Module 8 MCN lab 2
Kernicterus
"_________________" refers to the neurologic consequences of the deposition of unconjugated bilirubin in brain tissue. Subsequent damage and scarring of the basal ganglia and brainstem nuclei may occur".
Sclerema
- hide like character of skin, skin stretched over underlying structures, becomes unpingable, starts over face and legs and advances centripetally, if skin over the chest is involved breathing becomes shallow and rapid.
Bilirubin, insoluble
_______________ is the final product of heme degradation. At physiologic pH, bilirubin is _____________ in plasma and requires protein binding with albumin. After conjugation in the liver, it is excreted in bile
fiber optic blanket
A ___________________ is another form of phototherapy. The blanket is usually put under the baby. It may be used alone or with regular phototherapy.
pathologic, 24, 5 mg/dl per day, 17 mg/dL, 2 mg/dL
All etiologies of jaundice beyond physiologic and breastfeeding or breast milk jaundice are considered ________________. Features of ________________ jaundice include the appearance of jaundice within _____ hours after birth, a rapidly rising total serum bilirubin concentration (increase of more than ____ mg per dL per day), and a total serum bilirubin level higher than _____ mg per dL in a full-term newborn. Other features of concern include prolonged jaundice, evidence of underlying illness, and elevation of the serum conjugated bilirubin level to greater than ___ mg per dL or more than 20 percent of the total serum bilirubin concentration.
group B streptococcus
Although universal screening and intrapartum antibiotic prophylaxis for ______________________ have significantly decreased the rate of early-onset disease due to this organism, the rate of late-onset GBS sepsis has remained unchanged, which is consistent with the hypothesis that late-onset disease is usually acquired from the environment.
polymorphonuclear leukocytes
Because of large numbers of circulating bacteria, organisms can sometimes be seen in or associated with ____________________________ by applying Gram stain, methylene blue, or acridine orange to the buffy coat. Regardless of the results of the CBC or LP, in all neonates with suspected sepsis (eg, those who look sick or are febrile or hypothermic), antibiotics should be started immediately after cultures (eg, blood and CSF [if possible]) are taken.
12 mg/dL, 2 mg/dL, 17 mg/dL
Bilirubin elevations of up to ____ mg per dL, with less than ___ mg per dL (34 μ mol per L) of the conjugated form, can sometimes occur. Infants with multiple risk factors may develop an exaggerated form of physiologic jaundice in which the total serum bilirubin level may rise as high as ____ mg per dL (291 μ mol per L)
1. Fetal heart rate should be monitored to determine the sign of fetal distress. 2. Babies born to mothers with meconium stained liquor should have oropharyngeal suction before the delivery of the shoulder. 3. Timing and mode of delivery 4. Pregnancy that crosses the date should be induced as early as 41weeks which helps to prevent MAS by avoiding passage of meconium
NURSING INTERVENTIONS: INTRAPARTUM PERIOD (MAS)
vasospasm, hypertrophy
Aspirated meconium leads to ______________, _______________ of the pulmonary arterial musculature, and pulmonary hypertension that lead to extra pulmonary right- to -left shunting through the ductus arteriosus or the foramen ovale and results in worsened ventilation, leading to severe arterial hypoxemia .
> Lethargy > jaundice > Poor Feeding > High-pitched Cry > Hypotonia > Yellow sclera
SIGNS AND SYMPTOMS: of EARLY Hemolytic jaundice:
aerobic and anaerobic, 1.0 mL, < 2 mL, LP, renal mycetoma
Blood should be cultured for both ___________ and ____________ organisms. However, the minimum amount of blood per blood culture bottle is _____ mL; if < _____ mL is obtained, it should all be placed in a single aerobic blood culture bottle. If catheter-associated sepsis is suspected, a culture specimen should be obtained through the catheter as well as peripherally. In > 90% of positive bacterial blood cultures, growth occurs within 48 hours of incubation. Data on capillary blood cultures are insufficient to recommend them. Candida species grow in blood cultures and on blood agar plates, but if other fungi are suspected, a fungal culture medium should be used. For species other than Candida, fungal blood cultures may require 4 to 5 days of incubation before becoming positive and may be negative even in obviously disseminated disease. Proof of colonization (in mouth or stool or on skin) may be helpful before culture results are available. Neonates with candidemia should undergo ____ to identify candidal meningitis. Indirect ophthalmoscopy with dilation of the pupils is done to identify retinal candidal lesions. Renal ultrasonography is done to detect __________________.
Early-Onset Breastfeeding Jaundice, caloric deprivation, three to six, 12 mg/dL, 15 mg/dL
Breast-fed newborns may be at increased risk for _______-onset exaggerated physiologic jaundice because of relative ___________________ in the first few days of life. Decreased volume and frequency of feedings may result in mild dehydration and the delayed passage of meconium. Compared with formula-fed newborns, breastfed infants are _______ to ______ times more likely to experience moderate jaundice (total serum bilirubin level above ____ mg per dL) or severe jaundice (total serum bilirubin level above ____ mg per dL [257 μ mol per L]).
Pneumothorax PPHN( persistent pulmonary hypertension)
Complications of MAS:
PPHN( persistent pulmonary hypertension)
Complications of MAS: High blood pressure in the vessels of the lungs restricts blood flow and makes it difficult for newborn to breathe properly.
Pneumothorax
Complications of MAS: accumulation of meconium which can block the airways, can cause lung over expansion. If a lung over expands or inflates too much, it can rupture or collapse. Then air from inside the lung can accumulate in the chest cavity and around the lung, making it difficult to reinflate the lung.
● Infant death: in term and late preterm infants, the rate of mortality from neonatal sepsis has been estimated at around two to four percent ● Meningitis ● Developmental Delays ● Cerebral Palsy
Complications of Neonatal Sepsis If given prompt and proper treatment, babies with neonatal sepsis will likely recover with no lasting health issues (4). However, there are several very serious birth injuries/complications that may result from neonatal sepsis. These issues are more likely to arise when sepsis goes undiagnosed or is improperly treated:
Acute bilirubin encephalopathy Kernicterus
Complications of hemolytic jaundice: High levels of bilirubin that cause severe jaundice can result in serious complications if not treated.
transcutaneous bilirubinometer
Diagnosing neonatal jaundice: Skin test with a device called a __________________, which measures the reflection of a special light shone through the skin. This method is noninvasive and is based on the principle of multi wavelength spectral reflectance from the bilirubin staining in the skin. The accuracy of the instrument may be affected by variation of skin pigmentation and its thickness. > It is a hand-held device that measures the amount of bilirubin in the skin.
dermal icterus, 12
Diagnosis of hyperbilirubinemia (Physical Exam): The only consistently reliable estimation of total serum bilirubin occurs when ______________ is confined to above the nipple line. In this situation, the bilirubin level is invariably below ____ mg per dL. As jaundice extends below the middle of the chest, the correlation between physical signs and measured bilirubin levels becomes increasingly unreliable. Differences in skin color among races, delays in dermal deposition with rapidly rising bilirubin levels, interobserver variability, and other factors contribute to the difficulty of accurately predicting the total serum bilirubin concentration based on caudal progression alone
blanching, Neonatal dermal icterus, 4
Diagnosis of hyperbilirubinemia (Physical Exam): The presence of jaundice can be determined by examining the infant in a well-lit room and ___________ the skin with digital pressure to reveal the color of the skin and subcutaneous tissue. ________________________ is not noticeable at total serum bilirubin levels below ___ mg per dL (68 μmol per L).
dermal icterus, 5, 10, 12, 15
Diagnosis of hyperbilirubinemia (Physical Exam): Increasing total serum bilirubin levels are accompanied by the cephalocaudal progression of ______________, predictably from the face to the trunk and extremities, and finally to the palms and soles. The total serum bilirubin level can be estimated clinically by the degree of caudal extension: face, ___ mg per dL; upper chest, ___ mg per dL (171 μmol per L); abdomen, ____ mg per dL; palms and soles, greater than ____ mg per dL.
A diagnosis is made based on your newborn's symptoms and the presence of meconium in the amniotic fluid. ● Pulse oximetry or blood gases will reveal poor gas exchange evidenced by a decreased P o2 and an increased P co2 . Blood gas test to evaluate oxygen and carbon dioxide levels, Arterial blood gases may demonstrate metabolic acidosis, hypoxia and in severe cases hypercapnia with mixed respiratory and metabolic acidosis. ● Chest X-ray to see if material has entered your newborn's lungs- Chest X-ray is characterized by bilateral hyperaeration due to obstructive emphysema and coarse nodular opacities due to areas of atelectasis and consolidation. Findings are bilateral non- non-uniform and asymmetric. Pulmonary leaks including pneumothorax commonly complicate the clinical picture . The diaphragm will be pushed downward by the overexpanded lungs.
Diagnostic Procedure for meconium aspiration syndrome
CBC, Differential count and Smear
Diagnostic Procedure for neonatal sepsis:
> Irritability > opisthotonos > Seizure > Apnea > Hypertonia > Fever
SIGNS AND SYMPTOMS: of Late Hemolytic jaundice: :
total white blood cell count, absolute band count, 0.16, 6
Diagnostic Procedure for neonatal sepsis: The ________________________________ and _______________________ in neonates are poor predictors of early-onset sepsis. However, an elevated ratio of immature: total polymorphonuclear leukocytes of > ________ is sensitive, and values below this cutoff have a high negative predictive value. However, specificity is poor; up to 50% of term neonates have an elevated ratio. Values obtained after ____ hours of life are more likely to be abnormal and clinically useful than those obtained immediately after birth. The platelet count may fall hours to days before the onset of clinical sepsis but more often remains elevated until a day or so after the neonate becomes ill. This fall is sometimes accompanied by other findings of DIC (eg, increased fibrin degradation products, decreased fibrinogen, prolonged international normalized ratio [INR]). Given the timing of these changes, the platelet count is not typically helpful in evaluating a neonate for sepsis.
it causes inflammation of bronchioles because it is a foreign substance, it can block small bronchioles by mechanical plugging, and it can cause a decrease in surfactant production through lung trauma
EFFECTS OF MECONIUM ASPIRATION TO THE BABY: Meconium can cause severe respiratory distress in three ways: _____________________________________, _______________________________, and ____________________________.
polycythemia, erythrocyte life span, hepatic uptake, conjugation processes, enterohepatic circulation
Factors that contribute to the development of physiologic hyperbilirubinemia in the neonate include an increased bilirubin load because of relative _________________, a shortened _________________________ (80 days compared with the adult 120 days), immature __________________ and ___________________, and increased __________________________.
breast milk jaundice, 48 hours, 3 mg
If the diagnosis of ____________________ is in doubt or the total serum bilirubin level becomes markedly elevated, breastfeeding may be temporarily interrupted, although the mother should continue to express breast milk to maintain production. With formula substitution, the total serum bilirubin level should decline rapidly over _____ hours (at a rate of ___ mg per dL [51 μ mol per L] per day), confirming the diagnosis. Breastfeeding may then be resumed.
stress
If the fetus experiences _________ before or during birth it may cause the fetus to pass meconium while still in the uterus, the fetus may then breathe the meconium and amniotic fluid mixture into fetal lungs shortly before, during, or right after birth. ________ often results when the amount of oxygen available to the fetus is reduced.
10, formula supplementation, water or dextrose-water administration, iatrogenic hyponatremia
In a breastfed newborn with early-onset hyperbilirubinemia, the frequency of feedings needs to be increased to more than ____ per day. If the infant has a decline in weight gain, delayed stooling, and continued poor caloric intake, _______________________ may be necessary, but breastfeeding should be continued to maintain breast milk production. Supplemental ______________________________ should be avoided, as it decreases breast milk production and places the newborn at risk for ____________________________.
C-section
It is critical that expectant mothers be given a clean place to deliver their baby, so that infections do not ascend the genital tract during birth. Additionally, doctors should be aware of how long it has been since a woman's membranes ruptured. Too long an interval between membrane rupture and birth can increase the risk of infection; in some cases, a ____________ delivery may be necessary.
Intravenous immunoglobulin (IVIg)
Jaundice may be related to blood type differences between mother and baby. This condition results in the baby carrying antibodies from the mother that contribute to the rapid breakdown of the baby's red blood cells. Intravenous transfusion of an ____________________ — a blood protein that can reduce levels of antibodies — may decrease jaundice and lessen the need for an exchange transfusion, although results are not conclusive.
● involuntary and uncontrolled movements (athetoid cerebral palsy), ● permanent upward gaze, ● hearing loss, and ● improper development of tooth enamel.
Kernicterus may result in:
bound
Laboratory test of a sample of baby's blood: Direct and indirect bilirubin levels. These levels show if bilirubin is ____________ with other substances in the child's liver. Normal physiologic jaundice has indirect bilirubin. Jaundice due to more serious problems can have high levels of either type of bilirubin.
sixth to 14th, 12 to 20 mg/dL
Late-Onset Breast Milk Jaundice: Breast milk jaundice occurs later in the newborn period, with the bilirubin level usually peaking in the _____th to ____th days of life. This late-onset jaundice may develop in up to one third of healthy breastfed infants. Total serum bilirubin levels vary from ____ to ____ mg per dL (340 μ mol per L) and are nonpathologic.
cytokines, ballvalve
Meconium may also stimulate the release of ______________ and vasoactive substances that result in cardiovascular and inflammatory responses in the fetus .Meconium itself ,or the resultant chemical pneumonitis, mechanically obstructs the small airways, causes atelectasis and a "____________" effect with resultant air trapping and possible air leak.
● Monitor Infants Condition (Apgar Score upon delivery of the baby ) ● Monitor Vital Signs ● Provide TSB if > 37.5 ⁰ C (Increased Body Temperature) ● Ensure that all equipment used for infant is sterile, scrupulously clean. Do not share equipment with other infants ● Assess skin for changes in color, temperature and moisture ● Provide a quiet, restful atmosphere ● Note quality and strength of peripheral pulses ● Assess respiratory rate, depth, and quality ● Provide a quiet, restful atmosphere ● Administer antipyretics as ordered
NURSING INTERVENTIONS neonatal sepsis:
● Continuously monitor the fetus for signs and symptoms of distress. • Immediately inspect any fluid passed with rupture of the membrane. • Assist with immediate endotracheal suctioning before the first breaths, as indicated. • Monitor lung status closely, including breath sounds and respiratory rate and character. • Frequently assess the neonate's vital signs. • Administer oxygen and respiratory support as ordered. •Warm and humidify oxygen • Institute measures to maintain a neutral thermal environment • Provide the family with emotional support and guidance.
NURSING INTERVENTIONS: DURING LABOR (MAS)
A. The infant should be monitored and observed carefully for signs of respiratory distress, i.e., cyanosis, tachypnea, retractions, and grunting. B. Arterial blood gases and pH should be monitored for evidence of either metabolic or respiratory acidosis. C. Obtain a chest x-ray to rule out air leak (pneumothorax) secondary to air trapping from ballvalve obstruction. D. An infant with a history of meconium aspiration who develops respiratory distress should be placed in a hood to maintain O2 saturations greater or equal to 99% to prevent episodes of hypoxia and shunting. E. Postural drainage should be done as clinically indicated. F. Consider intubation and suctioning below the cords in the nursery, since meconium can be removed from the upper airways even after the infant has initiated spontaneous respirations. G. If the infant experiences persistent respiratory distress after one-half hour of life, antibiotics should be started after first obtaining blood, tracheal aspirate, and CSF cultures. Urine, for Group B Strep, antibiotics should not be withheld while waiting for urine. H. Monitor the infant for pulmonary hypertension with evidence of right-to-left shunting. Maintain a temperature neutral environment to prevent the infant from having to increase metabolic oxygen demands. J. A chest physiotherapy with percussion and vibration may be helpful to encourage the removal of remnants of meconium from the lungs
NURSING INTERVENTIONS: AT BIRTH (MAS)
group B streptococcus, Nontypeable Haemophilus influenzae sepsis, Neisseria meningitidis, gonorrhea, N. gonorrhoeae
Neonatal sepsis: Most cases are caused by _____________________ (GBS) and gram-negative enteric organisms (predominantly Escherichia coli). Vaginal or rectal cultures of women at term may show GBS colonization rates of up to 35%. At least 35% of their infants also become colonized. The density of infant colonization determines the risk of earlyonset invasive disease, which is 40 times higher with heavy colonization. Although only 1/100 of infants colonized develop invasive disease due to GBS, > 50% of those present within the first 6 hours of life. _____________________________________ has also been identified in neonates, especially premature neonates. Other cases tend to be caused by gram-negative enteric bacilli (eg, Klebsiella species) and certain gram-positive organisms (Listeria monocytogenes, enterococci [eg, Enterococcus faecalis, E. faecium], group D streptococci [eg, Streptococcus bovis], alpha-hemolytic streptococci, and staphylococci). Also, S. pneumoniae, H. influenzae type b, and, less commonly, _________________________ have been isolated. Asymptomatic __________________ occurs occasionally in pregnancy, so ________________________ may rarely be a pathogen.
6 to 8 mg, 10 to 14 days
Newborns produce bilirubin at a rate of approximately _____________ per kg per day. This is more than twice the production rate in adults, primarily because of relative polycythemia and increased red blood cell turnover in neonates. Bilirubin production typically declines to the adult level within _____ to _____ days after birth.
sepsis, rubella, toxoplasmosis, occult hemorrhage, and erythroblastosis fetalis.
Pathologic causes include disorders such as ____________, _______________, ________________, ____________________, and ____________________________
lung surfactant, cholesterol and bile acid
Presence of meconium in the alveoli can inactivate____________________, impair pulmonary surfactant is due to combined action of _________________ and ________________ present in meconium. It may change the viscosity and decrease the levels of surfactant proteins. The surfactant dysfunction is enhanced by leakage of plasma protein through an injured alveolar-capillary membrane, as well as the proteolytic enzymes, and oxygen-free radical release from activated cells during the inflammation. This causes atelectasis of the lung and can increase ventilation perfusion mismatch.
The best preventive of infant jaundice is adequate feeding. Breast-fed infants should have eight to 12 feedings a day for the first several days of life. Formula-fed infants usually should have 1 to 2 ounces (about 30 to 60 milliliters) of formula every two to three hours for the first week.
Prevention of kernicterus:
● Blood type ABO or Rh incompatibility: If the mother's blood type is different from baby's, the baby may have received antibodies through the placenta that cause abnormally rapid breakdown of red blood cells, ● Breastfeeding: Breast-fed babies, particularly those who have difficulty nursing or getting enough nutrition from breast-feeding, are at higher risk of jaundice. Dehydration or a low caloric intake may contribute to the onset of jaundice. However, because of the benefits of breast-feeding, experts still recommend it. It's important to make sure your baby gets enough to eat and is adequately hydrated and ● Drugs: diazepam (Valium), oxytocin (Pitocin) ● Ethnicity: Asian, Native American: Studies show that babies of East Asian ancestry have an increased risk of developing jaundice. ● Maternal illness: gestational diabetes
RISK FACTORS FOR HYPERBILIRUBINEMIA: MATERNAL FACTOR:
● Birth trauma: cephalohematoma, cutaneous bruising, instrumented delivery: may have higher levels of bilirubin from the breakdown of more red blood cells, ● Drugs: sulfisoxazole acetyl with erythromycin ethylsuccinate (Pediazole), chloramphenicol (Chloromycetin) ● Excessive weight loss after birth ● Infections: TORCH ● Infrequent feedings ● Male gender ● Polycythemia ● Prematurity: A baby born before 38 weeks of gestation may not be able to process bilirubin as quickly as full-term babies do. Premature babies also may feed less and have fewer bowel movements, resulting in less bilirubin eliminated through stool, ● Previous sibling with hyperbilirubinemia ● internal bleeding (hemorrhage), ● infection in baby's blood (sepsis), ● other viral or bacterial infections, ● incompatibility between the mother's blood and the baby's blood, ● liver malfunction, ● biliary atresia, a condition in which the baby's bile ducts are blocked or scarred ● enzyme deficiency, and ● abnormality of baby's red blood cells that causes them to break down rapidly.
RISK FACTORS FOR HYPERBILIRUBINEMIA: NEONATAL FACTOR:
Post maturity Prolonged and obstructed delivery Maternal hypertension or diabetes mellitus Placental dysfunction and infection like chorioamnionitis Intrauterine growth retardation Umbilical cord complications Ageing of placenta Intrauterine fetal hypoxia Maternal heavy smoking Oligohydraminous Preeclampsia and eclampsia
Risk Factors of aspirated meconium:
● Prematurity ( single most significant risk factor ) ● Prolonged Rupture of membranes ● Maternal peripartum infection ● Fetal and intrapartum distress ( meconium staining, traumatic delivery ) ● Invasive procedures ● Metabolic factors ( hypoxia, acidosis, inherited metabolic disorders ) ● Previous delivery of a neonate with GBS disease ● Multiple Gestation
Risk Factors of late onset neonatal sepsis
● Rapid or labored breathing/Difficulty in breathing ● Intercostal lRetractions( pulling in of the chest wall) ● Grunting sounds with breathing ● cyanosis (Bluish skin color) ● Tachypnea ● flaring ● Barrel chest(increased anteroposterior diameter due to presence of air trapping) ● Auscultated rales and rhonchi ● Low apgar score ● yellowed skin and nails (Exposure to meconium in the amniotic fluid for a long time may cause yellowed skin and nails).
Sign & Symptoms of MAS:
The early diagnosis of NNS is difficult since most of the symptoms & signs are non specific. • The possibility of sepsis must be considered with any clinical deterioration unless the event is readily explained by other causes.
Sign & Symptoms of neonatal sepsis:
● listlessness, ● difficulty waking, ● high-pitched crying, ● poor sucking or feeding, ● backward arching of the neck and body,and ● fever
Signs of acute bilirubin encephalopathy in a baby with jaundice include:
neonatal sepsis, antibiotics
Since ___________________ is a major threat to infant health, treatment can and should be given before diagnosis is confirmed. Infants with suspected sepsis should be given ______________ because most cases are bacterial. The duration of the antibiotic course will vary depending on whether bacteria are found in the blood or spinal fluid. If no bacteria are found, treatment will be shorter. If doctors determine that a baby has sepsis, but it was caused by a non-bacterial pathogen, different treatment may be necessary. For example, babies that have contracted HSV should be given an antiviral medication.
1. Physiologic jaundice 2. Breastmilk jaundice 3. PATHOLOGIC JAUNDICE 4. HEMOLYTIC JAUNDICE
TYPES OF HYPERBILIRUBINEMIA:
first week, 2 weeks, 3 to 12 weeks
TYPES OF HYPERBILIRUBINEMIA: About 2% of breastfed babies get jaundice. This happens later in their _______ week of life. It peaks at about __ weeks of age. It can last ____ to ____ weeks. It is not dangerous but tests may need to be done for other problems that are dangerous. This issue may be caused by a substance in breastmilk. This substance may increase how much bilirubin the baby's body can reabsorb.
bilirubin, Physiologic jaundice, 5 to 6 mg/dL
TYPES OF HYPERBILIRUBINEMIA: During the first few days of life, babies aren't able to get rid of much ___________. This normal type of jaundice happens as a response to a baby's reduced ability to remove bilirubin. But it may be hard at first to tell if jaundice is being caused by another problem. __________________ in healthy term newborns follows a typical pattern. The average total serum bilirubin level usually peaks at ___ to ____ mg per dL (86 to 103 μ mol per L) on the third to fourth day of life and then declines over the first week after birth.
high risk period
The __________________ encompasses human growth and development from the time of viability (the gestational age at which survival outside the uterus is believed to be possible, or as early as 23 weeks of gestation) up to 28 days after birth; thus it includes threats to life and health that occur during the prenatal, perinatal, and postnatal periods. High risk infants are most often classified according to birth weight, gestational age, and predominant pathophysiologic problems. The more common problems related to physiologic status are closely associated with the state of maturity of the infant and consequences of immature organs and usually this are Meconium Aspiration Pneumonia, Sepsis, and Hyperbilirubinemia
Physical Exam Laboratory test of a sample of baby's blood: Direct and indirect bilirubin levels. Skin test with a device called a transcutaneous bilirubinometer
The diagnosis of infant jaundice will likely be based on the baby's appearance. However, it's still necessary to measure the level of bilirubin in baby's blood. The level of bilirubin (severity of jaundice) will determine the course of treatment. Tests to detect jaundice and measure bilirubin include:
O, A or B, Routine cord blood screening
The incidence of the incompatibility of the ABO blood groups of the mother and fetus, when the mother has the blood group ___ and the newborn has the ___ or ___ blood group, is 15-20% of all pregnancies . Babies with O-blood group mothers should be closely checked for and discharged after 72 h. ________________________ is not recommended for newborns with O-group mothers . Jaundice owing to ABO incompatibility usually appears 24 h after the birth. In the presence of significant jaundice or jaundiced appearing within 24 h, the work up for pathological jaundice should be done
bilirubin, unconjugated bilirubin, Unconjugated bilirubin, glucuronic acid, enterohepatic circulation, beta-glucuronidase
The majority of _____________ is produced from the breakdown of hemoglobin into _____________________ (and other substances). _______________________ binds to albumin in the blood for transport to the liver, where it is taken up by hepatocytes and conjugated with __________________ by the enzyme uridine diphosphogluconurate glucuronosyltransferase (UGT) to make it water-soluble. The conjugated bilirubin is excreted in bile into the duodenum. In adults, conjugated bilirubin is reduced by gut bacteria to urobilin and excreted. Neonates, however, have less bacteria in their digestive tracts, so less bilirubin is reduced to urobilin and excreted. They also have the enzyme ___________________, which deconjugates bilirubin. The now unconjugated bilirubin can be reabsorbed and recycled into the circulation. This process is called ___________________________ of bilirubin.
(a) Rh hemolytic disease, (b) ABO incompatibility and (c) Glucose-6-phosphate dehydrogenase (G-6-PD) deficiency and minor blood group incompatibility
The most common causes of hemolytic jaundice include:
Listeria
__________ infection baby symptoms: -baby limp at birth, AF depressed, RDS, apnea, skin rash, hepatosplenomegaly.
Bilirubin, acute bilirubin encephalopathy
__________ is toxic to cells of the brain. If a baby has severe jaundice, there's a risk of ___________ passing into the brain, a condition called __________________________. Prompt treatment may prevent significant lasting damage
Meconium, vagus reflex
_____________ is present in the fetal bowel as early as 10 weeks of gestation. If hypoxia occurs, a ______________ is stimulated, resulting in relaxation of the rectal sphincter. This releases meconium into the amniotic fluid. Babies born breech may expel meconium into the amniotic fluid from pressure on the buttocks. In both instances, the appearance of the fluid at birth is green to greenish black from the staining. Meconium staining occurs in approximately 10% to 20% of all births; in 2% to 4% of these births, infants will aspirate enough meconium to cause MAS
● respiratory distress in Early onset ● alteration in the established feeding behaviour in Late onset ● Hypothermia is a more common manifestation of sepsis than fever. ● Pyelonephritis is common in males and preterms, enlarged palpable kidneys ● Necrotizing Enterocolitis presents as distended abdomen, passage of blood/mucus per rectum, bilious vomiting, diminished or absent bowel sounds, Peritonitis, stool is positive for occult blood ● Sclerema - hide like character of skin, skin stretched over underlying structures, becomes unpingable, starts over face and legs and advances centripetally, if skin over the chest is involved breathing becomes shallow and rapid. ● Any bone may be involved in osteomyelitis. ● Septic arthritis is more common in the hip, knee, wrist, joint swollen, red and tender, movement is limited. ● If child goes into shock: cool peripheries, prolonged CFT, peripheral pulses absent, pale ashen gray look. ● If prolonged acidosis/hypothermia: DIC with bleeding manifestations. ● For Staphylococcus infection - usually after 72 hours, present as pyoderma, conjunctivitis, umbilical sepsis, abscess, osteomyelitis, scalded skin syndrome. ● Listeria -baby limp at birth, AF depressed, RDS, apnea, skin rash, hepatosplenomegaly. ● Pseudomonas and Klebsiella - Grayish black gangrenous patches on the skin.
The most common manifestation of neonatal sepsis is :
β-glucuronidases, nonesterified fatty acids, two, one to three
The underlying cause of breast milk jaundice is not entirely understood. Substances in maternal milk, such as _____________________, and ____________________, may inhibit normal bilirubin metabolism. The bilirubin level usually falls continually after the infant is _____ weeks old, but it may remain persistently elevated for ______ to _________ months.
Mild infant jaundice often disappears on its own within two or three weeks. For moderate or severe jaundice,baby may need to stay longer in the newborn nursery or be readmitted to the hospital.
Therapeutic Management for neonatal jaundice:
LP (Lumbar puncture)
There is a risk of increasing hypoxia during an ____ in already hypoxemic neonates. However, ____ should be done in neonates with suspected sepsis as soon as they are able to tolerate the procedure (see also Diagnosis under Neonatal Bacterial Meningitis). Supplemental oxygen is given before and during ____ to prevent hypoxia. Because GBS pneumonia manifesting in the first day of life can be confused with respiratory distress syndrome, LP is often done routinely in neonates suspected of having these diseases.
Exchange transfusion
This treatment removes the baby's blood that has a high bilirubin level. It replaces it with fresh blood that has a normal bilirubin level. This raises. the baby's red blood cell count. It also lowers his or her bilirubin level. During the procedure, the baby will switch between giving and getting small amounts of blood. This will be done through a vein or artery in the baby's umbilical cord. It is only done in an intensive care nursery when bilirubin levels are extremely high. The baby may need to have this procedure again if his or her bilirubin levels stay high.
horizontally-transmitted infections
To prevent _____________________________, newborns should be kept in a clean environment. Newborns have relatively weak immune systems, especially if born prematurely, and are vulnerable to infection.
1. Meconium-stained amniotic fluid, an infant may be suctioned with a bulb syringe or catheter while at the perineum, before the birth of the shoulders, to avoid aspiration of meconium. 2. Infants with meconium staining need intubation, those with severe staining are usually intubated and meconium is suctioned from their trachea and bronchi . 3. Do not administer oxygen under pressure (bag and mask) routinely until a meconium-stained infant has been intubated and suctioned so the pressure of the oxygen does not drive small plugs of meconium farther down into the lungs, thus worsening the irritation and obstruction. 4. Amnioinfusion is previously advocated as one of the preventive measures for meconium aspiration syndrome. It is a simple and safe procedure in which normal saline at room temperature is infused transcervically into the uterine cavity during the labor after rupture of membranes. Amnioinfusion prevents fetal distress by diluting the concentrated meconium. 5. In serious cases nasal CPAP can initially be tried for assisting respiration with pressures of 2- 6cm of water. It is an intermediate step before the baby is put on mechanical ventilation. 6. Conventional mechanical ventilation is often adequate but increasing positive pressure requirements often result in barotraumas. 7. Pulmonary hypertension is an important problem developing secondary to meconium aspiration. Inhalation nitric oxide delivered through a ventilator circuit being blended with appropriate oxygen concentration is very effective in reducing pulmonary hypertension without causing systemic hypotension. 8. Extracorporeal membrane oxygenation (ECMO) has been successfully used for the treatment of reversible pulmonary hypertension . 9. Babies with meconium aspiration syndrome on mechanical ventilation, given four high doses surfactant (150 mg/Kg of Survanta) by infusion over 20 min every 6 hrs showed marked improvement of oxygen index along with resolving pulmonary hypertension and decreased requirement of ECMO. 10. To reduce pulmonary vasoconstriction, tolazoline an alpha-adrenergic blocker with a direct relaxant effect on vascular smooth muscle can be used. It is a vasodilator with potential hazard for systemic hypotension, so dopamine has to be used to maintain systemic blood pressure and renal blood flow. 11. Antibiotic therapy may be prescribed to forestall the development of pneumonia as a secondary problem.
Treatment modalities for meconium aspiration syndrome include:
It is very important that medical professionals do all they can to prevent neonatal sepsis. This entails properly screening expectant mothers for Group B Strep, as well as any other infections they are at risk of contracting or may have already contracted. Mothers who have infections should be given treatment to reduce the risk of transmission to their infant.
Treatment modalities for neonatal sepsis:
● Enhanced nutrition. To prevent weight loss, your doctor may recommend morefrequent feeding or supplementation to ensure that the baby receives adequate nutrition. ● Breastfeeding: Keep breastfeeding a baby with jaundice. If the baby has not been getting enough milk at the breast, the may need to supplement with pumped breastmilk or formula. ● Light therapy (phototherapy). The baby may be placed under a special lamp that emits light in the blue-green spectrum. The light changes the shape and structure of bilirubin molecules in such a way that they can be excreted in both the urine and stool. During treatment, the baby will wear only a diaper and protective eye patches. Light therapy may be supplemented with the use of a light-emitting pad or mattress.
Treatments to lower the level of bilirubin in baby's blood may include:
Blood Culture, venipuncture
Umbilical vessels are frequently contaminated by organisms on the umbilical stump, especially after a number of hours, so ______________________ from umbilical venous lines may not be reliable. Therefore, blood for culture should be obtained by _____________, preferably at 2 peripheral sites. Although the optimal skin preparation to do before obtaining blood cultures in neonates is not defined, clinicians can apply an iodine-containing liquid and allow the site to dry. Alternatively, blood obtained soon after placement of an umbilical arterial catheter may also be used for culture if necessary.
G6PD
_________, most common enzymopathy, is the deficiency of an enzyme in RBCs
Urine testing, pyuria, ≥ 5 white blood cells
________________ is needed only for evaluation of late-onset sepsis. Urine should be obtained by catheterization or suprapubic aspiration, not by urine collection bags. Although only culture is diagnostic, a finding of _____________________ /high-power field in the spun urine or any organisms in a fresh unspun gram-stained sample is presumptive evidence of a urinary tract infection (UTI). Absence of ________ does not rule out UTI.
Early-onset neonatal sepsis (Vertical Transmission)
________________ neonatal sepsis usually results from organisms acquired intrapartum. Most infants have symptoms within 6 hours of birth.
Staphylococcus infection
_________________ infection s&s: - usually after 72 hours, present as pyoderma, conjunctivitis, umbilical sepsis, abscess, osteomyelitis, scalded skin syndrome.
Neonatal Sepsis, vertical, horizontal
__________________ is an infection in the bloodstream that poses severe health risks to newborns, including permanent brain damage. It can be caused by a variety of bacteria, viruses, and other pathogens. A baby can acquire neonatal sepsis through either vertical or horizontal transmission. In ____________ transmission, a maternal infection is spread to the baby shortly before or during the birthing process. In ______________ transmission, the baby acquires an infection after birth, from contact with caregivers, medical personnel, or environmental contaminants.
Infant jaundice, 35 weeks' gestation, full
__________________ usually occurs because a baby's liver isn't mature enough to get rid of bilirubin in the bloodstream. In some babies, an underlying disease may cause infant jaundice. Most infants born between ____ weeks' gestation and _______ term need no treatment for jaundice. Rarely, an unusually high blood level of bilirubin can place a newborn at risk of brain damage, particularly in the presence of certain risk factors for severe jaundice.
Pseudomonas and Klebsiella
___________________ infections s&s: - Grayish black gangrenous patches on the skin.
Fetal hypoxic stress, Meconium Aspiration Syndrome, Pneumonia
_____________________ during parturition can stimulate colonic activity, by enhancing intestinal peristalsis and relaxing the anal sphincter, which results in the passage of meconium. Then, because of intrauterine gasping or from the first few breaths after delivery, _____________________ may develop. Aspiration of thick meconium leads to obstruction of airways resulting in a more severe hypoxia. ______________ can occur due to an infection or meconium aspiration.
Meconium Aspiration
_____________________ occurs when a fetus has been subjected to asphyxia or other intrauterine stress that causes relaxation of the anal sphincter and passage of meconium into the amniotic fluid.
Infant jaundice
______________________ is yellow discoloration of a newborn baby's skin and eyes. It occurs because the baby's blood contains an excess of bilirubin , a yellow pigment of red blood cells. ______________ typically results from the deposition of unconjugated bilirubin pigment in the skin and mucous membranes.
High risk neonate
_______________________ can be defined as a newborn, regardless of gestational age or birth weight, which has a greater-than-average chance of morbidity or mortality because of conditions or circumstances associated with birth and the adjustment to extrauterine existence.
Neonatal hyperbilirubinemia
___________________________, defined as a total serum bilirubin level above 5 mg per dL (86 μmol per L), is a frequently encountered problem. Although up to 60 percent of term newborns have clinical jaundice in the first week of life, few have significant underlying disease. About 60% of full-term newborns get jaundice. So do 80% of premature babies. Babies born to mothers with diabetes or Rh disease are more likely to have this condition.
Rhesus hemolytic disease, IgG
____________________________ of the newborns (RHDN) results from maternal red-cell alloimmunization. Maternal antibodies are produced against the fetal red blood cells, when fetal red blood cells are positive for a certain antigen, usually at what time a baby having Rh positive born to an Rh-negative mother (and Rh-positive father), then maternal immunoglobulin (____) antibodies might cross the placenta into the fetal circulation and cause a wide variety of symptoms in the fetus, ranging from mild to severe hemolytic anaemia and fetal hydrops
Maternal intrapartum antibiotic prophylaxis (IAP)
_________________________________ can reduce the risk of GBS vertical transmission, but it does not completely eliminate it - therefore, doctors and nurses should still carefully assess the baby's health.
Meconium
is a sticky dark-green substance which contains gastrointestinal secretions, it accumulates in the fetal gastrointestinal tract throughout the third trimester of pregnancy and it is the first intestinal discharge released within the first 48 hours after birth. The fetus beginsto produce meconium until later in pregnancy, so as a pregnancy goes past its due date, the fetus has the potential to be exposed to meconium for a longer period of time.
Late-onset neonatal sepsis (Horizontal Transmission), Staphylococci, E. coli, Pseudomonas aeruginosa
is usually acquired from the environment (see Neonatal Hospital-Acquired Infection). _________________ account for 30 to 60% of late-onset cases and are most frequently due to intravascular devices (particularly central vascular catheters). _______ is also becoming increasingly recognized as a significant cause of late-onset sepsis, especially in extremely LBW infants. Isolation of Enterobacter cloacae or Cronobacter sakazakii (formerly Enterobacter sakazakii) from blood or cerebrospinal fluid may be due to contaminated feedings. Contaminated respiratory equipment is suspected in outbreaks of hospital-acquired _________________________ pneumonia or sepsis.