NSG210 Durham Ch. 17: Complications of the Neonate and Nursing Care

Source: Durham & Chapman, Maternal-Newborn Nursing 4e, Chapter 17, pp. 547-590 (textbooks/DURHAM_OB_CH17.pdf, also in textbooks/exam03/). Week 10 reading; on Exam 3. Lecture slides: raw/nsg210_wk10_OBLecture4.md (The High-Risk Neonate, Cold Stress, Birth Weight Variations, Meconium Aspiration Syndrome, Respiratory Distress Syndrome, Necrotizing Enterocolitis, Neonatal Abstinence Syndrome, Cleft Lip and Palate, Atresia, Omphalocele and Gastroschisis, Neural Tube Defects). Normal newborn care is in nsg210-durham-ch15-neonate-and-family; preterm labor and maternal diabetes are in nsg210-exam-2-outline-durham-ch07.

Learning Outcomes

1. Describe the physiology and pathophysiology of selected neonatal complications.
2. Identify critical assessment and nursing care for neonates with complications.
3. Develop a discharge plan for these neonates.
4. Describe the loss and grief process of parents whose infant has died.

Nursing diagnoses: impaired gas exchange (surfactant deficiency, immature lungs); ineffective airway clearance (meconium); ineffective thermoregulation; imbalanced nutrition; risk for infection; pain; risk for injury (hypoxia, oxygen toxicity, drugs, birth trauma, hypoglycemia, kernicterus); ineffective family coping; grieving; impaired attachment from separation.

I. Overview

• US infant mortality 5.67 per 1,000 live births (2018), the lowest on record; 21,498 infant deaths
• Gestational age and birth weight are the two most important predictors of health and survival; prematurity and LBW are the leading causes of infant death after congenital malformations
• US preterm birth rate 10.02% (2018), rising four years in a row; highest in non-Hispanic Black women (13.8%)

II. Preterm Neonates

Classification by gestation:

• Preterm: any birth before 37 completed weeks
• Extremely preterm: under 28 weeks
• Very preterm: 28 to 31 6/7 weeks
• Moderately preterm: 32 to 33 6/7 weeks
• Late preterm: 34 to 36 6/7 weeks

Classification by birth weight (regardless of age):

• Extremely LBW: under 1,000 g
• Very LBW: 1,000 to 1,499 g
• LBW: 1,500 to 2,500 g

Risk factors for preterm birth (Table 17-1): previous preterm birth, multiples, uterine or cervical anomalies, age under 17 or over 35, unplanned pregnancy, low socioeconomic status, race, short interpregnancy interval, PROM, IVF, second- or third-trimester bleeding, low or high prepregnancy weight, hypertension, diabetes, infections and STIs, substance use, smoking, long hours standing, late or no prenatal care, toxins.

Common complications: RDS, BPD, PDA, IVH, NEC, ROP.

Assessment findings:

• Hypotonic, extended posture (tone and flexion increase with age)
• Thin, translucent skin (pale, red or mottled); little subcutaneous fat
• Lanugo from 20 to 28 weeks, then disappears from face and front of trunk
• Plantar creases absent until 28 to 30 weeks, then spread toward the heel
• Eyelids fused in very preterm; open at 26 to 28 weeks
• Before 34 weeks the pinna has little cartilage and stays folded
• Undescended testes; prominent clitoris with small, widely separated labia
• Tremors, weak cry, diminished reflexes
• Suck-swallow-breathe coordination is immature until about 34 WEEKS; needs tube or parenteral feeding before then
• Apnea of prematurity: no breathing for at least 20 seconds, or shorter with cyanosis, pallor, hypotonia or bradycardia (HR under 100)
• Hypotension, PDA murmur, anemia (frequent lab draws, low erythropoietin)

Medical management:

• Lung maturity tests (L/S ratio, phosphatidylglycerol) before elective delivery
• ANTENATAL CORTICOSTEROIDS (betamethasone or dexamethasone) to women in preterm labor or expected to deliver within 7 days: one of the most important interventions; reduces RDS and IVH
• Monitoring: cardiorespiratory, SpO2, blood gases, end-tidal CO2
• Respiratory support: low-flow or high-flow nasal cannula, nasal CPAP, intubation
• Labs: bilirubin, blood cultures, blood gas, glucose, CBC with differential, electrolytes, LFTs
• Transfusion for anemia; IV fluids; parenteral nutrition; central lines including umbilical artery and vein catheters
• Medications: antibiotics; dopamine or dobutamine for hypotension; erythropoietin (reduces transfusions, IVH and NEC; does not increase ROP); surfactant; opioids for procedural pain; sodium ACETATE for metabolic acidosis
• Sodium BICARBONATE is no longer recommended for metabolic acidosis (needs adequate ventilation to blow off CO2, can worsen intracellular acidosis, and rapid administration is linked to IVH)

Clinical Judgment, signs of respiratory distress (most NICU admissions are respiratory): audible expiratory grunting (air forced past a partly closed glottis), nasal flaring, retractions (sternal, subcostal, intercostal), duskiness or cyanosis, tachypnea over 60.

Critical Component, neutral thermal environment:

• Dry gently, remove wet linen, hat
• Preterm under 32 weeks: cover with a polyethylene plastic barrier after birth (reduces transepidermal water loss, TEWL)
• Chemical warming mattress during resuscitation and transport (blanket between it and the skin to prevent burns)
• Prewarm everything that touches the infant
• Servo control with the probe below the underarm at the midaxillary line; keep axillary 97.7 to 99.5 F (36.5 to 37.5 C)
• Double-walled incubator with humidity (reduces heat loss and TEWL)
• Kangaroo care once stable
• Wean to an open crib when medically stable and about 1,600 g or more

Nursing actions for preterm neonates:

• Review histories; attend high-risk births; stabilize and transfer to NICU; Ballard if gestational age is unknown
• Airway: suction as needed (small airways obstruct easily); warmed, humidified oxygen via LFNC, HFNC, CPAP or ventilator to ordered SpO2
• Cardiovascular: HR and rhythm, BP, murmurs, pulses, capillary refill; H&H; transfusions
• Fluids: weigh diapers for output; record all I&O including lab draws; fluid restriction as ordered (BPD, PDA); watch for hyperkalemia, hypo- and hypernatremia; check IV sites HOURLY for infiltration and extravasation; humidity reduces fluid needs
• Nutrition: glucose monitoring; parenteral nutrition for infants under 32 weeks or LBW; TROPHIC feedings (small volumes for gut maturation, not nutrition); gavage until oral feeding is possible (most over 34 weeks feed orally soon after birth)
• Human milk (mother’s or donor) reduces NEC and is preferred, but must be FORTIFIED for preterm infants
• Before each gavage feeding check for intolerance: abdominal distention, emesis, bloody stools, apnea, bradycardia
• Pacifier during gavage feeding (non-nutritive sucking shortens hospital stay)
• Daily weights; expected gain 15 to 20 g/kg/day (care plan: 20 to 30 g/day); head circumference and length weekly
• Ready for oral feeding when: stable cardiorespiratory regulation; coordinated suck-swallow-breathe and strong gag (about 34 weeks corrected); hunger cues; can maintain quiet alert. Feed side-lying semi-upright; pace with breathing breaks
• Breastfeeding: pump and bring milk; weigh before and after breastfeeding to show intake
• Skin: Braden QD scale (13 or less = at risk); minimal adhesives, careful removal without solvents; frequent diaper changes; reposition at least every 4 hours; hydrocolloid under devices
• Pain: assess frequently; sucrose with non-nutritive sucking; opioids for moderate to severe procedural pain; swaddling, positioning, kangaroo care, reduced stimuli
• Developmental care: quiet, dim; cycle lights for day and night (improves circadian rhythm and weight gain); cluster care but do NOT cluster painful procedures; break if stressed; minimal handling if unstable; reposition gently every 2 to 3 hours; side-lying or prone improves oxygenation and gastric emptying; HOB up 15 degrees; swaddle in flexion with hands midline; nesting
• Kangaroo care benefits: temperature stability, pain relief, more quiet sleep, better weight gain, attachment
• Involve parents; teach cues and care

III. Respiratory Distress Syndrome (RDS)

• Small underdeveloped alveoli and insufficient SURFACTANT increase surface tension and cause atelectasis
• Incidence rises as gestational age and weight fall (51% under 1,000 g)
• Effects: hypoxemia, hypercarbia, pulmonary vasoconstriction, right-to-left shunting through the ductus and foramen ovale, metabolic acidosis (lactic acid) and respiratory acidosis
• Surfactant: 90% phospholipids, 10% proteins; lowers surface tension and keeps alveoli open at end-expiration; made by type II alveolar cells from 24 to 28 weeks onward

Fetal lung maturity tests:

• Phosphatidylglycerol (PG): present in amniotic fluid 2 to 6 weeks before term; presence = mature lungs
• L/S ratio: greater than 2:1 = mature (nondiabetic); 3:1 needed in a diabetic mother

Assessment:

• Distress begins at birth or within a few hours and worsens
• Tachypnea, retractions, seesaw breathing, expiratory grunting (keeps alveoli open), nasal flaring
• Increasing oxygen needs to keep PaO2 60 to 70 and PaCO2 35 to 45 mm Hg
• Gray or dusky color; decreased breath sounds with crackles; lethargy, hypotonia
• Chest x-ray: RETICULOGRANULAR (“ground glass”) pattern with air bronchograms
• Hypoxemia (PaO2 under 50), acidosis, tachycardia over 160

Complications: PDA, pneumothorax, BPD, pulmonary edema, hypotension, anemia, oliguria, hypoglycemia, calcium and sodium changes, ROP, seizures, IVH.

Medical management:

• Monitoring; exogenous surfactant; CPAP (by nasal cannula, mask, prongs, ETT or nasopharyngeal) for at-risk or affected infants; intubation and mechanical ventilation if CPAP fails (use judiciously); high-frequency oscillatory ventilation (over 300 breaths/min, small volumes, less traumatic) if conventional ventilation fails
• Chest x-ray, blood gases, cultures; antibiotics as indicated

Surfactant replacement therapy:

• Natural (calf, pig or cow lung): Survanta, Curosurf, Infasurf. Synthetic: Exosurf
• Lowers alveolar surface tension, improves compliance, decreases work of breathing, improves oxygenation
• Given via endotracheal tube (or thin catheter or laryngeal mask to avoid intubation)
• Prophylaxis within 15 minutes of birth for high-risk infants (under 27 to 30 weeks, especially without antenatal steroids); rescue within 6 hours for confirmed RDS with FiO2 over 40% or mechanical ventilation
• Adverse effects: bradycardia, desaturation, tachycardia, reflux, gagging, cyanosis, ETT blockage, hypotension
• Benefits: less RDS and mortality, pneumothorax, IVH, BPD, pulmonary interstitial emphysema

Nursing actions:

• Confirm ETT placement (equal breath sounds and chest rise, CO2 detector)
• Oxygen to ordered SpO2 (hypoxemia and acidosis further reduce surfactant)
• Minimize oxygen demand: NTE, clustered care, treat acidosis
• Suction as needed, aware that suctioning can trigger vagal bradycardia, hypoxemia or bronchospasm
• NTE (cold stress raises oxygen use, worsens acidosis, impairs surfactant)
• I&O and daily weights (dehydration thickens mucus; overhydration causes pulmonary edema; weight loss with diuresis may signal the diuretic phase)
• Promote rest; minimize stimulation

IV. Bronchopulmonary Dysplasia (BPD)

• Chronic lung disease after prolonged mechanical ventilation and oxygen; at risk if oxygen dependent beyond 28 DAYS of life
• Fibrosis, atelectasis, increased airway resistance, overdistention, pulmonary edema
• Risk: under 32 weeks and under 1,500 g, RDS, oxygen toxicity, intubation, positive pressure ventilation, infection, excess fluids, poor nutrition, PDA
• Complications: bronchospasm, ventilator or oxygen dependence, recurrent pneumonia, URIs and otitis media, heart failure, developmental delay, cerebral palsy, GERD; long-term oxygen, ROP, hearing loss
• Findings: retractions, wheezes, rales, rhonchi, hypoxia, respiratory acidosis, fluid intolerance (edema, low output, weight gain); x-ray with a multicystic, SPONGE-like appearance
• Treatment: bronchodilators, corticosteroids, diuretics; RSV prophylaxis; chest physiotherapy; oxygen and ventilation; treatment is “support and time”
• Nursing: gradual weaning; chest PT; FLUID RESTRICTION with INCREASED CALORIES (fortified milk or formula); monitor I&O and daily weights for fluid overload

V. Patent Ductus Arteriosus (PDA)

• Ductus fails to close (normally closes within hours, up to 96 hours); 1 in 2,000 term births, but 45% of infants under 1,750 g and 80% under 1,200 g
• Complications: heart failure, chronic lung disease, renal insufficiency, feeding intolerance, NEC, IVH
• Findings: MURMUR at the upper left sternal border (may be absent); active precordium; BOUNDING pulses; WIDENED pulse pressure with low diastolic BP; tachycardia, tachypnea, apnea; increased oxygen or ventilator needs; echocardiogram confirms
• Treatment: fluid restriction under 130 mL/kg/day; diuretics; indomethacin or ibuprofen now rarely used (GI bleeding, decreased GFR and urine output); cardiology consult; surgical ligation (suture, clip or coil) if hemodynamically significant
• Nursing: oxygen and ventilation; medications; I&O for overload; NPO during treatment and surgery; prepare family for surgery

VI. Intraventricular Hemorrhage (IVH)

• Bleeding in the germinal matrix around the lateral ventricles; affects 40% to 60% of premature very LBW infants; rare at term (germinal matrix gone after 36 weeks)
• 90% occur within 72 HOURS of birth
• Grades: I germinal matrix only; II intraventricular without dilation; III with ventricular dilation (clots fill over 50%); IV extends into brain tissue (parenchymal)
• Risk: birth under 34 weeks, LBW, asphyxia or birth trauma, ventilated RDS, RAPID VOLUME EXPANSION, RAPID SODIUM BICARBONATE, low 5-minute Apgar, BP swings, acidosis, hypercarbia, low Hct, pneumothorax, PDA ligation
• Prognosis: death 5% (small), 10% (moderate), 50% (severe); neuro problems (CP, delay) in 10%, 40% and 80%
• Findings: sudden deterioration, desaturation, bradycardia, hypotonia, metabolic acidosis, shock, falling Hct, full or tense fontanel, hyperglycemia; worsening: apnea, more ventilator support, seizures, tense fontanels, decreased consciousness
• Diagnosis: cranial ultrasound in the first week for NICU infants; lumbar puncture (RBCs, high protein, xanthochromia, low glucose); H&H; transfusion as needed
• Nursing: watch for increased ICP; quiet dark environment; give volume SLOWLY
• Evidence-based practice, preventing IVH by reducing cerebral blood flow swings: supine MIDLINE head position; HOB flat or slightly elevated; keep hips below head during diaper changes (do not raise legs above head); normothermia; minimize crying; minimize light and noise

VII. Necrotizing Enterocolitis (NEC)

• Most common GI emergency in neonates: inflammation and necrosis of the bowel, usually terminal ileum or proximal colon; over 90% in preterm infants; 90% to 95% occur AFTER enteral feeding starts
• Preterm risk: low intestinal immune factors, higher gastric pH, immature barrier, low motility
• Other risks: prolonged ROM with amnionitis, asphyxia, SGA, congenital heart disease, anemia, FORMULA feeding (breast milk is protective)
• Onset usually days 3 to 10 (up to several weeks)
• Findings: lethargy, apnea, bradycardia, temperature instability, hypotension, shock, low output; ABDOMINAL DISTENTION, tenderness, BILIOUS vomiting, increased gastric residuals, discolored abdomen, visible bowel loops, occult or frank BLOODY stools
• X-ray: distended loops, uneven gas, air in the bowel wall (pneumatosis intestinalis) or portal vein, free air (perforation); serial films
• Treatment: STOP feedings (NPO), IV fluids, gastric decompression (orogastric tube to low suction), antibiotics, analgesia; labs (cultures, CBC, CRP, electrolytes, ABG, coags); surgery for necrosis or perforation (resection, temporary colostomy)
• Fatal in 20% to 30%; short bowel syndrome after surgery
• Nursing: early recognition (distention, loops, emesis, bloody stools, VS changes); hold feeds; IV access; OG to low suction; I&O; prepare for surgery

VIII. Retinopathy of Prematurity (ROP)

• Incompletely vascularized retina is injured; abnormal vessel growth leads to bleeding, scarring, retinal traction and detachment. Five stages (4 partial detachment, 5 complete)
• Up to 80% of infants under 1,000 g; severe in 1% to 43% of them
• Risk: prematurity, LBW, prolonged HYPEROXIA and ventilation, hypoxia, CO2 swings, acidosis, steroids, sepsis, PDA, multiples, IVH, transfusion, maternal diabetes, bleeding, smoking, hypertension
• Screening eye exam by a pediatric ophthalmologist for all infants under 30 WEEKS or under 1,500 g (and 1,500 to 2,000 g with complications) at 4 to 6 weeks after birth, repeated as needed
• Treatment: laser photocoagulation, cryotherapy, vitreoretinal surgery
• 90% recover with little or no vision loss; complications include glaucoma, strabismus, cataracts, amblyopia, detachment, blindness
• Nursing: continuous SpO2 monitoring to prescribed limits; careful oxygen during suctioning; oxygen blenders and calibrated systems; dim light, cover isolettes

IX. Postmature Neonates

• Post-term pregnancy: 42 weeks or more. Can produce an LGA infant, or, if the placenta fails, a wasted SGA “postmature” infant using up fat and glycogen
• Risk factors: anencephaly, prior post-term pregnancy, first pregnancy, grand multiparity
• Complications: MECONIUM ASPIRATION (less amniotic fluid makes meconium thicker), fetal hypoxia (oligohydramnios, cord compression), seizures, HYPOGLYCEMIA, hypothermia, POLYCYTHEMIA (Hct over 65%)
• Findings: dry, peeling, cracked skin; no vernix; profuse hair; long nails; thin wasted look; meconium staining; poor feeding
• Management and nursing: oxygen; Hct; glucose; gestational age; watch for distress and cyanosis; early frequent feedings; I&O

X. Meconium Aspiration Syndrome (MAS)

• Respiratory failure in term and post-term infants. Meconium-stained amniotic fluid (MSAF) in 8% to 20% of births (fetal hypoxia relaxes the anal sphincter); about 5% of those develop MAS
• Thick meconium obstructs airways (ball-valve air trapping, hyperinflation, air leaks, atelectasis), causes chemical pneumonitis and inactivates surfactant; risk of pulmonary hypertension and pneumonia
• Findings: MSAF; green or yellow staining of skin, nails and cord; respiratory depression, low Apgars, need for resuscitation; distress signs; BARREL-shaped overdistended chest; prolonged expiration; rales and rhonchi; x-ray with atelectasis and hyperinflation; low PaO2 despite 100% oxygen; acidosis
• Management: prevent fetal distress; a clinician skilled in intubation present when MSAF is present; bulb suction of the mouth for a NONVIGOROUS infant (no deep suctioning); intubation and tracheal suction ONLY if the airway is obstructed; ROUTINE ENDOTRACHEAL SUCTIONING is NOT recommended for vigorous or nonvigorous infants; ABGs; oxygen and ventilation; surfactant; sedation; antibiotics; therapeutic hypothermia, inhaled nitric oxide or ECMO
• Nursing: assist with resuscitation; watch for acidosis, hypoglycemia, hypocalcemia, pneumonia, pneumothorax, BPD, PPHN and neuro injury; monitor glucose (high metabolic rate)

XI. Persistent Pulmonary Hypertension of the Newborn (PPHN)

• Pulmonary vascular bed fails to relax after birth: high PVR and pulmonary artery pressure cause RIGHT-TO-LEFT shunting through the foramen ovale and ductus, leading to hypoxemia, low output, hypotension and acidosis (a vicious cycle)
• 2 to 6 per 1,000; mostly term or near-term infants with hypoxia, asphyxia, RDS, MAS, sepsis or lung anomalies (diaphragmatic hernia)
• Risk: hypoxia and asphyxia (most common), low Apgars, RDS, MAS, pneumonia, sepsis, delayed transition, hypothermia, hypoglycemia, polycythemia, maternal NSAIDs (premature ductal closure), late-pregnancy SSRIs
• Findings within 12 hours: slow to breathe, tachypnea, retractions, grunting, cyanosis, LOW PaO2 even on high oxygen; hypotension, murmur, enlarged right heart; hypocalcemia, hypoglycemia, acidosis; DIC, thrombocytopenia
• Diagnosis: preductal PaO2 15 mm Hg or more higher than postductal, or SpO2 difference 5% or more; echocardiogram
• Treatment: correct hypoxia and acidosis; keep PaO2 over 50 and PaCO2 normal (over 30; avoid hyperventilation); wean oxygen slowly; HFOV; ECMO; umbilical catheters; surfactant; INHALED NITRIC OXIDE (pulmonary vasodilator, reduces ECMO need); dopamine to keep systemic pressure above pulmonary pressure; sildenafil, prostaglandins; sedation (midazolam, morphine); antibiotics
• Long term: sensorineural hearing loss, neuro deficits, chronic lung disease, death
• Nursing: MINIMAL handling and stimulation (handling drops PaO2 and causes vasoconstriction); umbilical lines spare painful sticks; family support

XII. SGA and IUGR

• SGA: weight under the 10th percentile (clinical finding). IUGR: growth restriction in utero (ultrasound finding)
• SYMMETRIC IUGR: early insult (teratogens, congenital infection, genetic problems); all measures (weight, length, head) under the 10th percentile
• ASYMMETRIC IUGR (“head sparing”): later insult reducing placental flow (preeclampsia, infarcts, malnutrition); head and length normal, weight under 10th percentile
• Risk: maternal chronic disease, anemia, malnutrition, multiples, age, prior IUGR, low BMI, preeclampsia, drugs (beta blockers, thiazides), tobacco, alcohol and drugs; fetal TORCH, chromosomal and congenital anomalies; placental infarction, previa, abruption, abnormal cord insertion, twin-to-twin transfusion; high altitude, arsenic, lead
• Risks for the infant: labor intolerance, meconium aspiration, HYPOGLYCEMIA (low glycogen), HYPOCALCEMIA (under 7.5 mg/dL; jitteriness, tetany, seizures), hypothermia (little fat), polycythemia, RDS if preterm, NEC
• Findings: large head relative to body, long nails, large anterior fontanel, thin cord (little Wharton jelly), thin limbs and trunk, loose skin, dry flaky or meconium-stained skin
• Nursing: gestational age; NTE; glucose monitoring; early frequent feedings (may need gavage); watch for feeding intolerance; calcium; daily weights

XIII. LGA and Infants of Diabetic Mothers (IDM)

LGA: weight over the 90th percentile; macrosomia = over 4,000 g. Maternal diabetes is the leading cause.

• Risk: maternal diabetes, multiparity, prior macrosomic baby, prolonged pregnancy, obesity and high weight gain
• Risks: cesarean or operative birth, SHOULDER DYSTOCIA, birth trauma, hypoglycemia, polycythemia and hyperbilirubinemia, asphyxia, respiratory distress, MAS
• Birth trauma: molding, caput, FRACTURED CLAVICLE, BRACHIAL PLEXUS injury, facial nerve injury, skull fracture, cephalohematoma, subgaleal and intracranial hemorrhage
• Nursing: check for trauma; glucose per protocol; early frequent feedings (may feed poorly); Hct (ruddy skin = polycythemia); watch for jaundice

IDM:

• Up to 2% of pregnant women have type 1 or 2 diabetes; gestational diabetes in 6% to 9%
• Congenital anomalies 2 to 4 times more often: cardiac (transposition, VSD, hypertrophic cardiomyopathy, aortic stenosis), sacral agenesis and caudal regression, neural tube defects, small left colon, renal anomalies
• Also IUGR (placental insufficiency), neuro damage from hypoglycemia, later diabetes and obesity
• Macrosomia: fetal hyperinsulinemia drives fat and growth; head circumference often normal (insulin does not cross the blood-brain barrier)
• HYPOGLYCEMIA in up to 40%: maternal glucose supply stops at birth while the infant still makes high insulin
• Hypocalcemia, hypomagnesemia, polycythemia (hyperinsulinemia raises oxygen use and RBC production), hyperbilirubinemia, low tone, lethargy, poor feeding, RDS and transient tachypnea (delayed surfactant)
• Management: glucose by point-of-care meter (confirm in the lab); recheck 30 minutes after feeding if low; breastfeed within 1 to 2 hours and feed often; if hypoglycemic or unable to feed: 40% DEXTROSE GEL in the buccal cavity (first option in the first 48 hours) or IV D10W; Hct, calcium, magnesium; x-ray, echo as indicated
• Nursing: assess for distress, trauma, anomalies, hypoglycemia, hypocalcemia, polycythemia, jaundice; IV fluids with feeds if needed; may need gavage; NTE

XIV. Hyperbilirubinemia

• Jaundice in 60% to 70% of term and 80% of preterm infants in the first week; visible at serum bilirubin over 5 mg/dL; visual assessment is not reliable for diagnosis
• Unconjugated (indirect): fat-soluble, deposits in tissue and crosses the blood-brain barrier, cannot be excreted. Conjugated (direct): water-soluble, excreted
• Complication: acute bilirubin encephalopathy and KERNICTERUS (irreversible bilirubin deposits in the brain: deafness, motor delay, hypotonia, intellectual deficits)

Physiological jaundice (after 24 hours, first week) causes:

• More RBC mass; RBC life span 70 to 90 days (adult 120); bilirubin production 6 to 8 mg/kg/day
• Reabsorption of bilirubin from the gut (no gut bacteria, slow motility, beta-glucuronidase); low ligandin; low glucuronyl transferase
• Visible after 24 hours; peaks day 3 (term) or days 5 to 6 (preterm); spreads head to toe

Pathological jaundice:

• Conjugated hyperbilirubinemia is ALWAYS pathological: parenteral nutrition (most common in NICU), neonatal hepatitis, biliary atresia, bile duct stenosis, metabolic, endocrine, infection, drugs, shock, hypoxic liver injury
• Unconjugated causes: breastfeeding jaundice, breast milk jaundice, Rh and ABO incompatibility, G6PD deficiency, hemoglobinopathies, sequestered blood (bruising, cephalohematoma), polycythemia, metabolic and endocrine disorders, GI obstruction, infection
• Criteria in a term infant: jaundice in the first 24 hours; TSB rising more than 0.2 mg/dL per hour; jaundice lasting more than 2 weeks; TSB over the 95th percentile for age in hours; direct bilirubin 1.5 to 2 mg/dL or more

Risk factors: American Indian, East Asian or Mediterranean descent; ABO incompatibility (mother O, infant A or B); Rh incompatibility (mother negative, infant positive); breastfeeding; maternal diabetes; oxytocin or bupivacaine in labor; delayed cord clamping; hypoxia, acidosis, temperature instability; delayed or infrequent feeding; prematurity; excessive weight loss; bruising or cephalohematoma; G6PD deficiency; infection (TORCH); sibling with jaundice.

Table 17-2:

Medical management:

• AAP 2004 guidelines and the BHUTANI NOMOGRAM (TSB by age in hours plus neurotoxicity risks) set treatment thresholds; BiliTool online
• Tests: TSB fractionated into direct and indirect; DIRECT COOMBS (antibody-coated infant RBCs, can use cord blood) for Rh or ABO hemolytic disease; transcutaneous bilirubin (TcB) for screening; CBC; reticulocyte count (high = hemolysis)
• PHOTOTHERAPY: most widely used and effective; special blue fluorescent or blue LED lights (“intensive”); converts bilirubin to water-soluble isomers excreted in urine and stool without liver conjugation; fiber-optic “bili blanket” can be used at home, infant can be held and fed, no eye shields if used alone; double phototherapy more effective; TSB should fall 0.5 to 1 mg/dL per hour and 30% to 40% in 24 hours; continuous except for feeds and visits
• EXCHANGE TRANSFUSION if phototherapy fails or severe hemolysis: replaces about 85% of RBCs; lowers bilirubin up to 50%; removes antibody-coated cells and corrects anemia. RhoGAM and phototherapy have reduced the need
• IVIG for isoimmune hemolysis reduces exchange transfusions
• Discharged before 72 hours: follow-up within 1 to 2 days; recheck TSB within 24 hours after stopping phototherapy (rebound)

Clinical Judgment, phototherapy care:

• Assess jaundice by TcB and blanching; notify the provider; obtain TSB (rate of rise guides treatment)
• Feed every 2 to 3 hours (excretion and insensible losses)
• Lights 12 to 16 inches from the infant (2 inches above an incubator); irradiance at least 30 microwatts/cm2/nm with a photometer; Plexiglas cover
• DIAPER ONLY for maximum skin exposure
• EYE SHIELDS (retinal damage risk); remove every 4 hours to assess and during feedings; make sure they do not cover the nares
• Reposition frequently
• VS and temperature per protocol; I&O
• Side effects: eye discharge, LOOSE STOOLS, DEHYDRATION, HYPERTHERMIA, lethargy, skin rash
• Home teaching: hydration, stools, follow-up, home lights, signs of worsening jaundice

XV. Central Nervous System Injuries

Table 17-3, intracranial hemorrhages:

• Risk factors for CNS injury: prematurity, birth trauma, breech or malpresentation, precipitous or difficult labor, operative delivery, hypoxia, asphyxia, hypotension
• Workup: glucose, electrolytes, ABG, lactate, cultures, CBC, CT, ultrasound, MRI, LP, EEG; anticonvulsants
• Nursing: resuscitation, labs, VS, perfusion, I&O, neuro exam (tone, reflexes, behavior), assist with LP, family support

Critical Component, SUBGALEAL HEMORRHAGE (extracranial):

• Associated with VACUUM extraction; emissary vein rupture bleeds into the space between the epicranial aponeurosis and the periosteum; NO membrane to contain it, and the space can hold the infant’s ENTIRE blood volume (exsanguination, shock, death)
• Firm scalp mass that CROSSES suture lines; fluid wave; ears pushed forward; edema to the nape of the neck and around the eyes; lethargy, pallor, seizures, shock; rapidly falling Hct
• Assess HR, BP, HEAD CIRCUMFERENCE, consciousness, color, output, capillary refill; seizures; signs of shock and organ failure
• CBC, TSB, coags; central BP monitoring, blood products, vasopressors, vitamin K, phototherapy; recovery in 2 to 3 weeks if shock is survived

Critical Component, HYPOXIC-ISCHEMIC ENCEPHALOPATHY (HIE):

• Brain damage from low oxygen and poor perfusion after an acute event (abruption, cord prolapse, blood loss, uterine rupture, infection, arrest, shock)
• Primary neuronal death (necrosis) within 6 hours; secondary phase at 6 to 15 hours worsens injury
• Staged mild, moderate or severe by exam (consciousness, activity, posture, tone, reflexes, autonomic signs)
• THERAPEUTIC HYPOTHERMIA must start within 6 HOURS: core temperature cooled to 33.5 C with a cooling blanket (whole body) or cooling cap (head), then gradual rewarming after 72 HOURS. Reduces death and major disability in moderate to severe HIE in late preterm and term infants (Cochrane; AAP and ACOG recommend)
• Labs: CBC, blood culture, electrolytes, glucose, lactate, BUN, creatinine, coags, blood gases

XVI. Neonatal Infection and Sepsis

• Immature immunity; signs are subtle and nonspecific
• Sepsis: systemic illness with bacteremia in the first 28 days
  • Early onset: first 7 days (under 72 hours if under 1,500 g); usually vertical from the mother; higher mortality
  • Late onset: after 7 days (after 72 hours if under 1,500 g); lower mortality
  • Very late onset: after 3 months in preterm VLBW infants; linked to indwelling lines and tubes
• Transmission: vertical (transplacental: syphilis, CMV, Zika; ascending with prolonged ROM; intrapartum: herpes) or horizontal (nosocomial from equipment or staff)

Table 17-4 risk factors: maternal (poor nutrition, low SES, substance use, STI history, no prenatal care, PROM over 12 to 18 hours, GBS colonization, chorioamnionitis, intrapartum fever, preterm labor, UTI, invasive procedures, fetal scalp electrode, maternal or fetal tachycardia); neonatal (prematurity, under 2,500 g, difficult delivery, asphyxia, meconium, resuscitation, anomalies, Black, male, multiples); environmental (long stay, invasive procedures, humidified incubators or ventilators, routine broad-spectrum antibiotics).

Critical Component, congenital Zika: mosquito or sexual transmission, crosses the placenta; 5% to 10% of infected pregnancies have birth defects. Congenital Zika syndrome: severe MICROCEPHALY with partly collapsed skull, decreased brain tissue with calcifications, macular scarring, contractures (clubfoot), hypertonia. Test symptomatic pregnant women with travel exposure; routine testing of asymptomatic women not recommended.

Group B Streptococcus (GBS):

• Leading cause of neonatal sepsis and meningitis in the US; 20% to 30% of pregnant women are asymptomatic carriers
• Screen ALL pregnant women at 36 0/7 to 37 6/7 weeks (unless already indicated by GBS bacteriuria or a prior GBS-infected infant)
• Positive culture: intrapartum antibiotic prophylaxis, except planned cesarean before labor with intact membranes
• Unknown status: give prophylaxis if preterm labor, preterm PROM, ROM 18 hours or more at term, or intrapartum fever 100.4 F (38 C) or higher; reasonable to give if GBS-positive in a prior pregnancy
• IV PENICILLIN is the drug of choice; ampicillin acceptable; cefazolin if low-risk penicillin allergy
• Prophylaxis is ADEQUATE only if given more than 4 HOURS before delivery (but do not delay obstetric interventions for it)
• Early-onset GBS appears by 12 to 24 hours. Adequate prophylaxis: no routine antibiotics unless signs of sepsis. Infants at 35 weeks or more can be assessed with the Neonatal Early-Onset Sepsis Calculator or enhanced observation. Diagnosis by blood and CSF culture (CBC and CRP predict poorly)
• Late-onset GBS can occur even with negative screens or adequate prophylaxis
• Treatment: penicillin G preferred, ampicillin acceptable; septic-appearing infants get CBC with differential, blood cultures, chest x-ray if respiratory signs, then AMPICILLIN and GENTAMICIN right after cultures
• Healthy term infants whose mothers got 4 or more hours of prophylaxis may go home after 24 hours
• Evidence-based practice: the Kaiser sepsis calculator cut antibiotic use from 11% to 5% and blood cultures from 14.9% to 7.6%, but still requires enhanced nursing observation

COVID-19 (SARS-CoV-2):

• Droplet spread; incubation 2 to 14 days; vertical transmission rare; infected neonates usually have mild or no symptoms
• Test all infants of mothers with suspected or confirmed COVID-19 by RT-PCR at 24 hours (repeat at 48 hours if negative or unavailable; one test at 24 to 48 hours if discharged earlier)
• Positive mother is isolated from other mothers; rooming-in with a healthy term infant is acceptable (low risk; supports breastfeeding); mother masks and does hand hygiene; NEVER put a mask on a child under 2; separate if mother too ill or infant unstable; a negative test is not required for discharge; close follow-up

Signs of neonatal infection (Table 17-5):

• Respiratory: apnea, grunting, retractions, tachypnea, cyanosis
• Temperature: HYPOTHERMIA, fever, instability
• Cardiovascular: bradycardia, tachycardia, arrhythmias, hypo- or hypertension, pallor, poor perfusion
• Neuro: tremors, lethargy, irritability, high-pitched cry, hyper- or hypotonia, seizures, bulging fontanel
• GI: poor feeding, vomiting, diarrhea, distention, enlarged liver or spleen
• Skin: rash, pustules, vesicles, jaundice, petechiae
• Metabolic: glucose instability, metabolic acidosis

Labs suggesting infection: WBC over 20,000 or under 1,750; neutrophilia; NEUTROPENIA under 1,800 (strongly predictive); I/T ratio over 0.20 (“left shift”); platelets under 100,000. Definitive diagnosis only by positive BLOOD culture; also urine and CSF cultures; serial CRP (8 to 24 hours after birth and 24 hours later); PCR; procalcitonin.

Treatment: ampicillin plus an aminoglycoside (gentamicin) after cultures; stop after 36 to 48 hours if cultures negative; 10 to 14 days for confirmed sepsis, 21 days for meningitis; antivirals or antifungals as needed; dosing by weight, gestational and postnatal age, and liver and kidney function.

Nursing: review maternal history (GBS); VS, I&O, weight; watch for signs and notify the provider early; respiratory support; glucose and electrolytes; assist with LP (hold flexed and still); antibiotics on time; hand hygiene and isolation precautions; inform parents.

XVII. Neonatal Abstinence Syndrome (NAS) and Prenatal Substance Exposure

• Substance use in pregnancy (about 5% of pregnant women) raises stillbirth risk 2 to 3 times; tobacco and alcohol beyond the first trimester raise SIDS risk 12 times
• Research is confounded by unreliable self-report, urine tests that miss earlier use, polydrug use, and social, economic and racial factors
• NAS or neonatal opioid withdrawal syndrome (NOWS): CNS irritability, neurobehavioral disorganization, sympathetic activation. Substances include opioids, barbiturates, alcohol, amphetamines, cocaine, benzodiazepines, SSRIs, caffeine (Table 17-6)

Opioids (heroin, methadone, morphine, oxycodone, fentanyl):

• NOWS rose from 1.2 to 8.8 per 100 hospital births (2000 to 2016); higher in rural, tribal and Medicaid populations
• Withdrawal in 60% to 90% of exposed infants; usually within 24 to 72 hours but up to 2 WEEKS (especially METHADONE); may last up to 6 months
• Requires CHRONIC exposure (not just near delivery); severity affected by drug type, timing, maternal metabolism, and co-exposures (cigarettes, benzodiazepines, gabapentin)
• Associated with distress, growth restriction, low birth weight and head circumference; LESS RDS and hyperbilirubinemia

Cocaine: decreased placental flow, fetal hypoxemia, maternal hypertension; miscarriage, stillbirth, ABRUPTION, preterm labor, growth restriction; neonatal irritability, tremors, high-pitched cry, hyperreflexia, frantic fist sucking, feeding problems, sneezing, tachypnea, poor sleep; long-term growth, attention, language, motor and reasoning problems.

Alcohol: teratogen; miscarriage, preterm birth, SGA, stillbirth. FETAL ALCOHOL SPECTRUM DISORDER with heavy use (about 15 per 10,000 exposed births): irritability, tone changes, tremors, seizures; later low IQ, learning disability, speech delay, attention problems, hyperactivity, poor coordination; facial features: MICROCEPHALY, small eyes, SHORT PALPEBRAL FISSURES, poorly developed PHILTRUM, THIN UPPER LIP, hypoplastic maxilla.

Cannabis: low birth weight; possible effects on brain, reasoning, attention and school skills. Methamphetamine: anxiety, depression, attention and visual-motor problems. Nicotine: previa, abruption, PROM, preterm birth, LBW, oral clefts, SIDS (all household members should quit), lung function, obesity. SSRIs: possible anxiety, autism, language and executive function effects.

Critical Component, signs of neonatal withdrawal: apnea, diarrhea or loose stools, excessive and HIGH-PITCHED crying, excoriated skin, fever, hyperreflexia, hypertonia, increased rooting and FRANTIC sucking, irritability, tearing, nasal stuffiness, SNEEZING, poor uncoordinated feeding, seizures, mottling, poor sleep, sweating, tachypnea, TREMORS, vomiting, poor weight gain, YAWNING, hiccups.

Medical management:

• Interdisciplinary history (drugs, trauma, mental health, infection, family needs)
• Toxicology ASAP after birth: MECONIUM is optimal (detects use from about 20 weeks, misses abstinence near delivery); umbilical cord tissue is an alternative
• Rule out infection and hypoglycemia (similar signs)
• Scoring: FINNEGAN Neonatal Abstinence Scoring System (most common; every 3 to 4 hours; subjective) or EAT, SLEEP, CONSOLE (every 3 to 4 hours; can the infant feed 1 to 1.5 oz or breastfeed well, sleep 1 hour, be consoled within 10 to 20 minutes; fewer NICU admissions and drug treatment)
• Observe at least 72 hours, up to 7 days; ROOMING-IN with the mother reduces drug treatment and length of stay
• Drugs for severe withdrawal: MORPHINE first line; buprenorphine, methadone, clonidine, phenobarbital; benzodiazepines for alcohol withdrawal
• Small frequent HIGH-CALORIE feedings (22 to 24 cal/oz); daily weights
• Referrals; Child Protective Services per state law

Nursing actions:

• Review history; assess including gestational age, anomalies and withdrawal signs; toxicology (urine or meconium)
• Report abnormal Finnegan scores or unmet ESC criteria
• Daily weights; diaper-area skin care; small frequent upright feedings; slow-flow nipple for frantic sucking; gavage if needed
• Soothing environment: cuddlers, low light and noise, music, 1:2 staffing, swaddling, pacifier, breastfeeding, prone positioning (while monitored), rooming-in, warm swaddle baths, fewer stressful procedures, acupuncture
• Involve the mother in care; nonjudgmental support; early discharge teaching on behaviors and soothing, feeding, safe sleep, when to get help, maternal depression and relapse resources

Clinical Judgment, breastfeeding and substance use:

• Contraindicated with illicit drug use, polydrug use or HIV
• Methadone and buprenorphine enter milk in low amounts and breastfeeding may reduce NOWS: ENCOURAGED
• Sertraline and paroxetine transfer little; fluoxetine reaches high levels (discouraged)
• THC stays in milk up to 6 weeks; AAP and ACOG discourage marijuana while breastfeeding

XVIII. Congenital Anomalies

• 1 in 33 births; leading cause of infant death (20%); chromosomal or environmental (radiation, drugs, alcohol, diabetes, medications, TORCH)
• Nursing: depends on the defect; genetic screening before discharge; support; support groups; follow-up

Table 17-7 (selected):

• Esophageal atresia or tracheoesophageal fistula (1 in 1,000 to 2,500): surgical repair
• Diaphragmatic hernia (1 in 2,200 to 3,000): abdominal organs in the chest; gastric decompression, stabilization, surgery
• Omphalocele (2.5 in 10,000): abdominal contents through the UMBILICUS, COVERED by peritoneal sac; staged repair if large
• Gastroschisis (1 in 10,000): contents through a hole usually RIGHT of the umbilicus, NOT covered; surgery
• Cleft lip and palate (1 in 500 to 550): nasal and maxillary processes fail to fuse; surgery
• Spina bifida: meningocele (meninges and CSF) and myelomeningocele (meninges and nerve tissue); surgery
• Anencephaly (1 to 10 in 1,000): incomplete cranium and brain; 75% stillborn
• Developmental dysplasia of the hip (1 to 2 in 1,000): PAVLIK HARNESS (abduction and flexion); surgery if fails
• Polydactyly (2 in 1,000), syndactyly (1 in 2,200): surgery or ligation
• Talipes equinovarus (clubfoot, 1 in 1,000, usually bilateral): casting or splinting, surgery

Table 17-8, cardiac:

• VSD: most common CHD (37%); 90% of small defects close on their own; digoxin and diuretics for heart failure; surgery
• ASD (1 in 5,000): may close; treat heart failure; surgery
• Coarctation of the aorta (1 in 1,800): PROSTAGLANDIN E1 to keep the ductus open; treat heart failure; surgery
• Tetralogy of Fallot (1 in 5,000): VSD, overriding aorta, PULMONARY STENOSIS, RIGHT VENTRICULAR HYPERTROPHY; propranolol for cyanosis; PGE1 for severe forms until surgery
• Transposition of the great vessels (1 in 5,000): aorta from the right ventricle, pulmonary artery from the left; MEDICAL EMERGENCY; treat acidosis; PGE1 to keep the ductus open until surgery

Table 17-9, metabolic:

• PKU (1 in 10,000): cannot convert phenylalanine to tyrosine; untreated causes cognitive and physical problems; PHENYLALANINE-RESTRICTED diet
• Fatty acid oxidation disorders (MCAD): hypoglycemia, organ failure; treat hypoglycemia, avoid fasting
• Congenital adrenal hyperplasia: low cortisol, excess androgens, electrolyte imbalance; ambiguous genitalia in girls; steroids, surgery
• Maple syrup urine disease (1 in 200,000): cannot metabolize leucine, valine, isoleucine; fatal untreated; dialysis, low-protein diet
• Galactosemia (1 in 60,000): cannot convert galactose to glucose; liver disease, intellectual disability, cataracts; LACTOSE-FREE or soy formula (no breastfeeding)

XIX. Regional Transport and Discharge Planning

Transport: stabilize first; skilled team; maintain temperature, respiratory support and IV therapy; monitor VS, SpO2, glucose, pain; developmental care (eye and ear protection, gel mattress, positioning).

Discharge:

• Planning starts at NICU admission; parents involved from the start; interdisciplinary team
• Criteria: stable (weight gain, temperature stability, tolerating feeds, stable breathing); eye, genetic and metabolic, CCHD and hearing screens done
• CAR SEAT CHALLENGE for all infants born before 37 weeks: in their own car seat for at least 90 to 120 minutes (or the trip length if longer) maintaining oxygenation, HR and RR
• Family readiness, resources and home safety
• Teaching: routine care; car seat, back to sleep, infant CPR, babyproofing, shaken baby prevention; equipment (apnea monitor, oxygen, suction); medications; illness signs; growth and development; follow-up and immunizations; support groups

XX. Psychosocial Needs and Grief

Parents of NICU infants: grieve the ideal baby; going home without the baby is devastating; delayed attachment (risk of abuse and neglect), maternal guilt, emotional distancing for fear of death, anger, disappointment, disrupted family life.

Nursing: orient to the NICU and equipment; build trust and ask how they are coping; clear updates; invite questions and calls; involve in care; encourage touch and holding; pumping and milk storage; private space to breastfeed; photos; praise; support groups.

When an infant dies:

• Grief signs: sadness, despair, denial, numbness, shock, disbelief, anger, fatigue, sleep problems; individual and shaped by culture and religion
• Be present and listen; express sympathy and AVOID trite phrases (“you can have another baby”); use the baby’s NAME; explain grief; time with the baby before and after death; MEMENTOS (photos, blanket, hat, lock of hair, ID band, footprints, crib card); chaplain or own clergy, baptism or rites; discuss autopsy, services, burial or cremation; accept help; community resources

High-Yield Numbers

• Preterm under 37 weeks; extremely under 28; very 28 to 31 6/7; late 34 to 36 6/7
• ELBW under 1,000 g; VLBW 1,000 to 1,499; LBW 1,500 to 2,500
• Antenatal steroids if delivery expected within 7 days
• Suck-swallow-breathe coordination at about 34 weeks
• Apnea at least 20 seconds (or shorter with color change or HR under 100)
• Surfactant production from 24 to 28 weeks; L/S over 2:1 mature (3:1 if diabetic); PG present = mature
• Prophylactic surfactant within 15 minutes; rescue within 6 hours if FiO2 over 40%
• PaO2 60 to 70, PaCO2 35 to 45
• BPD: oxygen beyond 28 days
• PDA: fluids under 130 mL/kg/day
• IVH: 90% within 72 hours
• NEC: days 3 to 10; fatal in 20% to 30%
• ROP screen: under 30 weeks or under 1,500 g, at 4 to 6 weeks
• Post-term 42 weeks or more; polycythemia Hct over 65%
• MSAF 8% to 20%; MAS in 5% of those
• PPHN: preductal minus postductal PaO2 15 mm Hg or more, SpO2 5% or more
• SGA under 10th percentile; LGA over 90th; macrosomia over 4,000 g
• Hypocalcemia under 7.5 mg/dL; IDM hypoglycemia up to 40%; 40% dextrose gel
• Jaundice visible over 5 mg/dL; RBC life span 70 to 90 days; physiological peak day 3 (term), 5 to 6 (preterm)
• Pathological: first 24 hours, rise over 0.2 mg/dL/hr, over 2 weeks, over 95th percentile, direct 1.5 to 2
• Phototherapy lights 12 to 16 inches; 30 microwatts/cm2/nm; TSB falls 0.5 to 1 mg/dL/hr
• Exchange transfusion replaces 85% of RBCs
• Hypothermia for HIE: start within 6 hours, 33.5 C, rewarm after 72 hours
• Early-onset sepsis under 7 days (72 hours if under 1,500 g)
• GBS screen 36 0/7 to 37 6/7 weeks; prophylaxis adequate if over 4 hours; ROM 18 hours or more
• WBC over 20,000 or under 1,750; I/T over 0.20; platelets under 100,000
• Antibiotics stop at 36 to 48 hours if cultures negative; 10 to 14 days sepsis, 21 days meningitis
• NOWS onset 24 to 72 hours (up to 2 weeks with methadone); observe 72 hours to 7 days; formula 22 to 24 cal/oz
• Car seat challenge 90 to 120 minutes

Priority Nursing Actions and Red Flags

• Grunting, flaring, retractions, cyanosis, RR over 60: respiratory distress
• Preterm under 32 weeks: plastic wrap at birth
• Never give rapid volume or rapid bicarbonate to preterm infants (IVH); keep head midline and hips below head
• Feeding intolerance (distention, residuals, bilious emesis, bloody stools): hold feeds, suspect NEC
• Bounding pulses and wide pulse pressure in a preterm: PDA
• Expanding boggy scalp swelling crossing sutures after vacuum with falling Hct: subgaleal hemorrhage, a hemorrhage emergency (watch head circumference)
• Jaundice in the first 24 hours: pathological; check Coombs, TSB
• Phototherapy: eye shields, diaper only, hydration, temperature
• Septic newborns are often HYPOTHERMIC; get cultures, then ampicillin and gentamicin promptly
• Transposition of the great vessels: emergency; prostaglandin E1 keeps the ductus open
• Withdrawal: high-pitched cry, tremors, frantic sucking, sneezing, yawning; low stimulation, swaddle, small frequent feeds; methadone and buprenorphine are compatible with breastfeeding
• Galactosemia: no breast milk or regular formula
• When an infant dies: use the name, offer mementos and time with the baby

Medications

Related

• nsg210-durham-ch15-neonate-and-family
• nsg210-durham-ch16-newborn-nutrition
• nsg210-durham-ch14-high-risk-postpartum
• nsg210-exam-2-outline-durham-ch07 (preterm labor, diabetes in pregnancy, GBS)
• INDEX