Neonatal Medicine-IntroductionXiaoping Luo, MDProfessor and ChairmanDepartment of Pediatrics, Tongji HospitalDirector, Center for the Diagnosis of Genetic Metabolic Diseases Tongji Medical CollegeHuazhong University of Science and TechnologyAdjunct ProfessorDepartment of PaediatricsFaculty of MedicineUniversity of TorontoToronto, CanadaHistorical PerspectivesEarly History of Care of Infants (1900Early History of Care of Infants (1900 - small infants were not expected to live - small infants were not expected to live - temperature: hot-water bottles, heated cribs - temperature: hot-water bottles, heated cribs - feeding: tube feeding, diluted cow milk - feeding: tube feeding, diluted cow milk - separated facilities, isolation, washing hands - separated facilities, isolation, washing hands - - hyaline hyaline membrane membrane diseases-respiratory diseases-respiratory distress distress syndromesyndrome - 1940s, modernized incubator, more oxygen - 1940s, modernized incubator, more oxygen - 1940s, retrolental fibroplasia - 1940s, retrolental fibroplasia - - 1945, 1945, The -C. Infant-C. Smith Smith Historical PerspectivesRapid Advances in Neonatal Care (19551970)Rapid Advances in Neonatal Care (19551970) - - 1959, 1959, surfactant surfactant deficiency, deficiency, Avery Avery ME, ME, Mead Mead J. J. Am J Dis ChildAm J Dis Child - - 1960, 1960, Disease -Neonatology Newborn-Neonatology -A. -A. SchafferSchaffer - - culture, culture, blood blood counts, counts, urinalyses, urinalyses, radiographs, radiographs, biopsiesbiopsies - milk formulas, breast milk bank - milk formulas, breast milk bank - iv glucose & bicarbonate - iv glucose & bicarbonate - blood gas analysis - blood gas analysis - improved incubators - improved incubators - early attempts of mechanical ventilation - early attempts of mechanical ventilationHistorical PerspectivesEmergence of neonatal Intensive Care (19711989)Emergence of neonatal Intensive Care (19711989) - - 1971, 1971, continuous continuous positive positive airway airway pressure pressure (CPAP) (CPAP) -Gregory-Gregory - neonatal intensive care unit (NICU) - neonatal intensive care unit (NICU) - - designated designated by by level level according according to to the the intensity intensity of of serviceservice I: normal birthing and NB care, I: normal birthing and NB care, II: II: common common obstetric obstetric complications complications & & intermediate NB careintermediate NB care III: high risk maternal care and NICU III: high risk maternal care and NICU - transferring of high risk infants or mothers - transferring of high risk infants or mothers - high risk and long term outcome - high risk and long term outcome - - 1980s, 1980s, extracorporeal extracorporeal membrane membrane oxygenation oxygenation (ECMO)(ECMO)Historical PerspectivesExpansion of Clinical Trials to Assess Therapy:Expansion of Clinical Trials to Assess Therapy: the Surfactant Era (19801996) the Surfactant Era (19801996) - - 1970s1990s, 1970s1990s, glucocorticoids glucocorticoids to to accelerate accelerate lung lung maturationmaturation - - 1980, 1980, first first surfactant surfactant replacement replacement therapy therapy in in humanshumans - total parenteral nutrition (TPN) - total parenteral nutrition (TPN) - high frequency oscillators - high frequency oscillators - inhaled nitric oxide - inhaled nitric oxide - prenatal diagnosis and genetic counseling - prenatal diagnosis and genetic counseling - - prospective, prospective, controlled controlled clinical clinical trials trials for for interventionintervention - - “quiet “quiet premature premature nurserynursery to to “a “a bustling bustling space space stationstation Le Tour dabandon(Decertion Tower)Century of Progress International ExpositionChicago Worlds Fair, Chicago, IllinoisThe Dionne quintupletsMay 28, 1934,13 pounds 6 ounces,All together! Emelie, Cecile, Marie, Annette, YvonneJulius Hess“quiet premature nursery“quiet premature nurseryHow small is too small?How much is too much?Life support:To continue or discontinue?Definitions of TermsF Newborn or neonate refers to a infant period from birth to 28 days. Neonatologyhealth care, pathophysiology and managementF Early Neonate refers to the first 7 completed days of life.F Late Neonate refers to a period between 8 to 28 days of life.F Perinatal period extends from the 28th completed week of pregnancy to the 7th day of life. Perinatology or Perinatal MedicineDefinitions of TermsF Term defines births that occur from 37th to less than 42 completed weeks, measured from the day of onset of the last normal menstrual period (259293 days, with an average of 280 days). F Preterm is defined as less than 37 completed weeks, or 259 days, gestation. (37weeks of gestation birth weight of 3000g) F Post-term refers to births that occurs at 42 or more completed weeks (294 days).F Stillbirth and Fetal Death. F Early fetal death occurs at 20 and 28 completed weeks,F late fetal death occurs after 28weeks, or termed as stillbirth.F Live Birth. WHO defines live birth asF The complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy, which after such separation, breathes or any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached; each product of such a birth is considered liveborn. Definitions of TermsFBirth Weight (BW) F BW 2500g - Low Birth Weight (LBW); F 1500g - Very Low Birth Weight (VLBW); F 4000g - Fetal Macrosomia F (Beckwith-Wiedemann syndromeF Infant of Diabetic Mother, IDM)Definitions of TermsFBirth Weight vs Gestational Age (GA)F BW the 90th percentile - large for gestational age (LGA)F F ponderal index = BW(g)X100/Length3 (cm3) (22.2)F Length/Head Circumference (HC) (1.36)F symmetric or unsymmetric SGA Definitions of TermsBirthweight Curves California male singleton Caucasian non-Hispanic birthweights by gestational age: 10th, 50th, and 90th percentiles.FPregnancies in which factors exist that increase the likelihood of maternal or fetal diseasesFEconomic, cultural-behavioral, biologic-genetic, reproductive and medical factorsF1020% of pregnant patient can be identified as high riskF50% of all perinatal mortality and morbidity is associated with high risk pregnancyHigh Risk PregnancyFAn infant who should be under close observation by experienced physicians and nurses. F9% of all births require intensive careFFetal or neonatal factors:F premature labor, postdates, fetal distrass, breech presentation, F meconium-stained fluid, nuchal cord, Cesarean section, forceps F F low Apgar score, BW4000, SGA or LGA, congenital F malformation, tachypnea, cyanosis, pallor, plethora, petechiaeHigh Risk InfantFFetal Growth and Maturity F embryonic period (18 wks): early embryogenesis F fetal period (9 wksbirth): growth and maturationFFactors Affecting Fetal GrowthF genetic, geographic, social and economic factorsF maternal conditions: stature, age, disease and medicationF fetal: sex, multiple pregnancy, genetic disease, infectionFFetal MonitoringF maternal serum, chorion villi, amniotic fluid, placenta, F fetal heart rate, ultrasound, blood gas and pH Fetal Growth and MonitoringFPhysical CriteriaF Skin Lanugo hairF Plantar surface BreastF Hair Finger nailF Ear/Eye GenitalsF Neuromuscular CriteriaF Posture Square window (wrist)F Arm recoil Popliteal angleF Scarf sign Heel to ear F New Ballard Score (NBS) for Maturity RatingF Ballard JL, et al, J Pediatr 1991; 119:417Physical and Neuromuscular Criteria for MaturityDubowitz/Ballard Exam for Gestational Age Sucking Palmar grasp Response to traction Moro reflex Crossed extension Automatic walking Roof reflex Pupillary response Neurological ReflexesF Body temperatureF heat loss by evaporation, radiation and convectionF Neutral thermal enviromentF The range of ambient temperature and humidity at which heat loss is minimal and metabolic demands and oxygen consumption are the lowest. FDepends on body weight and age F31 to 34 C at 50% humidity for undressed normal term infantFSkin temperature vs central or core temperature (rectal)FRe-warming a hypothermic infant at moderate rate (24hrs)F Thermal regulationF Physiological CharacteristicsF Cardiopulmonary FunctionF heart rate: 120130bpmF tachycardia/bradycardia; transition from FCF blood pressure: 6595/3060mmHg, F lower in preterm, PDA in pretermF lung fluid: 3035ml/kg F “excretion/re-absorption , “wet lungF respiratory rate: 6080/min in the 1st hour, 40/min afterF brief pauses in respiration (20s, with bradycardia 100bpm)Physiological CharacteristicsF Gastrointestinal FunctionF vomiting and abdominal distensionF swallowed maternal blood, GI malformation, infectionF first feedingF nutritional issues, tracheo-esophageal fistula, jaundiceF passage of meconium F 70% within 12h, 25% in 1224h, 5% by 48hF distal intestinal obstruction, meconium plug syndrome,F Hirschsprungs disease, sepsis, hypothyroidism, nacorticF necrotizing enterocolitis (NEC) F premature, hypoxia and ischemia, infection, feedingPhysiological CharacteristicsF Urinary FunctionF urinateF 68% within 12h, 25% in 1224h, 7% by 48hF pre-renal causes: dehydration, shockF renal abnormality: renal agenesis, tubular necrosisF obstruction of urinary outflow: urethral valvesF late onset metabolic acidosis in premature infantF cow milk feeding with high protein load Physiological CharacteristicsF Hematological SystemF hemoglobin: cord blood 170g/L, change with age F Fetal hemoglobin: HbF 70%, HbA 30%F WBC:1520X109/L for term babyF 68X109/L for preterm babyF Platelet: 150250X 109/LF Blood volume: 50100ml/kg for term babyF 89105ml/kg for preterm babyPhysiological CharacteristicsF Neurological SystemF brain: 300400g, 1020% of body weight (adult 2%) F head circumference:3334cm, increase by 1cm/monthF spinal cord: ends at L34, caution for lumbar puncture F physiological reflexes: rooting, sucking, grasp, MoroF Pathological reflexes: Kernig, Babinski, Chvostek signPhysiological CharacteristicsF Immunological System - immaturityF skin and mucous membrane F complements and chemokine F T cell function F ImmunoglubulinsPhysiological CharacteristicsF Fluid requirement (ml/kg)F BW (kg) Day 1 Day 2 Day 37 F 2.5 6080 80100 100140Physiological CharacteristicsF Apgar scoreF Maintenance of body heatF Antiseptic skin and cord careF Eyes protectionF Respiratory managementRoutine CareF Feeding F Vitamin K1F VaccinationF Neonatal screening F Parent-infant bondingF Mechanical ventilationF Cardiopulmonary DisorderF Post surgery (24h)F GA30, VLBWIF TPNFSustained convulsionFCentral tubing Neonatal Intensive Care Unit (NICU)F HeartF RespirationF Blood pressureF Body temperatureF Blood GasFBiochemistryFImaging Tongji HospitalThanks for Thanks for learning, learning, Doc!Doc!