The Newborn At Risk: Conditions Present At Birth

Mary Milam, RN, MSN, CFNP 1

Reading

Required reading – Ladewig Table 28 – 2 p. 725 – 728 Table 29 – 1 p. 757 – 758 Table 29 – 5 p. 784 – 785 Recommended reading – Ladewig Chapter 28 p. 695 – 746 Chapter 29 p. 747 - 797 ATI reading 7.1 Edition p. 412 - 454

Newborns at Risk • Small-for-Gestational-Age (SGA) Newborn • Large-for-Gestational-Age (LGA) Newborn • Infant of a Diabetic Mother (IDM) • The Post-term Newborn • Preterm Newborn • Congenital Anomalies • Infant of Substance Abusing Mother • Newborn at Risk for HIV/AIDS • Congenital Heart Defects • Inborn Errors of Metabolism Slide 8 Slide16 Slide 20 Slide 24 Slide 27 Slide 41 Slide 42 Slide 56 Slide 59 Slide 64 3

REVIEW

•

Temperature regulation, page 569-572

– 4 ways infants lose heat, page 570 •

Carbohydrate metabolism, page 572

– hypoglycemia

REVIEW

•

Physiologic jaundice, page 573-576

– 60% of term newborns – High bilirubin affects the brain •

Estimating gestational age, page 588 596

– You should be doing these in newborn clinical

Gestational Age • Preterm: less than 38 weeks • Term: 38 – 42 weeks • Postterm: 42 + weeks, aka “post date” 6

Newborn Classifications Classified by gestational age and birth wt • SGA < 10th % • Small for gestational age – More prone for Thermal complications due to low birth fat • AGA = 10-90th % • Appropriate for gestational age • LGA > 90th % • Large for gestational age – More prone for CSection and Birth trauma 7

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ALL INFANTS

Nursing care

• A,B,C’s • Neutral Thermal Environment (NTE) • Early detection/treatment of

hypoglycemia

• Promote comfort and bonding 8

1) Newborn at risk SGA

• aka- Intrauterine Growth Restriction (IUGR) • Figure 28- 3 – AGA and SGA twins (discordant) 9

Contributing Factors to (SGA) Newborn • Maternal factors – Primip, grand multip, multiple gestations, low socioeconomic status • Maternal disease – heart disease, drug abuse, sickle cell, preeclampsia, HTN, diabetes (white’s class D-F) • Environmental factors – high altitude, exposure to x-rays, exposure to toxins, nicotine, drugs • Placental factors – small, infarcted, thrombosis • Fetal factors – congenital infections (rubella, toxoplasmosis, syphilis, CMV), sex of the fetus (girls usually smaller) – - chromosomal factors 10

Common Complications of the SGA Newborn • Perinatal asphyxia • Aspiration syndrome • Heat Loss • Hypoglycemia • Hypocalcemia • Polycythemia 11

Patterns of Intrauterine Growth Restriction (IUGR) • Symmetric – During whole pregnancy or for a long period of time – Caused by long-term maternal conditions – Detectable by ultrasound in second trimester • Asymmetric – A short term thing – Caused by acute compromise of uteroplacental blood flow 12

Classification of SGA • Symmetric – Causes prolonged retardation of growth – Weight, length, head circumference,& overall size is small • Asymmetric – Usually not evident before 3 rd trimester – Birth wt < 10% but head circumference & length may be normal. Long & skinny 13

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Prognosis for SGA Newborn Good News!

– The SGA infant is more physiologically mature than indicated by size &

less predisposed to the respiratory

complications of prematurity.

Bad News!

– Preterm infants that

are SGA have the highest mortality risk

(Small & Preterm = 2 bads)

– Congenital malformations occur more frequently in SGA infants 14

Prognosis for SGA Newborn • Bad News – Symmetric SGA infants tend not to catch up to their peers – SGA newborns can have poor brain development and subsequent disabilities.

– Intrauterine viral/bacterial infections resulting in SGA are very damaging 15

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Nursing Care for the SGA Newborn The SGA Newborn my look it, but is NOT Premature • Hypoglycemia – * extremely important to treat hypoglycemia to prevent damage to the CNS – The brain needs glucose! • Hyperviscosity – hypoxia and polycythemia – More RBC than normal b/c the baby responds to hypoxia by making more RBCs.

• Follow-up congenital infection & malformations 16

2) The Large-for-Gestational Age (LGA) Newborn

• A newborn whose birth weight is at or above the 90 th percentile on the intrauterine growth curve 17

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Factors Contributing to diagnosis of LGA Newborn • Miscalculation of the date of conception • Genetic predisposition • Multiparous mother • Male infants are typically larger than females • Infants with erythroblastosis fetalis, Beckwith-Wiedemann syndrome, or transposition of the great vessels • Maternal diabetes • Terms: – Multiparous- having given birth to more than one child – Erythroblastosis fetalis- hemolytic anemia in newborns that results from maternal-fetal blood group incompatibility – Beckwith-Wiedemann syndrome- umbilical hernia, visceromegaly, macroglossia, gigantism 18

Common Complications of the LGA Newborn • Birth Trauma due to Cephalopelvic disproportion (CPD) • Increased C/sections and oxytocin inductions • Hypoglycemia • Polycythemia • Hyperviscosity 19

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Nursing Care for the LGA Newborn • Monitor for hypoglycemia – b/c baby is prone for it • Screening for polycythemia – Labs: CBC, H&H • Address parental concerns about the appearance of the overweight infant • Careful assessment for birth injuries & address parental concerns about birth injuries – Ex: broken clavicle 20

3) Infant of a Diabetic Mother (IDM)

• This infant is at risk for hypoglycemia! – Macrosomic “large” – Ruddy “reddish” 21

21:10 IDM

Characteristics

• ↑ weight due to – ↑ wt of visceral organs – Cardiomegally – ↑ body fat • ↑ growth due to constant exposure to maternal glucose • Glucose crosses the placenta, but insulin doesn’t – Infant responds with ↑ insulin production (pseudo growth hormone) 22

Common Complications of the IDM • Hypoglycemia- After birth, infant continues to produce high levels of insulin causing hypoglycemia.

• Hypocalcemia- b/c people w/ DM generally are low in Calcium • Birth Trauma- b/c of size • Hyperbilirubinemia- b/c of immature liver • Respiratory Distress Syndrome (RDS) – Tachypnea- more than 60 respiration in a minute – Apnea- episode of non breathing for more than 20 seconds • Congenital birth defects- Skeletal/Cardiac (ex: sacral agenesis) 23

Nursing Care for the IDM Newborn • Early detection of hypoglycemia • Early detection of polycythemia and hyperbilirubinemia • Assess for birth trauma • Assess for congenital anomalies • Flash fact: Insulin antagonizes/prevents surfactant production 24

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4) The Post-term Newborn

• Post dates – any newborn born after due date • Post-term - any newborn born after 42 weeks gestation. • Postmature - newborn born after 42 completed weeks of gestation and demonstrating postmaturity syndrome. 25

Common Complications of the Post term Newborn • Postmaturity Syndrome - insufficiency of the aging placenta & continued exposure to amniotic fluid: – 2-3X higher morbidity than term infants – Hypoglycemia – glycogen stores b/c they’ve used up/ depleted their – Meconium Aspiration Syndrome – reponse to hypoxia – Polycythemia – increases RBCs in response to hypoxia – Congenital anomalies – Seizure activity if hypoxia has been severe – Prone to cold stress

b/c they start to lose wt in utero

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Nursing Care of the Post-term Newborn • Assess the newborn for postmaturity syndrome – Usually long and thin (lil’ old man looking) • May require prolonged monitoring and support of well-being due to wasting effect of insufficient in utero support • Early detection of polycythemia and hyperbilirubinemia 27

28:40 Story 34:20

5) Newborn at risk Preterm

• < 37 weeks gestation • 12% of US births are preterm • Risks – Multiple gestation – History preterm birth – Single, teen mother 28

The Preterm Newborn • As a wayfarer in a hostile environment, the preterm newborn requires external support • The major problem of the preterm infant is the immaturity of ALL systems depending on the length of gestation 29

35:50 To slide 31 Newborn at risk Preterm

• Nursing Care

• Monitor respiratory/cardiac status

•NTE

• Cluster care do procedures all at once, grouped to promote rest time • Nutrition • Prevention of Infection preterm before 3 rd baby misses out on immunity from mom.

trimester , • Parent-Infant attachment 30

Premature care in NICU

• Ventilation- Et tube and ventilator • Hydration • Thermoregulation • Nutrition • Infection control 31

The Preterm Newborn • Alteration in

respiratory physiology

• Inadequate amount of surfactant in the lungs allows alveoli to collapse = respiratory distress syndrome (RDS) • Treated with artificial surfactant down the ET tube • Ventilation Therapy 32

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The Preterm Newborn • Alteration in

cardiac physiology

• Pulmonary blood vessels immature • Decreased pulmonary resistance – L to R shunting through ductus arterious • Increased blood volume to lungs 33

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The Preterm Newborn • Alteration in

Thermoregulation

• Supported by incubator to provide body warmth • Limited supply of glycogen • Lack of brown fat • Higher ratio of surface area

to weight

– Radiant warmer req • Little subcutaneous fat for

insulation

• Thinner more permeable

skin

• Posture of non-flexion – Arms and legs flaccid 

prone to losing heat

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The Preterm Newborn • Alteration in

Gastrointestinal Physiology

• Terms: – Gavage- the process of feeding a patient through a Nasogastric tube – Lavage- the process of washing out an organ, usually the bladder – NEC- inflamed bowel blood supply   Necrosis Low • Ingestion – Poor suck-swallow coordination • < 36wks- needs gavage – Difficulty w/ nipple feeding • Digestion – Difficulty with absorption of nutrients – Hypoperfusion of bowel

during hypoxia – NEC

• Lead to surgery and

colostomy bag (best to prevent it)

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The Preterm Newborn • Alteration in Renal Physiology • Glomerular Filtration Rate is Lower • Decreased GFR* • Limited ability to concentrate urine • Predisposed to metabolic acidosis • *Ability to metabolize

& excrete drugs is unpredictable

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Common Complications of the Preterm Newborn • Short Term Complications – Apnea of prematurity b/c they forget to breathe • Treat w/ Theophylline (long-term bronchodilator ) – Patent Ductus Arteriosus (PDA) – Respiratory Distress Syndrome (RDS) – Intraventricular Hemorrhage of Brain (IVH) – Necrotizing Entercolitis of Bowel (NEC) – Hyperbilirubinemia – Hypoglycemia – Sepsis 37

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Long-Term Complications of the Preterm Newborn Can last for yrs • Higher mortality rates from SIDS • Retinopathy of prematurity (ROP) – Vessels in eyes can rupture prematurely • Bronchopulmonary dysplasia (BPD) – Due to high pressures caused by lack of surfactant which caused stiffness • Speech defects – Possibly from prolong vent tube • Neurologic defects • Auditory defects • Abuse and neglect – b/c of their high care demand 38

6) Congenital Anomalies

• Hydrocephalus • Choanal Atresia • Cleft lip/Cleft palate • Tracheoesophageal Fistula fistula between Trachea-esophag • Diaphragmatic Hernia hole in the diaphragm • Myelomengiocele spina bifida • Omphalocele/Gastroschisis 2) opening in the abd wall 1) abd contents thru umb cord, • Prune Belly Syndrome extremely large belly • Imperforate Anus no hole • Congenital dislocated hips • Clubfoot true club reqs surg intervention, Positional club can be ambulated 39

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7) Newborn of a Substance Abusing Mother

• Drug Dependency – Alcohol – Tobacco – Cocaine – PCP – Methamphetamines – Inhalants – Marijuana – Heroin – Methadone 40

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Newborn of a Substance-Abusing Mother • Newborn of alcohol or drug dependent mother may also be dependent • Suffers withdrawal when maternal blood supply of substance is unavailable • Drugs ingested by the mother may be teratogenic to the baby 41

Newborn of a Substance-Abusing Mother • Risks to fetus, prone to… – Intrauterine asphyxia – Intrauterine infection – Alterations in birthweight – Lower apgar scores 42

1:02:05 Newborn of Substance- Abusing Mother

• Common Complications – Respiratory distress (heroin may accelerate lung maturity) – Jaundice – Congenital anomalies & growth retardation 43

Newborn of Substance- Abusing Mother

• Common Complications – Behavioral abnormalities – Withdrawal – Long term difficulties with developmental delays and emotional dysfunction 44

Nursing Care of Newborn of Substance-Abusing Mother • Promote comfort (dimly lit/quiet area) • Promote bonding (w/ mom) • Refer for community intervention programs • Early identification of the newborn needing medical or pharmacologic interventions • Ascertain last maternal drug use and amount • Identify signs of newborn withdrawal (Table 28-3) – Next slide 45

Manifestations of Neonatal Withdrawal • Hyperactivity,

tachypnea (>60 breaths/min)

• Vigorous suck, hyperphagia • Inconsolable cry (Shrill) high-pitched and sharp • Sleeplessness • Hypertonicity, jitteriness, tremors • Hyperirritability & muscular rigidity • Excoriated buttocks, knees, elbows • Facial scratches give them mittens 46

Newborn with Fetal Alcohol Spectrum Disorders (FASDs)

• Umbrella term to describe the range of effects that can occur in an individual whose mother drank alcohol during pregnancy • Fetal Alcohol Syndrome (FAS) – Most clinically recognized form of FASDs 47

Newborn with Fetal Alcohol Spectrum Disorders (FASDs)

• Risk factors – Maternal age > 30 – Hx of binge drinking – Low socioeconomic status 48

Physical Characteristics of Fetal Alcohol Syndrome • SGA • Microcephaly • Functional or structural CNS abnormalities • Craniofacial abnormalities • Prenatal/Postnatal growth defects • Congenital Heart Defects • Mental retardation 49

Newborn with FAS Physical Characteristics

American Family Physician, July 15, 2005, Vol 72,#2 50

Nursing Care of Newborn of an Alcohol-Abusing Mother • Ensure newborn well-being. Follow checklist: airway, breathing, circulation, neutral thermal environment, - (may have seizures) • Early detection and intervention of hypoglycemia, (observe this infant for feeding difficulties) • Promote comfort- may need to adjust /REDUCE environment to infant’s tolerance level stimuli and • Bonding - reinforce positive parenting activity & refer to follow-up community intervention programs 51

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Newborn of Tobacco Dependant Mother

• 25% of women continue to smoke during their

pregnancy

• Preconception smoking ↑ in infertility – Can be reversed if stop smoking • Smoking during pregnancy

can cause

– Spontaneous abortion – Placenta previa – Abruptio placenta b/c smoking vasoconstricts – Maternal HTN 52

Newborn of Tobacco Dependant Mother

• Newborn Risks,

child will…

– IUGR – Intrauterine distress- mec stain – Lower APGARS – Hyper/hypotonia – S/S of nicotine toxicity (tachycardia, irritable, poor feeding) – Impaired neurobehaviors 53

8) Newborn at Risk for HIV/AIDS

• Transmission can occur across the placenta, through breast milk, or thru birth canal contaminated blood.

• Confirmatory testing (ELISA & Western blot tests) – not reliable until 18 months 54

1:13:18 Newborn with Exposure to HIV-AIDS Signs/Symptoms

– Enlarged spleen or liver – Lymphadenopathy – Recurrent respiratory infections – Recurrent GI and GU system infections – Persistent candidiasis – Developmental delay.

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Nursing Care for Newborn with HIV/AIDS • Use Standard body fluid isolation – Acyclovir for the mom in addition to possible C-Section • Bathe as soon as infant is physiologically

stable to clear away potentially infectious maternal body fluids before puncturing skin

• Do not encourage breastfeeding • Parental education 56

9) Newborn with Congenital Heart Defects

• Contributing factors • Majority of heart defects are multifactoral and

have no specific cause

57

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Newborn with Congenital Heart Defect-Contributing Factors • Environmental – Infections – Drugs – Pesticides – PKU – Chromosomal abnormalities 58

Newborn with Congenital Heart Defect-Contributing Factors • Genetic – Some defects have increased incidence and recurrence in families 59

1:16:40 Newborn with Congenital Heart Defect • Acyanotic – L to R shunt • Blood flows from lt to rt (Bld is not going to the body) – Causes pulmonary congestion – Patent Ductus Arteriosus (PDA); Atrial septal defect (ASD); Ventricular Septal defect (VSD); Coarctation of aorta; Hypoplastic left heart syndrome • Cyanotic – R to L shunt • Bld from lt to rt, blood bypasses the lungs.

– Little or no improvement in color with Oxygen – Tetralogy of Fallot; Transposition of great vessels; Hypoplastic Left Heart 60

Nursing Care of the Newborn with Congenital Heart Defect • The three most common manifestations: – Cyanosis – Heart murmur most are normal, but still should be noted.

– Congestive heart failure signs (tachycardia, tachypnea, diaphoresis, hepatomegaly, cardiomegaly) – Cardiac defects 61

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10) Newborn with Inborn Errors of Metabolism

• A hereditary disorders transmitted by mutant genes • Enzyme defect that blocks a metabolic pathway and leads to accumulation of toxic substances • Detected through “Newborn Screening”, a blood sample collected after 24hrs of feeding.

– Repeated after 2wks of life 62

Newborn with Inborn Errors of Metabolism • PKU* • Maple syrup urine disease • Homocystinuria • Galactosemia* • Hypothyroidism* • Congenital adrenal hyperplasia* • Sickle Cell Anemia* * Required by Texas Department of Health 63

Nursing Care of Newborn at Risk for Inborn Errors of Metabolism • Correct collection of mandatory newborn screening specimens • Treated w/ Dietary management and medication can prevent mental retardation • Parents will need extensive education and support.

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