Common neonatal disorders

Classification of common
neonatal disorders
Birth injuries
 Caput succedaneum
 Cephalhematoma
 Fractures
 Facial paralysis
 Erb’s/Brachial palsy

neonatal disorders(cont…)
Disorders related to physiological factors
 Hyperbilirubinemia
 Hemolytic disease of the newborn
 Respiratory distress syndrome

neonatal disorders
Disorders related to infectious process
 Sepsis
 Necrotizing enterocolitis

neonatal disorders(cont…)
Disorders related to maternal conditions
 Infants of diabetic mothers

Injuries to head
 Caput succedenum
 Cephalhematoma

Injuries to the head while
birth
S - Skin
C - Close connective tissue & cutaneous vessels
& nerves.
A - Aponeurosis (epicranial aponeurosis)
L - Loose connective tissue (scalping layer)
P - Periosteum of skull bones

Injuries to the head
CAPUT SUCCEDANEUM
 A caput succedaneum is an edema of the
scalp at the neonate’s presenting part of the
head
 It often appears over the vertex of the
newborn’s head as a result of pressure against
the mother’s cervix during labor.
 The edema in caput succedaneum crosses the
suture lines

CAPUT SUCCEDANEUM
 Causes
 Mechanical trauma of the initial portion of
scalp pushing through a narrowed cervix
 Prolonged or difficult delivery
 Vacuum extraction

Cephalhematoma
 It is a collection of blood between the
periosteum of a skull bone and the bone
itself. It occurs in one or both sides of the
head
 The swelling with cephalhematoma is not
present at birth rather it develops within the
first 24 to 48 hours after birth.
 Has clear edges that end at the suture lines

Cephalhematoma Causes
 Rupture of a periostal capillary due to the
pressure of birth
 Instrumental delivery

Nursing care management
 It is directed toward assessment and
observation of the common scalp injuries and
vigilance in observing for possible associated
complications such as infection or acute
blood loss and hypovolemia.
 Because of the visible injuries resolves
spontaneously, parents need reassurance of
their usual benign nature.

Fractured clavicle
 Bone most frequently fractured during
delivery
 Associated with CPD
Signs:
 limited ROM,
 crepitus,
 cries of pain when arm is moved,
 absent Moro reflex on Affected side

Fractured clavicle
 Heals quickly, handle gently, immobilize arm,
eliciting scarf sign is contraindicated.
 Any newborn that weighs more than 3855g
and is delivered vaginally should be evaluated
for a fractured clavicle.

Fractured clavicle
Nursing Management
 Often no intervention is needed other than
maintaining proper alignment, careful
dressing and undressing of infant.
 Supporting the patient from upper and lower
back other than from under the arms should
be practiced.
 The parents should be involved in the care.

Facial paralysis:
 From pressure on facial nerve
during delivery
 Affected side unresponsive when
crying
 Resolves in hours/days
NURSING MANAGEMENT-
a) Feedings may be given by gavage
in order to prevent aspiration
b) Since the eye on the effected side
cannot be closed completely, it is
covered with an eye shield to
prevent drying of the conjunctiva
and cornea.

Erb’s Palsy (Erb- Duchenne
Paralysis)
 Associated with stretching
or pulling head away from
shoulder during delivery
 Signs: Flaccid arm, elbow
extended, hand rotated
inward, Moro & grasp
reflexes absent on affected
side
 Requires immobilization &
reposition q 2 to 3 hr.

Paralysis)
NURSING MANAGEMENT-
a) The goal is to prevent
contractures in the paralyzed
muscles.The arm should be
partially mobilized in a position of
maximum relaxation so that the
non-paralyzed muscles cannot
exert pull on the affected muscles.
b) By use of a splint or brace when
upper arm is paralyzed, the arm is
abducted 90 degrees and rotated
externally at the shoulder with the
elbow flexed so that the palm of
the hand is turned towards the
head.

Paralysis)
 When any form of immobilization is used, the
fingers and the hand should be observed for
coldness and discoloration and the skin for
the signs of irritation.

Hemolytic disease of the
newborn Rh +ve blood – D antigen
 Rh -ve blood – lacks this D antigen

newborn
 When Rh-positive blood is infused into an Rh-
negative woman through error or when small
quantities (usually more than 1 mL) of Rh-
positive fetal blood containing D antigen
inherited from an Rh-positive father enter the
maternal circulation during pregnancy, with
spontaneous or induced abortion, or at
delivery, antibody formation against D
antigen

Hemolytic disease of the newborn

newborn
 “Why the fetus is affected in second delivery
and not in first delivery?”

newborn
 As the mixing of blood usually occurs at the
time of delivery so by the time antibodies are
formed the baby is already delivered.

newborn
 But what if the mixing of blood occurs before
the delivery? Lets say during some procedure
like amniocentesis or chorionic villi sampling?
Now will the fetus be at risk?

newborn

“But why fetus ain’t at risk
during 1st pregnancy even if the
blood is mixed before delivery?”

newborn
 The answer is because of the type of
antibodies formed during first and second
delivery.

Prevention of hemolytic
disease.
 Prevention: Rhogham/Anti-
RhD in un-sensitized mothers
 Treatment of a mother with
Anti-RhD antibodies prior to
and immediately after trauma
and delivery destroys Rh
antigen in the mother's
system from the fetus

newborn
Diagnosis:
 Indirect coombs test in mothers-antigen
 direct coombs test in infants with Rh-ve
mothers-antibodies

newborn
 Treatment: IVIG is given in infants, exchange
transfusion and phototherapy.

newborn
Nursing management:
 1. Early recognistion of Jaundice
 2. If an exchange transfusion is
required then the nurse
prepares the infant and family
and assists the physician.
 3.The nurse documents the
blood volume exchange.

newborn
 4. Signs of blood
transfusion reaction are
need to be monitored.
 5.Throughout the
procedure infant’s
thermoregulation need
to be monitored.
 6. After the procedure the
nurse monitors the
umblical cord for any kind
of bleeding.

Neonate Respiratory distress
syndrome/ hyaline membrane
disease
 RDS occurs primarily in premature infants;
 its incidence is inversely related to gestational
age and birth weight.
 It occurs in 60–80% of infants less than 28 wk of
gestational age,
 In 15–30% of those between 32 and 36 wk,
 In about 5% beyond 37 wk,
 and rarely at term.

syndrome
 The condition occurs due to lack of
pulmonary surfactant because of immaturity
of the lungs.
 Surfactant helps in reducing the surface
tension of alveoli.
 When surfactant active material is deficient in
the alveoli, there is alveolar collapse during
expiration

syndrome
 The pulmonary immaturity of the fetal lungs
can be assessed by determination of
lecithin/sphingomyelin ratio in the amniotic
fluid
 L/S ratio is 2 or more suggestive of adequet
lung maturity, while a ratio of less than 1.5 is
often associated with HMD

syndrome
Clinical features
 This is characterized by a triad of tachypnea,
expiratory grunt and inspiratory retractions in
a preterm.
 These symptoms may begin at birth or within
6 hours of birth.
 There is a gradual worsening of retrations,
grunting and cyanosis.

Neonate Respiratory distress syndrome/ hyaline
membrane disease
 Management
 Premature labor should be arrested by
appropriate tocolytic therapy to gain
pulmonary maturity.
 The induction of labor should be delayed
as far as the lung maturity is confirmed by
l/S ratio.
 When premature labor below 34 weeks of
gestation is unavoidable, the mother
should be given betamethasone 12mg IM
every 24hrs for two days or
dexamethasone 6mg IM four doses at an
interval of 12hrs.

syndrome
 The infant should be nursed in a
thermoneutral env and administered
oxygen through head box.
 An IV line should be established to
maintain fluid and electrolyte balance, for
correction of acidosis and administration
of drugs.
 Intratracheal administration of surfactant
should be done
 SPo2 should be monitored
 If infant cant monitor Spo2 above 90
despite of giving oxygen via hood the
infant should be put on CPAP

syndrome
 If CPAP is also ineffective then the
infant should be put on IPPV
 Acid-base parameters should be
monitored
 Unmonitored oxygen levels may lead
to retinopathy of prematurity to
oxygen toxicity.

syndrome
 Antibiotics are given in case of
superadded infections
 The management of HMD requires
supportive care by trained nurses and
the availability of high technology to
monitor and manage the hypoxia due
to ineffective ventilation.

disease
Nursing management
 Effective ventilation and oxygen
therapy
 Equipment should be ready and in
working condition
 Oxygen must be warm and humidified
 The condition of the infant can change in
a fraction of a second so it is vital for the
nurse to monitor neonate’s color, level of
activity and to note blood gas
measurements.
 When o2 is given, tracheal and
nasopharengial suctioning and chest
physical therapy is required.

disease
 Optimal environmental temperature:The
nurse has a important role in providing
regulation of surrounding temperature.
 Adequate nutrition: proper gavage
feedings at proper intervals is necessary
nursing action.
 Minimal handling of critically ill infants.
 Use of aseptic techniques.
 Infants should be positioned with head
elevated to decrease pressure on
diaphragm.

Necrotising Enterocolitis (NEC)
 This is characterized by necrosis of intestinal
wall , is a serious life threatening condition
that is being diagnosed with increasing
frequency in premature infants.

Necrotising Enterocolitis (NEC)
 Factors that place the infant at risk of this
disease include:
 Perinatal asphyxia
 Low apgar score
 IRDS
 Sepsis
 Enteral feedings
 Congenital cardiac disease
 Relative ischemia of the intestinal tract that is due to
hypotension
 Use of umbilical catheters
 Exchange transfusion

Pathophysiology
Factors
Depletion of the normal
blood flow
Ischemia with a reduction
in the protective mucosa.
Intestinal enzymes further
destroy the mucosal layer

Bacteria increases in the
presence of carbohydrate in
the infants feeding and form
gas
Intestines become dilated,
become necrotic
Necrosis may involve the full
thickness of the intestinal
wall leading to ultimate
perforation

Necrotising Enterocolitis
(NEC
Clinical manifestations:
 Abdominal distention
 Decreased bowel sounds
 Poor feeding
 Increased gastric residuals
 Blood streak bile vomiting
 Bloody or mucoid stools

(NEC
Nursing management
 As soon as the diagnose of NEC is
made the oral feedings are
discontinued and peripheral IV
fluids are given to the infant.
 Palpation of abdomen, abdominal
girth are checked daily
 Bowel sound monitoring
 TPN is to be started

(NEC
 I/v antibiotics are started to
against gram negative enteric
organisms
 Rectal temperature is not taken
so as to prevent rectal
perforation
 Affected infants are to be
placed in isolation

(NEC
 These infants are not diapered
because of the increased risk of
intra-abdominal pressure.
 These infants are nursed on their
back as much as possible to
reduce the external pressure on
the abdomen
 Postoperatively , as the suture
line is close to stoma so
measures should be taken to
avoid any infection to suture
line.

(NEC
 Fecal material can be drained
into urine collecting devices.
 Psychological support should be
given to parents.

Neonatal Sepsis
 Systemic bacterial infections of
newborn infants are termed as
neonatal sepsis
 They are the most common cause of
neonatal deaths in Indianatal sepsis
 This is a generic term which
incorporates neonatal septicemia,
pneumonia, meningitis and urinary
tract infections

Neonatal Sepsis
Neonatal sepsis can be divided into two
types
Early onset: this happens in first 72
hours of life
 This is mainly due to organisms
present in:
 the genital tract or
 in the labor room or
 in maternity operation

Neonatal Sepsis
Late-onset: this is caused by the
organisms thriving in exter
 The infection is often transmitted
by the care givers.

Neonatal Sepsis
The predisposing causes of LOS are
:
 Lack of breast feeding
 Superficial infections
 Aspiration of feeds
 Disruption of skin integrity with
needle pricks and use of IV fluids
 External env of homes or hospital.

Neonatal Sepsis
Clinical features:The manifestations
of neonatal sepsis are often vague
and nonspecific demanding high
index of suspicion for early
diagnosis.
 Any altern in feeding patterns
 Active baby suddenly becoming
lethargic

 Hypothermia in preterms and fever in
term babies especially in association
with gram –positive infections and
meningitis.
 Diarrhea, vomiting and abdominal
distention
 Jaundice and hepatosplenomegaly
may be present
 Episodes of apneic spells with
cyanosis may also be one of the sign.

Neonatal Sepsis
Management:
 The infant should be managed
in a thermo neutral env and
started on intravenous
antibiotics

Neonatal Sepsis
Nursing Management:
 Hand washing and thorough
scrubbing with soap and water
upto elbows for at least 2mons,
gowning and change of shoes
are mandatory.
 Rings, bangles and
wristwatches should be
removed
 Strict hand washing for 20 secs
and use of antiseptic solution in
between handling babies.

Neonatal Sepsis
 4. Babies should be fed
early and exclusively on
breast milk.
 5. Careful attention should
be paid to hygiene of the
katori and spoon.
 6.The umblical stump
should be left open. Local
application of spirit
reduces colonization.

Neonatal Sepsis
 All procedures should
be done wearing mask.
 Unnecessary needle
pricking should be
avoided.
 Strict housekeeping
routines for washing ,
disinfection, cleaning of
cots/incubators should
be ensured .

Infants of diabetic mothers IDM
 There has been
continuing
improvement in the
care of mothers with
diabetes mellitus and
their neonates,
resulting in a decline
in the morbidity and
mortality rates

Clinical manifestations of IDM:
 Large for gestational age
 Very plump and full faced
 Abundant vernix caseosa
 Pleothora
 Listlessness and lethargy
 Large placenta and umblical
cord
 Possibly meconium stained at
birth

Therapeutic management
 The most common management of IDMs
is careful monitoring of serum glucose
levels and observation for accompanying
complications such as RDS.
 Studies confirm that maintaining blood
glucose level more than 50mg/dl in IDMs
with hypoglycemia prevent serious
neurological conditions.
 Oral and IV backup may be titrated to
maintain adequate blood glucose levels.

 Nursing care management
 Early introduction of carbohydrate
feedings as appropriate
 Serum glucose monitoring.
 Because macrosomic infants are at
high risk for problems associated
with difficult delivery, they are
monitored for birth injuries.
 There is some evidence that IDMs
have an increased risk of acquiring
type 2 DM during childhood or
early adulthood therefore a nurse
should also focus on healthy
lifestyle and prevention later in life
with IDMs.

References
 WONG’S ESSENTIAL OF PAEDIATRIC
NURSING 8TH EDITION
 NELSON’STEXTBOOK OF PEDITRICS
15TH EDITION
 http://www.imedicine.com /display
topic
 DOROT HY R.M.MARLOWAND
BARBARAA. REDDING’STEXTBOOK
OF PEDIATRIC NURSING 6TH EDITION
 Www.wikipedia.org
 Textbook of Indian academy of
pediatrics

Common neonatal disorders

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Common neonatal disorders