IT IS RATIFIED

____ __________ In 2017

by the chief of the department of pediatrics
___________________________

METHODICAL RECOMMEDATIONS 1 (module 2)

FOR SUPERVISOR OF MEDICAL FACULTY FOR PRACTICAL LESSON:
SPECIFIC ADAPTATIONS, CARE AND FEEDING OF PREMATURE
NEWBORNS

FNU, 2017
. ACTUALITY OF THEME
Intensive care and nursing of premature babies belong to major problems of
health care all over the world. The structure of perinatal and neonatal mortality in
premature babies makes 70,0-75,0%. Incidence of premature infants exceeds
number of full-term children.
For postnatal adaptation of premature babies maitainance of adequate
enviroment due to intrauteral condition corresponding to gestational age is needed.
Since compliance with these conditions depends on the level of survival, health
status and quality of life of premature babies.
. EDUCATIONAL AIMS OF PRACTICAL LESSON:
STUDENT SHOULD BE ABLE TO KNOW:
1. Determination of prematurity and gestational age in premature baby.
2. Morphological and neurological signs of prematurity.
3. Clinical course and diagnosis of perinatal pathology in premature infants.
4. Features of intensive care and nursing of premature infants.

STUDENT SHOULD BE ABLE TO:

1.Assess the health of the newborn.
2.Collect medical history and physical examination of newborn.
3.Assess results of laboratory research.
4.Formulate the diagnosis according to modern classification.
5. Organize nursing of premature babies in specialized department and intensive
care unit and treatment of pathological conditions in preterm infants.

. INTERDISCIPLINARY INTEGRATION.

/ Disciplines To know To be able

1. Providing discipline:
1.Normal anatomy Features of the fetus in
different periods of
gestation
2. Normal physiology Functional
characteristics of fetal
organs and systems in
different periods of
gestation
Assess gestational age
of fetus due anatomic
features
Identify morpho-
functional features of
the fetus according to
gestational age

3. Pharmacology Features of Assign and calculate

pharmacokinetics, infusion therapy,
pharmacodynamics of symptomatic agents,
medicines in fetus and antibiotics in newborns
newborn depending on duration
of gestation
4. Propaedeutic of Anatomical and Calculate gestation age in
pediatrics physiological features premature baby, its
 of newborn and clinical status, make
premature baby with physical examination,
different gestation age organize nursing of
premature babies
2 Radiology: Peculiarities of lungs Calculate radiological
1.X-ray diagnosis and central nervous criteria of respiratory
system in premature distress syndrome,
infants ultrasound data for
ischemic and
hemorrhagic CNS
disorders
2. Genetics The most common Define stigma, appoint
stigma of genetic tests to
dysembriogenesis and diagnose chromosomal
principles of genetic disorders
examination
3. Integration between Prematurity and Assess clinical status
subjects gestational age and conduct the
assessment, examination of
morphological and premature baby,
neurological signs of organize nursing,
prematurity, clinical diagnostics and
features of perinatal treatment of main
pathology in premature pathological conditions
infants in premature infants

IV. TABLE OF CONTENTS OF PRACTICAL LESSON: Premature birth

(also known as preterm birth) is the birth of a baby before the standard period of
pregnancy is completed. In most systems of human pregnancy, prematurity is
considered to occur when the baby is born sooner than 37 weeks after the beginning
of the last menstrual period (LMP). The opposite condition, postmature birth, is
defined as birth more than 42 weeks after the LMP. The standard length of a human
gestation is 266 days. However, for convenience most timing is based on the LMP,
with conception being assumed to occur approximately 14 days after the LMP,
making a standard term pregnancy 280 days or 40 weeks. Premature or preterm
birth (the babies are called premies) is defined medically as childbirth occurring
earlier than 37 completed weeks of pregnancy. Approximately 12 percent of babies
in the United States or 1 in 8 are born prematurely each year. In 2003, more
than 490,000 babies in the U.S. were born prematurely. Worldwide rates of
prematurity are more difficult to obtain as the lack of widespread professional
obstetric care in developing regions makes determination of gestational age less
reliable. The World Health Organization instead tracks rates of low birth weight,
which occurred in 16.5 percent of births in less developed regions in 2000. It is
estimated that one-third of these low birth weight deliveries are due to premature
delivery. The shorter the term of pregnancy, the greater the risks of complications.
Infants born prematurely have an increased risk of death in the first year of life
(infant mortality), with most of that occurring in the first month of life (neonatal
mortality). Worldwide, prematurity accounts for 10% of neonatal mortality, or
around 500,000 deaths per year. In the U.S. where many infections and other causes
of neonatal death have been markedly reduced, prematurity is the leading cause of
neonatal mortality at 25%. Prematurely born infants are also at greater risk for
developing serious health problems such as cerebral palsy, chronic lung disease,
gastrointestinal problems, mental retardation, vision or hearing loss and are more
susceptible to developing depression as teenagers. Although there are several
known risk factors for prematurity (see below), nearly half of all premature births
have no known cause. When conditions permit, doctors may attempt to stop
premature labor, so that the pregnancy can have a chance to continue to full term,
thereby increasing the baby's chances of health and survival. However, there is
currently no reliable means to stop or prevent preterm labor in all cases. In fact, the
rate of preterm births in the United States has increased 30% in the past two
decades. In developed countries premature infants are usually cared for in a
Neonatal Intensive Care Unit (NICU). The physicians who specialize in the care of
very sick or premature babies are known as neonatologists. In the NICU, premature
babies are kept under radiant warmers or in incubators (also called isolettes), which
are bassinets enclosed in plastic with climate control equipment designed to keep
them warm and limit their exposure to germs. Modern neonatal intensive care
involves sophisticated measurement of temperature, respiration, cardiac function,
oxygenation, and brain activity. Treatments may include fluids and nutrition
through intravenous catheters, oxygen supplementation, mechanical ventilation
support, and medications. In developing countries where advanced equipment and
even electricity may not be available or reliable, simple measures such as kangaroo
care (skin to skin warming), encouraging breastfeeding, and basic infection control
measures can significantly reduce preterm morbidity and mortality."Ex-premies" is
the term given to preterm infants born before the normal 37 weeks gestation. There
are many different factors that may contribute to a preterm birth.

Factors related to maternal disease or condition that have been shown to increase
the risk of preterm birth, with associated odds ratio (OR) when known include:

Chromosomal abnormalities; Dr. Aaron Caughey, a perinatologist at UCSF,

states: "...it's important to note that the majority of miscarriages up to 80
percent happen due to chromosomal abnormalities that have nothing to do
with the mother's behavior. The last thing women who have had miscarriages
need to do is blame themselves...." source: high blood pressure (OR = 4.06)
pre-eclampsia (OR = 4.0)

age > 35 (OR = 1.8)

age < 18 (OR = 3.4) short cervix (the strongest predictor of premature birth)
 maternal diabetes

anxiety

periodontal disease (OR = 4.45)

Whether or not urinary tract infections directly cause preterm birth is uncertain,
however, it is known that urinary tract infections increase pre-eclampsia, which as
stated above, increases the risk of preterm birth. Sexually transmitted disease
(STD), Beta Strep, kidney disease, and uterine infections are also suspected of
increasing the risk of preterm birth.

Adequate maternal nutrition is important to fetal development and a diet low in

saturated fat and cholesterol may help reduce the risk of a preterm delivery. Factors
related to pregnancy history that have been shown to increase the risk of preterm
birth include:

prior preterm delivery (OR = 2.79)

prior induced abortion (OR = 1.6)
antepartum hemorrhage / vaginal bleeding during labor
prior miscarriage

Multiple pregnancies (twins, triplets, etc.) are another significant factor in preterm
birth. The March of Dimes Multicenter Prematurity and Prevention Study found
that 54% of twins were delivered preterm vs. 9.6% of singleton births. Women who
have tried to conceive for more than a year before getting pregnant are at a higher
risk for premature birth. A recent study done by Dr. Olga Basso of the University of
Aarhus in Denmark and Dr. Donna Baird of the U.S. National Institute of
Environmental Health Sciences suggests that women who had difficulty conceiving
were about 40 percent higher risk of preterm birth than those who had conceived
easily.

Finally, the use of tobacco and alcohol during pregnancy also increases the chance
of preterm delivery. Tobacco is the most commonly abused drug during pregnancy
and also contributes significantly to low birth weight delivery. Recent research has
identified possible methods to prevent preterm birth, pre-eclampsia/eclampsia,
premature rupture of membranes, and preterm labor. These include self-care
methods to reduce infections, nutritional and psychological interventions, and the
control of preterm birth risk factors (e.g. working long hours while standing on feet,
carbon monoxide exposure, domestic abuse, and other factors). Injection with a
form of progesterone (17 alpha-hydroxyprogesterone caproate) although the safety
of this treatment for the fetus has been questioned by the FDA and its expert panel
due to an associated increase in miscarriage and fetal death, the use of vaginal
progesterone,taking fish oil supplements, and self-monitoring vaginal PH followed
by yogurt treatment or Clindamycin treatment if the PH was too high all seem to be
effective at reducing the risk of preterm birth. This research is quite new; however,
doctors using these newer strategies have obtained preterm birth rates as low as 1 to
2%, compared to the 11 to 16% currently in the US. Although short term use of
folic acid may not have an effect, genetic variation in folate metabolism affects
prematurity, and a recent report suggests that usage by mothers for more than a year
before birth can reduce premature birth by 50 to 70 percent.

The symptoms of an imminent premature birth include:

Four or more uterine contractions in one hour, before 37 weeks' gestation.

A watery discharge from the vagina, which may indicate premature
rupture of the membranes surrounding the baby.
Pressure in the pelvis or the sensation that the baby has "dropped".
Menstrual cramps or abdominal pain.
Pain or rhythmic tightening in lower abdomen or back.
Vaginal spotting or bleeding.

There are two tactics that can be used to deal with a potential premature birth: delay
the arrival of birth as much as possible, or prepare the prospectively premature fetus
for arrival. Both of these tactics may be used simultaneously. Delaying the
premature birth from occurring is typically the most favored option. This gives the
fetus or fetuses as much time as possible to mature in the womb. There are a
number of techniques that can be used to try to accomplish this. The first resort is
usually complete bed rest. Maintaining a horizontal position reduces pressure on the
cervix, which may allow it to stay lengthened longer, and avoiding unnecessary
movement may reduce uterine irritation, which can lead to contractions. Likewise,
proper nutrition and especially hydration are important: dehydration can lead to
premature uterine contractions. In a hospital setting, a drug-free IV drip may be
used to try to stop premature labor simply by improving the mother's hydration.
Lastly, there are anti-contraction medications (tocolytics), such as ritodrine,
fenoterol, nifedipine and atosiban, although these do not appear to have more than a
short-term effect on delaying delivery. Premature birth can not always be
prevented. Severely premature infants may have underdeveloped lungs, because
they are not yet producing their own surfactant. This can lead directly to
Respiratory Distress Syndrome, also called hyaline membrane disease, in the
neonate. To try to reduce the risk of this outcome, pregnant mothers with threatened
premature delivery prior to 34 weeks are often administered at least one course of
glucocorticoids, a steroid that crosses the placental barrier and stimulates growth in
the lungs of the fetus. Typical glucocorticoids that would be administered in this
context are betamethasone or dexamethasone, often when the fetus has reached
viability at 23 weeks. In cases where premature birth is imminent, a second
"rescue" course of steroids may be administered 12 to 24 hours before the
anticipated birth. There is no research consensus on the efficacy and side-effects of
a second course of steroids, but the consequences of RDS are so severe that a
second course is often viewed as worth the risk. Research reported at the 2008
conference of the Society for Maternal-Fetal Medicine suggests that administration
of magnesium sulfate (Epsom salt) to women just before premature birth can cut
the rate of cerebral palsy in half. While the compound is cheap and safe, it may
make mothers and infants groggy, and details are pending scientific publication.
Premature infants show physical signs of their prematurity and may develop other
problems as well. These include, but are not limited to, the following:

Neurologic

Apnea of prematurity
Hypoxic-ischemic encephalopathy (HIE)
Intracranial hemorrhage
Retinopathy of prematurity (ROP)
Developmental disability

Cardiovascular

Patent ductus arteriosus (PDA)

Respiratory

Respiratory distress syndrome (RDS or IRDS) (previously called Hyaline

membrane disease)
Chronic lung disease (previously called bronchopulmonary dysplasia or
BPD)

Gastrointestinal / metabolic

Hypoglycemia
Feeding difficulties
Rickets of prematurity
Hypocalcemia
Inguinal hernia
Necrotizing enterocolitis (NEC)

Hematologic

Anemia of prematurity
Thrombocytopenia
Hyperbilirubinemia (jaundice)

Infectious

Sepsis
Urinary tract infection
 Formation of the functions responsible for homeostasis fetus and the
newborn, occurs in the early stages of pregnancy. Health care processes of
adaptation and compensation of basic body functions newborn begins long before
and continues after birth. Physiological methods of a delivery and nursing largely
depend on the morphological and functional maturity of the fetus. The main
requirements for these methods is:
-Preparation and maintenance of adaptive and compensatory processes fetus before
birth;
-Provide adequate routine and emergency care in childbirth, depending on the
maturity of the fetus;
-Control over the formation of pulmonary gas exchange and postnatal circulatory
adaptation- Maintaining a normal body temperature;
-Prevention of perinatal infection, maternal contamination of normal microflora;
-Consistent assistance in feeding, adequate maturity, support for water-salt
metabolism;
-Facilitate the excretory and detoxication functions;
-Establish emotional contact, mother-child in the area of biological comfort.
According to the WHO newborns divided by gestation periods:
1. Born in time and after 37 to 42 weeks (at term).
2. Born after 42 weeks (perenosheni).
3. Born to a term of 37 weeks (preterm).

VI. Plan and structure of the lesson:

6.1.Duration of the lesson: 2 hours.
6.2. Stages of the lesson:
Basic stages of the lesson and their Level of Students knowledge Time
content study control methods,
goals educational and
acquiring methodical means
1 Introductive stage: =- Students 10-20
- Organization of the lesson; questioning, use of min.
- Defining the study goals and tables, tests
motivation; (computer programs)
- Control of students primary
knowledge and skills;
- Clinics and the course of different
forms of intrauterine infections;
- Diagnostics of different forms of
intrauterine infections;
- Drug therapy and emergency care.
2 Basic stage: = Newborns with 70-80
Professional knowledge and skills intrauterine min.
training: infections (3
- Follow-up of the newborns with patients). Results of
intrauterine infections; the additional
 - Discussion and evaluation of the diagnostic methods
results of treatment and questions (neurosonography,
concerning clinico-laboratory electrocardiogram,
diagnostics, differential treatment ultrasound
and prophylaxy diagnostics),
doctors
prescriptions.
Means: tables,
lantern slides, blood
samples.
3 Final stage: = Individual control of 5-10
Control and correction of students students practical min.
professional knowledge and skills. skills and results of
Making conclusions and setting the patients
home task. management.
Clinical situation
tasks solving.

VII. IMATERIALS OF THE METHODICAL PROVIDING OF

PRACTICAL LESSON
CONTROL QUESTIONS:
1. Main reasons of immaturity and small-weight-before gestation age.
2. Morphological signs of immaturity.
3. Neurological signs of immaturity.
4. Features of postnatal adaptation of small-weight-before gestation age infants.
5. Regulation of body temperature in small-before-gestation age babies, regime
of management.
6. Feeding of prematurely born infants.
7. The main pathological conditions of IUGR infants.
8. Defeats of spinal cord, depending on the degree and localization of defeat.
9. Perinatal hypoxic-ischemic damages of central nervous system.
10. Pathogenesis, clinic, diagnostics, treatment, prophylaxis.
11. Respiratory distress syndrome in newborns. Pathogenesis, clinic, diagnostics,
prophylaxis, treatment.

TESTS:
1.Two infants are born at 36 weeks gestation. Infant A weighs 2600 g (5 lb, 12 oz)
and infant B weighs 1600 g (3 lb, 8 oz). Infant B is more likely to have which of the
following problems?
A. Congenital malformations
B. Low hematocrit
C. Hyperglycemia
D. Surfactant deficiency
E. Rapid catch-up growth retardation

2.An infant weighing 1400 g (3 lb) is born at 32 weeks gestation in a delivery

room that has an ambient temperature of 240C. If left in an open crib for a few
minutes, this child is likely to demonstrate
A. Ruddy complexion
B. Shivering
C. Hypertension
D. Increased respiratory rate
E. Metabolic alkalosis
3. A recovering premature infant who weighs 950 g (2 lb, 1 oz) is fed breast milk to
provide 120 cal/(kg_d). Over ensuing weeks, the baby is most apt to develop
A. Hypernatremia
B. Hypocalcemia
C. Blood in the stool
D. Hyperphosphatemia
E. Vitamin D toxicity
4. The second infant of a twin gestation in a primiparous mother weighed 1500 g at
36 weeks' gestation. Both twins were breast-fed and maintained in a neutral thermal
environment. On the third day of life, the infant was noted to be hypotonic and to
respond poorly to stimuli. The most likely diagnosis is
A. Polycythemia
B. Twin-twin transfusion syndrome
C. Kernicterus
D. Hypoglycemia
E. Renal vein thrombosis
5. Newborns (term or premature) should be given all of the following prophylactic
measures EXCEPT
A. Daily hexachlorophene baths
B. Triple dye on the cord
C. Silver nitrate in the eyes
D. Vitamin K intramuscularly
6. The most common cause of late-onset infections in infants weighing less than
1500 g is
A. Candida albicans
B. Coagulase-negative staphylococci
C. E. coli
D. Group B streptococci
E. Pseudomonas
7. A 21-day-old infant born at 27 weeks' gestational age is recovering from RDS
and a grade IV intraventricular hemorrhage. She now manifests increasing apnea
and bradycardia, a tense fontanel, lethargy, and split sutures. A sepsis evaluation
reveals a normal complete blood count (CBC), and analysis of the cerebrospinal
fluid (CSF) reveals a protein value of 290 mg/dL, glucose level of 10 mg/dL, and
159 leukocytes. The Gram stain is negative for bacteria. The most likely diagnosis
is
A. Bacterial meningitis
B. HSV encephalitis
C. Tuberculous meningitis
D. Posthemorrhagic hydrocephalus
E. Citrobacter brain abscess
8. A 2700-g 36-week-gestational-age white male is born after 22 hours of
premature rupture of the amniotic membranes. The Apgar scores are 3 and 5. He
immediately develops respiratory distress and cyanosis requiring endotracheal
intubation and mechanical ventilation with 100% oxygen. Vital signs are
temperature 35.7C, heart rate 195, and mean blood pressure 22 mm Hg.
Laboratory tests reveal a white blood cell count of 1500 and 59,000 platelets.
The next most appropriate treatment for this child is
A. Surfactant by aerosol
B. Intravenous ampicillin and gentamicin
C. Intravenous immunoglobulin
D. Intravenous acyclovir
E. Oscillator ventilation
9. Point out the gestation age of a fu;; term newly-born:
A. 28-38 weeks.
B.38-42 weeks.
C.39-40 weeks.
D.40-42 weeks.

10. A child is considered to be full-term if its weight is:

A. 2500-4000 gr.
B.3000-3500 gr.
C.2300-3800 gr.
D.2000-3500 gr.
11.Very low birth weight (VLBW) infants are all except: A) infants with
birthweight less than 1000-1500 gr.; B) infants with birthweight less than1500-
2000gr.; C) infants with birthweight less than 1000 gr.
12. Among disorders of respiratory adaptation in premature infants there are: A)
congenital heart failures; B) low blood pressure; C) hypovolemic condition; D) all
listed above.

13.Generalized cyanosis in first week of life infant testifies about: A) policytemia;

B) congenital heart failures; C) persistent fetal circulation (PFC); D) all the answers
are correct; E) all the answers are correct , except of a.
14. For VLBW infants there is not typical pathological condition: A) patent ductus
arteriosus; B) respiratory distress-syndrome of I type; C) neonatal necrotizing
enterocolitis (NEC); D) respiratory distress -syndrome of II type.
15. Which of the given below is characteristic feature of a newly-born unripeness?
A) Adequate development of hypodermic tissue. B) Head hair is 2-3 sm. long. C)
Nails are soft and do not reach finger-tips. D) Testicles are in the gate, girls large
lips of pudendum cover small lips of pudendum. E) Lanugo is found on shoulders
and upper part of body.

KEYS TO TESTS
1. A.
Small-for-dates infants are subject to a different set of complications than preterm
infants whose size is appropriate for gestational age. The small-for-dates infants
have a higher incidence of major congenital anomalies and are at increased risk for
future growth retardation, especially if length and head circumference as well as
weight are small for gestational age. Also more common are neonatal asphyxia and
the meconium aspiration syndrome, which can lead to pneumothorax,
pneumomediastinum, or pulmonary hemorrhage. These, rather than hyaline
membrane disease, are the major pulmonary problems in these infants. Because
neonatal symptomatic hypoglycemia is more commonly found in small-for dates
infants, careful blood glucose monitoring and early feeding are appropriate
precautions. Normal or elevated hematocrit is also more common in these infants.

2. D.
A room temperature of 24C (approximately 75F) provides a cold environment for
newborn infants. Aside from the fact that these infants emerge from a warm,
37.6C (99.5F) intrauterine environment, at birth, infants (and especially preterm
infants) are wet, have a relatively large surface area for their weight, and have little
subcutaneous fat. Within minutes of delivery, the infants are likely to become pale
or blue and their body temperatures will drop. In order to bring body temperature
back to normal, they must increase their metabolic rate; ventilation, in turn, must
increase proportionally to ensure an adequate oxygen supply. Because a preterm
infant is likely to have respiratory problems and be unable to oxygenate adequately,
lactate can accumulate and lead to a metabolic acidosis. Infants rarely shiver in
response to a need to increase heat production.
3. B
It is usually impossible with any combination of parenteral and enteral nutrition to
match what the infant would have accumulated in utero. The average, healthy, low-
birth-weight infant of this size requires a daily intake of calcium of about 200
mg/kg. Breast milk has much less calcium (and phosphorus) than do commercial
formulas. The breast milk can be supplemented with calcium, or it can be mixed
with commercial formulas designed for the premature infant. Breast milk promotes
gut maturation and prevents intestinal atrophy induced by lack of enteral feeding.
Breast milk, however, is likely to have insufficient calcium and phosphorus
for catch-up growth.
4.D.
Hypoglycemia is common in infants who are small for gestational age (1500 g at 36
weeks' gestation is SGA). Breast-feeding twins is often difficult, and this SGA
infant began life with diminished glycogen and fat stores. The poor nutrient intake
and this metabolic predisposition resulted in hypoglycemia. The blood glucose was
25 mg/dL. The infant responded to 2 mL/kg of intravenous 10% dextrose.
Polycythemia is possible, but if the twins are mono-ovular and monochorionic-
diamnionic, the small twin is usually anemic.
5. A.
Daily hexachlorophene bathing has been associated with neurotoxicity. A single
bath suffices if there is a Staphylococcus aureus epidemic.
6. B.
Coagulase-negative streptococci are the most common nosocomial cause of
bacteremia in premature infants in many neonatal intensive care units.

7. D.
A tense fontanel, wide sutures, lethargy, apnea, and bradycardia suggest increased
intracranial pressure. The CSF profile (other than a negative Gram stain) is
suggestive of meningitis or persistent unresolved CSF blood and inflammation.
Computed tomography or a head ultrasonogram will confirm the diagnosis. In most
neonatal intensive care units, pending the initial results of the sepsis evaluation, this
infant would receive broad-spectrum antibiotics.
8. B.
After an arterial blood gas determination that demonstrates hypoxia on an FIO2 of
1.0, surfactant should be administered by direct endotracheal installation, not by
aerosol. In addition, the patient described in the question demonstrates severe
hypotension, which should be treated first with intravenous fluids such as normal
saline and then by inotropic agents such as dopamine.
9. B.
10. A.
11.A;
12.A;
13.A;
14.A.
15.C.

VII.2 Materials of the methodical providing for

main stage of practical lesson:
Reference card for individual work of students with literature.
.
Task Guidelines Note
n/n
1. Consider: 1. Define prematurity and
1. Determination of prematurity and create classification.
gestational age in premature baby. 2. Reasons of prematurity
2. Morphological and neurological due to pregnancy.
signs of immaturity. 3. Major pathological
 3. Clinical course and diagnosis of conditions in babies.
perinatal pathology in premature 4. Develop algorithms for
infants. nursing and feeding of
4. Features of intensive care and premature infants according
nursing of premature babies. to gestational age.
5. Name diagnostic
algorithms of CNS
disorders, respiratory
distress syndrome, perinatal
infections, sepsis and
intrauteral retardation in
premature babies.

VII.3 Materials for control of final stage of the lesson:

CASE STUDY 1.
Mother came to neonatologist with baby 32 weeks of gestation age. Body weight of
it is 1600 grams, 5-6 points due to Apgar score, 4 points due to Silverman score.
On the third day of life child's condition get worsened: signs of respiratory distress
appeared, wheezing, periodic apnea, oral and acrocyanosis, regurgitation, bloating
were observed.
1. Preliminary diagnosis.
2. Treatment.
3. Make plan of treatment.
4. Prescribe respiratory therapy.
CASE STUDY 2.
Premature baby developed signs of severe respiratory distress, general edema, moist
rales in lower lobers of lungs during auscultation. On the second day multiple dermal
extravasates appeared. Bloody foam from the mouth appeared. X-ray of the chest
atelectasis of the right lung . CBC: Hb - 100 g / l, hematocrit - 0.45 g / liter.
1. Put the diagnosis.
2. Make plan of treatment.
3. Give medicines.
4. Assign respiratory therapy.
CASE STUDY 3.
Neonates with 33-34 weeks of gestation age developed flabby decreased muscle tone,
decreased reflexes, rapidly depleted, upper limbs tremor. Skin is pink, oral and
acrocyanosis, expressed puffiness developed. The body temperature is 36.3 0C,
repiratory rate is 56/min., heart rate is 140/min.
1. Put the diagnosis.
2. Treatment.
CASE STUDY 4.
On examination 34-35 weeks of gestation age newborn manifests with muscle
hypotension, decreased reflexes, quickly depleted, flabby breast sucking. Heart rate is
140 per 1 min, respiratory rate is 60 for 1 min, periodically gives apnea. Blood glucose
is 2.2 mmol / l.
1. Put the diagnosis.
2. Measures for correction of clinical condition.
3. Assign treatment.
CASE STUDY 5.
30-31 weeks of gestation age infant was born without asphyxia. In maternity
hall the boy began to moan. There is expressed involvement of interspaces between
ribs during first inhalation. Breathing is weakened, plenty of wheezed are heard.
Tones of heart are rhythmic; frequency of heart beating is 160 in 1 min. The
stomach is flat, liver comes forward 2,0 sm.
Questions:
1. Put the previous diagnosis.
2. Tactic of neonatologist in maternity hall.
3. Work out the plan of inspection.
4. Appoint primary therapy for this child.
5. Appoint feeding for this child.
6. Appoint antimicrobial therapy.
7. Appoint infusion therapy.
8. Is it needed to conduct haemostatic therapy and why?
ANSWERS
CASE STUDY 1.
1. RDS.
2. X-ray of the chest, common protein, electrolytes, blood gases.
3. Infusional therapy, maintainance of the adequate temperature, partial parenteral
nutrition, antibiotics, if necessary, introduction of artificial surfactant.
4. SRAR therapy, in progression of respiratory distress - mechanical ventilation.
CASE STUDY 2.
1. RDS, atelectasis of the right lung.
2. X-ray of the chest, common protein, electrolytes, blood gases.
3. Infusional therapy, maintainance of the adequate temperature, partial parenteral
nutrition, antibiotics, if necessary, introduction of artificial surfactant.
4. SRAR therapy, in progression of respiratory distress - mechanical ventilation.
CASE STUDY 3.
1. Hypothermia
2. Assign contact skin to skin or put the baby in termokar, check the temperature in
the room, determine the level of glucose in the blood, feed the baby, measure the
temperature over 15-30 min.
CASE STUDY 4.
1. Laboratory to determine glucose levels.
2. Start infusion therapy glucose solution (2 ml / kg) bolus into a peripheral vein, after
30 minutes of early correction of hypoglycemia glucose test.
Problem 5.
1. In utero infection
2. Conduct survey of TORCH infection.
Problem 6.
1. Hyperbilirubinemia premature baby.
2. phototherapy, dufalak
CASE STUDY 5
1. RDS of III degree .
2. The intubation, application of artificial surfactant are needed.
3. Common analysis of blood and urine, levels of protein, immunological
investigation, electrolytes, sugar of blood, X-rays investigation of the lungs,
ultrasonography of the heard, ultrasound investigation of internal organs.
4. Introduction of artificial surfactant.
5. Parenetral feeding. Appointing of mixture feeding is needed.
6. Appoint two antibiotic drugs: cephalosporins of III generation 40-80
mg/kg/min., micacyni 15 mg/kg/min.
7. 10% solution of glucose 60 mg/kg.
8. Yes, it is needed because of hemorrhagic syndrome in small-before-
gestation-age infants.

List of literature
Main literature
1. Departments lecture on prematurity
2. Pediatrics: textbook / O.V. Tiazhka. 2 nd edition, reprint.- Vinnytsia: Nova
Knyha, 2016. 544 p.: il.
Additional literature:
1. Tricia Gomella, M. Cunningham, Fabien Eyal and MD Tricia Lacy Gomella ,
Neonatology: Management, Procedures, On-Call Problems, Diseases, and
Drugs, Sixth Edition (LANGE Clinical Science) , (Jun 19, 2009)
2. Tom Lissauer and Avroy A. Fanaroff , Neonatology at a Glance (Mar 1,
2011)
3. John P. Cloherty, Eric C. Eichenwald, Anne R. Hansen MD MPH and Ann
R. Stark MD ,Manual of Neonatal Care (Lippincott Manual Series (Formerly
known as the Spiral Manual Series)), (Sep 28, 2011)
4. William Oh Evidenced-Based Handbook of Neonatology (Jun 10, 2011)
5. Merenstein & Gardner's Handbook of Neonatal Intensive Care, 7e by Sandra
Lee Gardner RN MS CNS PNP, Brian S. Carter MD FAAP, Mary I Enzman-
Hines RN PhD CNS CPNP AHN-BC and Jacinto A. Hernandez MD PhD
MHA FAAP (Apr 15, 2010)
6. Atlas of Procedures in Neonatology (MacDonald, Atlas of Procedures in
Neonatology) by Mhairi G. MacDonald and Jayashree Ramasethu (Jun 4,
2007)
Methodical development was done by assistant Golodnykh O.A.
It has been approved at the meeting of the department
Protocol 338 from 29.08.17.
Chief of the department of pediatrics professor Volosyanko A.B.