Neonatal disorders

• Jaundice


  Yellowish discoloration of skin and mucous membranes caused by increased serum bilirubin (hyperbilirubinemia)

  
• Bilirubin


  Breakdown product of hemoglobin

  
• Bilirubin is commonly found in the newborn and most instances it is benign
• Clinical jaundice


  • Appears at serum bilirubin 5 mg/dl
  • 25% to 50% of term newborn have clinical jaundice
  • 75% of bilirubin comes from haemoglobin and 25% from other sources

  
• Classification of jaundice


  • Benign
  • Pathological
• Physiological jaundice


  • Starts after the first 24hours
  • Peaks in the fourth or fifth day (not >12 mg/dl in term babies and not more than 15 mg/dl in premature)
  • Clears in a week in term and two weeks in premature
  • The rise is not more than 0.5 mg /h

  
• Causes of physiological jaundice

  • Increased RBC
  • Shortened RBC lifespan
  • Immature hepatic uptake & conjugation
  • Increased enterohepatic Circulation
• Pathologic jaundice


  • Jaundice in 1st 24 hrs
  • Rapidly rising TSB (> 5 mg/dL per day)
  • TSB > 17 mg/dL
• Categories of pathologic jaundice

  • Increased bilirubin load
  • Decreased conjugation
  • Impaired bilirubin excretion
• Types of pathologic jaundice

  • Hemolytic Disease
  • Non-hemolytic Disease
  • Biliary Obstruction
• Hemolytic Disease


  • Elevated reticulocytes, decreased Hgb
  • Rh incompatibility, ABO incompatibility, G6PD deficiency
• Non-hemolytic Disease


  • Normal reticulocytes
  • Extravascular sources – i.e. cephalohematoma
  • Polycythemia
• Biliary Obstruction


  • Structural defects – I.e. biliary atresia
  • Genetic defects – Rotor's & Dubin-Johnson syndromes
  • Infection – sepsis
  • Metabolic Disorders
  • Chromosomal Abnormalities
• Diagnosis & Evaluation


  • Physical Exam: Bilirubin > 5 mg/dL, Milder jaundice - face & upper thorax, Caudal progression generally signifies higher bilirubin levels
  • Laboratory: Blood, Transcutaneous

  
• Therapeutic management


  • Phototherapy
  • Exchange transfusion
• Phototherapy


  • Mechanism: converts bilirubin to water soluble form that is easily excreted
  • Forms: Fluorescent lighting, Fiberoptic blankets
  • Goal is to decrease TSB by 4-5 mg/dL or < 15 mg/dL total
  • Breastfed infants are slower to recover
• Complications of phototherapy


  • Retinal damage
  • Nasal obstruction
  • Mild diarrhea
  • Dehydration
  • Bronzed baby syndrome
• Exchange Transfusion


  • Mechanism: Removes bilirubin and antibodies from circulation and correct anemia
  • Most beneficial to infants with hemolysis
  • Generally used after intensive phototherapy attempted
• Indications for exchange transfusion

  • When bilirubin reach toxic level
  • Mortality 1%
  • Remove bilirubin, antibodies, correct anemia
  • Double blood volume is used 85 ml /kg

  
• Complications of exchange transfusion

  • Infection
  • Acidosis
  • Cardiac failure
  • Electrolytes imbalance
• Kernicterus


  • Yellow staining of nuclear centers of the brain due to high level of indirect bilirubin
  • Bilirubin cause neural loss, poor feeding, lethargy-fits, rigidity, spasticity, deafness

  
• Respiratory Distress Syndrome (RDS)


  • Condition of surfactant deficiency and physiologic immaturity of the thorax
  • Affects as many as 7% of newborns
  • Potentially life-threatening
  • Mostly seen in premature infants
• Causes of respiratory distress


  • Sepsis
  • Exposure to cold
  • Airway obstruction
  • Hypoglycemia
  • Cardiac defects (structural or functional)
  • Metabolic acidosis
  • Acute blood loss and drugs
  • Pneumonia
• Pathophysiology of RDS


  • Preterm infants are usually born before the lungs is fully mature
  • Final unfolding of the alveolar septa, which increases the surface area of the lungs occurs during the last trimester
  • Preterm infants with respiratory distress will not be able to adjust to extra-uterine pulmonary adjustments
  • The fetal lungs are deficient in surfactant
  • Deficient surfactant causes unequal alveolar expansion and collapse at the end of expiration
  • Numerous underdeveloped and many un-inflatable alveoli

  
• Atelectasis


  Without surfactant there is no ability to keep the lungs inflated and great deal of effort to re-expand the lungs each time
• Clinical manifestations of RDS

  • Rapid breathing
  • Retractions (subcostal, intercostal, suprasternal)
  • Crackles
  • Grunting
  • Nasal flaring
  • Tachypnea (> 60/min)
  • Central cyanosis
  • Stridor
  • Gasping
  • Apnea
  • Choking
• Management of RDS


  • Minimal handling
  • Maintenance of body temperature
  • Observation
  • Oxygenation can be enhanced by blow by oxygen, nasal cannula or mechanical ventilation in severe cases
  • Adequate calories intravenously
  • Antibiotics are often indicated if bacterial infection is identified
• RDS management


  • Oxygen therapy
  • Maintain acid-base balance
  • Maintain a neutral thermal environment
  • Maintain adequate tissue perfusion and Oxygenation
  • Surfactant
• Preterm infant


  Infant born before 37 completed weeks of gestation
• Categories of preterm infants

  • Late preterm infant (34 to 36 weeks gestation)
  • Moderately preterm infant (32 to 34 completed weeks of gestation)
  • Very preterm infant (before 32 completed weeks of gestation)
• Predisposing factors for preterm birth

  • Poor socioeconomic status
  • Pre-eclampsia
  • Smoking and alcoholism in pregnancy
  • Antepartum hemorrhage
  • Multiple pregnancy
  • Fetal development abnormalities
  • Primiparity
  • Short maternal structure
  • Maternal age below 18 years
• Characteristics of premature infants

  • Lies in a "relaxed attitude", limbs more extended, the body size small, head appears larger in proportion to the body size
  • Fontanels are wide and soft
  • Sutures are widely separated
  • Face appears smaller
  • Thin pinkish skin appears shiny due to generalized edema
  • Subcutaneous fat reduced
• Management of premature infants

  • Feeding (IV – Gavage)
  • Temperature control (incubator-heated bed)
  • Respiratory control (apneas, Respiratory support, Artificial ventilation)
  • Immature lungs – lack of surfactant (Oxygen supply, Respiratory support (CPAP, ventilator))
  • Immature brain (brain hemorrhage and cysts)
  • Immunology (risk of infections, antibiotics)
  • Organ injury (Brain, Eye, Lung, Intestine, Skin)
  • Long term consequences
• Care of premature infants before birth

  • Prevention: should be identified early during the course of pregnancy
  • Bed rest if suspected with uterine relaxing drugs
  • The mother should be delivered in a healthcare setting which is equipped with good quality obstetrical and neonatal care facilities
• Care of premature infants after birth

  • Provide in-utero milieu: Create uterus-like baby-friendly ecology in the nursery, Soft/comfortable cushioned bed, Avoid excessive light, Ensure asepsis
  • Monitoring: Body temperature, Heart rate, respiratory rate, Skin color, Abnormal movements, Fluid / electrolytes and tolerance of feeds, Minimize sensory overload by reducing the intensity of light noise
  • Emotional and developmental needs: adequate sleep and rest to conserve energy, Gentle and positive handling, Encourage the parents to visit the baby
  • Care of skin: Excessive cleaning to be minimized, Do not use creams, lotion and soap
  • Maintain adequate temperature: By controlling incubator temperature, Can practice kangaroo mother care if infant is stable
  • Precautions against cross infection: Practicing strict infection control procedures
  • Weight and occipitofrontal circumference
  • Feeding the preterm baby: Avoid starvation, Weight less than 1200gram / <30 weeks- IV dextrose and Oral gastric feed should be started, Non-nutritive sucking, EBM can be Fortified with human milk fortifier (HMF), Multivitamin and iron supplements should be started after having a steady weight gain
  • Kangaroo Mother care: Helps in early initiation of breastfeeding, Stabilizes body temperature, Promotes breastfeeding, Prevents infection, Positive impact on the parenting process
• Complications of preterm


  • Respiratory problems: periodic respiration, apneic attacks, Respiratory distress syndrome
  • Alimentary tract problems: gastro- esophageal reflux, abdominal distension
  • Jaundice
  • Edema
  • Sclerema
  • Anemia
  • Infections
• Post-term


  • Gestation of 42 weeks or later
  • Skin is parchment like, cracked and peeling in severe cases: yellowish green discoloration of nails and umbilical stump appears unusually alert, restless and hungry for feeds
• Management of post-term


  • Early feeding
  • Blood Glucose monitoring
  • Apply oil/moisturizing cream prevent dryness
• Nursing care of high risk newborn

  • Assessment
  • Monitoring of physiologic Data
  • Safety measure
  • Respiratory support
  • Thermoregulation
  • Protection from infection
  • Hydration
  • Nutrition
• Minor infections in the newborn

  • Conjunctivitis
  • Thrush – oral candiasis
  • Oomphalitis – umbilical infection
  • Rhinitis