Chapter 41: Neonatology

Neonate- an infant from the time of birth to one month of age. Newborn- a baby in the first few hours of its life Prenatal- time from before birth Gestation- time from conception to birth General Pathophysiology Assessment, and Management Epidemiology Antepartum- before the onset of labor. Intrapartum- occurring during childbirth Postpartum- occurring after birth o About 80% of newborns weighing <1500g (5lb. 5oz.) at birth require resuscitation. Pathophysiology Factors that stimulate the babys 1st breath include: o Mild acidosis o Initiation of stretch reflexes in the lungs o Hypoxia o Hypothermia Reality: Mamallion Reflex Persistent fetal circulation- condition in which blood continues to bypass the fetal respiratory system, resulting in ongoing hypoxia. Primary Apnea- after birth the period of time when the newborn has initial asphyxia and the newborn can be stimulated to increase response Secondary Apnea- the infant takes several last deep gasping respirations and becomes unresponsive. Congenital Anomalies Diaphragmatic hernia- protrusion of abdominal contents into the thoracic cavity through an opening in the diaphragm. Meningomyelocele- herniation of the spinal cord and membranes through a defect in the spinal column. Omphalocele- congenital hernia of the umbilicus. Choanal atresia- congenital closure of the passage between the nose and pharynx by a bony or membranous structure. Cleft palate- congenital fissure in the roof of the mouth forming a passageway between oral and nasal cavities. Cleft lip- congenital vertical fissure in the upper lip. Pierre Robin Syndrome- unusually small jaw, combined w/a cleft palate, downward displacement of the tongue, and an absent gag reflex. APGAR- +2 Good Response, +1 Some Response, 0 No response =<10 Appearance Pulse rate Grimace Activity

Respiratory effort APGAR is done at 1 & 5 minutes 7-10 score an active and vigorous newborn, needs only remote care. 4-6 score indicates a moderately distressed newborn <4 severely distressed newborn Treatment Establishing the Airwayo DeLee suction trap- a suction device that contains a suction trap connected to a suction catheter. o Meconium- dark green material found in the intestine of the full-term newborn. Prevention of Heat Loss o Immediately after birth, the newborns core temperature can drop 1C (1.8F) or more form its birth Temp. of 38C (100.4F) Cutting the Umbilical Cord the cord is clamped first @15cm from fetus then the second clamp 10cm from fetus or 5cm from the first clamp cut the cord between the 2 clamps polycythemia- an excess of red blood cells. May reflect Hypovolemia or prolonged intrauterine hypoxia. Hyperbilirubinemia- an excessive amount of bilirubin- the orangecolored pigment associated w/bile-- in the blood. The condition appears as jaundice. The Distressed Newborn Fetal heart rate is the most important indicator of neonatal distress. The Inverted Pyramid 1. Drying, warming, Positioning, Suction. Tactile Stimulation. Vagal response- stimulation of the Vagus nerve causing a parasympathetic response Suctioning- of the newborn should last <10sec Newborn Assessment Parameters Respiratory effort- normal 30-60 respirations/min Heart rate- normal 100-180bpm, b/p 60-90systolic, temp= 98-100 Color APGAR Score 2. O2- never deprive a newborn of O2 in the prehospital setting 3. BVM- Ventilation- begin if any below are present: HR <100bpm Apnea Persistence of central cyanosis after administration of supplemental O2. 4. Chest Compressions- initiate if either of the following exist: HR <60bpm

 HR is between 60-80, but does not increase w/ 30sec of PEEP 5. Intubation- should be done in the following situations: BVM malfunction Tracheal suctioning is required Prolonged ventilations required Diaphragmatic hernia is suspected Inadequate respiratory is found 6. Medications Epinephrine- (1st drug given to Pedis) 1/10,000 .1-.3ml/kg IV, IT Sodium Bicarbonate- 2mEq/kg IV Narcan- .1mg/kg IV, IM, SQ, IT Narcan may induce withdrawal reactions of infants born of narcotic-addicted mothers and thus give newborn a seizure. Dopamine- 5-20mcg/kg/min Titrated to effect Fluid challenge- 20cc/kg Specific Neonatal Situations Meconium-Stained Amniotic Fluid - is a result of fetal distress Apnea o Hypoxia o Hypothermia o Narcotics o Respiratory muscle weakness o Septicemia o Metabolic disorder o Central nervous system disorder Diaphragmatic hernia- protrusion of abdominal contents into the thoracic cavity through an opening in the diaphragm o If you suspect a Diaphragmatic hernia, DO NOT use BVM (can cause gastric distention) instead Intubate Bradycardia- most commonly caused by hypoxia o Treatment- follow the inverted pyramid Premature infants- neonate born <37weeks o Fetal viability is 23-24 weeks of gestation. o Primis are @ greater risks of respiratory suppression (which leads to cardiac suppression in Pedis) o Also Primis are also @ risks of hypothermia Respiratory distress/Cyanosis o Prematurity is the single most common factor causing Respiratory distress/cyanosis. o Assessment findings: Tachypnea Paradoxical breathing Intercostals retractions

Nasal flaring Expiratory grunt Hypovolemia o Signs of Hypovolemia Pale color Cool skin Diminished peripheral pulses Delayed capillary refill, despite normal ambient temperature Mental status changes Diminished urination (oliguria) o Do not treat Hypovolemia w/dextrose can produce hypokalemia or ischemic brain injury. Seizures- causes of neonatal seizures include; sepsis, fever, hypoglycemia, hypoxic/ischemic encephalopathy, metabolic disturbances, meningitis, developmental abnormalities, or drug withdrawal. o Types of seizures Subtle seizures- consist of chewing motions, excessive salivation, blinking, sucking, swimming movements or the arms, pedaling movements of the legs, apnea, and changes in color. Tonic seizures- rigid posturing of the extremities and trunk, fixed deviation of the eyes. Focal clonic seizures- rhythmic twitching of muscle groups, particularly the extremities and face. Multi focal seizures- similar to focal clonic except that multiple muscle groups are involved. Myoclonic seizures- brief focal or generalized jerks of the extremities or parts of the body that etend to involve distal muscle groups. Fever- neonates do not develop fever as readily as older children. o Normal newborn temp. is 37.5C (99.5F), Rectal = 38C (100.4F) o A neonate w/fever should be considered to have meningities until proven otherwise. o Assessment findings: AMI Decreased feeding Skin warm to touch Rashes or petechia (small, purplish, hemorrhagic spots on the skin) Hypothermia- cold stress kills more newborns o Assessment findings: Pale color Skin cool to the touch, particularly the extremities Acrocyanosis- cyanosis of the extremities Central cyanosis- cyanosis of the core Respiratory distress

Possible apnea Bradycardia Initial irritability Lethargy in later stages Hypoglycemia- newborns are the only age group that can develop severe hypoglycemia and not have diabetes mellitus o Assessment findings: Twitching or seizures Limpness Lethargy Eye-rolling High-pitched crying Apnea Irregular respirations Possible cyanosis Vomiting- watch for dehydration Diarrheao Causes of: Bacterial /viral infection Gastroenteritis Lactose intolerance Phototherapy- exposure to sunlight or artificial light for therapeutic purposes of treating Hyperbilirubinemia or jaundice. Neonatal abstinence syndrome (NAS) Thyrotoxicosis Cystic fibrosis Common Birth Injuries- most common to the head (forehead) Cardiac resuscitation, post resuscitation, and stabilization o Causes of neonatal cardiac arrest Primary or secondary apnea Bradycardia Persistent fetal circulation Pulmonary hypertension