week 12: intro to newborn complications

Question 1

trauma informed age-appropriate care (TIAAC)

Answer 1

Neonatal period is a critical phase in human development. Therefore trauma in the first few years of life may lead to toxic stress, issues in mental & physical health later in life due to epigenetic changes.
Potential sources of stress include separation from caregiver, unresponsive or inconsistent care, overwhelming sensory environment.
Use trauma informed care for newborns:
Keep dyad together.
Responding in a consistent manner.
Managing pain in a timely manner (skin to skin, breastfeeding, sucrose).
Protecting sleep.
Supportive environment with regulation of sensory input (careful with sounds and lights).

Question 2

Pregnancy related risks that increase the risk of preterm birth

Answer 2

Stress (racial issues, socio economic issues)
Previous preterm birth
Multiples/macrosomia/polyhydroaminos
Pre-eclampsia/hypertension
Drug use
Placental complications
Low or high BMI/maternal age
Infection in uterus or uterine track
PPROM
IUGR
Short interpregnancy intervals
Endocrine system abnormalities

Question 3

Shirt and long term risks associated with cannabis use in pregnancy for newborn

Answer 3

Short term risks:
Preterm labour, small for gestational age, IUGR, depressed CNS, increased risk stillbirth.

Long term risks:
Developmental abnormalities of the newborn, higher prevalence in neural tube defects, sleep disruption for children, decreased attention span and hyperactiveness.

Cannabis and breastfeeding
Can breastfeed if using cannabis depending on the individual’s risks and benefits. Cannabis appears in large quantities in breastmilk, higher than plasma levels. This may have detrimental effects on the infant, and it’s metabolism in a newborn is low therefore will be found in urine and stool. If the mother is using cannabis, approach from a harm reduction perspective, educating on risks and benefits of using formula.

*different drugs have different rules, ex: heroin is an absolute contraindication.

Question 4

Neonatal abstinence syndrome (NAS)

Answer 4

Due to in utero exposure to substances.
Initial symptoms of withdrawal occur from 24-48 hrs to 5-10 days after birth and in the CNS, GI and Resp systems.
Opioids (heroin, codeine, oxycodone)
Stimulants (amphetamines, cocaine)
Antidepressants (SSRIs)
Depressants (barbiturates, alcohol, cannabis)
Nicotine from cigarette smoking

Question 5

Signs of newborn withdrawal

Answer 5

Tremor/trembling
Irritability/excessive high pitched crying/difficulty to settle
Sleep problems
Seizures
Tight muscle tone/rigitidy
Hyperactive reflexes
Vomiting, diarrhea, feeding difficulty
Dehydration, sweating
Yawning, stuffy nose and sneezing
Low or high temperature

Question 6

Non-pharmacological interventions of newborn withdrawal

Answer 6

Rooming in of parents/caregivers and additional support in the room to provide parent/caregiver rest.
Protect sleep-wake cycles by clustering care.
Optimal feeding at early hunger cues.
Skin to skin contact and firm pressure.
Cues interpreted based on newborn-centered care
Baby held by parent/caregiver and safe swaddling
Non-nurtitive sucking/pacifier
Rhythmic movements like swaying

Question 7

Eat, sleep, console (ESC) care tool

Answer 7

Aims to support the newborn exposed to substances to achieve developmentally normal eating, sleeping, consoling and weight gain milestones.
Monitoring:
Excessive weight loss >10%
Feeding difficulties related to fussiness, tremors, uncoordinated suck, excessive rooting
Inability to sleep greater than one hour after feeding due to fussiness, restlessness, increased starle, tremors
Unable to console within 10 minutes and/or stay consoled for longer than 10 minutes

Question 8

Early onset sepsis

Answer 8

-Usually occurs in the first 24-48 hours and progresses rapidly (most often in the first 6 hrs).
-Acquired through contact with maternal GU/GI tract, sources of transplacental/transvaginal transmission.
-Commonly caused by E.coli (leading cause of sepsis in preterm baby), GBS (leading cause of sepsis in term baby), Haemophilus influenzae, HSV, chlamydia.
-Risk factors include preterm birth, prolonged rupture of membrane, chorioamnionitis.

Question 9

Late onset sepsis

Answer 9

-Usually occurs between day 7 and 30 days of age.
-Acquired in a hospital or community.
-Portals of entery such as eye, mouth, umbilical stump, invasive procedures, lines.
-Common causes include staphylococci, klebsiella, enterococci, E.coli, pseudomonas, candida.

Question 10

Perinatally acquired infections

Answer 10

Risk factors and causes of infection may include:
History of maternal group B streptococcal infection.
Early membrane rupture.
Maternal fever over 38 degrees.
Receiving antibiotics for an infection before delivery.
Untreated maternal urinary tract infection.
Preterm newborns.
No prenatal care.
Intrauterine infection.

Question 11

Neonatal signs of sepsis

Answer 11

Respiratory: altered RR, period of apnea, central/oral cyanosis, signs of increased WOB.
Cardiovascular: altered HR, hypotension, altered temperature, decreased cap refill.
Central nervous: seizures, lethargic, difficulty to console, hyper/hypotonic, high pitched cry, weak cry.
Gastrointestinal: poor feeding, excessive weight loss, vomiting, hypoglycemia.
Integumentary: colour changes, jaundice, clammy, petechiae on the body (on the face is okay)

Question 12

Herpes simplex virus

Answer 12

If the client has an active herpes simplex outbreak on their genitals they should not trial a vaginal delivery.
If a client has their first exposure in their third trimester it is recommended to have an elective c-section as there is a higher risk for complications as there are no maternal antibodies present.
Newborn herpes may be transmitted by the placenta but most is vertically through a vaginal birth.
Can lead to lesions on the skin, eyes, mouth and CNS.
If a client has an active lesion on their breast tissue should pump & dump until the lesion is gone.

Question 13

TORCH acronym

Answer 13

Acronym used to screen for parasites and viruses that can be harmful to the fetus.

T : Toxoplasmosis
Present in cat feces and birds and detrimental to the fetus
O : Other (parvovirus, varicella zoster, measles, mumps, syphilis)
Parvovirus/5th disease is common among those that work with children and increases the risk of fetal anemia. Exposure in the first trimester can lead to fetal hydrops.
Syphilis can increase risk of miscarriages, still birth, newborn jaundice and anemia. Treated with penicillin.
*cannot get these live vaccines during pregnancy.
R : Rubella
Exposure to rubella increases the chance of spontaneous abortion, still birth, heart abnormalities, brain defects and may lead to rash.
C : CMV
Many mothers may have flu-like symptoms and not be aware, may lead to defects in vision, hearing and brain development.
H : Herpes simplex
*Chlamydia infections can cause neonatal conjunctivitis and pneumonia.

Question 14

Late preterm infants

Answer 14

Born between 34-36^6 weeks and represents 70% of the total preterm infant population
Risk factors often overlooked:
Respiratory distress
Hypoglycemia
Tempurature instability
Poor feeding
Jaundice
Infections

Question 15

Hypoglycemia

Answer 15

Blood glucose concentration is less than the requirements for neurological, organ and tissue function. For neonates we are looking for blood sugar greater than 2.6.
Complications include neurological injury and long term neurological deficits.
At risk infants for hypoglycemia:
Preterm (antenatal corticosteroids)
SGA, LGA, IUGR
Maternal diabetes
Maternal use of labetalol
Perinatal asphyxia
Metabolic conditions or syndromes associated with hypoglycemia

Question 16

Hypoglycemia screening

Answer 16

Frequency and duration of screening depends on infants presenting risk factors
Infants of diabetic mothers (IDM) need screening for at least 12 hours, stop BG if >2.6mmol/L
Preterm, SGA for at least 24 hours, stop if feeding is well established and BG >2.6mmol/L
Symptomatic and unwell infants require immediate glucose testing

Question 17

Hypoglycemia signs and symptoms

Answer 17

Jitteriness, eye rolling, seizures
Lethargy
Respiratory distress, apnea
Abnormal cry
Hypotonia
Temperature instability
Poor feeding

*Important to remember that hypoglycemia can be present in the absence of clinical manifestations.

Question 18

Hypoglycemia management

Answer 18

Skin to skin
Maintain thermoregulation (cold stress can cause hypoglycemia)
Feeding by breast or supplemental breasmilk or formula
Dextrose 40% gel intrabuccal
IV administration of D10W (if not responsive to earlier interventions)

Question 19

Small & large for gestational age

Answer 19

Many risks factors associated with being SGA/LGA
Antepartum risk factors for SGA is anything that decreases placental perfusion, or receiving needed energy/growth requirements
LGA risk factors for LGA is anything that over-exceeds energy/growth requirements in utero.

Question 20

Newborn screening

Answer 20

Standard care involves screening every infant prior to discharge regardless of risk factors to ensure early identification of affected infants in time to prevent serious health problems.
Capillrary blood samples are taken at 24 hours and are screened at CHEO for a number of metabolic, endocrine, etc disorders. If positive results will receive referrals.

Question 21

Newborn hearing screening

Answer 21

Most common congenital disorder in newborns.
To identify newborns with permanent hearing loss for early interventions to be implemented to support later language development.
Must assess risk factors for hearing loss (genetic risk factors, CMV during pregnancy).

Question 21

Critical congenital heart disease

Answer 21

Group of heart defects within the structure or greater vessels of the heart interfering with effective circulation of oxygenated blood
Signs and symptoms:
Central cyanosis
Tachycardia
Poor feeding/sucking
LBW or delayed weight gain (faliure to thrive)
Tachypnea or increased WOB

Question 22

Critical congenital heart disease screening

Answer 22

Screening after 24 hours is recommended as the ductus is most likely closed
Pulse oximeter is placed on the right hand (pre-ductal leaving the aorta before the ductus arterioles) and either foot (leaves the aorta after the ductus arterioles)
If failed and a positive screen, repeat test is done in one hour, can perform a maximum of two repeats in one hour.
A pass is a negative screen
Both values must be over 90%, with at least one value 95% or over.
The difference between the two values must be 3% or less.

*If a value is below 90% the infant must be referred immediately

Question 23

Hyperbilirubinemia

Answer 23

Red blood cells are immature in newborns so breakdown quickers. As they break down there is the release of hemoglobin. This releases heme which needs to be broken down by the spleen, and then converted from unconjugated to conjugated bilirubin so it is water soluble and can be excreted in urine and stool. Newborn liver is immature, resulting in delayed conjugation of bilirubin, causing rising levels in the blood and bilirubin crossing the blood-brain barrier causing complications.

Question 24

Hyperbilirubinemia Physiological

Answer 24

Is a transiet finding that is in 60% term and 80% preterm newborns appearing after the first 24 hrs, most commonly after day three
Due to delayed elimination of bilirubin, over time the liver will mature to conjugate bilirubin.
Are occasions where treatment is needed to ensure bilirubin levels do not reach too high.

Question 25

Hyperbilirubinemia Pathological

Answer 25

Normally occurs within th efirst 24 hours of life, warrants further investigation to discover what is significantly increasing the risk of jaundice.
Increased production of bilirubin through hemolysis
Potential causes include maternal/newborn blood incompatibilities, G6PD (deficieny is this enzymes causes increased breakdown in RBCs), metabolic or endocrine disorder, congenital anomalies, hepatic obstruction.
Acute bilirubin encephalopathy, kericterus may be complications

Question 26

Hyperbilirubinemia Risk factors

Answer 26

Maternal/newborn blood group incompatibility, prematurity, liver immunity, delayed feeding, birth trauma causing bruising (cephalohematoma)
Metabolic disorders
Sepsis
Congenital red blood cell abnormalities

Question 27

Phototherapy

Answer 27

Inspect the sclera, palms of hands, soles of feet, nose or palpate for jaundice. Gently palpate the sternum or nose for jaundice
Evaluate blood work for bilirubin levels, maternal Rh factor and blood type
Ensure safe environment while delivery phototherapy by covering newborns eyes and removing this every two hours
Change the infants position every two hours and assess for skin breakdown
Monitor temperature
Assess for green loose stools, frequent pari care must be done and increase in feeding.

Question 28

Breastfeeding associated jaundice

Answer 28

Early onset between day 2-5 due to lack of effective breastfeeding leading to less caloric and fluid intake and dehydration. Leads to decreased output and bilirubin being reabsorbed from intestine to bloodstream

Question 29

Breast Milk jaundice

Answer 29

Later onset between 5-10 days and may persist for 3-12 weeks
Infant is feeding well and gaining weight appropriately, etiology is uncertain, it is thought that factors in breast milk may eithe rinhibit the conjugation or decrease excretion.
Bilirubin levels dont usually get too high here, but must be monitored

Question 30

Sudden infant death syndrome (SIDS) / Sudden unexplained death in infants (SUDI)

Answer 30

Sudden infant death of an infant younger than 1 year of age that remains unexplained (95% occur in the first 6 months). Occurs 0.3 per 1000 live births.
Risk factors include preterm, VLBW, multiples, low APGAR scores, CNS disturbances, family history, unsafe sleep.
Incidence has decreased since the back to sleep campaign, higher rates of breastfeeding, and decreased maternal smoking in pregnancy.

Question 31

Safe sleep environment

Answer 31

Smoke free environment
Firm surface with no pillows, quilts, bumper pads or toys in crib
Breastfeeding
Co-sleeping with an approved crib, cradle or bassinet next to parents
Sleep on back
Baby swings, bouncers, stroller, and car seats are not for sleeping
Introduce a harm reduction approach if families make the informed choice to bed share.