Chapter 3

Neonate part 2
Neonatal respiratory distress and neonatal resuscitation 1 - 14
Neonatal convulsion 15
Necrotizing enterocolitis 16
Sepsis 17-20
Hypoglycemia 21
Hypocalcemia 22-23
Prematurity 24
High risk newborns 25
Routine assessment and care of neonate 26-34
Birth trauma 35-39

M.khalil
 Neonatal Respiratory Distress:
Causes:

(1) pulmonary:

(A) upper airway : (stridor) + (respiratory distress)

(1)bilateral coanal atresia :
•may be missed if unilateral
•diagnosed by failure to pass NGT >>> refer to ENT specialist
•cyanosis when quiet or at rest
•cyanosis is aggravated by feeding >>> choking
•cyanosis is relieved by crying
(2)pierre robin syndrome >>> sever micrognathia
(3)vascular ring >>> congenitally the aorta or great vessels (ex: SVC) encircle the
trachea and esophagus
(4)laryngeomalacia
•commonest cause of chronic stridor
•immature laryngeal cartilage >>> inward laryngeal collapse >>> biphasic stridor
(inspiratory and expiratory)

managment Upper airway obstruction:

•Insert an oral airway ex: oropharyngeal

•Provide oxygen
•Suction secretions
•May require intubation

(B) lower pulmonary:

•TTN >>> transient taccypnea of newborn
•acute respiratory distress syndrome (hyaline membrane disease)
•congenital pneumonia and sepsis
•meconium aspiration
•pneumothorax

(
(2) extra pulmonary:
•congenital diaphragmatic hernia
•congenital heart disease
•birth asphyxia
•metabolic >>>> hypoglycemia and hypocalcemia
•hypothermia >>> increase in oxygen and glucose consumption >>> hypoxia and
hypoglycemia

Notes:
(1) most common causes of RD in neonates are:
•transient taccypnea of newborn
•acute respiratory distress syndrome (ARDS)
•meconium aspiration

(2) RD started within 6hours after birth in preterm baby think of :

•ARDS •pneumonia
(3) RD started after 6hours after birth in preterm baby think of :
•congenital heart disease •pneumonia
(4) RD started within 6hours after birth in term baby think of :
•transient taccypnea of newborn •meconium aspiration • asphyxia
(5) RD started after 6hours after birth in term baby think of :
•congenital heart disease •pneumonia
(6) in intrauterine life the lungs are filled with fluid and not working but there is
fetal respiratory movement >>> help in maturation

Signs of RD:
•taccypnea >>> (NN > 60 , 1 year >50 , 2 years >40 , 3 years >30) >>> grade1
•taccypnea + flaring of alae nasi >>> grade2
•taccypnea + flaring of alae nasi + recessions (intercostal , supracostal and subcostal)
>>> grade3
•taccypnea + flaring of alae nasi + recessions + grunting >>> grade 4
•taccypnea + flaring of alae nasi + recessions + grunting + cyanosis or apnea >>>
grade5

2
Grade 1,2 >>> mild RD
Grade 3 >>> moderate RD
Grade 4,5 >>> sever RD

Grunting:
•is
* an abnormal short deep expiratory sound due to Expiration through partially
↑

closed vocal cords to prevent lung collapse

•called physiological CPAP

Note: Central cyanosis is a sign of RD in NN not peripheral cyanosis

Congenital diaphragmatic hernia:

•Ass' with H/O no crying And cyanosis

•Is not a birth injury
F
•most cases are sporadic but some cases are familial (AR)
•Congenital defect most commonly in Left Posterior diaphragm Called bockdalek hernia
E
•Intestine or any abdominal organ herniates into the lung
•Scaphoid abdomen
•O2 by mouth is C/I >>> eg: Ambobag with oxygen mask
•Dx by chest X-ray
•treatment >>> O2 by ETT then Surgical repair

Acute Respiratory Distress Syndrome (ARDS) (Hyaline membrane

disease):
Expiration
•The most frequent through partiallydistress
cause of respiratory closed vocal cords
in premature infants
‫وكل ماجا بدري اكثر زادت نسبه انه يصيرله املرض هذا‬

3
•decrease in surfactant leads to increase in physiological dead space
•can be occured also in terms ex: IDM

Note:
Assessment of Fetal Lung Maturity is done by amniocentesis:
•Ratio is 1 upto 32 wk GA, then Lecithin increases while shingomyelin remains nearly
the same
•at 35 week if Lecithin/sphingomyelin (L/S) ratio is more than 2 indicates lung
maturity but if less than 1.5 indicates high risk of ARDS
•ARDS can be diagnosed antenataly by amniotic fluid sample >>> low lecithin >>> give
betamethasone 72 hours before delivery

• infection by Group B streptococcus infection >>> decrease surfactant >>> ARDS >>>
so give empirical ampicillin in the MX and give Also aminoglycosides to cover gram
negative for precaution

Risk factors:
1)Preferm before 35 weeks (seen in babies of birth weight less than 2.5 kg) ,
2)IDM >>> hyper insulinemia >>> decrease glucocorticoids
•Prevalence of hyaline membrane disease among newborn of uncontrolled mothers is
higher than newborn of controlled mother
3)Hyperglycemia >>> increase insulin >>> decrease glucocorticoids
4)Elective c/s >>> No stress
5)Male
6)positive family history
7)Twins (Multiple Pregnancy)
8) babies born from throid deficient mother
9) babies born from smoker mothers

Notes:
antePartum haemorrhage , birth asphyxia (hypoxia) and hypothermia >>> worsening
the condition and exacerbates RD

M
Note:
1)Emergency c/s (follow prolonged labor)
2)IUGR
3)PROM
4)Maternal addiction
5)female
•all the previous conditions decrease incidence of ARDs

Cx:
1)Hypoxia
2)Pneumothorax due to compensatory emphysema of the Opened alveoli
3)PDA due to hypoxia (normally closed by o2)
4)prolonged O2 exposure with high concentration >>> retinopathy of Prematurity
( retrolental fibroplasia ) and Broncho alveolar dysplasia also leads to further decrease
in surfactant (More damage) Called broncho alveolar dysplasia

Diagnosis:
CXR :
•decreased Lung volume with bilateral ground glass Appearance
•if sever >>> air bronchogram (characteristic CXR)
•ground glass and air broncogram appear after 6 hours on CXR but if ARDS is
complicated by peumothorax >>> pneumothorax appears immediately

Note:
Deterioration and death are common at 3-5 days due to an open ductus arteriosus
>>> heart failure
mx:
•Best is surfactant 4mL / kg through ETT >>> also can be given in any premature as a
preventive measure
•Supportive >>> avoid hypothermia , Fluid and nutrition to avoid hypoglycemia and
humidified oxygen
•Mechanical ventilation

5
 ⬆

Mechonium aspiration:

Incidence in :
•post term due to placental calcification and IUGR >>> stress >>> intrauterine
relaxation of anal sphincter

Signs:
A)Skin, Nails & U.C stained by meconium
B)Meconium in A.F during delievery
C)R.D (Aspiration in 5-10 % of meconium stained babies)

Meconium :
•If cause Comlete obstruction >>> Collapse
•If Partial obstruction >>> Emphysema & Pneumothorax
•Chemical pneumonitis >>> Release vasoconstrictors >>> Pulmonary HTN
•Chemical pneumonitis >>> Destruct local immunity >>> 2ndry bacterial infection
•irritating to stomach >>> gastritis

Radiologically:
Coarse , nodular , irregular pulmonary densities on chest xray

Mx :
1)Prevention:
A)Hot towel on his back
B)Suction >>> sucction of the mouth first then the nose

2)Mx:
A)first step is sucction
B)02 to prevent collapse , N.O inhalationally >>> vasodilator
C)Routine antibiotic therapy is not necessary (No significant difference) but it is given
in libya >>> For 2ndy bacterial infection
D)In resistant cases >>> CPAP (Continous positive airway pressure )
E) no role of steroid
F) bronchial lavage by surfactant >>> washing airway from the meconium and helps
the alveoli 6
 ➡ ➡ ➡ ➡

Transient tachypnea of NN:

• Commonest cause of R.D in term ( lung is mature )

Risk factors:
(1)C/S:
•common with C/S (term or preterm) No squeezing of the alveoli A.F remains in
the alveoli O2 entery mild Hypoxia thats why oxygen supplementation may
be required (that’s why it is called Wet lung disease)
(2)maternal asthma
(3)male sex
(4)macrosomia
(5)maternal diabetes

Note:
•affects some cases in normal vaginal delivery Therefore, some consider it an
unknown etiology

•Within 6 hours the amniotic fluid will be absorbed by the body that's why it's
a transient condition (usually settles within the first day of life but may be Resolve in
48-72 hours >>> maximum 6 days)

•mild respiratory distress >>> that’s why it is the least likely to cause neonatal seizure
Examination: >>> Auscultation is normal Good air entery

•Shows a characteristic chest X-ray findings >>> diffuse parenchymal patchy

infiltrates with fluid in the fissures (interstitial edema) and you may find Pleural
effusion

•DDX : (1) hyaline membrane disease (2) pneumonia (3) meconium aspiration

Treatment:
(1)observation >>> oxygen if needed
(2)in libya >>> antibiotic to prevent secondary bacterial infection

I
Apnea of prematurity:

•Definition:cessation of breathing for longer than 15 second

•associated with bradycardia or cyanosis
•Common in preterm due to immature R.C

Other causes of apnae other than prematurity :

1)Subtle seizure ( so apnea in neonates may be a sign of convulsions) >>> here you will
find apnea with tachycardia.
•So if the apnea caused by subtle seizure it will be associated with tachycardia, but if
the apnea caused by anything else other than subtle seizure it will be associated
with bradycardia.so in general the apnea is associated with bradycardia

2)Sepsis
3)Intracranial Hge:
•Established by brain uss
•Careful handling prevent it
4)Hypoglycemia

• Apnea of prematurity appears in the 2nd to 5th day not in the 1st day & considered
physiological apnea while 1st day apnea is always pathological

Mx:

(1)02 >>> CPAP or Mechanical ventilator depending on severity

(2) RC stimulation :
(A) drugs
•Theophylline
•Caffeine therapy orally or iv (more better and less side effects)

(B)Tactile stimulation : ex Kangaroo mother care (skin to skin contact)

(3) Apnea monitor

8
Birth asphyxia: (hypoxic ischemic encephalopath)

•deprivation of oxygen to a newborn infant that lasts long enough during the birth
process to cause physical harm, usually to the brain (permanent damage to CNS cells
which may result in neonatal death or convulsion or manifest later as cerebral palsy
or mental deficiency)
•oxygen deficit from the 28th week of gestation to the first seven days following
delivery , In most cases the disease manifests at birth or within a few hours after
birth.
•male = females and no race predilection
•after resuscitation >>> reperfusion injury in the brain may be occurred After
6-24hours (formation of free radicals because of ischemia causing apoptosis) >>> may
continue for days to weeks
Causes:
(1) maternal side:
•Failure of exchange across the placenta, eg: abruption
•Inadequate perfusion of maternal side of placenta, eg: maternal hypotension
•maternal drugs ex: sedatives
•pre-eclampsia

(2) labour
•Interruption of umbilical cord blood flow, eg: cord compression
•prolonged difficult labour

(3) fetal side:

•Failure to inflate lungs >>> lungs are compressed ex: congenital diaphragmatic hernia
or blocked ex: meconium aspiration (post term and IUGR) that’s why birth asphyxia is
defined as the failure to initiate and sustain breathing at birth (‫)تعريف الجامعه‬
•prematurity
•Baby’s blood cells cannot carry enough oxygen (anemia)
•malpresentation , fetal abnormalities

C
 Note:
Only half of the infants needing resuscitation
Primary cause of death in libya: ‫بالترتيب‬
1) sepsis
2) prematurity
3) CHD
4) birth asphyxia

predictors have been assessed for detection of perinatal asphyxia:

1-fetal movement counting
2-non stress testing (CTG) >>> abonormal fetal heart rate recording
3-Fetal biophysical profile (uss) >>> reduction of liquor volume
4-fetal scalp pH >>> acidosis

APGAR Score:
•to know if there is birth asphyxia and baby needs resuscitation or not but it doesn’t
reflect the future of the baby (imp)
•is done at the end of first minute after birth
(1)R.effort not R.R (2) Activity ( tone ) (3)Grinse ( Response to nasal catheter NGT )
(4)pulse rate (5)appearance

T" imant
in
DR.Virginia apgar
•its better to count the pulse rate by palpating umbilical cord than auscultation
because sometimes it’s difficult to hear but the best way to know the pulse rate is
ECG or pulse oximeter >>> ‫رمضان بعيو‬.‫د‬

•Total Score = 10
•score 7-10 >>> normal >>> Discharge
•score 5-6 mild birth asphyxia
•score 3-4 moderate birth asphyxia
•score 0-2 severe birth asphyxia

•Less than 7 >>> Resuscitation >>> then repeat APGAR score after 5 minutes if still
below 7 >>> repeat at 10 minutes if still below 7 >>> repeat at 15 minutes if still
below 7 >>> repeat at 20 minutes to know if there is a response to resuscitation or
not
•Resuscitation maximum is up to 20 minutes

Physical examination of birth asphyxia:

(1)Mild:
•hypertonia and slightly hyper reflexia
•poor feeding, irritability or excessive crying may occur.
•By 3-4 days of life the CNS examination finding became normal.

(2)Moderate:
•hypotonia , hyporeflexia and Lethargy
•Primitive reflexes are sluggish or absent.
•periods of apnea.
•Convulsions
•Full recovery within 1-2 weeks is possible and is associated with a long term
outcome.

(3)Severe:
•coma
•Breathing may be irregular requires ventilatory support
1
•Generalized hypotonia and hyporeflexia
•Primitive reflexes are absent
•Pupils may be dilated , fixed or poorly reactive.
•Seizures
•arrhythmia and hypotension

Other organs affected in birth asphyxia:

• acute tubular necrosis >>> Renal failure seen in about 40%
•Respiratory distress and persistent Pulmonary hypertension 25%
•Hypoxic cardiomyopathy, hypotension, tricasped regurge 25%
•DIC
•Hepatic failure.
•Adrenal hemorrhage  
•NEC
•metabolic: Hypoglycemia, hypocalcemia

Differential diagnosis:
•inherited metabolic disorders ex: maple syrup
•infection >>> meningitis
•intraventricular Hge

Laboratory studies:
•No specific test excluding or confirms a diagnosis of HIE
•if you suspect HIE >>> investigations for the complications ex: blood sugar
•it is a disease of exclusion

Imaging :
•brain uss is frequently used
•you may use MRI

Treatment:
•mainly prevention by obstetric monitoring
•supportive management >>>> treat the complications :
•ex: treat Hypoglycemia, hypocalcemia , hypotension,
,convulsion >>> drug of choice is luminal (phenobarbital) avoid valium (diazepam) >>>
risk of jaundice 12
•cool therapy (33-34 degrees) >>> cooling the brain below normal temperature from
birth up to 72 hours by a Cool Cap >>> decrease apoptosis and not effective in
preterm
‫لو بديتها بعد ثالث يوم مش حتفيد‬
•no role of steroid
•mannitol to decrease brain edema but you have to exclude brain hemorrhage but it
can increase the bleeding

•neural stem cells

•follow up

Prognosis:
Mild HIE: tends to be free from serious CNS complications.
•Moderate HIE: about 30-50% have serious long term complications
•Severe HIE: mortality rate about 50% , among survivals , 80% have serious
complications, the most frequent sequelae are mental retardation, epilepsy , and
cerebral palsy.

prediction of the severity of long term complication by :

(1) lack of spontaneous breathing within 20-30 minutes of birth
‫درتله انعاش وعاش بعدها‬
(2)The presence of seizures is an ominous sing
(3) Abnormal clinical neurological finding beyond 1st 7-10 days of life indicate poor
prognosis.
(4) Poor head growth (head circumference)

13
 Neonatal Resuscitation: ‫محمد مسعود‬.‫د‬

Adequate preparation For resuscitation:

1.self-inflating Ambo bag (newborn size) ‫بعد تضغطها اترد بروحها ماتحتاجش للهواء بش تنتفخ‬
2.masks (for normal and small newborn) should cover nose and mouth not eyes
3.suction device (mucus extractor)
4.heater (if available), warm towels, a blanket to prevent hypothermia
5.clock for APGAR score at 1min >>> 5 min >>> 10 min
>>> 15 min >>> 20 min

•resuscitation is done at least by two

A - establish open airway :
•Position (sniffing position)
by putting a pillow behind the upper back
•suction by a bulb syringe or by suction device (mouth first
Then nose)
B - initiate breathing
•Tactile stimulation ex: rubbing the back
•Oxygen by self inflating ambobag
C - maintain circulation :
•Chest compressions :
By two thumbs are placed over the lower third of the sternum,
with the fingers encircling the torso and supporting the back
to a depth about one third of AP diameter
Of the chest (the best technique) and
There should be a 3:1 ratio of compressions to ventilations
with 90 compressions and 30 breaths per minute

•Medications:
Epinephrine (adrenaline) is the only drug can be given in
Neonatal resuscitation >>> 0.01–0.03 mg/kg IV
or Intraosseous and 0.05–0.1 mg/kg through the ETT

I n
 ⬆ ➡➡

Neonatal Convulsion:
• Convulsion >>> Can't be stopped by holding the convulsion limb in contrast with
Jitterness
Causes :

F
·
Note : K+ is related to arrhythmia not to seizures

Other causes :
•IVH, subdural hematoma ,
•B6 deficiency ( Pyridoxine ):
Glutamate ( Stimulatory)
GABA (Inhibitory)
•Vit.B6 dependency >>> Mother with hyperemesis gravidarum >>> After delivery >>>
Vit. B6

• Note : Febrile convulsion occurs between 6 months to 6 years & wilson disease
(Copper deposition) >>> After 5 years >>> Not in NN period
• Subtle seizure is the commonest type ( Not generalized tonic clonic)

subtle seizure:
1)Eye (Repeated blinking or Nystagmus or sustained eye openine) Or
2)Oral >>> Lip smaking >>> Repeated sucking or Chewing Or
3)Motor >>> Bicycling or boxing
IS
INVX :
•Septic & electrolyte work up
•Uss & brain MRI
Mx:
•ABC
•Correct electrolytes disturbance if present
•Iv phenobarbiton or phenytoin or clonazebam or midazolam

Necrotizing enterocolitis:

• Manifested in neonatal period

•Acute intestinal necrosis with super added bacterial infection due to :

1)prematurity and intrauterine growth retardation >>> weak intestinal wall and wall
ischemia due to hypoxia
2)birth asphyxia, apnea and cows milk formula feeding
3)Indomethacin which is used to close PDA by PG
4)Bottle feeding ( note : Oxygen & breast feeding risk of necrotizing entercolitis)
( Resistance)

C/P:
1) Sepsis >>> May causes apnea
2) Abdominal distention
3)Bloody stool (Observed in the majority of cases )
4)Vomiting (Billous or bloody)
• No jaundice

INVX:
1) Triad of:

↑y
M

16
(2) X-ray >>> Pneumatosis intestinalis (Gas in the wall) >>> If rupture >>>
Pneumoperitonium ( Air under diaphragm)

Mx :
1)02 >>> So O2 therapy is not a cause of necrotizing enterocolitis
2)IV fluid, Antibiotic
1)and 2) >>> Conservative therapy if failed of rupture >>> Surgery is indicated

NN sepsis : ‫ وفاء املسماري‬.‫د‬

•Is one of the most serious neonatal infection
definition: presence of a bacterial blood stream infection (BSI) in a newborn baby
(Positive blood culture)
•sepsis it could be due to other organism such as viral or fungal but usually the
term sepsis is used for bacteria

MODE OF INFECTION:
1) antenatally
A) transplacental >>> usually viral
B) amnionitis >>> PROM
2) intranatal >>> aspiration of infected liquor or while the fetus is passing through
the infected vagina or due to repeated vaginal examination
3) post natal (nosocomial) due to human contact or from the environment such as
resuscitation

Risk factors:
(1)any disease needs resuscitation like perinatal asphyxia or meconium aspiration
(2)maternal infection , multiple gestation,PROM more than 18 hours
chorioaminitis , recent vaginal colonization
(3)black male
(4)preterm ,SGA (IUGR) , Malnourishment >>> immunity
(5)Prolonged hospitalization
(6)Congenital anomalies of skin or mucous membranes
(7) Umblical catheter or any invasive procedure or major malformation needs surgery

17
classification of NN sepsis:

A- Early (Most common)

• Less than 7 days (usually in the first 3 days)
• 95 % of early sepsis occur in the 1st 24 hours >>> usually respiratory not UTI or
meningitis that’s why >>> Very low yield for LP or urine cultures in first 24 hours
unless specific clinical indication
• usually the infection from birth canal (from the mother)
•multi systemic
•fulminant >>> high mortality upto 50%
• The most common focal site is lung & the commonest organism is Group B
Streptococcus (group A streptococci does not infect neonate)
• Commonest presentation is respiratory distress ( Not high grade fever )

B- Late
•after 7 days (>72hrs) to 3 months old (even after neonatal period the baby may
develops late sepsis)
•Lower mortality up to 6%
•infection from the mother or other eg: environment
•The most common focal site is meningitis 25% & the commonest organism >>>
Coagulase (-ve) Staph Eg: Staph epidermidis not aureus
• Commonest presentation is meningitis

18
Note:
•sepsis May cause DIC ( Most common cause of DIC is infection )

Clinical presentation:

1)Not breathing well:

•any respiratory distress in term baby think of sepsis
•dusky spells ‫مره مره ينزرق‬
•taccypnea
•apnea

2) Not feeding well (poor feeding):

•not hungry
•prolonged empty time of stomach >>> Residuals and distension
•Vomiting and diarrhea  
•Heme- positive stools
•Watery or mucousy stools

3) Not looking well:

•Lethargic >>> Absent sucking and Not arausable
•Cutis marmora (Vascular reaction of skin ) DDX:
1. Sepsis ( mottled skin )
2. Hypothermia
3. Any Trisomy
•Poor perfusion (more than 2 seconds)
•Temperature instability >>> not necessarily high fever, may present with
hypothermia , but fever is more specific
•Jaundice >>> sepsis affect the liver >>> you may find bleeding also

DDX:
(1) heart lesion (2) congenital adrenal hyperplasia (3) Hypoglycemia
Note: baby with sepsis may present with any complaint

Poor Prognostic features:

(1) WBC, PLT (2) Ominous late signs (A) Apnea (B)Convulsion (C) Hypotension/ shock
If
INVX:

(1) Septic work up :

•Blood culture
•X-ray
•L.P
•Suprapupic aspiration ( B/C below 2 years the U.B is an abdominal organ )
•Swap from any secretion , endotracheal aspirate if the baby is intubated , surface
culture >>> skin pustule or eyes
•stool culture if the stool is abnormal

(2) ESR & CRP >>> helpful in DX and follow up

(3) PBF :
A)Toxic granules
B)Immature neutrophils called band cells
(4) CBC >>> WBC & PLT >>> Severity
• wBC may be
(5) PT and APTT may be prolonged
(6) blood sugar usually high but may be low

Mx :
1) antibiotic
• Early :Ampicillin against group B and Gentamicin (aminoglycoside) against gram
negative
• Late :Vancomycin against coagulase negative and Gentamicin against gram
negative
2) General supportive measures >>> respiratory support and thermal regulation

Note :
A)Handwashing plays a major role in prevention
B)Early sepsis can be caused by listeria monocytogens D.O.C is ampicillin

20
 ⬆➡ ➡

NN Hypogylcemia
•Plasma glucose level less than 30 mg/dl in the 1st 24 hours of life & less than 45 mg/
dI there after
• The commonest metabolic problem in newborns
• The commonest presentation Asymptomatic but may symptomatic:
A)Tremor
B)Jitterness •Never in face •Triggered by stimulation •Stopped by holding limb
C)Crying D)Lethargy E)Cyanosis F)Convulsion

Causes :
(1) Insulin :
•IDM
•Beck with wiedemann syndrome
(2) Low storge of glucose :
•Preterm and IUGR >>> immature liver
•Sepsis >>> Utilization
•Hypothermia >>> Utilization
(3) G.H & Glucagon
(4) Glucocorticoids :
•Adrenal gland trauma or He
•Congenital adrenal hyperplasia
•Meningiococcemia (water house friderichsen syndrome)

Mx:

1)Early breast feeding & observe

( B.F is rich in CHO) If failed IV bollus dextrose 50 % 2 ml/Kg single injection
then give maintenance dose to avoid recurrence 5-10 % for 24 hours in peripheral vein
If not improved Give 15 % in a central vein If not improved Iv
hydrocortisone If no response Im glucagon If no response Diasoxide
inhibits K+ influx of membrane of B.cells hyperpolarized Prevent insulin secretion
If no response
called resistant hypoglycemia Partial pancreatectomy Discharge when blood
glucose becomes normal for 2 days

21
 ⬆⬆ ⬇ ➡ ➡⬆

NN Hypocalcemia:

• Normal level 8.5-10.5 mg/dI

•50 % bound to albumin ( inactive )
•50 % Free Physiological function ( active )
• Total serum calcium (8.5-10.5) = Bound + Free
• Nephrotic syndrome >>> albumin >>> bound >>> total >>> false hypocalcemia
So always check the serum albumin (normally 4-5.5) 4-albumin * 0.8 serum
Ca+ Corrected calcium
Ex: Albumin = 2 (Hypoalbuminaemia)
Ca+= 7.5 mg/dI
(4-2 * 0.8 ) + 7.5 = 9.1 Normal

Definition of NN hypocalcemia:
• Total serum Ca+ less than 7.5 mg/dl if term 8 > 7 if preterm

Normal physiological Points:

1)PTH Released under control of Mg+ (+ve ) Vit.D in kidney
• Ca+ & P by >>> Ca+ & P absorption from GIT to blood
• Bone resorption of Ca+ but making P remains in bone
• Ca+ reabsorption & P secretion by the kidney

(2) Vit.D >>> Ca+& P by

• Ca+& P absorption
• Ca+& P resorption
• Ca+& P reabsorption
(3) Calcitonin >>> Ca+ & P by inhibits bone resorption & reabsorption
(4) P >>> Binds to calcium >>> inactive >>> Serum Ca+
(5) Mg >>> stimulates PTH release >>> Ca+

Causes :
(1) PTH >>> Vit.D stimulation :
(A) Transient hypoparathyroidism >>> in IDM
(B) Mg+ >>> renal cause or IDM
22
 ⬇

(C)Digeorge syndrome ( absent 3rd pharyngeal arch):

•Absent PT glands & thymus >>> PTH and recurrent infection

• PTH >>> hypocalcemia >>> convulsions so any neonate with hypocalcemic
convulsion you have to exclude DiGeorge syndrome
•thymic aplasia >>> recurrent infection
•conotruncal heart defects >>> most commonly tetralogy of Fallot , second common is
truncus arteriosus
•cleft lip and/or palate
Mx: Ca+ & Vit.D life long

2) P (unmodified cow milk)

3)Hypoxia (NN asphyxia or NN sepsis) >>> ischemia >>> necrosis >>> calcitonin >>>
Ca+ precipitation on the necrotic tissue
4)Double volume exchange transfusion

C/P :
•Tremor, Jitternesss, Convulsion & Stridor ( Ca+ >>> Neuromuscular excitability
>>> Tetany)

INVX :
A)Corrected calcium >>> Ca+
B)PTH level >>> PTH ( Suppose to be )
C)Radiological >>> Absent thymus >>> Digeorge
• Mg+ level >>> Mg+
•If normal Mg+ >>> Advice to change the milk
• Rickets cause hypocalcemia & Vit.D but Not in neonatal period

TTT : 5 ml IV Ca+ gluconate (( 10 % )) over 10 min (( slowly )) >>> if quickly >>>

cardiac arrhythmia >>> if no response called resistant hypocalcemia >>> check serum
Mg+ >>> if low >>> give Mg+sulfate

Note : Normal Mg+ serum level is 2-3 mg/dI

23
Problems in preterm: ‫ فاطمه السعدواي‬.‫رمضان بعيو و د‬.‫د‬
A) early:

1-Respiratory: ARDS, recurrent apnea of prematurity (immature RC) with bradycardia ,

asphyxia, pneumothorax
2-CVS: PDA
3-Hematoloigic :anemia ( low iron storage )
4-GIT: NEC ,hyperbilirubinemia (immature conjugation) ,food intolerance due to
immature digestive enzymes and hormones
5-Metabolic: hypoglycemia ,hypocalcemia and hypophosphatemia
6-CNS: IVH (fragile BV) , seizures
7-Immunologic: deficiency >>> infection and sepsis >>> eg : pneumonia

Note : humoral immunity is low because the maximum period of gestation in which the
Mother IgG crosses placenta is 8th and 9th months also cellular immunity is
still immature
8-renal >>> electrolyte disturbance due to immature kidney
9-hypothermia because they have large surface area ,low subcutaneous tissue and
low glycogen storage so low heat production thats why they need incubators

B) late:
1-bronchopulmonary dyspleasia
2-retinopathy of prematurity (not cataract) due to introducing of excessive o2 >>>
blindness, kernicterus >>> deafness , cerebral palsy , mental retardation
3-poor growth , osteopenia

•premature baby >>> follow up for 2 to 3 years until the full maturation of the brain

note :
1)mother's milk is the optimum source ways of feeding in preterm if not available give
premature formula (high calorie) to catch the growth

2)sucking swallowing coordination (prevent aspiration) is developed at 34 weeks of

gestation , if there is a preterm born before 34 weeks >>> give breast milk by
nasogastric (NGT)or orogastric (OGT) tube not by sucking >>> to prevent aspiration
2c
 The high risk newborns : ‫فاطمه السعدواي‬.‫د‬
(1)preterm (2)SGA (small for gestational age) (3)LGA (large for gestational age)
(4)post term
•All will be discussed later in clinic sheet

Causes of high risk newborns:

1)social factors:
•maternal age <16 or >40 yrs , drugs ,alcohol or cigarette use , poverty ,
asymptomatic bacteriuria ,rheumatic disease ex : SLE ,longterm use of medications.

2)Past medical history:

•genetic disorders , DM , hypertensiopn

3)Previous pregnancies:
•intrauterine death , neonatal death , prematurity , IUGR ,congenital malformation
 ,neonatal hyperbilirubinemia ,neonatal thrombocytopenia ,inborn error or
metabolism

4)Present pregnancy:
•abruptio placenta, placenta previa , infection , multiple
gestation ,preeclampsia ,PROM ,polyhydramnios ,acute medical or surgical illness
,abnormal fetal USS

5)Labor and delivery:

•premature labor <37 wks , postdated >42wks , breech presentation ,meconium
stained fluid , Cesarean section ,forceps delivery ,Apgar score <4 at 1min.

6)Neonatal factors:
•birth <37 wks or >42 wks , small for gestational age or large for gestational age
(LGA) ,tachypnea or cyanosis ,congenital malformation ,pallor ,plethora or
petechiae.
 •About 9% of all births require special or neonatal intensive care .Usually needed
for only a few houres to several monthes .

2S
Routine assessment and care of neonate : ‫دكتور رمضان بعيو‬
Notes :
•NN period is 1st 28 days (1st 4 wk) but not the 1st month
•NN period is divided into early neonatal period (first 7 days) (newborn) and late
neonatal period (the remaining 3 weeks).
•from 28 days up to one year >>> infant
•1-3 years >>> toddler
•4-5 >>> preschool age group
•6-14 >>> school age
•Age of viability: 24 weeks
A) if delivered before 24 weeks >>> abortion
B) if died in uterus after 24 weeks called stillbirth
•full term newborn : complete 37 - complete 42 weeks
•preterm :delivered before complete 37 weeks
•post term :delivered after 42 weeks

acrocynosis (adaptation):

intrauterine hypoxia (oxygen saturation 65%) (thats why they have acrocyanosis
because the blood goes to the vital organs) this hypoxia is compensated by HBF (has
higher affinity to bind with oxygen) and produce more erythropoietin >>> more RBC
production that’s why the normal neonatal Hemoglobin is 16-20 gram/DL with 60%
hematocrit making the color is pink
•normal platelet in new born like in adults >>> 150,000-450,000
•GIT enzymes and hormones are normally not mature eg: pepsin, secretin ,trypsin >>>
normal overdistended abdomen after feeding called physiological food intolerance

•most of mortality occured in neonatal period (65% of mortality in the first year
occured in neonatal period) why?

1) immature immune system:

•immune system is slow to react against infection
•decrease in igG , igM and complement production
26
 ⬇

•poor phagocytosis specially against gram negative bacteria and poor migration of
WBC
•Inadequate T&B cells interaction
•low no. of T cells
•Adequate no. of B cells ; but their immunoglobulin production is reduced
>>> risk for infection and sepsis
2) if born premature >>> because premature babies are at high risk of infection,
ARDS, hypothermia

(1) Aseptic ( Sterile ) cutting of U.C by:

A- Clean hands B- Clean instruments C- Clean surface

• use bacitracin powder (Broad spectrum antibiotic) or use hexachlorophene 3% as
prophylaxis
• Hexachlorophene is C.I in preterm due to fat >>> absorption >>> Neurotoxicity
• Aseptic to prevent tetanus neonatorum caused by CL.tetani & to prevent Omphalitis
which may cause thrombophlebitis >>> Portal HTN
• Cutting >>> Stumb >>> 10-7 ‫ >>> يطيح بعد‬maximum 14 days

(2) Gentile drying (drying is very important , essential and the best in newborn care)
and then Cover the baby and give the baby to mother in the first hour >>> Skin to
skin contact to maintain baby temperature and enhance the emotions of the mother
and baby and start breast feeding as early as possible to maintain blood sugar

Hypothermia:
1)normal neonatal temperature: 36.5-37.5
‫ممكن تنقص ثالث درجات في نص ساعه اذا لم تهتم بتدفئه البيبي‬
2)ideal labour room temperature: 25-28 for terms

•any room temperature less than 25 >>> baby temperature decreases by one degree
centigrade every 30 minutes

27
Definition of hypothermia:
1) Mild hypothermia >>> decreased only half degree centigrade >>> 36
2) 35.9-34 >>> moderate hypothermia
3) below 34 >>> sever hypothermia

Complications of hypothermia:
1) death :
•mortality increases by 28 % for every degree centigrade below normal
2) increase o2 consumption >>> needs more oxygen to produce more heat (stress)
>>> RD (hypothermia is an extra pulmonary cause of RD) >>> hypoxia >>> brain insult
3) Hypoglycemia >>> due to increase in glucose consumption (Anerobic glycolysis) to
produce more ATP and heat >>> Hypoglycemia >>> brain insult
4)acidosis due to anaerobic glycolysis >>> lactate accumulation

Prevention of hypothermia:
1) maintain the labour room temperature 25-28
2) immediate gentle drying of the baby by (two prewarmed towels) then >>> well
wrapped clothing and cap (because the head is large so it has a large surface area)
3) heaters can be used
4) preterm is placed inside incubators because the ideal room temperature cannot
maintain the body temperature of preterm
‫اول يوم ابدأ بدرجه حراره عاليه زي مثال اثنني وثالثني وكل ماكان اصغر في العمر خلي الحراره اول يوم اعلي‬
‫وكل يوم نقص‬
So it depends on the gestational age and post natal age ‫هل توا عمره يوم يومني‬

5) don’t put the baby between air-drafts to prevent the covection

‫التيار اللي ايتكون مابني بابني مفتوحات او بني باب وروشن‬
6) don’t put any metal or steel beside the cold baby >>> radiation >>> absorp the
baby’s temperature >>> temperature lose

7) towel and sheet must be prewarmed before touching the baby to prevent the
conduction and heat losing
8) babies have large surface area >>> evaporation >>> heat loss >>> to prevent the
evaporation >>> set the humidity at least 70 percent in the incubator

28
•one of preventive measures to prevent evaporation
and heat loss in preterm is plastic bag

Factors increase hypothermia:

A) baby left wet while waiting the delivery of placenta
B) they have large surface area >>> evaporation and heat loss
C) subcutaneous tissue and fat are not well developed (poor thermal insulation)

Neutral thermal environment:

Definition:
the surrounding temperature in which you take care of baby to maintain the baby’s
core temperature within normal with less oxygen consumption and less energy
production

(3) initiation of breathing and resuscitation:

• if unable to initiate breathing >>> apnea >>> one of the common causes of apnea
is birth asphyxia due either maternal cause (abruptio placenta, antepartum HGE or
hypotension) or fetal cause (cord prolapse)

management:
1) early asphyxia identification 2) early management (resuscitation) 3) early and
exclusive BF

4) oronasal suction (mouth before nose) is not performed unless :

A) baby doesn’t cry B) not redpond to ambubag c) meconium stained liquor

Note:
A) if you perform sucction in crying baby (tube in posterior pharynx) >>> sucction
stimulates vagus nerve >>> parasympathetic :
1)bronchospasm >>> dyspnea 2)bradycardia

B) catching the non crying baby up side down and slapping is not performed
anymore because it may cause brain hemorrhage >>> instead of the do foot
stimulation

29
4) ophthalmianeonatorum :

A) Neonatal conjunctivitis in the first month of life developed specially within first
three days
B) early ophthalmianeonatorum is caused by neisseria gonorrhoea and staph aureus
C) late ophthalmianeonatorum (after 7 days) >>> chlamydia
D) may involve the cornea >>> ends with blindness
E) is prevented by Caring of the eye of NN with normal vaginal delivery by using
silver nitrate against gonococcus or by erythromycin 0.5 % protects against both
gonococcus & chlamydia >>> S/E >>> mild conjunctivitis
F) and may cause periorbital cellulitis >>> extends to cause brain infection

5) Im (in thigh) Vit.K 1 mg >>> Because NN has a sterile gut & the breast milk is a
poor source of vit.K >>> Vit.K >>> Hemorrhagic disease of NN typically after 1 wk
>>> Petechial Hge & melena (coagulation factors 2,7,9,10 are inactive)

6) NGT to make sure the patency of the nose and esophygus >>> to rule out coanal
and esophygeal atresia
7) thermometer >>> to rule out imperforated anus

•APGAR score

Vaccines given to baby:

1.Oral polio >>> live vaccine
2.Heb B >>> DNA recombinant
3.BCG >>> Live attenuated and given intradermally in left deltoid area

Guthrie test (heel prike test): ‫منيره رضوان‬.‫د‬

•universal newborn screening in asymptomatic babies
•is a public health program done for all newborns
•Used for screening for preventable diseases which are not manifested in the first
3months >>> apparently normal baby
• ideally is Done Between 48-72 hours of life to allow the non metabolized substrate
to be accumulated so its easy to be picked by the test

38
1)congenital Hypothyroidism (Will be discussed in details in endocrine system):

•1:4000 birth (important) thats why its a part of neonatal screening program And
Mandatory for all newborns >>> TFT
•characterized by umbilical hernia, jaundice and hypertrophied tongue
• most commonly caused by thyroid dysgenesis
• TSH to avoid cretinism ( M.R )
•No M.R in acquired hypothyroidism
•Single investigation for hypothyroidism is free T4 ( important )
•The prognosis is dependent on the onset of treatment

(2)congenital adrenal hyperplasia >>> salt losers >>> shock >>> death
(3)Glucose 6 phosphate dehydrogenase (G6PD) deficiency >>> hemolytic crisis >>> death

(4)Maple syrup urine disease: (MSUD)

•abnormal odor >>> maple syrup ‫ريحه العسل املحروق‬
•error in essential branched chain A.A (leucine, isoleucine and valine)
metabolism >>> (-ve ) branched chain A.A breakdown >>> Branched chain A.A in urine
•accumulation of branched chain A.A >>> mental retardation and sometimes death
•reduce the amount of amino acids received (special formula) especially leucine, valine
and isoleucine.

(5)Phenylketonuria ( A.R ) >>> ‫منيره رضوان‬.‫د‬

Phenyl alanine Hydroxylase
Phenyl alanine ——————————————————— tyrosine

•Decrease in tyrosine leads to decrease in catecholamines, thyroid hormones and

melanin
• Phenyl alanine >>> Converted to phenyl lactate & phenyl acetate >>> Brain damage
>>> Microcephaly, mental retardation and seizures
•Affected infants are normal at birth
•Vomiting is an early symptoms
•Affected infants usually are lighter in their complexion with blond hair (fair color of
the eyes and hair)

3
•developmental delay
•Autosomal recessive diseases are more sever than autosomal dominant , clinically
normal parents, male = female ,and the chance of recurrence among sibling is 1:4
•mx: phenyl alanine low diet life long

(6) Galactosemia:

•AR ( history of consanguinity)

•its a carbohydrate metabolic inborn error disorder
•failure to thrive, and mental retardation.
•Death often results from bloodstream infection with the bacteria E. coli
•presents in neonatal period with poor feeding , vomiting and lethargy (sepsis like
syndrome)
•affect the brain >>> convulsion
•Affect the liver >>> hepatospleenomegaly , hypoglycemia , prolonged direct
hyperbilirubinemia
•affect the eyes >>> cataract >>> (Eye examination is very important) >>> cataract in a
neonate + sepsis like >>> highly suggestive of galactosemia
•no role of peripheral blood smear in diagnosis
•mx: lactose (glucose + galactose) free milk life long

points in metabolic inborn diseases in general:

1)the most important point in history of metabolic inborn diseases is history
of unexplained neonatal death

2)Onset of symptoms of metabolic inborn diseases in general :

present with symptoms free period after birth as the toxic metabolites are not yet
accumulated in the first or second day of life but in galactosemia >>> Cataract may be
found as early as the first day of life in newborn babies

3)Metabolic disorders should be considered in any sick neonate. This includes sick
neonates with unexplained sepsis-like features (normal septic work up)

32
4)most of metabolic inborn diseases are due to enzyme deficiency (AR)
•the previous 6 diseases are the commonest diseases which are screened by guthrei
test
other diseases that may be involved in screening :
(7) SCA and betathalassemia
(8) Immunoreactive trypsinogen >>> To detect cystic fibrosis
Note: Mucopolysaccharidosis is not screened

(9) homocysteine urea

(10) Biotinidase Deficiency:
deficiency in Biotinidase enzyme which is important in vitamin b7 (biotin) synthesis >>>
deficiency of vitamin B7 >>> frequent infections, hearing loss, uncoordinated movements,
seizures and mental retardation.
•These consequences can be prevented by giving the baby extra biotin

Criteria of disease selected in the screening:

1) the disease should be an important health problem and reconizable latent or early
symptomatic state
2) diagnostic test after positive screening I
test should be available
3) treatment should be available
and accepted for patients
4) screening test should be suitable for patients
and economically balanced (cost effective)
5) case finding should be a continuing process

•Avoid the center of the heal to prevent bone injuries

"IP
•the first blood drop is not inculded ‫ألنها صغيره‬

•negative result >>> no action

•positive result >>> repeat two times >>>
if still positive >>> confirm by diagnostic test

33
notes about the screening test :

(1)not cover all metabolic diseases

(2) has false positive and false negative results
(3)diagnosis can only be reached after confirmation
(4)confirmatory test can be done by same technology or different

Indications of newborn admission:

(1) Esophygeal atresia , tracheo esophygeal fistula >>> detected by NGT
(2) coanal atresia >>> detected by NGT
(3) imperforated anus >>> detected by thermometer
(4) generalized cyanosis >>> you have to admit and evaluate the condition >>> CHD
(5) anaemia >>> you have to admit and evaluate the condition
(6) dysmorphic features >>> you have to admit and evaluate the condition
(7) respiratory distress >>> you have to admit and evaluate the condition
(8) decrease or absent movement >>> may be due to birth tauma

30
 Birth trauma: ‫محمد مسعود‬.‫د‬
•accounts less than 2% of neonatal deaths (most common cause of neonatal death >>>
prematurity and sepsis)

1) extracranial hemorrhage:
•scalp >>> s=skin , c= connective tissue , A = apponeurosis , L = loose connective
tissue , p= periosteum

(A) caput succedaneum

•diffuse poorly defined edematous boggy swelling of the soft tissue of the scalp
(subcutaneous) involving the portion presenting during vertex delivery due to scalp
compression by uterine contractions that’s why it is usually associated with molding.
• Extraperiosteal fluid collection
•occasionally hemorrhagic in this case it will be large >>> called large caput
• Immediate after birth
•Over the presenting part
•may show mild bruising
• Diffuse (Cross the midline and suture lines)
• Disappear gradually (resolves spontaneously) within few hours or few days after
birth without sequelae and moulding disappears during the first weeks of life.
• No complications >>> Rarely causes scalp necrosis with scarring and alopecia
vacuum caput :is a caput succedaneum with well defined well demarcated margins by
vacuum cup.  
•reassure , no need for treatment

(B) Cephalohematoma
• Subpriosteal blood collection resulting from rupture of the superficial veins between
the skull and periosteum
• May ass' with linear skull # 15%
• appears After several hours after birth
•Localized ( Not crossing midline ) and Commonly parietal or occipital
• Resolve spontaneously over few several weeks (8wks)
•Anaemia, Jaundice, infection which may lead to osteomyelitis , extracranial
calcification >>> Cx

35
• Conservative Mx >>> treat the Cx
•Incision and aspiration is contraindicated unless if it is already infected
•Large Cephalohematoma >>> request coagulation profile and CBC for platelet count ,
maybe caused by:
A) hemophilia b) vonwillibrand c) aspirin intake by the mother D) vit k deficiency E)
thrombocytopenia (congenital ITP)

DDX : Cranial meningocele >>> herniation of the meninges through saggital suture >>>
midline and differentiated from cephalohematoma by:
1.Pulsatile
2.Increased pressure on crying, and the
3.Radiologic evidence of bony defect.
•treated surgically

C) sugaleal hematoma:
•diffuse subapponeurotic bleeding >>> not localized ‫ >>> مافي شي يمسكه‬may cause shock
•anaemia and jaundice >>> cx
•less common than caphalohematoma and caput succedaneum
•you may find it behind the ear
•Birth trauma mostly due to forceps delivery
Mx :
•Conservative mx >>> trest complications and may give blood transfusion
• if large bleeding >>> drainge

D) skull fractures:
•linear or depressed
•depressed is more dangerous and often associated with forceps deliveries
•Most of the patients are asymptomatic

2)Ocular injuries:

1-Subconjunctival & retinal Hge

36
causes:
(1) after normal vaginal delivery ( Uterine contractions on the chest & abdomen ) >>>
Venous pressure of the face
(2) malpositioned forceps delivery
•Subconjunctival Hge disappears after 1-2 wks
•Retinal Hge disappears within 1-6 days

3) Sternomastoid injury : (sternomastoid tumor):

Causes:
(1)shoulder dystocia ‫يطلع الراس قبل والكتف يحصل‬
(2)breech delivery >>> aftercomming head ‫يطلع الجسم والراس حصل‬
(3)abnormal intrauterine positioning
•Birth trauma >>> Hematoma >>> Ch.inf >>> Fibrosis >>> Shortening >>> Torticollis
•appears after 2 weeks not at birth (imp)
•15% of hip dislocation is associated with torticollis that’s why it is may be idiopathic
•DDX: enlarged lymph node, heamangiomas
•Dx by USS
•Cx by Amblyopia
•treated by physiotherapy & surgery is needed if torticollis persists after 6 months.

(4) Cranial nerve injuries:

•facial nerve injury is the most common cranial nerve injury in
neonates (lower motor neuron facial palsy) >>> lead to asymmetry crying facies:
1) inability to close the eye
2) flattening of the nasolabial fold
3) mouth deviated to the normal side

Causes:
(1) forceps delivery (2) normal vaginal delivery >>> pressure on the nerve by maternal
sacrum
DDX : Moebius syndrome is a rare autosomal dominant disease caused by the
absence or underdevelopment of the 6th and 7th cranial nerves

treatment: physiotherapy Protect the open eye with patches and apply
methylcellulose drops And no role of steroid
37
•The prognosis of is excellent with recovery usually complete by 3 weeks

(5) Cervical nerve root injuries:

Brachial Plexus injury :

•Results from traction upon the neck

• treatment is Physiotherapy, should be delayed for 7-10 days (not immediately after
birth) (imp) to allow edema to be subsided >>> the affected patients will recover
•if not recover after 3-6 months of physiotherapy >>> surgery may be required
• C5, C6 >>> Upper trunk
• C7 >>> middle trunk
• C8, T1 >>> Lower trunk

Note:
•C3 ,C4 , C5 >>> phrenic nerve

(1) Duchene-Erb’s palsy:

•the most common type of brachial plexus injuries
•upper trunk injury (c5,c6)
•The deltoid, infraspinatus, biceps, supinator and brachioradialis muscles and
extensores of the wrist and fingers may be weak or paralysed
•triceps is spared (important)
•medial rotation, adduction extension and pronation >>> waiter’s tip sign or called
policeman’s tip
•The Moro, biceps and radial reflexes are absent on the affected side. The grasp
reflex (hand reflex) is intact.
•75% associated with phrenic nerve palsy (so diaghragm is usually involved) >>>
paralysis of the ipsilateral diaphragm >>> paradoxical movement of diaphragm >>>
respiratory distress >>> diagnosed by chest xray / fluoroscopy or uss

treatment:
•arm is immobilized for 7-10 days ‫عكس وضعيه االربس‬
•start physiotherapy after 7-10 days
•if not recover after 3-6 months of physiotherapy >>> surgery

38
2-Klumpke’s paralysis
•middle and lower trunk injury (C7,C8,T1)
•less common
•paralysis affects the interinsic muscles of the hand and the long flexors of the wrist
and fingers
•claw hand and sensory impairment on the ulner side of the arm and hand
•may be associated with horner syndrome
•absent grasp with preseved moro reflex
•sometimes moro reflex is absent
Treatment: physiotherapy after 7-10 days

3-kerer’s paralysis
•complete brachial plexus injury >>> c5 , c6 , c7 , c8 and T1 injury
•The entire arm is flaccid and all the reflexes are abcsent.

6) bone injuries
clavecular fracture:
•Most common bone to be injured then humerous
•Pseudoparalysis
• Crepetus at the site of # in palpation
• Swelling
• Confirmed by X-ray
•Excellent prognosis >>> Spontanous healing after 1 wk so Mx is just immobilize hand
by a band
•Can be due to birth trauma eg:IDM
•Unilateral clavicle # >>> Absent more unilaterally

7)VISCERAL INJURIES
(A) liver injury due to breech delivery or incorrect cardiopulmonary resuscitation
(B) adrenal hemorrhage :
•most of cases are asymptomatic presents with abdominal distension
•90% are unilateral; 75% are right sided
•diagnosed by uss

39