Neonatolgy - Lecture #2

Lecture 2 neonatology Routine Delivery Room Care Maintaining of breathing patency of airway (suction) postioning (sniffing postion) drying &stimulation Routine Delivery Room Care MAINTENANCE OF BODY HEAT Relative to body weight, the body surface area of a newborn infant is approximately three times that of an adult, and in low birth weight infants, The estimated rate of heat loss in a newborn is approximately four times that of an adult. Metabolic acidosis, hypoxemia, hypoglycemia, and increased renal excretion of water and solutes may develop in term infants exposed to cold after birth because of their effort to compensate for heat loss To reduce heat loss, it is desirable to ensure that infants are dried and either wrapped in blankets or placed under a warmer. Skin-to-skin contact with the mother is the optimal method to maintain temperature in the stable newborn (Kangaroo postion) ANTISEPTIC SKIN AND CORD CARE Careful removal of blood from the skin shortly after birth may reduce the risk of infection with blood-borne agents. Once a healthy infant's temperature has stabilized, the entire skin and cord should be cleansed with warm water or a mild non medicated soap solution and rinsed with water the umbilical cord may be treated daily with bactericidal or antimicrobial agents such as triple dye or bacitracin. One application of triple dye followed by twice-daily alcohol swabbing (until the cord falls off) reduces colonizatio The eyes of all infants must be protected against gonococcal infection by instilling 1% silver nitrate drops, the best-proven therapy; erythromycin (0.5%) and tetracycline (1.0%) sterile ophthalmic ointments are alternative measures that add coverage against chlamydia. Povidone-iodine (2.5% solution) may also be effective as a one-time prophylactic agent. An intramuscular injection of 1 mg of water-soluble vitamin K1 (phytonadione) is recommended for all infants immediately after birth to prevent hemorrhagic disease of the newborn Neonatal screening is available for various genetic, metabolic, hematologic, and endocrine diseases (hypothyroidism, phenylketonuria, galactosemia, maple syrup urine disease, homocystinuria, biotinidase deficiency, adrenal hyperplasia, hemoglobinopathy, cystic fibrosis, tyrosinemia, and other organic acid defects or aminoacidopathies) Feeding SKULL The suture lines and the size and fullness of the anterior and posterior fontanels should be determined digitally by palpation. Premature fusion of sutures (cranial synostosis) is identified by a hard nonmovable ridge over the suture and an abnormally shaped skull. Eyes • The eyes often open spontaneously if the infant is held up and tipped gently forward and backward. • Conjunctival and retinal hemorrhages are usually benign. • Retinal hemorrhages are more common with vacuum-assisted deliveries • The presence of bilateral red reflexes suggests the absence of cataracts and intraocular pathology • Leukokoria (white pupillary reflex) suggests cataracts, tumor, chorioretinitis, retinopathy of prematurity, or a persistent hyperplastic primary vitreous and warrants an immediate ophthalmologic consultation Mouth Natal (present at birth) or neonatal (eruption after birth) teeth in the lower incisor position or aberrantly placed; these teeth are shed before the deciduous ones erupt ( The soft and hard palate should be inspected and palpated for a complete or submucosal cleft and the contour noted if the arch is excessively high or the uvula is bifid. On the hard palate on either side of the raphe may be temporary accumulations of epithelial cells called Epstein pearls. Tongue-tied or ankyloglossia a reason for cutting it. If there are problems with feedings (breast or bottle) and the frenulum is short, frenulotomy may be indicated. The neck appears relatively short. Abnormalities are not common but include goiter, cystic hygroma, branchial cleft rests, teratoma, hemangioma, and lesions of the sternocleidomastoid muscle that are presumably traumatic or due to a fixed positioning in utero that produces either a hematoma or fibrosis, respectively. Congenital torticollis causes the head to turn toward and the face to turn away from the affected side. Redundant skin or webbing in a female infant suggests intrauterine lymphedema and Turner syndrome Both clavicles should be palpated for fractures ABDOMEN Abdominal distention at birth or shortly afterward suggests either obstruction or perforation of the gastrointestinal tract, often as a result of meconium ileus; later distention suggests lower bowel obstruction, sepsis, or peritonitis. A scaphoid abdomen in a newborn suggests diaphragmatic hernia. Abdominal wall defects produce an omphalocele when they occur through the umbilicus and gastroschisis when they occur lateral to the midline. Omphaloceles are associated with other anomalies and syndromes such as Beckwith-Wiedemann, conjoined twins, trisomy 18, meningomyelocele, and imperforate anus. Omphalitis is an acute local inflammation of the periumbilical tissue that may extend to the abdominal wall, the peritoneum, the umbilical vein or portal vessels, or the liver and may result in later portal hypertension. The umbilical cord should have two arteries and one vein. A single umbilical artery suggests an occult renal anomaly. GENITALS A normal scrotum at term is relatively large; its size may be increased by the trauma of breech delivery or by a transitory hydrocele, which is distinguished from a hernia by palpation and transillumination. The prepuce of a newborn infant is normally tight and adherent. Severe hypospadias or epispadias should always lead one to suspect either that abnormal sex chromosomes are present Most void by 12 hr, and about 95% of preterm and term infants void within 24 hr. ANUS Some passage of meconium usually occurs within the 1st 12 hr after birth; 99% of term infants and 95% of premature infants pass meconium within 48 hr of birth. Imperforate anus is not always visible and may require evidence obtained by gentle insertion of the little finger or a rectal tube. Roentgenographic study is required. Passage of meconium does not rule out an imperforate anus if a rectal-vaginal fistula is present. The dimple or irregularity in skinfold often normally present in the sacrococcygeal midline may be mistaken for an actual or potential neurocutaneous sinus Hips The hips should be examined for congenital dysplasia (dislocation). Gluteal fold asymmetry or leg length discrepancy is a suggestive sign of dysplasia, but the examiner should perform the Barlow test and the Ortolani maneuver to evaluate the stability of the hip joint. These tests determine whether the femoral head can be displaced from the acetabulum (Barlow test) and then replaced (Ortolani maneuver) Infant with intrauterine growth retardation as a result of placental insufficiency. Note the long, thin appearance with peeling, parchment-like dry skin, alert expression, meconium staining of the skin, and long nails.