special topics in pediatric nursing

Upload: richard-s-roxas

Post on 14-Apr-2018

225 views

Category:

Documents


3 download

TRANSCRIPT

  • 7/30/2019 Special Topics in Pediatric Nursing

    1/60

    SPECIAL TOPICS INSPECIAL TOPICS IN

    PEDIATRIC NURSINGPEDIATRIC NURSING

    PREMATURE NEONATE PREMATURE NEONATE

    Richard Benedict S. Roxas,Richard Benedict S. Roxas,

    R.N, MD, MSc. Physiology (u)R.N, MD, MSc. Physiology (u)

  • 7/30/2019 Special Topics in Pediatric Nursing

    2/60

    PREMATURE NEONATEPREMATURE NEONATE

    PrematurityPrematurity refers to the broad category ofrefers to the broad category of

    neonates born at less than 37 weeks'neonates born at less than 37 weeks'

    gestational age (GA). Although thegestational age (GA). Although the

    estimated date of confinement (EDC) is 40estimated date of confinement (EDC) is 40

    weeks' GA, the World Health Organizationweeks' GA, the World Health Organization

    broadened the range of full term to includebroadened the range of full term to include

    37-42 weeks' GA.37-42 weeks' GA.

  • 7/30/2019 Special Topics in Pediatric Nursing

    3/60

    Premature newborns have manyPremature newborns have manyphysiologic challenges when adapting tophysiologic challenges when adapting tothe extrauterine environment.the extrauterine environment.

    Serious morbidities occur in extremelySerious morbidities occur in extremelylow-birth-weight (LBW) infants.low-birth-weight (LBW) infants.

    The near-term neonate (34-36 weeks' GA)The near-term neonate (34-36 weeks' GA)

    has issues of prematurity that includehas issues of prematurity that includefeeding immaturity, temperature instability,feeding immaturity, temperature instability,and prolonged jaundice.and prolonged jaundice.

  • 7/30/2019 Special Topics in Pediatric Nursing

    4/60

    ROLE OF PLACENTAROLE OF PLACENTA

    The placenta serves 3 major roles for the fetus: provision of all theThe placenta serves 3 major roles for the fetus: provision of all thenutrients for growth, elimination of fetal waste products, andnutrients for growth, elimination of fetal waste products, andsynthesis of hormones that promote fetal growth.synthesis of hormones that promote fetal growth.

    With the exception of most electrolytes, the maternal circulationWith the exception of most electrolytes, the maternal circulationcontains more substrate (eg, blood glucose) than the fetalcontains more substrate (eg, blood glucose) than the fetalcirculation.circulation.

    In addition, the placenta is metabolically active and consumesIn addition, the placenta is metabolically active and consumesglucose. Waste products of fetal metabolism (eg, heat, urea,glucose. Waste products of fetal metabolism (eg, heat, urea,bilirubin, carbon dioxide) are transferred across the placenta andbilirubin, carbon dioxide) are transferred across the placenta andeliminated by the mother's excretory organs (ie, liver, lung, kidneys,eliminated by the mother's excretory organs (ie, liver, lung, kidneys,skin).skin).

    In addition, the placenta acts as a barrier to infection throughIn addition, the placenta acts as a barrier to infection throughmucosal macrophages and by allowing transfer of maternalmucosal macrophages and by allowing transfer of maternalimmunoglobulins (Igs, eg, IgG) to the fetus beginning at 32-34immunoglobulins (Igs, eg, IgG) to the fetus beginning at 32-34weeks of gestation. Placental dysfunction is involved in the transferweeks of gestation. Placental dysfunction is involved in the transferof IgG. Antibacterial activity of the amniotic fluid improves as GAof IgG. Antibacterial activity of the amniotic fluid improves as GAadvances.advances.

  • 7/30/2019 Special Topics in Pediatric Nursing

    5/60

    EXTREMELY LOW BIRTHEXTREMELY LOW BIRTH

    WEIGHTWEIGHT

    Extremely low birth weight (ELBW) is defined asExtremely low birth weight (ELBW) is defined as

    a birth weight less than 1000 g (2 lb, 3 oz).a birth weight less than 1000 g (2 lb, 3 oz).

    The majority of ELBW infants are also theThe majority of ELBW infants are also the

    youngest of premature newborns, usually bornyoungest of premature newborns, usually bornat 27 weeks' gestational age or younger.at 27 weeks' gestational age or younger.

    Nearly 1 in 10 infants with low birth weightNearly 1 in 10 infants with low birth weight

    (

  • 7/30/2019 Special Topics in Pediatric Nursing

    6/60

    Infants born at less than 1500 g are termed veryInfants born at less than 1500 g are termed verylow birth weight (VLBW).low birth weight (VLBW).

    Infants whose weight is appropriate for theirInfants whose weight is appropriate for theirgestational ages are considered appropriate forgestational ages are considered appropriate for

    gestational age (AGA).gestational age (AGA).Infants who are heavier than expected are largeInfants who are heavier than expected are largefor gestational age (LGA); conversely, thosefor gestational age (LGA); conversely, thosesmaller than expected are considered small forsmaller than expected are considered small for

    gestational age (SGA) and are usually alsogestational age (SGA) and are usually alsofound to be intrauterine growth restricted (IUGR)found to be intrauterine growth restricted (IUGR)prior to birth.prior to birth.

  • 7/30/2019 Special Topics in Pediatric Nursing

    7/60

    ELBW survival has improved with theELBW survival has improved with the

    widespread use of surfactant agents,widespread use of surfactant agents,

    maternal steroids, and advancements inmaternal steroids, and advancements in

    neonatal technologies.neonatal technologies.

    The minimum age of viability is now asThe minimum age of viability is now as

    young as 23 weeks, with scattered reportsyoung as 23 weeks, with scattered reports

    of survivors born at 21-22 weeks'of survivors born at 21-22 weeks'estimated gestational age.estimated gestational age.

  • 7/30/2019 Special Topics in Pediatric Nursing

    8/60

    Although the mortality rate has diminishedAlthough the mortality rate has diminished

    with the use of surfactants, the proportionwith the use of surfactants, the proportion

    of surviving infants with severe sequelae,of surviving infants with severe sequelae,

    such as chronic lung disease, cognitivesuch as chronic lung disease, cognitive

    delays, cerebral palsy, and neurosensorydelays, cerebral palsy, and neurosensory

    deficits (ie, deafness and blindness), hasdeficits (ie, deafness and blindness), has

    not.not.

  • 7/30/2019 Special Topics in Pediatric Nursing

    9/60

    ASSESSMENT TOOLSASSESSMENT TOOLS

    Confirmation of GA is based on physical andConfirmation of GA is based on physical and

    neurologic characteristics. In 1979, theneurologic characteristics. In 1979, the

    Dubowitz Scoring SystemDubowitz Scoring System for determining GAfor determining GA

    based on neurologic and physical parametersbased on neurologic and physical parameterswas revised to include 12 items.was revised to include 12 items.

    TheThe Ballard Scoring SystemBallard Scoring System, recently revised, recently revised

    again to include extremely LBW infants, remainsagain to include extremely LBW infants, remains

    the main tool clinicians use after delivery tothe main tool clinicians use after delivery to

    confirm GA by means of physical examination.confirm GA by means of physical examination.

  • 7/30/2019 Special Topics in Pediatric Nursing

    10/60

    Neurologic CriteriaNeurologic Criteria include muscle toneinclude muscle tone

    of the trunk and extremities and jointof the trunk and extremities and joint

    mobility.mobility.

    Reassessing the neurologic criteria 18-24Reassessing the neurologic criteria 18-24

    hours after birth is best to allow forhours after birth is best to allow for

    recovery from maternal medication (eg,recovery from maternal medication (eg,

    magnesium sulfate, analgesics), whichmagnesium sulfate, analgesics), whichmay decrease tone and responsivenessmay decrease tone and responsiveness

  • 7/30/2019 Special Topics in Pediatric Nursing

    11/60

    Preterm infant at 28 weeks' gestation. Note the smallPreterm infant at 28 weeks' gestation. Note the small

    amount of ear cartilage and/or flattened pinnaamount of ear cartilage and/or flattened pinna

  • 7/30/2019 Special Topics in Pediatric Nursing

    12/60

    Preterm infant at 33 weeks' gestation. Note thePreterm infant at 33 weeks' gestation. Note the

    increased cartilage, recoil, and outer ridge curvingincreased cartilage, recoil, and outer ridge curving

    inwardinward

  • 7/30/2019 Special Topics in Pediatric Nursing

    13/60

    NOTE & COMPARENOTE & COMPARE

  • 7/30/2019 Special Topics in Pediatric Nursing

    14/60

  • 7/30/2019 Special Topics in Pediatric Nursing

    15/60

  • 7/30/2019 Special Topics in Pediatric Nursing

    16/60

    MORBIDITY & MORTALITYMORBIDITY & MORTALITY

    Survivability correlates with gestational age forSurvivability correlates with gestational age for

    infants who are appropriately grown (AGA)infants who are appropriately grown (AGA)

    (13.8% for birth weights

  • 7/30/2019 Special Topics in Pediatric Nursing

    17/60

    CAUSESCAUSES

    Premature delivery can be the result of pretermPremature delivery can be the result of pretermlabor and PPROM or can occur for maternallabor and PPROM or can occur for maternalindications:indications:

    ChorioamnionitisChorioamnionitis

    Amniocentesis that demonstrates bacteria, WBCs,Amniocentesis that demonstrates bacteria, WBCs,and a low glucose concentration confirms theand a low glucose concentration confirms thediagnosis of chorioamnionitis and is an indication fordiagnosis of chorioamnionitis and is an indication fordelivery.delivery.

    A decrease in the biophysical score or profile inA decrease in the biophysical score or profile in

    association with chorioamnionitis is associated withassociation with chorioamnionitis is associated withfetal infection.fetal infection.

    Rates of perinatal mortality, neonatal infection, andRates of perinatal mortality, neonatal infection, andRDS increase in the presence of maternal fever andRDS increase in the presence of maternal fever andchorioamnionitis.chorioamnionitis.

  • 7/30/2019 Special Topics in Pediatric Nursing

    18/60

    Intrauterine Growth RestrictionIntrauterine Growth Restriction (10th(10th

    percentile for birth weight) is significantlypercentile for birth weight) is significantly

    associated with perinatal mortality andassociated with perinatal mortality and

    long-term morbidity.long-term morbidity.

    Low Socioeconomic Status:Low Socioeconomic Status: ProgramsPrograms

    offering additional social support for at-riskoffering additional social support for at-risk

    pregnant women have not beenpregnant women have not been

    demonstrated to reduce the numbers ofdemonstrated to reduce the numbers of

    LBW or preterm infantsLBW or preterm infantsPregnancy Induced HypertensionPregnancy Induced Hypertension

  • 7/30/2019 Special Topics in Pediatric Nursing

    19/60

    Maternal DiabetesMaternal Diabetes

    Pregnancies complicated by diabetes and poorPregnancies complicated by diabetes and poor

    glycemic control are associated with a high incidenceglycemic control are associated with a high incidence

    of prematurity, macrosomia, malformation, fetalof prematurity, macrosomia, malformation, fetaldeath, and neonatal death.death, and neonatal death.

    The rate of preterm birth (GA

  • 7/30/2019 Special Topics in Pediatric Nursing

    20/60

    Multiple-Gestation PregnanciesMultiple-Gestation Pregnancies

    Women with multiple-gestation pregnanciesWomen with multiple-gestation pregnancies

    are at high risk of preterm labor and deliveryare at high risk of preterm labor and deliveryand account for increasing percentage ofand account for increasing percentage of

    preterm births and LBW infants.preterm births and LBW infants.

    With advances in assisted reproductiveWith advances in assisted reproductive

    technology, multiple-gestation pregnanciestechnology, multiple-gestation pregnancies

    have increased.have increased.

    Preterm birth rate for twins has increasedPreterm birth rate for twins has increased

    from 40.9% in 1981 to 55% in 1997. Multiplefrom 40.9% in 1981 to 55% in 1997. Multiplebirths related to infertility treatment havebirths related to infertility treatment have

    increased dramatically (Fritz, 2002).increased dramatically (Fritz, 2002).

  • 7/30/2019 Special Topics in Pediatric Nursing

    21/60

    Prepregnancy counseling of prospectivePrepregnancy counseling of prospectiveparents regarding the risks related to multipleparents regarding the risks related to multiplegestations is important.gestations is important.

    Preterm birth (

  • 7/30/2019 Special Topics in Pediatric Nursing

    22/60

    Maternal AgeMaternal Age In women aged 13-15 years, the rate of preterm birthIn women aged 13-15 years, the rate of preterm birth

    is 5.9%. This rate declines to 1.7% in women agedis 5.9%. This rate declines to 1.7% in women aged18-19 years and 1.1% in women aged 20-24 years.18-19 years and 1.1% in women aged 20-24 years.

    The rate of preterm births increases in pregnancies inThe rate of preterm births increases in pregnancies inwhich the mother is older than 40 years. The scoringwhich the mother is older than 40 years. The scoringsystem for the risk of preterm delivery uses a criterionsystem for the risk of preterm delivery uses a criterion

    of >40 years of age.of >40 years of age.

    Tobacco UseTobacco Use Approximately 15-20% of pregnant women smokeApproximately 15-20% of pregnant women smoke

    tobacco.tobacco.

    Tobacco use is a risk factor for placental abruptionTobacco use is a risk factor for placental abruptionand accounts as a factor for 15% of preterm birthsand accounts as a factor for 15% of preterm birthsand 20-30% of LBW infants.and 20-30% of LBW infants.

  • 7/30/2019 Special Topics in Pediatric Nursing

    23/60

    DIAGNOSTICSDIAGNOSTICS

    Initial laboratory testing is performed to identify issues that,Initial laboratory testing is performed to identify issues that,if corrected, improve the patient's outcome.if corrected, improve the patient's outcome.

    Blood Tests Are Performed.Blood Tests Are Performed. CBC findings may reveal anemia or polycythemia that is notCBC findings may reveal anemia or polycythemia that is not

    clinically apparent.clinically apparent. A high or low WBC count and a number of immature neutrophilA high or low WBC count and a number of immature neutrophil

    types also may be found. An abnormal WBC count may suggesttypes also may be found. An abnormal WBC count may suggestsubtle infection.subtle infection.

    A blood type and antibody testing (Coombs test) are performedA blood type and antibody testing (Coombs test) are performedto detect blood-group incompatibilities between the mother andto detect blood-group incompatibilities between the mother andinfant and to identify antibodies against fetal RBCs. Suchinfant and to identify antibodies against fetal RBCs. Suchincompatibilities increase the risk for jaundice and kernicterus.incompatibilities increase the risk for jaundice and kernicterus.

  • 7/30/2019 Special Topics in Pediatric Nursing

    24/60

    Serum Electrolytes AnalysisSerum Electrolytes Analysis

    At birth, most serum electrolyte levels reflectAt birth, most serum electrolyte levels reflect

    those of the mother.those of the mother.

    If the mother received magnesium sulfate toIf the mother received magnesium sulfate to

    inhibit labor, the baby's respiratory effort mayinhibit labor, the baby's respiratory effort may

    be compromised, and the serum magnesiumbe compromised, and the serum magnesium

    value is elevated.value is elevated. The serum calcium may be low shortly afterThe serum calcium may be low shortly after

    birth in small preterm babies.birth in small preterm babies.

  • 7/30/2019 Special Topics in Pediatric Nursing

    25/60

    Immature renal function, as well as limited bone andImmature renal function, as well as limited bone and

    tissue reserves, result in the need for intravenoustissue reserves, result in the need for intravenous

    replacement of calcium, sodium, potassium,replacement of calcium, sodium, potassium,phosphate, and trace minerals in those infants whophosphate, and trace minerals in those infants who

    are taking nothing by mouth. Infants who can tolerateare taking nothing by mouth. Infants who can tolerate

    enteric nutrition receive ample electrolyte andenteric nutrition receive ample electrolyte and

    minerals from appropriate preterm formulas andminerals from appropriate preterm formulas and

    fortified human milk. These issues are more acutefortified human milk. These issues are more acutewith decreasing GA.with decreasing GA.

    Frequent laboratory determinations of serum sodium,Frequent laboratory determinations of serum sodium,

    potassium, and glucose in conjunction with monitoringpotassium, and glucose in conjunction with monitoring

    of daily weight and urine output in extremely LBWof daily weight and urine output in extremely LBWinfants assists the practitioner in determination of fluidinfants assists the practitioner in determination of fluid

    requirements.requirements.

  • 7/30/2019 Special Topics in Pediatric Nursing

    26/60

    Serum glucose concentrations must be monitored closely becauseSerum glucose concentrations must be monitored closely becauseof the risk of hypoglycemia and hyperglycemia in preterm infants.of the risk of hypoglycemia and hyperglycemia in preterm infants.The baby's GA and other medical conditions dictate the frequency ofThe baby's GA and other medical conditions dictate the frequency oftesting.testing.

    Metabolic Screening is done.Metabolic Screening is done. Every state has a metabolic screening program. All programs includeEvery state has a metabolic screening program. All programs include

    testing of newborn blood spots for a minimum of phenylketonuria,testing of newborn blood spots for a minimum of phenylketonuria,hypothyroidism, and galactosemia. The timing of obtaining the samplehypothyroidism, and galactosemia. The timing of obtaining the samplevaries.varies.

    In general, false-positive results are most common in preterm babies.In general, false-positive results are most common in preterm babies.

    Early detection and intervention minimizes the long-term neurologic risk.Early detection and intervention minimizes the long-term neurologic risk.

    Imaging Studies:Imaging Studies:

    Imaging studies are specific to the organ system affected.Imaging studies are specific to the organ system affected. Chest radiography is performed to assess lung parenchyma inChest radiography is performed to assess lung parenchyma in

    newborns with respiratory distressnewborns with respiratory distress Cranial ultrasonography is performed to detect occult intracranialCranial ultrasonography is performed to detect occult intracranial

    hemorrhage in very LBW newbornshemorrhage in very LBW newborns

  • 7/30/2019 Special Topics in Pediatric Nursing

    27/60

    MANAGEMENTMANAGEMENT

    Medical Care:Medical Care: Stabilization in the deliveryStabilization in the delivery

    room with prompt respiratory and thermalroom with prompt respiratory and thermal

    management is crucial to the immediatemanagement is crucial to the immediate

    and long-term outcome of prematureand long-term outcome of prematureinfants, particularly extremely prematureinfants, particularly extremely premature

    infants.infants.

    Principles of respiratory management arePrinciples of respiratory management areas follows:as follows:

  • 7/30/2019 Special Topics in Pediatric Nursing

    28/60

    Recruit and maintain adequate lung volume or optimalRecruit and maintain adequate lung volume or optimallung volume. In infants with respiratory distress, this steplung volume. In infants with respiratory distress, this stepmay be accomplished with early continuous positivemay be accomplished with early continuous positive

    airway pressure (CPAP) given nasally, by maskairway pressure (CPAP) given nasally, by mask(Neopuff), or by using an endotracheal tube when(Neopuff), or by using an endotracheal tube whenventilation and/or surfactant is administered.ventilation and/or surfactant is administered.

    Avoid hyperoxia and hypoxia by immediately attaching aAvoid hyperoxia and hypoxia by immediately attaching apulse oximeter and keeping the oxygen saturationpulse oximeter and keeping the oxygen saturation(SaO2) between 86% and 93% by using an oxygen(SaO2) between 86% and 93% by using an oxygenblender.blender.Prevent barotrauma or volutrauma by using a ventilatorPrevent barotrauma or volutrauma by using a ventilatorthat permits measurement of the expired tidal volumethat permits measurement of the expired tidal volumeand by keeping it 4-7 mL/kg.and by keeping it 4-7 mL/kg.

    Administer surfactant early (

  • 7/30/2019 Special Topics in Pediatric Nursing

    29/60

    ThermoregulationThermoregulation

    Maintenance of the neutral thermalMaintenance of the neutral thermal

    environment is critical for minimizing stressenvironment is critical for minimizing stress

    and optimizing growth of the premature infant.and optimizing growth of the premature infant.The neutral thermal environment is defined asThe neutral thermal environment is defined as

    the environmental temperature in which thethe environmental temperature in which the

    neonate maintains a normal temperature andneonate maintains a normal temperature and

    is consuming minimal oxygen for metabolism.is consuming minimal oxygen for metabolism.

  • 7/30/2019 Special Topics in Pediatric Nursing

    30/60

    Neonates lose heat by 4 means, as follows:Neonates lose heat by 4 means, as follows:

    Evaporation:Evaporation: Evaporation is energy consumed by aEvaporation is energy consumed by a

    fluid as it converts from a liquid to gas. This isfluid as it converts from a liquid to gas. This is

    primarily in the delivery room. Completely dryingprimarily in the delivery room. Completely drying

    the infant is of primary importance in prevention ofthe infant is of primary importance in prevention of

    hypothermia. This step can be omitted if otherhypothermia. This step can be omitted if other

    resuscitative measures are taking place.resuscitative measures are taking place.

    Conduction:Conduction: This is direct transfer of heat from aThis is direct transfer of heat from awarm body to a cool object by contact (eg, placingwarm body to a cool object by contact (eg, placing

    an infant on a cold scale).an infant on a cold scale).

    Convection:Convection: This is the loss of heat from the warmThis is the loss of heat from the warm

    air next to the skin to moving air currents (eg,air next to the skin to moving air currents (eg,windchill effect). Double-walled isolettes help towindchill effect). Double-walled isolettes help to

    reduce convective heat loss.reduce convective heat loss.

    Radiation:Radiation: This is the loss of heat that radiatesThis is the loss of heat that radiates

    from a warm body to a cool surface (eg, window,from a warm body to a cool surface (eg, window,

  • 7/30/2019 Special Topics in Pediatric Nursing

    31/60

    Preterm infants are relatively unable toPreterm infants are relatively unable to

    compensate for cold stress because of acompensate for cold stress because of a

    small amount of subcutaneous tissuesmall amount of subcutaneous tissue

    (insulation) and decreased brown fat to(insulation) and decreased brown fat toproduce heat.produce heat.

    Preterm infants do not shiver. The increasedPreterm infants do not shiver. The increased

    surface area to body mass allows for rapidsurface area to body mass allows for rapid

    heat loss, especially from the head.heat loss, especially from the head.

  • 7/30/2019 Special Topics in Pediatric Nursing

    32/60

    Decreased posturing ability further diminishes theirDecreased posturing ability further diminishes their

    ability to compensate.ability to compensate.

    In extremely LBW infants, immature skin furtherIn extremely LBW infants, immature skin further

    complicates thermoregulation due to increasedcomplicates thermoregulation due to increasedevaporative water loss.evaporative water loss.

    Consequences of cold stress are increasedConsequences of cold stress are increased

    metabolism with loss of weight or failure to gainmetabolism with loss of weight or failure to gain

    weight and increased use of glucose with depletion ofweight and increased use of glucose with depletion ofglycogen stores and hypoglycemia.glycogen stores and hypoglycemia.

    Metabolic acidosis results in a decreased surfactantMetabolic acidosis results in a decreased surfactant

    production and loss of functional alveolar number,production and loss of functional alveolar number,

    which results in hypoxia. The hypoxia causeswhich results in hypoxia. The hypoxia causespulmonary vasoconstriction, and further hypoxia.pulmonary vasoconstriction, and further hypoxia.

    Increased oxygen consumption results in hypoxia,Increased oxygen consumption results in hypoxia,

    anaerobic metabolism, and lactic acid production.anaerobic metabolism, and lactic acid production.

  • 7/30/2019 Special Topics in Pediatric Nursing

    33/60

    In the intensive care nursery, radiant decreases heatIn the intensive care nursery, radiant decreases heat

    loss due to conduction, convection, and radiation.loss due to conduction, convection, and radiation.

    With warmers may be used to compensate for heatWith warmers may be used to compensate for heatloss. Incubators are more efficient than radiantloss. Incubators are more efficient than radiant

    warmers because the heated environment radiantwarmers because the heated environment radiant

    warmers, consider using plastic wrap and awarmers, consider using plastic wrap and a

    humidified environment for extremely LBW infants.humidified environment for extremely LBW infants. New devices function as both an incubator and anNew devices function as both an incubator and an

    overhead warmer to enable access for procedures. Inoverhead warmer to enable access for procedures. In

    all nurseries, maintain the environmental temperatureall nurseries, maintain the environmental temperature

    at >70F (>21C).at >70F (>21C). Temperature maintenance is especially critical duringTemperature maintenance is especially critical during

    neonatal resuscitation, when the same principlesneonatal resuscitation, when the same principles

    apply.apply.

  • 7/30/2019 Special Topics in Pediatric Nursing

    34/60

    Skin CareSkin Care

    Premature infants have immature skin, aPremature infants have immature skin, a

    decreased or absent stratum corneum,decreased or absent stratum corneum,decreased cohesiveness between skin layers,decreased cohesiveness between skin layers,

    increased water fixation, and tissue edema.increased water fixation, and tissue edema.

    The immature skin integrity leads to easyThe immature skin integrity leads to easy

    injury, transdermal absorption of drugs andinjury, transdermal absorption of drugs and

    other materials in contact with the skin andother materials in contact with the skin and

    increased risk for infection..increased risk for infection..

  • 7/30/2019 Special Topics in Pediatric Nursing

    35/60

    TheThe National Association of Neonatal NursesNational Association of Neonatal Nurses (NANN)(NANN)and theand the

    Association of Women's Health, Obstetric and Neonatal NAssociation of Women's Health, Obstetric and Neonatal N(AWHONN) recommended the following areas of(AWHONN) recommended the following areas of

    newborn skin care, which are based on clinical andnewborn skin care, which are based on clinical andlaboratory research.laboratory research.

    Bathing:Bathing: Use only water and no soap for infantsUse only water and no soap for infantsweighing

  • 7/30/2019 Special Topics in Pediatric Nursing

    36/60

    AdhesivesAdhesives: Minimize their use. Use double-backed: Minimize their use. Use double-backedsilk tape versus tape with strong adhesivesilk tape versus tape with strong adhesive

    properties (Elastoplast). Use hydrogel electrodes.properties (Elastoplast). Use hydrogel electrodes.Avoid solvents or bonding agents.Avoid solvents or bonding agents.

    Transepidermal water loss:Transepidermal water loss: Place infants born atPlace infants born at30 weeks' GA in a high-humidity (>70%)30 weeks' GA in a high-humidity (>70%)

    environment.environment.Topical solutions:Topical solutions: Review ingredients of any topicalReview ingredients of any topicalsolution placed on the skin of a preterm infant.solution placed on the skin of a preterm infant.Transdermal absorption can occur. DiscourageTransdermal absorption can occur. Discourageuse of solvents for adhesive removal.use of solvents for adhesive removal.

    Pectin barriersPectin barriers (eg, DuoDERM extra thin, Restore(eg, DuoDERM extra thin, Restoreextra thin) are recommended: Anchoring devicesextra thin) are recommended: Anchoring devices(umbilical lines) to pectin barriers results in(umbilical lines) to pectin barriers results inimproved skin integrityimproved skin integrity

  • 7/30/2019 Special Topics in Pediatric Nursing

    37/60

    Fluid and Electrolyte ManagementFluid and Electrolyte Management Preterm infants need intense monitoring ofPreterm infants need intense monitoring of

    their fluid and electrolytes because of theirtheir fluid and electrolytes because of theirincreased transdermal water loss, immatureincreased transdermal water loss, immaturerenal function, and other environmental issuesrenal function, and other environmental issues(eg, radiant warming, phototherapy,(eg, radiant warming, phototherapy,mechanical ventilation).mechanical ventilation).

    Expected loss of extracellular water in the firstExpected loss of extracellular water in the firstweek of life in the term infant is 5% of birthweek of life in the term infant is 5% of birthweight, LBW infant is 10% of birth weight, andweight, LBW infant is 10% of birth weight, andin the extremely LBW infant is 15-20%. Datain the extremely LBW infant is 15-20%. Datacurves, which Dancis developed in the 1940s,curves, which Dancis developed in the 1940s,may be useful in monitoring weight loss inmay be useful in monitoring weight loss ineach group of infants.each group of infants.

  • 7/30/2019 Special Topics in Pediatric Nursing

    38/60

    The degree of prematurity and the infant's specificThe degree of prematurity and the infant's specificmedication problems dictate initial fluid therapy.medication problems dictate initial fluid therapy.However, the following general principles apply to allHowever, the following general principles apply to all

    preterm infants:preterm infants:Initial fluids should be a solution of glucose and water. MoreInitial fluids should be a solution of glucose and water. Moremature infants can be started at 60-80 mL/kg/day. The mostmature infants can be started at 60-80 mL/kg/day. The mostimmature infants may need up to 100-150 mL/kg/dimmature infants may need up to 100-150 mL/kg/d

    Environmental aspects of care, eg, radiant warming,Environmental aspects of care, eg, radiant warming,

    phototherapy, and a nonhumidified environment, increasephototherapy, and a nonhumidified environment, increaseinsensible water loss and the need for fluids. Mechanicalinsensible water loss and the need for fluids. Mechanicalventilation, use of double-walled isolettes, and provision ofventilation, use of double-walled isolettes, and provision ofhumidity decrease insensible water loss.humidity decrease insensible water loss.

    The glucose infusion rate (GIR) is usually started at 4-6The glucose infusion rate (GIR) is usually started at 4-6mg/kg/min. In general, to obtain this rate, a solution ofmg/kg/min. In general, to obtain this rate, a solution of

    dextrose 10% in water (D10W) should be used initially. Thedextrose 10% in water (D10W) should be used initially. Theexception is the extremely LBW infant who should initially beexception is the extremely LBW infant who should initially begiven dextrose 5% in water (D5W) to provide the same GIRgiven dextrose 5% in water (D5W) to provide the same GIRand to prevent hyperglycemia.and to prevent hyperglycemia.

  • 7/30/2019 Special Topics in Pediatric Nursing

    39/60

    Electrolytes should not be added until 24Electrolytes should not be added until 24

    hours of age, when urine output ishours of age, when urine output is

    adequate. Electrolytes and calcium shouldadequate. Electrolytes and calcium should

    be monitored at 12-24 hours of agebe monitored at 12-24 hours of age

    depending on the degree on prematuritydepending on the degree on prematurity

    and other medical issues.and other medical issues.

    Basal needs are sodium is 2-3 mEq/kg/d,Basal needs are sodium is 2-3 mEq/kg/d,potassium 1-2 mEq/kg/d, and calcium 600potassium 1-2 mEq/kg/d, and calcium 600

    mg/kg/d (as calcium gluconate). Urinarymg/kg/d (as calcium gluconate). Urinary

    losses, which may increase in the mostlosses, which may increase in the most

    immature of infants and in those exposedimmature of infants and in those exposedto diuretics, dictate the need forto diuretics, dictate the need for

    supplemental sodium.supplemental sodium.

  • 7/30/2019 Special Topics in Pediatric Nursing

    40/60

    Infants who develop acute tubular necrosisInfants who develop acute tubular necrosis

    (ATN) should be treated with fluid(ATN) should be treated with fluid

    restriction that equals insensible water lossrestriction that equals insensible water loss

    plus urine output. Additional fluid isplus urine output. Additional fluid isadministered by closely and frequentlyadministered by closely and frequently

    monitoring the output and electrolytesmonitoring the output and electrolytes

    during the post-ATN diuretic phase.during the post-ATN diuretic phase.

    Hyponatremia and weight gain should beHyponatremia and weight gain should be

    treated with decreasing fluid administration.treated with decreasing fluid administration.

    Monitoring of urinary electrolyte losses isMonitoring of urinary electrolyte losses is

    sometimes helpful in replacement therapy.sometimes helpful in replacement therapy.

  • 7/30/2019 Special Topics in Pediatric Nursing

    41/60

    The patient's weight should be followed upThe patient's weight should be followed up

    every 24 hours. Results of laboratoryevery 24 hours. Results of laboratory

    monitoring and change in weight dictatemonitoring and change in weight dictate

    changes in fluid and electrolyte support.changes in fluid and electrolyte support.

  • 7/30/2019 Special Topics in Pediatric Nursing

    42/60

    Diet:Diet: Preterm infants born at

  • 7/30/2019 Special Topics in Pediatric Nursing

    43/60

    Mature Breast MilkMature Breast Milk Mature breast milk replaces transitional milk by 10-12 days afterMature breast milk replaces transitional milk by 10-12 days after

    birth.birth. The caloric density varies among mothers based in part on theThe caloric density varies among mothers based in part on the

    mother's nutritional status.mother's nutritional status. For extremely LBW infants, breast milk is often inadequate toFor extremely LBW infants, breast milk is often inadequate to

    sustain growth.sustain growth. Most calories are contained in lactose (35%) and fat (50%). InMost calories are contained in lactose (35%) and fat (50%). In

    the more preterm infants, lactase activity is low which maythe more preterm infants, lactase activity is low which maycontribute to less-than-optimal digestion of lactose andcontribute to less-than-optimal digestion of lactose and

    absorption of carbohydrate. This improves with GA.absorption of carbohydrate. This improves with GA. Calcium, sodium, potassium, and trace mineral levels areCalcium, sodium, potassium, and trace mineral levels are

    insufficient to meet the needs of the preterm infant. Therefore,insufficient to meet the needs of the preterm infant. Therefore,minerals, protein, carbohydrates, and lipids often are added tominerals, protein, carbohydrates, and lipids often are added tobreast milk to support optimal growth in the form of commerciallybreast milk to support optimal growth in the form of commerciallyavailable breast milk fortifiers.available breast milk fortifiers.

    Approximately 120-150 cal/kg/d are required for growth. SmallApproximately 120-150 cal/kg/d are required for growth. Smallpreterm infants with increased metabolic needs due topreterm infants with increased metabolic needs due tocomplications such as bronchopulmonary dysplasia (BPD) maycomplications such as bronchopulmonary dysplasia (BPD) mayrequire up to 180 cal/kg/d to grow.require up to 180 cal/kg/d to grow.

  • 7/30/2019 Special Topics in Pediatric Nursing

    44/60

    PARENT EDUCATIONPARENT EDUCATION

    Discharge teaching of the premature infant includes theDischarge teaching of the premature infant includes thefollowing:following:

    Basic infant care - Bathing, skin care, taking a temperatureBasic infant care - Bathing, skin care, taking a temperature

    Infant feeding - Feeding cues, support of breastfeedingInfant feeding - Feeding cues, support of breastfeeding

    Infant safety - Use of car seats, avoiding exposure to a smokyInfant safety - Use of car seats, avoiding exposure to a smokyenvironmentenvironment

    Back to sleep - Strategies to help preterm infants return to sleepBack to sleep - Strategies to help preterm infants return to sleep

    Illness prevention (handwashing, avoid crowds, prophylaxisIllness prevention (handwashing, avoid crowds, prophylaxisagainst infection with respiratory syncytial virus (RSV) asagainst infection with respiratory syncytial virus (RSV) asindicated, immunization scheduleindicated, immunization schedule

    When to call healthcare provider - Poor feeding, signs of illness,When to call healthcare provider - Poor feeding, signs of illness,change in behavior, respiratory distresschange in behavior, respiratory distress

    Specifics related to chronic conditions - For example, use of aSpecifics related to chronic conditions - For example, use of anasal canula and home oxygen therapynasal canula and home oxygen therapy

  • 7/30/2019 Special Topics in Pediatric Nursing

    45/60

    COMPLICATIONSCOMPLICATIONSThermoregulationThermoregulation

    As a result of a high body surface areatobody weight ratio,As a result of a high body surface areatobody weight ratio,decreased brown fat stores, nonkeratinized skin, and decreaseddecreased brown fat stores, nonkeratinized skin, and decreasedglycogen supply, ELBW infants are particularly susceptible to heatglycogen supply, ELBW infants are particularly susceptible to heatloss immediately after birth. Hypothermia may result inloss immediately after birth. Hypothermia may result inhypoglycemia, apnea, and metabolic acidosis.hypoglycemia, apnea, and metabolic acidosis.

    Heat loss can occur in ELBW infants in 4 ways, namely, conduction,Heat loss can occur in ELBW infants in 4 ways, namely, conduction,

    convection, evaporation, and radiation. Conduction is the transfer ofconvection, evaporation, and radiation. Conduction is the transfer ofenergy from the molecules of a body to the molecules of a solidenergy from the molecules of a body to the molecules of a solidobject in contact with the body, resulting in heat loss, whileobject in contact with the body, resulting in heat loss, whileconvection is the similar loss of thermal energy to an adjacent gas.convection is the similar loss of thermal energy to an adjacent gas.Evaporative heat loss is the total heat transfer by energy-carryingEvaporative heat loss is the total heat transfer by energy-carryingwater molecules from the skin and respiratory tract to the drierwater molecules from the skin and respiratory tract to the drierenvironment, while radiant loss is the net rate of heat loss from theenvironment, while radiant loss is the net rate of heat loss from thebody to environmental surfaces not in contact with the body.body to environmental surfaces not in contact with the body.Extremely preterm infants are especially prone to these lossesExtremely preterm infants are especially prone to these lossessecondary to the poor barrier provided by their thin, poorlysecondary to the poor barrier provided by their thin, poorly

    keratinized skin.keratinized skin.

  • 7/30/2019 Special Topics in Pediatric Nursing

    46/60

    Temperature control is paramount to survivalTemperature control is paramount to survivaland typically is achieved with use of radiantand typically is achieved with use of radiantwarmers or double-walled incubators.warmers or double-walled incubators.Hypothermia (

  • 7/30/2019 Special Topics in Pediatric Nursing

    47/60

    For transport to the neonatal intensive care unit (NICU)For transport to the neonatal intensive care unit (NICU)from the delivery room, the infant should be covered withfrom the delivery room, the infant should be covered with

    either warmed blankets or cellophane wrap.either warmed blankets or cellophane wrap.For transport of more than very short distances, theFor transport of more than very short distances, theinfant should be placed in a double-walled, heatedinfant should be placed in a double-walled, heatedincubator.incubator.

    The delivery room and NICU should be kept warm to aidThe delivery room and NICU should be kept warm to aid

    in the prevention of hypothermia in the preterm infant.in the prevention of hypothermia in the preterm infant.Architectural designs should facilitate adjacent locationArchitectural designs should facilitate adjacent locationof delivery rooms and NICUs or at least provideof delivery rooms and NICUs or at least provideseparately heated resuscitation rooms.separately heated resuscitation rooms.

    Although chemical heating pads commonly are used toAlthough chemical heating pads commonly are used to

    provide a warm surface on which to place the baby, theprovide a warm surface on which to place the baby, theunregulated heat source may burn the very fragile skin ofunregulated heat source may burn the very fragile skin ofthe ELBW infant and are not recommended.the ELBW infant and are not recommended.

  • 7/30/2019 Special Topics in Pediatric Nursing

    48/60

    HypoglycemiaHypoglycemia

    Fetal euglycemia (maintenance of normal bloodFetal euglycemia (maintenance of normal blood

    glucose levels) is maintained during pregnancyglucose levels) is maintained during pregnancyby the mother via the placenta. ELBW infantsby the mother via the placenta. ELBW infantshave difficulty maintaining glucose levels withinhave difficulty maintaining glucose levels withinreference range after birth, when the maternalreference range after birth, when the maternal

    source of glucose has been lost. In addition,source of glucose has been lost. In addition,ELBW infants are usually under increased stressELBW infants are usually under increased stresscompared with their term counterparts, and theycompared with their term counterparts, and theyhave insufficient levels of glycogen stores.have insufficient levels of glycogen stores.

    Preterm infants are generally consideredPreterm infants are generally consideredhypoglycemic when whole-blood glucose levelshypoglycemic when whole-blood glucose levelsare lower than 45 mg/dL.are lower than 45 mg/dL.

    B t f h l i ( iB t f h l i ( i

  • 7/30/2019 Special Topics in Pediatric Nursing

    49/60

    Because symptoms of hypoglycemia (seizures,Because symptoms of hypoglycemia (seizures,jitteriness, lethargy, apnea, poor feeding) mayjitteriness, lethargy, apnea, poor feeding) maybe less obvious in preterm infants, hypoglycemiabe less obvious in preterm infants, hypoglycemia

    may only be detected on routine sampling.may only be detected on routine sampling.One form of accepted treatment consists of anOne form of accepted treatment consists of animmediate intravenous dextrose infusion of 2immediate intravenous dextrose infusion of 2mL/kg of 10% dextrose-in-water solution (200mL/kg of 10% dextrose-in-water solution (200mg/kg) followed by a continuous intravenousmg/kg) followed by a continuous intravenous

    infusion of dextrose at 6-8 mg/kg/min to maintaininfusion of dextrose at 6-8 mg/kg/min to maintaina constant supply of glucose for metabolic needsa constant supply of glucose for metabolic needsand to avoid further hypoglycemia.and to avoid further hypoglycemia.

    Rapid infusion of glucose concentrations greaterRapid infusion of glucose concentrations greater

    than 10% should be avoided because of thethan 10% should be avoided because of thehyperosmolarity of the solution and risk ofhyperosmolarity of the solution and risk ofcerebral hemorrhage.cerebral hemorrhage.

  • 7/30/2019 Special Topics in Pediatric Nursing

    50/60

    HyperbilirubinemiaHyperbilirubinemia

    Most ELBW infants develop clinically significantMost ELBW infants develop clinically significant

    hyperbilirubinemia (jaundice) requiring treatment.hyperbilirubinemia (jaundice) requiring treatment.Hyperbilirubinemia develops as a result of increased redHyperbilirubinemia develops as a result of increased redblood cell turnover and destruction in the context of anblood cell turnover and destruction in the context of animmature liver that has physiologically impairedimmature liver that has physiologically impairedconjugation and elimination of bilirubin. In addition, mostconjugation and elimination of bilirubin. In addition, mostpreterm infants have reduced bowel motility due topreterm infants have reduced bowel motility due toinadequate oral intake, which delays elimination ofinadequate oral intake, which delays elimination ofbilirubin-containing meconium, coupled with increasedbilirubin-containing meconium, coupled with increasedenterohepatic circulation of conjugated bilirubin thatenterohepatic circulation of conjugated bilirubin thatenters the intestinal tract. These complications ofenters the intestinal tract. These complications ofextreme prematurity, in addition to typical conditions thatextreme prematurity, in addition to typical conditions that

    cause jaundice (eg, ABO incompatibility, Rh disease,cause jaundice (eg, ABO incompatibility, Rh disease,sepsis, inherited diseases), is thought to place thesesepsis, inherited diseases), is thought to place theseinfants at higher risk for kernicterus at levels of bilirubininfants at higher risk for kernicterus at levels of bilirubinfar below those in more mature infants, although specificfar below those in more mature infants, although specificserum bilirubin levels that are safe versus toxic haveserum bilirubin levels that are safe versus toxic have

    never been elucidated.never been elucidated.

    Kernicterus occurs when free unconjugated bilirubinKernicterus occurs when free unconjugated bilirubin

  • 7/30/2019 Special Topics in Pediatric Nursing

    51/60

    Kernicterus occurs when free, unconjugated bilirubinKernicterus occurs when free, unconjugated bilirubincrosses the blood-brain barrier (BBB) and stains thecrosses the blood-brain barrier (BBB) and stains thebasal ganglia, pons, and cerebellum; diminished proteinbasal ganglia, pons, and cerebellum; diminished proteinstatus and the occurrence of acidosis in ELBW infantsstatus and the occurrence of acidosis in ELBW infants

    may potentiate the proportion of unbound bilirubinmay potentiate the proportion of unbound bilirubinavailable to cross the BBB. Infants with kernicterus whoavailable to cross the BBB. Infants with kernicterus whodo not die may have sequelae such as deafness, mentaldo not die may have sequelae such as deafness, mentalretardation, and cerebral palsy.retardation, and cerebral palsy.

    Phototherapy is used to decrease bilirubin levels toPhototherapy is used to decrease bilirubin levels toprevent the elevation of unconjugated bilirubin to levelsprevent the elevation of unconjugated bilirubin to levelsthat cause kernicterus. Special blue-green lamps withthat cause kernicterus. Special blue-green lamps withwavelengths of 420-475 nm are used to break downwavelengths of 420-475 nm are used to break downunconjugated bilirubin to the more water-soluble productunconjugated bilirubin to the more water-soluble productlumirubin via photoisomerization and photooxidationlumirubin via photoisomerization and photooxidationthrough the skin. This product can then be eliminated inthrough the skin. This product can then be eliminated in

    bile and urine. The fluorescent bulbs are positioned at 50bile and urine. The fluorescent bulbs are positioned at 50cm above the infant with the rate of bilirubin reductioncm above the infant with the rate of bilirubin reductionbeing directly proportional to the light intensity. Clinicalbeing directly proportional to the light intensity. Clinicalstudies have shown maximum effectiveness when thestudies have shown maximum effectiveness when theintensity of the light exceeds 12-15 W/cm2.intensity of the light exceeds 12-15 W/cm2.

  • 7/30/2019 Special Topics in Pediatric Nursing

    52/60

    Newer phototherapy lights have been developedNewer phototherapy lights have been developed

    in recent years that decrease the amount ofin recent years that decrease the amount of

    insensible water loss due to photo-inducedinsensible water loss due to photo-inducedvasodilatation. In extremely premature infants,vasodilatation. In extremely premature infants,

    insensible water loss can still be significant, andinsensible water loss can still be significant, and

    careful attention must be paid to fluid balance.careful attention must be paid to fluid balance.

    As with the older models, the infant's eyesAs with the older models, the infant's eyesshould be covered with patches to avoidshould be covered with patches to avoid

    exposure to the blue light. White lightexposure to the blue light. White light

    phototherapy is not as effective. Fiberopticphototherapy is not as effective. Fiberoptic

    blankets may be used, although some concernsblankets may be used, although some concernsexist regarding skin burns from the devices.exist regarding skin burns from the devices.

    While phototherap of ELBW infants is initiated at birth atWhile phototherapy of ELBW infants is initiated at birth at

  • 7/30/2019 Special Topics in Pediatric Nursing

    53/60

    While phototherapy of ELBW infants is initiated at birth atWhile phototherapy of ELBW infants is initiated at birth atsome institutions, others start phototherapy when thesome institutions, others start phototherapy when thebilirubin value approaches 50% of the birth weight valuebilirubin value approaches 50% of the birth weight value(eg, 4 mg/dL in an 800-g infant). Use of prophylactic(eg, 4 mg/dL in an 800-g infant). Use of prophylactic

    phototherapy has not been shown to decrease the peakphototherapy has not been shown to decrease the peaklevel of total serum bilirubin (TSB) or the duration oflevel of total serum bilirubin (TSB) or the duration ofphototherapy. If the level of bilirubin does not decreasephototherapy. If the level of bilirubin does not decreasesatisfactorily with phototherapy, exchange transfusion issatisfactorily with phototherapy, exchange transfusion isthe next therapeutic option. Exchange transfusion shouldthe next therapeutic option. Exchange transfusion shouldbe considered in ELBW infants if the level of bilirubinbe considered in ELBW infants if the level of bilirubinapproaches 10 mg/dL (or 10 mg/dL/kg). In otherwiseapproaches 10 mg/dL (or 10 mg/dL/kg). In otherwisehealthy term infants, exchange transfusion is nothealthy term infants, exchange transfusion is notconsidered until the bilirubin level approaches greaterconsidered until the bilirubin level approaches greaterthan 25 mg/dL and the infant has failed a trial ofthan 25 mg/dL and the infant has failed a trial ofphototherapy.phototherapy.

    In exchange transfusions, almost 90% of the infant'sIn exchange transfusions, almost 90% of the infant'sblood is replaced with donor blood, and, if performedblood is replaced with donor blood, and, if performedcorrectly, the bilirubin level usually falls to 50-60% of thecorrectly, the bilirubin level usually falls to 50-60% of thepreexchange level. Complications of exchangepreexchange level. Complications of exchangetransfusion include electrolyte abnormalities (eg,transfusion include electrolyte abnormalities (eg,

    hypocalcemia, hyperkalemia), acidosis, thrombosis,hypocalcemia, hyperkalemia), acidosis, thrombosis,se sis, and bleedinsepsis, and bleeding

    I f ti

  • 7/30/2019 Special Topics in Pediatric Nursing

    54/60

    InfectionInfection

    Infection remains a major contributing factor to the morbidity andInfection remains a major contributing factor to the morbidity andmortality of ELBW infants and can present at any point in the clinicalmortality of ELBW infants and can present at any point in the clinicalcourse. Early-onset infection (occurring within the first 72 h of life)course. Early-onset infection (occurring within the first 72 h of life)

    may present with immediate respiratory distress shortly after birth ormay present with immediate respiratory distress shortly after birth orafter an asymptomatic period. No matter the timing of presentation,after an asymptomatic period. No matter the timing of presentation,the sequence of events leading to early-onset infection begins withthe sequence of events leading to early-onset infection begins withcolonization of the maternal genital tract. Late infections typicallycolonization of the maternal genital tract. Late infections typicallyoccur after the first week of life and result from endogenous hospitaloccur after the first week of life and result from endogenous hospitalflora (nosocomial).flora (nosocomial).

    Signs of infection are myriad, may be nonspecific, and includeSigns of infection are myriad, may be nonspecific, and include

    temperature instability (hypothermia or hyperthermia), tachycardia,temperature instability (hypothermia or hyperthermia), tachycardia,decreased activity, poor perfusion, apnea, bradycardia, feedingdecreased activity, poor perfusion, apnea, bradycardia, feedingintolerance, increased need for oxygen or higher ventilatoryintolerance, increased need for oxygen or higher ventilatorysettings, and metabolic acidosis. Laboratory studies may includesettings, and metabolic acidosis. Laboratory studies may includecomplete blood count with differential, blood culture, cerebrospinalcomplete blood count with differential, blood culture, cerebrospinalfluid culture, urine culture, and cultures from indwelling foreignfluid culture, urine culture, and cultures from indwelling foreign

    bodies, such as central lines or endotracheal tubes.bodies, such as central lines or endotracheal tubes.

    fTh t f l i i th

  • 7/30/2019 Special Topics in Pediatric Nursing

    55/60

    The most common causes of early sepsis in theThe most common causes of early sepsis in theimmediate newborn period are group B streptococciimmediate newborn period are group B streptococci(GBS) and(GBS) and Escherichia coli.Escherichia coli. Nosocomial sources ofNosocomial sources ofinfection include coagulase-negative staphylococciinfection include coagulase-negative staphylococci

    (CoNS) and(CoNS) and KlebsiellaKlebsiella andand PseudomonasPseudomonas species, whichspecies, whichmay be resistant to the antibiotics typically started formay be resistant to the antibiotics typically started forearly-onset sepsis, necessitating a different treatmentearly-onset sepsis, necessitating a different treatmentregimen. Fungi, most commonlyregimen. Fungi, most commonly Candida albicans,Candida albicans, arearefrequently a cause of late-onset sepsis in the ELBWfrequently a cause of late-onset sepsis in the ELBW

    infant and may manifest with the above-mentionedinfant and may manifest with the above-mentionedsymptoms and with thrombocytopenia, particularly if thesymptoms and with thrombocytopenia, particularly if theinfant has been exposed to broad-spectrum antibiotics.infant has been exposed to broad-spectrum antibiotics.Indolent late-onset sepsis may be related to CoNS, butIndolent late-onset sepsis may be related to CoNS, butfulminant late-onset clinical sepsis is more commonlyfulminant late-onset clinical sepsis is more commonlysecondary to gram-negative organisms. Late-onsetsecondary to gram-negative organisms. Late-onset

    sepsis is especially common in ELBW infants who havesepsis is especially common in ELBW infants who haveindwelling catheters, and it may occur in as many asindwelling catheters, and it may occur in as many as40% of these infants.40% of these infants.

  • 7/30/2019 Special Topics in Pediatric Nursing

    56/60

    In most institutions, first-line therapy in infants with earlyIn most institutions, first-line therapy in infants with earlysepsis is with ampicillin and gentamicin or a third-sepsis is with ampicillin and gentamicin or a third-generation cephalosporin. Vancomycin should begeneration cephalosporin. Vancomycin should bereserved for proven CoNS infections and organismsreserved for proven CoNS infections and organismsresistant to other agents to prevent the emergence ofresistant to other agents to prevent the emergence of

    resistant organisms. Vancomycin and a third-generationresistant organisms. Vancomycin and a third-generationcephalosporin often are used to treat late-onset sepsiscephalosporin often are used to treat late-onset sepsisand may be adjusted based on sensitivity patterns ofand may be adjusted based on sensitivity patterns ofpositive cultures. Therapy with amphotericin commonly ispositive cultures. Therapy with amphotericin commonly isinitiated in infants with proven or suspected fungalinitiated in infants with proven or suspected fungalinfections, although fluconazole is frequently used as aninfections, although fluconazole is frequently used as analternative first-line therapy. Cultures should dictatealternative first-line therapy. Cultures should dictateantibiotic management whenever possible to helpantibiotic management whenever possible to helpprevent increased resistance.prevent increased resistance.

  • 7/30/2019 Special Topics in Pediatric Nursing

    57/60

    Respiratory Distress Syndrome and Chronic Lung DiseaseRespiratory Distress Syndrome and Chronic Lung Disease

    An early complication of extreme prematurity is respiratory distressAn early complication of extreme prematurity is respiratory distresssyndrome (RDS) caused by surfactant deficiency. Clinical signs includesyndrome (RDS) caused by surfactant deficiency. Clinical signs include

    tachypnea (>60 breaths/min), cyanosis, chest retractions, nasal flaring, andtachypnea (>60 breaths/min), cyanosis, chest retractions, nasal flaring, andgrunting. Untreated RDS results in increasing difficulty in breathing andgrunting. Untreated RDS results in increasing difficulty in breathing andincreasing oxygen requirement over the first 24-72 hours of life. Chestincreasing oxygen requirement over the first 24-72 hours of life. Chestradiographs reveal a uniform reticulogranular pattern with air bronchograms.radiographs reveal a uniform reticulogranular pattern with air bronchograms.As a result of surfactant deficiency, the alveoli collapse, causing aAs a result of surfactant deficiency, the alveoli collapse, causing aworsening of atelectasis, edema, and decreased total lung capacity.worsening of atelectasis, edema, and decreased total lung capacity.Surfactants decrease the surface tension of the smaller airways so that theSurfactants decrease the surface tension of the smaller airways so that thealveoli or the terminal air sacs do not collapse, which results in less need foralveoli or the terminal air sacs do not collapse, which results in less need for

    supplemental oxygen and ventilatory support.supplemental oxygen and ventilatory support.The incidence of RDS is inversely proportional to gestational age, with anThe incidence of RDS is inversely proportional to gestational age, with anincidence of 60% at 29 weeks' gestation. RDS affects about 40,000 infantsincidence of 60% at 29 weeks' gestation. RDS affects about 40,000 infantsin the United States annually, with most ELBW infants being affected.in the United States annually, with most ELBW infants being affected.Common complications include air leak syndromes, chronic lung diseaseCommon complications include air leak syndromes, chronic lung disease(CLD), and retinopathy of prematurity (ROP). Surfactant agents may be(CLD), and retinopathy of prematurity (ROP). Surfactant agents may beadministered as prophylaxis or as rescue intervention after RDS.administered as prophylaxis or as rescue intervention after RDS.

    Prophylactic use in infants younger than 28 weeks' gestation has beenProphylactic use in infants younger than 28 weeks' gestation has beenshown to decrease short-term ventilatory needs; neither strategy hasshown to decrease short-term ventilatory needs; neither strategy hasresulted in a decreased incidence of CLD/BPD.resulted in a decreased incidence of CLD/BPD.

    Synthetic surfactants currently on the market lack the proteins found inSynthetic surfactants currently on the market lack the proteins found in

  • 7/30/2019 Special Topics in Pediatric Nursing

    58/60

    y y py y panimal-derived surfactants and may not be as effective as the latter. Neweranimal-derived surfactants and may not be as effective as the latter. Newersynthetic surfactants with a synthetic surfactant protein analog are beingsynthetic surfactants with a synthetic surfactant protein analog are beingtested. The incidence of RDS in preterm infants has been significantlytested. The incidence of RDS in preterm infants has been significantlyreduced with the use of antenatal steroids to promote lung maturityanreduced with the use of antenatal steroids to promote lung maturityanadditive effect was seen with the use of both antenatal steroids and earlyadditive effect was seen with the use of both antenatal steroids and early

    surfactant treatment. The use of antenatal steroids also has been linked to asurfactant treatment. The use of antenatal steroids also has been linked to areduction in the incidence of clinically significant patent ductus arteriosusreduction in the incidence of clinically significant patent ductus arteriosus(PDA) and severe intraventricular hemorrhage (IVH), but concerns have(PDA) and severe intraventricular hemorrhage (IVH), but concerns havesurfaced regarding neurodevelopmental sequelae of repeated antenatalsurfaced regarding neurodevelopmental sequelae of repeated antenatalcourses of steroids.courses of steroids.

    In the last decade, surfactants have been widely used to treat RDS, and itIn the last decade, surfactants have been widely used to treat RDS, and itwas suggested that surfactants should be administered routinely aswas suggested that surfactants should be administered routinely as

    prophylaxis in infants younger than 30 weeks' gestation. However, thisprophylaxis in infants younger than 30 weeks' gestation. However, thisresults in unnecessary treatment in some infants. A shift in practice isresults in unnecessary treatment in some infants. A shift in practice isoccurring, and fewer infants are being intubated immediately after birth,occurring, and fewer infants are being intubated immediately after birth,making prophylactic treatment with surfactant impossible. Infants who aremaking prophylactic treatment with surfactant impossible. Infants who arenot immediately intubated usually are maintained with nasal continuousnot immediately intubated usually are maintained with nasal continuouspositive airway pressure (CPAP), which has been shown to improvepositive airway pressure (CPAP), which has been shown to improveendogenous surfactant production. These infants are intubated and givenendogenous surfactant production. These infants are intubated and given

    surfactant only if they fail the initial trial of CPAP, as evidenced bysurfactant only if they fail the initial trial of CPAP, as evidenced byincreasing PaCO2, increasing respiratory distress, or persistently highincreasing PaCO2, increasing respiratory distress, or persistently highoxygen requirement.oxygen requirement.

  • 7/30/2019 Special Topics in Pediatric Nursing

    59/60

    If used as prophylactic treatment, surfactants should beIf used as prophylactic treatment, surfactants should beadministered as soon after birth as possible. When administered asadministered as soon after birth as possible. When administered asrescue treatment, a reasonable approach is to treat most infants asrescue treatment, a reasonable approach is to treat most infants assoon as clinical signs of RDS appear, or if the respiratory picturesoon as clinical signs of RDS appear, or if the respiratory picturedoes not improve after the initial resuscitation.does not improve after the initial resuscitation.

    A major morbidity of premature birth is CLD (or bronchopulmonaryA major morbidity of premature birth is CLD (or bronchopulmonary

    dysplasia [BPD]), which is defined as receiving supplementaldysplasia [BPD]), which is defined as receiving supplementaloxygen or ventilatory support at 36 weeks' postmenstrual age. Thisoxygen or ventilatory support at 36 weeks' postmenstrual age. Thisdefinition has relatively replaced the former definition of oxygendefinition has relatively replaced the former definition of oxygendependence beyond 28 days of age. BPD is a staged disease thatdependence beyond 28 days of age. BPD is a staged disease thatwas originally described by Northway et al in 1967 as the clinicalwas originally described by Northway et al in 1967 as the clinicalsequelae of prolonged ventilation associated with radiographic andsequelae of prolonged ventilation associated with radiographic andpathologic findings; it is the result of abnormal reparative processespathologic findings; it is the result of abnormal reparative processesin response to injury and inflammationin response to injury and inflammation

  • 7/30/2019 Special Topics in Pediatric Nursing

    60/60

    Intraventricular hemorrhageIntraventricular hemorrhageA hemorrhage in the brain that begins in the periventricular subependymal germinal matrix can progress into the ventricular systemA hemorrhage in the brain that begins in the periventricular subependymal germinal matrix can progress into the ventricular systemcausing intraventricular hemorrhage (IVH). Both incidence and severity of IVH are inversely related to gestational age. ELBW babies arecausing intraventricular hemorrhage (IVH). Both incidence and severity of IVH are inversely related to gestational age. ELBW babies areat particular risk for IVH because development of the germinal matrix typically is incomplete and the protective cerebral autoregulationat particular risk for IVH because development of the germinal matrix typically is incomplete and the protective cerebral autoregulationpresent in older babies has not yet developed. Any event that results in disruption of vascular autoregulation can cause IVH, includingpresent in older babies has not yet developed. Any event that results in disruption of vascular autoregulation can cause IVH, includinghypoxia, ischemia, rapid fluid changes, and pneumothorax. Presentation can be asymptomatic or catastrophic, depending on the degreehypoxia, ischemia, rapid fluid changes, and pneumothorax. Presentation can be asymptomatic or catastrophic, depending on the degreeof the hemorrhage. Symptoms include apnea, hypertension or hypotension, sudden anemia, acidosis, changes in muscular tone, andof the hemorrhage. Symptoms include apnea, hypertension or hypotension, sudden anemia, acidosis, changes in muscular tone, andseizures. The most commonly used system classifies IVH into 4 grades, as follows:seizures. The most commonly used system classifies IVH into 4 grades, as follows:

    Grade I - Germinal matrix hemorrhageGrade I - Germinal matrix hemorrhage

    Grade II - IVH without ventricular dilatationGrade II - IVH without ventricular dilatation

    Grade III - IVH with ventricular dilatationGrade III - IVH with ventricular dilatation

    Grade IV - IVH with extension into the parenchymaGrade IV - IVH with extension into the parenchymaIVH is diagnosed using cranial ultrasonography. Since most IVHs occur within 72 hours of delivery, neurosonograms are usuallyIVH is diagnosed using cranial ultrasonography. Since most IVHs occur within 72 hours of delivery, neurosonograms are usuallyperformed on ELBW infants during the first week after birth and serially thereafter depending on clinical scenario. Use of antenatalperformed on ELBW infants during the first week after birth and serially thereafter depending on clinical scenario. Use of antenatalsteroids decreases incidence of IVH, and treatment consists of supportive care. Progressive intraventricular dilatation and hydrocephalussteroids decreases incidence of IVH, and treatment consists of supportive care. Progressive intraventricular dilatation and hydrocephalusmay necessitate surgical diversion of accumulating CSF. Early administration of indomethacin may reduce the incidence of grades III andmay necessitate surgical diversion of accumulating CSF. Early administration of indomethacin may reduce the incidence of grades III andIV IVH when used prophylactically in ELBW infants but may adversely affect urine output and platelet function, and it has not been shownIV IVH when used prophylactically in ELBW infants but may adversely affect urine output and platelet function, and it has not been shownto improve neurodevelopmental function at age 2 years. Prognosis is correlated with the grade of IVH. The outcome in infants with gradesto improve neurodevelopmental function at age 2 years. Prognosis is correlated with the grade of IVH. The outcome in infants with gradesI and II is good; as many as 40% of infants with grade III IVH have significant cognitive impairment, and as many as 90% of infants withI and II is good; as many as 40% of infants with grade III IVH have significant cognitive impairment, and as many as 90% of infants withgrade IV IVH have major neurologic sequelae.grade IV IVH have major neurologic sequelae.

    Prevention of preterm birth is the most effective method of preventing IVH. The risk of IVH is higher in infants who are transported afterPrevention of preterm birth is the most effective method of preventing IVH. The risk of IVH is higher in infants who are transported afterbirth, underlining the need for preterm births to occur at tertiary centers specializing in high-risk deliveries. Adequate resuscitation isbirth, underlining the need for preterm births to occur at tertiary centers specializing in high-risk deliveries. Adequate resuscitation isparamount, and hypocarbia and hypoxia should be avoided. Maintenance of adequate mean arterial pressure and avoiding elevations inparamount, and hypocarbia and hypoxia should be avoided. Maintenance of adequate mean arterial pressure and avoiding elevations incerebral blood flow as much as possible are vital. Multiple clinical trials have been undertaken to determine the effect of variouscerebral blood flow as much as possible are vital. Multiple clinical trials have been undertaken to determine the effect of variousmedications, either antenatally or perinatally, on incidence of IVH. One trial demonstrated a decrease in the incidence of severe grades ofmedications, either antenatally or perinatally, on incidence of IVH. One trial demonstrated a decrease in the incidence of severe grades ofIVH but no difference in neurodevelopmental outcomes at age 18-24 months with the use of postnatal indomethacin. Because of theIVH but no difference in neurodevelopmental outcomes at age 18-24 months with the use of postnatal indomethacin. Because of thepotentially serious complications of indomethacin, the question of using such an approach remains unanswered.potentially serious complications of indomethacin, the question of using such an approach remains unanswered.