Newborn

physiology
 Definition

• Gestational age
• Term newborn (37-41 GW)
• Preterm newborn (AGA) (<37. GW)
• Post-term newborn (>41. GW)
• Intrauterin retarded newborn (IUGR,
or SGA) (<10 percentile)
• Normal birth weight: 3250±700 g
Anthropometric characteristics of
term and preterm infants
I
U
G
R
I
U
G
R
 Estimation of gestational age

• Menstruation calendar
• Intrauterine anthropometry
• Semi-objective score system using
physical examination of the newborn
Estimation of the gestational age
according to Dubowitz
Preterm - postterm
Characteristics of preterm skin.
Estimation of the gestational age
Estimation of the gestational age
Muscle tone and posture
Maneuvers for the estimation of
gestational age
Scarf signs and heel-to ear maneuver
 Basic definition
characterizing the quality of pregnancy care,
neonatal and pediatric care in a country

• Infant mortality rate (6.6 %o)

Mortality per mille in a period of 0-365 day
• Neonatal mortality (3.4 %o)
Mortality between birth and 7th day of life
• Perinatal mortality (8.3 %o)
Mortality from 24. gest. week until the 7th day of
life
 Infant mortality rate (IMR) and neonatal
mortality rate (NMR) in Hungary and in the USA

35
30
25 IMR H
20 NM H
15 IMR USA
10 NMR USA
5
0

1970 1975 1980 1990 1995 1999

Infant mortality rate in different countries

10

0
CH

H
D

UK
S

USA
N
Percentage of premature babies in
Hungary
=BW<1000g

12

10

0
1970 1975 1980 1990 1995 1999 2000
 Main causes of death in developed countries

Adults Infants Children

Malignancies Perinatal Malignancies

diseases
Cardiovascular Malformations Accidents,
diseases drugs, terror

GI diseases Malignancies

Accidents, Accidents,
drugs, terror drugs, terror
 Physiology of
organ adaptation
after birth

Postnatal adaptation
Early contact to the mother
 Adaptation of vital organs

• Cardiac adaptation Îminutes

• Pulmonary adaptation Îminutes

Disturbed adaptation in the function of

these organs will result in a serious,
life-threatening sequences of event
Re-organization
of the fetal
circulation
 Fetal circulation

Characterized by the
presence of parallel
circulation, shunts in order
to prevent overperfusion of
“non-used” organs i.e. lung.
The major shunt is the
ductus arteriosus Botalli
 Neonatal circulation

In healthy newborns the

shunts close functionally
and later morphologically.

The most important shunt

is the ductus arteriosus.
Circulation in
asphyxiated newborn

• Asphyxia causes vaso-

constriction in pulmonary
arteries.
• PDA (L to R shunt)
• Congestive heart,
pulmonary edema
• Hypoxia maintains pulm.
vasocontriction(vitious circle)
• Abdominal organs hypoperfused
serious secondary diseases
Effects of
hypoxia
on
different
organ
function in
the
newborn
Consequences of failure to adapt of the
fetal circulation
• Persistent fetal circulation
• Long-lasting hypoxia
• Hypo-perfused organs with functional and later
morphological consequences
– CNS
– Kidney
– GI mucosa
– Myocardium
– Other parenchymal organs
 Characteristics of hemodynamics
Fetal Newborn

• Shunts • Pulm. resistanceÐ by

• RV provides 2/3 of the 80%
total myocardial work • TPVR increases
• Flow in the pre-ductal • Shunts functionally
aorta is only 10% of CO close within 10-15 h
• Flow in ductus art. is • Fetal circulation shows
60% of CO the adult pattern
• Lung perfusion 4-7% within 2 days
• pO2 in the aorta is low:
20-28 mmHg
 Characteristics of lung function

Fetal Newborn

• Low perfusion • First inspiration: 10-

• Alveoli filled with 70 cmH2O per 0.5 sec
liquid: • First volume: 50 ml
40-60 ml; pH:6.4; FRC: 20-30 ml
protein : 300 mg/dl • First expiration:
• Amnion fluid 20-30 cmH2O
• Respiratory • Stimuli for the first
movements during inspiration:
REM sleep chemical
temperature, tactile,
clamping the cord
 Adaptation of other organs

• Kidney
• Fluid and electrolyte homeostasis
• Gastrointestinal (GI) system
• Haematology
• CNS

Disturbed adaptation does not result in

an acute life-threatening event
 Kidney development and
maturation
• Nephrogenesis GFR
Functional
until the 36th maturation

gest. week
Nephrogenesis

• Functional
36
maturation
postnatally Gestational weeks

Guignard 1981
 Nephron number and intrauterine
development
• Genetic factors Nephron No (thousand)

• Lower maternal energy 1 440

supply
• Low vitamin A status 640

• Maternal diabetes
• Hormones 160

• Drugs
20 30 40
Gestational age
=control =IUGR

Hinchliffe SA et al: Brit J Obst Gynec 1992. 99: 296.

 Hypothesis: low birth weight and
premature birth are associated with
decreased renal function later in life

• Lower nephron
number
• Lower reserve
capacity
• Naturally occurring
decline in nephron
structure starts Total glomerular volume is
from a lower point negatively correlated to age
Nyengaard JR, Bendtsen TF:
Anat Rec 1992.232.194.
 LBW contributes to the high rates of early-
onset CRF in Southeast, South Carolina
(Lackland D et al: Arch Intern Med 2000. 160:1472)

• LBW is common in
South Carolina.
• This region has the
highest rate of ESRD
among young people in
the US.
• LBW not directly but by
multiple mechanisms
contributes to the
early-onset ESRD in
Carolina.
 Non-invasively induced nephron deficit
in two experimental models
(Merlet-Bénichou C et al: Pediatr Nephrol 1994. 8: 175)

• Uterine artery ligation

(z, panel “a” )“

• Low protein diet (z, panel “b”).

• The nephron No correlated

with birth weight.
• Nephron deficit was
remarkable
• Factors that regulate fetal
growth also govern nephro-
genesis
IGF-1 in the renal development
(Hammerman M: Nephrol Dial Transplant 1999. 14: 1853.)

• IGF-1-/- transgenic
mice are 10-20 %
smaller than wild type.
• Have 60% lower BW.
• Appr. 95% of IGF-1-/-
die perinatally.
• Kidney weights are
smaller, mean glom. No
is 20% less
 Newborn kidney function

• The role of fetal urine • High vasoactive

• Blood perfusion of hormone activity
fetal kidney is low • Down-regulation of
• GFR low their receptors
• RVR high • Some hormones play
• Immature tubular role in the nephro- and
transport system vasculogenesis (IGF1,
AngII)

First urine passage: 20% in the delivery room; 92% within

24 hours; No urine after 36 hrs means renal disease!
 Body water compartments
Friis-Hansen BJ: Pediatrics 1961.
Changes in Fluid Compartments in the
Immediate Perinatal Period (1)
Changes in Fluid Compartments at the Onset of
Labor:
• decrease in the production of fetal lung fluid
• 20% increase in fetal blood pressure

Changes in Fluid Compartments During Labor and

Delivery:
• 14% decrease in circulating blood volume
• 25% reduction in plasma volume
• placental transfusion induces a variable increase in
circulating blood volume

Increased Interstitial Fluid Compartment

 Changes in Fluid Compartments in the
Immediate Perinatal Period (2)

Mechanisms Mediating the Transcapillary Loss of Plasma

Volume:
z the increase in fetal blood pressure enhances transcapillary
distribution of fluid (and protein)
z mild hypoxia during labor and delivery increases transcapillary
leak
Hormonal Regulation of Transcapillary Loss of Plasma
Volume:
z norepinephrine, vasopressin, renin-angiotensin, cortisol
(vasoconstriction)
z bradykinin, prostaglandins, atrial natriuretic peptide (vasodilation)
 Changes in Fluid Compartments in the
Immediate Perinatal Period (3)

Neonatal Weight Loss:

z term infants lose 5-10% of their birthweight during the first week
of life
z preterm infants lose 10-15% of their birthweight during the first
two weeks of life

Fluid Compartments Involved in Neonatal Weight Loss:

z the perinatally expanded extracellular (extravascular) fluid

compartment
z intracellular fluid compartment (prolactin?)
 Fluid compartments in the postnatal
adaptation. Summary

• Fetal ECV increased (IFÏ).

• Term newborn looses 5-(10) %, preterm
10-15% of their birth weight
• It is a result of the isotonic contraction
of ECV
• Efferent limb is the kidney: Na and
water loss.
 Possible mechanism of isotonic
contraction of the ECV after birth
Pulmonary vascular resistance Ð

Pulmonary blood floow Ï

Right ventricular pressure Ï

ANP secretion Ï

Diuresis & nátriuresis Ï

Extracellular volumen Ð
 GI system

• Fetus swallows from • Air fills small

the 17th GW: 20 intestine:2-12 hr.
ml/h rectum: 24 hr.
• Motor functions are • First stool < 24 hr
mature (meconium)
• Transport and • Meconium leaves
secretory functions within 3-4 days
are immature
 GI tract
• The number of
stool loss depends
on the frequency
of feeding
• Color, consistence
related to breast
or formula feeding
 Newborn hematology
• Hb: 170-190 g/L
9M % HbF
• Ht: 60-65%
Iu. hypoxiaÎ polyglobulia (Ht>70 %)
• Leukocytes ~10 G/L .
Pathological <5.0 G/L; >15 G/L
• Thr: ~150 G/L
• Newborn jaundice
• „Physiologic” anaemia
 Blood disturbances and clinical
symptoms
• Thrombopenia DIC, isoimmunisation
• Neutropenia sepsis, isoimmunisation
• Polyglobulia hypoxia, twin-transfusion
• Acute anemia blood loss, isoimmunisation
twin-transfusion
• Chronic anemia “physiologic”, infection,
arterficial..
 Apgar score (3, 5, 10 minutes)
0 1 2

Heart No <100/min >100/min

Resp. No Hypoventila Good

tion
Muscle Tone less Flexion
tone
Irritability No answer Low Good crying
movements
Skin Cyanotic Acrocyan- Rose
osis
8-10 : normal. 5-7 : observation. <5 pont: resuscitacio
Rooting reflex
Sucking reflex
Palmar and plantar reflex
Moro reflex
Pathological signs o n the first day of life

• Respiratory distress
• Cyanosis, pallor
• Icterus (jaundice)
• Skin alterations
• Pyoderma, cord inflammation
• Bleeding
• Edema
• Rectal T: >37.5 ill., <36.5 oC
• Vomiting
• Abdominal distension
• Apathy, irritability, tremor, convulsion
Minor trauma
 Minor trauma jelei

Meconium Beech delivery Forceps

 Facial asymmetry

Small deformity Facial paresis

Brachial plexus injury (Klumpke, Erb)
Acrodysplasies
Polydactylia
Informative morphogenetic
variations
Ears are often involved as part of
different syndromes
Sacral
alterations

• hyperpigmentation
• hypertrychosis
• spina bifida
• pilonidal sinus
Ectodermal dysplasia
Intrauterin amniotic bands
Hernia umbilicalis
Scrotal haematoma
Cheilo-gnato-
palatoschisis
 Respiratory distress

• Tachypnoe,
• Dyspnoe (nasal, jugular, intercostal,
sternal drawings, paradox thoraco-
abdominal movements, grunting)
• Hypoxia
• Cyanosis
IRDS (hyalin
membrane disease

reticulo-granular
infiltrations
air-bronchogram
 Therapy

• Oxygen
• Resp Tx positive end exp. pressure:
Forms: CPAP
PEEP
• High frequency oscillation
. Indications:PFC
hernia diaphragmatica
• Surfactans - i.tracheal
• Relaxation
• Circulatory support
Atelectasia
Hyperinflation

„Honey in the comb”

pattern
Normal x-ray of
the newborn

•Cardiac
enlargement
•Peribronchial
edema
Newborn chest X-
ray IRDS, HMD
II.

• Cardiac enlargement
• reticulo-granular
pattern
• pneumomediastinum
 Chest X-ray
Pneumonia

• Infiltration
• Hyperinflation
• Art. umb.
catheter