HIGH RISK NEWBORNHIGH RISK NEWBORN

Lecture 13Lecture 13

LEVELS OF NICULEVELS OF NICULevel I Basic neonatal care; minimum requirement

for a facility that provides inpatient maternity care.

Able to perform neonatal resuscitation. Evaluate healthy newborns; provide standard

care. Stabilize newborns til transfer to intensive

care

Level II AKA Special Care Nurseries Basic care to moderately ill infants; ~ 32 – 42

wks. Step down from level III NICU; infants recover

Level III Newborns <32 wks, critical illness, needing

surgical intervention. RN’s - intensive training; ~ 6-8 mos.

National studies show: 30% survival rate for 23 wk preemies. 52 % for 24 wks. 76 % for 25 wks. African American women: twice as likely to deliver early, but babies more likely to survive.

High risk newborns in NICU:High risk newborns in NICU: Use cardiac & apnea monitors; radiant warmers; Use cardiac & apnea monitors; radiant warmers;

O2 sat, VS, BP monitoring. O2 sat, VS, BP monitoring. Assessed q 1-2 hrs. or continuouslyAssessed q 1-2 hrs. or continuously ^ risk of infections: GBS, septicemia, thrush^ risk of infections: GBS, septicemia, thrush Moms encouraged to visit NICU dailyMoms encouraged to visit NICU daily Skin care to prevent breakdown.Skin care to prevent breakdown. Good hand washing - parents/staff.Good hand washing - parents/staff.

RDS – Pre-TermRDS – Pre-Term Resp.distress syndrome: aka “hyaline membrane Resp.distress syndrome: aka “hyaline membrane

disease”disease”

In preemie, insufficient surfactant in alveoli causing In preemie, insufficient surfactant in alveoli causing lungs to collapse; not enough O2. lungs to collapse; not enough O2.

Most common disorder of preemies.Most common disorder of preemies. ^ resistance causes fibrous tissue in bronchioles & ^ resistance causes fibrous tissue in bronchioles &

alveolialveoli poor O2/CO2 exchange.poor O2/CO2 exchange. Self-limiting; ~ 72-96 hrs in Self-limiting; ~ 72-96 hrs in most late preterm or full most late preterm or full

term.term. VLBW (ELBW) - RDS can persist days/weeks. D/T VLBW (ELBW) - RDS can persist days/weeks. D/T

immature lungs, non-compliance, and low surfactant immature lungs, non-compliance, and low surfactant levels.levels.

Causes of Causes of RDS - TermRDS - TermIn term infant:In term infant:

– Sepsis [GBS]Sepsis [GBS]– Persistent Pulmonary Hypertension Persistent Pulmonary Hypertension

of Newborn (PPHN) – ductus of Newborn (PPHN) – ductus arteriosus does not close.arteriosus does not close.

– Meconium aspiration r/t oligo, Meconium aspiration r/t oligo, uteroplacental insufficiency, & uteroplacental insufficiency, & fetal fetal distressdistress

– Infants of diabetic moms.Infants of diabetic moms.– May need resuscitation @ birth. May need resuscitation @ birth. In Pre-term infantIn Pre-term infant: : Immature lungs, Immature lungs,

non-compliance, & low surfactant non-compliance, & low surfactant levels.levels.

S/S of RDS (In PRETERM)S/S of RDS (In PRETERM)

• Retractions - drawing back of chest muscles with Retractions - drawing back of chest muscles with breathing. Infant works harder at lung expansion.breathing. Infant works harder at lung expansion.

• SOB and SOB and expiratory gruntingexpiratory grunting –self-induced by infant - –self-induced by infant - maintains ^ pressure in lungs by causing expiratory maintains ^ pressure in lungs by causing expiratory braking using vocal cords (glottis partially closes braking using vocal cords (glottis partially closes increasing alveolar surface tension)increasing alveolar surface tension)

• Nasal flaring; TTN [transient tachypnea = ^ 60 R/min.]Nasal flaring; TTN [transient tachypnea = ^ 60 R/min.]

Management:Management: ABG’s, O2 sats, CBC, bl.cxABG’s, O2 sats, CBC, bl.cx Skin/mouth careSkin/mouth care Suctioning (prn)Suctioning (prn) Support for familySupport for family Adequate fluids and electrolytesAdequate fluids and electrolytes Replace surfactant Replace surfactant [Curasurf man made; ET tube][Curasurf man made; ET tube] O2 therapy [Oxyhood; CPAP; ventilator] [O2 therapy [Oxyhood; CPAP; ventilator] [CPAP= cont.+ airway CPAP= cont.+ airway

pressure]pressure] helps keep small air sacs from collapsing; suction helps keep small air sacs from collapsing; suction prnprn

TermsTerms AGA - Approp. for gestational age [5.7 – 9.1]AGA - Approp. for gestational age [5.7 – 9.1]SGA - Small for gestational age. ~ < 5.7 lbs.SGA - Small for gestational age. ~ < 5.7 lbs.LGA - Large for gestational age. ~ > 9.1 lbs.LGA - Large for gestational age. ~ > 9.1 lbs.

SGASGA: weight < 10: weight < 10thth percentile compared to others percentile compared to others of of

same gestational age. [38 wk. weighs 5 lbs.]same gestational age. [38 wk. weighs 5 lbs.] Aka IUGR aka Failure to thrive. Aka IUGR aka Failure to thrive. Most common cause: placental anomaly; placenta not Most common cause: placental anomaly; placenta not

receiving sufficient nutrition from uterine arteries or receiving sufficient nutrition from uterine arteries or placenta.placenta.

Severe DM, pre-eclampsia, poor nutrition, Severe DM, pre-eclampsia, poor nutrition, smoking, cocaine. Decreases blood flow to smoking, cocaine. Decreases blood flow to placenta.placenta.

Fundal height Fundal height lowerlower than expected for gest.age. than expected for gest.age.

Bio Physical Profile: assesses placental function. Bio Physical Profile: assesses placental function. If infant not thriving in utero, will do C/S; weigh If infant not thriving in utero, will do C/S; weigh

pros/cons.pros/cons.

SGA infant: wasted look, dull hair, small liver [^^ SGA infant: wasted look, dull hair, small liver [^^ bili’s], poor skin turgor, low glucose, low temp. bili’s], poor skin turgor, low glucose, low temp.

MatureMature neuro responses, sole creases, + ear neuro responses, sole creases, + ear cartilage. cartilage.

Lab findings: ^ HCT {low plasma levels} & ^ RBC Lab findings: ^ HCT {low plasma levels} & ^ RBC

{polycythemia} Causes thicker blood making heart {polycythemia} Causes thicker blood making heart work work

harder; ^ chance of thrombosis. Prolonged harder; ^ chance of thrombosis. Prolonged acrocyanosis.acrocyanosis.

Manage: ^ fluids & freq.feedings.Manage: ^ fluids & freq.feedings.

LGA: aka macrosomic infant. > 90% percentile. LGA: aka macrosomic infant. > 90% percentile. Appears healthy; may be gestationally immature Appears healthy; may be gestationally immature {immature neuro responses & respiratory effort}. {immature neuro responses & respiratory effort}.

Assess: larger than average uterine size for Assess: larger than average uterine size for gestational agegestational age

Do sono to estimate size. Check dates.Do sono to estimate size. Check dates. C/S for CPD or shoulder dystocia. C/S for CPD or shoulder dystocia. Causes: GDM, omphalocele, transposition great Causes: GDM, omphalocele, transposition great

vessels.vessels.

AppearanceAppearance: possible fx clavicles; facial/head : possible fx clavicles; facial/head bruising, facial/neck palsy, caput, bruising, facial/neck palsy, caput,

cephalohematoma.cephalohematoma.Observe: hypoglycemia, polycythemia, irregular Observe: hypoglycemia, polycythemia, irregular HR, cyanosis [in transposition]HR, cyanosis [in transposition]

Preterm InfantPreterm Infant

90% term births [full-term] & 11% preterm [< 37 90% term births [full-term] & 11% preterm [< 37 wks] wks]

Calculated by gestational age; not weight.Calculated by gestational age; not weight. Maturity determined by physical findings: sole Maturity determined by physical findings: sole

creases, skull firmness, ear cartilage, neurologic creases, skull firmness, ear cartilage, neurologic findings & pregnancy dates.findings & pregnancy dates.

SGA & Pre-terms: 2 different causes w. diff. SGA & Pre-terms: 2 different causes w. diff. problems. problems.

Preterm: fetus has been doing well in utero but Preterm: fetus has been doing well in utero but trigger initiates labor & infant is born early. trigger initiates labor & infant is born early.

Problems: poor thermoregulation, hypoglycemia, Problems: poor thermoregulation, hypoglycemia, intracranial bleed, RDS, NEC, immature kidney intracranial bleed, RDS, NEC, immature kidney function, infection.function, infection.

80-90% of infant mortality in 180-90% of infant mortality in 1stst yr. life esp. VLBW infants yr. life esp. VLBW infants

Risk Factors of Preterm DeliveryRisk Factors of Preterm Delivery

Women of middle/upper socioeconomic: ~ 4-8% Women of middle/upper socioeconomic: ~ 4-8% Lower socioeconomic levels: ~ 10-20%Lower socioeconomic levels: ~ 10-20% Inadequate nutrition; lack of money & knowledge Inadequate nutrition; lack of money & knowledge

about good nutrition; lack of support.about good nutrition; lack of support.

American Academy of Pediatrics: “live-born infant American Academy of Pediatrics: “live-born infant weighing 2500 g. or less”.weighing 2500 g. or less”.

World Health Organization (WHO) & American World Health Organization (WHO) & American College of Obstetricians and Gynecologists (ACOG) College of Obstetricians and Gynecologists (ACOG) – both define it as infant born prior to 37 wks.– both define it as infant born prior to 37 wks.

Appearance of Preterm InfantAppearance of Preterm Infant 24-36 weeks24-36 weeks

Small, underdeveloped, head disproportionately Small, underdeveloped, head disproportionately large; skin thin & ruddy [little subcut. fat]; veins large; skin thin & ruddy [little subcut. fat]; veins noticeable; prolonged acrocyanosis. vernix noticeable; prolonged acrocyanosis. vernix depends on gest.age.depends on gest.age.

< 24 wks.vernix not formed. < 24 wks.vernix not formed. None/few sole creases. None/few sole creases. Ear cartilage immature; no quick rebound of Ear cartilage immature; no quick rebound of

pinna. pinna. Extensive lanugo. Extensive lanugo. Suck/swallow absent, weak cry < 33 wks. Ballard Suck/swallow absent, weak cry < 33 wks. Ballard

Gestational scale to estimate age.Gestational scale to estimate age. Infection – decreased maternal antibodiesInfection – decreased maternal antibodies Skin fragile; limit alcohol; rinse with water. Skin fragile; limit alcohol; rinse with water.

Adhesives cause skin tearing. Use skin barriers to Adhesives cause skin tearing. Use skin barriers to protect skin. Tegaderm tape. Handwashing a protect skin. Tegaderm tape. Handwashing a must !must !

•13 year old female

•Ex-24 week preemie

•BPD, trach/vent

•15 mos in NICU

•G-tube 3 yrs

•Decannulated at age 4

•Intensive learning support

•Eating age-typical diet

•Mild articulation errors

**Former Extreme Premature Teen**

Thermoregulation: Thermoregulation:

risk for hypothermia r/t large surface in risk for hypothermia r/t large surface in relation to body weight.relation to body weight.Limited stores of brown fat Limited stores of brown fat Decreased or absent reflex control of skin Decreased or absent reflex control of skin capillariescapillariesImmature temperature regulation in brain Immature temperature regulation in brain Kangaroo care [skin to skin contact]Kangaroo care [skin to skin contact]Assess Respiratory EffortMay need intubation to maintain respirations. < 32 wks: irregular respiratory pattern normalSurvanta in ET tube

Urinary/EliminationUrinary/Elimination

Have high insensible water loss Have high insensible water loss d/t large body surface compared d/t large body surface compared w/ total body weight. Lower GFR w/ total body weight. Lower GFR d/t immature kidneys. Fluid d/t immature kidneys. Fluid overload or dehydration.overload or dehydration.

Strict I/OStrict I/O Immature kidneys secrete Immature kidneys secrete

glucose slowly > hyperglycemia glucose slowly > hyperglycemia can result.can result.

Insensible Water LossInsensible Water Loss[Approx. water loss in body][Approx. water loss in body]

Age group Water Age group Water Premature infant 90%Premature infant 90% Newborn infant 70-80%Newborn infant 70-80% 12-24 months 64%12-24 months 64% Adult 60%Adult 60%

Nutrition: promote normal growth & Nutrition: promote normal growth & developmentdevelopment

Tries to maintain rapid rate of intrauterine Tries to maintain rapid rate of intrauterine growth. growth.

Lack of cough reflex: can aspirate formula. Lack of cough reflex: can aspirate formula. Have weak sucking, swallowing, gag reflexesHave weak sucking, swallowing, gag reflexes Weak abdominal muscles; weak gag reflexWeak abdominal muscles; weak gag reflex ^ aspiration risk^ aspiration risk ^ BMR - High caloric needs but small ^ BMR - High caloric needs but small

stomach capacitystomach capacity Limited store of nutrientsLimited store of nutrients Decreased ability to digest proteins and Decreased ability to digest proteins and

absorb nutrients, and immature enzyme absorb nutrients, and immature enzyme systems.systems.

TPN, PPN, Gavage, or IV feedingsTPN, PPN, Gavage, or IV feedings

FeedingFeeding Caloric requirement: PT: 95-130 kcal./kg/day. Caloric requirement: PT: 95-130 kcal./kg/day. Term infant: 100-110. Term infant: 100-110. Smaller stomach capacity: sm.,freq. feedings Smaller stomach capacity: sm.,freq. feedings

[q 2-3 hrs]. [q 2-3 hrs]. Formula: Calories for premie: 24 cal./oz. Formula: Calories for premie: 24 cal./oz.

Term: 20 cal/oz. Term: 20 cal/oz. Breast milk good d/t immunologic properties.Breast milk good d/t immunologic properties. Gavage: nasogastric/orogastric. Gag reflex Gavage: nasogastric/orogastric. Gag reflex

not intact til infant 32 wks; avoid over filling not intact til infant 32 wks; avoid over filling stomach; may cause respiratory distress. stomach; may cause respiratory distress. Use Use premie nipple.premie nipple.

Developmentally Supportive Developmentally Supportive Activities Activities ** (new)** (new)

Kangaroo Care/Skin to Skin CareKangaroo Care/Skin to Skin Care

Non Nutritive Sucking Non Nutritive Sucking (Significantly (Significantly reduced length of hospital stay for reduced length of hospital stay for preterm infant)preterm infant)

Non Nutritive at the Breast Non Nutritive at the Breast (pacifer)(pacifer)

Parent Education & SupportParent Education & Support

Non-Nutritive Sucking Non-Nutritive Sucking at Breast at Breast **** Improved milk productionImproved milk production Provides sucking experienceProvides sucking experience Prepares infant for breastfeedingPrepares infant for breastfeeding Long term effects:Long term effects:

– Increased length of exclusive Increased length of exclusive breastfeedingbreastfeeding

– Increased length of total breastfeedingIncreased length of total breastfeeding

POTENTIAL COMPLICTATIONS of PT POTENTIAL COMPLICTATIONS of PT InfantInfant

Anemia of PrematurityAnemia of Prematurity: red blood cell life is short. : red blood cell life is short. Low bone marrow prod. until ~ 32 wks. Frequent Low bone marrow prod. until ~ 32 wks. Frequent blood testing.blood testing.

KernicterusKernicterus: destruction of brain cells by invasion of : destruction of brain cells by invasion of

indirect bilirubin [bili ~20]. PT infants: low serum indirect bilirubin [bili ~20]. PT infants: low serum

albumin available to bind indirect bili & excrete it.albumin available to bind indirect bili & excrete it.

Persistent Patent Ductus ArteriosuPersistent Patent Ductus Arteriosus: d/t hypoxia, lack s: d/t hypoxia, lack of of

surfactant, lack of musculature. Lungs are surfactant, lack of musculature. Lungs are noncompliant. noncompliant.

^ blood stays in pulmonary artery > pulmonary ^ blood stays in pulmonary artery > pulmonary artery HTN >persistent PDA. Indocin stimulates artery HTN >persistent PDA. Indocin stimulates PDA closure.PDA closure.

Bronchopulmonary Dysplasia. (Chronic Lung Bronchopulmonary Dysplasia. (Chronic Lung Disease)Disease)

Results from long term O2 & being vented (PPV).Results from long term O2 & being vented (PPV).Lungs immature; resp.infection, poor nutrition, Lungs immature; resp.infection, poor nutrition, Pressure damages & stretches lung tissue; results in Pressure damages & stretches lung tissue; results in

airway airway edema & fibrotic buildup. Alveolar walls thicken; buildup edema & fibrotic buildup. Alveolar walls thicken; buildup

of of secretions; pneumonia & atelectasis possible. Decreased secretions; pneumonia & atelectasis possible. Decreased oxygenation results. oxygenation results. • S/SS/S: tachypnea, tachycardia, hypoxia, grunting, : tachypnea, tachycardia, hypoxia, grunting,

retractions, feeding & activity intolerance.retractions, feeding & activity intolerance.• TX:TX: prevent further disease; promote oxygenation, prevent further disease; promote oxygenation,

promote lung healing. promote lung healing. • O2, nutrition, steriods, bronchodilators, diuretics, O2, nutrition, steriods, bronchodilators, diuretics,

antibiotic tx; stop PPV; maintain venting @ antibiotic tx; stop PPV; maintain venting @ lowest lowest pressure. pressure.

• Nitric oxide; Nitric oxide; Vitamin AVitamin A

Neonatal SepsisNeonatal Sepsis

Premies more susceptible; immature immune Premies more susceptible; immature immune sys.sys.

Transmission: viral, bacterial; transplacental Transmission: viral, bacterial; transplacental (syphilis, toxoplasmosis)(syphilis, toxoplasmosis)

S/S: low temps, resp. distress, hypotension, S/S: low temps, resp. distress, hypotension, ^HR, ^RR, lethargy, poor feeding, diarrhea, ^HR, ^RR, lethargy, poor feeding, diarrhea, vomiting.vomiting.

Mortality: 5-20%Mortality: 5-20% CBC with diff (^bands, decreased CBC with diff (^bands, decreased

neutrophils, decreased platelets), blood cx, neutrophils, decreased platelets), blood cx, TX: broad spectrum antibiotics; VS, nutrition, TX: broad spectrum antibiotics; VS, nutrition,

fluids, O2. Parental support.fluids, O2. Parental support.

ROPROP: : Retinopathy of Pre-maturityRetinopathy of Pre-maturity. . Caused by damage to immature blood vessels Caused by damage to immature blood vessels

in in retina. Results in scarring. Caused by high O2 retina. Results in scarring. Caused by high O2

levels. levels. Blindness may result. 90% of cases no Blindness may result. 90% of cases no

impairment. impairment. Occurs in VLBW <1500 g.Occurs in VLBW <1500 g.

TX: TX: reattachment of retina; Frequent eye reattachment of retina; Frequent eye evals. Laser to reduce scarringevals. Laser to reduce scarring. .

Nursing CareNursing Care: routine high risk premie care; : routine high risk premie care; sepsis; VS; support groups & educationsepsis; VS; support groups & education

Intracranial HemorrhageIntracranial Hemorrhage aka IVPaka IVP germinal matrix – made up of fragile & germinal matrix – made up of fragile &

vascular capillaries. vascular capillaries. Grades 1-4 (3 & 4 worse)Grades 1-4 (3 & 4 worse) Bleeding into ventricles d/t hypoxia, ^ BP, ^ Bleeding into ventricles d/t hypoxia, ^ BP, ^

fluids.fluids. Dx with Cranial ultrasoundDx with Cranial ultrasound Normal brain function assessed > bleed.Normal brain function assessed > bleed.

IVH occurs in 20-25% of VLBW premies; IVH occurs in 20-25% of VLBW premies; suffer more severe grades of IVHsuffer more severe grades of IVH

IVH is an important predictor of adverse IVH is an important predictor of adverse neurodevelopmental outcomeneurodevelopmental outcome

½-3/4 of infants with Grade 3-4 IVH develop ½-3/4 of infants with Grade 3-4 IVH develop CP & 75% in some type of special educationCP & 75% in some type of special education

NECNECNEC:NEC: necrotizing enterocolitis; common in PT necrotizing enterocolitis; common in PT

baby;baby;can result in ulcers/tissue necrosis in intestinal can result in ulcers/tissue necrosis in intestinal

wall.wall.Bacteria in bowel>infection>destroys bowel Bacteria in bowel>infection>destroys bowel

tissue> tissue> sepsis.sepsis.Primary risk factor: prematurity & tube Primary risk factor: prematurity & tube

feedings; feedings; RDS, congenital heart defects. RDS, congenital heart defects. S/S abd. swelling, septic infant, emesis, blood S/S abd. swelling, septic infant, emesis, blood

in stool.in stool.Tx: stop tube feedings, start IVF & TPN, AB Tx: stop tube feedings, start IVF & TPN, AB

[sepsis], [sepsis], ventilator, platelet transfusion [control ventilator, platelet transfusion [control

bleeding]bleeding] Prevention: Prevention: Delayed /Slow feedings: advance Delayed /Slow feedings: advance

< 20 ml/kg/day; Enteral Antibiotics; < 20 ml/kg/day; Enteral Antibiotics; Antenatal Steroids; enteral IgG, IgA; Human Antenatal Steroids; enteral IgG, IgA; Human Milk Feedings.Milk Feedings.

GDMGDM

Infants [GDM moms] macrosomic if not well Infants [GDM moms] macrosomic if not well controlled during pregnancy; lethargic d/t ^ controlled during pregnancy; lethargic d/t ^

glucose.glucose. Macrosomia: overstimulation of pituitary Macrosomia: overstimulation of pituitary

growth growth hormone in fetus in preg. d/t ^ maternal hormone in fetus in preg. d/t ^ maternal

insulin. insulin. Mom “insulin resistant”; glucose x placenta; Mom “insulin resistant”; glucose x placenta;

more insulin made by fetal pancreas.more insulin made by fetal pancreas. After delivery, glucose levels drop, but insulin After delivery, glucose levels drop, but insulin

remain ^ for several hours. remain ^ for several hours. Infant “jittery” on admission. Glucose checked Infant “jittery” on admission. Glucose checked

for 1st for 1st 4 hrs; Hypoglycemia = < 40 mg/100 ml whole 4 hrs; Hypoglycemia = < 40 mg/100 ml whole

blood.blood.

GDMGDM

Complications: Complications: Immature lungs d/t ^ fetal insulin which Immature lungs d/t ^ fetal insulin which

interferes interferes with cortisol release; blocks formation of with cortisol release; blocks formation of

lecithin & lecithin & prevents lung maturity. ^ chance of birth injury prevents lung maturity. ^ chance of birth injury d/t ^ size; shoulder dystocia.d/t ^ size; shoulder dystocia.

Hypoglycemia: Hypoglycemia: Check glucose on admission to NBN: 1, 1½, 2, 4 Check glucose on admission to NBN: 1, 1½, 2, 4 hrs. of life. If < 40; stat serum glucose & feed hrs. of life. If < 40; stat serum glucose & feed formula [1/2 oz.] Repeat in ½ - 1 hr. as formula [1/2 oz.] Repeat in ½ - 1 hr. as

protocol.protocol.

Transient Tachypnea of Newborn: “TTN”Transient Tachypnea of Newborn: “TTN” Rapid, shallow RR 70-80/min. d/t slow absorption Rapid, shallow RR 70-80/min. d/t slow absorption

of lung fluid. of lung fluid. Difficulty feeding; infant will not suck d/t rapid Difficulty feeding; infant will not suck d/t rapid

breathing. breathing. Chest x-ray shows fluid in lungs. Chest x-ray shows fluid in lungs. Infant must ^ resp.depth to aerate effectively. Infant must ^ resp.depth to aerate effectively. Can signify obstruction. VS, O2 sat; give O2. Can signify obstruction. VS, O2 sat; give O2. Send to NICU for close observation if not Send to NICU for close observation if not

resolved within 4-6 hrs.of life. resolved within 4-6 hrs.of life. Occurs more w. term C/S & preterm infants.Occurs more w. term C/S & preterm infants.

Meconium Aspiration SyndromeMeconium Aspiration Syndrome: :

Present in fetal bowel as early as 10 wks. Present in fetal bowel as early as 10 wks. Infant may aspirate meconium in utero or Infant may aspirate meconium in utero or with 1with 1stst breath. breath.

Can cause severe respiratory distress, Can cause severe respiratory distress, inflammation or blockage of small inflammation or blockage of small bronchioles by mechanical plugging bronchioles by mechanical plugging

Ductus arteriosus may remain open; Ductus arteriosus may remain open; causes blood to shunt from pulmonary causes blood to shunt from pulmonary artery to aorta instead of passing thru artery to aorta instead of passing thru lungs [^ pulmonary resistance], causing ^ lungs [^ pulmonary resistance], causing ^ hypoxia. hypoxia.

SymptomsSymptomsTachypnea [RR>60]Tachypnea [RR>60]Retractions Retractions SOB and SOB and expiratory gruntingexpiratory grunting Nasal flaringNasal flaringPeriods of apneaPeriods of apneaBluish color of skin and mucus membranesBluish color of skin and mucus membranesArms or legs puffy or swollenArms or legs puffy or swollen

PreventionOropharyngeal suctioning of infant > deliveryLaryngoscopic visualizaiton of vocal cords > intubation.Additional suctioning of trachea.Amnioinfusion: dilutes meconium. Thins out particulate meconium. Do sepsis workup; CBC, bl.cx., chest x-ray. AB therapy to prevent pneumonia.

SIDS: sudden infant death syndrome.SIDS: sudden infant death syndrome. Mainly in adolescent moms, closely spaced Mainly in adolescent moms, closely spaced

pregnancies, underweight, PT infants. 2pregnancies, underweight, PT infants. 2ndnd hand hand smoke.smoke.

Appear well nourished. ^ African American Appear well nourished. ^ African American males.males.

Silent death; poss.laryngospasm.Silent death; poss.laryngospasm. Use of sleep apnea monitor for first few wks.-mos. Use of sleep apnea monitor for first few wks.-mos.

Peak age: 2-4 mos. Cause unknown. Peak age: 2-4 mos. Cause unknown. Theories: HR abnormalities, decreased arousal Theories: HR abnormalities, decreased arousal

[moro][moro]responses, prone position, low surfactant, brain responses, prone position, low surfactant, brain

stem stem abnorm. abnorm. In 2000 Amer. Academy of Pediatrics In 2000 Amer. Academy of Pediatrics

recommended recommended back or side position; not prone. Incidence declined back or side position; not prone. Incidence declined

50%50%since then. New data: use of pacifier for 2-4 mos.since then. New data: use of pacifier for 2-4 mos.

HyperbilirubinemiaHyperbilirubinemia ^ levels of unconjugated (indirect) bilirubin in blood. ^ levels of unconjugated (indirect) bilirubin in blood.

Breakdown of RBC’s > Hgb > heme > Unconjugated Breakdown of RBC’s > Hgb > heme > Unconjugated bilirubin. bilirubin.

Bilirubin binds with plasma protein (albumin) = Bilirubin binds with plasma protein (albumin) = “bound” goes to liver & converts to conjugated or H2O “bound” goes to liver & converts to conjugated or H2O soluble where it ‘s excreted via bile by feces. soluble where it ‘s excreted via bile by feces.

Immature livers which cannot convert indirect to Immature livers which cannot convert indirect to direct; indirect bilirubin remains in bloodstream. direct; indirect bilirubin remains in bloodstream.

Unbound bilirubin = (indirect) jaundice.Unbound bilirubin = (indirect) jaundice.

If indirect level rises > 7, yellow color results.If indirect level rises > 7, yellow color results. Sclera, nail beds, then skin. Sclera, nail beds, then skin. Cephalocaudal progression: head to toe. Cephalocaudal progression: head to toe. Blanch skin Blanch skin

Depends on hours/days of life. Depends on hours/days of life. Younger infant (4-5 hrs.) high reading more Younger infant (4-5 hrs.) high reading more

significant; could rise steadily . significant; could rise steadily . Older infant (1-2 days), higher # less significant (more Older infant (1-2 days), higher # less significant (more

mature liver).mature liver).

Pathologic Pathologic [within 24 hrs.] [within 24 hrs.] Bili rises quickly. By 5-7 mg/dl/day or more.Bili rises quickly. By 5-7 mg/dl/day or more. Blood type incompatibilities ; sepsis; birth Blood type incompatibilities ; sepsis; birth

trauma.trauma. Interventions: Early & frequent feedings to Interventions: Early & frequent feedings to

speed up excretion in stool. speed up excretion in stool. Phototherapy - bilirubin becomes water Phototherapy - bilirubin becomes water

soluble to be excreted. soluble to be excreted. Cover genitalia & eyes. Prevent organ Cover genitalia & eyes. Prevent organ

damage. Single, double, triple phototherapy. damage. Single, double, triple phototherapy. Kernicterus: Indirect bilirubin of 20 > Kernicterus: Indirect bilirubin of 20 >

permanent brain damage; bilirubin permanent brain damage; bilirubin encephalophathy. encephalophathy.

Signs: hi-pitched cry, seizures, hypotonia Signs: hi-pitched cry, seizures, hypotonia Interventions: Immediate exchange Interventions: Immediate exchange

transfusion; followed by phototherapy & transfusion; followed by phototherapy & frequent bili levels.frequent bili levels.

Physiologic JaundicePhysiologic Jaundice: [> 24 hrs.] 2nd-3rd day. : [> 24 hrs.] 2nd-3rd day. R/T low albumin (decreased binding sites for R/T low albumin (decreased binding sites for

bilirubin). ^ levels of RBC’s. Yellowing of skin bilirubin). ^ levels of RBC’s. Yellowing of skin caused by breakdown of fetal red blood cells caused by breakdown of fetal red blood cells which produces excessive amts. of bilirubin which produces excessive amts. of bilirubin in blood stream. Excess bilirubin in blood in blood stream. Excess bilirubin in blood causes jaundice.causes jaundice.

Management: frequent feedings, frequent bili Management: frequent feedings, frequent bili levels. Bili declines within days.levels. Bili declines within days.

Teach parents to place near window to speed Teach parents to place near window to speed up breakdown of bili. Sunlight will ^ up breakdown of bili. Sunlight will ^ breakdown.breakdown.

Gastroschisis:Gastroschisis: weakness in abdominal weakness in abdominal wall wall

causing herniation of gut on umbilical causing herniation of gut on umbilical cord cord

during early development; most during early development; most commonly on commonly on

right side. Viscera lie outside abdominal right side. Viscera lie outside abdominal cavity; cavity;

not covered with sac. not covered with sac.

1 in 4,000 live births1 in 4,000 live births Mortality: 10%-15%Mortality: 10%-15% Assoc.w.prematurity; malrotation of Assoc.w.prematurity; malrotation of

intestines; decreased abdominal intestines; decreased abdominal capacity; other anomalies rare.capacity; other anomalies rare.

TX: IV & NG tubes immediately; TPN; TX: IV & NG tubes immediately; TPN; Silastic (synthetic covering) over Silastic (synthetic covering) over viscera; surgical closure after contents viscera; surgical closure after contents returned to abd.cavity. If necrotic bowel returned to abd.cavity. If necrotic bowel present, remove.present, remove.

Nursing CareNursing Care: : thermoregulation (monitor temps, radiant thermoregulation (monitor temps, radiant

warmer); sterile technique (cover viscera - warmer); sterile technique (cover viscera - warm, sterile, saline gauze & plastic); warm, sterile, saline gauze & plastic); monitor VS, color, etc.) strict I&O, daily monitor VS, color, etc.) strict I&O, daily weights, fontanels, pacifier, electrolytes. weights, fontanels, pacifier, electrolytes. Minimize movement of area.Minimize movement of area.

encourage bonding asap; developmental encourage bonding asap; developmental stimulation for long term hosp; support group stimulation for long term hosp; support group for parents; teach parents s/s bowel for parents; teach parents s/s bowel obstruction- ie. vomiting, pain, firm obstruction- ie. vomiting, pain, firm abdomen, anorexia, irritability.abdomen, anorexia, irritability.

OmphaloceleOmphalocele:: large herniation of gut large herniation of gut into umbilical cord. Viscera outside of into umbilical cord. Viscera outside of abd.cavity & covered with peritoneal & abd.cavity & covered with peritoneal & amniotic membranesamniotic membranes

1 in 5,000 to 10,000 live births1 in 5,000 to 10,000 live births Assoc.w.malrotation of intestines; Assoc.w.malrotation of intestines;

decreased abdominal capacity. decreased abdominal capacity. Stenosis common; cardiac, Stenosis common; cardiac, genitourinary, or chromosomal genitourinary, or chromosomal anomalies common (1/3 to ½ of cases)anomalies common (1/3 to ½ of cases)

Mortality: 20-30%; sepsis & intestinal Mortality: 20-30%; sepsis & intestinal obstruction.obstruction.

TX: same as for gastroschisisTX: same as for gastroschisis Nursing CareNursing Care: : Same as for Same as for

gastroschisis.gastroschisis.

Bladder ExstrophyBladder Exstrophy:: extrusion of extrusion of urinary bladder to the outside of body urinary bladder to the outside of body through developmental defect in lower through developmental defect in lower abdominal wall. Assoc.w.genital abdominal wall. Assoc.w.genital anomalies: wide symphysis pubis.anomalies: wide symphysis pubis.

Rare & congenital anomaly; bladder is Rare & congenital anomaly; bladder is “turned inside out”“turned inside out”

TX: TX: protect exposed bladder tissue; protect exposed bladder tissue; cover with saline gauze/plastic wrap til cover with saline gauze/plastic wrap til sugery. Prevent UTI. Reconstruction of sugery. Prevent UTI. Reconstruction of bladder & genitalia. Provide support & bladder & genitalia. Provide support & educationeducation

EA (esophageal atresia) TEF (tracheo-EA (esophageal atresia) TEF (tracheo-esophageal fistula) esophageal fistula)

Cause unknown.Cause unknown. Congenital malformations – esophagus ends Congenital malformations – esophagus ends

before reaching stomach. (TEF) fistula may before reaching stomach. (TEF) fistula may connect to trachea.connect to trachea.

1 in 2,000 - 4,500 live births. 30-50% have 1 in 2,000 - 4,500 live births. 30-50% have other anomalies (cardiac, GI, nervous sys). other anomalies (cardiac, GI, nervous sys).

Premature or LBW commonPremature or LBW common EA without TEF : Inability to pass suction or EA without TEF : Inability to pass suction or

NG tube catheter @ delivery. Confirm with NG tube catheter @ delivery. Confirm with abd.x-ray; Excessive oral secretions; abd.x-ray; Excessive oral secretions; vomiting; risk of aspiration; Abdominal vomiting; risk of aspiration; Abdominal distention; Airless/sunken abdomen.distention; Airless/sunken abdomen.

Hx maternal polyhydramniosHx maternal polyhydramnios TEF without EA: food enters trachea; choking; TEF without EA: food enters trachea; choking;

cyanosis.cyanosis.

StatisticsStatistics

Esophageal atresia with distal TEF 87%Esophageal atresia with distal TEF 87%Isolated esophageal atresia without Isolated esophageal atresia without TEF 8%TEF 8%Isolated TEF 4%Isolated TEF 4%Esophageal atresia with proximal TEF Esophageal atresia with proximal TEF 1%1%Esophageal atresia with proximal and Esophageal atresia with proximal and distal TEF 1%distal TEF 1%

Management: Management: infant supineinfant supine w. HOB to w. HOB to decrease secretions. NG tube for frequent decrease secretions. NG tube for frequent suctioning to prevent aspiration of gastric suctioning to prevent aspiration of gastric secretions; IVF; assess VS, resp.distress, secretions; IVF; assess VS, resp.distress, measure abd.girth; provide education & measure abd.girth; provide education & support to family. support to family.

Surgical repair: fistula ligation & end to end Surgical repair: fistula ligation & end to end anastomosis of atresia.anastomosis of atresia.

Provide post op care. IVF, G-tube & foley care; Provide post op care. IVF, G-tube & foley care; pain; VS, I&O, skin care.pain; VS, I&O, skin care.