NEONATES WITH SPECIAL NEEDS

BY MRS DAYAL

LEARNING OUTCOMES
Define key terms Identify neonates with special needs Discuss the various conditions associated with neonates Explain the physiology of each condition

Classifications
1. Low Birth Weight (LBW) - < 2500gms, regardless of gestation. (LBW) 2500gms, 1500gms, 2. Very Low Birth Weight (VLBW) - < 1500gms, regardless of gestation. 1000gms, 3. Extremely Low Birth Weight (ELBW) - < 1000gms, regardless of gestation. 4. Premature - < 37weeks completed gestation. 5. Term - delivery between 38 and 40 weeks gestation 6. Post-term - delivery beyond 42 weeks gestation Post7. Small for Gestational Age (SGA) birth weight on or below the 10th percentile for (SGA) gestation 8. Large for Gestational Age (LGA) birth weight on or above the 90th percentile for (LGA) gestation

Introduction
Majority of newborn babies are normal and healthy Require no intervention Need drying with warm towels and skin to skin contact Breastfeeding on demand

 Labour and birth have an obvious effect on the well being of baby Genetic background Mothers illnesses in pregnancy Any drugs she may have taken or received during pregnancy

Maternal Health
Pregnancy-induced hypertension History of epilepsy Maternal diabetes History of substance abuse History of sexually transmitted disease

Fetal well being during pregnancy

Estimated date of delivery Twin pregnancy Breech presentation Preterm baby Is the infant SGA Was there poor growth in utero Evidence of congenital abnormality

Perinatal and delivery

Prolonged rupture of membrane Abnormal fetal heart rate Meconium stained liquor Difficult or rapid delivery C/S and reason for it

Physical assessment
SKIN : a) Pallor haemolytic disease of newborn twin-to-twin transfusion maternal APH twin-to-twin transfusion large placental transfusion delayed clamping of cord

b) Plethora

CYANOSIS: a) Central mucus membrane & tongue appear blue, low oxygen saturation indicates cardiac problem b) Peripheral feet and hands during 1st 24 hrs, non-specific

JAUNDICE: a) Early onset jaundice in skin & sclera ( 1st 12 hrs of life) b) Jaundiced baby lethargic, poor feeder, vomiting, unstable temperature indicates infection needs investigation

SKIN RASHES: a) Petechiae or purpura rash b) Bruising c) Erythema toxicum Infectious Lesions a) Herpes simplex virus b) Umbilical sepsis c) Bullous impetigo

Respiratory System
RESPIRATORY INSPECTION: Observe baby s breathing a) Nose breathers b) Symmetrical rise of chest c) RR 40 -60/min

INCREASED WORK OF BREATHING: a) RR 60br/min tachypnoea b) Check for overheating cause fast breathing c) Check for chest indrawing, sternal recessions,intercostal retraction d) Nasal flaring e) Grunting f) Apnoea

Body Temperature
HYPOTHERMIA: a) Core temperature below 36 C risk of cold stress b) Increases infant mortality & morbidity rate c) Restless & adopt tightly flexed position d) Non-shivering thermogenesis- utilising brown adipose tissues e) Mottled, uninterested in feeding hypoglycaemia a) Jittery movements even though quiet & limp

HYPERTHERMIA: a) Core temperature 38 C b) Clinical sign of sepsis, brain injury c) Restless, red cheeks d) Increases his respiratory rate increased fluid loss by evaporation thru airways. Variability in body temperature, either high or low maybe the 1st and only sign that a baby is unwell

Cardiovascular System
Normal heart rate 110 160 b/min Lethargy and breathless whilst feeding Pale looking, sweaty, fast or labored breathing Congenital defect Failure of transition from fetal to adult circulation Murmur, cardiac failure

Central Nervous System

NEUROLOGICAL DISORDERS: Abnormal postures: a) Neck retraction, frog-like, hyperextension or hyper flexion of limbs b) Jittery or abnormal involuntary movements c) High-pitched or weak cry

Seizures
Extremely difficult to diagnose as they are often very subtle and easily missed. Apnoea with abnormal eye movement Blinking Fluttering eyelids Jerking, drooling Unusual movement of limbs rowing, paddling, swimming

Hypotonia (floppy infant)

Loss of body tension and tone Abnormal & requires investigation Causes: Maternal sedation, birth asphyxia, prematurity, Infection, Downs Syndrome, metabolic problems, neurological problems, endocrine, neuromuscular disorders.

Renal and Genito-Urinary System

Dribbling urine problem with posterior urethral valve Cloudy/smelly urine indicates infection (UTI) Genitourinary tract has the highest percentage of anomalies, of all the organ systems Record the initial urine output

Gastro-Intestinal Tract
STRUCTURAL DEFORMITIES: a) Oesophageal atresia copius salivation, gagging, choking, pallor or cyanosis b) Intestinal obstructions/malformations vomiting, abdominal distension, failure to pass stools, diarrhoea with or without blood

Duodenal atresia Malrotation of the gut Volvulus Meconium ileus Necrotising enterocolitis Imperforate anus Rectal fistulas Hirschsprungs disease Omphalocele Gastroschisis

Summary-Recognizing An Ill Infant

Pallor Central Cyanosis Jaundice Apnoea lasting longer than 20 seconds Heart rate 110 or 180 beats/min Respiratory rate 40 or 60 breaths/min Skin temperature 36.2 or 37.2 C Poor feeding Lethargy

 Continous crying Septic umbilical cord Lack of spontaneous movement and responsiveness Abnormal lying position either hypotonic or hypertonic Lack of interest in surrounding

Asphyxia
Inability of the infant to establish spontaneous respirations by 1 minute after birth. A condition caused by the inadequate intake of oxygen before, during, or just after birth.

Perinatal Asphyxia
Incidence Perinatal asphyxia happens in 2 to 10 per 1000 newborns born at term Deprivation of oxygen (hypoxia) to a newborn infant born at term

Causes of Perinatal Asphyxia

Hypoxia compression of IVC, umb.cord, immature lungs, meconium aspiration, interference with delivery of O to brain Analgesic and anaesthetic maternal narcotics, sedatives and anaesthetics Birth trauma intracranial haemorrhage, abnormal presentation, difficult deliveries

Pregnancy
Maternal age 16yrs, 35yrs Maternal illness diabetes, preeclampsia, severe anaemia H/O abortions, preterm labour, neonatal deaths, stillbirths Alcohol abuse and smoke antepartum haemorrhage multiple births no antenatal care Severe fetal growth retardation Low socio-economic status

Delivery
abnormal presentation pre or post term prolonged labour prolapsed cord meconium stained fluid (amniotic) fetal distress (heart rate < 120/min)

Physiology of Asphyxia
Asphyxia Constricted arterioles in bowels, kidneys, muscles, skin Re-distribution of blood to heart & brain Deterioration in myocardial fxn organ damage bld flow

 Extreme degrees of asphyxia can cause cardiac arrest & death. Successful resuscitation, transfer neonatal intensive care unit(NICU) Hypoxia damages infant's organs (heart, lungs, liver, gut, kidneys) BUT BRAIN DAMAGE is of most concern as it does not heal completely, displaying development delay and spasticity.

Primary Apnoea
Infant deprived of O (hypoxia) rapid breathing occurs if asphyxia continues respiration ceases/heart rate drops,pale or blue primary apnoea Oxygen & tactile stimulation induce respiration pinks up, moves, cries

Secondary Apnoea
Asphyxia continues deep gasping respiration drop in HR/BP last gasp, cyanosed drop in HR, BP, PaO further unresponsive to stimulation (tactile) Artificial ventilation with ambu bag & mask (100% O )

Anticipation
Crew should be prepared to handle problems Delivery of asphyxiated infants often can be anticipated on the basis of the ante-partum and intra-partum histories. Two major factors for prompt, effective resuscitation are: Anticipation of need for resuscitation Adequate preparation of equipment and personnel.

Clinical Manifestations
Bluish or gray skin color (cyanosis) Poor perfusion Slow heartbeat (bradycardia) Stiff or limp limbs (hypotonia) Poor response to stimulation Poor respiratory effort

Treatment
Initiate resuscitation - suction oropharynx with soft catheter - give 100% O by close fitting mask - if no response, bag with ambu bag and mask -no response, intubate with endotracheal tube - if still not breathing, do cardiac massage/CPR

Complications
Survivors have life-long neurological disabilities Cerebral palsy Mental retardation Vision and hearing impairments Learning disabilities Feeding difficulties

Follow-Up
Need follow-up for the first few years of life. specific assessments of motor development to detect possible problems with muscle tone (strength) and any evidence of cerebral palsy referral to appropriate interventional therapies at the earliest possible age.

Meconium Aspiration Syndrome

Meconium aspiration syndrome is a serious condition in which a newborn breathes a mixture of meconium and amniotic fluid into the lungs, before, during or at the time of delivery.

Physiology of MAS
Fetal Distress Intestine contracts, anal sphincter relaxes Meconium released in the amniotic fluid Baby inhales it before, or during birth

Three main problems occurs: The meconium blocks the airways Impaired gas exchange in the lungs Meconium-tainted fluid is irritating, it inflames airways (pneumonitis & chemical pneumonia

Signs & Symptoms

Bluish skin color (cyanosis) in the infant Breathing problems
Difficulty breathing (the infant needs to work hard to breathe) No breathing Rapid breathing

Limpness in infant at birth Barrel-shaped chest

Treatment
Paediatrician should be present @ delivery of all meconium stained liquor An individual trained in neonatal intubation Use of laryngoscope and endotracheal tube to suction meconium from below the vocal cords

The ABCs of Resuscitation The steps in resuscitating newborn infants follow the well-known ABCs of resuscitation. A- airway B- breathing C- circulation

A- Establish an open airway: Position the infant. Suction the mouth and nose. B- Initiate breathing: Use tactile stimulation to initiate respirations. Employ positive-pressure ventilation when necessary, using: Bag and valve mask C- Maintain circulation: Stimulate and maintain the circulation of blood with: Chest compressions

Complications
Aspiration pneumonia Brain damage due to lack of oxygen Breathing difficulty that lasts for several days Collapsed lung (pneumothorax) Persistent pulmonary hypertension of the newborn (inability to get enough blood into the lungs to take oxygen to the rest of the body

Diabetic Baby

 Blood sugar is the baby's food source and it passes from the mother through the placenta to the baby.

Physiology
High blood sugar from mum Excess sugar transported to baby Baby increases insulin production to cater for high sugar levels Converts sugar into body fats MACROSOMIC BABY

Clinical Features
Large baby - MACROSOMIC Thick umbilical cord Bulging cheeks Plethoric complexion Hirsuitism

Causes of Hypoglycaemia
As soon as baby is delivered supply of sugar cut down pancreas continues to produce insulin if feeding not commenced soon HYPOGLYCAEMIA

Signs of Hypoglycaemia
Blood sugar level < 2.5mmol/l The baby can become fussy Jittery Poor feeding Lethargy Seizure Breathing problems.

Management of IDM
Early feeding Monitor glucose Observe for signs of hypoglycaemia Complement breastfeeds with expressed breast milk Assist and supervise breastfeeds

Complications
Macrosomia Birth defects heart, spinal cord, brain. Stillbirths bld vessels damage placenta Trauma size,shoulder dystocia Jaundice excess insulin Metabolic calcium & magnesium imbalance

Jaundiced baby

What is Jaundice?
Is the yellow discoloration of the skin, sclera and mucosa due to hyperbilirubinaemia. Unconjugated bilirubin common for NNJ Able to pass through blood-brain barrier and cause kernicterus Permanent brain damage with chronic disability. Can cause death

Normal Conjugation
RBC breakdown by reticuloendothelial system unconjugated bilirubin (free & indirect) carried by albumin Liver converts to H O soluble (direct & conjugated) excreted by bile salts intestine urobilinogen

Excreted in faeces

Conjugated bilirubin Direct bilirubin Water soluble Easily excreted Safe

Unconjugated bilirubin Indirect bilirubin Fat soluble Cannot be excreted Dangerous kernicterus

Causes of Jaundice
Blood type/group incompatibility Breast milk jaundice Spherocytosis Extravasated blood- bruising, haematoma Polycythemia Sepsis Hypothermia, hypoxia, acidosis Obstructive jaundice prematurity

Assessment for jaundice

yellowing of skin colour and sclera of eyes lethargy poor feeding darkened urine dark stools

Appendix 1 Jaundice Action Chart

Phototherapy

What is Phototherapy?
Phototherapy is a safe and effective method of treating the neonate who has high levels of unconjugated bilirubin. It works through the blue part of the spectrum at around 450nm Inspite of double phototherapy, levels of bilirubin are rising at a rapid rate, an exchange transfusion may be needed

Treatment of Jaundice
Phototherapy use of fluorescent lights which photo- chemically converts fat-soluble unconjugated bilirubin water-soluble conjugated bilirubin excreted in bile and urine.

Administering Phototherapy
More than one set of phototherapy lights may be may be required if bilirubin levels are very high Perform a clinical hand wash. Undress the baby & open their nappy Remove any creams or oils from the baby s skin. Gently cover baby s eyes with eye shades . Place the overhead phototherapy light 40-50cms from the baby s skin & activate the unit

 Change the position of the baby after routine nursing care. Monitor the hydration of the baby An extra 30mls/kg/day of fluids may be required for insensible loss Monitor the baby s temperature. The baby may need to be placed in an incubator during phototherapy treatment Remove eye shields and check eyes regularly. Document time of commencement & completion of phototherapy

Side effects of Phototherapy

Hyperthermia Retinal damage Lethargy/ irritability, loose stools, eagerness to feed Skin rashes/skin burns Isolation & lack of usual sensory experience including visual deprivation Bronze baby syndrome