16 - Infant & Prenatal Care Flashcards
What are common cardiovascular changes in pregnancy?
- Increased blood volume
- Vascular distention
- Blood vessel proliferation
What is a common hemodynamic change in pregnancy?
Increased clotting factors
What are common immunologic changes in pregnancy?
- Altered immune response
- Decreased cell-mediated immunity (increased risk of infection for fetus and mother)
What are some nutritional requirements during pregnancy?
- Limit caffeine intake to under 300 mg/day
- No alcohol
- Eat foods high in calcium, heme iron and folic acid
- Eat foods w/ iodine
- Eat non-heme iron sources w/ vitamin C-containing foods
Which women are at high risk of their fetus having neural tube defects? What is the recommended folic acid supplementation pre and post-conception?
- Those who had a previous pregnancy or personal history of neural tube defects
- Preconception = 4-5 mg at least 3 months before until 12 weeks pregnant
- Postconception = 0.4-1 mg from 12 weeks gestation until 4-6 weeks postpartum or as long as breastfeeding
Which women are at medium risk of their fetus having neural tube defects?
- Taking folate inhibiting medications (anticonvulsants, metformin, sulfasalazine, triamterene, trimethoprim)
- 1st or 2nd degree relative or partner w/ history of NTD
- GI malabsorptive conditions (celiac, IBD, gastric bypass)
- Advanced kidney disease
- Prior pregnancy w/ folate sensitive congenital abnormality
What is the recommended folic acid supplementation pre and post-conception for women at medium risk of having a fetus w/ neural tube defects?
- Preconception = 1 mg at least 3 months before until 12 weeks gestation
- Postconception = 0.4-1 mg from 12 weeks gestation until 4-6 weeks postpartum or as long as breastfeeding
What is the recommended folic acid supplementation pre and post-conception for women at low risk of having a fetus w/ neural tube defects?
- Preconception = 0.4 mg 2-3 months before
- Postconception = 0.4 mg continued until 4-6 weeks postpartum or as long as breastfeeding
Which foods can carry listeria? What is a recommendation for a pregnant woman to prevent listeria?
- Unpasteurized milk, soft-ripened cheeses, deli met
- Avoid these foods; reheat until steaming hot; wash raw fruit and veggies well
Which foods can carry salmonella? What is a recommendation for a pregnant woman to prevent salmonella?
- Raw seafood and raw eggs
- Avoid raw or soft-cooked eggs
Is sushi safe during pregnancy?
Only if the raw meat has been kept at the proper temp (freezer) for the proper amount of time
Which foods contain methylmercury? What is the recommendation for methylmercury consumption during pregnancy?
- Fish (shark, swordfish, mackerel, albacore tuna)
- Can have a max. of 2 servings of fish/week
Where is toxoplasma found? What is the recommendation during pregnancy?
- Parasite in raw meat, soil and dirty cat litter
- Wear gloves if gardening, cook meat thoroughly, and avoid changing a cats litter box
Travel is safe up to ___ weeks before expected due date
4
What are some things to consider before travelling while pregnant?
- Increased risk of VT
- Comorbid conditions (respiratory and cardiac disease, pregnancy complications)
- Air line policies
- Medical resources and insurance at destination
- Exposure to infectious diseases at destination
What is the recommendation for hot tub and sauna use during pregnancy?
Avoid in first trimester (associated w/ NTDs and miscarriage)
What is the recommendation for hair treatments during pregnancy?
- Very limited systemic absorption, so unlikely to reach fetus
- Avoid if burns or open wounds present
- If pregnant woman is a hairdresser - wear gloves and ensure adequate ventilation in workplace
What are common prenatal discomforts?
- N/V, heartburn, constipation, hemorrhoids
- Leukorrhea (white-yellow mucous vaginal discharge)
- Gingivitis
- Edema
- Varicose veins
- Cutaneous changes (spider angioma’s, melasma)
What must you advise the px to do when you recommend a tx for a prenatal discomfort?
Must inform her to inform her prenatal provider at the next visit
What is normal vaginal discharge during pregnancy?
Thin, white, milky, mild smelling or odourless
What are symptoms of pregnancy gingivitis?
Increased redness and bleeding of gums
What causes physiological edema during pregnancy?
- Hormone-induced Na retention (increased plasma volume)
- Uterine compression of inferior vena cava
What are some differential diagnoses to consider when a pregnant woman is experiencing physiological edema?
- Pre-eclampsia
- DVT
- Cellulitis
What are sx of physiological edema?
- Bilateral
- Lessens w/ elevation
What sx can edema and varicose veins cause?
- Numbness
- Mild pain
- Aching or “heavy feeling”
- Itching
- Throbbing
- Irritation around vein
What causes varicose veins?
- Hormone-induced Na retention (increased plasma volume)
- Uterine compression of inferior vena cava
- Progesterone relaxes blood vessels
- Blood vessel valve weakens and blood stagnates in vein, causing distension
What are some non-pharms for edema and varicose veins?
- Compression stockings
- Sleep on left side
- Maintain adequate fluid intake
- Avoid prolonged standing
- Rest w/ legs elevated
- Don’t cross legs when sitting
- Maintain physical activity
What is melasma/chloasma? What causes it?
- Dark skin discolouration on sun exposed areas
- Due to excess melanin in skin
What are spider angiomas? When do they normally occur? Where are they most common on the body?
- Central red puncti w/ radiating braches
- Usually appear in 2nd to 5th month of pregnancy
- Most common around eyes and areas drained by SVC (neck, face, upper chest, arms, hands)
What are striae gravidarum?
Stretch marks
What are risk factors for stretch marks?
- Degree of abdominal distension
- Maternal weight gain
- Genetic predisposition
- Younger maternal age
What is the tx for melasma?
- Prevention is key (broad spectrum sunscreen)
- Pharm options = hydroquinolone, azelaic acid, tretinoin
- Other = chemical peels, laser treatment, microdermabrasion
What is the tx for angiomas?
Tx not required b/c most resolve in 3 months
What is the tx for striae gravidarum?
- Common agents for prevention = cocoa butter, hyaluronic acid, vitamin E
- No evidence supporting use of topical preparations in prevention
- Possible tx options = tretinoin cream, laser therapy
What are some prenatal signs of potential complications?
- Severe vomiting
- Signs of infection (fever, diarrhea, pain on urination)
- Abdominal cramping
- Vaginal bleeding
- Sudden loss or continued leakage of fluid from vagina
- Decreased fetal activity
- Signs of preterm labour (dull backache, increased uterine activity; menstrual-like cramps; diarrhea, spotting or bleeding)
What is the most common cause of premature discontinuation of breastfeeding?
Breast and nipple pain
What are common causes of breast and nipple pain?
- Engorgement and plugged ducts
- Nipple trauma/injury
- Breast/nipple infections
What is the main difference between engorgement and plugged ducts?
- Engorgement = bilateral; plugged duct = unilateral
- Pain in generalized in engorgement and localized in plugged duct
What is the main difference between mastitis and engorgement/plugged duct?
- Mastitis = sudden onset, localized intense pain, red/hot/swollen, flu-like symptoms
- Engorgement/plugged duct = gradual onset, mild pain, no fever or systemic sx
What is the recommended tx for engorgement and plugged ducts?
- Optimize feeding technique and encourage frequent feeding
- Avoid tight or restrictive clothes
- Warm compresses may facilitate milk removal
- Cool compresses between feeding to decrease swelling (ice 15 min on and 45 min off)
- Analgesics (acetaminophen, ibuprofen)
- For plugged ducts, massage breast from affected area toward nipple
What are risk factors for mastitis?
- Previous mastitis
- Engorgement
- Poor milk drainage
- Nipple damage
What is the tx for mastitis?
- Supportive measures as for engorgement
- Antibiotics if fever is present or if sx don’t improve w/in 12-24 h w/ supportive measures
- Tx duration = 10-14 days; sx should improve w/in 48-72 h of initiating antibiotics
What are signs and symptoms of normal nipple pain?
- Pain subsides w/in 30-60 seconds of initiation of feeding
- Often peaks around 3-6 days postpartum
- Usually resolves in about 1 week
What are signs and sx of nipple trauma?
- Pain persists or increases throughout feeding
- Lasts over 1 week
- Cracks, fissures, bleeding
What are signs and sx of a nipple bleb?
- Shiny, white bump at tip of nipple (blocked nipple pore)
- Pinpoint pain on feeding
What are signs and sx of nipple eczema?
- Bilateral
- History of eczema, assess for exposure to new irritant
- Red scaly rash usually not centered around nipple
What are signs of sx of Raynaud’s or nipple vasospasm?
- Triphasic colour change (white, gray, red)
- Intense pain, burning, numbness, prickling, stinging
- Pain on exposure to cold
What are signs and sx of nipple candidiasis?
- Sharp shooting pain, out of proportion to physical findings
- Affected nipple appears pink/red and shiny or skin may be flaky
- Exclusion of other causes of breast pain
What is the tx for nipple trauma?
Refer to lactation consultant to ensure proper latch
What are some non-pharms for nipple pain?
- Nipple care (avoid harsh cleansers and excessive moisture)
- Cool or warm compresses
- Acetaminophen or ibuprofen
- Lanolin or hydro-gel dressings
What is the tx for a nipple bleb?
Warm soaks, frequent feeding
What are predisposing factors to nipple candidiasis?
- History of infant oral or diaper candidal infection
- History of maternal VVC
- Previous antibiotic use
- Nipple damage
What is the first line tx for nipple candidiasis?
- Non-pharms to prevent reinfection and cross contamination
- Manage nipple trauma if present
- Treat mother and infant simultaneously (mother - topical antifungals; child - oral candidiasis)
- Improvement should be seen w/in 3-7 days
- Continue for 1 week after px is sx free
What are the common reasons for breast pump use?
- Stimulate milk production
- Maintain milk supply
- Provide infant w/ breast milk
What are some tips to give on pumping?
- Wash hands w/ soap and water before pumping
- Ensure that pump pieces and milk collection containers are clean
- Ensure flanges are appropriate size
What can be done if having difficulty pumping?
- Gently massage breasts before pumping
- Apply warm wet cloth to breasts before pumping
- Pump in a quiet, dark room to avoid distractions
- Look at picture of baby or smell baby’s blanket
What are signs of perineal pain that require referral?
- Pain is severe or associated w/ foul-smelling discharge
- Burning, bleeding
- High fever
What is lochia? What are the different stages?
- Uterine discharge after childbirth
- Lochia = 2-3 days postpartum; bright red, small clots
- Lochia serosa = 3-10 days postpartum; brown or pink
- Lochia alba = 10 days to 6 weeks postpartum; white or pale yellow
What are signs of lochia that require referral?
- Bleeding beyond 6 weeks
- Increasing bleeding or clots large than a loonie
- Increasing pain
What is the typical onset and duration of the postpartum “blues”?
Onset = day 3 or 4; duration = max. 2 weeks
What are some postnatal red flags?
- Abnormal vaginal bleeding
- Malodorous vaginal discharge
- Fever/chills
- Painful, difficult or frequent urination
- C-section incision site - increasing pain, redness, swelling or leakage
- Signs of mastitis
- Any worsening pain
- Signs of postpartum depression
- Signs of DVT (pain, redness, warmth, firmness in lower leg)
What does a normal umbilicus look like?
- Clean and dry
- Falls off 5-15 days after birth
- Slightly moist/sticky w/ slight mucoid discharge and odour
- Small amount of blood on separation
What are signs and sx of omphalitis?
- Erythema, edema, and tenderness extending beyond 5 mm => requires medical attention
- Accompanied by fever, lethargy, and/or poor feeding => requires urgent care
What are some tips to care for the umbilicus?
- Keep clean and dry
- Wash hands w/ soap and water before and after contact w/ umbilical area
- Clean around base of cord w/ water on cotton tipped applicator or soft washcloth after bathing and at diaper changes
- Fold diaper below cord stump
- Expose to air or cover w/ loose clothing
- Avoid cleaning w/ alcohol (delays falling off) and anti-microbials (increased risk of resistant bacteria)
What are some tips to care for a circumcised penis?
- Ensure effective pain relief (topical or local anesthetic during procedure; acetaminophen 24-48 h post-procedure)
- Apply non-stick gauze after procedure; apply petrolatum underneath to prevent sticking
- Remove and replace gauze w/ every diaper change for 24 hours
- Gently wash w/ warm water 1-2 times daily
- Continue to apply petrolatum for 3-5 days (no gauze)
How long does it take for a circumcised penis to fully heal?
7-10 days
What are red flags for a circumcised penis?
- Bleeding more than quarter size on diaper
- Worsening of redness/swelling (not starting to decrease w/in 48 h)
- Fever, lethargy/poor feeding
- No urination w/in 12 h of procedure
Should the foreskin of an uncircumcised penis be forced back?
- No, not fully retractable until age 3-5
- Can lead to tearing, which leads to scarring, which affects retraction later on
What are tips to care for an uncircumcised penis?
- Wash penis regularly during bathing, use mild soap
- As foreskin naturally retracts, clean and dry underneath foreskin during bathing
- As foreskin retracts, skin cells shed which may appear as white, cheesy lumps (smegma)
What is the standard recommended formula?
Cow milk based formula
What are sx of cow’s milk allergy?
- Vomiting
- Wheezing
- Hives
- Rash
- Bloody diarrhea
Are lactose intolerance and cow’s milk allergy the same?
No, lactose intolerance develops later in life
Does lactose-free cow milk based formula help w/ colic?
No
Is lactose-free cow milk based formula recommended for acute gastroenteritis?
No
Is lactose-free cow milk based formula recommended for galactosemia or congenital lactase deficiency?
No
When are soy-based formulas recommended?
- Vegan diets
- Galactosemia or congenital lactase deficiency
- Cow’s milk allergy
- Cannot consume dairy-based products for cultural or religious reasons
Are partially hydrolyzed protein formulas recommended?
No, little evidence of benefit
When are extensively hydrolyzed protein formulas recommended?
- Physician-confirmed food allergies
- Those that can’t tolerate cow milk or soy protein
- Malabsorption syndromes (short bowel syndrome, liver disease, cystic fibrosis)
When are amino acid based formulas recommended?
Those w/ severe allergies and malabsorption disorders that can’t tolerate extensively hydrolyzed formulas
What are the 3 types of therapeutic formulas? When are they recommended?
- High medium chain triglycerides and higher energy for pre term infants
- Low PRSL (potential renal solute load) for renal insufficiency
- Human milk fortifiers added to mother’s milk in premature infants
What are the recommendations for vitamin D in infants? What is the upper limit?
- 400 IU/day
- 800 IU/day between October and April for most Manitobans (esp. those w/ deficiency risk factors = non-white, antiepileptic therapy, and malabsorption conditions)
- Upper limit = 1000 IU/day for infants up to 12 months
1 ounce = ____ mL
30 mL
___ is the most common nutrient deficiency in children
Iron
What can iron deficiency cause?
Diminished mental, motor, and behavioural functioning
What are sx of iron deficiency?
- Pallor
- Irritability
- Poor appetite
- Delayed growth/development
Which infants are at risk of iron deficiency?
- Low birth weight
- Premature
- Born to iron-deficient mothers
- Those older than 6 months who don’t have adequate supply of iron-rich foods
Is breast milk or formula a better source of vitamin D?
Formula
Is breast milk or formula a better source of iron?
Breast milk b/c higher bioavailability
What can be done to prevent iron deficiency?
- Breastfeeding
- Iron-fortified formulas
- Start iron-rich foods at 6 months
- Don’t introduce cows milk until after 1 y/o
When does infant colic normally resolve?
60% by 3 months; 80-90% by 4 months
What is the Wessel’s rule of three regarding infant colic?
- Lasts 3 or more hours per day
- Occurs on 3 or more days per week
- Persists for 3 or more weeks
What is different about normal crying and colic crying?
- Louder, higher more variable pitch, more turbulent (distressed, urgent)
- Paroxysmal
- Hypertonia (baby gets rigid)
- Difficulty consoling
What are some other causes of prolonged/excessive crying?
- Inadequate feeding
- GERD
- Constipation
- Otitis media
- Trauma
When should infant colic be referred?
- Breathing difficulties
- Watery stools/blood in stool
- Fever
- Poor weight gain
- Signs of dehydration
- Excessive vomiting
What are the goals of therapy for infant colic?
- Decrease crying
- Minimize parental stress/frustration
- Minimize impact on infant-family relationship
What is the first line tx for infant colic?
- Parenteral support
- Feeding techniques
- Soothing techniques (physical methods, behavioural management, environmental manipulation)
When is dietary management recommended for infant colic?
If px has confirmed allergies
