PART-1. NEONATAL CLASSIFICATION & COMMON PROBLEMS.pptx

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1. 7/7/2024 BY BAYISA HIRPHA, C - I 1 Yekatit 12 Hospital Medical College Department Of Pediatric And Child Health Neonatal Classification And Common Neonatal Problems By Bayisa Hirpha And Bedhasa Girma, C_i Moderator Dr. Bethelhem d. (Assistant Professor of pediatrics & child health )

2. Objectives 7/7/2024 BY BAYISA HIRPHA, C - I 2 To know different classifications of neonates To understand common neonatal problems To understand basic management principles of common neonatal problems

3. Outlines 7/7/2024 BY BAYISA HIRPHA, C - I 3 Introduction Neonatal classifications Common neonatal problems pathogenesis Etiology Risk factors Clinical features Diagnosis Management principles

4. Introduction 7/10/2024 BY BAYISA HIRPHA, C - I 4 Perinatal period 28 weeks of gestation to 1 week after birth Neonatal period The 1 st 28 days of life after birth Very early (the 1 st 24hrs) Early (24hrs – 7 th days ) Late (8 th day – 28 th day) Infancy period Birth – 1 st year of life

5. Neonatal classification 7/7/2024 BY BAYISA HIRPHA, C - I 5 CLASSIFICATION GA SUBCLASSIFICATION Preterm Before 34 wks Early preterm 34wks- 36 6 /7wks Late preterm Term 37wks – 38 6/7 wks Early term 39wks - 40 6/7wks Full term 41wks – 41 6/7wks Late term Post term > 42wks Post term A) Based on GA Table -1 Neonatal classification Based on GA

6. Preterm Neonatal classification Based on GA, WHO 2020 Extremely preterm GA < 28wks Very preterm GA 28 to less than 32 weeks Moderate to late preterm GA 32 to less than 37 weeks 7/7/2024 BY BAYISA HIRPHA, C - I 6

7. Neonatal classification… B) Based on birth weight Macrosomia - ≥ 4000gm Normal birth weight - 2500 ─ 3999gm Low birth weight – 1500- 2499gm very low birth weight - 1000 - 1499 gm extremely very low birth weight < 1000gm 7/7/2024 BY BAYISA HIRPHA, C - I 7

8. Neonatal classification… 7/7/2024 BY BAYISA HIRPHA, C - I 8 C) Based on birth weight and GA Small for GA ˂ 10 th percentile of Lubchenco chart Appropriate for GA Between 10 th & 90 th percentile of Lubchenco chart Large for GA ˃90 th percentile of Lubchenco chart

9. Chart for classification of newborns based on GA and birth weight 7/7/2024 BY BAYISA HIRPHA, C - I 9

10. Common Neonatal problems 7/7/2024 BY BAYISA HIRPHA, C - I 10 Most neonatal problems especially early neonatal problems are related to antepartum, intra partum & post partum conditions These conditions could be attributed to:- Placental causes (AP, PP, Microplacentosis, infections, asphyxia, IUGR, …) Fetal causes , (prematurity, genetics, twin, congenital anomaly ) Maternal causes ,( DM , TORCH, GBS, anemia, RH …) Environmental cause e.g. hypothermia,

11. Common causes of neonatal death 7/7/2024 BY BAYISA HIRPHA, C - I 11

12. Common Neonatal problems… 7/7/2024 BY BAYISA HIRPHA, C - I 12 Prematurity Hypoglycemia Hypothermia hyperbilirubinemia Sepsis Respiratory problems RDS MAS PNA NEC

13. 1. Prematurity A newborn delivered before a gestational age of completed 37 weeks (259 days). Complications of preterm birth are the leading cause of death in children < 5 years of age worldwide. Epidemiology They have a higher morbidity and mortality when compared to full term newborns. accounts for 75-80% of all neonatal morbidity and mortality. It is most common cause of under-five mortality accounting for 16%. 7/7/2024 BY BAYISA HIRPHA, C - I 13

14. Risk Factors Of Prematurity Low socioeconomic status Acute or chronic maternal illnesses Multiparty Previous history of prematurity Multiple pregnancy Maternal age less than 20 or greater than 35 Obstetrics factors (hypertensive disorders, Antepartum hemorrhage, cervical incompetence, uterine anomalies) Maternal physical stress Trauma 7/7/2024 BY BAYISA HIRPHA, C - I 14

15. Common Problems Of Prematurity are related to difficulty in extra uterine adaptation due to immaturity of organ systems. Common problems include: Respiratory Respiratory distress syndrome (RDS) Apnea of prematurity Neurologic Respiratory center depression Intracranial hemorrhage 7/7/2024 BY BAYISA HIRPHA, C - I 15

16. Common Problems Of Prematurity… Cardiovascular Hypotension (due to hypovolemia, sepsis, cardiac problems) Patent ductus arteriosus (PDA) Hematologic Anemia of prematurity Hyperbilirubinemia Nutritional and Gastrointestinal Necrotizing enterocolitis (NEC) 7/7/2024 BY BAYISA HIRPHA, C - I 16

17. Common Problems Of Prematurity… Metabolic Hypo or hyperglycemia Fluid and electrolyte imbalance Renal low glomerular filtration rate and inability to handle water and solute loads Temperature regulation Immunologic – immature immune defenses Ophthalmologic – retinopathy of prematurity (ROP). 7/7/2024 BY BAYISA HIRPHA, C - I 17

18. 2 . Hypoglycemia 7/7/2024 BY BAYISA HIRPHA, C - I 18 a plasma glucose concentration low enough to cause signs and symptoms of brain dysfunction Plasma glucose level, AAP 2017, : < 40   mg/ dL during the first 4 hours of life or <45mg/ dL in 4-24 hrs of life < 50   mg/ dL  after 24 hours of age <60mg/ dL after 48 hours of age Patients with hypoglycemia may be asymptomatic or may present with severe central nervous system (CNS) and cardiopulmonary disturbances.

19. Fig. 2 Interpreting glucose levels and glucose treatment targets 7/9/2024 BY BAYISA HIRPHA, C - I 19

20. Hypoglycemia Transient neonatal hypoglycemia Inadequate storage e.g. preterm infant, SGA & PNA Immature enzyme function Transient hyperinsulinemia Persistent neonatal hypoglycemia Hyperinsulinism Defective counter-regulatory hormone release Inherited disorders of metabolism 7/9/2024 BY BAYISA HIRPHA, C - I 20

21. 7/7/2024 BY BAYISA HIRPHA, C - I 21 Fig. 1 The metabolic response to fasting.

22. Etiology Inadequate glucose supply Inadequate glycogen stores Impaired glucose production Increased glucose utilization primarily due to hyperinsulinism 7/7/2024 BY BAYISA HIRPHA, C - I 22

23. Newborns at risk for hypoglycemia include: Preterm infants Small for gestational age(SGA) Large for gestational age(LGA) Infants of diabetic mothers(IDM) Sick infants who require intensive care sepsis , asphyxia, respiratory distress Post exchange blood transfusion Infants on intravenous fluids or parenteral fluids Infants whose mothers were treated with beta adrenergic or oral hypoglycemic agents Intrapartum dextrose infusions Infants with polycythemia -12-40% Hypothermia congenital disorders 7/7/2024 BY BAYISA HIRPHA, C - I 23

24. Hypoglycemia… 7/7/2024 BY BAYISA HIRPHA, C - I 24 Symptoms The clinical presentation of neonatal hypoglycemia is variable. Clinical symptoms do not correlate with blood glucose levels. Healthy infant may remain asymptomatic despite extremely low blood glucose levels during the period of transitional hypoglycemia.

25. Sign & Symptoms of hypoglycemia 7/7/2024 BY BAYISA HIRPHA, C - I 25 Sweating  Feeding difficulties poor sucking  Weak or high-pitched cry  Tremors Hypothermia  Irritability Lethargy/stupor  Hypotonia Seizures Coma Apnea, grunting or tachypnea  Cyanosis 

26. Management of hypoglycemia Oral feedings - asymptomatic infants. Parenteral glucose infusion at a rate of at least 6 mg/kg per minute If hypoglycemia is persistent , glucose infusion rates can be increased and glucose infusion rates may exceed 12 mg/kg per minute. Glucocorticoid therapy - for two or more days.   Complex & diverse Increase Gluconeogenesis - liver Inhibit production & secretion of insulin – pancreas Antagonizes insulin response – skeletal muscle & adipose tissues Glucagon - stimulate glucose production in liver 7/7/2024 BY BAYISA HIRPHA, C - I 26

27. Management of hypoglycemia… Parenteral glucose infusion  indications : Symptomatic infants severe hypoglycemia defined as plasma glucose concentration less than 25   mg/ dL persistent hypoglycemia after feeding defined as plasma glucose concentration below 40  mg/ dL unable to feed or intolerant of enteral feedings with plasma glucose concentrations < 40   mg/ dL 7/7/2024 BY BAYISA HIRPHA, C - I 27

28. Hypothermia is skin (axillary) temperature < 36.5°C Immediate after delivery: newborn's skin temperature falls by ~ 0.3°C/min core temperature decreases by ~ 0.1°C/min Cumulative loss of 2-3°C in core body temperature (~200kcal/kg heat loss). 3 types Mild (Cold stress) - axillary temp 36°c-36.4°c Moderate hypothermia - axillary temp 32-35.9°c Severe hypothermia - axillary temp <32°c 3 . HYPOTHERMIA 28 7/7/2024 BY BAYISA HIRPHA, C - I

29. Mechanisms of heat loss 7/7/2024 BY BAYISA HIRPHA, C - I 29 Convection – movement of air or water molecules across the skin Radiation – infrared rays to a colder object Conduction - physical contact Evaporation – conversion water to air

30. Thermogenesis Mechanisms of heat production in neonates Non-shivering thermogenesis Peripheral vasoconstriction shivering thermogenesis Muscular contraction 30 7/7/2024 BY BAYISA HIRPHA, C - I

31. Non-shivering thermogenesis(Metabolic) Brown fat is the site of heat production: High number of mitochondria Highly vascularized Well innervated (sympathetic ) Important factors CNS Integrity Adequacy of brown fat Availability of glucose and oxygen 31 7/7/2024 BY BAYISA HIRPHA, C - I

32. Why newborns are at risk of hypothermia? Highly permeable skin large surface area for small body mass Deficient stores of brown fat and subcutaneous fat Immature central thermoregulation Poor caloric intake 32 7/7/2024 BY BAYISA HIRPHA, C - I

33. Clinical features Early signs Irritability Cold extremity Peripheral cyanosis Chronic signs Weight loss, poor weight gain Late signs CNS : poor sucking, weak crying, lethargic, hypotonia Cardiorespiratory: apnea, bradycardia, pulmonary hypertension Metabolic: hypoglycemia, metabolic acidosis 33 7/7/2024 BY BAYISA HIRPHA, C - I

34. Clinical features… Newborns with severe hypothermia may present with: Hypoglycemia Failure to suckle Bradycardia Disseminated intravascular coagulation Irregular and slow breathing Shock 7/7/2024 BY BAYISA HIRPHA, C - I 34

35. General Management Principles Remove wet clothes and replace with warm clothes Put hypothermic infants on KMC, in incubators or under radiant warmer Warm the newborn slowly Monitor axillary temperature every 30 minutes Monitor environmental temperature Identify and treat cause of hypothermia (disease process and environmental conditions) 35 7/7/2024 BY BAYISA HIRPHA, C - I

36. Management Cold stress (36.0 - 36.4 o C ) Cover adequately Warm room/bed skin-to-skin contact with mother; if not possible, keep next to mother after fully covering the baby Breast feeding 36 7/7/2024 BY BAYISA HIRPHA, C - I

37. Management… Moderate hypothermia ( 32.0°C to 35.9°C ) Skin to skin contact Feeding Warm room/ warmer Provide extra heat by Heater, warmer, incubator Apply warm towels 37 7/7/2024 BY BAYISA HIRPHA, C - I

38. Management… Severe hypothermia (<32 °C ) Provide extra heat: under radiant warmer or air heated incubator rapidly warm till 34°C, then slow re-warming IV fluids: 60-80 ml/kg of 10% Dextrose Oxygen if still hypothermic, consider antibiotics assuming sepsis Monitor HR , temperature and blood glucose 38 7/7/2024 BY BAYISA HIRPHA, C - I

39. Mgt… 7/7/2024 BY BAYISA HIRPHA, C - I 39 Monitor for complications and manage accordingly Look for respiratory problems Monitor vital signs Monitor urine output Monitor blood sugars Look for signs of multi organ failure Adverse effect of warmers : Hyperthermia, Dehydration, Mask serious infections

40. The 10 warm chains Warm delivery room Immediate drying Skin to skin contact Breast feeding Delay bathing & weighing Warm clothing & bedding Keep mother & baby together Warm transportation Warm resuscitation Health education 7/7/2024 BY BAYISA HIRPHA, C - I 40

41. 3. Neonatal Jaundice (Hyperbilirubinemia) Neonatal jaundice is a yellowish discoloration of the skin and or sclera due to bilirubin deposition . appears when total bilirubin (TB) is > 7 mg / dl 97 % healthy full-term babies have biochemical hyperbilirubinemia (1.5mg/dl) 7/7/2024 BY BAYISA HIRPHA, C - I 41

42. Bilirubin is derived from lysed erythrocyte in RES which result in heme and globulin . The Heme heme oxygenase Biliveridin reductase Free iron + CO + Biliveridin bilirubin R eutilized for Hgb Excreted in the lungs synthesis 42 Bilirubin Production 7/7/2024 BY BAYISA HIRPHA, C - I

43. Bilirubin Production… Unconjugated Bilirubin Is a weak acid Neither water soluble nor excreted at pH 7.4 To be excreted it must be conjugated to glucuronic acid by the enzyme uridine diphosphoglucuronate (UDP) glucuronosyltransferase -1 A1 (UGT1A1) . Conjugated bilirubin Is water soluble can be excreted into the bile reaches the bowel and is eliminated from the body. 7/7/2024 BY BAYISA HIRPHA, C - I 43

44. Bilirubin Production… 7/7/2024 BY BAYISA HIRPHA, C - I 44

45. Etiology based metabolism of bilirubin Increased production Isoimmune-mediated hemolysis ABO or Rh(D) incompatibility Inherited red blood cell membrane defects hereditary spherocytosis and elliptocytosis Sepsis increased oxidative stress results in cell injury . cephalohematoma Macrocosmic infants of diabetic mothers ( IDM) polycythemia or ineffective erythropoiesis . 7/7/2024 BY BAYISA HIRPHA, C - I 45

46. Etiology… Decreased clearance : Inherited defects in the UGT1A1 gene reduces hepatic bilirubin clearance and increases TB levels. Crigler-Najjar syndrome : types I and II relative or absolute UGT deficiency. responds to phenobarbital treatment. Gilbert's syndrome : is the most common inherited disorder of bilirubin glucuronidation . is a mutation in the promoter region of the UGT1A1 gene causes a reduced production of UGT, Leads to unconjugated hyperbilirubinemia. 7/7/2024 BY BAYISA HIRPHA, C - I 46

47. Etiology… Breast milk jaundice: jaundice after the first week of age occur in 2% of breast feed term baby . maximal concentrations become as high as 10-30mg/ dL reached during the 2 nd - 3 rd weeks Breastfeeding jaundice typically occurs within the first week of life as lactation failure leads to inadequate intake with significant weight and fluid loss resulting in hypovolemia . Decreased intake also causes slower bilirubin elimination and increased enterohepatic circulation that contribute to elevated TB . 7/7/2024 BY BAYISA HIRPHA, C - I 47

48. Etiology… Intestinal Obstruction Due to ileus or HPS increase the enterohepatic circulation of bilirubin TORCH infection Bile duct abnormality Metabolic disease (e.g. galactosemia , CF) Hypothyroidism 7/7/2024 BY BAYISA HIRPHA, C - I 48

49. Table -2 difference between physiologic and pathologic jaundice Features Physiologic jaundice Pathologic jaundice onset After 24hrs of delivery Before 24hrs of delivery Jaundice visible Term baby <8 days Preterm baby <14 days Term baby >8 days Preterm baby >14 days Peak Total Serum Bilirubin (TSB) Term < 10-12 mg/dl Preterm < 15 mg/dl Term >10-12 mg/dl Preterm >15 mg/dl Rise in TSB in 24hrs < 5mg/dl > 5mg/dl Conjugated serum bilirubin level < 2mg/dl >2mg/dl or 15 % of TB 7/7/2024 BY BAYISA HIRPHA, C - I 49

50. Clinical features Jaundice (sclera & skin) Anemia , hydrops fetalis, HF, liver dysfunction 7/7/2024 BY BAYISA HIRPHA, C - I 50

51. Clinical features … Hyperbilirubinemia with a TB >25 to 30 mg/ dL is associated with an increased risk for Bilirubin-Induced Neurologic Dysfunction (BIND), which occurs when bilirubin crosses the blood-brain barrier and binds to brain tissue . Indirect bilirubin deposited in basal ganglia & brainstem nuclei . Acute Bilirubin Encephalopathy ( ABE ) describe the acute manifestations of BIND , Chronic bilirubin encephalopathy - Kernicterus describe the chronic and permanent sequelae of BIND . 7/7/2024 BY BAYISA HIRPHA, C - I 51

52. Parameter Clinical signs Score Mental status Normal; Sleepy, poor feeding ; 1 Lethargic, irritable , and/or jittery 2 Apnea, unable to feed, seizure, coma 3 Muscle tone Normal flexed tone Hypertonia alternating with hypotonia 1 Neck stiffness, flexor spasm, hypertonia 2 Persistent retrocollis & opisthotonos , bicycling, twitching hands & feet, fisting, severe hypotonia with limp posture 3 Cry pattern Normal High-pitched cry 1 Shrill (very high pitched cry), hardly consolable; 2 weak or absent cry, inconsolable cry 3 Clinical features … Table -4 BIND score Score 1-3 mild acute bilirubin encephalopathy 4-6 moderate acute bilirubin encephalopathy 7-9 severe acute bilirubin encephalopathy 7/7/2024 BY BAYISA HIRPHA, C - I 52

53. Clinical features… acute bilirubin encephalopathy 3 phases Phase 1 (1st 2 days of age ) Poor motor reflex High pitched cry, Decreased tone, Lethargy, Poor feeding 7/7/2024 BY BAYISA HIRPHA, C - I 53

54. Clinical features… Phase 2 (middle of 1st week of age): Hypertonia seizure and depressed sensorium fever opisthotonos posturing paralysis of upward gazing Phase 3 (after 1 week of age) Hypertonia decreases Hearing and visual abnormality poor feeding Athetosis and seizure 7/7/2024 BY BAYISA HIRPHA, C - I 54

55. Kernicterus Chronic form o f bilirubin encephalopathy seen after 1 year of age and manifests with: - Choreoathetoid cerebral palsy Upward gaze palsy Sensorineural hearing loss The intellect may be spared with severe physical handicap 7/7/2024 BY BAYISA HIRPHA, C - I 55

56. Diagnosis Serum total and direct bilirubin Coombs test CBC RPI or reticulocyte count Maternal and neonate BG and Rh Peripheral morphology Liver function test A bdominal U/S if conjugated bilirubin is elevated Sepsis & TORCH screening 7/7/2024 BY BAYISA HIRPHA, C - I 56

57. Diagnosis… 7/7/2024 BY BAYISA HIRPHA, C - I 57

58. Management principles Correct hypoglycemia , hypothermia & hypoxia Avoid drug interfere with metabolism of bilirubin Drug therapy like phenobarbital to increase conjugation Improving the frequency and efficacy of breastfeeding or supplementing inadequate breastfeeding with formula Lowering serum bilirubin Phototherapy Exchange transfusion Iv immunoglobulin 7/7/2024 BY BAYISA HIRPHA, C - I 58

59. Management… Mechanism of Phototherapy Structural isomerization to lumirubin(not reversible ) - principal mechanism Photo isomerization to a less toxic bilirubin isomer( reversible) Photo-oxidation to polar molecules ( slow process and smaller elimination of bilirubin through urine) Indication Total serum bilirubin >15mg/ dL Total serum bilirubin >5x birth weight Bhutani Nomograph – high risk age-specific percentile curves to evaluate the risk of developing pathological neonatal jaundice . Depending on the measured serum bilirubin value , several risk zones are defined. 7/9/2024 BY BAYISA HIRPHA, C - I 59

60. Management… Exchange Transfusion Indications Threshold in a 24-hour-old term baby is TSB > 20 mg/ dL Inadequate response to phototherapy Acute bilirubin encephalopathy Hemolytic disease, severe anemia Procedure Use ABO-matched and Rh- negative erythrocyte concentrate Iv Immunoglobulin Indications : used in cases with immunologically mediated conditions, or in the presence of Rh, ABO, or other blood group incompatibilities that cause significant neonatal jaundice. 7/7/2024 BY BAYISA HIRPHA, C - I 60

61. References Nelson textbook Of pediatrics, 22 nd edition Clinical Reference Manual For Advanced Neonatal Care In Ethiopia, FMOH, January 2021 Upto date 21.6 7/9/2024 BY BAYISA HIRPHA, C - I 61

62. Thank you! 7/7/2024 BY BAYISA HIRPHA, C - I 62