CHAPTER 18 Newborn at Risk: Conditions Present at Birth

ASSESSMENT

Physical assessment characteristics of a postmature newborn are: • The infant will be more alert after birth • Decreased subcutaneous fat • Loose skin • Dry and peeling skin • Lack of vernix and lanugo • Long fingernails and toenails • Meconium staining on the umbilical cord

The Small-for-Gestational-Age (SGA

-A *small-for-gestational age (SGA)* newborn is defined as an infant whose weight is less than the 10th percentile for his gestational age. -There are many possible causes of SGA: • Abnormalities of the placenta or vessels that restricted nutrients and oxygen to the developing fetus • Maternal hypertension • Uncontrolled, severe diabetes • Poor maternal nutrition • Drug use • Heavy smoking • Exposure to teratogenic substances • Alcohol consumption • Twins, triplets, or other multiples • Small parents

Possible long-term complications of prematurity include:

• Retinopathy of prematurity, a potentially blinding disease caused by abnormal development of the retinal blood vessels. The retina receives light and turns it into visual messages that are sent to the brain. Retinopathy occurs in extremely low birth weight infants. A premature birth results in the cessation of normal growth of the blood vessels of the retina. Long-term outcomes include visual impairment and blindness. The American Academy of Pediatrics recommends that all premature infants be tested for retinopathy. Early surgical laser treatment is the treatment of choice • Cerebral palsy, a disorder of muscle tone and movement, can be caused by infection or inadequate blood flow to the developing premature infant's brain. A study by Oskoui et al (2015) indicates that there may be a genetic component that influences whether prenatal or birth stressors will cause cerebral palsy. This may explain why newborns with similar prenatal or birth stressors may have no disabilities or different types of cerebral palsy. • Premature babies are usually behind on meeting develop- mental milestones, may have learning disabilities, and are more like to have psychological problems such as attention-deficit hyperactivity disorder

Medical management of the newborn with NAS may include:

• Transferring any infant with signs of NAS to the NICU • Providing supportive therapy with IV fluids to prevent dehydration from nausea and vomiting • Providing pharmacological therapy to reduce symptoms and gradually wean the newborn from the substance; morphine is the most frequently used medication for opioid-addicted newborns to reduce symptoms and to wean slowly • Administering phenobarbital, which is effective in controlling seizures

THE POST-TERM NEWBORN

-A post-term newborn is born after 42 weeks' gestation. -The cause of postmaturity is unknown, but a previous post-term delivery increases the risk. -Usually, fetal growth between 39 and 43 weeks' gestation results in a large infant. -However, in some cases the placenta begins to involute and the villi begin to degenerate, causing placental insufficiency syndrome for the fetus. -The fetus receives inadequate nutrition and oxygen from the placenta, resulting in an SGA infant who is undernourished. -The fetus may have used stored glycogen for energy before birth. In addition, the amniotic fluid volume begins to decrease with postmaturity.

CARE OF THE NEWBORN EXPOSED TO HIV

-HIV transmission from mother to child during pregnancy, labor and delivery, or breastfeeding is known as perinatal transmission. -The Centers for Disease Control and Prevention (CDC) recommends routine HIV testing for all persons aged 13 to 64 years in health-care settings, including women during pregnancy. Medical management of the HIV-exposed newborn is: • Zidovudine (ZDV) 4 mg/kg twice a day through 6 weeks of age if the mother received antiretroviral medications during pregnancy • If the mother did not receive prenatal antiretroviral medications, the newborn should receive: • ZDV 4 mg/kg twice a day through 6 weeks of age plus Nevirapine (NVP) - three doses in the first week of life, 12 mg PO per dose if birth weight is greater than 2 kg and 8 mg per dose if birth weight is 1.5 to 2 kg (AIDS Institute, 2014) • Follow-up consultation with a pediatric infectious disease specialist • Obtaining a complete blood count for a baseline Nursing interventions for the HIV-exposed newborn includes: • Strictly maintaining standard precautions to avoid exposure • Making sure gloves are worn by anyone handling the newborn (including family members) until the first bath • Notifying the health-care provider of any abnormalities noted during physical assessment • Administering medications as ordered • Educating parents about the importance of following the drug prophylaxis plan after discharge • Advising the mother not to breastfeed

CONGENITAL MALFORMATIONS

-High blood sugar concentration is toxic to cell growth in the first trimester and explains cardiac and central nervous system (CNS) abnormalities of the IDM. -Cardiomegaly with an enlarged left ventricle occurs in approximately 30% of IDMs; the risk of *spina bifida (ie, a defect of the spinal cord)* is 20 times higher for the IDM -Nursing interventions include: • Promptly identifying the congenital abnormality, if obvious, at birth • Notifying the health-care provider of any physical abnormalities or abnormal vital signs

MINERAL/ELECTROLYTE METABOLISM

-Hypocalcemia and hypomagnesemia can occur in the neonate if the mother had poorly controlled diabetes. -In the newborn, hypocalcemia is defined as a calcium level less than 8 mg/dL; -hypomagnesemia is defined as a magnesium level less than 1.7 mg/dL - The mother's poor glycemic control leads to maternal glycosuria (ie, glucose in the urine), which is accompanied by magnesium loss. -Low maternal levels of magnesium lead to fetal deficiency. - If the magnesium level is insufficient, calcium will be lost in the urine and not deposited in the bones and soft tissues. -Severe hypomagnesemia causes a secondary hypocalcemia and *hypoparathyroidism*, because magnesium is needed for the appropriate secretin of the parathyroid hormone (PTH). -Medical management includes screening for hypocalcemia and hypomagnesemia and administration of calcium and magnesium to obtain normal levels.

HYPOGLYCEMIA

-IDMs often have a rapid fall in glucose within an hour of birth. Hypoglycemia can occur faster in an IDM than normal infants. -This is linked to fetal hyperinsulinism that occurs during gestation; maternal glucose comes across the placenta but insulin does not. -Prevention of hypoglycemia is a goal. Early feeding immediately after birth is suggested for the IDM.

FETAL MACROSOMIA

-Macrosomia, or an LGA infant weighing more than 4,000 g at birth, occurs in 15% to 45% of diabetic pregnancies. -High levels of maternal glucose during gestation lead to fetal hyperglycemia and *hyperinsulinemia (ie, excess insulin)*, which causes increased growth in the fetus. -The large infant is at risk for birth injuries caused by shoulder dystocia. -Frequently, the macrosomic IDM is delivered via Cesarean birth because of the large size. -At delivery, the macrosomic IDM appears ruddy, fat, puffy, and may have decreased muscle tone. Nursing interventions for the macrosomic infant include: • Notifying the pediatrician or nurse practitioner of birth weight and signs of macrosomia • Performing a gestational age assessment • Observing for signs of birth injuries • Observing for signs of hypoglycemia

CARE OF THE INFANT OF A DIABETIC MOTHER

-Neonatal complications for the infant of a diabetic mother (IDM) are directly related to inadequate glucose control in pregnancy. -Fetal malformation can occur because of poor glucose control in the first trimester. -High levels of glucose in late pregnancy can lead to macrosomia, hypoxia, polycythemia, and cardiomegaly

FETAL HYPOXIA

-Poorly controlled diabetes can lead to a hypoxia, a decreased supply of oxygen to the fetal tissues. -Uncontrolled high levels of glucose can cause vascular disease in the mother, leading to decreased blood flow to the placenta. -In addition, the fetus develops an increased need for oxygen consumption related to high levels of glucose coming from the mother.

THE PRETERM NEWBORN

-Preterm infants are born before 37 weeks' gestation and have an increased risk of complications and mortality. -Prematurity is classified as: • Extremely premature: Born less than 28 weeks' gestation • Very premature: Born less than 32 weeks' gestation • Moderately premature: Born less than 34 weeks' gestation • Late preterm: Born between 34 and 37 weeks' gestation Some neonatologists and neonatal intensive care nurseries also classify premature infants by weight: • Low birth weight: Less than 2,500 g (ie, 5 lbs. 8 oz.) • Very low birth weight (VLBW): Less than 1,500 g (ie, 3 lbs. 5 oz.) • Extremely low birth weight (ELBW): Less than 1,000 g (ie, 2 lbs. 3 oz.)

POLYCYTHEMIA

-This condition of extra red blood cells is known as polycythemia. Polycythemia is diagnosed when the hematocrit is greater than 65%. -The polycythemia makes the blood more viscous (ie, thicker or sticky), which can cause strokes or seizures in the fetus or newborn. -Polycythemia contributes to an increased risk of hyperbilirubinemia after birth when the extra red blood cells break down and the immature liver cannot manage the breakdown of the bilirubin. -Signs of polycythemia are: • A "ruddy" (ie, red) appearance of the skin • Sluggish capillary refill time • Respiratory distress • Poor feeding • Lethargy • Seizures • Apnea • Cyanosis • Hematuria

THE LARGE-FOR-GESTATIONAL AGE (LGA) NEWBORN

-newborn is an infant whose weight is greater than the 90% for gestational age -The most common com- plications for an LGA newborn are: • Shoulder dystocia • Fracture of the clavicle or limbs • Perinatal asphyxia • Meconium aspiration • Respiratory distress • Hypoglycemia Assessment findings would include: • Large, obese baby • Listless, apathetic baby • Performing a gestational age assessment • Assessing respiratory status • Assessing for signs of birth injuries and reporting them immediately • Monitoring for tremors, which are an early sign of hypoglycemia • Providing frequent feedings to decrease the risk of hypoglycemia

CARE OF CHEMICALLY EXPOSED INFANTS

Almost all drugs cross the placenta and have an effect on the fetus. In early gestation, drugs can have a teratogenic effect, causing structural birth defects. - The health-care provider may order a drug toxicology screen on a newborn's urine or meconium sample to be prepared for appropriate care for the infant in withdrawal. -Neonatal abstinence syndrome (NAS) is a group of similar behavioral and physiological signs and symptoms in the neonate caused by withdrawal from various pharmacological agents.

ETIOLOGY

Known risk factors for a premature delivery include: • Low socioeconomic status • Cigarette smoking • Prior premature births • Multiple prior therapeutic or spontaneous abortions • Little or no prenatal care • Poor nutrition • Untreated infections • Pre-eclampsia • Multiple gestation

SAFETY STAT

Newborns are at risk for fluid overload. Careful calculations of appropriate fluid amounts based upon the infant's weight should be confirmed by two licensed nurses. The symptoms of an electrolyte imbalance are very similar to hypoglycemia in the newborn. If symptoms persist with a normal blood sugar, the health-care provider should be notified immediately.

POTIENTAL COMPLICATIONS

Post-term infants have a higher rate of death and disease than term infants. • The incidence of stillbirth or neonatal death is increased in post-term infants. • The larger body size can lead to prolonged labor and birth trauma. • Hypoglycemia can occur owing to lack of stored glycogen. • During labor, the post-term infant is more likely to have a bowel movement in the uterus because of stress. There is a chance the newborn may inhale the meconium, causing breathing problems.

The vital signs, hematocrit, and blood glucose will be monitored frequently. The hematocrit levels usually peak 6 to 12 hours after birth and then decline until the infant is 24 hours old.

Some physicians will perform a partial blood exchange transfusion with saline to decrease the hematocrit quickly in symptomatic infants. -In asymptomatic infants, the common approach is to observe for the onset of any symptoms and let the newborn's body adjust the hematocrit. -Some physicians will hydrate the newborn with IV fluids to decrease the hematocrit. -Nursing interventions for the polycythemic infant include: • Notifying the health-care provider immediately of any signs and symptoms of polycythemia • Infusing IV fluids, if ordered, and observing closely for signs of fluid overload

Intrauterine Growth Restriction (IGR) Newborn

The SGA newborn may have been affected by intrauterine growth restriction (IGR), which is decreased fetal growth caused by a decrease in placenta perfusion during gestation. -IGR is often diagnosed during pregnancy at routine visits when the health-care provider measures fundal height and also through ultrasound examinations. -Assessment findings would include: • Weight, length, and head circumference all below the 10th percentile for gestational age • Large head in relationship to the rest of the body • Thin extremities and trunk • Loose skin caused by absence of subcutaneous fat • Thin umbilical cord

POTIENTAL COMPLICATIONS

• A premature baby may have problems with breathing be- cause of an immature respiratory system and the absence of surfactant to keep the alveoli open. • Thermoregulation is difficult for the premature infant because of the lack of subcutaneous fat and the infant may not have developed brown fat to assist with heat production during stress. Cold stress can occur easily in a premature newborn. • Heart problems are common in premature babies. The most common problems are a patent ductus arteriosus (PDA) and hypotension. The PDA is supposed to close on its own to allow more blood flow to the lungs, but in a premature infant, it may stay open, causing heart failure. • Intraventricular hemorrhage in the brain of the very pre-mature infant can occur because of the fragile underdevel- oped blood vessels in the brain. The blood vessels rupture and bleed into the ventricles of the brain. There may be no symptoms or the nurse may observe: • Apnea • Decreased muscle tone • Decreased reflexes • Excessive sleep • Weak suck • Seizure and other abnormal movements.

CARE OF NEWBORNS WITH PROBLEMS RELATED TO GESTATIONAL AGE AND DEVELOPMENT

• A preterm birth is less than 37 weeks, 6 days. • An early term birth is from 37 weeks, 6 days through 38 weeks, 6 days. • A full term birth is from 39 weeks through 40 weeks, 6 days. • A late term birth is from 41 weeks through 41 weeks, 6 days. • A post-term birth is 42 weeks and beyond.

Nursing interventions for a newborn with NAS are:

• Assessing daily for signs of withdrawal and reporting any signs and symptoms immediately • Administering and monitoring pharmacological treatment • Monitoring for skin breakdown and applying barrier ointments for prevention of diaper rash from diarrhea • Bottle-feeding with high-calorie formula to promote weight gain • Encouraging breastfeeding if not contraindicated • Providing parenting education to the caretakers of the infant • Communicating with and providing a referral to a social worker for postdischarge care and follow-up

ASSESSMENT

• Ear cartilage: For example, a preterm infant at 28 weeks has little ear cartridge. • Sole creases: For example, a preterm infant at 33 weeks has only an anterior crease. • Breast tissue: For example, a preterm infant at 28 weeks has no breast tissue. • Genitalia: For example, extremely preterm infant males will have undescended testicles. -During physical assessment of the premature infant, the nurse will also notice that: • The skin is thin and arteries and veins are visible. • The skin is fragile and looks smooth and shiny. • A moderately premature infant will have abundant lanugo. • Fingernails and toenails may only be partially formed. • The ears may fold over. • Very preterm infants have less muscle tone. • The premature baby does not lie in a fetal position until 35 weeks.

PROGNOSIS FOR A SMALL-FOR-GESTATIONAL-AGE NEWBORN

• If asphyxia was avoided at birth, the neurological prognosis for the SGA infant is excellent. • If the growth restriction was because of placental insufficiency, adequate nutrition after birth will allow the infant to "catch up." • A SGA situation caused by maternal drug use and smoking may contribute to a smaller child and adult.

Medical management includes stopping formula feedings, insertion of a nasal gastric tube, feeding with breastmilk, and the administration of antibiotics. Surgical intervention may be required to remove perforated or necrotic intestinal tissue

• Infection can occur easily in the premature newborn because of an immature immune system. Infection can quickly spread to the newborn's bloodstream, causing sepsis. • Fluid and electrolyte imbalances can be a problem for the premature infant because of the immature circulatory and renal system. Close monitoring of IV fluid intake and electrolyte balances are important to prevent fluid overload and heart failure. • The most common problem of the premature neonate is apnea. Apnea of prematurity is the cessation of breathing for more than 20 sec, or the cessation of breathing for less than 20 sec accompanied by bradycardia or oxygen saturation levels of less than 85%. Apnea of prematurity is related to immaturity and/or depression of the central respiratory drive to adequately stimulate the muscles of respiration. Medical management of apnea of prematurity includes tactile stimulation, administration of oxygen, the use of continuous positive airway pressure (CPAP), and pharmacotherapy. As the infant matures, the apnea will resolve.

Nursing interventions for the SGA infant are

• Performing a gestational age assessment • Assessing for respiratory distress • Assessing for tremors or jitteriness, which are early signs of hypoglycemia • Instituting early feeding to prevent hypoglycemia • Monitoring for hypothermia • Monitoring vital signs and daily weight • Teaching the parents about the need to keep the infant warm and to provide frequent feedings

Term SGA infants do not have complications related to immature organs such as a premature baby does; however, they do have risks for:

• Perinatal asphyxia during labor if the SGA was caused by placental insufficiency; the fetus may not receive enough oxygen during the stress of labor. • Meconium aspiration may occur during asphyxia. The infant may pass meconium into the amniotic fluid and then aspirate it into the lungs at birth, causing respiratory distress. • *Hypoglycemia* (ie, low blood sugar) may occur because of a lack of stored glycogen. Neonatal hypoglycemia is defined as a plasma glucose level of less than 30 mg/dL in the first 24 hours of life and less than 45 mg/dL thereafter. • Hypothermia may occur because of a lack of subcutaneous fat

Signs and symptoms of mineral/electrolyte imbalances in the newborn are

• Poor feeding • Lethargy • Tremors • Seizures • Cardiac arrhythmias • Respiratory distress -Nursing interventions for the infant with an abnormal electrolyte balance includes: • Recognizing abnormal signs and symptoms and reporting them immediately to the health-care provider • Maintaining close observation of the newborn to detect deterioration • Administering calcium and/or magnesium as ordered by the health-care provider • Providing education and emotional support to the family

Long-term effects related to prenatal drug exposure may be:

• Poor growth through childhood • Hyperactivity and attention-deficit disorder • Impaired cognition, leading to learning disabilities • Poor language development • Higher rates of criminal behavior and substance abuSE

NECROTIZING ENTEROCOLITIS NECROSIS HEMATOCHEZIA

• Premature babies have immature gastrointestinal systems, which predisposes the newborn to *necrotizing enterocolitis.* This complication occurs in the second to third week of life for a premature, formula-fed infant. The exact cause is unknown, but it is associated with formula feeding and characterized by damage to the intestinal tract that may have occurred from abnormal intestinal flora, immaturity of the intestinal mucosa, intestinal ischemia caused by decreased placental blood flow, and possibly a genetic predisposition. The damage may affect only the mucosal lining, or there may be full-thickness *necrosis (ie, death of the tissues)* and perforation of the bowel. The signs and symptoms are: • Vomiting • Diarrhea • Delayed gastric emptying • Decreased bowel sounds • Lethargy • Increased abdominal girth • Visible intestinal loops • Palpable abdominal mass • *Hematochezia* (ie, bright red blood in the stool)

CARE FOR THE CHEMICALLY EXPOSED NEWBORN

• Provide a calm quiet environment. • Swaddling is usually very calming for the newborn. • Avoid unnecessary handling. • Use a light dimmer to keep lights low. • Respond quickly to cries. • Limit stimuli such as stroking, direct speech, and strong fragrances. • Provide "space" by positioning the baby to face outward, away from the caregiver's body.