Exam 4 - Newborn Nutrition and Hyperbilirubinemia (sync) Flashcards
What percentage of body weight will newborns lose in their first few days of life? What is the nadir period?
Async says 5-8%, sync 7-10%
Nadir: 3-4 days after birth
What complications are associated with excessive weight loss of the newborn?
- Hypoglycemia
- Hyperbilirubinemia
- Dehydration
- Electrolyte imbalances
All affect brain development
What weight and height changes are seen in newborns by the end of the first year?
Weight tripled and height increased by 50% by the end of the first year
Most common factors causing poor weight gain in the newborn
- Infrequent or inadequate feedings
- Inadequate milk production in breastfed infants
- Error in formula reciple in bottle fed infants
- Genetic predisposition or organic diseases in infant
- Hypermetabolic
- Poor absorption of nutrients
- Infection
- Physical anomaly that prevents good suck/swallow
Method used to calculate weight loss in newborns (steps taken)
- Take birth weight (or last weight) in kg
- Take current weight in kg
- Subtract difference
- Divide by birth weight
What should the provider do if an infant is unable to feed with vigor?
Requires immediate referral to acute care for evaluation and potential rehydration
Infant hunger cues
- Wriggling or restless movements
- Rooting when face is stimulated
- Bringing hands to mouth
- Mouth movements/sucking
- Tongue protrusion
Late cues - crying, agitated body movements, color turning red
AAP recommendations for breastfeeding
Exclusive breastfeeding through 6 months of life and continuing when solids are introduced until at least 1 year (or when mom/baby decides to stop)
What are the benefits of breastfeeding for the infant and mother?
- Antibodies - IgA, first milk
- Reduces disease risk
- Respiratory, bowel, allergies, diabetes
- Promotes healthy weight, prevents obesity
- Leptin - regulates appetite and fat storage
- Positive effects on brain development
Stages of breastmilk - colostrum
- When does it first present?
- What nutrients does it provide?
Superfood pre-milk (“liquid gold”), teaspoons
- First 1-5 days after delivery
- Considered first immunization
- Rich in IgA antibodies, proteins, mineral, vitamins
Stages of breastmilk - transitional milk
- When does it first present?
- Comes in 5-10 days after delivery
- Breast milk that is mixed with some colostrum
- Thin, blue-grey in color
Stages of breastmilk - mature milk
- When does it present?
- What nutrients does it provide?
- Foremilk versus hindmilk
- Presents 10+ days (about 2 weeks after delivery)
- 90% water, 10% carbs, protein and fat
- Foremilk - beginning of feed, quenches thirst, lactose and protein but little fat or calories
Hindmilk - end of feed, higher in fat and calories
What two supplements can be given to breastfed infants?
- Vitamin D
- Iron
What are the benefits of vitamin D supplementation for breastfed infants?
Supports healthy bone development and prevents Rickets
What is the recommended vitamin D dosage for breastfed infants? When can supplementation stop?
- 400 IU liquid drops daily beginning first few days after birth
- Can stop supplementation once baby is taking equivalent of 1 L of formula per day, getting enough in solid foods, or drinking 4 cups whole milk per day
At what age will breastfed infants require iron supplementation? At what dosage?
- Iron stores are good for first 3-4 months due to maternal iron
- Starting at 4 months, need 1 mg/kg/day of supplementation
- At 6 months, iron needs to be met through iron fortified foods/cereals
Common issues of breastfeeding: nipple breakdown
- Cause? Treatment?
Inappropriate latch or candidal infection
Treatment
- Mupirocin
- Betamethasone
- Miconazole
Common issues with breastfeeding: thrush (candidal infection)
- When does it typically present?
- What systems does it affect?
- Risk factors
Usually occurs in the first 1-2 weeks after breastfeeding begins
- Affects the nipples and ductal systems
- Recent antibiotic therapy is a risk factor
- GBS (+) women can take probiotics for 3 weeks to rebalance their flora
Mastitis: treatment and management
- Heat
- Massage
- Frequent feeding/pumping
- Rest
- Fluids
- Pain relievers
- Antibiotics
Thrush (candida): infant symptoms
- White plaques on mucus membranes in mouth and tongue that does not wipe off
- Mouth pain
- Feeding refusal
- Monilial diaper rash with satellite lesions
Thrush (candida): mother symptoms
- Dry cracked, itchy or shiny nipples and areolas
- Shooting or burning pain during nursing
- Especially during letdown
- Vaginal yeast infection
Thrush (candida): treatment
Both mother and baby need to be treated otherwise reinfection is likely
- Topical nystatin for infant and nipples
- Consider systemic fluconazole for mother
Common issues with breastfeeding: mastitis
- When does it typically present?
- Symptoms
Most common 6-7 weeks after birth
- Sudden unilateral red hot swollen area on breast
- Warm to touch
- Flu like symptoms
- Fever over 101 F
Common issues with breastfeeding: mastitis
- Causes
Bacterial infection in breast tissue
- Due to milk stasis, nipple trauma, engorgement, maternal fatigue/stress
Formula fed infants should start with how much formula? On average, how much formula should infants take per pound of body weight?
Formula fed infants should start by being offered 1-2 oz every 2-3 hours in the first days of life
- Will feed at least 8 times/day
- Infants should take 2.5 oz of formula for every pound of body weight
Common issues: reflux
- Treatment and management
- Supportive care - upright position after feeding, small, frequent feeds
- Trial of AR (acid reflux) formula
- Recommended over thickened agents
- Decreases volume of regurgitation, reduces crying, improve sleep and weight gain
- Consider anti-reflux medication
- Famotidine (PPI)
Breastmilk versus formula stools
Breastmilk stools
- Seedy, yellow, thin
- Can range from 7+ times/day to once a week
Formula stools
- Tan, brown, green, soft consistency
- Can range from 1-4 times/day to once every 3-4 days
What would be considered abnormal stool findings in the newborn?
- Hard or formed stools (“logs” or “balls”)
- Blood or mucous in stool
Constipation in the newborn: treatment and management
- Consider formula change
- Supportive care with prune juice, +/- rectal stimulation
- Consider glycerin suppository
- Medications
- Lactulose if under 6 months
- Miralax if over 6 months
What is colic? At what age range does it normally present?
Develops suddenly from 1-3 months of age (most common in first 6 weeks)
Period of extended LOUD crying and difficult to soothe - rule of 3’s
- 3 or more hours/day
- 3 or more days/week
- 3 week period
Colic: treatment and management
Normally resolves by 3-6 months of age
- Provide support and reassurance to parents
- Provide coping strategies
- Teach strategies for soothing fussy baby
- Consider formula change/elimination diet
Causes of hyperbilirubinemia
- Immature liver function
- Decreased ability to conjugate bilirubin
- Decreased ability/rate to excretion
- Poor feeding causing mild dehydration
- Prematurity (less than 38 weeks gestation)
Hyperbilirubinemia: symptoms
- Yellow skin or sclerae (more severe cases)
- Drowsiness/lethargy
- Itchy skin
- Pale stools
- Poor sucking/feeding
- Dark urine
Physiologic jaundice
- Is it more common in breastfed or formula fed infants?
- When does it first present?
- Treatment and management
Presents when TSB levels peak (6mg/dL) between days 3-4 of life
- Most commonly resolves within 2 weeks (TSB <1 mg/dL)
- More common in breastfed infants
- Self-limiting
- Monitoring
- Further workup can be needed to rule out organic causes
Breastmilk jaundice: cause
Thought to be due to infant’s immature liver and intestines –> may be due to how substances in breastmilk affect the breakdown of bilirubin in the liver
Breastmilk jaundice: when does it present? peak? treatment?
Appears after day 7 of life; peaks during weeks 2 and 3
Not reason to stop breastfeeding as long as infant is feeding well and gaining weight
- Rarely needs treatment
Pathologic jaundice: causes
- Erythrocyte defects
- Structural abnormalities in liver (biliary atresia most common)
- Infection
- Sequestered blood
Pathologic jaundice: definition (including lab values)
Signs of jaundice within first 24 hours
TSB rise of 5 mg/dL or greater per day or TSB greater than 15 mg/dL
Requires prompt diagnosis and management
Screening for hyperbilirubinemia
- Clinical risk assessment/checklists
- Comprehensive history
- Visual inspection - can see when level is 5 mg/dL, press on bony areas
- Bilirubin measurement either via serum or transcutaneous
- Not as accurate over 15 mg/dL
- Use of tools to interpret results (nomogram)
How is screening for hyperbilirubinemia done?
All newborns should be screening prior to discharge and again 3-5 days after birth
- Screen earlier if signs of jaundice develop in first 24 hours
Use transcutaneous bilirubinometer device (TcB)
Complications of hyperbilirubinemia: acute bilirubin encephalopathy
If blood bilirubin levels rise too high bilirubin may get into the brain and cause reversible damage - requires immediate treatment
- Fever
- Lethargy
- High pitched cry
- Arching of body or neck
- Poor feeding
Complications of hyperbilirubinemia: kernicterus (nuclear jaundice)
Permanent damage
- Sight/hearing deficits
- Athetoid cerebral palsy
- Cognitive delays
- Death
How does phototherapy help with hyperbilirubinemia?
Exposes the skin to blue LEDs which helps break bilirubin down into parts that are easier to eliminate in urine and stool
- Can be done at home using biliblankets if health and low risk of complications
- Therapy should be continuous, breaks for feeding only
True/false: bilirubin levels can rebound after phototherapy
True - may rebound 18-24 hours after stopping phototherapy
Potential side effects of phototherapy
- Skin rash
- Loose stools
- Overheating/dehydration
- Hydration is very important
- May require supplementation
- “Bronze baby” syndrome - skin and urine
Management of hyperbilirubinemia: high risk
- Exchange transfusion
Procedure that is done urgently to prevent/minimize bilirubin related brain damage
- Replaces infants blood with donated blood to lower bilirubin levels
- Done in infants who have not responded to other treatments or have signs of neurologic risk (toxicity)
Management of hyperbilirubinemia: high risk
- Intravenous immunoglobin (IVIG)
If there is a Rh incompatability, the infant can get IVIG
- Protein in blood that can lower levels of any remaining antibodies from the mother which may be attacking the infants RBCs
