 * 2023eS rT rll ONS 06 Nelutamate SAD! Glutamic acid decarboxylase | Gran a (excitatory) | (inhibitory) ¥ Pyridoxine Management of Neonatal Seizures 00:35:42 Management of neonatal seizures 1, Stabilization of vital parameters ‘TREC Cemperoture, airway) breathing, circulation) a. Correction of hypoglycemia and hypocaleemia, 3, Antiepileptic drug therapy ! First line IV_Phorobaxbitnne. 4, Second line + Phenytoin Followed by Benzodiazepines. ridoxine. 5, Refractory seizures : Trial oF Paediatrics + v4.5 + Manow 6.9 +2023Ww no Se weet RESPIRATORY DISTRESS IN NEWBORN Features of respiratory distress 00:00:24 eee ete OE Any a of the Following must be present + * Respiratory rate > 6O/min, * Chest retractions / indrawing, * Grunting { cyanosis eunting > expiration in a Partially closed glottis > Produces positive end expiratory pressure > prevents alveolar collapse). Causes of respiratory distress : Pulmonary (more common) : L_ TING # Transient Tachypnea of Newborn (m/c). &. Respiratory Distress Syndrome (RDS). 3. Meconium Aspiration Syndrome (MAS). 4, Riir leaks (e.g, : Preumothorax. S. Pneumonia. ©. Anomalies : Congenital Diaphragmatic Hernia (CDH). Non pulmonary + 1. Cardiac failure d/t certain congenital heart diseases. a. Metabolic * Hypoglycemia. q hypocalcemia. Scoring systems to Monitor respiratory distress + * Silverman Anderson Score. * powne’s Score. Silverman Anderson Score : More useful in preterm. ¥ 1. Symptom ° ' a %_lupper chest | synchronized | Chest lag during | See saw Fetractions breathing, respiration | | | (ompore (Chest = @uring inspiration | (abdomen | movements | Abdomen) | abdomen moves | moves outwards, | of chest with outwards, chest _ | chest moves abdomen) moves only slightly | inwards : Severe | outwards) retraction). Paediatrics + v4.5 + Marrow 6.5 + 2023 ee ee Active paceleonatology qanw We 08 on™ ‘eoeds eanay ess | eS Lower chest No. mild Marked a retractions | wares is Triid tmorked dilatation/ nasal Maring | _ Xiphoid No mild pertied retraction erunting No Heard with Naked ear stethoscope Interpretation ' minimum score 0 # Normal. maximum score 10? Completely abnormal. Level of severity in respiratory distress based on Silverman Anderson Score * Score 80/min or apne | Rote | | cyanosis No Inroom air | cyanosis present ever unith ©, support at FO, 240% Gorely audible | ey No mild rf marked 1 erunting, No Heard with Weorauithout | stethoscope sretnoscope interpretation + score 7b + Severe distress 4 impending, respiratory Failure: monitoring, of ‘oxygen saturation + 690, <90% * Hypoxia. Paediatics + v4.5 + Marrow 6.5 +» 2023 dEco qq qi Ez 08 Respiratory Distress in Oxygen challenge test : Give 0, and observe change in Spo, etal * 2 80% improvement + Respiratory cause * No change or clears lung Suid. LSCS —> impaired expression of these channels. Presentation : Breathing difficulty Within © hours after birth. Chest x ray + Fluid in the lungs. * Perihilar streaks /sun burst appearance : Fluid in the bronchopulmonary structures. * Fluid in the interlobar fissure. mx: Transient condition lasts up to 1a hours — supportive treatment with O, inhalotion. Sallbutamol inhalation in early TTNS increases expression of { ENoL and No’ 4" ATPase channels (New guidelines of TTN6- 3 2 not routinely used). Paediatrics + v4.5 + Marrow 6.5 + 2023i oo logy os Respiratory distress syndrome 00:21:25 Oceurs in preterm babies (35 weeks). Surfactants mature after 35 weeks. Pathology * Hyaline Membrane Disease (ump). Cause : DeRcit or immature surfactant levels. Surfactant + Produced by, ye L Prnnmecyten prevents alveolar collapse by decreasing the surface tension. In ROS, Immature /deficit surfactant — Collapsed alveoli —> hypoxia § respiratory distress. Presentation ? < 6 hours. Chest x Ray: white out lungs / ground glass appearance (also seen in PRE). Bir bronchogram sign + fir enters the patent bronchi § appears block. Pulmonary Alveolar Proteinosis ap): futosomal recessive Fatal condition. Presents with white out lungs/ground glass appearance similar to ROS. Normally, old surfactant is removed by alveclor macrophages in PAP — surfactant is not degraded — Recumnulation of old uihite out lungs Tests for fetal lung maturity 00:27:55 Tests forfetallungmaturity 0 These can be done in amniotic Suid/gastric juice after bit * Lecithin : Sphingomyelin ratio (L : S) Lecithin (moture Sorm) § sphingomyelin Genmnature 80" ase the phospholipids that compose surfactant. L+S$7 a:1—>mature surfactant (Necithin> More moture surfoctand). Exception : infant of diabetic mother (iom) should be 7 35 # |. * Phosphotidy| glycerol test : Better 4 more sensitive. * Lamellar body count : Surfactant stored in Type 4 pneumocytes detected in amniotic Suid. ‘eowds aanoy Paediatrics + v4.6 + Marrow 6.5 + 2023a i= Mature lung + > $0,000/microlitre. Respiratory Distress in Newborn * Shake test 05 ml of gastric aspirate + 0.5 mi 95% ethy| alcohol —> Shake Vigorously For 10 - 1S min 4 leave it for another 10 - 1S min —> Full rim of bubbles indicate Positive test for lung maturation. Management of Respiratory Distress Syndrome Preterm baby } delivery room 00:31:52 <34 - 85 weeks with < a8 weeks of gestation. breathing difSiculty, ‘Suspect ROS, I Start CPAP (Continuous Positive J Airway Pressure) > Keeps alveoli | | Prophylactic surfactant ‘open § prevents its collapse. to prevent 205. Termed os + Early delivery room CPAP with selective surfactant. Hf baby develops RDS, after shifting to the ICL. al Silverman scoring. Torget Spo, levels + 90 - 95%. Spoa 7 95% + Excess 02 —> Retinopathy of premoturity leading 4o blindness. Initial Pressure + Sem H,0. “Ss s-7 7 mild 20S. Moderate RDS. | | Severe RDS. i J worm crap | {mechanical ventilation humidified O.. + endotracheal surfactant therapy, Standard + Insure technique. Pressure and O, concentration con ke adjusted according to Intubation Surfactant— extubation. Paediatrics + v4.5 + Marrow 6.5 + 2023 Active spacelogy [ee 62550 senate annoy 08 Newer techniques for surfactant therapy 00:98:26 Non invasive/less invasive. MIST + Minimally Invasive | Surfactant therapy, Done using a feeding tube LISA + Less Invasive etaen| or trachea! catheter Administration. ql Early rescue surfactant therapy * Goby with moderate RDS — Start CPAP —> No response (Ever with Fi0a 240%) — Start surfactant therapy —> Decreases the need for mechanical ventilation. Indications For surfactant therapy in a newborn + * Severe RDS. * Moderate RDS with no response to CPAP to decrease Prtenatol prevention of RDS + Corticosteroids +0 mothers who deliver ok a4 - 34 wees. * Sctamethosone : 1a mo/dose, a doses a4 hours apost. * Gexamethasone : & mo/dose, 4 doses Ia hours opast (Common in india) Geretis : Decreases incidence of * Resprotory distress syndrome. * Necrotizing enterocolitis. ° intro. ventriculor hemorrhage in preterm babies. * Qverci\ reorotos mortolity. Bronchopulmonary dysplasia (BPD)/ Chronic Lung Disease of newborn 00:44:31 Ren Sorters: Preterm tobies corn ot 4 23 cove of gestation, CORE OS. sucpert Sor 2 Gece, after th Bod 6 SEES Chron Lure Annoses ori otter 4% UALS FR OSE erctruslone. ~ _Congenital diophrogmotic hernia: Intestines hernioting from the abdominal co: ity to the thoracic cavity, Posterolateral ond let side | of diaphragm Anterior aspect and ris} side oF doptraam Features of CDH: * Compression oF kings Lung hupopiosia Respiratory distress ofter birth * Heart sounds on the right side d/t right shit of the thoracic contents. * Sunken (scapnoid) abdomen. Diagnosis of CDH 00:51:30 Fintenotol + USS b/w ie - a4 WEEKS. iter birth + Chest x roy * fir shodous in thoracic cavity indicoting intestinal snacons. * No definite diaphragm border on the le indicating detect in the degrrogn. * Heart shadow on the right side. * flosent a sradous in the abdomen. Active space.—=— 08 Management + First 48 hours after birth 7 48 hours of life Treatment : Ventilation Conventional ventilation. \ J HFOv (High Frequency, * Notive tissue repair. Oscillatory ventilation). * Patch Repair @olytetraSuoroethylene : ‘CMO (Extra Corporeo! @ore- TEX). membrane Oxygenation. Approach ' fim subcostal approach as * Promote lung expansion. |__| helps in better visualization, * Stobilize pulmonary hypertension 4/ lung, compression. Poor prognostic Factors of CDH + Antenatal Factors + USG? * Lung head rotio <1. * Liver in thoracic cavity. MRI: Derived Total Lung volume (TL) < 20 mi Postnatal factors + * Degree of pulmonary hypertension + most important prognostic Factor. * Size of the defect, * early onset of respiratory distress ( Increased motilin ~ Increased peristalsis of GIT —> expulsion of meconium in ute"? into amniotic cavity — Swallowed § aspirated —> MAS Paediatrics + v4.5 » Marrow 6.5 + 2023es EE ee 08 Respiratory Distress in Consequences of MAS : pie * Partial block of a main airway — Rir gets trapped inside lungs—> during exhalation —> Overdistension oF lungs —* Obstructive emphysema. Appears as hyperinflation in CXR. * Complete block of a small airway ! Segmental atelectasis. * Meconium in alveoli: Chemical pneumonitis. Chemical Preumonitis Diagnostic criteria for MAS 01:08:29 Diagnosis of exclusion + * meconium Stained Liquor (MSL) at birth + Respiratory distress. * Xray: Coarse, ill defined infiltrates. * exclude other Known conditions. Complication of mAs + * fiir leaks like Pneumothorax. * Persistent Pulmonary Hypertension of Newborn (PHN). Management : * Symptomotic management according +o ventilatory requirements like 0, therapy or CPAP. * PPHN: Inhaled Nitric Oxide (INO). Active space Paediatrics + v4.5 » Marrow 6.5 + 2023‘songs annoy. eee 08 - NEONATAL HYPOGLYCEMIA AND INFANT OF DIABETIC MOTHER Hypoglycemia. definition (WHO) # Blood glucose < 45 ma/dl. Hypoglycemia. can also be asymptomatic. Screening for neonatal hypoglycemia 00:01:16 ‘At risk? babies + * Low substrate Cow glycogen) : Preterm babies < 35 weeks of gestation, low birth weight a Koy intrauterine growth restriction (UE). * Relative hyperinsulinemia. Large For gestation babies, infant of diabetic mother, Rh incompatibility Gransient insulin inerease) * Sick baby + Neonatal sepsis, birth asphyxia, hypothermia. Hypoglycemia is screened by dipstick measurement of heel priek sample. Schedule of sereening For ot risk babies + At a, , 13, a4, 48 and 7a hours after birth. Features of neonotol hypoglycemia. : * £orliest : Jitteriness / tremors. - Other Features : Lethargy, Weak ery, poor feeding, pattern. * Con present with seizures. * Sutonomic changes include sudden changes in heart roke, sudden pallor or episodes of hypothermia. Gore in a. newborn eompored to older child or adults). ditteriness vs seizures + ‘Stimulus sitteriness, Seizures Siniis sensitive Not stimulus sensitive [eye eviction Not seen, ; Seen Autonomic changes | not tte sudden chamne iis seen in heart rote, Ie ocr Paws: “V4.5 + Marrow 6.5 + 2003Management of neonatal hypoglycemia + eel fees | (emergency) Treated immediately with Ee iv. bolus Oral feeds + Once 10% Dextrose | mA ern fe) Recheck after Followed by 30 to 45 minutes. iw pence val 10% Dextrose e 3 infusion ot > ea mg/m “se continue breastfeeding ever y a hour! ty or as per baby's requirements. Infant of diabetic mother 00:10:36 Pedersen’s hypothesis : maternal hyperglycemia — sugar crosses placenta — hyperglycemia in fetus — increased secretion of insulin in fetus > excess growth (anabolism) — macrosomia. large for gestational age). Complications of infant oF diabetic mother : * Delivery complications + Shoulder dystocia, brachial plexus injury ie. erb’s palsy Fractures of clavicle. * asymmetrical septal hypertrophy Gorm of hypertrophic cardiomyopathy) : Transient condition. * Increased demand of oxygen — increased RBC production — polycythemia > predisposition to thromboembolic manifestations. (hypercoagulable blood). * increased insulin — interferes with surfactant moturotion — respiratory distress syndrome. * Increased insulin > Impaired gut motility (colon) —> Lazy left colon syndrome can present with delayed passage of meconium. 09 Aective space Neonat Hypogly and Infa DiabeticSee eo™~ 09 * Increased sugar in the fetus congenital anomalies, m/c system affected ! Cardiovascular system. Vc heart defect : ventricular septal detect. nVe group of anomalies : Neural tube defect. Single m/e anomaly in an infant born to diabetic mother is VSO. most specific heart defect : Transposition oF great arteries. Overall most specific anomaly * Caudal regression syndrome. Example # Sacral agenesis. #¥ter birth of baby : L Hypoglycemia (After birth — placenta is cut loys —> sugar From mother is also cut of — insulin in infant still high). a. Hupocalcemia. 2. Hypomagnesemio, m/c metabolic abnormality associated with seizure in 0. bP! born to diabetic mother + Hypoglycemia > hypocalcem'a.EET 10 NEONATAL JAUNDICE Jaundice : Increased levels of bilirubin manifesting as yellowish discoloration. Bilirubin metabolism 00:00:40 Rec | Heme | Heme Oxygenase Biliverdin Biliverdin reductase Unconjugated bilirubin (woter insoluble, connot be excreted) | UDP glucuronide transferase (upP-4i7) in liver Conjugated bilirubin (water soluble, can be excreted) Released along with bile in bile duct a™ part of duodenum Large intestine # Colonic bacteria acts on the bilirubin 90% stercobilinogen (yellow stools) 410% urobilinogen (light yellow urine) Very small portion taken back to liver + enterohepatie circulation Assessment of jaundice + Serum bilirubin (best wou) + Bilirubin Normal levels Total 1-13 mf dL 7 Direct (conjugated) < 0.3 mo/ dt : 2 Indirect (unconjugated) 0.9 mo/dL Visible joundice : in neonates = S mg/dL, in adults = a ma/ aL, Paediatrics * v4.5 * Marrow 6.5 + 2023a ST ees lc itt 10 Screening tests for neonatal jaundice 00:06:17 peteening tes ee |. Transeutaneous bilirubinometer (C8) + Hand held device, Sternum + Common site, useful only if baby is 7 35 weeks of gestation. Reliable only if baby is 7 a4 hours old a. Visual assessment by Kevan ens Jule Stotes that jaundice spreads in cephalo caudal progression From head to trunk and limbs. I* develops in the eyes. Zones of jaundi¢e + Bs Zones Part of the body Bilirubin level | z| 1 Head: eyes & mo/ AL | J 0 Trunk amd Mw Lower abdomen § thigh 1a mo/d- | Vv Upper § lower limbs {is mo/aL | v Palms { soles smo de Unconjugated bilirubin : Water insoluble, Fox soluble ‘ 215 mo/at 1 4 Cross blood brain barrier i ey N 4 iN) Grain damage Zones Paediatrics + v4.5 + Marrow 6.5 « 2029eel allel Ee 10 Neonatal Jaun Forms of jaundice 00:12:01 Two Forms § Physiological > pathological, ‘aa | jaundice + * Increase in unconjugated bilirubin always. D/t physiological immaturity of neonates, UDP glucurony| transferase is not Sully mature —> delay in conjugation of bilirubin, * Appears by a4 to 7a hours of age. * Peaks by day 3. * May present upto | - a weeks, * No treatment required, Pathological jaundice + * Day! ! Any jaundice (@ s mg/dL). But; if it appears between 18 - a4 hours after birth, could be physiological. * Day a: Jaundice in arms and legs (7 10 mg/dL). (Thereafter jaundice 7 1a to 4 mo/dl is pathological). * Anytime + Joundice in palms § soles © IS mg /). * Rote of rise in bilirubin 75 mo/dl /day or > 0. mg/aL/nr. * TSS nomograms : Above 95" percentiles for age. * Signs of bilirubin encephalopathy. * Any jaundice persisting 7 a weeks in term babies and 7 3 weeks in preterm babies. Total Serum Bilirubin (TS@) nomograms : Compare serum bilirubin with age of the baby in hours after birth. 95" percentile Serum bilirubin Age (hours) These percentile lines depend on gestational age, risk Factors like asphyxio, sepsis, hypothermia, Any value 7 95" percentile is signiReant and pathological and indicates thot the jaundice requires treatment by Active space phototherapy or exchange transfusion. Paediatrics + v4.5 + Marrow 6.5 » 2023S00 ES 10 ovds onnoy - ™“~ Etiology of pathological jaundice 00:20:33 etiology Conditions i Hemolysis Inherited! @ePD deficiency, hereditary | iS. Acquired! Maternal antibodies mediotes | cis of baby's RECS | (Rh/ ABO blood group incompatibility). upp-er defects Crigler Najjar syndrome (a2) | Type | Absent UDP-€T. | Complication + Type at Low levels oF uDP-ar. Hypotyroidiem Intestinal obstruction Cephalohematona, bruising, Neonatal cholestasis. [ieabeeaalis Senos SC iirubin encephalopathy/6INo Gilirubin Induced Neurologic! Damage): * Brain damage due to increased levels of unconjugated bilirubin as it is lipid soluble and con cross blood brain barrier. * prea oStected : Gasol ganglia. * Pathologically, called Kernicterus. * may be acute or chronic,—i i On 10 Neonatal J Reute BIND. Chronic BIND te 0-3 doys: Older children, + Hypotonia, Basal ganglia damage ! ; * Decreased activity, * extrapyramidal Cerebral ‘ * High pitch Ghrill) ery, Palsy (CP) + chorea, athetosis, abnormal tone, 23 days posture ete, ; * Tiypertonia : opisthotonos * Sensorineural hearing loss f and retrocollis Gnu). Qryperextension of neck). ence eee ae Dental problems : Enamel Sse dysplasia, Opisthotonos § Retrocollis in acute BIND Management of neonatal jaundice 00:30:05 Monitor : visual assessment + TC6 every 8 - la hours for 3-S days ofter birth. Step 1: Look for serious jaundice. 1. Any jaundice on day |. . Jaundice in palms § soles. 3, TSS nomogram : 7 9S" percentile for age. 4, Signs oF bilirubin encephalopathy, _ Require immediote treatment. Step a: Look for signs of bilirubin encephalopathy, Present Absent. Exchange transfusion. Phototherapy (PT. ‘Active space v Send serum bilirubin for further management. If, no features of serious jaundice. Paediatrics + v4.5 + Marrow 6.5 + 2023S ‘eoeds eanoy. 10 Step 3+ Does baby have significant jaundice ? Criteria: 1, Day a + Jaundice in arms/ legs. a, Roke of rise in bilirubin! 7 S mg/dL /day or 7 0.8 ma/ct /ry, 3, Joundice persists for 7A Weeks in term babies § 73 weeks in preterm babies. Signifteant Jaundice Present Absent Investigations ' Serum bilirubin in Normogram. yo Volue above Value below cutof$ ——> Continue cut off in Normogram : Start PT. observation. ‘Treatment of neonatal jaundice 00:36:45 aeons auncice CO Phototherapy : Uv Rays + 400 - 490 nm, Lamps: Compact Fluorescent Lamps (CFL). Light Emitting Diode Len). Usoge : CFL LED, Sicacy : LED > CFL, Distance between baby and light + 30 - 45 em. Gaby must be naked except For eyes and gonads as it can couse \e to retina and testis, Pective irradiance : At least 30 [LW/em?/nm, Complications : * Damage to retina, § testis, Avoi * Dehydration due to heat. Avoi ‘Tirequency of breast 9 ided by covering them. ded by increased duration eeding, Paediatrics «v4.5 + Marrow 6.5 +2023EE 40 Neonatal * Hypocaleemia. ( vost) * Bronze baby syndrome : Occurs in baby with increased conjugated bilirubin or in baby with hepatic dysfunction. Formation of brown pigmentation all over baby’s skin and in body Sluids. Its an avoidable complication as phototherapy should not be given in babies with Conjugated bilirubinemia. exchange Transfusion (ET) : Indications * Signs of bilirubin encephalopathy. * Rh incompatibility + Cord blood bilirubin 7 S mo/dL or hemoglobin < 10 9/dL > Significant hemolysis. Nomograms : Cut off values 7 €T range > Start €T. Procedure of ET 00:42:26 "xchange of babys blood with twice its volume of fresh blood, Hence, also called Double Volume Exchange Transfusion @veD. Normal volume : 80 - 90 m\/4g, Volume transfused : eo - 180 mi/iig, Type of blood : Cross matched with baby's blood as well as mother’s blood. © ~ve blood commonly used as it doesn’t contain any antigens. Condition Blood type Rh Incompotibility | Rh -ve § blood group ‘0 suspended in AB plasma. 90 incompatibility | Rh compatible with baby's blood § blood group ‘0’ suspended in A® plasma. Other indications | Rh 4 blood group compatible with baby. Aative space Prolonged Joundice in Newborn + Persistent Jaundice ? a weeks in term, 7 3 weeks in preterm. Paodiatrics + v4.5 + Marrow 6.5 * 2023— ae ~~ 40 Risk Factors + Common + l. Greast feeding issues ' Transient conditions. * @reast feeding Jaundice ' Decreased duration/Frequency of feeds, Treatment ! Increase duration and Frequency of breast feed, © Breast milk Jaundice # milk contains components a, PregnanedioD that interfere with conjugation. Treatment : Continue breast feeds. a. Continuing, hemolysis. 3. Cholestasis. ‘uncommon * L. Inherited disorders : Criggler Najjar syndrome. a Hypothyroidism. 3, extrovasoted blood. Management of prolonged jaundice 00:50:03, Step 1: Does baby have Features oF cholestasis 2 ae Ss Lv \ Neonokol cholestasis step a: visual assessment + TS® i r Below PT range or Above PT range : TS 41S mo/dL- i s L Start PT. * Continue observation. Evaluate for causes: mc couse : ereast Decrn. Deron iD eh / AB0 incormpatibity g ii) Thyroid Function test ; Lo Criggler Najjar sya" Type! + Severe, may require liver transplantation Type a : Phenobarbitone, ee UDP @T, Pasdiatrcs + v4.5 + Marrow 6.5 + 2023 {