Alterations Newborn

Essential Transitions and Alterations in Early Newborn Life

• Upon birth, a newborn must successfully transition to extra-uterine life by achieving several critical physiological milestones:

  • Maintaining body heat to prevent cold stress.

  • Initiating and maintaining effective respiratory function.

  • Mitigating the risk of infection.

  • Establishing appropriate nutrition and hydration routines.

Neonatal Abstinence Syndrome (NAS)

• Definition: A clinical result of the sudden discontinuation of fetal exposure to substances utilized or abused by the pregnant mother.

• Pathophysiology: While the underlying mechanisms are not fully understood, newborns of women who use tobacco, illicit substances, caffeine, or alcohol can exhibit withdrawal behaviors.

• Statistics and Risks:

  • Approximately $60$% of exposed newborns will exhibit symptoms of withdrawal.

  • Virtually all drugs—including prescription narcotics—can have adverse effects on the fetus.

  • Maternal drug use is often associated with a lack of prenatal care and poor dietary habits.

  • Associated maternal outcomes include an increased likelihood of preterm delivery and infants with birth defects.

  • Long-term impacts for the child include learning and behavior problems, slower physical growth, and lower IQ.

Assessment and Manifestations of NAS

• Identification of At-Risk Infants:

  • Requires a comprehensive prenatal and drug history.

  • Toxicology screens are conducted for the mother during pregnancy.

  • Urine and meconium Drug of Abuse (DOA) screens are utilized for the newborn.

• Timing of Symptoms:

  • Symptoms may emerge as early as $24-48$ hours or as late as $5-10$ days postpartum.

  • Most facilities mandate a minimum assessment period of a 5-day observation stay for all NAS-eligible infants.

• Clinical Manifestations:

  • Central Nervous System (CNS) Dysfunction: Tremors, hypersensitivity, irritability, abnormal cry patterns, restlessness, and seizures (late-stage).

  • Metabolic, Vasomotor, and Respiratory Disturbances: Respiratory distress, fever, yawning, sneezing, sweating, hypertension, and tachycardia.

  • Gastrointestinal (GI) Dysfunction: Feeding difficulties, poor weight gain, loose watery stools, vomiting, and excessive weight loss.

  • Specific physical signs: High-pitched cry, hyperirritability, sleep deprivation or fragmentation, tachypnea, excessive suck, hyperthermia, hypertonia, and excoriation (e.g., around the chin).

The Finnegan Scoring Tool

• The Finnegan scale is the most widely utilized instrument for assessing NAS.

• Characteristics of the tool:

  • Examines the $21$ most common signs of withdrawal.

  • Scoring is based on the severity of symptoms and signs.

  • Requires specific clinical training to ensure accuracy.

  • Subject to potential clinician bias and subjectivity.

  • Scores are the primary determinant for the initiation of pharmacological interventions.

Interventions for Neonatal Abstinence Syndrome

• Treatment protocols vary by medical facility and healthcare provider.

• Non-Pharmacologic Interventions (Initial Approach):

  • Rooming-in to provide frequent contact with parents.

  • Skin-to-skin contact, holding, and active soothing.

  • Swaddling to provide comfort and reduce overstimulation.

  • Maintaining a quiet, non-stimulating environment.

  • Close monitoring of caloric intake.

• Pharmacologic Interventions:

  • Indicated when NAS scores are high or symptoms become severe.

  • Medications used: Morphine, methadone, and/or phenobarbital.

  • Strategy involves minimal dosing until the infant is less symptomatic, followed by a gradual weaning of the medication while continuing to monitor Finnegan scores.

Hyperbilirubinemia (Neonatal Jaundice)

• Definition: An elevation of serum bilirubin levels leading to jaundice, which is a yellowish discoloration of the skin and the sclera of the eyes.

• Progression: Jaundice typically begins on the head and progresses downward (cephalocaudal) toward the thorax, abdomen, and extremities.

• Background: It is commonly caused by the natural breakdown of Red Blood Cells (RBCs) after birth.

• Critical Note: Jaundice is never considered normal if it appears within the first $24$ hours of life.

Physiological vs. Pathological Jaundice

• Physiological Jaundice:

  • Generally considered benign.

  • Typically peaks between day $3$ and day $5$ of life.

  • Result of normal newborn physiology, specifically an imbalance between the rate of bilirubin production and the rate of elimination.

• Pathological Jaundice:

  • Result of an underlying pathological problem.

  • Common causes: Blood group incompatibility (e.g., Rh or ABO), infection, or RBC disorders.

  • Clinically visible either at birth or within the first $24$ hours of life.

Risks and Complications of Hyperbilirubinemia

• Predisposing Factors for Physiological Jaundice:

  • Polycythemia.

  • Blood incompatibility.

  • Cephalohematoma or bruising.

  • Poor feeding and delayed meconium passage.

  • Prematurity.

  • Infection.

  • Delayed cord clamping.

  • Sibling history of jaundice.

  • Trisomy 21.

• Kernicterus (Untreated Bilirubin Toxicity):

  • An abnormal accumulation of unconjugated bilirubin in brain cells.

  • Bilirubin becomes toxic to brain tissue once it accumulates, resulting in permanent neurological disorders.

  • Outcomes of Kernicterus: Deafness, delayed motor skills, hypotonia, and intellectual deficits.

Assessment and Management of Jaundice

• Nursing Assessment:

  • Observe skin, mucous membranes, and sclera for yellow tint.

  • Monitor vital signs and Intake/Output (I&Os).

  • Verify blood group and Rh factor.

  • Conduct Transcutaneous Bilirubin (TCB) or serum bilirubin tests.

  • Utilize tools like bilitool.org to plot bilirubin level relative to postnatal age (in hours) to determine risk zones (Low, Low Intermediate, High Intermediate, High).

• Interventions:

  • Use of phototherapy (lamp or blanket) as ordered.

  • Newborn should wear only a diaper and an eye mask for maximum exposure.

  • Remove the infant only for feedings and blood draws.

  • Monitor light intensity and observe for side effects of phototherapy.

  • Encourage parental interaction when the lights are turned off.

  • Order follow-up laboratory tests: Repeat bilirubin, reticulocyte count, and liver function tests.

Infants of Diabetic Mothers (IDM)

• Monitoring: Comprehensive monitoring during pregnancy is essential. Post-birth, IDMs require blood glucose monitoring for at least the first $12-24$ hours.

• Classification of Infants:

  • Large for Gestational Age (LGA): Weight > $90^{th}$ percentile for gestational age.

  • Small for Gestational Age (SGA): Weight < $10^{th}$ percentile for gestational age.

• Neonatal Hypoglycemia:

  • Defined as a blood glucose level lower than $40\,mg/dL$ (or $2.6\,mmol/L$).

  • Other high-risk groups requiring screening: SGA infants, post-term infants, infants experiencing fetal distress or infection.

• Risks and Characteristics of IDM:

  • Macrosomia: Resulting from high levels of maternal glucose entering fetal circulation.

  • Physical signs: Ruddy skin color, excessive adipose tissue, large umbilical cord and placenta, and decreased total body water.

  • Associated risks: Stillbirth, birth injury, respiratory distress, and brain injury due to hypoglycemia.

• Hypoglycemia Symptoms: Lethargy, temperature instability, apnea, and difficulty feeding.

Management and Emergency Protocol for Hypoglycemia

• Interventions:

  • Screen for risk factors and clinical signs (respiratory distress, birth trauma).

  • Frequent blood glucose monitoring per facility protocol.

  • Provide early and frequent feedings.

  • Maintain a neutral thermal environment to reduce metabolic energy needs.

• Clinical Treatment Pathway (Blood Sugar Level < $2.6\,mmol/L$):

  • If BSL < $2.6\,mmol/L$ without signs: Feed enterally and retest BSL after one hour.

  • If BSL remains < $2.6\,mmol/L$ after feeding: Use buccal glucose gel and increase feed by $20\,ml/kg/day$.

  • If BSL < $2.6\,mmol/L$ with clinical signs (sepsis, HIE) or BSL is $1.0\,mmol/L$/unrecordable: Administer IV bolus of $10$% Dextrose at $2\,mL/kg$, then commence IV infusion of $10$% Dextrose.

  • If BSL remains low on IV: Increase IV infusion by $20\,ml/kg/day$ and monitor serum sodium levels.

  • If further BSL gains are needed: Increase Dextrose concentration to $12.5$% then $15$%. Note: A central line is required for concentrations exceeding $12.5$%.

  • Persistent Hypoglycemia: Administer Glucagon bolus IV at $0.02\,mg/kg$. If it continues, start a glucagon infusion and consider an endocrinology consultation.

The Preterm Infant

• Definition: An infant born at less than $37$ completed weeks of gestation.

• General Principles: The primary challenge is the variable maturity of all organ systems, with the degree of immaturity dependent on the exact gestational age.

• Respiratory and Cardiac Impact:

  • Inadequate surfactant production leading to Respiratory Distress Syndrome (RDS).

  • Risk of Patent Ductus Arteriosus (PDA).

• Thermoregulation Challenges:

  • Limited brown fat and liver glycogen stores.

  • Reduced ability to constrict peripheral vessels.

  • Thin skin increases heat loss.

• Gastrointestinal (GI) and Nutritional Impact:

  • Poor suck and swallow coordination.

  • Small stomach capacity.

  • High risk for Necrotizing Enterocolitis (NEC).

• Neurological and Behavioral Impact:

  • Brain growth is most rapid in the third trimester; preterm birth interrupts this.

  • Higher risk for intraventricular (IVH) and intracranial hemorrhage.

  • Manifested by hypotonia and delayed reactivity.

Nutritional Management and Long-term Needs for Preterm Infants

• Nutrition Methods:

  • Gavage Feeding: Utilized for infants with poor suck/swallow reflexes, those on ventilators, or ill babies. Provides minimal enteral nutrition.

  • Breastfeeding: Highly encouraged; mothers are supported in pumping to provide breast milk, as it is tolerated better than formula.

  • Bottle Feeding: Introduced gradually; assessed based on infant readiness and transitioned from gavage.

• Long-Term Morbidities and Concerns:

  • Higher rates of morbidity and mortality.

  • Retinopathy of Prematurity (ROP).

  • Deficits in speech, auditory, and neurological function.

• Nursing Implementation:

  • Primary focus on respiratory support and temperature regulation.

  • Maintain fluid and electrolyte balance.

  • Promote attachment between parents and the high-risk infant.

  • Provide special discharge instruction for parents (CPR, oxygen therapy, suctioning, developmental care).

Questions & Discussion

• NAS Case Example 1: A newborn exhibits a continuous high-pitched cry for 10 minutes, hyperactive Moro reflex, mild tremors when undisturbed, temperature of $37.4\,^{\circ}C$ ($99.3\,^{\circ}F$), frequent sneezing, multiple episodes of spitting up during and after feeds, and excoriation around the chin.

  • Question: What is the NAS score and anticipated intervention?

• NAS Case Example 2: A newborn exhibits excessive crying lasting 2-3 minutes, sleeps two hours after feedings, mild tremors only when moving from scale to crib, normal muscle tone, temperature of $36.8\,^{\circ}C$ ($98.2\,^{\circ}F$), and a normal respiratory rate with no retractions or nasal flaring.

  • Question: What is the NAS score and anticipated intervention?

• Hyperbilirubinemia Case Study: Michael is a $38\,4/7$ week neonate (30 hours old) weighing $7\,lbs\,14\,oz$. Apgars were 8 and 9. He has developed jaundice with a serum bilirubin of $16\,mg/dL$.

  • Question 1: What is jaundice, and why does it occur?

  • Question 2: What can result if jaundice is left untreated?

  • Question 3: Plot the results on Bilitool. Recommendations?

  • Question 4: What are the nursing interventions for Michael during phototherapy?

  • Question 5: What do you tell the parents regarding feedings for a breastfed baby under phototherapy?

• General Discussion Summary:

  • Preterm, late preterm, and high-risk infants must be observed for early symptoms of physiologic disorders.

  • Fetal distress in postmature infants is often linked to progressive placental insufficiency.

  • Adaptation for parents of high-risk infants differs significantly from parents of healthy term infants.