Antiseptic skin and cord care; Skin and cord should be cleansed with warm water or non-medicated soap solution and rinsed with water. To reduce colonization with Staphylococcus aureus and other pathogenic bacteria, the umbilical cord may be treated daily with triple dye or bacitracin followed by twice-daily alcohol swabbing until the cord falls off.
Alternatively, chlorhexidine washing or, on rare occasion during S Alternatively, chlorhexidine washing or, on rare occasion during S. aureus epidemics, a single hexachlorophene bath may be used. Routine or repeated total body exposure to hexachlorophene may be neurotoxic, particularly in low-birth weight infants. Nursery personnel should use chlorhexidine for routine hand-washing. Hand-to-elbow washing for 2 min in the initial wash and 15-30 sec in subsequent washes is essential for staff and visitors.
Other measures; The eyes of all infants must be protected against gonococcal infection by 1% silver nitrate drops (the best-proven therapy). Erythromycin (0.5%) or tetracycline (1.0%) sterile ophthalmic ointments are alternative measures that add coverage against chlamydia.
Hemorrhage in newborn can be due to factors other than vitamin K deficiency, an intramuscular injection of 0.5-1mg of water-soluble vitamin K1 is recommended for all infants immediately after birth to prevent hemorrhagic disease of the newborn. Larger intravenous doses predispose to the development of hyperbilirubinemia and kernicterus and should be avoided.
Neonatal screening is available for various genetic, metabolic, hematologic, and endocrine diseases. Specific tests vary according to the country. Laboratory tests performed on infant heel puncture blood samples include those for hypothyroidism, phenylketonuria, galactosemia, maple syrup urine disease, homocystinuria, adrenal hyperplasia, hemoglobinopathy, cystic fibrosis, tyrosinemia, and other organic acid defects.
Hearing; Hearing impairment affects speech and language development, may be severe in 2/1.000 and overall affects 5/1.000 births.
Universal screening of infants is recommended to ensure early detection of hearing loss and intervention. Universal screening pulse oximetry detects ductal cyanotic congenital heart diseases. Universal screening for hyperbilirubinemia by serum or transcutaneous bilirubin levels. Universal screening for congenital hip dysplasia by Ortolani and Barlow tests. No routine ultrasonography indicated.
Parent-Infant bonding; normal infant development depends on bonding between mother and her newborn infant psychologically and physiologically. This bonding is reinforced by the emotional support of a loving family.
The quiet alert state of the infant provides the opportunity of eye to eye contact which is important in stimulating the loving feelings of parents to their babies. Successful breast-feeding; includes immediate postpartum mother-infant contact with suckling, rooming-in, demand feeding, and support from experienced women. Nursing at least 5 min at each breast is reasonable. Nursing episodes should then be extended according to the comfort and desire of the mother and infant.
Drugs contraindicating breast feeding; Maternal sedatives may result in sedation of the infant. Antimetabolites, immunosuppressants, methimazole (antithyroid), amphetamines, iodides and radiopharmaceuticals are contraindicated.
Medical contraindications of breast-feeding; in the United States include infection with HIV (in developed countries), human T-cell leukemia virus types 1 and 2, cytomegalovirus, active tuberculosis (until treated and not considered contagious), and hepatitis B virus (until an infant receives hepatitis B immune globulin and vaccine).
Prematurity: is live born infant delivered before 37 wk from the 1st day of the last menstrual period. Low birth weight (LBW): (birth weight <2500g) is due to either prematurity, poor intrauterine growth (IUGR, SGA), or both. Prematurity and IUGR are associated with increased neonatal morbidity and mortality more than gestational age-matched infants.
Very Low birth weight (VLBW): infants weigh <1,500g, and are predominantly prematures. Their survival is directly related to birth weight. VLBW infants have a higher incidence of re-hospitalization during the 1st yr of life, for sequelae of prematurity, including; infections, neurologic complications, and psychosocial disorders.
Factors Related to Premature Birth and Low Birth weight: A strong positive correlation exists between preterm birth, IUGR and low socioeconomic status. Families of low socio-economic status have higher rates of;
maternal under nutrition, anemia, illness, inadequate prenatal care, drug misuse, obstetric complications, and maternal histories of abortions, stillbirths, premature or LBW infants. Other associated factors include single-parent families, teenage pregnancies, short inter-pregnancy interval, maternal smoking.
Premature birth (weight appropriate for gestational age) is associated with; inability of the uterus to retain the fetus, premature rupture of the membranes, premature separation of the placenta. The etiology of preterm birth is multifactorial and involves a complex interaction between fetal, placenta, uterine, and maternal factors. Identifiable Causes of Preterm Birth include;
Dysmature Hydrops fetalis IUGR is associated with; medical conditions that interfere with the circulation and efficiency of the placenta, with the development or growth of the fetus, or with the general health and nutrition of the mother.
Twin transfusion syndrome Infant with intrauterine growth retardation as a result of placental insufficiency
Spectrum of disease in low-birth weight premature infants; prematurity increases the severity but reduces the distinctiveness of the clinical manifestations of most neonatal diseases. Among VLBW infants (predominantly premature), morbidity is inversely related to birth weight.
Problems of LBW premature infants; 1Respiratory distress syndrome, 2pulmonary hemorrhage, 3aspiration syndrome, 4pneumothorax, 5apnea, 6hypoglycemia, 7hypocalcemia, 8hyperbilirubinemia, 9anemia, 10hypothermia, 11feeding problems, 12bacterial sepsis, 13necrotizing enterocolitis and 14DIC.
Causes of death in LBW premature infants; Morbidity is inversely related to birth weight. These include; respiratory distress syndrome, intraventricular hemorrhage (IVH), sepsis, asphyxia, birth injuries, and congenital malformations.
Problems associated with IUGR LBW infants; 1Perinatal asphyxia (↓placental perfusion during labor, chronic fetal hypoxia–acidosis; meconium aspiration syndrome), 2hypoglycemia, 3polycythemia-hyperviscosity, 4hypothermia, 5pulmonary hemorrhage, 6meconium aspiration, 7necrotizing enterocolitis and 8illnesses related to congenital anomalies and syndromes. Causes of death in term infants; asphyxia, infection, anomalies and aspiration pneumonia.
Complications of prematurity as classified by systems; Respiratory; Respiratory distress syndrome, Broncho-pulrnonary dysplasia, Pneumothorax, pneumomediastinum, Pulmonary hypoplasia, Pulmonary hemorrhage and apnea. Cardiovascular; Patent ductus arteriosus, Hypotension, Hypertension, Bradycardia Hematologic; Anemia (early or late onset), disseminated intravascular coagulopathy, Vitamin K deficiency.
Gastrointestinal; Poor function and motility, necrotizing enterotolitis, hyperbilirubinemia(direct, indirect), spontaneous gastrointestinal isolated perforation. Metabolic-Endocrine; Hypocalcemia, Hypoglycemia, Hyperglycemia, Late metabolic acidosis, Hypothermia.
Central Nervous System; lntraventricular hemorrhage, Periventricular leukomalacia, Seizures, Retinopathy of prematurity, Deafness, Hypotonia, and Kernicterus. Renal; Hyponatremia, Hypernatremia, Hyperkalemia, Renal tubular acidosis, Renal glycosuria, Edema, Infections; congenital, perinatal, nosocomial (bacterial, viral, fungal, protozoal)
Apnea; Apnea is defined as the cessation of airflow Apnea; Apnea is defined as the cessation of airflow. Apnea is pathologic if cessation of breathing is for longer than 20 seconds or for any duration if accompanied by cyanosis and bradycardia. Periodic breathing (Cheyne-Stokes rhythm) must be distinguished from prolonged apneic pauses, because the latter may be associated with serious illnesses.
Causes of pathologic apnea include; 1Central nervous system depression, 2Respiratory infections and obstructions, 3Infections like sepsis or meningitis, 4Metabolic causes (↓ Glucose, ↓ calcium, ↓/↑ sodium, ↑ ammonia, ↑ organic acids, ↑ ambient temperature, hypothermia), 5Cardiovascular like hypotension, and 6Immaturity of respiratory center.
Cyanosis at birth; 1. Central or peripheral nervous system related hypoventilation; Intracranial hypertension, hemorrhage, over sedation, diaphragm palsy, seizures. 2. Respiratory causes; 1Airway; Choanal atresia/stenosis, laryngeal/tracheal stenosis, vascular compression. 2Lung; Respiratory distress syndrome, Transient tachypnea, Meconium aspiration, Pneumonia (sepsis), Pneumothorax, Congenital diaphragmatic hernia.
3. Cardiac (Rt Lt shunt) 1Abnormal connections (normal or increased pulmonary blood flow): Transposition of great vessels, Anomalous pulmonary venous return, Truncus arteriosus, Hypoplastic left heart syndrome, Single ventricle or tricuspid atresia. 2Obstructed pulmonary blood flow: Pulmonary atresia with intact ventricular septum, tetralogy of Fallot, critical pulmonic stenosis, tricuspid atresia, persistent pulmonary hypertension. 4. Methemoglobinemia 5. Others: Hypoglycemia, polycythemia, blood loss.
Retinopathy of prematurity (ROP): This retinal vasculopathy occurs almost exclusively in preterm infants; it is retinal vaso-proliferation, scarring, and potentially blinding retinal detachment. Etiology; Prematurity is the risk factor. Hyperoxia is a major factor, but other problems, such as respiratory distress, apnea, bradycardia, infection, hypoxia are contributory factors. Generally, the lower the birth weight and the sicker the infant, the greater the risk for ROP. Use of supplemental vitamin E as antioxidant has no proven efficacy.
No safe level of oxygen has yet been determined but each infant must be treated with whatever is necessary to sustain life and neurologic function. Ophthalmologic examination for ROP of infants (less than 1,500 g at birth and those born before 28 wk) at risk is recommended and performed at 4-6 wk of life. Treatment; in selected cases is cryotherapy or laser photocoagulation.
Retinopathy of prematurity; Retinal vessels are dilated and tortuous
Nursery care of premature; At birth, measures to clear the airway, initiate breathing, care for the umbilical cord and eyes, and administer vitamin K are the same as for normal weight and maturity infants. Additional considerations; 1- Thermal Control. the insulating layer of subcutaneous fat is thinner in low-birth weight infants than term infants. The survival rate of LBW and sick infants is higher when they are cared for near their neutral thermal environment.
Incubators or radiant warmers can be used to maintain body temperature Incubators or radiant warmers can be used to maintain body temperature. The optimal environmental temperature for minimal heat loss and minimal oxygen consumption for an unclothed infant is one that maintains the infant's core temperature at 36.5-37.0oC. Incubators setting temperature depends on an infant's size and maturity; the smaller and more immature the infant, the higher the environmental temperature required.
2- Administering oxygen 2- Administering oxygen. to reduce the risk of injury from hypoxia and circulatory insufficiency must be balanced against the risk of hyperoxia to the eyes (retinopathy of prematurity and bronchopulmonary dysplasia) and oxygen injury to the lungs. Oxygen is administered via a head hood, nasal cannula, continuous positive airway pressure apparatus, or endotracheal tube. The concentration of inspired oxygen is adjusted in accordance with the oxygen tension of arterial blood (PaO2) or noninvasive methods such as continuous pulse oximetry.
3- Prevention of Infection 3- Prevention of Infection. Premature infants have an increased susceptibility to infection. Prevention includes; hand-washing, avoiding crowding, meticulous skin care, and surveillance of nosocomial infection. Routine immunizations should be given on the regular schedule at standard doses.
Resuscitator Incubator