newborn nt ปี 5

NT ป 5

THERMOREGULATION

ลกษณะการหายใจของทารกแรกเกด

3-4 วนแรกหลงคลอด การหายใจไมสม าเสมอ

เมอหลบสนทการหายใจจะสม าเสมอ ไมเกน 60 คร งตอ

นาท

อาจม periodic breathing

THERMOREGULATION

1. Heat production

2. Heat loss

Heat production

1. Physical thermogenesis

– voluntory muscle activity

– involuntory muscle activity

shivering method

2. Nonshivering thermogenesis or chemical thermogenesis

– Brown fat (เรมมเมออายครรภ 26-30 wks

จนกระทงเตมทหลงเกด 3-5 wks)

– Brown fat พบทระหวางกระดกสะบก รอบคอ รกแร

– รอบๆไตและตอมหมวกไต

Chemical thermogenesis

Cold Thermal receptor Hypothalamus

Sympathetic nerve

Norepinephrine release

กระตน brown fat metabolism

Triglyceride NEFA + Glycerol

+ พลงงานความรอนhydrolysis

กระตนการท างานของ lipase

Heat loss

1. พนทผวกายเทยบกบน าหนนกววกาก

2. Subcutaneous fat นอย

3. Vasomotor activity ยงไกด

Heat loss

1. Convection

2. Conduction

3. Radiation

4. Evaporation

1. Convection 2. Conduction

Heat loss

3. Radiation

Heat loss

4. Evaporation

Cooling

Norepinephrine

Pulmonary vasoconstriction

Increased pulmonary

artery pressure

Increased right to leftshunting

Peripheral vasoconstriction

Accumulation of lactic acidosis

Anaerobic metabolism

Hypoxia

การเปลยนแปลงทเกดขนเมอทารกมอณหภมกายต า

ทารกแรกเกดเสยงวอการเกดภาวะอณหนภกกายว า

(hypothermia )

: BT < 36.5o C

ควรใหนทารกอยใน neutral thermal environment

Thermal neutral zone

ชวงอณหภมของสภาพแวดลอมทท าให

ทารกสามารถรกษาอณหภมรางกายให

ปกตอยได โดยมการใชพลงงานนอยทสด

ขนกบ อายครรภ อายหลงคลอด และ ขนาดของรางกาย

Neutral thermal environmental temperatures

Temperature

Age and weight At start (oC) Range

0-6 hours

< 1,200 g 35.0 34.0-35.4

1,200-1,500 g 34.1 33.9-34.4

1,501-2,500 g 33.4 32.8-33.8

> 2,500 g 32.9 32.0-33.8

Apgar score

• A practical method for assessing a neonate

• Assess at 1 and 5 minute after birth

http://en.wikipedia.org/wiki/File:Virginia_Apgar.jpg

http://en.wikipedia.org/wiki/File:Virginia_Apgar.jpg

Respiratory distress

• Clinical presentation of respiratory distress in

newborn :

apnea, cyanosis, grunting, tachypnea (>60/min)

inspiratory stridor, nasal flaring, poor feeding

chest retractions

(intercostal, subcostal, supracostal spaces)

Differential diagnosis of respiratory distress in newborn

Transient tachypnea of the newborn

Meconium aspiration syndrome

Respiratory distress syndrome

Pneumonia

Pneumothorax

Persistent pulmonary hypertension

of the newborn (PPHN)

Congenital malformation of lung

Diaphragmatic hernia

Pulmonary causes Nonpulmonary causes

Neuro : Meningitis, IVH

CVS : Congenital heart disease

Metabolic : Hypoglycemia

Hypo/Hypernatremia

Hemato : Anemia, Polycythemia

Others : Sepsis

Subtemperature

Maternal medications

Welty S, Hansen TN, Corbet A. Respiratory distress in the preterm infant. In: Taeusch HW, Ballard RA, Gleason CA, editors. Avery’s diseases of the newborn. 8th ed. Philadelphia: Saunders, 2005: 688-703

Hany Aly. Respiratory Disorders in the Newborn: Identification and Diagnosis Pediatr. Rev. 2004;25;201-208

Hany Aly. Respiratory Disorders in the Newborn: Identification and Diagnosis Pediatr. Rev. 2004;25;201-208

Chest examination

• MAS : Hyperinflated of chest

• RDS : Decreased in air entry

• Pneumothorax : Decreased breath sound or

distant heart sound

• Diaphragmatic hernia : hyperinflated of chest and

flatted abdomen

Investigation ?

Complete blood count

Chest X-Ray

± Arterial blood gas (severity of

baby)

Electrolyte

(as indicated)

Glucometer

Complete blood count

Consider sepsis

• Neutropenia (WBC < 5,000 cells/uL)

• Absolute neutrophil count < 1,750 cells/uL

• Absolute band count > 2,000 cells/uL

• Immature neutrophil/total neutrophil ratio

(I/T ratio) > 0.2

• Thrombocytopenia (platelet < 150,000 /uL)


Clinical signs:

• Term & Preterm

• Tachypnea (RR 60-120/min), chest wall retraction

• Self-limited disease

• Need O2 supplementation at the onset of disease and

then progressively decrease

• Symptoms usually resolve within 48-72 hours

Lokesh Guglani, Satyan Lakshminrusimha and Rita M. Ryan. Transient tachypnea of the newborn. Pediatr. Rev. 2008;29;e59-e65.


Radiographic abnormalities

• Hyperaeration

• Prominent perihilar streaking

• Prominent vascular marking, minor fissure

• Small pleural effusions may be seen

• Radiographic abnormalities resolve over the first

2-3 days after birth

http://www.radswiki.net/main/images/6/6f/Transient_tachypnea_of_the_newborn_001.jpg

http://www.radswiki.net/main/images/6/6f/Transient_tachypnea_of_the_newborn_001.jpg

Meconium aspiration syndrome: MAS


Meconium

• Viscous green liquid, odorless

• First evidence in fetal intestine 10th – 16th week of

gestation

• Composition: GI secretion, cellular debris, mucus,

bile, blood, lanugo


Clinical signs

• Mature, post mature, SGA

• Long finger nails, dry and peeling skin

• Meconium stain on nails, hair, skin and umbilical cord

Respiratory symptoms

• Begin at birth, shortly thereafter

• Tachypnea, retraction, nasal flaring, cyanosis

• Chest : barrel shaped

• Coarse crepitation, inspiratory and expiratory rhonchi

with prolonged exhalation


Ball-valve effect

Meconium aspiration

Proximal airway obstruction

AcidosisHypoxiaHypercapnea

Peripheral airwayobstruction

Completes

Atelectasis

V/Q mismatch

Partial

Ball-valve effect

Air-trapping

Air leaks

Inflammatory and chemical pneumonitis

Surfactant dysfunction

Diagnosis of MAS

Meconium-stained amniotic fluid or infant or both

Respiratory distress at birth or shortly after birth

Positive radiographic features

“Presence of meconium in endotracheal suctioning automatically established the diagnosis”

Tsu F. Yeh. Core concepts: meconiuma aspiration syndrome: pathogenesis and current management. NeoReviews 2010;11;e503-e512

Radiographic finding

• Variable

• Coarse linear peribronchial infiltrations

• Areas of atelectasis

• Pleural effusion 20-30%

• Severe cases :

- progress to diffuse and homogeneous opacification

- gradually resolve over weeks

• Pneumothorax, pneumomediastinum 25%


1. Antibiotic

Meconium is a good media for gram negative bacilli

Indication

• History of perinatal infection

• Undergone vigorous resuscitation

• Required mechanical ventilator

2. O2 supplement

Management MAS

Tsu F. Yeh. Core concepts: meconiuma aspiration syndrome: pathogenesis and current management. NeoReviews 2010;11;e503-e512

Respiratory distress syndrome:

RDS


• “Hyaline membrane disease”

• Most common cause of respiratory distress in

premature infants born at < 28 weeks’ gestation

• 1/3 infants born at 28 to 34 weeks’ gestation

• < 5% infants born after 34 weeks’ gestation

• Etiology : surfactant deficiency

Clinical signs

• Begin at or immediate after birth

• Rapid breathing, cyanosis in room air

• Grunting and chest retractions


Chest radiography

• Homogenous opaque infiltrates and air bronchograms

“Ground glass appearance”

• Diffuse, fine granular infiltration

• Usually hypoaeration


After surfactant replacementRDS

Infection : Pneumonia

Infection : Pneumonia

• Common pathogens : group B streptococci (GBS),

Staphylococcus aureus, Streptococcus pneumoniae,

and gram-negative enteric rods

• Risk factors for pneumonia include

prolonged rupture of membranes (PROM),

prematurity and maternal chorioamnionitis

• Signs and symptoms : temperature instability,

tachypnea, drowsiness

GROUP “B” STREPTOCCAL PNEUMONIA

Take home message

TTNB MAS RDS Pneumonia

Risk factor C/S MeconiumstainPost-term

Preterm, DM PROM, PretermMaternal fever

Natural history Onset earlyResolve within 48-72 hrs

Onset shortly after birthMild-severe

Immediate after birth

VarySigns of sepsis

CXR Normo-hyperaerationMinor fissureProminent vascular marking

HyperaerationConsolidationAtelectasisPneumothorax

HypoaerationGround-glass appearanceBilateral

NormalaerationInfiltration uni/bilateral

Cyanosis in newborn

Clinical conditions that may cause cyanosis in newborn

Respiratory Cardiac

Pulmonary vascular :

PPHN

Central nervous system

สาเหตจากทางปอดและทางเดนหายใจ

การตรวจพบ

หายใจเรว หายใจล าบาก

Chest retraction, expiratory grunting

เสยงปอดผดปกต

Chest x-ray ผดปกต

ใหออกซเจน อาการเขยว

จะดขนหรอหายไป

สาเหตจากโรคหวใจ


หายใจเรว มกไมม chest retraction

ฟงปอดปกต ยกเวน congestive heart failure

Heart murmur +

Chest x-ray : หวใจโต หรอ pulmonary vascular

markings ลดลง

ใหออกซเจน PaO2 เพมขนนอยมากหรอไม

เปลยนแปลง

สาเหตจาก PPHN


Severe hypoxemia

Severe acidosis

Tachypnea

No anatomical cardiac lesions

May have hypovascularity on the chest

radiograph, relatively clear lung fields

สาเหตทางระบบประสาทสวนกลาง


หายใจตน ไมสม าเสมอ

แขนขาออนแรง

อาการเขยวหายไปเมอกระตนหรอให ออกซเจน

แนวทางการวนจฉย

1. ประวต

Preterm, post-term

น าเดนกอนคลอดนาน

Perinatal distress, meconium

อาการเขยวเกดขนเมอไร*

เขยวคงทหรอมากขน

Mode of delivery

2. การตรวจรางกาย

ควรใหทารกสงบ หายใจ

room air (ถาไม distress มาก)

Central หรอ peripheral

cyanosis, different cyanosis

Heart murmur, ลกษณะการ

หายใจ


3. การตรวจทางหองปฏบตการ

1) Hct, dextrostix, calcium, drop of blood

2) ABG (pH, PaO2, PaCO2)

3) Chest x-ray

4) Hyperoxia test

5) Preductal & post ductal blood gas

6) EKG, echocardiography


Hyperoxia test

ให O2 100% ทาง oxygen hood อยางนอย 5-10 min

PaO2 < 100 mmHg

PaO2 > 150 mmHg ไมใชโรคหวใจชนดเขยวแนนอน

cyanotic congenital heart disease

PPHN

PaO2 100-150 mmHg อาจเปนโรคหวใจชนด complete

intracardiac mixing และ PBP มาก

การดแลรกษา

การดแลรกษาโดยทวไป

รกษาอณหภมกายใหปกต

IV fluid,glucose

Adequate tissue

oxygenation

การรกษาจ าเพาะ

แกไขตามสาเหตRespiratory failure

PPHN

CHD ตองอาศย PDA

Congenital cyanotic heart disease ท PBF ขนกบ flowทผาน ductus arteriosus ให Prostaglandin E1 เรม infusion 0.05-0.1 g/kg/min when desired effects dose 0.05, 0.025 & 0.01 g/kg/min

If unresponsive, dose may be increased to 0.4 g/kg/min

Side effects : fever, seizure, cutaneous flushing tachycardia, bradycardia, apnea, BP cardiac arrest

การดแลรกษา

Definition

Apnea : Cessation of breathing for longer than 20 seconds or

shorter duration + Pallor

Cyanosis

Bradycardia

Definition

Periodic breathing • Recurring cycles of breathing of 10 to 15 seconds

duration, interrupted by pauses of at least 3 seconds

in duration

• Without change in heart rate or skin color

• Immaturity of respiratory control

• REM sleep, not occur in first 2 days of life

• Prevalence : 100% in preterm BW < 1,000 gm

• No treatment

Definition

Etiology factors contribute to apnea in preterm infant

NeoReviews,

2002

Bacteria

Virus: RSV

Magnesium

Prostaglandin

Apnea of prematurity

• Common disorder in preterm infants who require

neonatal intensive care

• Immaturity of the respiratory control system

• Requires therapeutic intervention to avoid potential

morbidity

• Incidence inversely related to gestational age

Pathogenesis

• Poorly myelinated of central neurons generator

• Reduced number of dendrites and synaptic connection

-> impaired capability for sustained ventilatory drive

• Neurotransmitter deficiency

• Highly chest wall compliant

• Excessive neck flexion

Pathophysiologic mechanism predisposing to apnea of prematurity

NeoReviews,

2002

Type of apnea of prematurity

• 3 types based on the presence or absence of upper airway obstruction

1. Central apnea : Total cessation of inspiratory efforts with no evidence of obstruction

2. Obstructive apnea : Chest wall motion without air flow through out the entire apneic episode

3. Mixed apneas : Consists of obstructed respiratory efforts usually following central pauses

NeoReviews,

2002

Diagnostic procedures

• Physical examination• Blood tests : checking for blood counts, electrolyte

levels and infection• Measurement of the levels of oxygen in the baby's

blood• X-ray : check for problems in the lungs, heart, or

gastrointestinal system• Apnea study : monitoring breathing effort,

heart rate, and oxygenation

Treatment

First : Exclude other medical causes

Xanthine therapy: Aminophylline

• Major mechanism of action : competitive antagonism of adenosine receptors

• Increases minute ventilation • Improves CO2 sensitivity• Decreases hypoxic depression of breathing • Enhances diaphragmatic activity• Decreases periodic breathing

Aminophyline & Cafeine

Hyperbilirubinemia

Hyperbilirubinemia TSB > 2 mg/dl

Neonates appear jaundiced TSB > 5 to 7 mg/dL

Hyperbilirubinemia

Neonatal bilirubin

metabolism

Uptake

Conjugation

Excretion

Production

กลไกทางสรรวทยาของภาวะตวเหลองในทารกแรกเกด

1. มการสราง bilirubin กอนเขาสตบมากขน

• ปรมาณเมดเลอดแดงมาก

• อายของเมดเลอดแดงสน (70-90 วน) เมอเปรยบเทยบกบของ

ผใหญซงเทากบ 120 วน

• Bilirubin ทมาจากแหลงอนทไมใชจากเมดเลอดแดงมาก

• การดดซมกลบของ unconjugated bilirubin ในล าไส

(enterohepatic circulation of bilirubin) มาก

2. กระบวนการก าจด bilirubin ในเลอดท าไดนอย

• Hepatic uptake นอยเนองจากเซลลตบขาด bilirubin-binding

protein (ligandin)

• Conjugation นอยเนองจากเอนซยม UDP-glucuronyl

transferase มเพยงรอยละ 0.1-1 ของระดบในผใหญ

• การขบถายของ bilirubin ยงท าไดไมเตมท

กลไกทางสรรวทยาของภาวะตวเหลองในทารกแรกเกด

Physiologic jaundice

1 สปดาห 2 สปดาห3-5 วน

TSB 5-6 mg/dL

TSB 10-12 mg/dL

อาย

TSB mg/dL

Preterm

Fullterm

Pathologic jaundice

ทควรหาสาเหต มดงน

• อาการตวเหลองภายใน 24-36 ชวโมงหลงเกด

• TSB เพมขนในอตราทมากกวา 5 มก./ดล./24 ชม.

• TSB มากกวา 12 มก./ดล.ในทารกเกดครบก าหนด

หรอ 10-14 มก./ดล. ในทารกเกดกอนก าหนด

• อาการตวเหลองทนานเกน 10-14 วนหลงเกด

• Direct serum bilirubin > 20 %ของ total bilirubin

การประเมนอาการตวเหลอง

ประเมนภาวะตวเหลองรวมดวยทกครงเมอวด vital signs

Dermal zone of jaundice

Dermal Bilirubin (mg/dl)

zone Mean + SD range

1 5.9 + 0.3 4.3 - 7.9

2 8.9 + 1.7 5.4 - 12.2

3 11.8 + 1.8 8.1 - 16.5

4 15.0 + 1.7 11.1 - 18.3

5 > 15

K ramer Li 1969

5 5

3

2

1

4

5 5

◦

4

1. Over production

• Fetomaternal blood group incompathibility

• Congenital spherocytosis, eliptocytosis SAO

• G-6-PD deficiency

• Thalassemia

• Extravascular blood• Hematomas

• Enclosed hemorrhage

• Polycythemia

• Increased enterohepatic circulation• Gut obstruction

Causes of neonatal hyperbilirubinemia

2. Undersecretion

• Metabolic and endocrine condition

• Hypothyroidism

• Infants of diabetic mother

• Prematurity

• Obstructive disorders

• Biliary atresia


3. Mixed

• Sepsis

• Intrauterine infections

• Hepatitis

• Asphyxia

4. Uncertain mechanism

• Race - Thai - Chinese

• Breast milk jaundice



ประวตส าคญ

• การตงครรภ การคลอด

• การกนนม

• ประวตครอบครว บตรคนกอน ประวตภาวะเมดเลอด

แดงแตกงาย (G-6PD def, thalassemia เปนตน )

การตรวจรางกายทส าคญ

• อาการและอาการแสดงของโรคตดเชอตงแต

ในครรภหรอหลงเกด

• ภาวะเลอดออกทผวหนงหรอ soft tissue

• คล าไดตบมามโต

การตรวจทางหองปฏบตการทส าคญ

• ระดบ bilirubin, Hct

• Blood type, Rh, Direct Coombs’ test ในทารก

• Peripheral smear for RBC morphology

• Reticulocyte count

• G-6PD level

Laboratory investigation in prolonged jaundice

• Liver function test

• Congenital infection

• Sepsis

• Metabolic defect eg. hypothyroidism

แนวทางการประเมนอาการตวเหลองกอนจ าหนาย

กอน D/C ทารกแรกเกดทกคนควรไดรบการประเมนถง

ความเสยงทจะม severe hyperbilrubinemia

โดยเฉพาะ D/C กอนอายครบ 72 ชม.

1. กลม Low risk : ทารกแรกเกด GA ≥38 สปดาห ทปกตด

ไมมปจจยเสยง

2. กลม Medium risk : ทารกแรกเกด GA≥38 สปดาหทมปจจย

เสยงหรอ GA 35-37+6 สปดาหทปกต

3. กลม High risk : ทารกแรกเกด GA 35-37+6 สปดาห

ทมปจจยเสยง

แนวทางการดแลรกษาภาวะตวเหลอง

AAP. Pediatrics 2004;114 : 297-316

F:/../../My Documents/febrile neutropenia/scorenew.jpg

Guidelines for phototherapy in hospitalized infants of 35 or more weeks’ gestation.

• Use total bilirubin. Do not subtract direct

reacting or conjugated bilirubin.

• Risk factors = isoimmune hemolytic disease,

G6PD deficiency, asphyxia, significant lethargy,

temperature instability, sepsis, acidosis, or

albumin <3.0 g/dL.

Guidelines for phototherapy in hospitalized infants of 35 or more weeks’ gestation.

• It is an option to provide conventional phototherapy

in hospital or at home at TSB levels 2-3 mg/dL

below those shown but home phototherapy should

not be used in any infant with risk factors.

Management of hyperbilirubinemia :

Healthy term newborn

< 24 ---- ----

25-48 > 12 > 15

49-72 > 15 > 18

> 72 > 17 > 20

> 96 > 20

Age(hours)

Considerphoto

phototherapy

Guideline for Initial Phototherapy in

Preterm Neonates

Total serum bilirubin (mg/dL)

BW (g) Healthy Sick

2,001 - 2,500 12 - 15 10 - 12

1,500 - 2,000 10 - 12 8 - 10

1,001 - 1,500 7 - 10 6 - 8

< 1,000 5 - 7 4

Fanaroff & Martin’s neonatal-perinatal medicine: diseases of the fetus and infant. 9thed. St. Louis: Elsevier Mosby, 2011:1443-96.

Phototherapy

Response to phototherapy

MB Age Action

< 18 - Wean to conventional phototherapy

< 12 - Discharge home

< 14 49-72 Discontinue photo, D/C home

< 15 >72 h Discontinue photo, D/C home

Check rebound MB 24 hours after discontinue

Complication from phototherapy

1. insensible water loss

2. Loose stool

3. Retinal damage

4. Bronze baby syndrome

AAP. Pediatrics 2004;114 : 297-316

F:/../../My Documents/febrile neutropenia/scorenew.jpg

• Immediate exchange transfusion is recommended if infant

shows signs of acute bilirubin encephalopathy or if TSB is

≥ 5 mg/dL above these lines.

• Measure serum albumin and calculate B/A ratio.

• Use total bilirubin. Do not subtract direct reacting or

conjugated bilirubin.

Guidelines for exchange transfusion in

Infants 35 or more weeks’ gestation

Management of hyperbilirubinemia :

Healthy term newborn

< 24 ---- ----

25-48 > 20 > 25

49-72 > 25 > 30

> 72 > 25 > 30

Age(hours)

ExchangeTransfusionIf photo fails

Exchangetransfusion

And intensivephoto

Exchange transfusion

Blood for exchange transfusion1. Fresh blood <7 days old (Hct 45-50%)

ratio PRbC + FFP = 2 : 1

2. In Rh hemolytic disease

blood gr O Rh negative

Cross match against mother and infant

3. In ABO incompatibility

PRC gr. O + FFP gr. AB

cross match against mother and infant

4. In nonimmune hyperbilirubinemia cross

matched against plasma and Rbc of infant

5. Volume of exchange transfusion

double volume of infant blood

= 2 x 80 ml/kg

Exchange transfusion

Technique of exchange transfusion

1. Place on radiant warmer

2. Monitor BP, cardiac monitor

3. Assistants : record volumes of blood & US.

4. Check and warm blood to 37oC

5. Put on umbilical vein

6. Exchange by push-pull technique

BW <1,500 gm = 5 ml/time

BW 1,500 - 2,500 gm = 10 ml/time

BW 2,500 - 3,500 gm = 15 ml/time

BW >3,500 gm = 20 ml/time

Recommend time for exchange = 1 hour

7. After exchange transfusion continue phototherapy

Complication of exchange transfusion

1. Hypocalcemia and hypomagnesemia

2. Hypoglycemia

3. Acid-base balance

4. Hyperkalemia

5. Cardiovascular complication

6. Bleeding

7. Infection

8. Graft-versus-host disease

แนวทางการรกษาภาวะตวเหลองจากนมแม

• ประเมนวาทารกไดรบนมแมเพยงพอหรอไม หากไมเพยงพอ

ใหทารกดดนมแมบอยขนทก 2-3 ชม

• หากระดบบลรบนมากกวา 18-20 มก./ดล.

- Phototherapy ไมตองงดนมแม

- ตดตามดอาการและตรวจระดบบลรบน

• หากระดบบลรบนสง > 25 มก./ดล.

- Phototherapy + งดนมแมรวมดวย 24-48 ชม.

- ควรอธบายใหแมเขาใจเพอไมใหเกดทศนคตทไมด

เกยวกบนมแม

Neonatal resuscitation

1-112

การเตรยมตวส าหรบการชวยกชพ

ทารกแรกเกดทกรายควรไดรบการประเมนวา

ตองการการดแลชวยเหลอเบองตนหรอไม

Copyright ©2010 American Academy of Pediatrics

ขนตอนการชวยกชพ

2-114

Evaluating the Newborn

ทนทททารกเกด , ถามค าถามเหลาน:

Meconium stained amniotic fluid

1. Vigorous infant- ทารกหายใจด และ- Good muscle tone- Heart rate >100 ครง /นาท

2. Not vigorous

Meconium stained amniotic fluid

Not vigorous infants

(ไมหายใจ หายใจชา

poor muscle tone

HR < 100)

tracheal suction immediately after birth and before stimulation

Vigorous infant Bulb syringe or large-bore suction catheter (12-14 F) ดดในปาก และจมก

( No tracheal suction : not improve

outcome and may cause complications)

( หายใจด

good muscle tone

HR >100)

2-117

Meconium Present and Newborn Not Vigorous

Tracheal Suction

ให oxygen, monitor heart rate

ใส laryngoscope, use 12F or 14F suction

catheter ดดในปาก

ใส endotracheal tube ใน trachea

ตอ endotracheal tube กบ suction source

5-118

Suctioning Meconium via Endotracheal Tube

• ตอทอชวยหายใจกบ

meconium aspirator ซง

ตอกบเครองดดเสมหะ

• ใชนวมออดรเปดของ

meconium aspirator

เพอใหเกดแรงดด

• ท าการดดพรอมๆกบดงทอ

ชวยหายใจออก ท าซ าตามความจ าเปน

Click on the image to play video

2-119

Evaluating the Newborn

ทนทททารกเกด , ถามค าถามเหลาน:

2-120

Initial Steps

ใหความอบอนแกทารก วางทารกใต radiant warmer,

จดทาศรษะ open the airway

เชดตวใหแหง กระตนใหหายใจ

เอาผาเปยกออก จดทาศรษะ

2-121

Opening the Airway

Sniffing” position

2-122

Dry, Stimulate to Breathe, Reposition


2-123

Evaluation: Respirations, Heart Rate

Decisions and actions

during newborn

resuscitation are based

on Respirations

Heart Rate


1-124

การประเมน

ภายหลงการดแลชวยเหลอเบองตน การชวยเหลอขนตอไป ขนกบผลการประเมนดงตอไปน

2-125

Central Cyanosis and Acrocyanosis

Neonatal hypoglycemia

Definition hypoglycemia

• ภาวะน าตาลในเลอดต าในทารกทกคนไมวาอายเทาไร คอ

พลาสมากลโคส < 47 มก/ดล.

• น าตาลกลโคสในเลอดจะต ากวากลโคสในพลาสมา 10-15 %

• ในทางปฏบตระดบน าตาลกลโคสทถอวาต าและตองการการดแล

รกษาคอ พลาสมากลโคส < 40 มก/ดล.

หรอน าตาลกลโคสในเลอด< 35 มก/ดล

David H. Adamkin, Ccmmittee on Fetus and Newborn. Postnatal Glucose Homeostasis in Late-Preterm and Term Infants. Pediatrics 2011;127:575-9.

• Infants of diabetic mothers

Developed asymptomatic hypoglycemia early as 1 hour

after birth and usually by 12 hour of age

• Large for gestational age or small for gestational age

infant : hypoglycemia early as 3 hours of age

Risk factors

Antenatal : maternal diabetes mellitus, maternal obesity,

rapid infusion of glucose immediately before delivery,

ß-adrenergic agonist or antagonist therapy

Neonatal : SGA, LGA, prematurity, perinatal stress

(asphyxia), hypothermia, polycythemia

illed-infant (sepsis, respiratory distress)

suspected inborn errors of metabolism or endocrine

disorder, microphallus or midline defect

Hypoglycemia

Clinical manifestation

Irritability, tremors, jitteriness

Exaggerated Moro reflex

High-pitched cry

Seizure or myoclonic jerks

Lethargy, limpness, hypotonia

Coma, cyanosis

Apnea or irregular breathing or tachypnea

Temperature stability, vasomotor instability

Poor suck or refusal to feed

Hypoglycemia

Macrosomia : fetal weight >90th percentile for gestational ageA plethoric appearance and excessive fat accumulation

Cause of hypoglycemia

1. Utilization of glucose(Hyperinsulinism)

2. Production/store

3. Utilization of glucose and/or Production

Maternal hyperglycemia

Fetal hyperglycemia

Fetal hyperinsulinemia

Fetal substrate uptake

Increase metabolic rate and O2 consumption

Hypoxia

Increase synthesis erythropoietin and RBC mass

Polycythemia

Suppress production of surfactant


Macrosomia

Infant of diabetic mother

Treatment of hypoglycemia

• Asymptomatic + DTX 25-40 mg%

Enteral feeding : 10%D/W & infant formula ??

Infant formula : Carbohydrate, protein and fat

- Provide sustained supply substrate

- Stimulate gluconeogenesis

Increase blood glucose approximate 30 mg/dL after

feeding 30-60 mL of infant formula

• Asymptomatic + DTX < 20-25 mg/dL

IV therapy :

- Initial bolus 200 mg/kg of 10% D/W

(2 mL/kg of 10%D/W)

- Continuous infusion of dextrose GMR 6-8 mg/kg/min

- Check blood glucose 30 minutes after bolus, then

every 1-2 hours until stable

Avoid induction iatrogenic hyperglycemia

stimulate excess insulin secretion

induce rebound hypoglycemia

Treatment of hypoglycemia

• Symptomatic infant + DTX < 40 mg/dL

IV therapy

Maintain blood glucose > 50-60 mg/dL

Should be permitted to continue feeding (as tolerate)

Wean iv therapy if blood glucose stable for 12-24 hours

Decrease infusion rate by 10-20%

Failure to tolerate weaning from iv glucose

indicate of the pervasive disorder :

metabolic defect or idiopathic hyperinsulinism

BG < 35 มก/ดล BG <25 มก/ดล BG 25-40 มก/ดล

า ก LPT, LGA/IDM และ Term SGA

ม ม ากา แ ด ดปก

า ก าย 4-24 ม

ให ก นนม ก 2-3 ม จ BG ก นก นนมแ ละม

า กแ ก ก ด - 4 ม

มก นนม ายใน 1 ม หล ก ด

จ BG หล ก นนม 30 นา

ให ก นนม า า ม มป หา

และ จ BG หล ก น 1 ม

ให ก นนม า า ม มป หา

และ จ BG หล ก น 1 ม

IV glucose ให ก นนม ห

IV glucose าจ า ป น

ให ก นนม ห

IV glucose าจ า ป น

IV glucose

BG <25 มก/ดล

BG <35 มก/ดล

BG 35-40 มก/ดล

LPT = Late preterm

LGA = Large for gestational age

IDM = Infant of diabetic mother

BG = Blood glucose

IV glucose = 10%D/W 2 มล./กก ด ย glucose 5-8 มก/กก/นา

แ น ม แน า กา ดแล ก า า ก Late preterm (LPT), LGA/IDM และ า ก ก ด ก าหนด ป น SGA

ม ม ากา แ ด า ะน า าลใน ล ด า

Necrotizing enterocolitis

Stage I Suspected

a. Any or more historical factors producing perinatal stress

b. Systemic manifestation: temperature instability, lethargy, apnea,bradycardia

c. Gastrointestinal manifestation: poor feeding, increasing pregavageresiduals, emesis, mild abdominal distension, occult blood possiblepresent in stool

d. Abdominal radiographs demonstrate mild ileus.

Bowel rest

Repeat physical exams

Repeat abdominal films

Stage II Definite

a. Signs and symptoms listed in Stage I plus persistent occult orgross gastrointestinal bleeding, marked abdominal distension

b. Abdominal radiographs demonstrate significant intestinaldistension with ileus, small bowel separation (edema in bowel wallor peritoneal fluid), unchanging or persistent “rigid” loops,pneumatosis intestinalis, portal vein gas.

Bowel rest

Parenteral antibiotics

Parenteral nutrition

Repeat abdominalexam.

Repeat abd. Films, lab, U/S, paracentesis

Stage III Advanced

a. Any one or more historical factors

b. Signs and symptoms listed in stage I and II plus deterioration ofvital signs, evidence of septic shock or marked gastrointestinalhemorrhage.

c. Abdominal radiograph may demonstrate pneumoperitoneum inaddition to other findings listed in stage II c.

Surgical treatment

a. resection and stomas (most patients)

b. Primary anastomosis (selected patients)

c. VLBW with perforation – consider peritoneal drainage alone, initially

Congenital infection

Intrauterine infection

ToRCHS infection

To = Toxoplasmosis

R = Rubella infection

C = Cytomegalo virus infection CMV

H = Herpes simplex infection

S = Syphilis

3 forms of toxoplasma

Cyst

Tachyzoite

Oocyst

Congenital Toxoplasmosis

• Incidence of 0.1 to 1 in 1,000 live births

• Infection during pregnancy : by

- ingesting oocysts-infected cat feces

- ingestion of pseudocysts present in undercooked meat

• Most infected women :

- no symptoms

- 15% acute flu-like illness with lymphadenopathy

NeoReview. August 2010

Congenital Toxoplasmosis

• Risk of vertical transmission:

increase with GA at the time of infection

- 1st trimester : 10-20%

- 2nd trimester : 30%

- 3rd trimester : 65%

• Overall risk of transmission in pregnancy : 20-50%

• Severity of fetal disease inverse related to GA at the

time of infection

(50% in 1st trimester, 25% in 2nd trimester and <3% in

3rd trimester)

Fanaroff & Martin’s Neonatal-Perinatal Medicine. Disease of the fetus and infant. 9th edition, 2011

Clinical manifestations

• 70-90% of infected infant are asymptomatic at birth

• 10% to 30% symptomatic newborns present with

a systemic form of the disease

• Classic triad:

– Chorioretinitis: focal necrotizing retinitis, yellow-white

cotton like patches, retinal edema

– Hydrocephalus: periaqueductal obstruction

– Intracranial calcifications: scatter in white matter,

basal ganglia

http://www.isradiology.org/tropical_deseases/tmcr/chapter45/large45/45-05A.jpg


http://www.isradiology.org/tropical_deseases/tmcr/chapter45/large45/45-05B.jpg

http://www.isradiology.org/tropical_deseases/tmcr/chapter45/large45/45-05B.jpg




Systemic sign CNS Eyes

IUGR

Prematurity

Low APGAR score

Temperature instability

Lymphadenopathy

Hepatosplenomegaly

Myocarditis

Pneumonitis

Feeding problem

Band of metaphyseal

plate

Hydrocephalus

Seizure

Muscular twitching

Opisthotonus

Hypsarrthmia

Paralysis

Difficult swallowing

Respiratory distress

Microcephaly

Visual impairment

Chorioretinitis

Retinal detachment

Iris nodule

Glaucoma

Strabismus

Nystagmus

Micropthalmia

Skin Ears Endocrine

Rash PetechiaeEcchynosisJaundice Cyanosis Edema

Sensorineural hearing loss

MyxedemaDiabetes insipidusHypopituitarism


Diagnosis

• Antenatal diagnosis :

- PCR for parasite DNA detection in amniotic fluid or

fetal blood

- Isolating the organism from the placenta or fetal blood

• Postnatal diagnosis : IgM +ve and high titer of IgG

- IgG can detect for 1-2 months postinfection

- IgM can persist for 6-24 months

Investigations

Postnatal investigations

• CBC : anemia and thrombocytopenia

• Liver function tests

• CSF

• Cranial ultrasonography ± CT brain for hydrocephalus

and calcification

• Ophthalmologic examinations

Treatments

Pyrimethamine

• 2 MKD for 2 days followed by 1 MKD x 4 weeks

and then Mondays, Wednesdays, and Fridays to

complete 12 months of therapy

Sulfadiazine

• 100 MKD in 2 divided doses x 1 yr

Folic acid

• 10 mg 3 time/week

Infectious Diseases of the Fetus and Newborn Infant. 6th ed.

Treatments

Active chrorioretinitis

CNS involvement, eg. CSF protein >1 gm/dL

Treatments

Prednisolone 1 MKD PO bid

Pregnant women :

- Avoid foods/products that may be contaminated

with T gondii oocytes by cooking food at safe

temperatures; peeling or thoroughly washing fruits and

vegetables

- Washing kitchen utensils and hands with hot soapy

water

- Wearing gloves when touching soil, sand or cat litter

Prevention

Congenital rubella syndrome

Rubella infection :

• 30% subclinical

• Symptomatic pt. : mild, occur 14-21 days after infection

• Pregnant woman : low-grade fever, malaise, rash

(macular, begin face and neck, proceed downward,

disappear over 3-4 days)

• Postauricular, suboccipital and post. cervical

lymphadenopathies

• Dx: serology confirm of 4-fold increase in IgG,

positive IgM

Risk factor developing CRS

Maternal infection

gestational age Incidence CRS

first 12 weeks 81 %

13-16 weeks 54 %

17-22 weeks 36 %

23-30 weeks 30 %

31-36 weeks 60 %

> 36 weeks 100 %

The malformation depend on gestational age

• Multiple defects occur after very early exposure

• Almost every fetus expose during first month of

pregnancy develops abnormal

• Cardiac defect : before GA 10 wk

• Deafness : before GA 16 wk

• GA > 20 wk : rare

Antenatal diagnosis

• Cord blood rubella-specific IgM and PCR of amniotic fluid

• Ultrasound anomalies

Postnatal diagnosis

• Isolation of rubella virus from many body sites

(pharyngeal secretions, eye, throat, CSF, stool, and urine)

• Detect rubella specific IgM


Manifestations

• Sensorineural hearing loss

• Cardiac defect : PDA, pulmonary artery stenosis, TOF

• Eye : Congenital cataract, retinopathy, microphthalmia

Salt and-pepper chorioretinitis

• Radiolucencies of long bones

• Neuro : mental retardation, meningoencephalitis,

behavioral disorder

• Thrombocytopenia and dermal erythropoiesis

• Delayed manifestation : DM, thyroid disease


Investigations:

• CBC : anemia and thrombocytopenia

• liver function tests

• Echocardiography

• Lumbar puncture

• Chest and long bone radiographs

• Serial hearing and ophthalmologic assessments

• Screening for endocrine complications (DM and

hypothyroidism) indicated for long-term management


Treatment of mother and CRS

• No specific therapy

• Terminate pregnancy if infected before 5 month

• Follow up newborn

Prevention for CRS infant

Immunization : rubella vaccine Avoid within 1 month of conception or during pregnancy

Contact isolation of CRS infant

at least 1 year

Human Cytomegalovirus

Transmission

prenatal (congenital, placental)

natal (50% of exposed infants become infected)

postnatal (human milk in preterm infants, blood

transfusion, transplant)

Primary maternal infection results in fetal infection in

30% to 40% of cases

The risk of fetal infection correlates with viral load

in the fetal amniotic fluid or in the newborn’s plasma

Clinical Manifestations

Hepatosplenomegaly, conjugated hyperbilirubinemia

Thrombocytopenia with petechiae/purpura

(“blueberry muffin” spots)

Small size for gestational age, microcephaly

Intracranial calcifications

Chorioretinitis

CMV pneumonitis

Occur in infant < 4 months

Symptomatic and radiography

similar to afebrile pneumonia

CXR : Hyperinfaltion

Diffuse increase pulmonary

marking

Focal atelectasis

Thickening bronchial wall

3% of patient : death

Diagnosis

Prenatal Dx

- Viral culture of the amniotic fluid 100% specificity

- PCR of amniotic fluid (after 21 weeks’ gestation)

Postnatal Dx

- Isolation of CMV from urine, stool, respiratory tract

secretion or CSF obtained within 3 weeks of birth

- CMV IgG, IgM

IgG titer no detetced in 4-9 mo of age -> exclude CMV

• Antiviral agents indication

serious, life-threatening

Symptomatic CMV (pneumonitis, hepatitis,

thrombocytopenia) : Red book 2009

Ganciclovir : acts as a chain terminator during elongation of newly synthesized viral DNA

Treatment of CMV

Remington, Klein et al Infectious diseases of the fetus and newborn infant. 7th ed 2011

Herpes Simplex Virus

Epidemiology

• Neonatal herpes is usually the result of HSV-2 infection

• Most cases of neonatal infection, mothers do not give a history of

active genital herpes at the time of delivery

• In USA, prevalence of neonatal herpes = 0.05-0.3: 1,000 live births

• The transmission rate

intrapartum infection : 88% to 93%

postpartum infection 5-10%

intrauterine infection < 2%


• Neonatal HSV infection typically presents within 1-3 weeks

• 3 types : Localized disease, CNS disease

Disseminated disease

Localized disease : presents as vesicles or zoster-like eruptions on skin, eyes, or mouthIf left untreated, more than 70% of cases progress to disseminated disease

Disseminated disease - Nonspecific presentations : poor feeding, fever, lethargy,

apnea, convulsion, respiratory distress, hepatomegaly, jaundice and disseminated intravascular coagulation

• Associated with mortality rates between 50% (HSV-2) and70% (HSV-1)

• Poor prognosis : hemorrhagic pneumonitis, severecoagulopathy, liver failure, and meningoencephalitis

• >40% of patients who have disseminated disease do notdevelop skin lesions


CNS disease : 30% and 1/3 of cases without skin findings

- Clinical signs include seizures, lethargy, irritability, tremors,

poor feeding, temperature instability, and a bulging

fontanelle

- At least 50% of patients suffer long-term sequelae, despite

high-dose acyclovir treatment

- Seizures at or before initiation of antiviral therapy are

associated with an increased risk for morbidity


Diagnosis

• All infants should be examined for vesicles

• Viral cultures after 48 hours of age are collected from various

sites, including mouth, nasopharynx, conjunctiva, rectum,

skin vesicles, urine, stool, blood, and CSF

• HSV-PCR testing from CSF: HSV encephalitis

• Electroencephalography and brain imaging : useful adjuncts

to diagnosis if negative HSV-PCR

• Liver function and coagulation tests : to evaluate

disseminated disease

Treatment

• For skin-eye-mouth disease :

Acyclovir iv 20 mg/kg/dose q 8 hr for 14 days

• For disseminated disease and encephalitis, treatment for at

least 21 days

• For HSV encephalitis, acyclovir should be continued until CSF

PCR test results become negative

• Topical ophthalmic drugs are helpful for eye lesions

Congenital syphilis

Spirochete “Treponema pallidum”

Occurs after infection of the placenta in pregnant

women with secondary syphilis

Transmission can occur at any stage of pregnancy

40%of pregnancies with syphilis result in spontaneous

abortion, stillbirth and perinatal death

Congenital syphilis : early & late disease

Early disease : first 2 postnatal years

30-40% stillborn, 75% asymptomatic at birth

Most affected children develop symptoms between the

3rd -4th weeks after birth

Early disease : nonimmune hydrops fetalis, IUGR,

hepatosplenomegaly, jaundice (syphilitic hepatitis),

condyloma lata, pseudoparalysis, lymphadenopathy

snuffles (syphilitic rhinitis, followed by a maculopapular rash)


Dermatology : pink and oval macules-> coppery brown

and desquamate (40%)

vesiculobullous eruptions involving the palms and soles

Hematology : Coombs-negative hemolytic anemia

leukocytosis, thrombocytopenia or leukopenia

Renal : Nephrotic syndrome : 2 to 3 months

CNS : meningitis, choroiditis, hydrocephalus, seizures

optic nerve atrophy, or cranial nerve palsies

Bone: Osteochondritis, long bones and ribs (8 months)

Wimberger sign : bilateral destruction of the upper

medial tibial metaphyses (75-100%)


Saber shins

Higoumenakia sign (unilateral enlargement of the

sternoclavicular portion of the clavicle)

Clutton joints (bilateral knee effusions)

Late disease:

Interstitial keratitis: 5-20 yrs

8th nerve deafness : 10-40 yrs

Hutchinson teeth : peg- shaped, notched central incisors

Saddle nose, frontal bossing


Diagnosis

Presumptive diagnosis: treponemal, nontreponemal test

• Treponemal tests :

Fluorescent treponemal antibody absorption (FTA-ABS)

The particle agglutination (TP-PA) tests

• Nontreponemal tests :

Venereal Disease Research Laboratory (VDRL) slide test

Rapid plasma reagin (RPR) test

Diagnosis

VDRL or RPR titer of infant > mother at least four-fold

indicating fetal antibody synthesis->Congenital syphilis

sensitivity 4–13%, specificity 99%

Excluded congenital syphilis if

- VDRL/RPR tests : non-reactive before age of 6 months

in an infant who has not received treatment

- TPPA/TPHA and FTA-ABS : non-reactive before

1 year of age in an infant who has not received treatment

Eur J Clin Microbiol Infect Dis (2010) 29:495–501

• Infant should be evaluate if the mother

- Syphilis untreat or inadequately treated or treatment if

not document

- Syphilis during pregnancy treated with nonpenicillin

regimen (erythromicin)

- Syphilis treated less than 1 month before delivery

- Syphilis treated before pregnancy but with insufficient

serologic follow up

Investigation

Red book 27th edition, 2008

Nontreponemal test

Complete blood and platelet counts

Cerebrospinal fluid examination

(high wbc count, high protein)

Long bone radiographs

Ophthalmologic examination, neuroimaging, auditory

brainstem response, and liver function testing are added

if infection is strongly suspected

Investigation


Guide for interpretation of syphilis


VDRL/RPR TPPA, FTA-ABS Interpretation

Mother Infant Mother Infant

- - - - No syphilis, incubation syphilis

+ + - - No syphilis in mother and infant(false positive)

+ +/- + + Maternal syphilis with possible infant infection

+ + + + Recent or previous syphilis in mother and possible infant infection

- - + + Mother successfully treated for syphilis before or early pregnancy, or mother with Lyme disease (false positive)Infant syphilis unlikely

Mother : no Tx or Tx < 4 wk before deliveryInfant : normal physical examinationSingle dose of Benzathine penicillin 50,000 U/kg IM

PGS 50,000 U/kg iv q 12 hr (or q 8 hr if age > 1 wk) x 10 daysProcaine penicillin G 50,000 U/kg IM OD x 10 days

Single dose of Benzathine penicillin 50,000 U/kg IM

Varicella-Zoster Virus (VZV)


Herpesviridae family

VZV : transferred transplacentally from the mother

to the fetus

Perinatally acquired varicella in the newborn classically

occurs in the first 10 days after birth if the mother

is infected from 5 days before to 2 days after delivery

Fetal infection in the first 20 weeks of GA ->

varicella embryopathy or congenital varicella syndrome

The incidence CVS among infant born to mother with

varicella 1-2%

The usual interval from onset of rash in mother to onset

in neonate is 9-15 days



Clinical Manifestations of CVS

• Skin lesions with dermatomal distribution (72%)

• Neurologic defects (62%)

• Eye diseases (52%)

• Skeletal anomalies (44%)

• 30% of symptomatic infants die in the first postnatal

months

• The most characteristic findings of CVS :

limb hypoplasia with cicatricial skin scarring

chorioretinitis, cataracts, and brain abnormalities

(cortical atrophy, intellectual disability and seizures)

• Perinatally acquired varicella : serious complications

pneumonia

bacterial superinfections

(toxic shock syndrome and necrotizing fasciitis)

Cerebellar ataxia, encephalitis, meningitis

Clinical Manifestations of CVS

• PCR or by immunofluorescence techniques in skin

scrapings or from vesicle fluid

• Acute recent infection : IgM +ve and IgG +ve

• Persistence of VZV antibodies in the infant beyond

8 months of age is highly suggestive of intrauterine

acquisition of varicella

Diagnosis

Treatment

Infants who have clinical signs of active varicella

infection -> IV acyclovir until no new lesions develop

Antibiotics should be administered for bacterial

superinfections

Pregnant woman with varicella infection -> oral acyclovir

Pregnant with serious complication of varicella infection

-> Tx with IV acyclovir

Isolation of the hospitalized patient

Patient with varicella :

standard precaution, airborne and contact precaution

(until all lesions are crusted)

Exposes susceptible patients :

airborne and contact precautions from Day 10-21

after exposure (Day 10-28 for infant who received

VZIG or IVIG)

Candidate for VZIG/IVIG

-Susceptible pregnant woman (within 72-96 hr)

- Newborn infant whose mother had onset of chickenpox within 5 days before delivery or within 48 hours after delivery

- Hospitalized preterm infant (GA ≥28 wk) whose mother lacks a reliable history of chickenpox or serologic evidence of protection against varicella

- Hospitalized preterm infant (GA <28 wk or ≤1,000 gm birth weight) regardless of maternal history of varicella or varicella-zoster virus serostatus

Care of exposed people

Varicella vaccine adminstered by 3-5 days after exposure

All exposed susceptible patient should be dischaged as

soon as possible

Toxoplasmosis CMV

Maternal Asymptomatic

Lymphadeno-pathy, fever

fatique, headche

Asymptomatic

Neonatal Classic triad:

-Hydrocephalus

-Chorioretinitis (14%)

-Intracranial calcification (9%)

Other:

-Seizure

-Microcephaly (1-5%)

-Hepatosplenomegaly

-Jaundice

-Encephalitis

-Anemia

-Thrombocytopenia

-Microcephaly (37%)

-Chorioretinitis (20%)

-Intracranial calcification

(periventricular)

-Hearing loss (58%)

-Seizure (23%)

-IUGR

-Petechiae

-Hepatosplenomegaly

-Jaundice

-Mental retardation

-Prematurity

Herpes Rubella Syphilis

Maternal Oral or genital lesion Fever, coryza,

conjunctivitis, MP

rash

Lymphadenopathy

No ANC, VDRL result

Fever, rash, chancre

Neonatal 3 categoreis:

1. Localized lesion:

skin, eye, mouth,

lesion within 6-9 days

2. Encephalitis:

siezure, hypotonia

within 10-14 days

3. Dissiminated with

multiorgan

involvement: sepsis

Classic triad:

-Sensorineural

hearing loss

-Ocular: cataract,

-CHD: PDA,

pulmonic valve

stenosis

Other:

-Blueberry muffin

Hepatosplenome

galy

-Microcephaly

-Hydrop fetalis

-Persistent rhinitis

-Snuffles

-Rash

-Hepatosplenomegaly

-Anemia

-Jaundice

-Osteochonditis

-Failure to thrive

Hypospadia

• Urethral opening that is on the ventral surface of penile shaft

• >> penoscrotal hypospadia : consider VCUG

10% dilate prostatic utricle

>> 10% boy with hypospadia : undescendedtestis, inguinal hernia

newborn nt ปี 5

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