NCMA219 - WEEK 7 - MIDTERMS

WEEK 7 - Nursing Care of At-Risk/ High Risk/ Sick Child - ASSESSMENT OF THE HIGH-RISK NEWBORN
NEWBORN  At birth the newborn is given a brief yet thorough assessment
to determine any problems and identify conditions that needs
 The HIGH-RISK NEONATE is a newborn, regardless of immediate attention. The examination is most focused with the
gestational age or birth, who has a greater-than-average evaluation of the cardiopulmonary and neurologic functions.
chance of morbidity or mortality, usually because of The assessment includes Apgar score and an evaluation for
conditions beyond the normal events related to birth and the any obvious congenital anomalies or evidence of neonatal
adjustment to extrauterine life. The high-risk period begins at distress.
the time of viability up to 28 days after birth and includes
threats to life and health that occur during the prenatal, GENERAL ASSESSMENT
perinatal, and postnatal periods.  weight  measurements of length and
 posture circumferences,
CLASSIFICATION OF HIGH-RISK NEWBORNS  anomalies  body shape and size
High-risk infants are most often classified according to birthweight,  signs of distress  presence and location of edema
gestational age, and main pathophysiologic problems. The more  ease of breathing
common problems related to physiologic status involve the infant’s
maturity and usually chemical disturbances and consequences of RESPIRATORY ASSESSMENT
immature organs and systems.  shape of chest,  signs of respiratory distress
A. Classification According to SIZE symmetry  respiratory rate and regularity
1. LOW-birthweight (LBW) infant  if suctioning is  ambient oxygen and method of
 an infant whose birth weight is less than 2500grams (5.5 needed delivery
lbs.), regardless of gestational age.  oxygen saturation  adventitious breath sounds
2. VERY LOW-birthweight (VLBW) infant  other deviations  chest tubes
 An infant whose birth weight is less than 1500 grams (3.3
lbs.). CARDIOVASCULAR ASSESSMENT
3. EXTREMELY LOW-birthweight (ELBW) infant  heart rate and rhythm  peripheral perfusion
 An infant whose birth weight is less than 1000 grams (2.2  heart sounds  determination of PMI where
lbs.).  blood pressure the heartbeat sounds and
4. APPROPRIATE-for gestational-age (AGA) infant  peripheral pulses palpates the loudest
 An infant whose weight falls between the 10th and 90th  capillary refill  infant’s color including the
percentiles on intrauterine growth curves. mucous membranes and lips
5. SMALL-FOR-DATE (SFD) or small-for-gestational age
(SGA) infant GASTROINTESTINAL ASSESSMENT
 An infant whose rate of intrauterine growth was slowed  bowel sound  signs of regurgitation and
and whose birth weight falls below the 10th percentile on  palpate liver margin time related to feeding
intrauterine growth curves.  type of suction  amount, consistency and
6. INTRAUTERINE GROWTH RESTRICTION (IUGR) drainage color of any emesis
 Found in infants with whose intrauterine growth is  character and amount  amount, color, and
restricted. of residual consistency of stools
7. LARGE-for-gestational age (LGA) infant  presence of abdominal
 An infant whose birth weight falls above the 90th distention
percentile on intrauterine growth charts.
GENITOURINARY ASSESSMENT
B. Classification According to GESTATIONAL AGE  abnormalities of genitalia;
1. PRETERM (PREMATURE) INFANT  urine amount – weight, color, pH and specific gravity
 An infant born before completion of 37 weeks of gestation,
regardless of birth weight. NEUROLOGIC-MUSCULOSKELETAL ASSESSMENT
2. FULL-TERM INFANT  reflexes,  level of response and consolability
 An infant born between the beginning of 38 weeks and the  temperature  changes in head circumference
completion of 42 weeks of gestation, regardless of birth  infant’s  level of activity with stimulation,
weight. movements  infant’s position or attitude,
3. POST-TERM (POST MATURE) INFANT
 An infant born after 42 weeks of gestational age, SKIN ASSESSMENT
regardless of birth weight.
 rashes  reddened areas
4. LATE-PRETERM INFANT
 skin lesions  discoloration
 An infant born between 34 and 36 weeks of gestation,
 birthmarks  signs of irritation
regardless of birth weight.
 blisters  skin texture and turgor
 abrasions  signs of infiltration if IV is
C. Classification According to MORTALITY present
1. LIVE BIRTH
 Birth in which the neonate manifests any heartbeat,
breathes, or displays voluntary movement, regardless of
gestational age.
2. FETAL DEATH
 Death of the fetus after 20 weeks of gestation and before
delivery, with absence of any signs of life after birth.
3. NEONATAL DEATH
 Death that occurs in the first 27 days of life ; early neonatal
death occurs in the first week of life; late neonatal death
occurs at 7 to 27 days.
4. PERINATAL MORTALITY
 Describes the total number of fetal and early neonatal
deaths per 1000 live births.
5. POSTNATAL DEATH
 Death that occurs at 28 days to 1 year after birth.

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PROBLEMS RELATED TO MATURITY PROBLEMS RELATED TO GESTATIONAL WEIGHT
Classification of infants at birth by both birthweight and gestational
PRETERM INFANTS age provides more satisfactory method for predicting mortality risks
 Immaturity not only places infants at risk for neonatal and providing guidelines for management of the neonate than
complications, but it may also predispose the infant to problems estimating gestational age or birthweight alone. The infant’s
that persist into adulthood. A variety of maternal and birthweight, length, and head circumference are plotted on
pregnancy-related complications increase the risk of preterm standardized graphs that identify normal values for gestational age
delivery; however, the actual cause of prematurity is not known.
The incidence of prematurity is lowest in middle to high SMALL-FOR-GESTATIONAL AGE INFANT
socioeconomic classes, in which pregnant women are generally  An infant is SGA if the birth weight is below the 10th
in good health, are well nourished, and receive prompt and percentile on an intrauterine growth curve for that age.
comprehensive prenatal care. The incidence is highest in the SGA infants may be born;
lower socioeconomic classes, in which a combination of  preterm (before week 38 of gestation),
negative circumstances is present. Other FACTORS, such as
 term (between weeks 38 and 42), or
 multiple pregnancies,
 post term (past 42 weeks).
 gestational hypertension, and
 SGA infants are small for their age because they have
 placental problems experienced intrauterine growth restriction (IUGR) or failed to
…that interrupt the normal course of gestation, are responsible grow at the expected rate in utero.
for a large number of preterm births.
 The most common cause of IUGR is a Placental
 Preterm infants are very small and appear thin because they Anomaly: either the placenta did not obtain sufficient
have little to no subcutaneous fat deposits. nutrients from the uterine arteries, or it was inefficient at
 They also have a proportionately large head in relation to the transporting nutrients to the fetus.
body, which reflects the cephalocaudal direction of growth.  SGA infant may be detected in utero when fundal height during
 The skin is bright pink, smooth, and shiny, with small blood pregnancy becomes progressively less than expected.
vessels clearly visible.  An infant who suffers nutritional deprivation late in
 The fine lanugo is abundant over the body but is sparse, fine, pregnancy, when growth consists primarily of an increase in cell
and fuzzy on the head. size, may have only a reduction in weight.
 The ear cartilage is soft and pliable, and the soles and palms  The child may have a small liver, which can cause difficulty
have minimum creases, resulting in smooth appearance. regulating glucose, protein, and bilirubin levels after birth.
 The bones of the skull and ribs feel soft, and before 26  The infant also may have poor skin turgor and generally appear
weeks the eyes may be fused. to have a large head because the rest of the body is so small.
 Male infants have few scrotal rugae, and the testes are Skull sutures may be widely separated from lack of normal
undescended; the labia minora and clitoris are prominent in bone growth.
females.  Hair is dull and lusterless.
 Preterm infants are inactive and listless.  The abdomen may be sunken.
 Preterm infants are unable to maintain body temperature,  The umbilical cord often appears dry and may be stained
have limited ability to excrete solutes in the urine, and have yellow.
increased susceptibility to infection.  The skull may be firmer, and the infant may seem unusually
 A pliable thorax, immature lung tissue, and an immature alert and active for that weight.
regulatory center led to periodic breathing, hypoventilation, and  The increase in red blood cells occurs because anoxia during
frequent periods of apnea. intrauterine life stimulates the development of red blood cells.
 These infants are more susceptible to biochemical  The POLYCYTHEMIA that results causes increased blood
alterations such as hyperbilirubinemia and hypoglycemia, and viscosity, a condition that puts extra work on the infant’s heart
they have a higher extracellular water content that renders because it is more difficult to effectively circulate thick blood.
them more vulnerable to fluid and electrolyte imbalance.
 As a consequence, ACROCYANOSIS (blueness of the hands
 When delivery of a preterm infant is anticipated, the neonatal and feet) may be prolonged and persistently more marked than
intensive care unit (NICU) is alerted, and a team approach usual.
implemented. Infants who do not require resuscitation are
 Because SGA infants have decreased glycogen stores, one of
immediately transferred in a heated incubator to the NICU.
the most common problems is HYPOGLYCEMIA (decreased
Resuscitation is conducted in the delivery area until infant can
blood glucose, or a level below 45 mg/dL).
be transported to the NICU.

LARGE-FOR-GESTATIONAL AGE INFANT

POST TERM INFANTS
 An infant is LGA (also termed MACROSOMIA) if the birth
 Infants born after 42 weeks as calculated from the mother’s last
weight is above the 90th percentile on an intrauterine growth
menstrual period are post term, or postmature, regardless of
chart for that gestational age. Such a baby appears deceptively
birth weight. The cause of delayed birth is unknown.
healthy at birth because of the weight, but a gestational age
 Post term infants display the CHARACTERISTICS of infants examination will reveal immature development. Infants who are
who are 1 to 3 weeks of age, such as LGA have been subjected to an overproduction of growth
 absence of lanugo, hormone in utero.
 little if any vernix caseosa,  This happens most often to infants of women with diabetes
 abundant scalp hair, and mellitus or women who are obese. Extreme macrosomia occurs
 long fingernails. in fetuses of diabetic women whose symptoms are poorly
 The skin is often cracked, parchmentlike, and controlled, because these fetuses are exposed to high glucose
peeling. levels.
 A common finding in post term infants is a wasted physical  MULTIPAROUS WOMEN are also prone to have large babies
appearance that reflects intrauterine nutritional deprivation. because with each succeeding pregnancy, babies tend to grow
 Depletion of subcutaneous fat gives them a thin, elongated larger.
appearance. Other CONDITIONS associated with LGA infants include;
 The little vernix caseosa that remains in the skin folds may be  transposition of the great vessels,
stained a deep yellow or green, which is usually an indication of  Beckwith syndrome (a rare condition characterized by
meconium in the amniotic fluid. overgrowth),
 The post term infant is especially prone to fetal distress  congenital anomalies such as OMPHALOCELE
associated with the decreasing efficiency of the placenta,
macrosomia, and meconium aspiration syndrome (MAS).

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 LGA infants may show immature reflexes and low scores on  When using a Radiant Warmer, there is an increase in water
gestational age examinations in relation to their size. loss from convection and radiation.
 They may have extensive bruising or a birth injury such as a
broken clavicle or ERB-DUCHENNE PARALYSIS from  An output less than 2 mL/kg/hr or a specific gravity greater
trauma to the cervical nerves if they were born vaginally. than 1.015 to 1.020 suggests Inadequate Fluid Intake
 Because the head is large, it may have been exposed to more
than the usual amount of pressure during birth, causing a
prominent Caput Succedaneum, Cephalhematoma, or
MAINTAINING THERMONEUTRALITY
Molding.
 All high-risk infants may have difficulty maintaining a normal
temperature. This is because, in addition to stress from an
MANAGEMENT OF HIGH-RISK NEWBORN illness or immaturity, the infant’s body is often exposed during
Most neonates under intensive observation are placed in a procedures such as resuscitation and blood drawing.
controlled thermal environment and monitored for heart rate,  It is important to keep newborns in a neutral-temperature
respiratory activity, and temperature. The monitoring devices are environment, one that is neither too hot nor too cold, as doing
equipped with an alarm system that indicates when the vital signs so places less demand on them to maintain a minimal
are above or below preset limits. However, a “hands-on” metabolic rate necessary for effective body functioning.
assessment, including auscultation of heart tones and breath
 If the environment is too hot, they must decrease
sounds, is essential.
metabolism to cool their body.
 If it is too cold, they must increase metabolism to warm
INITIATING AND MAINTAINING RESPIRATIONS body cells.
 Ultimately, the prognosis of a high-risk newborn depends  The increased metabolism required calls for increased
primarily on how the first moments of life are managed. Most oxygen; without this oxygen available, body cells become
deaths occurring during the first 48 hours after birth result from HYPOXIC.
the newborn’s inability to establish or maintain adequate  To save oxygen for essential body functions, vasoconstriction
respirations. of blood vessels occurs. If this process continues for too long,
 Resuscitation follows an organized process: pulmonary vessels become affected and pulmonary perfusion
a. establish and maintain an airway, becomes decreased.
b. expand the lungs, and
c. initiate and maintain effective ventilation. ESTABLISHING ADEQUATE NUTRITIONAL INTAKE
 If respiratory depression becomes severe, a newborn’s heart
 Optimum nutrition is critical in the management of preterm
will fail. Resuscitation then must also include Cardiac
infants, but difficulties arise in providing for their nutritional
Massage.
needs. The various mechanisms for ingestion and digestion of
foods are not fully developed. The more immature the infant,
ESTABLISHING EXTRAUTERINE CIRCULATION the greater the problem. Although infants demonstrate some
 Lack of cardiac function may be present concurrently or may sucking and swallowing activities before birth, coordination of
develop if respiratory function cannot be quickly initiated and these mechanisms does not occur until approximately 32 to
maintained. If an infant has no audible heartbeat, or if the 34 weeks of gestation, and they are not fully synchronized
cardiac rate is below 80 beats per minute, CLOSED-CHEST until 36 to 37 weeks.
MASSAGE should be started.  The infant’s size and condition determine the amount and
 Hold an infant with fingers supporting the back and method of feeding. Nutrition can be provided by either the
depress the sternum with two fingers. Parenteral or Enteral Route, or both.
 Depress the sternum approximately one third of its depth (1 or  Breast milk, which contains more
2 cm) at a rate of 100 times per minute.  protein,
 Lung ventilation at a rate of 30 times per minute should be  sodium,
continued and interspersed with the cardiac massage at a ratio  chloride and
of 1:3.  immunoglobulin A (IgA),
 Continue to monitor transcutaneous oxygen or pulse oximetry …is the preferred source of milk for preterm infants.
to evaluate respiratory function and cardiac efficiency.
 If the pressure and the rate of massage are adequate, it should
ESTABLISHING WASTE ELIMINATION
be possible, in addition, to palpate a femoral pulse.
 Although most immature infants void within 24 hours of birth,
 If heart sounds are not resumed above 80 beats per minute
they may void later than term newborns because, as a result of
after 30 seconds of combined positive-pressure ventilation
all the procedures that may be necessary for resuscitation, their
and cardiac compressions, 0.1 to 0.3 mL/kg epinephrine
blood pressure may not be adequate to optimally supply their
(1:10,000) may be sprayed into the endotracheal tube to
kidneys.
stimulate cardiac function (AHA, 2008).
 Carefully document any voiding that occur during
 Newborns who have difficulty maintaining cardiac function need
resuscitation. This is proof that hypotension is improving, and
to be transferred to a Transitional or High-Risk Nursery for
the kidneys are being perfused. Immature infants also may
continuous cardiac surveillance.
pass stool later than the term infant because meconium has not
yet reached the end of the intestine at birth.
MAINTAINING FLUID AND ELECTROLYTE BALANCE
 After an initial resuscitation attempt, HYPOGLYCEMIA PROTECTION FROM INFECTION
(decreased blood glucose) may result from the effort the
 Contracting an infection could drastically complicate a high-risk
newborn expended to begin breathing.
newborn’s ability to adjust to extrauterine life. Infection, like
 DEHYDRATION may result from increased insensible water
chilling, increases metabolic oxygen demands, which the
loss from rapid respirations.
stressed newborn may not be able to meet. In addition,
 Infants with hypoglycemia are treated initially with 10% infection stresses the immature immune system and already
dextrose in water to restore their blood glucose level. Fluids stressed defense mechanisms of a high-risk newborn.
such as Ringer’s lactate or 5% dextrose in water are Infections may have prenatal, perinatal, or postnatal causes. In
commonly used to maintain fluid and electrolyte levels. some instances, such as preterm rupture of the membranes,
Electrolytes (particularly sodium and potassium) and glucose it is an infection such as pneumonia or skin lesions that place
are added as necessary, depending on electrolyte analysis. the infant in a high-risk category.
 The rate of fluid administration must be carefully monitored
because a high fluid intake can lead to PATENT DUCTUS
ARTERIOSUS or HEART FAILURE.

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 NCMA219 - WEEK 7 - MIDTERMS
SKIN CARE The TREATMENT FOR RDS includes all the general measures
 Preterm infants have immature skin with increased sensitivity required for any preterm infant, as well as those instituted to correct
and fragility. imbalances. The supportive measures most crucial to a favorable
 ALKALINE-BASED SOAP that might destroy the “acid-mantle” outcome are:
of the skin should be avoided.  Maintain adequate ventilation and oxygenation with
 The use of ZINC OXIDE-BASED TAPE is encouraged to continuous positive airway pressure (CPAP), high flow nasal
minimize epidermal stripping: the tape is flexible, waterproof, cannula, or mechanical ventilation.
and washable. Skin barriers protect healthy skin and help  Maintain adequate hydration and electrolyte status.
excoriated skin heal.  Maintain adequate tissue perfusion and oxygenation
 Maintain acid-base balance
ESTABLISHING PARENT-INFANT BONDING  Maintain a neutral thermal environment
 Be certain that the parents of a high-risk newborn are kept  Prevent hypotension
informed of what is happening during resuscitation at birth.
They should be able to visit the special nursing unit to which the NIPPLE and GAVAGE FEEDINGS are avoided in any situation that
child is admitted as often as they choose, and, after washing creates a marked increase in respiratory rate because of the greater
and gowning, hold and touch their child. Urge parents to hazards of aspiration. Administration of exogenous surfactant to
spend time with their infant in the intensive care nursery as preterm neonates with RDS, or infants at high risk for RDS has
the infant improves. Be certain that parents have access to become an accepted and common therapy worldwide.
health care personnel after discharge to help them care
confidently for the child at home. If an infant dies despite MECONIUM ASPIRATION SYNDROME - MAS
newborn resuscitation attempts, parents need to see the infant  Meconium aspiration occurs when a fetus has been subjected
without being covered by a myriad of equipment. This is a time to asphyxia or other intrauterine stress that causes
for parents to reassure themselves their newborn was a perfect relaxation of the anal sphincter and passage of meconium into
baby in every other way except lung function or whatever was the amniotic fluid. Most meconium aspiration occurs with the
the infant’s fatal disorder. Thinking this way can give them first breath; however a severely compromised fetus may
confidence to plan for other children or simply to continue their aspirate in utero. At delivery of the chest and initiation of the
lives after such a stressful experience. first breath, infants inhale fluid and meconium into the
nasopharynx. MAS involves the passage of meconium in
ACUTE CONDITIONS OF THE NEONATES utero because of HYPOXIC STRESS. Once the fetus ingests
meconium, any gasping activity occurring because of
RESPIRATORY DISTRESS SYNDROME (RDS) intrauterine stress may cause the sticky and tenacious
 is a condition of surfactant deficiency and physiologic substance to be aspirated into the lower airways.
immaturity of the thorax.  The result would be;
 It is seen almost exclusively in preterm infants but may also be  partial obstruction
associated with;  air trapping
 cold stress  multifetal pregnancies  hyperinflation distal to the obstruction
 asphyxia  infants of diabetic mothers  atelectasis caused by surfactant deactivation
 family history of RDS  caesarean section delivery  Infants who have released meconium in utero for some time
before birth are stained from green meconium stools
 Respiratory distress of a non-pulmonary origin in newborn tachypneic, hypoxic, and often depressed at birth.
may also be caused by;  They develop expiratory grunting, nasal flaring, and retractions.
 sepsis  hypoglycemia
 cardiac defects  metabolic acidosis APNEA OF PREMATURITY (AOP)
 exposure to cold  acute blood loss  Preterm infants are characteristically PERIODIC BREATHERS.
 airway obstruction  drugs They have periods of rapid respiration separated by periods of
very slow breathing, and often short periods with no visible or
 PNEUMONIA during the neonatal period is respiratory distress audible respirations.
caused either by bacterial or viral agents and may occur alone  APNEA is primarily an extension of this periodic breathing and
or as a complication of RDS. can be defined as a lapse of spontaneous breathing for 20 or
 This inability to maintain lung expansion produces widespread more seconds, or shorter pauses accompanied by bradycardia
ATELECTASIS. or oxygen desaturation. Apnea of prematurity is a common
 In the absence of alveolar stability and with progressive phenomenon in the preterm infant. Apneic spells increase in
atelectasis, PULMONARY VASCULAR RESISTANCE (PVR) prevalence the younger the gestational age. AOP may be
INCREASES. classified according to origin:
 Laboratory data are nonspecific, and the abnormalities 1. CENTRAL APNEA – an absence of diaphragmatic and other
observed are identical to those observed in numerous respiratory muscle function that causes a lack of respiratory
biochemical abnormalities of the newborn. effort and occurs when the CNS does not transmit signals to
the respiratory muscles
Specific test are used to determine complicating factors, such as;
2. OBSTRUCTIVE APNEA – when airflow stops because of upper
 Blood Glucose (for hypoglycemia), airway obstruction, yet chest or abdominal wall movement is
 Arterial Blood Gas (ABG – for acidosis and hypoxia). present
 PULSE OXIMETRY is also an important component in 3. MIXED APNEA – a combination of central and obstructive
determining hypoxia. apnea and the most common form of apnea seen in preterm
Radiologic findings characteristic of RDS include: infants.
 Diffuse Granular Pattern over both lung fields that resembles
ground glass and represents ALVEOLAR ATELECTASIS.  FACTORS like infection, intracranial hemorrhage (ICH), or PDA
 DARK STREAKS, or AIR BRONCHOGRAMS, within the can make apnea worse.
ground glass areas that represent dilated, air-filled bronchioles.  CAFFEINE is often effective in reducing the frequency of
primary apnea-bradycardia spells in newborns. Caffeine acts as
 Flaring of the nares is also a sign that accompanies a CNS stimulant to breathing though they needed to be
tachypnea, grunting, and retractions in respiratory distress. monitored for symptoms of toxicity.
 CENTRAL CYANOSIS is a late and serious sign of respiratory
distress.

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NEONATAL SEPSIS  Persistent jaundice over 2 weeks in a full-term formula-fed
 Sepsis or SEPTICEMIA is a generalized bacterial infection in infant
the bloodstream.  Total serum bilirubin levels over 12.9 mg/dl (term infant) or over
 Because of the newborn’s diminished NONSPECIFIC 15 mg/dl (preterm infant); the upper limit for breastfed infant is
(inflammatory) and SPECIFIC (humoral) immunity, they are 15 mg/dl
more prone to infections.  Increase in serum bilirubin by 5 mg/dl/day
 The newborn’s poor response to pathogenic agents causes no  Direct bilirubin exceeding 1.5 to 2 mg/dl
local inflammatory reaction at the portal of entry to signal an  Total serum bilirubin level over the 95th percentile for age (in
infection and may result to symptoms that are vague and not hours) on an hour-specific nomogram
specific. This may result to delayed diagnosis and treatment.
 Neonatal sepsis can be acquired across the placenta from the  TRANSCUTANEOUS BILIRUBINOMETRY (TCB) refers to the
maternal bloodstream or during labor from ingestion or noninvasive monitoring of bilirubin through cutaneous
aspiration of infected amniotic fluid. reflectance measurements allowing for repetitive estimations of
There were 2 classifications of sepsis: early-onset sepsis and bilirubin. Once phototherapy has been initiated TcB is no longer
late-onset sepsis. useful as screening tool.
1. EARLY-ONSET SEPSIS can be seen on infants less than 3
days after birth. It is usually acquired in the perinatal period; RISK FACTORS that have been identified and that may place
infection can occur from direct contact with organisms from newborns at high risk for hyperbilirubinemia include;
the maternal gastrointestinal and genitourinary tracts. The most  maternal race
common infecting organism in term infants is group B  late preterm birth
streptococcus (GBS); in preterm infants, it is Escherichia  jaundice observed in the first 24 hours of life
coli.  significant bruising
2. LATE-ONSET SEPSIS occurs 1 to 3 weeks after birth. It is
 cephalhematoma
primarily nosocomial, and the organisms involved are
 exclusive breastfeeding
staphylococci, Klebsiella organisms, enterococci, E. Coli, and
 blood group incompatibility or hemolytic disease such as
Pseudomonas or Candida.
G6PD
 history of sibling with hyperbilirubinemia.
 POSTNATAL INFECTION is acquired by cross contamination
 The most common cause of hyperbilirubinemia is relatively mild
from other infants, personnel, or objects in the environment.
and self-limited physiologic jaundice or ICTERUS
 The definitive diagnosis is established by laboratory and NEONATORUM. The degree of jaundice is determined by
radiographic examination. Blood, urine and CSF cultures serum bilirubin measurements.
were done to isolate the specific organism that causes the
 RECOMMENDATIONS for prevention and management of
infection. Blood studies may show signs of anemia,
early-onset jaundice in breastfed infants include;
leukocytosis or leukopenia, changes in neutrophil levels may
 encouraging frequent breastfeeding,
suggest a developing infection. Other diagnostic exam includes
 preferably every 2 hours;
C-reactive protein and other acute phase reactants.
 avoiding glucose water, formula,
 ANTIBIOTIC THERAPY is initiated before laboratory results
are available for confirmation and identification of the exact  water supplementation;
organism and is continued for 7 to 10 days if culture is positive  monitoring for early stooling.
and discontinued in 48 to 72 hours if negative and infant is  The infant’s weight, voiding, and stooling should be
asymptomatic. evaluated along with the breastfeeding pattern.
 SUPPORTIVE THERAPY usually involves administration of
oxygen, careful regulation of fluids, correction of electrolyte or DISEASES OF THE NEWBORN
acid–base imbalance, and temporary discontinuation of oral
feedings. NECROTIZING ENTEROCOLITIS (NEC)
 is the inflammation and death of intestinal tissue. It may
HYPERBILIRUBINEMIA involve just the lining of the intestine or the entire thickness of
 Hyperbilirubinemia refers to an excessive level of the intestine. In severe cases, the intestine may even
accumulated bilirubin in the blood and characterized by perforate. If this happens, the bacteria normally found only in
jaundice. the intestine can leak into the abdomen and cause widespread
 Hyperbilirubinemia may result from increased unconjugated infection. This is considered a medical emergency.
or conjugated bilirubin.  NEC is most common in premature infants. It usually develops
 The Most Common Type is the UNCONJUGATED FORM or within 2 weeks of birth.
INDIRECT HYPERBILIRUBINEMIA.  80% occurs in premature babies,
 BILIRUBIN is a breakdown product of the hemoglobin that  10% of infants who weigh less than 3 pounds and 5
results from RBC destruction. Normally, the body maintain a ounces develop NEC.
balance between the destruction of RBCs and the use or 3 FACTORS appear to play an important role in the development of
excretion of byproducts. However, when developmental NEC:
limitations or a pathologic process interferes with this balance, 1. intestinal ischemia,
bilirubin accumulates in the tissues to produce jaundice. 2. colonization by pathogenic bacteria, and
Possible causes of hyperbilirubinemia in newborns are as follows: 3. substrate (formula feeding) in the intestinal lumen.
 physiologic factors,
 association with breastfeeding or breast milk, excess RETINOPATHY OF PREMATURITY (ROP)
production of bilirubin,  is a serious VASO-PROLIFERATIVE DISORDER that affects
 disturbed capacity of liver to secrete conjugated bilirubin, extremely premature infants.
 combined overproduction and under secretion,  ROP often regresses or heals but can lead to severe visual
 some disease states, impairment or blindness.
 genetic predisposition to increased production.  Normally, the eye starts to develop at about 16 weeks of
pregnancy, when the blood vessels of the retina begin to form
Evaluation of jaundice is also based on the timing of appearance; at the optic nerve in the back of the eye. It grows
gestational age at birth; age in days since birth; family history, circumferentially and becomes fully mature at term. Premature
including maternal Rh factor; evidence of hemolysis; feeding birth results in the cessation of normal retinal vascular
method; infant’s physiologic status and the progression of serial maturation.
serum bilirubin levels.  Both laser treatment and cryotherapy destroy the peripheral
The following criteria are indicative of pathologic jaundice: areas of the retina, slowing or reversing the abnormal growth of

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 NCMA219 - WEEK 7 - MIDTERMS
blood vessels. Unfortunately, the treatments also destroy some and bilirubin levels should be assessed approximately every 12
side vision. This is done to save the most important part of our hours.
sight – the sharp, central vision we need for “straight ahead”
activities such as reading, sewing, and driving.  EXCHANGE TRANSFUSION. Intensive phototherapy in
conjunction with hydration and close monitoring of serum
HEMOLYTIC DISEASE OF THE NEWBORN bilirubin levels is the preferred method of treatment of neonatal
 The term “HEMOLYTIC” is derived from the Latin word for jaundice. Despite these measures if bilirubin levels continue to
“DESTRUCTION” (lysis) of red blood cells. rise, exchange transfusion may be necessary. Before the
 Lysis of red blood cells in the newborn leads to procedure, the baby’s stomach is aspirated to minimize the risk
hyperbilirubinemia (an elevated level of bilirubin in the blood). of aspiration from the manipulation involved. The umbilical vein
This can result from destruction of red blood cells by a normal is catheterized as the site for transfusion. The procedure
physiologic process. involves alternatively withdrawing small amounts (2–10 mL) of
 When abnormal destruction of red blood cells occurs, it is the infant’s blood and then replacing it with equal amounts of
termed hemolytic disease. donor blood. The blood is exchanged slowly this way to prevent
 In the past, hemolytic disease of the newborn was most often alternating hypovolemia and hypervolemia. This can make an
caused by an Rh blood type incompatibility. Because exchange transfusion a lengthy procedure of 1 to 3 hours.
prevention of Rh antibody formation has been available for Automatic pumps are helpful to perform the exhausting
almost 40 years, the disorder is now most often caused by an repeated ritual. At the end of the procedure, using the last
ABO incompatibility. specimen of blood withdrawn, hematocrit, bilirubin, electrolytes
 In both instances, the mother builds antibodies against an (especially calcium), glucose determination, and blood culture
infant’s red blood cells, leading to hemolysis (destruction) of the are taken. Exchange transfusion may need to be repeated
cells. because additional unconjugated bilirubin from tissue moves
 The destruction of red blood cells causes severe anemia and into the circulation after the exchange.
hyperbilirubinemia from the bilirubin released from red cells.
TRANSIENT TACHYPNEA OF THE NEWBORN (TTN)
 Initiation of EARLY FEEDING, use of phototherapy, and  is a respiratory disorder seen shortly after delivery in full-term
EXCHANGE TRANSFUSION all may be immediate measures or late preterm babies. Transient means it is short-lived
necessary to reduce indirect bilirubin levels in an infant affected (usually less than 24 hours). TACHYPNEA means rapid
by ABO or Rh incompatibility. breathing (most normal newborns take 40 - 60 breaths per
 In infants with severe hemolytic disease, the hemoglobin minute). As the baby grows in the womb, the lungs make a
concentration may continue to drop during the first 6 months of special fluid. This fluid fills the developing baby's lungs and
life, or their bone marrow may fail to increase production of helps them grow. When the baby is born at term, chemicals
erythrocytes in response to continuing hemolysis. If this occurs, released during labor tell the lungs to stop making this special
an infant may need an additional blood transfusion to correct fluid. The baby's lungs start removing or reabsorbing it. The first
this late anemia. Therapy with erythropoietin to stimulate red few breaths a baby takes after delivery fill the lungs with air and
blood cell production is also possible. help to clear most of the remaining lung fluid. Leftover fluid in
INITIATION OF EARLY FEEDING. the lungs causes the baby to breathe rapidly. It is harder for the
small air sacs of the lungs to stay open.
 Bilirubin is removed from the body by being incorporated into
feces. Therefore, the sooner bowel elimination begins, the
sooner bilirubin removal begins. Early feeding (either breast DOWN SYNDROME (TRISOMY 21)
milk or formula), therefore, stimulates bowel peristalsis and  Down syndrome is the most common chromosomal abnormality
accomplishes this. of a generalized syndrome, occurring in 1 in 691 to 1000 live
PHOTOTHERAPY. births. It occurs in people of all races and economic levels.
 An infant’s liver processes little bilirubin in utero because the  The cause of Down syndrome is not known, but evidence from
mother’s circulation does this for an infant. With birth, exposure cytogenetic and epidemiologic studies supports the concept of
to light apparently triggers the liver to assume this function. multiple causality. Approximately 95% of all cases of Down
Additional light supplied by phototherapy appears to speed the syndrome are attributable to an extra chromosome 21.
conversion potential of the liver. Although children with trisomy 21 are born to parents of all
ages, there is a statistically greater risk in older women,
 In phototherapy, an infant is continuously exposed to
particularly those older than 35 years of age. This genetic
specialized light such as;
disorder, which varies in severity, causes lifelong intellectual
 quartz halogen,
disability and developmental delays, and in some people it
 cool white daylight,
causes health problems.
 or special blue,
 Though not all children with Down syndrome have the same
 fluorescent light. features, some of the more common features are:
 The lights are placed 12 to 30 inches above the newborn’s
Flattened facial features;
bassinet or incubator.
 Small head;
 Specialized fiberoptic light systems incorporated into a
 Short neck,
fiberoptic blanket also have been developed and are ideal for
home care. The infant is undressed except for a di aper so as  Protruding tongue;
much skin surface as possible is exposed to the light.  Upward slanting eyes;
 unusual for the child's ethnic group;
Term newborns are generally scheduled for phototherapy when the  Unusually shaped or small ears;
total serum bilirubin level rises to 10 to 12 mg/dL at 24 hours of  Poor muscle tone; Broad, short hands with a single crease
age; preterm infants may have treatment begun at levels lower than in the palm;
this.  Relatively short fingers and small hands and feet;
 Excessive flexibility;
 HOME PHOTOTHERAPY is primarily used for decreasing  Tiny white spots on the colored part (iris) of the eye called
physiologic jaundice rather than that associated with blood “Brushfield” spots;
incompatibility. It has the advantage of allowing for  and Short height.
uninterrupted contact between the parents and a newborn and
therefore has the potential to aid bonding. Parents must
understand the importance of the therapy; the lights must be a
full 12 inches away from an infant to prevent burning; an infant
must continuously wear eye patches and a diaper during
phototherapy to protect the retinas and the ovaries or testes;

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