Fisiologi Neonatus

DR.DIAN R

Cardiovascular Adaptations
3

Fetal-Newborn Transitional Physiology Increased aortic pressure and decreased venous pressure Increased systemic pressure and decreased pulmonary artery

pressure Characteristics of Cardiac Function Closure of the foramen ovale Closure of the ductus arteriosus Closure of the ductus venosus

 Cardiovascular system
The reason for closure is not fully understood Umbilical vein flow ceases at birth Muscular contraction shuts off the ductus venosus, and portal venous pressure rises, directing flow through the liver

 Cardiovascular system Persistent fetal circulation

Hypercarbia, hypoxia, and acidosis can precipitate pulmonary vasoconstriction If RA pressure exceeds LA pressure, the foramen ovale can open, and exacerbate the shunt If the ductus arteriosus fails to close, a right to left shunt may continue

Cardiovascular Physiology (contd)

Neonatal myocardium contains immature contractile

elements and is less compliant than the adult myocardium Limited increase in CO by volume load in a normovolemic newborn CO rate dependent

Pediatric Anatomy/Physiology

Respiratory Adaptations
8

Fetal Lung Development Surfactant Lecithin sphingomyelin

Respiratory Adaptations
9

Fetal Breathing Movements Fluid-filled converted to gas-filled appliance Detected as early as 11 weeks gestation Initiation of Breathing dependent upon Establishment of pulmonary ventilation after birth Increase in pulmonary circulation must occur

Initiation of Breathing
10

Chemical Stimuli CO2 O2 pH Thermal Stimuli

Sensory Stimuli

Chloride Protein molecules

Removal of Lung Fluid at Birth

1. 2. 3. 4. 5.

6.

Fetus = Cl- pumps move fluid into potential air space. Very little protein in potential air space liquid. Newborn = Cl- pumping stops and Na+ pump moves fluid out of alveoli. Air pressure in the alveoli drives liquid out and into interstitium. Expansion of the lung stretches open the pulmonary vessels and thereby reducing pulmonary vessel pressure and hydrostatic pressure. Net result = liquid leaves air spaces and exits the interstitial space via the lymph and microcirculation.

Cardiopulmonary Adaptations
13

PO2 increase Pulmonary artery relaxation Decreased pulmonary vascular resistance

Vascular flow increase

Conversion from fetal to newborn circulation

Characteristics of Newborn Respiration

14

Respiratory rate and rhythm Abdominal breathing Periodic breathing

Tactile or sensory stimulation

Developmental Changes of the Rib Cage

Reproduced from - R. S. Litman: Pediatric Anesthesia The Requisites in Anesthesiology, Elsevier Mosby 2004

CENTRAL NERVOUS SYSTEM

FETAL CNS
Rapid growth of fetal brain during last half of fetal life with peak near time of birth Posture of late fetal flexion attitude Generalized symmetric muscular activity Simple & stereotyped response environmental and internal stimuli to various

CENTRAL NERVOUS SYSTEM

SPECIFIC REACTIONS: Moro reflex Tonic and righting reflex Rooting, sucking, tongue retrusion and swallowing reflexes

CENTRAL NERVOUS SYSTEM

RESPONSE stereotyped TO STIMULI: Simple and

SENSES: Regards moving objects & changing light intensity Hears loud sound

 Central Nervous System The brain at birth is 1/10 the body weight Only of the neuronal cells that exist in adults are present in the newborn Neuronal development finishes as age 12 Myelination is not complete until age 3

Primitive reflexes (Moro, grasp) disappear with myelination

HEMATOLOGIC SYSTEM
FETAL HEMATOPOIETIC SYSTEM Erythropoietin: hormone produced in the glomerular tuft responsible for the production of RBC

Due to relative hypoxia of the fetus stimulating the bone marrow, the fetal hemoglobin is as high as 20g/dl
Blood formation as early as 3rd wk after conception: Mesodermal tissue in the 1st month Liver in the 2nd month Medullary spaces from the 6th month onward

HEMATOLOGIC SYSTEM
NEOWBORN HEMATOPOIETIC SYSTEM At birth, still with high hgb. Starts to drop on the 3rd day of life until a minimum of 10-12g/dl on the 2nd-3rd month of life PHYSIOLOGIC ANEMIA - a result of the following: in bone marrow activity in rate of hemolysis hemodilution due to rapid expansion of blood volume Normal blood volume ranging from 80-90ml/kg WBC ranging from 10,000-30,000/mm3 with PMN predominance

Thermoregulation
Enhanced heat loss due to: relatively larger surface area, thinner layer of insulation and limited capability of heat production

Thermogenesis in brown fat is mediated by the

sympathetic system and stimulated by norepinephrine, resulting in triglyceride hydrolysis.

Pediatric Anatomy/Physiology
Renal System Full term infants have the same number of nephrons as adults Glomeruli are much smaller than in adults GFR in the newborn is 30% that of the adult Tubular immaturity leads to a relative inability to concentrate urine

Pediatric Anatomy/Physiology
Renal System Fluid turnover is 7 times greater than that of an adult Altered fluid balance can have catastrophic consequences Organ perfusion and metabolism count on adequate hydration Infants and children are at a much higher risk for developing dehydration

Pediatric Anatomy/Physiology
Hepatic System Neonatal liver is large Enzyme systems exist but have not been sensitized or induced Neonates rely on limited supply of stored fats Gluconeogensis is deficient Plasma proteins are lower, greater levels of free drug exist

Hepatic Considerations-Carbohydrate Metabolism

28

Stores of liver glycogen are depleted first, then

fat and protein are metabolized NO routine glucose levels obtained on newborn admission in MOST facilities Blood work is obtained on an as needed basis, including newborns blood type

Chapter 23

Hepatic Considerations-Conjugation of Bilirubin

29

Bilirubin is a yellow lipid-soluable pigment

Cojugation refers to the conversion of bilirubin into a

water-soluble pigment Unconjugated bilirubin is toxic and is not readily excreted (destroyed rbcs end-product)

Chapter 23

Hepatic Considerations-Physiologic Jaundice

30

Impaired conjugation of bilirubin

Increased bilirubin reabsorption from the

intestinal tract Pathologic if appears within the first 24 hours of life Peak bilirubin levels reached between days 3-5 of life in the term and 5-7 in the preterm

Hepatic Considerations-Coagulation 31
Coagulation Factors II, VII, IX, and X are

synthesized in the liver and are activated under the influence of vitamin K Vitamin K is produced in the liver Normal flora is needed to produce vitamin K

GASTROINTESTINAL SYSTEM
FETAL GI SYSTEM
Swallowing as early as the 12th week of gestation

Absence of excretion via the GIT unless with sphincter relaxation during hypoxic event.
Accumulation of epithelial debris and conjugated bilirubin in small intestine

Pediatric Anatomy/Physiology
GI System Gastroesophageal reflux is common until 5 months of age Gastric pH and volume are close to adult range by 2nd day of life Gastric pH is alkalotic at delivery Lactose is the primary CHO in breastfed newborns and is easily digested and well absorbed Pancreatic amylase is not present in the newborn, it arrives after the first few months of life (avoid starches until then)

Gastrointestional AdaptationsElimination 34
Meconium, road tar, . . ., first stool

Passed within 8-24 to 48 hours of life

Transitional stool may be seedy, think brown to

green or yellow and then fecal Frequency: 2-3 or as much as 10 per day NOT constipated, if stool is soft

Chapter 23

IMMUNOLOGIC SYSTEM
FETAL IMMUNE SYSTEM Liver serves as the repository for lymphoid precursor cells during early intrauterine life. T cell functions begin as early as 7 weeks Circulating B cells are seen as early as 13 weeks. IgM antibodies are first to develop

IMMUNOLOGIC SYSTEM
NEWBORN IMMUNE SYSTEM

Considered completely developed immunological system but with inadequate antigenic stimulus

38

IgG (G= given) crosses the placenta This is passive acquired immunity or active acquired immunity
IgM (M= mine, all mine) the babe develops the

Immunologic Adaptations

antibodies by him or herself

This is termed active immunity, but doesnt usually occur until about 18 months Immunizations are begun at 2 months of age to offer immunity

IgA (A= another gift from mom) immunity

transferred through breastmilk

Chapter 23

ENDOCRINE SYSTEM
FETAL ENDOCRINE SYSTEM
The pituitary adrenal axis and thyroid gland function separately from that of the mother to ensure adequate growth of infant. Peculiarities in the fetus: Maternal estrogenic effects urinary 17-ketosteroids

ENDOCRINE SYSTEM
NEONATAL ENDOCRINE SYSTEM
MATERNAL ESTROGENIC EFFECTS Hypertrophied mammary glands Witch milk Mucoid to bloody vaginal discharge