Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition
Chapter 08: Health Problems of Newborns
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Birth injuries are usually transient and may involve soft tissue, bone, or nervous
tissue. Common transient birth injuries include caput succedaneum, cephalhematoma,
and soft tissue bruising. Additional potential birth injuries that require careful
evaluation include subgaleal hemorrhage, fractured clavicle, facial paralysis, and
brachial plexus paralysis.
Soft tissue injury usually occurs when there is some degree of disproportion between
the presenting part and the maternal pelvis (cephalopelvic disproportion).
The most commonly observed scalp lesion is caput succedaneum, a vaguely outlined
area of edematous tissue situated over the portion of the scalp that presents in a vertex
delivery. The swelling consists of serum and/or blood that has accumulated in the
tissues above the bone. Typically the swelling extends beyond the bone margins (or
sutures) and may be associated with overlying petechiae or ecchymosis.
A cephalhematoma is formed when blood vessels rupture during labor or delivery to
produce bleeding into the area between the bone and its periosteum. The boundaries
of the cephalhematoma are sharply demarcated and do not extend beyond the limits
of the bone. The swelling is usually minimum or absent at birth and increases in size
on the second or third day.
Subgaleal hemorrhage is bleeding into the subgaleal compartment. The subgaleal
compartment is a potential space that contains loosely arranged connective tissue; it is
located beneath the galea aponeurosis, the tendinous sheath that connects the frontal
and occipital muscles and forms the inner surface of the scalp. The injury occurs as a
result of forces that compress and then drag the head through the pelvic outlet. The
bleeding extends beyond bone, often posterior into the neck, and continues after birth,
with the potential for serious complications and morbidity.
The clavicle or collarbone is the bone most frequently fractured during the birth
process. Crepitus may be heard or felt on examination. A palpable, spongy mass,
representing localized edema and hematoma, may also be a sign of a fractured
clavicle.
Common skin problems of the newborn include erythema toxicum, candidiasis, and
birthmarks.
Erythema toxicum neonatorum, also known as flea bite dermatitis or newborn
rash, is a benign, self-limiting eruption that usually appears within the first 2 days of
life. The 1- to 3-mm lesions are firm, pale yellow or white papules or pustules on an
erythematous base, which resemble flea bites. The rash appears most commonly on
the face, proximal extremities, trunk, and buttocks.
Candidiasis is a yeastlike fungus (produces yeast cells and spores) that can be
acquired from a maternal vaginal infection during delivery; by person-to-person
transmission (especially from poor hand washing technique); or from contaminated
hands, bottles, nipples, or other articles. Oral candidiasis (thrush) is characterized by
white adherent patches on the tongue, palate, and inner aspects of the cheeks.
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Neonatal herpes is one of the most serious viral infections in the newborn. The
disease may be classified according to the following types: (1) skin, eye, and mouth;
(2) localized central nervous system (CNS) disease; or (3) disseminated infection
involving multiple sites such as the lungs, liver, adrenal glands, CNS, skin, eyes, and
mouth. Approximately 86% to 90% of herpes simplex virus transmission occurs
during delivery.
Vascular birthmarks may be divided into vascular malformations and vascular tumors
(hemangiomas). Vascular tumors are known as hemangiomas of infancy or infantile
hemangiomas to differentiate them from other vascular tumors and malformations.
Localized superficial hemangiomas tend to manifest early in infancy, and
spontaneous resolution without therapy may occur within several years, whereas the
segmental variety is more likely to cause complications such as ulceration and vital
organ compromise and to involve developmental defects.
Vascular malformations are permanent lesions that are present at birth and are
initially flat and erythematous. The two most common vascular stains are port-wine
stains (nevus flammeus) and transient macular stains such as the stork bite or salmon
patch, usually located on the glabella or nape of the neck. Port-wine lesions are pink,
red, or rarely, purple stains of the skin that thicken, darken, and proportionately
enlarge as the child grows.
Brachial plexus injury results from forces that alter the normal position and
relationship of the arm, shoulder, and neck. Erb palsy (Erb-Duchenne paralysis) is
caused by damage to the upper plexus and usually results from stretching or pulling
away of the shoulder from the head, as might occur with shoulder dystocia or with a
difficult vertex or breech delivery. The arm hangs limp alongside the body. The
shoulder and arm are adducted and internally rotated. The elbow is extended, and the
forearm is pronated, with the wrist and fingers flexed; a grasp reflex may be present
because finger and wrist movement remain normal.
The less common lower plexus palsy, or Klumpke palsy, results from severe
stretching of the upper extremity while the trunk is relatively less mobile. In lower
plexus palsy, the muscles of the hand are paralyzed, with consequent wrist drop and
relaxed fingers.
Hyperbilirubinemia is an excessive level of accumulated bilirubin in the blood and
is characterized by jaundice, or icterus, a yellowish discoloration of the skin and other
organs. Hyperbilirubinemia may result from increased unconjugated or conjugated
bilirubin. The unconjugated form is the type most commonly seen in newborns.
Hour-specific serum bilirubin levels to predict newborns at risk for rapidly rising
levels are used to monitor healthy neonates at more than 35 weeks of gestation before
discharge from the hospital. Using a nomogram with three designated risk levels
(high, intermediate, or low risk) of hour-specific total serum bilirubin values assists in
the determination of which newborns might need further evaluation before and after
discharge
The primary goal in the treatment of hyperbilirubinemia is to prevent bilirubin
encephalopathy, a term that describes varying degrees of CNS damage resulting
from the deposition of unconjugated bilirubin in brain cells. Kernicterus describes
the yellow staining of the brain cells that may result in bilirubin encephalopathy. The
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condition occurs when the serum concentration reaches toxic levels, regardless of
cause.
The main treatment of hyperbilirubinemia involves the use of phototherapy, which
consists of the application of fluorescent light to the infant’s exposed skin.
Hemorrhagic disease of the newborn (HDN) is characterized by abnormally rapid
destruction of red blood cells (RBCs) as a result of blood incompatibility between
mother and fetus. The major causes of increased erythrocyte destruction are
isoimmunization (primarily RhD) and ABO incompatibility.
With ABO incompatibility, the incompatibility is between a mother with O blood
group and an infant with A or B blood group; hemolysis is more commonly due to
anti-A than anti-B.
In Rh incompatibility the problem occurs when the Rh-positive fetus’s blood cells
pass into the circulation of the Rh-negative mother in sufficient quantities to produce
anti-Rh antibodies, which in turn may enter the fetal circulation and cause fetal RBC
hemolysis.
In the most severe form of erythroblastosis fetalis (hydrops fetalis), the progressive
hemolysis causes fetal hypoxia; cardiac failure; generalized edema (anasarca);
hydrops; and effusions into the pericardial, pleural, and peritoneal spaces. The fetus
may be delivered stillborn or in severe respiratory distress. Maternal Rh
immunoglobulin (RhIg) administration, early intrauterine detection of fetal anemia by
ultrasonography (serial Doppler assessment of the peak velocity in the fetal middle
cerebral artery), and subsequent treatment by fetal blood transfusions or high-dose
intravenous immunoglobulins have dramatically improved the outcome of affected
fetuses.
Some of the most significant inborn errors of metabolism in the neonatal period
include congenital hypothyroidism, phenylketonuria (PKU), and galactosemia.
Specific newborn screening for inborn errors of metabolism should take place in
situations where their incidence is prevalent. Severe cognitive delays can result if
these conditions are undiagnosed and untreated.
In PKU the hepatic enzyme phenylalanine hydroxylase, which controls the
conversion of phenylalanine to tyrosine, is absent. This results in the accumulation of
phenylalanine in the bloodstream and urinary excretion of abnormal amounts of its
metabolites, the phenyl acids. Treatment of PKU involves the restriction of dietary
protein. Phenylalanine cannot be totally eliminated because it is an essential amino
acid in tissue growth. Therefore dietary management must (1) meet the child’s
nutritional need for optimum growth and (2) maintain phenylalanine levels within a
safe range. Inadequate treatment results in cognitive impairment, behavior problems,
and growth failure.
Galactosemia is a rare autosomal recessive disorder that results from various gene
mutations leading to three distinct enzymatic deficiencies. The most common type of
galactosemia (classic galactosemia) results from a deficiency of a hepatic enzyme,
galactose 1-phosphate uridyltransferase (GALT). Infants with galactosemia appear
normal at birth, but on ingestion of milk (which has a high lactose content) they begin
to show progressive symptoms, including vomiting, diarrhea, and weight loss.
Additional sequelae of untreated galactosemia include hepatic dysfunction and
cirrhosis, splenomegaly, cataracts, and cerebral damage. Treatment consists of
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eliminating all milk and lactose-containing formula, including breast milk; lifelong
treatment is imperative.
Congenital hypothyroidism, an inborn error of thyroid metabolism, occurs in
neonates who are born without the ability to synthesize adequate amounts of thyroid
hormone. Clinical manifestations include poor feeding, lethargy, and respiratory
difficulties. Treatment involves lifelong thyroid hormone replacement therapy with
synthetic levothyroxine sodium.
High-risk neonates are those newborn infants, regardless of gestational age or birth
weight, who have a greater than average chance of morbidity or mortality because of
conditions or circumstances that affect the normal course of events associated with
birth and adjustment to extrauterine life. Typically, the lower the gestational age, the
higher the morbidity potential.
Late-preterm infants, those infants born between 34 and 366/7 weeks of gestation,
may be able to make an effective transition to extrauterine life; however, such infants,
by nature of their limited gestation, remain at risk for problems related to feeding,
neurodevelopment, thermoregulation, hypoglycemia, hyperbilirubinemia, sepsis, and
respiratory function.
Appropriate developmental care for preterm infants focuses on individualized
neurobehavioral assessment, planning, diagnosis, intervention, and reevaluation to
foster appropriate growth and maturation in a potentially harmful environment.
Nursing care activities, such as taking vital signs, changing the infant’s position,
weighing, and changing diapers, are associated with frequent periods of hypoxia,
oxygen desaturation, and elevated intracranial pressure. The more immature the
infant, the less able he or she is to tolerate even a simple procedure, such as taking
blood pressure, without becoming overstimulated.
Parents are encouraged to interact with their high-risk infant and gradually assume
care of the infant based on the infant’s condition. Family-centered care of high-risk
newborns includes encouraging and facilitating parental involvement rather than
isolating parents from their infant and associated care. This aids in not only
promoting attachment but also minimizing the parents’ feelings of inadequacy and
helplessness.
Because of their immature physical status, preterm infants need special attention to
promote respiratory efforts, maintain body temperature, maintain fluid and electrolyte
balance, prevent infection, and provide adequate nutrition for growth.
Oxygen should be provided judiciously to high-risk infants to prevent hypoxemia and
hyperoxemia.
The preterm infant loses heat at a rapid rate, further compromising metabolic and
respiratory status.
Increased amounts of body fluid and inability to concentrate urine in the kidneys
further predispose the preterm infant to fluid and electrolyte imbalance.
Preterm infants are subject to a number of complications, including apnea, sepsis,
respiratory distress syndrome (RDS), necrotizing enterocolitis, and intraventricular
hemorrhage.
RDS refers to a condition of surfactant deficiency and physiologic immaturity of the
respiratory system, which hinders the infant’s ability to make a successful transition
to extrauterine life.
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The administration of exogenous surfactant to infants with or at high risk for RDS
demonstrates improvements in blood gas values and ventilator settings, decreased
incidence of pulmonary air leaks, decreased deaths from RDS, and an overall
decreased infant mortality rate.
Bronchopulmonary dysplasia (BPD), sometimes referred to as chronic lung
disease, is a pathologic process that develops primarily in extremely low– and very
low birth weight infants with RDS. Infants with BPD often require prolonged oxygen
administration and may have growth delay as a result of increased metabolic and
oxygen demands. Infants with BPD are at increased risk for respiratory tract
infections such as respiratory syncytial virus.
Retinopathy of prematurity (ROP) is a complex disorder with multiple causes that
involves changes in the immature retinal vasculature that may result in partial or
complete vision impairment.
Sepsis is a serious condition with generalized nonspecific manifestations that require
immediate intervention with broad-spectrum antibiotics and observation for
associated complications. Hand washing is crucial in preventing the spread of
organisms and viruses to the already compromised preterm infant.
Necrotizing enterocolitis (NEC) is an acute inflammatory disease of the bowel with
increased incidence in preterm and other high-risk infants. Three factors appear to
play an important role in the development of NEC: intestinal ischemia, colonization
by pathogenic bacteria, and substrate (formula feeding) in the intestinal lumen. The
prominent clinical signs of NEC are a distended abdomen, gastric residuals, and
blood in the stools. Nonspecific signs include lethargy, poor feeding, hypotension,
apnea, vomiting (often bile stained), decreased urinary output, and hypothermia.
Hypoxic-ischemic brain injury, or hypoxic-ischemic reperfusion injury, is the most
common cause of neurologic impairment observed in term and preterm infants. The
brain damage usually results from asphyxia before, during, or after delivery.
Hypoxic-ischemic injury leads to hypoxic-ischemic encephalopathy (HIE), the
cellular damage that causes the clinical manifestations observed in each case. In the
preterm infant HIE may occur in conjunction with intraventricular hemorrhage.
Therapeutic hypothermia is currently being used to decrease the CNS effects of
reperfusion injury. The major long-term sequelae of hypoxic-ischemic injury are
cognitive impairment, seizures, and cerebral palsy.
For parents neonatal loss represents a loss of a part of themselves (especially for
mothers), a loss of the potential for immortality that offspring represent, and the loss
of the dream child that has been fantasized about throughout the pregnancy. Parents
are afforded the opportunity to grieve for the loss of the child by touching and
holding the infant and by participating in decisions about the infant’s care before and
after death. Tangible mementoes such as pictures, lock of hair, footprints, and a baby
blanket may assist in the grieving process.
Maternal conditions that may pose health risks in the neonatal period include
maternal diabetes, perinatal infections, and substance abuse. Maternal viral infections
that may compromise the infant’s health include sexually transmitted infections such
as herpes, syphilis, gonorrhea, chlamydia, and cytomegalovirus, as well as other
infections such as toxoplasmosis, parvovirus B19, and varicella.
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Chemical substances taken by the mother easily cross the placenta and negatively
affect the fetus. These include cocaine, heroin, methamphetamines, opiates, tobacco,
and alcohol. Fetal alcohol syndrome is the leading preventable cause of childhood
cognitive impairment in the United States.
The infant of the diabetic mother is predisposed to respiratory distress, meconium
aspiration, glucose instability, structural congenital anomalies, and birth injuries. The
single most important factor influencing fetal well-being is the mother’s euglycemic
status. Effective management of these infants includes careful monitoring of serum
glucose levels and observation for accompanying complications such as RDS.
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