Pedia at Risk Lecture 1

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NCM 109 COMCA RISK (PEDIA)

The Newborn at Risk Because


of Altered Gestational Age

PREMATURE NEWBORN

- A live-born newborn before the end of week 37


of gestation
- Is a baby born before 37 completed weeks of
gestation (more than 3 weeks before the due
date)

Risk Factors:

1. Low socioeconomic level Physical Appearance


2. Poor nutritional status before and during
pregnancy • Head is disproportionately large
3. Lack of prenatal care • Skid
4. Multiple/multifetal pregnancies - Ruddy- skin is underdeveloped and
5. Previous early birth decreased subcutaneous fat; infant
6. Cigarette smoking has hypoxia
7. Age of mother - Decreased subcutaneous fat
8. Infections - Visible capillaries/veins
9. Closely spaced pregnancies • Extensive lanugo
10. Obstetric complications • Abundant vernix caseosa
- Premature rupture of membranes • Small both anterior and posterior fontanels
- Premature separation of the placenta • Few/no creases on the soles of the feet
11. Abnormalities of the mother’s reproductive • Ears are flat and pliable
system • Female genitalia
- Clitoris is very prominent
- Labia majora are very small
• Male genital
- Testes are commonly UNDECENDED
- Scrotum: fine/few rugae
• Abdomen is relatively large/protruding

PROBLEMS OF PRETERM INFANTS

A. Respiratory System
- Poorly developed lungs/respiratory muscles
- Decreased surfactant> alveoli produce
surfactant
- Difficulty of breathing with apnea and cyanosis
- Poorly/unstable chest walls
- Poor gag/cough reflex

12. Early induction of labor B. Thermoregulatory System


- Poor thermal control
13. Elective cesarean birth
POIKILOTHERMIA: newborn easily takes on the
temperature of the environment

- Decreased subcutaneous fat, muscles, fat, and


glycogen deposits
- Decreased activity
- Decreased sweat gland and cannot shiver

C. Digestive System
- Poor sucking and swallowing> refer pt to
pediatrician to avoid aspiration to order OGT
feeding
- Small stomach

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NCM 109 COMCA RISK (PEDIA)
- Poor cardiac sphincter tone > f the sphincter
does not close properly, food and liquid can
move backward into the esophagus.
- Decreased bile salts

D. Liver Function
- Decreased vitamin K
- Decreased hemoglobin and blood production
- Poor bilirubin conjugation
- Poor sugar storage and release
Glucuronyl transferase

E. Nervous System
- Centers of vital functions are poorly developed
- Poor reflexes
- Low response to stimuli
- Poor muscle tone

F. Immune System 4. Periventricular/intraventricular hemorrhage


- No IgM and IgG at birth - Bleeding into ventricles> intraventricular
- IgM- hemorrhage
- IgG-antibody response from past infection - Bleeding in tissue surrounding ventricles>
periventricular
G. Integumentary System 5. Respiratory distress syndrome
- Thin skin: increased risk of toxicity from topical 6. Apnea
applications

POTENTIAL COMPLICATIONS

1. Anemia of prematurity
- Normochromic, normocytic anemia (normal
cells, just few in number)
- Low reticulocyte count
- Immature hematopoietic system combined with
destruction of RBC’s (the effective production of
red cells with an elevated reticulocyte count
may not begin until 32 weeks of pregnancy)
- Excessive blood drawing

2. Kernicterus
- Destruction of brain cells by invasion of indirect
7. Retinopathy of prematurity
bilirubin.
8. Necrotizing enterocolitis

3. Persistent patent ductus arteriosus


- Because premature newborns may lack
surfactant depending on their gestational age,
their lungs are noncompliant
- There is persistent communication between the

9. Hypocalcemia- Parathyroid hormone doesn’t


descending thoracic aorta and the pulmonary
work in infants, doesn’t want to break down
artery that results from failure of normal
bone yet.
physiologic closure of fetal ductus

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NCM 109 COMCA RISK (PEDIA)
INTERVENTIONS • Common type of jaundice:
pathological> within 24 hrs and
1. Impaired gas exchange r/t immature physiologic> after 24 hrs
pulmonary functioning - Provide supplementary supplements and
- Maintain respirations between 30-60 cpm minerals
- Suction secretions as necessary - Implement BF or use mother’s pumped BM
- Administer oxygen as necessary whenever possible
- Turn every 2 hours • EBM- expressed breast milk
- Monitor for apnea • SAP- strict aspiration precautions
- Encourage breathing with gentle rubbing - 1. Elevate the head
of back and feet atleast 30 degree angle
- Evaluate ABG results and electrolytes - 2. Check the patency of
feeding tube
NORMAL ARTERIAL BLOOD GAS VALUES -
3. Ineffective Thermoregulation r/t immaturity.
• Po2 (partial pressure of oxygen) – 80-100 - Maintain in incubator or radiant warmer
mmHg> reflects the amount of oxygen gas monitor temperature per axilla (T=36.5-
dissolved in the blood. It primarily measures 37.2)
the effectiveness of the lungs in pulling - Keep dry; change wet diapers and blanket
oxygen into the blood stream from the - Use heat source when bathing the preterm
atmosphere. infant.
• PCo2 (partial pressure of carbon dioxide)- 4. Risk for infection r/t immature immune defenses
35-45 mmHg> is the measure of carbon - Meticulous handwashing before and after
dioxide within arterial or venous blood. It handling the infant
often serves as a marker of sufficient - Provide skin care giving special attention to
alveolar ventilation within the lungs. the:
• O2 saturation- 95% to 100%> is a measure of • Scalp
how much hemoglobin is currently bound to • Periumbilical area
oxygen compared to how much • Creases at the perianal region
hemoglobin remains unbound. - Administer prophylactic antibiotics as
• ph- 7.35-7.45 > The pH of blood refers ordered
to how acidic it is. A complex set of - Maintain high vitamin C, iron, and protein
mechanisms and feedback loops help formula as ordered
regulate blood pH and keep the body - Provide meticulous but careful skin care
working properly. and reposition to prevent breakdown
• HCO3 (bicarbonate)- 22-26 mEq/L >
Bicarbonate is also known as HCO3. It's a
byproduct of your body's metabolism. Your
blood brings bicarbonate to your lungs, and
then it is exhaled as carbon dioxide. Your
kidneys also help regulate bicarbonate.
Bicarbonate is excreted and reabsorbed by
your kidneys.
• Base excess: -2.5 or +2.5 mEq/L

2. Risk for imbalanced nutrition, less than body


requirements r/t additional nutrients needed for
maintenance of rapid growth, possible sucking
difficulty, and small stomach.
- Administration of IVF
- Use “PREEMIE” nipple
- Use small, rubber tipped syringe or dropper
- Use gavage feeding
- Feed slowly and carefully
- Monitor I & O, weight, passage of stools,
signs of dehydration, hypoglycemia,
and hyperbilirubinemia.
• Signs of dehydration: poor skin
turgor, fever, thirst
• Normal blood glucose level in
infant and young children: 40-120
mg/dl

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NCM 109 COMCA RISK (PEDIA)
POSTTERM INFANT

- Also known as post mature infant


- Is one born after 42nd week of a pregnancy
- Problems of the post mature newborns result
from progressive inefficiency of an aging
placenta
- Post term infants are at risk because
placenta can only last of function
effectively for atleast 40 weeks

Risk Factors:

• Post maturity is more likely to happen when


a mother has had a post-term pregnancy
before.
• After one post-term pregnancy, the risk of a
second post-term birth increases by 2 to 3
times.
• Other minor risk factors include:
- First pregnancy
- Male baby
- Older mother
- Obese mother
- Mother or father with personal history
of postmaturity

How is postmaturity in the newborn diagnosed?

• Physical appearance
• Length of pregnancy
• Ultrasound
• Nonstress testing
- Placental function
• Checking the amount of amniotic fluid

Assessment finding

• Dry, cracked, peeling, loose, and wrinkled skin


• Absent lanugo and vernix
• Malnourished appearance
• Depleted stored fats/subcutaneous tissue
• Open-eyed and alert baby> because they
experience decreased oxygenation or hypoxia
• Long nails and scalp hair.
• Oldman’s look
• Meconium staining
- Green staining of skin, nails, cord, and
placental membrane
- Signs of distress due to aspiration of
meconium

Common problems in Postterm newborns

• Perinatal asphyxia
• Hypoglycemia
• Meconium aspiration
• Polycythemia vera
• Thermal regulation problems
• Hypothermia

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NCM 109 COMCA RISK (PEDIA)
Causes:
High Risk Newborns with
1. Woman’s nutrition (major cause)
Problem of Birth Weight 2. Pregnant adolescent
3. Placental anomaly (most common)
4. Placental damage
5. Woman with systemic diseases
6. Woman who smokes heavily
SMALL FOR GESTATIONAL AGE
Associated Problems of SGA Newborns
- Refers to a newborn born with weight less than
the 10th percentile may be born premature, full • Hypoglycemia
term or post mature. • Polycythemia
• Hypothermia
• Hyper viscosity
• Meconium aspiration

TYPES OF IUGR

1. Symmetrical
- Cause occurs early in pregnancy
- Head circumference, abdominal
circumference, fetal length, and postnatal
weight all reduced/small.
- Is based on the cross-sectional evaluation and 2. Asymmetrical
this term has been used for those neonates - Cause occurs later in pregnancy
whose birth weight is less than the 10th - Abdominal circumference and weight
percentile for that particular age. reduced/small but other measurement normal.

LARGE FOR GESTATIONAL AGE

- Also termed macrosomia


- Weight that lies above the 90th percentile for
that gestational age.
- Infant weighs above 4000 grams (8lb and 13oz)
or 4500 grams (9lb and 15oz) regardless of
gestational age.

Causes:

1. Overproduction of growth hormone (IDM)


SGA - Maternal plasma glucose levels as well as
insulin, stimulates fetal growth.
- Considers only the birth weight without any 2. Multiparous women
consideration of the in-utero growth and 3. Genetic factors
physical characteristics at birth. 4. Excessive maternal weigh gain

SGA vs IUGR Common Problems of LGA Newborn

- A baby may not be SGA but may still be 1. Hypoglycemia


considered to have had IUGR if they have - Increase blood glucose level in utero causing
features of in-utero growth restriction and the infant to produce elevated level of insulin.
malnutrition at the time of birth. After birth, glucose levels fall rapidly due to
- Therefore, neonates with a birth weight less than absence of glucose from the mother resulting
the 10th percentile will be SGA but not an IUGR if to rebound hypoglycemia.
there are no features of malnutrition. 2. Polycythemia
- A neonate with a birth weight greater than the 3. Hyperbilirubinemia
10th percentile will be an IUGR, in spite of bot
being SGA, if the infants have no features of
malnutrition at birth.

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NCM 109 COMCA RISK (PEDIA)
Delivery Problems:
Illnesses that Occur in
• Prolonged vaginal delivery time


Difficult birth
Increase in cesarean delivery
Newborns
- To avoid shoulder dystocia (wide fetal
shoulders cannot pass through the outlet Respiratory Distress Syndrome
of the pelvis)
- Is the commonest respiratory disorder and a
major cause of neonatal mortality and
morbidity, especially in preterm infants
- Is also known as:
➢ Newborn respiratory distress syndrome
➢ Hyaline membrane disease
➢ Surfactant deficiency lung disease

Epidemiology

- Typically affects infant <35 weeks gestational


age (GA) but may affect older infants who
have delayed lung maturation.
- Low GA is the greatest risk factor for RDS, and
its incidence varies inversely with birth weight
among AGA infants
- Other factors may also influence the risk of RDS
among preterm infants

Other Risk Factors of RDS

• Prematurity
• Male gender
• Familial predisposition
• Cesarean section without labor
• Perinatal asphyxia
• Caucasian race
• Infant of diabetic mother

- the main cause of RDS is a lack of surfactant in


the lungs.

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NCM 109 COMCA RISK (PEDIA)
WHAT IS SURFACTANT? Manifestations/Clinical Features

Surfactant Cardinal signs:

- is released from the lung cells and spreads 1. Tachypnea (>60 breathe/min)
across the tissue that surrounds alveoli. This 2. Intercostal and subcostal retractions
substance lowers surface tension, which keeps 3. Nasal flaring
the alveoli from collapsing after exhalation and 4. Grunting
makes breathing easy. 5. Cyanosis in room air
- Is a complex mixture of phospholipids, neutral
lipids and proteins. Its major constituents are Other Manifestations:
dipalmitoylphosphatidylcholine (DPPC or
lecithin), phosphatidylglycerol, cholesterol and • Hypotension
apoproteins. • Acidosis
• Hyperkalemia
• Low lung volumes and a bilateral, reticular
graular pattern (ground glass appearance)
- Management: Application of positive airway
pressure

Complications:

• Air leaks
• Intracranial hemorrhage

Management:

The goals of management of an infant with RDS are to:

1. Avoid hypoxemia and acidosis


2. Optimize fluid management: avoid fluid
overload and resultant body and pulmonary
edema while averting hypovolemia and
hypotension.
3. Reduce metabolic demands and maximize
nutrition.
4. Minimize lung injury secondary due to
volutrauma and toxicity

Prevention/Treatment

- The three most important advances in prevention


and treatment of RDS have been:
a) Antenatal glucocorticoids
b) Continuous positive airway pressure (CPAP)
and positive end-expiratory pressure (PEEP)
c) Surfactant replacement therapy
Pathophysiology
“These have dramatically decreased morbidity and
mortality from RDS”

1. Antenatal Glucocorticoids
- Accelerate fetal lung maturity by increasing
formation and release of surfactant and
maturing the lung morphologically.
- Administration of glucocorticoids at least 24 to
48hrs (and no more than 7 days) before
preterm delivery decreases both incidence
and severity of RDS.
- They are most effective before 34 weeks.
However, antenatal steroids should still be
considered when therapy is less than 24hrs
before anticipated delivery because a
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NCM 109 COMCA RISK (PEDIA)
reduction in neonatal mortality and RDS can still
occur in this time frame.
- ANTENATAL STEROIDS also reduce the TRANSIENT TACHPNEA OF THE NEWBORN
incidence of intraventricular hemorrhage.
TTN
2. EXOGENOUS SURFACTANT
- Is a therapeutic option for newborn with acute - Is characterized by mild to moderate respiratory
respiratory distress disorder. distress that gradually improves during the first
- Two approaches have been used for 48-72 hours of life.
surfactant delivery: - Results from the delayed clearance of fetal lung
1. Prophylactic fluid and is more commonly observed in NBs with
2. Rescue treatment history of maternal diabetes and those born via
Cesarean section
Prophylactic administration involves giving surfactant - Wet lungs
after birth, as soon as the infant has been stabilized. - Type II respiratory distress syndrome

Rescue Administration involves giving surfactant to Transient Tachypnea of the Newborn


infants who have established RDS and require
mechanical ventilation and supplemental O2. The - During fetal life the lungs develops as a liquid-
advantage of this approach is that patients are not filled organs
treated unnecessarily. - This liquid is produced by the fetal lung and
leaves via the trachea where it is either
3. Oxygen swallowed or enters the amniotic sac.
- Should be administered to preterm infants in - Fetal lung liquid plays a crucial role in the growth
concentrations sufficient to maintain PO2 and development of the lungs by maintaining
between 50-70 mmHg or saturation (by pulse them in a distended state.
oximetry) between 85-92% -
- It is now recognized that the retention of liquid
4. Respiratory Management within the future airways is required to maintain
• Nasal CPAP the lungs at an appropriate level of expansion in
• Endotracheal intubation order to stimulate their growth.
• Surfactant therapy
• Mechanical ventilation
- The goals of ventilatory management in the
intubated infant are to maintain adequate
oxygenation and ventilation, while
minimizing ventilator induced lung injury.

5. Antibiotic Therapy
- The clinical and radiographic features of
pneumonia may be indistinguishable from RDS
at birth.
- As a result, all infants with RDS should have blood
cultures and CBC drawn, and should receive
empiric antibiotic therapy (Ampicillin and
Gentamicin)
- Generally, antibiotics may be discontinued if the
blood culture has no growth after 48 hours,
unless prenatal history or clinical scenario
warrants extended treatment. Risk Factors

6. Thermoregulation • Cesarean delivery without labor


- Careful temperature control is imperative in all
VLBW newborns and is especially important in Manner of Delivery Incidence of
infants with RDS to minimize metabolic demands Respiratory morbidity
and oxygen consumption. Cesarean section
- An incubator or radiant warmer must be utilized before the onset of 35.5 per 1,000 births
to maintain a neutral thermal environment for labor
the NB. Cesarean section with 12.2 per 1,000 births
labor
Vaginal delivery 5.3 per 1,000 births

• Precipitous delivery
• Prematurity
• Male sex

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NCM 109 COMCA RISK (PEDIA)
• Macrosomia

Diagnosis

Tests may also be needed to confirm the diagnosis.


These tests might include:

a. Complete blood count (CBC)and blood culture


b. Blood gas test
c. Chest Xray
d. Pulse oximetry monitoring

Manifestations:

The symptoms of respiratory distress typically start within


the first several hours after birth and result from failure of
adequate absorption of fetal lung fluid.

• Tachypnea (often in the range of 80-100


breaths/min, and sometimes higher)
❖ Resolves by 72 hours
❖ Peak respiratory rate of more than 90
bpm/min at 36 hours
• Grunting
• Retractions
• Nasal flaring
• Barrel-shaped chest
• Crackles

Treatment

• Supplemental oxygen
• Blood tests
• Continuous positive airway pressure
• IV (intravenous) fluid
• Tube Feeding

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NCM 109 COMCA RISK (PEDIA)

Meconium Aspiration
Syndrome

Meconium

- Is the green viscous fluid that consists of fetal


gastrointestinal secretions, cellular debris,
mucus, blood, lanugo, and vernix.
- First appears in the fetal ilium between 10- and
16-weeks’ gestation. Manifestations

Meconium Aspiration Syndrome • Low APGAR score


• Tachypnea
- Is respiratory distress in a newborn baby caused • Retractions
by the presence of meconium in the • Cyanosis
tracheobronchial airways. • Coarse bronchial sounds on auscultation
• Barrel chest
❖ The aspiration of meconium-stained amniotic • Decreased PO2 and increased PCO2.
fluid by the fetus can happen: • Bilateral coarse infiltrates in the lungs with
- While the baby is still in the uterus spaces of hyperaeration
- During delivery
- Immediately after birth. Therapeutic Management

Risk Factors ➢ Amnioinfusion


- Can be used to dilute the amniotic fluid.
• “Aging” of the placenta ➢ Elective cesarean birth
• Fetal hypoxia ➢ Oxygen administration and assisted ventilation.
• Difficult delivery or prolonged labor-because ➢ Antibiotic therapy
this is a stressful situation to the infant that can ➢ IVF therapy
lead to hypoxia. ➢ Surfactant therapy
• Breech presentation- pressure in the buttocks ➢ Air trapping monitoring
can trigger the passage of meconium. ➢ Chest physiotherapy
➢ Nitric oxide
- Pulmonary vasodilators
➢ ECMO-extracorporeal membrane oxygenation
PATHOPHYSIOLOGY - Is similar to the heart-lung by-pass machine used
in open heart surgery.
- Has been successful as a rescue therapy for NBs
with respiratory failure with some diagnoses such
as meconium aspiration syndrome (MAS) having
a survival rate of more than 94%
- Is used to help NBs whose:
• Lungs cannot provide enough oxygen to
the body even when given extra oxygen.
• Lungs cannot get rid of carbon dioxide
even with help from a mechanical
ventilator.
• Heart cannot pump enough blood to the
body.

• If Vagus reflex is stimulated it can trigger PREVENTION


bradycardia, it will cause relaxation of
relaxation of rectal sphincter. Thus, it will release ➢ Tracheobronchial toileting
meconium to amniotic fluid.

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