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1、Neonatal Medicine -Introduction,Xiaoping Luo, MD Professor and Chairman Department of Pediatrics, Tongji Hospital Director, Center for the Diagnosis of Genetic Metabolic Diseases Tongji Medical College Huazhong University of Science and Technology Adjunct Professor Department of Paediatrics Faculty
2、of Medicine University of Toronto Toronto, Canada,Historical Perspectives,Early History of Care of Infants (1900 - small infants were not expected to live - temperature: hot-water bottles, heated cribs - feeding: tube feeding, diluted cow milk - separated facilities, isolation, washing hands - hyali
3、ne membrane diseases-respiratory distress syndrome - 1940s, modernized incubator, more oxygen - 1940s, retrolental fibroplasia - 1945, The Physiology of the Newborn Infant-C. Smith,Historical Perspectives,Rapid Advances in Neonatal Care (19551970) - 1959, surfactant deficiency, Avery ME, Mead J. Am
4、J Dis Child - 1960, Disease of the Newborn-Neonatology -A. Schaffer - culture, blood counts, urinalyses, radiographs, biopsies - milk formulas, breast milk bank - iv glucose & bicarbonate - blood gas analysis - improved incubators - early attempts of mechanical ventilation,Historical Perspectives,Em
5、ergence of neonatal Intensive Care (19711989) - 1971, continuous positive airway pressure (CPAP) -Gregory - neonatal intensive care unit (NICU) - designated by level according to the intensity of service I: normal birthing and NB care, II: common obstetric complications & intermediate NB care III: h
6、igh risk maternal care and NICU - transferring of high risk infants or mothers - high risk and long term outcome - 1980s, extracorporeal membrane oxygenation (ECMO),Historical Perspectives,Expansion of Clinical Trials to Assess Therapy: the Surfactant Era (19801996) - 1970s1990s, glucocorticoids to
7、accelerate lung maturation - 1980, first surfactant replacement therapy in humans - total parenteral nutrition (TPN) - high frequency oscillators - inhaled nitric oxide - prenatal diagnosis and genetic counseling - prospective, controlled clinical trials for intervention - “quiet premature nursery”
8、to “a bustling space station”,Le Tour dabandon (Decertion Tower),Century of Progress International Exposition Chicago Worlds Fair, Chicago, Illinois,The Dionne quintuplets May 28, 1934, 13 pounds 6 ounces, All together!,Emelie, Cecile, Marie, Annette, Yvonne,Julius Hess,“quiet premature nursery”,How
9、 small is too small?,How much is too much?,Life support: To continue or discontinue?,Definitions of Terms,Newborn or neonate refers to a infant period from birth to 28 days. Neonatologyhealth care, pathophysiology and management Early Neonate refers to the first 7 completed days of life. Late Neonat
10、e refers to a period between 8 to 28 days of life. Perinatal period extends from the 28th completed week of pregnancy to the 7th day of life. Perinatology or Perinatal Medicine,Definitions of Terms,Term defines births that occur from 37th to less than 42 completed weeks, measured from the day of ons
11、et of the last normal menstrual period (259293 days, with an average of 280 days). Preterm is defined as less than 37 completed weeks, or 259 days, gestation. (37weeks of gestation birth weight of 3000g) Post-term refers to births that occurs at 42 or more completed weeks (294 days).,Stillbirth and
12、Fetal Death. Early fetal death occurs at 20 and 28 completed weeks, late fetal death occurs after 28weeks, or termed as stillbirth. Live Birth. WHO defines live birth as The complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy, which
13、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.,De
14、finitions of Terms,Birth Weight (BW) BW 4000g - Fetal Macrosomia (Beckwith-Wiedemann syndrome Infant of Diabetic Mother, IDM),Definitions of Terms,Birth Weight vs Gestational Age (GA) BW the 90th percentile - large for gestational age (LGA) ponderal index = BW(g)X100/Length3 (cm3) (22.2) Length/Head
15、 Circumference (HC) (1.36) symmetric or unsymmetric SGA,Definitions of Terms,Birthweight Curves,California male singleton Caucasian non-Hispanic birthweights by gestational age: 10th, 50th, and 90th percentiles.,Pregnancies in which factors exist that increase the likelihood of maternal or fetal dis
16、eases Economic, cultural-behavioral, biologic-genetic, reproductive and medical factors 1020% of pregnant patient can be identified as high risk 50% of all perinatal mortality and morbidity is associated with high risk pregnancy,High Risk Pregnancy,An infant who should be under close observation by
17、experienced physicians and nurses. 9% of all births require intensive care Fetal or neonatal factors: premature labor, postdates, fetal distrass, breech presentation, meconium-stained fluid, nuchal cord, Cesarean section, forceps low Apgar score, BW4000, SGA or LGA, congenital malformation, tachypne
18、a, cyanosis, pallor, plethora, petechiae,High Risk Infant,Fetal Growth and Maturity embryonic period (18 wks): early embryogenesis fetal period (9 wksbirth): growth and maturation Factors Affecting Fetal Growth genetic, geographic, social and economic factors maternal conditions: stature, age, disea
19、se and medication fetal: sex, multiple pregnancy, genetic disease, infection Fetal Monitoring maternal serum, chorion villi, amniotic fluid, placenta, fetal heart rate, ultrasound, blood gas and pH,Fetal Growth and Monitoring,Physical Criteria Skin Lanugo hair Plantar surface Breast Hair Finger nail
20、 Ear/Eye Genitals Neuromuscular Criteria Posture Square window (wrist) Arm recoil Popliteal angle Scarf sign Heel to ear New Ballard Score (NBS) for Maturity Rating Ballard JL, et al, J Pediatr 1991; 119:417,Physical and Neuromuscular Criteria for Maturity,Dubowitz/Ballard Exam for Gestational Age,S
21、ucking Palmar grasp Response to traction Moro reflex Crossed extension Automatic walking Roof reflex Pupillary response,Neurological Reflexes,Body temperature heat loss by evaporation, radiation and convection Neutral thermal enviroment The range of ambient temperature and humidity at which heat los
22、s is minimal and metabolic demands and oxygen consumption are the lowest. Depends on body weight and age 31 to 34 C at 50% humidity for undressed normal term infant Skin temperature vs central or core temperature (rectal) Re-warming a hypothermic infant at moderate rate (24hrs) Thermal regulation,Ph
23、ysiological Characteristics,Cardiopulmonary Function heart rate: 120130bpm tachycardia/bradycardia; transition from FC blood pressure: 6595/3060mmHg, lower in preterm, PDA in preterm lung fluid: 3035ml/kg “excretion/re-absorption” , “wet lung” respiratory rate: 6080/min in the 1st hour, 40/min after
24、 brief pauses in respiration (20s, with bradycardia 100bpm),Physiological Characteristics,Gastrointestinal Function vomiting and abdominal distension swallowed maternal blood, GI malformation, infection first feeding nutritional issues, tracheo-esophageal fistula, jaundice passage of meconium 70% wi
25、thin 12h, 25% in 1224h, 5% by 48h distal intestinal obstruction, meconium plug syndrome, Hirschsprungs disease, sepsis, hypothyroidism, nacortic necrotizing enterocolitis (NEC) premature, hypoxia and ischemia, infection, feeding,Physiological Characteristics,Urinary Function urinate 68% within 12h,
26、25% in 1224h, 7% by 48h pre-renal causes: dehydration, shock renal abnormality: renal agenesis, tubular necrosis obstruction of urinary outflow: urethral valves late onset metabolic acidosis in premature infant cow milk feeding with high protein load,Physiological Characteristics,Hematological Syste
27、m hemoglobin: cord blood 170g/L, change with age Fetal hemoglobin: HbF 70%, HbA 30% WBC:1520X109/L for term baby 68X109/L for preterm baby Platelet: 150250X 109/L Blood volume: 50100ml/kg for term baby 89105ml/kg for preterm baby,Physiological Characteristics,Neurological System brain: 300400g, 1020
28、% of body weight (adult 2%) head circumference:3334cm, increase by 1cm/month spinal cord: ends at L34, caution for lumbar puncture physiological reflexes: rooting, sucking, grasp, Moro Pathological reflexes: Kernig, Babinski, Chvostek sign,Physiological Characteristics,Immunological System - immatur
29、ity skin and mucous membrane complements and chemokine T cell function Immunoglubulins,Physiological Characteristics,Fluid requirement (ml/kg) BW (kg) Day 1 Day 2 Day 37 2.5 6080 80100 100140,Physiological Characteristics,Apgar score Maintenance of body heat Antiseptic skin and cord care Eyes protec
30、tion Respiratory management,Routine Care,Feeding Vitamin K1 Vaccination Neonatal screening Parent-infant bonding,Mechanical ventilation Cardiopulmonary Disorder Post surgery (24h) GA30, VLBWI TPN Sustained convulsion Central tubing,Neonatal Intensive Care Unit (NICU),Heart Respiration Blood pressure Body temperature Blood Gas Biochemistry Imaging,Tongji Hospital,Thanks for learning, Doc!,