Pediatric Physiology All

Pediatrics
Physiology
Definitions
Preterm or Premature Infant: < 37 weeks
Term Infant: 38-42 weeks gestation
Post Term Infant: > 42 weeks gestation
Newborn: up to 24 hours old
Neonate: 1-30 days old
Infant: 1-14 months old
Child: 14 months to puberty (~12-13 years)
Body Size
The most obvious difference between children & adults
is size
It makes a difference which factor is used for
comparison: a newborn weighing 3kg is
1/3 the size of an adult in length
1/9 the body surface area
1/21 the weight
Body surface area (BSA) most closely parallels

variations in BMR & for this reason BSA is a better
criterion than age or weight for calculating fluid &
nutritional requirements
Body Size
Fetal Development
The circulatory system is the first to achieve a functional
state in early gestation
The developing fetus outgrows its ability to obtain &
distribute nutrients and O2 by diffusion from the placenta
The functioning heart grows & develops at the same

time it is working to serve the growing fetus
At 2 months gestation the development of the heart and blood
vessels is complete
In comparison, the development of the lung begins later & is
not complete until the fetus is near term
Fetal Circulation
Placenta
Gas exchange
Waste elimination
Umbilical Venous Tension is 32-35mmHg

Similar to maternal mixed venous blood
Result:
O2 saturation of ~65% in maternal blood, but ~80% in the fetal
umbilical vein (UV)
Low affinity of fetal Hb (HbF) for 2,3-DPG as compared with

adult Hb (HbA)
Low concentration of 2,3-DPG in fetal blood
O2 & 2,3-DPG compete with Hb for binding, the

reduced affinity of HbF for 2,3-DPG causes the Hb to
bind to O2 tighter
Higher fetal O2 saturation
Fetal Circulation
P50 is 27mmHg for adult Hgb, but only 20mmHg for

fetal Hb
This causes a left shift in the O2 dissociation curve
Because the bridge between arterial & tissue O2 tension

crosses the steep part of the curve, HbF readily unloads
O2 to the tissue despite its relatively low arterial
saturation
Fetal Circulation
Fetal Circulatory Flow
Starts at the placenta with the umbilical vein
Carries essential nutrients & O2 from the placenta to

the fetus (towards the fetal heart, but with O2 saturated
blood)
The liver is the first major organ to receive blood

from the UV
Essential substrates such as O2, glucose & amino acids

are present for protein synthesis
40-60% of the UV flow enters the hepatic
microcirculation where it mixes with blood draining
from the GI tract via the portal vein
The remaining 40-60% bypasses the liver and

flows through the ductus venosus into the upper
IVC to the right atrium (RA)

The fetal heart does not distribute O2 uniformly
Essential organs receive blood that contains more
oxygen than nonessential organs
This is accomplished by routing blood through
preferred pathways
From the RA the blood is distributed in two

directions:
1. To the right ventricle (RV)
2. To the left atrium (LA)
Approximately 1/3 of IVC flow deflects off the

crista dividens & passes through the foramen
ovale of the intraatrial septum to the LA

Flow then enters the LV & ascending aorta
This is where blood perfuses the coronary and cerebral
arteries
The remaining 2/3 of the IVC flow joins the

desaterated SVC (returning from the upper body)
mixes in the RA and travels to the RV & main
pulmonary artery
Blood then preferentially shunts from the right to the
left across the ductus arteriosus from the main
pulmonary artery to the descending aorta rather than
traversing the pulmonary vascular bed
The ductus enters the descending aorta distal to the
innominate and left carotid artery
It joins the small amount of LV blood that did not perfuse the
heart, brain or upper extremities

The remaining blood (with the lowest sat of 55%)
perfuses the abdominal viscera
The blood then returns to the placenta via the
paired umbilical arteries that arise from the
internal iliac arteries
Carries unsaturated blood from the fetal heart
The fetal heart is considered a Parallel

circulation with each chamber contributing
separately, but additively to the total ventricular
output
Right side contributing 67%
Left side contributing 33%
The adult heart is considered Serial
Cardiac Malformations
The parallel nature of the two ventricles enables

fetuses with certain types of cardiac malformations
to undergo normal fetal growth & development until
term because systemic blood flow is adequate in
utero
Complete left to right heart obstruction does not
impede fetal aortic blood flow
The foramen ovale & ductus arteriosus provide
alternate pathways to bypass obstruction
Summary:
Ductus Venosus shunts blood from the UV to
the IVC bypassing the liver
Foramen Ovale shunts blood from the RA to
the LA
Ductus Arteriosus shunts blood from the PA
to the descending aorta bypassing the lungs
Fetal circulation is parallel
Blood from the LV perfuses the heart & brain
with well oxygenated blood
Fetal Pulmonary Circulation
Fetal Lungs
Extract O2 from blood with its main purpose to
provide nutrients for lung growth
Neonatal Lungs
Supply O2 to the blood
Fetal lung growth requires only 7% of combined

ventricular output
Fetal Pulmonary Circulation
Fetal pulmonary vascular resistance (PVR) is high &

helps restrict the amount of pulmonary blood flow
If not for the low resistance ductus arteriosus (DA) &
adjoining peripheral vascular bed the RV would need to pump
against a higher pulmonary resistance than the LV
Instead, both ventricles face relatively low systemic vascular
resistance established by the low resistance / high flow from
the placenta
Transitional & Neonatal Circulation

There are 3 steps to understanding transitional
circulation
1. Foramen Ovale: ductus arteriosus & ductus venosus
close to establish a heart whose chambers pump in series
rather than parallel
Closure is initially reversible in certain circumstances & the
pattern of blood flow may revert to fetal pathways
2. Anatomic & Physiologic: Changes in one part of the

circulation affect other parts
3. Decrease in PVR: The principal force causing a change
in the direction & path of blood flow in the newborn

Changes that establish the newborn circulation
are an orchestrated series of interrelated events
As soon as the infant is separated from the low
resistance placenta & takes the initial breath
creating a negative pressure (40-60cm H2O),
expanding the lungs, a dramatic decrease in
PVR occurs
Exposure of the vessels to alveolar O2 increases
the pulmonary blood flow dramatically &
oxygenation improves

Hypoxia and/or acidosis can reverse this causing
severe pulmonary constriction
The pulmonary vasculature of the newborn can also
respond to chemical mediators such as
Acetylcholine
Histamine
Prostaglandins
**All are vasodilators

Most of the decrease in PVR (80%) occurs in the first 24
hours & the PAP usually falls below systemic pressure
in normal infants
PVR & PAP continue to fall at a moderate rate
throughout the first 5-6 weeks of life then at a more
gradual rate over the next 2-3 years
Babies delivered by C-section have a higher PVR than
those born vaginally & it may take them up to 3 hours
after birth to decrease to the normal range
Ductus Arteriosus
Closure occurs in two stages

Functional closure occurs 10-15 hours after birth
This is reversible in the presence of hypoxemia
or hypovolemia
Permanent closure occurs in 2-3 weeks
Fibrous connective tissue forms & permanently
seals the lumen
This becomes the ligamentum arteriosum
Foramen Ovale
Increased pulmonary blood flow & left atrial distention

help to approximate the two margins of the foramen
ovale
This is a flap like valve & eventually the opening seals closed
This hole also provides a potential right to left shunt
Crying, coughing & valsalva maneuver increases PVR which
increases RA & RV pressure
A right to left atrial & intrapulmonary shunt may therefore
readily occur in newborns & young infants
Foramen Ovale
Probe Patency
Is present in 50% of children < 5 years old & in more
than 25% of adults
Therefore, the possibility of right to left atrial shunting
exists throughout life & there is a potential avenue for
air emboli to enter the systemic circulation
A patent FO may be beneficial in certain heart
malformations where mixing of blood is essential for
oxygenation to occur such as in transposition of the
great vessels
Patients who rely on the patency of the foramen require
a balloon atrial septoplasty during a cardiac cath or a
surgical atrial septectomy
Ductus Venosus
This has no purpose after the fetus is separated from

the placenta at delivery
Cardiovascular Differences in the Infant

There are gross structural differences & changes in the
heart during infancy
At birth the right & left ventricles are essentially the same in
size & wall thickness
During the 1st month volume load & afterload of the LV
increases whereas there is minimal increase in volume load &
decrease in afterload on the RV
By four weeks the LV weighs more than the RV
This continues through infancy & early childhood until the LV is twice
as heavy as the RV as it is in the adult

Cell structure is also different
The myocardial tissues contain a large number of
nuclei & mitochondria with an extensive endoplasmic
reticulum to support cell growth & protein synthesis
during infancy
The amount of cellular mass dedicated to
contractile protein in the neonate & infant is less
than the adult
30% vs. 60%
These differences in the organization, structure &
contractile mass are partly responsible for the
decreased functional capacity of the young heart
Both ventricles are relatively noncompliant & this

has two implications for the anesthesia provider
1. Reduced compliance with similar size & wall
thickness makes the interrelationship of the
ventricular function more intimate
Failure of either ventricle with increased filling pressure
quickly causes a septal shift & encroachment on stroke
volume of the opposite ventricle

2. Decreased compliance makes it less sensitive to
volume overload & their ability to change stroke
volume is nearly nonexistent
CO is not rate dependent at low filling pressures
but small amounts of fluid rapidly change filling
pressures to the plateau of the Frank-Starling
length tension curve where stroke volume is
fixed
This changes the CO to strictly being rate dependent
Additional small amounts of fluid can push the filling
pressure to the descending part of the curve & the
ventricles begin to fail
The normal immature heart is sensitive to volume
overloading
Functional capacity of the neonatal & infant heart is

reduced in proportion to age & as age increases
functional capacity increases
The time over which growth & development
overcome these limitations is uncertain & variable
When adult levels of systemic artery pressure &
PVR are achieved by age of 3 or 4 years the above
limitations probably no longer apply
Autonomic Control of the Heart

Parasympathetic
Sympathetic
innervation has been
innervation of the heart
shown to be complete at
is incomplete at birth
birth therefore we see an
with decreased cardiac
catecholamine stores &
increased sensitivity to
it has an increased
vagal stimulation
sensitivity to
exogenous
norepinephrine
It does not mature until 4-6
months of age
Circulation
The vasomotor reflex arcs are functional in the

newborn as they are in adults
Baroreceptors of the carotid sinus lead to
parasympathetic stimulation & sympathetic
inhibition
There are less catecholamine stores & a
blunted response to catecholamines
Therefore neonates & infants can show
vascular volume depletion by hypotention
without tachycardia
Cardiovascular Parameters
Parameters are much different for the infant than

for the adult
Heart rate: higher

Decreasing to adult levels at ~5 years old
Cardiac output: higher
Especially when calculated according to body
weight & it parallels O2 consumption
Cardiac index: constant
Because of the infants high ratio of surface area to
body weight
O2 consumption: depends heavily on temperature
There is a 10-13% increase in O2 consumption for
each degree rise in core temperature
Circulation Variables in Infants
Respiratory System
Neonatal adaptation of lung mechanics &
respiratory control
Takes several weeks to complete
Beyond this immediate period the lungs are
not fully mature for another few years
Formation of adult type alveoli begins at 36
weeks postconception
Represents only a fraction of the terminal air
sacs with thick septa
It takes more than several years for functional
and morphologic development to be complete
Respiratory System
Neural & chemical controls of breathing in older
infants & children are similar to those in adolescents &
adults
A major exception to this is found in neonates and
young infants, especially in premature infants less than
40-44 weeks postconception
In these infants, hypoxia is a potent respiratory
depressant, rather than a stimulant
This is due either to central mediation or to changes
in respiratory mechanics
These infants tend to develop periodic breathing or
central apnea with or without apparent hypoxia
This is most likely because of immature
respiratory control mechanisms
Respiratory System
During the early years of childhood,

development of the lungs continues at a rapid
pace
This is with respect to the development of new
alveoli
By 12-18 months the number of alveoli reaches

the adult level of 300 million or more
Subsequent lung growth is associated with an
increase in alveolar size
Respiratory System
Lung volumes of infants is disproportionately small in
relation to body size
Since the infants metabolic rate, in relation to body weight, is twice
that of the adult, more marked differences are seen in respiratory
frequency and in alveolar ventilation
The higher level of alveolar ventilation in relation to FRC makes
the FRC a less effective buffer between inspired gases & pulmonary
circulation
Any interruption of ventilation will lead rapidly to hypoxemia &
the function of anesthetic gases in the alveolus will equilibrate
with the inspired fraction more rapidly than occurs in adults
Respiratory System
Functional Residual Capacity (FRC)

Determined by the balance between the outward
stretch of the thorax & the inward recoil of the
lungs
In infants, outward recoil of the thorax is very
low
They have cartilaginous chest walls that make
their chest walls very compliant & their
respiratory muscles are not well developed
Inward recoil of the lungs is only slightly lower
than that of an adults
Respiratory System
The FRC of young infants in conditions such as
apnea , under general anesthesia and/or in paralysis
decrease to 10-15% of TLC
Total Lung Capacity (TLC) is normally ~50% of an adults
10-15% TLC is incompatible with normal gas exchange
because airway closure, atelectasis &
ventilation/perfusion imbalance result
Awake infants are normally as capable of maintaining
FRC as older children & adults
This is important because it limits O2 reserve during
apnea and greatly reduces the time before you see a drop
in oxygen saturation
Respiratory System
Breathing Patterns of Infants
Less than 6 months of age

Predominantly abdominal (diaphragmatic) and the rib
cage (intercostal muscles) contribution to tidal
volume is relatively small (20-40%)
After 9 months of age
The rib cage component of tidal volume increases to a
level (50%) similar to that of older children &
adolescents, reflecting the maturation of the thoracic
structure
By 12 months
Chest wall compliance decreases
The chest wall becomes stable & can resist the inward
recoil of the lungs while maintaining FRC
This supports the theory that the stability of the
respiratory system is achieved by 1 year of age
Anatomic Differences in the Respiratory System

Anatomic Airway Differences are Many
Upper Airway: the nasal airway is the primary pathway for normal
breathing
During quiet breathing the resistance through the nasal passages
accounts for more than 50% of the total airway resistance (twice
that of mouth breathing)
Except when crying, the newborns are considered obligate nose
breathers
This is because the epiglottis is positioned high in the pharynx
and almost meets the soft palate, making oral ventilation
difficult
If the nasal airway becomes occluded the infant may not rapidly
or effectively convert to oral ventilation
Nasal obstruction usually can be relieved by causing the infant
to cry
Anatomic Differences in the Respiratory

System
The Tongue: is large & occupies most of the cavity

of the mouth & oropharynx
With the absence of teeth, airway obstruction can
easily occur
The airway usually can be cleared by holding the
mouth open and/or lifting the jaw
An oral airway may also be helpful

System
Pharyngeal Airway: is not supported by a rigid

bony or cartilaginous structure
Is easily collapsed by:
The posterior displacement of the mandible
during sleep
Flexion of the neck
Compression over the hyoid bone
Chemoreceptor stimuli such as hypercapnia &
hypoxia stimulate the airway dilators
preferentially over the stimulation of the
diaphragm so as to maintain airway patency

Laryngeal Airway: this maintains the airway &
functions as a valve to occlude & protect the lower
airway
In the infant the larynx is located high (anterior &
cephlad) opposite C-4 (adults is C-6)
The body of the hyoid bone is between C2-3 & in the
adult is at C-4
The high position of the epiglottis & larynx allows the
infant to breathe & swallow simultaneously
The larynx descends with growth
Most of this descent occurs in the 1st year but the
adult position is not reached until the 4th year
The vocal cords of the neonate are slanted so

that the anterior portion is more caudal than the
posterior

System
Laryngeal Reflex: is activated by stimulation of
receptors on the face, nose & upper airways of the
newborn
Reflex apnea, bradycardia & laryngospasm may occur
Various mechanical stimuli can trigger response
including:
Water
Foreign bodies
Noxious gases
This response is very strong in newborns
Narrowest area of the airway

Adult is between the vocal cords
Infant is in the cricoid region of the larynx
The cricoid is circular & cartilaginous and consequently not
expansible
An endotracheal tube may pass easily through an infants vocal
cords but be tight at the cricoid area
The limiting factor here becomes the cricoid ring
This is also frequently the site of trauma during intubation
1mm of edema on the cross sectional area at the level of the

cricoid ring in a pediatric airway can decrease the opening
75% vs. 19% in an adult
There should be an audible air leak at 15-20cm H2O airway
pressure when applied

System

System
Trachea
Infant: the alignment is directed caudally &
posteriorly
Adult: it is directed caudally
Cricoid pressure is more effective in facilitating

passage of the endotracheal tube in the infant

System
Newborn Trachea
Distance between the bifurcation of the trachea &
the vocal cords is 4-5cm
Endotracheal tube (ETT) must be carefully
positioned & fixed
Because of the large size of the infants head the
tip of the tube can move about 2cm during
flexion & extension of the head
It is extremely important to check the ETT
placement every time the babys head is moved

System

System
Tonsils & Adenoids

Grow markedly during childhood
Reach their largest size at 4-7 years & then
recedes gradually
This can make visualization of the larynx more
difficult

System
The compliant nature of the major airways of the
infant are also different than adults
The diameter of infant airways changes more easily
when exposed to distending or compressing forces
With obstruction at the level of the larynx, stridor will be heard
mainly on inspiration
With obstruction at the level of the trachea (foreign body),
stridor may be heard during both inspiration & expiration
In contrast, during lower airway obstruction (asthma or
bronchiolitis), most of the collapse occurs during expiration
thus producing expiratory wheeze

System
The configuration of the thoracic cage differs in the infant
& adult
Infant: ribs are horizontal & do not rise as much as an
adults during inspiration
The diaphragm is more important in ventilation & the
consequences of abdominal distention are much
greater
As the child grows (learns to stand) gravity pulls on
the abdominal contents encouraging the chest wall to
lengthen
Now the chest cavity can be expanded by raising
the ribs into a more horizontal position

System
Lower Airway
Diaphragmatic & intercostal muscles of infants are more
liable to fatigue than those of adults
This is due to a difference in muscle fiber type
Adult diaphragm has 60% of type I: slow twitch, high oxidative,
fatigue resistant
Newborns diaphragm has 75% of type II: fast twitch, low oxidative,
less energy efficient
The same pattern is seen in intercostal muscles
The newborn is more prone to respiratory fatigue & may not be able
to cope when suffering from conditions that result in reduced lung
compliance (RDS)
Ventilation/Perfusion Ratio (V/Q)
Infants & children: the distribution of

pulmonary blood flow is more uniform than
adults
Adults changes from base to apex because of
gravity
Infants & children PAP is relatively high & the
effect of gravity is less
V/Q changes in anesthesia
General anesthesia (GA)

FRC & diaphragmatic movements are reduced
Airway closure tends to be exaggerated & the
dependent parts of the lung are poorly ventilated
Hypoxic pulmonary vasoconstriction, which
diverts blood flow from areas of the lung that are
under ventilated, is abolished during GA
This increases the hypoxic tendency
Physiologics differences in the Respiratory System
In General:
Rate & depth of respiration are regulated to expend
the least amount of energy
At their given rates, both the infant & the adult
expend about 1% of their metabolic energy in
ventilation
Periodic Breathing
Can be observed in the normal newborn infant &
frequently occurs during REM sleep
Manifested as rapid ventilation followed by a
period of apnea of less than 10secs
During this period arterial oxygenation tension
remains in the normal range
Usually not seen in healthy infants after 6 weeks of
age
Apneic spells longer than 20secs are frequently

seen in premature infants & are frequently
associated with arterial desaturation &
bradycardia
Episodes of apnea increase in frequency during stressful
situations such as respiratory infection or the
postanesthetic & postsurgical states
Apneic spells can be central (originating in the CNS) or
obstructive (d/t upper airway obstruction)
Treatment with caffeine & theophylline has been show
to be effective in reducing both types in preterm infants

Tidal Volume
7-10ml/kg
Dead Space
2-2.5ml/kg
These two measures

remain constant
between infants &
adults
Oxygen Transport
Blood volume of a healthy newborn is 70-90ml/kg
Hemoglobin tends to be high (approx. 19g/dl)
Consisting primarily of HbF
Hb rises slightly in the first few days because of the decrease in
extracellular fluid volume
Thereafter, it declines & is referred to as physiologic anemia of infancy
HbF has a greater affinity for oxygen than HgA

After birth, the total Hgb level decreases rapidly as the proportion
of HbF diminishes (it can drop below 10g/dl at 2-3 months)
creating the anemia
Oxygen Transport
The P-50 rapidly increases at the same time the HbF is
replaced by HbA which has a high concentration of 2,3-DPG
& so insures efficient oxygen off-loading at the tissues
The gradual decrease in O2 carrying capacity in the first few months of
life is thus well tolerated by normal, healthy infants
There is no consensus about the lowest tolerable Hb

concentration for an infant
The lowest limit will depend on factors such as duration of anemia, the
acuity of blood loss, the intravascular volume & more important the
impact of other conditions that might interfere with O2 transport
Oxygen Transport
Key Points
Respiratory control mechanisms are not fully

developed until 42-44 weeks postconception
Most alveolar formation & elastogenesis occurs
during the first year of life
The thoracic structure is insufficient to support
the negative pleural pressure during the
respiratory cycle until the infant develops
muscle strength from upright posture around 1
year old
Key Points
Weakness of the thoracic structure is partly compensated
for by contractions of the intercostal & accessory muscles
Anesthesia abolishes this compensatory mechanism & the end
expiratory lung volume (FRC) decreases to the point of airway
closure & alveolar collapse
Infants are prone to upper airway obstruction

Due to anatomic & physiologic differences
Anesthesia depresses pharyngeal & other neck muscles which
resist the collapsing forces in the pharynx
Key Points
HbF has high oxygen affinity & limits oxygen

unloading at the tissue level
This decreases O2 delivery to the tissues that have high
oxygen demand
Infants & young children are prone to perioperative
hypoxemia & tissue hypoxia
Renal Differences
Body Fluid
Compartments
Full term infants have
a large % of TBW &
ECF
TBW decreases with
age mainly as a result
of loss of water in
extracellular fluid
Renal Differences
Significance for Anesthesia Provider

Higher dose of water soluble drug is needed
due to the greater volume of distribution
However, due to the immaturity of clearance &

metabolism the dose given is equal to the dose used
in adults
In the fetus the placenta is the excretory organ

However, it still produces a large volume of
hypotonic urine & helps amniotic fluid volume
It is only after birth that the kidney begins to
maintain metabolic function
Renal Differences
The healthy newborn has a complete set of nephrons at

birth
The glomeruli are smaller than adults
The filtration surface related to body weight is similar
The tubules are not fully grown at birth & may not
pass into the medulla
Renal Differences
Glomerular Filtration Rate (GFR)
At birth is ~30% of the adult
It increases quickly during the first two weeks, but then is relatively
slow to approach the adult level by the end of the first year
Low GFR in the full term infant affects the babys ability to
excrete saline & water loads as well as drugs
Full term infants can conserve Na+, as GFR increases so does the
filtered load of Na+ increase & the ability of the proximal tubule to
reabsorb the ion
In premature infants a glomerulotubular imbalance is present which
may result in Na+ wastage & hyponatremia
Renal Differences
Factors that contribute to the increase in GFR

Increase in CO
Changes in renovascular resistance
Altered regional blood flow
Changes in the glomeruli
Maturation of the glomerular function is complete

at 5-6 months of age
Renal Differences
Tubular Function & Permeability

Not fully mature in the term neonate & even less in the premature
infant
The neonate can excrete dilute urine (50mOsm/L)
However, the rate of excretion of H2O is less & it cannot concentrate to more
than 700mOsm/L (adult, 1200mOsm/L)
This is due, in part, to the lack of urea-forming solids in the diet, but mostly
due to the hypotonicity of the renal medulla
Maturation of the tubules is behind that of the glomeruli

Peak renal capacity is reached at 2-3 years after which it decreases at a rate of
2.5% per year
Renal Differences
The kidney does show some response to antidiuretic
hormone (ADH), but is less sensitive to ADH than the
cells of mature nephrons
Diluting Capacity
Matures by 3-5 weeks postnatal age
The ability to handle a water load is reduced & the neonate
may be unable to increase water excretion to compensate for
excessive water intake
They are very sensitive to over hydration
In infants & children, hyponatremia occurs more frequently

than hypernatremia
Renal Differences
Creatinine
Normal value is lower in infants than in adults
This is due to the anabolic state of the newborn & the small
muscle mass relative to body weight (0.4mg/dl vs. 1mg/dl in the
adult)
Bicarbonate (NaHCO3)
Renal tubular threshold is also lower in the newborn
(20mmol/L vs. 25mmol/L in the adult)
Therefore, the infant has a lower pH, of about 7.34
BUN
The infants urea production is reduced as a result of growth
& so the immature kidney is able to maintain a normal
BUN
Hepatic Differences
Glucose from the mother is the main source of energy
for the fetus
Stored as fat & glycogen with storage occurring mostly in
last trimester
At 28 weeks gestation the fetus has practically no fat stored, but
by term 16% of the body is fat & 35gms of glycogen is stored
In utero liver function is essential for fetal survival

Maintains glucose regulation, protein / lipid synthesis & drug
metabolism
The excretory products go across the placenta & are excreted by
the maternal liver
Liver volume represents 4% of the total body weight in the

neonate (2% in adult)
However, the enzyme concentration & activity are lower in the
neonatal liver
Hepatic Differences
Glucose is the infants main source of energy
In the 1st few hours following delivery there is a rapid drop
in plasma glucose levels
Hepatic & glycogen stores are rapidly depleted with fat
becoming the principle source of energy
The newborn should not be kept for a long period of time
from enteral or IV nutrition
The lower limit of normal for glucose is 30mg/dl in
the term infant
Infants do not usually show neurological signs &
symptoms, but may develop sweating pallor or
tachycardia
A glucose level < 20mg/dl usually precipitates
neurological signs such as apnea or convulsions
Premature infants may have a tendency for
hypoglycemia for weeks
Hepatic Differences
Increased hepatic metabolic activity

Occurs at about 3 months of age
Reaches a peak at 2-3 years by which time the enzymes are
fully mature, then they start to decline reaching adult values at
puberty
Renin, angiotensin, aldosterone, cortisol & thyroxine

levels are high in the newborn & decrease in the first
few weeks of life
Hepatic Differences
Physiologic Jaundice
Increased concentrations of bilirubin occur in
the first few days of life
This is excessive bilirubin from the breakdown of
red blood cells & deficient hepatic conjugation due
to immature liver function
Treatment is phototherapy & occasionally exchange
transfusions
If left untreated it can lead to encephalopathy
(kernicterus)
Hepatic Differences
Coagulation
At birth, Vit K dependent factors (II, VII, IX &
X) are at a level of 20-60% of the adult volume
This results in prolonged prothrombin times
Synthesis of Vit K dependent factors occurs in

the liver which being immature leads to
relatively lower levels of these factors even
with the administration of Vit K
It takes several weeks for the levels of coagulation
factors to reach adult values
Administration of Vit K immediately after birth is
important to prevent hemorrhagic disease
CNS Differences
The brain of the neonate is relatively large

1/10 of the weight as compared to 1/50 of adult
The brain grows rapidly
Doubles in weight by 6 months
Triples in weight by 1 year
At birth ~25% of the neonatal cells are present
By one year the development of cells in the cortex
& brain stem is complete
CNS Differences
Myelination & Elaboration of Dendritic

Processes
Continue into the third year of life
Incomplete myelinization is associated with
primitive reflexes such as motor and grasp
Spinal Cord
At birth the spinal cord extends to L-3
By one year old the infant spinal cord has
assumed its permanent position at L-1
CNS Differences
Structure & Function of the Neuromuscular

System
Incomplete at birth
There are immature myoneural junctions &
larger amount of extrajunctional receptors
Throughout Infancy:
Contractile properties change
The amount of muscle increases
The neuromuscular junction &
acetylcholine receptors mature
CNS Differences
Junctions & Receptors

The presence of immature myoneural junctions
might cause a predisposition to sensitivity
A large number of extrajunctional receptors might
result in resistance
Within a short interval, (< 1 month) this variation
diminishes & the myoneural junction of the infant
behaves almost like that of an adult
Temperature Regulation
Body Temperature is a result of the balance

between the factors leading to heat loss & gain
and the distribution of heat within the body
The potential exists for unstable conditions to progress

to a positive feedback cycle
The decrease in body temperature will lead to a
decrease in the metabolic rate, leading to further
heat loss & diminished metabolic rate
The body normally safeguards against this unstable
state by increasing BMR during the initial exposure to
cold or by reducing heat loss through vasoconstriction
Central Temperature Control Mechanism
This is intact in the newborn
It is limited, however, by autonomic & physiologic factors

Is only able to maintain a constant body temperature within
a narrow range of environmental conditions
O2 consumption is at a minimum when the environmental
temp is within 3-5% (1-2C) of body temp (an abdominal
skin temp of 36C)
This is known as the neutral thermal environment (NTE)

A deviation in either direction from the NTE will increase O2
consumption
An adult can sustain body temperature in an environment as cold as
0C where as a full term infant starts developing hypothermia at
about 22C
Generation of Heat
Depends mostly on body mass
Heat loss to the environment is mainly due to surface area
Neonates have a ratio of surface area to mass about 3Xs
higher than that of adults
Therefore they have difficulty regulating body temperature in a
cold environment
Premature Infants & Temperature Control

Are more susceptible to environmental changes in temperature
The preemie has skin only 2-3 cells thick & has a lack of
keratin
This allows for a marked increase in evaporative water loss (in
extremes this can be in excess of heat production)
Important Mechanisms for Heat Production

Metabolic activity
Shivering
Non-shivering thermogenesis
Newborns usually do not shiver
Heat is produced primarily by non-shivering thermogenesis
Shivering does not occur until about 3 months of age
Non-shivering Thermogenesis
Exposure to cold leads to production of Norepi
This in turn increases the metabolic activity of
brown fat
Brown fat is highly specialized tissue with a great
number of mitochondrial cytochromes (these are
what provide the brown color)
The cells have small vacuoles of fat & are rich in
sympathetic nerve endings
They are mostly in the nape & between the scapulae but
some are found in the mediastinal (around the internal
mammary arteries & the perirenal regions (around the
kidneys & adrenals)
Once released Norepinephrine acts on the &
adrenergic receptors on the brown adipocytes
This stimulates the release of lipase, which in turn splits
triglycerides into glycerol & fatty acids, thus increasing
heat production
The increase in brown fat metabolism raises the
proportion of CO diverted through the brown fat
(sometimes as much as 25%), which in turn facilitates
the direct warming of blood
The increased levels of Norepinephrine also causes

peripheral vasoconstriction & mottling of the skin
Heat Loss
The major source of heat loss in the infant is
through the respiratory system
A 3kg infant with a Minute Volume (TV x RR) of
500ml spends 3.5cal/min to raise the temperature
of inspired gases
To saturate the gases with water vapor takes an
additional 12cal/min
The total represents about 10-20% of the total
oxygen consumption of an infant
The sweating mechanism is present in the neonate,
but is less effective than in adults
Possibly because of the immaturity of the
cholinergic receptors in the sweat glands
Full term infants display structurally well
developed sweat glands, but these do not function
appropriately
Sweating during the first day of life is actually
confined mostly to the head
Heat Exchange Review

1. Conduction:
The kinetic energy of the vibratory motion
of the molecules at the surface of the skin
or other exposed surfaces is transmitted to
the molecules of the medium immediately
adjacent to the skin
Rate of transfer is related to temperature
difference between the skin & this
medium
Use warm blankets, Bair huggers &
warmed gel pads
2. Convection:
Free movement of air over a surface
Air is warmed by exposure to the
surface of the body then rises & is
replaced by cooler air from the
environment
Increase OR temp, radiant warmers,
wrap in saran wrap, cover with blankets
and/or OR drapes
3. Radiation:
Radiation emitted from the body is in the
infrared region of the electromagnetic
spectrum
The quantity radiated is related to the
temperature of the surrounding objects
Radiation is the major mechanism of heat
loss under normal conditions (same
techniques to prevent as used in Convection)
4. Evaporation:
Under normal conditions ~20% of the total
body heat loss is due to evaporation
This occurs both at the skin & lungs
Since the infants skin is thinner & more
permeable than the older childs or adults
evaporative heat loss from the skin is greater
In the anesthetized infant the MV (relative to
body weight) is high thus increasing
evaporative heat loss through the respiratory
system
Summary
Decreased body temperature is initially
compensated for by increased metabolism
If this fails & temperature continues to decrease,
regional blood flow shifts, causing a metabolic
acidosis & eventually apnea

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Pediatrics

Body surface area (BSA) most closely parallels

The functioning heart grows & develops at the same

Umbilical Venous Tension is 32-35mmHg

Low affinity of fetal Hb (HbF) for 2,3-DPG as compared with

O2 & 2,3-DPG compete with Hb for binding, the

P50 is 27mmHg for adult Hgb, but only 20mmHg for

Because the bridge between arterial & tissue O2 tension

Fetal Circulatory Flow

Starts at the placenta with the umbilical vein

Carries essential nutrients & O2 from the placenta to

The liver is the first major organ to receive blood

Essential substrates such as O2, glucose & amino acids

The remaining 40-60% bypasses the liver and

Fetal Circulatory Flow

From the RA the blood is distributed in two

Approximately 1/3 of IVC flow deflects off the

Fetal Circulatory Flow

The remaining 2/3 of the IVC flow joins the

Fetal Circulatory Flow

The fetal heart is considered a Parallel

The adult heart is considered Serial

Fetal Circulatory Flow

Fetal Circulatory Flow

The parallel nature of the two ventricles enables

Fetal Circulatory Flow

Fetal Pulmonary Circulation

Fetal lung growth requires only 7% of combined

Fetal Pulmonary Circulation

Fetal pulmonary vascular resistance (PVR) is high &

Transitional & Neonatal Circulation

2. Anatomic & Physiologic: Changes in one part of the

Transitional & Neonatal Circulation

Transitional & Neonatal Circulation

Transitional & Neonatal Circulation

Transitional & Neonatal Circulation

Transitional & Neonatal Circulation

Closure occurs in two stages

Increased pulmonary blood flow & left atrial distention

This has no purpose after the fetus is separated from

Cardiovascular Differences in the Infant

Cardiovascular Differences in the Infant

Cardiovascular Differences in the Infant

Both ventricles are relatively noncompliant & this

Cardiovascular Differences in the Infant

Cardiovascular Differences in the Infant

Functional capacity of the neonatal & infant heart is

Autonomic Control of the Heart

The vasomotor reflex arcs are functional in the

Parameters are much different for the infant than

Heart rate: higher

Circulation Variables in Infants

During the early years of childhood,

By 12-18 months the number of alveoli reaches

Functional Residual Capacity (FRC)

Less than 6 months of age

Anatomic Differences in the Respiratory System

Anatomic Differences in the Respiratory

The Tongue: is large & occupies most of the cavity

Anatomic Differences in the Respiratory

Pharyngeal Airway: is not supported by a rigid

Anatomic Differences in the Respiratory System

The vocal cords of the neonate are slanted so

Anatomic Differences in the Respiratory