Neonatal Period Flashcards by Francisco Andrade

Weeks 25-30, Type II alveolar cells begin production
Mature amount at 35-37 weeks gestation
Phospholipid

Surfactant

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Decrease surface tension of pulmonary fluids
Prevents alveolar collapse at end of expiration
Facilitates gas exchange
Lower inflation pressures needed to open airway
Improves lung compliance
Decreases labor of breathing

Functions of Surfactant

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Marker of fetal lung maturity; test of fetal amniotic fluid to assess for fetal lung immaturity; surfactant

lecithin–sphingomyelin ratio ( L/S ratio): 2:1 or >

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A phosphatidic acid that is a constituent in human amniotic fluid and is used as an indicator of fetal lung maturity when present in the last trimester of gestation (36 weeks)

Phosphatidyl glycerol

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Secreted by lungs, amniotic cavity, trachea
Air must replace lung fluid
1/3 removed at birth; 2/3 pulmonary circulation and lymphatic system
Total time to clear = 6-24 hours after vaginal delivery
Inadequate clearance = TTN

Lung fluid

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Term
Delivery route - cesarean birth
Low dose oxygen thereapy
Rapid improvement (3 days)

TTN - Transient Tachypnea of Newborn

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Mild asphyxia in normal birth - high carbon dioxide and low oxygen
Others: thermal, tactile stimulation (flicking the soles of the feet; rubbing the back gently), lights, noise, cord occlusion

Breathing stimuli at birth

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Respiratory rate in neonates

30-60

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Diaphragmatic, shallow, irregular depth and rhythm
Abdominal, synchronous with chest movement
Short periods of apnea
Deep sleep - regular breathing
REM sleep - periodic breathing
Crying/ motor activity - grossly irregular

Characteristics of respirations in neonates

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Until age 3 weeks, obstruction → respiratory distress (sleep on the back)
Reflex takes over
Relation to SIDS (Sudden infant death syndrome)
Oral mucus secretions, cough/gag

Obligatory Nose Breathers

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Assessment tool to determine the degree of respiratory distress (0,1 or 2) ; > 7 - severe respiratory distress 
Features observed:
1. Chest movement 
2. Intercostal retraction
3. Xiphoid retraction
4. Nares dilation
5. Expiratory grunt

Silverman-Anderson Index - RDS : respiratory distress syndrome (resulting from lung immaturity and lack of alveolar surfactant )

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Purposes:
Decrease blood flow to fetal lungs
Direct blood to the placenta
Increase blood flow to head & heart

Fetal Circulation

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Fetal pulmonary BP > adult pulmonary BP

Diverts blood flow away from non-functioning fetal lungs

Decrease Blood Flow to Fetal Lungs

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Fetal systemic BP lower than adult

Flow leads to the placenta readily

Direct Blood to the Placenta

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Umbilical vein - oxygenated blood from the placenta to the fetus
Umbilical artery - waste
Wharton’s jelly - keep vein and artery from tangling ; keep them separated

Umbilical Cord

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Ductus venosus
Ductus arteriosus
Foramen ovale

Increase Blood Flow to Head and Heart

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Shunts arterial blood into inferior vena cava
Functional closure - few hours after birth
Anatomic closure - turns into ligament

Ductus venosus

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Shunts arterial and some venous blood from pulmonary artery to aorta; allows blood to go around lungs
Functional closure
Anatomic closure

Ductus arteriosus

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Leads to abnormal blood flow between the aorta and pulmonary artery, two major blood vessels that carry blood from the heart.

Patent Ductus Arteriosus (PDA)

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Connects right and left atria ( allows more than half the blood entering the right atrium to cross immediately to the left atrium, passing the pulmonary circulation)
Usually obliterated within hours after birth
Pressure highest right atrium

Foramen ovale

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Umbilical cord clamped - neonate draws first breath - Systemic vascular resistance increases- Blood flow through ductus arteriosus decreases - Most of right ventricular output flows through lungs, boosting pulmonary venous return to the left atrium - Left atrial pressure rises in response to the increased blood volume to the lung - This, combined with increased systemic resistance causes functional closure of foramen ovale

Changes to Neonatal Circulation

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Neonatal Heart Rate
Check apical for full minute
Also evaluate peripheral pulses (brachial, femoral)

120-150 awake

Range: 70-90 asleep, 180 crying

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Blood Pressure
Sensitive to changes in blood volume that occur with transition to neonatal circulation
Most accurate: measure in quiet newborn

At term, 60-80/40-50 mm Hg. (75/42 avg.)

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Turbulent blood flow, transient
Abnormal valve, ASD (atrial septal defect) or VSD (ventrical) , too high a blood flow across normal valves
Check all 4 extremity BPs if heard, record MAP, pulse ox.

Heart Murmurs

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- blotchy and mottled skin in the extremities; feels "chilly" - first few hours after delivery - response to exposure to cold - normal and intermittent

Acrocyanosis

Blue around philtrum & lips Tongue & mucous membranes pink Type of acrocyanosis Resolves spontaneously

Perioral (Circumoral) Cyanosis

10-15% total body weight Low O2 tension of maternal blood stimulates fetal RBCs (↑ HCT) About 300 ml. Mode of delivery effects TBV Vaginal vs. C/S - clamping of the umbilical cord : early ( before 30-40 sec) vs late (after 3 min additional 150 ml of blood)

Total Blood Volume

- clamping of the umbilical cord : early ( before 30-40 sec) vs late (after 3 min additional 150 ml of blood) ↓ anemia →↓ transfusions Stem cells ↓ disorders R/T prematurity

Delayed Cord Clamping benefits

R/T normal destruction of fetal RBCs Bilirubin transported to liver for conjugation Immature livers 50%+ develop

Physiologic Jaundice

Hemolysis of erythrocytes (normal after birth) - bilirubin - liver - water soluble pigment - GI system via bile - feces + urine

Bilirubin

Predisposition: Asians, Greeks, Native Americans Less likely: African-Americans Differentiate from pathologic jaundic - if not treated - kernicterus - brain damage - death

Physiologic Jaundice

Yellowish skin , mucous membranes, and sclera within the first 3 days of life ; asses by pressing gently with a fingertip on the bridge of the nose , sternum, or forehead - if present the blanched area will appear yellow before the cap refill

Visual Inspection for Jaundice

Involves exposing the newborn to ultraviolet light , which converts unconjugated bilirubin into products that can be excreted through feces and urine

Phototherapy ( Light changes the angle of bonds within bilirubin molecule, making it easier to excrete it (unconjugated) in the bile)

is a way to find out how much bilirubin is in the blood; The test sends a quick flash of light through the skin; The measurement is usually taken by gently pressing the meter against the sternum or forehead ; no blood test.

Transcutaneous Bilirubin Measurement

Place the automated lancing device on the appropriate area on the side of the heel

Heelstick

``` First 24 hours of life Rises 5 mg/dL every 24 hours Premature neonates LBW neonates Rh or ABO incompatibility G6PD deficiency: x-linked recessive High H/H 17-20 g/dL, 52-63% normal ```

Pathologic Jaundice

Bilirubin neurotoxic at high levels | Crosses blood-brain barrier, causes irreversible CNS damage

Kernicterus

Watch temperature Watch hydration status Protect eyes and genitals Positioning

Nursing Care of Neonate “Under the Lights”

removes the newborn's blood and replaces it with nonhemolyzed RBC from a donor ; monitor cardiovascular status continuously ; second line therapy after phototherapy

Exchange Transfusion - Treatment for Severe Hyperbilirubinemia

After first week of life → 6 weeks 1 - 2% of newborns Unclear cause Calories, wt. loss, components of breast milk Avoid by frequent nursing, supplementing If 14-16 mg/dL, stop breastfeeding for 24-48 hours Rapid drop in bilirubin

Breastmilk Jaundice

Normal finding, due to birth trauma 10,000-30,000 ccm Neutrophils predominate in first week of life, then overall WBC count falls and lymphocyctes primary form

Leukocytosis (elevated WBC)

Low at birth (7, 9, 10, prothrombin) Synthesized by intestinal bacteria Untreated, transitory deficiency in clotting, days 2-5

Vitamin K-Dependent Clotting Factors

Aquamephyton 1 mg. IM

Vitamin K ; Treats blood clotting problems.

Give Vitamin K into ...

Vastus Lateralis of Thigh

Same range of adults at birth, but may have mild transient aggregation defect ( 150000-400000 ) Phototherapy makes this worse

Platelets/Bleeding Problems

Score 8-10: good condition Score 4-7: fair condition, call peds Score 0-3: poor condition; need immediate resuscitation

Apgar Score Meaning ( done at 1 and 5 min of age; can be extended prn )

``` Appearance (skin color) Pulse (heart rate) Grimace (reflex irritability) Activity (muscle tone) Respirations (crying & breathing) ```

Apgar Score Mnemonic

At birth, enters cooler environment Temperature varies with environmental temperature Limited subcutaneous fat Large surface area in relation to body weight Blood vessels closer to skin

Thermoregulation in Newborns

1. Conduction - objects in direct contact with each other (cold surface ) 2. Convection - flow of heat from the body surface to cooler surrounding surface ( e: cool breeze) 3. Evaporation - when a liquid is converted to a vapor (e: amniotic fluid that covers body) 4. Radiation - to cooler, solid surfaces in close proximity but not in direct contact with the newborn (e: away from walls, windows, air conditioners )

Means of Heat Loss

Taking Axillary Temperature

36.5-37.5 C

Transition to Extrauterine Life: Initial VS Checks

Every 15 minutes x 4 (=1 hour) Every 30 minutes x 2 (=1 hour) Every 60 minutes x 2 (=2 hours)

1. Double-wrapping (36.4 C ) 2. Kangaroo care ( 36.4 C ) 3. Radiant heat warmer ( 36 C - for 1 hour)

Warming a Neonate

Primary mechanism of heat production Increase metabolic rate Chemical reaction in brown fat ( good blood supply )

Non-shivering Thermogenesis

 ⁭ metabolic rate, non-shivering thermogenesis Leads to ⁭ O2 and energy use Causes physiologic stress Leads to metabolic acidosis Result → hypoxia, hypoglycemia, acidosis

Cold Stressed Neonates

``` Thermal balance O2 consumption and metabolism are at minimal level Internal body temperature maintained Needs high environmental temperature Flexed, term vs. extended, preterm NBs ```

Thermal Neutral Zone (TNZ)

Liver is large, 40% abdominal cavity Palpate 2-3 cm. below right costal margin Aids in Fe storage Aids in carbohydrate metabolism

Hepatic Adaptation

Fe stores determined by total body Hgb. content & length of gestation If maternal diet was adequate, Fe stores last until age 5 months Need Fe for RBC production

Fe Storage

Glycogen in fetal liver, starting at 9-10 weeks’ gestation Major energy source for fetus Major energy source for neonate until begins feeding Glucose level influenced by liver output and uptake, body temp., insulin, muscular activity

Carbohydrate Metabolism

``` Diabetic mother SGA or LGA status Premature Postmature Fetal distress in labor/low Apgars Maternal corticosteroid use (asthmatic moms) ```

Neonates at Risk: Hypoglycemia

Signs of Hypoglycemia

1. Lethargy 2. Jitteriness 3. Poor feeding 4. Pallor 5. Vomiting 6. Apnea 7. Respiratory distress 8. Cyanosis 9. Loss of swallowing reflex 10. Seizure activity 11. High-pitched cry

Glucose-checking is part of differential diagnosis if sepsis, CNS disease, metabolic disorders, drug withdrawal, temperature instability, hypocalcemia, polycythemia, heart disease occur or are suspected.

Hypoglycemia

Vary from one institution to another Most check 1 heelstick on all newborns, then more prn At-risk newborns: check hourly x4, then 4 before-meal checks

Glucose Protocols

Normal glucose

40 – 80 mg/dL

Critical glucose value

< (25) 30 mg/dL

Early feeding | Check blood glucose, feed, re-check 30-60 minutes after feeding

Prevent Hypoglycemia

If feeding doesn’t resolve issue or blood glucose is

Dextrose 5 – 10% IV @ 6-8 mg/kg/minute (NICU)

Causes kernicterus at lower bilirubin levels (10 mg/dL or less), due to baby switching to fat metabolism instead of carbohydrate metabolism Untreated hypoglycemia can cause permanent, irreversible CNS damage or death

Prevent Hypoglycemia!!!!!

NBs swallow, digest, metabolize, absorb proteins & simple carbohydrates Fat digestion poor GI tract proportionately longer Immature motility & sphincter control

Gastrointestinal Adaptation

Feeding behavior rehearsed in utero: rooting Reflexes: gag, suck & swallow Salivary glands immature Sucking pads

Gastrointestinal Adaptation

Stomach capacity 50 -60 ml. Problems with vomiting, regurgitation Calorie requirements vary; however, most books state 108 cal/kg/day Regular formula 20 cal/oz. Initial weight loss of 5 -10% within first 5 – 10 days

Gastrointestinal Adaptation

Lose water to respirations, from skin, stool, urine Radiant warmers & phototherapy Need ⁭to 150 ml/kg/day

Hydration Requirements

Formed in utero: amniotic fluid, intestinal secretions, mucosal cells Thick, tarry, green-black Usually passed within first 48 hours

Stool: Meconium | ~ meconium plug - 24 hr (tickle anus with thermometer; measure abdomen); 48 hr ( pediatrics put finger in anus )

Part meconium, part feces Have these for a couple days, then entirely fecal Bright green or yellow “Seedy” appearance of milk curds

Stool: Transitional

Pale yellow or pasty green color More liquid, more frequent Not watery

Stool: Breastfed Newborn

Pale color | Firmer than stool of breastfed newborn

Stool: Formula-fed NB

Perform gastric lavage in all babies born with meconium stained amniotic fluid after stabilisation

stomach pumping or gastric irrigation, is the process of cleaning out the contents of the stomach.

Relatively immature Susceptible to dehydration, acidosis, electrolyte imbalance if vomiting or diarrhea occur Limited ability to reabsorb sodium and hydrogen Low GFR until 34 weeks’ gestation

Renal System

Birth: 70% body is water, 40% extracellular Most void by 24 hours First void: dark red & cloudy, no odor, low specific gravity As intake ⁭, output ⁭& urine clears 6 – 10 voids/day expected

Fluid Balance

Many immunologic mechanisms not fully-developed in NB; therefore, resistance to disease is limited Phagocyctes (destroy) Serum immunoglobulins (antibodies)

Immune System Changes

``` - IgG ( cross the placenta) Infections that generated maternal antibody response IgM Bloodborne infections IgE Hypersensitivity (allergy) reactions ```

Serum Immunoglobulins

NB produce little or no IgA IgA provides local mucosal immunity to respiratory and GI viruses and bacteria Predominant immunoglobulin in colostrum (pre-milk) Breastfeeding gives some passive immunity

Serum Immunoglobulin: IgA

Immature | Traditional measures for detecting inflammation not valuable (fever, leukocytosis)

Response to Inflammation

Immature All neurons present, but takes 4 years to fully myelinate them Brain ¼ adult size Uncoordinated, labile temperature regulation, poor control over musculature Development rapid in neonatal period

Neurologic System

Indicators of development Assist in safety and survival Primitive reflexes (Moro, palmar & plantar grasp) give way to righting reflexes (righting of head & neck) and protective reactions: blinking, sneezing, gagging, caughing Feeding reflexes

Newborn Reflexes

1. Sucking reflex - touch lips 2. Moro reflex - startled baby 3. Stepping reflex - walking 4. Tonic neck reflex - 5. Rooting reflex - stroking cheek 6. Babinski reflex - toes fan out (disappears at 1 year) 7. Palmar&plantar grasp reflexes -

``` Range of focus Poor acuity Contrast sensitivity Peripheral vision Can defend against unpleasant visual stimuli ```

Vision

Innate preference for human face 2 months: follow object smoothly ~2 months: differentiate colors (red/green)

Visual Response

T. Berry Brazelton

Optimal responses Orientation Habituation

``` Hearing threshold 40-50 dB > adults Can’t hear quiet sounds Limited range of frequencies •Hear low frequencies better •Soothing Can discriminate between voices Brazelton: orientation/habituation ```

Hearing

``` Scent-memory: Amniotic fluid Breast odors •Breast pad experiments •Painful stimuli experiments •Well-developed Prefer sweet odors (breastmilk & vanilla) ```

Smell

5 primary tastes: sweet, salt, bitter, sour, umami (glutamate) Can’t taste salt until ~4 months Sweet: the sweeter the better Breastmilk: glutamate Bitter & sour: negative reactions Research, July 2011: newborn taste influenced by mother’s diet

Taste

Most advanced sense at birth Important cognitive, emotional development, immune function Best able to feel using mouth Can recognize temperature differences, but can’t regular own body temperature Move more/sleep less if cold

Touch

Predictable Generally within first 24 hours of life Physiologic & behavioral adjustments Influenced by difficulty of L & D, intrapartal medications taken by mother

Periods of Reactivity in NB

First Period of Reactivity: 30 Minutes

``` 15 minutes: quiet alert •Eyes open, bright •Focus on faces, attend to voices, especially mom’s 15 minutes: active alert •Bursts of movements •May be crying •Strong sucking reflex •Act hungry ```

1. Deep sleep 2. Light sleep 3. Drowsiness or semidozing 4. Quiet alert 5. Active alert 6. Intense crying

Brazelton: Behavior in Newborns, 6 Levels of Arousal

Diurnal pattern desirable Nighttime sleep periods > daytime by 4-6 weeks •Longest stretch 3-5 hours Sleeps 13 hours/day (5.4 day/7.8 night) 2-6 night wakings Diurnal influences: feeding, nurturing, fussing, weight

Sleep – Wake Cycles

``` Orientation/habituation Consolability: change from crying state Self-quieting: sucking, motor activity Cuddliness: response to being held Motor Organization: help NB control & coordinate movements; rhythmic & spontaneous, CNS organization ```

Behavioral Responses to Environment & Caregivers