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         •An Massaro, MD
   •Department of Neonatology
•Children’s National Medical Center
Preterm infant: <37 completed weeks gestation
Term: 38-42 wks
Post-Term: >42wks
Low birth weight (LBW): <2500g at birth
Very low birth weight (VLBW): <1500g at birth
Extremely low birth weight (ELBW): <1000g at birth
Small for gestational age (SGA): <10th %ile
Large for gestational age (LGA): >90th %ile
Appropriate for gestational age (AGA): 10-90th %ile
Fetal Death= death before infant is fully
extracted at >20wks GA. (“late fetal death”
>28wks GA)
Infant Death= death before 1 year of age
Perinatal Death= death between 28th wk
gestation and 28 DOL
Neonatal Death= death of liveborn infant before
28 DOL
          Prenatal Diagnosis
• Chorionic Villus Sampling (CVS)
  • chromosomes, 1st trimester
• Ultrasound
  • GA, size, major anomalies, nuchal fold
• Quad screen (15-20 wks):
  • AFP, hCG, unconjugated estradiol, inhibin-A
  • neural tube defects, trisomies (18, 21), gastroschisis (AFP)
• Amniocentesis
  • chromosomes, L/S ratio
• Fetal Blood Sampling
  • Rh incompatibility, anemia, chromosomes
• Non-Stress Test
• Contraction Stress Test
• Biophysical Profile: fetal movement, tone,
     reactivity, breathing, AFI
• Doppler Umbilical Flow
• Fetal scalp pH
Fetal Heart Rate (FHR)

NonReassuring: fetal tachycardia (>180),
bradycardia (<120), variable decels
Ominous: late decels, prolonged fetal
DR Resuscitation
Baby is cyanotic, HR <100 at 30 seconds of life.
   Next step is to:
A. Start chest compressions
B. Intubate and give Epinephrine (1:10,000) via ET
C. Continue to warm, dry, and stimulate infant
D. Start PPV via bag and mask
E. Give Narcan 0.1mg/kg IM
•A appearance (color)
•P pulse
•G grimace
•A activity (tone)
•R respirations
Based on physical/neurologic characteristics
Key physical features:
     • Plantar creases    Key neurologic features:
     • Genitalia               •Posture
     • Breast buds             •Square window
     • Lanugo                  •Arm recoil
     • Ears                    •Scarf sign
                               •Heel to ear
Skin           Sticky,     Gelatinous red, Smooth pink, Superficial     Cracking,              Parchment,          Leathery,
               friable,    translucent     visible veins peeling and/or pale areas,            deep cracking,      cracked,
               transparent                               rash, few      rare veins             no vessels          wrinkled
                        24-31 wks                         32-37 wks                      38-41 wks                   >42 wks
Lanugo         None         Sparse            Abundant         Thinning        Bald areas      Mostly bald
                                                25-32 wks                 33-37wks                 >37wks
Plantar        Heel-toe 40- Heel-toe >50      Faint red        Anterior        Creases over Creases over
Creases        50mm,        mm, no            marks            transverse      anterior 2/3 entire sole
               <40=-2       creases                            crease only
                        <31 wks                           32-35wks                       36-37wks
Breast         Imperceptibl Barely            Flat areola, no Stippled         Raised          Full areola, 5-10
               e            perceptible       bud             areola, 1-2      areola, 3-4     mm bud
                                                              mm bud           mm bud
                                24-33 wks                                 36-38 wks                >39 wks
Eye & Ear      Lids fused, Lids open,         Slightly         Well-curved     Formed and Thick cartilage,
               loosely = -1, pinna flat,      curved pinna,    pinna, soft     firm, with     ear stiff
               tightly = -2 stays folded      soft with slow   but ready       instant recoil
                                              recoil           recoil
                             24-31 wks        32-35 wks                36-39 wks                  >40 wks
Genitals, male Scrotum      Scrotum           Testes in     Testes             Testes down, Testes
               flat, smooth empty, faint      upper cannal, descending,        good rugae pendulous,
                            rugae             rare rugae    few rugae                       deep rugae
                         <28wks                           28-35wks                           >36 wks
Genitals,      Clitoris     Prominent         Prominent        Majora and      Majora large, Majora cover
female         prominent,   clitoris, small   clitoris,        minora          minora small clitoris and
               labia flat   labia minora      enlarging        equally                       minora
                                              minora           prominent
                                                       30-35 wks                 36-39 wks (full cover >40)
You are called to perform the initial examination
of an infant born to a mother with no prenatal care.

Mother provides a last menstrual period that is
consistent with a gestational age of 42 weeks.

Of the following, the physical finding that would be MOST
characteristic of a post-term infant is

A. absence of creases on the soles of the feet
B. body weight below the 10th percentile
C. cracked, peeling skin
D. elevated weight-to-length ratio
E. excessive vernix caseosa
• Pulmonary artery pressure and pulmonary vascular
• Pulmonary blood flow
•Foramen ovale, ductus arteriosus and ductus venosus close
• airway resistance, lung compliance, FRC established =>
•Lung fluid is resorbed
•Glycogenolysis and gluconeogenesis start- glucose fully
supplied by placenta before birth
Postnatal Considerations
•   Delay in voiding (>99% normal newborns void in 24 hrs)
       • Failure to observe/record
       • Inadequate fluid intake
       • Renal problem
•   Delay in stooling (>96% pass meconium in 24 hrs)
       • Failure to record
       • Prematurity
       • Delayed feeds
       • Meconium plug/ileus (think CF)
       • Imperforate anus
       • Hirschprung’s disease
•    Incidence      1:200-400 if not treated
•    Presentation   Unexpected bleeding in healthy
                    appearing neonate in first week
                    Usually ecchymosis,
                    GI /nasal/circumcision bleeding
•    Prevention     0.5-1 mg Vitamin K parenterally,
                    <1 hr of age
 Hepatitis B
A woman delivers a 3800 gm infant at term. The mother’s medical
record reveals that she recently emigrated from Southeast Asia and
is hepatitis B surface antigen (HBsAg)-positive. She denies drug
use or having any sexually transmitted diseases.
Of the following, the MOST appropriate treatment of the
infant at this time would be to administer
    A. Hepatitis B immune globulin
    B. Hepatitis B immune globulin & hepatitis B vaccine
    C. Hepatitis B vaccine
    D. IV Immune globulin and hepatitis B vaccine
    E. Interferon-alpha
Newborn Exam - Head
                  What is it?       Distinguishing      Therapy/
                                    Features            considerations

Capput            Edema in soft     Crosses suture      None
Succadaneum       tissue of         lines
                  presenting part

Cephalohematoma   Blood under      Does NOT cross       Monitor for
                  periosteum       suture lines. May    jaundice as blood
                                   be associated with   resorbs
                                   linear skull fx.
Subgaleal         Bleeding beneath Swelling extends     Bleeding may be
hemorrhage        scalp            posteriorly and in   significant.
                  aponeurotica     may push out ears
 Newborn Exam - Abdomen
•Scaphoid: think CDH
•Abdominal wall defects:
  •Diastasis recti       No rx needed-
  •Umbilical hernia      resolves in 1st year of life

  •Prune belly- look for urogenital abnormalities
   • Large surface area (prematures)
   • Scant subcutaneous tissue
   • Damp after delivery
   • Radiation (fire)
   • Evaporation (water)
   • Convection (wind)
   • Conduction (earth)
   • Dry after delivery, Swaddling AND HAT!!!
   • Radiant warmer
   • Incubator (prematures)
Causes:                     Problems
•Chromosome anomalies       •Perinatal asphyxia
•Infection                  •Temperature instability
•multiple gestation         •Glucose abnormalities
•Maternal conditions        •Polycythemia
(hypertension/ chronic      •Protein/lipid intolerance
illness/ substance abuse)
                            •Feeding intolerance/NEC
•Placental insufficiency
                            •Immune dysfunction
•Unknown (30%)
Causes:                   Problems:
•Maternal diabetes        •Perinatal asphyxia
•Post-dates               •Traumatic/ operative
•Familial                 delivery
•Syndromes (Beckwith-     •Hip dislocation
Wiedemann/Sotos)          •Hypoglycemia
Infant of a Diabetic Mother
•Fetal Death                 •Hypoglycemia
•Macrosomia (>4kg)           •Hypocalcemia (also low
•Birth Trauma                Mg, Phos)
•Cesarean delivery           •Polycythemia
•IUGR                        •Hyperbilirubinemia
•Congenital abnormalities    •Respiratory distress/
(VSD, NTD, caudal            HMD
regression, bowel atresia,   •Increased obesity and
microcolon)                  DM later in life
          Multiple Gestation
•Twins are most common, higher order
multiples with assisted reproduction
•Monozygotic twins: can be monoamnionic/
monochorionic, di/mono (most common), or
di/di if separation <3d
•Dizogotic twins: diamnionic/ dichorionic
•Increase in prematurity/IUGR
•Twin-twin transfusion syndrome- occurs in
monochorionic twins only
•Morbidity and mortality inversely related to
gestational age and birth weight
  •   ROP
  •   NEC
  •   IVH
Prematurity - considerations
•Fluid/ electrolyte balance
•Infection risk
•Respiratory support
  • Apnea of prematurity
  • RDS
•Neurodevelopmental outcome
•Incidence: 1-8:1000 Live Births

•Mortality 10-25%

•Predisposing factors
   • Prematurity (ROM <37 wks), maternal GBS,
     PROM (>18 hrs), chorioamnionitis
•Signs : non-specific to shock
•Causes: GBS, E.Coli, (Listeria), HSV, others
•Treatment: Culture & prompt antibiotics
Neonatal Sepsis
• Early onset (in utero):
  •   Birth through 7 days
  •   Fulminant presentation (before 12 hrs)
  •   Pneumonia common, meningitis 10%
  •   Associated with complications of pregnancy &
• Late onset:
  •   Days 8 through 28 days
  •   Presents more insidiously
  •   Meningitis more common
  •   Doubt that obstetric complications contribute
Maternal GBS
Which infant requires only a limited evaluation
   for infection (CBC and blood culture)?
A. Mom GBS-, ill appearing term infant
B. Mom GBS+, IAP 4hrs PTD, PROM, well
C. Mom GBS+, IAP 1hr PTD, well infant
D. Mom GBS?, IAP x24hrs PTD, sick preterm
Respiratory Diseases
  of the Newborn
•Most common cause of respiratory failure in newborn
  • Overall incidence 1-2%
  • 60-80% <28 wks GA
  • Preterm white males with highest risk
  • Lack of alveolar development
  • Surfactant deficiency (synthesized by Type II alveolar cells)
  • Prenatal steroids
  • Surfactant

      can look the
Transient Tachypnea of
the Newborn
•Term infants with respiratory distress
  • Tachypnea, grunting, hypoxia
•Retained fetal lung fluid
•Associated with cesarean delivery
•May require supplemental O2
•Resolves by 3-4 days of life
•9-15% term infants and up to 30% of post-term
infants pass meconium prior to delivery
•Physiology: airway obstruction, PPHN, pneumonia,
inflammation, surfactant deactivation
•Presentation: respiratory distress, hypoxia
•Treatment: suction at delivery (if depressed),
mechanical ventilation, NO, ECMO
•Complications: air leak, pneumonia, CLD, asphyxia
    Persistent Pulmonary
 Hypertension of the Newborn
•Etiologies: MAS, sepsis, pneumonia, pulmonary
hypoplasia (i.e. CDH), idiopathic
•Pathophysiology: failure to transition to low
resistance pulmonary circulation       persistent
fetal circulation (R   L shunt via PDA/PFO)
•Clinical sx: HYPOXIA, Pre/post ductal O2
differential , TR murmur, DDx CHD
•CXR will be nl to decreased pulmonary vascular
markings in idiopathic PPHN
A term infant presents with respiratory failure secondary to
GBS pneumonia. The infant requires assisted ventilation.
Secondary to poor oxygenation, the positive end-expiratory
pressure (PEEP) was increased from 5 to 8 cm H20. Shortly
thereafter, you are called to the bedside for an acute
decrease in oxygenation and blood pressure. The baby is
now on 100% FiO2. Which of the following therapeutic
interventions would be MOST indicated at this time?

A)Decrease the PEEP
B)Increase the ventilator peak inspiratory pressure (PIP)
C)Transilluminate the chest
D)Begin oscillatory high-frequency ventilation
E)Start Dopamine
•Occurs 1-2% of all newborns
•Higher risk with prematurity, mechanical
ventilation, can also occur spontaneously
•Clinical presentation: asymptomatic, respiratory
distress, respiratory failure/ acute
decompensation (i.e. tension PTX)
•Rx: none, nitrogen washout (O2 via NC),
thoracentesis, chest tube
Disorders in the
      Meconium Plug Syndrome
•Usually in lower colon/
•Associated dx:
  •   Small Left Colon Syndrome
  •   CF
  •   Hypothyroidism
  •   Hirschprungs
  •   Maternal drug abuse
•Rx: saline/contrast enemas
           Meconium Ileus
•Sx of bowel obstruction:
emesis, distension
•Associated microcolon
•Risk for perforation,
meconium peritonitis
•AXR: “soap bubble” RLQ
•Think CF!!!

•Incidence: 5-15% VLBW, can happen at term
  • Clinical s/sx: emesis/residuals, distension,
    heme+ stools, non-specific (A&Bs),
    thrombocytopenia, metabolic acidosis
  • Pneumatosis intestinalis- commonly terminal
•Rx: decompression, NPO/TPN, broad spectrum
antibiotics, surgery
Pneumatosis intestinalis
An infant is born at 34 weeks gestation. He develops
abdominal distention, lethargy and gastrointestinal
bleeding 72 hours after feedings with human milk are
begun. A radiograph of the abdomen reveals
pneumatosis intestinalis; there is no evidence of free
air. The MOST common late complication of this
disorder is
A. Abscess
B. Cholestasis
C. Fistula
D. Malabsorption
E. Short Gut Syndrome
F. Stricture
Abdominal Wall Defects

  • Midline
  • Covered with sac
  • Associated congenital anomalies
  • No sac
  • Usually right side
  • Associated GI abnormalities
Neurological Disorders
   in the Newborn
Of the following, the condition that is MOST
likely to present with seizures during the first 24
hours of life is

A.fetal alcohol syndrome
B.herpes simplex infection
C.hypoxic-ischemic encephalopathy acidemia
E.urea cycle defect
         Neonatal Seizures
  •subtle, tonic, clonic, myoclonic
  •HIE, ICH, glucose, calcium, infection, CNS
   anomalies, idiopathic (epilepsy)
•Treatment: cause &/or Phenobarbital
          Last Question…
An infant born at 26 weeks gestational age has a
   history of resolved Grade 2 intraventricular
   hemorrhage and bilateral periventricular
   leukomalacia. At 2 year developmental
   follow-up he is most likely to present with:
A. Spastic quadriplegia
B. Spastic hemiplegia
C. Spastic diplegia
D. Athetoid cerebral palsy

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