20070601cao02-1 - Common Disorders and Common Management in...

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Unformatted text preview: Common Disorders and Common Management in Newborn Yun Cao Children’s Hospital of Fudan University Shanghai, China Respiratory Disorders Respiratory • Apnea of prematurity (AOP) • Respiratory distress syndrome (RDS) • Transient Tachypnea of the Newborn (TTN) • Meconium aspiration syndrome (MAS) • Chronic lung disease (CLD) Apnea of Preterm Infant Apnea • Apnea – Cessation of breathing • Pathologic Apnea – Respiratory pauses > 20 secs – any pause accompanied by bradycardia or significant desaturation Periodic Breathing Periodic • • • • • • • A type of central apnea Brief pauses in breathing of <10 Repeat itself for several cycles Significant immaturity of respiratory control and a variant of apnea Many preterm infants demonstrate 20-30% of total sleep time A normal maturative process Epidemiology Epidemiology • Most prevalent in premature infants prior to 36 weeks’ gestation • 59 - 78% of all preterm infants – ↓with increasing gestational age • > 50% of infants <1500g require intervention for apnea • Majority of AOP resolve by 37 weeks’ postconceptional age • Persists longer with ↓ GA • Most infants reach respiratory maturity by 42 - 44 weeks CGA Treatments Treatments Stimulation CPAP Intubation Medication: Caffeine Methylxanthines Theophylline Doxapram • Oxygen • • • • Application Application • Apnea and bradycardia is a common problem • Adverse neurodevelopmental outcome may result from more frequent and significant desaturations/bradycardias • Long term effects on infant is less clear and under investigation Respiratory Distress Syndrome Respiratory • Primary cause of respiratory disorders and deaths in the newborn • Most frequently occurs in premature infants • 15% of all low birth weight infants (<2.5k) • Cause of 30% of all neonatal deaths and 70% of deaths among preterm newborns • Mortality declined significantly with the introduction of exogenous surfactant RDS RDS • Incidence higher & more severe in: – – – – – – – – – – Males Asphyxia Maternal Diabetes Second born twin Familial predisposition Maternal hypotension C/S without labour Hydrops fetalis 3rd Trimester bleeds 26-28 wks gestation age (50% incidence) RDS RDS • Caused by lack of pulmonary surfactant • Leads to progressive atelectasis • Loss of functional residual capacity • Ventilation - perfusion imbalance • Also called “Hyaline Membrane Disease” Pulmonary Surfactant Pulmonary • Complex material containing different lipids and proteins • Produced in Type II Granular Pneumocytes in the alveoli and secreted into the air surface • Decreases surface tension and establishes stable respiratory interface and lung volume Surfactant Deficiency Surfactant • Surfactant production starts only in late pregnancy • Insufficient amount of surfactant causes collapse of the alveoli, loss of lung volume due to the abnormally high surface tension Normal Alveolar Normal RDS RDS - Treatments RDS • RDS - is a self-limiting disease - it usually subsides within 72 hours • Treatments include – – – – – – Antenatal steroids Surfactant Oxygen therapy CPAP / Intubation Maintaining normal acid/base balance, pH Neutral thermal environment Transient Tachypnea of the Transient Newborn • Results from slow absorption of lung fluid • C/S • Mild respiratory distress • Peaks at about 36 hours of life • Resolve spontaneously Meconium Aspiration Syndrome Meconium • 10-20% of all deliveries have in utero passage of meconium • Meconium staining alone is not a good marker of asphyxia • Meconium-stained amniotic fluid (MSAF) is found all races and socioeconomic strata in human • The thicker the consistency of MSAF, the greater the likelihood of MAS Diffuse patchy Diffuse infiltrates throughout the lung fields Air leak syndrome Occurs in 41% of babies with MAS To Recognize Potential Problems with To Meconium- Stained Fluid • fetal distress • meconium aspiration • multisystem hypoxic-ischemic injury Effective communication with obstetricians To Recognize Predictor Risk Factors of MAS • post maturity • non reassuring fetal heart tracings • oligohydramnios • need for suctioning of baby’s trachea • one minute Apgar score < 4 = neonatal depression • C/S delivery Prevention To Describe the Benefits of Early Intrapartum Interventions • attendance at delivery: skilled personnel • suctioning mouth & oropharynx – as soon as head delivered – as soon as in resuscitation surface – keep baby warm • Assessment at delivery A = airways B = breathing C = circulation Apgar scores Treatment of MAS Treatment • • • • • Oxygen Ventilation (high frequency) Exogenous surfactant Inhaled nitric oxide ECMO Chronic lung disease (CLD) Chronic • Most frequently occurs in very premature infants • Oxygen dependent > 28 days, > 36 wks post conception • Due to - pulmonary immaturity – – – – – ↓ Surfactant Lung injury Barotrauma Inflammation (due to oxygen therapy) Genetic predisposition CLD CLD • Treatments: – Oxygen therapy – Fluid restrictions / diuretics – Steroids, broncodilators • Outcome: Death often occurs within the 1st year of life Death due to cardiorespiratory failure; sepsis; or respiratory infections Jaundice and Hyperbilirubinemia Jaundice Jaundice Jaundice • • • Most common Neonatal “Problem” Occurs in 50-60% of newborns Duration varies by – Ethnic group • AA/Caucasians – earlier peak and earlier decline • Asians/native Americans – later and higher peak and later decline – Methods of feeding • Breast • bottle – – – Gestational age Maternal health Drug exposure Physiologic Jaundice Physiologic • Classic pattern – Rise in bilirubin on day 3 – Decline to normal by 10-12days • Physiology – RBCs have shortened life span – Erythrocyte precursors degrade post birth – Increased enterohepatic circulation – Relatively deficient hepatic transport system – Resultant retention of unconjugated hyperbilirubinemia Breastfeeding Jaundice Breastfeeding • Abnormal • Early onset exaggeration of physiologic jaundice • Result of suboptimal frequency and volume of feeding • Common to see weight loss and decreased number of stools • High levels of bilirubin in meconium • Increased enterohepatic circulation Consequences of Lactation Failure Consequences • • • Hypernatremic dehydration Seizures Long term sequelae – CP – Mental Retardation • And jaundice….. Prevention Prevention • Promote early frequent feeding – Early frequent contact • Check infant in first few days after discharge home or on day 4 – Ask about feeding/urine output – Weigh • Educate Mothers Signs that your baby is BREASTSigns FEEDING WELL • By 3-4 days of age your baby: – Has 4-5 wet diapers per day – Has 2-3 BM per day (colour progressing to seedy mustard yellow) – Breast feeds at least 8 times per 24 h – Is content after most feedings Signs that your baby is BREASTSigns FEEDING WELL • Other signs that your baby is breastfeeding well: – You can hear your baby swallowing during feeding – Your breasts are full before feedings and soft after feedings. – Your baby is only drinking breast milk. Breastmilk Jaundice Breastmilk • Normal • Late onset prolonged physiologic jaundice • Transitional and mature milk increases intestinal bilirubin absorption • Unidentified factor in milk interferes with conjugation • May persist as long as 3 months Natural History Natural 300 250 200 Breast Formula 150 100 50 0 0 1 2 3 4 5 6 7 8 9 10 Pathologic Jaundice Pathologic • Onset in the first 24hrs post birth • Rate of increase of 0.5mg/dL/hr • Conjugated hyperbilirubinemia Is Jaundice Pathological? Is • ? If there is an underlying disease If process – Bruising/polycythemia? – Inborn error of metabolism – Blood group incompatibility – Infant starving? – Infection? • ?If it causes neurological damage Assessing Jaundice Clinically Assessing • Visible at 5-7mg/dL • Progresses cephalocaudal (head-to-toe) – 4-8mg/dL at head/neck – 5-12mg/dL at upper trunk – 8-16mg/dL at lower trunk and thighs – 11-18mg/dL at arms and lower legs – >15mg/dL at palms and soles Blanching Skin Blanching Maternal education: an alternative strategy for ensuring safety with early newborn discharge Chandran L, et al. Journal of Perinatal Education 1997 No concerns at this time Discuss with caller Repeat after 2 days Call MD now BiliChek BiliChek ™ Blood Brain Barrier and Blood Bilirubin Encephalopathy • • • • Prevents free unconj bilirubin from crossing Less effective in premature infants Less effective in unwell infants Bilirubin encephalopathy – – – – Hypotonia High pitched cry Seizures Long term sequalae • Athetoid CP • Sensoneural deafness Necessary Labs Necessary • Maternal ABO and Rh typing and isoimmune Ab screen/direct Coombs • Neonate ABO and Rh typing • Bilirubin panel – includes total and direct – Repeat bili q6-12hrs • Peripheral blood smear – hemolysis? • CBC – anemic? • Consider reticulocyte count • Sepsis work up if suspicious for infection Treatment Treatment • Consider Phototherapy while waiting for investigations • Optimize enteral intake • Options: – Observe – Phototherapy – Phototherapy and exchange transfusion New AAP Guidelines for Starting New Phototherapy 400 350 300 Term, well Consider... <2.5kg/unwell <1.8kg <1.2kg 250 200 150 100 50 0 0 1 2 3 Days New AAP Guidelines for Exchange New Transfusion: No hemolysis 600 Exchange transfusion + Intensive PT 500 Exchange only if PT fails… 400 Term, well Consider PT Exch if PT fails Exch! 300 Investigate 200 100 0 0 1 2 3 Days Guidelines for PT/Exchange Guidelines transfusion: Hemolysis 600 500 Exchange transfusion + Intensive PT 400 Phototh/Invest PT if unwell Exch if PT fails Exch! 300 200 100 Investigate & Rx 0 0 1 2 3 Days Recommendation • Prior to the discharge of every newborn, there should be a process and protocol in place for assessing the risk for development of significant hyperbilirubinemia in all newborns nurseries • There should be a systematic approach to the assessment of all infants before discharge for this risk and program and follow up should be in place if the infant develops jaundice • All newborn infants who are visibly jaundiced, near (between 35 – 37 weeks) and full (>38 weeks) term should have a bilirubin level determined Recommendation, cont. • Infants, although not visibly jaundiced but with two or more risk factors should have at least one bilirubin level preformed prior to discharge • Serum bilirubin may be done on either capillary or venous blood sample • Infants with severe or prolonged jaundice should have further investigations including an analysis of the conjugated component of the bilirubin • A Transcutaneous Bilirubin measurement may be used if available as a screening device Follow Up • TSB that needs photo therapy should mandate an investigation for cause • History, physical examination, lab tests, etc. etc. Recommendation • Adequate follow-up should be ensured for all infants who are jaundiced. • Infants under phototherapy should be investigated for determination of the cause of jaundice. Prolonged Jaundice Prolonged • Common in breast fed infants; ? 20% • VERY common in premature breast fed infants….? >30% Does Prolonged Jaundice Does Require Investigation? • Pathological vs physiological? – Breast fed? – Feeding well? – Thriving? – TSH screen negative? No investigation needed until 2-3 weeks Prolonged Persistent Jaundice Prolonged (>2 weeks) Investigations • Pathological vs physiological? – Breast fed? – Feeding well? – Thriving? – TSH screen negative? Blood for split bilirubin Check urine for wbc’s, urobilinogen Neonatal Infection Neonatal Global Impact (1) Global •Infection associated with 7-54% of early neonatal death •Infection associated with 30-73% of late neonatal death •Neonatal sepsis in hospital 5-6 per 1000 livebirths •Neonatal meningitis 0.7 –1 .0 per 1000 livebirths Global Impact (2) Global • Acute respiratory infection – 800,000 deaths per annum • Neonatal tetanus – 438,000 per annum, 372,000 died • Omphalitis – 2-54 per 1000 livebirths with 0-15% died • Diarrhea – responsible for 1-12% of neonatal deaths Neonatal Sepsis Neonatal • Illness with positive blood culture in first 30 days of life • Early onset sepsis • Late onset sepsis Clinical Signs: Nonspecific Clinical • Hyperthermia 55% • Jaundice 35% • Respiratory distress 33% • Anorexia 28% • Vomiting 25% • Apnea 22% • Abdominal distension 17% • Hypothermia 15% • Diarrhea 11% • Less frequent – – – – Lethargy Poor feeding Poor perfusion Bloody stools Strategies to Reduce Neonatal Infections • Antenatal Care Tetanus immunization, Management of STD, urinary infection, malaria, TB Identify pregnancy related maternal diseases and GBS carriers • Intrapartum/delivery care Prevent prolonged labor Optimal management of complications: fever, PROM, puerperal sepsis Clean delivery, cutting of cord and optimal cord care • Breast feeding Promote early and exclusive breast feeding Strategies to Reduce Neonatal Infections • Gender issues Promote gender equality Encourage education of girls • Interventions to decrease incidence of LBW or prematurity Delay childbearing in young adolescents Promote maternal education Improve maternal nutrition Reduce tobacco use Treatment of STD, Malaria treatment and prophylaxis Limit maternal work load during pregnancy Maternal support to decrease stress/anxiety Strategies to Reduce Neonatal Infections Strategies Community-based intervention Train birth attendants to identify problems in the newborn, refer with serious problems Promote and support breast feeding Maternal education regarding personal and domestic hygiene, newborn care, and childhood immunization Public health care follow-up after delivery, early diagnosis and treatment of newborn infection and mother, immunization Early identification and improved treatment of neonates with infection Integrated approach to the sick infant Improve newborn care at all levels Antibiotic Duration Antibiotic • Asymptomatic, normal lab, 2-3 days • Symptomatic or + screen at 3 days, 7d • + blood culture 10 days • + CSF culture 14-21 d Infection Control Infection Hand Hygiene The Infection Control Department So Why All Concern About Hand Hygiene? Most common mode of transmission Most of pathogens is via hands! Infections acquired in healthcare Infections Spread of antimicrobial resistance Spread Hand Hygiene • Hand washing with antimicrobial soap and water • Alcohol-based hand rub Indications for Hand Hygiene Indications • Before: – Direct contact with a patient and/or donning gloves Guideline for Hand Hygiene in Health-care Settings. Guideline MMWR 2002; vol. 51, no. RR-16. MMWR Indications for Hand Hygiene Indications • After: – Contact with a patient’s intact skin – Contact with blood, body fluids, excretions, secretions non-intact skin, mucous membranes, wound dressings in which glove use is indicated. – Removing gloves – Removal of any personal protective equipment – Contact with environmental surfaces in the patient’s immediate environment Asphyxia and Neonatal Asphyxia Hypoxic-Ischemic Encephalopathy Causes Hypoxia Perinatal asphyxia, apnea, respiratory failure, right to left shunt Ischemia Heart failure, Shock, maternal hypotension Onset of HIE Timing of Insults Antepartum Intrapartum Antepartum ± antepartum Postnatal Percentage 20 35 35 10 Diagnosis • • • • • History of hypoxia or ischemia Clinical features Neuroimaging Electrodiagnostic techniques Neuronal biochemistry Sequela • • • • Cerebral palsy Mental retardation Visual deficit Hearing loss Management 1. Monitoring of vital signs NICU, CNS, respiration, cardiovascular, renal, GI, fluid …… Management 2. Maintenance of Adequate Ventilation and Perfusion Respiratory support, blood gas Avoidance of systemic hypotension or hypertension Avoidance of hyperviscosity Management 3. Maintenance of Adequate Glucose Levels Normal level: 3.9-6.6 mmol/L 4. Control of Seizure Phenobarbital 5. Control of Brain swelling Prevention of fluid overload Mannitol Management 6. Other Therapeutic Approaches Mild hypothemia …… 7. Follow-up and Rehabilitation Feeding Preterm infants Feeding Beneficial Effect of Feeding HM to Beneficial Preterm Infants • Improved later cognitive development • Reduced risk of NEC, infection, atopy • Nutritional programming of later cardiovascular disease Breastfeeding Premature Infants Breastfeeding • • • • • • Skin-to-skin Maintaining milk supply Non-nutritive suckling Initiation of breastfeeding Test-weighting Breast vs bottle Skin to Skin Contact Skin • • • • • • • Temperature Regulation Oxygenation Control of Breathing Behavioral State Rates of Infection Maternal Milk Production Duration of Lactation Bioactive Factors in Human Milk Bioactive With Effects on GI Tract • • • • • • • • Secretory IgA Lactoferrin Cytokines (IL-10) Enzymes (PAF- acetylhydrolase) Growth factors (EGF) Nucleotides Antioxidants Nutrients: Glutamine, Taurine Glutamine, Human Milk Fortifier Human • HM provides adequate nutrition for term infants • HM contains insufficient quantities of some nutrients to satisfy the rapid growth rate of premature infants • HM fortifiers provide additional nutrients: protein, Ca, P, carbohydrates, vitamins, trace elements • HM fortifiers have short term benefits on growth with absence of documented long term benefits Cochrane review 2004 ...
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