Common neonatal disorders

peds

1. Common neonatal disorders

2. Classification of common neonatal disorders Birth injuries Caput succedaneum Cephalhematoma Fractures Facial paralysis Erb’s /Brachial palsy

3. Classification of common neonatal disorders(cont…) Disorders related to physiological factors Hyperbilirubinemia Hemolytic disease of the newborn Respiratory distress syndrome

4. Classification of common neonatal disorders Disorders related to infectious process Sepsis Necrotizing enterocolitis

5. Classification of common neonatal disorders(cont…) Disorders related to maternal conditions Infants of diabetic mothers

6. Injuries to head Caput succedenum Cephalhematoma

7. Injuries to the head while birth S  -  S kin C  -  C lose connective tissue & cutaneous vessels & nerves. A   -  A poneurosis ( epicranial aponeurosis ) L  -  L oose connective tissue (scalping layer) P  -  P eriosteum of skull bones

8. 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

9. Injuries to the head CAPUT SUCCEDANEUM Causes Mechanical trauma of the initial portion of scalp pushing through a narrowed cervix Prolonged or difficult delivery Vacuum extraction

10. Injuries to the head 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

11. Injuries to the head Cephalhematoma Causes Rupture of a periostal capillary due to the pressure of birth Instrumental delivery

12. Injuries to the head 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.

13. 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

14. 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.

15. 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.

16. Facial paralysis:   From pressure on facial nerve during delivery Affected side unresponsive when crying Resolves in hours/days NURSING 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 .

17. 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.

18. Erb’s Palsy ( Erb - Duchenne Paralysis) NURSING MANAGEMENT- 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. 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.

19. Erb’s Palsy ( Erb - Duchenne Paralysis) 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.

20. Hemolytic disease of the newborn Rh + ve blood – D antigen Rh - ve blood – lacks this D antigen

21. Hemolytic disease of the newborn 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

22. Hemolytic disease of the newborn

23. Hemolytic disease of the newborn “Why the fetus is affected in second delivery and not in first delivery?”

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

25. Hemolytic disease of the newborn 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 ?

26. Hemolytic disease of the newborn

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

28. Hemolytic disease of the newborn The answer is because of the type of antibodies formed during first and second delivery.

29. 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

30. Hemolytic disease of the newborn Diagnosis: Indirect coombs test in mothers-antigen direct coombs test in infants with Rh-ve mothers-antibodies

31. Hemolytic disease of the newborn Treatment: IVIG is given in infants, exchange transfusion and phototherapy.

32. Hemolytic disease of the newborn 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.

33. Hemolytic disease of the newborn 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.

34. 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.

35. 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

36. Neonate Respiratory distress syndrome 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

37. Neonate Respiratory distress syndrome 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.

38. Neonate Respiratory distress syndrome/ hyaline membrane disease 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.

39. Neonate Respiratory distress syndrome 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

40. Neonate Respiratory distress syndrome 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.

41. Neonate Respiratory distress syndrome 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.

42. Neonate Respiratory distress syndrome/ hyaline membrane disease 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 .

43. Neonate Respiratory distress syndrome/ hyaline membrane disease 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.

44. 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.

45. 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

46. Pathophysiology

47. Necrotising Enterocolitis (NEC Clinical manifestations: Abdominal distention Decreased bowel sounds Poor feeding Increased gastric residuals Blood streak bile vomiting Bloody or mucoid stools

48. Necrotising Enterocolitis (NEC 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

49. Necrotising Enterocolitis (NEC 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

50. Necrotising Enterocolitis (NEC 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.

51. Necrotising Enterocolitis (NEC Fecal material can be drained into urine collecting devices. Psychological support should be given to parents.

52. 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

53. Neonatal Sepsis Neonatal sepsis can be divided into two types Early 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

54. Neonatal Sepsis Late-onset: this is caused by the organisms thriving in exter The infection is often transmitted by the care givers.

55. Neonatal Sepsis The 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.

56. 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

57. 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.

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

59. Neonatal Sepsis Nursing 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.

60. 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.

61. 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 .

62. 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

63. Infants of diabetic mothers IDM Clinical 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

64. Infants of diabetic mothers IDM Therapeutic 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.

65. 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.

66. References WONG’S ESSENTIAL OF PAEDIATRIC NURSING 8 TH EDITION NELSON’S TEXTBOOK OF PEDITRICS 15 TH EDITION http://www.imedicine.com /display topic DOROT HY R.M.MARLOW AND BARBARA A. REDDING’S TEXTBOOK OF PEDIATRIC NURSING 6 TH EDITION Www.wikipedia.org Textbook of Indian academy of pediatrics

67. Any questions