8. Selected Newborn Complications



Selected Newborn Complications


Birth Trauma


Birth trauma (injury) is physical injury sustained by a neonate during labor and birth. In theory, some birth injuries are avoidable. Fetal ultrasonography for antepartum diagnosis and elective cesarean birth can aid in preventing significant birth injury. The prompt reporting of signs that indicate deviations from normal permits early initiation of appropriate therapy.


Soft-Tissue Injuries


See Table 8-1 for a description of soft-tissue injuries, their causes, and treatment.



Skeletal Injuries



ent Two types of skull fractures in the newborn are linear fractures and depressed fractures.


ent If an artery is torn as a result of the fracture, increased intracranial pressure (ICP) will follow. Unless a blood vessel is involved, linear fractures, which account for 70% of all fractures for this age-group, heal without special treatment.


ent Depressed fractures (or ping-pong ball indentations) can resolve without treatment or can be elevated by using a hand breast pump or vacuum extractor.


ent The clavicle is the bone most often fractured during birth. Generally the break is in the middle third of the bone.


ent Risk factors in clavicular fracture are dystocia, particularly shoulder impaction, vacuum-assisted birth, and birth weight greater than 4000 g. Limitation of motion of the arm, crepitus over the bone, and the absence of the Moro reflex on the affected side are diagnostic.


ent Except for use of gentle rather than vigorous handling, no accepted treatment for fractured clavicle in the newborn exists, and the prognosis is good. The figure-eight bandage should not be used for the newborn.


ent The humerus and femur can be fractured during a difficult birth. Fractures in newborns generally heal rapidly. Immobilization is accomplished with slings, splints, swaddling, and other immobilization devices.


Management



Peripheral Nervous System Injuries



ent Erb-Duchenne palsy or brachial plexus injury (brachial paralysis) of the upper portion of the arm results from a stretching or pulling of the head away from the shoulder during a difficult birth.


ent The arm hangs limp alongside the body. The shoulder and arm are adducted and internally rotated. The elbow is extended, and the forearm is pronated, with the wrist and fingers flexed; a grasp reflex can be present because finger and wrist movement remains normal.


ent Treatment is by intermittent immobilization across the upper abdomen, proper positioning, and range of motion (ROM) exercises starting about the tenth day to prevent additional injury to the brachial plexus. Immobilization can be accomplished with a brace or splint or by pinning the infant’s sleeve to his or her shirt.


ent Damage to the lower plexus, Klumpke palsy, is less common and results from severe stretching of the upper extremity while the trunk is relatively less mobile.


ent The wrist and hand are flaccid, the grasp reflex is absent, deep tendon reflexes are present, and dependent edema and cyanosis can be apparent (in the affected hand).


ent Treatment consists of placing the hand in a neutral position, padding the fist, and gently exercising the wrist and fingers.


ent In a third and more severe form of brachial palsy, the entire arm is paralyzed and hangs limp and motionless at the side.


ent The Moro reflex is absent on the affected side for all forms of brachial palsy.


ent Parents are taught to position and immobilize the arm or wrist or both. They can gently massage and manipulate the muscles to prevent contractures while the arm is healing. If edema or hemorrhage is responsible for the paralysis, the prognosis is good, and recovery can be expected in a few weeks.


ent Dress the infant beginning with the affected arm, and undress beginning with the unaffected arm to prevent unnecessary manipulation and stress on the paralyzed muscles.


ent Teach parents to use the “football” (under the arm or clutch) position when holding the infant and to avoid picking the child up from under the axillae or by pulling on the arms.


ent Full recovery is expected in 88% to 92% of infants. Complete recovery from stretched nerves usually takes 3 to 6 months.


ent Facial paralysis (palsy) generally is caused by pressure on the facial nerve during birth. Risk factors include a prolonged second stage of labor and forceps-assisted birth. The face on the affected side is flattened and unresponsive to the grimace that accompanies crying or stimulation, the eye remains open on the affected side, and the forehead will not wrinkle. The infant’s face appears distorted, especially when crying. Often the condition is transitory, resolving within hours or days of birth. Permanent paralysis is rare.


ent Treatment involves assistance with feeding, prevention of damage to the cornea of the open eye with the application of artificial tears or taping the eye closed, and supportive care of the parents.


Central Nervous System Injuries


All types of intracranial hemorrhage (ICH) occur in newborns. ICH as a result of birth trauma is more likely to occur in the full-term, large infant. Risk factors for ICH include primiparity, advanced maternal age, vacuum- or forceps-assisted birth, precipitous or prolonged second stage of labor, and increased fetal size.


Subdural Hematoma


A subdural hematoma (hemorrhage) is most often produced by the stretching and tearing of the large veins in the tentorium of the cerebellum, the dural membrane that separates the cerebrum from the cerebellum.



Subarachnoid Hemorrhage


Subarachnoid hemorrhage, the most common type of ICH, occurs in term infants as a result of trauma and in preterm infants as a result of hypoxia. Small hemorrhages are the most common. Bleeding is of venous origin, and underlying contusion also can occur.



Management


Neonatal Infections


Sepsis


Sepsis is the presence of microorganisms or their toxins in the blood or other tissues and continues to be one of the most significant causes of neonatal morbidity and mortality.



ent Table 8-2 outlines risk factors for neonatal sepsis. Special precautions for preventing infection, as well as prompt recognition when it occurs, are necessary for optimum newborn care. Neonatal infections can be health care–associated or acquired in utero or during birth or resuscitation. Table 8-3 outlines the clinical signs associated with neonatal sepsis.




TABLE 8-3


Signs of Sepsis


















































































System Signs
Respiratory Apnea, bradycardia
  Tachypnea
  Grunting, nasal flaring
  Retractions
  Decreased oxygen saturation
  Acidosis
Cardiovascular Decreased cardiac output
  Tachycardia
  Hypotension
  Decreased perfusion
Central nervous Temperature instability
  Lethargy
  Hypotonia
  Irritability, seizures
Gastrointestinal Feeding intolerance
  Abdominal distention
  Vomiting, diarrhea
Integumentary Jaundice
  Pallor
  Petechiae
Metabolic Hypoglycemia
  Hyperglycemia
  Metabolic acidosis
Hematologic Thrombocytopenia
  Neutropenia

Source: Edwards, M. (2006). Postnatal bacterial infections. In R. Martin, A. Fanaroff, & M. Walsh (Eds.), Fanaroff and Martin’s neonatal-perinatal medicine: Diseases of the fetus and infant (8th ed.). Philadelphia: Mosby.


Early-Onset or Congenital Sepsis


Early-onset or congenital sepsis usually manifests within 24 to 72 hours after birth, progresses more rapidly than later-onset infection, and has a mortality rate ranging between 3% and 50%.



Late-Onset Infection


Late-onset sepsis occurs at 7 to 30 days of age and can include maternally derived infection or health care–associated infection.



Septicemia


Septicemia refers to a generalized infection in the bloodstream.


Other Infections



Management


Viral Infections


Viral infections can cause intrauterine infection, congenital malformations, and acute neonatal disease. These pathogens also can cause chronic infection. It is important to recognize and treat the acute infection to prevent health care–associated infections in other infants and to anticipate effects on the infant’s subsequent growth and development.


Fungal Infections


Fungal infections are of greatest concern in the immunocompromised or premature infant. Occasionally fungal infections such as thrush are found in otherwise healthy term infants.


Candidiasis

Candida albicans can cause disease in any organ system. It is a yeastlike fungus that can be acquired from a maternal vaginal infection during birth, by person-to-person transmission, or from contaminated hands, bottles, nipples, or other articles. It usually is a benign disorder in the neonate, often confined to the oral and diaper regions



ent Candidal diaper dermatitis appears on the perianal area, inguinal folds, and lower portion of the abdomen. The affected area is intensely erythematous, with a sharply demarcated, scalloped edge, frequently with numerous satellite lesions that extend beyond the larger lesion. The source of the infection is through the gastrointestinal tract.


ent Treatment is with applications of an antifungal ointment, such as nystatin (Mycostatin) or miconazole 2% (Monistat), with each diaper change. The infant also can be given an oral antifungal preparation to eliminate any gastrointestinal source of infection.


ent Oral candidiasis (thrush, or mycotic stomatitis) is characterized by the appearance of white plaques on the oral mucosa, gums, and tongue. The white patches are easily differentiated from milk curds; the patches cannot be removed and tend to bleed when touched. In most cases, the infant does not seem to be in discomfort from the infection. A few infants seem to have some difficulty swallowing.


ent Topical application of 1 ml nystatin over the surfaces of the oral cavity four times a day, or every 6 hours, is usually sufficient to prevent spread of the disease or prolongation of its course. To prevent relapse, therapy should be continued for at least 2 days after the lesions disappear. Gentian violet solution can be used in long-term cases of oral thrush (gentian violet permanently stains clothing or other material).


ent Infants who are breastfed can acquire thrush from the mother; in the event that the mother is colonized, treatment for mother and infant is recommended. There is no need to stop breastfeeding even if the mother is receiving systemic antifungal medications.


ent Scrupulous cleanliness (by nursing personnel, parents, and others) must be maintained. Good hand hygiene is imperative.


Transplacental Infections


The occurrence of certain maternal infections during early pregnancy is known to be associated with various congenital malformations and disorders. The most common and best understood infections are traditionally represented by the acronym TORCH.



Additional organisms known to cause congenital infection include enteroviruses and parvovirus, leading some clinicians to suggest the need for a new, more comprehensive acronym.


Toxoplasmosis


Toxoplasmosis is a multisystem disease caused by the protozoan Toxoplasma gondii commonly found in cats, dogs, pigs, sheep, and cattle, with cats being the most common host. In the United States risk factors for acquisition of toxoplasmosis include exposure to contaminated soil and consumption of raw or undercooked meats or seafood (oysters, clams, or mussels). The transplacental transmission rate increases as pregnancy progresses: 15% in the first trimester, 30% in the second trimester, and 60% in the third trimester.



Gonorrhea


Gonorrhea is caused by Neisseria gonorrhoeae. The incidence of gonococcal infection in pregnant women ranges from 2.5% to 7.3%.



ent After rupture of membranes, ascending infection can result in orogastric contamination of the fetus. The organism can also invade mucosal surfaces, such as the conjunctiva (ophthalmia neonatorum), rectal mucosa, and pharynx. Neonatal gonococcal arthritis, septicemia, meningitis, vaginitis, and scalp abscesses can also develop.


ent Eye prophylaxis (e.g., with 0.5% erythromycin ointment) is administered within the first hour after birth to prevent ophthalmia neonatorum. Eye prophylaxis alone does not prevent systemic infection; therefore, infants with a gonococcal eye infection should receive one dose of ceftriaxone. Infants with systemic gonococcal infection require hospitalization and 7 days of IV antibiotic therapy. Rarely, infants die of overwhelming infection in the early neonatal period.


Syphilis


Syphilis is caused by the spirochete Treponema pallidum. If syphilis during pregnancy is untreated, 40% to 50% of neonates born to these women will have symptomatic congenital syphilis. If maternal infection is treated adequately before the eighteenth week, neonates seldom demonstrate signs of the disease. Treatment failure can occur, particularly when treatment is given in the third trimester; therefore, infants born to women treated within 4 weeks of birth should be evaluated for congenital syphilis.



ent Early congenital syphilis can result in prematurity, hydrops fetalis, and failure to thrive. Hepatosplenomegaly and jaundice are common. Hematologic findings include anemia, leukocytosis, and thrombocytopenia. Characteristic bony lesions occur in the long bones, the cranium, and the spine and include osteochondritis, osteomyelitis, and periostitis. Other findings include snuffles, mucocutaneous lesions, edema, and a copper-colored maculopapular dermal rash on the palms, the soles, and in the perioral, perinasal, and the diaper region (Fig. 8-1). The maculopapular lesions can become vesicular and confluent and extend over the trunk and extremities. Poor feeding, slight hyperthermia, and snuffles can be nonspecific signs.


ent If the mother was adequately treated before giving birth and serologic testing of the infant does not show syphilis, generally the infant is not treated with antibiotics. The infant is checked for antibody titer (received from the mother through the placenta) every 2 weeks for 3 months, at which time the test result should be negative. Some physicians recommend antibiotic therapy for asymptomatic or inconclusive cases.


ent Treatment should be carried out in the following situations: when the diagnosis of congenital syphilis is confirmed or suspected, when maternal treatment status is unknown, when the mother is treated within 4 weeks of giving birth or does not respond to treatment, when medications other than penicillin are used to treat the mother, and when inadequate neonatal follow-up is anticipated.



Varicella Zoster


The varicella-zoster virus, responsible for chickenpox and shingles, is a member of the herpes family. Approximately 90% of women in their childbearing years are immune; therefore, the risk of infection in pregnancy is low.



ent When transmission to the fetus occurs in the early part of pregnancy (relatively infrequently, about 2%), the effects on the fetus include limb atrophy, neurologic abnormalities (hydrocephalus or microcephaly), and eye abnormalities. When maternal infection occurs in the last 3 weeks of pregnancy, 25% of infants born to these mothers will develop clinical varicella. The severity of the infant’s illness increases greatly if maternal infection occurred within 5 days before or 2 days after birth. The mortality in severe illness is 30%.


ent Infants born to mothers who develop chickenpox between 5 days before birth and 48 hours after birth should be given varicella-zoster immune globulin (VZIG) at birth because of the risk of severe disease. Acyclovir can be used to treat infants with generalized involvement and pneumonia.


ent Term infants exposed to chickenpox after birth have a mild or no infection if they are born to immune mothers. In those born to nonimmune mothers, chickenpox can develop but the course is not usually severe. Experts are divided as to whether this group of infants should receive VZIG. Infants younger than 28 weeks are at risk regardless of their mother’s status and probably benefit from VZIG if exposed to chickenpox.


Hepatitis B Virus


Transmission of hepatitis B virus (HBV) occurs transplacentally, serum to serum, and by contact with contaminated urine, feces, saliva, semen, or vaginal secretions during birth. The transmission rate of HBV to the newborn is high when the mother is seropositive for both hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg). Diagnosis is made by viral culture of amniotic fluid as well as the presence of HBsAg and immunoglobulin M (IgM) in the cord blood or newborn’s serum.



ent There is no association between infection during pregnancy and an increase in malformations, stillbirths, or intrauterine growth restriction (IUGR); however, there is a significant risk for preterm birth. Infants can be symptom free at birth or show evidence of acute hepatitis with changes in liver function. The mortality for full-blown hepatitis is 75%. Infants who become carriers are at high risk for chronic hepatitis, cirrhosis of the liver, or liver cancer even years later.


ent Infants whose mothers have antibodies for HBsAg or who have developed hepatitis during pregnancy or the postpartum period should be treated with hepatitis B immunoglobulin (HBIG), 0.5 ml intramuscularly, as soon as possible after birth or within the first 12 hours of life. Hepatitis B vaccine should also be given concurrently but at a different site.


ent The second dose of vaccine is given at 1 month and the third dose at 6 months of age. After the infant has been cleansed thoroughly and has received the vaccine, breastfeeding can be initiated.


ent Vaccination for infants not exposed to maternal HBV is recommended before discharge from the hospital; breastfeeding for these infants can begin before the vaccine is given.


Human Immunodeficiency Virus (Type 1)


Transmission of HIV from the mother to the infant can occur transplacentally at various gestational ages. The majority of cases of pediatric acquired immunodeficiency syndrome (AIDS) (90% or more) result from maternal-to-fetal transmission.



ent With antepartum, intrapartum, and neonatal zidovudine (ZDV) treatment the incidence of neonatal HIV infection is decreased to 5% to 8%, and compliance with highly active antiretroviral therapy (HAART) is said to further reduce newborn infection rates to 1% to 2%.


ent Postpartum transmission can occur, with an additional risk of 14% attributed to breast milk contact. Diagnosis of HIV infection in the neonate is complicated by the presence of maternal immunoglobulin G (IgG) antibodies, which cross the placenta after 32 weeks of gestation.


ent The most accurate test for newborns and infants younger than 18 months is the HIV-1 DNA polymerase chain reaction (PCR) assay, which is performed on neonatal blood, not cord blood.


ent Typically the HIV-infected neonate is asymptomatic at birth. Early-onset illness (i.e., virus detected within 48 hours of birth) is attributed to prenatal infection and occurs in 10% to 15% of infected infants. These infants develop opportunistic infections (Candida and Pneumocystis jiroveci pneumonia) and rapid progression of immunodeficiency, which progresses to death in the first 1 to 2 years of life. The presenting signs and symptoms of HIV infection vary from severe immunodeficiency to nonspecific findings such as growth failure, parotitis, and recurrent or persistent upper respiratory tract infections.


ent Universal counseling and screening of pregnant women are recommended in the United States and Canada.


ent Standard Precautions are used to protect the infant from further exposure to maternal blood and body fluids.


ent In the United States, breastfeeding by the HIV-positive mother is contraindicated. However, in developing countries, the risks versus benefits in relation to number of infant deaths attributed to poor sanitary conditions and availability of an appropriate food supply for infants are considered. The World Health Organization recommends that HIV-positive mothers who are taking antiretroviral medications should breastfeed for at least 12 months.


ent Children who are HIV positive can be treated with a combination of three antiretroviral drugs: two nucleoside reverse transcriptase inhibitors, such as zidovudine and stavudine, plus either a protease inhibitor such as nelfinavir, lopinavir, or saquinavir, or a nonnucleoside reverse transcriptase such as nevirapine.


ent If the infant is diagnosed with HIV infection, the family should be counseled about conventional and investigational treatment options, the care of the mother herself, the family’s care of the infant, and future pregnancies. The risk for transmission among members of the same household is minimal. Social services are required in these cases.


Rubella Infection


Since rubella vaccination was begun in 1969, cases of congenital rubella infection have been reduced by 99%. Vaccination failures, lack of compliance, and the migration of nonimmunized persons result in periodic outbreaks of rubella, also known as German, or 3-day, measles. The risk of a congenitally infected infant varies with the gestational age of the fetus when maternal infection occurs. Abnormalities are most severe if the mother contracts the virus during the first trimester and rare if the disease occurs after that time.



ent More than two thirds of infected infants have no symptoms obvious at birth, but sequelae can develop years later.


ent Hearing loss, the most common result, appears to be progressive after birth.


ent Congenital rubella syndrome includes cataracts or glaucoma, hearing loss, and cardiac defects (pulmonary artery stenosis, patent ductus arteriosus, or coarctation of the aorta).


ent Multiple other abnormalities can be present including IUGR, microphthalmia, hypotonia, hepatosplenomegaly, thrombocytopenic purpura, dermatoglyphic abnormalities, bony radiolucencies, microcephaly, and brain wave abnormalities.


ent Severe infection can result in fetal death.


ent The rubella virus has been cultured in infants for up to 18 months after their birth. These infants are a serious source of infection to susceptible individuals, particularly women in the childbearing years. Extended pediatric isolation is mandatory until the noncontagious stage of rubella has been reached. The infant should be isolated until pharyngeal mucus and the urine are free of virus.


Cytomegalovirus Infection


Cytomegalovirus (CMV) infection during pregnancy can result in congenital or neonatal cytomegalic inclusion disease (CMID). It is the most common cause of congenital viral infections in the United States. Most (90%) affected infants are asymptomatic at birth; however, hearing loss and learning disabilities have been reported in 10% to 15% of previously asymptomatic infants.



Herpes Simplex Virus


HSV infections among newborns are being diagnosed more frequently and are estimated to occur in as many as 1 in 3000 to 1 in 20,000 births. HSV type 2 is the most common cause of illness in neonates (75%). The neonate can acquire the virus by any of four modes of transmission: (1) transplacental infection, (2) ascending infection by way of the birth canal, (3) direct contamination during passage through an infected birth canal, and (4) direct transmission from infected personnel or family.



ent Congenital infection is rare and is characterized by in utero destruction of normally formed organs. Affected infants are growth restricted. They have severe psychomotor delays, intracranial calcifications, microcephaly, hypertonicity, and seizures as well as eye involvement, including microphthalmos, cataracts, chorioretinitis, blindness, and retinal dysplasia. Some infants have patent ductus arteriosus, limb anomalies, recurrent skin vesicles, and a short life expectancy. Most infants are infected directly during passage through the birth canal.


ent Standard Precautions should be observed when caregivers have contact with these infants.


ent Nursery personnel with cold sores should practice strict hand hygiene and wear a mask, but no evidence indicates they should be removed from the nursery unless they have a herpetic whitlow (primary HSV infection of the terminal segment of a finger).


ent The neonate’s eyes, oral cavity, and skin are inspected carefully for lesions. Cultures are obtained from the mouth, eyes, and any lesions.


ent Circumcision, if performed, is delayed until the infant is ready to be discharged.


ent The infant can be discharged with the mother if his or her cultures are negative for the virus.


ent As long as no suspicious lesions are on the mother’s breasts, breastfeeding is encouraged.


ent For the infant at risk, prophylactic topical eye ointment (vidarabine) is administered for 5 days to prevent keratoconjunctivitis.


ent Blood, urine, and cerebrospinal fluid (CSF) specimens should be cultured when indicated clinically.


ent Therapy includes general supportive measures, as well as treatment with acyclovir or vidarabine. Ophthalmic ointment should be administered simultaneously.

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Related posts:

  1. 7. The Newborn
  2. 1. Pregnancy
  3. 6. Selected Postpartum Complications
  4. 2. Selected Pregnancy Complications

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Jul 18, 2016 | Posted by in NURSING | Comments Off on 8. Selected Newborn Complications

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