Acquired and Congenital Conditions in Newborns

What is birth trauma in newborns?

Physical injury sustained during labor and birth, which may be avoidable.

Clavicle

Bone most often fractured during birth as a result of shoulder dystocia or from force of labour. generally the break is in the middle third of the bone.

Limited arm motion

Crepitus over the bone

Absence of Moro reflex on the affected side

What role does ultrasonography play in birth trauma?

It enables antepartum diagnosis of potential birth injuries.

What are some types of skeletal injuries that can occur during birth?

Peripheral nervous system injuries, including Brachial palsy, Erb palsy, Klumpke Palsy, facial nerve paralysis, and phrenic nerve paralysis.

Brachial Plexus Injury

Results from trauma to the spinal roots of the fifth cervical nerve to the first thoracic nerve and alter the normal position and relationship of the arm, shoulder, and neck

Macrosomia and shoulder dystocia are associated with this

The Moro reflex is absent on the affected side in all forms

Erb Palsy (Erb Duchenne Paralysis)

Caused by damage to the upper brachial plexus and usually results from lateral traction of the head and neck away from the shoulder as the fetus goes through the birthing process.

May occur with shoulder dystocia or with a difficult vertex or breech birth.

Clinical Manifestations of Erb Palsy

The clinical manifestations are related to the paralysis of the affected extremity and muscles.

The arm hangs limply alongside the body. The shoulder and arm are adducted and internally rotated; the elbow is extended, and the forearm is pronated, with the wrist and fingers flexed.

In newborns with very severe deficits, the arm may be cooler because of the sympathetic nervous system outflow at T1.

Torticollis is commonly present and almost always with the face turned away from the involved arm

Torticollis

Is a stiff neck that makes it hard or painful to turn your head.

Klumpke Palsy

A less common lower plexus palsy, results from severe stretching of the upper extremity while the trunk is relatively less mobile.

Clinical Manifestation of Lower Brachial palsy

The muscles of the hand are paralyzed, with resultant wrist drop and relaxed fingers. In a third and more severe form of brachial palsy, the entire arm is paralyzed and hangs limply and motionless at the infant’s side.

Goal of treatment of Brachial Plexus Palsies

Prevention of contractures, and maintenance of correct placement

of the humeral head within the glenoid fossa of the scapula.

Complete recovery from stretched nerves usually takes 3 to 6 months.

However, avulsion (disconnection) of the nerves of the ganglia from the spinal cord results in permanent damage. For those injuries that do not improve by 3 to 6 months, surgical intervention may be needed torelieve pressure on the nerves or to repair the nerves with grafting

Care of the Newborn with Brachial Palsy

Focuses on positioning of the affected arm through 90-degree abduction with external shoulder rotation, forearm supination, and extension at the wrist with the palm facing the newborn’s face.

Occupational therapy or physiotherapy, initiated in the second week, involves passive range-of-motion exercises of the shoulder, wrist, elbow, and fingers.

Wrist flexion contractures may be prevented with the use of a wrist splint with padding in the fist.

In dressing the newborn, preference is given to the affected arm. Undressing begins with the unaffected arm, and re-dressing begins with the affected arm to prevent unnecessary manipulation and stress on the paralyzed muscles.

Parent education includes newborn positioning in the football position and avoiding picking up the baby from under the axillae or by pulling on the arms.

Facial Palsy

Pressure on the facial nerve (cranial nerve VII) during birth may result in injury. Most noticeable when the newborn cries.

Clinical Manifestation of Facial Palsy

The primary clinical manifestations are loss of movement on the affected side, such as an inability to completely close the eye, drooping of the mouth, and absence of wrinkling of the forehead and nasolabial fold The mouth is drawn to the unaffected side, wrinkles are deeper on the normal side, and the eye on the involved side remains open.

Often the condition is temporary, resolving within hours or days of birth. Permanent paralysis is rare.

Nursing Care of Neborn with Facial Palsy

Assisting the newborn to suck and helping the parent with feeding techniques.

The newborn may require gavage feeding to prevent aspiration.

Breastfeeding is not contraindicated, but the breastfeeding parent may need additional assistance to help the newborn latch on to the breast.

If the eyelid on the affected side does not close completely, artificial tears can be instilled daily to prevent drying of the conjunctiva, sclera, and cornea. The lid may be taped shut to prevent accidental injury.

Phreni nerve Paralysis

Results in diaphragmatic paralysis. Ultrasonography shows paradoxical chest movement and an elevated diaphragm

Diaphragmatic paralysis often occurs in conjuction with brachial palsy

Usually unilateral, the lung on the affected side does not expand and respiratory efforts are ineffective.

Signs of Possible diaphragm injury

Cyanosis

Respiratory distress

Care for newborn with phrenic nerve paralysis

Same nursing care for infant in respiratory distress

What is hypoxic ischemic encephalopathy (HIE)?

Nonprogressive neurological (brain) impairment caused by intrauterine or postnatal asphyxia resulting in hypoxemia or cerebral ischemia

Hypoxic-ischemic encephalopathy—the resultant cellular damage that causes the clinical manifestations

Hypoxic-Ischemic Encephalopathy

Considered a form of brain injury stemming from perinatal complications Acute placental bleeding or maternal conditions that contribute to placental insufficiency, umbilical cord accidents, abnormal fetal presentation, or prolonged late stages of labour are several factors that may be associated with a reduction in oxygen delivery to the fetus.

Sentinel events including maternal amniotic fluid embolism or uterine rupture are related to moderate or severe __________.

Total body therapeutic hypothermia

Total Body Therapeutic Hypothermia

Provides a mechanism for neuroprotection and reduces the severity of the brain injury in HIE, leading to improved neurological outcomes for many newborns.

Initiation of total body cooling needs to occur in the early stages of injury (first 6 hours after birth) for infants who meet all eligibility criteria

Eligibility Criteria for Total body therapeutic hypothermia

•Gestational age greater than 35 weeks

• Less than 6 hours postnatal age

• Cord or postnatal gas within 1 hour of birth with pH less than 7.0

OR base deficit greater than –16 OR

• APGAR score of 5 or less at 10 minutes and continued need for ventilation

or resuscitation at 10 minutes

• Signs of moderate or severe encephalopathy

Clinical Manifestations of Hypoxic Ischemic Brain Injury

Appears within first 6–12 hours after hypoxic episode

Seizures

Abnormal muscle tone (usually hypotonia)

Disturbance of sucking and swallowing

Apneic episodes

Stupor or coma

Muscular weakness in hips and shoulders (full term), lower-limb weakness (preterm)

Therapeutic Management of Hypoxic Ischemic Brain Injury

Prevent hypoxia.

Provide supportive care.

Provide adequate ventilation.

Maintain cerebral perfusion.

Prevent cerebral edema.

Treat underlying cause.

Administer antiseizure medications.

Initiate therapeutic hypothermia if criteria met.

Germinal Matrix or Intraventricular Hemmorrhage

Hemorrhage into and around ventricles caused by ruptured vessels as a result of an event that increases cerebral blood flow to area

Clinical Manifestation of Intraventricular Hemmorrhage

Most bleeds are initially asymptomatic.

Sudden deterioration in condition if bleed is large:

• Oxygen desaturation

• Bradycardia

• Hypotonia

• Metabolic acidosis

• Shock

• Significant drop in hematocrit

• Tense anterior fontanel

Signs of worsening

hemorrhage:

• Twitching

• Decreased level of

consciousness, stupor

• Apnea

• Seizures

• Full, tense fontanels

Evident on cranial

ultrasonography or

magnetic resonance

imaging

Therapeutic Management of Intraventricular Hemmorrhage

Provide supportive care.

Provide ventilatory support.

Maintain oxygenation.

Regulate fluid, electrolytes, acid–base balance.

Suppress or prevent seizures.

Provide ventricular shunting or drainage of cerebrospinal fluid

Care Management of Intraventricular Hemmorhage

Prevent increased cerebral blood pressure.

Avoid events that may increase or decrease cerebral blood flow (e.g., pain, unnecessary stimulation, endotracheal suctioning, hypoxia, hyperosmolar medications, rapid volume expansion).

Elevate head of bed 20–30 degrees; keep head in midline.

Support family.

Monitor for posthemorrhagic ventricular dilatation after diagnosis.

Provide developmental care and enhancement

What are the two types of newborn infections?

Early onset and late onset infections.

Early Onset Infections

Usually manifests within 72 hrs of birth and often within first 24 hrs of life.

Acquired by vertical transmission through amniotic fluid infection ir from bacterial flora within the mother’s anogenital tract during vaginal birth.

Caused by E-coli, S. aureus, enterococci, Klebsiella, Citrobacter, Enterobacterm, and Streptococcus viridians.

Other pathogens harbored in the vagina include gonococci, Candida albicansm, HSV type 2, and Chlamydia

Associated with Obstetric events such as preterm labour, prolonged rupture of membrane, maternal fever during labour and chorioamnioitis.

Late Onset Infections

Occurs after 72 hrs

Considered to be primarily an infection acquired through the infant’s environment.

Organisms include coagulase-negative staphylococci, Staphylococcus aureus, Klebsiella organisms, enterococci, Pseudomonas, and Candida species.

GBS and E. coli, also frequently identified in ____________, are commonly found to be the cause of septicemia in extremely-low-birth-weight (ELBW) and VLBW infants residing in the neonatal intensive care unit (NICU).

Most common Bacterial organism in preterm infants

E. Coli

Most common bacterial organisms in term infants

Group B Streptococci

Earliest Clinical Signs of Newborn Sepsis

Characterized by lack of specificity

Lethargy, poor feeding, poor weight, and irritability.

The nurse/ parent may simply note that the newborn is not doing as well as before

Sequelae to Septicemia in Newborn

Icludes

Meningitis

Disseminated Intravascular Coagulation

Pneumonia

Septic Shock

Most Common Signs of Septic Shock

Decreasing oxygen saturation

Respiratory distress

Tachycardia

Evolving features of hemodynamic instability with reduced cardiac output (Prolonged capillary refill, cool extremities, motttling, reduced urine output)

What is the TORCH complex?

Stands for a group of infectious diseases that may contribute to newborn illness and negative long-term sequelae

To determine the causative agent in a symptomatic newborn, tests are performed to rule out each of these infections. The O category may involve testing for several viral infections (e.g., HBV, varicella zoster, measles, mumps, HIV, syphilis, and human parvovirus).

Bacterial infections are not included in the TORCH workup because they are usually identified by clinical manifestations and readily available laboratory tests.

T

Toxoplasmosis

O

Other: HBV, Parvovirus, HIV, West nile

R

Rubella

C

Cytomegalovirus (CMV) Infection

Leading infectious cause of hearing impairment and cognitive delay in infants and children; there is no effective and safe immunization against CMV

Transmitted during the perinatal period

Newborns with congenital CMV may experience intrauterine growth restriction, microcephaly, hepatosplenomegaly, thrombocytopenia, and/or jaundice at birth.

Hearing impairment may not be apparent until after the first year of life

Approximately 20 to 30% of symptomatic infants will die of DIC and liver dysfunction

H

Herpes Simplex

What are the prevention methods for Toxoplasmosis?

Avoid consuming raw or poorly cooked meat, avoid contact with cat feces, and wash vegetables thoroughly.

What are the risks associated with Group B Streptococcus (GBS) in pregnant women?

Can cause urinary tract infections, chorioamnionitis, endometritis, pneumonia, and meningitis.

What is the significance of screening for Hepatitis B in pregnant women?

It allows for early intervention to prevent transmission to the neonate.

What is the risk of chronic Hepatitis B infection in neonates compared to adults?

90% risk in neonates versus 1-5% risk in adults.

What are the steps to prevent HIV transmission from mother to child?

Test mothers for HIV, start antiretrovirals if positive, manage delivery based on viral load, and administer AZT to the baby.

What are the classic symptoms of Congenital Rubella Syndrome (CRS)?

Deafness, cataracts, and cardiac lesions.

What is the most common congenital viral infection?

Cytomegalovirus (CMV).

What are the treatment options for neonatal herpes simplex virus (HSV) infection?

IV Acyclovir and supportive care.

What is the Finnegan Neonatal Abstinence Scoring System used for?

To assess the severity of neonatal abstinence syndrome (NAS) due to opioid exposure.

What are some common congenital anomalies in newborns?

Congenital heart disease, abdominal wall defects, imperforate anus, neural tube defects, cleft lip or palate, clubfoot, and developmental dysplasia of the hip.

What is the most common STI that can affect newborns?

Chlamydia trachomatis.

What are the potential effects of untreated syphilis in pregnant women?

High risk of congenital syphilis transmission, fetal death, and other complications.

What is the treatment for neonatal conjunctivitis caused by Neisseria gonorrhea?

Ceftriaxone or cefotaxime.

What is congenital varicella syndrome (CVS)?

A condition resulting from intrauterine exposure to varicella, affecting infants if maternal infection occurs close to delivery.

What are the features of congenital Zika syndrome (CZS)?

Microcephaly, incomplete brain development, increased muscle tone, club foot, and visual problems.

What is the primary treatment for congenital syphilis?

IV penicillin.

What are the non-pharmacological interventions for managing neonatal abstinence syndrome?

Reducing environmental stimuli, swaddling, rocking, feeding on demand, and clustering care.