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Neonatology

October 2013
by

Peter Schmidt

on 7 October 2015

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Transcript of Neonatology

Topics to Cover
What topics are important?
Respiratory Distress
Jaundice
Newborn
Examination
Vital topics:
Respiratory distress
Jaundice
Neonatal infection
Hypoglycaemia
Newborn examination
Important topics:
Feeding, especially breastfeeding
Outcomes of premature infants
CP
others (NEC, PDA, ROP)
Newborn screening
DDH
How we categorise babies
How big is the problem?
How big is the problem?
Survival to discharge: ANZNN
Days to discharge
Trends in CP rates
Respiratory Distress
RDS:
Previously known as hyaline membrane disease
Occurs in incompletely developed lungs
Disease of prematurity
Immature lungs are functionally deficient in mature surfactant
increased surface tension
alveolar collapse
increased work of breathing
intrapulmonary shunting
V:Q mismatch
hypoxia
respiratory failure
Epidemiology
Risk of RDS decreases with increasing GA
>60% if born <28/40
30% if born between 28-34/40
<5% if born >34/40
Mortality <10%
Other risk factors:
male
maternal GDM
perinatal asphyxia
hypothermia
multiple pregnancy
Protective factors:
antenatal steroids
prolonged ROM

Pathophysiology
Before the alveolisation stage:
delay in production and secretion of functional surfactant
decreased lung compliance
unstable alveoli
decreased FRC
hypoxia
increased WOB
lung oedema
Diagnosis
Presents at birth or soon after; symptoms worse over time
Symptoms are of increased work of breathing
tachypnoea, nasal flaring, recession, grunting, cyanosis
In the extreme preterm, the only symptom may be apnoea
Important clues on history:
gestational age
antenatal steroids
gestational diabetes
course of labour, including ROM, maternal fever, GBS status, antibiotics therapy, mode of delivery and resuscitation
CXR Features
Small volume lungs
Homogenous "ground glass" opacity
Air bronchograms
These findings may be altered by:
CPAP
surfactant administration
Differential diagnosis includes:
Pneumonia
Retained fetal lung fluid (RFLF)
Management
Antenatal steroids (ANS):
Given to women at high risk of preterm delivery 24-34 weeks GA
Decreased RDS, IVH and neonatal death
Both betamethasone and dexamethasone have been studied:
betamethasone associated with decreased PVL and decreased maternal infection
2 doses betamethasone administered 24 hours apart
Decreased RDS in infants born < 7 days after 1st dose ANS
Repeat doses are beneficial to decrease RDS but may alter growth and HC

Postnatal management:
supplemental oxygen
CPAP
mechanical ventilation / surfactant
Bloods
FBC
B/C
Blood gas
hypercarbia
hypoxia
metabolic acidosis
Neonatology
October 2015
Dr Peter Schmidt

Jaundice
Jaundice during the first week of life seen in:
60% term infants
80% preterm infants
Due to:
breakdown of RBC's with high Hct at birth
Short RBC survival (70-80 days)
inefficient hepatic conjugation of bilirubin
Important to recognise pathological and severe jaundice
even though most jaundice if physiological
Age at onset
< 24 hours:
Rhesus haemolytic disease
ABO incompatibility
Other RBC antibodies
G6PD deficiency
Spherocytosis
Congenital infection (conjugated)
Age at onset
2 days - 3 weeks
PHYSIOLOGICAL
breast milk jaundice
infection
birth trauma/bruising
Haemolysis
Gilbert's syndrome
> 3 weeks
Breast milk jaundice
Infection
Hypothyroidism
urgent TFTs
Metabolic
galactossaemia
Case study:
term infant, elective LUSCS, lethargy & jaundice at 18 hours
Clinical review:
Kramer's rule (less accurate if premature or dark skin)
?premature, ?mother's blood group, ?feeding/dehydration
Investigations:
Group and Coombs
Bilirubin (total and conjugated)
FBC
B/C
Lower threshold for infants with:
haemolysis
asphyxia
sepsis
acidosis
prematurity
low serum albumin
Phototherapy:
converts unconjugated bilirubin to harmless pigment
overhead lights, bilibed or biliblanket
effect depends on body surface area covered
may result in temperature instability and macular rash
Exchange transfusion:
whole blood
2-3 times total blood volume (2-3 x 80ml/kg)
large transfusion complications
Further reading
Evans, N. Neonatal Jaundice. Australian doctor. February 2008:21-28
Tachypnoea
normal breath rate 30-60/minute
infants with RDS may have shallow breathing
Isolated tachypnoea may be seen in CHD
Nasal Flaring
attempt to decrease airway resistance and work of breathing
Differential Diagnosis
Preterm (<35 weeks GA)
RDS/HMD/Surfactant deficiency

Sepsis
Pneumothorax
Near Term/Term (>34 weeks GA)
Retained Fetal Lung Fluid/TTN
Meconium Aspiration Syndrome
Sepsis
Pneumothorax
Congenital Heart Disease
Hypoglycaemia
Acidosis
Recession
suprasternal recession may indicate upper airway obstruction
increased retractions with decreased lung compliance
Grunting
partially closes glottis to increase PEEP and lung volume/FRC
Cyanosis, gasping, apnoea
Respiratory distress
Retained Fetal Lung Fluid
Full transcript