Lec:2 Neonatology Dr.

Musaab Mazin

Objectives: At the end of this lecture you should be able to answer the following

 Understanding routine delivery care and resuscitation

 Recognize APGAR score

 Demonstration of thermoregulation

 Distinguish between (SGA) and (IUGR) .

 Assess the Common problems associated with prematurity.

 Complication of IUGR &LGA

Further reading is required from

*Nelson essentials of pediatrics 9 th edition 2023 ,page 233-237

* Nelson text book of Pediatrics 21 th edition chapter 113,121 ,page 867-876,925

Neonatal resuscitation:

Although the majority of babies undergo a smooth physiologic transition

and breathe effectively after delivery, 5-10% require active intervention
to establish normal cardio respiratory function. The goals of neonatal
resuscitation are to prevent the morbidity and mortality associated with
hypoxic-ischemic tissue injury to important organs (brain, heart, kidney)
and to reestablish adequate spontaneous respiration and cardiac output.

The Apgar examination, a rapid scoring system based on physiologic

responses to the birth process, is a good method for assessing the need to
resuscitate a newborn

APGAR Scoring System

Infants who are born limp, cyanotic, apneic, or pulseless require
immediate resuscitation before assignment of the 1-min Apgar score.
At intervals of 1 minute and 5 minutes after birth, each of the five
physiologic parameters is observed frequently. Full-term infants with a
normal cardiopulmonary adaptation should score 8 to 9 at 1 and 5
minutes respectively.

Apgar scores of 4 to 7 need close observation

 An Apgar score of 0 to 3 represents either a cardiopulmonary arrest

or central nervous system depression.
Resuscitation follows ABCD approach:

A: Airway : establish a patent airway by positioning the baby with the

head slightly extended, sniffing position, and suctioning if secretions are
blocking the airway. An infant in need of resuscitation should be placed
under a radiant heater and dried (to avoid hypothermia),

B: represents breathing. Initiated by gentle tactile stimulation (slapping

the foot, rubbing the back) & some time oxygen supplementation
needed. Simultaneously, the infant's color, heart rate, and respiratory
effort should be assessed .But if the neonate is apneic , cyanotic& heart
rate ˂100 but not˂60 beat /min, positive pressure ventilation should be
initiated by:
 a well-fitted face mask attached to an anesthesia bag and a
manometer(to prevent extremely high pressures from being
given to the newborn); the bag mask device will continue for
30sec. If the infant does not improve,
 an endotracheal tube should be placed, attached to an anesthesia
bag and a manometer , pressure of 20-25 cm Hg, the ventilation
rate of 40 to 60 breaths/min ,also will continue for30 sec.
initially with 21% fraction of inspired oxygen (FIO2 ) for full-term
infants. An adequate response to ventilation includes good chest rise,
return of breath sounds, well-oxygenated color, heart rate returning to
the normal range (120 to 160 beats/min) and, later, increased muscle
activity and wakefulness.

C: represents circulation and external cardiac massage. If neonate remain

apneic , heart rate ˂60 beat/min & artificial ventilation does not improve
bradycardia, so external cardiac massage should be performed( in
addition to artificial ventilation) at a rate of 120 compressions/min with
compressions and breaths given at a ratio of 3:1, and FIO 2increased to
100%. also this will continued for 60 sec.

D: represents the administration of drugs. If bradycardia is unresponsive

to ventilation &cardiac compression or if asystole is present, resuscitation
drugs should be administered.
1. Intravenous (IV) epinephrine (1:10,000), 0.1 to 0.3 mL/kg, should
be given through an umbilical venous line or 0.5 to1 ml/kg
injected into the endotracheal tube.
2. Fluid :a rapid infusion of fluids (normal saline, or O-negative blood
if anemia is present) if poor perfusion suggest hypovolemia.
3. If there is cardiac electrical activity with poor pulses, it is
important to determine whether there is a pneumothorax by
Transillumination test or by auscultation that show decreasing
breath sound over a pneumothorax and there may be a shift of the
heart tones away from the side of a tension pneumothorax
treatment by urgent evacuation by syringe.
4. If central nervous system depression in the infant due to a narcotic
medication given to the mother during labour like pethidine,
So….naloxone (anti dote of narcotic) can be given to the infant
intravenously or endotracheal.
The American College of Obstetricians and Gynecologists (ACOG)
recommends at least 30-60 sec of delayed cord clamping after birth
for vigorous term and preterm infants.
Routine Delivery Room Care :

1.Maintenance of Body Heat: its estimated that rate of heat loss in a

newborn is approximately 4 times that of an adult because of large
surface area in comparison to body weight , the body temperature usually
maintained by

• Drying& wrapped in blankets.

• a radiant heat source for those need resuscitation

• Skin-to-skin contact with the mother in stable newborn(kangaroo

care) .

2. Antiseptic skin care & cord care:

Careful removal of the amniotic fluid and blood from the skin shortly
after birth may reduce the risk of infection with blood borne agents..
Antiseptic skin or cord care is routine in many nurseries to prevent the
spread of pathologic bacteria from one infant to another and to prevent
disease in the individual infant. Antibiotic ointment, topical alcohol, or
chlorhexidine may be applied to the umbilical cord to reduce its
colonization with gram-positive bacteria. Nonetheless, many newborn
units recommend dry cord care involves leaving the umbilical cord
exposed to air or loosely covered, cleaning it with soap and water if it
becomes soiled ,Epidemics of S. aureus nursery infections are managed
with strict infectious disease control measures (cohorting, handwashing,
and monitoring for colonization). For the infant’s first bath, the entire
skin and cord should be cleansed with warm water or a mild non-
medicated soap solution and rinsed with water to reduce the incidence of
skin and periumbilical colonization with pathogenic bacteria and
subsequent infectious complications. Based on World Health
Organization (WHO) recommendations, this should be delayed until 24
hr of life to allow full transition to extra uterine life with emphasis on
maternal–infant bonding and early breastfeeding. To avoid heat loss, the
infant should then be dried and wrapped in clean blankets.

3.The eyes: The eyes of all infants, including those born by cesarean
section, must be protected against gonococcal ophthalmia neonatorum by
application of erythromycin (0.5%) or tetracycline (1.0%) sterile
ophthalmic ointments in each lower conjunctival sac. many hospitals use
erythromycin drops to prevent both neonatal gonococcal and chlamydial
eye disease. A 1% silver nitrate solution is an acceptable alternative but
leads to a transient chemical conjunctivitis in 10–20% of cases.

4. Vit K:1mg of water soluble given I.M to prevent hemorrhagic disease

of new born

5.Hepatitis B immunization: should be given for all neonate those ˃2

kg BWT, before discharge.

6.Position: healthy infants should be placed supine to reduce the risk of

sudden infant death syndrome

Hypothermia:
Newborn infants are at risk for heat loss and hypothermia especially
preterm infants because:
1. They have a large surface area relative to their body mass.
2. Their skin is thin and heat permeable.
3. They have little subcutaneous fat .
4. They cannot generate heat by shivering.
The heat loss occurs by four mechanisms:
(1) convection of heat energy to the cooler surrounding air.
(2) conduction of heat to the colder materials touching the infant.
(3) heat radiation from the infant to other nearby cooler objects.
(4) evaporation from skin and lungs.
neutral thermal environment, is the ambient temperature that results in
the lowest rate of heat being produced by the infant and maintains normal
body temperature.
If environmental temperatures decreased will result in increasing rates
of oxygen consumption for heat production, lead to hypoxia in ill neonate
Heat production by a newborn is created predominantly by nonshivering
mechanism in specialized areas of tissue containing brown adipose
tissue. Brown fat is highly vascular, contains many mitochondria per cell,
and innervated by the sympathetic nervous fibers ,it`s situated around
large blood vessels, in the neck, thorax, and interscapular region
resulting in rapid heat transfer to the circulation.

Hypothermia mean that body temperature is below 36 c

1- Mild [ rectal temp. 34-36c]
2- Moderate [ rectal temp.30-34c]
3- Severe [ rectal temp.below 30c]
Etiology:
1-Accidental hypothermia: due to cold exposure in hospital or at home
specially in low birth weight baby due to inadequate clothing or cold
environment.
2- Other causes:
 Sepsis
 severe heart failure or with marked cyanosis
 malnutrition
 hypothyroidism
Clinical features:
Symptoms develop when temp. falls below 34c.
Early features: baby lethargic, poorly feed, week crying, reduced
movement. IN severe hypothermia: profound bradycardia, slow
shallow respiration ,hypoxia ,apnea, hypoglycemia, acidosis,
pulmonary hemorrhage& infant appear to be dead. Neonate may
have facial erythema (pink skin color) . The color is caused by
trapping of oxygenated hemoglobin in the cutaneous capillaries

Diagnosis: is by recording temp.by using low reading rectal thermometer

Prevention of heat loss in newborn infants

 raise temperature of ambient air& using humidified air in the
incubator.
 clothing, including covering head.
 dry and wrap the baby with dry blanket at birth to prevent loss
from skin
 nurse on mattress
Treatment:
1. Rewarming Using
• A radiant warmer.
• An incubator
• A heated cot.
2. Use of a plasma expander(iv. Fluid) during rewarming especially in
hypovolemic neonate.
3. Hypoglycemia may occur should be treated or better prevented by a
slow intravenous infusion of 10% dextrose.
4.Underlying cause should be treated

Complications:
1. Abdominal distention is common as a result of ileus
2. NEC (necrotizing enterocolitis)
3. pulmonary Hemorrhage
4. associated with high mortality rate &brain damage
Prematurity and Intrauterine Growth Restriction
Infants born before 37 wks from the 1st day of the Last Mensural Period
are termed premature by World Health Organization.

IDENTIFIABLE CAUSES OF PRETERM BIRTH

Fetal causes:

 Fetal distress

 Multiple gestation

 Erythroblastosis

 Nonimmune hydrops

Placental causes:

 Placental dysfunction

 Placenta previa

 Abruptio placentae

Uterine causes:

 Bicornuate uterus

 Incompetent cervix (premature dilatation)

Maternal causes:

 Preeclampsia

 Chronic medical illness (cyanotic heart disease, renal disease)

 Infection (Listeria monocytogenes, group B streptococcus, urinary tract

infection, bacterial vaginosis, chorioamnionitis)

 Drug abuse (cocaine)

 Premature rupture of membranes

 Polyhydramnios

NEONATAL PROBLEMS ASSOCIATED WITH PREMATURE INFANTS

 Respiratory complications

 Respiratory distress syndrome (hyaline membrane disease)

 Bronchopulmonary dysplasia

 Pneumothorax, pneumomediastinum; interstitial emphysema

 Congenital pneumonia

 Apnea

 Cardiovascular complications:

 Patent ductus arteriosus

 Hypotension

 Bradycardia (with apnea)

 Hematological complications:

 Anemia (early or late onset)

 Gastrointestinal complications:

 Poor gastrointestinal function—poor motility

 Necrotizing enterocolitis

 Hyperbilirubinemia—direct and indirect

 Spontaneous gastrointestinal isolated perforation

 Metabolic-Endocrine complications:

 Hypocalcemia

 Hypoglycemia

 Hyperglycemia

 Late metabolic acidosis

 Hypothermia

 CNS complications

 Intraventricular hemorrhage

 Periventricular leukomalacia

 Seizures

 Retinopathy of prematurity
 Deafness

 Hypotonia

 Renal complications:

 Hyponatremia

 Hypernatremia

 Hyperkalemia

 Renal tubular acidosis

 Edema

 Others Infections (congenital, perinatal, bacterial, viral, fungal,

protozoal)

INTRA UTERINE GROWTH RESTRICTION

There is an important distinction between the terms small for gestational

age (SGA) and intrauterine growth restriction (IUGR). SGA is based on
physical evaluation of an infant at birth, usually by a pediatrician or
neonatologist. If the infant’s weight is <10th percentile

IUGR: is present when fetal growth stops and, over time, declines to less
than the 5th percentile of growth for gestational age is a prenatal
diagnosis to describe a fetus who fails to reach in utero growth potential,
often diagnosed by the obstetricians. often classified as reduced growth
that is symmetric (head circumference, length, and weight equally
affected) or asymmetric (with relative sparing of head growth)

Symmetric IUGR often has an earlier onset and is associated with

diseases that seriously affect fetal cell number, such as

 Chromosomal

 Genetic

 Congenital malformation

 teratogenic,
 infectious

 severe maternal hypertension.

Asymmetric IUGR is often of late onset, demonstrates preservation of

Doppler waveform velocity to the carotid vessels, and is associated with
poor maternal nutrition or with late onset or exacerbation of maternal
vascular disease.

Factors associated with intra uterine growth restriction

 Fetal causes:

• Chromosomal disorders

• Chronic fetal infections (cytomegalic inclusion disease, congenital rubella,

syphilis)

• Congenital anomalies—syndrome complexes

• Irradiation

• Multiple gestation

• Pancreatic hypoplasia

• Insulin deficiency (production or action of insulin)

• Insulin-like growth factor type I deficiency

 Placental causes:

• Decreased placental weight, cellularity, or both

• Decrease in surface area

• Villous placentitis (bacterial, viral, parasitic)

• Infarction

• Tumor (chorioangioma, hydatidiform mole)

• Placental separation

• Twin transfusion syndrome

 Maternal causes:

• Toxemia
• Hypertension or renal disease,

• Hypoxemia (high altitude, cyanotic cardiac or pulmonary disease)

• Malnutrition (micronutrient or macronutrient deficiencies)

• Chronic illness like Sickle cell anemia

• Drugs (narcotics, alcohol, cigarettes)

Large-for-Gestational-Age Infants
Infants with birthweight > the 90th percentile for gestational age are
called large for gestational age (LGA). Neonatal mortality rates decrease
with increasing birthweight until approximately 4,000 g, after which they
increase.
Predisposing factors

 maternal diabetes and obesity.

 large size parents

LGA infants, have a higher incidence of: birth injuries like:

 cervical and brachial plexus injuries

 phrenic nerve damage with paralysis of the diaphragm,

 fractured clavicles,

 cephalohematomas,

 subdural hematomas,

 ecchymoses of the head and face.

LGA infants are also at increased risk for :

 hypoglycemia

 polycythemia.

 congenital anomalies, particularly congenital heart disease

Large-for-Gestational-Age