common neonatal disorders

COMMON NEONATAL DISORDERS

Classification of common neonatal disorders

Birth injuries Caput succedaneum Cephalhematoma Fractures Facial paralysis Erb’s/Brachial palsy

Classification of common neonatal disorders(cont…)

Disorders related to physiological factors

Hyperbilirubinemia Hemolytic disease of the newborn Respiratory distress syndrome

Classification of common neonatal disorders

Disorders related to infectious process Sepsis Necrotizing enterocolitis

Classification of common neonatal disorders(cont…)

Disorders related to maternal conditions

Infants of diabetic mothers

Injuries to head

Caput succedenum Cephalhematoma

Injuries to the head while birthS - SkinC - Close connective tissue &

cutaneous vessels & nerves.A - Aponeurosis (epicranial

aponeurosis)L - Loose connective tissue (scalping

layer)P - Periosteum of skull bones

Injuries to the head

CAPUT SUCCEDANEUM A caput succedaneum is an edema of

the scalp at the neonate’s presenting part of the head

It often appears over the vertex of the newborn’s head as a result of pressure against the mother’s cervix during labor.

The edema in caput succedaneum crosses the suture lines


CAPUT SUCCEDANEUM Causes Mechanical trauma of the initial

portion of scalp pushing through a narrowed cervix

Prolonged or difficult delivery Vacuum extraction


Cephalhematoma It is a collection of blood between the

periosteum of a skull bone and the bone itself. It occurs in one or both sides of the head

The swelling with cephalhematoma is not present at birth rather it develops within the first 24 to 48 hours after birth.

Has clear edges that end at the suture lines


Cephalhematoma Causes Rupture of a periostal capillary due

to the pressure of birth Instrumental delivery


Nursing care management It is directed toward assessment and

observation of the common scalp injuries and vigilance in observing for possible associated complications such as infection or acute blood loss and hypovolemia.

Because of the visible injuries resolves spontaneously, parents need reassurance of their usual benign nature.

Fractured clavicle

Bone most frequently fractured during delivery

Associated with CPD Signs: limited ROM, crepitus, cries of pain when arm is moved, absent Moro reflex on Affected side

Fractured clavicle

Heals quickly, handle gently, immobilize arm, eliciting scarf sign is contraindicated.

Any newborn that weighs more than 3855g and is delivered vaginally should be evaluated for a fractured clavicle.

Fractured clavicle

Nursing Management Often no intervention is needed

other than maintaining proper alignment, careful dressing and undressing of infant.

Supporting the patient from upper and lower back other than from under the arms should be practiced.

The parents should be involved in the care.

Facial paralysis:

From pressure on facial nerve during delivery

Affected side unresponsive when crying

Resolves in hours/daysNURSING MANAGEMENT-a) Feedings may be given by

gavage in order to prevent aspiration

b) Since the eye on the effected side cannot be closed completely, it is covered with an eye shield to prevent drying of the conjunctiva and cornea.

Erb’s Palsy (Erb- Duchenne Paralysis)

Associated with stretching or pulling head away from shoulder during delivery

Signs: Flaccid arm, elbow extended, hand rotated inward, Moro & grasp reflexes absent on affected side

Requires immobilization & reposition q 2 to 3 hr.


NURSING MANAGEMENT-a) The goal is to prevent contractures

in the paralyzed muscles. The arm should be partially mobilized in a position of maximum relaxation so that the non-paralyzed muscles cannot exert pull on the affected muscles.

b) By use of a splint or brace when upper arm is paralyzed, the arm is abducted 90 degrees and rotated externally at the shoulder with the elbow flexed so that the palm of the hand is turned towards the head.


When any form of immobilization is used, the fingers and the hand should be observed for coldness and discoloration and the skin for the signs of irritation.

Hemolytic disease of the newborn

Rh +ve blood – D antigen Rh -ve blood – lacks this D antigen


When Rh-positive blood is infused into an Rh-negative woman through error or when small quantities (usually more than 1 mL) of Rh-positive fetal blood containing D antigen inherited from an Rh-positive father enter the maternal circulation during pregnancy, with spontaneous or induced abortion, or at delivery, antibody formation against D antigen


“Why the fetus is affected in second delivery and not in first delivery?”


As the mixing of blood usually occurs at the time of delivery so by the time antibodies are formed the baby is already delivered.


But what if the mixing of blood occurs before the delivery? Lets say during some procedure like amniocentesis or chorionic villi sampling? Now will the fetus be at risk?

“But why fetus ain’t at risk during 1st pregnancy even if the blood is mixed before delivery?”


The answer is because of the type of antibodies formed during first and second delivery.

Prevention of hemolytic disease.

Prevention: Rhogham/Anti-RhD in un-sensitized mothers

Treatment of a mother with Anti-RhD antibodies prior to and immediately after trauma and delivery destroys Rh antigen in the mother's system from the fetus


Diagnosis: Indirect coombs test in mothers-

antigen direct coombs test in infants with Rh-

ve mothers-antibodies


Treatment: IVIG is given in infants, exchange transfusion and phototherapy.


Nursing management: 1. Early recognistion of

Jaundice 2. If an exchange

transfusion is required then the nurse prepares the infant and family and assists the physician.

3. The nurse documents the blood volume exchange.


4. Signs of blood transfusion reaction are need to be monitored.

5. Throughout the procedure infant’s thermoregulation need to be monitored.

6. After the procedure the nurse monitors the umblical cord for any kind of bleeding.

Neonate Respiratory distress syndrome/ hyaline membrane disease

RDS occurs primarily in premature infants; its incidence is inversely related to

gestational age and birth weight. It occurs in 60–80% of infants less than 28

wk of gestational age, In 15–30% of those between 32 and 36 wk, In about 5% beyond 37 wk, and rarely at term.

Neonate Respiratory distress syndrome

The condition occurs due to lack of pulmonary surfactant because of immaturity of the lungs.

Surfactant helps in reducing the surface tension of alveoli.

When surfactant active material is deficient in the alveoli, there is alveolar collapse during expiration


The pulmonary immaturity of the fetal lungs can be assessed by determination of lecithin/sphingomyelin ratio in the amniotic fluid

L/S ratio is 2 or more suggestive of adequet lung maturity, while a ratio of less than 1.5 is often associated with HMD


Clinical features This is characterized by a triad of

tachypnea, expiratory grunt and inspiratory retractions in a preterm.

These symptoms may begin at birth or within 6 hours of birth.

There is a gradual worsening of retrations, grunting and cyanosis.


Management Premature labor should be arrested

by appropriate tocolytic therapy to gain pulmonary maturity.

The induction of labor should be delayed as far as the lung maturity is confirmed by l/S ratio.

When premature labor below 34 weeks of gestation is unavoidable, the mother should be given betamethasone 12mg IM every 24hrs for two days or dexamethasone 6mg IM four doses at an interval of 12hrs.


The infant should be nursed in a thermoneutral env and administered oxygen through head box.

An IV line should be established to maintain fluid and electrolyte balance, for correction of acidosis and administration of drugs.

Intratracheal administration of surfactant should be done

SPo2 should be monitored If infant cant monitor Spo2 above 90

despite of giving oxygen via hood the infant should be put on CPAP


If CPAP is also ineffective then the infant should be put on IPPV

Acid-base parameters should be monitored

Unmonitored oxygen levels may lead to retinopathy of prematurity to oxygen toxicity.


Antibiotics are given in case of superadded infections

The management of HMD requires supportive care by trained nurses and the availability of high technology to monitor and manage the hypoxia due to ineffective ventilation.


Nursing management Effective ventilation and oxygen

therapy Equipment should be ready and in

working condition Oxygen must be warm and

humidified The condition of the infant can

change in a fraction of a second so it is vital for the nurse to monitor neonate’s color, level of activity and to note blood gas measurements.

When o2 is given, tracheal and nasopharengial suctioning and chest physical therapy is required.


Optimal environmental temperature: The nurse has a important role in providing regulation of surrounding temperature.

Adequate nutrition: proper gavage feedings at proper intervals is necessary nursing action.

Minimal handling of critically ill infants. Use of aseptic techniques. Infants should be positioned with head

elevated to decrease pressure on diaphragm.

Necrotising Enterocolitis (NEC)

This is characterized by necrosis of intestinal wall , is a serious life threatening condition that is being diagnosed with increasing frequency in premature infants.

Necrotising Enterocolitis (NEC) Factors that place the infant at risk of

this disease include: Perinatal asphyxia Low apgar score IRDS Sepsis Enteral feedings Congenital cardiac disease Relative ischemia of the intestinal tract that

is due to hypotension Use of umbilical catheters Exchange transfusion

PathophysiologyFactors

Depletion of the normal blood flow

Ischemia with a reduction in the protective mucosa.

Intestinal enzymes further destroy the mucosal layer

Bacteria increases in the presence of carbohydrate in the infants feeding and form gas

Intestines become dilated, become necrotic

Necrosis may involve the full thickness of the intestinal wall leading to ultimate perforation

Necrotising Enterocolitis (NEC

Clinical manifestations: Abdominal distention Decreased bowel sounds Poor feeding Increased gastric residuals Blood streak bile vomiting Bloody or mucoid stools


Nursing management As soon as the diagnose of NEC

is made the oral feedings are discontinued and peripheral IV fluids are given to the infant.

Palpation of abdomen, abdominal girth are checked daily

Bowel sound monitoring TPN is to be started


I/v antibiotics are started to against gram negative enteric organisms

Rectal temperature is not taken so as to prevent rectal perforation

Affected infants are to be placed in isolation


These infants are not diapered because of the increased risk of intra-abdominal pressure.

These infants are nursed on their back as much as possible to reduce the external pressure on the abdomen

Postoperatively , as the suture line is close to stoma so measures should be taken to avoid any infection to suture line.


Fecal material can be drained into urine collecting devices.

Psychological support should be given to parents.

Neonatal Sepsis

Systemic bacterial infections of newborn infants are termed as neonatal sepsis

They are the most common cause of neonatal deaths in Indianatal sepsis

This is a generic term which incorporates neonatal septicemia, pneumonia, meningitis and urinary tract infections

Neonatal SepsisNeonatal sepsis can be divided

into two typesEarly onset: this happens in first

72 hours of life This is mainly due to

organisms present in: the genital tract or in the labor room or in maternity operation

Neonatal Sepsis

Late-onset: this is caused by the organisms thriving in exter

The infection is often transmitted by the care givers.

Neonatal SepsisThe predisposing causes of LOS are

: Lack of breast feeding Superficial infections Aspiration of feeds Disruption of skin integrity with

needle pricks and use of IV fluids External env of homes or hospital.

Neonatal Sepsis

Clinical features: The manifestations of neonatal sepsis are often vague and nonspecific demanding high index of suspicion for early diagnosis.

Any altern in feeding patterns Active baby suddenly becoming

lethargic

Hypothermia in preterms and fever in term babies especially in association with gram –positive infections and meningitis.

Diarrhea, vomiting and abdominal distention

Jaundice and hepatosplenomegaly may be present

Episodes of apneic spells with cyanosis may also be one of the sign.

Neonatal Sepsis

Management: The infant should be managed in a thermo neutral env and started on intravenous antibiotics

Neonatal SepsisNursing Management: Hand washing and thorough

scrubbing with soap and water upto elbows for at least 2mons, gowning and change of shoes are mandatory.

Rings, bangles and wristwatches should be removed

Strict hand washing for 20 secs and use of antiseptic solution in between handling babies.

Neonatal Sepsis 4. Babies should be fed

early and exclusively on breast milk.

5. Careful attention should be paid to hygiene of the katori and spoon.

6. The umblical stump should be left open. Local application of spirit reduces colonization.

Neonatal Sepsis All procedures

should be done wearing mask.

Unnecessary needle pricking should be avoided.

Strict housekeeping routines for washing , disinfection, cleaning of cots/incubators should be ensured .

Infants of diabetic mothers IDM

There has been continuing improvement in the care of mothers with diabetes mellitus and their neonates, resulting in a decline in the morbidity and mortality rates

Infants of diabetic mothers IDMClinical manifestations of IDM: Large for gestational age Very plump and full faced Abundant vernix caseosa Pleothora Listlessness and lethargy Large placenta and umblical cord Possibly meconium stained

at birth

Infants of diabetic mothers IDMTherapeutic management The most common management of IDMs

is careful monitoring of serum glucose levels and observation for accompanying complications such as RDS.

Studies confirm that maintaining blood glucose level more than 50mg/dl in IDMs with hypoglycemia prevent serious neurological conditions.

Oral and IV backup may be titrated to maintain adequate blood glucose levels.

Nursing care management Early introduction of carbohydrate

feedings as appropriate Serum glucose monitoring. Because macrosomic infants are at

high risk for problems associated with difficult delivery, they are monitored for birth injuries.

There is some evidence that IDMs have an increased risk of acquiring type 2 DM during childhood or early adulthood therefore a nurse should also focus on healthy lifestyle and prevention later in life with IDMs.

References

WONG’S ESSENTIAL OF PAEDIATRIC NURSING 8TH EDITION

NELSON’S TEXTBOOK OF PEDITRICS 15TH EDITION

http://www.imedicine.com /display topic

DOROT HY R.M.MARLOW AND BARBARA A. REDDING’S TEXTBOOK OF PEDIATRIC NURSING 6TH EDITION

Www.wikipedia.org Textbook of Indian academy of

pediatrics

Any questions

common neonatal disorders

Health & Medicine