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Ali Kazaz P2 Pediatrics

The document provides an overview of various pediatric nephrology conditions, including glomerular injuries, nephritic and nephrotic syndromes, and acute renal failure. It details clinical presentations, laboratory findings, and treatment options for these conditions, emphasizing the importance of timely diagnosis and management. Additionally, it discusses complications and differential diagnoses related to renal disorders in children.

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186 views172 pages

Ali Kazaz P2 Pediatrics

The document provides an overview of various pediatric nephrology conditions, including glomerular injuries, nephritic and nephrotic syndromes, and acute renal failure. It details clinical presentations, laboratory findings, and treatment options for these conditions, emphasizing the importance of timely diagnosis and management. Additionally, it discusses complications and differential diagnoses related to renal disorders in children.

Uploaded by

aseels2102
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF or read online on Scribd
DR/ AW Lecturer Of Pediatrics (MD) Scanned with CamScanner Telegram: @AUData_bot’~~ .~~ | | Book Index LAA Nepmecieny \-\o wens aa Saburday \o-20 ey Neonatology riday ~ Sides Wedeesd Hematology “(vis Neurology *\%°, a Rheumatology Endocrinology ~ gree ATNING eal os tad og A 4 aa a hal dy iy od Ma A aly pa al Ag gt Lea Ll gy Ag git IWMsilgs js gull g jill & gion pL_o ll AGRA lel paY) RSGI pian A gle Qube yl very | opie Scanned with CamScanner Glomerular injury can presents in one or more of the following disorders: Bae ay hats nash syndrome 2) Nephrotic syndrome 3) Nephritic- Nephrotic syndrome 4) Renal failure (Acute AKI or Chronic CKD) Disorders result from injury of one or more of the components of renal glomeruti Nephron Anatomy 5 32 = = & a < ey 5 by : Gj =} is oO © Ciinical syndrome characterized by: Renal insufficiency (ARF): 497 Oliguria (<1 mV’ kg/ hour) Yuring, \47 SZotemia (retention of toxins BUN, Creatinine) Colftivertensio) “or its complications: © Heart failure (3Ts Encephalopathy (Convulsions or Coma). Red urine (RBCs > 10 Cells) © Gross (Scen by naked eyes) * Microscopic hematuria (Only under microscopy) 4. Mild edema— Tei: CaRIGPD ((e Then: May also involve hands and feet st _. Scanned with CamScanner ul ata bot p fa Telegram @ ne Swotten ang . Organism:(@-hemoltic Streptococci > «Sites: Pharynx (tonsilitis ) or skin ( Scarlet fever ) Skin Rashes??? Antigen — Abs deposition in renal basement membrane # Due to Antigenic similarity between strep. And renal antigens GFR* glomerular filtration © ==> Oliguria alt and water retention "==> Edema and Hypertension © Activation of the ( Ag- Ab Complex ) by the Complement systehea) © Injury & inflammation of the glomerular basement membrane Scanned with CamScanner “Nephrology Telegram: AU Data BO bn \ © Acute nephritic syndrome: 4 rae A) Nephi icedema: © Site :C1" 5 (Puffiness), then LL ( Dorsum of the foot ) localized © Course: Mild , Acute, become generalized if (HF or nephritic ~ nephrotic syndrome) C8) Oliguria: (ARE or Azotemia ) « Less than ec / kg / hour or 400 cc / day (itemataria — ~ + Red or dark urine (gross hematuria visible to the naked eyes), May be microscopic ©) Hypertension « Caused by : volume overload due to decreased GFR & salt, water retention E. General manifestations: « Fever, vomiting (due to streptococcal infection). « Pallor (due to associated hematuria). oye Hematuria (red urine) Hypertensive heart failure © Compli : Hypertensive heart failure Wiee"t °° i. Auch A. Laboratory: 1. Urine analysis: © Aspect: Concentrated, dark o Contents: Hematuria, mild proteinuria and Red cell casts 2. Blood: ean * Renal function test ; Impaired (increased blood urea and creatinine ) ;C3.(complement) : aie ah amas © CBC: Anemia Is very common = -. =. - Scanned with CamScanner MeP hig, {more specific) BI Imosieat penal utrasourd shows wollen & echogenic kidneys "Inflammation", alee Doct ITS «Germal oieres5e) Complem: =a © From other causes. of Hematuria: drugs (Cyclophosphamide) and renal malignancies, Urinary stones, : Urinary tract ana! natomical defects . fections : Cystitis or Pyelonephritis Urinary tract in Henatogial disease as coagulopathy (Hemophilia) or sickle cell anemia 1. Supportive: « Diet_; Restrict intake off ar Sassi9) andPhosphorus > 2. Specific: & Controlofedema + «Fluid & salt restriction. . Duras as Frusemidel - 2mg / kg ‘Controf of hypertension: ye rae! Oral captopril 1 mg\kg\day or (P . Frusemidel - 2 mg / kg“ Lasix " Hl Control of infection: (P ‘Daily IM injection of penicillin to eradicate any residual throat infection, 3. Complications: © Renal failure + o Dialysis if fluid overload & Correction of acidosis. © Heart failure: & Dopamine not digitalis (Impaired renal function) npalred le Sincere bey; No role for steroid therapy ene rOQNOSs: most cases recover completely, | Renal impairment (CRF) may occur in some cases. Signs of volume overload: Paufly eyes, congested neck veins, basal crepitations, hepatomegaly, heart failure and hyperteasS Scanned with CamScanner Clinlco- laboratory syndrome characterized by : 7, Heavy proteinuria 2. Hypoproteinemia. 3. Generalized ede 40° Hyperlipidemia, « The proteinuria is explained by: @ Glomerular_abnormality (lost negative charges and distorted padocytes) that causes leak and excessive | ing in urine (proteinuria). + The hypoproteinemia is explained by: G Belactivel(atbumen only) or Pon-BaTECHIVSY both albumen_and globulin) = So this leads to serum hypoproteinemia (mainly hypo-albuminemia). «The generalized edema is due to: Cx Hypoproteinemia & low plasma osmoti re” 1} permeability * (2? Increased activity of both(fenin-angiotensin-aldosterone axis, and antidiuretic hormone) «Hyperlipidemia : occurs as a consequence to altered_protein_metabolism »2 Decreased lipid destruction ( lost lipase in urine ) Ge 11 formation by the liver “ lipoproteins " \2 Types: (11 cholesterol, Triglycerides and Lipoproteins) ox | IDIOPATHIC (Ary ) nephrotic Minimal Tesion nephrotic SECONDARY nephrotic syndrome Immune 4\SLE — Henoch Schonlein 1 Purpura { Focal segmental sclerosis "FSGS" (20%) Infections : hepatitis B, HCV & malaria Mesangial proliferation (5%) Diabetes mellitus & Amyloidosis, Lymphoma Drugs: Penicillamine, Gold ‘x Congenital nephrotic syndrome: UD, Presents in the first 3 months of life. Autosomal recessive disease. RCL defect C& Also called finnish type nephrosis with renal failure and High mortality, + Bilateral nephrectomy may be necessary for control, Dialysis then renal transplantation Scanned with CamScanner fo Telegram: @AUData_bot Q It is by far the commonest type of nephrotic drom&75 - 85.95) + Patient: Child between = G years usually male, Male to female ratio (2:1). CT © Idiopathic or may be immune. B Nephrotic edema: ®) Site : 1% eroune the eyes (Puffy lids especially in Morning ) and in lower limbs ———<—— Onset: Me Characters Pitting, soft and Generalized usually Massive. . qa > Weight gain and (Scrotfedema in males, a in females ® Ascites and pleural effusion may appear ‘Generalized Anasarcy) © Mechanism: » Hypoproteinemia: \ow osmotic pressure with fluid extravasation > Hypovolemia: Will stimulate Renin, anti-diuretic hormone "ADH" perenne clrezewomone. 401 Respiratory distress? due to pneumonia, effusion or with marked ascites © GIT: abdominal pain and vomiting "due to gastritis & peritonitis" oa (A. hypertension : no salt and water retention (may be transient, due to rennin and ADH) Fe Bn jematuria : no glomerular injury or immune reaction (only microscopic hematuria) ‘ever: no organisms “Afebrile disease" ( if present suspect complications ??? ) Scanned with CamScanner Nephrology Complications: 1. Ciatections; tthe Major complication***) > Risk factors: ‘Good medium for infections: due to Edema, Effusions & Ascites (Decreased immunity: Lost Igs in urine, TTT with steroids & Immunosuppressive “SBP’ Renal thrombos Gs {ypovolemie shoe) (Muid extravasation and aggressive diuretics) agressive diuretics iyperlipidemig) Vascular complications G “5 Gusele wasting and growth retardation (in corticosteroid dependent patients) Causes of generalized edema ( Cardiac, hepatic, allergic & nutritional) [XRG Causes Mechanisms Features Hepatic Decreased osmotic pressure Hepatomegaly & Jaundice "Albumin" GIT "Protein loosing | Decreased osmotic pressure Chronic diarrhea Enteropathy” “yalbumin" Cardiac Increased venous pressure Cardiomegaly & HF "31" Nutritional Decreased osmotic pressure Kwashiorkor features... “Albumin” Allergic Increased capillary permeability | Itching, rashes + History Renal "Nephritic” Decreased osmotic pressure Mild edema, fever & Hematuria “Albumin” Scanned with CamScanner fa Telegram DAUData_bot Nephrotegy a @) Proteinuria +++, +444 (Frothy urine), usually Sel Tiyoline caste cm to detect proteinuria?? ORAL Q — . 24\h urinary proteins: ¥ 40 mg/m?/hour (Normal:150 mg\24h) ¥ Ormore than 1 gm / m2 / day bumin / Creatinine ratio: (single sample): ¥ Normal ratio 0.2, if > 0.2_- 2. is considered as proteinuria 7 ic > 2 is considered Heavy proteimurla a Blood: R Proteins ;_1 albumin below 2.5 gm% (N: 4.5-5.5gm) Ca: 1] due to albumin loss ( Albumin bound fraction) Cholesterol: 11 above 200 ma%. High Ii ‘typical nephrotic or Non minimal type Renal blepsgi al (OQ) gare EF Age less than one year 1 Y or more than 8 years. 22" Persistent hypertension or Persistent hematuria, 34 Jmpaired renal function (Azotemia), Gore CBlevel. began history of renal disease esence of systemic manifestations as skin rash (SLE??) r° Absent steroid response after 4 - 6 weeks (sterold resistance) Electron microscope: v Retraction & fusion of epithelial cell foot process, ¥ Also decreased |-ve charges on basement membrane Scanned with CamScanner Nephrology JData_bot Ey 1. Diet ; * ttor normal Protein Intake * |{Fat content” hyperlipidemia “ 2. Diuretics (minimize edema) :4-—— s Salt free albumin IV, then followed by frusemide1-2mg? . Obeid. ma ssive diuretics * may precipitate hypovolemic shock sis 2. Specifies A. Induction of remission (daily therapy) -;—__» LS © DosePrednisone )2-tha\kg\day 13 doses\day \orally * Duration ¢4=6 weeks\response to treatment is through improvement of proteimuria) B. Maintenance of remission (alternate day therapy) »3 22) a3 4 * Dose: the’Sdoses given as Ginale bne every ather day with breakfast Duration? 3 months, =~ —{ nd month > Patients who are non-responders to sterolds "RNS": © If sterold dependent : (get relapse of proteinuria during withdrawal) *. Need further evaluation by Renal biopsy (usually non minimal "FSGN") + If thrombosis: give anticoagulants Scanned with CamScanner Telegram: @AUData_bot Nephrology, > Comparison between nephritie “PSGN™ and nephrotic syndromes ) Nephritic (PSGN) Nephrotic syndrome ‘Age > 3 years 2- 6 years Strept. infection Present (+ ASOT) -VE Edema Mild Massive Hypertension + : Hematuria + = Fever + A febrile (Infection if +ve) Renal function & C3 | Impaired -DecreasedC3, Normal Urine analysis Mild proteinuria <1gm RBC cast Heavy proteinuria >2gm Hyaline cast Serum proteins Normal Decreased Serum cholesterol Normal Increased Course Acute No recurrence Remission & Relapses Complications ARF, AHF, Encephalopathy _| Peritonitis & Thrombosis Relapre Recurrence of Edema OR Proteinuria Remission Resolving from Edema AND Proteinuria BOTH Frequent relapse More than 4 relapses per year Steroid dependent Relapse with Tapering or Termination of treatment Sterold resistance No remission after 4 — 6 weeks of treatment Scanned with CamScanner ‘UData_t ’ he ae Eg acute Kidney Injury pean | ; judden reduction (days or weeks) of the renal function (eversible) with inability to maintain normal body chemistry, acid - base and fiuid homeostasis a] LL Aeute Renal Failure (ARF) rine output < 400 cc / m?/ day or less than 1 ml / kg / hour (Neonate) 1, Preenal failure jypoxta)"renal ischemia” * Prolonged renal ischemia (Pre-renal cause) * Glomerular: Glomeniloriephritis (PSGN, SLE, HUS). + Vascular: thrombosis or vasculitis * Congenital: Urinary defects as Posterior urethral valve (PUV) + Acquired: Urinary stones (bilateral) = Functional: Vesico — Ureteric Reflux (VUR) peo (Ad eeteri| PNK aa alas Cee Terese tail) Pa waar us PONSA Ce NC utes eee eccestin) ites se 1 FI Pan OMT La Tce) Nephrotoxicity or Hypofusion Scanned with CamScanner = \WData_bot Nephrotog iy fo Telegram: € Ci YQ (2 = | Risk for renal dysfunction (serum creatinine rises 1,5 initial value) | ES | Injury for the kidney (serum creatinine rises x 2 initial value) ES | Failure of kidney function (serum creatinine rises x 3 initial value) | | bessof kidney function | E__ | End stage renal disease | L— ero @ rey Suggestive of @ specific etiology (diarrhea or drug intake) © Pre-renal: Oliguria + hypotension (Dehydration "dry mouth") * Intrinsic- renal: Oliguria + hypertension + Congested neck veins © Post- renal: Oliguria + full Bladder, Poor urinary stream or pain due to renal stones. D> 2 — i esos Iremic syndrome (HUS) It : AY RUE Zena failure or AKI. Py Femoiytic anemia: fragmented red cells (burr and helmet cells) with increased retics ——————— L3)Thrombocytopenia early in disease (age < 4years) ‘ ie ny" 1. Typical HUS : Secondary to toxins of E, coli & Shigella (history of bloody diarrhea) 2. A Typical HUS: Due to complement system abnormalities (no history of diarrhea) 3. Secondary HUS: Idiopathic or Drug related or post transplantation a a functions: Increased (BUN & Creatinine) «Serum electrolytes: Hyperkalemia, Hyponatremia (Diluted) 4“ ABG: Metabolic acidosis (Low pH & HCO3) @>Renal ultrasound: Kidney size, Obstruction, > Conservative measures: 4) Treatment of oliquria or anuria: ¥ Fluid balance: fluid intake = urine output + insensible water loss 2) Correction of Acidosis: ¥ Give Na HCO3 IV 1 mEq/kg Scanned with CamScanner Sa Nephrology 3) Correction of Hyperkalemia: ae Stop all potassium sources , If no improvement or ECG changes start : Y Stabilize the myocardium: Ca Gluconate 10 %, IV very slowly over 10 minutes v ‘Shift of K intracellular: . Glucose = Insulin infusion . Na HCO3: correct acidosis ¥ Diuretics "Frusemide": increase K excretion outside the body 2 Correction of the cause (carly if possible) + Inpre-renal cause: Rapid volume expansion (IV) by saline or ringer solutions + In post- renal cause: If obstruction, may needs surgical treatment > Dialysis if: ¥ Failure of conservative measures (Oliguria & Volume overload) CHRONIC RENAL FAILURE ( CRF ) Chronic Kidney Disease (CKD) Si + Renal insuticlency (irreversible) due to roaressive bilateral) renal lesion leading to decreased GFR UGE tess han 60 en eminjn? for more than 3 months or (GFR more than 60 ml/min but associated with : © Renal parenchymal damage or tubular disorders © Imaging evidence of rehal damage © Markers of abnormal kidney function (proteinuria or raised BUN & creatinine) * fissessment of GF > Importance; more accurate in diagnosis than elevated BUN and creatinine > Howto measure? (Shwartz formula) * Height (crm) « 0.5 / plasma creatinine (mg/dl) [2 Format Glomerular filtration rate “ GFR “ according to age ; Newborn: 40 — 80 ml/min Infant: 80 — 100 mi\min Older children: 100 - 120 ml / min Scanned with CamScanner JAUData_bot Telegram: BD Infants and young children: Congenital defects: Bilateral renal Hypoplasia. Posterior Uretheral Valve (PUY), . Genetic: Poly cystic kidney disease (PCK) either AR or AD. Neglected (or recurrent) urinary tract infections as Chronic pyelonephritis B Older children: . Glomerular disorders: Glomerulonephritis (lupus nephritis) Obstructive uropathy: Renal stones ( oxalosis ). AM Asymptomatic in early stages 2. Renal function abnormalities" Lab findings - Recurrent infections ?!! \3¢ Anorexia, Chronic vomiting Seas Bleeding tendency) (C6 Anemia (Pallor) 7? Explain? JIC Hypertension (HTN). 8 Failure to thrive (FIT) And short stature * Diagnosis Depend on high index of suspesion because of the nonspecific symptoms Clinical presentation occurs if 60%- 80% of renal function Is lost (late presentation) ° POP EEC Stage | GFR Features: Parenchymal disease present with Normal GER Biochemical abnormalities only No Symptoms .Slocnernce eonormeS No Symptc 90 - 60 60-30 30 - 15 | Clinical features very evident Kidney failure so Renal replacement therapy "RRT” _t <15 ——. Scanned with CamScanner wn] we Clinical features & Biochemical abnormalities “| Nephrology Blood urea (BUN) & creatinine ; persistent elevation. Blood gases (ABG): metabolic acidosis. Blood picture : anemia (Normocytic) Serum electrolytes : |1Ca, {1 PO4 Urine analysis: 2 For blood, protein, pus, casts 2 Urine osmolarity pee o 6. Detect th ¥ Renal ultrasound: 2 Usually small atrophic kidneys (except obstructive uropathy & PCK) ¥ Renal biopsy: > For detection of the cause. . 2 Should be avoided (identical pathology in late cases) so may help in early stages © fits ¥ Proper clinical and laboratory evaluation Y Preserve limb blood vessels | Y Maintain adequate growth rates ¥ Slower the progression Y Screen other family members if possibilities of inherited disorders @ steps: > Conservative treatment « Restrict intake of: > Proteins??, Potassium & phosphorus "Add phosphate binding agents” * Give: © Iron, Ca and active vitamin D supplementation Acidosis : NaHCO3 Anemia _: Erythropoietin Hypertension : Salt / fluid || & Anti-hypertensive drugs Hypocalcemia: Vitamin D & Ca therapy. Proteinuria: ACE Inhibitors as Captopril. ‘Short stature: Growth hormone may be used and balanced adequate diet eeccee Scanned with CamScanner Nephrology fa Telegram UData_bat Infusion Drain Hemodialysis machine = (TL Dialysis solution Catheter > Renal Replacement Therapy (RRT): "2" Chronic Dialysis © Peritoneal dialysis : = Done in pediatrics due to easy route, more physiological. + Catheter: Malfunction, infection (peritonitis), dislocation. ‘+ Abdominal discomfort (impaired appetite) G Hemodialysis ; * More efficient, but difficult vascular access in children. Renal transplantation = Ideal dramatic therapy * Problems: Graft rejection and finding suitable donors. + Scanned with CamScanner “Nephrology Telegram: @AUData_bot an Ea Pec Le * Urinary tract infection’ (UTI) As one of theMost common-hfection * Itis more common in females (except in neonatal and early infancy). * About 3-8 % of girls and 1- 2 % of boys will acquire UTI in childhood Organisms: ~ WCE coli)(commonest-cause-80%) ¥ Proteus and Pseudomones. = Gram +ve: v Streptococcus fecalis & ¥ Staph. Aureus (coagulase negative staph) Source : = Bowel flora or post catheterization Ccins) Routes : —— C2 Ascending spread)-bowel flora entering urethra (more in older children) Hematogenous spread) In neonates “neonatal sepsis * Wiping from back to front after a movement, may force germs $) renal infection ™ Ss Sor Cas} Scanned with CamScanner UData_bot Rephroiogy factor: 1, Congenital or Structural anomalies of the urinary system. 2, Immunodeficiency or prolonged antibiotic treatment. 3. Urinary Catheterization (catheter associated cystitis). 4. Poor perineal hygiene. 5. Stones, Vesicoureteral reflux ( VUR ). & More common in young girls (short urethra with close proximity to anal canal) > 1 ye} 2, More common in males "Uncircumcised" < 1 year (A, Sumptoms depends on the patient age and the infection location B, Newborn § young Infante“) + Temperature instability: Fever or hypothermia * Jaundice — = ~ May be vomiting , irritability & poor feeding * Failure to thrive "FIT" C. Older Children) w\ Syme wal $ . ea ger 1. igh fever, chills 2. Abdominaf (Loin) pain )¥ pain in the back} & Vomiting 3. (Eliperten'sigh( Hematuria) . Sigos e€girs ot wpdor Ao Secondary nocturnal enuresis. ‘2° Supra-puble pain if cystitis is present. Urinary symptoms: dysuria (painful), frequency (frequent) & incontinence (leakage) D. Complications: * Pyelonephritis may produce renal parenchymal scars. "Such scars in infancy and childhood may contribute to: Y Hypertension, Y Renal disease and renal failure later in life, Scanned with CamScanner Me ao Peal Nephrology Telegram: 1) Urine analysis: + For detection o(Pyurla (> 5 WBCs per HPF may be false positive "fever & dehydration” + Hematuria a + Asymptomatic Bacteriuria (may be urinary colonization) DAUData_bot ser) Ho’ collect urine sampl oS Adhesive plastic bag)applied to the perineum after washin j. Only helpful if negative (CSuprapubic aspiration (SPA) : the method of choice In the severely ill infant . 2 Are used as an alternative in some centers. Vv “Midstream sample? In the older, cooperative and toilet trained children, > Fordetection of Bacteriura Jit i: more reliable than analys 5) Bloods * CBC, CRP & Blood culture: ® Done for neonates & young infants with UTI (excl ide * Renal function test : (clude Sepsis) ® To exclude Chronic renal failure (increased urea & Creatininey BY Betect the cowret t * Abdominal US : "an detect renal size, anomalies. ¥ Indications: done if no response to TTT or dribbling of urine LXeiaing or Micturition cysto-urethrogeaphy y Nii tadeteci(Vesicoureterie reflux (V1 Scanned with CamScanner ~ «ieee Bitinats’ vot lanagement of UTI is based on clinical av, ent Ci tecnateses ouaitir: Home management ral antibiotic as amoxicillin or trimethoprim: oxazole. ‘The recommended duration of treatment i 7-10 days. 3. Puelonephritis arenteral antimicrobials (third-generation cephalosporin or aminoglycoside). The initial [Link]-i fter-culture and susceptibility are known s_ A repeat urine culture 24- 48 hours after beginning therapy is required. 7 Crue pyelonephritis is usually treated for 10a ys ) a * Hospital admission. (Given immediately, do not wait for C& S results). Changed according to the result of C&S. 4. General measures: High fluid intake Regular voiding with complete bladder emptying Good perineal hygiene Control the constipation 5. “After one to two months of previous UTI by urine analysis 6. long: term prophylactic therapy * Indications: frequently recurring UTI. Or organic urinary tract anomalies ¢ Trimethoprim-sulfamethoxazole, or first generation cephalosporin may be used 7. Surgical measures: * Surgical correction of VUR may be required in severe cases. Scanned with CamScanner =o [Nephrology aa Telegram: ENURESIS] | ble » Repeated involuntary urination beyond the expected age of bladder control ? ¥ Most children are continent for urine during day hours by the age of 4 year y¥ And obtain bladder control during the day and night by the age of five year = Positive family history in 50 % of cases, Boys are three times more than girls (Genetic role) Ba caer itary Voiding in previously trained child No dry period before Dry period > 6 months before Causes « Maturational delay of CNS + Psychogenic, the commonest cause * Urological anomalies * Organic causes: «+ Ve family & Genetic role Urinary tract infection (UTI) iria (DM) or Chronic renal failure (CRE) 1. According to the time : 1, Mocturnal : Night time bed wetting (more common with good prognosis). 2, Diurnal _: Daytime wetting (less common with poor prognosis) = The most common cause of daytime enuresis in the preschool child © is waiting until the last minute to void urine Coa * Nocturnal enuresis is a common complaint Affecting about : 10 % of children at 5-years 5% of 10 years 2% at 15 years Boys are more frequently affected than girls. j SANK Scanned with CamScanner Inve (eens 1. [Link] sample ; is examined for microscopy (analysis),for infections (Pus) or sugar (DM), 2, An ultrasound : may show bladder pathology 3. An X-ray of the spine : may reveal a vertebral anomaly. 4. An MRI scan : to exclude a non-bony spina/ defect such as tethering of the cord. Treatment is usually not recommended before 6 years of age. * Explain to both (child and parents) that the problem is common and beyond conscious contr 4. Simple measures: During the day hours: Fluid intake Is encouraged to improve bladder capacity. Before sleep _: Fluid restriction & Urination ( complete emptying the bladder ) During sleep —_: Wake the child up to urinate ( don't let bladder to be filled ) At the morning : Rewarding for dry nights "Avoid punishment” . During the day hours: Fluid intake is encouraged to improve bladder capacity. 2. Drug therapy: ‘¢ Anti-cholinergic drugs to increase the bladder capacity © Desmopressin "Antidiuretic hormone (ADH). «Tricyclic Antidepressant drugs 3. Alarm device: Ifthe previous steps failed © Gives a ring at the beginning of wetting so the child wakes up for urination ¢ Takes several weeks to achieve dryness but is effective in most cases. 4. Treatment of organic causes: UTI “ short account “... Scanned with CamScanner Udo bot A. According to the amount : * Gross hematuria: Seen with naked eye as Red , Brown or tea like urine ¢ Microscopic: > 5 RBCs per HPF in freshly voided urine sample, 8. According to the symptoms : * Asymptomatic (Silent) ¢ Symptomatic; Accompanied by other manifestations as edema or fever. Glomerular 1. Acute post streptococcal glomerulonephritis ( PSGN) 2. Recurrent gross hematuria syndrome : ‘© Familial (Idiopathic) hematuria * Alport syndrome (renal failure, nerve deafness, cataract ) 3. Hemolytic uremic syndrome HUS (Hematuria, purpura& ARF) 1, Congenital anomalies : polycystic kidney (PCK) 2. Infections: Cystitis 3. Traumatic injury: renal trauma or Stones. 4, Tumors: Willm's tumor (firm, smooth surface & don’t cross the middle line). 5. Bleeding disorders : Thrombocytopenia, Hemophilia A, Sickle cell nephropathy Y Urine analysis and culture. ¥ Plasma urea , electrolytes, creatinine, calcium, phosphate, albumin. ” Full blood count, clotting screen (PT,PC,PTT), sickle cell screen ESR, ¥ Ultrasound (Kidney and urinary tract) Color Brown, tea or cola like Bright red RBCs shape Dysmorphic Normal RBCs Casts Yes No Proteinuria Yes No Scanned with CamScanner The normal newborn isa baby born ane, + 37- 41weeks gestation & his birth welght > 24 ist 28 days of | O (Reonatal period is the first © During the 1" 5 days he loses up to 10% of his bith weight (Physiological weight loss). © It may be duc to due to fluid loss and relatively scanty milk intake. 1, Heart rate / minute : ‘= 120-160 / min (femoral or apical ) : detected in both lower & upper limbs " Coarctation’ * Pattern: variable (during sleep = 90 while at crying = 180) 2. Respiratory rate/min Cie + 35-45 / min, regular with normal periods of short apnea during sleep {if >60 = Tachypy «Pattern: rapid, shallow and irregular with normal periods of apnea 3. Temperature ‘© Should be kept normal * range 36.5 to 37 C by examining under radiant warmer. A, Blood pressure + Average 70 / 50, better to be measured in both lower & upper limbs “ Coarctation "_— * Measured byDINAMAP} Device for Indirect Non Invasive Automated Mean Arterial Presst’ . Scanned with CamScanner 4, Bones of cranial vault are soft and the sutures are closed by fibrous tissue 2. Fontanols: = ¥ Anterior fontanel: diamond shape. Variable in size (average 3 fin v Posterior fontanely’ closed/or < 0.5 cm (opened in preterm or cretinism). Sof f the scal The covering skin may [Link] & bruising © Crosses the suture Une Dsappea spontaneously aftet 2- 3 days) Cause: prolonged or o! labor. = © DD: cephathematoma?? Firm localized and not crossing suture line. Takes weeks to resolve & Cranial bones: * Craniotabes (soft cranial bones), especially at the parietal bone((Ping bong sensation) * Can be seen also in preterms, hydrocephalus 6. Cradle cap: . * Greasy, crusted layer of sebaceous gland secretions on the scalp orice bluish discoloration of the hands and. pecially-in ‘avironment. are complete in full term babies. In preterm)it is incomplete, ) Scanned with CamScanner Dilla F 4. Color: ‘© Color depends on ¢ of capillary circwlationand___ © Varies betweenffale pink (during sleep) And (onenini)y ae 2. Physiological jaundice: * Noticed (ons ay £0.60 % of ll newboms #_ Reogjgmximum peak tt 1" wesk And fades by the end of 2" wee DDD pathological jaundice”, Appears a1 day, Lass for weeks and liable for complicaticy 3. Lanugo holt: ‘© Fine hair covering the face and body at birth but is gradually lost during the first month, 4. Yernix careora: « Protective whitish cheesy material (Lipid in nature) © Lost gradually within 3-4 days, « Protective to the baby skin from amniotic fluid and prevent the hypothermia after birth | C Nevus simplex (Salmon patch): =e ink macules, formed of distended dermal capillaries" a . ite; face “forehead, upper eye lids, glabella” & neck (“Midline vascular malformation’) o «Fate: disappear spontaneously after 1 year = 2 Nevus flammeus (Port — wine stai — Bab te purple Tesiony may be slightly elevated « Site: face mnilaterab int the region_of the 1 branch of tri . me te Ha cao Surge Webe yma - - - \@ _ Association‘ivascular malformations in the bral reast & Genitals oC May occur irv6ath male and female newiboras—— \A5 Insome babies, itis associated with actual mile secretion) G Itis due to stimulation ary tissue _by(high levels of maternal hormones, + Needs To treatment (only reassuranceand ask the parents not to squeez: Genitalia > Both the scrotum in the male and labia minora in female newborns are relatively large. _¢ The lly descend by the eighth month of fetal life. * In female newborns, a grayish-white mucoid vaginal disc jarge?? * Cause: (shedding due to hormonal threw ee cu Scanned with CamScanner NEONATOLOGY * Normally, the newborn assumes the In-utero position soon after birth * Transient abnormalities : Head: excess moulding with shape deformity “Dolicocephaly” Mandible: Mandibular asymmetry or micro-gnathia with distortion of the chin, Neck: muscle contracture and torticollis (head tilt) Chest : compression (pectus excavatum), Hip : dislocation (common with breech presentation), Limbs: Talipes equines (club hand and club foot) = Causes due to intrauterine position when © Small amount of amniotic fluid (baby may become packed in the uterus ) * — Amniotic fluid hands © Multiple pregnancy (twins, sriplets) or abnormal uterine cavity (septate uterus) (2 SYSTEMIC EXAMINATION : @ Breathing : Abdominal (Diaphragmatic), shallow and periodic " short periods of apnea" «Rate: 30-40 / min. respiratory rate more than 60 Is RD “cardiac or pulmonary disorders” Factors affecting the rate: crying, physical activities and sleep «Apex: 3 or 4 it space, lateral to mid - clavicular line, the heart lies transversely. «Rate; 120-160 / min, extreme variability “with sleep (90) or crying (180)” © Pulse: checked femoral. Bp: as before. «Murmurs: transient murmurs are common, ¢ Contour: flat at birth, Soon becomes distended (may show divarication of recti). © Liver: is palpable for 2 -4 cm. below costal margin in the right MCL. «Umbilical cord: three vessels, slough off between 6 — 10 days. “may fall in 1* 2 days” © Bowel sounds auscultated within two hours, Meconium passed within 24 - 48 hours of bi") Scanned with CamScanner a term 37-41 weeks aol} TC aC aL Cd Bich nei (ig) We S35 37 39 41 of gestation a3 46 Promature [_Term _[Postmaturs) ¢ )Normal birth weight:_> 2,532 (2500 gm) + / Low birth weight: < Scanned with CamScanner Uli ay ¥ The preterm Is the one delivered sal ysis Of gestation regardless the birth weight, 2 Maternal a Fetal urews, M4 G torus : Anomalies "Bicomat ites" genital anomalies | GF Cervix : Incompetent cervix-7ee Le+ infec © Placenta Separation (*) Membranes: Premature ruptured \branes. In the majority of cases, there is no known cause (Idiopathic) or (weal Coon | * General: Hypoactive, with Gad) ands icing) + Skin: Reddish skin covered with excess fine hain(Ganago bait), CD reson: postin anda nd ea 2 Ears: Underdeveloped ear lobule Plable 2) Srewble > Breast bud /Small)not palpable%go ni pol) Scanned with CamScanner GIT * Difficult feeding (poor suckling and swallowing) + immature bowel functions Necrotizing enterocolitis NeCWith intestinal perforation. Respiratory * Hyaline membrane disease RDS (surfactant deficiency). : th suchuckand > 357 * Apnea : immaturity of respiratory center ion pneumonia : weak gag and cough reflexes. And Pneumothorai Chronic lung injury :prolonged ventilation (Broncho-Pulmonary-Dysplasia BPD). Cardiovascular * Patent ductus arteriosug POA)(underdeveloped smooth muscle coat Hematology a WY Ancmiaof prematurity ‘Bleedin}y higher risk of Sepsis "Poor Immune Response” & DIC Metabolic problems: P-— \«fypogiycemia : low glycogen stores cortt\,/fiypocalcaemia t immature parathyroid. / typothermia : decreased subcutaneous fat, large surface area and thin skin. Hyper SiirubTAeRIA immature liver enzymes (Jaundice),) CNS a Intracranial hemorrhage & convulsions (fragile blood vessels). Seater eee g Hypoxic ischemic encephalopathy Periventricular leukomalacia ( softening of brain white matter around ventricles ») Scanned with CamScanner * Chronic maternal diseases: iypertensioh and heart or renal diseases * Fetal factors: Chromosomal abnormality and Congenital infections (early onset TORQ, * Placental factors: infarctions or vascular malformations (nsuffiency) | ara “ Tonge > Wei nd head circumference are all below/10" for gestational age, LE re skin 3 loose, dry/Wrinkded with Titel subcutaneous fat. ars, ee and genitals are maturey/~ luscles : Good muscle tone —_sone tee MeConium aspiratio. Pulmonary hemorthage. Asphyxia 'ypoglycemia (no stores ‘Hypothermia (decreased subcutaneous fat). lyper inemia (polycythemia). ‘Congenital infection TORCH (may be the cause for SGA) and anomalies are common. Scanned with CamScanner (elt CLs «The birth weight is more than the 90" percentile for his calculated gestational age. The LGA could be a full term, a preterm or a post - term. amilial or constitutional_(large parents) jaternal diabetes: Infant of-diabetic. mother (IDM) rythroblastosis fetalis ((Rh Incompatibility) * Hydrops fetalis " © Beckwith- Seemann ee y Beckwith-Wiedemann syndrome ad Weight, length, and head circumference are all above 90” percentile for gestational age. erates )f cases “Hyperinsulinemia" =—_— 2) vaginally: fractures (dlavicle) Gestational Diabetes iopeaeerigin erythroblastosis fetalis), | Ca, Mg (Polycythemiayand Hyperbilirubinemia 4) . “Transient tachyone& TN ( bom by cesarean section) + ROS I (surfactant defieneys insulin gut, 5) © (aor Hypertrophic cardiomyopathy & iptal hypertrop! « = Sacralanomalié 6) Central nervous system: « _jitterness, convulsions, abnormal muscle tone , HIE Scanned with CamScanner fl OTe ele Dg ~ Wy Neonatal Respiratory Distress = Pattern: More rapid, shallower, and less regular (Periods of apnea) * Cause: Lower pulmonary compliance (Stiff lungs) in neonates. + Rate: 35 - 45 breaths/min. + Grades: © Grade (I): Tachypnea & working alae nasal © Grode (II), 1 + Intercostal & Subcostal Retraction © Grade (Ill): 1 & 2 + Expiratory Grunting + Grade (IV): Cyanosis & Coma 1) Pulmonary causes: Lungs: © Respiratory distress syndrome (RDS) ‘* Transient tachypnea of the newborn (TTN) + Aspiration pneumonia (meconium, secretions and milk) (MAS) + Neonatal Pneumonia by streptococcal infection * Broncho-Pulmonary dysplasia (BPD) + Congenital lobar emphysema «Pulmonary hemorrhage. Pulmonary air leak: pneumothorax Diaphragmatic hernia Airways disorders: * Congenital anomalies: Bilateral choanal atresia and trachea-esophageal fistul Chest wall disorders: © Myasthenia gravis (Muscles), thoracic (Bones) dystrophy 2- Extra pulmonary: * Central causes: Hemorrhage or Hypoxia / Asphyxia or Meningitis © Cardiovascular causes: Congenital heart diseases CHD «Drugs: Narcotics Scanned with CamScanner is mainly seen infSeaipewbvors 287 Weck) is ae o Acti e alv thus preventing their collapse during expiration, Formation: in the 1% pathway (22 — 24 week of gestation), and then after (35 weeks) * Surfactant help to | the surface tension inside the alveoli» ~~ Prevent the alveolar collapse during expiration (Proper Compliance) Surfactant secretion is accelerated in: @ Premature rupture of membranes for more than 48 hours. ) Prematu C2) Placental insufficiency C2 Infants to mothers receiving steroids 48 hours prior to delivery. © Infants of hypertensive mothers. Surfactant secretion is delayed ia: GD) Infants of diabetic mothers "IDM"__ C2 Enythroblastosis fetalis " Rh Incompatibility” Babies with Surfactant deficiency : Qu jon * So difficult inflation during inspira High pressure is needed to expand the lungs @ Th ds to: 1d metal Prolongation of there abnormalities results in: TT RD Y Pulmonary vasoconstriction and hypertension "Impaired Perfusion" Y Depression of the myocardial contractility: «Hypotension (BP) & Hypo perfusion (more alveolar damage) * Clinically: Preterm newborn RD" respiratory distress" immediately or shortly after birth imInished air entry. Scanned with CamScanner (areas of collapse’ n (Complete opacification bilateral ) 4 D4) Pa02, and metabo GCE) pH. ¥ CBC, CRP, ESR ; increased if evidence of infections (should be excluded) Y Others: serum electrolytes, glucose, albumen — Sy heart rate, respiratory rate, temperature and blood pressure. * 02 saturation (pulse oxymeter) or ABG * Electrolytes (glucose & calcium), hemoglobin (CBC) © Cardiovascular support: * Tilladequate amount of surfactant is formed (36-48 hours after birth) oe © Proper IV fluids and inotropes uous posit Vr nasal (Nasal CPAP), or via to maintain the alveoli distended. (intermittent v (e.g. incubator care) IV fluids or total parenteral nutrition (TPN) Y Insevere cases via the endotracheal tube 4ml / kg single dose (may be repeé Y Side effects: Expensive , may cause pulmonary hemorrhage Scanned with CamScanner per veh gers ymphate) issures may be seen. ¥ — Supportive: - Oo ‘asl pO2aueeby (nasal prongs or face mask) > Tem, re control 9 "NGT" ta_avoid aspiration or IV fluids + antibiotics oO or the condition is getting worse, WECONIUM ASPIRATION SYNDROME Meconium is the early stools passed by the newborn after birth, before he starts to digest milk (eee cana © Inutero: > Passage of meconium in distressed babies due to placental insufficiency, = * The baby may inhale this meconium in the amniotic fluid =) © Causing blocking of his airways. aa ee Scanned with CamScanner eit Patel and pre-eclampsia = or obstructed delivery Cine) Es Es JOXR may show: if a with flat diaphragm) if * & Airleak : (pneumd-mediastinum or pneumothorax ) 2. Supportive measures: the larynx and the trachea under vision (laryngoscope & ETT) ¥ Oxygen, correction of acidosis, trol body temperature. > Banteay be resttinsoee a ‘ v4 on aire en Henini ae rth, Scanned with CamScanner Group of inherited disorders that can be detected earlier after birth Even before any clinical manifestations, so decreases infants morbidity and mortality These tests, known as neonatal sts, lone by getting a drop of blood from the Gaantsheelon a fiter paper A (TSH and T4) jtaract, MR, HSM and convulsions) sudden pallor, jaundice and red urine) ‘sepsis like picture) « Other disea: 3 ve maple syrup urine disease and Homocystinuria Are still waiting to be included in the neonatal screening «These are a number of reflexes mediated by the spinal cord and brain stem (subcortical level) as the cerebral cortex is still functionally immature ".normally elicited In all newborns «These reflexes gradually disappear at 4 — 6 months after cortical maturation. « Normal reflexes Indicate norma! neurological state. «Persistence of these reflexes after 6 months indicates cortical damage. with a hand supporting shoulders near the infant's ear. underneath the infant. Scanned with CamScanner Won Data be — CEC emnali sedation: narcotics oF anesthesia) | i Z 1 Za» Wieth trauma: intracranial hemorthege. | & pany (birth before 37 weeks)_— Bicssinun)_ Fracture cle (> 6 months) camage of CNS (CP) ov REMe TERS tal retardation (yp) ma ae Grasp teflen: yak (a7 Stimulus : Press finger lightly against the palm (Palmer: grasp) or the sole (Plantar drasp) * Positive response: The infant responds by holding on the stimulating finger tightly ¥ Suckling reflex we" Co Stimulus: Introduce a nipple or finger in'thélinfant’s mouth Wp) Suckling ‘© Absent reflex: CNS depression, narcosis, intracranial hemorrhage aa Stimulus ; Touching thé lips (upper or lower lip at the middle ) or the mouth corners Positive response : The moutli opens & the head turns towards the!sidél6f the stimulus. 1 (yz 7 ] Hewttum Tonic neck reflen t co Set the infant In the supine position: Rapid turn of the head to. + Onthe same (ipsilateral) side of rotation: extension of ten + Onthe other side of rotation: flexion of both arm and leg: om and ea Sigalficonce ea 7 tr smal or per Spinal cord disease, reflex: Cerebral damage et ig reflex Scanned with CamScanner Stepping (walking) reflen: ‘Stimulus: Hold the infant erect with feet sole on a firm surface (touching a table) 2) Spostive tesponse: The baby elevates one mb andl makes stepping movarients| Placing reflen: Stimulus : Hold the infant erect with dorsal surface of feet touching the table edge Posi response : The infant 's feet is elevated and placed on the table. Babinski reflen : ) Scratching the outer aspect of the sole of the feet by a key: \) Response: dorsiflexion of toes or big toe moves upward or fanning (disappears at one year) NB : it is normally present in infants < 1-2 year (after 2Y = UMNL as CP) , deep sleep or coma ———— a eae Blinking and pupillary reflexes: hoe \tfe Blinking reflex: sudden exposure to bright light leads to blinking. Pupillary reflexes: Exposure to bright light (pupillary constriction) 8 While to:dim light (pupiliary dilatation) 79 Both reflexes are present at birth and remain till death. Importance: They are needed for visual and neurological evaluation. Scanned with CamScanner Was Neonatal apn ly, About 10 % of neonates may need some help and < 1 % requires extensive Fesuscty Maintain adequate stable circulation and spontaneous respiration, Prevent or decrease the neonatal morbidity “Brain damage “and mortality, Primary apnea: ¥ Period of initial rapid breathing followed by a period of no breathing ¥ Stimulation of breathing (by warming and drying the baby) will resume respira, Secondary apnea: ¥ Tf apnea and hypoxia continues ¥Bradycardia, hypotension then gets flaccid and apnic (2ry apnea) which is fatal * Pevonnel required: ‘© Normal delivery expected: 2 persons + Expected problems as fetal distress : 3 persons are needed es" HCO3 or Glucose 7 Scanned with CamScanner UG tied tla g + Observation for any problems as meconium in amniotic fluid. * Suctioning of the mouth (first), pharynx and nose to ensure patency of the airways. Anitiol asresrment: Is needed to onrwer S questions: « Is the baby a full term? Ishe breathing or crying? * Does he have a good tone? + Ifthe answer to 3 questions is YES, then no resuscitation is needed. + Ifthe answerto one or more questions is } starts the resuscitation by: @ baby and bythe preheated warmer, ool co gM ncaa and maintain Circulation. > —_——— & Proper position: Put the baby on his back with his neck slightly extended (avoid hyper-extension), + Arolled towel placed under the baby’s shoulders helping neck extension. B suetion: * Start with the mouth, then the nose, (babies are obligatory nasal breathers), * Avoid deep oral suction (vagal stimulation, apnea and bradycardia) | & Reevalvate: * Take less than 30 sec to check respirations and heart rate. If no breathing + heart rate less than 100/min, proceed to (B) B Initiate Breathing + Method: by of 3 ways: self- inflating (Ambo) bag, flow inflating bag and the T-piece © Start ventilation at a rate of 40-60 min. 0 groan aC ra (c Scanned with CamScanner ODay ~ & — «The team leader intubates the trachea then do PPV «Another team member performs chest compressions coordinated with Ppy Bete + Use a cardiac monitor and a pulse oximeter without interrupting the compression, ‘© Compressions are stopped when heart rate is greater than 60 /min, while «PPV stopped only when baby is breathing regularly at a rate of 40-60/min, Site: firm surface Technique: GEES ET P . umbs at the middle of the sternum, while other fingers si Supporting tx ‘© Depth: * press for 1 2 cm depth about 1/3 of the AP diameter of the ches! a Ty «Use the index & middle fingers of one hand for compression, Scanned with CamScanner Endertracheal intubation ETT excess chest s yeconium aspiration” Prolonged ventila , cri ‘or respiratory muscle paralysis Inspection: Bilateral symmetrical chest rise. Mist is seen in the tube . Auscultation: equal breath sound bilaterally. Absent gastric bubbling sounds. Chest X ray to confirm site. If misdirected to right lung it may cause pneumothorax. lay in initiating effective ventilation. Apgarscore O-S SRY U2 Zo[s P mod Exysce (- Score 2 Score 1 Score 0 a Appearance { Pink Extremities blue Pale orblue Putse > 100 bpm <100 bpm No pulse ae Cries and Grimaces or No response to i Grimace pulls away weak cry stimulation { ) pr a | Rainy BE ep | Active movement Arms, legs flexed No movement f Respiration Strong cry Slow, irregular No breathing L Scanned with CamScanner Y Action :tt [HR , Force of contraction , Peripheral resistance (VC) ¥ Route; Endotracheal tube , IV or Intra-cardiac In complete cardiac arrest, ¥ , ¢ Dose : 0.1 - 0,3 ec/kg IV or 0.5- 1 cc/ kg if given through ETT indication : HR below 60 bpm and not increasing after ventilation Volume expanders ¥ Types: Normal Saline (0.9%) or ringer lactate ¥ Indications: if hypotension or hypovolemia increase vascular volume & improve acidosis ¥ Amount: 10 - 20 cc / kg IV. ¥ Narcan: 0.1 ma/kg/dose IV or ETT. It is narcotic antagonist. Y Indications: if ( morphine ) were given to mother ¥ Action: correct acidosis and provides some volume expansion, ¥ Route: IV route, very slowly, as It Is hypertonic Aeonatel Autrition(>) (© oot ess suznstres ang ot bat near, 5 Factors to ensure successful breast feoding for the a: * Frequent milk expression * Apply the kangaroo mother care strategy Scanned with CamScanner «Jaundice: Yellow discoloration of the skin, sclera and mucous membranes «Clinically observed in the newborn infant when serum bilirubin reaches (Zmg/ dl) eID [einwal) 3) Production: «Hemoglobin (in red blood cells) breaking down Into heme and globin. * The Aeme molecules in 1gm hemoglobin yield 35 mg of unconjugated bilirubin. The normal term infant breaks down 0.5 am of hemoglobin every 24 hours 2) Transport: « Unconjugated bilirubin is fat-so/ub/e carried by albumen in the circulation to the liver « This binding prevents it from crossing the blood-brain barrier causing brain injury 3) Uptake and conjugation: © The liver uptakes unconjugated bilirubin transforming It into conjugated bilirubin «This conjugated bilirubin is ivater-so/uble, not injurious to the brain 4) Excretion: * This bilirubin is excreted from the liver through bile into the gut. * Inthe intestine, it is changed into stercobilinogen (responsible for color of the stools) 5) Enterohepatic circulation: * Some of conjugated bilirubin is reabsorbed in blood to reach the liver and adds to the total pool of bilirubin in the liver (entero-hepatic circulation). * All these hepatic functions are impaired in preterm, asphyxiated and hypoglycemic newborn + Direct bilirubin-conjugated with glucuronic acid become water soluble and excreted in stools. +__Indirect bilirubin “Unconjugated” Is Fat soluble and can cross the Blood Brain Barrier Sit So Scanned with CamScanner a Eas wey ANA One ey, RH & ABO Incompatibility (iso-immune) ¥ GE6PD} 1, H. spherocytosis (non immune) pticemia and TORCH ematoma > Eee: defect in uptake & transferase activity 3) Deceased conjugation 2 ye tet Sion Tatras at may be: Y Absent: Crigler — najjar syndrome I (AR) and II (AD) ¥ Unstimulated : Hypothyroidism ¥ Inhibited: Breast milk jaundice:- Causes: Matemal hormones in milk inhibit the hepatic transferase enzyme Bilirubin remains to rise after the 4th day, and may reach >20me/dl by 2 +« Stopping breast milk for few days leads to rapid drop in the bilirubin levels 4) Increased entero-hepatic circulation: © Bowel obstructions: congenital pyloric stenosis or meconium plug * Breast feeding jaundice?? [feniuscted | Gholestasis): neonatal hepatitis, sepsis, TORCH and biliary atresi Ko? This ist Tt occurs in al newborn infants, Causes: 1. Production of bilirubin (High Load): ‘Short life span (90 - 100 days ) and high mass of the fetal RBCS (Polycythemia) * Enterohepatic circulation of bilirubin increased ( — glucuronidase enzyme prese") 2. Uptake of bilirubin by the liver: transient immaturity of Z & Y proteins. 3. Conjugation of bilirubin by the liver: transient immaturity of glucuronyl transferase &°7* Scanned with CamScanner Duration [Treatment l ¥ First day: Hemolytic anemia, TORCH infection and cephalheratoma ¥ After 2"d day: Physiological jaundice, sepsis, polycythemia ; ¥ Prolonged after 2-3 weeks: Cholestasis, Breast milk jaundice, Hypothyroidism & CHPS. ! ¥ Hemolytic anemia, matemaliliness or drug intake. i ¥ Instrumental delivery as forceps or ventose use for hematomas. r: ¥ Yellow-orange (unconjugated) ¥ Deep olive green (cholestasis) ee ¥ Microcephaly or congenital anomalies in TORCH infection ¥ Pallor (hemolytic) and cephalhematoma (firm scalp mass) ¥ Umbllcal infection (omphalitis) or hernia (hypothyroidism). | ¥ Hepatosplenomegaly (HSM) in TORCH infection or septicemia (Lethargy) v Absent Moro & suckling reflexes if Kernicterus occur. Bilirubin ( total and direct) most essential test. Blood grouping ( ABO and RH) for baby and mother Blood count and reticulocytic count to exclude hemolysis * Blood smear for red cell morphology ([Link]) & enzyme assay in G6PD deficiency . for baby and mother * to detect * CRP , ESR and blood culture to detect septicemia + If Conjugated hyperbilirubinemia (Cholestasis): ¥ Radiology: abdominal ultrasonography and radio-nucleotide scanning (HIDA scan) ¥ Liver biopsy in cases of cholestasis (Giant cell hepatitis). Scanned with CamScanner a rain barrier. « Bilirubin induced neurologic dysfunction(BIND) | « Decreased carrier protein (albumin) : hypoprotelnemia and septicemia + Competition with binding sites: displaced bilirubin from albumin by * Drugs (salicylates and synthetic vitamin K) * Free fatty acids: during starvation or hypothermia (secondary to hypoglycemia) * Acute severe hemolysis: heavy bilirubin load foe * Gross picture: Yellow staining of the brain tissues “basal ganglia, cerebellum “ [—damdice ___Feritensa inical manifestations of brain Injury | iirubin moves ices biteubin trom bloodstream trblood ‘nto brain tusve Ee aaa” a : a feeding & High pitched ery orGosaonay) | Intermediate: (sang) misc tne (up to opisthotonus) and Convulsions occur. tabilty «Proper treatment and follow up for any pathological jaundice.. * Exchange transfusion if early may help to decreases the complications. ’ Scanned with CamScanner teps of management of neonatal hyperbilirubinemia: 1, Monitoring : bilirubin level before discharge using Nomogram 2, Others: Phototherapy, Exchange transfusion and Drugs * IVIG & Phenobarbitone” © Light: ¥ Blue, white or Green at certain wave lengt! —) p ¥ From special lamps or fiber optic blanket or Intesive phototherapy "Double or Bilisphere phototherapy" «Action: ¥ Can change bilirubin to “ photo bilirubin * that is not neurotoxic, ¥ These bilirubin isomers (water soluble pigments) can be excreted in the urine. «Distance: the distay y 1. Serum bilirubin levels reach more than 15 mg/ di ( below that necessitate exchange) 2. Before and after doing excffange transfusion ( Complementary step ) 3. Prophylactic therapy: in hemolytic diseases, very low birth weight "LBW" infants " | aa discoloration of the baby, | 1. Depends on : Wave length (450) & distance between bab and light source (45 cm 2, Rate of hemolysis, Amount of skin exposed i : ‘ : 3._Hepatic metabolism (liver maturation) Scanned with CamScanner Yeutelesas Exchange transfusion (| + Reduce the unconjugated bilirubin level, «Remove the sensitized RBCs, + Remove the antibodies and correct anemia. in a healthy full term baby (under phototherapy) jof the newborn to correct anemia and heart fail! rd blood at birth: Hb less than 10 gm or bilirubin more than 5 ma/ di. _22F Bilin rises more than 0.5 = mg) hour © History of kernicterus or severe erythroblastosis in a previous sibling + use O group cross matched with maternal blood O group & Rh —ve. (blood group of baby & Rh of the mothe} & Necrotizing enterocolitis (NEC). HCY & Hypoglycemia, Hypocalcemia, Hye la and Hyperkalemia (1K) Volume overload leading to arrhythmia and heart failure « Death in less than 1 % of cases Drug therapy Dose: 500 - 1000 mg (1 gm) / kg IV over 2- 4 hours. © — Effect: Reduce the need for exchange In patients with iso-immune hemolysis (ABO & Fi © Can increase the bilirubin uptake, conjugation and excretion * Tt makes the baby sleepy and its effect Is delayed for 3-4 days. © Correct the causes: ‘* Infections: Broad spectrum antibiotics + Hemolysis: Blood transfusion Scanned with CamScanner val eIRe Neonatal Apnea — ‘Associated wit 1, Npnea of prematurity: ‘e Immaturity of the respiratory center (brainstem). «The upper airways collapse easily 2 feoondery epnea: * Metabolic disorders: Hypoglycemia, Hypocelcemia and Hypo or hyperthermia, + Maternal drugs (heavy sedation) «Neonatal: Sepsis & Hypoxia (RDS) + Interventions: as deep suction or endotracheal intubation. » Sepsis screen: CBC with differential, CRP, ESR, Cultures “blood, CSF © Cranial US or CT brain: for hemorrhage or hypoxic changes + CXR and echocardiography: if chest infections, pneumothorax or cardiac disorders. * Blood electrolytes: Ca, Mg, Pos, Glucose. Fe Proper Suction for the nose, mouth and airways. * NaHCO3 for correction of acidosis 2. Onygen therapy: v-é eriods o' entilation in severe non responding cases * Maintenance dose: 5 mg / kg/ day once / day (has longer half life and less toxic) 4. Comet the cause: * Sepsis: gives broad spectrum antibiotics Scanned with CamScanner Prase eonatal Convulsions eee... in neurological functions (as consciousness, muscle tone, eye move, + Faron (se : Encephalopathy of unknown etiology «Hemorrhage: Intraventricular, Subdural & Epidural ‘Maternal lupus (SLE) © Hyperviscosity & polycythemia (venous or arterial occlusion) * Acquired Infections: Neonatal meningitis & Bacterial sepsis + Congenital "TORCH" infection: Toxoplasmosis, Rubella, HSV, CMV 4. Metabolic: ‘Hypoglycemia, Hypocaicemia + Hypo or Hypernatremia. + Organic academia (Acidosis, Ketosis, Hypoglycemia and Hyperammonemia) 5. i + Cerebral dysgenesis Or + Neuro-cutaneous disorders as neurofibromatosis 6. Idiopathic: may be in some cases (3 ~ 20 %). 7. Drug related: theophyline, corticosteroids and sedative withdrawal jpward eye gaze or re| Scanned with CamScanner Tica cere AL Jitteriness (benign tremors) which may be due to hypoglycemia or hypocalcaemia characterized by : Symmetrical rapid movements of the hands and feet Increased by hand stretch or noise and decreased by passive flexion(stimulus sensitive) No gaze or eye deviation (Alert ) No EEG changes ( Normal ) No autonomic manifestations are associated with (changes in HR or BP). Benign neonatal sleep myoclonus: Bilateral or unilateral jerking during active sleep * Not stimulus sensitive * Affects mainly upper trunk than lower part Laboratory: + Metabolic screening: blood glucose. Ca, mg, ammonia level & amino acids in urine. + TORCH screening: IgM level. + Sepsis screening: CBC ( leucocytosis ), CRP & ESR ( elevated ). «Lumbar puncture & CSF examination (to exclude meningitis, intracranial hemorrhage) reste Sankar mahbo7 for intracranial hemorrhage especially intraventricular type “ r hemorrhage ': for malformati | | most sensitive imaging method * | uncontrollable cases | 4 Supportive measures ‘es open the airway Biloxygen therapy /@! IV fluids (1* aid measures) | 2 2 aaa . | ¥ Loading dose 20 mg/kg slowly IV over 30 minutes ( The drug of choice in neonates ) ¥ The maintenance dose is § mg/kg/day in two divided doses I.V or oral 2. Others: ¥ Benzodiazepins: Midazolam, Diazepamjor Lorazepam. Clonazepam 3+ Correcting the cause : 1. Treatment of Septicemia and meningitis : by proper antibiotic therapy 2. Correction of : * Hypoglycemia: ghicose 10%, 2 ml /kg IV in a bolus then maintenance © Hypocalcemia _: calcium gluconate 10 % slowly IV Scanned with CamScanner Pes Metabolic Problems in Newborn] Fmt (CONDI? 1, Premature infants more common due to : «Immature heat regularity center + Thin skin with low SC fat & increased surface area 2. Cold environment with inadequate clothing or warming or drying after birth. 3. Septicemia: due to vasomotor instability 1. Earl 2 Lat BEND) Weak suckling , weak ery and ( tachycardia and fachypnee ) + Apathy, refusal of food with (apnea or grunting) + Limbs edema, sclerema (hardening) « GIT: vomiting and abdominal distention + Renal: Oliguria, hyperkalemia and Azotemia 3. Coldness to touch (VC), Cyanosis and Convulsions (Hypoglycemia), 1. Prevention of the heat los In newborn Infaals © Dry and wrap the baby at birth (including head cover) © Use incubators with double wall & optimum humidity with oxygen therapy «Also nurse on mattress 2. Correction of ; hypoglycemia, acidosis and septicemia if present 33 Denon <= Infections, Dehydration, © Skin: warm, flushed or pink initially, then pale la ». (TTT: Fluids & body cooling) ct Scanned with CamScanner

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