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Late Preterm Infants: Immediate problems after birth

Any baby born before 37 completed weeks of gestation are preterm babies.
Looking at the pathophysiology of babies who are extremly tiny and who are mature, there is a transitional range of babies in between called Late Preterm babies. Late preterm babies are those who are born 34 to 36 weeks and 6 days.
[Late preterm” was defined by participants of the 2005 Workshop on “Optimizing Care and Outcome of the Near-Term Pregnancy and the Near-Term Newborn Infant”  National Institutes of Heath ].

late preterm baby

Term neonates are those who are born between 37 completed weeks of gestation to 41 weeks and 6 days. Those babies who are born between 37 weeks and 38 weeks 6days are Early Term babies. Full Term babies are those who are born after 39 weeks.
Post term newborns are those born after 42 completed weeks of gestation.

preterm definitions

Late Preterm Infants

Late preterm infants are often notrious in any NICUs. They are metabolically and functionally immature and often present with mutitudes of problem, while some of them behave like full mature term infants and transit uneventfully.

Some of the commonly encountered problems in Late preterm neonates are

Respiratory distress

As late preterm babies tend to have delayed cardiopulmonary adaptation to ex-utero environment, they present with Transient Tachypnea of Newborn and Hyaline membrane disease. They are more prone to developing pneumothorax because of secondary lung pathologies like RDS.

PPHN

One of the dreaded complication of any pathology in neonates in Persistent pulmonary Hypertension of Newborn which is rarer in extreme preterms and more common in Late preterm and term babies.

Apnea of Prematurity: 

Although rare, 4-7% of LPT babies can develop apnea due to functional immaturity of the Central nervous system.

Hypothermia

As they have low brown adipose tissue response, late preterms are more prone to Hypothermia.

Jaundice

Jaundice during neonatal period is a frequent problem in LPT infants due to functional immaturity of Liver enzymes. The duration of jaundice is often more prolonged, and peak concentrations of indirect bilirubin frequently are higher than found in term infants. Delayed maturation and lower concentrations of uridine diphosphoglucuronate glucuronosyltransferase, Increased enterohepatic circulation, increased RBC load lead to development of exaggerated neonatal jaundice in this age group.

neonatal jaundice phototherapy

Feeding Problems

Poor Suck-swallow coordination, feeding intolerance and seldom Nectrotizing enterocolitis are seen in these infants.

Metabolic and other Problems

Hypoglycemia, Hypocalcemia and Polycythemia are specifically seen problems in late preterm infants. Polycythemia and hypoglycemia are more common in IUGR infants.
Some of the References Quoted them as: 1. 'Late preterm infants: near term but still in a critical developmental time period.' Kugelman A Pediatrics 2013 
2. 'Late preterm Infants: A population at risk' William A, Pediatrics 2007 Neoreviews: Infant born Late preterm


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Breastfeeding Terminologies

Breastfeeding in newborn should start right after birth as early as possible. Breastfeeding is the nature's rule and has tremendous benefit over artificial feeding.

breastfeeding


Few terminologies are important in regard to Breastfeeding:

Exclusive Breast milk: No food or liquid other than breast milk, not even water, is given to the infant from birth by the mother, health care provider, or family member/supporter.

Total breast milk: No food or liquid other than breast milk, not even water, is given to the infant from birth by the mother, health care provider, or family member/supporter during the past 7 days.

Predominant breast milk: Breast milk, given by the mother, health care provider, or family member/supporter plus 1 or a maximum of 2 feeds of any food or liquid including nonhuman milk, during the past 7 days.

Partial breast milk: Breast milk, given by the mother, health care provider, or family member/supporter plus 3 or more feeds of any food or liquid including nonhuman milk, during the past 7 days.

No breast milk: The infant/child receives no breast milk.

Breast milk includes breastfeeding, expressed breast milk or donor milk and undiluted drops or syrups consisting of vitamins, mineral supplements or medicines.

[Source- The Breastfeeding Committee for Canada Breastfeeding Definitions, March 2004.]


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New National Immunization schedule of Nepal includes Rotavirus vaccine : 2018


The National Immunization schedule of Nepal has included Rota viral vaccine over existing 11 Antigens.

Rota virus is the leading cause of Acute viral diarrhea in children and leads to substantial mortality and morbidity. The vaccine is given Orally  at 6 and 10 weeks.


About Fractional dose of IPV : As an alternative to the intramuscular injection of a full dose of IPV, countries may consider using fractional doses (1/5 of the full IPV dose) via the intradermal route.In the context of an IPV shortage, countries should consider instituting a 2-dose fractional dose schedule, where feasible, 
fIPV has been introduced at 6 and 14 weeks in our schedule as recommended by WHO.


New immunization schedule Nepal

IPV vs fIPV


Also read the Old Schedule-2014 


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Interpreting Pedigree chart to recognize pattern of inheritance


One of the problem faced by students is solving a pedigree chart and recognizing pattern of inheritance, which is even important in day to day clinical practice.

Inheritance that needs to be differentiated in pedigree can be

Mendelian ( Single Gene defect )
 Autosomal Dominant
Autosomal Recessive
X linked

Non traditional inheritance like
Mitochondrial inheritance

In a Step Wise approach

1. Identify whether pattern of inheritance is Autosomal or Sex linked.
If only Males are affected , it is likely X linked inheritance ( Recessive, X linked dominant disorders are very rare)
If both males and females are equally affected, it is Autosomal inheritance


2. Determine whether the disorder is dominant or recessive.
If only Affected parent transmit the disease , it is Dominant disorder
If non-affected parent transmit the disease, it is Recessive disorder.
In other words,
If the disorder is dominant, one of the parents must have the disorder.
If the disorder is recessive, neither parent has to have the disorder because they can be heterozygous.

If disease skips generations, it is likely Recessive disorder.



Rules of Inheritance: Understanding Mendelian disorder by Dr Sulabh Shrestha

Understanding Mendelian inheritance - Epomedicine




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Swelling over newborn's scalp: What can it be?


The swelling over the scalp in newborn can be of benign significant to rapidly fatal and emergency condition. Before learning about the differential diagnosis of scalp swelling after birth, we must understand the anatomy of Scalp.


Here we will not discuss congenital lesions like Dermoid cyst, Encephaloceles and Hemangiomas as such.

Scalp Anatomy:


The layers of scalp include- Skin, Connective tissue, Aponeurotic layer ( Galea aponeurotica), Loose connective tissue ( Subgaleal ) and Periosteum . ( SCALP )


Mainly 3 swellings are important in newborn period

1. Caput succedaneum: Most commonly encountered in newborn period.  It occurs as a result of accumulation of serosangineous fluid in subcutaneous tissue layer, located over the presenting part of fetus during delivery.  The swelling is fluctuant , boggy and crosses suture lines. There is minimal blood loss and usually swelling resolved by 72 hours without residual effects. Complications are less likely.

2.Cephalhematoma : There is accumulation of blood between periosteum and skull ( subperiosteal bleed). The swelling usually is limited by suture lines and are seen over parietal and occipital bones. The swelling is initially firm and becomes fluctuant after 48 hours. Blood loss is rarely severe but severe cases have been documented. It can be present bilaterally. Underlying skull fracture might be palpable. Xray can demonstrate it if fracture is suspected. The swelling takes 2 weeks to 3 months to resolve.
Complications can be Hyperbilirubinemia and Infection.
Avoid massaging or aspiration with needle.



3. Subgaleal bleed: The most dreaded diagnosis.

The subgaleal space can accomodate entire volume of blood of a neonate, so bleeding to exsanguiation is a possibility. Rupture of an emissary vein may result in subtle to massive hemorrhage into the subgaleal space. 
Crosses suture lines and may entend to nape of neck and eyes. Ecchymosis around the eyes can be seen. Swelling is boggy ( firm to fluctuant ) and dependent. Usually resolves in 2-3 weeks. 
Subgaleal bleed has high morbidity and mortality.
Blood loss may lead to severe anemia, hypovolemic shock and death.


Risk factors are:
Assisted deliveries ( Vacuum, forceps ), Difficult deliveries, Congenital coagulation disorders.

Guidelines for monitoring:

All difficult or assisted deliveries need to be notified to Pediatrician, in responsibility of Obstetrician.
Observe babies for atleast 8 hours even when APGAR is normal.
Assess vital signs hourly, scalp examination, head circumference and swelling.
Assess neurological status, change in consiousness.
Baseline Hb, PCV and platelet may be needed, if SG bleed is suspected, repeat every 4 to 8 hours.

If Subgaleal bleed is seen:

Send PT, aPTT and fibrinogen.
Skull Xray to rule out fractures.
Imaging may be needed- CT, MRI

Management:

1. Blood transfusion
2. Blood products
3. Inotropes.

Suggested reading: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC81073/

Therefore, subgaleal bleed being fatal should always be kept in mind, while assessing swelling in newborn born via assisted or difficult deliveries.

Resource: STABLE course



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