Advanced Care of HIGH RISK NEWBORN in LMICs .ppt

Advanced Care of HIGH RISK NEWBORN in LMICs .ppt

1. HIGH RISK NEWBORNHIGH RISK NEWBORN

2. LEVELS OF NICULEVELS OF NICU
Level 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.

3. 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; O2 Use cardiac & apnea monitors; radiant warmers; O2
sat, VS, BP monitoring. 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.

4. 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.

5. Causes of Causes of RDS - TermRDS - Term
In term infant:In term infant:
–Sepsis [GBS]Sepsis [GBS]
–Persistent Pulmonary Hypertension of Persistent Pulmonary Hypertension of
Newborn (PPHN) – ductus arteriosus Newborn (PPHN) – ductus arteriosus
does not close.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.

6. S/S of RDS (In PRETERM)S/S of RDS (In PRETERM)
•Retractions - drawing back of chest muscles with breathing. Retractions - drawing back of chest muscles with breathing.
Infant works harder at lung expansion.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 braking maintains ^ pressure in lungs by causing expiratory braking
using vocal cords (glottis partially closes increasing alveolar using vocal cords (glottis partially closes increasing alveolar
surface tension)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 prn helps keep small air sacs from collapsing; suction prn

7. 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.

8. SGASGA: weight < 10: weight < 10
thth
percentile compared to others of percentile compared to others 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 receiving Most common cause: placental anomaly; placenta not receiving
sufficient nutrition from uterine arteries or placenta.sufficient nutrition from uterine arteries or placenta.
Severe DM, pre-eclampsia, poor nutrition, smoking, Severe DM, pre-eclampsia, poor nutrition, smoking,
cocaine. Decreases blood flow to placenta.cocaine. Decreases blood flow to 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.

9. SGA infant: wasted look, dull hair, small liver [^^ bili’s], SGA infant: wasted look, dull hair, small liver [^^ bili’s],
poor skin turgor, low glucose, low temp. poor skin turgor, low glucose, low temp.
MatureMature neuro responses, sole creases, + ear cartilage. neuro responses, sole creases, + ear cartilage.
Lab findings: ^ HCT {low plasma levels} & ^ RBC Lab findings: ^ HCT {low plasma levels} & ^ RBC
{polycythemia} Causes thicker blood making heart work {polycythemia} Causes thicker blood making heart work
harder; ^ chance of thrombosis. Prolonged harder; ^ chance of thrombosis. Prolonged
acrocyanosis.acrocyanosis.
Manage: ^ fluids & freq.feedings.Manage: ^ fluids & freq.feedings.

10. 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 gestational Assess: larger than average uterine size for gestational
ageage
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 vessels.Causes: GDM, omphalocele, transposition great vessels.
AppearanceAppearance: possible fx clavicles; facial/head : possible fx clavicles; facial/head
bruising, facial/neck palsy, caput, cephalohematoma.bruising, facial/neck palsy, caput, cephalohematoma.
Observe: hypoglycemia, polycythemia, irregular Observe: hypoglycemia, polycythemia, irregular
HR, cyanosis [in transposition]HR, cyanosis [in transposition]

11. Preterm InfantPreterm Infant
90% term births [full-term] & 11% preterm [< 37 wks] 90% term births [full-term] & 11% preterm [< 37 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. problems. SGA & Pre-terms: 2 different causes w. diff. 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 1
stst
yr. life esp. VLBW infants yr. life esp. VLBW infants

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

13. 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 depends noticeable; prolonged acrocyanosis. vernix depends
on gest.age.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 pinna. Ear cartilage immature; no quick rebound of 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. Adhesives Skin fragile; limit alcohol; rinse with water. Adhesives
cause skin tearing. Use skin barriers to protect skin. cause skin tearing. Use skin barriers to protect skin.
Tegaderm tape. Handwashing a must !Tegaderm tape. Handwashing a must !

14. •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**

15. Thermoregulation: Thermoregulation:
risk for hypothermia r/t large surface in relation risk for hypothermia r/t large surface in relation
to body weight.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
capillariescapillaries
Immature temperature regulation in brain Immature temperature regulation in brain
Kangaroo care [skin to skin contact]Kangaroo care [skin to skin contact]
Assess Respiratory Effort
May need intubation to maintain respirations.
 < 32 wks: irregular respiratory pattern normal
Survanta in ET tube

16. Urinary/EliminationUrinary/Elimination
Have high insensible water loss d/t Have high insensible water loss d/t
large body surface compared w/ large body surface compared w/
total body weight. Lower GFR d/t total body weight. Lower GFR d/t
immature kidneys. Fluid overload or immature kidneys. Fluid overload or
dehydration.dehydration.
 Strict I/OStrict I/O
 Immature kidneys secrete glucose Immature kidneys secrete glucose
slowly > hyperglycemia can result.slowly > hyperglycemia can result.

17. 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%

18. Nutrition: promote normal growth & developmentNutrition: promote normal growth & development
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 stomach ^ BMR - High caloric needs but small stomach
capacitycapacity
Limited store of nutrientsLimited store of nutrients
Decreased ability to digest proteins and absorb Decreased ability to digest proteins and absorb
nutrients, and immature enzyme systems.nutrients, and immature enzyme systems.
TPN, PPN, Gavage, or IV feedingsTPN, PPN, Gavage, or IV feedings

19. 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 [q Smaller stomach capacity: sm.,freq. feedings [q
2-3 hrs]. 2-3 hrs].
Formula: Calories for premie: 24 cal./oz. Term: Formula: Calories for premie: 24 cal./oz. Term:
20 cal/oz. 20 cal/oz.
Breast milk good d/t immunologic properties.Breast milk good d/t immunologic properties.
Gavage: nasogastric/orogastric. Gag reflex not Gavage: nasogastric/orogastric. Gag reflex not
intact til infant 32 wks; avoid over filling intact til infant 32 wks; avoid over filling
stomach; may cause respiratory distress. stomach; may cause respiratory distress. Use Use
premie nipple.premie nipple.

20. 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

21. Non-Nutritive Sucking at Non-Nutritive Sucking at
Breast 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 breastfeedingIncreased length of exclusive breastfeeding
–Increased length of total breastfeedingIncreased length of total breastfeeding

22. POTENTIAL COMPLICTATIONS of PT InfantPOTENTIAL COMPLICTATIONS of PT Infant
Anemia of PrematurityAnemia of Prematurity: red blood cell life is short. Low : red blood cell life is short. Low
bone marrow prod. until ~ 32 wks. Frequent blood bone marrow prod. until ~ 32 wks. Frequent blood
testing.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 of s: d/t hypoxia, lack of
surfactant, lack of musculature. Lungs are noncompliant. surfactant, lack of musculature. Lungs are noncompliant.
^ blood stays in pulmonary artery > pulmonary artery ^ blood stays in pulmonary artery > pulmonary artery
HTN >persistent PDA. Indocin stimulates PDA closure.HTN >persistent PDA. Indocin stimulates PDA closure.

23. 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 airway Pressure damages & stretches lung tissue; results in airway
edema & fibrotic buildup. Alveolar walls thicken; buildup of edema & fibrotic buildup. Alveolar walls thicken; buildup 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

24. 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, ^HR, S/S: low temps, resp. distress, hypotension, ^HR,
^RR, lethargy, poor feeding, diarrhea, vomiting.^RR, lethargy, poor feeding, diarrhea, vomiting.
Mortality: 5-20%Mortality: 5-20%
CBC with diff (^bands, decreased neutrophils, CBC with diff (^bands, decreased neutrophils,
decreased platelets), blood cx, decreased platelets), blood cx,
TX: broad spectrum antibiotics; VS, nutrition, TX: broad spectrum antibiotics; VS, nutrition,
fluids, O2. Parental support.fluids, O2. Parental support.

25. ROPROP: : Retinopathy of Pre-maturityRetinopathy of Pre-maturity. .
Caused by damage to immature blood vessels in Caused by damage to immature blood vessels 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 impairment. Blindness may result. 90% of cases no impairment.
Occurs in VLBW <1500 g.Occurs in VLBW <1500 g.
TX: TX: reattachment of retina; Frequent eye evals. reattachment of retina; Frequent eye evals.
Laser to reduce scarringLaser 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

26. Intracranial HemorrhageIntracranial Hemorrhage aka IVPaka IVP
germinal matrix – made up of fragile & vascular germinal matrix – made up of fragile & vascular
capillaries. 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; suffer IVH occurs in 20-25% of VLBW premies; suffer
more severe grades of IVHmore 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 CP & ½-3/4 of infants with Grade 3-4 IVH develop CP &
75% in some type of special education75% in some type of special education

27. NECNEC
NEC:NEC: necrotizing enterocolitis; common in PT baby; necrotizing enterocolitis; common in PT 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 tissue> Bacteria in bowel>infection>destroys bowel tissue>
sepsis.sepsis.
Primary risk factor: prematurity & tube feedings; Primary risk factor: prematurity & tube feedings;
RDS, congenital heart defects. RDS, congenital heart defects.
S/S abd. swelling, septic infant, emesis, blood in S/S abd. swelling, septic infant, emesis, blood in
stool.stool.
Tx: stop tube feedings, start IVF & TPN, AB [sepsis], Tx: stop tube feedings, start IVF & TPN, AB [sepsis],
ventilator, platelet transfusion [control bleeding]ventilator, platelet transfusion [control bleeding]
Prevention: Prevention: Delayed /Slow feedings: advance < Delayed /Slow feedings: advance <
20 ml/kg/day; Enteral Antibiotics; Antenatal 20 ml/kg/day; Enteral Antibiotics; Antenatal
Steroids; enteral IgG, IgA; Human Milk Feedings.Steroids; enteral IgG, IgA; Human Milk Feedings.

28. 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 growth Macrosomia: overstimulation of pituitary growth
hormone in fetus in preg. d/t ^ maternal insulin. hormone in fetus in preg. d/t ^ maternal 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 for Infant “jittery” on admission. Glucose checked for
1st 1st
4 hrs; Hypoglycemia = < 40 mg/100 ml whole 4 hrs; Hypoglycemia = < 40 mg/100 ml whole
blood.blood.

29. GDMGDM
Complications: Complications:
Immature lungs d/t ^ fetal insulin which interferes Immature lungs d/t ^ fetal insulin which interferes
with cortisol release; blocks formation of lecithin & with cortisol release; blocks formation of 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 protocol.formula [1/2 oz.] Repeat in ½ - 1 hr. as protocol.

30. Transient Tachypnea of Newborn: “TTN”Transient Tachypnea of Newborn: “TTN”
Rapid, shallow RR 70-80/min. d/t slow absorption of Rapid, shallow RR 70-80/min. d/t slow absorption of
lung fluid. 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 resolved Send to NICU for close observation if not resolved
within 4-6 hrs.of life. within 4-6 hrs.of life.
Occurs more w. term C/S & preterm infants.Occurs more w. term C/S & preterm infants.

31. 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 1
stst
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; causes Ductus arteriosus may remain open; causes
blood to shunt from pulmonary artery to blood to shunt from pulmonary artery to
aorta instead of passing thru lungs [^ aorta instead of passing thru lungs [^
pulmonary resistance], causing ^ hypoxia. pulmonary resistance], causing ^ hypoxia.

32. SymptomsSymptoms
Tachypnea [RR>60]Tachypnea [RR>60]
Retractions Retractions
SOB and SOB and expiratory gruntingexpiratory grunting
Nasal flaringNasal flaring
Periods of apneaPeriods of apnea
Bluish color of skin and mucus membranesBluish color of skin and mucus membranes
Arms or legs puffy or swollenArms or legs puffy or swollen
Prevention
Oropharyngeal suctioning of infant > delivery
Laryngoscopic 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.

33. 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. 2
ndnd
hand hand
smoke.smoke.
 Appear well nourished. ^ African American males.Appear well nourished. ^ African American 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 stem responses, prone position, low surfactant, brain stem
abnorm. abnorm.
In 2000 Amer. Academy of Pediatrics recommended In 2000 Amer. Academy of Pediatrics 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.

34. 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) = “bound” Bilirubin binds with plasma protein (albumin) = “bound”
goes to liver & converts to conjugated or H2O soluble goes to liver & converts to conjugated or H2O soluble
where it ‘s excreted via bile by feces. where it ‘s excreted via bile by feces.
Immature livers which cannot convert indirect to direct; Immature livers which cannot convert indirect to direct;
indirect bilirubin remains in bloodstream. 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 significant; Younger infant (4-5 hrs.) high reading more significant;
could rise steadily . 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).

35. 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 soluble Phototherapy - bilirubin becomes water soluble
to be excreted. to be excreted.
Cover genitalia & eyes. Prevent organ damage. Cover genitalia & eyes. Prevent organ damage.
Single, double, triple phototherapy. Single, double, triple phototherapy.
Kernicterus: Indirect bilirubin of 20 > permanent Kernicterus: Indirect bilirubin of 20 > permanent
brain damage; bilirubin encephalophathy. brain damage; bilirubin encephalophathy.
Signs: hi-pitched cry, seizures, hypotonia Signs: hi-pitched cry, seizures, hypotonia
Interventions: Immediate exchange transfusion; Interventions: Immediate exchange transfusion;
followed by phototherapy & frequent bili levels.followed by phototherapy & frequent bili levels.

36. 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 in which produces excessive amts. of bilirubin in
blood stream. Excess bilirubin in blood causes blood stream. Excess bilirubin in blood causes
jaundice.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 up Teach parents to place near window to speed up
breakdown of bili. Sunlight will ^ breakdown.breakdown of bili. Sunlight will ^ breakdown.

37. Gastroschisis:Gastroschisis: weakness in abdominal wall weakness in abdominal wall
causing herniation of gut on umbilical cord causing herniation of gut on umbilical cord
during early development; most commonly on during early development; most commonly on
right side. Viscera lie outside abdominal cavity; right side. Viscera lie outside abdominal 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 capacity; intestines; decreased abdominal capacity;
other anomalies rare.other anomalies rare.
TX: IV & NG tubes immediately; TPN; Silastic TX: IV & NG tubes immediately; TPN; Silastic
(synthetic covering) over viscera; surgical (synthetic covering) over viscera; surgical
closure after contents returned to abd.cavity. closure after contents returned to abd.cavity.
If necrotic bowel present, remove.If necrotic bowel present, remove.

38. Nursing CareNursing Care: :
thermoregulation (monitor temps, radiant thermoregulation (monitor temps, radiant
warmer); sterile technique (cover viscera - warm, warmer); sterile technique (cover viscera - warm,
sterile, saline gauze & plastic); monitor VS, color, sterile, saline gauze & plastic); monitor VS, color,
etc.) strict I&O, daily weights, fontanels, pacifier, etc.) strict I&O, daily weights, fontanels, pacifier,
electrolytes. Minimize movement of area.electrolytes. 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 obstruction- for parents; teach parents s/s bowel obstruction-
ie. vomiting, pain, firm abdomen, anorexia, ie. vomiting, pain, firm abdomen, anorexia,
irritability.irritability.

39. OmphaloceleOmphalocele:: large herniation of gut into large herniation of gut into
umbilical cord. Viscera outside of 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. Stenosis decreased abdominal capacity. Stenosis
common; cardiac, genitourinary, or common; cardiac, genitourinary, or
chromosomal anomalies common (1/3 to chromosomal anomalies common (1/3 to
½ of cases)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 gastroschisis.Same as for gastroschisis.

40. Bladder ExstrophyBladder Exstrophy:: extrusion of urinary extrusion of urinary
bladder to the outside of body through bladder to the outside of body through
developmental defect in lower abdominal developmental defect in lower abdominal
wall. Assoc.w.genital anomalies: wide wall. Assoc.w.genital anomalies: wide
symphysis pubis.symphysis pubis.
Rare & congenital anomaly; bladder is “turned Rare & congenital anomaly; bladder is “turned
inside out”inside out”
TX: TX: protect exposed bladder tissue; cover protect exposed bladder tissue; cover
with saline gauze/plastic wrap til sugery. with saline gauze/plastic wrap til sugery.
Prevent UTI. Reconstruction of bladder & Prevent UTI. Reconstruction of bladder &
genitalia. Provide support & educationgenitalia. Provide support & education

41. 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 other 1 in 2,000 - 4,500 live births. 30-50% have other
anomalies (cardiac, GI, nervous sys). anomalies (cardiac, GI, nervous sys).
Premature or LBW commonPremature or LBW common
EA without TEF : Inability to pass suction or NG EA without TEF : Inability to pass suction or NG
tube catheter @ delivery. Confirm with abd.x-tube catheter @ delivery. Confirm with abd.x-
ray; Excessive oral secretions; vomiting; risk of ray; Excessive oral secretions; vomiting; risk of
aspiration; Abdominal distention; Airless/sunken aspiration; Abdominal distention; Airless/sunken
abdomen.abdomen.
Hx maternal polyhydramniosHx maternal polyhydramnios
TEF without EA: food enters trachea; choking; TEF without EA: food enters trachea; choking;
cyanosis.cyanosis.

42. StatisticsStatistics
Esophageal atresia with distal TEF 87%Esophageal atresia with distal TEF 87%
Isolated esophageal atresia without TEF Isolated esophageal atresia without TEF
8%8%
Isolated TEF 4%Isolated TEF 4%
Esophageal atresia with proximal TEF 1%Esophageal atresia with proximal TEF 1%
Esophageal atresia with proximal and Esophageal atresia with proximal and
distal TEF 1%distal TEF 1%

43. 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, measure secretions; IVF; assess VS, resp.distress, measure
abd.girth; provide education & support to family. abd.girth; provide education & 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; pain; Provide post op care. IVF, G-tube & foley care; pain;
VS, I&O, skin care.VS, I&O, skin care.