Complications in Newborns

Complications in the newborn period

Thermoregulation

Hypoglycemia

Hyperbilirubinemia

Less common...but important

◦ NAS

◦ Sepsis

◦ Prematurity

Thermoregulation Predisposing Factors to Heat Loss:

• Thin skin with blood vessels close to the surface

• Little subcutaneous (white) fat

• Newborns have 3x more surface area to body mass than the adults

• Rate of heat loss is 4x greater than that of adults

thermoregulation protective factor:

Flexed position reduces the amount of skin surface exposed and decreases heat loss

Signs of cold infant:

• Restlessness,

• Crying

• Increased flexion and activity

• Vasoconstriction → acrocyanosis

• Body metabolism rises → increased need for O2 and glucose

Thermogenesis Maintain a neutral thermal environment

• Undressed: 89.6F to 92.3F

• Dressed: 75.2F to 80.6F

Acrocyanosis

• Normal finding in newborns

• Caused by peripheral vasoconstriction

• Can be an early sign of cold stress

Non Shivering Thermogenesis (NST)

•Primary source of heat production

•Metabolism of brown fat/ brown adipose tissue) to produce heat

•Brown fat appears at 26-30 weeks and increases until 2-5 weeks afterbirth

•Newborns can increase heat production by 100% using this method

Nursing intervention

Dry off newborn

Place with parent skin/skin

Warm blankets w/swaddle

Warmers

◦ Incubator, radiant warming panel

◦ Monitor temp (36-36.5 C)

Hat on head

Environment

Risk factors of hypoglycemia

• Pre-term, Post term

• SGA, LGA

• IUGR

• Maternal gestational diabetes

• Cold stress

• Asphyxia/fetal distress

signs of hypoglycemia

• Jitteriness

• Irritability

hypoglycemia treatment

• Feedings

• Glucose gel or fluids D10, D20

• Frequent checks

• Protocols

A laboring person at 37w1d is being induced for gestational hypertension and concern for IUGR. She is pushing and her baby has had some late decelerations.

1. Name 2-3 things you are concerned about for this baby and why?

• later deceleration → placenta insufficiency

• HTN

• induce

The 37w 1d baby is born and at 1 minute is vigorous/active at birth, a good cry, pink body with blue extremities, responding to stimulation and HR 120 bpm. The NNP is okay with the baby staying with the parents as long as it can be closely monitored.

2. What is the baby’s APGAR score?

3. How as a nurse would you promote thermoregulation?

• 9

• skin-to-skin, warmer, blankets

You notice after an hour the baby's respiratory rate has increased from 58 to 72 bpm and has a weak cry.

4. Are these signs or symptoms that are concerning? What might they indicate?

5. What nursing interventions would you initiate?

• Concerning vitals and grimace → fetal distress

• reassessment, skin-to-skin, swaddle

It has been 1 hours since the infant’s birth and the birthing parent has tried

several times to get the baby to breastfeed. The infant has only taken a few

sucks at the breast but then continues to turn sleepy. The birthing parent then

calls the nurse in to let them know that their baby now appears to be jittery.

6. Do you think we need to be checking this baby’s blood glucose levels? Why?

7. What if the mom had gestational diabetes? Explain how that adds extra risk?

8. If blood glucose is 38 mg/dL, how might you treat the infant’s hypoglycemia ?

• yes the baby is jittery and that is sign of hypoglycemia

• risk of hypoglycemia. The baby is used to all the glucose in the mother's stomach so the baby overproduces insulin. 

• Stimulate the baby to eat, then recheck glucose. if it doesn't work, check protocol and get an IV and glucose. 

Hyperbilirubinemia (jaundice)

• Primary source of bilirubin is hemolysis of fetal Red Blood Cells

• Unconjugated bilirubin is toxic to the body and must be excreted

• This is fat soluble → absorbed by subQ fat → causes jaundice →

• Can lead to accumulation in brain tissue → bilirubin encephalopathy →

permanent neurologic injury called kernicterus

• Unconjugated bilirubin is not soluble in water, in order to be excreted it

must be conjugated to water soluble form (conjugation)

Hyperbilirubinemia diagnosis physical exam

signs of jaundice

Hyperbilirubinemia diagnosis lab testing

Total Serum Bilirubin

• A TSB level above 12 mg/dL in the first 48-72 hours of life can be a

concern.

• A level exceeding 15 mg/dL in the first week of life warrants attention.

Physiologic Jaundice

Transient hyperbilirubinemia

• Normal process

• Occurs 2-4 days after birth, when bilirubin level peaks at 5-6 mg/dL,

and then the levels begin to fall by days 5-7

• Occurs in 50% of term and 80% of preterm newborns

When does physiologic jaundice occur?

2-4 days after birth

Peak levels of bilirubin

5-6 mg/dL

risks of early-onset breastfeeding jaundice

• sleepy

• poor suck

• nurse infrequently

• BF babies are more likely to develop moderate jaundice or severe jaundice

interventions Early-Onset Breastfeeding jaundice

helping the parent with breastfeeding to stimulate milk production and increase the infant’s intake

what is early-onset breastfeeding jaundice due to?

due to insufficient fluid intake

when does Early-Onset Breastfeeding jaundice occur

first weeks of life

When does Late-Onset Breastfeeding jaundice occur?

lasts 3 weeks to 3 months

Late-Onset Breastfeeding jaundice

Substances in maternal milk may increase absorption of bilirubin from the intestine or interfere with conjugation.

Late-Onset Breastfeeding jaundice treatment

• Close monitoring of total serum bilirubin (TSB)

• Goal is at least 8-12 feedings in 24 hours

• If TSB levels rise too high, phototherapy is begun; breastfeeding is typically continued to be recommended

When does pathologic jaundice usually appear?

24 h of birth

A result of excessive destruction of RBCS or problems in bilirubin conjugation; some examples include

• Sepsis (infection interferes with conjugation)

• Blood incompatibilities

• Metabolic disorders

• Increased hemolysis of RBCs (ex: bruising, cephalohematoma from birth process)

pathologic jaundice

Jaundice that is not physiologic or related to breastfeeding

Hyperbilirubinemia Management :

• Treatment may be inpatient or outpatient

• Phototherapy

• If severe, transfer to NICU

• Exchanged transfusion

Sepsis occurance

Typically in first 72 hours, may occur up to 90 days

Sepsis risk factors in birthing person

• Prolonged rupture of membranes

• GBS positive

• Other infections (ex:chorio)

poor hand hygiene 

Sepsis risk factors in newborn

• SGA

• Prematurity

• Meconium aspiration

poor hand hygiene 

Sepsis signs

• Respiratory distress

• tachycardia

• Abdominal distension (always a worry sign)

Sepsis Nursing interventions

• Early identification of maternal and infant risk factors

• Hand hygiene

• Education to parents on infection risk and reduction

• Follow monitoring guidelines

• Labs as indicated (including cultures)

• **Administer antibiotics as ordered (within an hour)

• Prepare for increased support:

• Respiratory

• Feedings/fluids

• Glucose

• Temperature

Acute Respiratory Distress

• Transient Tachypnea of the Newborn

• Respiratory Distress Syndrome

Acute Respiratory Distress signs

• Rapid breathing rate: More than 60 breaths per minute

• Grunting: A low-pitched sound made when the baby exhales

• Nasal flaring: The nostrils widen with each breath

• Retractions: Skin pulling in between the ribs or under the breastbone with each breath

• Cyanosis: Bluish tint to the skin, especially around the lips and nose

• May have difficulty feeding: Due to rapid breathing and grunting, the baby may have trouble coordinating feeding

• Mild lethargy: The baby may appear less active than usual

Neonatal Abstinence Syndrome (NAS) Signs

• Fussiness

• High pitched cry

• Jittery, hyper-reactive

• Poor feeding

• Blotchy, mottled

• Uncoordinated suck/swallow

• Diarrhea

Neonatal Abstinence Syndrome (NAS) medication

• Methadone or morphine (long half life, less dosing)

• Benzodiazepines

• Phenobarbitol

Neonatal Abstinence Syndrome (NAS) non-medicine 

• Co-rooming

• Skin to skin

• Swaddle/hold

• Low lights, quiet room

• Feed early

• Allow for soothing (pacifier, finger)

• Limit visitors

level I nursery 

normal newborn

level II nursery

Special Care >32 weeks

◦ A - no respiratory support

◦ B- Non invasive respiratory support

level III nursery

NICU >27 weeks

◦ Respiratory support

◦ IV fluids/TPN

Level IV nursery

early preterm 22-28 weeks

◦ ECMO

Prematurity

Underdeveloped organ systems. Typically require advanced respiratory and nutritional support.

Prematurity increased for common issues

◦ Hyperbilirubinemia

◦ Thermoregulation issues

◦ Hypoglycemia

◦ Sepsis

Prematurity at risk for more serious issues

• Respiratory Distress Syndrome (RDS)

• Pulmonary Hypertension

• Retinopathy of Prematurity(ROP)

• Necrotizing Enterocolitis (NEC)

• Intraventricular hemorrhage (IVH)

• Broncholpulmonary Dysplasia (BPD)

A 25-year-old G1 P1 has a precipitous delivery in the ER with a 35- and 2-day old infant. At the birth the medical team notes that the amniotic fluid is meconium stained. The team brings the infant to the level 2 nursery.

1. What neonatal complications is this infant at risk for?

meconium aspiration syndrome

A 25-year-old G1 P1 has a precipitous delivery in the ER with a 35- and 2-

day old infant. At the birth the medical team notes that the amniotic fluid is

meconium stained. The team brings the infant to the level 2 nursery.

2. Describe the nursing assessment you would complete as the nurse who

admits this infant to the special care nursery.

Vitals- RR, HR, Vital, temp

Glucose

feeding and gastrointesinal

maternal hx

physical examination

A 25-year-old G1 P1 has a precipitous delivery in the ER with a 35- and 2-

day old infant. At the birth the medical team notes that the amniotic fluid is

meconium stained. The team brings the infant to the level 2 nursery.

3. What interventions might be done for this infant to prevent:

• Cold stress

• Hypoglycemia

• Jaundice

• How could they be interrelated?

• Cold stress: skin-to-skin, swaddle, temp warmer

• Hypoglycemia: monitor feedings, glucose levels, latching and breastfeeding

• Jaundice: feeding, monitor bilirubin levels, hydration and phototherapy

vicious cycle on vulnerable infants

The infant's blood sugar was low the next day (35) so the infant was

placed on monitors and as the nurse was hanging the fluids (D10),

took the infants temperature 35.8 C. The nurse then notes the baby

starting to make a grunting noise and RR is 65.

4. What might be going on with this infant?

The infant is showing signs of clinical deterioration, likely due to cold stress, hypoglycemia, and developing respiratory distress—possibly from respiratory distress syndrome, meconium aspiration, or early-onset sepsis. These conditions are interrelated and require immediate intervention to stabilize temperature, correct blood glucose, support breathing, and notify the provider.

The infant's blood sugar was low the next day (35) so the infant was

placed on monitors and as the nurse was hanging the fluids (D10),

took the infants temperature 35.8 C. The nurse then notes the baby

starting to make a grunting noise and RR is 65.

5. What maternal risk factors make this infant at risk for infection?

The infant is at risk for infection due to preterm birth, meconium-stained fluid, and precipitous delivery, which may have limited infection prevention and increased exposure to pathogens.

The infant's blood sugar was low the next day (35) so the infant was

placed on monitors and as the nurse was hanging the fluids (D10),

took the infants temperature 35.8 C. The nurse then notes the baby

starting to make a grunting noise and RR is 65.

6. Could this infant be developing in RDS or TTN? What is the difference?

Yes, the infant could be developing RDS or TTN. RDS is caused by surfactant deficiency and typically affects preterm infants, while TTN is due to delayed lung fluid clearance and usually resolves faster; clinical course and imaging help distinguish them.

The infant's blood sugar was low the next day (35) so the infant was

placed on monitors and as the nurse was hanging the fluids (D10),

took the infants temperature 35.8 C. The nurse then notes the baby

starting to make a grunting noise and RR is 65.

7. What are some nursing interventions/treatments for this condition?

antibiotics

The infant's blood sugar was low the next day (35) so the infant was

placed on monitors and as the nurse was hanging the fluids (D10),

took the infants temperature 35.8 C. The nurse then notes the baby

starting to make a grunting noise and RR is 65.

8. How as a nurse could you support the family and the premature infant in

the level 2 care?

Explain what’s going on. Make sure birthing parent gets all their basic needs.