Neonatal and Paediatric

Anatomy and Physiology

Dr Alison Chalmers
Consultant Anaesthetist
Queen Victoria Hospital
 What you need to know

 Fetal circulation and changes at birth

 Anatomical differences in the airway, head
and spinal cord from the adult
 Physiological differences from the adult
 Haematological and biochemical changes
with age
 Estimation of blood volume
Fetal circulation
 Ductus venosus

 Foramen ovale

 Ductus arteriosus
Changes at birth
 Changes at birth
 First breath generates negative pressure
 ↑ FRC ↓ PVR
 Blood flows from right ventricle through lungs
 ↑ SVR with clamping of umbilical vessels
 Reversal of right to left flow through DA
 Oxygen and ↓ PGE2 stimulates ductal constriction
 ↑ LAP and ↑ SVR cause closure of the FO
 DV closes passively as flow ceases
 Fetal haemoglobin

 2 ά chains and 2 λ chains

 Binds 2,3-DPG less avidly than HbA
 Shifts ODC to left (P50 2.4KPa)
 Favours O2 transfer from mother to fetus
 Gives up more O2 to fetal tissues than HbA
 80% circulating Hb at birth
 Replaced within 3-5months by HbA
 Neonatal physiology
 CVS
 RV=LV at birth
 ↑ ratio of connective to
contractile tissue
 Flat Starling curve
 Fixed SV
 Lungs
 Bronchial tree fully
developed
 Alveoli develop fully after
birth
 Compliant chest wall
 Diaphragmatic breathing
 Less ventilatory responses
to PaO2 and PaCO2
 Neonatal physiology
 Kidneys  CNS
 No of nephrons  Pathways complete at
complete by birth birth
 RBF increases from  Temp control
5% CO at birth to  High SA to body
20% at 1 month weight ratio
 Low GFR; adult by 2  Less SC fat
years
 Non shivering
 Liver thermogenesis
 Immature enzymes
Paediatric anatomy and physiology

 Airway
 Lungs
 CVS
 BMR
 CNS
 Temp regulation
 Fluid balance
 Pharmacology
Paediatric Airway
 Paediatric respiratory system

 Diaphragmatic
 Neonates – obligate nasal breathers
 Increased respiratory rate
 Very compliant chest wall – horizontal ribs
 CC > FRC in normal breathing
 Ventilatory response to CO2 reduced
 BMR/O2 consumption high
Paediatric cardiovascular system
AGE SYSTOLIC DIASTOLIC HEART
BP (mmHg) BP (mmHg) RATE
Preterm 45 25 >120
Birth 60 35 >120
Neonate 70-80 40-50 120-150
3-6 months 80-90 50-60 120-140
1 year 90-100 60-80 110-130
5 years 95-100 50-80 90-100
12 years 110-120 60-70 80-100
 Paediatric nervous system

 Spinal cord ends L3; recedes by

adolescence
 Immature BBB
 Pronounced vagal reflexes
 Fluid balance
 Blood volumes
 Birth: 90ml/kg
 Child: 80ml/kg
 Teenager: 70ml/kg
 Maintenance fluid requirements
 4ml/kg/h for first 10kg
 2ml/kg/h for next 10kg
 1ml/kg/h for each kg after
 Pharmacokinetics/dynamics

 Lower plasma albumin levels up to 1 year

 Renal and hepatic immaturity
 MAC increased in neonates
 Neonates sensitive to NMB; more resistant
to sux
 Haematological changes with age

 Hb
 Birth: 14-22g/l, 3-6 months: 11-14, 6-12 years: 11.5-
15.5
 WCC
 Birth: 10-26 x109/l, 3-6 months: 6-18, 6-12: years 5-
13
 Platelets – fairly stable between 150-500 x109/l
 All vit K dependant clotting factors are low at
birth – reach adult values by 6 months
 Biochemical changes with age

 Albumin: low up to 1 year

 Bilirubin: high at birth (17-170umol/l),
normal adult levels by 1 month
 Ca2+: low neonate (1.9-2.8mmol/l),
normal adult levels by 1 year
 T4: high neonate, falls to adult range
steadily up to 10 years
Any questions?
 Summary

 Fetal circulation and changes at birth

 Anatomical differences in the airway, head
and spinal cord from the adult
 Physiological differences from the adult
 Haematological and biochemical changes
with age
 Estimation of blood volume