Transcript Chapter 27 THE NEWBORN AT RISK: CONDITIONS PRESENT AT …

The Newborn At Risk:
Conditions Present At Birth
Mary Milam, RN, MSN, CFNP
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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
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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
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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 588596
– 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”
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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
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7:00
ALL INFANTS
Nursing care
• A,B,C’s
• Neutral Thermal Environment (NTE)
• Early detection/treatment of
hypoglycemia
• Promote comfort and bonding
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1) Newborn at risk SGA
• aka- Intrauterine Growth Restriction (IUGR)
• Figure 28- 3 – AGA and SGA twins (discordant)
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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
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Common Complications of the SGA
Newborn
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Perinatal asphyxia
Aspiration syndrome
Heat Loss
Hypoglycemia
Hypocalcemia
Polycythemia
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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
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Classification of SGA
• Symmetric
– Causes prolonged
retardation of
growth
– Weight, length, head
circumference,&
overall size is small
• Asymmetric
– Usually not evident
before 3rd trimester
– Birth wt < 10% but
head circumference
& length may be
normal. Long &
skinny
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11:15
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
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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
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14:08
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
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2) The Large-for-GestationalAge (LGA) Newborn
• A newborn whose birth weight is at or above
the 90th percentile on the intrauterine growth
curve
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16:20
Factors Contributing to diagnosis of
LGA Newborn
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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
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Common Complications of the LGA
Newborn
• Birth Trauma due to Cephalopelvic disproportion
(CPD)
• Increased C/sections and oxytocin inductions
• Hypoglycemia
• Polycythemia
• Hyperviscosity
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18:10
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
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3) Infant of a Diabetic
Mother (IDM)
• This infant is at risk for hypoglycemia!
– Macrosomic “large”
– Ruddy “reddish”
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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)
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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)
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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
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25:17
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.
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Common Complications of the Postterm Newborn
• Postmaturity Syndrome - insufficiency of the aging placenta
& continued exposure to amniotic fluid:
– 2-3X higher morbidity than term infants
– Hypoglycemia – b/c they’ve used up/depleted their
glycogen stores
– 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
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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
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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
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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 3rd trimester ,
baby misses out on immunity from mom.
• Parent-Infant attachment
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Premature care in NICU
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Ventilation- Et tube and ventilator
Hydration
Thermoregulation
Nutrition
Infection control
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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
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43:00
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
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44:40
The Preterm Newborn
• Alteration in
Thermoregulation
• Limited supply of glycogen
• Lack of brown fat
• Higher ratio of surface area
to weight
– Radiant warmer req
• Supported by incubator to
provide body warmth
• 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  Low
blood supply  Necrosis
• 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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48:00
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 )
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Patent Ductus Arteriosus (PDA)
Respiratory Distress Syndrome (RDS)
Intraventricular Hemorrhage of Brain (IVH)
Necrotizing Entercolitis of Bowel (NEC)
Hyperbilirubinemia
Hypoglycemia
Sepsis
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52:30
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
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6) Congenital Anomalies
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Hydrocephalus
Choanal Atresia
Cleft lip/Cleft palate
Tracheoesophageal Fistula- fistula between Trachea-esophag
Diaphragmatic Hernia- hole in the diaphragm
Myelomengiocele- spina bifida
Omphalocele/Gastroschisis- 1) abd contents thru umb cord,
2) opening in the abd wall
Prune Belly Syndrome- extremely large belly
Imperforate Anus- no hole
Congenital dislocated hips
Clubfoot- true club reqs surg intervention, Positional club can
be ambulated
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1:00:10
7) Newborn of a SubstanceAbusing Mother
• Drug Dependency
– Alcohol
– Tobacco
– Cocaine
– PCP
– Methamphetamines
– Inhalants
– Marijuana
– Heroin
– Methadone
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1:01:15
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
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Newborn of a Substance-Abusing
Mother
• Risks to fetus, prone to…
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Intrauterine asphyxia
Intrauterine infection
Alterations in birthweight
Lower apgar scores
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1:02:05
Newborn of
Substance- Abusing Mother
• Common Complications
– Respiratory distress (heroin may accelerate lung
maturity)
– Jaundice
– Congenital anomalies & growth retardation
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Newborn of
Substance- Abusing Mother
• Common Complications
– Behavioral abnormalities
– Withdrawal
– Long term difficulties with developmental delays
and emotional dysfunction
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Nursing Care of Newborn of
Substance-Abusing Mother
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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
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Manifestations of Neonatal
Withdrawal
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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
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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
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Newborn with
Fetal Alcohol Spectrum Disorders
(FASDs)
• Risk factors
– Maternal age > 30
– Hx of binge drinking
– Low socioeconomic status
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Physical Characteristics of Fetal
Alcohol Syndrome
• SGA
• Microcephaly
• Functional or structural CNS
abnormalities
• Craniofacial abnormalities
• Prenatal/Postnatal growth
defects
• Congenital Heart Defects
• Mental retardation
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Newborn with
FAS
Physical Characteristics
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American Family Physician, July 15, 2005, Vol 72,#2
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 stimuli and
environment to infant’s tolerance level
• Bonding - reinforce positive parenting activity & refer to
follow-up community intervention programs
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1:10:20
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
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Newborn of
Tobacco Dependant Mother
• Newborn Risks, child will…
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IUGR
Intrauterine distress- mec stain
Lower APGARS
Hyper/hypotonia
S/S of nicotine toxicity (tachycardia, irritable, poor
feeding)
– Impaired neurobehaviors
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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
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1:13:18
Newborn with
Exposure to HIV-AIDS
Signs/Symptoms
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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
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9) Newborn with
Congenital Heart Defects
• Contributing factors
• Majority of heart defects are multifactoral and
have no specific cause
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1:16:18
Newborn with Congenital Heart
Defect-Contributing Factors
• Environmental
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Infections
Drugs
Pesticides
PKU
Chromosomal abnormalities
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Newborn with Congenital Heart
Defect-Contributing Factors
• Genetic
– Some defects have increased incidence and
recurrence in families
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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
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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
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1:20:20
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
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Newborn with Inborn Errors of
Metabolism
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PKU*
Maple syrup urine disease
Homocystinuria
Galactosemia*
Hypothyroidism*
Congenital adrenal hyperplasia*
Sickle Cell Anemia*
*Required by Texas Department of Health
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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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