STATE ESTABLISHMENT «DNEPROPETROVSK MEDICAL ACADEMY
OF MINISTRY OF HEALTH UKRAINE »
“Сonfirmed;”
at methodical meeting
of hospital pediatrics №1 department
Сhief of department
professor _____________V. A. Kondratyev
“______” _________________
METHODICAL INSTRUCTIONS
FOR STUDENTS` SELF-WORK
WHILE PREPARING FOR PRACTICAL LESSONS
Educational discipline
module №
Substantial module №
Theme of the lesson
Course
Faculty
pediatrics
2
8
Respiratory diseases in the neonate
5
medical
Dnepropetrovsk, 2013.
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1. Theme urgency:
The syndrome of the respiratory disorders takes first place among the causes of the lethality of the
preterm infants. This syndrome is caused by pneumopathies. This problem is extremely actual
because of the severity of pneumopathies` course and disadvantageous prognosis in most cases.
Problems of diagnostics and treatment of pneumonia at newborn children also should be taken into
account. Even nowadays pneumonia can cause lethality among newborns and infants. Early revealing
and timely liquidation of inflammatory pulmonary process in the neonate provides favorable outcome
and more proper development of the child in the future.
2. Specific goals:
А. Student should know:
1. Definition of term “the syndrome of respiratory disorders” (SRD).
2. Principal causes of SRD development.
3. Pathogenesis of pneumopathies.
4. Structure and functions of surfactant.
5. Principles of estimation of SRD severity at newborns.
6. Clinical manifestations of pneumopathies:
- disease of gialine membranes
- atelectasis of the lungs
-edematous-hemorrhagic syndrome
7. Laboratory and instrumental diagnostics of pneumopathies.
8. Principles of the urgent help to children having SRD.
9. Principles of treatment of children having pneumopathies.
10. Complications and the prognosis of pneumopathies.
11. Outcomes of SRD.
12. Etiologial structure of pneumonia of newborns (PN).
13. The reasons of susceptibility of the fetus and the newborn to infectious agents - factors of
pneumonia.
14. Factors which assist development of PN.
15. Pathogenesis of disorders which occur in the organism of the child at PN.
16. Features of the clinical picture at PN.
17. Features of the pneumonia depending upon the etiological factor.
18. Differences between congenital and postnatal PN.
19. Early signs of PN.
20. Classification of PN.
21. Principles of treatment of children with PN.
22. Principles of dispensary supervision over reconvalescents of PN.
В. Student should be able::
1. To reveal clinical signs of «the syndrome of respiratory disorders” (SRD) at the newborn.
2. To define the SRD severity.
3. To appoint investigation for the specification of the SRD origin.
4. To estimate the obtained data.
5. To make a plan of treatment of the child having SRD.
6. To define complications of SRD.
7. To carry out prophylaxis of pulmonary infectious and non infectious diseases at newborns.
8. To define the severity of respiratory disorders at PN.
9. To reveal clinical signs of PN.
10. To appoint investigation to the child for the confirmation of diagnosis of PN.
11. To carry out differential diagnostics of antenatal and postnatal PN.
12. To formulate the pneumonia diagnosis according to classification.
13. To make the plan of treatment of the child with PN.
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14. To appoint etiotropic therapy to the child with PN.
3. Tasks for students` self-dependent work during preparation for the classes.
3.1. List of main terms, parameters, characteristics, which students has to
master preparing for the classes.
The term
1. The syndrome of
respiratory disorders
2. Pneumopathies
3. Gialine membranes.
4.Surfactant
5. Pneumonia of newborns
6. Sylverman-Andersen and
Dawns` scales
Definition
Acute respiratory insufficiency with expressed arterial
hypoxia, which arises during the first hours and days of
the newborn life.
Alterations in lungs which causes asphyxia of newborns.
Pneumopathies: disease of gialine membranes,
edematous-hemorrhagic syndrome, disseminated
pulmonary atelectases and edematous syndrome.
The most severe form of pneumopathies.
High-molecular lipoproteid which provides
antiatelectatic function. Deficiency of which causes
diosorders of ventilatory-perfusional relation in lungs
with the development of hypoxia, hypercapnia,
metabolic-respiratory acidosis.
Infectious disease with localisation of inflammatory
process in pulmonary parenhima and disorders of
functions of other systems of an organism
Scales for the estimation of the severity of the syndrome
of respiratory disorders at newborns.
3.2. Theoretical questions for classes:
1. Definition of the term “the syndrome of respiratory disorders” (SRD).
2. Causes of SRD.
3. Pneumopathies, as the most frequent cause of SRD at premature infants.
4. Causes of pneumopathies .
5. Estimation of SDR severity.
6. Surfaktant, its structure and functions.
7. Clinical manifestations of pneumopathies .
8. Additional methods of pneumopathies` diagnostics.
9. Complications of pneumopathies.
10. Main principles of treatment of pneumopathies. Pathogenetic and replacement therapy.
11. Outcomes of SDR.
12. Definition of the term «pneumonia of the newborn».
13. Features of the aetiology of PN.
14. Oxygen starvation as the basic pathogenetic mechanism at PN.
15. Classification of PN.
16. The basic clinical manifestations of PN, features of various forms.
17. Features of the pneumonia depending upon etiologic factor.
18. Features of the pneumonia depending upon the term of infection.
19. Outcomes of PN.
20. The basic therapeutic approaches to PN.
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21. Principles of the antibiotic prescription to the newbor having PN.
22. Rehabilitation and dispensary supervision at PN.
3.3 . Practical works (tasks) which are performed on occupation:
1 To establish the main etiologic factors of the development of pneumonia at he
newborns
2. To collect antenatal and intranatal history
3. To reveal factors that predispose the infant to the respiratory diseases
4. To inspect the child and reveal the symptoms of pneumonia
5. To make the presumptive diagnosis
6. To make the plan of investigations
7. To make the treatment plan.
8. To administer antibiotics to the infant
9. To make recommendations of dispensary supervision of the children who had pneumonia.
10. To make recommendations of the follow-up.
11. During survey to reveal RDS signs at the newborn child.
12. During survey of the newborn child to define severity of RDS.
13. To establish the reasons of development of RDS.
14. During survey of the newborn child to define severity of respiratory disorders.
15. To appoint additional methods of inspection for diagnostics of pneumopathy.
16. To define the plan of treatment of the child with RDS.
17. To define the forecast at RDS.
5.1. Respiratory distress syndrome (RDS) МКХ-Х Code -Р.22.
It is an acute respiratory failure with severe arterial hypoxemia, which occurs in the first hours and
days of the life of a newborn.
1. Causes of the RDS
 - Lack of formation and release of surfactant
 ;- Quality defect surfactant;
 - Destruction of surfactant;
 - Immaturity of fetal lung tissue structure.
2. Clinical signs of RDSs
appear in the newborn immediately after birth or through some hours. In last case there is a
so-called "lucid interval" that more typically for hyaline membrane disease, the first minute life has
been a gradual shortness of breath, Nasal flaring, breathing "trumpeter" appearance Expiratory
grunting (from partial closure of glottis), cyanosis and Substernal retraction Breathing arrhythmia,
periods of apnea, the lips appear frothy, the characteristics of the functional state of the central
nervous system depression.
Regardless of whether there is shortness of breath, nares dialation points to the emergence of
respiratory violations. Cyanosis may occur early in the disease, but often at a later date.
Simultaneously with the appearance of cyanosis and swelling of the nose(dialatin of nares),
swelling cheeks and noticeable loud groaning breath . Auscultation : respiratory depression listened
kriptation scattered rales. Tones heart muffeled, tachycardia. The child first excitable, seizures can
occur, then appears atony, fading reflexes, the pressure drops. With the development of edematous
hemorrhagic syndrome on first plan - a phenomenon swelling of the soft tissues and the lungs. The
lips appear frothy. Petechiae on the skin, increased bleeding. Cardiovascular disorders - the typical
complications of SDRs. Threatening danger is infection. The smaller the gestational age, the less
are typical symptoms.
Pneumopathy, as the most common cause of premature RDS
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Pneumopathy - changes in the lungs, which are the cause of newborn asphyxia. By pneumopathies
include hyaline membrane disease, edema - haemorrhagic syndrome, disseminated pulmonary
atelectasis and edema.
The most difficult form of pneumopathy are hyaline membrane. They are more common in children
less mature, such that develop in the pathological course of pregnancy and childbirth. From the first
hours after birth, grow rapidly classic symptoms of respiratory distress syndrome (RDS) II or III
degree. Frequent bouts of apnea, increases edema and cardio - vascular insufficiency.
Causes of pneumopathy
 Prematurity;
 Intrauterine infection;
 Perinatal hypoxia and asphyxia, and they cause lung ischemia and acidosis;
 Diabetes in the mother;
 Acute blood loss during delivery.

Assessment of the severity of respiratory disorders in the newborn on a scale Silverman-Andersen
STAGE 0
The upper part of the chest
(at the position of the child
on the back) and the
anterior abdominal wall is
simultaneously involved in
breathing
No retraction of
intercostal spaces on
inspiration
STAGE 1
The upper part of the chest
(at the position of the child
on the back) and the
anterior abdominal wall is
simultaneously involved in
breathing
Slight retraction of
intercostal spaces on
inspiration
STAGE 2
Noticeable retraction upper
chest while lifting the anterior
abdominal wall on the breath,
a symptom of "swing"
Noticeable retraction of
intercostal spaces on
inspiration
No retraction of the
Slight retraction of the
Noticeable retraction of the
xiphoid process of sternum xiphoid process of sternum xiphoid process of sternum on
on inspiration
on inspiration
inspiration
There is no movement of
the chin when breathing
No noise at expiration
Lowering his chin on the
Lowering his chin on the
breath, the mouth is closed breath, the mouth is closed
Expiratory noise
Expiratory noise when
("expiratory grunting An
brought near to the mouth of
e") audible on auscultation stethoscope or no stethoscope.
of the chest.
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Or by scales Downes.
Symptoms
Scoring
1
Cyanosis of the
skin
None
retraction of the
xiphoid process
retraction of the
xiphoid process
None
Wheezing when
breathing
No
2
While breathing
room air
slight
Heard on
auscultation
3
When breathing
40% 0 2
Expressed
Heard at a
distance
Cry
Loud
Deaf
Groan
Breath.Freq / min
Less than 60
60-80
More than 80
Classification of respiratory disorders:
Severe respiratory disorders: Score more than 7 points for scales or Dovnes Silverman, or
"heavy" on a simplified scale e WHO
Moderate respiratory distress: total score of 4-6 points or scales Dovnes Silverman, or
"moderate" on a simplified scale e in W
Lungs breathing disorders: total score of 1-3 points or scales Dovnes Silverman, or "light" for a
simplified scale Boaz
The classification of the severity of respiratory problems (WHO, 2003)
Groan at expiration or re t
Respiration rate
Classification
diffraction
Over 90 per 1 min
60-90 in 1 min
present
absent
present
absent
Severe
Moderate
Light
Surfactant, its function and secretion
Full respiratory adaptation depends on the degree of distending and stabilizing the alveoli
state blood flow in the lungs. Air entering the Lung and formation functional residual capacity is
impossible in the absence of factor which reduces the forces of surface tension. This factor is
surfactant - a high-lipoprotein which prevent atelectasis (collapse of the lung), the main component
of which - dipalmitin lecithin. Surfactant in the fetus begins to produce from 20 to 24 weeks of fetal
development. Especially intensive use of surfactant occurs during birth child. The main surfactant
system matures fully only to 36 week of pregnancy. At his deficit is violation ventilation-perfusion
ratio in the lung to the development of hypoxia, hypercapnia, metabolic and respiratory acidosis.
Spasm and contraction of pulmonary artery leads to increased pressure in the blood vessels of the
lungs and appearance shunting of blood to the right to the left. As a result of hypoperfusion of lungs
the hypoxic state of pulmonary capillaries develops with exudation of elements of plasma and and
fibrin and appearance of hyaline membranes.
The main functions of surfactant:
- prevent collaps of alveolar during exhalation;
- Protection from epithelial lung damage;
- Stimulation of macrophage reaction in the lungs, which has bactericidal activity against grampositive bacteria;
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- Involved in the regulation of microcirculation in the lungs and the permeability of the walls of the
alveoli, prevents the development of pulmonary edema
Clinical manifestations of pneumopathies
Most children who are born with pneumopathy will devlope asphyxia and innate hypoxia,
respiratory distress may occur immediately, or after a few hours of birth. Typical are pronounced
signs of respiratory failure: shortness of breath 60 or more for 1 minute (often with non-rhythmic
breathing), cyanosis, pallor, participation ofauxiliary muscles in breathing, retraction of the chest intercostal spaces, retraction of the xiphoid process retraction supraclavicular fossae), rigidity of the
chest, sometimes the foam around the mouth, breathing difficulties (spasm of the glottis), swelling
of cheeks. A decrease in physical activity, hyporeflexia, hypotonia. In a measure of disease
progression and symptoms of respiratory disorders of the nervous system depression are increasing,
increasing cyanosis, apnea appear, "grunts u s" exhale and paradoxical breathing (expiratory
anteroinferior part of chest is drawn, and the belly bulge), small scattered rales are heard. Often,
there are local and generalized edema, frothy, sometimes bleeding from the mouth. cardiovascular
system, there is tachycardia, muffled heart sounds, develops hypertrophy of heart and liver.
Complications of pneumopathies
Edematous - hemorrhagic syndrome. The clinical picture of puffiness - haemorrhagic
syndrome typical of the RDS. However children with hyaline membranes disease have more severe
symptoms and bad outcome . In the anamneses the mother often has a history of cardio - vascular
and allergic diseases. Status of children of moderate or severe typical have frothy mouth. Rigidity
of the chest and respiratory parameters decreased. Percussion sound is shortened in the medial
portions of the chest. Breathing relaxed, listened many small moist rales. Accelerated pulse, weak,
there are no clear boundaries of the relative dullness of the heart, often auscultated systole. Noted an
increase in liver size and swelling in the background of metabolic acidosis and hypercapnia.
Massive bleeding in the lung may be due to the ICE syndrome that develops during asphyxia
or intrauterine infection. Morphologically thus can be detected scattered clots in vessels of the
lungs, kidneys, brain, and small ischemic necrosis.
Atelectasis are seen mostly in premature infants, as immature lungs easily collapses due to
underdevelopment of elastic tissue, immature antiatelectatic of surfactant. Also their reasons may be
a violation of the act of breathing associated with intracranial hemorrhages during asphyxia and
birth trauma. Atelectasis can be subsegmental, segmental, polysegmental, focal and total
Basic principles of treatment pneumopathies
The presence of respiratory disorders in the newborn child is a contraindication to breast-feeding. In
the mild respiratory symptoms (1-3 points) is appropriate to start feeding expressed breast milk, and
in his absence - adapted milk mixture, using alternative methods (cup or gavage) respectively
secular needs of the child.
Specific activities - oxygen therapy and respiratory support (see Clinical Protocol). Post respiratory
therapy according to the available testimony and adjust it according to the dynamics of the state of
the newborn.
Non-specific events:
Antibiotics. In the acute phase, and even in cases of suspected use of penicillin (ampicillin) in
combination with gentamicin often. 3 days after the results of blood cultures and clinical blood tests
addressed the issue of the presence of infection, and if it is not present, antibiotics are canceled.
Vitamin - Prescribe vitamin. E intramuscularly to 10 ml / kg each den v using an oxygen-air mixture
(by reducing the incidence and severity of retinopathy in premature infants), the rate of 7.10
injections vitamin. A parenterally to 2000 IU a day, administered to the top of enteral nutrition
(reduces the incidence of necrotizing enterocolitis, and bronchopulmonary dysplasia).
Diuretics - Furosemide is prescribed only for pulmonary edema, edema, 1-3 mg / kg / day.
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From drinking glyukokortik oidov to stimulate the synthesis of surfactant at this time refused.
Dexamethasone was administered only to patients with adrenal insufficiency established short
courses - 3-7 days (0.5 mg / kg / day, 3 days, 0.25 mg / kg / day - 4 days 3 use). Partly justified its
use can be considered only in neonates with critical severe lung disease, which at the end of the
early neonatal period, NE require mechanical ventilation with rigid parameters and Fi2 > 80%.
Correction of metabolic disorders: hypoglycemia / hyperglycemia, significant acidemia (pH of
arterial / capillary blood <7.2), anemia, polycythemia (hematocrit ≥ 65%).
Ensuring stable hemodynamics.
Basic principles of stable hemodynamics in newborn infants with respiratory disorders meet the
guidelines section 8 of Section XIII of the Protocol "resuscitation and post-operative care for the
newborn" (approved by the Order of the MOH of Ukraine 08.06.2007 № 312).
Replacement surfactant is used for lack of it at pneumopathies in very preterm infants. Use a
surfactant, which contain, in addition of phospholipids, surfactant protein A is introduced in the first
15 minutes of life (period of effective administration - the first 6-8 hours of life). A dose of 100 mg
/ kg body weight (about 4 ml / kg), infused through an endotracheal tube into the trachea for 4 doses
with an interval of about 1 min. When the need for a repeat in 6 hours. Just do not spend more than
4 injections in 48 hours.
Outcomes of RDS
Pneumomyelographies on the essence are asphyxial pathology and accompanied by respiratory
insufficiency and secondary attacks of asphyxia. Frequency of СДР varies in limits from 25 to 80%
to the general amount of the born prematurely born children. The high mortality rate of children
with RDS.
Complications.
Local: - Pneumothorax
- Hemorrhage in lung
- Pulmonary edema
- Pneumonia
- Bronchopulmonary dysplasia
- Complications OF Intubation
Systemic: - Syndrome of fetal circulation
- Septic shock
- DIC-syndrome
- Intraventricular hemorrhage
- hypoglycemia
- Necrotizing enterocolitis
- Renal failure
- Retinopathy of Prematurity
5.2. . Pneumonia of the newborn. МКХ-Х Code-Р23.
The concept of neonatal pneumonia.
Neonatal pneumonia - an infection disease with the localization of the inflammatory process in
the lung parenchyma and the dysfunction of other organ systems. A child can be infected
antenatal at presence of for the mother of diseases of urogenital tract, a certain role will be
played by a hypoxia or asphyxia, respiratory pathology (atelectasis, and other abnormalities),
birth trauma, diseases of other organs and systems. Negative impact on the reactivity of child
the care - the wrong temperature, inadequate ventilation, irrational feeding. The source of
infection in neonatal nursing home may be the children's department staff and the infected
equipment. Neonatal pneumonia is always a serious disease. This is how the reactivity, the
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immaturity of the adaptive protective mechanisms, especially premorbid background
Features of etiology of pneumonia.
Intrauterine pneumonia often called group B streptococcus (Streptococcus agalactiae) and
Gram-negative bacteria - Escherichia coli, Klebsiella pneumoniae, rarely - Staphylococcus aureus,
Listeria monocytogenes. Possible association with cytomegalovirus, herpes simplex herpes and
fungi Candida. etiologic significance of intracellular microorganisms such as Mycoplasma hominis
and Ureaplasma urealyticum, not fully proven and is the subject of research..
Premature babies in some cases pneumonia can be caused Pneumocystis carinii. The most
common pathogens are Viruses (Respiratory syncytial, paragripa etc.), E.coli and other Gram E.
microflora staphylococci. Even more rarely, community-acquired n nevmonii caused Moraxella
catarrhalis and Bordetella pertussis. Pneumococci and H aemophilus influenzae in this age are
rarely isolated (About 10%). The main causative agent of SARS is Chlamydia trachomatis.
C.trachomatis infection occurs during labor.
The main pathogenetic point at pneumonia - anaerobics.
Classification.
A. The period of occurrence: prenatal and postnatal
B. Etiology - viral, microbial, parasitic, fungal, mixed
Contributing factors - immaturity body pneumopathy, (aspiration, atelectasis, edematoushemorrhagic syndrome) and violation of
B. Clinical forms: polysegmentary, interstitial.
B. severity: a) mild (uncomplicated) form, b) moderate form
c) severe (respiratory distress syndrome II - III degree, cardiovascular syndrome, neurotoxicity,
syndrome disorders of acid-base balance).
G. Course of the disease: a) acute, b) sub-acute, and c) a prolonged
Example 1) I postnatal small focal bilateral bronchopneumonia, viral and bacterial etiology,
moderate, NAM Іst.
2) Fetal bilateral pneumonia microfocal against atelectasis, with severe cardiovascular syndrome,
acute course, NAM II - І11st
The main clinical manifestations of PN, especially different forms.
With pneumonia caused by respiratory syncytial virus infection is often found difficulty in
breathing .adenovirus infection - conjunctivitis, runny nose rhinitis, cough, wheezing thick, with
influenza - affects the nervous system, with herpes infection - bleeding, acute renal and hepatic
failure (increase liver toxicity - pallor, lethargy, lack of appetite, vomiting, loss, and then the
absence of urination, depression of consciousness, signs of dehydration), staph. aureus – lung
abscesses, pustular skin lesions, umbilical wound, osteomyelitis, klebsiela - enteritis, pyelonephritis
Outcomes .
Prognosis depends on the severity of the condition, the presence of comorbidities. With
adequate treatment and no other pathology for 2-3 weeks start to improve state: reduced signs of
respiratory failure, reduced appetite, normalizes the nervous system, but in some cases pneumonia
takes protracted.
The most frequent complications such as otitis media, atelectasis, abscesses, often in the
lungs, the concentration of pus and air in the chest (pneumoempyema), bronchiectasis with
stagnation in their sputum, and the emergence of inflammatory processes (bronhoektazy), anemia,
acute adrenal insufficiency, encephalitis, meningitis, sepsis, secondary enterocolitis.
The main therapeutic approaches .
In order to carry out detoxification infusion therapy: 10% glucose, cocarboxylase (0.5 - 1 ml),
0.02% solution of vitamin B y 5% solution of vitamin C (1-2 mL), eufilin (0.15-0.2 ml of 2.4%
solution). Decompensated acidosis n th to introduction of a solution of sodium bicarbonate.
Common the amount of fluid in the jet introduction of 10-12 ml / kg, at drip total liquid up to 80 100 ml. With cardiovascular disease - or korglikon strophanthin, digoxin, sulfokamfokain. At toxic
syndrome shown glucocorticoids
9
Compliant with Symptomatic therapy.
When intrauterine pneumonia drugs of choice are ampicillin,
ampicillin / sulbactam in combination with aminoglycosides.
Principles of antibiotic Neonatal pneumonia
Antibiotic
Way
introducti
on
Dose interval introduction
Children
of the first
Children older than 1 week
week of life
Body
Body weight
weight more
weight less Body weight over
less than
2000г. 2000.
than 2000. 2000.
2000.
Aminoglycosides
Amikacin
Gentamicin
in / in /
m
in / m
7.5 mg 12 h 7.5 mg 12 h
10 mg 8 hours
2.5 mg 8
hours
4mg 12 hours
2 mg 8
hours
2.5 mg 8 hours
2.5 mg 12 h 2.5 mg 12 h
in / m
2 mg 12
hours
Cephalosporins
Cefotaxime
/ in / m
Ceftazidime
in / m
Ceftriaxone
in / m
50 mg 12
hours
50 mg 12
hours
50 mg 24
hours
Tobramycin
7.5-10 mg 8
hours
50 mg 8-12
50 mg 8
hours
30 mg 8 hours 30 mg 8
hours
50 mg 24 hours
50mg 24
hours
2mg 8 hours
50mg 6-12 hours
30mg 8 hours
50-75mg 12 hours
Macrolides
Erythrom внутренне
10 мг 12 ч 10 5мг 5mg
8 hours
4mg 5 hours 10-15 mg 8
ycin
internally
mg 12 hours
hours
Clindamy
в/в, в/м, 5-8мг 12 ч 5- 5мг 5mg
8 hours
5mg 8 hours
4mg 8
cin
внутренне in / 8mg 12 hours
hours
in / m,
internally
Penicillin
в/в, в/м in 25 mg 12
2-4 mg 5 hours
25 mg 8
/ in / m
hours
hours
Oksatsilin
/ in / m 25 mg 12
25mg
8 hours
25 mg 8 hours
251
hours
Maftsilin
in / m
25mg
8 hours
25 mg 8 hours
25 mg
Ampicillin
in / m
Karbenitsiln
в/в in /
Vancomycin
в/в in /
10mg 12
hours
10 mg 12
hours
25 mg 24
hours
100 mg 8 hours
100 mg 8
hours
10mg 12 hours 10mg 8 hours
25 mg 24 hours
50 mg 24
hours
10mg
10 mg
50 mg 24 hours
11. Rehabilitation and medical check-up for pnemonia
Prescribe vitamin therapy (vitamins C, B1, B2, B6, B15), physiotherapy (UHF and electrophoresis),
transfusion of blood plasma, the use of antibodies. Children who are ill with pneumonia, prone to
relapse, so after discharge should be repeated courses of vitamin take bioregulators
(Eleutherococcus extract, aloe, etc.) for 3-4 months. Under medical supervision for the child is 1
year old.
Additional materials for the self-control
А. Clinical cases
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Case study 1
A 2 hour old, 38 week gestation, 3 kg male infant was born to a 25 year old G1P1 A+,
VDRL negative, Hepatitis B negative, GBS unscreened, Rubella immune, woman who had an
uncomplicated pregnancy, labor and delivery. Apgar scores were 9/9. He was sent to the newborn
nursery. He breast fed 1 hour ago without concerns. He now presents with respiratory distress.
Exam: VS T 37, HR 160, RR 80, BP 60/35 (mean 45), oxygen saturation 95% in 2 L/min oxygen
via mask. Wt 3kg (50%), Lt 48cm (50%), HC 33.5 cm (50%). He is a term male with obvious
respiratory distress and tachypnea. Skin is pale and pink without petechiae, ecchymoses, or lesions.
His head is normocephalic with molding. His anterior fontanel is flat. His face is symmetrical with
normal palpebral fissures, normal red reflexes, patent nares, normal ears, no clefts, and no neck
masses. His chest is symmetric with equal and clear breath sounds. Mild to moderate chest
retractions are present. Heart is regular with a normal S1, split S2, and no murmurs. His pulses are
normal. His abdomen is soft and round with normal bowel sounds, no masses and no
organomegaly. He has normal male genitalia with descended testes. His hips and anus are normal.
He has mild hypotonia.
Laboratory results: CBC: WBC 15,000, 8% bands, 50% segs, 40% lymphs, 2% monos, Hct
55%, Plt 250,000. No toxic granulations or vacuoles of the neutrophils are noted. ABG: pH 7.35,
PCO2 55 torr, PO2 70 torr, BE -7 in a 30% oxygen hood. CXR: 10 ribs of inflation, streaky linear
perihilar densities, and small scattered patchy densities bilaterally.
Over the next several hours, the infant develops progressively more distress and a greater
oxygen requirement. He is sent to the newborn special care nursery with worsening tachypnea (RR
90), more retractions and grunting. He is now in 50% O2 by hood.
Questions:
1.What is your differential diagnoses?
2. How to confirm diagnosis?
2. How would you manage this infant?
B. Tests
Question 1. A 3.5-kg female born following repeat cesarean section is noted by the nurses to be
grunting at 10 min of age. You come to see the baby and note that the grunting has stopped, the
respiratory rate is 36/min, the pulse oximetry reading is 99%, and the child looks vigorous. The
most appropriate next step is to:
A. Perform a sepsis evaluation
B. Obtain a chest film
C. Observe, and if grunting returns, admit to the neonatal intensive care unit
D. Begin surfactant therapy
E. Begin nasal continuous positive airway pressure
Answer C. Explanation: Grunting is common, particularly after a cesarean section without prior
labor. If grunting persists beyond 30 min or if there are other signs of distress, the child should be
evaluated for sepsis, respiratory distress syndrome (RDS), or congenital heart disease.
Question 2. A 32-wk gestational age infant develops grunting, flaring, and retraction after birth. He
requires 50% oxygen (O2) by hood to keep his oxygen saturation above 95%. The next step in
management, if he requires more O2, is to:
A. Institute inhalation of nitric oxide
B. Perform a blood transfusion
C. Begin nasal continuous positive airway pressure (CPAP)
D. Begin penicillin infusion
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E. Begin dexamethasone infusion
Answer C. Explanation: Nasal CPAP is often quite effective when larger premature infants develop
respiratory distress syndrome (RDS).
Question 3. In addition to administration of CPAP, immediate approaches to the patient described
in Question 35, would include all of the following except:
A. Head ultrasonography
B. Blood culture
C. Chest x-ray
D. Complete blood count
E. Blood gas analysis
Answer A. Explanation: In a neonate with no signs of intraventricular hemorrhage (IVH) and on the
first day of life, one does not need a head ultrasound. The others (B-E) are important to look for
other causes of respiratory distress and prepare to treat empirically for the possibility of early-onset
group B streptococcal pneumonia.
Question 4. A 30-wk-old average-for-gestational-age male infant is born after 24 hr of ruptured
membranes and another 10 hr of labor. After birth, he develops grunting, flaring, and restrictions, as
well as cyanosis. He requires intubation, ventilation, and surfactant therapy. Despite these measures
he is still hypoxic and hypotensive. You should now:
A. Do a blood culture and await results
B. Do a Gram stain of the tracheal fluid
C. Do a blood culture and begin intravenous antibiotics
D. Begin intravenous antibiotics
E. Obtain blood and CSF for culture and begin intravenous antibiotics
Answer C. Explanation: Premature infants with respiratory distress syndrome (RDS) may look
indistinguishable from infants with early-onset sepsis. Waiting for culture results in this situation
would be dangerous, as the infant will die without therapy before the culture is reported positive. A
lumbar puncture is not wise in this case, as the infant is hypotensive and hypoxic; theblood culture
is the only needed initial culture. If the blood culture is positive, when the patient's condition
becomes more stable, a lumbar puncture can be performed.
Question 5. A 3.5-kg girl is delivered by spontaneous vaginal delivery, with Apgar scores of 2 and
3. Respiratory distress is apparent in the delivery room, with diminished breath sounds on the left
and heart tones displaced to the right. The abdomen is scaphoid. The most appropriate next step in
treatment is to:
A. Administer sodium bicarbonate, 3.5 mEq
B. Perform left tube thoracostomy
C. Perform emergency laparotomy
D. Perform endotracheal intubation
E. Perform umbilical artery catheterization
Answer D. Explanation: This is a classic presentation for a left-sided diaphragmatic hernia. This
infant needs to be resuscitated immediately and have the airway protected and ventilation begun.
Mask-bag ventilation would increase gas in the intestines, which could increase the mass effect in
the left thorax. Therefore, immediate endotracheal intubation is indicated.
Question 6. A premature infant is undergoing mechanical ventilation for respiratory distress
syndrome. Peak inspiratory pressure is 32 cm H2O, positive end-expiratory pressure (PEEP) is 5
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cm H2O, and ventilatory rate is 30 breaths/min. The infant has decreased peripheral perfusion,
manifested as a prolonged capillary refill time and weak arterial pulses. The central venous pressure
measured at the right atrium with an umbilical venous catheter is 2 mm Hg (or approximately 3 cm
H2O). Arterial PO2 is 80 mm Hg, and arterial PCO2 is 38 mm Hg.Which of the following measures
is most likely to result in an improvement in this infant's perfusion?
A. Reduce PEEP to 3 cm H2O
B. Reduce peak inspiratory pressure to 28 cm H2O
C. Reduce ventilatory rate to 26 breaths/min
D. Administer 10 mL/kg of normal saline
E. Begin an infusion of dopamine at 5 μg/kg/min
Answer D. Explanation: The PaO2 and PCO2 are quite appropriate and in the target range for
appropriate therapy.Poor peripheral perfusion and weak pulses (and presumably low blood
pressure) in this setting should respond to expansion of the intravascular volume with normal
saline.The poor perfusion may have preceded the initiation of PEEP, but may have also been
exacerbated by the PEEP.
Question 7. A 3.2-kg full-term female infant is delivered by vaginal delivery. She is initially
cyanotic and is in significant respiratory distress. Auscultation of the chest reveals diminished
breath sounds in the left hemithorax and a scaphoid abdomen. After bag and mask ventilation, an
endotracheal tube is placed. The point of maximal impulse (PMI) is shifted to the right side of the
chest.The most important initial intervention is:
A. Immediate bronchoscopy
B. Placement of a nasogastric tube
C. A chest radiograph to assess placement of endotracheal tube
D. Immediate surgery
E. Administration of epinephrine
Answer B. Explanation: This patient potentially has a diaphragmatic hernia and needs gas to be
removed or prevented from entering the bowel, which acts as a spaceoccupying lesion in the chest
Question 8 A 35-week-gestation infant is delivered via cesarean section because of macrosomia
and fetal distress. The mother has class D pregestational diabetes (insulin-dependent, with vascular
disease); her hemoglobin A1C is 20% (normal 8%). This infant is at risk for birth asphyxia, cardiac
septal hypertrophy, polycythemia, and which of the following?
A. Congenital dislocated hip
B. Dacryostenosis
C. Hyaline membrane disease
D. Hyperglycemia
E. Pneumothorax
Answer C. Infants born to mothers with poorly controlled diabetes are at risk for respiratory distress
syndrome (surfactant deficiency) at later gestational ages than seen in infants born to mothers who
do not have diabetes.
Question 9. A premature infant of a class B pregestational (insulin-requiring, but without vascular
disease) diabetic mother is delivered via cesarean section due to fetal distress. The mother’s axillary
temperature at delivery is 98.6°F (37°C). The child has poor color and tone, no spontaneous
cry, minimal respiratory effort, and a weak pulse of 80 bpm. After endotracheal intubation, the
color and tone improve a bit, but she still has perioral cyanosis and her heart rate is 90 bpm. Which
of the following is the most likely cause of her persistent distress?
A. Hypocalcemia
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B. Hypoglycemia
C. Impaired cardiac function
D. Renal failure
E. Sepsis
Answer C. Infants born to mothers with poorly controlled gestational diabetes are at risk for
congenital heart anomalies, cardiomyopathy, septal hypertrophy, and subaortic stenosis. This
child’s symptoms and the maternal diabetes history indicate a risk for cardiac problems. Sepsis can
cause similar symptoms, but no risk factors for infectious disease are noted. This child is at risk for
hypoglycemia, but hypoglycemia alone would less likely explain all of his symptoms.
Question 10. A term 3500-g female delivered by cesarean section develops a respiratory rate of 70
breaths/min and expiratory grunting at 1 hour of life. She has good tone, good color, and a strong
suck. Which of the following is the most likely diagnosis?
A. Intubation and suctioning below the vocal cords
B. Administration of surfactant
C. Initiation of antibiotic therapy
D. Swallow study and upper GI series
E. Observation for a period of several hours
Answer E. Transient tachypnea of the newborn is a respiratory condition resulting from incomplete
evacuation of fetal lung fluid in full-term infants. It occurs more commonly with cesarean deliveries
and usually disappears within 24 to 48 hours of life. Often no treatment is indicated unless the
infant requires low amounts of supplemental oxygen. Antibiotics would be indicated for a child for
whom pneumonia would be suspected; these children usually do not have a vigorous suck as
outlined in the question. Intubation and suctioning below the vocal folds hints at meconium
aspiration; the intubation would appropriately be accomplished in the delivery room and not hours
later. The barium swallow and upper GI series might be helpful to identify a tracheoesophageal
fistula. Exogenous surfactant is used for premature infants for whom surfactant deficiency is
suspected.
Question 11. A child was born at a gestational age of 34 weeks in grave condition. The leading
symptoms were respiratory distress symptoms, namely sonorous and prolonged expiration,
involving additional muscles into respiratory process. The Silverman score at birth was 0
points, in 3 hours it was 3 points with clinical findings. Which diagnostic study will allow to
diagnose the form of pneumopathy?
A X-ray of chest
B Clinical blood test
C Determination of blood gas composition
D Proteinogram
E Immunoassay
Question 12. Newborn child experienced intranatal asphyxia. While suctioning the mucus from the
upper respiratory tract miconium is reveaked. Independent breath is absent. The further actions of
neonatologist provide:
A Tracheal intubation, sanation of respiratory tract
B External heart massage
C Application of 100 %oxygen.
D Adrenaline introduction.
E Tactile stimulation of breathing.
Question 13. 12-hour-old girl was born from the second pregnancy, complicated by toxicosis,
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chronic adnexitis. The weight is 2900 g, length is 52 cm. the Evaluation on Apgar scale: 4/6.
Objectively: a condition of the child is severe. Cry is silent, congenital reflexes are diminished,
muscular tonus is lowered. Skin is with a grayish shade, acrocyanosis. Breathing is superficial,
arrythmic, 70/minute Auscultation: weakened breathing, wet different-sized rales. Heart rate 140/minute. Liver is + 2 cm. Mekony has discharged. What is the preliminary diagnosis?
A Intrauterine pneumonia
B Early postnatal pneumonia
C Late postnatal pneumonia
D Sepsis
E Primary disseminated atelectases
Question 14. 2-day-old infant, born at 32 weeks` gestation with weight 1700 g, has worsenning
respiratory disorders, which appeared 8 hours after birth. This is the ІІІ pregnancy, ІІ childbirth,
abortions weren't present. The previous born child was lost as the result of syndrome of respiratory
disorders. Objectively: an estimation at the Silverman`s scale is 6 points, breathing is arrhythmic,
apnoe, noisy exhalation, nodding the head while breathing, decrease in muscular tone. At
auscultation: breathing is moderately weakened, a lot of rales on both sides. X-ray investigation:
ground glass appearance oppacities.What is the cause of the syndrome of respiratory disorders at
the child?
A Syndrome of hyaline membranes
B Diaphragmatic hernia
C Lung atelectases
D Intrauterine pneumonia
E Edematous-hemorrhagic syndrome
Question 15. Weight of the newborn is 2000 g. The term of gestation is 30 weeks. Three hours
after birth dyspnea, acrocyanosis are evident. Objectively: respirations - 80/min, expiratory rales,
heart rate - 186/min. Percussion sound is shortened, crepitation is auscultated. The doctor has
suspected the syndrome of respiratory disorders. What investigation will give us the most evidence
for confirmation of the diagnosis?
A Chest X-ray investigation
B Blood Analysis
C Biochemical investigation of blood serum
D Measurement of arterial pressure
E Electrocardiography
Question 16. The child was born at gestational age of 34 weeks in severe condition. Symptoms of
respiratory disorders were marked: the sonorous extended exhalation, participation of auxiliary
muscles in the breathing act, presence crepitous rales against rigid breath. An estimation by the
Silverman scale at a birth - 0 points, in 3 hours - 6 points with the presence of the clinical data.
What method of diagnostics will allow to establish the kind of pneumopathy at the child?
A Radiological investigation of chest
B Clinical analysis of blood
C Investigation of gas structure of blood
D Proteinogramme
E Immunological investigation
Question 17. The child was born from II preterm birth with body weight 1800 g with an estimation
by Apgar scale of 7 points, by s Silverman scale - 3 points. 2 hours after birth the condition of the
child has detiorated. The child began to groan, dispnea, perioral cyanosis and acrocyanosis
developed. The exhalation is complicated, sonorous. By percussion over lungs timpanous sounds,
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by auscultation - disseminated crepitation. Tachycardia. What is the most probable diagnosis?
A Syndrome of respiratory disorders
B Intrauterine pneumonia
C Aspiratsional pneumonia
D Perinatal CNS disorder
E Bronhopulmonary dysplasia
4. LITERATURE FOR STUDENTS
1. Nelson Textbook of Pediatrics. - 18th ed. / Ed. by R. Kliegman et al.-Philadelphia: Saunders Co,
2007.- 3146 p.
2. Pediatry. Guidance Aid / За ред. О.В. Тяжка; О.П. Вінницька, Т.І. Лутай – К. : Медицина,
2007 . – 158 с.
3. Current Pediatric Diagnosis & Treatment (CPDT). - 18th ed./ Ed. By W.W.Hay et al. - The
McGraw-Hill Companies. – 2006.
4. Current pediatric therapy -18th ed. / Ed. by F.D.Burg et al. - Elsevier Inc. – 2007.
5. Nelson Essentials of Pediatrics -5th ed. / Ed. by B.S.Siegel, J.J.Siegel. - Elsevier Inc. – 2007.
6. Examination of the Newborn. A Practical Guide / Ed. by Helen Baston and Heather Durward. the Taylor & Francis e-Library. - 2005.
7. Fetal and neonatal secrets. - second edition . / Ed. by R.A.Polin, A.R.Spitzer. - Elsevier.- 2006.
8. Key Topics in Neonatology / Ed. by R.H. Mupanemunda, M. Watkinson. - Oxford Washington
DC. -1999.
Performed by ass. Vaculenko L.I., ass. Tkachenko N.P.
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