儿童保健 (3)

nullNeonatal Medicine --IntroductionNeonatal Medicine --IntroductionXiaoping Luo, MD Professor and Chairman Department of Pediatrics, Tongji Hospital Director, Center for the Diagnosis of Genetic Metabolic Diseases Tongji Medical College Huazhong University of Science and Technology Adjunct Professor Department of Paediatrics Faculty of Medicine University of Toronto Toronto, CanadaHistorical PerspectivesHistorical PerspectivesEarly History of Care of Infants (1900~ - small infants were not expected to live - temperature: hot-water bottles, heated cribs - feeding: tube feeding, diluted cow milk - separated facilities, isolation, washing hands - hyaline membrane diseases---respiratory distress syndrome - 1940s, modernized incubator, more oxygen - 1940s, retrolental fibroplasia - 1945, 《The Physiology of the Newborn Infant》--C. Smith Historical PerspectivesHistorical PerspectivesRapid Advances in Neonatal Care (1955~1970) - 1959, surfactant deficiency, Avery ME, Mead J. Am J Dis Child - 1960, 《Disease of the Newborn》-Neonatology -A. Schaffer - culture, blood counts, urinalyses, radiographs, biopsies - milk formulas, breast milk bank - iv glucose & bicarbonate - blood gas analysis - improved incubators - early attempts of mechanical ventilationHistorical PerspectivesHistorical PerspectivesEmergence of neonatal Intensive Care (1971~1989) - 1971, continuous positive airway pressure (CPAP) --Gregory - neonatal intensive care unit (NICU) - designated by level according to the intensity of service I: normal birthing and NB care, II: common obstetric complications & intermediate NB care III: high risk maternal care and NICU - transferring of high risk infants or mothers - high risk and long term outcome - 1980s, extracorporeal membrane oxygenation (ECMO)Historical PerspectivesHistorical PerspectivesExpansion of Clinical Trials to Assess Therapy: the Surfactant Era (1980~1996) - 1970s~1990s, glucocorticoids to accelerate lung maturation - 1980, first surfactant replacement therapy in humans - total parenteral nutrition (TPN) - high frequency oscillators - inhaled nitric oxide - prenatal diagnosis and genetic counseling - prospective, controlled clinical trials for intervention - “quiet premature nursery” to “a bustling space station” nullLe Tour d’abandon (Decertion Tower)nullCentury of Progress International Exposition Chicago World's Fair, Chicago, Illinois nullnullThe Dionne quintuplets May 28, 1934, 13 pounds 6 ounces, All together! Emelie, Cecile, Marie, Annette, YvonneJulius Hess“quiet premature nursery”nullHow small is too small?How small is too small?How much is too much?Life support: To continue or discontinue?Definitions of TermsDefinitions of Terms Newborn or neonate refers to a infant period from birth to 28 days. Neonatology—health care, pathophysiology and management Early Neonate refers to the first 7 completed days of life. Late Neonate refers to a period between 8 to 28 days of life. Perinatal period extends from the 28th completed week of pregnancy to the 7th day of life. Perinatology or Perinatal MedicineDefinitions of TermsDefinitions of Terms Term defines births that occur from 37th to less than 42 completed weeks, measured from the day of onset of the last normal menstrual period (259~293 days, with an average of 280 days). Preterm is defined as less than 37 completed weeks’, or 259 days, gestation. (37weeks of gestation ≈birth weight of 3000g) Post-term refers to births that occurs at 42 or more completed weeks (294 days).Definitions of TermsDefinitions of Terms Stillbirth and Fetal Death. Early fetal death occurs at < 20 completed weeks of gestation, intermediate fetal death occurs >20 and < 28 completed weeks, late fetal death occurs after 28weeks, or termed as stillbirth. Live Birth. WHO defines live birth as The complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy, which after such separation, breathes or any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached; each product of such a birth is considered liveborn. Definitions of TermsDefinitions of TermsBirth Weight (BW) BW <2500g --- Low Birth Weight (LBW); <1500g --- Very Low Birth Weight (VLBW); <1000g --- Extremely Low Birth Weight (ELBW); >4000g --- Fetal Macrosomia (Beckwith-Wiedemann syndrome Infant of Diabetic Mother, IDM)Definitions of TermsDefinitions of TermsBirth Weight vs Gestational Age (GA) BW the 90th percentile --- large for gestational age (LGA) ponderal index = BW(g)X100/Length3 (cm3) (>2~2.2) Length/Head Circumference (HC) (>1.36) symmetric or unsymmetric SGA Birthweight Curves Birthweight Curves California male singleton Caucasian non-Hispanic birthweights by gestational age: 10th, 50th, and 90th percentiles.High Risk PregnancyHigh Risk PregnancyPregnancies in which factors exist that increase the likelihood of maternal or fetal diseases Economic, cultural-behavioral, biologic-genetic, reproductive and medical factors 10~20% of pregnant patient can be identified as high risk ~50% of all perinatal mortality and morbidity is associated with high risk pregnancyHigh Risk InfantHigh Risk InfantAn infant who should be under close observation by experienced physicians and nurses. ~9% of all births require intensive care Fetal or neonatal factors: premature labor, postdates, fetal distrass, breech presentation, meconium-stained fluid, nuchal cord, Cesarean section, forceps low Apgar score, BW<2500 or >4000, SGA or LGA, congenital malformation, tachypnea, cyanosis, pallor, plethora, petechiaeFetal Growth and MonitoringFetal Growth and MonitoringFetal Growth and Maturity embryonic period (1~8 wks): early embryogenesis fetal period (9 wks~birth): growth and maturation Factors Affecting Fetal Growth genetic, geographic, social and economic factors maternal conditions: stature, age, disease and medication fetal: sex, multiple pregnancy, genetic disease, infection Fetal Monitoring maternal serum, chorion villi, amniotic fluid, placenta, fetal heart rate, ultrasound, blood gas and pH Physical and Neuromuscular Criteria for MaturityPhysical and Neuromuscular Criteria for MaturityPhysical Criteria Skin Lanugo hair Plantar surface Breast Hair Finger nail Ear/Eye Genitals Neuromuscular Criteria Posture Square window (wrist) Arm recoil Popliteal angle Scarf sign Heel to ear New Ballard Score (NBS) for Maturity Rating Ballard JL, et al, J Pediatr 1991; 119:417nullDubowitz/Ballard Exam for Gestational AgeNeurological ReflexesNeurological Reflexes Sucking Palmar grasp Response to traction Moro reflex Crossed extension Automatic walking Roof reflex Pupillary response Physiological CharacteristicsPhysiological Characteristics Body temperature heat loss by evaporation, radiation and convection Neutral thermal enviroment The range of ambient temperature and humidity at which heat loss is minimal and metabolic demands and oxygen consumption are the lowest. Depends on body weight and age 31 to 34 ºC at 50% humidity for undressed normal term infant Skin temperature vs central or core temperature (rectal) Re-warming a hypothermic infant at moderate rate (2~4hrs) Thermal regulation Physiological CharacteristicsPhysiological Characteristics Cardiopulmonary Function heart rate: 120~130bpm tachycardia/bradycardia; transition from FC blood pressure: 65~95/30~60mmHg, lower in preterm, PDA in preterm lung fluid: 30~35ml/kg “excretion/re-absorption” , “wet lung” respiratory rate: 60~80/min in the 1st hour, 40/min after brief pauses in respiration (<5~9’s) apnea (>20’s, with bradycardia <100bpm)Physiological CharacteristicsPhysiological Characteristics Gastrointestinal Function vomiting and abdominal distension swallowed maternal blood, GI malformation, infection first feeding nutritional issues, tracheo-esophageal fistula, jaundice passage of meconium 70% within 12h, 25% in 12~24h, 5% by 48h distal intestinal obstruction, meconium plug syndrome, Hirschsprung’s disease, sepsis, hypothyroidism, nacortic necrotizing enterocolitis (NEC) premature, hypoxia and ischemia, infection, feedingPhysiological CharacteristicsPhysiological Characteristics Urinary Function urinate 68% within 12h, 25% in 12~24h, 7% by 48h pre-renal causes: dehydration, shock renal abnormality: renal agenesis, tubular necrosis obstruction of urinary outflow: urethral valves late onset metabolic acidosis in premature infant cow milk feeding with high protein load Physiological CharacteristicsPhysiological Characteristics Hematological System hemoglobin: cord blood 170g/L, change with age Fetal hemoglobin: HbF 70%, HbA 30% WBC:15~20X109/L for term baby 6~8X109/L for preterm baby Platelet: 150~250X 109/L Blood volume: 50~100ml/kg for term baby 89~105ml/kg for preterm babyPhysiological CharacteristicsPhysiological Characteristics Neurological System brain: 300~400g, 10~20% of body weight (adult 2%) head circumference:33~34cm, increase by ~1cm/month spinal cord: ends at L3~4, caution for lumbar puncture physiological reflexes: rooting, sucking, grasp, Moro Pathological reflexes: Kernig, Babinski, Chvostek signPhysiological CharacteristicsPhysiological Characteristics Immunological System -- immaturity skin and mucous membrane complements and chemokine T cell function ImmunoglubulinsPhysiological CharacteristicsPhysiological Characteristics Fluid requirement (ml/kg) BW (kg) Day 1 Day 2 Day 3~7 <1.0 70~100 100~120 120~180 1.0~1.5 70~100 100~120 120~180 1.5~2.5 60~80 80~100 110~140 >2.5 60~80 80~100 100~140Routine CareRoutine Care Apgar score Maintenance of body heat Antiseptic skin and cord care Eyes protection Respiratory management Feeding Vitamin K1 Vaccination Neonatal screening Parent-infant bondingNeonatal Intensive Care Unit (NICU)Neonatal Intensive Care Unit (NICU) Mechanical ventilation Cardiopulmonary Disorder Post surgery (<24h) GA<30, VLBWI TPN Sustained convulsion Central tubing Heart Respiration Blood pressure Body temperature Blood Gas Biochemistry Imaging nullTongji HospitalThanks for learning, Doc!