compromised newborn hatfield 1.8.19 · 14 the function of brown fat is to: a) generate heat when it...

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CSI Baby!Early Recognition of the Compromised Newborn

Tanya Kamka, RNC-NIC, MSNUCSF Benioff Children’s Hospital

▪ Discuss maternal, fetal and intrapartum risk factors that contribute to a compromised newborn

▪ Describe the physiologic changes that must occur at birth for successful transition to extrauterine life

▪ Discuss the nursing assessments and interventions for an infant who becomes compromised

Course Objectives

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Recipe for Success When Caring for Compromised Newborns…(S.T.A.B.L.E.)

Anticipate Recognize Act Reassess

▪ Antenatal risk factors that can lead to a compromised newborn

▪ Maternal risk factors

▪ Fetal risk factors

▪ Intrapartum risk factors

Identifying newborns at risk

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▪ Age

▪ Lifestyle

▪ Support system

▪ Access to care

▪ Mental Health

▪ Chronic illness

▪ Genetics

▪ Stress

Maternal risk factors

• Prenatal Diagnosis– Genetics: CVS, amniocentesis

– Nuchal translucency

– Ultrasound

– Fetal ECHO

– Fetal MRI

• Entry to care• Pregnancy nutrition and weight gain

Prenatal Care

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• Obstetric History

○ Infertility

○ Past delivery history

○ Bleeding

○ PROM

○ Infection

○ Pregnancy loss

Maternal Factors

• Multiple gestation

• Abnormal growth

• Abnormal fetal position

• Abnormal placentation

• Decreased activity/FHR abnormality

• Poly/oligohydramnios

Fetal Factors

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• Fetal distress• Fetal presentation

• Premature/postmature labor

• Rapid or prolonged labor

• Rupture of membranes

• Maternal bleeding

• Cord prolapse

• Eclampsia

• Instrumentation at delivery

• Mode of delivery

• Medications

Intrapartum Factors

• Prematurity

• Low Apgars

• Encephalopathy

• Shock/pallor

• Chorioamnionitis

• Small for dates

• Large for dates

• Undiagnosed congenital anomalies/conditions

Immediate Neonatal Conditions

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▪ LBW ≤2500 gms▪ VLBW ≤1500gms▪ ELBW ≤1000gms

▪ SGA - Weight below the 10th percentile for gestational age

▪ IUGR - Fetus is unable to reach its genetically determined potential size

▪ LGA - Weight above 90th percentile for gestational age

▪ Macrosomia - Estimated fetal weight>4500gm in IDM and >5000gm in others

Birth Weight Categories & Classifications

Symmetric Asymmetric

IUGRLGASGA or IUGRAGA

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1 Does this make sense? I wanted to try and make a visual of the differencesTanya Hatfield, 5/18/2018

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▪Extreme prematurity ≤ 28 weeks

▪Very preterm < 32 weeks

▪Late preterm (LPI) 34 0/7‐36 6/7

weeks

▪Early term pregnancy 37 0/7‐38 6/7

weeks

▪Term pregnancy 39 0/7‐40

Maturity Classifications

Risks related to Prematurity

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Characteristics of the LPI

%

Low Birth Weight

Delay in bilirubin metabolism

Immature suck and swallow

Immature Immune system

Poor state regulation

Low tone

Low glycogen stores

Poor thermoregulation

Low Body Fat

Clinical Outcomes: Full term vs. LPI

Modified from Wang, et al. Pediatrics, 2004

%

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Post Maturity Risks

Post Maturity Risks

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Transition to Extrauterine Life

REMEMBER!Blood

follows thepath of least resistance

The fetus gets oxygen

from the placenta

Pressure in the blood vessels of the lungs is high

so blood is shunted away

Review of

FETAL SHUNTS

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Fetal Circulation▪ Gas exchange is liquid to liquid

▪ Organ of respiration is placenta

• High flow, low resistance

▪ Fetal lungs

• Low flow, high resistance

• Pulmonary Arteries constricted

▪ High right heart and lung pressures

▪ Low left heart pressures

▪ Open fetal shunts

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5 things must happen at birth:

• Lungs expand to terminal airways

• Alveoli become oxygenated

• Pulmonary Vasculature must dilate (↓ PVR)

• Cardiac output to lungs goes from 10% →100% (↑ SVR, closure of fetal shunts)

• Establishment of continuous breathing

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• Independent breathing

• Fetal to neonatal circulation

• Non-shivering thermogenesis

• Independent glucose production

• Fluid balance shifts


• Good news! 90% of infants transition with no

problem!

• But...10% require some assistance

• 1% require extensive resuscitation

• Remember… difficulty transitioning in one area will

affect the others

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What are the goals of Resuscitation?

● Maintain temp 36.5-37.5-Room 25C/77F-Skin to skin-Servo-Thermal devices

● Support breathing● Gentle ventilation● Judicious use of oxygen● Support cardio-respiratory transition● Normoglycemia

Do you know…???

A naked newborn exposed to an environmental temperature of 23°C (73.4°F) suffers the same

heat loss as a naked adult in 0°C (32°F)

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The function of brown fat is to:

a) generate heat when it is metabolized.b) provide a rapidly available source of glucose in the first day of life.c) provide an insulating layer of fat in the first month of life.

Cold Stress Response

• Peripheral and core sensors detect cold stress

• Hypothalamus signals norepinephrine release which leads to:

– Peripheral and pulmonary vasoconstriction

– Increased metabolic rate

– Increased 02 and glucose consumption

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The mother-baby unit is extremely busy today. An infant born several hours ago at 37-weeks gestation has the following vital signs:

Temperature 36.0°C (96.8°F) Heart rate 170 Respiratory rate 65You have a heavy patient load and need to bathe the infant. Should the infant be bathed at this time?

a) No, the vital signs are not in a normal range and the bath should waitb) Yes, providing a radiant warmer is used so the infant doesn't get coldc) Yes, the vital signs are in an acceptable range and the infant is term

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▪ Interventions• Delay interventions at birth that increase heat

loss (temp. affects other VS too)• Skin to skin care with mother immediately after

birth and as frequently as medical condition allows

• Dress infant with hat, double blankets if necessary

• Use servo-control and temp. probe while in warmer/incubator

Temperature Instability

▪ Interventions• Document ambient temperature/clothing

necessary to maintain optimal body temp• Assess carefully for cause of changes in

temperature

‒ Primary thermo-regulation vs. sepsis, respiratory issues, hypoglycemia

• Warm consistently: incubator, servo-control, monitor NTE, slow transition to OC, additional clothing when in open crib

• Notify provider of episodes of hypothermia

Temperature Instability

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Initial Assessments

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Cortical Thumb

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Port Wine Stain

Café Au Lait

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Sacral Skin Tag

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Sacral Dimple

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Size

▪ Alertness/activity level

▪ Symmetry of movement

▪ Response to stimuli

▪ Posture

▪ Tone

▪ Reflexes

Neurological Assessment

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Abnormal Newborn Exam

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Tone? Activity?

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Sarnat scoring (for encephalopathy)

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Assessment of the Baby at Risk for Encephalopathy

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Seizures▪ Quality of movement

• Tonic - stiff posturing

• Clonic – rhythmic single body part

• Subtle (ex bicycling, orofacial movements, tremulous movements)

• Myoclonic - rapid “shock-like”

• Erratic, non-rhythmic

▪Body part

▪ Level of consciousness

▪Response to stimulus: Extinguishable?

▪Duration

Seizures: what else could it be?Benign Neonatal Sleep Myoclonus

Typical presentation:• 1st DOL to 1st 3 weeks

of life• Distal parts of upper

extremities• 10-20 seconds• Can worsen with

restraint• Stops when awakened

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Seizures

▪Check Calcium and Glucose

▪ Lorazepam 0.1 mg/kg IV

▪Phenobarbital 20mg/kg IV

“This baby seems jittery…”

▪What is the history

▪When is the onset

▪Are there electrolyte abnormalities?

○ Hypoglycemia

○ Hypomagnesemia

○ Hypocalcemia

▪Hyperviscosity

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Hypoglycemia

How low is too low?

How low is too low for too long?

Hypoglycemia-Who is at Risk?▪Preemies

▪SGA

▪ IUGR

▪LGA

▪ IDM

▪Sick babies

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▪ High risk groups

• Inadequate glycogen stores and decreased glucose production

• Hyperinsulinemia

• ALL sick babies

‒ Metabolic acidosis/increased energy demands

‒ ↑ work of breathing, thermal regulation, etc

‒ Lack of excess oxygen for conversion

Hypoglycemia

Hypoglycemia

▪Abnormal cry

▪Apnea

▪Cyanosis

▪Feeding Difficulty

▪Grunting, Tachypnea

▪Hypothermia

▪Hypotonia

▪ Irritability

▪Jitteriness, tremors

▪Lethargy

▪Seizures

▪Diaphoresis

▪Tachycardia

▪NO SYMPTOMS

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UCSF NC2 Asymptomatic Infants/at-risk

UCSF NC2 Asymptomatic Infants-at risk

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UCSF NC2 Symptomatic Infants

▪Maximize energy intake

• Encourage early, frequent, effective BF

• Supplement as clinically indicated (not as routine) following evidence-based guidelines

Hypoglycemia-Interventions2

2 Can you talk about glucose gel a little here?Tanya Hatfield, 5/18/2018

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Color & Perfusion

Polycythemia

▪Hematocrit >65%

▪Birth or iatrogenic

• Twin To Twin Syndrome (TTTS), SGA, LGA, IDM

• Delayed cord clamping, hypertransfusion

▪Risks from polycythemia

• hyperviscosity

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“Does my baby look yellow to you?”

Hyperbilirubinemia

▪ Recognition-visual

▪ Potential causes▪ Sepsis, extravascular blood, hypoxia,

bowel obstruction, Increased formation/ synthesis of bilirubin

▪ Hemolysis▪ Sequestered blood▪ Decreased/altered conjugation▪ Delayed passage of meconium▪ Dehydration

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Hyperbilirubinemia• Hyperbilirubinemia is defined as an

elevated serum total bilirubin (TB) level

• > 10-12 mg/dl in term• > 4-5 mg/dl in preterm infants

• Usually peaks around 5-7 days• Later peak in preterm infants

• Values vary depending on the infant’s age in hours, gestational age, and pathology• http://bilitool.org/

Phototherapy

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Assessment of the Head

▪Head circumference

▪Shape and symmetry

▪Molding

▪Head trauma

▪Fontanels

▪Sutures

▪Quality of scalp hair

•Hair whorl

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Head

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Full term head circumference = 35 cm +/- 2 cm

1 What does the hair whorl mean again? I know its not good.amay22, 5/18/2018

3 Abnormal brain development :)Tanya Hatfield, 5/18/2018

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Sutures and Fontanelles

• There are a total of 6 fontanelles

• Palpate anterior and posterior fontanelles as part of your neuro assessment

• Fontanelles are commonly used to evaluate ICP

• Size in newborns is quite variable

Bulging Fontanelle

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Head Shapes

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Sagittal Craniosynostosis

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Microcephaly

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Macrocephaly

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Hydrocephalus

Hydrocephalus means water on the brain• An accumulation of CSF due to impaired flow, reabsorption or

excessive production

Symptoms• Increasing head circumference• Full/bulging fontanelle• Split sutures• Setting sun sign• High shrill cry

Treatment• Shunting

Hemorrhage Locations

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Scalp swellings

Cephalhematoma Subgaleal Hemorrhage

Abnormal facial features

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Pierre Robin Sequence

Features• Micrognathia• Glossoptosis• Cleft palate

Nursing management

Treatment• Prone• Distraction• Trach

Choanal Atresia

• Characteristics

• Nursing Management

• Obligate nose breathers

• Cotton ball test

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Oral airways

• The appropriate size can be estimated by holding the airway next to the face

Oral Clefts• Happens in the 6th-

9th week pregnancy

• Infants of smokers, IDM

Considerations• Language

development• Hearing loss• Dental issues• Repair• Parental bonding

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Chest and Lungs

• Shape• Breasts and

nipples• Respiratory rate• Respiratory effort• Grunting• Flaring • Retractions

• Location• Severity

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“This Baby won’t pink up”

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Case Study- Baby M

31 year old G1P0

• Full prenatal care

• Multiple u/s for marginal placenta previa

• Scheduled c/s

Case Study-Baby M• Taken back to nursery

• NC 2.0L FiO2 1.0

• Diminished left lung sounds

• UVC/UAC placed

• OGT to gravity

• Chest/abdomen X ray

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Case Study• Transported to regional level 4 NICU• Diagnosed Congenital Diaphragmatic

Hernia• Surgery on DOL 3

• Home on DOL 10

Congenital Diaphragmatic Hernia

Signs & Symptoms• Flat or scaphoid abdomen• Respiratory distress• Shifted heart sounds• Bowel sounds in chest• S/S Pulmonary hypertension

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Tip of Replogle

Bowel Dilated with Air Inhibiting Lung Expansion

Left CDH

Stomach Up and Full of

Air

Tip of Replogle in Stomach

Amount of Gas in Bowel Decreased

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Congenital Diaphragmatic Hernia

Management• Immediate intubation• Decompress stomach• IV access• Sedation/pain management• Paralytics• Correct acid base disturbances• Transfer to the NICU

Be nice to families ☺ Post-traumatic stress disorder from NICU admission is real

Persistent Pulmonary Hypertension of the newborn (PPHN)

• 2 per 1,000 births

• Etiology of PPHN - 3 Types– Maldevelopment

– Maladaptation

– Underdevelopment

• PPHN is primarily condition of term and post-term infants– 77% infants diagnosed by 24 hours of age– 93% by 48 hours– 97% by 72 hours

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Perfusion

• Heart Rate

• Pulses

• Capillary fill time

• Blood Pressure

Cyanosis Yes Yes

Respiratory Rate“Comfortably tachypneic”

Work of Breathing Easy but (with CHF)

Acid/Base Balance

PC02 Respiratory acidosis

PC02 Metabolic acidosis

Chest X-ray Asymmetric pattern of infiltrates

or Pulmonary vascular

markings

Heart Size,shape,location

Normal Abnormal

02 Challenge P02>150 P02<150

Cardiac versus Respiratory Disease Respiratory Cardiac

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Gastrointestinal Assessment

• Abdominal exam• Shape, size, symmetry• Cord• Feeding history• Presence of bowel sounds• Stooling history• Emesis

Abnormal Findings: Vomiting and Residuals

Walker, G. (2006). Colour of bile vomiting in intestinal obstruction in the newborn: questionnaire study. BMJ, 332(7554), 1363-0. http://dx.doi.org/10.1136/bmj.38859.614352.55

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Gastrointestinal Obstructions: warning signs…

▪ Polyhydramnios

▪ Abdominal distention

▪ Bilious emesis

▪ Failure to pass meconium in the first 48 hours of life

▪ Bilious vomiting and blood from rectum suggests vascular compromise to small bowel, particularly with associated acidosis

▪ Acute abdomen requires immediate surgical intervention

GI Obstructions

Varvelicious.wordpress.com,. (2015). duodenal atresia | Varvelicious. Retrieved 27 October 2015, from https://varvelicious.wordpress.com/tag/duodenal-atresia/Pedsradiology.com,. (2015). Duodenal Atresia images, diagnosis, treatment options, answer review - Pediatric Radiology. Retrieved 27 October 2015, from http://www.pedsradiology.com/Historyanswer.aspx?qid=77&fid=1

Double bubble…

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Assessment of the Extremities

• Shape, size and symmetry

• Range of motion• Digits• Nails• Creases (hands,

feet)• Axillae• Fractures• Hips

Case Study

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• Baby Boy G was born to a G3-P2 with hx of 2 prior c-sections at 38 3/7 weeks at 11 am

• Mom was GBS + but did not receive abx because she was a scheduled c/s and not ruptured prior to delivery

• Baby was born with Apgars of 9 and 9 and no resuscitative ,measures required at delivery

• Birth took place at a hospital with a level II NICU

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Case Study

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• At 1 pm (2 HOL) during bath, baby “turned blue”, had emesis clear fluid and required BB O2

• A 2nd episode 10 minutes later prompted transfer to the special nursery

• Blood cx and cbc was ordered

• During blood draw baby had 2 more episodes

• Pediatrician to bedside, ECHO ordered

• ECHO was done and was “clear”

• Pediatrician went home with orders to get labs and call with results

• RR 88; baby irritable

Case Study

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• At 2 pm (3 HOL) Lab and NICU staff still unable to get lab draws

• PIV placed

• Bruising noted at tourniquet sites

• MD called back in to assist/place line

• Baby now on 60% nasal cannula

• Intermittent emesis; described as “very fussy”

• VS at 3:15 pm (4 HOL): HR 168; RR 143; intermittent grunting; Temp 101.3, RN adjusted RW

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Case Study

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• At 6 pm UAC placed; blood cultures drawn and Amp and Gent ordered

• Amp started at 7:15; nursing note states that “Amp infusing, IV infiltrated” IV d/c’d

• Gent given via UAC

• The long story short…

Group Beta Strep “GBS”

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• Normal vaginal flora in many women (10-30%)

• Ascending infection

• A major cause of morbidity & mortality in neonates

• Stillbirth, sepsis, pneumonia

• Risk factors:

• GBS bacteruria

• Previous infant with GBS disease

• < 37 weeks

• ROM > 18 hours

• Fever in labor > 38.0 C

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Clinical Presentation…

103

• Respiratory signs

• Unstable Temperature, usually hypothermic

• Change in baseline color (pale, mottling, cyanotic and/or evidence of petechiae)

• Change in tone-lethargic or irritable

• Glucose instability

The Key isNoting a

Change From Normal

Early Identification… A New Approach: The Probability of Neonatal Early Onset Infection

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▪Based on the work by Drs Gabriel Escobar and Karen Puopolo, et al. (2014)

▪Goal: To define a quantitative stratification algorithm for the risk of EOS in newborns greater than or equal to 34 weeks gestation

▪ The question: Is there a way to use maternal OBJECTIVE data with OBJECTIVE neonatal clinical findings to define more efficient strategies for the evaluation and treatment of EOS in term and late preterm infants?

▪ The potential result: Decreased antibiotic treatment in newborns

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Probability of Sepsis

▪Using the information gathered from the 350 cases of proven EOS and their matched controls, the probability of sepsis was predicted using only objective clinical data available at the time of birth

▪Based on 350 cases of 608,014 births, the sepsis rate for the population was 0.58 per thousand live births

▪The model uses 5 predictors to compute a potential risk of sepsis at birth

▪The risk is then adjusted based on infant-specific data to guide evaluation and treatment decision (Bayesian approach)

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“The Calculator” – Let’s try it!

▪http://www.dor.kaiser.org/external/DORExternal/research/infectionprobabilitycalculator.aspx

▪CASE: 39 1/7 week G3P1 presents with c/o labor. Contractions every 3 - 5 minutes. Cervical exam at 1.5 cm. BOW intact. Labors to complete in 1.5 hours. Ruptures 20 min prior to delivery. GBS negative, no antibiotics administered. Last temperature prior to delivery 98.9 degrees F.

▪Based on the calculator, what is the baseline risk of EOS?

▪What if the gestational is 35 1/7 weeks?

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Equivocal Signs

▪In the first 12 hours of life, the baby experiences either:

•Two (2) of the following abnormalities that persist for 2 hours, or

•One (1) abnormality that persists for 4 hours

▪Heart rate ≥ 160

▪Respiratory rate ≥ 60

▪Temperature ≥ 100.4F or < 97.5F

▪Respiratory distress (grunting, flaring or retracting)

(Escobar, et al. 2014)

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You Got a Number, Now What?

▪Labs: timing is clearly an issue

•Blood Culture (at birth or prior to starting antibiotics)

•CBC with WBC differential and platelet count

•CRP

•Blood Gas

•Blood Glucose

•LP

▪Are the lab results enough to start or stop antibiotics?

▪There is still value in RN assessment!

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Case Study

▪ 39-week infant, unremarkable delivery

• Mother denies any history of drug use.

• 2 weeks prior to delivery, the mother had a severe URI for which she was prescribed a combination cough preparation.

‒ 6.25mg promethazine HCl / 5 ml

‒ 10 mg codeine phosphate / 5 ml

▪ Total dose 500-600 mg of codeine

Case Study

▪At a few hours of life the baby had abnormal posturing with arching and seizures.

▪Baby drug screen positive for codeine and morphine.

‒ (Codeine is metabolized to morphine.)

▪Evaluation

• EEG

‒Subclinical seizures arising from the left hemisphere

▪ All other work-ups including sepsis, coagulopathy, cardiology and metabolic disease profiling were negative.

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Case Study

▪ Imaging

• MRI on DOL 3

‒Left middle and anterior cerebral artery infarction

‒Edema of the left cerebral peduncle and pons

‒Residual clot in the internal carotid artery

Symptom Chart

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Symptom Chart

Other Risk Factors for Increased Severity of NAS

•Term Infant

•Polydrug or polysubstance abuse

•Combination with benzodiazepines

•Smoking

•Methadone

•Combination with SSRIs

Kocherlakota (2014).

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Identifying Infants At Risk for NAS▪When to Screen

▪Mothers identified as at-risk by primary or OB caregivers

▪High-risk behavior (use of street drugs)

▪Identified by CPS

▪Disclosed use during pregnancy

▪Under the influence during admission or visits

▪Previous positive screenA Retrospective Cohort Comparison Study of 3 Screening ApproachesMurphy-Oikonen, et al. J of Perinat Neonat Nurs Vol. 24, No. 4 ,2010

Newborn Toxicology▪Detailed history is more helpful than a toxicology screening

▪Correlation between maternal and newborn test results is poor

•Dependent on time of maternal use, properties of placental transfer, time of birth, specimen collection

▪Specimen collection:

•Meconium

•Urine

•Umbilical cord

•Hair

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No biological specimen, when obtained randomly, identifies prenatal drug

use with 100% accuracy (AAP, 2013)

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“Because opiate receptors are concentrated in the CNS and the gastrointestinal tract, the predominant signs and symptoms of pure opioid withdrawal reflect CNS irritability, autonomic over-reactivity and GI dysfunction.”

Neonatal Drug Withdrawal AAP Committee on Drugs, Pediatrics 2012

Clinical Presentation of Withdrawal

Clinical Features ofNeonatal Abstinence SyndromeAAP, Committee on Drugs,Neonatal Drug Withdrawal, Pediatrics Vol..101, No.6

Neurologic Excitability

▪Irritability, increased wakefulness

▪Restlessness, tremors

▪Hyperactive deep tendon reflexes

▪High pitched cry

▪Increased muscle tone, exaggerated Moro

▪Seizures

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Clinical Features ofNeonatal Abstinence SyndromeAAP, Committee on Drugs,Neonatal Drug Withdrawal, Pediatrics Vol..101, No.6

Gastrointestinal dysfunction

▪Poor Feeding- “Messy Feeder”

▪Uncoordinated and constant sucking

▪Regurgitation

▪Vomiting

▪Diarrhea

▪Dehydration

▪Poor weight gain

Clinical Features ofNeonatal Abstinence Syndrome

▪Autonomic dysregulation

▪Nasal stuffiness

▪Fever, temperature instability

▪Hiccups

▪Sneezing

▪Mottling

▪Sweating

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Multidisciplinary NAS Approach

▪ Identify neonates at risk for NAS and make appropriate referrals rapidly

▪Consistently evaluate the presence and severity of withdrawal symptoms

▪Standardize and simplify the opioid withdrawal treatment plan

▪ Initiate appropriate non-pharmacologic and pharmacologic interventions to control symptoms

▪Safely minimize length of stay

▪Discharge infants successfully weaned from opioids

D’Apolito, K (2014); Saunders, C, et al (2015).

Implications for all patients…

Family support• Stages of grief• Bonding needs• Normalizing

experience• Addressing the

fears• Empowering the

families

Guiller, C., Dupas, G., & Pettengill, M. (2009). Suffering eases over time: the experience of families in the care of children with congenital anomalies. Revista Latino-Americana De Enfermagem, 17(4). http://dx.doi.org/10.1590/s0104-11692009000400010

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Questions?

Thank you!!

[email protected]

compromised newborn hatfield 1.8.19 · 14 the function of brown fat is to: a) generate heat when it...

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