Neonatology

At a glance

Author

Dr / Ali Abdel-Hakam
Computerized By

Dr / Noha Mokhtar Dr / Ola Allam

Dr / Mai Ghanem Dr / Randa Mohamed
Dr / Mervat Fathy Dr / Ahmed Khatab
Dr / Ahmed El-kalashy Dr / Ahmed Omar
Dr / wagdy Assar Dr / Ahmed Ez-Eldeen
Dr / Amr Gamal Soliman Dr /Ahmed Sorour
1
 Special Thanks to
Dr / Ahmed Abdel-Hakam

1st Edition , September 2012

(

)

Patients trust doctors with their lives and health. To justify that trust you must show
respect for human life and you must:

Make the care of your patient your first concern

Protect and promote the health of patients and the public
Provide a good standard of practice and care
o Keep your professional knowledge and skills up to date
o Recognize and work within the limits of your competence
o Work with colleagues in the ways that best serve patients' interests
Treat patients as individuals and respect their dignity
o Treat patients politely and considerately
o Respect patients' right to confidentiality
Work in partnership with patients
o Listen to patients and respond to their concerns and preferences
o Give patients the information they want or need in a way they can
understand
o Respect patients' right to reach decisions with you about their
treatment and care
o Support patients in caring for themselves to improve and maintain
their health
Be honest and open and act with integrity
o Act without delay if you have good reason to believe that you or a
colleague may be putting patients at risk
o Never discriminate unfairly against patients or colleagues

2
You are personally accountable for your professional practice and must always be
prepared to justify your decisions and actions.

Author

Special Thanks to
Dr / Ali Abdel-Hakam
Dr / Noha Mokhtar
Dr / wagdy Assar
Dr / Ahmed Sorour

Lecture Page
History 1
Examination 3
The Report 5
I.V. Fluids 6
G I ratio 10
Blood & Plasma 11
Dehydration 13
Feeding 14
Drugs 21
Sets 29
Post vent. Care 30
A,B,G notes 31
Full & Preterm Sings 34

3
During your shift 36
Nursing care 37
Respiratory distress 38
HMD 39
Broncho-pulmonary
41
dysplasia
Meconium aspiration
42
syndrome
TTN 44
Pneumonia 45
Pulm. Hemorrhage 46
Pulm. Hypertension 47
Pneumothorax 48
Neonatal cyanosis 51
Apnea 53

Lecture Page
CPR 54
Vomiting 55
Diaphragmatic hernia 56
Infant of diabetic
56
Mother
Prematurity 59
I.U.G.R. 61
Jaundice 61
Neonatal convulsions 69
CNS Infections 71
UVC 72
ETT 73
Hyperglycemia 75
Hypoglycemia 76
4
Hypocalcemia 78
Hypotension & Shock 78
Hypertension 79
Hyperthermia 80
Hypothermia 80
81
Poor perfusion 82
Tachycardia 82
Bradycardia 82
NEC 83
D.D. of tense Fontanels 83
I.C.H 84
Edema 84
Down Syndrome 85

5
 History
(Done in 1st report)
1) Name : Mothers name + childs name +
2) Sex ( male or female ) : medico legal
3) Residence
4) Sibling :
- See if precious baby.
- If number of siblings take care of D.M. + Large baby
5) Consanguinity for congenital anomalies
6) C.S. or Vaginal delivery
+ Maternal administration of cortisone if early labor

Vaginal delivery C.S.

1- Labor pain 1- Why??
( spontaneous , induced ) e.g.
- Pre-eclampsia
2- Obstructed \ difficult labor - Heart disease
- D.M.
- Obstruction
- PROM +

Why we ask about these items?

Obstructed labor ( vaginal ) leads to :
- Caput succedaneum
- Cephalohematoma ( esp. with forceps)
- Cephalohematoma :leads to anemia , Jaundice
- Traumatic cyanosis ( 2-1 )
C.S. liable for respiratory distress as vaginal delivery compress secretions
out , So may find TTN.
Anesthesia in C.S. affect in respiration.
D.M. infant of diabetic mother.
Heart disease congenital heart disease

7) Age of baby :
esp. in Jaundice ,and if it started at 1st day or not

8) Full term or Preterm

- Food - Ventilation - Other problems of Preterm
6
9) Maternal history of :
- D.M. I.D.M.
- HTN ( Pre-eclampsia )
- PROM
(If MAS)
Sepsis 24
Triple antibiotics
N.B. PROM > 3 months lead to creation of stressful environment
around the baby >>>> corticosteroid release & lung maturity

10) Conditions of baby just after birth :

- Cry
- Cyanosis
- Any problems
- Need incubator or not
- MAS

11) Presentations by :
- Respiratory distress , grads :
I. >>Tachypnea
II. >> I + Retraction
III. >> II + Grunting
IV. >> III + Central Cyanosis
- Jaundice - Meconium aspiration - Pneumonia - convulsions

12) Report :
-

- \
- ,
- :
----- :
- :
1- Nasal : maximum 2 L \ min
2- CPAP : ---- %
3- IMV ( Intermittent Mechanical Ventilation )
4- A\C ( Assisted ventilation )
5- SIMV ( Synchronized IMV )
- :

7
N.B. In case of Jaundice, ask about:
- Time of start ,
- Previous J. baby
- Feeding pattern
- Rh + ABO
- Prenatal, natal, Postnatal History
- Family history of hemolysis

Examination
1) General :

1. Look for appearance :

- Large baby IDM
- Small baby IUGR or Preterm
2. Colors :
- Pallor ( in lip , nails esp. if cyanosed as the blue color mask pallor)
- Jaundice ( in the body better than eye )
- Cyanosis ( central or peripheral )
- Mottling : poor perfusion in ( anemia , acidosis)
3. Activity :
Activity - poor suckling Sepsis (1st alarm)
Dont judge on baby with IMV because he is sedated
4. weight

2) Head :

1. Shape of head : microcephaly , macrocephaly ( hydrocephalous )

Centile chart
2. Fontanels :
- opened or closed
- Normally: Ant. 2 cm & Post. Closed
- Bulging fontanel : CNS presser esp. if with convulsions
(IC hg, encephalitis, hydrocephalous)
- Depressed : indicate dehydration
3. Face : colors
4. Dysmorphic features : cleft lip or palate
5. Suckling : good or poor

8
3- Chest

- Rate counted / 1 min , as neonate has cyclic respiration

( Don't count RR after suckling , due to there is some exertion with tachypnea which
disappear after few minutes )

- Symmetry between 2 sides ( no bulging or depression )

- Signs & Grades of RD ( I , II , III , IV )

- Auscultation : air entry in 2 sides equal or not ( listen at MCL & MAL ) & presence

of additional sounds as Wheezes or Crepitation

- Don't forget grunting :- listen to his voice

4- Abdomen

a. umbilicus: if there is signs of infection or not as it is important source of

infection.

b. distention

c. liver and spleen palpation

d .intestinal sounds : if heard ,suckling is allowed.

5- Genitalia:

to exclude congenital anomalies, examine both testes and anus to exclude

imperforate anus.

6- Heart

- S1,S2

- murmurs (may not be present in the 1st three days even with congenital heart)

- bradycardia ,tachycardia

9
 - blood pressure

- capillary refill time (for perfusion)

sepsis .... sternum

7- Sepsis

Clinical picture:

1.hypothermia or fever

2.decreased activity :very important

3.hypoglycemia due to hypothermia and the reverse is true

4.decreased motility

5.system impairment (score >3) (every item take one )

A .Heart: tachycardia or bradycardia (<120)

B .Renal : oliguria

C .Respiratory : tachypnea , bradyapnea

D .CNS : convulsions ,lethargy, DIC and disturbed level of consciousness.

8-Cannula

Extravasation ,tissue necrosis with Ca .

Edema : you will find place of cannula either blue or red .

. UAC

9- Investigations(routine):

- CBC - CRP - Chest X-ray - ABG

- TLC : leucocytosis or leucopenia (normal value 4000 :11000)

10
10- limbs

A . tone :frog leg , flaccidity

B .edema in lower limbs :give lasix and plasma

11- Reflexes : the most important reflexes are Moro and suckling reflexes

12- Skin :

A . pinch for dehydration if on phototherapy.

B . press : if perfusion > 3 sec delay , give dopamine.

C . sclerema >>>> sepsis

D . ecchymosis >>>> anemia ,PT

Normal examination

CNS: Good general conditions , Active cry , Good suckling , +ve Moro reflex

Respiratory: Equal air entry bilaterally , No adventious sounds

CVS : Normal S1,S2 , No murmurs

GIT : Lax abdomen , No organomegally , Intestinal sounds

11
 Report

Items

1.history :

-D/D /

- Male or female - Cesarean section or vaginal delivery

- DM , HTN , PROM

2.Age

3.Presentation:-

NB: - type of Oxygen :- now he is on (esp IMV)

4.Examination

A . general examination :

1.body weight 2.pulse ,BP, temperature and fontanelles

3.RR ,colors ,suckling and feeding

B . local examination

1.Chest: .RR , chest symmetry , air entry , crepitations, wheezes and grunting.

2.Heart : S1 ,S2 , murmers and perfusion .

3.Abdomen:distention ,lax or not and if there is hepatomegaly

5.Investigations done :

6.Treatment : especially last treatment >>> Fluids , Drugs , Phototherapy , O2

7.Recommendations

12
 IV fluids

) (

Indications :

1- all sick babies 2- babies with low blood sugar

3- all babies weighting <1,800 gm 4- RD ( R.R >80 or grade II , III , IV)

5- ventillated or CPAP infant 6- dehydration

7- all babies who is NPO or who can't take an adequate amount of fluids with nipple
or tube feeding

Solutions :

1- dextrose: 5% - 10% - 25% ( 5% means 100 c.c >>>>5 gm )

2- normal saline : ( Ns ) .9% .each 100 ml has 15.4 mEq Na & 15.4 cl& .9 Nacl

3- Kcl (potassium chloride ): ( 15% 1mmol for each 100 ml fluids )

4- Ca gluconate 10 % >>>ca

5- neo/ment : in < 30 day

- glucose 12 % (12.5% ) - saline -potassium -No Ca

6-pediament:contains ca given if the infant > 30 day

Monitoring I.V fluids :

1-day to day change in body weight

2-volume of urine out put : ( normally 1-2 ml / kg /hr )

3- general app. & and vital signs

13
4-urine s. Gravity & blood electrolytes( Na , K , CA)

When to discontinue :

) 3 / 20 -(

1- has adequate calories intake & fluid by nipple or tube feeding ( 120 ml
/kg/day)

2-has recovered from an illness

3- no longer needs I.V for glucose

I.V line I.V Line

:

1- allow 1ml /hr continuous I.V infusion to keep the canal patent

2- flush periodically with 1ml heparinized saline ( not done )

14
 ) (

A- In babies less than 30 days :

1- During the 1st day of life

-what to give :

- Glucose 10 %

- Glucose 7,5 % or 5% if preterm less than 1.5 kg(N.B: glucose 7.5 by mix

glucose 5% ,10 % by1:1)

- Ca : not in 1st day except in ( Ca is withdrawn if HR <120 )

1- infant of diabetic mother 2-preterm

3-hypocalcemia 4-hypoxia 5-perinatal asphyxia 6- HIE

-NB: ca is withdrawn if HR<120

-Amount: ( according to weight )

- <2 kg >>> 90 ml /kg /day

- 2 - 2.5 kg >>>> 80 ml /kg/day

- 2.5 3 kg >>> 70 ml/kg/day

- > 3 kg >>>> 60 ml/kg/day

2- During 2nd day of life

-what to give :

1-Neoment

2-Ca : 1cc.c / kg /day ( divided on 4 doses )

3-if no pass urine : give >> glucose 10% + 13 ml Ns / kg + 4 ml ca /kg

NB -stop Ca when feeding reach 15 cc milk / 3hs

15
- Amount

increase by 10-20 ml/kg till reach 150ml/kg/day

-2 . -1

Net fluids **

NF ,, ))Aminovein)) -

Neoment-

Dormicum , dopamine or any drugs which is add to solutions -

rate 24 -

-: -

- TF ( total fluid ) = ( this is the amount that enter circulation )

- Dr ( drugs ) = .. Calculate the total amount of drugs for this day

- Feeding = .. the total amount of feeding for this day

- NF ( net fluid ) =.. include neoment + aminovein + drugs on them

-: **

iv line -

16
Ex: we give iv fluids by rate 6cc/hr & give plasma by 10cc/hr for 24hr so in 2hr we
give 20cc plasma& 12cc iv fluids so ,

= 20 12 = 8 cc

3-During the third day of life

Add aminovein if : baby micturate &still no feeding till 3rd day ((esp. if edema is
present ,or preterm baby(start here by 1.5) ))

stop it in :

1-feeding 15 cm/3hr 2- renal problems( due to increased protein)& use plasma

here

Dose:

Start with 0.5 gm/kg/day or 1gm (the best ) or 1.5 gm ( different schools )

Max. dose ( ) , 0.5gm/kg

FT >> 3gm/kg/day

PT >>3.5/kg/day

10 X X =

NB:- Concentration of aminovein 10 cm / 1 gm

..... 3/ 15 -

line ..... 3/20 -

B ) In babies more than 30days:

We give pediament without giving Ca as it contain Ca

Max of pediament 100cc/kg/day

RD
17


) Glucose : saline = 4 : 1 + ( kcl 1cc for each 100ml fluid

*N.B: max of neoment >> 150

Special cases

- Preterm < 1.5 give Glucose 7.5 or 5% in the 1st day to avoid hyperglycemia
but better guided by RBS
- Jaundice
1st day or on 3 photo .>>dehydration &give 20cm/photo
.... -
-: RD

10

- 12 2.5 150

NB:- Dose of pediament

1st 10 kg>> 100ml/kg

2nd 10 kg>>50ml/kg

Above 20 >>20ml/kg

10 100.

-: NF ...
Emprical 1 ...

Restriction

*20% ( TF X 0.8 ) in case of :

)- Chest(RDS - meconium aspiration - pneumothorax

*30% ( TF X 0.7 ) in case of: IC Hge - Cardiac (overload) hydrocephalus CNS

(brain edema> tense fontanel)- renal

18
*No restriction& even addition in case of :

*Dehydration : *sepsis :

1-dry tongue 1-poor feeding

2-suken eye 2-hypo or hyperthermia

3-depressed fontanel 3-hpo or hyperglycemia

4-pinch test which is inaccurate in 4-hypoactivity

PT as there is little or no SC fat
5-hepatomegally

6-sclerma

7-jaundice

8-DIC

Addition

1-10%for each photo ( so double >> 20 % )

restriction

2-extreme low birth weight >> sepsis dehydration

NB:- To calculate 120 % >>> multiply TF * 1.2

Why restriction?

In previously mentioned cases there is SIADH (syndrome of inappropriate ADH

secretion) >> increase ADH >> fluid retention by 10-20%

Shock therapy ?

In case of shock: pallor - cold clammy skin - rapid thready pulse

Dose :10-20ml /kg over 30 1hr normal saline or ringer lactate

19


) Glucose Infusion Ratio ( GIR

24
:

or

- Normally : GIR = 4 8 mg \ kg \ min

Maximum is 12 , Minimum is 4
- Uses in cases of hypoglycemia & hyperglycemia
- In hypoglycemia :
GIR 12 12
hypoglycemia Corticosteroids
- In hyperglycemia :
GIR 4
hyperglycemia Insulin

- N.B.
hyperglycemia Sepsis
hypoglycemia Canula
Sepsis
? - Now the question is how to control GIR
)By changing glucose concentration (eg. Replacing G 10% by G 7.5%
Rate
To avoid volume overload

20

Blood & Plasma
Plasma :

- Indications : )(
1- Sever sepsis ( as it contains Ig ) ,
2- bleeding tendency
3- Edema ( osmotic effect ) every 12 hr if sever
- Dose : 15 ml \ kg \ dose
- ) ( \ 3 2
- e.g. >>> Request
3-2 15


Blood ( packed RBCs ) :
- Indications : anemia (judge by degree of pallor plus HB level esp. if < 10
gm/dl) but take care of laboratory mistakes so c/p is important.
- sever ecchymosis
- Dose : 10 ml \ kg \ dose & 15 ml \ kg \ dose in sever anemia
- e.g. for the request
15

N.B.
- Whole blood ) ( 20 ml \ kg \ dose
- 6 4
6
- After blood or plasma , we need to :
1-Measure blood pressure
2-Give lasix to decrease overload ) 9 + 1 (

N.B.
- Challenge test ( preterm no urine + edema )
If patient with no urine :give fluids ( shock therapy or plasma ) then lasix within 20
min then see urine out put :
If +ve pre renal failure ( hypovolemia and so measure the BP )

21
If ve renal or post renal causes
N.B.- Plasma given if aminonein Is contraindicated esp. if urea & creat
Also if plasma is given stop aminovein for that day.

Transfusion of RBCs & Plasma

Packed Red Blood Cells :

- Indications :
1- Ideal for who requiring red cells not volume .
2- O2 carrying capacity of blood in a cutely in infants with sever RDs & on
IMV .
3- Try to maintain HB > 13 gm \ dl .
4- Cardiac patients ( cyanosis , HF ) .
5- Symptomatic anemia ( tachypnea , apnea , tachycardia , bradycardia ,
feeding , lethargy , pallor ) .

Fresh Frozen Plasma :

- Indications :
1- Replace clotting factors TTT of shock .
2- Dilutional exchange transfusion .
3- Sepsis DIC .
4- Premature .
5- Sever RD , coagulation disorders .
No cross matching or ABO compatibility is needed for the plasma.
Both warmed to 37oc before transfusion , But by blood warmers not direct heat to
avoid Agglutination .

22
 Dehydration

Types of dehydration Therapy :

Step I : shock therapy

10 20 ml \ kg \ dose
30 20
Step II : Deficit therapy
- If can drink or
- Mild degree 40 ml \ kg \ 8 hr ,Moderate degree 80 ml \ kg\8 hr , Sever degree
120 ml \ kg \ 8 hr
Step III : Maintenance therapy
1st 10 kg 100 cm \ kg \ day , 2nd 10 kg 50 cm \ kg \ day ,
3rd 10 kg 20 cm \ kg \ day
How to diagnose :
1- Dry Tongue
2- Depressed Fontanels
3- Fever
4- Hyperglycemia
5- Decrease urine out put

23
 Feeding

Types of feeding :
1) Enteral nutrition :
- Breast feeding
- Bottle feeding
- Tube feeding ( Gavage feeding )

2) Parental feeding

Enteral nutrition :
- Types of milk :
1) Breast milk
2) Expressed breast milk
3) Standard formula
4) Premature formula
5) Special formula :
- low phenylalanine ,
- low phosphate ,
- S26AR
N.B. Calories :
-To maintain weight & essential body functions , The baby needs 50 60 Kcal \ kg \
day.
-To induce weight gain .
Full term give 100 120 Kcal \ kg \ day , Preterm give 110 140 Kcal \ kg \
day .
-Formulas :
ordinary 100 cc 67 Kcal , Premature 100 cc 81 Kcal .
-To calculate total daily calories :

Kcal \ kg \ day =

24
 When to start enteral feeding :
1- if baby has good suckling with no history of excessive oral secretions .
2- not distended soft abdomen with normal sounds .
3- RR < 60 br \ min for oral feeding & < 90 br \ min for Gavage (Ryle)
feeding.
4- For premature infants :
- Feeding should be initiated as soon as clinically possible .
- Early entered feeding is associated with better endocrinal adaptation ,
enhanced immune functions & earlies discharge .
- Feeding is started in 1st 3 days of life , aiming for full entered feeding in
2-3 weeks .
- For stable , larger premature infants > 1500 gm , the 1st feeding may
be given within the 1st 24 hrs of the life , early feeding may allow the
release of enteric hormones which exert trophic effect on intestine .
5- For sick infants of any birth weight , usually have concomitant ileus , So
start only if :
- The babys condition is improving .
- They dont have abdominal distention .
- They passed meconium .
- They have normal bowel sounds .
6- Prescience of umbilical catheter is not an absolute contraindication for
feeding .
When not to give Enteral feeding :
1- When gastric aspirate every 4 hrs is more than the milk given .
2- If there are signs of intestinal obstruction .
3- If feeding triggers apneic attacks .
4- In the acute phase of any illness , the 1st 24-48 hours , or while bowel
sounds are absent .
5- In babies with NEC .
6- In 12 hr post extubation .
7- In babies with repeated convulsions ( aspiration ) .
8- During exchange transfusion .

Babies at risk of developing feeding difficulties :

25
 Warning sign
Excessive mucus , frothy secretion or
history of maternal poly hydramonus
Distended abdomen
RD , rapid breathing or depressed
activity
Premature infants < 32-34 wk may
able to suck , swallow & breath , but
usually cant co-ordinate these
activities
Vomiting of green material or
persistent vomiting or spitting
No meconium by 48 hr of age
Babies who required prolonged
resuscitation
Excessive gagging , irritation &
secretion due to NG tube
Regurgitation , vomiting &
Abdominal Distention
Excessive gastric residual
Action
Dont feed till you pass a tube into the
baby stomach to exclude esophageal
atresia .
Insert NG or OG tube & withdrawal air /
fluid to decompress the babies stomach ,
dont feed till rule out obstruction Or illus
.
Dont feed by bottle nor allow breast
feeding until RR is about ??? & the baby
can co-ordinate suckling , swallowing ,
breathing .
Feed by NG or OG or IVF till tube feeding
can be administrated .
Stop feeding & obtain Abdominal X-ray to
evaluate for possible I.O.
Stop feeding until you evaluate for
obstruction .
Keep NPO till baby is stable for 24-48 hr
till bowel sounds appear to avoid NEC &
renal pr. .
Remove NG tube , give bolus feeds by OG
tube .
Suspect sepsis . NEC or intestinal
obstruction .
Decrease the volume of next feed &
more gradual , use jejunal route

Tube feeding : NG or OG

When are tube feeding required :

1- Preterm babes < 32 34 W. gestation.

Some babes are able to do sucking , swallowing, breathing & gagging but
coordination between these activities may be deficient
2- Infants weighting < 1.4 KG ( poor suckling )
3- For certain sick babes : > 34 W with certain conditions that prevent them from
being fed safety with nipple :

26
 * Severe neurological problems : with absent gag reflex
* Babies who tires easily from exertion from nipple feeding
4- Babes recovering from RD but still tachypneic ( RR > 60 Br. / Min. )

When to stop tube feeding :

1 when they are no longer needed :

- The infant developed gag reflex & can coordinate suckling , swallowing &
breathing
- No respiratory problems
2- when they are not tolerated : significant residual volume is found consistently
before each feeding or if bile appears in residual stop tube feeding start IVF and
investigate the case
3 if respiratory distress is increased : RR > 90 Br. / Min.

Complications

1- Malposition : tube to airway

2- Over & under feeding
3- Perforation of esophagus , stomach or ulcer at mucosa

( )

27
 Clinical application)(

When to Method Dose (FT , PT )

start

1- When to start ?

-Usually , not in the first day

-usually Not in infant on IMV or CPAP(some prefer to start feeding on IMV &
CPAP)

-When respiratory distress resolves

(( RD >> no feeding for fear of aspiration ( As swallowing reflex and respiration are

still not coordinated ) . ))

-Do 1st gastric wash > if clear > start

2- Method ?

- 1st by Ryle then by suckling (when to shift >> see N.B. )

3- Dose ?

A) Full term baby :

-Start trophic feeding : 3 / 5 ( fixed )

Clear

28
 - 2 11 11 99 77 55
Full dose 30 cm / 3 h r

( )

5 3 /

( ) 10 15 ml / kg / day

fixed 8 3
))

: 8
.....

fixed

Tolerate easily <<<< GIT

1- 1.5 KG

)2- Full dose + bottle(good suckling

B) preterm

-NEC

-clear gastric wash 2 6 / ( 1 )

- 2 3 / 2

- 2 6 /

29
 -:

- 15 3 / > Ca

- 20 3 / >
canula rate

- 30 3 / > +

) 4) Drugs :- (Prophylactic

Prokinetic (regulates motility) >Motiluim , H2 blocker > Zantac

Decrease distention > Simithicone

*Some say if the case take dopamine or doputamine they should be stopped
but

(gradually )

As they cause V.C. at splanchnic vessels & so > tolerance

git

distension

5) monitoring & complications

( )

) ) -- Monitoring : by Ryle > see the residual

1) 1st problem >> residual

No residual brownish

Continue as )< 10% (or 20% )> 10% (or 20% Means gastritis
the regimen

30
 +
(
)

2 ) 2nd problem : distention

<<< :

Give glycerin sup. + Motiluim+ Simithicone

? Do CRP > why

Sepsis NEC

Stop feeding & shift to IV fluids

suckling

3 ) 3rd problem : tachypnea

> <
( )

N.Bs

) 1

-NG residual with Ryle

10 3 /-

-RR < 60 Br/min - Suckling is good

? NB:- when to continue with Ryle even if the previous three conditions exist

)1- anemia ( as suckling is much effort for baby

2- if the suckling leads to increased RD a lot.

31
 2) 1st day of any diseased neonate > NPO + Ryle (opened to get rid of
secretion) > if on nasal / CPAP

3) In RDS :

RR >90 NPO , RR 60 90 Ryle , RR < 60 oral feeding

4) stop aminovelin when reach 15cm / 3hr

residual 5) Ryle Aspiration

asphyxia + vagal stimulation

6) zantac not given in sepsis ( as it decrease gastric acid which is an important line
for defense

3 / 30
(Full amount )

> -

-<< > gain weight

* Calculate needed caloriesusually the range between 120 150 K. Cal/ kg/
day

* Take e.g. we now want to make 2 KG baby gain weight using 150 Kcal/ kg/ day:

-1K.cal / day = 150 X 2 = 300 K cal

-2K.cal \ 100 cm 100cc > 67 K.cal

-3

100 >> 67

??? << 300

8 -4

32
 K.cal / Kg -:

30 cc / 3 hr so 30 X 8 = 240 cc/day

100 >>> 67

??? >>> 240

>

K.cal -:

K.cal ( 1 _.5 ) 1 = 40

30 3 / 5. ( )

3 2 -: 1 ..........

_6 _5 _ 4

Drugs

Antibiotics :-

A) uses :

1- any invasive procedure eg canula

2- when to start immediately :- e.g. - history of PROM > 24 hr & we give triple

antibiotics.

) B) when to change AB :- If 3 days with no response (clinically & CRP

C) Duration :-

( = ) + CRP ve

33
 1- if no evidence of infection. (CRP ve) >>>>> 7 days

2- if there evidence of infection. (CRP + ve) >>>>> 14 days

3- if CNS evidence of infection.>>>>> = 21 days

d) Flow up by CBC & CRP after 7 days

Lines of drugs:-

1st line drugs :- Unasyn Amikin Ampicillin Garamycin

2nd line drugs :-

- -

3rd line drugs :-

NB :- sually start with unasyn amikin ( you can add fortum as atriple therapy in
some cases )

-if no response >> give Vanco & Fortum

- If no response >> give Vanco & Meronam

- You can add Flagyl (anti-anaerobe ) & Diflucan (anti-fungal )

- The last line of drugs is ceftriaxone & liquid penicillin

- Cipro isn't common used nowdays

NB :- Another regimen

1st line :- Ampicillin & garamycin

34
 ) 2nd line :- unasyn & fortum ( we can't add amikin as it nephrotoxic

3rd line :- Vanco & fortum

4th line :- Vanco & Meronam

5th line :- liquid penicillin & ceftriaxone

) / X X = (

12 375 8.3 / 1
8 2 3
750 16.6 / 150 m g / kg /

day

1500 33.3 /




40 20 10

14 10

1.2 7.5 / 100 2 / 2

12 /
24 7.5 mg / kg /

dose

1.2 ) (gram ve
12

-This drug is nephrotoxic so not given more than 7 days & not given more
than 7 days & not given in renal or pre-renal failure e.g. generalized anasarca

35
 If used > 7 days > asses renal functions (UREA & CREAT.)-

12 500 10 / 3
12
100 mg / kg /

day

Given in 3rd day if preterm or 5th in fullterm

)(triple AB

Sepsis umbilical catheter cong. Infection history of maternal UTI or

PROM

8 X / 3 500 100 / 4
8
\ 15 mg \ kg

dose

Duration:12 14 for nephrotoxicity fear ( max 21 day ) -

8 4 X 500 100 / 5
8
20 mg / kg /
dose

BBB CNS infection

40 mg / kg / dose

/ 8 8X

)For gram ve ( B-lactam

12 200 100 / ( 6
)

36
 10 mg / kg /
dose

8 5 / Antiviral 7
% 5
10 mg / kg / dose

400 =

12 2 / 20 8

2 / 80 5 7.5 mg / kg / day

In case of infective endocarditis ( fever + cong heart )

24 / 10 / 500 9
24
100 mg / kg / day

oral 24 5 / 100 10

(once) 5 / 200 ( macrolides )

Gastric 10 mg / kg / day
wash

- Given for 3 5 day only & oral as it accumulates in tissue

- Used for atypical infection

8 -X 1.5 100 / 500 11

8
7.5 mg / kg / dose
-
%5

- Given against anaerobes & with glucose 5 % same amount

37
 - Given post vent ( anerobic infection ) + in sepsis + in NEC

24 5 1 / 2 12
%
( once ) ( nystatin )

6 mg / kg / day or
dose

Anti fungal >

Vent 7

Sepsis resistant sepsis NEC

12 12 / 10 / 500 13

100 mg / kg / day

6 )4 /( Vial 10 / 14

Vial =1000000 IU 100,000 IU / KG / day

CNS infection

200,000 : 300,000
IU/kg /day

Infusion - renal 5 / 200 15

dose
-Renal dose : 5 micro /
18 kg / min

- cardiac
-Cardiac dose : 10 micro
36 / kg / min
15

V.C dose in (Severe

38
 hypotension,septic
shock )

N.B.

- acts mainly on heart for ( hypotension , hypoperfusion , brady < 100 + good sat )

- withdrawal gradually

- if HR > 150 >>> dont give cardiac dose

- dopamine VC dose ( 15 ) in hypotension

- given to improve perfusion > (( How to know defective perfusion ? ))

>> mottling ( indicate decreased perfusion & acidosis hypoxia ) +

>> Pallor

---- test of perfusion >>

.. 3 2 1

wt (?) X dose (5) X dil. (5) X 24 X 60 (min) / conc ( 200) X 1000 (micro)

X 24( 1.44 X 1000 / ) 60

5 / 250 16

20 / 250 Renal : 5 micro / kg /
min
1044 Cardiac : 10 micro / kg
/ min

- Act on blood vessel mainly esp. pul. Vs. so improve asphyxia

- Usually , more than dopamine by 5 (not givin alone )

- Withdraw gradually

: X 1.44

39
 ** Relations between Dopamine & Doptrex **

- both +ve inotropic

- doptrex decrease tachy. Produced by dopamine

- Both withdraw gradually

12 1 / 100 17
12 /
) ( 9 + 1 1mg / kg / dose

10 1
1
1 10
1mg / kg /
day 1


/
12

- Given in cardiac hydrocephalus IC He HTN after plasma & blood

12 1 / 4 ) ( 18

.)9+1( 0.15 mg / kg / dose

> 1 <0.4 But :0.25 mg / kg / dose

In off vent. & severe
+ 1 ( pneumonia
) 3

- In off vent. Give dexa for 24 hr. before off so 2 doses

Function : decrease laryngeal edema due to ETT

Also in brain edema , allergy -

Allergy > anaphylactic shock & skin rash

- Also in MAS > for chemical pneumonitis

40
 12 25 1 / 19
2 12
()9+1. 2 mg / kg / day

2.5< 1 >

- Some say it is given in all cases till reach full amount

But its indications are :-

Green , brown residual with open ryle

)Or when take Lasix (cause stress gastric ulcer

Contraindicated in sepsis(as the gastric acid is the ist line of defence)-

6 20
% 5 +
1 cc / kg / dose
5
%

- brady

( - Na bicarb )

Cautinous. necrosis -

- DM , preterm , hypoxia

15 3 / -

) - CVP ( central line

Hypo Ca double

12 10< 1 > 21
24 8
()9+1. 1 cc / kg / day
12

1< 1 > )(vit K1.
24 2 1
IM

Reddish sec. by ryle

41
 preterm - FT

12 + + - gastritis +

12 22

0.25 12 /

Active bleeding

Iv slow or 12 24 2 10 2 / 23
per oral
9+1 ) 0.3 mg / kg / day
)0.5
< 0.5 1 >
Cortigen
B6
)

Vomiting , colic ( cry ) , bring leg to abdomen

- side effects : extrapyramidal if overdose so give cortigen b6

8 24

5 8 /

Given in distention

prophylaxis

8 3/1 = 25
8
1.5 cc / kg / day

M 25 1 / 26

Loading : 5 mg / kg /
42
 8 .)9+1( dose
1 Maintenance : 2 mg /
, 2.5 kg / dose ( every 8 hr. )

2.5

- it's bronchodilator + respiratory stimulant

( post-vent )

+ apnea + preterm + post CPAP

chest

Side effect :arrhythmia which is not present in caffine citrate (another R.stimulant)

12 / 40 27
1 phenobarb
L = 1.5
M cc / kg )3+1( Loading :
. 15-20 mg /

kg / dose
> 1
M (if 5mg
10 Maintenance
/ dose ) =
Weight /4
: 5 mg(3-8) /
every 12 kg / dose
hrs 12

- given in ventillated pt. + in convulsions

- it's a sedative drug + gradual wuthdrawal 8 - 5 - 3

convulsions 8 Gradual 8 - 6 - 4

- Also it is atreatment for jaundice (phenobarb)>>enzyme inducer

L 1 / 5 28

M 20 - 10 (midazolam
)4+1( )

.
Loading :
43
 M 1 0.1 - 0.2 mg
1 / kg / dose
2.4 - 1.2
( 10
Maintenance
)
: 0.05 - 0.1
or 0.2 mg /
(
kg / hr
)
^
-
x
) 10.1( 24
20
) (.05
) 5.2(

It's ms relaxant-

-Given in vent. pt

- -

shots 15 / + 1 29
( <<<<<9

) safer

7 /
+ 1

<<<<<4

- Keep your eyes on O2 sat. as it cause Hypotension - cardiac arrest -

respiratory arrest

IMV -fight

12 50 / 30
1
L = 15 mg /
()4+1 kg / dose
1
M = 5 mg /
10

44
 kg / dose

- Anticonvulsant used when someniletta Reach 8 & no responce

6 6 12 12

Adrenaline ( epinephrine ) 31

- in bradycardia or CPR or hypotension or acute CVS collapse

- dilute in 9 cm ( 1 + 9 )

- Dose :- 0.1 0.3 ml/kg/dose ( of 1/10000 conc. Iv bolus ) if bolus over 3-5
minutes ( or endotracheal tube followed immediately by 1ml normal saline )

- given every 3 minutes up to 3 times

- If no response give >> concentrated (not diluted) in ETT >> 0.3 1

ml/kg/dose(usually 1 cm )

- infusion : start at 0.1 mg/kg/min and adjust to desired response to a

maximum of 1mg/kg/min

- infusion done practically by giving 1cm of concentrated adrenaline on

23cm glucose given by a rate of 1cm/hr

- Preparation :- 1mg/1ml ampule >> 1 + 9 D 5% or normal saline So, 0.1

mg/1ml = 1/10000

- VIP :- if infant enter in bradycardia more and more >> adrenaline infusion

Lanoxin ( digoxin ) 32

- 0.01 -0.05 mg/kg/day

- ampule ( 0.5 mg / 2ml )

- Loading and maintenance doses :acc. To age (see ur text)

- For HF & HTN

- not given if HR less than 100

- not given directly after Ca

45
 Oral drugs

A) oral antibiotics :- oral or by Ryle

when to you use :

1- Body with pneumonia or sepsis , you will discharge him &want to complete the
course.

2- If no Canula is present.

e.g :-

1- Unasyn >> 25-50 mg/kg/day >> half of weight / 12 h

Every 12 hrs , oral (Dilution = 250 / 5 cm )

2- ximacef >> 8 mg/kg/day , (oral 3rd generations)

Every 12 hrs (conc. = 100/5 cm)

3-Zithromax >> 10 15 ml/ kg/day

Once every 24 hrs , oral (conc.= 100/5 cm)

-Ursogol >> 1cm /kg/day , In Direct jaundice (cholagouge)

- Cholestran >> 2cm/kg/dose every 12 h , ( sach. / 10cm glucose 5% ) (in direct

Jaundice as bile acid sequestrant)

Tablet drug ( taken oral or by Ryle )

1- Sildinafel >> 1 mg/kg/dose ( Virecta )

every 8 - 12 hrs Tab is 100 mg

dil of does: tab on 10 cm of sterile water (50 mg = 10 cm) (5 mg = 1 cm )

46
 (taken by Ryle )

2- Lovear (Antiviral) see before

3- capoten 25 mg (Tab) for HTN >> 0.1- 0.4 mg/kg/does

6 / 10 +

4- Folic acid

) 24 / 40( % 0.2 10 :

: - Others

-Baby - vit / poly vit = 5 drops / 24 hs

24 / 5 :

24 / 5 ) (:

- 12 8 1 5 -

- Lactobacillus stimulating factor ,thus increase immunity

- given in PT as prophylaxix against NEC + gain weight

L-Carnitine

- 5 drops/24hours

Cetal drops

- 2 drops/kg/dose /6hours

For Gaining weight

- Adjust feeding for suppying infant with 120-150 Kcal / kg

47
 >> - Drugs

Ointements

Thrombophob :- for contusion & sites of canula

Fucidin :- Antibiotic

Muconaz gel

- for oral fungal infection

- gel for mouth & tongue every 6 hours

- done with mouth wash by bicarbonate

Uses :

>>> 1- Post-vent

>>> 2- chest problems

5 : 1.5 + ( 5) - + ( )
secretion

2 : /

: 3 6 12

) function : bronchodilator + decrease secretion ( salbutamol B2 agonist

>
48
 )function: post vent > decrease vocal cord inflammation(vasoconstrictor

1 : 9 ( )

0.5 1.5 +

3 : 3

3 V.C.

>

function: decrease secretion & in wheezy chest ( as bronchodilator ) , it is

ipratropium bromide

5 : 1.5 +

: 12 ( 8 )

-1chest
pneumonia

3 ... -2 post vent

-3chest

-4

pulm. cort.

) long acting bechlomethazone (inhaler

chest infection atrovent neonate

49
 IMV & CPAP
- Better read Sayed & Helmy for mechanical ventilation

weaning from IMV :

1- Indications :

1 - Fio2 < 40 %

2- PIP > 15 cm h2o or less

3- low VR

4- stable HR & BL. Pr. & o2 saturation

5- ABG acceptable

-- when to off

1- CXR >>> good

2- ABG >>> good

3- clinical :R. rate < 40 , colour , auscultation

2- method : (start by cessation of dormicum &gradual cessation of somineletta )

1- decrease setting very gradual either FIO2 - PIP - VR - EEP till previous values

2- put on endo tracheal CPAP (maximum 2 hours to avoid pulm.collapse) then

on CPAP or nasal ( extubation )

3- keep o2 sat. normal ( 90 - 95 )

4- may put on assisted AIC for spontanous breathing + decrease dormicum &
somineletta)

3- Dexa :- before stopping by 24 hours ( 2 doses ) (( why > laryngeal edema ))

50
 4- post. vent

3 / 3

5- aminophyline > respiratory stimulant + bronchodilator > when indicated

6- Flagyl >> for Anerobes and diflucan for fungi

-: sepsis hypo activity sedation,

CPAP bubble ETT CPAP test

nasal preterm retraction
CPAP bubble work of breathing

-: ETT CPAP 2 lung collapse

ARTERIAL BLOOD GASES (ABG)

1 ) NORMAL FINDINGS :

PH : 7.35 7.45 OR 7.40

PO2 : 60 mmHg ( after clamping umbilical cord )

PCO2 : 35 45 mmHg

HCO3 : 1822 mmol / L or 20 26 mEq / L

BASE DIFICIT : BE (- ) = +2 : -2

2 ) INDICATION :
51
 1 RD esp .(if PRETERM )

2 SEPSIS eg . pneumonia

3 severe diarrhea and vomiting

4 DKA

5 RENAL PROBLEM

6 ANEMIA

3 ) CASES WE FACE :

1 RESPIRATORY ACIDOSIS

2 METABOLIC ACIDOSIS

3 MIXED RESPIRATORY AND METABOLIC ACIDOSIS

** alkalosis is uncommon and usually is iatrogenic

NB : higher PH limits is desirable in the prescence of hyperbilirubinemia since

acidosis esp. respiratory may potentiate encephalopathy .

4) COMPLICATION OF MARKED ACIDOSIS :

1 increase pulmonary vascular resistance .

2 inhibition of surfactant synthesis .

3 impaired myocardial contractility

4 impaired diaphragmatic contraction

5 impaired renal excretion of acid

5 ) CAUSES OF METABOLIC CAUSES OF RESP

ACIDOSIS ACIDOSIS

1 - hypoxia - Asphyxia

2 shock and hypoperfusion ( sepsis,HF - Apnea

,NEC)

52
 3 inborn error of metabolism - obstructed ETT

4 RTA - bronchospasm

5 feeding acidosis in premature - pulm. Edema

- central hypoventilation

- Chronic lung disease

6 ) HOW TO INTERPRET ABG: >>>>>> LOOK AT PH

ALKALOSIS ACIDOSIS

PCO2 HCO3 PCO2 HCO3

IF LOW IF HIGH IF HIGH IF LOW

RESPIRATO METABOL RESPIRATO METABOL

RY ALK. IC ALK. RY ACID IC ACID

** MIXED RESP. AND METAB . ACIDOSIS **

PH .... <<< EXPECTED PCO2 <<< = ( HCO3 2 ) + 8

1PCO2 ( PURE METABOLIC ACIDOSIS )

...... 1 MIXED ( CO2 retention )

............ 3normal ) COMPENSATED ( if PH

7 ) WHEN TO COMPENSATE by bicarb ??

If 2 or more of these criteria :

1 PH 7.25

2 HCO3 12 mEq / L

3 BASE DIFICIT -10

53
 8 ) N.B

CLINICAL

As bicarb is acalculated data ( there is no electrode that measure bicarb but the
computer calculate it from PCO2 , PH

PH PCO2 ,

9 ) MANAGEMENT :

1 RESP. ACIDOSIS

If unventilated ventilated

mostly due to Respiratory Causes >> ETT block , ETT dislodged ,

failure pneumothorax

Intubate and ventilate or - Reintubate

CPAP
suction and aspirate-

- increase rate & decrease time

2 METABLOIC ACIDOSIS

Correct bicarb ( give more antibiotics if failed

criteria ) for (sepsis ) ventilation

3 MIXED CASES

1 don't give bicarb ist as it will give co2 inside the body(practically we give
it together with increasing co2 wash)

2 correct resp. acidosis 1st by increasing vent . rate

3 then give bicarb

4 also decrease inspiratory time if good expansion to increase expiratory

time to wash co2

54
 10 ) HOW TO CORRECT HCO3 :

A EMERGENCY CORRECTION : ( if there is no ABG )

In case of acetotic breathing ( rapid deep ) give :

bicarb % 5 +

B - USUAL CORRECTION :

half correction kidney total

severe + sepsis

So we give : body wt (kg ) base deficit .3

30 15 % 5 +

N.B maximum dose : 10 Na bicarb

2 10 ....

- Some give maintenance of bicarb is 1 ml / kg / dose/12 h slow IV but it isn't

preferred

11) INFORMATION ABOUT BICARBONATE

- Na bicarb 8.4 % conc. Per ampule

- Dilute 1:1 with glucose 5% not Ringer lactate

- Bicarb should be given very slowly to prevent rapid increase of osmolarity which
may lead to IV hge .
- Bicarb should be given in good acting peripheral vein ( irritant )
- Never infuse Ca with it to prevent form of ( Ca Carbonate )
- Don't dilute with saline ( increase sodium level and increase osmolarity )

12) ANION GAP :

55
 Def :- The amount of uncalculated cations which if added to calculated cations can
conteract anions

(Na + K ) ( Cl + HCO3 )

It is arrange between 8 : 16 mEq/l

Important in cases of metabolic acidosis

metabolic acidosis With normal Metabolic acidosis With

anion gap increased gap

-- Cause :- loss of alkali -- Cause :- increased acids

-- E,g :- diarrhea -- E.g :- RF

- RTA DKA

-- Not corrected by HCO3 -- Corrected by HCO3

13) EXCESS HEPARIN may give false metabolic acidosis

Repeat test if the result is suspicious
Extreme hypothermia lead to false increase PO2
Extreme hyperthermia lead to false decrease PO2
NB :- Sample of ABG should taken arterial , but some take it venous ,

so PO2 isn't important finding in the report to judge

NB :- Ringrer lactate

Bicarb Bicarb

Signs of Preterm and Full term

-:
POST TERM > 42 W
FULL TERM > 37 PRETERM < 37 W

56
 42 W

SOLE Crease is complete Very PT has no

creases and increase
by time

Genitalia Male : undescended

testis

Skin without rugue

Pigmentation

Female : small labia
majora

Prominent clitoris

Nipple Present Faint areola

No bud or nipple

Ear Normal Thin

No cartilage , No
recoil

Skin Thick no veins Thin red

apparent veins

Lanugo hair No Fine hair

:
1 1 day glucose 10 % or 7.5
st

2 2 day neoment + rest or add +Ca

nd

3- you can add aminovein from 3rd day & written with solutions
12 -4
4 ) + (...... 4
) ( 24 -5
..... -6
7 - increase by 10 ml / day till 150

57
 :
( )1
( )2
( )3
7 ,
)Write with drugs that have loading and maintince >> L , M (4
) )5 Preterm , asphyxia , IDM
)(6 Total dose
)Aminophyline .. after vent and for premature (7
) )8 Gradual

-1Ca 15 3

-2 20 3

-3 30 3

-4 .....

2 3 -5jaundice

58


- Day in unit/Days of the baby (age)

- History

- O2(type of O2 used now)

- phototherapy + its investigations(TSB & DSB)

- RR in one minute

- feeding (Ryle or suckling residual amount- .. )

- Examination

** general **

*Colors ( pallor , jaundice , cyanosis , mottling , capillary refill )

*activity

*temp

*BP

*Weight

** chest **

*Auscultate :- air entry + additional sounds

** Heart **

*S1 , S2

*HR

** Abdomen **

59
 *Distension HSM

** Investigations **

*CXR RBS-ABG

** Recommindations **

Follow up ( During Shift )

- RR - Color -Saturation - Feeding - HR - In IMV >> auscultate Tube

1 check temp of incubators

2 if photo :
*check fluids ( rest/ add)
*distance numbers of lamps
* ...
3 O2 :
*nasal : fitted or not
* CPAP :
1- Percentage ?? >> if more 70 % and the neonate still unstable shift to IMV
2- tube >> hear , aspirate
* IMV : - setting
- FiO2 . Decrease gradually if there is improvement
- Tube . If obstructed , change
- auscultate chest
4- Solutions
Check rate type of solution
Rest / add aminovein
5 feeding : distension vomit
6- drugs :
AB
-
60
 Dopamine HR
7- investigation : done or not
8- chest examination >>>>> apnea , preterm
9 abdominal examination
10 vitals
11 special care for each case
12- Ekteb El-tazaker
13- detect Jaundice
14- Detect pallor (( Pallor + jaundice = hemolysis ))

3 / . . -
3 -
12 -
-
-
- : -
: -
: -
-
-
-

RESPIRATORY DISTRESS

- Respiratory problems are the commonest cause of serious neonatal illness of death

GRADES :

Grade 1 : tachypnea ( RR 60 Br / min )

Grade 2 : retraction + grade 1

Grade 3 : grunting + grade 2

61
 Grade 4 : cyanosis + grade 3

CAUSES :

1) RESPIRATORY : respiratory distress syndrome MAS pneumonia -

pneumothorax airway obstruction as Bil . choanal atresia - bronchopulmonary
dysplasia
2) CARDIAC : HF PDA PP HTN
3) CENTRAL : HIE IC Hge meningitis
4) HEMATOLOGICAL : severe anemia polycythemia
5) OTHERS : sepsis hypoglycemia metabolic acidosis - hyper / hypothermia
D hernia

APROACH TO DIAGNOSE :
A ) HISTORY :
1)PRENATAL : any disease of the mother befor birth leading to hypoxia ,
Maternal
drugs , previous baby with RD
2) NATAL : PROM fetal distress obstructed labor AF (meconium staining )
3) POSTNATAL : APGAR resuscitation time of RD TTT Given

B) EXAMINATION :
1) Grades
2) chest auscultation
Grades :
Grade 1 : tachypnea 60 Br / min
Grade 2 :retractions ( interscostal subcostal suprasternal )nasal flaring which
represent attempt to decrease airway resistance(air hunger)+ pursing of lips
Grade 3 : GRUNTING :- ( better by stethoscope )
>> Forced expiration against closed glottis .
Why ? to produce +ve end expiratory pressure (PEEP) that keep
the small airway opened and improve distribution of ventilation .
Grade 4 : CYANOSIS . IMV or ambu + mask or ETT
1st you should know if central >> lips , tongue , mucus membrane
Or peripheral (acrocyanosis) >> hands , feet
Also see pallor >>>> shock anemia HF V.C
Examination >>> abd chest Heart genitalia
Take care of stridor ( large airway obstruction )
C) INVESTIGATION :
1) Chest x-ray : may find : opacity " pneumonia " MAS Ground glass opacity
HMD: white lung
2) ABG routine
3) CBC HB- HCT CRP
62
 4) ECHO

D) Monitor the PT
1-RESPIRATORY :RR apnea cyanosis chest movement auscaltation
o2 saturation
2 CARDIAC : HR BP pallor anemia
3 activity sepsis
4 investigation
5 change position ( ventilation ) suction
6 physiotherapy

Respiratory disress syndrome (HMD)

- Common disease caused by surfactant deficiency

- CAUSES :
1- prematurity especially 32 wk 2 prenatal asphaxia
3- IDM 4 C.S

- Decrease INCIDENCE nowadays due to : 1 prenatal steroids

2 surfactant injection by ETT
- DIAGNOSIS :
History : as usual esp . prematurity DM C.S acute partum hge male sex
CP : RD . Rate 60 retraction cyanosis within 1st 4hours after birth and
progress over 1st 48 96 hrs of life then begin to resolve spontaneously -
apnea from 2nd day

EXAMINATION :
RDS grades , Breath sounds decrease bilaterally + crepitation , Pallor +
edema

INVESTIGATION :
1) XRAY : grades :-
Grade 1 :fine reticulogranules mottling + good lung exp.
Grade 2 : mottling ( ground glass app ) + air bronchogram
Grade 3 : diffuse mottling and increase air bronchogram
Grade 4 : white lung

NB:- white lung >>is a term in CXR >>it indicates RDS in PT (preterm) ,

If it's found in a full term suspect congenital pneumonia

63
 2) ABG 3) RBS
4) CBC CRP CULTURE SEPSIS WORK UP
5) ECHO PDA

- PROBLEMS AND HOW TO MANAGE :

1) HYPOXIA : ( PAO2 normally 70% ) by ABG
- Keep SPO2 bet. 90 95 % by oximeter
- Use head box or nasal ( grade 1 2 )
- CPAP in grade 3 ( also if PAO2 60% OR in apnea )
- If grade 4 >> IMV
2) HYPERCAPNIA AND RESPIRATORY ACIDOSIS :
- CO2 is more diffusible than O2 so hypoxia appear before hypercapnea
- PACO2 is normally bet ( 35-45)
- So do : good suction.. do ABG and manage( If PCO2 reach 60 IMV)
** Specific therapy to HMD :
- Surfactant injection but expensive
- Prophylactic CPAP has arole here ??!
- IMV early intubation leads to early extubation
Indication :
- PH 7.2 PCO2 60 PO2 50
- sitting :- FiO2 90 , VR 40-60 , time 0.36 , PIP 20 : 22 , PEEP 3-4 ,
Flow 8-10 L/m2 (( decreased Inspiratory time + increased VR to
manage respiratory acidosis ))

3) FLUIDS & ELECTROLYTES : do 20 % rest as increased fluids >>

pulmonary edema
- hypoglycemia bolus Dextrose 10% 4 ml / kg then
maintince 6mg/ kg / min
4) FEEDING
5) CIRCULATION inotropics blood plasma
6) INFECTION AB
7) TEMPERATURE
8) APNEA esp . on prematures and on 2nd day
9) IC Hge
10) NURSING
11) MONITORING

NB :- Heart failure in neonates is diagnosed by >> tachycardia , liver enlarged

64
 Broncho-pulmonary dysplasia ( BPD )

Def. :
is a neonatal form of chronic pulmonary disorders that that follows a primary
course of respiratory failure ,
e.g. RDs - MAS in the 1st day of life .
also defined as persistence O2 dependency up to 28 days .

Incidence :
is more in ELBW infant < 1000 gm

Risk factors and causes :

1- IMV , volutrauma / barotrauma
2- Inflammation
3- Prolonged O2 exposure > 150 hr by > 60 %
4- Prematurity , white race , males , tracheal colonization with ureaplasma ,
ELBW , sepsis .

Pathology :
O2 proliferation of type II alveolar cells and fibroblast alternation in
surfactant system increase inflammatory cells , cytokines & collagen .

C\P :
- Infant with progressive deterioration in pulmonary function , requiring
IMV beyond 1st week of life , poor growth , pulmonary edema , apnea ,
bradycardia
- Examination : retractions , rules ??? , wheezes , hepatomegaly .
- Investigation :
1- ABG & electrolytes .
2- Urine analysis .
3- CXR : diffuse haziness , lung hypoinflation, streaky markings , patchy
atelectasis , intermingled with cystic area , may lung hyperinflation .
4- Renal U\S , Echo .

Management :
The most effective solution is prevention of BPD by :
1- TTT of prematurity , RDs , antenatal steroid .
2- Decreases risk factors by O2 exposure , early surfactant + early CPAP
and avoid IMV .
3- Vit A .
4- Caffie - nitric oxide?
65
 Treatment :
1- Respiratory support : maintain supplied O2 bet. 90% to 99% .
2- Improve lung functions :
- Fluid restriction
- diuretics therapy as lasix to decrease pulmonary edema .
- bronchodilator as B2 agonist & theiophyline .
3- corticosteroid as Dexa .
4- Growth & nutrition 120 150 ?? \ day

NB : the most important three lines in ttt of BPD are:

1- steroids
2- aminophyline
3- lasix

Meconium aspiration syndrome

Factors that risk :

1- Amount
2- Thickness
3- Duration
4- Complications

Usually MAS occur in mature baby , if premature suggest listeria infection

or bilious reflex 2ry to intestinal obstruction .

Types of meconium :
1- Thin 2- thick

Complications :
1- Thin meconium aspiration by the baby chemical pneumanitis 2ry
bacterial infection bacterial pneumonia
2- Thick meconium aspiration
- Airway obstruction which may be :
Complete cause lung collapse
Or Partial cause 1 way valve lung hyperinflation air leak &
spontaneous pneumothorax .
- Chemical pneumanitis .
- PPHTN ( persistence pulmonary HTN ) .

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 Now how to Diagnose :
1- History : obstetric history of meconium stained labor + history of fetal
distress .

2- Examination :
- Skin , nail , umbilical cord meconium stained
- Lung over distention + bowing of sternum ( AP diameter )
- Auscultation Ronchi + Crepitation
3- CXR :
- Over expansion multiple atelectesis
- Opacity pneumonia
- Pneumothorax , pneumomediastinum
4- Lab . : ABG
5- Echo : for PPHTN
* Treatment

A) Prophylactic : Better & recommended

When head is delivered and before respiration stimulation suction of

mouth (1st)and nose very well &wrap baby with heated towel to prevent
respiration and intubate &suction of trachea +O2

B) Curative : TTT of problems

1)) Respiratory distress :

-humid o2 according to case with saturation >95%

- humidity

-endotracheal

-UAC for regular ABG

-If severe case IMV & setting is : Fio2 (80:100%) , VR:60

, PIP : 20-220 or PEEB :3 ( ) + expiration

time , make inspire 3

-early surfactant cause P.HTN , P.hge

2)) IVF & Feeding

-start low level fluid 60/kg D10% 1st day & gradually

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 -RBS + serum electrolytes

-feeding gradually 1st by ryle tube

3)) Infection

- All infants give broad spectrum Abs

- Change acc. To culture

- Start with Tripple

4)) Pneumothorax 15%

- Diagnose: deterioration of condition ,cyanosis, air entry +unequal ,

CXR

- TTT:emergent butter fly then chest tube

5)) PPHTN

- virecta , Dopamine to systolic bp

6)) HIE

7)) No rule of steroids ( but Dexa better to be given due to

chemical pneumonitis )

8)) Strict nurse care (position , suction , CPT , ABC regular)

Transient Tachypnea of Neonate (TTN)

-It is due to delayed clearance of fetal lung fluid as fetus in intrauterine life lung
filled with AF during normal labor baby is squeezed in birth canal squeeze AF
from lung AF absorbed through lymphatics

-Other names

Wet lung type 2 RDS

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- It is common and resolve whithin 3:5 days (self-limited )

-Risk factors

- C.S &term baby

- maternal sedation ---delayed clamping of cord

- Prematurity -maternal asthma -polycythemia

-Diagnosis

1- History

-Gestational age -Type of delivery C.S -maternal sedation

- onset of distress( within 1-2 hrs after birth ) -Breech - maternal asthma

** The usual presentation is ** : Term infant delivered by C.S , shortly

after delivery has tachypnea up to 100-120 br/min & last for 1-5 days

2- Examination

-RR > 100-120 - Grunting - Retraction - Cyanosis by corrected easily

-Barrel chest

3-CXR : (NO) HMD (ground glass appearance )

-the hallmark is : hyper-expansion of lung -prominent pulm. Vascular marking

4- ABG :

- Hypxia , Hypercapnia , R. acidosis

-Management

1- Hypoxia : O2 therapy nasal or head box < 60% , CPAP may be needed ,

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 Suction , Change position

2- Fluid , electrolytes feeding :- IVF 1st then ryle then oral , Rest 20% ,

Start feeding when RR < 90 by ryle, then when <60 oral & gradually

3-Antibiotics

4- Temp. control

5-Nursing

6-Monitoring

7-Discharging when :- RDS ( RR 50-60) is good , Oral feeding , No jaundice

, infection

Pneumonia

-Organisms :- Bacterial Viral Spirochetal Protozoal Fungal

-Routes :-

- Trnspalcental during delivery (GBS . Ecoli )

- Nosocomial (stph , strepr , GBS . Ecoli .)
-Risk factors

- PROM maternal history of (fever & discharge) - MAS

- Preterm baby ( immunity &mat. antibodies )
- Following IMV due to septic technique
- Diagnosis

- History :- Congenital infection : Critically ill baby at delivery + history of

maternal infection

- Examination:- As sepsis :Poor feeding - RD - Apnea - Cough - Lethargy

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 or temp , Rales are present ( Crepitation )

- CXR :- Densities Opacities Abscess cavity in staph , E.coli , klebsiella

- Lab :- Blood culture or CSF CRP CBC ( sepsis work up ) , ABG for

oxygenation

- Management

1.Respiratory support :- Acc. to grade + suctioning

If IMV is needed it is a respective lung disease so use high pressures

fio2 time

2.Antibiotics :as you see e.g :

.1for atypical pneumonia

+ .2

( + + + .3severe cases )

.4

3.Circulatory support if : -hypotension colloid (10-15 ml/ kg )

-inotropes -Fresh blood improve also immunity

4.Fluids & Feeding :- Rest 20%

5.Monitoring & Nursing : -Suction -RR BP Urine Saturation

NB :- Congenital pneumonia

1.RD early in life 2.Tachypnea is high 3.Cyanosis

4. Vent increase VR

5.CXR white lung 6.Ausc air entry

NB: IF you find opacity & You aren't sure , confirm by C/P (tachypnea + retraction +
all One lobe ) AS collapse give same appearance on CXR but wz shift to mediastinum

Imp . Appearance of pneumonia

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 1) Lobar all one lobe ( homogenous )
2) Bronchial pneumonia patchy opacities
NB : TTT of collapse >> good physiotherapy &

NB: follow up of pneumonia by CXR & auscultation

Pulmonary hemorrhage ( P.Hge )

P.Hge is a very serious sign that have very poor prognosis , So the best
management for P.Hge is PREVENT its occur .

Def. :
Gross bloody secretions are seen in the ETT ,
It occurs most commonly in acutely in infants on mechanical ventilation
between 2-4 days of age .

C\P :
The infant has sudden deterioration in respiratory status , suddenly becomes
hypoxic , sever retractions , pallor , shock , apnea , bradycardia , cyanosis .

Causes :
Hypoxia & trauma are the main causes
1- Usually direct trauma to the air way with intubation or vigorous suctioning ,
esp. if the suction catheter is out the ETT .
2- Also with coagulopathy ( DIC ) & bleeding from other areas is present .
3- Babies with large amount of blood transfusion ( over transfusion ) lead to
increase pulmonary capillary pressure , So P.Hge .
4- Congenital HF , pulmonary edema accompanies PDA .
5- RDs esp. after surfactant injections .

Management :
Again PREVENTION is the rule , how :
- The most common cause is delayed management of hypoxia esp. in premature
babies , So acidosis & prematurity lead to Hge .
- The aim is to correct hypoxia & acidosis from early by doing :
ABG & see if need to IMV , TTT of acidosis / CBC , CPR , Hct , coagulation
profile , PT , PTT
N.B:- CXR Hge may be focal ( focal , linear , nodular densities ) or

Massive ( complete white out ) & also may be clear .

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 - Auscultation tight chest .

Treatment :
I. Emergency measures :
1- Suction the air way till bleeding subsides
2- O2 concentration
3- PEEP to 6-8 cm H2O ( tapenade of capillaries )
4- PIP
5- Give epinephrine through ETT (V.C. to pulmonary capillaries )
6- IMV
7- , , ,
8- Shock therapy
II. General measures :
1- Support & correct BP ( shock measures , colloids as plasma )
2- Correct acidosis
3- Blood & plasma \ 12 hr
4- Avoid excessive volume which lead to pulmonary edema
5- ABG
III. Specific measures :
1- If trauma surgery
2- If aspirated maternal blood usually no TTT , self limited
3- For coagulopathy HDN : vit K, fresh frozen plasma 10ml\kg\12-
24 hr , platelets & monitor coagulation profile .

N.B. HDN ( hemolytic disease of newborn )

Pulmonary hypertension

Old name : Persistence fetal circulation ( but placenta in no more present ) .

During intrauterine life , shutting of blood occur from Rt to Lt through ductus
arteriosus & V.C. of vascular bed ,
After birth , pulmonary vasculature start to open & ductus start to close .
Failure of this changes lead to Pulmonary hypertension .

Causes :
1- 1ry Thick pulmonary capillaries & arterioles with V.C. of ductus
arteriosus in utero , due to maternal ingestions of aspirin or indomethacin or
chronic intrauterine hypoxia or idiopathic .
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 2- 2ry due to birth asphyxia ( hypoxemia , acidosis ) RDs ( sever ) MAS
sever bacterial pneumonia pneumothorax PDA diaphragmatic hernia

Risk factors :
1- Congenital heart disease e.g. PDA .
2- MAS , HIE ?? , RDs , GBS infection.
3- Maternal Ant PG intake.
4- Maternal Lithium TTT .

Diagnosis :
- History :
1. Term or post term + risk factor .
2. Cyanosis in 1st 12 hrs + respiratory distress is minimal mostly cardiac .
3. Saturation even with ambo , it is slowly .
- Examination :
Cyanosis , tachypnea , RDs sings ( if lung disease ) ,P2 load, Murmur ( TR)

- CXR : cardiomegaly + under lying lung disease if 2ry .

- ABG : hypoxia + acidosis .
- Echo & Doppler : for any congenital anomalies + shunts .

Management : desataturation
1- Ambo bag & see what the baby need , observe rate & pressure till
saturation .
2- O2 demand by control temp. & if no IMV give proper sedation & gentle
handle & suction ( V.C. ) .
3- O2 delivery : see the proper route , up to IMV & FiO2 .
4- Correct acidosis : by Na bicarbonate even you did induced alkalosis ,
it help to oxygenation & PHTN .
5- Restrictions of fluids 30 % .
6- Vasodilator : ( ambo ) .
7- No indomethacin if suspect PDA , till you know is it dependant or not .
8- Inotropes ( Dobutrex ) to C.O.P. + Pulm. V.D. but BP ( it acts mainly
on blood vessels )

Pneumothorax

Def. :
Collection of air within the close cavity ( pleural ) .
Cause :
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 Rupture in lung tissue that may be spontaneous ,
If it sever may cause shift in heart ( mediastinum area ) .

Risk factors :
1- IMV : esp. in
- preterm(common)
- Assisted ventilation with RDs
- High PIP , longer time
- Slow VR ( rate )
- Baby fight with IMV , So by sedation or ms. Relaxant or shift to
assisted.
2- CPAP also (6 (
3- Babies who required resuscitation with bag & mask or ETT(
)
4- Staph pneumonia ( abscess & rupture )
5- Meconium aspiration syndrome or blood or amniotic fluid aspiration , or
any aspirated material that cause ball-valve effect in airway small branches
esp if on IMV .

Complications :
1- Hypoxia
2- Acidosis
3- IV Hge due to decreases VR to the heart from cerebral veins , hypercarbia
and peripheral arterial constrictions .

Diagnosis :
I. History :
- At risk infant .
- Sudden deterioration in the ventilated baby .
- Case of cyanosis improved then deterioration with ambo .
N.B. Pneumothorax is an emergency case that need high level of suspicion

II. Examination :
- Inspection :
1- Cyanosis ( sudden )
2- R.R. or effort
3- One side become high ( of chest )
4- Abd. Distension ( as diaphragmatic is pushed down )
5- Apnea
- Palpation :
1- Deterioration of general conditions like mottling of the skin , sluggish
peripheral blood flow .
2- Trans illumination test .
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 3- Low blood pressure ( pressure in major veins prevent venous
return ) .
- Auscultation :
1- Breath sounds are louder over one lung ( not easily detected due to
radiation ) .
2- Shift of the heart beat ( ) and you think it is arrest as you don't
hear heart beats on apex.
3- Tachycardia (heart failure) then Bradycardia then arrest.

III. CXR :
- AP & Lat. View jet black appearance , shift of mediastinum .
- AP may under estimate the extent of pneumothorax .

IV. ABG :
- PCo2
- PO2 & saturation
- PH
- Mixed respiratory & metabolic acidosis

Management :
1- Small volume , asymptomatic cases :
Observation & monitoring .
2- Emergency cases like tension pneumothorax :
Air must be aspirated by needle (butterfly) then >>>>chest canula >>>>.if
controlled >>>leave the canula till complete evacuation
-if not improved >>>>chest tube is needed.
3- Symptomatic infant who are in IMV may need chest tube insertion.
NB: pnemothorax is not an absolute indication for mechanical ventilation.

Needle insertion

Needle aspiration for pneumothorax

1.Materials used

Butterfly size 23 or 25
Trifle valve
10ml syringe:- under water seal
Betadine and alchol
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 2.Sterilization firstbetadine and alcohol

3.Positin supine and someone fix him

4.Attach butterfly to triple valve to syringe

5.Avoid 3rd space and nipple area

6.Determine 2nd space mid clavicular line by determining 3rd first or by sternal angle

(against 2nd space )

7.Insertion is just above 3rd rib to avoid intercostals blood vessels

8.Hold the needle perpendicular to chest and insert

9.As soon as needle enter skin the second person should pull back syringe plugger

(-ve pressure )stop insertion as soon as u get air return

forceps

Transillumination: - See your text

-: IMV

Change setting as follow :- PIP 22 : 26(some say decrease pip but better to judge by
saturation) , Rate 60 : 70 , O2 100 % , Flow 10 , Time 0.38 , PEEP
decreased to 3

: endotracheal tube

Chest tube insertion

See your text

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 Chest canula

1.Sterilization first

2.Insert canula in 4th or 5th space MAL or AAL(angle 45) till you become below ribs
then be horizontal thenpush towards same shoulder under water seal till air
appearance

Do not remove it never till x-ray show cure

Important: insertion above lower rib to avoid the (VAN)
After removal sterilize and cover wound

NB:the most sure sign of the corret canula is the oscillation of the fluid level at the
end of the line

Neonatal cyanosis
Def.

- Arterial saturation less than 90% and pao2 less than 60

- bluish app. Of lips and mucosal membranes

- Cyanosis is emergency and need rapid response

Acrocyanosis:

Hands and feets only are blue and is a normal phenomena after delivery

-Black infant may show lips color that mistakes cyanosis

Central cyanosis :

-site :lips tongue conj. skin- extremities

Pao2 is low -
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 Extremities are warm and well perfused-

Peripheral cyanosis :

Site: extremities but tongue-lips-conj. Are pink-

Pao2 is normal-

- Extremities are cold poor refill time

How to manage

First see central or peripheral-

- Causes of central cyanosis(CC):

1. Pulmonary causes:-
CC + Signs of RDS present if :

Obstructive : ETT obstruction Or MAS or chonal atresia

Restrictive : RDS pneumonia
2.Cardiac causes:

- CC + No signs of RDS

- Increase with cry

- no improve with O2:-

*It may be lesion with increase pulmonary blood flow TGA-TAPVR-TA

OR

* lesion with decrease pulmonary blood flow TOF- PS

3. Others:

- CNS (apnea)

- polycythemai(viscosity)

- sepsis(acidosis ,hypoxia , hypotension ,VC ,hypoglycemia >>> cyanosis ,

& hypothermia>>>(lead to acidosis , VC in lung)

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 What to do ?

1. Give O2 as high aspossible to relieve cyanosis

2. Bag and mask even vent.
3. Attach oximeter to check SPO2
4. If apnea tactile stimulation bag and mask or ETT.
5. If on vent: think first in obstructed and ttt
So suck the tube + auscltate chest +see expansion of chest or change tube

NB:- How you know that ETT isn't opened ?

1- cyanosis 2- no air entry 3- no expansion

If suspect pneumothorax confirm then butterfly

1. Order: ABG RBS (hypoglycemia) - CBC(sepsis-polycuthemia)
- CRP- CXR

2. Examine:-
Vital :temp - blood pressure , Chonal atresia , HT murmur

HSM(sepsis) , Diaphragmatic hernia(scaphoid abd.)

If suspect pulm. Hypertensionvirecta(sildenfil )

If suspect PDA know first PDA dependant or not
N.Bs

1. Sudden cyanosis suspect pneumothorax or obstructed ETT .

2. Cyanosis decreased with crying bilateral chonal atresia
Obligatory nasal breath

3.Cardiac lesion may also present with RDs murmurmay be absent in

TGA cyanosis limited to lower 1/2 of bodyPDA with LT to RT shunt

4. Cyanosis in upper half of body PHTN -PDA-coarctaion of aorta

5. Patient has Palor + cyanosis >> Pallor may cover on cyanosis in lip and tongue

6. Continous cyanosis Heart & lung disease & Intermittent cyanosis CNS

(apnea)

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 7. Cyanosis with feeding oesphageal atresia-reflux

Apnea
Def :cessation of respire.for 20 sec. or more (some say 15)

Or for shorter time if with bradycardia or cyanosis

Periodic breathing: a regular sequence of resp. pause ?? 10-15 sec. follwed by

periods of hyperventilation and occurring at least 3 times /min with no cyanosis or
bradycardia ????

Risk factors :

1. Apnea of prematurity (inversely related to gestational age

2. CNS disorders (seizure IC Hge hydrocephalus)
3. RDs
4. Sepsis
5. Aspiration
6. Metabolic(acidosis- hypo Na hypo Ca hypoglycemia - hypo or hyper thermia
)
7. Upper airway obstruction , GERD
8. Hypovolemia anemia
9. NEC narcotics(maternal) or excess sedation by somonelta or dormicum
10.Cold stress

Apnea of prematurity
(needs continuous observation of premature baby)

Causes:

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 CENTRAL:

1. no signals from CNS to resp. ms (immature brain stem)

2. May be induced also by ryle deep suction reflux
OBSTRUCTIVE

1. Upper airway obs.+ ineffective resp

2. Obstructed by milk or secretion
3. Neck hyper extension
4. Eye cover
MIXED

Same risk factors + or bradycardia

- The chance of apnea increased as birth weight decrease

- All prematuraties <1800 gm will have at least one apneic spell

- All babies <1000gm will hame apnea

- Usually begin in 2nd 3rd day if onset in second week think other cause

- Also if onset in 1st day pathological

Onset of apnea:

- Within hours after brithmaternal drugs asphyxia

- Less than 1 week apnea of prematuraty-PDA- IC hge Post vent

- >1 week ++I.C.T

- 6-10weeksanemaiof prematurity

- At any time sepsis-NEC .. (risk factors)

Mangement

Babies at risk you should do monitoring of

1.HR esp. >100 (set the alarm)

2.resp. monitor(alarm if >20 sec apnea )

3.oximeter (hypoxia)
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 TTT:

1.Tactile stimulation if no emergency on chest and feet

2.Bag and mask (begin with this step)

3.Then suction of secretion

4.Continue O2 by CPAP or vent(the last step)

5.If brady cardiac massage + PPV + adrenaline

6.Try to know cause by: ABG - RBS BL.PRESSURE (give inotropes) Temp

CBC - CRP- electrolytes- PDA(exam and murmer)

7.give aminophylline as respiratory stimulant (aminophylline is theophylline +

ethlendiamine to increase water solubility >>> increase sensitivity of

respiratory center to increased CO2 tension ) or caffine cetrate which is better

as it avoids aaythmia caused by aminophyline

8. Inotropics :- It is important to continuously observe baby esp. premature

Conclusion

Lines of apnea

1. aminophylline

2.caffine cetrate 5mg /kg/dose(9+1) /24 hours (1cm > 20mg so,after dilution 1cm
>2mg )

3.CPAP

4.IMV ( NB > If IMV used > put low setting(why>>> to increase CO2 retention and
avoid O2 toxicity )

CPR

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In case of cardiorespiratory arrest : ( no respiration + Bradycardia or no HR )

1. ambu + chest compression

2. Na Bicarb (+ glucose 5 % ) for acidosis up to 3 times
3. Ringer lactate (shock therapy) 10-20 cc/kg up to 2 times
4. adrenaline I.V 10 ) ( / kg
5. dopamine if on 10 micro 36 /kg / dopamine if on 1554 /kg
-:

) 9+ ( -

If no response , can be repeated every 3 minutes up to 3 times

Also you can increase the dose up to 30 /kg
If no response give adrenaline (tube ) 1 cm

How to do CPR

function of external cardiac massage:

- Compress heart against spine

- ++ intrathoacic pressure

- Circulate blood to vital organs of body

- 2 people are required one to compress and the other to ventilate

Technique 2(thumb or 2 finger) (( Thumb tech. ))

2 thumb to depress sternum while hands encircle the chest and 2 fingers
support spine (baby on firm thing) , Thumb flexed at 1st joint and pressure applied
vertically to compress heart between sternum and spine , Thumbs are side by side
or in small baby make them one over the other , Neck slightly extended+ baby one
firm matter , Site: lower 1/3 of stetrnum between xiphoid and line between two
nipples avoid direct preesure on xiphoid

Pressure : same Rate . depth . loction

Dept: 1/3 of AP of chest

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 Rate : 3 compress:1 vent. Or 4:1 and 30 breath and 90 compress /min

When heart rate exceeds 100 >>> stop compress and do breathing

, -: CPR ,
Arrest , Compression ,
Severe

Infusion

-:

Adrenaline infusion

/ 1 24 ..... % 5 23 + 1 -

Vomiting

Vomiting in well doing baby:

1.over feeding / faulty feeding

2.swallowed aminiotic fluid or blood(maternal)
3.GERD
4.CHPS (pyloric stenosis)
vomiting in sick baby

1.intestinal obstruction
2.NEC (inborn error of metabolism )
3.sepsis(Pneumonia - UTI gastroenteritis meningitis)
4.increased I.C.T
Investigations :- sepsis work up x-ray erect&supine barium cranial US
electrolytes Bicarb metabolic screen

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NB:- You should compensate the loss + if severe >> NPO

Diaphragmatic hernia
Diagnosis:

- mainly prenatal

- severe RDs in first few hours

- scaphoid abdomen

- inflated chest

- unequal breath sound +intestinal sounds

- x-ray shows gas of stomach and intestine in chest + shift of heart + small lung

Treatment:

Surgery (emergency) >> ( Pre operative) : - Good oxygenation

- intubation

- Metabolic support

- NG( Ryle)

- Arterial catheter for ABG

NB: Do gastric decompression by Ryle /// Not inflate by ambu and mask as by this
action , You will inflate stomach & intestine &compress chest more and more

More details about diaphragmatic hernia

- it is apredisposing factor for pulmonary HTN & HF

- C/P ( white lung in CXR )

* worsing with bag and mask

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 *asymmetrical breath sounds following ETT depending on location of CDH

* if suspected do CXR with injection of air in ryle

* auscultation reveals diminished breath sounds on the affected side & some times
intestinal sounds on affected side

---- ----- Crepitations

* shift of heart impulse to right side

Misdiagnosed as Dextrocardia

Infant of diabetic mother

IDM

3 :
1- Hypoglycemia : mainly in macrosomia
= RBS 40 mg\dl , Onset 1 2 hr of age , Cause : neonatal
hyperinsulinemia hypoglycemia
Management :
C\P : lethargy , poor feeding , apnea , jitterness

Measure blood glucose ( RBS ) at :

- Once \ hr in the 1st 4 hrs
- Once \ 6 hr till end of the 1st day
- Once \ 12 hr till end of the 2nd day
So : at 1,2,3,4,6,12,24,36,48 , If hypoglycemia : manage

2- Respiratory distress :
Cause : delayed lung maturity caused by hyperinsulinemia that blocks cortisol
induction of the lung maturity
Others : cardiac & pulmonary anomalies , polycythemia , pneumothorax ,
pneumonia , C.S. delivery( TTN ) , diaphragmatic hernia.
Management : CXR , ABG , ECG , ECHO , CBC , Blood cultures
87
 If RD : manage

3- Hypocalcaemia : in 50 % of cases
Cause : controverse : delayed in parathromone or Vit D antagonize by cortisol
, asphyxia , prematurity
Occure in the 1st 24 27 hr , Ca 7 mg \dl ( total )
Invest. : total serum Ca / ionized Ca
Management : prophylactic : Ca from 1st day , curative : C/P & TTT

3 :
1- Resuscitation
2- Search for any congenital anomalies
3- Vital data specially RR , HR , BP , Perfusion
4- Trauma : brachial plexus , fracture clavicle or limbs
5- Small for G.A. : suspect mother with renal or cardiac diseases , prematurity
6- Reflexes
7- Invest. for CBC , HB , HCT , CXR , Ca , Bilirubin , ABG
8- Feeding :

Other problems :
1- Polycythemia : partial exchange transfusion ??
2- Jaundice :
Cause :
- indirect : polycythemia more distruction , prematurity
- direct : inspisated bile $ ( Treatment : as jaundice
, early obstruction , early lab. , early phototherapy )
3- Congenital anomalies : see with bad contol
as cardiac , CNS & Vertebra , skeletal , renal
4- Macrosomia 4 kg or 90 %
Cause : insulin & glucose
C\P : hypoglycemia & trauma

5- Myocardial dysfunction :
Cause : ventricular septal hypertrophy ( idiopathic )
C\P : CHF , poor C.O.P. , Cardiomegaly
CXR : cardiomegaly
Echo is diagnostic
Resolve in 4 months & symptoms at 2 weeks
Inotropics contraindicated unless myocardial dysfunction by Echo
N.B. HOCM TTT : Inderal ,NOT lazix , capoten, lanoxine

6- Renal vein thrombosis :

C\P : hematuria , flank mass , hypertension , embolic phenomena + +

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 Inv. : U\S , TTT : conserve

7- Poor feeding

8- Small left colon syndrome :

Generalized abd. Distension due to inability to pass meconium
TTT : enema or glycerin supp. + feed + IV fluid

9- Hepatosplenomegaly

Post maturity :
- Problems :
1- RD
2- Hypoglycemia
3- Hypocalcemia
4- Polycythemia
5- Birth trauma , very large size baby

Jitteriness DD :
1- Hypocalcaemia : exclude 1st ( double ca )
2- Hypoglycemia : exclude 2nd
3- Renal impairment : ask renal inv.
4- Hyperbilirubinemia : esp. direct type
Jitteriness ,Convulsions Jitteriness -:

Prematurity ) (
- Def. & class :
1) Late preterm 35 w mild problems need monitoring
2) Early preterm 35 w have problems
If 32 w need intubation
- Problems :
1- Respiratory distress :
ABG CPAP 1500
See the grades
Inv. : CXR , ABG , CRP , CBC
TTT : oxygen , CPAP , IMV , surfactant
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2- Apnea :
Esp. in 35 w , esp. from 2nd day ,
TTT : Tactile stimulation , bag & mask , drug like aminophyline , CPAP
, IMV
3- Blood glucose :
Hypoglycemia : due to stores & lead to brain damage, So RBS is a role
Hyperglycemia :
4- Hypothermia :
Measure temp. regularly
TTT :
5- Feeding & fluid :
Hypocalcaemia ( Ca add from 1st day ) : manage & TTT
There is in-coordination between suckling , swallowing &
breathing in 34w SO start with IV fluid & Rest. If RD
glucose 10 % 2 days at least ,
Then ryle D 5 % then milk baby lac PT & monitor residual &
distension to avoid NEC + regular weighting
6- Hypotension :
Cause : blood loss , infection , hypoxia , acidosis
Check BP regularly
TTT : of the cause , use for Inotropics drug as dopamine & dobutrex ,
give blood & albumin .
7- Anemia :
Inv. : CBC , HCT , Hb
TTT :
N.B. IF there is frequent Hb deterioration in general condition
apnea seizures search for IChge
8- Hyperbilirubinemia :
Very common esp. those on IVF and delayed feeding & liable for
toxicity at lower levels
Inv. : TSB , DSB
& photo in indirect type & exchanges in sever cases & add IVF 10% -
20%
9- Sepsis and low immunity :
Triple
Common esp. if PROM
Inv. ( routine ) : CBC , CRP
Start AB if suspected
C\P : not doing well, poor suckling , feeding intolerance, abdominal
distension , apnea , lethargy , irritability , seizures 3
10- CNS problems :
CNS infection , IChge
C\P : seizures

90
 Prophylactic: maneuvers, gentle care , avoid sudden change in fluid ,
IMV, ..
Inv. : lumbar puncture & U\S
Manage seizures
11- PDA :
Due to hypoxia murmer & HF
Confirm by Echo
TTT : good oxygenation , diuretics , fluids ,Indomethacin , surgery
12- GIT :
NEC so take care in feeding
13- Ophthalmology.:
ROP esp in < 32 w , or < 1500 gm
14- Good nursing
15- When to discharge :
o no RD or apnea
o good feeding
o temperature stable
o gain of weight, Esp. > 1700 gm

Preterm

-CPAP or Vent

For hypothermia -

-Minimal handling

- Glucose 10% 2 days

-Ca from 1st day

-Unacin, Amikin, Fortum

-Konakion

-Dopamin, Dobutamine

-Plasma for anemia

-Moitor Bl.Pr >>shock

- Urination

91
 IUGR <2500 gm

Problems:

1-RD & asphyxia

2-Hypoglycemia

3- Congenital Malformation

4- Sepsis

5- Hypocalcemia

6-Hypothermia

7- Polycythemia >> increase fluids

8-PPHN (Persistant pulmonary HTN of Newborn)

Due to chronic intrauterine hypoxia >> thickening of smooth ms of small

pulmonary arteries.

So don't forget,,

1-O2

2-Aminophylline>>for apnea

3- Ca Dobule

4- Zantac for stress ulcer

5-Abs

Jaundice ) (

1-Bilirubin::

92
 -Formed from hemoglobin due to red cell breakdown

-2 forms> Direct(conjugated) ,Indirect(un conjugated)

-Bounded to albumin (Indirect) conjugated in liver (direct) & excreted in stool

-measured by mg/dl or M mol/l & (mg/dl X 17.1= m mol/l)

-indirect is orange yellow & direct is greenish yellow.

-in dark babies >>press your finger on skin & observe

2- Why bilirubin is dangerous??

-can stain the brain if inexcess amount or if no sufficient albumin so free bilirubin
forms pass BBB . Also if baby is severly distressed(acidosis, hypoxia, hypoglycemia,
hypothermia, PT) BBB disturbed &even bounded bilirubin can pass.

3- Factors increase the risk of hyperbilirubinemia:

1) Prematurity:due to immature liver , low serum albumin , stress so liable to

Kerinctrous at lower levels.

2) Hemolysis: due to Rh or ABO incompitability or drugs or sepsis

3) Free fatty acids: if malnourished, cold, hypoglycemia.

4) Drugs: cefriaxone, gentamicin, Lasix, digoxin, aminophylline, indomethacine,

valum, salfa, salicylate

4- Causes of hyperbilirubinemia::

a-Physiological jaundice

b-hemolytic states: Indirect+ anemia

-Isoimmune; Rh , ABO

-Congenital hemolytic anemia: G6PD, Thalassemia, spherocytosis

93
 -Hematoma, excess brusies, polycythemia

c-Mixed hemolytic &hepatotoxic states: increase direct & indirect bilirubin.

As bacterial infection, TORCH, Drugs, vit K deficiency

d-Hepatocellular damage: Both direct(>20% of Total) +indirect , like biliary

atresia , galactosemia, hepatitis

e-Uncertain mechanism: breast milk jaundice, racial

5-DD of neonatal jaundice::

Physical Exam. Lab Cause TTT

1-jaundice + normal -ve combs, normal -immature liver Good hydration

appearance (+-) PT HCT, retics ,film ( + -)photo
-decrease
conjugation

2- J + normal app. + +ve combs +low HCT -hemolysis:Rh -antibodies&

pallor + tachypnea + + high retics + ab.film or ABO anemia for longer
CHF

3-J + HSM + Leathergy + -increase direct + -sepsis -Abs

hypothermia + poor indirect , -ve combs,
feeding low HCT, +ve sepsis -no photo if high
work up direct

4-J + Plerthoric + SGA -ve combs, high Polycythemia -as before

or one of twins HCT , normal retics
-partial exchange

5-J + CHD + HSM + -high direct, +ve -congenital Medical ttt of

Catarct + microcephaly culture or AB for intrauterine cause
torch infection

6- J + Abd distension + -increase indirect, GIT obstruction -hydration + NPO +

vomiting + no stool others > normal NG suction + X-ray

7- J+ multiple brusies -ve combs, others Cephalo- As before

+ difficult labor + head :normal hematoma

94
 swelling

8- J + long time + All normal Breast milk Follow up, stop

breast fed + all normal jaundice breast fed 2 days,
artificial milk

6- Types in details::

1-Physiological jaundice:

-Very common 2/3 -rise >12 mg/dl up to 15 -In preterm: peak 10mg/dl

-Doesn't appear in 1st 24 h -In PT appear later but stay longer

-Increase by less than 0.5mg/dl/h

-N.B:: No signs of ill health: Vomiting, lethargy, poor feeding, excessive wt loss,

apnea , tachypnea, temperature instability

Physiological

FT PT

Appearance 2 , 3 Appearance 3 , 4

Up to 12 14

Duration 7 10 14

2- Prolonged jaundice :

Def. : apparent jaundice for 10 days after birth in full term baby & for 2 weeks
in preterm baby .
Cause : breast milk jaundice is the commonest & non specific hepatitis in
VLBW
Other causes : sepsis ( UTI ) hypothyroidism inspissated bile syndrome
( very high unconjugated bilirubin followed by conj. ) delayed passage of
stool pyloric stenosis obstructed jaundice syndrome .
3- Breast milk jaundice :

95
 Usually at day 4 , bilirubin fall but here it continues to rise up to 20 mg\dl at 10
14 day of age .
If breast feeding is continued , the level stay elevated then fall slowly .
If breast feeding stopped , bilirubin level fall rapidly within 48 hr & when
breast feeding resumed the level rises again but not the previous high level .

Recurrence is common in next pregnancy 70 %
Can lead to kernicterus .
Unknown cause but some say pregnandiol in milk suppress conjugated enzyme
4- Breast feeding jaundice :

Infants who are breast feed have higher bilirubin level compared to formula
feed infants .
Cause : intake of milk enterohepatic circulation
Cholostrum constipation enterohepatic circulation
5- Inspissated bile syndrome :

Persistence icterus in association. With significance elevation in direct &

indirect bilirubin in infant with hemolytic disease
cause unknown but jaundice spontaneously in weeks or months .
6- Jaundice with G6PD

7- ABO incompatibility :

It is an iso immune hemolysis occur with blood type A or B infants born to

type O mother , transplacental transport of maternal iso antibodies ( of the IgG
type ) , results in an immune reaction with the A or B antigen of fetal
erythrocytes , which produces ch.ch. micro spherocytes .
Risk factors :
A1 ( type A has A1 & A2 ) antepartum intestinal parasitic infections 3rd
trimester immunization with tetanus toxiod or pneumococcal vaccine .
Jaundice appear in 1st 24 hr with rapid increase of the indirect element , anemia
is not sever due to effective compensation by reticulocytosis .
Diagnosis : blood group of the mother & baby , Rh retics, direct Combs test ,
blood smear for spherocytes , total serum bilirubin .
Phototherapy : is the usual TTT ( if exchange transfusion )
8- Rh incompatibility :

In Rh ve mother ( sensitized to Rh +ve ) & Rh +ve baby

Prophylaxis by ( Rho GAM )
Risk factors : not in the 1st pregnancy unless previously sensitized ,
fetomaternal hge , male > female , C.S. , trauma .

96
 If accompanied with ABO incompatibility , the risk of Rh incompatibility will
decrease due to rapid immune clearance of the fetal blood cells after entry to
mother .
C\P : jaundice + anemia in 1st 24 hr + or HSM
Inv. : blood group & Rh of infant & mother , retics , direct Combs test , TSB ,
DSB , RBS .
TTT
9- Emergency management of sever erythroplastosis ( hydrops fetalis ) :

Most of infant are delivered by C.S.

Resuscitation may need intubation , aspiration of pleural or peritoneal effusion.
UMC ( umbilical vein cath. ) check Hb & bilirubin Combs test - transfer
to NICU .
Mechanical ventilation if RD , HF , pulmonary hypoplasia
Early exchange transfusion .
May need digitalis , diuretics .
Clotting screen after 1 hr from combination of ex. transfusion .
10- Kernicterus ( apnea & convulsion ) :

Def. : it is a pathological diagnosis describing by yellow staining of the basal

ganglia due to high level of free bilirubin or due to increase permeability of the
brain , esp. seen in preterm babies .
Cells of basal ganglia in the midbrain are metabolic active & receive the largest
blood flow .
It is risk with immaturity , rapidly raising bilirubin , low albumin , hypoxia ,
acidosis , sepsis , hypoglycemia .
C\P : initially , infant has non sp. Signs of like poor suck , lethargy of
hypotonia + high jaundice & within hours , it progresses to fever , hypertonia
of extensor ms. Groups leading to opisthotones (trunk & neck arching) ,also
convulsions may be +ve
If left un treated : fetal or sever brain damage can occur
Preterm infant may develop apnea with tone .
Immediate exchange transfusion better proceeded by albumin transfusion ,
should be done .
11- Indirect hyperbilirubinemia ( cong. ) :

Def. : if direct bilirubin > 20 % of total or > 2 mg\dl , A persistence or

elevated direct bilirubin is always pathological & must be evaluated & a value
> 5 mg\dl is consider sever case .
Causes :
Idiopathic neonatal hepatitis , the most common (by exclusion).
Biliry atresia : 2nd common cause , need surgery otherwise LCF
TPN ( unknown mechanism ) if > 2 w esp. in preterm infant .
97
 Sepsis or UTI
Intrauterine infections ( TORCH )
Inspissated bile syndrome
Choledocal cyst , antitrypsin
Galactosemia
Inv. : liver functions CBC urine & blood culture reties Coombs test
TORCH screen U\S for liver & biliary tract liver biopsy radionuclide
scan .

Clinical application
Jaundice

a) History :
- Prenatal , natal , postnatal history
- feeding pattern family history of hemolysis
- previous jaundiced baby .
- Rh status
- Time of start

b) Examination :
- Color : indirect \ direct
- Distribution :
6
9
12
15
15
- Look of signs of infections
- Look for area of accumulated blood as cephalohematoma or bruises .
- Liver & spleen size ( if hemolysis )
- Pallor , suckling , feeding ability

c) Investigation :
Start TSB , DSB , reties
- Severity bilirubin
Indirect hemolysis reties
: reties
- ABO groups for infant & mother
( usual In the 1st 3 days ,esp. in the 1st day 3 )

98
 - ABO incompatibility B or A O
Rh
- Direct bilirubin
inspissated bile syndrome
CBC for anemia
CRP for infections esp. UTI
N.B.

* Jaundice > 14 days must be investigated At least by TSB - DSB Hct

thyroid function urine culture .

* It is not physiologic if appear in the 1st 24 hr or by 0.5 mg\dl\hr or > 2 in 4 hr or

evidence of hemolysis abd. examination or direct > 20 % or

persistence > 3 weeks .

* Infant with breast feeding jaundice are liable for hemorrhagic diseases , So be

sure that baby take prophylactic dose of Vit K

* Skin color is not guide for hyperbilirubinemia in infant under photo.

d) Treatment :
) 7 ( ) 12 (
Triple 20
1- Phototherapy like tables
2- Exchange transfusion :
( Triple )
( Photo + + 6 )
3- Good hydration , effective feeding , IVF
3 - 2
4- In breast milk jaundice , stop for 2 days & give artificial
5- Kernicterus & convulsion give anti convulsion
6- Sepsis give Antibiotics
( exchange 19 18 do triple + good feeding \ 2 hr )

e) Management of hyperbilirubinemia in healthy term baby :

Day Age (hr) Photo ( TSB\mg\dl ) Exchange transfusion

1st Up to 24 10 - 12 20

99
 2nd 25-48 12 15 20 25

3rd 49-72 15 18 25 30

4th >73 18 20 25 30

f) Management of hyperbilirubinemia in sick term baby :

Age (hr) Photo ( TSB\mg\dl ) Exchange transfusion

Up to 24 7 - 10 18

25-48 10 12 20

49-72 12 15 20

>73 12 15 20

g) Management of hyperbilirubinemia in healthy & sick preterm <37w baby :

Healthy baby Sick baby

Weight photo exchange photo Exchange

Up to 1 kg 57 10 46 8 - 10

1 : 1.5 7 - 10 10 15 6-8 10 12

1.5 : 2 10 17 8 10 15

> 2 kg 10 12 18 10 17

h) TTT of direct jaundice :

1- Over hydration +
2- ( Cholaguoge) 1cm \ kg \ day
3- )bile acid sequestration ) 1sach. \ 10cm glucose 5 % ,
2cm \ kg \ dose \ 12hr
3 2 -:

100
 Phototherapy

Used for indirect hyperbilirubinemia not the direct .

- lamps have wavelength between 425 475 nm .

- there is no benefit from ordinary fluorescent lamps .

- light produced well convert indirect to non harmful substance .
- double photo is used in high level .
- contraindicated in porphyria .

Types of phototherapy :
1- Conventional
2- Prophylactic : in VLBW , cephalohematoma , polycythemia .
3- Intensive photo :
- Put lamps within 15-20 cm of infant
- number of lamps
- May use phototherapy blankets under the infant

Procedure ( single or double ) :

- Distance : 35-50 cm , and if baby inside incubator put 5-8 cm distance
between lamps & incubator .
- Baby undressed except napkin area & eyes .
- Turn baby every 2 hr to surface area .
- Temp. follow up regularly ( heat , loose stool , dehydration ) .
- Clean baby only by water , no oil or creams .
- Weight baby daily .
- 10-20 % add to fluids .
- Dont judge by skin color any more .
- Check bilirubin every 12-24 hr up to 48 hr .
- Remove photo when bilirubin became < 7-10 mg\dl .
- Then follow up bilirubin 24 hr after TTT for rebound hyperbilirubinemia .
- Good feeding .

Bli-bild device

Advan :- more exposure ( increase surface area )

Disadvantage :- hypothermia >> poor suckling

101
 Problems :
1- transit time diarrhea .
2- Dehydration .
3- Hyperthermia .
4- Rash examine regularly .
5- Eye problems if exposed so turn off

6- Bronze baby syndrome if used in direct bilirubin .
7- Genital problems if exposed .
8- Anxiety to parents .

Other N.Bs in Jaundice

Indirect bilirubin : fat soluble , carried on albumin , not excreted by kidney but
pass BBB & cause kernicterus .
Direct bilirubin : water soluble , excreted in bile & kidney , not pass BBB but
its underlying cause is dangerous .
Indirect hyperbilirubinemia may lead to direct one by inspissated bile
syndrome .
Rate of rise in pathological jaundice > 5 mg \ dl \ day
If childe on curve need exchange , we may try intensive photo
( 45cm 25cm ) .
Rate of 0.2 mg \ dl \ hr , So after 4 hr 0.8 .
Breast feeding jaundice :
3

Breast milk jaundice :
10-7

Phenobarbitone = sominalette 5 mg \ kg \ dose

Mechanism enzyme inducer

:
1- Feeding ( frequency ) +

2- Abd. Distension
3- Suckling power
4- Hypoactivity >> sleep with no cry

102
 :
- TSB , DSB - CBC

Neonatal convulsions ( seizures )

It is critical to recognize neonatal seizures & known their etiology & TTT them
urgently .

Complications :
1- The cause is usually serious
2- O2 consumption , So hypoxia & brain injury .
3- Interfere with supportive measurement as ventilation & elimination .

Causes :
1- HIE : the single most common cause ( see later )
2- IChge
3- CNS infection : see later
4- Metabolic as :
- Hypoglycemia
- Hypocalcaemia
- Hypothermia
- Vit B6 ( cortigen B6 )
Exclusion
Convulsion resistance to TTT & TTT by 0.5 cm IM cortigen B6
5- Kernicterus
6- Polycythemia
7- Developmental
8- Drug withdrawal
9- Familial
10- Others like : Fifth day Fits , hydrocephalus

N.B.

it is important to diff. between jitteriness & convulsion ( for jitteriness see IDM ):-

Limb .... Jitteriness

Convulsion

103
 Management :

Emergent measures

1- check ETT + increase FIO2 + glucose measurement

+give ca

2-anti convulsant drugs + search cause

1- TTT of cause
So inv. ( Ca total ionized , glucose , bilirubin , CRP )
2- Supportive measurement ( ABC ) : O2 , suction , position(see later)
3- Anticonvulsant drug
Significant convulsion
saturation Significant

Drugs :

) (

1- give somonileta 15 mg/kg as (L) & wait 0.5 hour if no Response give another loading
& wait 0.5 hour

2- If no R give epanutin then

6 6 12 12

1- Phenobarbitol ( PB ) =
- Is the 1st line drug & it is sedative
- It is give loading dose of 15 mg \ kg \dose over 10 min.
+ careful monitoring of respiration .
- If initial dose is effective wait for 0.5 hr , the additional dose of
5 mg \kg \ dose can be given every 5 min. till seizures or a total dose
of 40 mg \ kg is reached .
- Then maintenance 5 mg\kg\day is given &started 12 hr after loading dose
2-phenytoin = epanutin

104
 - If convulsion persist or total dose of Phenobarbitol ( 40 mg\kg ) is
reached .
- Give loading dose 15 mg \ kg \ dose & monitor cardiac rate & rhythm (
cause cardiac dysfunction ) .
- Maintenance : 5 8 mg \ kg \ day in 2 doses
- Maintenance dose 6
- Withdrawal :
If 5 days free without convulsion
Very slowly withdrawal
After 4 months do EEG , complete neurological examination &
CT .
N.B.

1st of all do ABC for the infant :

- A : airway by suction & change tube
- B : O2 ( give adequate O2 ) + Fio2
- C : cannula + shock TTT + dopamine & dobutrex dose 5
Search & TTT the cause , e.g. :
- Hypoglycemia if asymptomatic give 2 ml \ kg
If symptomatic as convulsion give 4 ml \ kg
- Hypotension : measure BP & TTT
- Hypocalcaemia : double Ca dose
- Vit B6 : 0.5 cm IM cortigen B6
Conv. Resist for TTT

CNS infection ( Meningitis )

Diagnosis :
The organism may be streptococci ( GBS ) E.coli H.influanza .
C\P :
1- Bulging fontanel ( anterior )
2- Arching back
3- Convulsions
4- Hypo or hyperthermia
5- Neck rigidity

Investigations :
105
 CBC , CRP
LP ( lumbar puncher ) for CSF

Treatment :
1- Drugs
100.000 200.000 : 300.000
2- +
3- May +
4- May + antiviral ( tab = 400 mg )
0.5 tab \ 5cm glucose 5 % \ 8 hr =
Dose = 10 mg \ kg \ dose
5- +
6- TTT of convulsions anticonvulsant drug
7- Supportive measurement

Umbilical venous catheter

A- Indications :

1_ Urgent administration of resuscitation drugs or adrenline .

2 Hypertonic solution 12.5 .

3 Giving blood and blood products .

4 Measure CVP .

5 Exchange transfusion .

6 In no cannula can be done

B- Contraindications :

1 Omphalitis

2 Omphalocele

3 NEC

4 Peritoritis

106
 C- Tools :

1 dressing - betadine alcohol

2 blade forceps syringe silk suture 3/ 0

3 Flush solution ( Normal.saline + 1 unit . heparin )

4 unbilical catheter

a - 3.5 for ELBW b - 5 for < 3.5 kg c - 8 for > 3.5 kg

D- Steralization (Clean , Tie , Cut )

1 Betadine ( 3 times )

2 alcohol ( one time )

E-

cord ( base ( blood

F-

G- cut the cord and remove clots and leave 1- 1.5 cm

H- identify the vein (one vein has wide small lumen and 2 thick arteries)

I- measure distance >> from umbilicus to xiphoid + 1cm of cord

>> or from umbilicus to shoulder and take 2/3 only

>> or (Wt X 3 ) + 9 / 2

NB:- Don't touch infant body by catheter

J- insert UVC No resistance is must >> if present >> aspirate clots

107
 K- confirm >>

-superficial

-continous flow and not pulsating

- IVC liver sinusoids interrupted flow

x_ray( )

L- suture by silk >> by purse string suture

M- fix catheter

N-nursing care & frequent cleaning of catheter

O-removal (7-14) days without complications / or reached 15cm

Complications

A. Air embolism

B. thrombosis

C. malposition>>>> If inserted in

1. right atrium or SVC >>> pericardial effusion 2. arrhythmia

3. hydrothorax if inserted in pulmonary veins

4. may leads to distention if inserted in liver 5. leakage

D. hepatic necrosis ( not give drugs contain Ca )

E. sepsis >>>depend on >> 1.maturity 2.technique 3.days

4.malcare 5.heparin

-: purse string cord , artery

cord

Problems >> resistance

108
 .1clots

.2

.3saline

.4

.5

( .6silk Weak)

-: resistance

NB :- x-ray findings

1. if to right >> hepatic

2.above >>>upper border of liver

3.run in middle of vertebral column till T9 at least

Endotracheal intubation (ETI)

Sizes

1. < 1 kg >>>>2.5 (if <28 wk)

2. (1-2)kg >>>>3 (from 28 wk to 34 wk)

3. (2-3)kg >>>>3.5 (from 34 wk to 38 wk)

4. > 3 kg >>>>4 (>38 wk)

N.B

1. problems with use of smaller tubes than need leads to leakage of air

2.problems with use of larger tubes than need leads to laryngeal odema and injury

109
 Indications

1.IMV

2.tracheal suction

3.In CPR

Procedure

1.position : slight extension

2.use laryngoscope (check light)

3.when you insert , you will find darkness , so pull it backwards till you find epiglottis

4.push it forward till you find vocal cords (moving)

5.insert the tube but avoid forced insertion

Fixation

1.if oral >>> 6 cm +wt

2.if nasal (not used) >>> 7 cm +wt

N.B

You should use ambo first to improve saturation and also for suction

Confirmation of position

1.you can see water vapour with breath

2.auscultation: by ambo better on rt axilla and left axilla and both sides of chest and if
air entry

is heard equally or not (you may find right side more , so pull the tube above and hear
again)

110
 3.symmetrical chest inflation

4.no gastric distention with breath

Complication

1.obstructed ETT by secretions or kinking:will find cyanosis , desaturation and by

auscultation , you will find diminished Sounds and decreased chest inflation ,so change

the tube or make suction

2.infection

3.injury to vocal cords and esophageus

4.pneumothorax if there is increase in PV or in case of right side intubation

5.bradycardia due to hypoxia or vagal stimulation

6.hypoxia

Hyperglycemia

-Definition:- blood glucose >150 mg/dl (>8mmol/L )

-Complication:

1-if blood glucose >a80 mg / dl >>>osmotic diuresis , dehydration ,acidosis

2-if serum osmolality >300mosm /L>>> cerebral He

111
 N.B:

-serum osmolality=2 (Na by mmol/L+K by m mol/L)+urea by m mol L+glucose by

mmol/L

-Urea (mg/ dl)/ 6 =m mol/L

-glucose(mg/dl) / 18 ==m mol /L

- Causes:

1-iatrogenic ( TPN )

2-prematurity & ELBW ( due to decreased glucose utilization )

3-sepsis: stress asphyxia intracranial Hge

4-drug as steroid , theophyllin

5-neonatal DM

6-ingestion of hyperosmolar formula

- Diagnosis:

*monitoring for high risk

*N.B: don't take sample from vein where i.v line is present with glucose infusion

- TTT:

A-Prevention :- ELBW < 1gh >>> give D 5 or 7.5 not 10 % in first few days

B- Curative : ( don't stop solutions , but You can decrease rate )

1-reduce the concentration of glucose >> 10 - 5 - 7.5 ( that if in the first few days )

2- :

- if no response & > 180 mg/dl >>>

give glucose ( 5-7.5-10) : saline or ringer lactate

4 : 1

112
 + 1cm Kcl every 100 cm or 1 cc/kg/day

+ monitoring every 30 min

- if no response >>>

4:1 1:1

-if no response or still RBS > 250 or GI ration reached 4 with no Response

give insulin:

-Rules to give insulin :

1- regular insulin

2-maintain glucose infusion to avoid abrupt change in glucose

3- measure RBS every 15 min

Methods:

A-Bolus:

- 0.1 or 0.2 unit / kg / 6 hrs IV or sc /6 hrs or 12 hrs

But this may lead to rapid drop in glucose >>>brain damage ( disadvantage )

B- infusion: 0.01:0.1 u/kg/hr

NB:10ml>>>>100u

Another rough method :infuse 5+50cm saline at arate of (the child weight/hour)

N.B: DKA >>>> 50 marks of insulin + 50 cm normal saline

NB:

-HYPOGLYCEMIA is more dangerous than hyperglycemia

- don't elevate blood glucose by D 25 as it increase the osmolarity and cause brain
damage

113
-to infuse concentrated glucose . 12.5 % need central line as if in peripheral line
>>>tissue damage

- IV glucose terminated gradually to avoid rebound hypoglycemia

- if RBS ,25 correct it 1st before feeding as may aspirate ( no coordination )

--How to give 4-8 mg/ kg / min:

e.g : 6 in 4 kg baby

1- calculate daily need of glucose = 6 x 4 x 60 x 24 = 34.5 gm / day

2- calculate fluid / day e.g 70 ml / kg = 4 x 70 =280

3-see others ( e.g Ca)

>>>N F = 265 ml

4- use diff. conc to reach targets

Remember : D 5% >>> 100 ml contain 5gm , D 10 >>>100 ml>>>>10 gm

D25>>>>100ml>>>>>25gm

5- measure concentration of glucose if >12.5>>>>>>>need central line

Hypoglycemia

-DEFINITION:- GLUCOSE LEVEL < 40 Mg / DL (Recently , < 25 mg )

N.B:- Early detection and TTT is essential otherwise brain damage may occur

-causes:

1- low glucose stores : premature , IUGR , asphyxia , hypothermia , meconium

aspiration ,$

2- IDM

114
 3-sepsis

4- others : polycythemia , exchange transfusion ,drugs as propranolol ,

oral hypoglycemic

-C/P:

1- of cause as sepsis

2- absent c/p

3- non sp : tremors , jitteriness , exaggerated Moro reflex , poor feeding , irregular

respiration , apnea , seizures , cyanosis , hypothermia

- TTT:

-most important >>good monitoring in high risk as IDM plan

-start feeding as early as possible

TTT plan

A- Asymptomatic :

glucose < 25 mg / dl glucose 25-40

Give iv D 10% -early feeding or D 10% as before

-loading : 2 ml / kg at rate of 1 ml /
min then infusion(maintenance) at 5
ml / kg / hr

( 4:8 mg /kg / min )

+ Begin feeding + Monitor every

115
 30 min

B-symptomatic :

without convulsion : with convulsion:

-give 2 ml D10 % bolus by ml/min -4 ml D10% bolus then

then maintainance by 5 ml /kg / hr maintenance with 5 ml / kg / hr or
or 6-8 mg/ kg / min 6-8 mg / kg /min

-Glucagon

Glucose

- RBS > 40 or with no symptoms >> give 2cm/kg/dose of G 10% or 5 %

- RBS < 40 with symptoms especially convulsions >>> give 4cm/kg/dose

N.B:- Persistent hypoglycemia :

- continue glucose + increase concentration of IV glucose up to ( 12- 16 mg/kg/ min)

+ GI ratio + investigate

---- when to give cortisone :

If GI ration reached 12 + no improvement

give 5 mg / kg / day i.v in 2 didided doses

116
 Hypocalcemia

Def:- Serum Ca level < 7 mg / dl ( Most important is level of ionized Ca )

Causes :

1- early onset ( 1st 3 days ) normal , preterm , IDM , asphyxia

2- late onset (end of week ) :- hypoparathyroidism , vit D deficiency , RF ,

anticonvulsant in mother

3- others : alkalosis , bicarbonate , exchange transfusion , lasix , photo , albumin

rapidly

C/P:- non specific>>>, apnea , seizers , jitteriness , arrhythmia

TTT: measure serum ca / ionized

- start Ca in 1st day in risky patient

- double dose

- add Ca to maintenance solution if infant on intra venous fluids ( Not done )

- most common is Ca gluconate 10 % add 2-5 ml/ kg 1 day to iv solution

- if there is c/p of it give 1-2 ml ca gluconate diluted 1: 4 in D 5% & Do :-

1- infuse very slowly

2- auscultate HR if decrease stop the infusion and continue when HR be

normal & then give maintenance on solution

3- Ca is very irritant so not to be extravasated >>> tissue necrosis

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 4- not by UVC >>> hepatic necrosis

5- never with Na bicarb >> Ca carbonate precipitation

Hypercalcemia (rare)

TTT:- -ttt of cause -adequate fluid -lasix

Hypotension & shock

Causes:

A - hypovolemic : B - Distributive : C - cardiogenic :

-placental -sepsis -myocardial

hge(placenta previa) dysfunction as
-drug as muscle
asphyxia &
-fetomaternal hge relaxant
myopathy
-twin to twin
-outflow obstruction
transfusion
as coartication of
-adrenocortical aorta ,
insufficiency
-arrythemia

-inflow obstruction
e.g pneumothorax

-TAPVR

C/P:

- PALLOR , METABOLIC ACIDOSIS , Low blood pressure

- Urine < 0.5 ml/kg/hr, tachycardia , poor perfusion , cold extremities with
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 normal core temp , tachypnea

TTT:

- reconfirm the reading & c/p

-exclude : PAD , hypovolemia , pneumothorax , sepsis , adrenocortical insufficiency

in preterm

- high mean airway pressure on IMV ( cause vc of vessels >>>decrease C.O.P )

CVP measurement 5-8 mmhg-

Lines :

1-volume replacement : albumin 10 ml/kg of 5% albumin over 20-30 min or

shock therapy

2-inotropes : dopamine & dobutamine & adrenaline .05 mg / kg / min up to

1 mg /kg /min

3-indomethacin:.1 mg/kg if PDA

4- hydrocortisone : 2.5 mg/kg in 2 doses 4 hrs apart if preterm with

adrenocortical insufficiency

5- sepsis :AB

Hypertension

- blood pressure > 100/ 75 in term and 80/ 45 in preterm

-infant must be at rest & cuff width should be at least 2/3 upper arm length

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 C/p:

tachypnea , lethargy , abnormal muscle tone , impaired renal function ,

congestive HF, hematruia , proteinuria , edema , seizures

Causes :

-drugs : dopamine ,dexamethazone

-stress : pain , cold

-renal :renal artery stenosis , obstructive uropathy

-coarcitation of aorta

-endocrinal : Renin-angiotensin path

-increased intracranial pressure : inrta ventricular hge , cerebral edema

TTT:

1-drugs : - Lasix -Captopril ( 100-300 micro gm / kg/8 hrs ) in sever cases

- B-blocker: propranolol .5-4 mg / kg /day/ 8 hrs

2-investigations : -renal u/s ( IMP ) -echo for coarcitation if UL BP > LL BP

HYPERTHERMIA

Def:-temperature > 37.5 c

Causes:

-direct overheating : photo , radiant warmer

-overheated environment : increase incubator temperature , incubator in sun

light , exess clothes , warm room
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 -infection : but more hypothermia

-dehydration fever >>>decreased fluid intake

-drug effect: PG E

Complications:

-increased metabolic rate & o2 consumption >>> increased RR, HR , fluid loss ,
irritability , apnea , periodic breathing , dehydration , acidosis , brain damage

Responses & c/p :

-V.D >>>sweating but less in preterm

TTT:

1- determine source :endogenous ( infection ) or exogenous

2-turn off any heats source & remove excess clothes

3-feeding or drink water (thirst usually )

4- sepsis work out

5-significant temp elevation

-tepid water sponge bath

-paracetamol 5-10 mg / kg / dose / 4 hrs oral or rectal

Hypotheremia

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 Def:- temp < 36.5 c

-normal temperature :36.5 -37.5 c -measured : best by axilla

Causes :

-heat loss to environment by 4 methods:

1-conduction: contact with cold object

2-convection : cold air circulating around body

3- evaporation : evaporation of liquid from wet warm

4- radiation :baby near but not in contact with cold object

-sepsis: lead to hypo or hyper

Complication :

1- hypoglycemia : due to increased metabolic rate to increased heat

2-acidosis : due to conversion of brown fat to heat & fatty acid & lactic acid (
by glucose )

3-hypoxia :consumed o2 in metabolism + acidosis cause V.C of pulmonary

vessels

4-others : apathy , feeding problems , paralytic ileus , brady , IC hge , bleeding

Risk factors :

1-preterm: low brown fat , increased surface area

2-SGA

3-sick baby

TTT:

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 -warm slowly as rapid warming may lead to apnea , hypotension

- Rewarm at 1 c/ hr

1-take a brief history ( Name ,age , sibling , type of labour.. CS/VD , FT/PT ,
maternal DM, HTN ,PROM , state at birth , cause of presentation , times in
incubator )

2- Questions to mother ?

( ) -:-

-:activity -

cough , fever( infection ) -

- examination -

a-auscultate chest

b-colors >>>pallor , jaundice ( Lab. Tests )

c- Heart , abdomen

d-umblicus care >> If pus >> anaflex powder (AB) + regular cleaning

by alcohol

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 Poor perfusion

C/p:- mottling, doesn't look good or washed out appearance.

Eamination: Temperature & all vitals (BP)

Lab:CBC, CRP, ABG , Culture

Radiological: CXR, Abd US (NEC) , Echo

TTT: aims to the cause:

1-sepsis:Abs

2-cold stress: rewarm

3-hypotension: shock therapy

4-Hypoventilation: give O2

5-pneumothorax

6-NEC

7- Lt sided heart lesions as hypoplastic Lt heart syndrome

8- cutis marmorato: due to cold

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 Tachycardia
-Normal HR :120-160 may reach 70-90 during sleep & 170-190 during cry

-transient tachy or arrhythmia or brady <15 s are begun

-see associated : tachypnea, poor perfusion, lethargy,

-causes:

1-Benign :post delivery , cold , heat, painful stimuli, drugs as

(atropine- epinephrine, aminophylline)

2-Pathology: fever, shock, hypoxia, anemia, sepsis, PDA, CHF ,

Hyperthyroidism

Bradycardia ( HR < 120 )

Transient bradycardia is benign if less than 15 sec

Causes: 1- defecation 2- vomiting 3-micturation

4-gavage feeding 5-suction (vagal stimulation)

6-drugs: B-blocker (inderal) digitals atropine

VIP : any infant with bradycardia , Ca must be stopped

Pathophysology:

Hypoxia Apnea convulsion airway obstruction air leak (pneumothorax)

CHF

IC Hge severe acidosis severe hypothermia

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 Others causes: 1- hyperkalamia 2-cardiac arrhythmia 3-diaphragmatic
hernia

4-hypothyrodism 5-hydrocephalus

Treatment

1- prevent the causative drug

2- treatment of the cause

3- in severe hypotension or arrest CPR

4- Atropine + Adrenaline / epinephrine

DD of tense fontanels

1-hydrocephalus: * measure head circumference routinely

* Ask CT

2- ICH

2- CNS infection

4- brain edema : need mannitol cortisone

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 NEC (necrotizing enterocolitis)

>>Very dangerous (usually fatal) disease

Risk factors

1-prematurity 2-sepsis 3-hypoxia 4-overfeeding 5-ischemia

Diagnosis : by a triad of

1-distension 2-metabolic acidosis (by ABG) 3- thrombocytopenia (by CBC

with differentials )

By CXR : pneumonitis intestinalis ( air in wall of intestine )

TTT:

14-7

strong antibiotic( Combination of (Vanco , Meronam , Flagyl , Diflucan

ICH (intracranial hge)

- Very serious disease that lead to death or cp ,has very bad prognosis

- Once suspected>>ask CT
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 - These are the most important signs:

1-pallor

85 ( X )

2-convulsions

3- tense fontanels VIP

4-signs of lateralization :- tonicity in one side - unequal pupils

5-neck rigidity

6-opisthotonus

- Need immediate konakion - diacenon kapron + see your text

Neonatal edema

- Common especially in preterm

- Common causes :

1- Sepsis
2- Prematurity
3- Delay or decrease dose of aminovein
4- Renal failure : either
1- prerenal >>> hypotension
2- renal problem
3- post renal obstruction
How to manage :

-1nephrotoxic

2- ask u

rea ,creat. + Na , K

128
 3-press on urinary bladder >> why

post renal obstruction

( renal, pre renal, atonic bladder) in H.I.E cases >>

4-give challenge test>>> shock therapy +lasix ( if urine come , the cause is prerenal )

5-measure blood pressure

6-give plasma / 12 hr >> to increase osmolarity

edema pre renal fluid tissue

masked hypovolemia fluids

Down syndrome

* How to suspect? The most important signs are

1-low set ears >>

medial canthus lateral canthus

low set ears

2-wide spaced medial canthus + epicanthus

3- simian crease.

4-wide space between 1st & 2nd toe.

NBs from Practice

There are notes I learned from actual practice:

129
 Shift 1

- 11 infant at my 1st shift (3 Vent, 1 Postvent, anemia, jaundice, pnemothorax,

-frequent sampling is the most common cause of neonatal anemia

-to follow up jaundice : ask TSB/ DSB every other day.

-anemic baby better to be fed by Ryle even suckling is good as it is effort for him

-baby who give residual digested >> give it to him & see how much( < or> 10%) &
mange as before

-Brownish secretions from stomach before starting feeding isn't contraindication for
feeding

-
) 6/2(

-anemia>> hemic murmur

... ) 6( -

-vent x-ray areation, pneumonia ABG

-ETT ... Ryle

- << vent
RR setting A/C CPAP NASAL

:- PT Vent CBC,
CRP ecchymosis X-ray

-Double

-Post vent Anerobes

-hypoactive sepsis Sedation

130
 ** The worest experience (Pneumothorax)

-Case: 28 Ws baby ,2W bad chest put on IMV but extubated early (W2 RR 63) &put
on CPAP then nasal then RD reappear & vent was decided.

-After intubation &from 1st air pressure>>sever cyanosis(sudden) , abd distension

,no HT heared, no airentry, no expansion ,decreased perfusion & baby gasping>>>
CPR (chest compression, adrenaline, bicarb, shock therapy)>>no RR( pnce suspected
pneumothorax) >>bilateral Butterfly >>air was muchthen the baby suddenly become
pink with good condition.

-Then pulmonary Hge occurred>>given konacion , Dicynon , Kapron , asked plasma,

Bicarb, +Vent with (PIP 25, Time 3, PEEP 3, FIO2 100)

-The chest cannula was done + butterfly

New case of RD:

1-Examination & auscultation

2- good aspiration

3-may give Na bicarb empirical 4- solutions

Shift 2

10 :-1-Anemia 2-RD

-X-ray Quality Gases ( Jet black)

Soft

:- << post vent 2

- UVC >>below costal margin >> in CXR

- Indication of off vent: 1-clinical: color, RR , auscultation 2-ABG >>> on CPAP 3-

CXR

131
 ,, :-sepsis

-glycerin

- Ca HR 120 Bradycardia

Shift 3

- In Premature 29 Ws >> if TSB 10 >>it is too high

- If RBS is low>>> suspect solutions mistakes

- convulsion - Rebound

-start w2 1.5 aminovein if edema or Preterm

- - male or female

-if acase aspirated by milk >> do CRP & shift to Ryle

- Distension avoided by prophylactic drugs

- In x-ray take care of collapse as it simulate pneumonia but clinically pneumonia

presented by tachypnea & retraction

- c/p of pneumonia>>tachypnea & retraction

ABs

- Jaundice high for ling time >> Retics &suspect ABO, or Rh

+ 1.5 - Full amount -

Shift 4

+ Preterm on IMV -1

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 sedative fight IMV
sedative hypoxia fight

2- preterm who are 1 kg or less

nasopharyngeal CPAP ..... IMV

3- in CPAP PEEP do not exceed 7 + F1O2 do not exceed 70%

....... retraction + decreased saturation+

Retinopathy ) FiO2 (low sitting mechanical ventilation

4- take care of retionpathy in preterm so low setting is better is increase saturation

PIP 16 Fi O2 40% PEEP 3 time 0.36 rate 40:35 inspir/respir 1 : 3

-5ventillator

HCO3 -6acidosis 10
sedation a\c

-7

-8pulm.cort

9- pulm cort ( Beclomethazone ) :- inhalation long acting steriod

chest infection neonate

atrovent

10- Hepatomegally is present with UVC

-11photo TSB & DSB

-12preterm + oedema
133
 Causes: 1- prematurity or decreased aminovien 2- sepsis

3- renal failure( prerenal / renal / postrenal )

Treatment:

1- 1st do urea and creatinine

2- ask for plasma \ 12 hours to increase osmolarity

hypovolemic shock oedema fluids

vessels tissue

A - bood preassure is low

B - challenge test shock therapy + lasix >> infant urinate

3- stop amikin & aminovein NOW

4- detect if infant urinate or not ?? IF no urine >>

1- full bladder 2- empty bladder

-bladder distended - bladder

-
challenge test
obstruction
renal failure ( pre renal or renal
-
causes)

-Atonic bladder

circulation 5- shock therapy

6- hyperkalamia

134
 -13Hb pallor .. hypoxia

-14adrenaline infusion %5 24 + ((

)) 24 \ 1

15- Treatment of BPD is steroid , lasix , amionphyline

16- In x-ray if you find apical patch it should not be pneumonia and it may be collapse

As pneumonia need: 1-tachypnea and chest retraction

2-if broncho (patchy) or lobar take whole lobe

+ If collapse shift of mediastinum.

17- cases of HIE have POOR Prognosis>> hypoactive , spastic ( detect grade 1,2,3 )

+ tense fontanels +THC brain oedema

+ pale due to hypoxia not due to anemia

Treatment >> rest 30% + manitol (brain edema)

Do CT You find brain edema and IC Hge ( appear white )

Or may be calcification which apear in neonate especially if there is congenital

infection.

Shift 5

1- if child is blue with feeding , it may with infection and must do chest x-ray

-2

-3trauma

-4temperature

135
 dry air -5flow meter

136