PRESENTED BY VISSALINI JAYABALAN 090100432

SUPERVISED BYDR. BUGIS MADINA LUBIS SP.A (K)

RESPIRATORY DISTRESS SYNDROME IN A PREMATURE BABY

PREMATURE BABY

A baby born before 37 weeks of gestation have passed. The current World Health Organization definition of prematurity is a baby born before 37 weeks of gestation, counting from the first day of the Last Menstrual Period (the LMP).

Classification Of Preterm And Low Birth Weight Babies

Different degrees of prematurity are defined by gestational age (GA) or birth weight.

Newborn classification based on gestational agePreterm (premature)  —  born at 37 weeks' gestation or lessTerm  —  born between the beginning of week 38 and the

end of week 41 of gestationPost-term (postmature)  —  born at 42 weeks' gestation or

moreNewborn classification based on birth weightLow birth weight (LBW)  —  less than 2500 g Very low birth weight (VLBW)  —  less than 1500 gExtremely low birth weight (ELBW)  —  less than 1000 g

Classification On Birth WeightIn relation to birth weight, most preterm

babies are low birth weight or very low birth weightLow birth weight:

born with birth weight between 1,500-2,499 gm

usually be managed safely at home with some extra care and support.

Very low birth weight:born with birth weight less

than 1,500 gmA life-threatening problem in

such tiny babies is that suckling, swallowing and breathing are not well coordinated, so they require special attention in order to feed them adequately and safely

difficulty in maintaining their body temperature, so they are at increased risk of hypothermia

Classification on gestational agepremature baby

Preterm baby Very preterm baby

•baby born before 37 completed weeks of pregnancy

•Babies born between the gestational ages of 32-36 weeks of gestation•calculated from the mother’s last normal menstrual period (LNMP date). •can usually be managed safely at home with some extra care and support

•born between the gestational ages of 28-31 weeks as calculated from the LNMP date•Like very low birth weight babies •have problems in feeding and maintaining their body temperature

premature baby Preterm baby

Very preterm

baby

Term baby

Classification of newborn babies according to birth weight and gestational age.

Birth weight and gestational age Classification Action

Weight less than 1,500 gm Very low birth weight

Refer URGENTLY to a hospital, making sure to keep the baby warm on the journey

Gestational age less than 32 weeks Very preterm

Keep the newborn baby warm and refer it soon.

Weight 1,500 to 2,500 gm Low birth weight

If there is no other problem:counsel on optimal breast feeding, prevention of infection and keeping the baby warm

Gestational age 32-36 weeks Preterm As above for low birth

weight babiesWeight equal to or above 2,500 gm; gestational age equal to or above 37 weeks

Normal weight and full term

As above for low birth weight and preterm

Associated FactorsMaternal Low socioeconomic status Lack of prenatal care Substance abuse, smoking Maternal age < 16yrs or > 35yrs Maternal illness e.g. renal, heart, lung, HPT, DM, etc Multiple gestation Prior preterm delivery Obstetric factors e.g. uterine malformations, cervical

incompetence, polyhydramnios, premature rupture of membranes, infection (e.g. chorioamnionitis), placenta praevia, abruptio, etc

Abdominal trauma / surgeryFoetal

Foetal distress, IUGR, etc

SIGNSCORE

SIGN SCORE-1 0 1 2 3 4 5

Posture      

Square Window    

Arm Recoil      

Popliteal Angle  

Scarf Sign    

Heel To Ear    

TOTAL NEUROMUSCULAR SCORE

NEUROMUSCULAR MATURITY

BALLARD SCOREUse this score sheet to assess the gestational

maturity of your baby. At the end of the examination the total score determines the gestational maturity in weeks.

SIGNSCORE SIGN

SCORE-1 0 1 2 3 4 5

SkinSticky, friable, transparent

gelatinous, red, translucent 

smooth pink, visible veins

superficial peeling &/or rash, few veins

cracking, pale areas, rare veins

parchment, deep cracking, no vessels

leathery, cracked, wrinkled

   

Lanugo 

none sparse abundant thinning bald areas mostly bald    

Plantar Surface

 heel-toe40-50mm: -1 <40mm: -2

>50 mmno crease

faint red marks

anteriortransverse crease only

creases ant. 2/3

creases over entire sole

 

Breast imperceptable

barely perceptable

flat areolano bud

stippled areola1-2 mm bud

raised areola3-4 mm bud

full areola5-10 mm bud

 

Eye / Earlids fusedloosely: -1tightly: -2

lids openpinna flatstays folded

sl. curved pinna; soft; slow recoil

well-curved pinna; soft but ready recoil

formed & firminstant recoil

thick cartilageear stiff

   

Genitals (Male)

scrotum flat, smooth

scrotum empty,faint rugae

testes in upper canal,rare rugae

testes descending,few rugae

testes down,good rugae

testes pendulous,deep rugae

   

Genitals (Female)

clitorisprominent & labia flat

prominentclitoris & small labia minora

prominentclitoris & enlarging minora

majora & minora equally prominent

majora large,minora small

majora cover clitoris & minora

   

TOTAL PHYSICAL MATURITY SCORE

PHYSICAL MATURITY

TOTAL SCORE  (NEUROMUSCULAR + PHYSICAL) WEEKS

-10 20

-5 22

0 24

5 26

10 28

15 30

20 32

25 34

30 36

35 38

40 40

45 42

50

MATURITY RATING

Newborn first exam: Apgar score

Factor  Score 0  Score 1  Score 2   Heart rate  No heart rate  Below 100

beats/min Above 100 beats/min

  Breathing  No breathing  Slow and irregular  Good  Muscle tone

 Limp and loose  Some flexing of arms and legs

 Actively moving

  Reflexes  No reflex responses

 Grimaces or frowns when  reflexes are stimulated

 Vigorously cries when reflexes are stimulated

  Colour  Blue and pale  Body is pink but hands and feet are blue

 Entire body is pink

 Characteristics of premature babies• may be reddened. The skin may be thin so blood

vessels are easily seen.Skin• there is a lot of fine hair all over the baby’s body.Lanugo• the limbs are thin and may be poorly flexed or

floppy due to poor muscle tone.Limbs• appears large in proportion to the body. The

fontanelles (open spaces where skull bones join) are smooth and flat.

Head size• no breast tissue before 34 weeks of pregnancy.Chest

• weak or absent.Sucking ability• in boys the testes may not be descended and the

scrotum may be small; in girls the clitoris and labia minora may be large.

Genitals• creases are located only in the anterior (front) of

the sole, not all over, as in the term babySoles of feet

Possible Complications

Respiratory distress syndrome (Hyalin Membran disease)Respiratory distress is a symptom complex arising from disease processes that cause failure to maintain adequate gaseous exchange

•Tachypnea (>60bpm)

•Grunting, Flaring, Retractions/ recessions (GFR)

•Cynosis

•Reduced air entry

>> premature infants, correlating with structural and functional lung immaturity

>> infants born at fewer than 28 weeks’ gestation

1/3 of infants born at 28 to 34 weeks’ gestation

< 5 % of those born after 34 weeks’ gestation.

The condition is more common in boys, and the incidence is approximately six times higher in infants whose mothers have diabetes, because of delayed pulmonary maturity despite macrosomia1.

Obstruction of the airway Lung parenchymal disease 1- Choanal atresia 2- Congenital stridor 3- Tracheal or bronchial stenosis

1- Meconium aspiration 2- Respiratory distress syndrome 3- Pneumonia 4- Transient tachypnea of the newborn

(retained lung fluid) 5- Pneumothorax 6- Atelectasis 7- Congenital lobar emphysema

Non-pulmonary causes Miscellaneous 1- Heart failure 2- Intracranial lesions 3- Metabolic acidosis

1- Disorders of the diaphragm e.g. (diaphragmatic hernia)

2- Pulmonary haemorrhage 3- Pulmonary hypoplasia

CAUSES OF RESPIRATORY DISTRESS

Distinguishing Feature of TTN, RDS and MAS

In Silverman-Anderson score, inspection or auscultation of the upper and lower chest and nares are scored on a scale of 0, 1 or 2 using this system are:

A score greater than 7 indicates that the baby is in respiratory failure.

  0   1  2

 Cyanosis  None  In room air  In 40% FIO2

 Retractions None  Mild  Severe

 Grunting  None  Audible with stethoscope

 Audible without stethoscope

 Air entry Clear  Decreased or delayed  Barely audible

 Respiratory rate Under 60   60-80  Over 80 or apnea

 Score:  > 4 = Clinical respiratory distress; monitor arterial blood gases > 8 = Impending respiratory failure

DOWNE’s SCORING OF RESPIRATORY DISTRESS

RISK FACTORS•Neonates younger than 33-38 weeks•Weight less than 2500g•Maternal diabetes•Cesarean delivery without preceding labor•Precipitous labor•Fetal asphyxia•Second of twins•Cold stress•Previous history of RDS in sibling•Males•whites

ETIOLOGY AND PATHOPHYSIOLOGY.

Surfactant deficiency is the 1O cause of RDS. Low levels of surfactant cause high surface

tension High surface tension makes it hard to expand the

alveoli.Tendency of affected lungs to become atelectatic

at end-expiration when alveolar pressures are too low to maintain alveoli in expansion

Leads to failure to attain an adequate lung inflation and therefore reduced gaseous exchange

Pulmonary Surfactant decreases surface tension

PATHOPHYSIOLOGY

RadiographyHomogenous

opaque infiltrates and

air bronchograms,

indicating contrast in airless lung tissue seen against air-

filled bronchi, decreased lung volumes also

can be detected

Oxygenation with blow-by oxygen, nasal cannula, or mechanical ventilation (CPAP).

Corticosteroid therapy accelerates fetal lung maturation by increasing formation and release of surfactant.

Surfactant replacement therapies Nutrition

MANAGEMENT

Management of Neonatal

Respiratory Distress

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