breast feeding, HIE, birth injuries - Copy - Copy.pptx

Breast feeding and birth injury

1. Breast Feeding Safwat M. Abdel-Aziz Assistant professor of pediatrics Assiut university

2. Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants WHO and UNICEF Recommendations for optimal infant feeding as set out in the Global Strategy for Infant and Young Child Feeding are: - Exclusive breastfeeding for 6 months: means that an infant receives only breast milk, and no other liquids or solids, not even water, with the exception of oral rehydration solution, drops or syrups consisting of vitamins, minerals supplements or medicines. - Nutritionally adequate and safe complementary feeding starting from the age of 6 months with continued breastfeeding up to 2 years of age or beyond.

3. To empower women to breastfeeding, the following instructions should be explained to mothers : - Initiate immediate skin to skin contact and early breastfeeding -Avoid giving the infant prelacteals (e.g., glucose, anise) -Ensure correct positioning and attachment -Provide feeding on demand -The infant should empty the breast -Night feeds are very important -Avoid bottles and pacifiers -Avoid supplements before 6 months

4. Infants who are kept skin to skin with the mother immediately after birth are more likely to latch on without any help, are more likely to latch on well, and are more likely to exclusively breastfeed longer.

5. Proper positioning ► The mother needs to be relaxed and comfortable. In the first few weeks the mother can put the infant on a pillow, so as not to lean forward. ► The infant should be straight and supported by the mother’s arm. ► The infant’s body should be close to and facing the mother’s body.

6. Proper Attachment All of these signs should be present if the attachment is good: ► Infant's mouth is wide open. ► Infant's chin is touching the breast. ► Infant's nose is lightly resting on breast. ► Infant's upper and lower lips turned outward ► More areola is visible above the infant's mouth than below the mouth. ► The infant suckles effectively with slow deep sucks, sometimes pausing. ► The cheeks should look full.

7. Feeding on demand The infant should be allowed to feed on demand with no scheduling. Usually in the first few weeks, infants need to nurse often and fully. The more the infant suckles, the more prolactin and oxytocin produced.

8. Assessment of the Breast Milk Supply -Adequate weight gain: the healthy infant loses 5-7% of his/her birth weight after delivery, and then the weight is usually regained within 2 weeks. Once gaining weight;the average newborn weight gain is 25-35 gm/day, - Wetting 6 heavy diapers every 24 hrs, and - Expelling 2 or more bowel movements every 24 hrs.

9. False Alarms of Insufficient Milk -The infant feeds frequently or for a long time . -The infant seems hungry shortly after feeding. - The mother’s breasts seem softer. - Infant accepts bottle after feeding. - The mother cannot express a lot of milk. - The mother doesn’t feel the let down. - Fussy infant.

10. Storage of the expressed breast milk 1-Freshly expressed milk: refrigerate, as soon as possible, if not using within 4 hours. -Room temperature (24-26ºC) 4 hours 2-Refrigerated milk: store at back; do not store in-door -Refrigerator (fresh milk) 48 hours 3-Frozen milk: store at back; do not store in door; do not refreeze - Freezer compartment inside refrigerator door Not recommended - Freezer compartment with separate door 3 months - Deep freeze (not attached to refrigerator) 6 months

11. Maternal conditions that may justify permanent avoidance of breastfeeding HIV infection: if replacement feeding is Acceptable, Feasible, Affordable, Sustainable and Safe (AFASS). Otherwise, exclusive breastfeeding for the first six months is recommended.

12. Maternal conditions that may justify temporary avoidance of breastfeeding -Severe illness that prevents a mother from caring for her infant, for example sepsis. - Herpes simplex virus type 1 (HSV-1): direct contact between lesions on the mother's breasts and the infant's mouth should be avoided until all active lesions have resolved. - Maternal medication: ► Sedating psychotherapeutic drugs, anti-epileptic drugs and opioids and their combinations . ► Excessive use of topical iodine or iodophors (e.g., povidone -iodine), especially on open wounds or mucous membranes, can result in thyroid suppression. ► Cytotoxic chemotherapy requires that a mother stops breastfeeding during therapy. if a safer alternative is available.

13. Maternal conditions during which breastfeeding can still continue, although health problems may be of concern -Breast abscess: breastfeeding should continue on the unaffected breast; feeding from the affected breast can resume once treatment has started. - Hepatitis B: infants should be given hepatitis B vaccine, within the first 48 hours or as soon as possible thereafter. - Hepatitis C. - Mastitis: if breastfeeding is very painful, milk must be removed by expression to prevent progression of the condition. - Tuberculosis: mother and baby should be managed according to national tuberculosis guidelines. - Substance use

14. Thank you

15. Perinatal Asphyxia and Hypoxic Ischemic Encephalopathy

16. Definitions Hypoxia or anoxia It is defined as partial (hypoxia) or complete (anoxia) lack of oxygen in the tissues or blood. Ischemia It is defined as a reduction or cessation of blood flow to the tissues which compromises both oxygen and substrate delivery to the tissue. Asphyxia It is the state of impaired gas exchange in the placenta or lungs leading to progressive hypoxemia, hypercarbia , and acidosis.

17. Essential characteristics of perinatal asphyxia (AAP) -Profound metabolic or mixed acidosis (pH <7.0) in umbilical cord arterial blood sample, if obtained. - Persistence of an Apgar score of 0-3 for >5 minutes. - Neurologic manifestations in the immediate neonatal period to include seizures,hypotonia , coma, or hypoxic-ischemic encephalopathy (HIE). - Evidence of multiorgan system dysfunction in the immediate neonatal period.

18. Hypoxic-ischemic encephalopathy (HIE) A clinically defined syndrome of disturbed neurological function with an abnormal neurobehavioral state in the earliest days of life, manifested by difficulty with initiating and maintaining respiration, depression of tone and reflexes, subnormal level of consciousness, and often seizures as a result of a hypoxic-ischemic event.

19. Etiology In term infants, 90% of asphyxial events occur in the antepartum or intrapartum periods as a result of impaired gas exchange across the placenta. The remainder of these events occurs in the postpartum period, and is usually secondary to pulmonary, cardiovascular, or neurologic abnormalities.

20. Maternal factors I nadequate oxygenation of maternal blood Low maternal blood pressure Uteroplacental factors -Uterine tetany and inadequate relaxation of the uterus as a result of administration of excessive oxytocin . - Uterine rupture. - Placental abruption. - Placental insufficiency from toxemia or postmaturity . - Umbilical cord accidents: prolapse , compression, or true knot .

21. Fetal/neonatal factors 1- Failure of oxygenation ► Severe forms of cyanotic congenital heart disease ► Severe pulmonary disease (e.g. RDS, MAS, or pneumonia) 2-Anemia, severe enough to lower the oxygen content of the blood ► Severe hemorrhage (e.g., twin-to-twin transfusion syndrome, or fetomaternal hemorrhage) ► Severe isoimmune hemolytic disease 3- Shock, severe enough to interfere with the transport of oxygen to vital organs ► Overwhelming sepsis ► Massive blood loss ► Intracranial or adrenal hemorrhage ► Cardiac arrhythmia

22. Clinical Manifestations The incidence of perinatal asphyxia is inversely related to the gestational age and birthweight . A higher incidence is noted in term infants of diabetic or toxemic mothers, infants with IURG, breech presentation, and postdates infants.

23. During labor -Slow fetal heart rate, and loss of beat-to-beat variability - Variable or late deceleration pattern - Fetal scalp blood analysis may show a pH <7.20 - Yellow, meconium -stained amniotic fluid

24. After birth - At birth, these infants are frequently depressed and fail to breathe spontaneously. Diagnosis of perinatal HIE requires an abnormal neurologic examination on the first day after birth. - According to Sarnat and Sarnat , HIE can be classified into 3 stages , Infants can progress from mild to moderate and/or severe encephalopathy over the 72hrs following the insult . - Other multi-organ system dysfunctions secondary to inadequate perfusion

25. Management of Perinatal Asphyxia Time is crucial in managing HIE and even a few minutes of delay can lead to long-term disability or death. Prevention Prevention is the best management -Proper antenatal care for pregnant mothers and identification of high risk pregnancies. - Proper antenatal fetal assessment ( nonstress test, contraction stress test, and biophysical profile). - Proper intrapartum fetal assessment (fetal heart rate and rhythm abnormalities). - Proper resuscitation measures.

26. Supportive measures Adequate ventilation and oxygenation Thermoregulation Correction of metabolic acidosis Cardiovascular support Maintenance of an optimum metabolic status Feeding Renal & Liver support Hematological support Control of brain edema Control of seizures Emerging Neuroprotective Strategie

27. Prognosis The outcome of HIE correlates to the timing and severity of the insult and ranges from complete recovery to death. -The prognosis varies depending on whether the metabolic and cardiopulmonary complications (hypoxia, hypoglycemia, shock) are treated, the infant's GA (outcome is poorest if the infant is preterm), and the severity of the encephalopathy. - The overall mortality rate is 10-30%. The frequency of neurodevelopmental sequelae is 15-45%. - A low Apgar score at 20 minutes, absence of spontaneous respirations at 20 minutes of age, and the persistence of abnormal neurologic signs at 2 weeks of age also predict death or severe cognitive and motor deficits. -presence of seizures increases an infant risk of cerebral palsy 50-70 times.

28. Birth Injuries

29. Risk Factors - Primiparity - Cephalopelvic disproportion - Dystocia - Prolonged or unusually rapid labor - Oligohydramnios - Abnormal presentation of the fetus - Very low birth weight or extreme prematurity - Macrosomia - Fetal anomalies - Use of forceps or vacuum extraction

30. 1- Caput succedaneum An area of edema of the soft tissues over the presenting part of the scalp during vertex delivery. Clinical manifestations Soft swelling that may extend across the middle line and cross the suture lines (external to periosteum). It usually resolves within several days of life and it may be difficult to distinguish from a cephalhematoma. Treatment: no specific treatment is needed.

31. 2- Cephalhematoma A subperiosteal collection of blood overlying a cranial bone, higher frequency occurs in infants born to primiparous women. Etiology Rupture of blood vessels, that traverse from skull periosteum, secondary to difficult labor or mechanical trauma. Clinical manifestations • It is usually limited to surface of one cranial bone. • Bleeding is limited by suture lines. • Swelling is not visible until several hours or days after birth (subperiosteal bleeding is a slow process). • It resolves within 2 weeks to 3 months.

32. Treatment • No treatment is needed for uncomplicated cephalhematoma. • Significant hyperbilirubinemia may result necessitating phototherapy or even exchange transfusion according to the level of serum bilirubin. • Blood transfusion may be administered in cases with large cephalhematoma.

33. 3- Intracranial hemorrhage It commonly occurs in infants with birth weight <1500 gm. It results from trauma, asphyxia or hemorrhagic disorders. Sites of intracranial hemorrhage a- Epidural, subdural or subarachnoid space. b- Parenchyma of the cerebrum or cerebellum. c- Ventricles. Clinical manifestations 1- A silent presentation may occur in up to 50% of cases. 2- Signs of blood loss: shock, pallor, respiratory distress, disseminated intravascular coagulation. 3- Signs of neurologic dysfunction: diminished or absent Moro reflex, hypotonia, seizures, paralysis, apnea and irregularity of respiration, cyanosis, temperature instability and bulging anterior fontanel.

34. Diagnosis This is based on history of delivery, clinical manifestations and it is confirmed by cranial ultrasonography and CT scan. Treatment • The infant should be handled as gently as possible and maintained in an incubator. • Vitamin k1 and transfusion of fresh frozen plasma or blood are indicated. • Anticonvulsant drugs may be used to control seizures. • Respiratory support.

35. II- Peripheral nerve injuries 1- Brachial palsy Paralysis of the muscles of the upper limb following mechanical trauma to the spinal roots of the brachial plexus. These injuries occur when lateral traction is exerted on the head and neck during delivery of the shoulder in a vertex presentation.

36. a- Erb’s paralysis: is the most common form resulting from injury of the fifth and sixth cervical nerves (C5, C6 ). Clinical manifestations of Erb’s palsy The affected infant is frequently large and asphyxiated. The affected arm is held in shoulder adduction and internal rotation, with elbow extension, pronation of the forearm, and flexion of the wrist. Treatment 1- Partial immobilization for 1 to 2 weeks by splint in a position opposite to that held by the baby to prevent development of contracture. 2- Gentle muscle massage and passive exercises may be started after 1 week and up to 3 months. 3- If paralysis persists without improvement, neuroplasty is needed.

37. b- Klumpke paralysis: injury to the 7th and 8th cervical nerves and 1st thorathic nerve produces a paralyzed hand. 2- Facial nerve palsy It results from pressure over facial nerve during labor. When the infant cries, the mouth is deviated to the non-paralyzed side. On the affected side, the eye cannot be closed and the nasolabial fold is absent. Improvement occurs within a few weeks. Care of the exposed eye is essential. Neuroplasty may be indicated when the paralysis is persistent.

38. III- Intra-abdominal injuries These involve rupture or sub capsular hemorrhage of the liver, spleen or adrenal gland. Clinical picture History of a difficult delivery, sudden shock and abdominal distension. Gradual onset of jaundice, pallor, poor feeding, tachypnea or tachycardia may be present. Diagnosis It is confirmed by abdominal ultrasonography. Treatment Laparotomy is indicated in cases of hepatic or splenic injuries and surgical repair of a laceration may be required.

39. Thank you