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Miss : Kamlah Olaimat 3
Objectives:
1. To discuss Thermoregulation.
2. To discuss Low birth weight and jaundice.
Miss : Kamlah Olaimat 4
Thermoregulation• Is a balance between heat loss and heat gain .
– The main goal is to control the neonates environment in order to maintain a neutral thermal environment .
• Normal temperature of the neonate 36.5 c-37.5c (auxiliary may be .5-1 c lower )
• Hypothermia : temp<36.5c• Hyperthermia: temp>37.5c
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Mechanism of thermogulation
• Heat production result from the release of norepinephrine resulting in the metabolism of brown fat store and the consumption of oxygen and glucose.
• At birth , an immediate fall in body temperature and cold stress occurs .
• Preterm neonate do not have the ability to increase their body temperature by increase metabolic rate and they have much smaller store of brown fat than term neonate .
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Newborn lose heat by four mechanisms:
1- convection: heat flow from newborn to cooler air. 2- radiation: transfer heat from body to cold solid object not in contact with the body. 3- evaporation: conversion of liquid to vapor. 4- conduction: transfer heat from body to cold solid object in contact with the body.
Insulation is not efficient because little fat available.** How newborn conserve heat?From the brown fat that available in the
intrascapular, thorax and perineal area. It found in the mature newborn and produce heat by increasing metabolism.
Temperature
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Heat ProductionThe human body responds to cold in three ways:
1.Voluntary muscular activity (vasoconstriction and increased movement)
2.Shivering (inefficient in the term newborn)
3.Chemical or nonshivering thermogenesis (brown-fat metabolism for several hours after birth)
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Hypothermia
• Condition associated with hypothermia:-
C old environment
Incorrect care of the neonate immediately after birth .
Inadequate drying
Insufficient clothing
Separation from mother
Inadequate warming procedure ( before and during transport)
Diseased and stressed infant
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Hypothermia
• Symptoms and signs :-
Measuring the neonate temperature may not detect early changes of cold stress as the neonate will initially use energy store to maintain central temperature
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Hypothermia
• Initial signs that may be present include:-
o Feet are cold to touch
o Week sucking ability or inability
o Lethargy and week cry.
o Skin color changes from pale and cyanosis to peripheral mottling or plethora
o Tachypnea and tachycardia.
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Later signs
• Lethargy
• Apnea and bradycardia.
• There is a high risk for hypoglycaemia , metabolic acidosis
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HYPERTHERMIA
• Condition associated with :-
o High temperature environment
o Intracranial hemorrhage
o Infection
• Signs and symptoms:
• Warm skin ( flushed and pink initially and pale later )
• Tachycardia and tachypnea
• Dehydratin increase , heat stroke and death .
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Management
1. Temperature control:-
In the delivery room :-
- Provide warm environment
- Dry neonate immediately
- Direct skin – to – skin contact with mother
- Use radiant warmers at birth
- Cover the neonates head with a cap
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Low Birth WIEGHT
• Alow birth weight ( LBW ) neonate is one whose birth weight is less than 2.500 gm .
• Very low birth weight ( VLBW ) <1.500gm
• Extremely very low birth weight ( ELBW) < 1.000gm.
• Causes of LBW:-
• 1. Prematurety ( gestational age < 37gw)
• 2. Growth restriction ( below 10th percentile )
• 3. Both .
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Preterm infant
• A preterm neonate is one whose birth occurs before the end of the last day of thirty seventh week following the onset of last menstrual period
• Prematurety with its complication is the leading cause of neonatal mortality in Jordan ( 35%)
Causes of preterm birth :-
• 1. Fetal
- Fetal distress
- Multiple gestation
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Preterm infant• 2. Placental
- Placenta previa
- Abruptio placenta
3. Maternal
- Pre – eclampsia
- Chronic medical illness ( e.g. heart disease )
- Infection( UTI)
- Drug abuse
4. Other :-
- Premature rupture of membrane
- Polyhydramnios
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Complication of Prematurety• 1. Difficulty in maintain body temperature due to • Increased heat loss• Reduced subcutaneous fat • Large surface area – to body weight ratio• Reduced heat production because inadequate
brown fat and inability to shiver .• 2. Respiratory difficulties:-• Deficiency of pulmonary surfactant • Risk of aspiration due to poor gag and cough
reflexes , uncoordinated sucking and swallowing• Week respiratory muscles• Periodic breathing Apnea
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Complication of Prematurety
• 3. Gastrointestinal and nutritional problem:-• Poor sucking reflexes especially before 34 gw
• Decreased intestinal motility
• Delayed gastric emptying
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Complication of Prematurety
• 4. Hepatic immaturity:-• Impaired conjugation and excretion of bilriubin
• Deficincy of vitamin k – depending clotting factors
• 5. Renal immaturity:-
• Renal elimination of drug may be diminished
• Electrolyte implance
• Immunologic immaturity :-• High risk for infection
• Lack transplacental transfers of maternal IgG during third trimester
• Impaired phagocytosis
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Management
• 1. In delivery room :-
• Resuscitation immediately
• Adequate oxygenation
• Maintenance of temperature
• 2. Neonatal management :-
• Thermal regulation
• Oxygen therapy
• Fluid and electrolyte therapy
• Nutrition( gavages feeding or parenteral)
• Monitor of billirubin( phototherapy, bld exchange )
X
Hyperbilirubinemia
Its refer to an exaccessive level of billirubin in the blood>2mg\dl.
Its represent in tow form :
1. Conjugated hyperbilirubinemia
2. Un Conjugated hyperbilirubinemia
Both form characterized by “yellowish”
Discoloration of skin , sclera ,and mucous
Membrane.
Serum billirubin level between 5-7mg\dl
Miss : Kamlah Olaimat 23
Hyperbilirubinemia
• Incidence:-
60%in full term .
80% of preterm neonate
Source of billirubin :-
75% from break down of hemoglobin
25% comes from breakdown of non Hb – protein and ineffective erythropoisis .
Notes:- neonate produce about twice as much bilirubin daily (6-8 mg\kg\daily) than adult (3-4 mg \kg\daily) .
Miss : Kamlah Olaimat 24
Bilirubin
turnover in
Newborn
Hb Haem + Globin
Other sourcesBILIRUBIN
UCB binds to S albumin
Dissociates from albumin
UDPG - T
Bil monoglucoronide +
Bil Diglucoronide
Water sol Bil
Binds to cytoplasmic
Ligandin (Y protein)
Excreted into bile canaliculi
Enters Gut
Excreted in stool
Biliverdin + CO + FeBilirubin Reductase
Haem oxygenase
Beta Glucoronidase
UCB
Production
transport
uptakeUptake
Excretion
Conjugation
Miss : Kamlah Olaimat 25
Bilirubin load causing jaundice in
Newborn>ed RBC vol & <ed RBC survival
>ed Bil monoglucoronide
<ed Bil Diglucoronide
UCB
Pro
du
cti
on
Tra
nsp
ort
Uptake
Excretion
Conjugation
>ed Ineffective erythropoiesis & >ed Heam
turnover
Non availability of Albumin
binding sites
Defective conjugation
<ed LIigandin
Decreased excretion
<ed gut motility
Poor evacuation
>>ed beta glucoronidase, <ed
intestinal bacteria
>ed BILIRUBIN load
Defective uptake from plasma
>ed Entero-hepatic circulation
Miss : Kamlah Olaimat 26
Hyperbilirubinemia
• Classification of Hyperbilirubinemia :
• 1. Unconjugated ( indirect)
physiological jaundice.
Breast milk jaundice
-Early onset jaundice
- Late onset jaundice
Hemolytic jaundice ( most common)
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Nursing assessment and intervention
• Be alert for signs and symptoms of jaundice:-
o Sclera appear yellow before skin yellow
o Skin appear light to bright yellow
o Lethargy
o dark amber, concentrated urine
o Poor feeding
o Color and amount of stool
o Support breast feeding
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Investigation for all neonate with jaundice
• Total serum billirubin ( direct and indirect)
• CBC
• Blood group for both mother and baby
• Blood film
• Direct Coombs test
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Management
• PhototherapyLight therapy provides energy to exposed skin in order to
convert Unconjugated billirubin to water soluble form to enhance its excretion .
• Technique:-o Blue light with wave length 425-475nmo Plastic covero White linens in cot to reflect lighto Baby undressed o Cover eye and genital area o Lamp should be 5-8 cm over incubator and 45-50cm above
baby
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Management
1. Phototherapy
o Neutral thermal environment
o Monitor wight daily
o Monetored fluied balance
o Bilirubin level should be followed after 24 hours after stop phototherapy
o Skin color assessment not affective during phototherapy
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Complication of phototherapy
• Loose stools
• Skin rashes
• Overheating
• Dehydration
• Eye injury
• Bronze baby syndrome
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Babies under phototherapy
Baby under conventional
phototherapyBaby under triple unit intense
phototherapy
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2. Exchange transfusion
• This procedure to remove billirubin and hemolytic antibodies and correct anemia
• Why to start Exchange transfusion:-
o Sick or well neonate
o Birth weight
o Gestational age
o Cases of hemolysis( as Rh or ABO incompatibility , or G6PD)
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Exchange transfusion
• Monitor billirubin level 4-6 hours after exchange
• If billirubin level persist a second exchange considered
• Continue phototherapy before and after exchange
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Complication of exchange
• Vascular( thrombosis)• Cardiac( overload)• Electrolyte disturbance• InfectionNursing care after exchange:-o Neonate isolatedo Observe color and toneo Monitor site for bleeding and infectiono V\S q 1\2 hour for sex hourso Girth measurement and bowel sound
Miss : Kamlah Olaimat 39
2. kernicterus
• It deposit of Unconjugated billirubin in the
basal ganglia of the brain .
• Cell injury , yellow staining , neural loss
• In preterm infant even billirubin level in low range may cause kernicterus .
Miss : Kamlah Olaimat 40
kernicterus
• Clinical presentation :-Through 4 stages :-1. General neurological depression , poor motor
reflex , poor feeding , vomiting , high pitch cry, lethargy
2. Seizures , fever , paralysis mortality high 3. After one week spasticity decrease and may
disappear4. After the period of neonatal and reflect the
damage happened as spasticity, deafness , mental retardation
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kernicterus
• The level at which kernicterus can occur variable and no specific billirubin level safe or toxic .
• Management :-
• Phototherapy and exchange immediately
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3. Conjugated hyperbilirubinemia :-
Conjugated hyperbilirubinemia :-Increased level of direct billirubin >20% of
total serum Its signs of hepatobiliary dysfunction
• Etiology:-• Extra hepatic biliary obstruction• Biliary atresia• External compression • Infection
Miss : Kamlah Olaimat 44
3. Conjugated hyperbilirubinemia :-
• Clinical manifestation:-• Signs of sepses • Abdominal distention• Vomiting• Clay-colored stool• Dark urineInvestigation:-Liver function testAbdominal ultrasoundLiver biopsy
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3. Conjugated hyperbilirubinemia :-
• Management:-
• Key is to identify the underlying cause
• Phototherapy should not use