1. MD Chula 2010
y
nl
O
se
U
al
rn
Baby boy born at 38 weeks GA, by C/S ,
te
No ANC Apgar score at 1 and 5 mins. =
4, 5 Grunting at 30 min. after birth
In
RR 60 /min. PR 150 /min. BT 36.5°c
BW 4,200 g Ht 50 cm. HC 34 cm. puffy
face, hairy ears ,Suprasternal and
subcostal retraction,Lungs: fine
crepitations both sides
At 2 hours of age, DTX 30 mg/dl, Hct 67%

2. MD Chula 2010
y
nl
O
se
U
al
rn
ž No ANC (no GDM screening)
te
ž Term 38 wk LGA ( but normal Ht, HC)
ž Hypoglycemia
In
Infant of diabetic
mother

3. MD Chula 2010
y
nl
O
se
U
al
rn
ž Chest x-rayà diffuse reticulogranular
te
pattern ,hypoaeration
ž Dx..
In
ž Respiratory distress syndrome

4. MD Chula 2010
y
nl
O
se
U
al
rn
ž Respiratory distressà RDS
te
ž Hypoglycemia ( BS < 40 mg%)
ž Polycythemia (Hct > 65%)
In
ž Infant of diabetic mother (IDM)

5. MD Chula 2010
y
nl
O
se
U
al
rn
ž Surfactant deficiency (decreased
te
production and secretion) is the primary
cause
In
ž Mature levels of pulmonary surfactant
are usually present after 35 wk.
ž Synthesis of surfactant depends in part
on normal pH, temperature, and
perfusion

6. MD Chula 2010
Increase Risk Decrease Risk
•Prematurity •pregnancy-associated
•maternal diabetes hypertension
•multiple births •maternal heroin use
y
•cesarean section •prolonged rupture of
•precipitous delivery membranes
nl
•asphyxia •Antenatal corticosteroid
O
•cold stress prophylaxis
•history of previously
affected infants se
U
al
Which of following decrease the risk for this
rn
condition?
ž Cold stress
te
ž Maternal DM
In
ž Birth asphyxia
ž Cesarean section
ž Prolong rupture of membrane

7. MD Chula 2010
y
nl
O
(lecithin)
se
U
al
rn
ž Alveolar atelectasis, hyaline membrane
formation, and interstitial edema make the
te
lungs less compliant
ž Sign of respiratory distress appear within
In
minutes of birth
ž Breath sounds may be normal or diminished
, on deep inspiration, fine rales may be
heard
ž symptoms and signs reach a peak within 3
days, after which improvement is gradual

8. MD Chula 2010
ž blood glucose < 40 mg/dL
ž sustained or repetitive hypoglycemia in
infants and children can retard brain
development and function
y
ž Long term sequeleà mental retardation,
nl
seizure disorder
O
se
U
al
rn
ž Limited glycogen supplyà preterm,
te
perinatal stress
ž Diminished glucose productionà SGA
In
ž HyperinsulinismàIDM, Hydrops fetalis
ž Othersàhypothermia,
sepsis,polycythemia

9. MD Chula 2010
y
nl
O
se
U
al
rn
ž Apnea/ tachypnea
te
ž Bradycardia/ Tachycardia
ž Cyanosis
In
ž Lethargy
ž Poor feeding
ž Jitteriness
ž Seizure

10. MD Chula 2010
ž asymptomatic infantsà frequent feeding
and/or intravenous infusion of glucose
ž acute symptomatic infant à 2 mL/kg of
D10 W IV push, followed by IV drip
glucose at 6–8 mg/kg/min
y
adjusting the rate to maintain blood
nl
ž
glucose levels in the normal range.
O
ž If hypoglycemic seizures are present,
some recommend a 4 mL/kg bolus of D10
W. se
U
al
rn
the most appropriate fluid management..E
te
ž 10% D/W 2 ml/kg IV push then
ž IV drip 85 ml/kg/day à glucose rate 6
In
mg/kg/min.
(if drip 65 ml/kg/dayà glucose rate 4
mg/kg/min.)

11. MD Chula 2010
y
nl
O
se
U
al
rn
ž Due to slow absorption of fetal lung fluid
ž early onset of tachypnea, sometimes with
te
retractions, or expiratory grunting and,
occasionally, cyanosis that is relieved by
In
minimal oxygen (<40%).
ž usually recover rapidly within 3 days. The
lungs are generally clear without rales or
rhonchi
ž chest x-ray shows prominent pulmonary
vascular markings, fluid in the intralobar
fissures, overaeration, flat diaphragms, and,
rarely, pleural effusions.

12. In
te
rn
al
U
MD Chula 2010
se
O
nl
y

13. MD Chula 2010
ž 40 % atrophic or absent testis
ž 60% undescended testis
ž Between 2 and 5 percent of full-term
and 30 percent of premature male
y
infants are born with an undescended
testicle
nl
ž Most undescended testicles descend
O
spontaneously before six months of age
àthe optimal time for surgical correction
ž
se
no later than 9–15 mo (∵↓ fertility)
U
al
rn
may be…
te
ž genetic female with congenital adrenal
hyperplasia(esp.with hypospadias)*
In
ž disorder of the androgen receptor
ž true hermaphrodite
ž Anorchia
ž bilaterally undescended testis
*immediately life-threatening and must be
excluded.

14. MD Chula 2010
The initial laboratory evaluation
includes
ž Karyotype
ž ultrasound of the pelvic
structures
y
nl
ž 17-hydroxyprogesterone
ž measurement of electrolytes and
O
glucose
se
U
al
The following investigations are needed
rn
except?
ž Karyotype
te
ž Pelvic ultrasound
In
ž Serum creatinine
ž Serum electrolyte
ž 17 hydroxyprogesterone

15. MD Chula 2010
At what child age is the appropriate time
for surgery?
ž 1 - 4 weeks
ž 2 – 6 months
ž 9– 15 months
ž 2 – 3 years
y
nl
ž 3 – 5 years
O
se
U
al
rn
te
In

16. MD Chula 2010
ž Depressed infants (those with
hypotonia, bradycardia, fetal
acidosis, or apnea) should
undergo endotracheal intubation,
y
and suction should be applied
nl
directly to the endotracheal tube
O
to remove meconium from the
airway. se
U
al
rn
ž Routine intrapartum nasopharyngeal
te
suctioning in pregnancies with
meconium-stained amniotic fluid does
In
not reduce the risk for MAS
ž Routine intubation to aspirate the lungs
of vigorous infants born through
meconium-stained fluid is not
recommended

17. MD Chula 2010
y
nl
O
Meconium aspirator
se
U
al
ž After resuscitation the baby was sent to
rn
Nursery . He developed tachypnea RR
70 /min., subcostal retraction, increase
te
chest AP diameter and diminished
breath sound on the right . Oxygen box
In
was given which achieved O2 saturation
of 88%.

18. MD Chula 2010
ž Pneumonia
ž Pneumothorax
ž Lung atelectasis
Congenital Lung cyst
y
ž
Transient tachypnea of the newborn
nl
ž
O
se
U
al
rn
ž “ball-valve”
type of bronchial or
te
bronchiolar obstruction resulting
from meconium aspiration
In
ž Air leaks occur during the 1st 24–
36 hr

19. MD Chula 2010
y
nl
O
se
U
al
rn
What is the most appropriate fluid
te
management in the first 24 hours?
ž 5%D/W rate 8 ml/hr
In
ž 10%D/W rate 8ml/hr
ž 10%D N/5 rate 8ml/hr
ž 10%D N/5 +KCl 20 mEq/L rate 8 ml/hr
ž Infant formula 20 ml× 8 feeds by OG
tube

20. MD Chula 2010
ž Respiratory
distress
ž Hypoxia àNPO
ž Circulatory IV fluid
insufficiency
y
Excessive 10%D/W
nl
ž
secretion
O
ž Sepsis
ž CNS depression
se
U
al
rn
In the first day of life
te
ž Neonate s have low GFR à low urine
output, Na+, K+ excretion
In
ž Do not give Na+ and K+ just water
ž Why 10% not 5%

21. MD Chula 2010
ml/kg/day Fullterm Preterm
Day 1 60-
60-70 70-
70-80
y
nl
Day 2-3 100-
100 -120 150
O
se
U
al
rn
ž Fluid requirement 60-70 ml/kg/day (not
te
100)
ž Glucose requirement 4-8 mg/kg/min.
In
ž If give 5%D/W at this volume ,glucose
rate just 2 mg/kg/min.
ž The answer is B(10%D/W rate 8 ml/hr)

22. MD Chula 2010
y
nl
O
se
U
al
rn
In most cases, benign peoblem in neonate
te
However:
ž Untreated severe indirect
In
hyperbillirubinemiaàneurotoxic
ž Conjugated hyperbillirubinemiaànot
neurotoxic but indicate serious hepatic
or systemic illness

23. MD Chula 2010
ž 60% of full-term newborn becomes visibly
jaundice on the 2nd–3rd day
ž Rising <5 mg/dL/24 hr
ž peaking between the 2nd and 4th days
y
ž bilirubin levels rarely rise above 12 mg/dL
nl
ž decreasing to below 2 mg/dL between
O
the 5th and 7th days of life
se
U
al
rn
result from..
te
ž increased bilirubin production from the
breakdown of fetal red blood cells (high
In
Hct, short RBC survival)
ž transient limitation in the conjugation of
bilirubin by the immature neonatal liver.
ž Enterohepatic circulation

24. MD Chula 2010
y
nl
O
se
U
al
rn
5 mg/dl
te
face à
In
abdomen à
15 mg/dl
sole à
20 mg/dl

25. MD Chula 2010
ž Male
ž East Asian race
ž Late preterm
ž polycythemia
ž Cephalhematoma /bruising
y
ž Blood group incompatibility
nl
ž Exclusive breast feeding
Sibling with neonatal jaundice
O
ž
ž Delayed bowel movement
ž Mother with DM, oxytocin Rx se
U
al
rn
te
In
Distribution of maximal bilirubin levels during the 1st wk of life in breast-fed and
formula-fed white infants over 2,500 g.
(From Maisels J, Gifford K: Normal serum bilirubin levels in the newborn and
the effect of breast-feeding. Pediatrics 1986;78:837.)

26. MD Chula 2010
žBreast-feeding jaundice
žBreast milk jaundice
y
nl
O
se
U
al
rn
• in the 1st week of life
te
• due to decreased milk intake with
dehydration and/or reduced caloric intake.
In
• Rx:Frequent breast-feeding (>10/24 hr),
rooming-in with night feeding, discouraging
5% dextrose or water supplementation

27. MD Chula 2010
ž after the 7th day of life
ž Peak during the 2nd–3rd week
ž gradually decreases but may persist for
3–10 wk
y
ž may be due to the presence of
nl
glucuronidase in some breast milk.
O
se
U
al
rn
(1) it appears in the 1st 24–36 hr of life
te
(2) serum bilirubin is rising at a rate faster
than 5 mg/dL/24 hr
In
(3) serum bilirubin is >12 mg/dL in full-term
infants (especially in the absence of risk
factors) or 10–14 mg/dL in preterm
infants
(4) jaundice persists after 10–14 days of life
(5) Direct bilirubin is >2 mg/dL at any time.

28. MD Chula 2010
ž A 24-hour-old female infant, term, NL,
Apgar score 8,9, Birth weight 2,900 gm. His
mother G1P1 had good prenatal care,
VDRL-NR, HBsAg+, blood group O-positive ,
is giving breast feeding.
ž PE: Alert, active infant. Jaundice from face
to abdomen. Heart& Lungs are within
normal limit. Liver 1 cm. below RCM. Hct
y
43%, MB 12.5 mg/dl, blood group A-positive.
Blood smear show nucleated RBC,
nl
microspherocyte.
O
se
U
al
rn
ž First born
te
ž Female gender
ž Breast feeding
In
ž Term gestation
ž Mother’s HBV carrier

29. MD Chula 2010
ž G6PD deficiency
ž Neonatal hepatitis
ž ABO incompatibility
Physiologic jaundice
y
ž
Breast feeding jaundice
nl
ž
O
se
U
al
rn
ž G6PD level
te
ž Liver function test
ž Direct Coombs’ test
In
ž Indirect Coombs’ test
ž No need for investigation

30. MD Chula 2010
Mother blood group O, infant group A or B
and
ž Positive direct Coombs’ test
ž Jaundice appear within 12-24 hours
y
ž Microspherocyte on blood smear
nl
O
se
U
al
rn
ž Phototherapy
te
ž Exchange transfusion
ž Change to formula feeding
In
ž Blood for liver function test
ž Increase frequency of breast feeding

31. MD Chula 2010
ž BCG
ž Hepatitis B vaccine(HBV)
ž BCG and HBV
BCG and Hepatitis B immunoglobulin(HB
y
ž
IG)
nl
ž BCG, HBV and HBIG
O
se
U
al
rn
ž Hepatitis B within 12 hr.
te
ž HBIG within 12 hr.
ž BCG
In

32. MD Chula 2010
y
nl
O
se
U
al
rn
2 wk-term infant with breast feeding
te
PE: well active, jaundice face to sole
TSH screening at 48 hr. of age was 15 mIU/L
In
TSB 27 mg%, dB 1 mg%, Hct 50%
ž What is the most likely diagnosis?

33. MD Chula 2010
ž Hemolysis
ž hereditary glucuronyl transferase
deficiency
y
ž breast-milk jaundice
nl
ž Hypothyroidism
O
ž intestinal obstruction
se
U
al
rn
ž Jaundice persisting for more than
te
2 wk or associated with acholic
stools and dark urine suggests
In
biliary atresia
ž Increase direct bilirubin >20% of
total bilirubin

34. MD Chula 2010
ž Because most of these infants are
asymptomatic at birth
ž all newborns are screen for this serious
and treatable disease.
y
ž In Thailand use TSH for screening
nl
ž A heel-stick blood sample is taken at
O
discharge or 3 days of life.
se
U
al
rn
te
In

35. MD Chula 2010
ž Biliary atresia
ž Hypothyroidism
ž hyperthyroidism
Breast milk jaundice
y
ž
Breast feeding jaundice
nl
ž
O
se
U
al
rn
ž Surgery
te
ž Antithyroid drug
ž Thyroid hormone
In
ž Exchange transfusion
ž Intensive phototherapy

36. MD Chula 2010
exchange transfusion if TSB rise to this level
despite intensive phototherapy >6 hours
Age(day) TSB (mg/dl)
y
nl
1 20
2 22
O
3 24
≥4 se 25
U
al
rn
te
In

37. MD Chula 2010
ž 45 xo
ž 46 xx
ž 47 xxy
47 xx, +18
y
ž
47 xx, +21
nl
ž
O
se
U
al
rn
te
In

38. MD Chula 2010
y
nl
O
se
U
al
rn
ž Gasless abdomen
te
ž Double bubble sign
ž Pneumatosis intestinalis
In
ž Generalized intestinal dilatation
ž Dilatation of the stomach with little gas in
the small bowel

39. MD Chula 2010
ž Down syndrome occurs in 20–30% of
patients with duodenal atresia
ž The hallmark of duodenal obstruction is
bilious vomiting without abdominal
y
distention, which is usually noted on the
nl
1st day of life
The diagnosis is suggested by the
O
ž
presence of a “double-bubble sign” on
plain abdominal radiographs
se
U
al
rn
te
In

40. MD Chula 2010
y
nl
O
se
U
al
rn
ž Clinical sign Percentage of infants
Hyperthermia 51
te
Hypothermia 15
Lethargy 25
Irritability 16
In
Respiratory distress 33
Apnea 22
Cyanosis 24
Jaundice 35
Hepatomegaly 33
Anorexia 28
Vomiting 25
Abdominal distention 17

41. MD Chula 2010
y
nl
O
se
U
Neonatal Early onset Late onset
sepsis
al
Onset <3 days 3-28 days
rn
Mode of Vertical Community
infection acquired or
•preterm premature nosocomial
te
Predisposing rupture of •Prematurity
factor membranes(15%) •Teenage mother
In
(incidence • chorioamnionitis(20%) •Hospitalized infant
sepsis) •Preterm birth <31 weeks
Fulminant Subtle, nonspecific
§Group B streptococcus §Community
Clinical §E. Coli acquired; as early
presentation §H. Influenzae onset plus
Bacteriology §Enterococcus species S.pneumoniae,
§Listeria monocytogenes N.meningitidis
§Hospital acquired;
CONS, candida,
S.aureus,acinetobac
ter,…

42. MD Chula 2010
ž CBC
ž Blood culture
ž Urine culture (late onset)
Lumbar puncture (25% of late onset
y
ž
community acquired sepsis develop
nl
meningitis without meningeal sign)
O
se
U
al
rn
ž Antibiotic cover gram positive and gram
te
negative bacteria
ž Duration
In
organism Without With
meningitis meningitis
Gram 7-10 days 14-21 days
positive 10-14 days
Gram
negative

43. In
te
rn
al
U
MD Chula 2010
se
O
nl
y