Pediatrics Newborn child

IFNMUChair of Children’s Surgery and

Propedeutics of Pediatrics

Theme of the lecture:

A Newborn Child Physiological and Transition

States in the Newborn Period.Premature and Immature

Newborn Children.

PLAN OF THE LECTURE:Neonatology as a speciality.Notion about maturity of a newborn.Bordering states in the newborn period.Assessment of viability of newborn children.- Reasons of the birth of premature children. A scale of assessment of RDS.Primary toilet of newborns.Every day toilet of newborns.Sanitary-hygienic demands to maternity departments.

Neonatology – a science which studies physiological and pathological states in newborn children

The birth of a child leads to destruction of the whole system of mother-placenta-fetus and the changes of the conditions of the outer surroundings, which leads in its turn to the activation of the system of adaptation mechanisms of a newborn. Thanks to this the newborns adapt to the new conditions of the environments.From the moment of tying the umbilical cord and disconnecting the fetus from the mother an extrauterine life begins. In the first hours and days rebuilding of the functions of separate organs and systems with deep changes in exchange of substances.

SOME STAGES OF CARE-FREE ANTENATAL LIFE OF

A CHILD IS DEMONSTRATED IN THE

FOLLOWING SLIDES

18 weeks. Almost 14 cm. The fetus now can percieve sounds from the surrounding world. Be careful in talking.

I hear everything. Speak and behave yourself friendly and humane as good people. Life is given only once !24 weeks

6 months. There 8-10 care-free weeks, but a little man is too restricted in the womb of the mother, and he is going to leave it. He turns down with his head- this way it is easier to go out and

get freedom…

36 weeks. In 4 weeks this child will see the outer space.

Wait for me ! Soon I will be a new worthy Resident of the Earth.

Processes going on in the organism of a newborn child after the birth

Pulmonary type of respiration is established,the lesser blood circle begins functioning ,the child starts selfdependently take food,proper thermoregulation appears,properties of the blood are changed,metabolism is increased, etc.

The main terms of in neonatology

Neonatal period- the period of life of a child from the moment of tying up the umbilical cord to 28 days of life (1 month).- Gestational age or the term of gestation (GT-the number of full weeks between the last day of menstruation (but not conception) and the date of delivery.

The Main Terms in NeonatologyMature baby - born in GT from 37 to 41 weeks of gestation (between 260 and 294 days of gestation).Premature baby - a baby born on the 36 and earlier weeks.Overmature baby - a baby born on the 42nd week of gestation or later.Delay of intrauterine development (DIUD) - the mass of body at the time of the birth does not correspond to gestation age.

Indications of Physical Development of a Mature Baby:

• the length of the body – more than 45 cm (average 55-52 cm);• body mass –more than 2500g (medium 3200-3500g);• medium head circumference -34-36 cm;• medium circumference of chest 32-34cm.

Signs of Maturity of Newborn Babies

• Mature, in-time born baby - a baby, born between 37-41 weeks of gestation, the length of the body is more than 45 cm (medium 50-52cdm), the body mass more than 2500g (medium 3200-3500g), the middle head circumference 34-36cm, middle chest circumference 32-34 cm. Such child is crying loudly, he actively sucks, holds warmness well, there are marked physical reflexes, enough muscular tone, marked moving activity, reaction of pupils on light is preserved (under the action of light the pupils are widened). The child reacts on bad smell and taste.

Periods of Perinatal Development

Late antenatal period – from 22 to 40 weeks of i/uterine development;Intranatal period - from the beginning of delivery activity up to the birth;Perinatal period - from 22nd week of i/uterine development to 7 days of extra-uterine life;Neonatal period - from the moment of tying up the umbilical cord to 28 days (1 month) of life;Early neonatal period – from the moment of tying up the umbilical cord to the 7th day of life;Late neonatal period – from the 8 to 28th days of life.

Signs of Maturity of Newborn Babies

The skin is smooth, elastic, some how inflamed, covered with lubricant, reach of blood vessels, well developed sebaceous glands. The skin can be the entrance gate to infection.Subcutaneous fatty layer is laid down in the last 2 months of intrauterine development. Characteristic is greyish-brown fat, which takes the main part in the process of permanent thermogenesis.

Signs of Maturity of Newborn BabiesMuscular system – characteristic is high muscular tone of bending muscles.The nervous system is characterized by a number of physiological reflexes.Sense organs are underdeveloped, but there is reaction on light, sound, taste, smell.Hair covering and its accessories. Hair on the head is well marked, the nails go up to the end of the phalanxes of the fingers, on the shoulders there is bloom of hair.External ears are formed, the cartilages are compact and elastic.Sex organs –ovaries are go down in the boys, in girls – the large sex lips close the little ones. Diameter of breast gland is more than 10 mm.

The Aphar ScalePointsPoints 00 11 22

Colour of skin paleness or general cyanosis

cyanotic extremities

pink color

Muscle tone decreased weak movement of

extremities

active

Reflectory activity

-- weak cry, cough

Respiratory rate -- bradypnea 40-60-min.

Heart beat rate -- less than 100 in 1 min

more than 100 in 1 min.

The Aphar ScaleThe condition of the child is assessed as satisfactory, if the child is born with a mark on Aphar scale 8-10 balls.4-7 balls -noticeable asphyxia,0-3 balls - grave asphyxia.Assessment on Aphar scale is performed on the 1-th and 5-th min. after the child is born.

Bordering States in the Newborn Period

In the process of adaptation with truly physiological can arise reactions, which stand on the border between the normal and pathological. These are bordering states, which are accompanied with changes in the child’s organism and connected with adaptation to the new conditions of life. There are the following bordering states:

Physiological (transitory) loss of body weight.Transitory violation of heat balance. These disturbances

develop due to insufficiency of thermoregulation processes, unadequate care of a newborn baby (increase or decrease of the environmental temperature ): - transitory hypothermia; - transitory hyperthermia.


3.Transitory changes of skin coverings. Develop in all newborn babies.- simple erythema; - Physiological shell of skin coverings;- Toxic erythema;4. Transitory (physiological) hyperbilirubinemia.


5. Hormonal crisis. - Thickening of breast glands (physiological mastopathy); - Metrorrhagia (bleeding from the groin); - Desquamative vulvovaginitis; - Miliaria.6. Transitory peculiarities of kidney functions. - Transitory oliguria; - Proteinuria; - Urate infarction.


7. Transitory changes on the side of GIT. - Physiological dyspepsia; - Transitory dysbacteriosis.8. Transitory changes in blood circulation.

Physiological (transitory) loss of body mass.

Loosing of weight begins from the 2nd day of life. Maximal - on the 3-4th day, in rare cases- on the 5th day. Loss of weight is connected with:Insufficient coming of liquid and relative hunger of a child;With loss of liquid through the skin;With discharge of meconium and primary urine;With drying and falling out the umbilical remnant.

Physiological (transitory) loss of body mass.

Loss of the primary body weight more than by 10% is supposed to be pathological.Renovation of primary body weight under correct care and regime takes place at the 1st or 2nd week of postnatal life.

Pathogenesis of transitory jaundice in newborn babies

Increase of bilirubin formation as a result of:shortened life span of erythrocytes;uneffective erythropoiesis; increase of bilirubin formation from nonerythrocytary sources of gem (myoglobin, cytiochrome of the liver, etc.). Decrease of ability of hepatocytes to catch indirect bilirubin;low activity of glucuroniltransferase and uridindiphosphoglucoso-dehydrogenase;decrease of ability of bilirubin excretion from hepatocyte.

Transitory Violation of Heat Balance • These violations develop because of unperfect processes of thermoregulation , unadequate care of newborn babies (increase or decrease of environmental temperature).• Hypothermia – under the birth the environmental temperature decreases by 12-15 C.* So, the body temperature of a child becomes 35.5-35.8*C. So, measures must be taken to keep warmth of a child (wrapping, heating of the table while weighing the baby, etc).- Hyperthermia develops, as a rule, on the 3-4th day of life in overheating the child or insufficient entering of liquid. Body temperature can increase up to 38.5-39.5*C. The measures taken are: giving more to drink, physical cooling, etc.

Transitory changes in skin integument

Simple erythema (physiological catarrh of skin) appears from the first hours of life in the form of skin hyperemia and lasts for 3-7 days. It develops due to widening of capillaries as a reaction on irritation of the skin receptors with different external irritants.


Physiological shell of skin integument - arises on the 3-5th day of life (more often – in overmature babies) with especially bright physiological erythema during its fading (more often on the head, chest). It does not require treatment.


Tocxic erythema (TE) is present in 40-50% of children and is manifested with arising small dense papules of whitish color, circled by red or pink corolla.TE arises around joints, buttocks, on the abdomen, on face. Mostly it appears on the 2-5 days. The condition of the baby’s health is not violated. It is a kind of allergic reaction on cooling, proteins taken, endotoxins, etc.

Hormonal crisisDevelops as a result of action of the mother’s estrogens, discharged in large numbers at the end of mature pregnancy and pass with the blood to the baby. Due to physiological immaturity of the liver these hormones in newborn babies do not inactivate.

Manifestations of hormonal crisis:physiological masteopathy;metrorrhagia (hemorrhage from the groin);desquamative vulvovaginitis.

Swelling of milk glands (physiological mastopathy)

Arises on the 3-4 day of life independently of sex of a baby, maximum of swelling is on the 7-8th day, enlargement is symmetrical, the skin is unchanged, sometimes a whitish-grey contents is discharged. No treatment is required. Do not stamp out the contents !!!It is necessary to remember - in entering bacteriological infection mastitis can develop. If hyperemia appears in the area of swelling and temperature increases, the surgeon’s consultation is necessary.

Pathogenesis of transitory jaundice in newborn babies

Increase of entering of indirect bilirubin from the intestine into the blood as a result of:

a) high activity of B-gluguronidase in the wall of intestine;b) entering the part of blood out of the liver from the intestine

into the lower vein;c) sterility of the intestine with weak reduction of biliary

pigments. - Normal level of bilirubin in the blood serum of newborn

babies is - 26-34mcmol/L.

Transitory jaundice in newborn babies

The main difference of TJ from pathological jaundices is:arises on the 3-4 day of life;lasts less than 10 days;there is no increasing the amount of bilirubin.

Transitory changes in the functions of the kidneys

Transitory olyguria is observed in all newborns in the first 3 days of life – discharge of urine less than 15-20 ml/kg/d. Proteinuria is a consequence of increased permeability of glomerular epithelium, canaliculi at a background of hemodynamical peculiarities.Urate infarction - laying of uric acid in the form of crystals in the lumen of collecting tubules. “Infarction” urine is of yellow-brick-red color. The reason of an increased amount of uric acid is decomposition of a large number of cells in the first days of the baby’s life, mostly decomposition of leukocytes.

Transitory changes of the gastro-intestinal tract

Physiological dyspepsia – violation of the stool, observed almost in all newborn babies in the 1st week of life (transitory stool). The basis - disturbances connected with increased sensibility of secretory-motile apparatus of the intestine to the fats, proteins, which earlier did not enter it.Transitory dysbacteriosis - physiological phenomenon, connected with settling in sterile intestine of a newborn baby conditionally-pathogenic microflora. Maternal milk is a deliverer of bifidoflora leading to force out pathogenic flora or strict decreasing its amount. Phase of sterility (the first 2 hours), the phase of settling (the first 2-3 days of life) and the phase of transformation of microflora – establishin prevailing of bifidum-flora in condition of breast feeding.

Transitory changes in the blood circulation

Are connected with: tying up of umbilical cord;starting the functioning of the lesser blood circulation circuit; closing fetal ways of communication in the cardiovascular system.

A premature baby

A premature baby

Premature babiesPremature are very little babies, which compose very extreme problems:problems of morbidity;problems of mortality;problems of disability.Premature babies are born dead in 8-13 times more frequently than mature ones and 30 times more often dye in the first week of life (M.S. Kramer et al., 2000). Especially this concerns the babies with very little body mass (less than 1500g).

Premature babiesPrematurity is an experiment made by the nature. The result of the experiment depends on our knowledge of the peculiarities of premature babies, on our ability to compose for every such baby proper conditions for existence. Only this can help to solve the problems connected with prematurity.The rate of premature deliveries is very variable, but in the most of industrially developed countries in recent years it stays enough stable and reaches 5-10%.

Premature babies Assessment of the degree of immaturity is performed on the basis of total indices: term of gestation, body mass of a baby at birth and is taken into consideration total combination of morphological and functional signs.Premature are supposed babies in the term of gestation 36 and less weeks, body mass less than 2500g, body length less than 45 cm.

Premature baby

-- In the old textbooks there is division in degrees of prematurity (there are 4 degrees). Now it is not used.- At present the babies with body weight at birth less than 1500g and less are called premature babies with very small body mass” (formerly – deep premature).- A baby with body mass less than 1000g at birth is a baby with extreme low weight.

Reasons of prematurity

Social-economical conditions of life, absence or insufficient medical service, poor nutrition, professional harmful conditions of work, level of education.Social-biological: the mother’s age less than 18 and more than 30 for the 1st delivery, the father’s age less than 18 and more than 50, previous abortions, spontaneous miscarriage,Little interval between gestations.Climatic factors.

Morpho-functional peculiarities of a premature baby

The skull - the bones are soft, sutures and small sinciput are open. External ears are close to the head.The skin is thin, wrinkled. Subcutaneous fatty layer is very thin or absent, nails do not reach the ends of the fingers.Sex glottis in girls is open, ovaries in boys are not put in place.The baby is flaccid, weak, underdeveloped or weak swallowing and sucking reflexes, imperfect thermoregulation.

Morpho-functional peculiarities of a premature baby

Respiratory organs: higher rate and less deepness of respiratory movements, respiratory movements are weak.There are respiratory pauses.

Peculiarities of the nervous system of premature babies

In deeply premature babies (up to 32 weeks of gestation) is noticed absence or hindered swallowing and sucking reflexes.Loosing reflexes of inborn automatism (by Babkin, Robinson, Moro, Halant).Prevailing of subcortical activity appears a tendency to chaotic movements and trembling.Characteristic is slow development of orientation reflex and producing conditioned reflexes.

Normative Documents of MPHU on the Care of a Healthy Newborn Baby

Clinical Protocol of Medical Care of Healthy Newborn Child - Order of MPH of Ukraine, N 152, 04.04.2005.

Clinical Protocol of Medical Care of a Healthy Child at the Age up to 3 Years – Order of MPH of Ukraine, N 149, 20.03.2008.

Abstract from Order No 152 of MPH of Ukraine

3.2 Weighing of a newborn baby.3.7.1 The first weighing of a newborn is carried out in the maternity room after performing the contact “skin-to-skin” and putting the baby to the mother’s breast before removing the baby to the hospital ward for mother and child. 3.7.2 During the weighing the principle of heat keeping chain is held aimed at preventing the overcooling of a child.3.7.3 A healthy newborn child does not need every day weighing.3.7.4 Every day weighing is carried out if there is a medical indication.3.7.5 Before discharging the baby from the maternity department weighing is obligatory.

Medical care of a healthy newborn baby in maternity room

Primary medical examination of a newborn,Contact “skin-to-skin” is performed, it lasts not les than 2 hours.Tying up the umbilical cord at the end of the 1st min after pulsation stopped.Starting of breast feeding.Taking the temperature in 30 min after the baby is born.Prophylaxis of ophthalmia Tobrex, but not later than 1 hour.

Heat chain- Warm maternity or operation room > 25*C.- Urgent drying (take out moist wraps).- Early contact “skin-to-skin” with the mother (not less than 2 hours). - Early breast feeding (during an hour after the birth).- Postponed bath, weighing and full examination of the baby. - Adequate dressing for the baby. - Staying together of mother and a child. - Heat defense of a newborn during reanimation and transporting. - Medical personnel must know every step of heat chain.

Routine medical procedures in the maternity home

The majority of newborns do not require Routine medical procedures.Routine medical check ups by narrow specialists.

Every medical examination must be:

evidential well-founded;not harmful for the baby;carried out with the mother’s consent

A V O I D ::Routine aspiration of the contents of respiratory ways

If aspiration is yet needed, it is less harmful to use the pear shaped ballRoutine checking of esophageal permeability.Only in cases of:Much water;If before the deliver USE showed “small stomach” or absence of the stomach; If the baby has discharges from the mouth;If the regurgitate milk;If the baby has an attack of cough with episodes of apnoe or cyanosis.

A V O I D::Routine bacteriological examinations of gastric aspirate of a newborn baby;Bacteriological examination of feces, samples from the skin, umbilicus.Routine laboratory tests (general blood analysis, determining of blood group, serum bilirubin, etc.Determining of blood group and Resus-factor, if :

a) The mother’s blood group is 0(1); b) The mother’s Resus-factor is negative; c) The mother’s blood group isn’t known. If the mother has negative Resus-factor, determine bilirubin of umbilical

blood.Routine Roentgenological and ultrasound research; Routine medical interventions by doctors-specialists;Every day weighing.The baby must be weighed only after birth and before discharge from the hospital

Common staying of the mother and the baby

Common staying is when the baby and the mother are in one hospital ward all the day round from the moment, when the baby is born and up to the discharge from the hospital.Absolute contraindications for the common staying of the baby and the mother are:Open form of tuberculosis;Acute psychological diseases of the mother.

“All day round staying together in one ward with the mother from birth to the

moment of discharge”Common staying includes the following: Care of the mother her baby with introduction of family members;

- The mother feeds the baby with breast milk; - The interference of medical personnel is minimized; - The baby’s temperature is taken and registered twice a day; - Wash and dress the baby; - All administrations and manipulations are carried out in

the presence and agreement of the mother;The hospital personnel must teach the mother to take care of her baby, give her consultations in all questions.

Care of umbilical cord remnant

Thorough washing the hands;No need to cover with a wrap or dressing;No need in treatment with any antiseptic;in the condition of common staying in a separate room.In the absence of the contact “skin-to-skin” and the following separation of the baby from the mother with the aim of prevention of colonization of hospital flora to treat it with brilliant solution;The child’s dresses must be clean;If dirt entered the umbilical remnant (urine or feces), wash it with clean boiled water with soup and thoroughly dry it with clean wrap.

Care of the umbilical cord remnant (umbilical wound) after discharge from the

hospital The baby can be discharge from the hospital with umbilical wound, if there are no signs of infection under the condition if the medical personnel taught the mother all hygienic measures with this wound; The umbilical remnant always must be clean and dry; Do not cover the umbilical wound with wrap or dressing; Up to the full healing of the umbilical wound bathe the baby only with boiled water;Strictly follow the possible signs of infection.

Care of the skinDelivery oiling protects a delicate skin of the baby, violation of its integrity can promote entering infection;It isn’t expedient without medical indication to use different powders and ointments to care about the umbilical wound;Wash the child under warm running water;The child’s dresses must be clean;The first taking a bath is done after leaving the hospital.

Life threatening conditions for the newborn babies:

The mother must be informed about all conditions which are dangerous for the baby’s life and urgent medical assistance is required:The child poorly sucks the breast;Convulsions;Violation of respiration (quick or difficult);Hypo- or hyperthermia;Umbilical wound is red or pus appeared;Hypotension or increased excitability;Vomiting or diarrhea.

Sanitary-hygienic requirements to maternity departments

In the maternity homes the conditions of the surrounding environment must correspond to the peculiarities of the newborns and sanitary-hygienic requirements. The wards must be light and warm with good ventilation and with the rooming area for every healthy baby baby -2,5m and for the premature ones not less than 4,5 m. Obligatory is the principle of cyclic settling of the wards.

Sanitary-hygienic requirements to maternity departments

Every day wet cleaning of the wards is carried out not less than 4 times with using disinfecting solutions. Then the wards are radiated with bactericidal lamps. General cleaning of the wards is done after the discharge of the baby. There are special instructions for choosing personnel for the children’s out-patient departments. Once a year is carried out a full medical check up of the medical personnel working with newborn babies.

The baby can be discharged from the maternity department, if:

Umbilical cord remnant is clean, dry, without signs of infection.The temperature of the baby is stabile , 36.5*C - 37.5 *C.The baby sucks the breast well.Performed all vaccinations and screening examinations.Clinical state of the baby is good.The mother can take care of the baby.The mother got consultations about prevention children’s diseases.The mother got consultation about the cases when there is urgent need in calling a doctor.

Terms of examination by the family doctor he newborn baby

The primary check up is done at home, not later than on the second day after discharge from the hospital.In a day after the doctor’s visit - a check up by the district nurse.At the age of two weeks - the doctor’s check up at home.At the age of 3 weeks - a nurse’s check up at home.At the age of 1 month - check up by the doctor at the polyclinic.

The number of obligatory prophylactic medical check ups of a child at the age up to 3 years (13 check ups and 6 check ups by the nurse) cannot be less. The doctor can make more visits, if there is need on the side of the baby. There is no need in increasing the number of check ups without any serious reason. This does not lead to making better the condition of a health of the baby (A).

Obligatory medical prophylactic check ups of the children at the age up to 3 years are carried out in terms, determined by the Order of MPH of Ukraine (in the 1st month - once a week, in the 1st year of life - once a month, in the 2nd year of life - once in half a year, in the 3rd year of life - once at the age of 3 years) (Appendix 2 to the Protocol N 149).

Education

Pediatrics Newborn child