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Hours after birth Days after birth

Figure 83-7

Fall in body temperature of the neonate immediately after birth, and instability of body temperature during the first few days of life.

as 90 per cent of the ingested amino acids are used for formation of body proteins. This is a much higher percentage than in adults.

Metabolic Rate and Body Temperature. The normal metabolic rate of the neonate in relation to body weight is about twice that of the adult, which accounts also for the twice as great cardiac output and twice as great minute respiratory volume in relation to body weight in the infant.

Because the body surface area is large in relation to body mass, heat is readily lost from the body. As a result, the body temperature of the neonate, particularly of premature infants, falls easily. Figure 83-7 shows that the body temperature of even a normal infant often falls several degrees during the first few hours after birth but returns to normal in 7 to 10 hours. Still, the body temperature regulatory mechanisms remain poor during the early days of life, allowing marked deviations in temperature, which are also shown in Figure 83-7.

Nutritional Needs During the Early Weeks of Life. At birth, a neonate is usually in complete nutritional balance, provided the mother has had an adequate diet. Furthermore, function of the gastrointestinal system is usually more than adequate to digest and assimilate all the nutritional needs of the infant if appropriate nutrients are provided in the diet. However, three specific problems do occur in the early nutrition of the infant.

Need for Calcium and Vitamin D

The neonate is in a stage of rapid ossification of its bones at birth, so that a ready supply of calcium throughout infancy is needed. This is ordinarily supplied adequately by the usual diet of milk. Yet absorption of calcium by the gastrointestinal tract is poor in the absence of vitamin D. Therefore, the vitamin D-deficient infant can develop severe rickets in only a few weeks. This is particularly true in premature babies because their gastrointestinal tracts absorb calcium even less effectively than those of normal infants.

Necessity for Iron in the Diet

If the mother has had adequate amounts of iron in her diet, the liver of the infant usually has stored enough iron to keep forming blood cells for 4 to 6 months after birth. But if the mother has had insufficient iron in her diet, severe anemia is likely to occur in the infant after about 3 months of life. To prevent this possibility, early feeding of the infant with egg yolk, which contains reasonably large quantities of iron, or the administration of iron in some other form is desirable by the second or third month of life.

Vitamin C Deficiency in Infants

Ascorbic acid (vitamin C) is not stored in significant quantities in the fetal tissues; yet it is required for proper formation of cartilage, bone, and other intercellular structures of the infant. Furthermore, milk has poor supplies of ascorbic acid, especially cow's milk, which has only one fourth as much as human milk. For this reason, orange juice or other sources of ascorbic acid are often prescribed by the third week of life.

Immunity

The neonate inherits much immunity from the mother because many protein antibodies diffuse from the mother's blood through the placenta into the fetus. However, the neonate does not form antibodies of its own to a significant extent. By the end of the first month, the baby's gamma globulins, which contain the antibodies, have decreased to less than one half the original level, with a corresponding decrease in immunity. Thereafter, the baby's own immunity system begins to form antibodies, and the gamma globulin concentration returns essentially to normal by the age of 12 to 20 months.

Despite the decrease in gamma globulins soon after birth, the antibodies inherited from the mother protect the infant for about 6 months against most major childhood infectious diseases, including diphtheria, measles, and polio. Therefore, immunization against these diseases before 6 months is usually unnecessary. Conversely, the inherited antibodies against whooping cough are normally insufficient to protect the neonate; therefore, for full safety, the infant requires immunization against this disease within the first month or so of life.

Allergy. The newborn infant is seldom subject to allergy. Several months later, however, when the infant's own antibodies first begin to form, extreme allergic states can develop, often resulting in serious eczema, gastrointestinal abnormalities, and even anaphylaxis. As the child grows older and still higher degrees of immunity develop, these allergic manifestations usually disappear. This relation of immunity to allergy is discussed in Chapter 34.

Endocrine Problems

Ordinarily, the endocrine system of the infant is highly developed at birth, and the infant seldom exhibits any immediate endocrine abnormalities. However, there are special instances in which the endocrinology of infancy is important:

1. If a pregnant mother bearing a female child is treated with an androgenic hormone or if an androgenic tumor develops during pregnancy, the child will be born with a high degree of masculinization of her sexual organs, thus resulting in a type of hermaphroditism.

2. The sex hormones secreted by the placenta and by the mother's glands during pregnancy occasionally cause the neonate's breasts to form milk during the first days of life. Sometimes the breasts then become inflamed, or infectious mastitis develops.

3. An infant born of an untreated diabetic mother will have considerable hypertrophy and hyperfunction of the islets of Langerhans in the pancreas.

As a consequence, the infant's blood glucose concentration may fall to lower than 20 mg/dl shortly after birth. Fortunately, however, in the neonate, unlike in the adult, insulin shock or coma from this low level of blood glucose concentration only rarely develops.

Maternal type II diabetes is the most common cause of large babies. Type II diabetes in the mother is associated with resistance to the metabolic effects of insulin and compensatory increases in plasma insulin concentration. The high levels of insulin are believed to stimulate fetal growth factor and contribute to increased birth weight. Increased supply of glucose and other nutrients to the fetus may also contribute to increased fetal growth. However, most of the increased fetal weight is due to increased body fat; there is usually little increase in body length although the size of some organs may be increased (organomegaly).

In the mother with uncontrolled type I diabetes (caused by lack of insulin secretion), fetal growth may be stunted because of metabolic deficits in the mother, and growth and tissue maturation of the neonate are often impaired. Also, there is a high rate of intrauterine mortality, and among those fetuses that do come to term, there is still a high mortality rate. Two thirds of the infants who die succumb to respiratory distress syndrome, described earlier in the chapter.

4. Occasionally a child is born with hypofunctional adrenal cortices, often resulting from agenesis of the adrenal glands or exhaustion atrophy, which can occur when the adrenal glands have been vastly overstimulated.

5. If a pregnant woman has hyperthyroidism or is treated with excess thyroid hormone, the infant is likely to be born with a temporarily hyposecreting thyroid gland. Conversely, if before pregnancy a woman had had her thyroid gland removed, her pituitary gland may secrete great quantities of thyrotropin during gestation, and the child might be born with temporary hyperthyroidism.

6. In a fetus lacking thyroid hormone secretion, the bones grow poorly and there is mental retardation. This causes the condition called cretin dwarfism, discussed in Chapter 76.

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