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Diseases of the Newborn Part2

Diseases of the Newborn Part2

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Published by: sarguss14 on Feb 20, 2009
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PEDIATRICS 2
BLOOD AND HEMOSTATIC MECHANISM
Dr. Alabastro
2nd shifting / Sept. 15, 2008
Trans group: Chubimbonbon
Blood and Hemostatic Mechanism:
\u2022
Hgb = 17\u201319 mg/dL
\u2022
Leucocytosis and elative neutrophilia in 1st 24 hours
\u2022
Relative lymphocytosis after 1st week
\u2022
RBC with relatively low levels of reduced Glutathione
\u2022
Deficient capacity of liver to conjugate Bilirubin
\u2022
Normal
hemostatic
mechanism
depends

upon establishment of normal intestinal flora and elaboration of Vitamin K

Anemia
Definition:
\u2022
Full term : Hct < 45%; Hgb < 14.0 g/dL
\u2022
Pre-term: Hct < 40%; Hgb < 13.5 g/dL
\u2022
Acute hemorrhage at time of bit may not be reflected
in initial Hct
\u2022
Capillary Hct is higher than central hematocrit due to
sludging
\u2022
If pH is low, central H\u201dct may be inaccurate (high)
because of vasoconstriction
Causes:
\u2022
Blood Loss: pre-natal, intrapartum, post-natal
\u2022

Hemolysis: isoimmune hemolysis, congenital defects of the erythrocytes, abnormalities of erythrocyte membrane, disorders of hemoglobin synthesis, acquired defects of erythrocytes

\u2022
Underproduction of erythrocytes: Damond-Blackfan
Syndrome, parvovirus, vitamin deficiencies
History Data:
\u2022
Hemorrhage: feto-fetal transfusion, internal/external
hemorrhage, OB bleeding, post-natal bleeding
\u2022
Obstruction to placental blood flow: tight nuchal cord
\u2022
Accelerated RBC hemolysis: isoimmunohemolysis,
infection, hemoglobinopathies, erythrocyte enzyme
defects, red cell membrane disorders, DIC
Clinical Manifestations:
\u2022
Pallor
\u2022
Tachycardia with or without hemic murmur
\u2022
Respiratory distress initially tachypnea
\u2022
Weak pulse
\u2022
Shock
\u2022
Combination of sign points to decompensation:
EMERGENCY
Laboratory:
\u2022

Samples of work-up obtained before treating CBC with peripheral smear, reticulocyte count, Coomb\u2019s test, blood type and cross-matching, coagulation studies if indicated

\u2022
Serial Hbg/Hct necessary to detect anemia early before
signs of decompensation occur
Management:
\u2022
Immediately transfusion in baby with pallor and/or
respiratory distress in 1-3 hours
\u2022
Immediate plasma expanders or resuscitation in baby
with hypotension or shcok
\u2022
Partial exchange with packed RBC in anemic hydrops
baby
\u2022
Whole blood or packed RBC diluted with plasma may
be pushed IV in continuing hemorrhage
Features of Coagulation System
\u2022

Prothrombin time of full-term and pre-term infants is only slightly outside the adult range of 10-12 sec (14+/1.3)

\u2022
PTT longer in newborn than adults (51/57+/-10/10.5)
\u2022
Factors XI and XII low in preterm infants
\u2022
PTT is of little value in the sick newborn prolonged
even without evidence of hemorrhage
BLEEDING DISORDERS

MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY KC JAM CECILLE DENESSE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC
PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU
RACHE ESTHER JOEL GLENN TONI

Low Hgb
Retic count
LOW
Congenital
Hypoplastin
A n e m ia
NORMAL OR HIGH
Coombs Test
(-)
MCV
LOW
Chronic IU Blood Loss
a-thalassemia

NORMAL OR HIGH
Peripheral Blood
Smear

(+)
Immunoe Hemolytic
Anemia
ABO, Rh
Minor Blood Group

ABNORMAL
\u2026.

NORMAL
Infection
Blood Loss
Misc

Subject:
Topic:
Page 2 of 6
\u2022
Local cord, scalp, GIT, abdomen, lung, intraventricular
hemorrhage
\u2022
Generalized
acquired
hemorrhage:
Hemorrhagic
disease of the newborn, DIC, liver
BILIRUBIN PATHWAY
\u2022
Unconjugated bilirubin \u2013 nonpolar, insoluble, indirect
bilirubin (B1) causes kernicterus
CAUSES OF INDIRECT HYPERBILIRUBINEMIA
\u2022
Overproduction of bilirubin: hemolysis, extravated
blood,
polycythemia,
increased
enterohepatic
circulation
\u2022

Undersecretion of bilirubin: decreased hepatic uptake of bilirubin, decreased conjugation, decreased transport of conjugated bile out of hepatocytes

\u2022
Combined: perinatal infection, multisystem disorder
NON-PHYSIOLOGIC JAUNDICE
Definition:
\u2022
Cord bilirubin > 3 mg/dL
\u2022
Clinical jaundice in the 1st 24 hours
\u2022
Rate of rise of bilirubin > 5 mg/d/day
\u2022
Total serum bilirubin >12.9/mg/dL in term, >15 mg/dL
in preterm
\u2022
Direct bilirubin >1.5 mg/dL
\u2022
Jaundice persisting > 1 week in term, > 2 weeks in
preterm
FACTORS ASSOCIATED WITH AN INCREASE IN BILIRUBIN LEVELS:
\u2022
Race: Oriental, American, Indian, Greek
\u2022
Maternal: diabetes, HPN, OCP, 1st trimester bleeding,
decreased plasma zinc
\u2022
Drugs: Diazepam, Oxytocin, epidural anesthesia
\u2022
Labor and delivery: PROM, breech delivery
\u2022
Infant: LBW, prematurity, breastfeeding, caloric

deprivation, infection, increase in weight loss, delayed meconium passage and cord clamping, decrease fluid intake, low Zinc and Mg, male sex

Management
\u2022
Surgical determination of serum bilirubin, Hgb, Hct
reticulocyte count if hemolytic
\u2022
Do specific testing if non-hemolytic
\u2022

For indirect phototherapy, decrease enterohepatic circulation, stop breastfeeding for 1-3 days, supportive, exchange transfusion, Phenobarbital

\u2022
For direct: depends upon case
\u2022
Manage underlying cause or refer to surgery
SEPSIS AND MENINGITIS
Etiology: bacterial, viral, fungal, parasitic
Predisposing factors:
\u2022
Prolonged ROM
\u2022
PROM
\u2022
Foul smelling amniotic fluid and baby
\u2022
Maternal fever
\u2022
Prematuriy
\u2022
Unexplained fetal distress
\u2022
Previous septic infant
\u2022
Unsterile delivery
\u2022
Unsterile practices
\u2022
Contaminated equipments
\u2022
Infected personnel/caretakers
Manifestations
\u2022
Lethargy
\u2022
Poor feeding
Jaundice
Blood types, Rb, Coombs, Hct, Red cell
morphology, reticulocyte count
Measure total and direct
bilirubin
Inc indirect
Inc Direct
Coomb\u2019s (+)
isoimmunizatio
n

Intrauterine
infection
Sepsis
Biliary atresia
Bile plugs
Galactosemia
Choledochal

cyst
Tyrosinosis
Cystic fibrosis
A-1 antitrypsin
def

Coomb\u2019s (-)
Hct Normal or
Low

High
transfusion
Delayed

c lu m p in g S G A
Normal or Low Hct
Red cell morphology & reticulocyte count
Abnormal
Normal
Sp Morpho
Abnormalities
Non Sp Morpho
Abnormalities

Spherocytosis
Elliptocytosis
Stomatocytosis
pyknocytosis

ABO

incompatibility
G6PD deficiency
Pyruvate kinase
def
Other enzyme def

a
-
t h a la s s e m ia

Extravascular blood
Inc. Enterohepatic
Circulation
-Breastfeeding
-Pyloric Stenosis
Metab.-Endocrine
-Galactosemia
-Hypothyroidism
Other
-IDM

Subject:
Topic:
Page 3 of 6
\u2022
Apnea
\u2022
Tachypnea
\u2022
Cyanosis
\u2022
Diarrhea
\u2022
Metabolic acidosis
\u2022
Temperature instability
\u2022
Abdominal distention
\u2022
Petechiae/purpura
\u2022
Hepatospenomegaly
\u2022
Seizures
\u2022
Tense fontanelle
Laboratory
-
Sepsis work-up
\u2022
CBC (WBC and differential)
\u2022
Urinalysis
\u2022
CSF analysis (WBC and differential, glucose,
protein)
\u2022
Chest and abdominal X-ray
\u2022
Cultures (blood, CSF, urine)
-

Other work up as appropriate: ABG, coagulation studies, stool culture and sensitivity ang gram stain, CRP

-
Cranial UTZ / CT Scan
Management
-
Do sepsis word-up on all babies considered as septic
-
Antibiotic coverage, penicillin derivative and amino
glycoside
-
Supportive management as needed: transfusion,
thermoregulation, glucose, seizures, vital signs
-
Anticipate complications
\u2022
DIC
\u2022
NEC
\u2022
Feeding problems
\u2022
Complications
of
meningitis

(SIADH, ventricular obstruction, seizures, subdural effusion, relapse)

BASIC REQUIREMENTS IN CARE OF NEWBORN
1. Immediate resuscitation
2. Establishment of respiration
3. Adequate nutrition
4. Normal body temperature

5. Avoidance of contact with infection
ASPHYXIAImbalance in oxygenation
Causes:

Fetal1. Placental separation
2. Inadequate perfusion of maternal side of
placenta
3. Interruption of umbilical blood flow
Neonal
1. Airway obstruction

2. Excessive fluid in lungs 3. Weak respiratory effort 4. Sequel to fetal hypoxia

CRITERIA FOR ASPHYXIA
1. Historical factors (relative)
-Fetal distress fetal scalp acidosis

2. Physical exam (relative)
1 min APGAR score of 2 or less
5 min APGAR score of 5 or less

3. Blood gas pH (absolute)

- pH 7.5 or less at 5 min
- pH 7.2 or less at 10 min
- base deficit of 10 at 10 min

RESUSCITATION
1. Drying, warming, positioning, suction
2. Tactile stimulation
3. Oxygen
4. Bag and mask ventilation
5. Chest compression
6. Medications
ITEMS READILY ACCESSIBLE FOR RESUSCITATION

1. Ambu bag
2. Respiratory mask
3. Endotracheal tube
4. Laryngoscope
5. Suction apparatus

OXYGEN
- Blow by oxygen for cyanosis with spontaneous respiration and

a heart rate >100 bpm
- initial oxygen concentration close at 100%
- Nasal cannula or facial mask

- The closer the distance to the nostril, the higher concentration
of O2 delivered

BIG VALVE MASK
- use of apnea and HR < 100 bpm
- appropriate for baby\u2019s size and gestation not to exceed 750ml
- arte at 40-60 mins
- CI: thick meconium stain and diaphragmatic hernia

ENDOTRACHEAL INTUBATION

Indications:
1. Need for prolonged positive pressure ventilation
2. Ineffective bag and mask ventilation
3. Suspected diaphragmatic hernia

UMBILICAL CANNULATION
Medications used in resuscitation
1. Epinephrine 0.1-0.3 ml/kg of 1:10,000 rapid IV bolus
2.NaHCO3 2 mEq/kg slow IV

3. Glucose 10% 2ml/kg IV then infusion of 8-10mg/kg/min
4. Naloxone HCl 0.01mg/kg rapid IV bolus
5. Ca gluconate 100mg/kg slow IV
6. Atropine 0.01 mg/kg slow IV or IM

NECROTIZING ENTEROCOLITIS (NEC)
\u2022
Most common life threatening emergency of the GIT in
the newborn period
\u2022
Necrosis \u2013 final common pathway of response to in the
newborn gut
\u2022
Onset usually occurs in the 1st 2 weeks or as late as 3
month of age in VLBW infants
\u2022
Most frequent site: distal ileum and proximal colon
\u2022
Triad: intestinal ischemia, oral feedings,(metabolic
substrate) and pathological organisms
\u2022
Greatest risk factor: prematurity
\u2022
Complications: perforation, adhesion, diarrhea and
malabsorption
Pathogenic/Predisposing Factors
\u2022
Bowel immaturity and bowel injury
\u2022
Perinatal asphyxia
\u2022
Infection: E. coli, Klebsiella, Pseudomonas, Salmonella,
Clostridium, Staphylococcus epidermidis, and rotavirus
\u2022
Hypertonic substances in gut
\u2022
Indwelling umbilical catheter
\u2022
Exchange transfusion

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