1. Neonatal Cold Injury Syndrome (sclerema neonatorum)

2. Objectives What will I learn? Etiologies and pathophysiology Symptoms Diagnosis Treatment

3. Definition -- mainly caused by cold stress --the clinical features are low body temperature and scleredema --serious one may appear multiple organ dysfunction. Scleredema --- hardening of the skin and subcutaneous tissue

4. Etiology and pathophysiology Characteristics of temperature regulation and subcutaneous fatty composition in newborn ● immaturity of temperature regulation center ● relative large surface area and rich blood flow cause poor thermal insulation

5. ● limited storage of energy, heat production mainly by brown fatty metabolism, lacking shivery thermogenesis ● more quantity of saturated fatty acid with higher melting point Imbalance between heat production and loss

6. Distribution of neonatal brown fat

7. Cold injury ● Cold environment increase heat loss, low body temperature causes constriction of peripheral blood vessels, dysfunction of microcirculation ● Low body temperature and cold environment cause anoxia , metabolic disturbance and acidosis even multiple organ dysfunction ( MOD )

8. Other Factors ● severe infection, ● premature, ● asphyxia, ICH, ● erythroblastosis

9. Imbalance between heat production and loss Heat production Non-enough intake √ √ √ cold √ asphyxia infection

10. Imbalance between heat production and loss Heat loss cold √ relative larger surface √ cold √ immature of temperature center

11. immature of temperature center relative larger surface cold 、 non-enough intake infection 、 asphyxia heat production of brown fat↓ anoxia, acidosis higher saturated fatty acid higher melt point body temperature ↓ coagulation of subcutaneous fat Pathogenesis of Neonatal Scleredema

12. Anoxia, acidosis coagulation of subcutaneous fat constriction of skin vessels anoxia of tissue hardening of skin Slowly blood flow disturbance of microcirculation capillary permeability ↑ edema circulating volume↓ shock multiple organs dysfunction DIC

13. ● usually occur in cold season ● during first 3 days or any time in preterm infants ● Low body temperature ● Scleredema ● MOD in severe case Clinical Manifestations

14. ● feature: skin and subcutaneous tissue become indurated, woody, non-pitting, cold to touch, involved area may with edema, redness, cyanosis; symmetrical ● Sequence : calves->thighs->low extremities->buttock->cheeks->upper extremities->whole body Scleredema

15. Neonatal scleredema

17. multiple organ dysfunction ● bradycardia, dyspnea, ● microcirculation disturbance, ● shock, DIC , ● acute renal failure, ● pulmonary hemorrhage

18. Evaluation of body surface area Head and neck 20% Upper limbs 18% Anterior part of trunk 14% Posterior part of trunk 14% Buttock 8% Lower limbs 26% 20% 9% 9% 14% 14% 8% 13% 13%

19. Degrees of NCIS Body temperature(℃) involved area change of organic anus T axil – anus T (% 、 color) function I 0 ≥ 35 positive < 20 no change (mild) pale II 0 < 35 0 or positive 20 ～ 50 poor reaction (moderate) dark red bradycardia III 0 < 35 negative > 50 shock 、 DIC 、 (severe) or < 30 cyanotic PH or ARF

20. nonspecific examination for diagnosis. blood gas analysis, CT, PT, blood glucose level, platelet, electrolytes, BUN, fibrogen, etc. EKG, X - ray Laboratory Examination

22. Neonatal edema

24. Neonatal Subcutaneous Gangrene

25. treatment Heat loss Heat production Correction of organ dysfunction normal body temperature organs function

26. Treatment ● Restoration of body temperature ● Energy supply and fluid infusion ● Correction of organ dysfunction · correction of acidosis and volume expansion · treatment of pulmonary hemorrhage · arrangement of ARF and DIC ● Others: antibiotics, symtomatic therapy

29. Treatment Ways of re-warming ● Incubator ● Open radiant warmer bed ● Others water bath, electric blanket , Kangaroo Care, etc

30. Incubator

32. Open radiant warmer bed

33. Huge omphalocele( 巨大脐膨出）

39. kangaroo care

40. Prevention ● Neonatal care: warm environment, enough clothes ● Encourage early breast feeding ● Prevent high risk factors: premature, infection, asphyxia

42. Conclusion and Review ● How to diagnose neonatal sepsis? ● Which marker can indicate neonatal infection? ● How many factors can cause NCIS? ● Which complication is caused by NCIS? ● State the clinic S/S and degrees of NCIS.

43. Thank You

44. Mini case discussion

46.  PROM of 2days intrapartum ampicillin because of PROM( pre-rupture of membrane ） and maternal elevation of CRP  Admitted to NICU duo to prematurity  General condition is unstable

49. 05/26/10