Neonates
Mini-Me & More
Neonatalogy
•Newborn
–First few hours of life
•Neonate
–First 28 days of life
Morbidity/Mortality
•Complications increase as birth weight decreases.
•Resuscitation rate of those less than 1500 g is 80%
•Approximately 6% of field deliveries require life support.
Risk Factors
•Antepartum
–Multiple gestation
–Inadequate prenatal care
–Mother’s age <16 or >35
–History of perinatal morbidity or mortality
–Post-term gestation
–Drugs/ medications
–Toxemia, hypertension, diabetes
Risk Factors
•Intrapartum factors
–Premature labor
–Meconium-stained amniotic fluid
–Rupture of membranes greater than 24 hours prior to delivery
–Use of narcotics within four hours of delivery
–Abnormal presentation
–Prolonged labor or precipitous delivery
–Prolapsed cord
–Bleeding
Fetal Circulation
Respiratory Changes
•Fetus
–Lungs filled with fluid
–Arterioles and capillaries closed
–Ductus arteriosus
•Stimulation of first breath
–Mild acidosis
–Initiation of stretch reflex in the lung
–Hypoxia
–Hypothermia
Respiratory Changes
•Air displaces fluid
–Pulmonary arterioles and capillaries open
–Decreases vascular resistance
•Blood diverted from ductus arteriosus
•Ductus arteriosus eventually closes
–Persistent fetal circulation
Cardiovascular Changes
•Fetus
–Most of blood from placenta bypasses liver
•Ductus Venosus
– Most blood passes from right to left atria
•Foramen ovale
•Extrauterine Life
–Blood diverted from placenta
–Lungs expand
–Changes pressure levels in heart
Cardiovascular Changes
•Closure of Foramen Ovale
–Low right atrial pressure
–High left atrial pressure
–Blood flows backwards towards right side
–Valve closes
Cardiovascular Changes
•Closure of the Ductus Venosus
–Ductus venosus contracts
–Blood forced through liver sinuses
Congenital Anomalies
•Diaphragmatic hernia
•Meningomyelocele
•Exposed abdominal contents
•Choanal atresia
•Cleft lip/palate
•Pierre Robin Syndrome
Assessment of newborn
•Time of delivery
•Vital Signs
–Respirations
–Heart rate
–Systolic BP
–Temp
30-60
100-180
60-90 mmHg
36.7o - 37.8o C (98o - 100o F)
Assessment of the newborn
•Color
–Central vs peripheral cyanosis
–Mucosal membranes
•End organ perfusion
–Central pulses vs peripheral pulses
–Capillary refill
APGAR Scoring
APGAR
•One minute postpartum
•Five minutes postpartum
APGAR
•7 - 10
–Normal Infant
–Suction oropharnyx
–Keep warm
APGAR
•4 - 6
APGAR
•0 - 3
–Moderate asphyxia
–Suction oropharnyx
–Keep warm
–Oxygenate
–If 5 minute score < 7, repeat every 5 minutes for 20 minutes
–Asphyxia neonatorum
–Resuscitate aggressively
APGAR
•Scores can be misleading
–Do not work well with pre-term infants
–Primarily measure brainstem function
APGAR
•Do not wait 1 minute in obviously distressed infant
Treatment
•Prior to delivery, prepare environment and equipment
•During delivery, suction mouth, then nose as head delivers
•Note amniotic fluid color, thickness
Treatment
•Control Temperature
–All newborns have difficulty with cold
–Dry infant
–Wrap in warm, dry blanket
–Aluminum foil wrap
–Well - insulated warm water containers
–Do NOT use chemical hot packs
Treatment
•Position
–On back - slight Trendelenburg
–1-inch thick towel under shoulders
–Avoid neck under, overextension
–If secretions heavy, place on left side
Treatment
•Suction
–Bulb syringe
•Mouth first, then nose
•Neonates are obligate nasal breathers
•Monitor heart rate for bradycardia
–Meconium
Treatment
•Tactile Stimulation (optional)
–Flicking soles of feet
–Stroking back
Treatment
•Evaluate respirations
–Spontaneous
•Evaluate heart rate
–Absent or gasping
•Brief tactile stimulation (optional)
•PPV with 100% Oxygen
•15 - 30 seconds
–Primary Apnea vs. Secondary Apnea
Treatment
•Evaluate Heart Rate
–Above 100
•Evaluate Color
–Below 60
•Continue PPV with 100% Oxygen
•Initiate compressions
•Reevaluate after 30 seconds
•Initiate medications if below 80
Treatment
•Evaluate Heart Rate
–Between 60 - 100
•HR not increasing
–Continue PPV with 100% Oxygen
–Initiate compressions
–After 30 seconds reevaluate
–Initiate medications if below 80
•HR increasing
–Continue PPV with 100% Oxygen
Treatment
•Evaluate Color
–Central cyanosis
•Provide free flow oxygen
•When pink, gradually remove oxygen
•If no improvement consider PPV with 100% O2
–Acrocyanosis
•Observe, monitor
Meconium
•10 - 15% of deliveries
•Risk factors
–Fetal distress
–Post-term infants
•Complications
–Hypoxemia
–Aspiration pneumonia
–Pneumothorax
–Pulmonary hypertension
Meconium
•Management
–In depressed infant
•Do not stimulate
•Tracheal suction under direct visualization
–End Points
»Airway is clear
»Infant breathes on own
»Bradycardia
–Ventilate with 100% Oxygen
Diaphragmatic Hernia
•1 in 2200 live births
•Most commonly on left side (90%)
•Failure of the pleurperitoneal canal (Foramen of Bochdalek) to close
completely
•50% survival if mechanical ventilation required
•Near 100% survival if no respiratory distress
Diaphragmatic Hernia
•Assessment
–Little to severe distress present from birth
–Dyspnea and cyanosis unresponsive to ventilation and
oxygenation
–Scaphoid abdomen
–Bowel sounds in thorax
–Heart sounds displaced to the right
Diaphragmatic Hernia
•Management
–Elevate head, chest
–Intubation PRN
–Do NOT use BVM
–Orogastric tube (low, intermittent suction)
–Requires surgical repair
Congenital Heart Defects – Etiology
•Environmental factors
–Maternal alcoholism
–Maternal age > 40 years
–Maternal insulin dependent diabetes
•Genetic factors
–Chromosomal
–Trisomy 21, 18
•Trisomy 21 - Down’s
•Trisomy 18 - Edwards’s Syndrome
–Rh incompatibility
Congenital Heart Defects – Incidence
•8 of every 1000 infants born in the U.S.
•40,000 defects per year in the U.S.
Ventricular Septal
Defect (VSD)
Atrial Septal
Defect (ASD)
Patent Ductus
Arteriosus (PDA)
Coarctation of the
Aorta (COA)
Tetrology of Fallot
12%
(TOF)
Transposition of
12% the Great Arteries
(TGA)
25%
12%
9%
9%
Pulmonary
Stenosis (PS)
Aortic Stenosis
(AS)
Others
6-9%
8%
4-7%
Acyanotic Heart Disease
•Left to Right shunts
–Oxygenated blood remains in the left heart related to high left
heart pressure
–Decreased O2 delivery
–Pulmonary edema
–Results in ventricular hypertrophy and eventually cardiogenic
shock
Cyanotic Heart Disease
•Right to Left shunts
–Mixing of right and left heart blood
•Intracardiac (ASD, VSD)
•Extracardiac (PDA)
•A greater pressure gradient on the right side of the heart
causing a shunt to the left side
–Low O2 saturations (75–85%)
Acyanotic CHD Overview
•Patent ductus arteriosis
•Atrial septal defect
•Ventricular septal defect
•Coarctation of the aorta
•Aortic stenosis
•Pulmonary stenosis
Patent Ductus Arteriosus
•Etiology
–Congenital rubella syndrome is seen in 60–70% of PDAs.
–Up to 60% of the cases are in pre-term infants if less than 1500
grams.
•Incidence
–~12% of all CHD
•More common in females
Patent Ductus Arteriosus
Atrial Septal Defect
•Incidence
–Approximately 12% of all CHD
–More common in females
Atrial Septal Defect
Ventricular Septal Defect
•Incidence
–Approximately 25% of all CHD
•Most common of all CHD
–Often associated with other defects
–More frequent in males
Ventricular Septal Defect
Coarctation of the Aorta
•Incidence
–Approximately 12% of all CHD
• Many will have VSD
• More common in males
Coarctation of the Aorta
Aortic and Pulmonary Stenosis
•Incidence
–Aortic stenosis approximately 8% of all CHD
–Pulmonary stenosis approximately 6–9% of all CHD
–More common in males
Aortic and Pulmonary Stenosis
Cyanotic CHD Overview
•Tetralogy of Fallot
•Transposition of the great arteries
Tetralogy of Fallot
•Incidence
–~9% of all CHD
•4 Anomalies
–Ventricular septal defect
–Pulmonary stenosis
–Overriding aorta
–RVH
•Shunt
–Right to Left
–Left to Right
•Assessment
–Cyanosis after several months
–“TET” spells
•Sudden increase in cyanosis
•Irritability
•Tachypnea
–Hypercyanotic spells
–CHF and low CO
–Arrhythmias
Tetralogy of Fallot
Transposition of the Great Arteries
•Incidence
–~9% of all CHD
–More common in males
Transposition of the Great Arteries
Management of Congenital Heart Defects
•Acyanotic defects
–Oxygenate.
–Provide judicious fluid administration.
–Consult medical direction early and as needed.
•Cyanotic defects
–Oxygenate to a target pulse oximeter reading.
–Provide judicious fluid administration
–Consult medical direction early and as needed.
Bradycardia
•Possible causes
–Hypoxia
–Increased intracranial pressure
–Hypothyroidism
–Acidosis
•Minimal risk if corrected quickly
Bradycardia
•Assessment
–Upper airway for obstruction
•Foreign object
•Secretions
•Tongue/soft tissue
–Hypoventilations
Bradycardia
•Management
–Position
–Suction
–Heart rate less than 100
•BVM with 100% O2 and reassess
–Heart rate less than 60
•Chest compressions with PPV 100% O2 and reassess
–Heart rate 60 - 80 but not improving
•Chest compressions with PPV 100% O2 and reassess
–Maintain Temperature
Bradycardia
•Discontinue chest compressions when HR > 100
•Pharmacological
–Use as last resort
–Epinepherine
Premature Infants
•Born prior to 37 weeks gestation
•Weigh less than 2.2 kg (4 lb., 13 oz.)
•Healthy infants weighing < 1700 g (3 lb., 12 oz.) have good prognosis
•Fetal viability considered 23 -24 weeks gestation
Premature Infants
•Complications from
–Respiratory suppression
–Head/brain injury
–Hypothermia
–Change in blood pressure
–Hypoxemia
–Intraventricular hemorrhage
–Fluctuations in serum osmolarity
Premature Infants
•Assessment
–Large trunk
–Short extremities
–Transparent skin
–Less wrinkles
–Less subcutaneous fat
Premature Infants
•Management
–Same as with full term newborn
•Transport
–Appropriate facility
Respiratory Distress/Cyanosis
•Prematurity is most common factor
–Most frequently in infants less than
•1200 grams (2 lb., 10 0z.)
•30 weeks gestation
•Multiple gestations
•Prenatal maternal complications
Respiratory Distress/Cyanosis
•Immature central respiratory control center
•Easily affected by environmental or metabolic changes
•Lung or heart disease
•Aspiration
•Shock
•Sepsis
•Infection
•Diaphragmatic hernia
•CNS disorders
•Airway Obstruction
Respiratory Distress/Cyanosis
•Assessment findings
–Tachypnea
–Paradoxical breathing
–Periodic breathing
–Intercostal retractions
–Nasal flaring
–Expiratory grunt
Respiratory Distress/Cyanosis
•Management
–Airway/Breathing
•Position
•Suction
•High concentration oxygen
•PPV/Intubation PRN
–Circulation
•Compression PRN
–Maintain warmth
Seizures
•Rare in newborns
•Indicate serious underlying medical abnormality
•Prolonged, frequent seizures may result in metabolic, cardiopulmonary
difficulties
Seizures
•Tonic/clonic seizures typically do not occur in first month of life
•Subtle seizures
–Eye deviation, blinking, sucking, swimming movements, apnea,
changes in color
•Tonic seizures
–Posturing of extremities, trunk
–More common in premature infants
–Intraventricular hemorrhage
Seizures
•Focal clonic seizures
–Rhythmic twitching of muscle group
–Can migrate to other areas
•Multifocal seizures
–Multiple muscle groups involved
–Can migrate to other areas
•Myoclonic seizures
–Generalized jerks of extremities
–May occur singly or repetitively
Seizures
•Causes
–Hypoglycemia
–Sepsis
–Fever
–Infection
–Developmental abnormalities
–Drug withdrawal
Seizures
•Assessment
–Decreased level of consciousness
–Seizure activity
•Management
–ABC’s
–High concentration Oxygen
–Benzodiazepines
–Dextrose (D10W or D25W)
–Maintain Warmth
–Rapid Transport
Fever
•> 100.4o F (average temp 99.5o F)
•Life-threatening condition
•Limited ability to control temperature
•Increased use of glucose may lead to anaerobic metabolism
Fever
•Assessment
–Irritability
–Somnolence
–Decreased intake
–Rashes, petechia
–Sweat
•On brow only of term newborns
•Not present on premature newborns
Fever
•Management
–Assure adequate oxygenation, ventilation
–Avoid rapid cooling
–Avoid cold packs
–Avoid antipyretic agents
Hypothermia
•Infants cannot tolerate temperatures comfortable to adults
Hypothermia
•Below 35o C (95o F)
•Increased surface to volume ratio
•Can be an indicator of sepsis
•Can lead to:
–metabolic acidosis
–pulmonary hypertension
–hypoxemia
Hypothermia
•Assessment
–Acrocyanosis
–Irritability (early)
–Lethargy (late)
–Pale, cool to touch
–Respiratory distress/Apnea
–Bradycardia
–NEWBORNS DO NOT SHIVER
Hypothermia
•Management
–Assure adequate oxygenation and ventilation
–Chest compressions if indicated
–Warm infant
•Ambient temperature
•Cover infant
•Warm IV Fluids
Hypoglycemia
•Less than 45 mg/dL
•Causes
–Do not have to have diabetes mellitus
–Inadequate glucose stores
–Inadequate intake
–Increased glucose utilization
–Stress
Hypoglycemia
•Assessment
–Twitching/Seizures
–Limpness
–Lethargy
–Eye rolling
–High pitched cry
–Apnea
–Irregular respirations
Hypoglycemia
•ALL SICK INFANTS REQUIRE BLOOD GLUCOSE ASSESSMENT
Hypoglycemia
•Management
–Assure adequate oxygenation, ventilation
–IV/IO TKO
–ECG
–Dextrose (D10W or D25W)
–Maintain warmth
Vomiting
•Rare during first weeks of life
•May be confused with regurgitation
•Life threatening if contains blood
•Symptom of underlying problem
–Upper digestive tract obstruction
–Increased intracranial hemorrhage
–Infection
•May lead to dehydration, electrolyte imbalance
Vomiting
•Assessment
–Distended stomach
–Infection
–Increased ICP
–Drug withdrawal
Vomiting
•Management
–Maintain a patent airway
–Assure adequate oxygenation
–Vagal stimulation may cause bradycardia
–IV NS TKO (if concerned about dehydration)
Diarrhea
•5 - 6 stools pre day normal
•Can lead to
–Dehydration
–Electrolyte imbalance
Diarrhea
•Causes
–Bacterial or viral infection
–Gastroenteritis
–Phototherapy
–Thyrotoxicosis
–Cystic fibrosis
Diarrhea
•Assessment
–Loose stools
–Decreased urinary output
–Listlessness
–Prolonged capillary refill
–Number of diapers per day
Diarrhea
•Management
–Assure adequate oxygenation
–Maintain temperature
–IV NS TKO (if concerned with dehydration)
Birth Injuries
•Avoidable and unavoidable trauma during labor and delivery
•Occur in 2 to 7 of every 1,000 live births
•5 to 8 of every 100,000 die of birth trauma
•25 of every 100,000 die of anoxic injuries
•2 - 3 % of infant deaths
Birth Injuries
•Cranial Injuries
–Molding of head, overriding of parietal bones
–Skull fracture
–Subperiosteal hemorrhage
–Subconjunctival and retinal hemorrhage
–Erythema, abrasions, ecchymosis, and subcutaneous fat necrosis
Birth Injuries
•Intracranial Hemorrhage
–Trauma
–Asphyxia
•Spinal Cord Damage
–Traction when spine is hyperextended
–Lateral pull
Birth Injuries
•Peripheral nerve injury
•Liver or spleen rupture
•Fracture
–Clavicle
–Extremities
•Hypoxia – ischemia
Birth Injuries
•Assessment
–Edema, ecchymosis to soft tissue
–Paralysis below level of spinal cord injury
–Paralysis of upper arm with or without paralysis of forearm
–Hypoxia
–Shock
Birth Injuries
•Management
–Assure adequate oxygenation ventilation
–Chest compressions as needed
–Pharmacology as needed
–Maintain warmth
Cardiac Arrest
•Primarily related to hypoxia
•Outcome is poor if interventions not initiated quickly
Cardiac Arrest
•Risk factors
–Intrauterine asphyxia
–Prematurity
–Drugs administered or taken by mother
–Congenital neuromuscular diseases
–Congenital malformations
–Intrapartum hypoxemia
Cardiac Arrest
•Causes
–Primary apnea
–Secondary apnea
–Bradycardia
–Pulmonary hypertension
–Persistent fetal circulation
Cardiac Arrest
•Central cyanosis
•Inadequate respiratory effort
•Ineffective or absent heart rate
Inverted Pyramid of Resuscitation
Drying, Warming, Positioning,
Suction, Tactile Stimulation
Oxygen
BVM Ventilations
Chest
Compressions
Intubation
Meds
Cardiac Arrest
•Management
–Dry
–Warm
–Position
–Suction
–Evaluate Respiration
–Evaluate Heart Rate
–
Most depressed infants will respond to warming, positioning, suction,
stimulation
Oxygenation
•If pale or cyanotic, O2 until pink
Oxygenation
•Mask tent over head with sheet or hold mask near face; flow at 4 - 5 LPM
•Avoid blowing O2 directly onto face; can produce bradycardia
•O2 toxicity NOT a concern
Ventilation
•Indications
–Apnea
–Heart rate < 100
–Persistent central cyanosis on 100% 0 2
•Infant BVM
•NOT adult equipment
Ventilation
•Judge by chest expansion
–Tidal volume is 7cc/kg
–Ventilation rate is 40 - 60/minute
Chest Compressions
•If heart rate <60
•1/2 to 1 inch at 120/minute
•3:1 ratio
Endotracheal Intubation
•If ventilations, chest compressions ineffective
•Especially important if < 28 weeks gestation
•Place gastric tube if ventilated under mask for extended time
Medication
•Epinephrine
•Fluid
•Sodium Bicarbonate
•Glucose
Epinephrine
•For asystole, bradycardia (rate <60)
–0.01 mg/kg every 5 minutes
–1:10,000 in a 1 cc syringe
•May be given down ET tube 0.03mg/kg
Volume Expansion
•Consider if:
–Pallor continues after oxygenation
–Pulses weak after oxygenation
–Response to resuscitation poor
–History of hemorrhage from maternal/fetal unit
•10cc/kg LR or NS over 5 - 10 minutes
Sodium Bicarbonate
•Rarely given
–Only if known or suspected metabolic acidosis
•Must be adequately ventilated first
•2 mEq / kg
–Prepared in 4.2% solution (half strength)
–4 mL/kg
–Given over 2 minutes
Hypoglycemia Symptoms
•Jitters
•Lethargy
•Apnea
•Color changes
•Respiratory distress
•Seizures
Hypoglycemia Symptoms
•Hypoglycemia may mimic hypoxemia
•Some hypoglycemic infants are asymptomatic
•Consider blood glucose test 20 - 30 minutes postpartum
Hypoglycemia Management
•Blood glucose < 40 mg%
–4 cc/kg D10W
–Do not use D50W
Neonatal Resuscitation
•Most respond to simple measures
•Stepwise resuscitation, frequent reassessment
•Heart rate guides resuscitation
Neonatal Transport
•Best transport device = Mom’s uterus
•Second best = Specialized team
Neonatal Transport
•Assessment
–Vital signs
•Axillary temperature (96.5 - 990F)
•Pulse (120 - 160/minute)
•Respirations (30 - 60/minute)
–APGAR scores
Neonatal Transport
•Cardiovascular Stabilization
–Keep airway clear (obligate nasal breathers)
–Maintain body temperature
–Humidified oxygen
Neonatal Transport
•Cardiovascular Stabilization
–Assist ventilation if cyanosis / pallor / respiratory distress present
–Vascular access D10W 4cc/kg/hr
–Nasogastric intubation
Neonatal Transport
•Documentation
–Copies of infant’s/mother’s charts
–Names of infant, parent’s referring physician, parent’s telephone
number
–Any X-rays
–Maternal/umbilical cord blood samples
–Consent forms
Tocolytic Therapy
•Indications for tocolysis
–20 - 36 weeks gestation
–Preterm labor
–Healthy fetus
–Dilated 4cm or less/membranes intact
Tocolytic Therapy
•Left side position, supplemental O2, IV fluids (1 liter LR)
–Improves uterine oxygenation
–Inhibits oxytocin release from posterior pituitary
Tocolytic Therapy
•2 Adrenergic agents
–Cause uterine smooth muscle relation
–Ritodrine (Yutopar)
–Terbutaline
Tocolytic Therapy
•Magnesium Sulfate
–Competes with calcium at cellular level
–Blocks actin/myosin interaction/inhibits contraction