0. Classification of Newborn.pptx

New born care

1. ADAMA HOSPITAL MEDICAL COLLEGE DEPARTMENT OF PEDIATRIC CLASSIFICATION OF THE NEWBORN AND CARE OF LBW/PRETERM BY Nasir Mohammed Natnael Kidanu Negash Begashaw 1 3/3/2017

2. Presentation Outline Introduction Classification of newborn by gestational age birth weight other classification Essential newborn care 2 3/3/2017

3. Objectives At the end of this presentation students will able to: Describe the classification of newborn Explain the essential elements of early newborn care describe the principles of each elements of newborn care 3 3/3/2017

4. Introduction A live born child is a fetus that shows at least one sign of life after birth & weighs at least 500 g or, in case of lower birth weight, survives 24 hours after birth. Signs of life are breathing, beating of the heart, umbilical cord pulsation or definite movement of voluntary muscles . 4 3/3/2017

5. A fetus that shows none of these signs of life and weighs 1000 g or more is classified as still born child. If fetus shows no sign of life and weighs less than 1000 g, the termination of pregnancy is classified as abortion. Immediately following birth, infant survival depends on a prompt and orderly conversion to air breathing. 5 3/3/2017

6. Cont … Fluid-filled alveoli expand with air, perfusion must be established, and oxygen and carbon dioxide exchanged Perinatal mortality is influenced by prenatal , maternal, and fetal conditions circumstances surrounding delivery. Perinatal deaths are associated with IUGR; conditions that predispose the fetus to asphyxia, such as placental insufficiency ; severe congenital malformations ; and overwhelming early-onset neonatal infections 6

7. Cont … The major causes of neonatal mortality are prematurity/low birthweight (LBW) and congenital anomalies Mortality is highest during the 1 st 24 hr after birth . Neonatal mortality (4.04/1,000 in 2011) accounts for about two thirds of all infant deaths. Factors related to the decline in mortality include improved obstetric and neonatal intensive care management with a significant reduction in birth weight-specific neonatal mortality Further reduction in neonatal mortality will depend on prevention of preterm delivery and LBW, prenatal diagnosis and early management of congenital anomalies, and effective diagnosis and treatment of diseases that result from adverse factors during pregnancy, labor, and/or delivery 7

8. Cont … Infant mortality rates (deaths occurring from birth to 12 mo per 1,000 live births) vary by country; in 2010, rates were lowest in Hong Kong (1.7/1,000 births), moderate in the United States (6.1/1,000), and highest in developing, resource-poor countries (30-150/1,000). Medical, socioeconomic, and cultural factors influence perinatal and neonatal mortality. Preventive variables such as health education, prenatal care, nutrition, social support, risk identification, and obstetric care can effectively reduce perinatal, neonatal, and infant mortality. 8

9. Classification of newborn by gestational age Preterm : less than 37 weeks gestation Term : completed 37 weeks gestation till 42 weeks Post-term: born after completed 42 weeks' gestation or more 9 3/3/2017

10. C lassification of Newborn based on birth weight Irrespective of the cause & without regard to the duration of the gestation, newborn can be classified as Normal birth weight (NBW) is b/n 2500-4500g Low birth weight (LBW)    < 2500 g Very low birth weight (VLBW)   < 1500 g Extremely low birth weight (ELBW)   < 1000 g 10 3/3/2017

11. Other Classification Newborn classification based on birth weight and gestation is valuable in predicting the outcome . At any gestation the poorest outcome is seen in infants with marked IUGR. Small for gestational age (SGA) <10 th percentile Large for gestational age (LGA) >90 th percentile Average for gestational age (AGA) = 10-90 th percentile 11 3/3/2017

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13. Epidemiology 20 million LBW births /year 20% of 4 million neonatal deaths /year 33% are SGA and 67% are AGA and Preterm Low birth weight

14. Factors associated with LBW Pregnancy in women who: Are less than 20 or older than 35 Have births that are less than 3 years apart Women who: Had a LBW baby before Do hard physical work for many hours with no rest Are very poor Are underweight and have poor nutrition

15. cont.. Women who have pregnancy problems such as: Severe anemia Pre- eclampsia or hypertension   Multiple pregnancy Infections during pregnancy (bladder and kidney infections, hepatitis, STIs, HIV/AIDS, malaria) Babies who have: Congenital or genetic abnormalities Infection while in the uterus

16. What Problems Do Low Birth Weight Babies Have? Breathing problems at birth and later like apnea and HMD Low body temperature because there is little fat on the body and the newborn’s temperature regulating system is immature. Low blood sugar because there is very little stored energy in the LBW baby’s body . Feeding problems because of their small size, lack of energy, small stomach and inability to suck.

17. 3/3/2017 1:57 PM 17 Infections because the infection fighting system is not mature. Jaundice (high bilirubin ) because the liver is not mature. Premature LBW babies become yellow earlier and it lasts longer than in term babies . Bleeding problems due to immature clotting ability at birth. Perinatal asphyxia due to compromized oxygen delivery in utero

18. Preterm birth Definition: PTB refers to a birth that occurs before 37 weeks of gestation . Subtypes of preterm birth are variably defined. B y gestational age: Moderate preterm: 32 to <37 weeks Late preterm: 34  to   36   weeks Very preterm: 28 to <32 weeks 18

19. Cont… BY birth weight (BW): Low birth weight (LBW): less than 2500 g Very low birth weight (VLBW): less than 1500 Extremely low birth weight (ELBW): less than 1000 g 19

20. Significance PTB is the leading direct cause of neonatal death (death in the first 28 days of life). It is responsible for 27 % of neonatal deaths worldwide, comprising over one million deaths annually. The risk of neonatal mortality decreases as gestational age at birth increases, but the relationship is nonlinear . 20

21. Cont … The burden of PTB includes neonatal morbidity and long-term sequelae , including neurodevelopmental deficits & an increased risk of chronic disease in adulthood The percentage of newborns delivered at VLBW has declined only minimally from 1.46 % in 2008 to 1.45 % in 2010 PTB is the 2 nd most common cause of-death (after pneumonia) in children younger than 5 years. 21

22. Prevalence Worldwide , the PTB rate is estimated to be about 11% range 5 % in parts of Europe to 18 % in parts of Africa, On average about 15 million children are born preterm each yr Of these PTBs , 84 % occurred at 32 to 36 weeks, 10 % occurred at 28 to <32 weeks A study done by Bekele T. et al, in Debremarkos Town Health Institutions showed that 11.6% from the total 422 mothers gave a PTB. 22

23. Pathogenesis Clinical & laboratory evidence suggest that a number of pathogenic processes can lead to a final common pathway that results in preterm labor and delivery . The four primary processes are: Activation of the maternal or fetal hypothalamic-pituitary-adrenal axis Infection Decidual hemorrhage (placental abruption) Pathological uterine distention 23

24. Approximately 70 % of preterm deliveries occur spontaneously as a result of preterm labor (45 % ) or PPROM (25 % ); intervention for maternal or fetal problems account for the remaining 30 %  24

25. RISK FACTORS N on modifiable Prior preterm birth African-American race Age <18 or >40 years Uterine malformation Over distended uterus like in case of multiple gestation 25 M odifiable Substance abuse Absent prenatal care Short interpregnancy intervals Anemia urinary tract infection High personal stress Occupational issues STI

26. Identifiable causes of PTB FETAL Fetal distress Multiple gestation Congenital anomalies PLACENTAL Placental dysfunction Placenta previa Abruptio placentae    MATERNAL Preeclampsia, Chronic medical illness Infection Drug abuse (cocaine) Uterine associated like Bicornuate uterus Incompetent cervix (premature dilatation ) OTHERs :-   PROM Polyhydramnios Trauma 26

27. CLINICAL MANIFESTATIONS Four or more uterine contractions in one hour. vaginal bleeding in the third trimester. Heavy pressure in the pelvis, or abdominal or back pain could be indicators that a PTB is about to occur. A watery discharge from the vagina may indicate PROM that surround the baby. While the rupture of the membranes may not be followed by labor. In some cases the cervix dilates prematurely without pain or perceived contractions. 27

28. Complications The shorter the term of pregnancy, the greater the risks of mortality and morbidity for the baby cognitive dysfunction Cardiovascular complications may arise from the failure of the ductus arteriosus to close after birth Respiratory distress syndrome Hypoglycemia ,feeding difficulties , hypocalcemia , inguinal hernia, and necrotizing enterocolitis (NEC). Anemia of prematurity, thrombocytopenia, and hyperbilirubinemia (jaundice) that can lead to kernicterus . 28

29. Diagnosis C ontinuous evaluation of   Maternal vital signs and fetal heart rate and contraction frequency/duration/intensity. Evaluation for signs and symptoms of preterm labor and presence of risk factors for PTB Examination of the uterus to assess firmness, tenderness, fetal size, and fetal position . Speculum examination using a wet non-lubricated speculum The presence and amount of uterine bleeding should be assessed.   29

30. Cont … The status of the fetal membranes, intact or ruptured, should be determined. PPROM often precedes or occurs during preterm labor S end swab to lab for fFN determination if the cervical length is 20 to 30 mm A rectovaginal GBS culture should be performed if not done within the previous five weeks; antibiotic prophylaxis depends on the results. STI Screening 30

31. Cont … Triage based upon cervical length Cervical length >30 mm   —  women are at  low  risk of PTB, no need of sending their swabs for fFN testing to the lab. Cervical length 20 to 30 mm   — Women are at increased risk of PTB send the swab for fFN testing. If the test is positive, fFN level > 50   ng/mL,  we actively manage the pregnancy in an attempt to prevent morbidity associated with preterm birth . Cervical length <20 mm   —  women are at  high  risk of PTB regardless of the fFN result. do not send swabs for fFN testing to the lab and we actively manage the patient in an attempt to prevent morbidity associated with PTB. 31

32. Cont.. Fetal fibronectin The most important biomarker , indicates that the border between the chorion and deciduas has been disrupted . Ultra sonography of the cervix A cervical length of less than 25 mm at or before 24 weeks of GA is the most common definition of cervical incompetence . 32

33. Management Glucocorticosteroids Fluids and nutrition through intravenous catheters. Oxygen supplementation and medications. Kangaroo care (skin to skin warming). Encouraging breastfeeding. Prophylactic Rx are also used to care for preterm infants. indomethacin is commonly used to help with the closure of a PDA 33

34. Post-term (PT) PT infants are born at a GA > 42 weeks or 294 days from the 1 st day of the LMP. PT infants have higher rates of morbidity and mortality than term infants The etiology of most PT pregnancies is unknown.   34

35. RISK FACTORS  Primigravidity Prior PT pregnancy Genetic predisposition as concordance for PT pregnancy is higher in monozygotic than dizygotic twin mothers Maternal obesity & older age Male fetal gender Specific conditions in the offspring associated with prolonged gestation include adrenal gland hypoplasia & congenital adrenal hyperplasia due to 21-hydroxylase deficiency. 35

36. CLINICAL MANIFESTATIONS B ased primarily on fetal growth. Usually continued fetal growth results in higher birth weights in the PT than term infant with an increased likelihood of macrosomia . However , FGR occurs in some PT infants, most likely caused by a poorly functioning placenta that is unable to provide adequate nutrition results in the birth of a SGA infant, who usually appears malnourished. Macrosomia ( >4000g)    — Infant size and birth weight are affected by extended gestational length. PT macrosomic infants are at risk for birth injury due to prolonged labor, cephalopelvic disproportion, and shoulder dystocia. 36

37. SMALL FOR GESTETIONAL AGE(SGA) Definition : SGA refers to a weight below the 10 th percentile for gestational age Moderate SGA is defined as birth weight in the 3 rd to 10 th percentile Sever SGA is defined as birth weight less than 3 rd percentile Normal term infants typically weigh more than 2500 g by 37 weeks gestation 37

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39. Interautrine Growth Restriction IUGR is defined as a rate of fetal growth that is less than normal for the population and for the growth potential of a specific infant or It is the term used to designate a fetus that has not reached its growth potential because of genetic or environmental factors. FGR results in the birth of an infant who is SGA Mortality and morbidity are increased in SGA infants compared to those who are AGA 39

40. CLASSIFICATION SGA infants have either symmetric or asymmetric fetal growth restriction (FGR). Symmetric FGR Have reductions in both body and head growth . Begins early in gestation Usually caused by intrinsic factors such as congenital infections or chromosomal abnormalities. However, decreased nutrient supply early in development can restrict growth of all organs . 40

41. Asymmetric FGR Have reduced body weight and relatively normal length and head growth. Begins in the late 2 nd or 3 rd trimesters . Results from reductions in fetal nutrients that limit glycogen and fat storage yet allow continued brain growth . 41

42. Fig. 1. Causes of FGR 42 Maternal Infections Nutrition Medical conditions Substance abuse Pregnancy pathology Ethnic background Placental Insufficiency Abruption Structural abnormalities Fetal Genetic abnormalities Down syndrome Congenital malformations Metabolic problems Multiple gestations ETIOLOGY OF FGR

43. CLINICAL FEATURES SGA infants appear thin with loose , peeling skin and decreased skeletal muscle mass and subcutaneous fat tissue . The face has a typical shrunken or "wizened" appearance , and the umbilical cord often is thin. Meconium staining may be present . In newborns with asymmetric FGR, the head appears relatively large compared to the size of the trunk and extremities 43

44. Fig. 2. The infant has the typical shrunken or "wizened" appearance of an SGA infant. 44

45. 45 Fig. 3. The infant has the characteristic appearance of an SGA infant. Note the loose, peeling skin, decreased subcutaneous tissue and muscle mass, and meconium staining.

46. COMPLICATIONS Deprived of oxygen and nutrients . P erinatal asphyxia. M econium aspiration. P ersistent pulmonary hypertension . Poor thermoregulation. Hypoglycemia. P olycythemia . Impaired immune function. Impaired growth and neurodevelopment(late complication. 46

47. DIAGNOSIS Maternal history Maternal examination Soft tissue measurements Doppler velocimetry Amniotic fluid volume 47

48. MANAGEMENT H eat loss should be avoided by immediate drying and placement under a radiant warmer Prompt resuscitation, including clearing the airway of meconium if needed, should be instituted. Appropriate therapy is begun for disorders of transition , including meconium aspiration pneumonia, myocardial dysfunction, or persistent pulmonary hypertension, that develop. 48

49. Essential Newborn care

50. NEWBORN CARE Newborn care is important because major causes of newborn death are birth asphyxia and infection. A skilled attendant at childbirth who can assess the newborn correctly, perform essential interventions and does not delay resuscitation if indicated, is crucial. The attendant should also be able to care for or transport a sick newborn if needed . 50 3/3/2017

51. NEWBORN CARE After birth, most newborn infants require only routine care to make a successful transition to extrauterine life. The major components of routine care for neonate are: Delivery room and transitional care, including early bonding Newborn assessment ( maternal HX and neonates PE ) Prophylaxis care to prevent serious disorders Family education Discharge evaluation

52. Delivery room care Six cleans during delivery (WHO) Clean attendant's hands (washed with soap). Clean delivery surface. C lean cord- cutting instrument (e.g. scissors). Clean string to tie cord. Clean cloth to dry the baby. Clean cloth to wrap t he baby with the mother.

53. Delivery room care ….. After delivery, immediate neonatal care includes; drying the infant, clearing the airway secretion providing warmth . Delivery room care

54. clinical status is quickly performed by addressing these questions Is the infant full-term? Is the infant breathing or crying? Does the infant have good muscle tone? Delivery room care

55. Delivery room care ….. If yes is the answer to all the questions, infant does not require further intervention and should be given to the mother. Healthy term or late preterm infants should remain with the mother to promote infant-maternal bonding by skin-to-skin contact and early initiation of breastfeeding . Delivery room care

56. Delivery room care ….. If the answer to any of the questions is no , I nfant requires further evaluation and intervention . Oxygen administration Positive pressure ventilation Chest compressions Use of resuscitative medications ( eg , epinephrine ) Delivery room care

57. Delivery room care ….. Apgar score is a practical method of systematically assessing newborn infants immediately after birth Evaluation at one and five minutes of age. The following signs are given values of 0, 1, or 2 and added to compute the Apgar score. Heart rate Respiratory effort Muscle tone Reflex irritability Color Delivery room care

58. Delivery room care ….. Delivery room care

59. Resuscitation 5-10% newborn require active intervention to establish normal cardiorespiratory function . The elements of resuscitation include : 1. Initial steps: thermal management, clearing the airway, tactile stimulation 2 . Establishment of ventilation 3. Chest compression 4. Medication

60. Thermal Protection To minimize heat loss , placed in a warmed towel or blanket under a pre-warmed radiant heat source, dried with other warmed towel or blanket. If infant is placed on the warmer ( radiant heat) should be regulated at 36.5ºC to avoid hyperthermia.

61. Factors leading to heat loss 1 . Thin skin and proximity of blood vessels to surface increase heat loss. 2. Little subcutaneous fat to protect against heat loss 3. High proportion of surface area to body mass. 4 .Preterm infants at risk for cold stress 61 T.U

62. Four mechanisms of heat loss and corresponding interventions Evaporation Dry infant immediately Conduction Place on mothers body skin to skin Convection Cover with a blanket, wear a cap , close door Radiation Keep away from cold windows and cold objects

63. resuscitation ….. Evaluating breathing; Check if the baby is crying . If the baby does not cry, see if the baby is breathing properly. The baby should not have any chest in-drawing or grunting. The infant is positioned with the neck in a neutral to slightly extended position.

64. resuscitation ….. Tactile stimulation stimulation include briefly slapping or flicking the soles of the feet, and rubbing the infant's back. More vigorous stimulation is not helpful and may cause injury. If the infant still remains apneic, PPV should be initiated. NB The time elapsed from the baby's birth to placing the baby under the warmer, positioning, suctioning, and providing additional stimulation should be no more than 30 seconds

65. Resuscitation ….. Positive pressure ventilation Usually can be provided quickly by bag and mask. Endotrachial intubation should be performed in any infant who does not respond to initial bag and mask ventilation, If after 30 seconds heart rate remains low, chest compression may be needed

66. Delivery room and transitional care ….. Chest compression is recommended if : The chest should be compressed between 100-120 times per minute with ventilation occurring 40 to 60 times per minute. If chest compressions and ventilation do not raise the heart rate above 80 within 30 seconds, support for the cardiovascular system with medications is needed.

67. Resuscitation ….. Medications are rarely required but should be administered when the heart rate is <60 beats/min after 30 sec of combined ventilation and chest compressions. Epinephrine , (0.1- 0.3 ml/kg ) stimulates the heart and increases non-cerebral peripheral vascular resistance.

68. Delivery room and transitional care ….. normal saline, ringers lactate or blood should be given for hypovolemia, history of blood loss, hypotension or poor response to resuscitation . Sodium bicarbonate , should be given slowly if there is a documented metabolic acidosis or if there is no adequate response to proper ventilation. Dopamine and dobutamine and volume expanders should be started.

69. Transitional period is during the first four to six hours of life after delivery. Physiological changes that occur during the transitional period include decreased pulmonary vascular resistance increased blood flow to the lungs, lung expansion with clearance of alveolar fluid and improved oxygenation, and closure of the ductus arteriosus.

70. the clinical status of the infant should be assessed every 30 to 60 minutes Temperature — normal 36.5 to 37.5ºC (axillary ) Respiratory rate — normal is 40 to 60 b/min Heart rate — normal heart rate is 120 to 160 beats per minute but may decrease to 85 to 90 per minute in some term infants during sleep. Color — Central cyanosis (lips, tongue, and central trunk) may be indicative of respiratory or cardiac disease. Tone — Hypotonia may be secondary to exposure to maternal medications or fever, sepsis, or neurologic impairment.

71. Routine care The following are routine procedures performed after birth to prevent serious disorders. Umbilical cord care Prophylactic eye care Administration of vitamin k Early initiation of Breast feeding Immunization Monitoring for hyperbilirubinemia and hypoglycemia T.U 72

72. Umbilical cord care Optimal cord care consists of the following : Clamping /tying the cord: wait for cord pulsations to cease or approximately 1-3 minutes after birth , Cutting the cord : Cut the cord with sterile scissors or surgical blade, under a piece of gauze in order to avoid splashing of blood . Omphalitis is a neonatal infection resulting from inadequate care of the umbilical cord. T.U 73

73. Prophylactic eye care To Prevent or Manage Ophthalmia Neonatorum Ophthalmia neonatorum - Is aform of conjunctivitis - occurring < 4 wk of age - Is the most common eye disease of newborn. - Neisseria gonorrhoeae can cause corneal perforation, blindness, and death. 74 T.U

74. 75 T.U Prevention…Clean eyes immediately after birth then apply one of:- 0.5% erythromycin drop 1% Tetracycline ointment Silver nitrates

75. Administration of vitamin K Prophylactic vitamin K1 is given to newborns shortly after birth to prevent vitamin K deficient bleeding ( VKDB ), previously referred to as hemorrhagic disease of the newborn . American Academy of Pediatrics recommends a single dose of 0.5 to 1 mg IM. 76

76. Early and Exclusive Breastfeeding Early contact between mother and newborn. Enables immediate initiation of breastfeeding. prevents nosocomial infection. Best practices No prelacteal feeds or other supplement. Giving first breastfeed within one hr/immediately after birth. Positioning the infant and determining adequate latch-on. EBF with frequency of 8 -12 times/24 hrs. No frequent change of breast Psycho-social support to breastfeeding mother. 77 T.U

77. Immunization Give bacille Calmette-Guerin ( BCG), OPVo and Hepatitis B vaccination at birth. BCG 0.01 ml intradermal on right arm. Single dose ( 2 drops po ) of OPV 0 ( zero) at birth or in the two weeks after birth. HBV vaccination( 0.5 ml given IM) at as soon as possible where perinatal infections are common. 78 T.U

78. Monitoring for hyperbilirubinemia & hypoglycemia Hyperbilirubinemia with a total serum bilirubin level > 25 mg/L is associated with an increased risk for bilirubin-induced neurologic dysfunction (BIND). during the birth, infants should be routinely assessed every 8 to 12 hours and at discharge check for the presence of jaundice. . T.U 79

79. Assess serum glucose level for hypoglycemia before discharge. treatment or further evaluation is considered if Less than 40 mg/ dL during the first 24 hours of life for asymptomatic infants and 45 mg/ dL for symptomatic infants Less than 50 mg/ dL after 24 hours of age T.U 80

80. Family Education   I mportance and benefits of breastfeeding. Positioning the infant and determining adequate latch-on and swallowing. Appropriate frequency of urination, and defecation and appearance of urine and stool. Cord, skin, and genital care. Recognition of the signs of common neonatal illnesses, particularly hyperbilirubinemia and sepsis. Proper infant safety, including supine sleeping position. T.U 81

81. Discharge evaluation made jointly with the family, and the obstetric and neonatal care providers. No neonatal abnormality vital signs are within normal ranges has urinated and passed at least one stool spontaneously. successful feedings and is able to coordinate sucking, swallowing, and breathing while feeding. T.U 82

82. Reference Kliegman M, et al. Nelson text book of pediatrics. In: Carlo A. The Newborn Infant. Elsevier; 2015. 20 th ed. p794-812 Upto date 21.2 Hospital care for children WHO 2013. Bekele T, Amanon A, Gebreslasie KZ (2015) Preterm Birth and Associated Factors among Mothers Who gave Birth in Debremarkos Town Health Institutions, 2013 Institutional Based Cross Sectional Study. 83 T.U

83. Thank you 84