PEARLS 1

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'"></scr' + 'ipt>'); </script> </td></tr></table><!POP YES 1 0catch 1257897085-0 visited=11%2F10%2F2009; visited=11%2F10%2F2009; visited=11%2F10%2F2009; visited=11%2F10%2F2009; visited=11%2F10%2F2009; visited=11%2F10%2F2009><table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=125 BGCOLOR="#996699" TEXT="#080000" bgproperties="fixed" background="040467d1erlcll.gif"> <div> <FONT SIZE="5" COLOR="#FFFFFF" FACE="Arial" ><B>paediatry part 2</B></FONT><B>     </B><B>|     </B><A HREF="index.htm" TARGET="_top" TITLE="paediatry part 2"><U><B>home</B></U></A></div> <div> <B>PEARLS 1</B>   |   <A HREF="id27.htm" TARGET="_top" TITLE="pearls2"><U>pearls2</U></A>   |   <A HREF="id30.htm" TARGET="_top" TITLE="Phenylketonuria (PKU)"><U>Phenylketonuria (PKU)</U></A>   |   <A HREF="id31.htm" TARGET="_top" TITLE="food poisoning"><U>food poisoning</U></A>   |   <A HREF="id32.htm" TARGET="_top" TITLE="acute otitis"><U>acute otitis</U></A>   |   <A HREF="id33.htm" TARGET="_top" TITLE="immunization"><U>immunization</U></A>   |   <A HREF="id34.htm" TARGET="_top" TITLE="craniofacial anomaly"><U>craniofacial anomaly</U></A>   |   <A HREF="id35.htm" TARGET="_top" TITLE="chiari malformation"><U>chiari malformation</U></A>   |   <A HREF="id36.htm" TARGET="_top" TITLE="PEDIATRIC RESPIRATORY DISORDERS"><U>PEDIATRIC RESPIRATORY DISORDERS</U></A>   |   <A HREF="id37.htm" TARGET="_top" TITLE="Cephalhematoma "><U>Cephalhematoma </U></A>   |   <A HREF="id38.htm" TARGET="_top" TITLE="Subgaleal Hematoma"><U>Subgaleal Hematoma</U></A>   |   <A HREF="id39.htm" TARGET="_top" TITLE="BIRTH INJURY "><U>BIRTH INJURY </U></A>   |   <A HREF="id40.htm" TARGET="_top" TITLE="infectious in a new born"><U>infectious in a new born</U></A>   |   <A HREF="id41.htm" TARGET="_top" TITLE="jaundice"><U>jaundice</U></A>   |   <A HREF="id42.htm" TARGET="_top" TITLE="INFANT OF DIABETIC MOTHER (IDM) "><U>INFANT OF DIABETIC MOTHER (IDM) </U></A>   |   <A HREF="id43.htm" TARGET="_top" TITLE="FETAL GROWTH "><U>FETAL GROWTH </U></A>   |   <A HREF="id44.htm" TARGET="_top" TITLE="Moebius Syndrome"><U>Moebius Syndrome</U></A>   |   <A HREF="id45.htm" TARGET="_top" TITLE="SHORT STATURE"><U>SHORT STATURE</U></A>   |   <A HREF="id46.htm" TARGET="_top" TITLE="MICROCEPHALIA"><U>MICROCEPHALIA</U></A>   |   <A HREF="id47.htm" TARGET="_top" TITLE="PIERRE ROBIN SYNDROME "><U>PIERRE ROBIN SYNDROME </U></A>   |   <A HREF="id19.htm" TARGET="_top" TITLE="Prenatal Diagnosis"><U>Prenatal Diagnosis</U></A>   |   <A HREF="id28.htm" TARGET="_top" TITLE="Febrile Seizures "><U>Febrile Seizures </U></A>   |   <A HREF="id20.htm" TARGET="_top" TITLE="dvlp bis"><U>dvlp bis</U></A>   |   <A HREF="id21.htm" TARGET="_top" TITLE="DEVELOPMENTAL NEUROLOGIC DISEASES"><U>DEVELOPMENTAL NEUROLOGIC DISEASES</U></A>   |   <A HREF="id22.htm" TARGET="_top" TITLE="GENETIC DISEASES "><U>GENETIC DISEASES </U></A>   |   <A HREF="id26.htm" TARGET="_top" TITLE="angelman syndrome"><U>angelman syndrome</U></A>   |   <A HREF="id23.htm" TARGET="_top" TITLE="TAYSACHS DISEASE"><U>TAY-SACHS DISEASE</U></A>   |   <A HREF="id24.htm" TARGET="_top" TITLE="krabbes disease"><U>krabbe's disease</U></A>   |   <A HREF="id25.htm" TARGET="_top" TITLE="Refsums Disease"><U>Refsum's Disease</U></A>   |   <A HREF="id29.htm" TARGET="_top" TITLE="meningitis"><U>meningitis</U></A>   |   <A HREF="id17.htm" TARGET="_top" TITLE="Contact Me"><U>Contact Me</U></A></div> <div> </div> </td> </tr><tr> <td valign="top" width=190 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <B><IMG SRC="05ec8910.jpg" border=0 width="200" height="145" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="060b57a0.jpg" border=0 width="181" height="122" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B><B>PEARLS 1</B></div> <div> <A HREF="id27.htm" TARGET="_top" TITLE="pearls2"><U><B>pearls2</B></U></A></div> <div> <A HREF="id30.htm" TARGET="_top" TITLE="Phenylketonuria (PKU)"><U><B>Phenylketonuria (PKU)</B></U></A></div> <div> <A HREF="id31.htm" TARGET="_top" TITLE="food poisoning"><U><B>food poisoning</B></U></A></div> <div> <A HREF="id32.htm" TARGET="_top" TITLE="acute otitis"><U><B>acute otitis</B></U></A></div> <div> <A HREF="id33.htm" TARGET="_top" TITLE="immunization"><U><B>immunization</B></U></A></div> <div> <A HREF="id34.htm" TARGET="_top" TITLE="craniofacial anomaly"><U><B>craniofacial anomaly</B></U></A></div> <div> <A HREF="id35.htm" TARGET="_top" TITLE="chiari malformation"><U><B>chiari malformation</B></U></A></div> <div> <A HREF="id36.htm" TARGET="_top" TITLE="PEDIATRIC RESPIRATORY DISORDERS"><U><B>PEDIATRIC RESPIRATORY DISORDERS</B></U></A></div> <div> <A HREF="id37.htm" TARGET="_top" TITLE="Cephalhematoma "><U><B>Cephalhematoma </B></U></A></div> <div> <A HREF="id38.htm" TARGET="_top" TITLE="Subgaleal Hematoma"><U><B>Subgaleal Hematoma</B></U></A></div> <div> <A HREF="id39.htm" TARGET="_top" TITLE="BIRTH INJURY "><U><B>BIRTH INJURY </B></U></A></div> <div> <A HREF="id40.htm" TARGET="_top" TITLE="infectious in a new born"><U><B>infectious in a new born</B></U></A></div> <div> <A HREF="id41.htm" TARGET="_top" TITLE="jaundice"><U><B>jaundice</B></U></A></div> <div> <A HREF="id42.htm" TARGET="_top" TITLE="INFANT OF DIABETIC MOTHER (IDM) "><U><B>INFANT OF DIABETIC MOTHER (IDM) </B></U></A></div> <div> <A HREF="id43.htm" TARGET="_top" TITLE="FETAL GROWTH "><U><B>FETAL GROWTH </B></U></A></div> <div> <A HREF="id44.htm" TARGET="_top" TITLE="Moebius Syndrome"><U><B>Moebius Syndrome</B></U></A></div> <div> <A HREF="id45.htm" TARGET="_top" TITLE="SHORT STATURE"><U><B>SHORT STATURE</B></U></A></div> <div> <A HREF="id46.htm" TARGET="_top" TITLE="MICROCEPHALIA"><U><B>MICROCEPHALIA</B></U></A></div> <div> <A HREF="id47.htm" TARGET="_top" TITLE="PIERRE ROBIN SYNDROME "><U><B>PIERRE ROBIN SYNDROME </B></U></A></div> <div> <A HREF="id19.htm" TARGET="_top" TITLE="Prenatal Diagnosis"><U><B>Prenatal Diagnosis</B></U></A></div> <div> <A HREF="id28.htm" TARGET="_top" TITLE="Febrile Seizures "><U><B>Febrile Seizures </B></U></A></div> <div> <A HREF="id20.htm" TARGET="_top" TITLE="dvlp bis"><U><B>dvlp bis</B></U></A></div> <div> <A HREF="id21.htm" TARGET="_top" TITLE="DEVELOPMENTAL NEUROLOGIC DISEASES"><U><B>DEVELOPMENTAL NEUROLOGIC DISEASES</B></U></A></div> <div> <A HREF="id22.htm" TARGET="_top" TITLE="GENETIC DISEASES "><U><B>GENETIC DISEASES </B></U></A></div> <div> <A HREF="id26.htm" TARGET="_top" TITLE="angelman syndrome"><U><B>angelman syndrome</B></U></A></div> <div> <A HREF="id23.htm" TARGET="_top" TITLE="TAYSACHS DISEASE"><U><B>TAY-SACHS DISEASE</B></U></A></div> <div> <A HREF="id24.htm" TARGET="_top" TITLE="krabbes disease"><U><B>krabbe's disease</B></U></A></div> <div> <A HREF="id25.htm" TARGET="_top" TITLE="Refsums Disease"><U><B>Refsum's Disease</B></U></A></div> <div> <A HREF="id29.htm" TARGET="_top" TITLE="meningitis"><U><B>meningitis</B></U></A></div> <div> <A HREF="id17.htm" TARGET="_top" TITLE="Contact Me"><U><B>Contact Me</B></U></A></div> </td> <td valign="top" height=355 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> PEARLS 1</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A female fetus is delivered stillborn at 19 weeks gestation. The macerated fetus shows marked generalized hydrops fetalis. There is a large posterior septated cystic hygroma of the neck. Autopsy reveals internal anomalies including aortic coarctation and a horseshoe kidney</div> <div> <B>45X</B></div> <bR> <div> These are typical features of Turner's syndrome</div> <div> <B>=======================================================================================================</B></div> <div> At 30 weeks gestation, a stillborn fetus is noted to have a</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> small face </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">with micrognathia, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">overlapping fingers, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">an omphalocele</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> a horseshoe kidney, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and rocker-bottom feet. </div> <bR> <bR> <div> 47 XY, +18 </div> <div> <B>TRISOMY 18</B></div> <div> <B>========================================================================================================</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A 15 year old mentally retarded male has a karyotype demonstrating findings of the fragile X syndrome</div> <div> The testes with Klinefelter's syndrome are small.</div> <div> <B>The testes in males with fragile X syndrome are large.</B></div> <bR> <div> <B>=========================================================================================================</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A 20 year old phenotypic female is found to have a 46 XY karyotype</div> <div> <B>Cryptorchid testes </B></div> <div> <B>Testicular feminization is characterized by testes that are cryptorchid.</B></div> <div> <B> They are removed because of the risk for seminoma</B></div> <bR> <div> <B>==========================================================================================================</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">An 18-month-old child has poor neurologic development and decreased<FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B> hexosaminidase A</B></FONT> in serum. </div> <bR> <div> <B>Tay-Sachs disease </B></div> <bR> <div> <B>There is early neurologic impairment and blindness.</B></div> <div> <B> Most affected children die by age 2.</B></div> <div> <B>========================================================================================================</B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Cultured fibroblasts from amniocentesis performed at 17 weeks gestation show decreased <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B>sphingomyelinase activity. </B></FONT></div> <bR> <div> <B>Affected children may show neurologic deterioration and hepatosplenomegaly</B></div> <bR> <div> <B>Niemann-Pick disease </B></div> <div> <B>========================================================================================================</B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A 6 cm mass is present over the sacrococcygeal region of a newborn who has a normal weight and size for term gestation. No anomalies are noted. Radiographically, the mass has areas of calcification. </div> <bR> <div> <B>Teratoma </B></div> <div> <B>. Teratomas, though composed of benign elements of all germ layers, may be large and impinge upon vital structures and be difficult to resect. </B></div> <div> <B>They tend to arise in the midline.</B></div> <div> <B>========================================================================================================</B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> A left cerebellar hemispheric 3.5 cm cystic mass is seen by CT scan of the head in an 8-year-old girl. </div> <div> <B>Astrocytoma</B></div> <div> <B>. Brain tumors in children are not uncommon, and are usually medulloblastomas or astrocytomas, and most are located below the tentorium in the posterior fossa.</B></div> <bR> <div> <B>=========================================================================================================</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Aortic dissection of the dilated proximal aorta at a location 7 cm from the aortic valve occurs in a tall 31-year-old male with long fingers.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">He has also has loss of vision from a subluxation of the crystalline lens of the right eye. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A mid systolic click is audible upon auscultation of the chest, and an echocardiogram reveals a floppy mitral valve.</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> His brother and his cousin are also affected by these conditions. </div> <bR> <div> <B>FIBRILLIN</B></div> <div> <B>Marfan syndrome is an autosomal dominant condition that is due to quantitative and qualitative defects in</B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B> fibrillin </B></FONT><B>from mutations in the fibrillin gene.</B></div> <div> <B> Aortic dissection from cystic medial necrosis is the worst complication, and requires that a synthetic graft be placed.</B></div> <bR> <div> =========================================================================================================</div> <bR> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> A 28-year-old female with multiple 1 to 3 cm light brown skin macules over her trunk, arms, and legs also has multiple 0.2 to 0.7 cm firm skin nodules scatttered in the same distribution. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">She develops a malignant neoplasm in the soft tissue of the right wrist region. </div> <bR> <div> <B>.NF-1 protein </B></div> <bR> <div> <B> Cafe-au-lait spots are typical of neurofibromatosis. </B></div> <div> <B>These people are at risk for development of malignant neoplasms of neural origin, such </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">as malignant schwannomas, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">neurofibrosarcomas, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">malignant peripheral nerve sheath tumors, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and pheochromocytomas</B></div> <div> <B>=======================================================================================================</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">An 18-month-old boy is found to have an elevated sweat chloride test. </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A newborn develops abdominal distension with lack of stool in the first week of life and is found to have a meconium ileus</div> <bR> <div> <B>CYSTIC FIBROSIS</B></div> <div> <B>This laboratory finding is characteristic. When meconium ileus occurs it strongly suggests that the baby has cystic fibrosis.</B></div> <bR> <div> <B>========================================================================================================</B></div> <div> A 28 week gestational age stillborn is noted to have multiple anomalies including a large abdominal wall defect to the left of the umbilical cord, which is short. Through the defect is herniated small and large bowel, a portion of liver, and left kidney. There is marked scoliosis. A fibrous band runs from the upper edge of the defect across the chest and through a cleft in the mid-face. The left arm is absent. Which of the following conditions best explains these findings: </div> <bR> <div> <B>Limb-body wall complex </B></div> <div> <B>The fibrous bands, which are known as amnionic bands, may be lacking. The body wall defect is known as a gastroschisis and does not involve the umbilical cord. This sporadic condition probably results from early amnion disruption of the embryo.</B></div> <div> <B>========================================================================================================</B></div> <div> Soon after birth, a term infant develops tetany with marked hypocalcemia. This is treated, but at one month of age, a systolic heart murmur is heard on auscultation of the chest. Later in infancy, it is noted that the baby has been almost constantly ill with one infection after another, including respiratory syncytial virus, Candida, and Pneumocystis carinii diagnosed. The baby is most likely to have which of the following diseases: </div> <bR> <div> <B>DiGeorge syndrome </B></div> <div> <B>The DiGeorge syndrome involves not only the thymus, which markedly reduces cell-mediated immunity, but also the parathyroids (derived from the same branchial pouches as the thymus) and the heart, leading to congenital heart disease</B></div> <bR> <div> <B>========================================================================================================</B></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="906" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 2211 WIDTH="902"><bR> <div> A 23 year old woman has the sudden onset of severe lower abdominal pain. </div> <div> An ultrasound reveals a 4 cm mass involving the right fallopian tube. </div> <div> The uterus is normal in size.</div> <div>  There is no vaginal bleeding, but a culdocentesis (insertion of a needle through the vaginal vault into the pelvic peritoneal cavity) yields fresh blood. </div> <div> A urine pregnancy test is positive</div> <div> . Which of the following conditions has most likely occurred to produce these findings: </div> <bR> <div> This is a classic presentation for a ruptured tubal ectopic pregnancy. Prior infection with tubal scarring may increase the risk for this event..</div> <bR> <div> ==========================================================================================================</div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Over 75% of all perinatally-acquired HIV infections are secondary to intravenous drug use by an infected mother or her sexual partner </B></div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The extent of damage caused by prenatal alcohol exposure depends on the stage of fetal development, biological and environmental variables, and the amount and timing of the mother's alcohol consumption</B><I> </I></div> <bR> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Maternal age, ethnic and/or socioeconomic differences, genetic influences and the severity of alcoholism in women while pregnant are factors that may make their children more vulnerable to FAS </B></div> <bR> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Once a woman bears a child with FAS, the probability that subsequent children will have FAS is 70 percent </B></div> <bR> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pregnant women consuming between one and two drinks per day are twice as likely as nondrinkers to have a growth-retarded infant weighing less than 5.5 pounds</B></div> <bR> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Newborns whose mothers drink heavily (an average of five drinks per day, especially during the last three months of pregnancy) may show signs of alcohol withdrawal such as tremors, sleeping problems, inconsolable crying, and abnormal reflexes </B></div> <bR> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cigarette smoking during pregnancy has long been associated with adverse outcomes, including low birth weight, preterm birth, and intrauterine growth retardation and with infant morbidity and mortality (including sudden infant death syndrome)</B></div> <bR> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Increased tremulousness, altered visual response patterns to a light stimulus, and some withdrawal-like crying have been noted in the newborn infants of women who smoked marijuana heavily while pregnant </B></div> <bR> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cocaine use can precipitate miscarriage or premature delivery because it raises blood pressure and increases contractions of the uterus </B><I> </I></div> <bR> <bR> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Babies born to cocaine-using mothers appear to have fewer clearly discernible withdrawal symptoms than babies exposed to heroin and other narcotics in the womb.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Although cocaine-exposed newborns tend to be jittery, to cry shrilly, and to startle at even the slightest stimulation these effects have generally been attributed to neurobehavioral abnormalities than withdrawal</B><I> </I></div> <bR> <bR> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The long-term effects of perinatal cocaine exposure are yet to be established. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The most consistent findings show obstetrical complications,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> low birth weight, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">smaller head circumference, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">abnormal neonatal behavior, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and cerebral infarction at birth.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Children with this exposure are easily distracted, passive and face a variety of visual-perceptual problems and difficulties with fine motor skills </B></div> <bR> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Dramatic withdrawal symptoms are the most frequently observed consequence to newborns from prenatal narcotics exposure. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Restlessness, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">tremulousness,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> disturbed sleep and feeding,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> stuffy nose, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">vomiting, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">diarrhea, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">a high-pitched cry,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> fever, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">irregular breathing, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">or seizures usually start within 48-72 hours.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The heroin-exposed infant also </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">sneezes,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> twitches, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">hiccups,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> and weeps.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Occasionally, these symptoms do not begin until 2-4 weeks after delivery. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This irritability, resulting from overarousal of the central nervous system, usually ends after a month, but can persist for 3 months or more</B><I> </I></div> <bR> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Growth disturbances and other behavioral effects such as</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">hyperactivity, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">shortened attention spans,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> temper tantrums, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">slowed psychomotor development, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and impaired visual motor functioning </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">have been noted in infants and older children born to opiate-dependent mothers </B><I> </I></div> <bR> <bR> <bR> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Caffeine intake before and during pregnancy has been associated with an increase risk of fetal loss </B></div> <bR> <bR> <bR> </tD> </tR> </TABLE></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The rate of</B><FONT SIZE="3" COLOR="#FF0000" FACE="Arial" ><B> alcohol use among white women was significantly higher than the rate for Hispanics</B></FONT><B>, </B><FONT SIZE="3" COLOR="#000066" FACE="Arial" ><B>while rates of cigarette use for both whites and blacks were significantly higher than the rate for Hispanic women.</B></FONT></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In regard to age, rates of alcohol use for women ages 25-29 and 30 and older were both significantly greater than the rate for women under age 25. For cigarette use, differences between rates among the three age groups were not statistically significant </B></div> <bR> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Marijuana was used during pregnancy by an estimated 2.9 percent or 119,000 women; </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">cocaine by 1.1 percent or 45,000 women;</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> and a psychotherapeutic medication without physician orders by 1.5 percent or 61,000 women.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Crack was the form of cocaine use most frequently reported. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Observed rates of use for each of the other illicit drugs included in the survey appeared to be much lower </B></div> <bR> <bR> <bR> <div> <FONT SIZE="3" COLOR="#660000" FACE="Arial" ><B><IMG BORDER="0" SRC="Symb075c00b700f000006600.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Black women had significantly higher rates than white women for use of any illicit drug and cocaine, and significantly higher rates than Hispanic women for use of any illicit drug and marijuana.</B></FONT><B> </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">However, the</B><FONT SIZE="3" COLOR="#660099" FACE="Arial" ><B> estimated number of white women using any illicit drug or marijuana was substantially greater than the number in other race/ethnic groups</B></FONT><B>.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In comparing differences in illicit drug use among age groups, the rates of crack cocaine use in women ages 25-29 and 30 and older were significantly higher than the rate for those under age 25.</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Differences by age within race/ethnic groups appeared to vary by drug, but the statistical significance of these differences was not determined </B></div> <bR> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Overall and within race/ethnic groups, rates of use during pregnancy of marijuana, cocaine, and cigarettes often were significantly higher for women who were not married, currently not employed, had less than 16 years of formal education, or relied on public aid for payment of the hospital. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This pattern was reversed for alcohol use, with significantly higher rates found in women who were currently employed, had completed college, or had private insurance </B></div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Of those women who reported no illicit drug use during pregnancy, only 6 percent had used both alcohol and cigarettes. In contrast, 32 percent of those using at least one illicit drug during pregnancy also used both alcohol and cigarettes </B></div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fetal alcohol syndrome (FAS), the leading known cause of mental retardation </B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Features of FAS include growth deficiency before and after birth; effects on the central nervous system such as intellectual impairment, developmental delays and behavioral problems; and changes in facial features such as a flattened midface, a small jaw, and a thin upper lip </B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fetal alcohol effects (FAE) is used to describe individuals exposed to alcohol in the womb who exhibit only some of the attributes of FAS and do not fulfill the diagnostic criteria for FAS </B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Children with FAS commonly have problems with</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> learning, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">attention, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">memory, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and problem solving, along with incoordination,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> impulsiveness, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and speech and hearing impairments </B></div> <bR> <div> <B>==================================================================================================</B></div> <bR> <div> <B>Infant</B><FONT SIZE="4" COLOR="#000080" FACE="Arial" ><B> Risks of Multiple Gestation:</B></FONT><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Most of the risks to <FONT SIZE="3" COLOR="#800000" FACE="Arial" >infant</FONT>s resulting from multiple gestation pregnancies are due to the increased liklihood of premature delivery. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The more babies who result from a pregnancy, the greater the likelihood of premature delivery. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The average length of pregnancy is as follows:<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Single baby: 40 weeks<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Twins: 36 weeks<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Triplets: 32 weeks<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Quadruplets: 28 weeks<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Each additional baby in the uterus shortens the pregnancy by about 4 weeks on average. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The survival and outcomes of premature <FONT SIZE="3" COLOR="#800000" FACE="Arial" >infant</FONT>s are improving year by year as a result of new developments in high-risk obstetrics and newborn intensive care.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> However, significant risks remain, particularly for <FONT SIZE="3" COLOR="#800000" FACE="Arial" >infant</FONT>s born very early in pregnancy (before 30 weeks).<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> Complications<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Another important consideration is the risk of complications of prematurity. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The risk increases with shorter pregnancies. The most important complications of prematurity are :</div> <bR> <div> <I><B><U>Lung problems</U></B></I><B><U> </U></B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The most common problem confronting premature <FONT SIZE="3" COLOR="#800000" FACE="Arial" >infant</FONT>s is immaturity of their lungs.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> This problem often requries special treatment and may occasionally cause long-term problems in survivors;</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> it may also delay the recovery of some <FONT SIZE="3" COLOR="#800000" FACE="Arial" >premture</FONT> babies, especially those born before 28 weeks.<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <bR> <div> <I><B><U>Bleeding complications</U></B></I><B><U> </U></B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">One of the most serious potential complications of prematurity is spontaneous bleeding in the brain.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> This occurs in 10 to 20% of babies born before 32 weeks. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A chance of hemorrhage of any severity in <FONT SIZE="3" COLOR="#800000" FACE="Arial" >infant</FONT>s <32 weeks is 20%,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> and the chance of severe brain hemorrhage is 11%. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The risk is higher in the earliest babies. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Many of these hemorrhages are small and cause no long-term effects,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> but more severe bleeding episodes may be associated with permanent impairment of brain function.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Bleeding in the lungs is another serious potential complication in very early premature babies.<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <bR> <div> <I><B><U>Gastrointestinal</U></B></I><B><U> </U></B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Necrotizing enterocolitis i</B>s a complication of prematurity resulting in nonviable portions of the intestines. [see my pediatry surgery page]</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This may result in sepsis of the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >infant</FONT>, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">often requiring bowel segmental resection.<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <bR> <div> <I><B><U>Eye problems</U></B></I><B><U> </U></B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000008000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Infant<FONT SIZE="3" COLOR="#000080" FACE="Arial" >s born very prematurely (before 28 weeks) may have abnormal growth of blood vessels on the retina, the back of the eye. </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This is a common complication that usually goes away spontaneously. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In severe cases, the problem, if untreated, may progress to<B><U> retinal detachment and blindness</U></B>. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Premature <FONT SIZE="3" COLOR="#800000" FACE="Arial" >infant</FONT>s are also at increased risk of other eye problems such as nearsightedness and eye muscle problems.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f080000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> It is quite common for premature <FONT SIZE="3" COLOR="#800000" FACE="Arial" >infant</FONT>s to require glasses later in childhood because of one or more of these problems.<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> =====================================================================================================================</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">prematurely or at a low birth weight.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">These babies are likely to require high-technology intensive and specialized care in the hospital and prolonged out patient follow-up care as <FONT SIZE="3" COLOR="#800000" FACE="Arial" >infant</FONT>s and children. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">As a result, many have chronic medical and developmental problems such as:</div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">brain hemorrhages</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">chronic lung disease</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">respiratory distress</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">visual impairment</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">feeding issues</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">cerebral palsy</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">language delays</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">fine and gross motor skills delays </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">sensory integration issues</B></div> <div> <B>=====================================================================================================================</B></div> <div> <B>HYPOXIC-ISCHAEMIC ENCEPHALOPATHY</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"><A NAME="1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Hypoxic-ischaemic encephalopathy (HIE) is a clinical condition which presents with neurological signs in the immediate newborn period. It is usually caused by severe fetal hypoxia with secondary cerebral ischaemia. These infants often have fetal distress with asphyxia and a metabolic acidosis at birth. However some of these infants appear normal for many hours after delivery. </div> <div>  <A NAME="2"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Clinical signs:</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">lethargy with poor sucking, decreased tone and poor Moro reflex </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">irritability, increased tone, fisting, convulsions </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">full fontanelle </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">apnoea </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The HIE scoring method may be used to measure the severity of the clinical signs. The score usually increases for the first few days and then returns to normal by a week. A high score is associated with a high mortality while a slow return to normal is associated with a high risk of abnormal neurological development. </div> <div>  <A NAME="3"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Management:</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">prevent fetal hypoxia if possible with good labour management </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">prompt resuscitation of the newborn if needed </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">treat convulsions with phenobarb 20 mg/kg IV as a single dose </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">restrict fluid intake to reduce cerebral oedema </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">headbox oxygen if needed </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">provide good supportive care </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">monitor vital signs </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">neurodevelopmental assessment after discharge home </div> <div> <B>=====================================================================================================================</B></div> <div> <B>CONVULSIONS</B> </div> <div>  <A NAME="1_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>The clinical presentation is very variable. Instead of the generalised "grand mal" convulsion seen in the child, the most usual pattern in the first week of life is one of jerking or twitching of a focal nature, often shifting rapidly from one part of the body to another. At times focal repetitive twitching of one extremity or one side of the face is all that is seen. </div> <div> Tonic episodes with hyperextension of trunk, neck and limbs may also occur. Convulsions may even present as apnoeic attacks, flickering eyelids, tonic deviation of eyes to one side or lip smacking. </div> <div>  <A NAME="2_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Causes:</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Brain damage: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">hypoxia, bleeding, oedema </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Brain deformities: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">microcephaly </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">hydrocephaly </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">porencephalic cyst </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Infection: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">acute meningitis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">chronic e.g. toxoplasmosis, CMV </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bilirubin encephalopathy </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Biochemical: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">hypoglycaemia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">hypocalcaemia and/or hypomagnesaemia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">hypernatraemia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">hyponatraemia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">water intoxication </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Inborn errors of: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">phenylketonuria </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">metabolism (rare) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">galactosaemia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">pyridoxine dependency </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">drug withdrawal </div> <div> A convulsion presenting within 48 hours of birth is most likely to be due to birth asphyxia, birth trauma, hypoglycaemia or meningitis. </div> <div>  <A NAME="3_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Treatment:</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Provide: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">airway </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">oxygen if required </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">ventilate if necessary </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Anticonvulsant: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">immediate - diazepam PR or paraldehyde IM </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">later - IM phenobarbitone, or phenytoin </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Treat specific disorder. </div> <div> <B>=====================================================================================================================</B></div> <bR> <div> <B>Choice of milk</B> - consider: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">age and maturity of infant </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">socio-economic status of family </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">availability of milk produce, e.g. local clinic </div> <div>  <A NAME="7"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Fluid requirements</B> </div> <div> General guidelines - per 24 hours: </div> <div> day 1 - 60 ml/kg </div> <div> day 2 - 75 ml/kg </div> <div> day 3 - 100 ml/kg </div> <div> day 4 - 125 ml/kg </div> <div> day 5 - 150 ml/kg</div> <div> Thereafter: </div> <div> The volume of feeds should be increased more slowly in preterm infants </div> <div> Preterm infants may require up to 180 ml/kg </div> <div> Term infants continue with 150 ml/kg</div> <div>  <A NAME="8"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Energy requirements</B> </div> <div> Calculate according to actual weight. Breast milk and most modified and partially modified milk contain 294 kJ/100 ml (70 kcal/100 ml). </div> <div> Recommended daily requirements: </div> <div> Preterm 546-630 kJ/kg/24 hrs (130-150 kcal/kg/24 hours) </div> <div> Term 420-504 kJ/kg/24 hrs (100-120 kcal/kg/24 hours) </div> <div> (Note : 4.2 kJ = 1 kcal) </div> <div>  <A NAME="9"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Reconstitution of milk products</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Powdered milks: 1 measure (provided) scraped level and not packed, to 25 ml water </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">(i.e. 2.5 g powder to 25 ml water) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Evaporated milk: add equal quantity of water </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Dilution of milks for the first month of life: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">modified milks (once reconstituted) do not need to be diluted </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">evaporated milk:- make up 2 parts milk to 3 parts water </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">cow's milk:- add 1 part water to 3 parts milk </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">partially modified milks require dilution:- follow manufacturers instructions</div> <div>  <A NAME="10"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Energy content</B> </div> <div> Adjust energy content when necessary by adding one teaspoonful (5 g) of sugar to 100 ml milk. </div> <div> Do not add sugar to milk used for complementing breast feeds. </div> <div> Modified milk formulas do not require added sugar. </div> <div>  <A NAME="11"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Frequency</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">term babies - demand feed, or 4-hourly i.e. 5-6 feeds a day </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">preterm babies - 3 hourly feeds (or more if necessary) </div> <div>  <A NAME="12"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Vitamins, iron and fluoride</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">All infants, whether breast or bottle fed, may be given vitamins D and C (in multivitamin syrup) and fluoride from birth. This is important in breast fed infants from poor communities. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Iron should be given from 1 month in preterm infants. Term infants may also be given iron. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Extra vitamins and iron can normally be stopped at 6 months if the infants is receiving adequate solids. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"><A NAME="13"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Daily requirements: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Vitamins </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Vitamin A : 1500 - 3000 u/day </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Vitamin C : 25 -50 mg/day </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Vitamin D : 400 u/day (preterm : 800 u/day) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Vitamin K1 : 1 mg at birth</div> <div> Term infants should receive 0.3 ml and preterm infants 0.6 ml of multivite drops a day. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Iron </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Term infants: 1 mg/kg/day (maximum 15 mg/day) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Preterm: 2 mg/kg/day (maximum 15 mg/day)</div> <div> 1 ml of iron drops contains 25 mg Fe </div> <div> Term infants usually receive 0.3 ml and preterm infants 0.6 ml of multivite drops a day. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fluoride - 0.25 mg/day </div> <div>  <A NAME="14"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Introduction to solids</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">solids may be started after 12 weeks. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">the age at which the infant is weaned depends largely on mother's interpretation of the baby's needs </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">introduce small amounts of food, one at a time, starting with cereals, puree fruits and vegetables </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">gradually progress to a full mixed diet </div> <div> <B>N.B</B>. Infants with a strong history of allergy in the family: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">avoid cow's milk for at least 6 months (breast or soya) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">delay introduction of solids </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">no citrus, eggs or cheese before 9-12 months </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">only wheat-free cereals </div> <div>  <A NAME="15"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Assessment of satisfactory feeding</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">helpful sign = a content infant with a satisfactory weight gain (according to the growth chart) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">if there is failure to thrive: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">examine to exclude disease </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">assess adequacy of milk and kilojoule intake </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">exclude abnormal losses, infection, acidosis and metabolic disturbances, congenital or acquired conditions</div> <div>  <A NAME="16"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Feeding technique</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cup feeding is preferable to bottle feeding as a cup is far easier to clean </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">"Prop-feeding"' is out! </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">no normal infants should be fed for longer than 20 minutes </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">give advice on cleanliness of cup, bottle and teat, sterilization, storage of reconstituted milk, correct temperature </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">warn mothers about common mistakes e.g. making feeds too strong (hypernatraemia) or too weak (failure to thrive), and the difference between thirst and hunger (a thirsty baby needs cooled, boiled water, not milk). </div> <div>  <A NAME="17"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Feeding preterm and underweight for gestational age infants</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Less than 1.5 kg </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">IV fluids for first 48 hours (using Neonatalyte) then </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Nasogastric tube feeds: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Tube feeding is necessary until the baby is able to suck strongly enough around 35-36 weeks </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Note: </div> <div> Nasogastric tube length to be passed = 2x distance from suprasternal notch to xiphisternum, plus 2.5 cm.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Over 1.5 kg </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">start feeding shortly after birth (preferably breast milk) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">may require nasogastric tube feeds at first, depending on gestational age. (Use expressed breast milk) </div> <bR> </td> </tr></table></body>