. Newborn AssessmentDr Mohd Maghayreh

PRTH

General Survey

Appearance• Symmetry, any

obvious deformities, size, smell, muscle tone, sex, posture

Behavior• Crying, lethargic,

responsive, reflexes, jittery

Measurements• Normal Weight

• 2500-4000gms

• 5 ½lbs. – 8lbs, 13 oz.

• (AGA-appropriate for gestational age)

• Below normal (SGA- small for gestational age)- <10%

• Above normal (LGA-large for gestational age)- >90%

• Normal Length- 18-22” or 48-52 cm.

• Head circumference- 13-14” or 32-36 cm. (measure right above eyebrows)

• Chest circumference- 12-13” or 30-34cm (measure at nipple line)

Vital Signs• Temperature- first is usually

taken axillary, but may be taken rectally to assure anal patency (36.5-37.5C or 97.5-99.5F)

• Pulse- 110-160 bpm, unless sleeping (100) or crying (180)

• Respirations- 30-60 with periodic breathing

• B/P- only if suspected heart problem or premature infant

Skin• Color- • Pink • Pink with blue hands and feet (Acrocyanosis)• Jaundiced (yellow)• Blue/cyanotic• Mottled (lacy appearance)• Pale (white)• Harlequin (pink on one side, pale or blue on other)

Jaundice

Mottling

Acrocyanosis

Skin Appearance

• Vernix- white cheesy substance

• Lanugo- fine hair (usually on shoulders, ears and back)

• Milia- plugged oil glands (usually on chin or nose)

Vernix

Milia

Rashes/Marks- Erythema Toxicum (Newborn Rash)- Forcep marks- Mongolian spots- Birthmarks:• Port wine stain• Stork bite/Nevi• Strawberry mark• Café au lait- Petechiae

Erythema Toxicum

Forcep mark

Mongolian spot

Port wine stain

Strawberry hemangioma

Stork bite/ Nevi

Cafe au lait birthmark

Petechiae

Head• Size- 1” larger than chest ( > 1” may be

indicative of hydrocephalus)• Shape:• Round• Moulding (suture lines overlap and head

elongates)• Caput Succedaneum (head elongates and

there is also edema of the soft tissue)• Cephalohematoma (hemorrhage into the

cranial bone, swelling and bluish color on one side of the head- does not cross suture line)

MouldingCaput

Cephalohematoma

• Fontanels/Sutures- 2 fontanels

• anterior one is diamond shaped- closes at about 18 months old

• posterior one is triangular shaped- closes by 2-3 months

• Facial Symmetry

• Eyes- shape, slanted, hemorrhages, edema, strabismus

Asymmetry

Slanted eyeshemorrhagesStrabismus

•Nose- patency of each nares to r/o “Choanal Atresia”

• Mouth- for cleft lip and palate, for neonatal teeth, Epstein’s pearls, Thrush

Cleft lipCleft palate

Epstein’s Pearls Thrush

Neonatal teeth

• Hair- fine with consistent hair pattern (abnormal hair patterns indicated genetic abnormalities)

                                           

     

•Ears-

•normal shape

•patent

•even with eyes (low set ears indicate congenital abnormalities)

•Pits or tags

Major birth defects of the Head• 1. Anencephaly- a neural tube defect where only the brain stem

grows and there is no brain tissue

• 2. Encephalocele- anotherneural tube defect where thecranium does not close andthe meninges protrude out of the head

• Neck and Clavicles- is the neck thick or webbed, do the clavicles feel intact, no crepitus.

Chest

- Size- 1” smaller than head- Shape- cylinder shape is normal.

Asymmetry can be caused by Pneumothorax or Diaphragmatic Hernia

- Nipples- location, distance apart, any accessory nipples

Pneumothorax

Lung Sounds

- clear or moist, equal, bowel sounds in chest?

- S/S of respiratory distress

- (tachypnea, grunting, retractions, nasal flaring, cyanosis)

- Rate (listen for 1 full minute)

Heart Sounds• - auscultate for rate & rhythm • - presence of murmurs (murmurs are

common in the newborn period- 90% are transient and considered normal)

• Listen for 1 full minute• Report any abnormal rate, rhythms or

sounds to pediatrician• If suspected heart problem- take B/P on all

four extremities

• Abdomen:

- Size- same or smaller than chest

- Shape- rounded, no distention

- Any obvious deformities (Gastrochesis, Omphalocele)

- Bowel sounds- present, hypo, hyper

- Cord- color, # of vessels, clamp on tight (no skin attached), no bleeding noted

Omphalocele

Gastrochesis

Genitalia:

- Female- labia may be swollen and red from delivery, hymenal tag, pseudomenses, whitish drainage

- Male- testes should be descended at term, rugae on scrotum, check where urinary meatus comes out

- Hypospadias- urethral opening is on the underside- Epispadias- urethral opening is on the upperside

Hypospadius with repair

Extremities• Arms & Hands

• Symmetry

• 10 fingers

• Simian crease

• Polydactyly- extra digits

• Syndactyly- webbing of digits

• Brachial pulse

Polydactly

Syndactyly

Simian Crease

Hips- check for congenital hip dysplasia

Normal Hip Hip Dysplasia

S/S of Hip Dysplasia: Hip click +Ortalani’s testOne leg shorterGluteal creases assymetrical

Legs and Feet

• Symmetry

• 10 toes

• Femoral pulse

• no club feet

• Creases on bottom of feet

Back and Buttocks

- Straight spine

- Spina Bifida Occulta- dimple or tuft of hair

- Meningocele (sac with fluid only)

- Meningomyelocele (sac with fluid and spinal cord)

Neurologic

• Reflexes (see page 533)

• Babinski, Plantar, Moro, Rooting, Sucking, Stepping, Tonic neck

• Sensory assessments

• (do eyes track, does infant respond to sound?)

Gestational Exam

• EDD is not always correct (only accurate 75-85% of the time)

• Performing a gestational exam helps the nurse evaluate for potential age-related problems. Should be done in the first 4 hours of life.

• Gestational age tools have 2 components: physical maturity and neuromuscular maturity

• Most common tool is the “Ballard”• (see pages 538-545 in text)

Lab Assessments• Blood Glucose (>40 mg/dl is

normal)• Bilirubin Level- < 12 is

normal. Peaks on 3rd day of life

• Newborn Screening Test (NBS)- State required test

-Phenylketonuria (PKU)-Hypothyroidism-Galactosemia-Hemoglobinopathies

IV. Adaptation of the Newborn Infant

Initiation and Maintenance of Respirations

• 1) Lung Development- as a baby nears birth, fluid begins to move to interstitial space. Production of Surfactant by 34-36 weeks. Keeps alveoli of lungs from collapsing when exhalation occurs.

Factors that initiate Respirations• 1) Chemical Factors- in O2 and in CO2

causes impulses to stimulate the respiratory center in the medulla of the brain.

• 2) Thermal Factors- abrupt temperature change sends impulses to brain

• 3) Mechanical Factors- fetal chest is compressed during birth, forcing fluid out.

• 4) Factors that maintain respirations- surfactant, functional residual capacity

Cardiovascular Adaptation: Transition from fetal to neonatal circulation

• What is fetal circulation?• A combination of structures/vessels that are

present only during the fetal period, which help shunt the highest oxygenated blood to the head, brain and heart.

• 1) Ductus Arteriosus• 2) Foramen Ovale• 3) Ductus Venosus

At birth, after the first few breaths, the following cardiovascular changes occur:

• 1) Ductus Arteriosus closes in response to O2 and resistance in lungs

• 2) Pulmonary blood vessels dilate in response to demand in lungs

• 3) Foramen Ovale is forced to close because of increased pressure in left side of heart

• 4) Ductus Venosis constricts when umbilical cord is clamped

Neurologic Adaptation: Thermoregulation

• The maintenance of body temperature is a major task for the NB infant (normal temperature is 97.7-98.6)

• 1) their skin is thin and blood vessels are close to the surface

• 2) they have little SQ fat to serve as a barrier to heat loss• 3) they have 3x the surface to body mass as an adult• 4) Preterm infants are especially susceptible to heat loss

because their tone is poor and they have even less fat and thinner skin than full term babies.

Methods of Heat Loss• 1) Evaporation-occurs when wet surfaces

are exposed to air.• 2) Conduction- occurs when the NB comes

in direct contact with objects that are cooler than their skin.

• 3) Convection- occurs when heat is transferred to air that surrounds the NB.

• 4) Radiation- occurs when there is a transfer of heat to cooler objects that are not in direct contact with the infant.

Effects of Cold Stress• 1) Metabolic Rate: leads to use of glucose and

production of Surfactant. This can lead to hypoglycemia and respiratory distress.

• 2) Non-Shivering Thermogenesis-metabolism of Brown fat. This leads to increased production of free fatty acids, which leads to metabolic acidosis and jaundice.

• 3) Vasoconstriction: leads to pale, mottled skin and shut down of pulmonary vessels, which leads to fetal circulation patterns.

Brown Fat

“Neutral Thermal Environment”

• NTE helps prevent heat loss in newborns.

• Maintains stable temp without an increase in oxygen or metabolic rate.

• In healthy unclothed NB’s, 89.6 to 92.3.

Hematologic Adaptation

• 1) Blood Values-

• RBC’s- Newborns have a higher # of RBC’s than adults, and their RBC’s are larger in order to receive adequate O2 to cells. “Polycythemia” =a high RBC count. Increases risk of jaundice and brain infarct.

• Hematocrit- higher than in the adult. 48%-69% is normal (heel stick) 65% venous blood

• WBC’s- Elevation is normal, because the stress of birth increases production.

• Infection can cause either decreased or increased WBC’s with large # of immature WBC’s (Bands or Stabs).

• 2) Risk of Clotting deficiencies- the NB is at risk because they lack Vitamin K, which activates several clotting factors in the body- factors 2, 7 and 10.

• To decrease this risk, NB’s are given an injection of Vitamin K at birth.

Gastrointestinal System Adaptation• 1) Stomach- capacity is low at birth, but expands to about

90ml within a few days. The cardiac sphincter is relaxed, which causes a tendency to regurgitate.

• 2) Intestines- sterile at birth, once the infant takes in food, bacteria enters the GI tract.

• 3) Digestive enzymes- deficient in amylase and lipase until 3-6 months of age. Breast milk has these two enzymes.

• 4) Stools- 1st stool is meconium, which has accumulated in the intestines throughout gestation. Usually the 1st Meconium stool is passed within first 24 hrs of live. Passage during labor is a sign of fetal stress.

Hepatic System Adaptation• 1) Blood Glucose Maintenance- glucose is

stored in the liver during the last 4-8 weeks of pregnancy. This is used for the energy of birth, heat production and stores until the first feedings are taken.

• Normal blood glucose for infants is 40-60. < 40 is considered hypoglycemia.

• Infants at risk for hypoglycemia: • SGA, LGA, stressful deliveries, infection,

cold stress.

2) Conjugation of Bilirubin• “Bilirubin” is a byproduct of the breakdown of

RBC’s. • It is released in the unconjugated form.• Unconjugated bilirubin is fat-soluble and is

absorbed by the SQ fat, causing a yellowish discoloration of the skin, called jaundice.

• The liver must conjugate the bilirubin (change it into a water-soluble form) in order for the body to excrete it through the urine and the stool.

The conjugation of Bilirubin by the Liver:

Hyperbilirubinemia

• Definition: excessive levels of bilirubin in the blood >12 mg/dl.

• Extremely high levels >25 mg/dl can lead to brain damage because the brain tissues are stained (“Kernicterus”)

• Two types:• 1) Physiologic Jaundice• 2) Pathologic Jaundice

1) Physiologic Jaundice:Timing: Occurs after 24 hrsPeaks on 3rd day of life Incidence: Occurs in 60-80% of NB’s Etiology: Caused by breakdown of excessive RBC’s after birth.

The immature liver can’t handle them all, so build up of unconjugated bilirubin occurs, and skin becomes yellow.

Bruising, cephalohematoma, or poor feeding (dehydration) worsens this normal occurrence

Breast Milk Jaundice- sleepy infants who have a poor suck do not receive enough colostrum (laxative effect clears bilirubin rich meconium)

• Treatment: If level goes > 12mg/dl; • 1. Phototherapy lights are started- high intensity

flourescent lights that convert the bilirubin under the skin so that it can be excreted in the stool.

• *The eyes and the genitals of the infant must be protected.

• 2. Feedings are increased to promote stooling and urination (with breast milk jaundice- formula is given for 24-48 hours)

• 3. IV fluids may be needed if infant not feeding well.

Phototherapy Bed

Phototherapy Lights

Phototherapy Blanket

2) Pathologic Jaundice• Timing: Occurs in the first 24 hours of life, some

infants born jaundiced. Level reaches 12 mg/dl by 24 hrs.

• Etiology: anything that causes the destruction of RBC’s

• 1) Incompatabilities between maternal and fetal blood

• Rh Incompatability• ABO Incompatability• 2) Infection• 3) Metabolic Disorders

Rh Incompatability

• This occurs when the expectant mother is Rh-, the father is Rh+ and the fetus is Rh+.

Rh- Rh+Rh+

Pathophysiology

• People who are Rh+ have the Rh antigen on their RBC’s. People who are Rh- do not.

• If blood that is Rh+ enters the body of a person who is Rh-, the body reacts as it would to any foreign substance, and develops antibodies that destroy the invading antigen (this is called “sensitization”)

A “sensitized” mother who has built up antibodies

• Theoretically, there is no mixing of fetal and maternal blood during pregnancy.

• However, small placental accidents can occur (usually at the time of birth) that allow a drop or two of fetal blood to enter the maternal circulation.

• This can also occur during a spontaneous or elective abortion, or during antepartal procedures, such as amniocentesis, or with placental problems, such as abruptio placenta.

•Maternal antibodies cross the placental barrier and cause massive destruction of the fetus’ RBC’s.•To destroy the Rh antigen (which exists as part of the RBC), the antibody must destroy the entire RBC.

Fetal and Neonatal Implications• 1) Pathophysiology: • Once the mother is sensitized and has developed antibodies, the

current fetus (if occurs early in pregnancy) and any subsequent Rh+ fetus will develop a condition called “Erythroblastosis Fetalis”.

• 2) S/S: • Infant born severely anemic and jaundiced• Infant has generalized edema because of the profound anemia

-“Hydrops Fetalis”• Congestive heart failure • Ascites • High risk for death

Treatment

• Phototherapy

• IV fluids

• Exchange Transfusion

• Cardiac support (Dopamine)

• Infusion of Albumin

                                                            

Maternal Implications• All pregnant women tested for Blood type and Rh. • Any Rh- woman also tested for “Coomb’s Test”

(determines presence of Rh antibodies in maternal blood). • If unsensitized: A Rh Immunoglobulin (RhoGAM) is

given at 28 weeks. • If sensitized: Coomb’s test is repeated throughout

pregnancy to determine if the titer is rising. Any increase means this infant is Rh+ and is in jeopardy. Amniocentesis is done to determine fetus’ Rh factor. Fetal diagnostic tests are done weekly to determine fetus’ well-being. Intrauterine transfusion and/or early delivery may be needed.

Postpartum Management

• Infant is tested from cord blood to determine blood type and Rh, also a Coomb’s test is done.

• If infant is Rh+, mother must receive another dose of RhoGAm within 72 hrs of birth to prevent antibody formation.

• If infant is Rh-, no treatment is needed.

ABO Incompatability• 1) Occurs when the mother is type O blood and the

infant is A, B, or AB.• 2) not as severe as Rh incompatability, but can lead

to jaundice in the NB.• 3) Pathophysiology: Type A, B, or AB blood has an

antigen that is not present in type O blood. People with type O develop anti-A or anti-B antibodies naturally as a result of exposure to antigens in foods, or to infections by gram-negative bacteria. IgG or IgM antibodies are formed. The IgG antibodies cross the placenta and cause hemolysis in the fetus.

• The first fetus can be affected.

• IgG are the only antibodies that can cross the placental barrier, and usually most of the antibodies formed are IgM, so this condition is usually much milder than the Rh issue.

• At birth, the coomb’s test will detect whether antibodies are present. If so, serial bilirubin level checks are done, and the infant is watched closely for jaundice.

Other Liver functions• 4) Iron Storage- Iron is stored from the mother in

the last weeks of pregnancy. If the infant is full term, enough iron should be present to last 4-6 months. By then the infant should be started on foods that have iron, such as infant cereal.

• 5) Metabolism of drugs- NB’s metabolize drugs slower than older children because their liver is immature. Any drug taken in labor may take a while to get out of the baby’s system. Also, breastfeeding women need to be cautious what they take.

Urinary System Adaptation1) Blood flow to the kidneys increases

following birth, because of decreased resistance in the Renal blood vessels.

2) 1st void should occur within 24 hrs.3) Absence of urine could indicate

hypovolemia, absence of kidneys, or kidney anomalies.

4) Usually Oligohydramnios is also present when there is a kidney dysfunction.

Psychosocial Adaptation• Behavioral States:• 1) Quiet sleep- deep sleep, no eye movement,

resp. quiet and slower• 2) Active sleep-rapid eye movements, may

move extremities or stretch• 3) Drowsy- transitional period, yawns, eyes

glazed• 4) Quiet alert-infant able to focus on objects or

people, tuned into environment• 5) Active alert-restless, starting to fuss, faster

respirations, more aware of discomfort• 6) Crying- follows quickly if parent doesn’t

intervene during active alert state.

V. Care of the Newborn

• 1) Vitamin K- 1 mg. given IM (Vastus Lateralis) to promote clotting factor formation.

• 2) Eye treatment- Antibiotic eye ointment is given to protect against organisms contracted in the birth canal.

• Gonorrhea and Chlamydia cause “Opthalmia Neonatorum”, a serious eye infection that can cause blindness if not caught early.

• 3) Blood glucose• Checked on all babies who are SGA, LGA, have

low temperatures, are jittery, or who had a stressful delivery.

• If below 40 mg/dl, start feeding protocol per hospital.

• 4) Circumcision• Pros/Cons• Techniques (Gomco or Plastibell- page 563)• Pain Relief• Nursing Responsibilities

Plastibell method

Gomco method

• 5) Bathing- • *remember Thermoregulation• Good time to observe for any

missed abnormalities• Sponge bath until cord falls

off

• 6) Cord care- • Alcohol, Betadine, Triple dye• Teach parents how to care for

cord and when to expect it to fall off

• 7) Protection of Infant- Security, ID badges, observation of any suspicious looking people

• 8) Teaching Parents• NB Care• Feeding• When to call the Doctor• Lab tests• Hearing Screen

VI. Care of the High Risk Newborn

Levels of Care

• Level 1 nurseries- Newborn• Care for minor problems and transitional issues

(TTN, Jaundice, hypothermia)• Level 2 nurseries- care of preterm infants 32 weeks

or >, conditions that will resolve rapidly (sepsis, mild RDS)

• Level 3 nurseries- care of severely preterm and infants with long term problems

• Level 4 nurseries- “Tertiary” centers that do specialty care, such as heart surgery

Infants at risk because of gestational age or size

• SGA/IUGR- an infant born at <10% normal weight for it’s gestational age.

• -Symmetric growth restriction indicates long-term complications because the total # of cells are decreased. Caused by congenital anomalies, exposure to infection or drugs early in pregnancy

• -Asymmetric growth restriction (head looks big in comparison to body) Brain and heart size are normal, other organs may be small. Growth problem starts in the 3rd trimester. These babies generally “catch up”.

Etiology of SGA/IUGR

• Maternal factors

• Maternal disease

• Environmental factors

• Placental factors

• Fetal factors

Nursing considerations

• 1. Assess for hypoglycemia

• Feedings- early and more frequent

• 2. Assess for hypothermia

• Extra clothing and blankets, overhead warming units, isolettes

LGA

• Definition: an infant whose birth weight is at or above the 90th % at any week of gestation.

• Etiology: Most commonly infants born to Diabetic mothers

Common complications of the LGA newborn

• 1) Birth trauma & increased incidence of cesarean births

• 2) Hypoglycemia

• 3) Polycythemia & Hyperviscosity

• 4) Respiratory Distress syndrome

• 5) Congenital birth defects- particularly in the Infant of a Diabetic mother

Nursing Considerations

• 1. Assess for birth injuries

• Fractured clavicles, brachial palsy

• 2. Assess for hypoglycemia

• Follow hospital protocol for obtaining blood glucose by heel stick

• 3. Assess respiratory functioning

• Rate, effort, breath sounds

Post term Infants

• Definition: an infant born p 42 weeks.• 12% of all pregnancies• 5% of these infants exhibit “Postmaturity

syndrome”, caused by decreased placental functioning which leads to low oxygen levels and nutrition transport.

• S/S: Hypoxia, malnourished, loose skin, long nails, wrinkled and cracked, peeling, meconium stained cord, skin and nails.

Common complications of the post-term newborn

• 1) Hypoglycemia

• 2) Meconium aspiration

• 3) Polycythemia

• 4) Seizures

• 5) Cold Stress/Hypothermia

Nursing considerations

• Assess respiratory functioning (especially if meconium was passed)

• Assess for hypoglycemia- early and more frequent feedings

• Assess for hypothermia- blankets, warming units, etc.

• Assess for polycythemia which can increase the risk for hyperbilirubinemia

Preterm Infants

Scope of Problem:In 2004, 12% of all births were preterm. This # has not

decreased, in spite of advances in technology to save these infants.

• In fact, since 1982, there has been a 27% increase in premature births

• Some of the reasons for this increase: rate of births to women 35+ years old rates of multiple births (ART) substance abuse in childbearing women Stress

Survival rates of Preterm Infants

Birth weight of 1000-1500gms: 85-90% Birth weight of 500-600gms: 20% In terms of medical expense, lost potential and suffering

of infants and their parents, prematurity is very costly # 1 cause of neonatal mortality (1st four weeks) # 1 cause of infant mortality (1st year) # 1 cause of black infant mortality Major cause of childhood disabilities Total U.S. hospital charges for infant stays due to

prematurity/LBW: $11.9 Billion

Etiology and Risk Factorsfor Premature Birth

• Etiology: Unknown• Risk Factors:• Infection• Multifetal pregnancy• Hx of previous preterm delivery• Maternal disease: PIH, Diabetes, heart disease• Low socioeconomic status of mother• Substance abuse• Maternal age <17 or >35 years old

Prevention of Premature Birth

• *Adequate prenatal Care• Identification of high risk mothers/

fFN test• Identify and treat infections early• Teach mothers s/s of premature

labor• Adequate nutritional state of mother• Early identification of substance

abuse• March of Dimes (5 year Campaign

to decrease Prematurity)• Professionals and Researchers:

Common problems in the Preterm Infant

• 1) RDS- Respiratory Distress Syndrome (also called Hyaline Membrane Disease)

• Etiology: Insufficient production of Surfactant (allows alveoli to remain open with exhalation).

• Pathophysiology: When surfactant is insufficient, the alveoli collapse each time the infant exhales. The lungs become “stiff” and resistant to expansion. Atelectasis and hypoxia eventually occur, along with respiratory acidosis.

• 20% of Neonatal deaths in the U.S. are from RDS.

• Signs/Symptoms of RDS:• 1) *Grunting on expiration• 2) Tachypnea• 3) Retractions• 4) Cyanosis• 5) Nasal Flaring• 6) Respiratory Acidosis

• Diagnosis: Made by s/s and Chest X-ray (ground glass appearance)

Treatment: • Supportive (mechanical ventilation,

correction of acidosis, IV fluids)

• Surfactant Replacement (can be repeated several times)

• *Infants treated with “Survanta” have higher survival rates and fewer complications of RDS

Nursing Care of the Patient with RDS

• Strict I & O• Watch blood sugar• Maintain Umbilical catheter• Draw and interpret blood gases, and work with

respiratory therapist in adjusting ventilator or O2 settings

• Watch for complications: Pneumothorax, worsening RDS, Intraventricular Hemorrhage

Other considerations

• Position Infant for Optimal Neurological Development

Promote Bonding with Parents (Kangaroo Care)

Other common problems of the premature infant

• 1) Apnea• 2) Thermoregulation• 3) Poor feeding/ GI infections (Necrotizing

Entercolitis)• 4) Bronchopulmonary Dysplasia (BPD)• 5) Intraventricular Hemorrhage• 6) Retinopathy of Prematurity• 7) Poor parent-infant bonding

Nursing Interventions to promote bonding

• 1) give photographs• 2) place infant’s first name on the

incubator ASAP• 3) provide information on infant’s

progress• 4) involve parents in decision making• 5) teach parents about unique

behavioral clues of the preterm infant• 6) Kangaroo care• 7) allow to do cares when infant is

stable

                                                                                                                                        

           

Infants at risk because of maternal substance abuse

• Identifying drug-exposed infants (Red flags!)

• - lack of prenatal care

• - placental abruption (cocaine or speed)

• - abnormal behavior of mother

Abnormal s/s of infant

• irritable • jittery• restless• prolonged high-pitched cry• difficult to console• poor feeding (uncoordinated suck, frequent vomiting)• diarrhea• poor sleep patterns• yawning• sneezing & nasal stuffiness• tachypnea • seizures

“Narcotic Abstinence Syndrome” (NAS)

• Seen in infants who have been exposed to opiates, such as Heroin or Methadone

• Infants experience severe withdrawal symptoms

• Drug therapy is used to control s/s- Phenobarbital, oral morphine, paregoric, tincture of opium, methadone (drug dosage is tapered over time)

Nursing considerations• Substance testing when

suspicious- urine or meconium is obtained

• Scoring on Abstinence Scale

stimulation: Swaddling, lights low, group cares together, quiet spot in Nursery

• Medication if needed

Legal and Parental Considerations

• Maternal drug test can only be done with consent• Infant drug test can be done without consent,

based on suspicions because of mother’s behavior or infant’s s/s.

• A positive drug test usually results in a CPS referral. They interview mother, and then determine placement of child.

• Nurses need to promote bonding and document mother’s visits and behavior well.

Infants at risk because of Infection

• Bacterial infection of the newborn affects 1-4 in every 1000 live births.

• NB’s acquire infection in one of two ways:• 1) Vertical transmission- In utero, either by

passage across the placenta, or during labor, as organisms ascend the vagina.

• 2) Horizontal transmission- After birth, from hospital staff or equipment (Nosocomial), or family members

Common organisms:

• Group B strep• E. coli• Haemophilus influenzae• Staph Aureaus• Viral (CMV, herpes,

HIV, Rubella)• Syphillis, Gonorrhea• Toxoplasmosis

Signs/Symptoms

• *Temperature instability (usually with low temperatures, rather than high)

• Respiratory problems

• Feeding Intolerance

• Lethargy

• Hypoglycemia

• Apnea

Therapeutic Management

• 1) Testing- blood cultures, urine samples, CBC, CSF, C-reactive Protein

• 2) Broad–spectrum Antibiotics (Ampicillin and Gentamicin)

• 3) Supportive Care- fluids, oxygen, warmth, glucose stabilization

Infants at risk because of respiratory problems

1) Transient Tachypnea of the Newborn (TTNB) • Etiology: Retained lung fluid• Risk Factors: Cesarean Birth, asphyxia at birth,

maternal analgesia, bleeding, diabetes.• S/S: Tachypnea (as high as 120/min), retractions,

nasal flaring, may or may not have grunting, mild cyanosis. Chest X-ray shows streaking and presence of fluid in the lungs.

• Condition is self-limiting and treatment is supportive.

Same baby with TTNB, x-rays are 24 hours apart

2) Meconium Aspiration Syndrome (MAS)

• MAS develops when meconium in the amniotic fluid enters the lungs during fetal life, or at birth.

• Risk Factors: Postterm infants, Intrauterine asphyxia

• Meconium in the lungs causes obstruction of the airways and air trapping. This can result in pneumothorax and/ or respiratory distress.

Therapeutic Management

• At birth, the airway must be cleared. The obstetrician suctions the mouth and pharynx, then the NICU team intubates the trachea, and deep suctioning is done (prior to the infant crying/breathing).

• Treatment includes respiratory support (oxygen, ventilation), Antibiotics, and possible ECMO.

Please take good care of me!

I’m the Future!