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Neonatology

By:

Dr. Noha

احب اقىه انا اوال واكتبتش كن حاجة فاملمف ده حمتاج يرتاجع كذا ورة قبن وا ينتهي سىاءكىمف

لمتداوه عمي النت والفاسبىك او لمطباعة

ة حلضان وال االالت يف ا اradiant warmer

1 examinationinitial resuscitation

intubation

2 exchange transfusion

3

simple

procedure3

concentration

1 Head boxheadconcentration

concentration

2 Nasal prongsoxygen mask

3 oxygenpressureCPAP

mechanical ventilatorairpressure

phototherapy

3horizontal

fibro-optic blanket

surface area3

2

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syringe pumpfluid

infusion pump

55

endotracheal tubeT-tubetube

upper airway obstruction

15

T-piece to bypass obstruction of upper airway (nose, vocal cords)

Infection of neonates may present with Fever or Hypothermia

Newborn heart rate between 120 -160 bradycardia if < 100

Bilateral Choanal atresianeonate obligate mouth breather

Neonatal jaundice

isoimmune hemolytic jaundice

RH incompatibility

RH-veRH+veAB

1 not sensitizedantigen

2 AntibodiesIgM

IgG

RH+ve bloodabortion

Or ABO incompatibility

ABOblood group OA, B1st

pregnancynatural occurring IgGPlacenta

RHABOchartphototherapy

exchange transfusion3curvesrisk

factors

curvehigh risk 35risk factor

risk factors

Risk factorsisoimmune hemolytic anemia

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G6PD dhemolysissynthetic Vit Kneonatal

resuscitationhemolytic anemiajaundicefamily history

enzyme

Asphyxia, lethargic, significant, sepsis, acidosis, Temp instability

Intermediate risk: >38 +risk factors or > 35+ well

Mild risk: > 38+well

chartphototherapy

PHOTOTHERAPY CHART

chart

EXCHANGE TRANSFUSION

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Jaundice= yellowish discoloration of skin & mucous membranes due to

hyperbilirubinemia

neonate >7adult >3

Cephalocaudal progression

Face 5

Mid abdomen 15

Foot 20

blood levelbilirubinblood

risk

levellevel

level

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Jaundice

Physiological or Pathological

Pathological in 1st 24 hour

2types:

Indirect (unconjugated) hyperbilirubinemia → fat soluble, carried on albumin,

not excreted by the kidney but pass blood brain barrier ⇒ Kernicterus

Direct (conjugated) hyperbilirubinemia → water soluble, excreted in the bile &

kidney, don't pass blood brain barrier but IT Means there's a CATASROPHE

(congenital anomaly, obstruction, neonatal hepatitis)

Direct hyperbilirubinemia if direct bilirubin > 20% total bilirubin

N.B

Indirect hyperbilirubinemia → inspissated bile syndrome → ↑ direct bilirubin →

direct hyperbilirubinemia ⇒ treated by Good hydration & feeding

Rate of rise of pathological jaundice >5mg/dl per day

If the child on the curve needs exchange (level of exchange transfusion ± 3) → we

may try intensive phototherapy

conventional phototherapy45

intensive phototherapy25fibro-

optic blanket

0.2mg/dl/h

45.8

Exchange transfusion

Gangrene, portal vein thrombosis, necrotizing enterocolitis, acute heart failure

phototherapyDNA change in the baby

curvephototherapy

level of phototherapy

single phototherapy

2double photo

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Breast feeding jaundice & breast milk jaundice

Breast feeding jaundice: ↓ feeding in first 2-3 days → dehydration & ↑

enterohepatic circulation

3

level of phototherapy

Breast milk jaundice: enzyme in breast milk that decrease conjugation of

bilirubin → indirect hyperbilirubinemia

24bilirubinnormal level

don't underestimate jaundice

Sominaletta 5mg/kg/dose →

Hepaticum

hepatotoxicity(

Neonatal resuscitation

Support breathing & airway

APGAR155pink

flaccid

Routine care of newborn:

1) Radiant warmer to supply heat for warmth

2)

A. ↓ & prevent hypothermia

B. Tactile stimulation → ↑ respiration

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3) Suction 1st from the mouth ⇒ 2nd from nose

aspiration →

4)

bilateral Choanal atresia →

emergency surgery (as neonate is obligate nose breather) →

5) If bilateral Choanal atresia → search for other congenital anomalies (heart,

spine, duodenum, anus, limbs) →

congenital heart disease

pressure gradientmurmur

4

35

Avoid vigorous suction → vasovagal stimulation → bradycardia →

6) Oxygen: not used as routine care

full history

full term, preterm

amniotic fluidmeconiumthinthick

infant of diabetic motherPE

Ambotube

2.533.54

Meconium aspiration

If Meconium → → to prevent meconium aspiration

by 1st suction even on head over perineum before stimulation of respiration →

→ meconium aspiration syndrome

meconium extractor

meconium

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GITfetusdistressedhypoxiarelaxation of

anal sphincterAmniotic FluidThin meconium

hypoxiaThick meconium

Thin meconium → aspiration by baby → chemical pneumonitis → 2ry bacterial

infection → bacterial pneumonia

Thick meconium → aspiration by the baby → plug in respiratory tract →

⇒ complete obstruction → lung collapse

⇒ Partial obstruction → 1 way valve → lung hyperinflation → air leak

(interstitial air leak ⇒ or spontaneous pneumothorax)

pressure

May rupture in any time → ↓ peak of ventilator as much as I can

←

Under observation for 2 hours → air entry on 2 sides of chest → any degree of

respiratory distress = Admission

Infant of diabetic mother

45

Respiratory distress syndrome, Macrosomia (birth injury), Hepatosplenomegaly,

idiopathic hypertrophy of the heart

Macrosomiabirth traumaErb's palsy

hypoglycemiahyperglycemia

polypeptideplacenta

hyperglycemia↑ insulin

hypoglycemia

Diabetic mother → hyperglycemia → pass placenta → fetal hyperglycemia → ↑

fetal insulin –labor→ (no glucose from mother) neonatal hypoglycemia

hypoxia

Relative hypoxia due to placental insufficiency → polycythemia → jaundice

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Insulin antagonize secretion of surfactant → full term with hyaline membrane

disease

Congenital heart disease

Hypoglycemia → central injury → respiratory distress

3612122424

12366121224

hypoglycemia⇦hypoglycemia = indicate

for admission

breast milk

Preterm

Preterm33mild preeclampsia

Preeclampsia → stressful condition → ↑ fetus cortisone → ↑ surfactant (no

respiratory distress)

severe PE or eclampsiaseverely distressed

Routine care + weight the baby → less than 1700gm = admission

Less than 2500 with poor suckling →

17551755

CPR

suppressed

Tube

Mild head extension

Ambo + mask well fitting on nose & mouth (well sealed)

Ambo + mask = ambo + tube

tube

open Rylestomach

Congenital diaphragmatic hernia ⇒ inflation of intestine ⇒ more respiratory

distress

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Scaphoid abdomen: normal mild distention

ambo & tubemask

Heart rate ↑↑↑ with ambo

If decreased ↓↓ = indication of cardiac massage (= indication of endotracheal

intubation)

35

Cardiac massage in a rate of 3:2 or 4:1

sternum2

thumbs

Drugs:

Adrenaline

1915intra-

umbilical

15endotracheal

33

response

NaHCO3 IV

2glucose 5%2.55

55

Acidosis → ↓ decrease adrenaline effect on the heart

IV lines

Interosseous → butterfly shaped in upper end of tibia 1 cm below knee or lower

end of femur

←

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4

lines

If no good perfusion (decreased capillary circulation) ⇒ cardiac massage + shock

therapy

Shock therapy: 10-20ml/kg (normal saline or ringer lactate)

3

A-B-S = Adrenaline-Bicarbonate-Shock therapy

Intubation

Respiratory Distress

Causes of Respiratory distress

1. Pulmonary causes:

1. Hyaline membrane disease

2. Transient tachypnea of newborn (TTN)

3. Meconium aspiration

4. Upper airway obstruction (bilateral Choanal atresia)

5. Pneumothorax (air leak)

6. Diaphragmatic hernia

7. Non pulmonary causes

2. Central (respiratory center depression)

1. IC Hge

2. Sedation (drug abuse, general anesthesia)

3. Hypoglycemia

4. Hypothermia

3. Cardiac causes

1. Heart failure

under observationmaneuvers during labor

hypothermiaanesthesia

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admission to neonatal care unit

General anesthesia←under observation for 1 hour

ايه بقا المشاكل الي ممكن تقابلك

TTN (Wet lung): lung filled with amniotic fluid

Fetus in intrauterine life → lung filled with amniotic fluid → during normal

labor the baby is squeezed in the birth canal → squeeze amniotic fluid from the

lung → Amniotic fluid absorbed through the lymphatics

full termC Sectionby exclusion

Chest X-Ray⇦NO ground glass appearancehyaline membrane

disease

RDS (Hyaline Membrane disease)

Preterm → ↓ surfactant → lung collapse

Or Full term → infant of diabetic mother (as insulin antagonize surfactant

secretion)

Chest X-Ray: Ground glass appearance (white hazy lung)

Cardiac:

Cyanosis if cyanotic heart disease

Chest X-ray: cardiomegaly

Auscultation: murmur in 2nd or 3rd day

Echo: congenital anomaly (VSD, ASD, Fallot, pulmonary stenosis)

Respiratory distress management management

Oxygen

1.

2. Head box Oxygen only →

3. Nasal

4. CPAP

5. Ventilator Oxygen + air + under pressure

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nasalhead box

ventilator

recurrent apnea

apnea

Apnea: cessation of respiration for > 20 seconds or any time + bradycardia (<90)

or cyanosis

Causes of apnea:

Prematurity: mostly physiological ⇒

Central causes: respiratory center & respiratory muscle not well developed

Obstructive apnea:

Secretion in mouth & nose

Hypercapnia & hypoxia ⇒ depress ↓ respiratory center

Full term: mainly pathological apnea:

Apnea > 30 sec ⇒ poor perfusion of total circulation →

Apnea just observation especially in preterm

Unless recurrent apnea (> 3-4 times /hour) = CPAP

Unless post cardiac arrest = Tube & ventilator

CPAP ⇒ prevent collapse lung alveoli during expiration

recurrent apnea←drugs to stimulate Respiratory center

←aminophylline

Respiratory distressfeedingaspiration

IV fluidsrestriction of IV fluids by 70-90%

85fluid

In respiratory distress & head trauma & convulsions ⇒ volume overload due to

⇒ Syndrome of inappropriate ADH secretion (SIADH)

respiratory distress←chest X-ray

CPAP: Continuous Positive Airway Pressure

It's a mix between oxygen and air (calculated ad ratio between oxygen & air from

20%, 30% … ……………..100%)

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25

flow meterline of oxygen

line of airCPAP 30%

28

air

CPAP 40%4228826air

CPAP 40%2air6

8oxygen + air = 8 liter

CPAP 60%624air84444

CPAPCPAP60%44air

CPAP 100%10-28air885 CPAP

8

CPAPCPAP 60%

2440 %24

25 24CPAPnasal

CPAP155 75

⇦CPAP > 70% = ventilator

ventilator

PH < 7.2 → respiratory acidosis → CO2 retention → respiratory depression

Asthma → no responding to physiotherapy + CPAP

CO2 retention

Obstructive cyanosis:

RD not responding to CPAP 70%

Tachypnea for prolonged time: e.g. if RR =90 ⇒

(don't forget respiratory muscles are skeletal muscles) → after some time ⇒

respiratory depression ⇒

→ RD with desaturation PaO2 < 90%

Any degree of RD with PaO2 < 90%

Shock: not responsive to medical treatment

ventilator

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inspiration & expirationratecomponent

parameterrate

1st parameter: Rate

inspiratory timeT.I

Time of expirationT.E2frequencyrate

2nd parameter: Oxygen concentration

component⇦CPAP

FIO22115521

oxygen toxicity

1 Retro-lenticular fibro-dysplasia ⇒ blindness

2 Broncho-pulmonary dysplasia ⇒ he become oxygen dependent (oxygen

addict)

child with disability

oxygen toxicitypermanent

oxygen toxicity

100% oxygen for less than 24 hour

70% oxygen for 3 days max

753

concentration

toxicity

ventilator155

ventilator

degree of

distress & saturation

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155

12

15534

155155saturation

155

3rd parameter: pressure

ventilatorpressure

Pressure

PIP: positive Inspiratory Pressure

PEEP: Positive End Expiratory Pressure

PIP, PEEP → →

pneumothorax

Good chest expansion ⇒ not low (no adequate respiration) & Not high (

)

PIPpreterm with Hyaline membrane Disease

stiff lungPIPpressure

⇦PIP

tubefitting & sealed⇦

pressurenot sealed

tubeneonates

2.5tube2.5

2.53tube3

3tube3.5

PIP15191835maximum35

chest tubearresttension

pneumothorax

solid

pneumothorax

pneumothoraxarrestedventilator

pneumothorax until proved otherwise

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↓ air entry on 1 side

PIPparametersventilator34⇦

provided that ABG is NormalPaCO2: 35-45mmHg

PaCO2CO2 washRate4545555565

tubetubePaCO2

PIP

PIP 20

PEEP46

PEEP

↑ PEEP if: pulmonary Hemorrhage (blood from the tube with frothy secretion) so

we ↑ PEEP to close interstitial space (that contain capillaries) to ↓ bleeding

PEEP maximum is 8 ⇒

PEEP

Meconium aspirationPEEP3

ventilatorsaturation

component

tube

Alarm

1 lung collapse, pneumothorax, sepsis, heart failure

Pneumothorax is a mechanical emergency

2 Tube

3 air leak

4

5

oxygen alarmoxygen from source is decreased

phototherapysaturation

air entry

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1 tube

2 tube

3 pneumothorax

Examination of Newborn

infant of diabetic mother

Preterm or full term with IUGR

Shape of the head (microcephaly, macrocephaly (hydrocephalus))

centiles of head of neonate

Fontanelles: opened / closed (normal anterior about 2cm & posterior closed)

Bulging Fontanelles: CNS problem esp. with CNS manifestation as convulsions

(IC Hge, hydrocephalus, encephalitis)

Depressed fontanelle: dehydration

Face: colors (jaundice, cyanosis, pallor0

Dysmorphic features: cleft lip, cleft palate

Suckling: good or poor suckling → if poor suckling = decreased activity = sepsis

sepsis poor suckling

Chest:

Respiratory rate: → neonate have cyclic

respiration

RR

tachypnea

Symmetry between 2 sides (no bulging or depression on 1 side)

Signs of respiratory distress (retractions, grunting and cyanosis)

Auscultation: air entry on 2 sides equal or not, no wheezes? No crepitations?

Abdomen

Umbilicus: infection or not

sepsisumbilical infection

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still patent

Abdominal distention (normal mild distention)

Liver, spleen

Intestinal sounds :

Cannula

Extravasation if Ca → tissue necrosis

←umbilical catheter15

Examination of genitalia: e.g. for congenital anomaly

Capillary refill time

sternum←sepsis

Sepsis: hypothermia or fever

Hypothermia may be due to hypoglycemia

mottling

Sepsis score

system

Heart: Tachycardia, bradycardia

Respiratory: Tachypnea, bradypnea

CNS: Convulsions, lethargy, DLC (disturbed level of consciousness)

Renal: Oliguria

>3 = sepsis

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capillary refill time

Color pallor, jaundice, cyanosis, mottling

Activity → ↓ activity = poor suckling ⇒ sepsis

ventilatorsedated

CBC:

TLC: leukocytosis or↓↓↓ leucopenia (normal 4-11,000)

Segmented neutrophils ↑↑

CRP quantitative

Antibiotics: response to A.B

Blood culture

Examination: chest, heart, abdomen

Treatment

thermal zoneneonatology

Above thermal zone → hypothermia

↓below thermal zone → feverish

Oxygen: → nasal, head box, etc.

thermal zone

: TF

:F

: DR

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volume overload

feeding feeding

Neonates:

25538

932725525527173

اول حاجة احملاليل

Shock therapy used in shock manifested by

Pallor →

Cold clammy skin

Rapid thread pulse

Dose: 10-20ml/kg over 30min to 1 hour normal saline or ringer lactate

shocked

Deficit therapy

Some dehydration

Burn →

Some dehydration

75-85ml/kg over 4-6 hours

ringer (lactate or acetate)

Malnutrition →

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Glucose 5%: ringer lactates: 1:1 + K 1ml/100ml 1100

Maintenance:

15100ml/kg

1550ml/kg

15 20ml/kg

Max 2500ml (30kg)

Pediament

Glucose 10%: saline=4:1 + K + Ca

Fluid restriction: if Respiratory distress, mechanical ventilator, brain

(convulsions, head injury) due to SIADH $ (↑ ADH → fluid retention) by 10-20%

up to 30%

Sepsis: in sepsis → ↓ perfusion of capillaries

Pooling of blood in the microvasculature

Brain→ DLC & convulsions

Heart: bradycardia, tachycardia, arrhythmia

Kidney: oliguria

Intestine: NEC, abdominal distention

Metabolic acidosis → arrhythmia, block effect of adrenaline on heart

↑ Fluids: perfusion to vital organs, ↓ Acidosis (dilution), ↑ cardiac

contractility, ↑ flow of circulation

↑ Fluid by 120-150%

± +ve inotropes

Dopamine

To ↑ kidney circulation 3-5mic/kg/min infusion

To ↑ cardiac contractility: 5-8mic/kg/min

Sepsis dose: 8-10mic/kg/min

↑ 10mic/kg/min = ↑ α receptors (V.C)

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Dobutamine (Dobutrex)

Low dose: 10-15mic/kg/min = V.D

High dose > 15mic/kg/min = V.C

Dobutrex dopamine → higher safety margin for V.C and less

arrhythmogenic

Fluids in Neonates:

Shock & deficit therapy nearly the same

Maintenance therapy

> 2.5 Kg & full term

70ml/kg

80ml/kg

90ml/kg

100ml/kg

… …………………max 150ml/kg/day ( )

glu 10%

Neoment

Pediament

Glucose 12.5%: saline= 4:1 + K (NO Ca)

24

Ca → veins

Arrhythmogenic effect

Neoment

hyperglycemia glucose

Glucose infusion rate (GIR): 24

Concentration ( 12.5) rate (glucose/kg

70)

144

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Neoment

Neoment

45

854564

GIR12.5641445.5

Normal range for GIR 4-12

4 is the lowest possible

12 is the maximum

hyperglycemia

GIR 44hyperglycemia insulin

hypoglycemiaGIR1212

hypoglycemia corticosteroids

GIRhyper & hypoglycemia

infant of diabetic mother →

glucose 10% 70ml/kg

GIR15751444.8hypoglycemicglucose

Concentration

ratevolume overloadGIR6

675144←61447512.3Neoment

Neomentglucose 10%

GIRHypohyperglycemic

GIR12hypoglycemic

drugssteroids

GIR4hyperglycemicinsulin

Hyperglycemia + GIR=4 ⇒ Insulin

Hypoglycemia + GIR=12 ⇒ steroids

hypoglycemia

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Infant of diabetic mother → 45

55

1st day > 45, 2nd day > 50

Ca3

Infant of diabetic mother

Preterm

Asphyxia

3delayed release of parathormone

1cm/kgglucose 5%6

Ca gluconate 10% 1m/kg IV slowly over 10min 4 times daily every 6 hours

routine

hypocalcemiano source of Ca

155

proteinfat

Parenteral nutrition

Partial parenteral nutrition: : Neoment + Ca +

PTN (only)

Total parental nutrition (TPN): Neoment + Ca + PTN + Fat

Protein اوال

Pan Amin G: 1gm/36cm →

Amino acids

Pan-Amin SG → 1gm/12cm

Aminoven → → 1gm/10cm (10%) →

Pan-Amin G or pan-Amin SG G or SG

Dose:

0.5g/kg/day

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0.5 max 3gm

→ 0.5gm/kg/day

5th day → 1gm/kg/day

6th day: 1.5gm/kg/day

7th day: 2gm/kg/day

8th day: 2.5gm/kg/day

9th day: 3gm/kg/day

10th day: 3gm/kg/day … …………………..

15.5

0.5gm/kg/day ⇒ 5th day 1gm/kg/day ⇒ 6th day 2gm/kg/day ⇒ 7th day

3gm/kg/day ⇒ 8th day 3gm/kg/day … ………………………………12Th day

3gm/kg/day (max)

5.51

3Pan-Amin SG

0.5×3×12=18cm

Pan-Amin G

0.5×3×36=54cm

Aminoven

0.5×3×10=15cm

partial parenteral nutrition

1gm carbohydrate

1gm CHO = 3.4 kilocalories

1gm Protein: 4 Kilocalories

1gm Fat: 9 Kilocalories

3

CHO + electrolytes + PTN + FAT + ( )

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Fat

To maintain his weight

To maintain weight 40-50 Kcal/kg

15

To gain weight: 80Kcal/kg

For proper gaining weight: 120Kcal/kg

malnutrition

mechanical ventilation Kcal

Muscle wasting ( ) → respiratory muscle →

vicious circle ventilator

fat

Fat: polyunsaturated fatty acids (needed for normal development of brain &

retina)

↑ → free radicals → oxidants →

→ Sepsis ↑ damage of tissue

Displacement of bilirubin from albumin → hyperbilirubinemia

sepsis & jaundice

Theoretically ↑ Respiratory distress → affect surfactant

Dose

0.5gm/kg/day → 5.5 → max 3gm/kg/day

Intralipid

Lipovenoes

152525

fatty acids

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Free radicals

line

3

Intralipid 10% →

0.5×WT×10=0.5×3×10= 15cm/day

central line

iso-osmolar → peripheral line

If solution hyperosmolar → central line

hyperosmolar glucose 15%

15 CVP umbilical cath. 15

Intralipid iso-osmolar

CVP

3

TF Total fluid

100ml/kg 3155355

Fluid restriction by 10-20% as in R.D, Head trauma

Or increase IV fluids as in sepsis 120% or phototherapy 15

25

R.D & sepsis

Fluid restriction by 20% in R.D and ↑ fluid by 20% due to sepsis

DR: Drugs

Ca

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1cm/kg + same amount Glucose 5% = 3+3 every 6 hour = 6×4 = 24ml/day

Ampicillin 1cm/8h = 3cm/day

Garamycin 0.5cm/12 = 1cm/day

drugs 24312835

355 total fluid

35528272

Feeding: No feeding

272drugs(

Pan-Amin SG

0.5×3×12=18 cm

18272

272-18 = 254ml

2525524

2752411.25

2525511

15

0.5×3×10=15cm

25515235

2523515.5

155.6

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Feeding of the newborn

Normal neonate

full term 1

glucose 5%congenital anomaly

(tracheoesophageal fistula)aspirationlung

pneumonia

5ml/kg3155

baby drinkglucose 5%aspiration pneumonia

←delayed Breast feeding←breast

feeding jaundice

breast feeding3

3colostrum 30-100ml

normal physiology of newbornbaby drink

newborn155

breast feeding jaundice

glucose 5% 5ml/kgbaby drink 5ml/kg

abdominal distention

والذي قدر فهدي(

Full term with respiratory distress

واستي عليه head boxنفسه بدء يتحسن احطه علي nasalساعة علي 24ده طفل محجىز في الحضانة قعد

IV fluids onlyالن الطفل كان بياخد – feedingساعة و بعدين ابدأ لدخل ال 24

Why? Because the gut in some sort of Ischemia → gradual feeding to prevent

NEC (Necrotizing EnteroColitis)

NEC: needs to occur

1- Ischemic gut

2- Pathogen

3- Rapid feeding technique

NEC is more common in preterm than full term

feeding gradual

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5ml/6h5620ml24

IV fluids25

Bebelac

No respiratory distress

No sepsis (CRP –ve)

jaundice

phototherapy

level of exchange transfusion ± 3umbilical catheter

intensive

phototherapy for 4 hours15phototherapy←umbilical catheter

feeding

hypoactivedehydration

feeding

respiratory distress

R.D → oxygen + IV fluids (restricted 70-80%)

RDmildintestinal sounds

5ml/6hIV fluids

5ml/3h45

5ml/3h53

5ml → 5ml →10ml→10ml→ 15ml→ 15ml →20ml → 20ml

2525

tolerate

No tolerate

Abdominal distention

Ryle → residual > 10% of previous feeding or vomiting

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Ryle → bloody residual

15154

5

bloody residualNEC

Preterm

Weight < 1700gm for gaining weight → suckling

Respiratory distress

Pretermfeeding

Ryleweight loss feedingresidual amount / bloody

feeding

2cm/6h8

trophic feedingpriming of GIT

preterm

breast milk → ↑ gastric emptying & enhance absorption from

GIT

special formulaBebelac P.T

tolerateresidual > 10%

2ml/3h16

13

2ml → 2ml → 3ml → 3ml → 4ml → 4ml → 5ml → 5ml

abdominal distention – vomiting – residual > 10% in Rylebloody

residual

15ml/3h

oralfull amount353tolerate

16551655

suckling1515oral35

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Fat 1gm = 9 Kcal

11

4.5836←fluidcalories

tolerate

1tolerate27 Kcal

full term

Respiratory distress

Special conditions: E.g. bilateral choanal atresia

NEC Bloody residual in Ryle

↓ Activity

Abdominal distention

sepsis

On X- Ray

1st: double wall of intestine

2nd: air in the wall

3rd: perforation → air under the diaphragm

Clinical NEC → NO X-ray FINDING (suspected NEC)

feeding15generally bad15

+ Good antibiotics against G +ve & G -ve

Investigation FOR NEC: Na, ABG, CBC

Persistent hyponatremia

Metabolic Acidosis

Thrombocytopenia

sepsismanagement

←bile in the residual

gastric washfeeding

feeding

pylorus

noseearxiphisternum

Gastric wash←salinedistilled water

pretermfull termosmolality

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kidney neonateosmolarity