Neonatal Medicine Fetal Assessment Gestational Age Pediatrics - PDF document

HIHIM 409 Pediatrics Neonatal Medicine • Fetal Assessment • Gestational Age Pediatrics • –amniocentesis, c ‐ section, inevitable premature delivery delivery • LMP, quickening, first fetal heart tones, Fernando Vega, MD • Physical exam, • Ultrasound HIHIM 409 – 1 st trimester: crown ‐ rump – 2 nd and 3 rd trimester: BPD Neonatal Medicine Neonatal Medicine • Alpha ‐ fetoprotein (AFP) – maternal and fetal • Fetal Growth • IUGR – Anencephaly, spina bifida • Hydrocephalus – Down’s syndrome, Trisomy 13, Turner’s syndrome, • Macrosomia Twins Twins • Fetal well being l ll b i • Lungs • Amniotic fluid: liquid and cellular elements • Fetal movement • Chromosomal abnormalities, f/u on 20 week labs • Non stress test • Percutaneous umbilical blood sampling • Fetal activity is accompanied by a reflex acceleration of fetal heart rate ‐ a reflex present by 32 weeks of gestation Neonatal Medicine Neonatal Medicine • Timing of delivery • Labor and Delivery – Fetal well being – Stages of Labor: – Maternal well being • 1 st ,is from onset of labor to 10 cm dilation • 2 nd ,passage through the birth canal 2 ,passage through the birth canal • 3 rd ,from delivery of baby to passage of placenta – Fetal well being • Fetal heart monitors • Fetal scalp pH Fernando Vega, M.D. 1

HIHIM 409 Pediatrics Neonatal Medicine Neonatal Medicine • Physiologic changes during transition from fetal to neonatal life. – Expansion of lungs – Air exchange Air exchange – Termination of right to left circulatory shunt Neonatal Medicine Neonatal Medicine Resuscitation in the Delivery room: High risk infants that need an experienced resuscitator • Fetal distress: abnormalities in heart rate, scalp pH<7.20 • Thick meconium in amniotic fluid • Prematurity <36wks, postmaturity>42wks • Low BW <2.0kg, high BW >4.5kg Low BW <2 0kg high BW >4 5kg • Detected congenital anomalies Multiple births • • Abn presentation • Cord prolapse • Significant vaginal bleeding • Midforcepts delivery • Prolonged, difficult unusual labor Neonatal Medicine Neonatal Medicine • Respiratory distress APGAR SCORE 0 1 2 • Apgar score <6 at 5 minutes Heart Rate absent <100bpm >100 bpm • Signs of maternal infection Respiratory effort Respiratory effort absent absent slow (irreg) slow (irreg) Good crying Good crying • Prolonged rupture Muscle tone Limp some flexion of Active motion • Foul smelling amniotic fluid extremities Reflex irritability No response Grimace Cough or snz Maternal diabetes, Rh sensitization, PIH, • Color Blue, Paile Pink body, blue All pink extrmities Add up five numbers to get a final score Fernando Vega, M.D. 2

HIHIM 409 Pediatrics Neonatal Medicine Neonatal Medicine • Normal newborn • Caridorespiratory system: color, respiratory rate, heart sounds, rate, pulses • • Abdomen • History: family, maternal, paternal, pregnancy, • GU/Rectum perinatal • Skin • Physical exam Ph i l • Extremities, Spine, Joints Signs of gestational age • Head neck mouth • Neuro Congenital Anomalies • Neuromuscular maturity: Posture.square window,arm Successful Transition to Air breathing recoil, popliteal angle, scarf sign, heel to ear. Impact of labor, delivery • Physical maturity: skin,m lanugo, plantar creases, breast, ear, genitals Signs of infection or metabolic diseases Neonatal Medicine Neonatal Medicine • Problem newborn • • Respiratory Tract Disorders • Respiratory distress • Transition to Pulmonary Respiration • • Congenital heart disease • Apnea • • RDS • RDS Birth trauma • • TTNB • • Orthopedic problems • Meconium apiration • • Pulmonary Hemorrhage • Metabolic problems • Digestive System Disorders Hypoglycemia • • Hyperglycemia • Meconium Ileus in Cystic Fibrosis • Dermatological problems Neonatal Medicine Infant Care • Breast feeding, benefits • Baby bottle tooth decay • Neonatal Necrotizing Enterocolitis • Solids • Jaundice of the Newborn • Formula • Formula • Blood Disorders • Elimination • Anemia • Developmental Milestones • Hemolytic Disease of the Newborn • Day/Night routine • Hemorrhage in the Newborn • Child Abuse Fernando Vega, M.D. 3

HIHIM 409 Pediatrics The Older Older Child Pediatric Infectious Disease • Allergic Disorders • Fever • Allergic Rhinitis • URI’s • Asthma • Otitis Media • Atopic Dermatitis • Gastroenteritis • Urticaria ‐ Angioedema • Pneumonia • Anaphylaxis • Menningitis • Adverse reaction to Foods • Sepsis Pediatric Rheumatology Pediatric Oncology – Leukemia • Juvenile Rheumatoid Arthritis • White cell proliferation in blood – Arthritis may not be evident early in the course of the – Lymphoma disease • White cell tumors – High fevers, rashes, markedly elevated white blood cell – Wilm’s Tumor counts, and anemia = thought to be leukemia or Kawasaki’s • Kidney malignancy • Vasculitis – Neuroblastoma • Malignancy of Sympathetic ganglion cells – Henoch Schoenlein Purpura – Retinoblastoma – Kawasaki’s • Retina malignancy Pediatric Nephrology Pediatric Neurology • UTI’s in children • Seizures in Childhood • Evaluation of Hematuria • Febrile Seizures • Evaluation of Proteinuria • Headaches Fernando Vega, M.D. 4

HIHIM 409 Pediatrics Febrile Seizures Febrile Seizures Criteria: • Febrile seizures are a common cause of convulsions in young children. • A convulsion associated with an elevated temperature greater than 38ºC • They occur in 2 to 4 percent of children younger than five years of age, but the younger than five years of age but the • A child younger than six years of age A hild th i f incidence is as high as 15 percent in some • No central nervous system infection or populations. inflammation • No acute systemic metabolic abnormality that may produce convulsions • No history of previous afebrile seizures Febrile Seizures Febrile Seizures • Simple febrile seizures are the most common • ETIOLOGY AND PATHOGENESIS — Febrile and are characterized by seizures that last less seizures occur in children between the ages of than 15 minutes, have no focal features, and, six months and six years, with the majority if they occur in a series, the total duration is if they occur in a series the total duration is occurring in children between 12 to 18 occurring in children between 12 to 18 less than 30 minutes. months of age. They are often seen as the temperature is increasing rapidly but may • Complex febrile seizures are characterized by develop as the fever is declining. episodes that last more than 15 minutes, have focal features or postictal paresis, and occur in a series with a total duration greater than 30 minutes Febrile Seizures Febrile Seizures • Simple febrile seizures are the most common • The majority of children have their febrile type encountered in children. Generalized seizures on the first day of illness and, in some seizures are mainly clonic, but other forms cases, it is the first manifestation that the child include atonic and tonic spells. include atonic and tonic spells is ill. is ill • Complex febrile seizures (focal features longer • Recurrent febrile seizures do not necessarily than 15 minutes or multiple episodes within occur with the same degree of fever as the 24 hours) are unusual first episode and do not occur every time the child has a fever. • An initial simple febrile seizure may be followed by complex seizures Fernando Vega, M.D. 5

HIHIM 409 Pediatrics Recurring Febrile Seizures Recurring Febrile Seizures • A major factor influencing the recurrence rate • Young age at onset is the age of the infant at the time of the first • History of febrile seizures in a first ‐ degree seizure. relative • The overall recurrence rate is approximately • The overall recurrence rate is approximately • Low degree of fever while in the emergency d f f hil i h 30 to 35 percent department • 50 to 65 percent in children who are younger • Brief duration between the onset of fever and than one year of age at the time of the first the initial seizure seizure to • 20 percent in older children Febrile Status Epilepticus Prolonged febrile seizures in 119 children, aged 1 month through 5 years: • The median duration was 68 minutes • The seizures were convulsive in all but one child • The seizures were continuous in 52 percent and intermittent in 48 percent • Two ‐ thirds of seizures were partial • This was the first febrile seizure in 76 percent of children Fernando Vega, M.D. 6