1、新生儿医学-简介（英文）Historical Perspectives?EarlyHistoryofCareofInfants(1900-smallinfants werenotexpected tolive-temperature: hot-waterbottles, heated cribs-feeding:tubefeeding, diluted cowmilk-separated facilities, isolation, washing hands-hyaline membrane diseases-respiratorydistress syndrome-1940s, moder
2、nized incubator, moreoxygen-1940s, retrolental fibroplasia-1945, ThePhysiology oftheNewborn Infant - C. SmithHistorical Perspectives?RapidAdvances inNeonatal Care(19551970)-1959, surfactant deficiency, Avery ME,MeadJ.AmJDisChild-1960, DiseaseoftheNewborn - Neonatology - A.Schaffer-culture, bloodcoun
3、ts, urinalyses, radiographs, biopsies-milkformulas, breastmilkbank-ivglucose&bicarbonate-bloodgasanalysis-improved incubators-earlyattempts ofmechanical ventilationHistorical Perspectives?Emergence ofneonatal IntensiveCare (19711989)-1971, continuous positive airway pressure (CPAP)- Gregory-neonatal
4、 intensive careunit(NICU)-designated bylevelaccording totheintensity ofserviceI: normal birthing andNBcare,II: common obstetric complications &intermediateNBcareIII: highriskmaternal careandNICU-transferring ofhighriskinfants ormothers-highriskandlongterm outcome-1980s, extracorporeal membrane oxyge
5、nation (ECMO)Historical Perspectives?ExpansionofClinicalTrialstoAssessTherapy:theSurfactant Era (19801996)-1970s1990s,glucocorticoids toaccelerate lungmaturation-1980, firstsurfactant replacement therapy inhumans-totalparenteral nutrition (TPN)-highfrequency oscillators-inhaled nitricoxide-prenatal
6、diagnosis andgenetic counseling-prospective, controlled clinicaltrialsforintervention-“quiet premature nursery” to“a bustling spacestation”Le Tour dabandon(Decertion Tower)Century of Progress International ExpositionChicago Worlds Fair, Chicago, IllinoisThe Dionne quintupletsMay 28, 1934,13 pounds 6
7、 ounces,All together!Emelie, Cecile, Marie, Annette, YvonneJulius Hess“quiet premature nursery”How small is too small?How much is too much?Life support:To continue or discontinue?Definitions of Terms?Newborn or neonate refers to a infant period from birth to 28 days. Neonatology health care, pathoph
8、ysiology and management?Early Neonaterefers to the first 7 completed days of life.?Late Neonaterefers to a period between 8 to 28 days of life.?Perinatal periodextends from the 28thcompleted week of pregnancy to the 7thday of life. Perinatology or Perinatal MedicineDefinitions of Terms?Termdefines b
9、irths that occur from 37thto less than 42 completed weeks, measured from the day of onset of the last normal menstrual period (259293 days, with an average of 280 days). ?Pretermis defined as less than 37 completed weeks, or 259 days, gestation. (37weeks of gestation birth weight of 3000g) ?Post-ter
10、m refers to births that occurs at 42 or more completed weeks (294 days).?Stillbirth and Fetal Death. Early fetal deathoccurs at 20 and 28 completed weeks,late fetal deathoccurs after 28weeks, or termed as stillbirth.?Live Birth. WHO defines live birth asThe complete expulsion or extraction from its
11、mother of a product of conception, irrespective of the duration of pregnancy, which after such separation, breathes or any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, whether or not the umbilical cord has been cut
12、or the placenta is attached; each product of such a birth is considered liveborn. Definitions of Terms?Birth Weight (BW) BW 2500g -Low Birth Weight (LBW);1500g -Very Low Birth Weight (VLBW);4000g -Fetal Macrosomia (Beckwith-Wiedemann syndromeInfant of Diabetic Mother, IDM)Definitions of Terms?Birth
13、Weight vs Gestational Age (GA)BW the 90thpercentile - large for gestational age (LGA)ponderal index = BW(g)X100/Length3(cm3) (22.2)Length/Head Circumference (HC) (1.36)symmetric or unsymmetric SGA Definitions of TermsBirthweight Curves California male singleton Caucasian non-Hispanic birthweights by
14、 gestational age: 10th, 50th, and 90th percentiles.?Pregnancies in which factors exist that increase the likelihood of maternal or fetal diseases?Economic, cultural-behavioral, biologic-genetic, reproductive and medical factors?1020% of pregnant patient can be identified as high risk?50% of all peri
15、natal mortality and morbidity is associated with high risk pregnancyHigh Risk Pregnancy?An infant who should be under close observation by experienced physicians and nurses. ?9% of all births require intensive care?Fetal or neonatal factors:premature labor, postdates, fetal distrass, breech presenta
16、tion, meconium-stained fluid, nuchal cord, Cesarean section, forceps low Apgar score, BW4000, SGA or LGA, congenital malformation, tachypnea, cyanosis, pallor, plethora, petechiaeHigh Risk Infant?Fetal Growth and Maturity embryonic period (18 wks): early embryogenesis fetal period (9 wksbirth): grow
17、th and maturation?Factors Affecting Fetal Growthgenetic, geographic, social and economic factorsmaternal conditions: stature, age, disease and medicationfetal: sex, multiple pregnancy, genetic disease, infection?Fetal Monitoringmaternal serum, chorion villi, amniotic fluid, placenta, fetal heart rat
18、e, ultrasound, blood gas and pH Fetal Growth and Monitoring?Physical CriteriaSkin Lanugo hairPlantar surface BreastHair Finger nailEar/Eye Genitals?Neuromuscular CriteriaPosture Square window (wrist)Arm recoil Popliteal angleScarf sign Heel to earNew Ballard Score (NBS) for Maturity RatingBallard JL
19、, et al, J Pediatr 1991; 119:417Physical and Neuromuscular Criteria for MaturityDubowitz/Ballard Exam for Gestational Age?Sucking?Palmar grasp?Response to traction?Moro reflex?Crossed extension?Automatic walking?Roof reflex?Pupillary responseNeurological Reflexes?Body temperatureheat loss by evapora
20、tion, radiation and convection?Neutral thermal enviromentThe range of ambient temperature and humidity at which heat loss is minimal and metabolic demands and oxygen consumption are the lowest. ?Depends on body weight and age?31 to 34 oC at 50% humidity for undressed normal term infant?Skin temperat
21、ure vs central or core temperature (rectal)?Re-warming a hypothermic infant at moderate rate (24hrs)?Thermal regulationPhysiological Characteristics?Cardiopulmonary Functionheart rate: 120130bpmtachycardia/bradycardia; transition from FCblood pressure: 6595/3060mmHg, lower in preterm, PDA in preterm
22、lung fluid: 3035ml/kg “excretion/re- absorption” , “wet lung”respiratory rate: 6080/min in the 1sthour, 40/min afterbrief pauses in respiration (20s, with bradycardia 100bpm)Physiological Characteristics?Gastrointestinal Functionvomiting and abdominal distensionswallowed maternal blood, GI malformat
23、ion, infectionfirst feedingnutritional issues,tracheo-esophageal fistula, jaundicepassage of meconium 70% within 12h, 25% in 1224h, 5% by 48hdistal intestinal obstruction, meconium plug syndrome,Hirschsprungs disease, sepsis, hypothyroidism, nacorticnecrotizing enterocolitis (NEC) premature, hypoxia
24、 and ischemia, infection, feedingPhysiological Characteristics?Urinary Functionurinate68% within 12h, 25% in 1224h, 7% by 48hpre-renal causes: dehydration, shockrenal abnormality: renal agenesis, tubular necrosisobstruction of urinary outflow: urethral valveslate onset metabolic acidosis in prematur
25、e infantcow milk feeding with high protein loadPhysiological Characteristics?Hematological Systemhemoglobin: cord blood 170g/L, change with ageFetal hemoglobin: HbF 70%, HbA 30%WBC:1520X109/L for term baby68X109/L for preterm babyPlatelet: 150250X 109/LBlood volume: 50100ml/kg for term baby89105ml/k
26、g for preterm babyPhysiological Characteristics?Neurological Systembrain: 300400g,1020% of body weight (adult 2%)head circumference:3334cm, increase by 1cm/monthspinal cord: ends at L34, caution for lumbar puncture physiological reflexes: rooting, sucking, grasp, MoroPathological reflexes:Kernig, Ba
27、binski, Chvostek signPhysiological Characteristics?Immunological System -immaturityskin and mucous membrane complements and chemokine T cell function ImmunoglubulinsPhysiological Characteristics?Fluid requirement (ml/kg)BW (kg) Day 1 Day 2 Day 372.5 6080 80100 100140Physiological Characteristics?Apg
28、ar score?Maintenance of body heat?Antiseptic skin and cord care?Eyes protection?Respiratory managementRoutine Care?Feeding ?Vitamin K1?Vaccination?Neonatal screening ?Parent-infant bonding?Mechanical ventilation?Cardiopulmonary Disorder?Post surgery (24h)?GA30, VLBWI?TPN?Sustained convulsion?Central tubing Neonatal Intensive Care Unit(NICU)?Heart?Respiration?Blood pressure?Body temperature?Blood Gas?Biochemistry?Imaging Tongji HospitalThanks for learning, Doc!
