The Newborn

Leah F. Fajutagana,M.D. MPH

Outline:
● Physiology of the newborn
● Management of the newborn
● High Risks Infants
● Common Diseases of the Newborn
 Question #1

Organogenesis is completed by :
a. 13th week of life
b. 12th week of life
th
c. 10 week of life
th
d. 14 week of life
 Physiology of the Newborn
● Newborn infant has to undergo physiological
adaptations to prepare him for life in the
extrauterine environment.
●
Organogenesis is completed by the 12th week
of intrauterine life.
– Any genetic or environmental abnormality have
little effect after organogenesis is completed
Question #2

● In utero, the link between mother and fetus is

through:
a)Placental circulation only
b)Umbilical vessels( artery and vein)
c)Placental circulation and umbilical vessels
d)Umbilical vein only
Question #3

● The oxygenated blood that passes through the

umbilical veins, hepatic veins, inferior vena
cava, and shunted to the foramen ovale into the
left ventricle and ascending aorta supplies:
a)Lower half of the body
b)Brain and upper half of the body
c)both
 Circulatory System

● In utero, the link between the mother and fetus

is through the placental circulation and
umbilical vessels.
● Fetal circulation : 2 shunts
– Patent foramen ovale-bet. two auricles/atrium
– Patent ductus arteriosus- bet. Pulmonary artery
and aorta
● Oxygenated blood passes through the umbilical
vein, ductus venosus in the liver, hepatic veins,
 Circulatory System
– Inferior vena cava then reaches the right atrium
● The right atrium receives unoxygenated blood
from the superior vena cava and oxygenated
blood from the inferior vena cava.
● Oxygenated blood in the right atrium, shunted
to the patent foramen ovale left atrium left
ventricle ascending aorta to supply the brain
and upper half of the body.
● Unoxygenated blood R ventricle Pulmonary
artery descending aorta lower ½ of the body.
Events when the infant is born:
– Placental circulation stops soon as the cord is
clamped respiration occurs infants lungs
expand pulmonary circulation is established.
– Pressure in the R atrium decreases – patent
foramen ovale closes
– Increase oxygenation causes muscular
constriction of patent ductus arteriosus hence
this shunt closes.
– Adult type of circulation is established
 Respiratory System
● The newborn infant has all the equipment
necessary for respiration- lungs,
chemoreceptors, and baroreceptors
● In utero, lungs are unexpanded but not
collapsed, air spaces are filled with fluid
● The fluid gushes out of mouth and nose during
NSD, fluid is replaced by air.
● Full term newborn, may have pauses during
regular breathing
● Premature's may shift from regular to apneic
episodes of 5-10 seconds
 Respiratory system

● Surfactant - phospholipid substance produce by

alveolar cells.
– Lowers the surface tension of the alveolar lining
epithelium preventing atelectasis.
– Component: lecithin and sphingomyelin
– High lecithin to sphingomyelin ratio indicates
lung maturity and lower ratio means lungs is
less mature.
Question #4

● Swallowing movements of fetus is observed on

what Age of gestation:
a) 13The week AOG
b)12th week AOG
c) 15th week AOG
d)10th week AOG
 Gastrointestinal System
●
Swallowing is observed as early as 12th week of
gestation
● No excretion via gastrointestinal tract occurs
unless the anal sphincter relaxes ffg a hypoxic
episode.
● Epithelial debris accumulates in the SI and as
the liver starts to function,conjugated bilirubin
finds its way to the SI – Meconium.
● Meconium is black viscid substance composed
of mucopolysaccharide and epithelial debris.
 Gastrointestinal System
●
Meconium is expelled within the 1st 24 hrs of life
followed by transitional stools ( greenish soft
stool) in the next 3-4 days of age.
● Stool assumes its yellow color and normal
pasty consistency as the infant increases milk
intake.
● Pancreatic enzymes are found in adequate
amount at birth except amylase.
Question #5

● Urine is produced by the fetus at what AOG.

a)15th week AOG
b)16th week AOG
c)12th week AOG
d)13th week AOG
Question #6

● The 10% weight loss in newborn infants is due

to:
a) Diuresis
b)Expulsion of meconium
c)Withholding of water and calories
d)All of the above
 Renal System

th
●
The kidneys produce urine as early as the 4
month of gestation
● Renal function as measured by glomerular
filtration rate, tubular mass and resorption,renal
plasma flow reach the adult levels about the 2nd
year of life.
● The newborn is unable to concentrate urine
adequately, thus his urine is dilute
 Renal System

st
●
10% weight loss is observed during the 1 days
of life and regained after the 1st week of life.
● Weight loss maybe due to: Diuresis, expulsion
of meconium, and withholding of water and
calories- physiologic
Question #7

● Vaginal bleeding on the first few days of life is

pathologic.
a)True
b) False
 Endocrine System

● Maternal estrogenic effects on both male and

female newborn infants are manifested in
hypertophied mammary tissue. Sometimes
secretes milky discharge called witch milk.
● Hymeneal tags and mucoid vaginal discharge
with vaginal bleeding may also be present.
● Infant born to diabetic mother has hyperplastic
islets of langerhans, result in excessive insulin
production causing hyperglycemia.
 Endocrine System

● Infants are usually fat and have facies –

“cushingoid”
● The pituitary- adrenal axis and thyroid gland
function separately from that of the mother.
Question #8

● A violent startle reaction of an infant when

sudden noise or movements occur in the
environment.
a) Moro reflex
b)Righting reflex
c)Tonic reflex
d)Rooting reflex
 Central Nervous System
● Rapid growth of the brain is usually observed
during the last half of fetal life with a peak near
or at the time of birth, then decreases over the
first year of life.
● All limbs are in flexion, the hands are closed
and thumbs are adducted.
● During the waking state, the infant manifests
generalized muscular activity.
● Any sudden noise/ vigorous movement around
may evoke violent startle reaction- Moro reflex
 Central Nervous System
● Important Specific Reactions:
– Moro reflex, grasp reaction, swimming reflex,
tonic and righting reflexes
– Reflexes associated with feeding: sucking,
rooting,and tongue retrusion reflex
● Hunger/ or discomfort from any cause, infant
cries and increases his motor activity.
● After feeding, if kept dry and warm, he is quite
and relaxed.
● Cerebral cortex participates very little at this
stage.
Question #9

● Which of the ffg blood picture is true at birth:

a) Hemoglobin value is low
b) Hemoglobin value is high
c)Predominance of lymphocytes
d)Segmenters normal
 Hematologic System

● At birth, infant has high hgb 15-20g/dl due to

relative hypoxia in utero causing stimulation of
the bone marrow.
● Blood volume is from 80-90ml/kg- depend on
early clamping of the umbilical cord ( <10sec
after delivery)
● WBC and differential ct- range 6,000 to
20,000/mm3 with predominaance of
st
segmenters on the 1 24hrs.
 Hematologic System
● Lymphocytic predominance is attained as the
infant grows older.
● Hgb start to drop on the third day of
life( physiologic anemia), 10-12g/dl is reached
on the 2nd- 3rd month of life.
● Physiologic anemia is due to:
– Relative dec. in bone marrow erythropoietic
activity, relative inc. in the rate of hemolysis,
and hemodilution due to the rapid expansion
of bld volume.
 Immunologic System
● Newborn infant- completely developed
if challenged by antigenic stimuli can produce
antibodies.
● Abs present in the newborn infant are maternal
in origin: 7S or IgG antibodies
● Antibodies in cord blood =/ > maternal blood
are:
– Tetanus antitoxin, diphtheria antitoxin, smallpox
agglutinins, antistreptolysin, toxoplasma Abs,
and Rh antiblocking Abs
 Immunologic System

● 19 s gamma globulins specific for protecting

against gram (-) and some gram (+) organisms
do not cross the placental barrier.
– Infants prone to gm (-) infections
Question #10

● The main source of energy of a newborn is/ are

a)Brown adipose tissue
b)White adipose tissue
c)White and brown adipose tissue
d)None of the above
 Thermoregulation

● Newborn infant is homoiotherm ( stable T° )

● Infants maintain deep body temp. constant bet.
36-37 0C.
● Factors that affect thermoregulation:
– Chemical thermoregulation
– Physical thermoregulation
– Thermal stimulation
 Thermoregulation

1.Chemical thermoregulation: 2 response

– Shivering thermogenesis- heat production
accompanied by electrical activity of skeletal
muscle
– Non-shivering thermogenesis- without visible
or electrical muscular activity
– Newborn has both white and brown adipose
tissue, utilize for non shivering thermogenesis.
– Brown adipose tissue more effective supplier of
heat
 Thermoregulation

2. Physical thermoregulation – defines the

mechanism of heat loss from the body core to the
surface, from the surface to the environment.
3. Thermal insulation – heat exchange bet the
body and environment.
– Internal thermal insulation -subcutaneous fat
layer, skin blood flow
– External thermal insulation- clothing and
incubator temp.
 Thermoregulation

● Cold environment, more energy utilized for heat

production and increase oxygen consumption.
● Normal fetal heart tone (term) 120-160/min
– Fetal bradycardia (<120/min) or fetal
tachycardia (>120/min) are signs of fetal
distress
● Hypoxia is the most common cause of fetal
distress
 Fetus: Assessment of Growth,
Maturity and well being
th
●
12 week of life- intrauterine assessment
● X-ray and UTZ
– periodic determination of bi parietal diameter
– Fetal size and implantation
– Measurement of fetal head and amount
amniotic fluid
– Estimation of gestational age
 Fetus: assessment of Growth ,
Maturity and well being
● Lung maturity- analysis of the amount of
surfactant in the amniotic fluid
● Placental maturity index- determined by the
degree of calcification (by UTZ)
● Fetal distress can be assess through cardiac
rhythms and fetal movements
 Fetus: assessment of growth,
maturity and well being
● Biochemical test for monitoring fetal well being
1.Non- stress test (NST)
2.Oxytocin challenge Test (OCT)
● Fetus is challenged with maternal oxytocin drip to
produce 3 uterine contraction every ten minutes
● 3 late decelerations suggests fetus at risk
 Fetal Assessmnet, growth,
maturity and well being
● High Risks factors:
1.Maternal
2.Fetal
3.Placental
● Maternal infections
1.TORCHES, diabetes, toxemia, thyroid disorders
● Congenital malformations
2.Ingestion of teratogenic drugs- malformation or
death
 Fetus: Assessment of Growth ,
maturity, and well being
● Heroin and alcohol- withdrawal and growth
retardation
● Maternal age and poor obstetric history
● Fetal factors:
– Erythroblastosis fetalis, error of metabolism, sex
linked disorders, gladular dysfunction, lung
maturity, growth retardation, prematurity,
malpresentation and hypoxia
 Fetus: Assessment of growth,
Maturity, and well being
● Placental factors;
– Placental insufficiency, cord and amniotic fluid
abnormality( meconium staining, oligo and
polyhyramnios
Question #11

● A newborn was noted pale, with a heart rate of

<100, sneezes on suction, active and with
good strong cry, what is the APGAR score of
the newborn at 1minute?
a) 9
b) 8
c)7
d)6
Question #12

● A newborn was delivered cyanotic, with fair

muscle tone,doesn't cough or sneeze on
suctioning, HR >100, and irregular respiration.
What is the best management?
a)Assisted ventilation
b)Tracheal intubation
c)O2 by mask
d) Slapping of the sole
Question # 13

● Babies with an Apgar score of 7 at one minute

is considered:
a)Moderately depressed
b)Severely depressed
c)Vigorous
d)Needs resuscitation
 Management of the Newborn

● Initial care
● Clinical Appraisal
● Resuscitation
● Temperature regulation
● Physical examination
 Initial Care

● Done in the delivery room or where the delivery

took place with good lighting conditions.
● First objective is the establishment of a clear
airway
● Gentle suctioning of secretions from the mouth,
then the pharynx, and nose
● The nose is suctioned last to avoid sudden
inspiratory gasp which may result in the
aspiration of the amniotic fluid in the mouth.
 Clinical Appraisal
● The evaluation of the baby's condition is noted
right after birth, with the first gasp, cry and
onset of sustained respiration.
● Clearing of the newborn airway start as soon as
the head is delivered.
 APGAR SCORE
sign 0 1 2

A- appearance Blue; pale Body pink Completely pink

(color) Extremities blue

P-Pulse(HR) absent Below 100 Over 100

G- Grimace No respone grimace Cry, cough or

sneeze

A- Activity limp Some flexion of Active motion

(muscle tone) extremities

R- respiration absent Slow; irregular Good strong cry

 APGAR SCORE
● Recorded at 1 minute and 5 minutes
● One minute scoring gives the index of necessity
of resuscitation
● Five minute -valuable in predicting mortality and
neurologic deficit of infant at one year old
● Scores: one minute
– 7-10 – vigorous
– 4-6 – moderately depressed, assisted
ventilation
– 0-3 – severely depressed, tracheal intubation,
oxygen administration
 APGAR score
● HEART RATE is the most important parameter
nHR bet 100-160/ min
– HR < 100- usually asphyxiated- newborn need
assistance
– HR >160 – indicates distress
● Respiratory rate
● Muscle tone
● Reflex irritability
● color
 Temperature Regulation

● The baby should be dried and wrapped in a

blanket soon after birth.
● The fall in temperature in a newborn is about 2-
3 degrees celcius after birth
● The heat losses/ unit body weight in newborn is
4x that of an adult due to its greater surface
area in relation to the body weight.
● Prematures are more affected
 Physical Examination
● 2 Stages
– Initial Examination
– Detailed Examination
● Initial Examination
1.Color- persistent cyanosis after sustained
respiration and given high conc. of oxygen –
indicate failure of the ductus to close, high
pulmonary resistance or preductal
coarctation.
● Deeply asphyxiated babies are pale due to
severe cutaneous vasoconstriction.
 Initial Examination

● Pallor is also prominent in erythroblastosis and

fetomaternal and feto-fetal transfusion.
2.Respiration
● Grunting with prolonged expiration is an early
sign of respiratory distress syndrome (RDS)
– Diaphragmatic hernia- respiratory distress
appears after sustained respiration has been
established. Diminished breath sounds and
scaphoid abdomen.
 Initial examination

● 3. Umbilical vessels and placenta

– Presence of single umbilical artery- anomalies
found in genito - urinary/ gastrointestinal
tracts, skeletal and cardiovascular and CNS.
– Placental exam done to detect infection and
placental insufficiency.
Question #14

● A newborn was delivered via NSD, edema with

ecchymosis was noted on the head and
borders are not well defined merging with the
rest of the tissues. The most likely diagnosis is:
a)Cephalhematoma
b) Caput succedaneum
c)Craniotabes
d)Cranial meningocele
Question #15

● At birth, the liver is always palpable about 2-

3cm below the right costal arch.
a)True
b)False
Question #16

● The ffg are normally seen in newborn babies,

except:
a) Milia
b)Erythema toxicum
c)Mongolian spots
d)Petechia
 DETAILED EXAMINATION

● Measurements of weight, length, circumference

of head, chest, and abdomen, cardiac and
respiratory rate and temperature.
1.Skin- babies are covered with vernix
caseosa, to protect the skin from maceration in
utero.
– Pinkish, smooth and elastic with fair amount of
subcutaneous tissue.
– Lanugo hair maybe present in the back,
shoulders and upper arms.
 DETAILED EXAMINATION
● Preterm infants has less subcutaneous tissue
and skin is almost transparent
● Post term, has paler or dry and desquamating
skin; pallor/plethora noted.
● Mottling of the skin occurs when the body is
exposed to cold, due to instability of the
circulation
● Mongolian spots- blue grey pigmented areas,
seen in buttocks, back and extremities
● Milia- small whitish papules which covers the
nose, made up of sebaceous glands.
 DETAILED EXAMINATION
– Erythema toxicum- small, firm, yellow-white 1-
2mm papules topped by vesicles at the tip and
surrounded by patch of erythema.
2. Head- rounded if babies are born by cesarean
section, varying degrees of molding if delivered by
NSD.
● Caput succedaneum- edema w/or w/o ecchymosis,
extend across the midline and across the suture line,
disappears after few days
● Cephalhematoma- due to subperiostial bleeding,
does not cross the suture line.
 Detailed Examination

● Craniotabes- soft areas in the parietal bones,

“pingpong ball' when pressed;preterm infants
– If persist beyond infancy, pathologic as seen in
Rickets and Osteogenesis imperfecta.
● Cranial meningocele – pulsating mass which
become more tense when the baby cries.
● Fontanels- vary in size
● small or closed – microcephaly /
craniocynostosis.
● Tense fontanel- increase ICP
 Detailed examination
– Face- symmetrical
● Down syndrome- common facies seen at birth
– Eyes: Subconjunctival hemorrhages, congenital
cataracts; fundoscopic exam prior to
discharge
– Ears: low set ears associated with chromosomal
disorders and renal anomalies; ear tags
– Nose- patency; cleft palate; high palatine arch
– Tongue- small; large – seen in cretin; Tongue
tie- short lingual frenulum
– Neck- Laxity /webbing found in down syndrome
and Turner; cystic hygroma;
 Detailed Examination
● Chest- size, shape and movement shld be
noted. RR= 40/min
● Heart – 120-140/min; slowing of HR- congenital
heart block, anoxia, intracrnial hemorrhage
● Mammary glands- engorged, (+) witch milk
● Abdomen- globular
– Distention and vomiting after feeding- intestinal
obstruction
– Liver is palpable 2-3 cm below the R coastal
arch
 Detailed Examination
● Genitalia- hymen with prominent tags; clitoris large; labia
minora prominent than majora
– Female- mucoid nonpurulent/ bloody vaginal
discharge
– Male- size of the penis and scrotum varies; hydrocele
may be present.
● Extremities
– Creases of the palms and sole should be examined for
peculiar lines like simian line in Down syndrome
– Non development of distal portion- hemimelia
 Detailed Examination

– Nondevelopment of proximal portion-

phocomelia
– Palpation of the femoral pulses should be done
for early detection of Coarctation of Aorta
● Neurological examination
– Muscle tone and reflexes should be tested
– Moro, grasp, rooting and sucking reflexes
should be elicited
 Nursing Care

● Routine newborn care

– Vitamin K 1mg or 0.5 mg in preterm- to prevent
prothrombin defficiency
– Erythromycin ophthalmic ointment- toprevent
ophthalmia neonatorum
– Cord care with 70% isoprophyl alcohol
– Thermoregulation
– Breastfeeding- started as soon as baby can
suck
 Physiologic process in the
newborn
events Term Preterm

Anemia time 6-12 weeks 5-10 wks

Hgb 9.5-11gms 8-10 gms

Weight loss < /=10% of the BW 1st 10 days 14-21 days

Jaundice Time 3-4 days 5-7 days

level 6-8mg/dl 10-12 mg/dl

Passage of 0-48 hrs 99% 95%

meconium
Passage of urine 0-24 hrs 95% 95%

24-48 hrs 100% 100%

Question #16

● All of the ffg are contributory factors in

perinatal morbidity and mortality except:
a)Maternal age
b)Multiple pregnancies
c)Paternal age
d) Socioeconomic status
 HIGH- RISK INFANTS

● 1. Babies of low birth weight

– Factors related to perinatal morbidity and
mortality
● Maternal age,race, marital status, past obstetric
history, multiple pregnancies.
– Premature – babies born before the 37th week of
gestation, BW < 2500 g
– Small for gestational age – babies born term but
BW <2500 g
 HIGH RISKS INFANTS

2. Post-term infants
– Babies delivered after 42 weeks of gestation
● Babies have little vernix, absent lanugo hair, pale
skin usually dry and desquamating with finger
nails are longer.
● Common among babies born of toxemic mothers,
mothers with renal dse, with chronic illness,
elderly primigravid or mothers with placental
abnormalities.
 HIGH RISKS INFANTS
● 3. Multiple pregnancies or twinning
– Babies are delivered prematurely or small for
gestational age
– Malformations are common in multiple
pregnancies.
Management:
– Babies of low birth weight and other high risks
infants are placed in heated incubators to
maintain body temperature between 36-37oC
with humidity of 60-70% and oxygen flow of
40%
 HIGH RISKS INFANTS

● Heated bassinets are used with piped -in

humidified oxygen in a hood just to enough to
relieve cyanosis and respiratory distress.
● Feeding witheld for smaller infants for 2-3 days
to prevent fatigue and danger of aspiration.
● Infants <1250 grams and sick newborns are
given parenteral feeding of 10% glucose.
● Depressed infants given 50ml/kg/day q12
 HIGH RISKS INFANTS

● Infants who appear well are fed 4-6 hrs after

birth.Sterile water or 5% glucose at 2-3 hrs
interval, given by gavage.
● Initial volume 2-3 ml for infant 1000-1500,
increase the amount by 2ml/feeding/day.
Ideally, 120-140 cal/kg/day reached by the end
of 2nd week.
● Protein intake 4-5gms/kg/day
 Ballard Maturational
assessment
● Commonly used technique of gestational age
assessment
● 2 Criteria:
– Physical maturity- relies on anatomical changes
– Neuromuscular – relies on muscle tone
● Assigns scores to various criteria, the sum is
extrapolated to the gestational age of the baby.
● Scoring relies on intrauterine changes that fetus
underwent during its maturation
 Neuromuscular rating

●
Posture- -total body muscle tone is reflected in infants
posture at rest
● Square window- wrist flexibility and resistance to
extensor stretching
● Arm recoil- paassive flexor tone of the biceps muscle
● Popliteal anglematuration of passive flexor tone above
the knee joint
● Scarf sign- passive flexor about the shoulder girdle
● Heel to ear – passive flexor about the pelvic girdle
 Ballard Scoring
Physical Maturity Rating

-1 0 1 2 3 4 5

Sticky, Gelatinou Smooth Superficia Cracking Parchme Leathery,

friable s, red pink, l peeling/ pale nt deep cracked,
SKIN transpare transluce visible rash, few areas cracking wrinkled
nt nt veins veins no veins

LANUGO none sparse abundant thinning Bald Mostly

areas bald

Heel-toe >50mm Faint red Anterior Creases Creases

PLANTA 40- no marks tranverse ant. 2/3 over
R 50mm-1 creases creases entire
SURFAC <40mm-2 sole
E
 Ballard scoring
Physical Maturity Rating
-1 1 2 3 4 5

IMPERCE BARELY FLAT STIPPLED RISED Full areola

BREAST PTIBLE IMPERCE AREOLA AREOLA AREOLA 5-10mm
PTIBLE NO BUD 1-2MM 3-4MM
BUD
Lids fused Lids open sl. curved Well Formed Thick
EYE/EAR loosely-1 pinna flat pinna; soft, curved and firm cartilage
Tightly- 2 stays slow recoil pinna, soft instant ear stff
folded ready to recoil
recoil

Scrotum Scrotum Testes in Testes Testes Testes

GENITALI flat, empty, upper descendin down good pendulous
A- MALE smooth faint canal, rare g few ruggae deep
ruggae ruggae ruggae ruggae
GENITALI Clitoris Clitoris Clitoris Majora and Majora Majora
A-FEMALE prominent prominent prominent minora = large cover
labia flat small labia enlarging prominent minora minora and
minora minora smll clitoris
 Maturity Rating
SCORE WEEKS
-10 20
-5 22
0 24
5 26
10 28
15 30
20 32
25 34
30 36
35 38
40 40
45 42
50 44
 Maturity rating

● Example:
● Neuromuscular maturity score = 13
● Physical maturity score = 28
------
total 41
AOG 40 weeks
Diagnosis: newborn

● Chart: Live term baby girl delivered via NSD,

AS 9/9, BW 3 kg, 41 weeks by ballards,
Appropriate for gestational age (AGA)
Question #17

● Which of the ffg is the most common site of

fatal and disabling injuries in the newborn
during delivery .
a)Spinal cord
b)Intracranial cavity
c)Nerve
d)abdominal
 DISEASES OF THE NEWBORN

● Birth injuries
– 1.Intracranial injuries- most common site of
fatal and disabling injuries
● S/S: cyanosis or pallor, apnea and respiratory
difficulty, poor response to stimuli, convulsion,
bulging fontanel
● Usually caused by difficult delivery
●
Prognosis: usually die on the 1st 72 hrs or survive
but develop cerebral palsy, epilepsy or mental
defficiency
● Mgt:: keep the baby warm, give O2, Vit K,
Sodium phenobarbital
● Do lumbar puncture
 Birth injuries

● 2. Spinal cord injuries

– Cause by difficulty in the delivery of the
shoulder in head presentation and head in
breech presentation
– Paralysis may occur due to compression of the
cord by edema and hemorrhage
● 3. Nerve injuries
– May result with excessive tension on one side of
the neck producing brachial palsy.
 Nerve Injuries

● 1. Erb- Duchenne paralysis

– Injury to C5-C6, loss of function of biceps,
deltoid, brachialis and brachioradialis
● 2. Klumpke's paralyis
– Injury to C7-C8, wrist and hand movement are
lost
● 3. Horner's Syndrome
– Injury to the sympathetic nerve fibers with
concomitant meiosis of the pupil and eyelid
ptosis of the same side
 Birth Injuries

● 4. Fractures
– Involve the long bones or the clavicle
associated with difficult delivery
– Mgt: immobilization of the affected extremity
● 5. Intra-abdominal injuries
– Hemorrhages from the liver, adrenal glands and
spleen are encountered in breech extraction
– Mgt: blood transfusion and exploratory
laparotomy
Question #18

● All of the ffg pathogens are likely cause of early

onset neonatal sepsis except
a)Group b streptococcus
b)Escherichia coli
c)Staphylococcus epidermidis
d)Hemophilus Influenza
Question #19

● Late onset neonatal sepsis in full term infants is

associated with which of the ffg?
a)75% rate of meningitis
b)Group B Streptococcus
c)Escherichia coli
d)Onset as late as 60 days of life
e)All of the above
Question #20

● The most common focus of infection of group b

Streptococcal early onset disease of the
newborn is the
a)Lungs
b)Skin
c)Menibges
d)Urinary tract
 INFECTIONS IN THE NEWBORN

● Predisposing factors:
– 1. maternal infections
● UTI, Toxoplasma gondii, rubella,
cytomegalovirus, herpes, syphylis (TORCH)
– 2.Infections acquired after delivery
– 3. prematurity
●
 Infections in the Newborn

● Routes of Entry:
– 1. Hematogenous- microorganism is carried into
the intervillous spaces of the placenta to the
fetal bloodstream
– 2. Ascent of the vaginal bacteria into the
amniotic cavity after rupture of the membrane
– 3.Ingestion/aspiration of infected fluid
– 4. direct contact with infected material in the
birth canal
 Sepsis Neonatorum

● Common bacterial causes: E.coli, Klebsiella

aerobacter, proteus specie, pseudomonas
aerogenosa, Group B streptococci.
● Candida albicans, chlamydia
● Two types:
– 1.Early onset
– 2.Late onset
 Sepsis Neonatorum

● Early onset- usually serious and progressive

multisystemic infection during the first week of
life.
– Most cases there is a history of obstetrical
complications like prematurity or low birth
weight
– Mortality is high
● Late onset – insidious and ecognized after the
first week
– Obstetric complication less characteristic
 Clinical Manifestation:

– Maternal history can greatly help the diagnosis

of infection.
– S/S: Poor feeding, lethargy, hyporeflexia,,
irritability, apnea, cyanosis, jaundice,
abdominal distention, petechia, diarrhea and
temperature instability.
Laboratory:
– CBC- wbc >30,000/cu.mm or <5,000/cu.mm
after 24 hrs, neutrophils exceeding 16% of the
WBC
– Blood culture
 Sepsis Neonatorum

● Mgt:
– Early onset- gm (-) enteric bacilli and grp B
strep are prevalent
– Late onset – Staph Aureus and hospital
acquired enteric bacilli like pseudomonas and
serratia
– DOC: Penicillin 100,000U/K/day q 12 combined
with aminoglycoside ( gentamycin 5-
7mg/kg/day or amikacin 10-15 mg/kg/day q
12.) given for 7-10 days
 Jaundice in the Newborn
● The degree of jaundice is measured in terms of
bilirubin concentration.
● Clinically: yellow color of the skin, mucous
membranes of the mouth and sclerae.
● Etiology:
– 1.overproduction of bilirubin – liver cells are
not able to cope with the increased load of
indirect bilirubin
– 2.Undersecretion of bilirubin- caused by
decrease conjugation of IB.
 Over production of bilirubin
● Eg; Isoimmune hemolytic anemias arise from
blood group incompatibilities bet. fetus and the
mother w/c results in formation by the mother of
antibodies against her infants red cells.
● Type O mother with type A or B infant, Type O
has both Anti- A and Anti B agglutinins easily
traverse the placenta to fetal circulation
resulting to hemolysis.
● Occurs in rh (-)mother who has an rh (+) infant
 Undersecretion of bilirubin

Eg: Physiologic jaundice

– Deficient in glucoronyl transferase activity in the
first few days of life.
– Jaundice on the 2nd or 3rd day of life and
subsides on the 5th day.
 Phototherapy and exchange
transfusion
BILIRUBIN LEVEL Bilirubin level

Birth weight Phototherapy Exchange transfusion

<100gms Within 24 hrs 10-12 mg/dl

1000-1500 gms 7-9mg/dl 12-15 mg/dl

1500-2000 gms 10-12 mg/dl 15-18mg/dl

2000-2500 gms 13-15 mg/dl 18-20mg/dl

 Management

● Indirect bilirubin 20mg/dl

– Double volume exchange transfusion using the
patent umbilical vein
● Donors blood should match mothers blood to
prevent heolytic reaction
– If IB not rising rapidly: Phenobrbital
administration and Phototherapy
– Phenobarbital – increasing glucoronyl
transferase necessary for conjugation and
increase “y” transport protein
 Management

● Phototherapy -reduce bilirubin through

photoisomerization in intracanalicular and
interstitial spaces to soluble breakdown
products, excreted rapidly in bile and urine.
– Infant unclothed and exposed to ten 20 watt
daylight or blue fluorescent light at 30 inches
above
– Baby's eyes should be shielded, to avoid retinal
degeneration
 Management

● Complictions of phototherapy:
1.Dehydration
2.Diarrhea
3.Bronze baby syndrome
4.thrombocytopenia
 Breast milk Jaundice
(Physiologic)
Parameters Breastfeeding jaundice Breast milk jaundice

Onset 3rd-4th DOL Start to rise on 4th Dol,

may reach 20-30mg/dl on
day 14, then decrease
slowly, normal by 4--12
weeks
Pathophysiology Dec. milk intake increase Due to B- glucoronidase
enterohepatic circulation in breastmilk which
increase entrerohepatic
circulation

Management Fluid and caloric Stop breastfeeding, rapid

supplementation dec in bilirubin in 48 hrs
 Kernicterus
● High level of indirect bilirubin above 15-20mg/dl
● Dangerous because its depositon in the basal
ganglia of the CNS occurs producing toxicity to
the brain.
● S/s: lethargy, hypotonia and poor feeding
● Mgt: double volume exchange transfusion using
the umbilical vein, phototherapy, phenobarbital
5mg/kg/day
● Donors blood should match mothers blood to
prevent hemolytic reaction.
 Hyaline Membrane Disease
● 60% of preterm infants <28 weeks and 50% die
of this dse.
● Highest among 1000-1500gms
● etiology: due to defect in pulmonary surfactant
● S/S:
– respiratory distress RR 60/min, 1st 6-8 hrs
– Chest retractions
– Flaring of alae nasi
 Hyaline membrane disease

● CXR: diffuse reticogranular infiltrate throughout

the lung field with typical air-filled
tracheobronchial tree- air bronchogram
● Mgt:
– Baby dried and keep warm
– O2 by hood, Mechanical ventilation
– Correction of the acid base balance
 Apnea of the newborn

● Apnea of the new born-respiratory pause is prolonged,

>20 seconds, HR decrease 80/min
● Periodic breathing – respiratory pause is shorter 5-10
secs alternating with breathing movement.
● Common among pre- term infants;
● Term infants apnea occur few hrs after birth- due to
accumulation of secretions around the oropharynx
● Etiology unknown
● May lead to CNS damage
 Apnea of the newborn

● Management:
– Physical stimulation
– Theophylline LD 5mg/kg IV, MD 2mg/kgTID
oral
● Reduces apnea by increasing alveolar
ventilation through cntral stimulations.
 THANK YOU!
GOOD LUCK TO EVERYONE