Neonatal Medicine
--Introduction
Xiaoping Luo,MD
Professor and Chairman
Department of Pediatrics,Tongji Hospital
Director,Center for the Diagnosis of Genetic Metabolic Diseases
Tongji Medical College
Huazhong University of Science and Technology
Adjunct Professor
Department of Paediatrics
Faculty of Medicine
University of Toronto
Toronto,Canada
Historical Perspectives
?Early History of Care of Infants (1900~
- small infants were not expected to live
- temperature,hot-water bottles,heated cribs
- feeding,tube feeding,diluted cow milk
- separated facilities,isolation,washing hands
- hyaline membrane diseases---respiratory distress syndrome
- 1940s,modernized incubator,more oxygen
- 1940s,retrolental fibroplasia
- 1945,,The Physiology of the Newborn Infant,--C,Smith
Historical Perspectives
?Rapid Advances in Neonatal Care (1955~1970)
- 1959,surfactant deficiency,Avery ME,Mead J,Am J Dis Child
- 1960,,Disease of the Newborn,-Neonatology -A,Schaffer
- culture,blood counts,urinalyses,radiographs,biopsies
- milk formulas,breast milk bank
- iv glucose & bicarbonate
- blood gas analysis
- improved incubators
- early attempts of mechanical ventilation
Historical Perspectives
?Emergence of neonatal Intensive Care (1971~1989)
- 1971,continuous positive airway pressure (CPAP) --Gregory
- neonatal intensive care unit (NICU)
- designated by level according to the intensity of service
I,normal birthing and NB care,
II,common obstetric complications & intermediate NB care
III,high risk maternal care and NICU
- transferring of high risk infants or mothers
- high risk and long term outcome
- 1980s,extracorporeal membrane oxygenation (ECMO)
Historical Perspectives
?Expansion of Clinical Trials to Assess Therapy:
the Surfactant Era (1980~1996)
- 1970s~1990s,glucocorticoids to accelerate lung maturation
- 1980,first surfactant replacement therapy in humans
- total parenteral nutrition (TPN)
- high frequency oscillators
- inhaled nitric oxide
- prenatal diagnosis and genetic counseling
- prospective,controlled clinical trials for intervention
-,quiet premature nursery” to,a bustling space station”
Le Tour d’abandon
(Decertion Tower)
Century of Progress International Exposition
Chicago World's Fair,Chicago,Illinois
The Dionne quintuplets
May 28,1934,
13 pounds 6 ounces,
All together!
Emelie,Cecile,Marie,Annette,Yvonne
Julius 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,pathophysiology and management
?Early Neonate refers to the first 7 completed days of life.
?Late Neonate refers to a period between 8 to 28 days of life.
? Perinatal period extends from the 28th completed week of
pregnancy to the 7th day of life,Perinatology or Perinatal Medicine
Definitions of Terms
? Term defines births that occur from 37th to less than 42 completed
weeks,measured from the day of onset of the last normal menstrual
period (259~293 days,with an average of 280 days),
? Preterm is defined as less than 37 completed weeks’,or 259 days,
gestation,(37weeks of gestation ≈birth weight of 3000g)
? Post-term refers to births that occurs at 42 or more completed
weeks (294 days).
? Stillbirth and Fetal Death,
Early fetal death occurs at < 20 completed weeks of gestation,
intermediate fetal death occurs >20 and < 28 completed weeks,
late fetal death occurs after 28weeks,or termed as stillbirth.
?Live Birth,WHO defines live birth as
The complete expulsion or extraction from its 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 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);
<1000g --- Extremely Low Birth Weight (ELBW);
>4000g --- Fetal Macrosomia
(Beckwith-Wiedemann syndrome
Infant of Diabetic Mother,IDM)
Definitions of Terms
?Birth Weight vs Gestational Age (GA)
BW <the 10th percentile --- small for gestational age (SGA)
intrauterine growth restriction (IUGR)
10 ~ 90th percentile --- appropriate for gestational age (AGA)
>the 90th percentile --- large for gestational age (LGA)
ponderal index = BW(g)X100/Length3 (cm3) (>2~2.2)
Length/Head Circumference (HC) (>1.36)
symmetric or unsymmetric SGA
Definitions of Terms
Birthweight Curves
California male singleton Caucasian non-Hispanic birthweights
by 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
?10~20% of pregnant patient can be identified as
high risk
?~50% of all perinatal mortality and morbidity is
associated with high risk pregnancy
High 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 presentation,
meconium-stained fluid,nuchal cord,Cesarean section,forceps
low Apgar score,BW<2500 or >4000,SGA or LGA,congenital
malformation,tachypnea,cyanosis,pallor,plethora,petechiae
High Risk Infant
?Fetal Growth and Maturity
embryonic period (1~8 wks),early embryogenesis
fetal period (9 wks~birth),growth and maturation
?Factors Affecting Fetal Growth
genetic,geographic,social and economic factors
maternal conditions,stature,age,disease and medication
fetal,sex,multiple pregnancy,genetic disease,infection
?Fetal Monitoring
maternal serum,chorion villi,amniotic fluid,placenta,
fetal heart rate,ultrasound,blood gas and pH
Fetal Growth and Monitoring
?Physical Criteria
Skin Lanugo hair
Plantar surface Breast
Hair Finger nail
Ear/Eye Genitals
?Neuromuscular Criteria
Posture Square window (wrist)
Arm recoil Popliteal angle
Scarf sign Heel to ear
New Ballard Score (NBS) for Maturity Rating
Ballard JL,et al,J Pediatr 1991; 119:417
Physical and Neuromuscular
Criteria for Maturity
Dubowitz/Ballard Exam
for Gestational Age
? Sucking
? Palmar grasp
? Response to traction
? Moro reflex
? Crossed extension
? Automatic walking
? Roof reflex
? Pupillary response
Neurological Reflexes
? Body temperature
heat loss by evaporation,radiation and convection
? Neutral thermal enviroment
The 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 temperature vs central or core temperature (rectal)
?Re-warming a hypothermic infant at moderate rate (2~4hrs)
?Thermal regulation
Physiological Characteristics
? Cardiopulmonary Function
heart rate,120~130bpm
tachycardia/bradycardia; transition from FC
blood pressure,65~95/30~60mmHg,
lower in preterm,PDA in preterm
lung fluid,30~35ml/kg
“excretion/re-absorption”,“wet lung”
respiratory rate,60~80/min in the 1st hour,40/min after
brief pauses in respiration (<5~9’s)
apnea (>20’s,with bradycardia <100bpm)
Physiological Characteristics
?Gastrointestinal Function
vomiting and abdominal distension
swallowed maternal blood,GI malformation,infection
first feeding
nutritional issues,tracheo-esophageal fistula,jaundice
passage of meconium
70% within 12h,25% in 12~24h,5% by 48h
distal intestinal obstruction,meconium plug syndrome,
Hirschsprung’s disease,sepsis,hypothyroidism,nacortic
necrotizing enterocolitis (NEC)
premature,hypoxia and ischemia,infection,feeding
Physiological Characteristics
? Urinary Function
urinate
68% within 12h,25% in 12~24h,7% by 48h
pre-renal causes,dehydration,shock
renal abnormality,renal agenesis,tubular necrosis
obstruction of urinary outflow,urethral valves
late onset metabolic acidosis in premature infant
cow milk feeding with high protein load
Physiological Characteristics
? Hematological System
hemoglobin,cord blood 170g/L,change with age
Fetal hemoglobin,HbF 70%,HbA 30%
WBC:15~20X109/L for term baby
6~8X109/L for preterm baby
Platelet,150~250X 109/L
Blood volume,50~100ml/kg for term baby
89~105ml/kg for preterm baby
Physiological Characteristics
? Neurological System
brain,300~400g,10~20% of body weight (adult 2%)
head circumference:33~34cm,increase by ~1cm/month
spinal cord,ends at L3~4,caution for lumbar puncture
physiological reflexes,rooting,sucking,grasp,Moro
Pathological reflexes,Kernig,Babinski,Chvostek sign
Physiological Characteristics
?Immunological System -- immaturity
skin and mucous membrane
complements and chemokine
T cell function
Immunoglubulins
Physiological Characteristics
?Fluid requirement (ml/kg)
BW (kg) Day 1 Day 2 Day 3~7
<1.0 70~100 100~120 120~180
1.0~1.5 70~100 100~120 120~180
1.5~2.5 60~80 80~100 110~140
>2.5 60~80 80~100 100~140
Physiological Characteristics
? Apgar score
? Maintenance of body heat
? Antiseptic skin and cord care
? Eyes protection
? Respiratory management
Routine Care
? Feeding
? Vitamin K1
? Vaccination
? Neonatal screening
? Parent-infant bonding
? Mechanical ventilation
? Cardiopulmonary Disorder
? Post surgery (<24h)
? GA<30,VLBWI
? TPN
?Sustained convulsion
?Central tubing
Neonatal Intensive Care Unit
(NICU)
? Heart
? Respiration
? Blood pressure
? Body temperature
? Blood Gas
?Biochemistry
?Imaging
Tongji Hospital
Thanks for
learning,Doc!
--Introduction
Xiaoping Luo,MD
Professor and Chairman
Department of Pediatrics,Tongji Hospital
Director,Center for the Diagnosis of Genetic Metabolic Diseases
Tongji Medical College
Huazhong University of Science and Technology
Adjunct Professor
Department of Paediatrics
Faculty of Medicine
University of Toronto
Toronto,Canada
Historical Perspectives
?Early History of Care of Infants (1900~
- small infants were not expected to live
- temperature,hot-water bottles,heated cribs
- feeding,tube feeding,diluted cow milk
- separated facilities,isolation,washing hands
- hyaline membrane diseases---respiratory distress syndrome
- 1940s,modernized incubator,more oxygen
- 1940s,retrolental fibroplasia
- 1945,,The Physiology of the Newborn Infant,--C,Smith
Historical Perspectives
?Rapid Advances in Neonatal Care (1955~1970)
- 1959,surfactant deficiency,Avery ME,Mead J,Am J Dis Child
- 1960,,Disease of the Newborn,-Neonatology -A,Schaffer
- culture,blood counts,urinalyses,radiographs,biopsies
- milk formulas,breast milk bank
- iv glucose & bicarbonate
- blood gas analysis
- improved incubators
- early attempts of mechanical ventilation
Historical Perspectives
?Emergence of neonatal Intensive Care (1971~1989)
- 1971,continuous positive airway pressure (CPAP) --Gregory
- neonatal intensive care unit (NICU)
- designated by level according to the intensity of service
I,normal birthing and NB care,
II,common obstetric complications & intermediate NB care
III,high risk maternal care and NICU
- transferring of high risk infants or mothers
- high risk and long term outcome
- 1980s,extracorporeal membrane oxygenation (ECMO)
Historical Perspectives
?Expansion of Clinical Trials to Assess Therapy:
the Surfactant Era (1980~1996)
- 1970s~1990s,glucocorticoids to accelerate lung maturation
- 1980,first surfactant replacement therapy in humans
- total parenteral nutrition (TPN)
- high frequency oscillators
- inhaled nitric oxide
- prenatal diagnosis and genetic counseling
- prospective,controlled clinical trials for intervention
-,quiet premature nursery” to,a bustling space station”
Le Tour d’abandon
(Decertion Tower)
Century of Progress International Exposition
Chicago World's Fair,Chicago,Illinois
The Dionne quintuplets
May 28,1934,
13 pounds 6 ounces,
All together!
Emelie,Cecile,Marie,Annette,Yvonne
Julius 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,pathophysiology and management
?Early Neonate refers to the first 7 completed days of life.
?Late Neonate refers to a period between 8 to 28 days of life.
? Perinatal period extends from the 28th completed week of
pregnancy to the 7th day of life,Perinatology or Perinatal Medicine
Definitions of Terms
? Term defines births that occur from 37th to less than 42 completed
weeks,measured from the day of onset of the last normal menstrual
period (259~293 days,with an average of 280 days),
? Preterm is defined as less than 37 completed weeks’,or 259 days,
gestation,(37weeks of gestation ≈birth weight of 3000g)
? Post-term refers to births that occurs at 42 or more completed
weeks (294 days).
? Stillbirth and Fetal Death,
Early fetal death occurs at < 20 completed weeks of gestation,
intermediate fetal death occurs >20 and < 28 completed weeks,
late fetal death occurs after 28weeks,or termed as stillbirth.
?Live Birth,WHO defines live birth as
The complete expulsion or extraction from its 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 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);
<1000g --- Extremely Low Birth Weight (ELBW);
>4000g --- Fetal Macrosomia
(Beckwith-Wiedemann syndrome
Infant of Diabetic Mother,IDM)
Definitions of Terms
?Birth Weight vs Gestational Age (GA)
BW <the 10th percentile --- small for gestational age (SGA)
intrauterine growth restriction (IUGR)
10 ~ 90th percentile --- appropriate for gestational age (AGA)
>the 90th percentile --- large for gestational age (LGA)
ponderal index = BW(g)X100/Length3 (cm3) (>2~2.2)
Length/Head Circumference (HC) (>1.36)
symmetric or unsymmetric SGA
Definitions of Terms
Birthweight Curves
California male singleton Caucasian non-Hispanic birthweights
by 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
?10~20% of pregnant patient can be identified as
high risk
?~50% of all perinatal mortality and morbidity is
associated with high risk pregnancy
High 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 presentation,
meconium-stained fluid,nuchal cord,Cesarean section,forceps
low Apgar score,BW<2500 or >4000,SGA or LGA,congenital
malformation,tachypnea,cyanosis,pallor,plethora,petechiae
High Risk Infant
?Fetal Growth and Maturity
embryonic period (1~8 wks),early embryogenesis
fetal period (9 wks~birth),growth and maturation
?Factors Affecting Fetal Growth
genetic,geographic,social and economic factors
maternal conditions,stature,age,disease and medication
fetal,sex,multiple pregnancy,genetic disease,infection
?Fetal Monitoring
maternal serum,chorion villi,amniotic fluid,placenta,
fetal heart rate,ultrasound,blood gas and pH
Fetal Growth and Monitoring
?Physical Criteria
Skin Lanugo hair
Plantar surface Breast
Hair Finger nail
Ear/Eye Genitals
?Neuromuscular Criteria
Posture Square window (wrist)
Arm recoil Popliteal angle
Scarf sign Heel to ear
New Ballard Score (NBS) for Maturity Rating
Ballard JL,et al,J Pediatr 1991; 119:417
Physical and Neuromuscular
Criteria for Maturity
Dubowitz/Ballard Exam
for Gestational Age
? Sucking
? Palmar grasp
? Response to traction
? Moro reflex
? Crossed extension
? Automatic walking
? Roof reflex
? Pupillary response
Neurological Reflexes
? Body temperature
heat loss by evaporation,radiation and convection
? Neutral thermal enviroment
The 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 temperature vs central or core temperature (rectal)
?Re-warming a hypothermic infant at moderate rate (2~4hrs)
?Thermal regulation
Physiological Characteristics
? Cardiopulmonary Function
heart rate,120~130bpm
tachycardia/bradycardia; transition from FC
blood pressure,65~95/30~60mmHg,
lower in preterm,PDA in preterm
lung fluid,30~35ml/kg
“excretion/re-absorption”,“wet lung”
respiratory rate,60~80/min in the 1st hour,40/min after
brief pauses in respiration (<5~9’s)
apnea (>20’s,with bradycardia <100bpm)
Physiological Characteristics
?Gastrointestinal Function
vomiting and abdominal distension
swallowed maternal blood,GI malformation,infection
first feeding
nutritional issues,tracheo-esophageal fistula,jaundice
passage of meconium
70% within 12h,25% in 12~24h,5% by 48h
distal intestinal obstruction,meconium plug syndrome,
Hirschsprung’s disease,sepsis,hypothyroidism,nacortic
necrotizing enterocolitis (NEC)
premature,hypoxia and ischemia,infection,feeding
Physiological Characteristics
? Urinary Function
urinate
68% within 12h,25% in 12~24h,7% by 48h
pre-renal causes,dehydration,shock
renal abnormality,renal agenesis,tubular necrosis
obstruction of urinary outflow,urethral valves
late onset metabolic acidosis in premature infant
cow milk feeding with high protein load
Physiological Characteristics
? Hematological System
hemoglobin,cord blood 170g/L,change with age
Fetal hemoglobin,HbF 70%,HbA 30%
WBC:15~20X109/L for term baby
6~8X109/L for preterm baby
Platelet,150~250X 109/L
Blood volume,50~100ml/kg for term baby
89~105ml/kg for preterm baby
Physiological Characteristics
? Neurological System
brain,300~400g,10~20% of body weight (adult 2%)
head circumference:33~34cm,increase by ~1cm/month
spinal cord,ends at L3~4,caution for lumbar puncture
physiological reflexes,rooting,sucking,grasp,Moro
Pathological reflexes,Kernig,Babinski,Chvostek sign
Physiological Characteristics
?Immunological System -- immaturity
skin and mucous membrane
complements and chemokine
T cell function
Immunoglubulins
Physiological Characteristics
?Fluid requirement (ml/kg)
BW (kg) Day 1 Day 2 Day 3~7
<1.0 70~100 100~120 120~180
1.0~1.5 70~100 100~120 120~180
1.5~2.5 60~80 80~100 110~140
>2.5 60~80 80~100 100~140
Physiological Characteristics
? Apgar score
? Maintenance of body heat
? Antiseptic skin and cord care
? Eyes protection
? Respiratory management
Routine Care
? Feeding
? Vitamin K1
? Vaccination
? Neonatal screening
? Parent-infant bonding
? Mechanical ventilation
? Cardiopulmonary Disorder
? Post surgery (<24h)
? GA<30,VLBWI
? TPN
?Sustained convulsion
?Central tubing
Neonatal Intensive Care Unit
(NICU)
? Heart
? Respiration
? Blood pressure
? Body temperature
? Blood Gas
?Biochemistry
?Imaging
Tongji Hospital
Thanks for
learning,Doc!
