ASSESSMENT OF HIGH RISK NEW BORN - PRINCIPLES , CONCEPTS, AND

GOALS, BABY OF DIABETIC AND SUBSTANCE USE MOTHERS

INTRODUCTION

A newborn should have a thorough evaluation performed within 24 hours of birth to identify
any abnormality that would alter the normal newborn course or identify a medical condition
that should be addressed (e.g., anomalies, birth injuries, jaundice, or cardiopulmonary
disorders) . This assessment includes review of the maternal, family, and prenatal history and
a complete examination. Depending upon the length of stay, another examination should be
performed within 24 hours before discharge from the hospital.

The high-risk period begins at the time of viability (the gestational age at which survival
outside the uterus is believed to be possible, or as early as 23 weeks of gestation) up to 28
days after birth and includes threats to Life and health that occur during The prenatal,
perinatal, and postnatal periods.

CONCEPT OF HIGH RISK NEWBORN

MEANING OF NEONATE

From birth to under four weeks of age (<28 days), the infant is called neonate or newborn.
First week of life (<7 days or <168 hours is known as early neonatal period. Late neonatal
period extends from 7th to < 28th day.

DEFINITION OF HIGH RISK NEWBORN

A newborn regardless of gestational age or birth weight, who has a greater –than average
chance of morbidity or mortality because of conditions or circumstances superimposed on the
normal course of events associated with birth and the adjustment to extrauterine existence.

Encompasses human growth and development from the time of viability ±28 days following
birth and includes threat to life and health that occur during the prenatal, perinatal, and
postnatal periods.

Nurses in newborn nurseries should be familiar with the characteristics of neonates and
recognize the significance of serious deviations from expected observations. When providers
can anticipate the need for specialized care and plan for it, the probability of successful
outcome is increased.

IDENTIFICATION

 Birth weight less than 2.5kg

 Twins
 Birth order 5 and more
 Artificial feeding
 Infection
GOALS

 Perinatal prevention
 Resuscitation and stabilization
 Evaluate and manage
 Monitoring and therapeutic modalities
 Family centered care
Classification of High-Risk Newborns

 High-risk infants are most often classified according to birth weight, gestational age,
and predominant pathophysiologic problems.
 The more common problems related to physiologic status are closely associated with
the state of maturity of the infant and usually involve chemical disturbances (e.g.,
hypoglycemia, hypocalcemia) or consequences of immature organs and systems (e.g.,
hyperbilirubinemia, respiratory distress, hypothermia).
 Because high-risk factors are common to several specialty areas-particularly
obstetrics, paediatrics, and neonatology- specific terminology is needed to describe
the developmental status of the newborn.
 Formerly, weight at birth was considered to reflect a reasonably accurate estimation
of gestational age; that is, if an infant's birth weight exceeded 2500 g (5.5 pounds), the
infant was considered to be mature. However, accumulated data have shown that
intrauterine growth rates are not the same for all infants and that other factors (e.g.,
heredity, placental insufficiency, maternal disease) influence intrauterine growth and
birth weight.
  From these data, a more definitive and meaningful classification system that
encompasses birth weight, gestational age, and neonatal outcome has been developed

CLASSIFICATION ACCORDING TO SIZE

Low-Birth-Weight (LBW) Infant—An infant whose birth weight is less than 2500 g
(5.5 lb), regardless of gestational age
Very Low–Birth-Weight (VLBW) Infant—An infant whose birth weight is less than
1500 g (3.3lb)
Extremely Low–Birth-Weight (ELBW) Infant—An infant whose birth weight is less
than 1000 g (2.2 lb)
Appropriate-For-Gestational-Age (AGA) Infant—An infant whose weight falls
between the 10th and 90th percentiles on intrauterine growth curves.
Small-For-Date (SFD) Or Small-For-Gestational-Age (SGA) Infant—An infant
whose rate of intrauterine growth was slowed and whose birth weight falls below the
10th percentile on intrauterine growth curves.
Intrauterine Growth Restriction (IUGR)—Found in infants whose intrauterine
growth is retarded (sometimes used as a more descriptive term for the SGA infant)
Large-For-Gestational-Age (LGA) Infant—An infant whose birth weight falls above
the 90th percentile on intrauterine growth charts

CLASSIFICATION ACCORDING TO GESTATIONAL AGE

Preterm (premature) infant—An infant born before completion of 37 weeks of

gestation, regardless of birth weight
Full-Term Infant—An infant born between the beginning of 38 weeks and the
completion of 42 weeks of gestation, regardless of birth weight
Posterm (Postmature) Infant—An infant born after 42 weeks of gestational age,
regardless of birth weight
Late-Preterm Infant—An infant born between 34 and 36 weeks of gestation,
regardless of birth weight

CLASSIFICATION ACCORDING TO MORTALITY

 Live Birth—Birth in which the neonate manifests any heartbeat, breathes, or displays
voluntary movement, regardless of gestational age
Fetal Death—Death of the fetus after 20 weeks of gestation and before delivery, with
absence of any signs of life after birth
Neonatal Death—Death that occurs in the first 27 days of life; early neonatal death
occurs in the first week of life; late neonatal death occurs at 7 to 27 days
Perinatal Mortality—Describes the total number of fetal and early neonatal deaths
per 1000 live births
Postnatal Death—Death that occurs at 28 days to 1 year after birth

CLASSIFICATION ACCORDING TO BIRTH WEIGHT

Low Birth Weight - Birth weight less than 2500g regardless of gestational age
Moderately Low Birth Weight - birth weight is between 1501g to 2500g.
Very Low Birth Weight -birth weight is less than 1500g.
Extremely Low Birth Weight - birth weight less than 1000g.

CLASSIFICATION ACCORDING TO SIZE

Appropriate for Gestational Age (AGA) - birth weight falls between the 10 and 90
percentile
Small for Gestational Age ( SGA) - birth weight falls below the 10 percentile
Large for Gestational Age (LGA)- birth weight falls above the 90 percentile

MEDICALLY HIGH RISK NEWBORN (MHRN) ELIGIBILITY CRITERIA

PREMATURITY (less than 32 weeks gestation)

VERY LOW BIRTH WEIGHT (less than 1500 grams)
SIGNIFICANTLY SGA (small for gestational age) failure to thrive, IUGR (intrauterine
growth retardation) less than 5th percentile.
PROLONGED hypoxemia, academia, repetitive apnea, required assisted
ventilation .40 hours.
METABOLIC PROBLEMS, i.e hypoglycemia, hypocalcemia
 HYPERBILIRUBINEMIA (considered when persistent and untreated
hyperbilirubinemia requires exchange transfusions and/or is associated with
congenital anomalies).
NEONATAL SEIZURES or seizures beyond the neonatal period.
SERIOUS BIOMEDICAL FACTORS i.e. CNS bleeds, RDS (respiratory distress
syndrome) confirmed infection, chronic lung disease.
MULTIPLE CONGENITAL ANOMALIES requiring special services, but with
presumed potential for normal developmental outcome.
HISTORY OF MATERNAL CHEMICAL EXPOSURE and/or substance abuse i.e.
alcohol hydantoin, warfarin and cocaine.
PERSISTENT FEEDING PROBLEMS
PERSISTENT TONAL PROBLEMS
CONTINUED evidence of delay in one or more developmental areas and poor parent-
infant attachment.

IDENTIFICATION OF HIGH RISK NEWBORNS

Maternal diabetes
Maternal narcotics during labor
Maternal substance abuse
Fetal asphyxia
Difficult/prolonged labor causing birth trauma
Multiple gestation
Preterm or postterm delivery
Congenital anomalies
Maternal or neonatal infection
SGA or LGA
Apgar score < 6 at 1 min or < 7 at 5 min
HIGH RISK NEWBORN ASSESSMENT

A thorough systematic physical assessment is an essential component in the care of high-risk

infants. Subtle changes in feeding behavior, activity, color, oxygen saturation or vital signs
often indicate an underlying problem. Low-birth- weight (LBW) preterm infants, especially
very low-birth-weight

SYSTEMATIC ASSESSMENT

(VLBW) or extremely low-birth-weight (ELBW) infants, are ill equipped to withstand

prolonged physiologic stress and may die within minutes of exhibiting abnormal symptoms if
the underlying pathologic process is not corrected. Alert nurses are aware of subtle changes
and react promptly to implement interventions that promote optimum functioning in high-risk
neonates. Changes in the infant's status are noted through ongoing observations of the infant's
adaptation to the extrauterine environment.

Observational assessments of high-risk infants are made accord-ing to each infant's acuity;
critically ill infants require close observa-tion and assessment of respiratory function,
including continuous pulse oximetry, electrolytes, and evaluation of blood documentation of
the infant's status is an integral component of gases. Accurate nursing care. With the aid of
continuous, sophisticated cardiopulmonary monitoring, nursing assessments and daily care
may be coordinated to allow for minimal handling of the infant (especially VLBW or ELBW
infants) to decrease the effects of environmental stress.

GENERAL ASSESSMENT

 Using an electronic scale, weigh daily, or more often if indicated. Measure length and
head circumference at birth.
 Describe general body shape and size, posture at rest, ease of breathing, presence and
location of edema. Describe any apparent deformities. Describe any signs of distress-
poor color, hypotonia, lethargy, apnea.
RESPIRATORY ASSESSMENT

 Describe shape of chest (barrel, concave), symmetry, and presence of incisions,

chesttubes, or other deviations. Describe use of accessory muscles-nasal flaring or
substernal, intercostal, or suprasternal retractions. Determine respiratory rate and
regularity.
 Auscultate and describe breath sounds-crackles, wheezing, wet or diminished sounds,
grunting, diminished air movement, stridor, equality of breath sounds. Describe cry if
not intubated.
 Describe ambient oxygen and method of delivery, if intubated, describe size and
position of tube, type of ventilator, and settings.
 Determine oxygen saturation by pulse oximetry and partial pressure of oxygen, and
describe carbon dioxide by transcutaneous carbon dioxide (tcPCO₂).

CARDIOVASCULAR ASSESSMENT

 Determine heart rate and rhythm.

 Describe heart sounds, including any murmurs,
 Determine the point of maximum impulse (PMI), the point at which the heartbeat
sounds and palpates loudest (a change in the PMI may indicate a mediastinal shift).
Describe infant's color: cyanosis (may be of cardiac, respiratory, or hematopoietic
origin), pallor, plethora, jaundice, mottling. Assess color of mucous membranes, lips.
 Determine blood pressure as indicated. Indicate extremity used and cuff size
 Describe peripheral pulses, capillary refill, and peripheral perfusion (mattling).
Describe monitors, their parameters, and whether alarms are in the "on" position

GASTROINTESTINAL ASSESSMENT

 Determine presence of abdominal distention-increase in circumference, shiny skin,

evidence of abdominal wall erythema, visible peristalsis, visible loops of bowel, status
of umbilicus.
 Determine any signs of regurgitation and time related to feeding, describe character
and amount of residual if gavage fed, if nasogastric tube is in place, describe type of
suction and drainage (color, consistency, pH).
 Describe amount, color, consistency, and odor of any emesis.
 Palpate liver margin (1-3 cm below right costal margin).
  Describe amount, color, and consistency of stools. Describe bowel sounds-presence or
absence (must be present if feeding)

GENITOURINARY ASSESSMENT

 Describe any abnormalities of genitalia.

 Describe amount (as determined by weight), color, pH, labstick findings, and specific
gravity of urine.
 Check weight.

NEUROLOGIC-MUSCULOSKELETAL ASSESSMENT

 Describe infant's movements-random, purposeful, jittery, twitching, spontane ous,

elicited; describe level of activity with stimulation; evaluate based on gestational age.
 Describe infant's position or attitude-flexed, extended.
 Describe reflexes observed-Moro, sucking, Babinski, plantar, and other expected
reflexes.
 Determine level of response and consolability.
 Determine changes in head circumference (if indicated), size and tension of fontanels,
suture lines.
 Determine pupillary responses in infant older than 32 weeks of gestation.
 Check hip alignment (only experienced practitioner should perform).

TEMPERATURE

 Determine axillary temperature.

 Determine relationship to environmental temperature.
SKIN ASSESSMENT

 Note any skin lesions or birthmarks.

 Describe any discoloration, reddened area, signs of irritation, blisters, abrasions or
denuded areas, especially where monitoring equipment, infusions, or other apparatus
come in contact with skin, also check and note any skin preparation used (e.g, skin
disinfectants)
 Determine texture and turgor of skin-dry, smooth, flaky, peeling, and so on Describe
any rash, skin lesion, or birthmarks. Determine whether intravenous infusion catheter
is in place and observe for signs of infiltration.
 Describe parenteral infusion lines-location, type (arterial, venous, peripheral
umbilical, central, peripheral central venous), type of infusion (medication saline,
dextrose, electrolyte, lipids, total parenteral nutrition), type of infusion pump and rate
of flow, type of catheter, and appearance of insertion site.

APGAR SCORE

INTRODUCTION:

 DR.virginiaapgar created the system in 1952 and used her name as a nemonic for
each of the five categories that a person will score .since that time the medical
professional across the world have used the scoring to assess the newborn in their
moment of life.
 The medical professor use this assessment to quickly relay the status of a newborn‘s
overall condition. Low apgar score may indicate the baby needs special care such as
extra help with their breathing.
 Usually after birth, a nurse or doctor may announced the apgar scores to the labor
room.
 This lets all present medical personnel know how a baby is doing even if some of the
medical personnel are tending to the mom.
 When a parents hears these numbers they should know they are one of many different
assessment medical provider will use. Other example: includes heart rate monitoring
and umbilical artery blood gases. However, assigning an apgar score is a quickly way
to help other understand the baby’s condition immediately after birth.
DEFINITION:

 The apgar scoring is a scoring system doctors and nurse use to assess newborn one
minutes and five minutes after the are born.
 The score is named for these prominent American anesthiologist Dr. Virginia apgar
(1909 – 1974). Who invented the scoring method in 1952.

APGAR SCORE:

0 1 2

Activity Absent Some movement Active movement

(tone)
pulse Absent <100 >100

Grimace (reflex Flaccid Slightly cry Active motion

irritability (sneeze, vigorous,
cry)
Appearance Blue (pale) Body pink All pink
(colour) extremities blue
Respiration Absent Slow, irregular Strong, crying

1. Muscle tone ( activity) :

Limp, flaccid =0
Some flexing or bending=1
Active motion=2

2 - Points for vigorous motion

 1 - Points for small flexing

0 - Points for no movement

2. Heart rate:

Absent heartbeat=0
Slow heartbeat (less than 100 beats/minutes) = 1
Adequate heartbeat (more than 100 beat/ minutes) = 2

2- Good strong heartbeat

1- Slow but steady heartbeats

0 - little or no heartbeat.

3. Reflex:

No responds = 0
Grimace (facial expression) = 1
Vigorous cry or withdrawal=2

2= points if the baby cries

1=points if the bay grimace (facial expression)

0=points for no movement or sound.

4. Colour:

Pake or blue =0
Normal body color, but blue extremities (arm, and legs) =1
Normal color=2 completely pink.

5. Respiration:

Breathing effort:

 If the infant is not breathing, the respiratory score is 0.

 If the respirations are slow or irregular, the infant scores 1 for respiratory effort.
 If the infant cries well, the respiratory score is 2.
 Strong cry=2
6. Grimace response:

 Grimace response or reflex irritability is a term describing response to stimulation,

such as a mild pinch.
 If there is no reaction, the infant scores 0 for reflex irritability.
 If there is grimacing, the infant scores 1 for reflex irritability.
 If there is grimacing and a cough, sneeze, or vigorous cry, the infant scores 2 for
reflex irritability.

CLINICAL SIGNIFICANT:

 A score of 7 to 10 after five minutes is “reassuring.” A score of 4 to 6 is “moderately

abnormal.”
 A score of 0 to 3 is concerning. It indicates a need for increased intervention, usually
in assistance for breathing. A parent may see nurses drying off a child vigorously or
delivering oxygen via a mask. Sometimes a doctor, midwife, or nurse practitioner
may recommend transferring a patient to a neonatal intensive care nursery for further
assistance.
 Many doctors don’t consider trusted Source the Apgar scoring system to be perfect.
There are modifications to this scoring system, such as the Combined-Apgar score.
This scoring system describes not only the baby’s Apgar score, but also the
interventions an infant has received.
 The maximum score of the Combined-Apgar score is 17, which indicates a baby who
hasn’t received any interventions and receives all points. A score of 0 indicates the
baby didn’t respond to interventions.

ASSESSMENT OF GESTATIONAL AGE

INTRODUCTION
 A method to determine the gestational age is New Ballard Scale (NBS). It was
proposed by Dr. Jenne L Ballard in 1991. NBS assesses 6 external physical and 6
neuromuscular signs of maturity. Assessment of gestational age from 20 to 44 weeks Scores
range from -10 to +50 .Optimal time for assessment if from birth to 90 hours

DEFINITION

Gestational age assessment means figuring out the number of weeks of your
pregnancy. A full-term pregnancy is usually 40 weeks. It's important to assess if gestational
age is uncertain or if your baby is smaller or larger than expected.

A fetus or newborn infant whose size is within the normal range for height, weight,
head size, and developmental level for a child of the same gestational age and gender. Full-
term infant is heavier than 2,5kg and lighter than 4 kg.

 The new Ballard score is commonly used to determine gestational age. Here’s
how it works
 Scores are given for 6 physical and 6 nerve and muscle development
(neuromuscular) signs of maturity.
 The scores for each may range from -1 to 5.The scores are added together to
determine the baby’s gestational age. The total score may range from -10 to
50.
 Premature babies have low scores. Babies born late have high scores.

Newborn physical examination findings also allow clinicians to estimate gestational age
using the new Ballard score. The Ballard score is based on the neonate's physical and
neuromuscular maturity and can be used up to 4 days after birth (in practice, the Ballard score
is usually used in the first 24 hours). The neuromuscular components are more consistent
over time because the physical components mature quickly after birth.

Neuromuscular components can be affected by illness and drugs (eg, magnesium sulfate
given during labor). Because the Ballard score is accurate only within plus or minus 2 weeks,
it should be used to assign gestational age only when there is no reliable obstetrical
information about the estimated date of confinement or there is a major discrepancy between
the obstetrically defined gestational age and the findings on physical examination.

BASED ON GESTATIONAL AGE, NEONATES ARE CLASSIFIED AS

  Premature: < 34 weeks gestation
 Late pre-term: 34 to < 37 weeks
 Early term: 37 0/7 weeks through 38 6/7 weeks
 Full term: 39 0/7 weeks through 40 6/7 weeks
 Late term: 41 0/7 weeks through 41 6/7 weeks
 Post term: 42 0/7 weeks and beyond
 Postmature: > 42 weeks

PHYSICAL MATURITY ASSESSMENT

The physical assessment includes an exam of the following physical characteristics:

 Skin texture. Skin may be sticky, smooth, or peeling.

 Lanugo. This is the soft downy hair on a baby's body. It's absent in premature babies.
It's present in full-term babies, but not in babies born late.
 Plantar creases. These are the creases on the soles of the feet. They range from absent
to covering the entire foot.
 Breast. The thickness and size of the breast tissue and the areola (the darkened area
around each nipple) are assessed.
 Eyes and ears. Eyelids are checked to see if they are open or fused shut (more likely
in a premature baby). The amount of cartilage and stiffness of the ear tissue are also
noted.
 Male genitals. The presence of testes and the look of the scrotum, from smooth to
wrinkled, is verified.
 Female genitals. The appearance and size of the clitoris and the labia are noted.
NEUROMUSCULAR MATURITY ASSESSMENT

Muscle tone: progressively increases in utero as maturity proceeds. The tone in the newborn
baby is assessed by 3 parameters.

a) Posture or attitude

b) Passive tone is evaluated by assessing popliteal angle and scrf sign

c) Active tone is assessed by traction response and recoil.

Joint mobility: The degree of flexion at ankle and wrist (square window) is limited in the
preterm babies because of relatively greater stiffness of joints in early gestation. As term
approaches the joints become more flexible and relaxed to allow for easy moulding during
delivery.

Certain automatic reflexes: It appears at specific ages of gestational maturity e.g. Moro
reflex appears as early as 28 to 30 weeks but lacks complete adduction phase till 38 weeks of
gestation.pupillary response to light is present after 30 weeks and infant may turn his head
towards diffuse light during 32-36 weeks of gestation. Grasp response makes its appearance
around 30 weeks but a strong grasp is elicit able after 36 weeks. neck flexors are able to
contract in response to traction around 33 weeks of maturity. Rooting and co-ordinate
sucking efforts are present by 34 weeks of gestation.

Fundus examination: The disappearance of the anterior vascular capsule of the lens has
been used to assess the gestation age. After 34 weeks of maturity anterior capsular vessels are
almost completely atrophies with graded changes in babies between 28 and 34 weeks of
gestation.

The neuromuscular assessment includes an exam of the following:

 Posture. How the baby holds his or her arms and legs.
 Square window. How far the baby's hands can be flexed toward the wrist.
 Arm recoil. How well the baby's arms spring back to a flexed position.
 Popliteal angle. How well the baby's knees bend and straighten.
  Scarf sign. How far the elbows can be moved across the baby's chest.
 Heel to ear. How close the baby's feet can be moved to the ears.

 Posture. Score 0 if the arms and legs are extended, and score 1 if the infant has
beginning flexion of the knees and hips, with arms extended
 Square window. Flex the hand on the forearm between the thumb and index finger of
the examiner. Apply sufficient pressure to achieve as much flexion as possible.
Visually measure the angle between the hypothenar eminence and the ventral aspect
of the forearm
 Arm recoil. Flex the forearms for 5 s; then grasp the hand and fully extend the arm
and release. If the arm returns to full flexion, give a score of 4. For lesser degrees of
flexion, score as noted on the diagram.
 Popliteal angle. Hold the thigh in the knee-chest position with the left index finger
and the thumb supporting the knee. Then extend the leg by gentle pressure from the
right index finger behind the ankle. Measure the angle at the popliteal space and score
accordingly.
 Scarf sign. Take the infant's hand and try to put it around the neck posteriorly as far
as possible over the opposite shoulder
 Heel to ear. Keeping the pelvis flat on the table, take the infant's foot and try to put it
as close to the head as possible without forcing it.
INFANTS OF DIABETIC MOTHERS

INTRODUCTION

 Before insulin therapy, few women with diabetes were able to conceive; for those
who did, the mortality rate for both the mother and the infant was high. The morbidity
and mortality of infants of diabetic mothers (IDMs) have been significantly reduced
as a result of effective control of maternal diabetes and an increased understanding of
fetal disorders. Because infants born to women with gestational diabetes mellitus are
at risk for the same complications as IDMs, the following discussion of IDMs
includes infants born to women with gestational diabetes mellitus.
 The severity of the maternal diabetes affects infant survival. The severity of maternal
diabetes is determined by the duration of the disease before pregnancy; age of onset;
extent of vascular complications; and abnormalities of the current pregnancy, such as
pyelonephritis, diabetic ketoacidosis, pregnancy-induced hypertension, and
noncompliance.
 The single most important factor influencing fetal well-being is the euglycemic status
of the mother. It has been found that reasonable metabolic control that begins before
conception and continues during the first weeks of pregnancy can prevent
malformation in an IDM.
 Elevated levels of hemoglobin A1c during the periconception period appear to be
associated with a higher incidence of congenital malformations. In the case of
gestational diabetes, macrosomia is the most common finding; serious complications
are rare (Mitanchez, 2010).

PATHOGENESIS

 Hypoglycemia in IDMs is related to hypertrophy and hyperplasia of the pancreatic

islet cells and thus is a transient state of hyperinsulinism. High maternal blood glucose
levels during fetal life provide a continual stimulus to the fetal islet cells for insulin
production (glucose easily passes the placental barrier from maternal to fetal side;
insulin, however, does not cross the placental barrier). This sustained state of
hyperglycemia promotes fetal insulin secretion that ultimately leads to excessive
 growth and deposition of fat, which probably accounts for the infants who are large
for gestational age, or macrosomic (Ogata, 2010).
 IDMs are more likely to have disproportionately large abdominal circumferences and
shoulders, leading to an increased risk of shoulder dystocia and birth injury (Dailey
and Coustan, 2010).
 When the neonate's glucose supply is removed abruptly at the time of birth, the
continued production of insulin soon depletes the blood of circulating glucose,
creating a state of hyperinsulinism and hypoglycemia within 0.5 to 4 hours, especially
in infants of mothers with poorly controlled diabetes (formerly class C diabetes or
beyond (class D through R]). Precipitous drops in blood glucose levels can cause
serious neurologic damage or death.
 Infants of mothers with advanced diabetes may be small for gestational age, may have
IUGR, or maybe the appropriate size for gestational age because of the maternal
vascular (placental) involvement. There is an increase in congenital anomalies in
IDMs in addition to a high susceptibility to hypoglycemia, hypocalcemia,
hypomagnesemia, polycythemia, hyperbilirubinemia, cardiomyopathy, and RDS
(Dailey and Coustan, 2010). Hyperinsulinemia and hyperglycemia in the diabetic
mother may be factors in reducing fetal surfactant synthesis, thus contributing to the
development of RDS. Although large, these infants may be delivered before term as a
result of maternal complications or increased fetal size.
 Congenital hyperinulinism, a condition which causes neonatal macrosomia and
profound hypoglycemia, is often present in the neneonatal period. However, this
condition is usually not associated with maternal diabetes mellitus, but appears to
have a genetic etiology: the condition is also associated with syndromes such as
Beckwith- Wiedemann syndrome (Sperling, 2011).

PROBLEMS SEEN IN FETUS/NEONATES

 Congenital malformations
 Fetal heart malformations are seen in 3%-9% of diabetic pregnancies
 Most common heart defect is transposition of the great arteries followed by double
outlet right ventricle, VSD, PDA, Truncus arteriosus and Tricuspid atresia
 CNS malformations include neural tube defects, Caudal regression (Specific for
IDM), spinal abnormalities and syringomyelia
  Small left colon syndrome-Descending colon, sigmoid colon and rectum appears
smaller than normal. Child presents with bilious emesis and abdominal distension.
 Prematurity, Intrauterine death
 Macrosomia
 Infants have bigger head: chest and shoulder. head ratios, more body fat and
visceromegaly. Size of all organs except brain increases.
 Hairy pinna, Clefts in thigh, typical cherubic facies
 Increased risk of operative deliveries, birth asphyxia and birth trauma
 Metabolic abnormalities - Hypoglycemia (due to postnatal hyperinsulinemia)
 Hypocalcemia (due to diminished production of parathormone after birth)
Hypomagnesaemia
 Polycythemia- Increased oxygen consumption leading to increased bone marrow
response, red blood cell production, increased viscosity and decreased blood flow
leading to flushed appearance
 Unconjugated Hyperbilirubinemia due to increased red cell mass
 Transient Cardiomyopathy-Due to asymmetrical septal hypertrophy. May cause heart
failure during neonatal period. This condition is often resolved spontaneously by 6
months of age
 Increased risk of Respiratory distress syndrome
 Maternal diabetes places the fetus and newborn at risk for serious complications.
Perinatal outcome has a di- rect relationship with the severity and control of the
mother's diabetes. The diabetic woman who closely controls her blood glucose level
before conception and throughout pregnancy, particularly in the early months,
decreases her risk of having an infant with congenital anomalies. Fetal death is less
likely with excellent control.

CLINICAL MANIFESTATIONS OF INFANTS OF DIABETIC MOTHERS

CLINICAL MANIFESTATIONS

 Infants of mothers with poorly controlled type 2 or gestational diabetes have a

distinctive appearance. They are LGA, plump and full-faced with bulky shoulders,
 and coated with vernix caseosa. Both the placenta and the umbilical cord are
oversized. In contrast, infants of mothers with poorly controlled, long-term, or severe
type 1 diabetes actually may suffer from IUGR.
 Consistently elevated fetal insulin levels cause the distinctive growth pattern. Because
maternal glucose levels are elevated and glucose readily crosses the placenta, the fetus
responds by increasing insulin production. Be-cause insulin acts as a fetal growth
hormone, consistently high levels cause fetal macrosomia, birth weight of greater than
4,500 g (9 lb, 14 oz). Insulin also causes disproportionate fat build up to the shoulders
and upper body, increasing the risk for shoulder dystocia and birth trauma.
 Newborns of diabetic mothers are at risk for hypoglycemia in the first few hours after
birth. In utero, the fetal pancreas adapts to the high blood glucose levels by producing
and secreting more insulin. After birth, the glucose source is abruptly cut off when the
umbilical cord is cut. The newborn's pancreas cannot readjust quickly enough, so it
continues to produce insulin, leading to neonatal hypoglycemia. This condition may
cause permanent brain damage or death unless care providers detect it quickly and
treat the newborn with oral or IV glucose.
 High insulin levels can also delay fetal lung maturity; therefore, newborns of diabetic
mothers have a higher incidence of respiratory distress syndrome and other res-
piratory difficulties. These infants are subject to many other hazards, including
congenital anomalies, preterm delivery, difficult cardiopulmonary transition at birth,
and enlarged heart. Other issues include hypocalcemia, hypomagnesemia,
polycythemia with hyperviscosity, and hyperbilirubinemia. This infant is at increased
risk for developing early onset diabetes in adolescence or early adulthood.
Signs and symptoms

o LGA (Large for Gestational Age)

o Hypoglycemia
o RDS (Respiratory Distress Syndrome)
o False positive L/S ratio,
o Increased risk for congenital anomalies (especially cardiac and spinal)
o Very plump and full faced
o Abundant verix caseosa
o Plethora
 o Listless and lethargic
o Possibly meconium stained at birth anomalies or birth injuries, and blood
studies for determination of glucose, calcium, hematocrit, and bilirubin are
obtained on a regular basis.

THERAPEUTIC MANAGEMENT

 The most important management of IDMs is careful monitoring of serum glucose

levels and observation for accompanying complications such as RDS.
 Approximately half of these infants do well and adjust without complications. Infants
born to mothers with poorly controlled diabetes may require IV dextrose infusions.
 Treatment with 10% dextrose and water (IV) is initiated with the goal of maintaining
serum blood glucose levels between 40 and 50 mg/dl (Adamkin and AAP, Commit-
tee on Fetus and Newborn, 2011).
 Oral and IV intake may be titrated to maintain adequate blood glucose levels.
Frequent blood glucose determinations are needed for the first 2 to 4 days of life to
assess the degree of hypoglycemia present at any given time.
 Testing blood taken from the heel with calibrated portable reflectance meters (e.g.,
glucometers) is a simple and effective screening evaluation that can then be confirmed
by laboratory examination.

NURSING CARE MANAGEMENT

 The nursing care of IDMs involves early examination for congenital anomalies, signs
of possible respiratory or cardiac problems, maintenance of adequate
thermoregulation, early introduction of carbohydrate feedings as appropriate, and
monitoring of serum blood glucose levels. The latter is of particular importance
because many infants with bypoglycemia may remain asymptomatic. IV glucose
infusion requires careful monitoring of the site and the neonate's reaction to therapy;
high glucose concentrations (212.5%) should be infused via a central line instead of a
peripheral site.
 Because macrosomic infants are at risk for problems associated with a difficult
delivery, they are monitored for birth injuries such as brachial plexus injury and palsy,
 fractured clavicle, and phrenic nerve palsy. Additional monitoring of the infant for
problems associated with this condition (polycythemia, hypocalcemia, poor feeding,
and hyper- bilirubinemia) is also a vital nursing function.
 Some evidence indicates that IDMs have an increased risk of acquiring type 2
diabetes and metabolic syndrome in childhood or early adulthood (Ogata, 2010);
therefore, nursing care should also focus on healthy lifestyle and prevention later in
life with IDMs.
 Newborns of diabetic mothers require especially careful observation. Perform early
(as soon as possible after birth) and frequent blood glucose checks.
 Administer early feedings or if the newborn has respiratory distress or is otherwise ill
give IV glucose, as ordered Hypo-glycemiaia can return after treatment, so watch for
signs and symptoms.
 Watch for signs of respiratory distress. Anticipate supplemental oxygen and surfactant
therapy. Some infants need ventilator support.
 Monitor electrolytete levels, especially magnesium and calcium,ordered. Assist the
RN to perform a gestational agassessment, as these infants can be deceptively large
and still be preterm. Watch for and report any heart murmurs or other signs of cardiac
dysfunction.

NEWBORN OF A MOTHER WITH SUBSTANCE ABUSE

INTRODUCTION

 Alcohol and illicit drug use by the mother during preg- nancy can lead to many
problems in the newborn. The newborn of a woman who uses alcohol is at risk for fe-
tal alcohol syndrome (FAS). The newborn of a chemi- cally dependent woman may
be SGA and/or experience withdrawal symptoms.

 Unfortunately, identifying the pregnant woman who abuses alcohol or drugs is often
difficult. Many of these women have no prenatal care or only infrequent care. They
may not keep appointments because of apathy or simply because they are not awake
during the day. As a result, many of these infants suffer prenatal insults the result in
intrauterine growth retardation, congenital abnormalities, and premature birth.
FETAL ALCOHOL SYNDROME ALCOHOL

Fetal Alcohol Syndrome Alcohol is one of the many teratogenic substances the readily cross
the placenta to the fetus. Many newborn exposed to alcohol in utero exhibit withdrawal
symptoms during the first few hours after delivery. FAS is often apparent in newborns of
mothers with chronic alcholism and sometimes appears in newborns whose mothers are low
to moderate consumers of alcohol. Binge drinking appears to be more harmful to the
developing fetus than does drinking small amounts every day Because we do not know
exactly how much alcohols safe, the woman should stop drinking at least 3 months before she
plans to become pregnant.

PATHOGENESIS

Alcohol crosses placenta

Interferes with protein synthesis

Increasing risk of congenital anomalies,

Mental deficiency & IUGR

Clinical Manifestations

The newborn that is withdrawing from alcohol typically, is hyperactive, irritable, has trouble
reping, and may have tremors or seizures. Characteristics of FAS include LBW, small height
and head comference, short palpebral fissures (eyelid folds), reduced ocular growth, and a
flattened nasal bridge. This newborns prone to respiratory difficulties, hypoglycemia,
hypocalcemia and hyperbilirubinemia. Growth during infancy, and childhood continues to
fall below age growth rates. Unfortunately, the brain damage that occurs during fetal
development is permanent, result in mental retardation.
 Signs
o SGA
o Small eyes
o Flat midface
o Long, thin upper lip
o Flat upper lip groove
o Irritable
o Hyperactive
o High pitched cry

NURSING CARE

FAS is highly preventable. Societal intentions, of which nurses can be a part, include
increasing the public's awareness of the detrimental effects of alcohol use during pregnancy.
Other helpful interventions include screening women of reproductive age for alcohol
problems and encouraging women to obtain adequate prenatal care and use appropriate
resources for decreasing alcohol use.

Nursing care for the newborn that is withdrawing from alcohol includes the
supportive interventions of swaddling, decreasing sensory stimulation, and ensuring
adequate nutrition. Keep the newborn's environment quiet and dark during the first
few days of withdrawal Administer benzodiazepine or other anticonvulsants, as
ordered, to prevent or treat seizure activity. Adequate nutrition is key to supporting
weight gain. The newborn's sucking reflex may be weak, and he or she may be too
irritable to feed. Give small amounts of formula or breast milk frequently. Monitor the
newborn's daily weight, intake, and output. Encourage the parents to feed the
newborn. This measure also helps to promote bonding.

o Reduce environmental stimuli

 o Swaddle to increase feelings of security
o Sedatives for withdrawal side effects

Neonatal Substance Withdrawal

The newborn of the woman addicted to cocaine, heroin, methadone, or other drugs is born
dependent upon these substances. Newborns may also be born dependent on a certain class of
antidepressants, serotonin reuptake inhibitors. Many of these infants suffer withdrawal
symptoms during the early neonatal period. However, the time of onset varies widely. For
example, the newborn experiencing withdrawal from opioids typically experiences
withdrawal symptoms within 24 to 48 hours after birth. However, it may take up to 2 weeks
before the newborn exhibits any symptoms.

Clinical Manifestations

Withdrawal symptoms commonly include tremors, restlessness, hyperactivity, disorganized

or hyperactive reflexes, increased muscle tone, sneezing, tachypnea, vomiting, diarrhea,
disturbed sleep patterns, and a shrill high-pitched cry. Swallowing reflexes create feeding
problems, and regur- gitation and vomiting occur often after feeding.

NURSING CARE

 Care of the newborn experiencing substance withdrawal focuses on providing

physical and emotional support.
 Medications such as chlorpromazine, clonidine, diazepam, methadone, morphine,
paregoric, or phenobar- bital may ease the withdrawal and prevent complications,
such as seizures.
 Because of neuromuscular irritability, many of these newborns respond favorably to
gentle rocking move- ments while in close bodily contact with their caregivers.
 Therefore, some nurseries place the newborns in special carriers that hold them close
to the nurse's chest while the nurse moves about the nursery.
 Swaddling the infant (wrapping securely in a small blanket) with arms across the
chest also is a method of quieting the agitated new- born.
 Keep the newborn's environment dimly lit to minimize stimulation. Maintain the
airway and monitor respiratory status closely.
 Provide small frequent feedings.
 Keep the newborn's head elevated to promote effective sucking and reduce the risk of
aspiration.
 Vomiting and diarrhea may lead to fluid and electrolyte imbalances. Monitor intake
and output closely and give supplemental fluids as ordered.
 Use a non-judgmental approach when interacting with the newborn and his or her
mother.
o Position infant on side to facilitate drainage of mucus
o Suction PRN to maintain patent airway
o Decrease environmental stimuli, swaddle for comfort
o Intake & output, daily weight
o Obtain meconium and/or urine for drug screening
o Meds may include paregoric elixir, thorazine &Valium, methadone,
phenobarbital
o Pacifier for non-nutritive sucking
o Don’t give Narcan to infant born to narcotic addict

CONCLUSION

Some newborns are considered high risk. This means that a newborn has a greater
chance of complications because of conditions that occur during fetal development,
pregnancy conditions of the mother, or problems that may occur during labor and
birth.
Some complications are unexpected and may occur without warning. Other times,
there are certain risk factors that make problems more likely.
Fortunately, advances in technology have helped improve the care of sick newborns.
Under the care of specialized physicians and other healthcare providers, babies have
much greater chances for surviving and getting better today than ever before.
NEONATAL COMPLICATIONS IN INFANTS BORN TO DIABETIC MOTHERS

Abstract

Objective: To determine the range of complications occurring in infants of diabetic mothers

(IDMs).

Design: An observational cross-sectional study.

Place and duration of study: Federal Government Services Hospital, Islamabad and
National Institute of Child Health, Karachi, from August 1999 to January 2000.

Subjects and methods: All IDMs born during the study period were immediately admitted
to the neonatal intensive care unit after delivery. Maternal history was obtained and a detailed
physical examination was performed to detect congenital abnormalities. Babies were
screened for hypoglycemia, hypocalcemia, hyperbilirubinemia, birth asphyxia, respiratory
distress syndrome (RDS) and birth trauma. Outcome of IDMs and relative frequencies of
various complications were evaluated. Results were analyzed using statistical package for
social sciences (SPSS) version 11.

Results: A total number of 40 babies with IDM were included in the study. Out of diabetic
mothers, only 19 (47.5%) were taking insulin albeit irregularly. No mother was taking oral
hypoglycemic agents, 5 (12.5%) were following only dietary advice while 16 (40%) were not
following any advise for control of diabetes. Twenty-two (55%) mothers were delivered by
C-section and 18 (45%) had vaginal delivery. Seven (17.5%) mothers experienced birth
injuries, all of them were delivered vaginally and majority of them were large babies. Fifteen
percent IDMs suffered from birth asphyxia. Most (82.5%) were delivered vaginally.
Congenital anomalies were found in 10 (25%) babies. Eighteen (45%) were macrosomic, 20
(50%) were appropriate for gestational age (AGA) and 02 (5%) were small for gestational
age (SGA) or growth retarded. Hypoglycemia was noted in 35% and hypocalcemia in 15%.
Hyperbilirubinemia was observed in 12 (30%) newborns. Mortality was 7.5%.

Conclusion: The results of this study show a high frequency complications in IDMs. The
diabetic mothers should have regular antenatal follow-up and maintain good glycemic control
throughout pregnancy. Cesarean section may be allowed more liberally, especially with
clinical evidence of macrosomic baby, to avoid birth injury and asphyxia. All deliveries of
diabetic mother should be attended by pediatrician to minimize complications.

SOME EFFECTS OF MATERNAL DRUG ADDICTION ON THE NEONATE

Abstract

The effect of in utero exposure to drugs of abuse on certain neurological and behavioral
characteristics of the newborn was studied in 10 infants of drug-dependent mothers. Fourteen
newborns of mothers not receiving drugs served as matched controls. Infants exposed to
drugs of abuse during fetal life exhibited a high level of arousal and irritability, and extreme
muscle tone fluctuations--i.e., a predominant hypertonicity (rigidity) alternating with short
periods of a very low tone (flaccidity). These newborns were also highly active, tremulous,
and motorically immature, and displayed near-constant crying and disturbed sleep patterns.
However, their orientation to external stimuli and the findings on neurological examination
were similar to those of control neonates.

PENDER'S HEALTH PROMOTION MODEL

The Health Promotion Model was designed by Nola J. Pender to be a “complementary

counterpart to models of health protection.” It defines health as a positive dynamic state
rather than simply the absence of disease. Health promotion is directed at increasing a
patient’s level of well-being. The health promotion model describes the multidimensional
nature of persons as they interact within their environment to pursue health.

Pender’s model focuses on three areas: individual characteristics and experiences, behavior-
specific cognitions and affect, and behavioral outcomes. The theory notes that each person
has unique personal characteristics and experiences that affect subsequent actions. The set of
variables for behavior specific knowledge and affect have important motivational
significance. The variables can be modified through nursing actions. Health promoting
behavior is the desired behavioral outcome, which makes it the end point in the Health
Promotion Model. These behaviors should result in improved health, enhanced functional
ability and better quality of life at all stages of development. The final behavioral demand is
also influenced by the immediate competing demand and preferences, which can derail
intended actions for promoting health.

The Health Promotion Model makes four assumptions:

1. Individuals seek to actively regulate their own behavior.

2. Individuals, in all their biopsychosocial complexity, interact with the environment,
progressively transforming the environment as well as being transformed over time.
3. Health professionals, such as nurses, constitute a part of the interpersonal
environment, which exerts influence on people through their life span.
4. Self-initiated reconfiguration of the person-environment interactive patterns is
essential to changing behavior.

BIBLIOGRAPHY
 Meharban Singh, Care of Newborn. 6th ed. Jaypee brothers medical publisher,pvt
ltd ,New Delhi.
 D.K.Guha, Book of neonatology principles and practice ,2nd edition,Jaypee brothers
medical publisher,pvt ltd ,New Delhi,page no-30-37.
 Hockenberry JM, Wilson D Wong’s nursing care of infant’s and children. 8 th ed.
Missouri: Elsevier; 2007. p.271-80

 Marlow RD Textbook of paediatric nursing. 6 th ed. Pennsylvania: Elsevier;

2007.p.250-8.

 Pilliteri A Child health nursing. 1st ed. Philadelphia: Lippincott;1999.p.432-8.

 Parthasarathy A IAP textbook of paediatrics. 3rd ed. New Delhi: Jaypee;2006.p.442-6.

 Dutta AK, Sachdeva A Advances in paediatrics. 1st ed. New Delhi: Jaypee;2007.p.89-
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