NeonatologyNeonatology

The perfect care for both low and high risk newborn The perfect care for both low and high risk newborn infants depends on knowledge of the family history , the infants depends on knowledge of the family history , the history of prior and current pregnancies and the events of history of prior and current pregnancies and the events of labor and delivery .labor and delivery .

There are some significant influences that may result in There are some significant influences that may result in poor neonatal outcome like : poor maternal nutrition , poor neonatal outcome like : poor maternal nutrition , poverty , physical or psychological stresses , extremes of poverty , physical or psychological stresses , extremes of maternal age ( <16 yr , > 35 yr ) , black race , medical maternal age ( <16 yr , > 35 yr ) , black race , medical illnesses present prior pregnancy , obstetric complications illnesses present prior pregnancy , obstetric complications during the antepartum and intrapartum periods , and the during the antepartum and intrapartum periods , and the inherited genetic predisposition to the fetus .inherited genetic predisposition to the fetus .

Perinatal periodPerinatal period : : is defined as the period from the 28 wk is defined as the period from the 28 wk of gestation through the 7of gestation through the 7thth day after birth ( additional day after birth ( additional definition include the 20definition include the 20thth wk of gestation to the 7 wk of gestation to the 7thth days , days , and the 20and the 20thth wk of gestation to the 28 wk of gestation to the 28thth day ) . day ) .

Neonatal periodNeonatal period : : is defined as less than 28 is defined as less than 28thth day of life day of life and may be further subdivided into :-and may be further subdivided into :-

Period 1 = birth to less than 24 hr , Period 2 = 24 hr to Period 1 = birth to less than 24 hr , Period 2 = 24 hr to less than 7 days and Period 3 = from 7 days to less than 28 less than 7 days and Period 3 = from 7 days to less than 28 day of life .day of life .

Perinatal mortality :Perinatal mortality : refers to the fetal deaths occurring from the refers to the fetal deaths occurring from the 2020thth wk of gestation until the 7 wk of gestation until the 7thth or ( 28 or ( 28thth day ) after birth and is day ) after birth and is expressed as number of death per 1000 live birth .expressed as number of death per 1000 live birth .

Neonatal mortality rate : Neonatal mortality rate : include all infants dying during the period include all infants dying during the period beginning after birth and continuing up to the first 28 days of life beginning after birth and continuing up to the first 28 days of life also it is expressed as number of death per 1000 live births .also it is expressed as number of death per 1000 live births .

Postnatal period : Postnatal period : which begins after 28 days of life and extend to which begins after 28 days of life and extend to the end of the 1the end of the 1stst year of life . year of life .

Infant mortality rate : Infant mortality rate : include both the neonatal and the post-include both the neonatal and the post-neonatal period and also expressed as number of death per 1000 neonatal period and also expressed as number of death per 1000 live birth .live birth .

Major causes of perinatal and neonatal mortality :Major causes of perinatal and neonatal mortality :Fetal Fetal Preterm Preterm Full term Full term -placental insufficiency -severe immaturity - cong. Malf.-placental insufficiency -severe immaturity - cong. Malf.

-intrauterine infections - R.D.S. - birth asphy. -intrauterine infections - R.D.S. - birth asphy. -severe congenital - I.V.H. - infections -severe congenital - I.V.H. - infections malformation malformation

- - Umbilical cord accidents - congenital anomalies - meconium Umbilical cord accidents - congenital anomalies - meconium aspiration aspiration

pneumonia pneumonia - Abruptio placenta - infections - persistent pul. HT .Abruptio placenta - infections - persistent pul. HT .- Hydropis fetalis - B.P.D.Hydropis fetalis - B.P.D.

Birth weightBirth weight :- :-

Normal birth weight for full term neonate is range from 2500 gm -4500 gm Normal birth weight for full term neonate is range from 2500 gm -4500 gm ( some time 4300 gm or 4000 gm accordingly ) .( some time 4300 gm or 4000 gm accordingly ) .

Low birth weight (L.B.W.) < 2500 gm ( 1500-2500 gm ) .Low birth weight (L.B.W.) < 2500 gm ( 1500-2500 gm ) .

Very low birth weight (V.L.B.W.) < 1500 gm ( 1000-1500 gm ) .Very low birth weight (V.L.B.W.) < 1500 gm ( 1000-1500 gm ) .

Extreme low birth weight (E.L.B.W.) < 1000 gm .Extreme low birth weight (E.L.B.W.) < 1000 gm .

Large for gestational weight neonate > 4300 gm or > 4500 gm .Large for gestational weight neonate > 4300 gm or > 4500 gm .

Maturity :-Maturity :-

Mature or term delivery : Mature or term delivery : completed 38 wks from the first day of the last completed 38 wks from the first day of the last menstrual period .menstrual period .

Preterm delivery : Preterm delivery : occurs less than 37 completed wks from the first day of occurs less than 37 completed wks from the first day of the last menstrual period the last menstrual period

Post –term delivery : Post –term delivery : delivery occurs 42 wks or more from delivery occurs 42 wks or more from the first day of the last menstrual period .the first day of the last menstrual period .

Evaluation of the newborn :-Evaluation of the newborn :- Features of the newborn examination that differ from those Features of the newborn examination that differ from those

of children and adolescents include : of children and adolescents include :

A- A- General appearanceGeneral appearance : : 1- careful observation is necessary to assess spontaneous 1- careful observation is necessary to assess spontaneous

activity , passive muscle tone , respirations , and abnormal activity , passive muscle tone , respirations , and abnormal signs , such as cyanosis , intercostal muscle retractions , or signs , such as cyanosis , intercostal muscle retractions , or meconium staining .meconium staining .

2- Apgar score : are a simple , systematic assessments of 2- Apgar score : are a simple , systematic assessments of intrapartum stress and neurologic depression at birth , intrapartum stress and neurologic depression at birth , conducted at 1 and 5 minutes after birth . A persistently conducted at 1 and 5 minutes after birth . A persistently very low Apgar score indicates the need for resuscitation , very low Apgar score indicates the need for resuscitation , and scoring should be continued every 5 minutes until a and scoring should be continued every 5 minutes until a final score of 7 or more is reached .final score of 7 or more is reached .

Apgar scoreApgar score

Score Score 001122

H.RH.R..AbsentAbsent <<100100//minmin>>100100//minmin

RespirationRespiration AbsentAbsentSlow , Slow , irregularirregular

Good , cryingGood , crying

Muscle toneMuscle tone LimpLimp Some , flexionSome , flexion Active motionActive motion

Reflex IrritabilityReflex Irritability No responseNo response GrimaceGrimace Cough , Cough , sneeze ,crysneeze ,cry

ColorColor Blue , paleBlue , pale Body Body pink ,blue pink ,blue

extremetiesextremeties

Completel Completel pinkpink

Apgar score are generally obtained and totaled at 1 min and 5 Apgar score are generally obtained and totaled at 1 min and 5 min following birth , and scores should be recorded for longer min following birth , and scores should be recorded for longer periods ( at 10 , 15 and even 20 min ) if they are low ( until the periods ( at 10 , 15 and even 20 min ) if they are low ( until the score is about or more 7 ) . score is about or more 7 ) .

Score ofScore of 0-3 indicate that neonate required immediate 0-3 indicate that neonate required immediate resuscitation , 4-7 required observation and admission to N.I.C.U. resuscitation , 4-7 required observation and admission to N.I.C.U. and 7-10 indicate good condition . and 7-10 indicate good condition .

B- B- Skin examinationSkin examination : Texture differ with gestational age ; skin is : Texture differ with gestational age ; skin is softer and thinner in premature infant .softer and thinner in premature infant .

1- Lanugo hair : is the thin hair that covers the skin of preterm 1- Lanugo hair : is the thin hair that covers the skin of preterm infants . It is minimally present in term infants .infants . It is minimally present in term infants .

2- Vernix caseosa : is a thick , white , creamy material found in 2- Vernix caseosa : is a thick , white , creamy material found in term infants ; it covers large areas of the skin in preterm infants . term infants ; it covers large areas of the skin in preterm infants . It is usually absent in post-term infants .It is usually absent in post-term infants .

3- Color : is pink a few hr after birth , but acrocyanosis : is cyanosis 3- Color : is pink a few hr after birth , but acrocyanosis : is cyanosis of the hand and feet , it is very frequent during the first 48-72 hr of the hand and feet , it is very frequent during the first 48-72 hr and in some infants it can last throughout the first month of life , and in some infants it can last throughout the first month of life , particularly when the infant is cold . Acrocyanosis and cutis particularly when the infant is cold . Acrocyanosis and cutis marmorata ( mottling of the skin with venous prominence ) are marmorata ( mottling of the skin with venous prominence ) are frequent intermittent signs of the vasomotor instability .frequent intermittent signs of the vasomotor instability .

4- Pallor : may be a sign of neonatal asphyxia , shock , sepsis or 4- Pallor : may be a sign of neonatal asphyxia , shock , sepsis or anemia .anemia .

Preterm newbornPreterm newborn

Fat NecrosisFat Necrosis

Vernix caseosaVernix caseosa

5- Jaundice : is always abnormal if detected with in the first 24 5- Jaundice : is always abnormal if detected with in the first 24 hr of life .hr of life .

6- Milia : are very small cysts formed around the pilosabaceous 6- Milia : are very small cysts formed around the pilosabaceous follicles which appear as tiny , whitish papules that are seen follicles which appear as tiny , whitish papules that are seen over the nose , cheeks , forehead and chin . They usually over the nose , cheeks , forehead and chin . They usually disappear with in few wks and do not require treatment .disappear with in few wks and do not require treatment .

7- Mongolian spots : are dark blue hyperpigmented macules 7- Mongolian spots : are dark blue hyperpigmented macules over the lumbosacral area and buttock of no pathologic over the lumbosacral area and buttock of no pathologic significant , these most frequently seen in Asian , Hispanic significant , these most frequently seen in Asian , Hispanic and African – American infants .and African – American infants .

8- Pastular melanosis : is a benign transient rash characterized 8- Pastular melanosis : is a benign transient rash characterized by small , dry superficial vesicles over a dark macular base .by small , dry superficial vesicles over a dark macular base .

9- Erythema toxicam neonatorum : is a benign rash seen most 9- Erythema toxicam neonatorum : is a benign rash seen most frequently in the first 72 hr after birth , characterized by frequently in the first 72 hr after birth , characterized by erythematous macules , papules and pastules .( resembling erythematous macules , papules and pastules .( resembling flea bites ) present on the trunk and extremities but not on flea bites ) present on the trunk and extremities but not on the palms and soles . The rash occur in about 50% of full the palms and soles . The rash occur in about 50% of full term infants and found much less frequently in preterm term infants and found much less frequently in preterm infants . Lesions are filled with eosinophils , and culture of infants . Lesions are filled with eosinophils , and culture of the fluid content is negative or sterile .No treatment is the fluid content is negative or sterile .No treatment is required .required .

MiliaMilia

Port wine stain Port wine stain hemangioma , mongolian hemangioma , mongolian

spotspot

Mongolian SpotMongolian Spot

Milia , erythema toxicumMilia , erythema toxicum

Erythema toxicumErythema toxicum

10- Nevus simplex : or Salmon patch or stork bites : it is 10- Nevus simplex : or Salmon patch or stork bites : it is telangiectatic nevus , it is the most common vascular lesion telangiectatic nevus , it is the most common vascular lesion of infancy , occurring in about 30-40% of newborns and of infancy , occurring in about 30-40% of newborns and appearing as a pink macular lesion on the nape of the neck appearing as a pink macular lesion on the nape of the neck ( stork bite ) , upper eyelids , glabella , or nasolabial ( stork bite ) , upper eyelids , glabella , or nasolabial region , it is usually transient lesion .region , it is usually transient lesion .

11- Nevus flammeus or port wine stain : it is congenital 11- Nevus flammeus or port wine stain : it is congenital vascular malformation composed of dilated capillary vascular malformation composed of dilated capillary vessels ( a form of capillary hemangioma ) , it may be vessels ( a form of capillary hemangioma ) , it may be associated with intracranial or spinal vascular associated with intracranial or spinal vascular malformations , seizures , and intracranial calcifications malformations , seizures , and intracranial calcifications ( Sturge – Weber syndrome ) .( Sturge – Weber syndrome ) .

12 – Strawberry hemangiomas .12 – Strawberry hemangiomas .

13- Neonatal acne : occurs in approximately 20% of newborns. 13- Neonatal acne : occurs in approximately 20% of newborns. It appears after 1-2 wk of life and is virtually never present It appears after 1-2 wk of life and is virtually never present at birth , typically the lesions are comedones , but at birth , typically the lesions are comedones , but inflammatory pustules and papules may be present . No inflammatory pustules and papules may be present . No treatment is necessary .treatment is necessary .

Erythema toxicum , Erythema toxicum , physiological desquamationphysiological desquamation