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ЗмістPrefaceThe book “Neonatology”
Introduction to neonatology
The mode of providing medical care to healthy newborn in the delivery room
Head and scull
Face: location of the eyes, nose, and signs of dismorphy are examined. Oral cavity
External organs of hearing
Genitals and anus
Limbs, the spinal cord, joints
Pathological position of the hands
Rooming-in of mother and newborn
Advantages of breast feeding
Contraindications for breast feeding
Formula of Fincelstein
Vaccination of newborns against Hepatitis B
Screening inspection of newborns for phenylketonuria
Inspection of newborn for inborn hypothyroidism
Discharge of newborn from the hospital
Educational - methodical book
Is recommended by the Ministry of Health of Ukraine as educational - methodical book for the students of higher educational institutions of III-IV accreditation levels
Sumy State University
О.P.Volosovets (professor), V.Е.Мarkevich (professor), І.V.Tarasova (associate professor), А.М.Loboda (associate professor)
E.E.Shunko – doctor of medical sciences, professor
(P.L.Shupik National Medical Academy of Post-Graduate education);
V.V.Berezhnoy – doctor of medical sciences, professor
(P.L.Shupik National Medical Academy of Post-Graduate education)
О.І.Smiyan – doctor of medical sciences, professor
(Sumy State University)
Н 52 Neonatology: educational - methodical book for the students of higher educational institutions of III-IV accreditation levels / О.P. Volosovets, V.Е.Мarkevich, І.V.Tarasova, А.М.Loboda. – Sumy: Sumy State University, 2011. - 214 p.
The manual covers issues of diagnosis and treatment of main physiological and pathological conditions in infants during the neonatal period. It is necessary for students of higher educational institutions of III-IV accreditation levels who learn the academic discipline in English.
Посібник висвітлює питання діагностики та лікування основних фізіологічних та патологічних станів у немовлят протягом неонатального періоду.
Для студентів вищих медичних навчальних закладів ІІІ-IV рівнів акредитації, які опановують навчальну дисципліну англійською мовою.
О.P. Volosovets, V.Е.Мarkevich, І.V.Tarasova, А.М.Loboda, 2011
ISBN 978-966-657-345-5 Sumy State University, 2011
The book “Neonatology” is intended to be a practical bedside reference – not a comprehensive textbook – for problems likely to be encountered in the Newborn Nursery or Newborn Intensive Care Unit by residents, Neonatal-Perinatal Medicine Fellows, family physicians, pediatricians, and neonatologists.
This book aims to provide the reader with a very up-to-date summary of the current concepts and practices in neonatal medicine. The book presents easily read topics set in a unique format which encourages the adoption of a problem-based approach ideal for day-to-day clinical practice.
The readers will find in this manual post-course questions and other helpful information.
We hope you find our book useful in your day-to-day encounters with sick newborn infants and their families.
Neonatology is a young subspecialty of pediatrics that was formed at the beginning of 70s of the XX century.
The main task of neonatology is ensuring life and health of children during neonatal period of 28 days from the moment of birth.
Periods of antenatal and perinatal development:
- Early fetal period – 76-180th day of pregnancy
- Late fetal period – 181-280th day of pregnancy
Gestational age is veritable age of child since the moment of conception.
Subject to gestational age of newborn is divided to:
Full term infant - gestational term - 37-41 weeks.
Premature infant – gestational term is <37 weeks.
Postmature infant – gestational term is >41 weeks.
Basic requirements of caring newborn:
Signs of life-born (1 sign is enough):
GENERAL care of healthy newborns
Modern methods of perinatal care are based on the conception of WHO related to physiological pregnancy management, labor management and physiological care of a baby with limitation of medical interference without clear indications.
100% of newborns are to be primarily estimated.
The main task of primary estimation of newborn infant in the delivery room is to get answers to the following questions:
If the amniotic fluid and/or skin of a newborn are colored with meconium and the newborn is not active, right after the birth intubation of trachea and sanation of the tracheobronchial tracts are conducted. If the child is active (breathing or crying, muscle tonus is satisfactory, heart rate is faster than 100 per minute), the child is put on the stomach of the mother and then medical staff take care of him for the next 15 minutes. If the respiratory disorders are absent, routine medical care is provided.
The main principles of ligation the umbilical cord:
Neonatologist examines a newborn and fills in a newborn’s development card.
A baby and mother are covered with the blanket and transported to the ward of rooming-in; the rules of heat chain are followed.
Even non-fulfilment of one step of heat chain leads to its rupture, overcooling of newborn with the risk of hypoglycemia, metabolic acidosis, infection, respiratory disorders, haemorrhages, convulsions.
Ten steps of heat chain
Routine medical interference
The majority of newborns don’t need routine medical interference. Medical interference has to be well grounded and be performed only in agreement with mother. Before discharge from the hospital the weighing of the baby is obligatory.
Medical care of newborns
The plan of medical examination of newborn infant
If the baby is healthy, the skin is pale pink, smoothy, elastic, on attempt to fold it it’s straightened up in a moment, slightly dry. Pathological changes of the skin are cyanosis, paleness, grey, yellowish color and mottled skin.
On examination the skin of newborn some clinical signs that aren’t considered to be pathologic ones can be observed.
Postmature newborns have dry skin that can be exfoliated, and they don’t need medical care. The presence of edema and palpable lymphatic nodes has to be noted. The symptom of white spot is checked: if the child is healthy, the spot disappears 3 seconds after pressing. Inspection of the umbilical wound and umbilical ring includes estimation of its size, condition of the skin around it, character of the rate of healing.
^ : the shape of the head can be brachycephalic, dolichocephalic. Circumference of the head of full term infant goes to 32-38cm (see figure 1).
It is necessary to estimate the size, borders, consistency for the presence of birth tumor or cephalohematoma (see figure 2).
Examine the sutures and fontanelles carefully (see figure 3). The bones of the skull are separated from one another by membranous tissue spaces called sutures. The area where the major sutures intersect in the anterior and posterior portions of the skull is known as fontanelle.
On palpation, the sutures are felt like ridges and the fontanelles like soft concavities. The anterior fontanelle at birth measures 2cm to 3cm in diameter and usually closes to the end of the 1st year of life. The posterior fontanelle measures 0,5cm to 1cm at birth and usually closes up to 2 months. In full-term newborn posterior fontanelle is usually closed at birth.
^ location of the eyes, nose, and signs of dismorphy are examined.
Oral cavity: the color of the mucous membrane, symmetry of the angle of mouth, integrity of the palate and the upper lip are estimated.
Eyes: presence or absence of the anomaly of the development and haemorrhages into the sclerae, their color, symmetry and size of pupils.
^ : external aucustic meatus, the shape and location of the auricules are inspected.
Nose: examine the shape of the nose.
Neck: the presence or absence of torticollis has to be determined.
Chest: normally has cylindrical shape, the low aperture is extended; the location of the ribs is symmetric, coming to horizontal. Palpate along the clavicle of the newborn noting any lumps, tenderness, or crepitus; these may indicate a fracture. A fracture of the clavicle can occur at complicated delivery.
Lungs: the presence or absence of the retractions of the jugular fossa, intercostal spaces, and xiphoid process during inspiration are taken into consideration. At auscultation there is puerile type of breathing above the total surface of the lungs. The average rate of breathing is 40-50 per minute.
Heart: auscultation of the heart is performed, determining the presence of the tones and extra murmurs. Heart rate is variable; the average is 110-140 per minute.
Stomach: of round shape, participates in breathing, soft, accessible to deep palpation. The low edge of the liver and spleen is detected by palpation. The liver can outcome below the edge of the costal margin for 1-2cm. The edge of the spleen is not palpable normally or palpable under the costal arch.
^ : they must be formed according to feminizing or virilizing type. Phimosis is a physiological sign of boys. Testicles are in scrotum in full-term boys. In full-term girls the large lips of pudendum cover the small lips of pudendum. The presence of anus is detected.
^ : the pulse on the femoral artery is palpated.
^ : the shape of the limbs, the number of fingers on the hands and the number of toes on the feet are examined. Check the absence of displasia of the femoral bones in the coxofemoral joint: during swinging in the coxofemoral joints it is full, the symptom of the “clunk” is absent.
The following photos demonstrate the two major techniques, the first - to check the presence of a posteriorly dislocated hip (see fig.4), and the second - to check for the ability to sublux or dislocate an intact but unstable hip (see fig.5). With a hip dysplasia, you feel a “clunk” as the femoral head which lies posterior to the acetabulum, enters the acetabulum.
The back of newborn is examined for the presence of myelocele and dermal sinus.
Typical signs of full-term newborn: quiet face, original expression of the face. The beginning of the inspection is signed by emotional noisy cry. The motions are redundant and uncoordinated. Physiological hypertonus of the muscles-flexors is characteristic to stipulate the flexor position. The head is easily inclined to the chest, the hands are flexed in the elbow joint and adducted to the lateral surfaces of the chest and the hand is tight into the fist. The legs are flexed in the knee and coxofemoral joints.
Neurological inspection of a newborn requires the following criteria:
Fig.6 Fig.7 Fig.8 Fig.9
Fig.10 Fig.11 Fig.12 Fig.13
- A muscle tone (resistance of muscles to the tension at passive bending and unbending of extremities) can be increased or decreased. Changes of muscle tone cause pathological positions of a newborn.
Pathological positions of newborns:
The position of the “frog” – the hands are inertly streched along the body, the legs are widely moved apart in the coxofemoral joints and easily flexed in the knee joints. For deeply premature infants this position is physiological. In full term children it appears at intracranial hemorrhages, damages of the upper segments of the cervical part of the spinal cord, severe somatic diseases.
Opisthotonus - the head is thrown back, hands are in fists stretched along the body, the legs are straightened in the knee joints, crossed in the low third part of the shin. This position is typical for the purulent meningitis, subarachnoidal hemorrhage and bilirubinic encephalopathy.
At purulent meningitis the head is easily thrown back, the legs are flexed in the knee joints and adducted to the abdomen closely. On attempt to straighten the legs the cry and nervousness appear.
Hemitype: the hand and the leg on one side are in the physiological position, on the other side the limbs are straightened, their muscle tonus is reduced. Paraplegia - reduction of the muscle tonus of the upper or lower limbs is possible. Monotype - decrease of the motion activity and muscle tonus of one limb alongside with physiological position of the healthy limbs.
^ : the symptom of the griffin claw, wristdrop, monkey hand (adduction of the first finger to the palmary surface of the hand with flexor position of the rest fingers).
Pathological position of the feet: bow position (deflection of the foot from the axis of the limb to the medial direction), valgus position (deflection of the foot from the axis of the limb to the lateral direction), calcaneal position, drop foot.
Rooming-in is the staying of mother with her baby in the same room for 24 hours a day since the birth till the discharge from the hospital.
- contact “skin-to-skin” in the delivery room
- transportation of the mother with her baby to the ward
- all the administrations and manipulations should be performed only at presence and in agreement with mother.
Daily care of newborn includes:
Care of the umbilical wound, care of the skin, measuring of the body temperature (2 times a day).
Principles of early breast feeding
|Exem questions in Neonatology|