Common Problems In Neonates
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Common Problems In
Neonates
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Neonates
• Neonatal period is defned as the period rombirth until 28 days o lie
•
Term: Babies born alive within 3 !ompletedwee"s to #2 !ompleted wee"s$
• Preterm is defned as babies born alive beore 3
wee"s o pre%nan!y are !ompleted$ – e&tremely preterm '(28 wee"s) – very preterm '28 to (32 wee"s) – moderate to late preterm '32 to (3 wee"s)$
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Content
Common in all neonates:• *ei%ht and +rowth• ,aundi!e• Cerebral In-ury• .epsis• Con%enital Ine!tions
/ore !ommon in premature neonates:• 0espiratory 1istress .yndrome• Intraventri!ular emorrha%e• Ne!rotiin% 4ntero!olitis
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,aundi!ePhysiolo%i!al ,aundi!e
Breast /il" ,aundi!e
5B6 in!ompaitibility0h in!ompatibility
+7P 1ef!ien!y
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1efnition
• yperbilirubinemia : .erum bilirubin 9mol; in neonates$
• ,aundi!e is the yellowishdis!olouration o the s"in< mu!ousmembrane and s!lera due todeposition o bilirubin$
• Babies be!ome !lini!ally -aundi!ewhen serum bilirubin levels rea!h 8=>
?2@ 9mol;?m% bilirubin A ?
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Bilirubin /etabolism
• 'Indire!t) Unconjugatedbilirubin is lipid soluble andbinds to albumin in the blood$
• I albumin bindin% sites areull< bilirubin !an be displa!ed$
ree un!on-u%ated bilirubin!an !ross blood brain barrier
• n!on-u%ated bilirubin is!onverted to bilirubindi%lu!uronide '!on-u%ated) inthe liver by %lu!uronyltranserase$
• Con-u%ated bilirubin is watersoluble and !an be e&!retedinto the urine
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Classif!ation and !auses
• Con-u%ated vs n!on-u%ated• Pre>hepati!< intrahepati!< post
hepati!
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Clini!ally
Onset <24 hours(pathological)
Onset >24 hours to 2 weeks Prolon ged Duration over 2weeks
eamolysis :• 0hesus In!ompaitibility•5B6 in!ompatibility•+7P def!ien!y•.phero!ytosis•Pyruvate Dinase•1ru%s• Poly!ythemia
Physiolo%i!al -aundi!e .ur%i!al:• Biliary 5tresia• Choledo!al Cyst
Con%enital Ine!tions:• C/E• T60C4.
Breast /il" ,aundi!e Neonatal hepatitis
Ine!tions:• TI•.epsis• /enin%itis
.ur%i!al:• Biliary atresia•Choledo!al !yst
emolysis Inborn error o metabolism
4nyme def!ien!y• Cri%%ler na--ar•+ilbert syndome
ypothyroidism
.ur%i!al
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one
!aundiice "sti#ated$%&
? ead 5nd ne!" 78 F ?3=
2 pper trun" 8= F 2@#
3 ;ower trun" andthi%hs
?37 F 22
# 5rms and below"nee
?8 F 3@7
= ands< eet 3@7
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Physiolo%i!al ,aundi!e'ncreased& #ass .horter 0BC
liespan Immaturity o
%lu!uronyltranserase
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Physiolo%i!al ,aundi!e
• 1ia%nosis o e&!lusion on!e all other!auses have been ruled out
• owever< it is the most !ommon!ause o -aundi!e in neonates
• 4pidemiolo%y: 6!!urs in 7@G oneonates
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Breast /il" ,aundi!e
Possibly due to : – /il" !ontainin% inhibitor o bilirubin !on-u%ation – Breast mil" %lu!uronidase in!reases enterohepati!
re!ir!ulation
• Interruption o o breast eedin% or ?>2 days<may !ause de!line in bilirubin levels< whi!h doesnot in!rease si%nif!antly ater breasteedin%resumes
• /ana%ement: – !ontinue breasteedin% despite this be!ause bilriubin
levels rarely rea!hes more than 3@@ 9mol; '2@m%d;)
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Patholo%i!al ,aundi!e:5B6 In!ompatibility
*e#ol+tic disease o,the newborn
• 6!!urs when: –
/other: Blood %roup 6'sensitied to anti%en 5 or B)
– Baby: Blood %roup 5 or B
• I%+ !ross pla!enta bya!tive transport
•
Be!omes less severe withea!h pre%nan!y – Probably due to anti>5 or
anti>B bindin% to nonerythro!yti! !ells that!ontain 5 or B anti%en
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0h in!ompaitibility
"r+throblastosis-etalis• 0h Hve '1) anti%ens o the etus
sensities the 0h >ve 'd) mother• 0esults in I%+ antibody
produ!tion• 1ete!ted by Coombs test• ?st baby: /ay maniest anemia
and hyperbilirubinemia• *orsens whith subseuent
pre%nan!ies
• etal ydrops F 5s!ites<pleuralperi!ardial eJusion<anasar!a$ In!reased ris" o etaldeath is hi%h
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Preventin% 0h sensitiation
• +ive 0h> mother anti h. i##uneglobulin (ho/01)
• 1one at: – 28 wee"s %estational a%e – *ithin 2 hours ater birth
• ow it wor"s: – Binds to to all possible etal 0hH erythro!ytes
enterin% maternal !ir!ulation – Interers with maternal anti 0hH antibody
produ!tion 'un"nown me!hanism)
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+7P 1ef!ien!y
• Common hetero%enous K lin"edre!essive trait
• .!reenin% by !ord blood•
/ana%ement: 5voidan!e o
/lutathion #aintainsintegrit+ o, & andprevents oidant
injur+ to &
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Prolon%ed ,aundi!eUnconjugated*+perbilirubine#ia
• .epsis• emolysis• ypothyroidism
onjugated*+perbilirubine#ia
• .ur%i!al !ause – Biliary atresia –
Choledo!al !yst• Neonatal epatitis• Con%enital Ine!tions
'C/E< T60C4.)
• /etaboli! disorders – L> ? antitrypsin
def!ien!y – %las!tosemia
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Clini!al /aniestation o Derni!terus
• 4arly: – ;ethar%y< ypotonia< irritability< poor /orro
reMe&< poor eedin%
•
;ate: – Bul%in% ontanelle< opisthotoni! posture<
hypertoni!ity< paralysis o upward %ae< seiures
• Compli!ations: – Nerve deaness< !horeoathetoid !erebral palsy<
mental retardation< dis!olouration o teeth<enamel dysplasia
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Derni!terus
• Bilirubin is to&i! to developin% !entralnervous system$ 1isrupts neuronalmetabolism and un!tion< espe!ially
in basal %an%lia• 0emember 'Indire!t)
Unconjugated bilirubin is lipid
soluble and !an !ross blood brainbarrier
• n!on-u%ated bilirubin levels e&!eed
bindin% !apa!ity o albumin and
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Treatment o un!on-u%ated hyperbilirubinemia :Phototherapy
nder E li%ht '#2=>#=mm wavelen%th)<photo!hemi!al rea!tion o!!urs< un!on-u%atedbilirubin transormed into water soluble iso#ers<b+pass hepatic conjugation< and is easily
e&!reted
• Term: *hen T.B is =@ umoll below levels orintensive phototherapy
• Preterm: 5t lower levels based on a%e oprematurity – *hy To prevent hi%h levels o bilirubin that may reuire
e&!han%e transusion
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rea men o n!on u%a e
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rea men o n!on u%a eyperbilirubinemia: 4&!han%e
Transusion• Indi!ations:
– Total bilirubin 3@@ umol; – 4arly onset ,aundi!e 'frst 2# hours) –
0apidly risin% -aundi!e 'more than 8$=umol;hr)• Perormed throu%h umbili!al venous
!atheter enterin% inerior vena !ava< or!onMuen!e o umbili!al vein and portal vein$
• 5mount o blood transused: double bloodvolume$
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Compli!ations o treatment
• Phototherapy: – Insensible water loss – 1airrhoea –
1ehydration – /a!ulopapular rash – Potential or retinal dama%e
• 4&!han%e Therapy: – Blood related F transusion rea!tion – Catheter F vessel peroration – Pro!edure F hypotension< N4C
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Cerebral In-ury
-
ypo&i! Is!hemi!4n!ephalopaty-Intraventri!ular hemorrha%e
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ypo&i! Is!hemi! 4n!ephalopathy'I4)
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Pathophysiolo%ytero>pla!entalblood Mow
Perinatal hypo&ia
5naerobi!
o&idation
Eas!ularendothelial
4dema
Intereren!e ospontaneousrespiration
Cerebral Is!hemia;a!ti! 5!idosis
Tissue in-ury
0edu!ed!ardia!output
Term inant :•Cerebral 4dema•!orti!al ne!rosis•basal %an%lia involvement
Preterm inant:•Periventri!ular leu"omala!ia
eper,usion3
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Clini!al /aniestation andsta%in%
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Pro%nosis
• Cerebral insult: – Corti!al 5trophy
– /ental 0etardation
–
.pasti! diuadriple%ia
• Based on 5p%ar .!ore• 5p%ar @>3
– ?@ mins : /oratlity '2@G)< !erebral palsy '=G)
– 2@ mins : /ortality '7@G)< cerebral pals+(56)
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/ana%ement
• .upportive mana%ement – Initial 0esus!itation and stabiliation
– Eentilation support – Perusion and blood pressure mana%ement – luid and ele!trolyte mana%ement – 5void hyperthermia –
ypothermia therapyO – Treat seiures
– Consultation to !are ta"ers$
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Neonatal .epsis
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4pidemiolo%y
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1efnition:
• 5 disease o inants who are less than a monthold and are !lini!ally ill with positive !ultures$
•
4arly onset : a!uired beore or durin% delivery
• ;ate onset : a!uired ater delivery in the!ommunity or the nursery
• Noso!omial sepsis : o!!urs ater 2 hours ohospital stay
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i k f f d
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Risk Factors of Infants andMother
5ny sta%e
Prematurity< low birth wei%ht$
/ale %ender$
Neutropenia due to other !auses$
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4arly 6nset .epsis
• /aternal +B. 'Group B Streptococcus) !arrier 'hi%h va%inalswab QE.R<
urine !ulture< previous pre%nan!y o baby with +B. sepsis)$• Prolon%ed rupture o membranes 'P06/) '?8 hours)$•
Preterm labourPP06/$• /aternal pyre&ia 38S C< maternal peripartum ine!tion<
!lini!al
!horioamnionitis< dis!oloured or oul>smellin% liuor<maternal urinary tra!t ine!tion$
• .epti! or traumati! delivery< etal hypo&ia$• Inant with %ala!tosaemia 'in!reased sus!eptibility to E.
coli)$
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;ate 6nset .epsis
ospital a!uired 'noso!omial) sepsis$
> 6ver!rowded nursery$
> Poor hand hy%iene$
> Central lines< peripheral venous !atheters< umbili!al
!atheters$> /e!hani!al ventilation$
> 5sso!iation with indometha!in or !losure o P15< IElipid administration with !oa%ulase>ne%ativeStaphylococcal 'CoN.) ba!teriemia$• Coloniation o patients by !ertain or%anisms$• Ine!tion rom amily members or !onta!ts$• Cultural pra!ti!es< housin% and so!ioe!onomi! status$
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Presentation o disease
• +eneral F temperature instability (37! or 3!in thermoneutral environment< poor eedin%
• 0espi F apnoea< ta!hypnoea< %runtin%< !yanosis<in!reasin% 62 reuirement
• CE. F ta!hy!ardia< poor perusion< hypotension• +I F vomitin%< abdominal distension< diarrhoea<
hepatome%aly< splenome%aly< -aundi!e•
CN. F lethar%y< irritability< seiures< bul%in%ontanelle< hypotoni!
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• /etaboli! F hyper%ly!aemia< hypo%ly!aemia<metaboli! a!idosis
• ."in F pustules< !ellulitis< omphalitis< pete!hiae<
thrombophleblitis• 4ye F eye dis!har%e• /us!ulos"eletal F septi! arthritis< osteomyelitis<
pseudoparesisU
• 6ther systemi! illness: PPN< N4C< intestinalperoration< I4/
• 0is" o ine!tion: Transient parenteral nutrient< !entralvenous line
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Investi%ation
• 4viden!e o inMammation – ;eu"o!ytosis 2@&?@VW; or leu"openia (=&?@VW; – C>rea!tive protein 'raised in 2 samples 2# hours apart) – 1IEC< CK0
• 4viden!e o ine!tion – Positive !ulture rom normally sterile site 'blood< C.< urine)
• 4viden!e o multior%an ailure – /etaboli! a!idosis – Impaired pulmonary un!tion 'hyper!arbiaXhypo&ia) – Impaired renal un!tion 'raised urea and !reatinine) – ;iver dysun!tion 'raised liver enymes< prolon%ed PT) – Bone marrow suppression 'pan!ytopenia)
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/ana%ement
4mpiri!al antibioti!s
.tart immediately when dia%nosis issuspe!ted and ater all appropriatespe!imens ta"en$ 1o not wait or!ulture results$
Tra!e !ulture results ater #8 > 2
hours$ 5d-ust antibioti!s a!!ordin% toresults$ .top antibioti!s i !ultures aresterile< ine!tion is !lini!ally unli"ely$
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4mpiri!al antibioti! treatment (Early Onset)
• IE C$Peni!illin5mpi!illin and +entami!in• .pe!if! !hoi!e when spe!if! or%anisms
suspe!ted!onfrmed$
• Chan%e antibioti!s a!!ordin% to !ulture and sensitivityresult
4mpiri!al antibioti! treatment F (Late Onset)
•
or !ommunity a!uired ine!tion< start on> Clo&a!illin5mpi!illin and +entami!in or non>CN.ine!tion< and
> C$Peni!illin and Ceota&ime or CN. ine!tion
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or hospital a!uired 'noso!omial) sepsis> Choi!e depends on prevalent or%anisms in the
nursery and its sensitivity$
> or nursery where /0CoN. /0.5 are !ommon<
!onsider Ean!omy!inY or non>4.B; %ram ne%ativerods< !onsider !ephalosporinY or 4.B;s !onsider!arbapenamsY or seudo!onas !onsider Cetaidime$
> 5naerobi! ine!tions 'e$%$ Intraabdominal sepsis)<!onsider /etronidaole$
> Consider un%al sepsis i patient not respondin% toantibioti!s espe!ially i preterm E;B* or withindwellin% lon% lines$
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1uration o 5ntibioti!s
>?@ days or pneumonia or provenneonatal sepsis
?# days or +B. menin%itis
5t least 2? days or +ram>ne%ativemenin%itis
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Consider removin% !entral lines Compli!ations and .upportive Therapy
0espiratory: ensure adeuate o&y%enation '%ive o&y%en<ventilator support)
Cardiovas!ular: support BP and perusion to prevent sho!"$
ematolo%i!al: monitor or 1IEC
CN.: seiure !ontrol and monitor or .I51
/etaboli!: loo" or hypohyper%ly!aemia< ele!trolyte< a!id>base disorder
Therapy with IE immune %lobulin had no eJe!t on the out!omeso
suspe!ted or proven neonatal sepsis$
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Prematurity
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Classif!ation
&+ Date
• /oderate to ;ate
Preterm A 32>(3*6+
• Eery Preterm A 28>(32 *6+
• 4&treme Preterm A(28 *6+
&+ 7eight
• ;B* A (2$="%• E;B* A (?$="%• 4;B* A (?"%
-acts ,ro# 7*O•4very year< an estimated ?= million babies are born preterm$•Preterm birth !ompli!ations are the leadin% !ause o deathamon% !hildren under = years o a%e< responsible or nearly ?million deaths in 2@?3$
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Problems in Prematurity
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$e#perature egulation• .us!eptible or hypothermia
– ;ar%e sura!e area to body wei%ht ratio – ;ess sub!utaneous at< brown at and %ly!o%en – Inability to shiver
• Compli!ation – /etaboli! a!idosis dt peripheral vaso!onstri!tion X anaerobi!
metabolism – ypo%ly!emia dt depletion o %ly!o%en stora%e – ypo&aemia – In!reased !alories reuirement – 5pnea – .ho!" with redu!ed !ardia! output – Pulmonary hemorrha%e
• /ana%ement >>> In!ubator 's"in temperature set at 37$=SC)
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espirator+
espirator+ Distress %+ndro#e (D%)• dt absen!e or def!ient o sura!tant• ;un% .ura!tant 'le!ithin)
– /ade by type 2 Pneumo!ytes based on etal ree !ortisol levelby 3#>37 wee"s +5 suZ!iently
– ;owers the sura!e tension at low lun% volumes to preventatele!tasis
• 5s a result< neonates lun%s are non>!ompliantstiJ<!ollapsedinadeuate ventilation < whi!h leads to hypo&ia< a!idosis
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• /aniestations o 01. – Cyanosis – Ta!hpnoea –
Nasal Marin% – Chest 0e!essions – +runtin% Y !losure o %lottis durin% inspiration to
maintain lun% E< preventin% atele!tasis – 0espiratory distress rom 7hrs o lie< worsens over 2>
3days and improves over ?>2 wee"s• Predisposin% a!tors:
– Prematurity – ypo&ia< a!idosis< sho!"< asphy&ia< hypothermia
•
CK0:?$ ine reti!ular %round %lass appearan!e
2$5ir bron!ho%rams
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http:emedi!ine$meds!ape$!omarti!le#@W#@W>overview
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• Treatment: – .ura!tant repla!ement admin via 4TT – Eentilatory support as needed – /inimal handlin%
• Compli!ations: – Pneumothora& 'ventilation o stiJ lun%s) – Bron!hopulmonary dysplasia –
IE – P15
• Prevention : /aternal steroids i planneed to deliver early
0
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0pnea 1efnition :>
.top breathin% or ?= se!onds
0 (8@min .P62 (8@G
Causes ypo%ly!emia luid X ele!trolyte imbalan!e Temperature Mu!tuation .epsis 5naemia Brain lesion
/& >>> monitor< theophylline X CP5P
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ardiovascularPatent Ductus 0rteriosus (PD0)
1ia%nosis :> Clini!al : !ontinuossystoli! murmur in let 2IC.< wide pulse
pressure 2=mm%< in!rease prae!ordial a!tivity< in!reaseventilatory reuirement
CK0 : !ardiome%aly< pulmonary venous !on%estion
Confrmatory : 21 1oppler 4!ho
Compli!ation :> CC IE Pulmonary hemorrha%e
0enal impairment N4C Chroni! lun% disease
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/ana%ement :> 1edical
luid restri!tion< avoid dehydration IEoral Indometha!in or Ibuproen CI in :> untreated ine!tion< bleedin% '+I or !ranial)< Platelet
(7@< N4C< du!t dependent C1< impaired renal un!tion ' !r?#@< urea ?#)
%urgical
Primary trans!atheter ballon an%ioplasty .tent .ur%ery
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*e#atolog+
0ne#ia o, Pre#aturit+ Causes :>
Phlebotomy 'small total blood volume) 0apid rate o %rowth
Prolon%ed !essation o erythropoietin release until C+5 3#>37 *6+
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*+perbilirubinae#ia
Preterm more prone to %et bilirubinen!ephalopathy
?$ ;ow albunin
2$ ypo&ia
3$ 5!idosis#$ 1ru%s
Total Bilirubin 'mi!romol;)
Birth *ei%ht '%) Phototherapy 4T
(?=@@ 8=>?#@ 22@>2=?=@@>?WWW ?#@>2@@ 2=>3@@
2@@@>2#WW ?W@>2#@ 3@@>3#@
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/astrointestinal
8ecroti9ing "nterocolitis (8") 5!ute bowel ne!rosis< ass with prematurity andor bowel
is!hemia =>?@G in E;B*< with #@G mortality
Breast mil" >>> prote!tive 0is" a!tor
5PProlon%ed rupture o membrane 37Co!aine abusin% mother
I+0Cyanoti! heart diseasePoly!ythemia Twin
1ia%nosis :>
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1ia%nosis : 5bdominal ss
?$ 1istention H Tenderness
2$ Eomit
3$ Bloody stool#$ 5bdominal wall erythemainduration
.ystemi! ss?$ 0espiratory distress
2$ 5pnea3$ Brady!ardia
#$ Temperature instability
=$ Poor eedin%
7$ ypotension
$ 5!idosis
0adiolo%y indin%s:>
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0adiolo%y indin%s: .uspi!ious : thi!"en bowel wall< as!ites< f&ed>position loops 1efnitive : intramural %as 'pneumatosis intestinalis)< portal
or hepati! vein %as< pneumoperitoneum
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/ana%ement:> .epti! wor" up NP6
Broad .pe!trum antibioti! >>> ampi!ilin and %entami!in TPN .ur%ery
.ta%in% Treatment
': %uspected
>mild si%ns >no blood in stool > 5K0 normalmild ileus
•NP6•5ntibioti! K3
'': De;nite >abdominal erythema
>intramural %as H> portal %as
•NP6•5ntibioti! K >?@
''': 0dvanced >!ompli!ated by a!idosis<sho!"< 1IEC< peritonitis >intramural %as with portal %asH> peroration
•NP6•5ntibioti! K 2=2•Eentilation•luid•Inotropes•.ur%ery
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8eurolog+
'ntraventricular *e#orrhage ('*) Bleedin% into the subependymal %erminal matri& o
brain 'hi%hly vas!ular) 0is" a!tor :>
ypertension ypotension ypovolaemia 0apid volume e&pansion : !olloid inusion< 4T ypo&ia< yper!arbia
5!idosis< anaemia
Clini!al presentation :>
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C !a p ese a o 6ver minute to hour
.tupor Coma
0espiratory abnormalities .eiure la!!id
6ver hours to days 5ltered level o !ons!iousness 1e!reased movement
ypotonia 5bnormal eye position and movement Ti%ht popliteal an%le
.ilent
1ia%nosis >>> !ranial ultrasound
+radin% :>
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% I : (?@G ventri!ular area II : ?@>=@G ventri!ular area III : =@G ventri!ular area< distended
Periventri!ular hemorrha%e 'PE) : periventri!ulare!hodensity
/ana%ement :> /aintain !erebral perusion >>> !ontrol BP
Prevent !erebral hemodynami! disturban!e Prevent post>hemorrha%i! hydro!ephalus
.euele :> /otor def!it Co%nitive def!it Post>hemorrha%i! hydro!ephalus
Periventricular =euko#alacia (P=)
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Ne!rosis o white matter 1oral and lateral to e&ternal an%le o lateral ventri!les .ymmetri!al bilateral Clini!al : apnea < seiure Cranial ultrasound :
4!hodense o!i '?!m) by ? wee" 4!holu!ent !yst '3mm) by ?>3 wee"s
Eentri!le enlar%e by ?>3 months .euele : .pasti! diple%ia Co%nitive < intelle!tual X visual def!it .eiure
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Ophthal#olog+
etinopath+ o, Pre#aturit+• Caused by eJe!ts o o&y%en to&i!ity on the developin% blood
vessels o prem babies• Patho%enesis:
4&!essive arterial 62 tension !auses vaso!onstri!tion >>>retinal
hypo&ia>>> neovas!ularisation >>> bleedin% >>>>retinal deta!hment• sually both eyes involved but severity may vary• Careul monitorin% o 5B+ Pa62 win =@>@mm%• .!reenin% : '[ # w"s old3#w"s C+5)
– Babies (?=@@% 'E;B*)
– (28wee"s +5• Treatment
– 0eer to ophthalmolo%ist – ;ess severe 06P would resolve spontaneously without visual impairment
Orthopedic
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Orthopedic 6steopenia o Prematurity•
5 de!rease in the amount o or%ani! bone matri& !alledosteoid seen in premature inants resultin% in wea" andbrittle bones< hi%h ris" o ra!tures
• Causes – ;ar%e amt o Ca and Phosphate are transerred rom mother to
etus win the last 3 months o %estationY premature inant may
not have re!eived adeuate amounts – In!rease in a!tivity in the womb win last 3 months thou%ht to
have aided bone developmentY premature inants have limitedphysi!al a!tivity
– Preterm inants loses more phosphate in urine than term inants
• Clini!al eatures – 5symptomati! – 0ib ra!tures are not un!ommon in babies with !hroni! lun%
disease – 0edu!ed movement or swellin% o limb – Clini!al ri!"ets is rare
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• 1& X I& – ;on% bone K>ray –
.erum Ca !an be normal – .erum Phosphates 'low) – 5l"aline phosphatase 'hi%h)
• Treatment – Cal!iumPhosphate supplements into breast mil"IE Muids – .pe!ial premature ormulas when breast mil" is not
available