LEC 7: Health Challenges in the Newborn

Question 1

Common Complications

Answer 1

• Prematurity
• Thermoregulation
• Respiratory distress
• Hyperbilirubinemia
• Hypoglycemia
• Sepsis
• Neonatal abstinence syndrome

Question 2

The Pre-Term Infant and Complications

Answer 2

• Respiratory
  
  • Lack of surfactant
  • Pronlems include
    
    • Respiratory distress syndrome (RDS)
    • Apnea
    • Bronchoulmonary dusplasia (BPD)
• Cardiovascular
  
  • Patent ductus arteriosis (PDA)
  • Increased respiratory effort
  • CO2 retention
• Thermoregulation
  
  • Decreased brown fat
  • Decreased subcutaneous fate, poor muscular development
  • Less felxed tone
  • Thin skin
  • Increased BSA
  • Increased exposure during resuscitation
• Gastrointestinal
  
  • Small stomach, immature feeding reflexes
  • Nectrotizing enterocoitis (NEC)
• Renal
  
  • Decreased ability to concentrate urine
  • Decreased ability to excrete drugs
• Hepatic/ Hematologic
  
  • Immature liver leads to decreased conjugate bilirubin and leads to jaundice
  • At risk for hypoglycemia
  • Limited iron stores leads to anemia
• Neurological
  
  • Periventricular-intraventricular hemorrhage (IVH)
  • Hydrocephalus
  • Hearing loss
  • Retinopathy of prematurity (ROP)

Question 3

Corticosteroids in PTL

Answer 3

• All pregnant women between 24 and 34 weeks gestation, who are at risk of preterm delivery within 7 days should be candicates for antenatel treatment with a single course of corticosteroids
  
  • A single course of corticosteroids reduces prenatal mortality, respiratory distress syndrome, and intraventricular hemorrhage
  • Betamethasone 12mg IM q24h x2 doses or Dexamethason 6mg IM q12h x 2 doses

Question 4

MgSO4 for Fetal Neuroprotection

Answer 4

• New evidence that antenatel MgSO4 is neuro protective
• When women present with imminent preterm birth at <31 +6weeks
  
  • Active labour with >4cm dilation with or without ROM
  • Planned preterm birth for fetal or maternal idnications
• 4g IV loading dose over 30 minutes then 1g/hour maintennace until delivery

Question 5

Preterm Temperature Control: Why are babys at increased risk?

Answer 5

• Less able to produce heat related to the higher ration of body surface to weight
• Lack of brown fat
• Think skin, causes greater insensible water loss
• Resuscitation efforts
• LDR or O.R abient temperature
• Try to keep infant as dry as possible
• Neutral temperature environments
• Use of food grad plastic abd to put babies inot is severly SGGA or preterm
• A could baby can lead to serious complications

Question 6

Preterm Temperature Control: CPS and NRP Guidelines

Answer 6

• Maintenance of delivery room temperature aroun 25 to 26C will diminish heat loss
• In order to minimize heat loss, babies <28 weeks should immediately be palced wet, up to their neck, in a food grade polyethylene bag

Question 7

The Late Preterm Infant: 34 to 36 Completed Weeks

Answer 7

• Often overlooked; do not appear dramatically sick
• Immature at birth; have missed 4 to 6 weeks of the 3rd trimester
• Brain size at 34 tp 35 weeks is 60% of that of infant at term
• The largest poportion of preterm births

Question 8

Discharge of the Preterm Infant

Answer 8

• 24 hours of siccessful feeding must be established before discharged home
• First-time mothers require carefule suppervision when infants are leaving from an intesive care environment and should have a rooming-in experience
• Discharge plans must consider the health, parenting, and feeding skills, availability of support in the home
• Post-discharge assessment in community
• Developmental follow-up

Question 9

Signs and Symptoms of Neonatal Respiratory Distress

Answer 9

• Tachypnea
• Apnea
• Cyanosis (circumoral)
• Grunting/ Cooing
• Nasal flaring
• Retractions/ indrawing
• Poor feeding
• Accessory muscle use

Question 10

What are common causes of respiratory distress in neonates?

Answer 10

• Respiratory distress syndrome (RDS)
• Meconium aspiration (MSAF, MAS)
• Transient tachypnea of the newborn

Question 11

Respiratory distress syndrome (RDS)

Answer 11

• Usually found in neonatal
• 20% of neonatal deaths (0 to 28d)
• Lack of sufficient surfactant
  
  • Surfactant: Reduces the risk of collapse
• Stress of protector
  
  • Found during chronic stress
• Will develop signs of breathing quickly; first few hours of life
• RDS occurs due to a surfactant deficiency
• Onset- minutes to hours of birth

Question 12

Risk Factors for Respiratory distress syndrome (RDS)

Answer 12

• Prematurity/ ummaturity of lung
• C/S without labour
• Males
• Caucasians
• Maternal diabetes
• Twin B
  
  • Can delay surfactant delivery
• Perinatal asphyxia

Question 13

Managment of Respiratory Distress Syndrome (RDS)

Answer 13

• Antenatal corticosteroids
• Exogenous surfactant
  
  • Given endotracheal
  • Surfactant can be produced synthetically
• Cont. positive airway pressure (CPAP) and positive end-expiratory pressure (PEEP)
• Fluid and other supporitve care
• Vital signs
• Blood glucose
• Colour, edema, respiratory signs and symptoms

Question 14

Meconium Stained Amniotic Fluid (MSAF)

Answer 14

• Fluid aspirated (think, thick, particulate)
• Amount and consistency vary
• Presence of mec below vocal cords
  
  • Risk for airway abstraction
• Around 5% of MSAF result in Meconium Aspiration Syndrome
  
  • Peripheral airway obstruction
  • Proximsl airway obstruction
  • Cytokine activation
  • Worry about infection later (next few days)

Question 15

Why does Meconium Stained Amniotic Fluid (MSAF) occur in 12% of live births?

Answer 15

• Fetus compromised (stress, cord compression, hypoxia)
• Physiologic
  
  • Breach
    
    • Post-term: More mature bowel

Question 16

What happens with a few breaths taken by nebown with MSAF)?

Answer 16

• Newborn is aspirating the mex with the first few breaths
• Suctioning is important, but does not mean it will prevent meconium aspiration syndrome

Question 17

Care with Meconium Aspiration

Answer 17

• Prevent
  
  • Avoid post maturity
  • Amniotic infusion, routine suctioning of nose and pharynx
    
    • Done in situations wheere there is less amniotic solution
    • Not goign to necessarily fix the problem
  • Endotracheal suction, by trained individual (only if poor tone and significant respiratory depression)
• Assisted ventilation
• Surfaxin (exogenous surfactant), steroids
• Close observation, supportive, nutrition
  
  • Signs of respiratory distress, crackles, rhonci

Question 18

Transient Tachypnea of Newborn

Answer 18

• Sometimes called “wet lung syndrome”
• Excess fluid in the lungs or delayed re-absorption of fetal lung fluid
• Around 1% of all deliveries
• Normal at birth
  
  • Develops respiratory distress symptosm in 4 to 6 hours
• May be related to aspiration of amniotic fluid, excess secretions or tracheal fluid
  
  • C-section or preterm
• Usually occurs within a few hours of birth and resolves within 12 to 72 hours
  
  • May need O2, fluids, restric feeds

Question 19

Hyperbilirubinemia

Answer 19

• Excessive concentration of bilirubin in the blood
• Leads to jaundice

Question 20

Jaundice

Answer 20

• Bile pirment deposite in the skin, mucous embranes and sclare
• Leads to kernicterus

Question 21

Kernicterus

Answer 21

• Bilirubin levels ris >accepted levles at a given age or rate of rise is high enough
• Leads to deposited in brain and encephalopathy
• If jaundice moves to kernicterus severe issues- can only looka tit during an autopsy

Question 22

How Jaundice Develops in Newborn Babies

Answer 22

1. Red blood cells die off in large numbers after birth
2. A lot of bilirubin is created
3. Because the liver is not yet matured, it processes bilirubin very slowly
4. Very little bilirubin leaves the body
5. The excess, unprocessed bilirubin builds up everywhere in the body. It colours the skin and eyes yellow.

Question 23

Physiological Jaundice

Answer 23

• Most common cause of jaundice
  
  • 50 to 60% of newborns
• Primary Mechanism:
  
  • Increased RBC volume, short RBC life span → Increased RBC hemolysis after briths → Increased bilirubin load
• Additional Mechanisms Include:
  
  • Decreased clearance of bilirubin from plasma
  • Liver immature, decreased ability to excrete conjugated bilirubin
  • Immaturity of bilirubin conjugation on the liver at birth
• Usually peaks at 3 to 5 days
• Typically resolved by day 8

Question 24

Pathological Jaundice

Answer 24

• Excessive erythrocyte destruction
  
  • Occurs more often when there is incompatibility of blood (mixing of blood)
• Increased extravascular blood
  
  • Bruising-extra RBC that they need to break down
• Polycythemia
  
  • Occurs when mom is insulin diabetic
• Other: Hederitary conditions
  
  • Metabolic conditions with the gut or liver
• Clinical Evidence of jaundice in first 24 hours of life is pathological

Question 25

Assesment of Jaundice

Answer 25

• Yellowing of skin and sclara
  
  • Jaundice progresses to the sclera then should be worried
• Cephalocaudal (head to toe) progression
• Well-lit area, preferably natural daylight
  
  • best way to look at the skin and do a visual inspection
• Gentele pressuer blanch skin to reveal udnerlying color of skin/ subcutaneous tissue
  
  • Psuh on babies nose and look at the colour before all the blood comes back
  • Look at skin tone of the general popualtion that baby os part of- can infuluence th perception of baby is yellow or not
  • Visual inspection is not reliable alone
• Possible associate findings
  
  • Poor feeding, resuses feeds, weight loss, changes in number of wet or soild dipers, slow weight gain, sleepiness, difficutl to awaken, fever
• TcB - Transcutaneous Bilirubin
  
  • Measures the amount of bilirubin transcutaneous
• TSB - Total Serum Bilirubin
  
  • Severe hyperbilirubinemia – TSB >340 μmol/L at any time during the first 28 days of life.
  • Critical hyperbilirubinemia – TSB >425 μmol/L during the first 28 days
• Coomb’s Test (aka DAT) for ABO incompatibility

Question 26

Guidelines for Testing

Answer 26

• Either TSB or transcutaneous bilirubin (TcB) concentration should be measured in all infants between 24 h and 72 h of life, the results plotted on the predictive nomogram to determine the risk of progression to severe hyperbilirubinemia.
• When to intervene? Based on TcB (greater than 38+ weeks)
  
  • Green Zone: 0 to 100
    
    • Routine care
  • Yellow Zone: 100 to 150
    
    • If DAT + do TSB
    • If DAT- or unknown F/U 24-48 hours
  • Red Zone: 150 to 450
    
    • Need to draw blood
    • TSB/DAT
• When to Treat? Based on TSB

Question 27

Bilirubin Encephalopathy

Answer 27

• Neurological effects of unconjugated bilirubin in the brain may be reversible or permanante
  
  • The pathological finding of deep-yellow staining of neurons and neuronal necrosis of the basal ganglia and brainstem nuclei
• Also called Kernicterus

Question 28

Phototherapy

Answer 28

• Additional light helps breakdwon bilirubin
• Onlu diaper for maximum exposure of skin/ protect genitalia
• Turn regularly
• Isiletter for thermoregulation
• Eye protection
• Phototherapy blankets
• Placing infant in sunlight, regular lights NOT effective
• Breastfeeding should continue
• Do vital signs ebery q4h- increased risk for hypothermia

Question 29

Other Treatmens for Jaundice

Answer 29

• Early and frequent feedings increase intestinal transit time to assist excretion through feces and urine
• Prevention of dehydration
• Supplemental fluids should be given in infants receiving phototherapy who are at risk of progressing to exchange transfusion
• Exchange transfusion for severe cases – very rare.

Question 30

Cocain and Increased Risk

Answer 30

• Risk of placental problems
• Risk fo miscarriage
• Risk of preterm labour
• Risk of SIDS
• Incidence and severoty of withdrawal symptoms

Question 31

Neonatal Abstinence Syndrome (NAS)

Answer 31

• Manage newborn complications
• Serologic tests for syphilis, HIV, and hepatitis B
• Meconium, cord, or urine drug screen
• Social service referral
• Nutritional support
• Reduce withdrawal symptoms
  
  • Reducing the amount of light
  • Minimizing excessive noise
  • Avoiding unnecessary handling
• Promote adequate respiration, temperature
• Avoid second-hand smoke/drugs
• Support and teach patient and family
  
  • Supportive measures
  • Signs and symptoms of withdrawal

Question 32

Cannabis and Pregnancy

Answer 32

• Can negatively impact fertility
• Crosses placenta
  
  • May harm and developing detus (preterm delivery, low birth weight, brith defects)
  • Associated with negative long-term effects in childhood and beyong (poor memory and verbal skills, behavioural issues)
• Passess into breastmilk- may cause negative developmental effects
• Can negatively impact parenting
• Majo gaps about what is known

Question 33

Treating Withdrwal in Neonates

Answer 33

• Naloxone (Narcan) contraindicated can cause rapid withdrwal and seizures
• Treating the symptoms of complications
  
  • May need to use morphine → need to wean of slowly

Question 34

A Word About Anti-Depressants

Answer 34

• Benefits may outweigh the risks of use during pregnancy
• SSRIs are most commonly used
  
  • The benefits outweigh the risk
• Newborns may manifest S & S after exposure in utero
  
  • Usually resolve within a couple of weeks
• Mild symptoms (neuro-behavioral, respiratory, feeding issues, poor temp control)
• May be seen within hours but resolves within 2 weeks
• Not contraindicated for Breastfeeding
• Anticipatory guidance for families about the possibility of side effects

Question 35

Therapeutic Handeling

Answer 35

• Reduce stimulation
  
  • Calm subdued environment (↓ light, ↓ noise)
  • Avoid eye contact
  • Soother
  • Take cues from baby
• Swaddling to help control body and tremors
• “C” position to feed and cuddle
  
  • Hold baby and move up and down carefully with baby held away from person swaddled in c position
• Important to take cues from baby because not everything works for baby

Question 36

Hypoglycemia

Answer 36

• IDMs, SGA infants, Preterm AGA, LGA
• Stressed, infection
• Symptomatic
• Blood glucose
  
  • Q 1-4h in high risk
  • At or below 2.5 mmol/L
  • Varies with insitution
  • CPS guidlones > 2.6 mmol/L

Question 37

Infants at Risk for Hypoglycemia

Answer 37

• Small for gestational age (SGA)
• Large for gestational age (LGA)
• Infant of diabetic mother (IDM)
• Premature
• Stress/ sick/ cold

Question 38

Puncture Site on Babies for Glucose Monitoring

Answer 38

Bottom of the foot close to the sides to avoid nerve puncture

Question 39

Symptoms of Hypoglycemia

Answer 39

• Jitterness or tremors
  
  • ​Most common
• Apathy
• Episodes of cyanosis
• Convulsions
• Intermittent apneic spells
• Tachypnea
• Weak or high-pitched cry
• Limpness or lethargy
• Difficulty in feeding
• Eye rolling
• Episodes of sweating, sudden pallow, hypothermia, cardiac arrest, and failure

Question 40

Treatment og Hypoglycemia: Asypmtomatic

Answer 40

• Feeding interventions
  
  • Increase frequency of breastfeeding
  • Supplementation with BM
  • BM fortifier or formula
• Evaluate for response in 1 hour

Question 41

Treatment og Hypoglycemia: Symptomatic or <2mmol/L

Answer 41

• IV infusion of glucose
• Target 2.6 mmol/L or increase

Question 42

Why can newbrons get sepsis?

Answer 42

• Immature immune system
• Exposure to bacteria (GBS most common)
• (P)PROM
  
  • Especialy if prolinged >18 hours
• Maternal fever
• Chorioamnionities

Question 43

Nerbown Sepsis Symptoms

Answer 43

• Subtle behaviour changes
  
  • Infant not dowing well
  • Lethargy or irritability
  • Feeding intolerance
• Temperature INSTABILITY
  
  • Newborn that is septic will normally have a low temperature
• Tachyacrdia
• Poor perioheral circulation
  
  • Pallor
  • Duskiness
  • Cyanosis
• Respiratory distress
• Hyperbilirubinemia

Question 44

Parents of Newborn with Complications

Answer 44

• Sick or preterm baby may have:
  
  • Delayed or lack of periods of reactivity due to poor condition of newborn
  • More disorganized in sleep-wake cycle
  • Mom ruptured pre-maturely graeter than 18 hours
  • Mom fibril during labour- can be a red flag
  • Immature immune system
• Assess: Knowledge of infant’s condition or anomaly
• Communication: Keep informed about infant condition
• Prmote care
  
  • Flexibile visits
  • Skin-to-skin care
  • Breastfeeding/ pumping

Question 45

Parents

Answer 45

• High levels of stress/anxiety
  
  • More in 1^st week
  • More for mother - Guilt, own recovery, grief
  • Financial – especially if out of region
  • Moms may have feelings of guilt- especially within the first week
• PTSD - delivery
• NICU
  
  • Stressful environment
  • Buddy
  • Social work
  • Discharge nurse
  • LC

Question 46

As Baby Recovers

Answer 46

• Ensure parents understand
  
  • Routine well-baby care
  • Special procedures
  • Expected growth and development of infant
• Referral
  
  • Infant screening procedures
  • Follow-up care: team approach
  • Special equipment required at home

Question 47

Nursing Diagnoses

Answer 47

• Ineffective thermoregulation
• Impaired gas exchange
• Ineffective airway clearance
• Risk for unstable blood glucose
• Neonatal jaundice
• Nutrition less than body requirments
• Interrupted breastfeeding
• Impaired family bounding (parent infant attachment)
• Knowledge deficit
• Readiness for enhanced learning