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Classification of Newborn,

Prematurity, Thermoregulation
Amanuel Hadgu
pediatrician
Classification of newborns
Based on GA
term 37 t0 42 weeks
Preterm <37 completed weeks
Post term > 42 completed weeks or 294 days

Based on BWT
Normal >/=2500 and <4000 gram
Macrosomic >/= 4000 g
LBW >/=1500 and < 2500 g
VLBW >/= 1000, < 1500 g
EVLBW< 1000 g
Based on both BWT and GA with lebchenko
chart
AGA b/n 10-90%
LGA>90%
SGA <10%
o Symetric SGA
o Asymmetric SGA
Prematurity
Live born infants delivered before 37wk from
the first day of LNMP
Different degrees of prematurity are defined
by gestational age (GA) or birth weight
Classification of prematurity
Based on BW Based on GA
olate preterm birth
o LBW (<2500gm) (34-37 wks
o VLBW (<1500gm) oModerate preterm: 32
o ELBW (<1000gm) to <34 weeks
overy preterm birth
(28-32 wks)
oextremely preterm
birth (< 28 wks)
Epidemiology
Each year 15 million babies are born preterm!
95% preterm births are in developing countries
Most premature babies (>80%) are born
between 32 and 37 weeks of gestation
About 10% of preterm babies are born 28 to <32
weeks gestation.
App. 70 % of preterm deliveries occur
spontaneously as a result of
preterm labor ( 45%) or
preterm premature rupture of membranes (25%)
Estimated Causes of Neonatal Deaths in Ethiopia
Congenital, 6 % Diarrhoea, 1 % Other, 4 %

Severe infection,
24 %
Intrapartum
related, 28%

Preterm birth
complications
37%

Source: Liu L. et al. 2012. Global, regional, and national causes of child mortality in 20002010: an updated systematic
analysis. The Lancet. doi:10.1016/S0140-6736(12)60560-1.)
Three causes (preterm complications, intrapartum related, & severe infection) account for 89%
of all newborn deaths
Pathogenesis
Four primary processes:
Premature activation of the maternal or fetal
hypothalamic-pituitary-adrenal axis
Exaggerated inflammatory response/infection
Decidual hemorrhage
Pathological uterine distension
Causes of preterm birth
Fetal Placental
fetal distress placental dysfuction
multiple gestation placenta previa
erythroblastosis abruptio placentae
Nonimmune hydrops

Uterine Maternal
bicornuate uterus infection
incompetent cervix (premature preeclampsia
dilatation) chronic medical illness

Other
PROM
polyhydraminos
iatrogenic
trauma
Risk factors
Stress
Single women
Low socioeconomic status
Anxiety Depression
Life events (divorce, separation, death)
Abdominal surgery during pregnancy

Miscellaneous
Previous preterm delivery
Maternal age (<18 or >40)
Poor nutrition and low body mass index
Inadequate prenatal care
Anemia (hemoglobin <10 g/dL)
level of educational achievement
Complications of Premature Infants
Major causes of neonatal mortality in
premature are
complications associated with preterm birth
and LBW
Neonatal infection
Prenatal asphyxia
Complications of prematurity results from
anatomic or functional immaturity
Complications of Premature Infants
Respiratory System Cardiovascular system
RDS (HMD) PDA
BPD Hypotension
Pneumothorax Bradycardia (with apnea)
Congenital pneumonia
Pulmonary hypoplasia
Apnea
Hematology
anemia (early or late onset)
GIT Metabolic
NEC Hypocalcaemia
Hyperbilirubinemia Hypoglycemia
Hyperglycemia
metabolic acidosis
Hypothermia
Renal CNS
hyponatremia IVH
hypernatremia Periventricular leukomalcia
hyperkalemia Seizures
Renal tubular acidosis Retinopathy of prematurity
Renal glycosuria
Edema

Other
GENERAL PRINCIPLES OF PREMATURE BABY CARE

At birth, the routine delivery care such as clear the airway,


initiate breathing, care for the umbilical cord and eyes, and
administer vitamin K are the same for immature infants as for
those of normal weight and maturity.
Maintaining Normal Body Temperature
Oxygen Therapy
Feeding and Fluid Management
Antibiotics & Infection Prevention
Immunization
Assessing Growth
Communication and Emotional Support
Discharge and Follow-Up
1. Maintaining Normal Body T0
There are different methods of
Skin to skin contact (KMC)
Radiant warmer
Incubator
2. KMC

Indication
Moderate hypothermia
No Respiratory distress
Feeding well
Stable NB with BW 1500-
1800g
3.Radiant Warmer

- Works by radiation
Indications
sick babies and babies weighing> 1.5 kg
keep baby warm during P/E, Tx, and
procedures
rewarm a cold baby
4. INCUBATORS
Indications:
wt < 1800gm
isolating infected baby
envtal Temp extremely low
transport patient
INCUBATOR

RADIANT
WARMER
Oxygen therapy
O2 can be given by nasal prong & bag and
mask , CPAP, or MV
Feeding and Fluid Management
Feeding Problems in preterms due to
lack of coordination b/n suckling, swallowing
and breathing
Limited gastric capacity and GI motility
Deficient enzymes
Trophic feeding
stimulate development of the immature
gastrointestinal tract to VLBW preterm
initial trophic feedings
10-20 mL/kg/24 hr of expressed BM every 2-3
hr for 5-10 days.
If the initial feedings are tolerated, the volume
is increased by 20-30 mL/kg/24 hr until a
volume of 150 mL/kg/24 hr has been achieved
Benefits of trophic feeding include
enhanced gut motility,
improved growth,
decreased need for parenteral nutrition,
fewer episodes of sepsis, and
shortened hospital stays.
Fluid management
Fluid needs vary according to gestational age,
environmental conditions, and disease states
Give IV fluid only if
Infant <1500g in 1st 24 hrs
severe asphyxia, RD, Szs, hypoglycemia, dehydration.
Fluid intake in term infants 60-70 mL/kg on day 1
and increased to 100-120 mL/kg by days 2-3.
premature infants may need to start with 70-80
mL/kg on day 1 and advance gradually to 150
mL/kg/day.
CHOICE OF IV FLUID

Give 10% glucose for the 1st day


After 2nd day with 1/3 NS+ 10% dextrose
After 2nd day - Electrolytes- Ca, vit D, iron
We should MONITOR babies receiving IV
fluid

vital sign
Inspect the infusion site Q hr
RBS Q 6hrs
Document UOP & Wight daily
Infection Px & Antibiotics
Provide routine care of the newborn baby.
choice begins empirically with the selection of
the drug(s) that is most likely to be effective
against most MO
First line- Ampcillin and gentamycin
Second line Ceftriaxone and gentamycin
Others ( Prevention of infection)
Consider every person (including the baby and staff) as
potentially infectious.

Wash hands or use an alcohol-based hand rub.

Wear protective clothing and gloves.

Handle sharp instruments carefully, and clean and, if necessary,


sterilize or disinfect instruments and equipment.

Routinely clean the newborn special care unit, and dispose of


waste.

Avoid overcrowding and understaffing.

Isolate babies with infections to prevent nosocomial infections.


Assessing Growth
The most commonly used method for
monitoring and assessing growth is weight
gain.
A newborn's weight may decrease 10% below
birth weight in the 1st wk.
Infants regain or exceed birth weight by 2 wk of
age and
grow at approximately 30 g /day during the 1st
mo.
This is the period of fastest postnatal growth.
Catch up growth
The weight by 24 mo
height by 40 mo
head circumference by 18 months.
The average rate of head growth in a healthy
premature infant is
0.5 cm in the 1st 2 wk,
0.75 cm in the 3rd wk, and
1.0 cm in the 4th wk and every week thereafter
until the 40th wk of development
Discharge and Follow-up
parents have received appropriate training and
education.
premature infant should be taking all nutrition by
nipple, either bottle or breast
Growth should be occurring at steady increments
of approximately 1030 g/24 hr.
Temp should be stabilized for 3 consecutive days.
no recent episodes of apnea or bradycardia,
IV drug should be discontinued or converted to
oral dosing.
Target weight should be 1800-2100g
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Prognosis
Infants born weighing 1,501-2,500 g have a
95% or greater chance of survival, but those
weighing still less have significantly higher
mortality.
The greater the immaturity and the lower the
birthweight, the greater the likelihood of
intellectual and neurodevelopmental
impairment (mental retardation, cerebral
palsy, blindness, deafness).
Follow up of preterm infants

eye examination to screen for retinopathy of


prematurity.
hearing screening
blood pressure for renal vascular hypertension.
hemoglobin level or hematocrit
feeding condition
anthropometry
assess for complications such as BPD, IVH, short
bowel syndrome, rickets , anemia, apenia etc.
NEONATAL THERMOREGULATION
Thermo neutral environment - is narrow range of
environmental temperature at which a neonate
can maintain normal body temperature with
minimal oxygen and fuel consumption.
Temperature control of the environment is
essential part of neonatal care.
Both cold and excessive heat increase risk of
mortality and morbidity.
Fetus in utero has slightly higher temperature than
the mother.

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Neonates have high surface area to volume ratio ,so
heat loss is much higher.
After birth , the skin and core temperature of the
baby fall by 0.1 and 0.3c/min respectively .Which is
equivalent to heat loss of 200kcal/kg body
weight/minute

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Mechanism of heat production
1. Muscular activity (shivering) not significant source in
neonates.
2. Metabolic thermo genesis- main source.
The optimal function of heat generating system is
dependent up on the integrity of
CNS thermo regulation system
adequacy of brown fat
availability of glucose and oxygen

Brown fat is located on the nape, nake, interscapular area,


axila, groin, around the kidneys and adrenals.

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Mechanisms of heat loss
1. Convection-is loss of heat to moving air
2. Conduction-is loss of heat through contact
3. Radiation-is loss from neonate to a colder object
at a distance
4. Evaporation-is major source of heat loss in the
newborn.

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Picture illustrating physical
mechanisms of heat lose

Federal Democratic Republic of Ethiopia 41


HYPOTHERMIA
Definition:
Skin temperature of <36.5 and
core temperature of <35.5
Normal axilary temp. - 36.5 to 37.5c
Stages of hypothermia
36-36.4 c (96.8-97.5f)
-Mild hypothermia (cold stress)
32-35.9 c (89.6-96.6f)
-Moderate hypothermia
<32 c (89.6f)
-Severe hypothermia (neonatal cold injury)
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CAUSES
1. External factors- cold envt,naked baby
2. Poor ability to conserve heat - large surface area, poor
insulation, paucity of fat.
3. Poor metabolic heat production
A. Low brown fat- preterm ,SGA
B.CNS- infection ,damage due to anoxia,haemorage
C.Hypoxia
D.Hypoglycemia

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Sign and symptoms of hypothermia
1 peripheral vasoconstriction
Acrocyanosis
cold extrimity
decreased peripheral perfusion
2 CNS depression
Lethargy
Poor feeding
Apnea and bradycardia
3 Increased metabolism
hypoglycemia
hypoxia
metabolic acidosis
4 Increased pulmonary arterial pressure
tachypenia
respiratory distress
Prevention
Warm chain system
System of keeping the baby warm immediately after
birth, in delivery room, post partum ward,
transportation and while nursing the baby at home.
components:
-immediate drying
-warm resuscitation
-skin to skin contact with the mother
-immediate initiation of breast feeding
-bathing and weighing post pond
-appropriate clothing and bedding
-warm transportation.
General management of
hypothermia
Identify and treat causes(disease process and
environmental conditions)
Put the infant on KMC, in incubators or under
radiant warmer.
Warm the new born slowly
0.5 C per hour
Measure the babys temperature every hour.
Once the babys temperature is normal, measure
the temperature every three hours for 12 hours
and then 12 hourly.

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Thank you