1 Guidelines for workshops on Pediatrics for medical students of the 5 th year Topic: Preterm newborns: anatomical and physiological peculiarities. Features of preterm postnatal transition. Provision of medical care and nutrition for the preterm and small newborns Content section: Neonatology Teaching hours: 4 Self-preparation hours: 2 1. INTRODUCTION Prematurity is the single most important perinatal risk factor because preterm baby is 40 times more likely to die than is normal term infant. The incidence of preterm deliveries in majority countries varies from 5 to 10 %. Only one of every 20 deliveries in average is preterm but every 2 of 3 cases of neonatal death are connected with prematurity. Among preterm infants who survived there are higher incidences of acute and chronic morbidity including severe disability. Newborns with birth weight less than 1500 gm (VLBW infants) represent up to 1,5% of all live- born infants, but their mortality determines more than 50% of total infant mortality rate. VLBW infants are about 200 times more likely to die than the infants of normal birth weight are. VLBW and preterm infants in general represent today the main group of patients at the modern neonatal intensive care units. 2. LEARNING AIM To know the specific features of preterm and small newborns; to be able to develop a plan for care and nutrition. 3. OBJECTIVES Knowledge: - Epidemiology of prematurity (main causes, incidence etc.) - Definitions of a small (low-birth-weight) baby, a premature (preterm) baby, small for gestational age (for date) baby, and a growth-retarded baby. - Clinical classification of newborns based on birth weight - Postnatal methods of gestational age determination (Ballard score) - Etiology of intrauterine growth retardation (delivery small for gestational age (for date) baby) - Classification of intrauterine growth retardation - Physiologic peculiarities of preterm newborns - Principles of physical assessment of the premature newborn - Physical environment - Nutrition and feeding of premature newborns Performance: - Assessment of fetal intrauterine growth - Ballard assessment/scoring - Physical assessment of the premature newborn - Feeding administration to preterm infant - Intravenous fluid administration to preterm infant 4. PREREQUISITES Subjects Knowledge Performance Physiology Normal newborn transition to postnatal life. Pathophysiological consequences of preterm birth for the newborn. Pediatrics Ontogenic development and maturation of main To perform basic physical assessment of the
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1
Guidelines for workshops on Pediatrics for medical students of the 5th
year
Topic: Preterm newborns: anatomical and physiological peculiarities. Features of
preterm postnatal transition. Provision of medical care and nutrition for the
preterm and small newborns
Content section: Neonatology
Teaching hours: 4
Self-preparation hours: 2
1. INTRODUCTION
Prematurity is the single most important perinatal risk factor because preterm baby is 40 times
more likely to die than is normal term infant.
The incidence of preterm deliveries in majority countries varies from 5 to 10 %.
Only one of every 20 deliveries in average is preterm but every 2 of 3 cases of neonatal death are
connected with prematurity.
Among preterm infants who survived there are higher incidences of acute and chronic morbidity
including severe disability.
Newborns with birth weight less than 1500 gm (VLBW infants) represent up to 1,5% of all live-
born infants, but their mortality determines more than 50% of total infant mortality rate. VLBW
infants are about 200 times more likely to die than the infants of normal birth weight are. VLBW and
preterm infants in general represent today the main group of patients at the modern neonatal
intensive care units.
2. LEARNING AIM
To know the specific features of preterm and small newborns; to be able to develop a plan for care
and nutrition.
3. OBJECTIVES
Knowledge:
- Epidemiology of prematurity (main causes, incidence etc.)
- Definitions of a small (low-birth-weight) baby, a premature (preterm) baby, small for
gestational age (for date) baby, and a growth-retarded baby.
- Clinical classification of newborns based on birth weight
- Postnatal methods of gestational age determination (Ballard score)
- Etiology of intrauterine growth retardation (delivery small for gestational age (for date) baby)
- Classification of intrauterine growth retardation
- Physiologic peculiarities of preterm newborns
- Principles of physical assessment of the premature newborn
- Physical environment
- Nutrition and feeding of premature newborns
Performance:
- Assessment of fetal intrauterine growth
- Ballard assessment/scoring
- Physical assessment of the premature newborn
- Feeding administration to preterm infant
- Intravenous fluid administration to preterm infant
4. PREREQUISITES
Subjects Knowledge Performance
Physiology
Normal newborn transition to postnatal life.
Pathophysiological consequences of preterm birth
for the newborn.
Pediatrics Ontogenic development and maturation of main To perform basic physical assessment of the
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human organs and systems. Feeding of the term
newborn
normal newborn.
Obstetrics Preterm birth. Fetal growth retardation. To assist with preterm birth. To assess fetal
condition.
5. MATERIALS FOR SELF-STUDY PREPARATION
Brief topic content
1. Basics of newborn’s physical assessment
Certain themes recur throughout this text in the discussions of assessment of each system. The repetition is
intentional and reflects the importance of these activities. These basic principles of physical assessment include the fol-
lowing:
Review the perinatal history for clues to potential pathology. The newborn's history begins with conception and
includes events that occurred throughout gestation, labor, and delivery. The newborn is also affected by the genetic
histories of both parents and of their families. For example, a maternal history that includes diabetes mellitus directs the
experienced practitioner to carefully assess the cardiovascular and neurologic systems and the extremities because infants
of diabetic mothers show an increased incidence of abnormalities in these systems. The labor and delivery history may
reveal that the mother received medication for pain relief just before delivery; that may account for the depression of the
newborn's respiration. With this knowledge, the examiner need not pursue a more serious etiology for the depressed
respirations, as long as the respiratory pattern improves over time or with the aid of a narcotic antagonist.
Assess the infant's color for clues to potential pathology. The infant's color provides important information about
several body systems. For example, the very red or ruddy infant may have polycythemia and may be more prone to
complications, such as respiratory distress, that are associated with this phenomenon. The infant whose tongue and
mucous membranes are pale or blue (central cyanosis) may be anemic or may have a heart lesion or respiratory disease.
Proper lighting is essential for accurate assessment of color. Auscultate only in a quiet environment. It is difficult to
assess the sounds produced by the body if there are noises, such as people talking or a radio playing, in the room.
External interferences inhibit accurate evaluation of heart and breath sounds.
Keep the infant warm during examination. After undressing the infant, prevention of heat loss is crucial to the
infant's comfort and to the maintenance of a normal temperature and glucose homeostasis. The undressed infant is
examined in a warm environment with an external heat source, such as an overhead radiant warmer. To keep from
startling the newborn and to maintain a stable metabolic status, warm the stethoscope and, especially, your hands.
Have the necessary tools at hand. A stethoscope, an ophthalmoscope, and a tape measure are used in all newborn
examinations. Having them ready saves time.
Calm the infant before beginning the exam. A quiet infant provides the best opportunity for data gathering. If a
crying infant must be examined, patience – and possibly the aid of a second person to help calm the infant – is required.
Handle the infant gently. The newly born infant is amazingly cooperative when the examiner is gentle. A soothing
voice and a soft touch often allow the examiner to complete the entire physical assessment without disturbing the infant
greatly or at all. Parents enjoy watching their infant interact with the examiner and appreciate the gentleness of touch.
Certain portions of the examination cause the infant more distress than others. Examination of the hips is usually the
most disturbing part of the exam; it is therefore performed last.
Complete the exam. Redress the infant to maintain a normal temperature. Notify the primary caregiver that the
exam is over, and of any abnormalities that were found or observations that need to be made.
Observations for physical assessment
To assess Observe
Distress Facial expression, respiratory effort, activity, tone
Color Tongue, mucous membranes (centrally pink vs cyanotic), nail beds, hands, feet (peripherally