Fetus and Newborn Infant I. Fetal Assessment Routine testing of the fetus in utero start early in pregnancy with the mother having a hemoglobin and hematocrit, a urinalysis, blood group, an Rh determination, an antibody screen, rubella titer measurement, syphilis screen, cervical cytology, and hepatitis B virus Testing During pregnancy screen.. Time (week) Assessment As pregnancy goes on, an ultrasound should be done between 8 and 18 weeks if it's being used for dating purposes. Also, for an amniocentesis for diagnostic purposes. Chorionic Initial (as early as Hemoglobin or hematocrit measurement villus biopsy sampling, of course, is also for chromosome imbalances and should also be possible) Urinalysis, including microscopic examination and done prior to 18 weeks. Maternal serum alpha-fetoprotein screening for neural tube defects infection screen should be done between 16 and 18 weeks. If the initial value is elevated, then it should be repeated. Subsequently, if that one is elevated, then an amniotic fluid alpha-fetoprotein Blood group and Rh type determinations should be done. Antibody screen At 26-28 weeks, diabetes screening is recommended and repeat hemoglobin in the mother. Rubella antibody titer measurement An antibody test for Rh negative patients should be done by 28 weeks and prophylactic Syphilis screen administration of RhoGAM should be done at that time. An ultrasound can be repeated at 32-36 weeks if one is suspicious of congenital malformations or for identification of sex, Cervical cytology although it is very important to recognize that that is not a completely accurate test. Hepatitis B virus screen Prenatal diagnostic tests for birth defects. Cytogenetic indications are generally advanced 8-18 Ultrasound maternal age; previous offspring with chromosome abnormality, especially trisomy; Amniocentesis chromosome abnormality in either parent, especially if there is translocation such as in Down's syndrome; a need to determine the fetal sex when there is a family history of serious Chorionic villus sampling X-linked disease. Also, if there is a single gene disorder in a sibling or carrier or Maternal serum alpha-fetoprotein multifactorial disorders in first-degree relatives. 26-28 Diabetes screening Repeat hemoglobin or hematocrit measurement 28 Repeat antibody test for unsensitized Rh-negative patients Prophylactic administration of Rho(D) immune globulin 32-36 Ultrasound Testing for sexually transmitted disease Repeat hemoglobin or hematocrit measurement Culture for Group B streptococcal colonization A. Indications for Prenatal Diagnostic Testing for Birth Defects 1. Cytogenetic Indications a. Advanced maternal age (>35 yrs) b. Previous offspring with chromosome abnormality, especially trisomy c. Chromosome abnormality in either parent, especially translocation d. Need to determine fetal sex when there is a family history of serious X-linked disease 2. Single gene disorder in a sibling or carrier parent 3. Multifactorial disorder in first-degree relatives B. Routine Assessment of Intrauterine Growth and Maturation Documentation of dates. This should be done by the presence of fetal heart tones for 20 weeks by nonelectronic stethoscope, or 30 weeks by a Doppler ultrasound, or a positive 1. Document maturity and EDC pregnancy test of 36 weeks duration, or an ultrasound examination documenting a crown a. Documentation of fetal heart tones for 30 weeks by Doppler rump length between 6-11 weeks, or an evaluation at 12-20 weeks that confirms the clinical history and physical examination. An assessment of continued growth includes crown rump ultrasound. length, femur length, chest/abdominal circumference, and head circumference. Of course, b. 36 weeks of positive pregnancy test (HCG). the point here is to identify the baby's continued growth in utero. The femur length is really c. Ultrasound examination documenting one of following: a very accurate tool to use in length of gestation throughout pregnancy. (1)Crown rump length between 6-11 weeks In the absence of documenting length of pregnancy by any of the aforementioned methods (2)Evaluation at 12-20 weeks that confirms clinical history and above, the assessment of the fetal pulmonary maturity should be done when the pregnancy has to be induced, one of the most common tests to do this is a phosphatidylglycerol (PG) physical examination and if there is fetal maturity the presence of PG is positive. An L:S ratio is somewhat more 2. Assessment of Continued Growth accurate. It takes a longer period of time. An L:S ratio greater than two is equal to maturity. Other tests that are done, somewhat less commonly but are fairly reliable, are the foam a. Crown rump length, femur length, chest and abdominal stability index and a Delta OD 650 with a value greater than 0.15 indicating maturity. circumference, head circumference 3. Assessment of Pulmonary Maturity Assessment of placental integrity is being done more and more frequently by our OB colleagues by ultrasound and by Doppler studies of blood flow. We can grade the placenta a. Presence of phosphatidylglycerol (PG) indicates maturity. by ultrasound and determine whether or not there is calcium deposition, get a rough idea b. A ratio of lecithin to sphingomyelin (L:S) ratio >2 is consistent of the size placenta and whether or not placental function is normal with flow studies. There are two indices, the pulsatility index and BD index that are calculated and two ratios, with maturity systolic and diastolic and diastolic over average ratios that are being assessed as c. Foam stability index: complete bubble ring indicates maturity obstetricians evaluate blood flow through the umbilical vein. Absence of diastolic flow is a very bad prognostic sign suggesting that the fetus is not being perfused well and may well d. Delta optical density 650 >0.15 indicates maturity be better off out than in. 4. Assessment of Placental Integrity a. Ultrasound evaluation of placenta and fetus (location, size, Moving along to periumbilical blood sampling (PUBS. Hematocrit determination can be done. It is not necessary very often, but from time to time in patients that are Rh sensitized, morphology) hematocrit determination in intrauterine transfusions are accomplished through a b. Doppler Flow Studies. Assessment of blood flow velocity in periumbilical blood sampling. Occasionally, a rapid karyotype might be necessary in circumstances where we missed the window of opportunity with chorionic villus biopsy uterus, placenta, cord vessels, and fetal aorta/carotid arteries. sampling. Platelet assessment can be done and is pertinent in patients subjected to May be useful in conditions of compromised blood flow (eg, isoimmune thrombocytopenia. This is really the best way of knowing what the baby's platelet count is. Biochemical and serologic studies can be done in cases of inborn errors of IUGR, hypertension, diabetes mellitus and postmaturity). metabolism. Elevated systolic:diastolic umbilical artery velocity ratio, elevated pulsatility index and reduced end-diastolic flow velocity suggest Near term, assessing the fetus is done by non-stress tests, stress tests and a biophysical profile. The non-stress test, the NST is a test of cardiovascular reflex activity through fetal distress. assessment of acute spontaneous acceleration of heart rate in response to fetal movement. 5. Periumbilical Blood Sampling (PUBS) In other words, you watch the fetus and see if the heart rate accelerates during spontaneous movement. The way this is done is to simply have the mother assume the semi-Fowler a. HCT determination position with a left lateral tilt, and put an abdominal Doppler or EKG source to evaluate the b. Rapid karyotype fetal heart rate. Place a transducer to help assist with evidence of fetal movement, but actually have the mother determine whether the baby is moving. What we are looking for c. Platelet assessment is a reactive non-stress test. In other words, when the baby moves spontaneously, the heart d. Acid-base assessment should accelerate 15 beats/minute from a baseline of 110-150. There should be some long- e. Biochemical and serologic studies term variability. A reactive, non-stress test is a good sign. On the other hand, a nonreactive, non-stress test is of concern. It means there is no acceleration of the baby's heart rate with C. Intrapartum Assessment fetal movement and there is decreased long-term variability and the baseline of the heart 1. Non-stress Test. This test evaluates cardiovascular reflex activity rate is probably in the upper range of normal, like 150 or so. through assessment of acute spontaneous acceleration of heart rate If the non-stress test is nonreactive, then frequently a contraction stress test is done, which in response to fetal movement. is a determination of uteroplacental reserve in response to induced contractions. In this technique, the mother is again placed on her side, with a left lateral tilt, an IV is started and 2. Stress test. This test evaluates uteroplacental reserve through an assessment of fetal heart rate is done. Tokodynamometer is done to assess the intensity observation of heart rate in response to contractions. of contractions and a dilute oxytocin drip is started until contractions occur every four minutes. A positive test is repetitive, uniform, late decelerations. So remember a positive 3. Biophysical Profile (fetal Apgar score with ultrasonography) stress test is a bad prognostic sign. A negative stress test means that there is an absence a. Heart rate of late decelerations, and that is of course a good sign, although there are some that are b. Respiration difficult to interpret. c. Fetal movement (assesses tone) Under circumstances of surveillance then, one can move to the biophysical profile which d. Non-stress test (response) involves either four or five observations of the fetus. This is like a fetal Apgar score, one b. Late decelerations indicate uteroplacental insufficiency acceleration of heart rate, and the fetal Apgar score is in the 2-4 range, then the baby is probably better off out than in. c. Variable decelerations indicate cord compression d. Variability consists of long-term and short-term variability, and it Early and late decelerations. Early decelerations are thought to be due to head compression indicate normal reflex variability. when looking at fetal heart rate responses to intrauterine pressure increases from contractions. There is normally a vagal response of the fetal heart rate, so the heart rate 5. Scalp pH Measurements. Provide an acute assessment of fetal drops during a contraction but returns to baseline at the end of the contraction. That is an acid-base status although limited value in assessing outcome. early deceleration and that would be normal. On the other hand, uteroplacental insufficiency is suggested when the fetal heart rate deceleration persists beyond the end of the II. Immediate Neonatal Assessment contraction. This is a late deceleration or a type II deceleration which is a bad sign of uteroplacental insufficiency. A third type of deceleration that is seen is between contractions and is thought to be due to cord compression, and it can occur anyplace. Sometimes it Normal Cord Blood Gases occurs at the end of a contraction, sometimes it occurs without regard to the timing of the contraction, and it is a sign of cord compression. Baseline variability is also a very important Artery Vein measure. This is actually a fluctuation in the baby's fetal heart rate, both long-term and short-term. The short-term variability is R-R variability. Increased R-R variability is a bad pH 7.24 7.32 prognostic sign and the baby would be better off out than in. PCO2 56 44 PO2 18 29 If you look at umbilical artery samples of abnormal pHs less than 7.1, only 15% of the time is the cord pH less than 7.1 when the Apgar is less than 7. Or in other words, 85% of the low Base deficit 3.6 2.9 Apgar scores at one minute are associated with a normal cord pH. Even at five minutes, 64% of babies who had low Apgar scores had pHs which were normal. Only 36% of those were low. So certainly not all neonatal depression is due to acute perinatal asphyxia. Relationship of Arterial Cord pH with 1 and 5 Minute Apgar Scores We separate the terms neonatal depression and neonatal asphyxia. Neonatal depression can be defined as a baby who has a low Apgar score, less than 7 at one minute or 5 at 1 min 5 min minute. But it means just that - neonatal depression. A baby who has poor tone, poor color, poor response, and is depressed. Perinatal asphyxia is a term which should be confined in <7 >7 <7 >7 babies in whom you know there is an asphyxial episode, manifest by abnormal blood gas, and that should be cord pH of less than 7.1 in the artery and 7.2 in the vein. So asphyxia cord pHa <7.1 15% 2% 36% 2% should be defined only if you really know the blood gases are abnormal, because asphyxia means interruption of respiration. The majority of babies who have low Apgar scores don't cord pHa >7.1 85% 98% 64% 98% have low cord pH. It happened simply on the basis of prematurity or perhaps the baby was ill from some cause, a central nervous system malformation or defect, perhaps drugs, perhaps the baby is septic but not necessarily from uteroplacental insufficiency. The limitations of the Apgar score are that it does not tell us the long term prognosis of the Apgar Score baby. It is simply a semiquantitative estimation of the physical exam and response to things Sign 0 1 2 at that point in time. If one is going to ascribe neonatal depression to asphyxia and hypoxic- ischemic encephalopathy, you need to have, in addition to a low Apgar score, evidence of Heart rate absent <100 >100 a metabolic acidosis, evidence of multisystem organ damage, and probably a seizure. Respiratory absent weak, strong cry effort irregular Muscle tone limp some flexion well flexed Reflex no response some motion cry Color blue, pale extremely completely. pink blue Resuscitative Response to Apgar Score Apgar Score Resuscitation 8, 9, 10 None 5, 6, 7 Face mask 02 only upper airway (nose, mouth, pharynx) must be cleared with a 12 French suction catheter before beginning any resuscitative effort. Management of the neonate. Temperature regulation is and has been of very serious concern, and we need to prevent heat loss from the four methods that heat is exchanged, A. Apgar Score Assessment radiation, evaporation, conduction, and convection. We place them on a dry warm towel and dry them off thoroughly to prevent evaporative heat losses. We can prevent conductive heat 1. The Apgar score is useful in assessing the condition of the infant at birth. loss by being sure that those towels are nice and warm and that the surface they are lying 2. The Apgar score alone should not be used as evidence that neurologic on is warm. We can prevent the radiant heat losses with a radiant warmer convective heat losses are the temperature of the air around the baby. Simply surface cooling is enough to damage was caused by hypoxia. produce epinephrine and norepinephrine-mediated pulmonary restriction, so careful 3. An infant, having had asphyxia proximate to delivery that is severe attention to temperature regulation is a very important issue. enough to result in acute neurologic injury, should demonstrate all of the Cardiopulmonary stabilization is consists of making sure that the airway is open, the baby following signs: is positioned properly. Suctioning is then done to remove mucus or other material, suction a. Profound metabolic or mixed acidemia (pH 7.00) on an umbilical trachea if necessary, provide oxygen if necessary, assisted ventilation if necessary, external cardiac massage and drug therapy if necessary. artery sample b. An Apgar score of 0-3 for longer than 5 minutes The distending airway pressures in the newborn infant with the first breath indicate that pressures of 40-50 mmHg are generated by the infant in order to create the first breath and c. Neurologic manifestation such as a seizure, coma, or hypotonia a volume of gas up to about 40 ml/kg. After that, the second breath requires pressures of d. Evidence of multiorgan dysfunction only 20-30 mmHg. Fairly high pressures are required to open the lungs of a baby who has never breathed and if you encounter, in the delivery room, an infant who has not taken a first III. Immediate Neonatal Management breath because it is so depressed, you may need to generate fairly high airway pressures. A. Temperature Regulation You can usually do that with a bag and mask but sometimes those babies require assisted 1. Heat loss from radiation, evaporation, conduction and convection should ventilation. A simple overview of that would be to say, always try bag and mask ventilation. The baby will continue to respond to bag and mask ventilation, and you can continue that be prevented. form of respiration until spontaneous respiration is established. If they fail to have their own a. Place on dry, warm towel spontaneous respiration, then that is the baby who needs to be intubated. You will also know that that baby needs to be intubated because the heart rate will fall less than 100, b. Place under radiant warmer on warm blankets, dry thoroughly. usually less than 80, and that's the time you should intubate that baby. 2. A fall in skin temperature may produce pulmonary and systemic Size of the endotracheal tube is very important. In general, you should remember that there vasoconstriction leading to hypoxia, acidosis and persistent pulmonary are three sizes that are most commonly used. There is 3.5 for a normal, full-term baby, 3.0 hypertension. for a baby between 1000-2000 gm and 2.5 for the little tiny babies. We rarely use a 4.0 B. Cardiopulmonary Stabilization endotracheal tube. You should also remember what size suction catheter goes through what size endotracheal tube. For example, you can't put an #8 suction catheter through a 3.0 1. Establish airway by positioning the head, suctioning the mouth, then endotracheal tube so you need to consult a chart to remind you what size tube is necessary. nose, and providing tactile stimulation. I'm also asked to remind you about management scheme for meconium stained amniotic 2. Suction trachea if necessary. fluid. The algorithm looks like this. If there is meconium stained amniotic fluid, the person 3. Provide O2 and initiate assisted ventilation if necessary who delivers the baby should carefully suction the mouth and pharynx as the head presents on the perineum or through the uterine incision. This will be done either with a ball syringe 4. Provide external cardiac massage if necessary or the suction catheter, clearing the pharynx of meconium stained amniotic fluid. That will 5. Administer appropriate drugs if necessary be successful about 90% of the time within one aspiration. But about 10% of the time, there is already meconium down in the trachea that the baby has aspirated before birth. Therefore, the algorithm goes on to say that if there is thick meconium, you should intubate Approximate Endotracheal Tube Size and Suction Catheter based on the trachea and suction that meconium out, which will be there about 10% of the time. On the other hand, if the meconium is very thin and the infant is vigorous, you don't need to Infant Weight suction the trachea. Those babies will cough that meconium out. But if the infant is depressed, even that thin meconium should be suctioned out. Weight (gm) Infant's Endotracheal Tube Suction Catheter Internal Diameter (mm) Size (Fr) Eye prophylaxis. Prenatal care should include routine screening of all mothers for gonococcal infection and treatment of those who are infected. However, even when this is <1000 2.5 #5 consistently done, routine prophylaxis in all newborns is recommended. This consists of either silver nitrate, tetracycline or erythromycin. However, if the infant is born to a mother 1000-2000 3.0 #6 - 6.5 who had gonorrhea at delivery, this baby should be treated with a single dose of ceftriaxone 50 mg/kg. Vitamin K prophylaxis continues to be recommended in newborns, especially 2000-3500 3.5 #8 premature or breast-fed infants, who should receive intramuscular vitamin K or an oral dose of vitamin K. >3500 4.0 #8 or #10 C. Ocular Prophylaxis Against Conjunctivitis With respect to fetal growth we initially screen to identify whether the baby is small for gestational age, appropriate for gestational age or large for gestational age. I think one of 1. Perinatal care should include routine screening of all mothers for the tools that really helps us do that is the Ponderal index, which is the growth rate in grams ceftriaxone 50 mg/kg. Postmaturity is a little bit different than postdate. Post maturity refers to a syndrome that we talk about in three stages. There is a rough correlation between postmaturity and postdates, 3. Newborn infants whose mothers have chlamydia infection at the time of in that Stage I babies have a tendency to be 41 weeks, Stage II 42 weeks, and Stage III 43 delivery should be treated with oral erythromycin. weeks. reflects the fact that there is a decrease in intrauterine nutrition. So that the Stage D. Vitamin K Prophylaxis. The newborn, especially if premature, breast fed or I baby has parchment skin, decreased vernix, long nails and evidence of recent weight loss by decreased skin fold thickness. Stage II has all those things plus green meconium. Stage fasted more than 12 hours -- has a deficiency of vitamin K-dependent III has all those things plus yellow meconium. These babies have a tendency to be very coagulation factors. A single parenteral dose of 0.5 - 1.0 mg, or an oral dose hyperalert and usually gain weight, but they have an increased incidence of complications such as polycythemia, hyperviscosity, spontaneous intravascular thromboses, including of 1-2 mg should be administered to all newborn infants. renal vein thromboses and even central nervous system thromboses - strokes. E. Cord Care. Currently, use of local antibiotic ointment such as bacitracin or Blood pressure is another assessment of which you should be aware. It is recommended triple dye is recommended for preventing bacterial colonization and disease. that babies who are at risk receive blood pressure measurements. Those who are at risk IV. Assessment for Growth and Maturity are those babies born prematurely and those who are ill. Increases in blood pressure, both mean and systolic blood pressures, are found with increasing birth weight, increasing A. Weight, length, head circumference for gestational age gestational age and increasing age after birth. 1. SGA: BW 10th (or 3rd) percentile for gestational age 2. AGA: BW 10-90th (or 3rd-97th) percentile for gestational age Admission screening. Not all babies need a blood type and Coombs. If the mother is type O or Rh negative, then it should be done, but if the baby is a type A or a type B and antibody 3. LGA: BW >90th (or 97th) percentile for gestational age screens on the mom are negative, then this can be skipped and perhaps the cord blood can B. Ponderal Index be saved in patients who have hyperbilirubinemia. VDRL, however, does need to be screened. It is very important that you remember a screening of pregnant women should be 1. Measurement' of leanness done in the first trimester and at delivery. Mothers can certainly get syphilis during 2. Weight gram x 100 + length cm3 pregnancy and a first trimester VDRL is not sufficient. The VDRL, the RPR and ART are nontreponemal tests. If they are positive we need to go to a specific test and make sure it C. Assessment of Maturity is a treponema and not a false positive test. 1. Ballard Score D. Postmaturity Hepatitis B should be screened. Remember that the surface antigen and antibodies are markers of infection. Hepatitis core antigen and antibody are evidence of continued viral 1. Stage I: Alert expression, parchment skin, decreased vernix, long nails, replication and the E antigen and antibody are specific indicators of infectivity. So, the recent weight loss (mean GA 41 wk) mother should be screened at the time of delivery or near the time of delivery. It is now recommended that all babies receive vaccinations. Remember that there is a slightly 2. Stage II: All Stage I findings plus green meconium staining (mean GA 42 different dose depending on whether you are using Recombivax or Engerix. There is a wk) different dose for hepatitis B surface antigen positive mothers between these two preparations, so make sure that you check and know which you are using and then follow 3. Stage II1: All Stage II finding plus yellow meconium staining, decreased the immunization schedule. Ponderal index (mean GA 43 wk) V. Nursery Management If the mother is surface antigen positive, you need to give hepatitis B immunoglobulin in addition to the vaccine. The problem is that oftentimes when the mother has hepatitis B surface antigen, it is unknown. She just walks in off the street or has not had the screening test, and those babies clearly need to be vaccinated. The most recent recommendation is Normal Neonatal Vital Signs that you can wait until you know the test when it's done on the mother, up to one week, before you make a decision about giving hepatitis B immune surface globulin. However, my Heart Rate 100-140/min own personal point of view about that is that if the mother has been unreliable enough not to have prenatal care and has not had a screening test, it probably is prudent to give a Respiratory Rate 40-60/min hepatitis B immune globulin before you let the baby go home. If it is a hepatitis B negative Temperature 37.0 + O.2°F mother, you don't need to give immune globulin, of course, just give the vaccine. We are now giving it all before they go home and in their initial hospitalization for premature babies. A. Almost all neonatal illness is associated with abnormalities of one or more Group B streptococcus. It is a screening test which is being done by our obstetrical colleagues then. The Committee on Fetus and Newborns and the Committee on Infectious vital signs. Careful attention to TPR is important for early detection of Disease got together with their colleagues at the CDC and the American College of abnormalities. Obstetricians and Gynecologists and now we are down to two recommendations. B. Blood pressure The AAP and CDC agree that screening should be done, but ACOG says, "We don't want 1. Blood pressure should be determined on all at-risk infants. to screen mothers routinely for group B streptococcus." So the AAP and the CDC simply say 2. Blood pressure varies with birthweight and gestational age both during that all mothers should be screened at 35-37 weeks. The downside of course is that there are a number of babies who deliver before 35-37 weeks and so you sort of miss those and the first hour of life maybe those are the babies that are most at risk for group B Streptococcus. So it is now C. Admission Screening recommended by the AAP and CDC that screening be done at 35-37 weeks. 1. Blood type and Coombs are completed if mother is type O or Rh neg or ACOG still maintains that screening cultures are optional at 35-37 weeks. They do has positive RBC antibody. recommend treatment of mothers with intrapartum antibiotics if high-risk factors are 2. Syphilis. Screening of all pregnant women during the first trimester and present. The high risk factors are premature labor less than 37 weeks and premature unique about twins except that they have a tendency to be born prematurely. Guidelines for Interpretation of Syphilis Serology of Mothers and their Infants According to the AAP and CDC, all colonized mothers and all high risk mothers get intrapartum antibiotics. Which means about 27% of the obstetric population will receive Nontreponemal Test Treponemal Test Interpretation intrapartum antibiotics and therefore our babies receive antibiotics with the estimate that 86% of early onset group B strep disease can be prevented. (VDRL, RPR, RST, EIA) The prevention strategy for early-onset group B strep is using prenatal screening cultures at 35-37 weeks recommended by the American Academy of Pediatrics.. If there are risk Mother Infant Mother Infant factors, a previous infant with invasive disease, bacteriuria during pregnancy, delivery less than 37 weeks, then the mother will receive intrapartum penicillin. If they are not present it - - - - No syphilis is recommended that a rectal and vaginal culture be done at 35-37 weeks and if it is positive, it says "offer" intrapartum penicillin. If cultures were not done or are incomplete, + + - - False positive then we go to the risk factors. If the risk factors are there, now it says "give" intrapartum penicillin. If there were no risk factors, then no intrapartum prophylaxis is needed and if their + + or- + + Maternal syphilis with culture was negative. So this is the group of babies that won't get intrapartum prophylaxis. possible infant infection That is, no risk factors and no positive cultures. But those who had positive cultures or positive risk factors in this algorithm will have received intrapartum antibiotics. - - + + Mother successfully treated If the mother receives intrapartum antibiotics and the baby has signs of sepsis, then clearly we need to do a full diagnostic evaluation and initiate empiric therapy. Most people will use ampicillin and aminoglycoside or ampicillin and a third generation cephalosporin for empiric 3. Infants should be treated for congenital syphilis if they have proven or therapy. If there are no signs of sepsis, then the algorithm goes on to say let's consider the highly-probable disease demonstrated by one of the following: gestational age. If the baby has a gestational age less than 35 weeks and has no symptoms, do a limited evaluation and observe for 48 hours. If sepsis is suspected, then a full a. Physical or radiographic evidence of disease diagnostic evaluation and empiric therapy. The duration of therapy will vary depending on b. Nontreponemal test is fourfold higher than mother results of blood culture and CSF findings. A full diagnostic evaluation means a CBC, a blood culture and a spinal tap. A limited evaluation means a CBC and a blood culture and a hold c. CSF VDRL, cell count or protein abnormal on the spinal tap until you make a decision. So, you have an asymptomatic baby, less than d. Inadequate maternal therapy. Adequate therapy consists of 35 weeks gestation, you need to get a CBC, a blood culture, and make a decision about adequate doses of penicillin and treatment more than 1 month before whether you are going to start antibiotics based on that CBC and differential. delivery There is another caveat. If the baby has received fewer than two doses of antibiotics then 4. Neonatal Treatment they need to be considered in the same category, even if they are more than 35 weeks gestation, so the algorithm is a little confusing. a. Aqueous crystalline penicillin G, 100,000 u/kg/d in 2 doses q 12 hr during first week of life, then 150,000 u/kg/d in 3 doses q 8 hr for total 1014 days b. Aqueous procaine penicillin G, 50,000 u/kg/d IM for 10 days c. If more than 1 day of therapy is missed, the entire course must be repeated. 5. Hepatitis B a. Routine screening of all pregnant women for HBsAg is recommended. b. Serologies (1) HBsAg and anti-HBs are markers of infection (2) HBcAg and anti-HBc are markers for continued viral replication (3) HBeAg and anti-HBe are specific indicators of infectivity c. Routine immunization of all infants is recommended. Hepatitis B Vaccine Recommended Doses Clinical Condition of Recombivax HB Engerix-B Infant HBsAg -positive 5 ug (0.5 ml) 10 ug (0.5 ml) mothers HBsAg -negative 2.5 ug (0.25 ml) 10 ug (0.5 ml) Recommended Schedule for Hepatitis B Vaccine Hematocrit screening is no longer recommended. Long-term followup has shown to Clinical Condition of Dose Age probably not be beneficial, so only selected screening high-risk patients such as post term, Infant post mature and polycythemic babies. For hypoglycemia, routine screening is no longer recommended. Selected screening of at-risk infants is recommended for the SGA, LGA, HBsAg positive HB vaccine 1 Birth -- within 12 hrs infants of diabetic mothers, preterm, asphyxiated and those with signs and symptoms of tremor. So this is probably going to include 20-30% of your population for a screen. If you mothers HBIg (0.5 ml IM) Birth -- within 12 hrs do so, it should be done at about an hour of age, or any other time when the baby is HB Vaccine 2 1 mo symptomatic. Chromogen sensitive screening tests are the best, probably. The definition of HB Vaccine 3 6 mo hypoglycemia is less than 25 plasma glucose, which translates to less than 20 for a whole blood glucose sample. Remember that when you do chemistry strip tests, that if the HBsAg unknown HB Vaccine 1 Birth - within 12 hrs chromogen test you are using is for whole blood, less than 20 is the official definition in a preterm baby, less than 30 for a full-term baby. mothers HBIg Birth - within 12 hrs If mother HBsAg pos, give 0.5 ml IM as soon as possible, not less HB Vaccine 2 than 1 wk after birth HB Vaccine 3 1-2 mo 6 mo HBsAg negative HB Vaccine Birth - within 12 hrs mothers HB Vaccine 2 1-2 mo HB Vaccine 3 6-18 mo 6. Group B Streptococcus Screening and Prophylaxis a. American Academy of Pediatrics and Centers for Disease Control. Prenatal screening for all mothers for group B streptococcus carrier status at 35-37 weeks. b. Recommendations for Intrapartum Antibiotic Treatment. All colonized mothers and all high risk mothers are given antibiotic prophylaxis. c. Hypoglycemia. Routine screening not recommended. Selective screening of at-risk infants: SGA, LGA, IDM, preterm, asphyxiated and those with symptoms of tremors, irritability, tachypnea, tachycardia, pallor, sweating, seizures. (1) "Significant" Hypoglycemia (a) Serum or plasma glucose <25 mg/dl (whole blood glucose 20 mg/dl) in preterm infant from birth to 24 hrs age. (b) Serum or plasma glucose 35 mg/dl (whole blood glucose 30 mg/dl) in term infant from birth-24 hrs age. (c) Serum or plasma glucose <45 mg/dl (whole blood glucose <40 mg/dl) after 24 hrs age. (2) Screening Methods. Most use whole blood; e.g., from capillary (heel-stick) samples, utilizing glucose oxidase chromogen test strips (3) Causes of Neonatal Hypoglycemia (a) Early onset i) Hyperinsulinemia. Betacell hyperplasia, islet cell adenoma, nesidioblastosis, EMG syndrome of We have sort of ended up using the screening tests and saying that if it less than 40, then Wiedeman-Beckwith, acute withdrawal of glucose they are probably in the danger zone of having hypoglycemia and the treatment for infusion (iatrogenic), defective gluconeogenesis and/or symptomatic hypoglycemia is IV glucose. The treatment for asymptomatic hypoglycemia is simply D 5 W 10-15 ml/kg given p.o. or p.g. On the other hand, if the baby is symptomatic, glycolysis (adrenal insufficiency, congenital you need to start an IV, give them a push of 2 cc/kg of D10, all with an infusion rate of about hypopituitarism, ? Hypothalamic hormone deficiency, 8-10 mg/kg/min, which is about 100-140 ml/kg/day of D10. If symptoms persist, then we have to consider other diagnostic considerations and other therapies like hydrocortisone or hereditary defects in carbohydrate metabolism, diazoxide. acid hereditary defects in amino metabolism Bilirubin. Breast fed babies have higher levels of bilirubin than formula fed babies - in a d. Treatment of Symptomatic Hypoglycemia formula fed baby on the second day it is about 10, on the third day it's around 13 and then (1) Eliminate underlying cause it begins to fall after that. In a breast fed baby, it goes up to 15. We do not need to worry (2) 200 mg/kg (2 ml/kg) dextrose 10% IV push about babies who are being breast fed whose bilirubin levels are less than 15, and I would even go up to 18 in a breast fed baby and not worry about that baby very much, at least in (3) Follow with infusion at 8-10 mg/kg/min (115-144 ml/kg/day terms of bilirubin. dextrose 10%) Lots of breast fed babies have jaundice. The incidence is 3-26%. If you consider anything (4) If symptoms persist -- Hydrocortisone 5-10 mg/kg/day less than 17 or 18 to be normal, only 3% have jaundice. If you use the formula fed babies (5) For persistent hypoglycemia -- Diazoxide 10-25 mg/kg/day standard, then 25-26% of breast fed babies will have jaundice. It is commonly found and begins on day 3, peaks at around a week of age and then declines to normal. The peak 7. Hyperbilirubinemia bilirubin in these babies can be as high as 18-20 mg/dl. The etiology is thought to be a. Bilirubin photometer useful for screening patients who require bilirubin decreased nutritional intake and increased enterohepatic circulation. Is there a physiologic determination reason to have physiologic hyperbilirubinemia? So that the normal baby is not the baby who has a bilirubin of 5-10 who is formula fed, but the normal baby is really the baby who has b. Evaluate cause for hyperbilirubinemia on D 1 if >5, D 2 >10, D 3 >15 the bilirubin level of 10-15 who is breast fed. The answer seems to be emerging that bilirubin mg/dl is a very effective oxygen radical scavenger and protects the baby from effects of hyperoxia. Remember that the infant in utero has pO2s in the 20's and all of the sudden the pO2s are c. Laboratory Evaluation in the 60 to 90 to 100 range, and it may well be that bilirubin protects the baby from (1) Bilirubin, total and direct hyperoxia. That is the theory. The treatment for breast feeding jaundice is to keep it from getting above 20. Encourage frequent breast feeding on demand, follow the bilirubin levels, (2) Serology for syphilis and evaluate for other causes. Feeding should not be interrupted, frequent feedings should (3) Blood type & Coomb's (mother and baby) be encouraged. (4) Complete blood count, including differential & peripheral smear Now the hypothesis goes on to say that there is a small percentage of infants who really (5) Consider blood and urine cultures have breast milk jaundice, which suggests that in some mothers there is really something (6) T4 and TSH abnormal about the breast milk that makes them have jaundice above and beyond normal. That usually begins at the end of the first week, after lactation is established and large (7) Urine for total reducing substances (Clinitest) amounts of breast milk are being given as opposed to early in lactation establishment when d. Jaundice associated with breast milk feeding breast feeding jaundice occurs. There is something about the breast milk that interferes with bilirubin conjugation and these babies can get very high bilirubin levels. The etiology has (1) Breast milk jaundice been speculated to be an abnormal breast milk lipase or a steroid. (a) Incidence: 0.5-2.7% of breast fed infants (b) Age: Beginning at end of first week, peak at 10-15 days age, Use of a photometer is not helpful because of skin pigmentation which affects the light that goes through the skin and affects the bilirubin level. So we haven't found it all that useful but declining to normal by 3-12 wks age we still use the normal values that I have given you in that chart to evaluate bilirubin levels. (c) Peak bilirubin: 10-30 mg/dl If one is going to evaluate babies that fall outside that physiologic range, remember that you (d) Etiology: Abnormal breast lipase, steroid probably ought to do a direct bilirubin if you haven't already done one. Make sure the baby's (e) Treatment: Discontinue breast feeding 24-48 hrs, follow VDRL is negative. Recheck the type and Coomb's if it hasn't been done and get a CBC bilirubin level, evaluate for other causes including a differential and peripheral smear. Consider doing a blood culture. Make sure the T4 is done. Consider doing an IgM or urine for total reducing substances. (2) Breast feeding jaundice (a) Incidence: 3-26% Phototherapy. I think halogen phototherapy has really been a marvelous jump forward. You can almost watch the bilirubin pigment go out of the skin. With halogen phototherapy (b) Age: Beginning day 3, peak at 7- 10 days, declining to normal produces about 20 µWATTS/cm2/nm of energy compared with double blue phototherapy by 6 wks age which is about 12,and blue-white which is about 6 µWATTS/cm2/nm. So, if you are really serious about dropping bilirubin levels in these kids that come into your hospital on day (c) Peak bilirubin: Approximately 18-20 mg/dl three or four with a bilirubin of 25, halogen phototherapy can really make a difference. (d) Etiology: Decreased nutritional intake, increased enterohepatic recirculation (?) (e) Treatment: Encourage frequent breast feeding (on demand), (Westinghouse. 20 watt F20 T12 BB) and 2 daylight lamps on either side produces 10 Watts/cm2/nm. (d) Effective fluorescent lamp life may be up to 2000 hrs or as little as 200 hrs (e) Indications i) Rate of bilirubin rise >0.5 mgm/hr ii) Bilirubin levels <5 mgm below exchange level iii) To avoid an exchange transfusion (f) Complications. Rash, diarrhea, gastric distention, increased insensible water loss, lethargy, "bronze baby syndrome." (2) Indications for Exchange Transfusion (a) Initial hemoglobin <12 gm/dl with isoimmune Rh disease (b) Rate of bilirubin rise >1 mg/hr with hemolytic disease (c) Bilirubin >20-25 mg/dl in term infants with hemolytic disease, 25-30 mg/dl (d) Bilirubin >15-20 mgm/dl in preterm infants with hemolytic diseases (e) Complications. Fluid and electrolyte shifts, arrhythmias, sepsis, hemorrhage, thromboembolic phenomena 8. Metabolic and Endocrine Disease Screening a. Thyroid RIA for T4, TSH or both. Screen >12 hours age. Six to 12% of cases are detected only by a second screening at 2-6 weeks age. b. Galactosemia. Qualitative measurement for galactose and galactose- 1-phosphate uridyl transferase enzyme. c. Phenylketonuria. Blood phenylalanine (1) Initial screen > 2.4 hours, <7 days (2) All infants should be screened prior to transfer or discharge regardless of age d. Hemoglobinopathies. Electrophoresis. Screen before transfusion. 9. Screening Physical Examination a. Malformation. Defined as a morphologic defect of an organ, part of an organ, or larger region of the body resulting from an intrinsically abnormal developmental process (eg, cleft palate in Trisomy 15). b. Disruption. Defined as a morphologic defect of an organ, part of an organ, or a larger region of the body caused by extrinsic breakdown or interference with an originally normal developmental process; e.g., phocomelia due to a teratogenic drug c. Deformation. Defined as an abnormal form, shape or position of a part of the body caused by mechanical forces (eg, cleft palate in Pierre Robin sequence) d. Dysplasia. Abnormal organization of cells into tissue and its morphologic results (eg, hemangiomas, osteogenesis imperfecta and achondroplasia) e. Syndrome. A recurrent pattern of multiple anomalies which are pathogenetically related (eg, Down's with characteristic facial VATER association (vertebral anomalies, anorectal anomalies, tracheoesophageal fistula, renal and/or radial anomalies and congenital heart disease)] 10. Newborn hearing screening a. Auditory brainstem evoked response (ABER) is recommended for infants considered to be at risk for hearing loss: (1) Family history of hearing impairment (2) Congenital perinatal infection; i.e., TORCH group (3) Anatomic malformations of the head and neck (4) Birth weight <1500 gm (5) Hyperbilirubinemia at levels exceeding indications for exchange transfusion (6) Bacterial meningitis (7) Severe asphyxia (ie, Apgar scores 0-4 at 1 min or 0-6 at 5 min) (8) Ototoxic drugs (9) Mechanical ventilation >5 days duration b. The hearing of these infants should be screened optimally by 3 months, but no later than 6 months of age. c. Otoacoustic emissions (OAE) are being evaluated as a screening tool which is less expensive and faster than ABER. 11. Newborn Eye Examination a. In addition to routine inspection and direct ophthalmoscopic exam, indirect ophthalmoscopy is recommended by an experienced ophthalmologist for the following infants: (1) < 1800 gm, 35 weeks gestation who require supplemental 02 (2) < 1300 gm, 30 weeks gestation regardless of 02 exposure b. The examination is best done prior to initial hospital discharge or at 5-7 weeks of age if the infant is still hospitalized. Annual follow-up is recommended for those who have had significant active disease. 12. Nutritional Considerations of High-risk Infants Estimated Calorie Needs of a Typical Growing Premature Infant Item Calories Resting calorie expenditure 50 Intermittent activity 15 Cold stress 10 Specific dynamic action 8 Fecal loss 12 Growth 25 Total 120 13. Nutrient Requirements of Premature Infants decreased bile salt synthesis (2) Medium chain triglycerides (MCT) in formula improves fat absorption, increases weight gain, enhances calcium absorption and nitrogen retention (3) Essential fatty acids, linolenic and linoleic, should constitute a minimum of 0.7% (78 mg/100 Kcal) and 2.7% of energy (300 mg/100 Kcal), respectively c. Carbohydrate Requirements (1) Lactase does not reach normal maturation until close to term (2) Low levels of lactase may cause lactose malabsorption causing fermentative, watery, acid diarrhea (3) Substitution of dextrose, maltose, sucrose or glucose polymers may be helpful D. Nutritional Problems of NICU Graduates 1. Low Birth Weight Infants: >1500 gm, <2000 gm (approximately 32-34 wks gestation a. Caloric Requirements 120 Kcal/kg/day: (1) Generally can be met with cow milk formula (20 kcal/oz) or breast milk (180 cc/kg/day). Enriched formula (22 Kcal/oz) may be a desirable alternative. (2) Some infants may require 24 cal/oz which can be prepared by adding 8 1/2 oz of water to 13 oz liquid formula concentrate. (3) Additional concentration of calories may be achieved by adding vegetable oil (8 Kcal/cc) or Polycose (8 Kcal/tsp) to formula. Adding 0.5 cc vegetable oil or 0.5 tsp glucose polymers to 1 oz formula increases caloric density by 4 cal/oz. (4) Breast fed infants may require fortification of some human milk feedings with vegetable oil, glucose polymers or powdered formula (1 tsp/4 oz = 24 cal/oz). Alternatively, some breast feedings can be substituted with 24 kcal/oz formula. (5) The best measure of caloric adequacy is weight gain utilizing standard growth curves. b. Vitamins. Those present in formula are adequate for formula fed infants following discharge. Breast fed infants should receive multivitamins with iron and fluoride, 1 cc daily after reaching 2500 gm. c. Bone mineralization may be decreased in breast fed infants. Check calcium, phosphorus, alkaline phosphatase 4-8 weeks following discharge. If phosphorus is less than 4.5 mg/dl, the infant should receive supplementation with calcium 100 mg/kg/day and phosphorus 50 mg/kg/day. Ten percent calcium lactate (18 mg/ml), 5.5 cc/kg/day and neutral oral phosphate (22 mg/ml) 2.3 cc/kg/day will provide these intakes. 2. Infants with Chronic Lung Disease a. Increased caloric needs may be as high as 140180 Kcal/kg/day. (3) Continuous gastric drip may be helpful during night, and perhaps day as well to supplement nipple feedings. b. Diuretics may be necessary with higher and perhaps even normal fluid and electrolyte intakes. Check serum electrolytes weekly while initiating diuretic therapy and at least monthly thereafter. (1) Chlorthiazide -- good diuretic for maintenance therapy (10-20 mg/kg/dose q 12 hrs p.o.) (2) Aldactone -- may prevent potassium wasting (1-3 mg/kg/dose given q 24 hrs p.o.) (3) Furosemide -- very effective for pulmonary edema (1-3 mg/kg/d p.o.) (4) Adverse Effects (a) Potassium and chloride wasting may need replacement. Hypochloremic metabolic alkalosis (CL < 90 mg/dl) is a serious complication. (b) High CO2 content may be misinterpreted as entirely primary respiratory acidosis when in fact primary metabolic alkalosis may be present. Check pH, pCO2, BE, blood gas as well as electrolytes if hypochloremia is present. (c) Increased calcium excretion may cause nephrolithiasis and nephrocalcinosis. This in turn may result in long-term tubular injury. c. Growth, however, is the key to resolution of chronic lung disease. 3. Infants with malabsorption and/or short bowel a. Elemental formulas may be beneficial. b. Special attention may be required for infants with loss of distal ileum; i.e., bile salt malabsorption with B12 and folic acid deficiency. Watch for megaloblastic anemia. E. Hematologic Surveillance 1. All infants in the above four categories may become anemic because of iron and/or erythropoietin deficiency. The prescribed regimens containing formula with iron and multivitamins with iron are designed to prevent iron deficiency. However, a CBC and reticulocyte count 4-8 weeks following discharge is prudent in these infants. 2. Human recombinant erythropoietin (HrEPO) is recommended for VLBW infants (especially < 1000 gm BW) during hospitalization for 2-3 weeks beginning at 1-2 weeks age. 3. Dose: 200 u/kg subcutaneously qod, plus 6 mg/kg/day oral iron, or 200 u/kg/d IV in TPN x 10 days plus 1 mg/kg/day iron dextran IV Nutritional Needs of NICU Graduates Premature Premature Infants with Infants with BW >1500 BW <1500 Chronic Malabsorpti gm,<2000 gm Lung/Heart on/Short gm (Very Low Disease Gut Feeding 20 cal/oz 22 cal/oz 24 cal/oz Elemental Type cow milk enhanced cow milk formulas formula formula or (8.5 oz H20 may be w/iron or 24 cal/oz + 13 oz useful; i.e., breast milk cow milk concentrate) 20-24 cal/oz or 22 cal/oz (8.5 oz H20 or fortified enhanced + 13 oz breast milk formula concentrate) if weight gain inadequate on 20 cal/oz Multivitamins None for 0.5 cc/day None for None for with iron and formula-fed. for formula- formula-fed formula-fed. fluoride 1 cc/day for fed until 1 cc/day for 1 cc/day for breast fed 3000 gm 1.0 breast fed breast fed. cc/day for Watch for breast fed B12 and folic acid deficiency Calcium None None for None None (100 routinely. formula-fed. routinely routinely mg/kg/day) Check Ca, Check Ca, unless very unless very and phosphate, phosphate low birth low birth phosphorus alkaline and alkaline weight weight (50 phosphatase phosphatase mg/kg/day) in breast fed in breast-fed supplementa infants 4-8 infants 4-8 tion for wks post wks post breast fed discharge discharge infants only References 1. AAP/ACOG: Guidelines for perinatal care. 3rd edition, 1992. ,Antepartum Care pp 49-66. 2. O'Brien CD and Queenan JT. Growth of the ultrasound femur length during normal pregnancy. Part I. Am J Obstet Gynecol 1981 ;141:833-7. 3. Hohler CW and Quetel TA. Comparison of ultrasound femur length and biparietal diameter in late pregnancy. Am J Obstet Gynecol 1981 ;141:759-62. 4. Hipshitz J. Comparison of the lumadex-foam stability index, lecithin: 6. Daffos F et al. Fetal blood sampling during pregnancy with use of a needle guided by ultrasound. A study of 606 consecutive cases. Am J Obstet Gynecol 1985:153:655. 7. Freeman R et al. A prospective multi-institutional study of antepartum fetal heart rate monitoring. Risk of perinatal mortality and morbidity according to antepartum fetal heart rate results. Am J Obstet Gynecol 1982;143:771-81. 8. Manning F et al. Fetal assessment based on fetal biophysical profile scoring: experience in 12, 620 referred high-risk pregnancies. I Perinatal mortality by frequency and etiology. Am J Obstet Gynecol 1985;151:343-50.