HIGH RISK NEWBORN

Monday, 24 January 2022 4:45 pm

PROBLEMS RELATED TO MATURITY

PRETERM NEWBORN
• Description: A neonate born before 37 weeks of gestation
• Primary concern relates to immaturity of all body systems
• Cause: unknown
• Maternal factors: age, smoking, poor nutrition, Placental problem , Preeclampsia/ eclampsia
• Fetal factors: multiple pregnancy, infection
• Other factors: poor socioeconomic status, environmental exposure to harmful substance
• Placenta Abruptio vs placenta previa

Assessment
○ Respirations are irregular with periods of apnea
○ Body temperature is below normal
○ Skin is thin, with visible blood vessels and minimal subcutaneous fat pads, may appear jaundiced (Poikilothermic-
easily take on the temperature of the environment)
○ Poor sucking and swallowing reflexes
○ Bowel sounds are diminished
○ extremities are the, with minimal creasing on soles and palms
○ extension of extremities and does not maintain flexion
○ abundance of lanugo hair
○ labia are narrow in girls
○ testes are undescended in boys
○ sqaure window wrist

Common or special problem of preterm neonates

1. Respiratory Distress Syndrome
 Hyaline membrane disease
□ due to lung immaturity; deficient in surfactant
2. Hyperbilirubinemia
 high level of bilirubin in the blood,
 neonate become jaundice due to immaturity of the liver
 Kernicterus staining of brain cells with bilirubin, causing irreversible brain damage
 treatment: phototherapy
3. Infection - not able to receive IgG globulins
4. Cold stress- less subcutaneous tissue, poikilothermic
5. Anemia – less iron stores

Management
1. Improving respiratory function- Oxygen therapy, Mechanical ventilator
2. Maintaining body temperature- Isolette – maintains ideal temperature, humidity and oxygen concentration isolates
infant from infection, Kangaroo Care
3. Preventing infection- Handwashing
4. Promoting nutrition- Gavage feeding, Milk feeding
5. Promoting Sensory stimulation- Gentle touch, speaking gently and softly, music box or low tuned radio

Nursing Interventions
1. Monitor vital signs every 2 to 4 hours
2. Administer oxygen and humidification as prescribed.
3. Monitor intake and output
4. Monitor daily weight.
5. Maintain newborn in a warming device.
6. Reposition every 1 to 2 hours, and handle newborn carefully
7. Avoid exposure to infections.
8. Provide newborn with appropriate stimulation, such as touch
9. Suctioning of secretions as needed
10. Monitor for signs of infection
11. Provide skin care
12. Provide complete explanations for parents

POST-TERM NEWBORN
• Description:
○ Neonate born after 42 weeks of gestation
○ About 12% of all infants are post-term
○ Causes of delayed birth is unknown
• Maternal factors:
 ○ First pregnancies between the ages 15 to 19years
○ Woman older than 35 years
○ Multiparity
• Fetal factors:
○ Fetal anomalies such as anencephaly

Assessment
○ Depleted subcutaneous fat: old looking “old man facies”
○ Parchment-like skin (dry, wrinkled and cracked) without lanugo
○ Fingernails long and extended over ends of fingers
○ Abundant scalp hair
○ Long and thin body
○ Sign of meconium staining
○ Nails and umbilical cord (yellow to green)

COMPLICATIONS OF POST MATURITY

1. The placenta begins to aged toward the end of pregnancy, and may not function as efficiently as before.
2. The failing placental function will place infant at risk for intrauterine hypoxia during labor and delivery.
3. MECONIUM ASPIRATION SYNDROME
4. HYPOGLYCEMIA - FROM NUTRITIONAL DEPRIVATION AND POOR STORAGE OF GLYCOGEN AT BIRTH
5. POLYCYTHEMIA- increase RBC

Management
1. Ultrasound is done to evaluate fetal development, amount of amniotic fluids and the placenta signs of aging
2. To reduce the chance of meconium aspiration, upon delivery of newborn’s head and just before the baby takes his
first breath suctioning of the mouth and nose is done

Nursing management
1. Closely monitor the newborn cardiopulmonary status
2. Administer supplemental oxygen therapy as needed
3. Frequent monitoring of blood sugar; assess for sign of hypoglycemia
4. Provide thermoregulated environment– use of isolette or radiant heat warmer
5. Monitor for signs of meconium aspiration syndrome

DIFFERENCES PRETERM FULL TERM

Posture “Relaxed attitude” limbs more extended More flexed attitude
Ear Ear cartilages are poorly developed, may fold easily Well formed cartilages
Sole Only fine wrinkles Well and deeply creased
Female genitalia Clitoris is prominent; labia majora poorly developed Clitoris is not as prominent; labia majora fully developed
Male genitalia Scrotum is under developed and not pendulous, with Scrotum is fully developed, pendulous, rugated
minimal rugae
Scarf sign Elbow is easily brought across the chest with little or With resisting attempt when elbow is brought to the
no resistance midline of the chest
Grasp reflex Weak Strong, allowing the infant to be lifted up from the
mattress

PROBLEMS RELATED TO GESTATIONAL WEIGHT

SMALL FOR GESTATIONAL AGE
• (SGA) babies are those whose birth weight lies below the 10th percentile for that gestational age
• SGA babies may be:
○ premature (born before 37 weeks of pregnancy),
○ full term (37 to 41 weeks), or
○ post term (after 42 weeks of pregnancy)
• Intrauterine growth restriction (IUGR) - is the most common underlying condition leading to SGA newborn
• Some factors that may contribute to SGA are the following:
○ Maternal factors:
 high blood pressure
 chronic kidney disease
 advanced diabetes
 heart or respiratory disease
 malnutrition, anemia
 infection
 substance use (alcohol, drugs)
 cigarette smoking
 Placental anomaly is the most common cause of IUGR
○ Factors related to the fetus
 multiple gestation (twins)
 infection
 chromosomal abnormality

Assessment
○ Respiratory distress - hypoxic episodes
○ Loose and dry skin ,little fat, little muscle mass
○ Wasted Appearance
 ○ Small liver
○ Head is larger compared to body
○ Wide skull sutures
○ Poor skin turgor
○ Sunken abdomen

Babies with SGA may have problems at birth such as:

○ Respiratory distress (asphyxia)
○ Meconium aspiration
○ Hypoglycemia
○ Difficulty maintaining normal body temperature
○ Polycythemia too many red blood cells

Nursing Interventions
○ Observe for signs of respiratory distress
○ Maintain body temperature
○ Monitor for infection and initiate measures to prevent sepsis
○ Monitor blood glucose levels and for signs of hypoglycemia
○ Initiate early feedings and monitor for signs of aspiration.
○ Provide stimulation, such as touch and cuddling

LARGE FOR GESTATIONAL AGE

• Description: Neonate who is plotted at or above the 90th percentile on the intrauterine growth curve
• Weigh more than 4,000 grams
• Cause – unknown (genetic factors and maternal conditions)
• Maternal diabetes – is the most widely known contributing factor
• Increase insulin acts as a fetal growth hormone
• Macrosomia – an unusually large newborn with birth weight of more than 4500grams

Assessment
• large, obese
• Lethargic and limp
• May feed poorly
• Sign and symptoms of birth trauma
 Bruising
 Broken clavicle
 Evidence of molding
 Cephalhematoma
 Caput succedaneum

Problems of LGA babies

1. Hypoglycemia (low blood sugar) of baby after delivery
2. Respiratory distress
3. Hyperbilirubinemia
4. Potential complications related to increase in body size:
a. Leading cause of breech position and shoulder dystocia
b. Fractured skull, clavicles, cervical or brachial plexus injury and erb’s palsy

Management
Routine newborn care with special emphasis on the following:
1. Monitor vital signs frequently, especially respiratory status.
2. Monitor blood glucose levels and for signs of hypoglycemia
3. Initiate early feedings
4. Note any signs of birth trauma or injury
5. Monitor for infection and initiate measures to prevent sepsis
6. Provide stimulation, such as touch and cuddling.

COMMON ACUTE CONDITIONS OF NEWBORN

RESPIRATORY DISTRESS SYNDROME (RDS)
• Description: Serious lung disorder caused by immaturity and inability to produce surfactant, resulting in hypoxia and
acidosis
• Surfactant – a biochemical compound that reduces surface tension inside the air sac
• decrease in surfactant results to lung collapse, thus greatly reducing infant’s vital supply of oxygen
• Damaged lung cells combines with other substance present in the lungs to form fibrous substance called hyaline
membrane (Hyaline membrane disease)
• this membrane lines the alveoli and blocks gas exchange in the alveoli
 Assessment
1. Expiratory grunting –major- is the body's way of trying to keep air in the lungs so they will stay open
2. Tachypnea
3. Nasal flaring
4. Retractions
5. Seesaw – like respirations (chest wall retracts and the abdomen protrudes)
6. Decreased breath sounds
7. Apnea
8. Pallor and cyanosis
9. Hypothermia

Management
○ Oxygen therapy- hood, nasal prong, mask, endotracheal tube , CPAP (Continuous
 Positive Airway Pressure) or PEEP (Positive End –Expiratory Pressure) may be used
○ Muscle relaxants – Pancuronium (Pavulon)
 Reduces muscular resistance
 Prevents pneumothorax
 Prepare Atropine or Neostigmine Methylsulfate
○ Liquid Ventilation- Uses perfluorocarbons – substances used in industry to assess leaks
○ Nitric Acid- Causes pulmonary vasodilation – increases blood flow to the alveoli

Nursing Interventions
1. Monitor color, respiratory rate, and degree of effort in breathing.
2. Support respirations as prescribed
3. Monitor arterial blood gases and oxygen saturation levels
(arterial blood gases from umbilical artery).so that oxygen administered to the newborn is at the lowest possible
concentration necessary to maintain adequate arterial oxygenation.

RETINOPATHY OF PREMATURITY
• Vascular disorder involving gradual replacement of retina by fibrous tissue and blood vessels
• Primarily caused by prematurity and use of supplemental oxygen (longer than 30 days)
• Oxygen administration should never be more than 40% unless hypoxia is documented
• Any premature newborn who required oxygen support should be scheduled for an eye examination before discharge to
assess for retinal damage.
• Bronchopulmonary Dysplasia- over expanded lungs prolonged use of O2

Management:
○ Suction every 2 hours or more often as necessary.
○ Prepare to administer surfactant replacement therapy (instilled into the endotracheal tube)
○ Administer respiratory therapy (percussion and vibration)
○ Provide nutrition
○ Support bonding
○ Encourage as much parental participation in newborn's care as condition allows.

HYPERBILIRUBINEMIA
• Description: is an abnormally high level of Bilirubin in the blood; results to jaundiced
• In physiologic jaundiced:
○ occurs on the second day to seventh day
○ average increase of 2mg/dl; not exceeding 12mg/dl
• Pathological Jaundice of Neonates
○ Any of the following features characterizes pathological jaundice:
○ Clinical jaundice appearing in the first 24 hours.
○ Increases in the level of total bilirubin by more than 12 mg/dl
• Therapy is aimed at preventing Kernicterus, which results in permanent neurological damage resulting from the
deposition of bilirubin in the brain cells.
• Causes:
○ Immaturity of the liver
○ Rh or ABO incompatibility
○ Infections
○ Birth trauma
○ Maternal diabetes
○ Medications
 Assessment
○ Jaundice
○ Dark concentrated urine
○ Enlarged liver
○ Poor muscle tone
○ Lethargy
○ Poor sucking reflex

Management
1. Phototherapy
• is use of intense florescent lights to reduce serum bilirubin levels
• The use of blue lights overhead or in blanket –device wrapped around infant
• is use of intense florescent lights to reduce serum bilirubin levels in the newborn
• Injury from treatment, such as: eye damage, dehydration, or sensory deprivation
• Possible complication of phototherapy: eye damage, dehydration, sensory deprivation
• Wallaby blanket-a blanket which, when wrapped around the infant’s torso, delivers effective therapy to
jaundiced babies
• no need to cover the baby’s eyes as all light treatment is delivered through the blanket
2. Exchange blood transfusion via umbilical catheter-for very severe cases
• infants blood – remove = 5 / 10ml at a time

Nursing Interventions
1. Expose as much of the newborn's skin as possible.
2. Cover the genital area, and monitor the genital area for skin irritation or breakdown.
3. Cover the newborn's eyes with eye shields or patches; make sure that eyelids are closed when shields or patches are
applied.
4. Remove the shields or patches at least once per shift (during a feeding time) to inspect the eyes for infection or
irritation and to allow eye contact and bonding with parents.
5. Monitor skin temperature closely.
6. Increase fluids to compensate for water loss.
7. Expect loose green stools and green urine.
8. Monitor the newborn's skin color with the fluorescent light turned off, every 4 to 8 hours.
9. Monitor the skin for bronze baby syndrome- a grayish-brown discoloration of the skin.
10. Reposition newborn every 2 hours.
11. Provide stimulation.
12. After treatment, continue monitoring for signs of hyperbilirubinemia, because rebound elevations are normal after
therapy is discontinued.
13. Turn off phototherapy lights before drawing blood specimen for serum bilirubin levels and avoid allowing blood
specimen to remain uncovered under fluorescent lights (to prevent the breakdown of bilirubin in the blood
specimen).
14. Monitor for the presence of jaundice; assess skin and sclera for jaundice.
15. Examine the newborn's skin color in natural light.
16. Press finger over a bony prominence or tip of the newborn's nose to press out capillary blood from the tissues.
17. Jaundice starts at the head first, spreads to the chest, abdomen, and then the arms and legs, followed by the hands
and feet
18. Keep newborn well hydrated to maintain blood volume.
19. Facilitate early, frequent feeding to hasten passage of meconium and encourage excretion of bilirubin.
20. Report to the physician any signs of jaundice in the first 24 hours of life and any abnormal S&S
21. Prepare for phototherapy, and monitor the newborn closely during the treatment.

MECONIUM ASPIRATION SYNDROME (MAS)

• occurs when infants take meconium into their lungs during or before delivery
• Occurs in term or post-term infants
• During fetal distress there is increases intestinal peristalsis, relaxing the anal sphincter and releasing meconium into the
amniotic fluid.
• Aspiration can occur in utero or with the first breath.
• Meconium can block the airway partially or completely and can irritate the newborn’ airway, causing respiratory distress

Assessment:
1. Respiratory distress is present at birth:
 tachypnea,
 cyanosis,
 retractions,
 nasal flaring,
 grunting,
 crackles, and rhonchi may be present.
 infant's nails, skin, and umbilical cord may be stained a yellow-green color.

CAUSES and RISK FACTORS:

1. Common to post mature
2. Maternal history of diabetes
3. Hypertension
4. Difficult delivery
5. Poor intrauterine growth

Management
1. Suctioning must be done immediately after the head is delivered before the first breath is taken;
2. Vocal cords should be viewed to see if the airway is clear before stimulation and crying
Extracorporeal membrane oxygenation (ECMO)- Cardiopulmonary bypass to support gas exchange allows the lungs to
 rest - help newborn to breath normally - highest life support

Nursing interventions
1. Observing neonates respiratory status closely
2. Ensuring adequate oxygenation
3. Administration of antibiotic therapy
4. Maintain thermoregulation

SEPSIS
• Description: Generalized infection resulting from the presence of bacteria in the blood
• Major common cause is group B beta- hemolytic streptococci
• Contributing factors:
○ Prolonged rupture of membranes
○ Prolonged or difficult labor
○ Maternal infection
○ Cross contamination
○ Aspiration

Assessment findings – often does not have specific sign of illness

○ Poor feeding
○ Irritability
○ Lethargy
○ Pallor
○ Tachypnea
○ Tachycardia
○ Abdominal distention
○ Temperature instability – difficulty keeping temperature within normal range

Diagnosis:
a. Blood, urine, and cerebrospinal fluid cultures
b. Routine CBC, urinalysis, fecalysis
c. Radiographic test

Management
a. Intensive antibiotic therapy
b. IV fluids
c. Respiratory therapy

Nursing interventions- Routine newborn care with special emphasis on the following:
a. Monitor vital signs, assess for periods of apnea or irregular respirations..
b. Administer oxygen as prescribed
c. Provide isolation as necessary- Monitor and limit visitors
d. Handwashing before after handling neonate

SUDDEN INFANT DEATH SYNDROME

• Sudden death of any young child that is unexpected by history and which thorough postmortem examination fails to
demonstrate adequate cause of death
• Usually occurs during sleep
• Diagnosis is made after autopsy
• High incidence in preterm infants, infants with abnormalities in respiration
• Unknown cause : may be related to a brainstem abnormality in the neurological regulation of cardio-respiratory control
• Nursing Role:
a. Care is directed at supporting parents/family
b. Provide a room for the family to be alone
c. Reinforce that death was not their fault
d. Provide appropriate support referrals
e. Explain how parents can receive autopsy results
• Prevention:
a. Infants should be placed in the supine position for sleep.
b. Soft moldable mattresses and bedding, such as pillows or quilts, should not be used for bedding.
c. Stuffed animals should be removed from the crib while the infant is sleeping.
d. Discourage bed sharing (sleeping with an adult).
e. Home apnea monitor to infant with near miss SIDS

CONGENITAL HEART DEFECT

ACYANOTIC TYPE
A. ATRIAL SEPTAL DEFECT
○ Abnormal opening in the septum between left and right atria
○ Usually detected after neonatal period
○ S/S:
 - decrease activity tolerance
 - dyspnea
 + murmur – upper left sternal border Mgt: Surgery – 2 and 4 yrs of age
B. VENTRICULAR SEPTAL DEFECT
○ Opening in the septum between ventricles, causing a left to right shunt
○ Small VSD – asymptomatic
○ Large – hypertrophy and/or failure of right ventricle
 ○ S/S:
 increase respiratory effort
 Frequent respiratory infection
 + murmur – heard best @ lower left sternal border
 Congestion - pulmonary
○ Mgt : Surgery
C. PATENT DUCTUS ARTERIOSUS
○ Connects pulmonary trunk to aorta
○ S/S:
 + murmur – machinery type @ middle to upper left sternal border
 poor feeding
 tiring easily
○ Mgt: Indomethacin
○ Surgery – ligation
D. COARCTATION OF AORTA
○ Narrowing of the aorta
○ Significant decrease in blood flow to abdomen and legs
○ Blood shunted to head and arms
○ S/S:
 BP /pulse - higher in arms than legs
 High pulse pressure in carotid and radial pulses
 Warm upper body
○ Mgt: surgery – angioplasty – repaired of narrowed vessel
E. VALVULAR DEFECTS
a. right side
 tricuspid
 pulmonic valve
b. left side
 mitral
 aortic valve
○ S/S:
 palpitations
 Pain
 Edema
 Weakness, dizziness
○ Mgt: Surgery – valvotomy, valvuloplasty, valve replacement

CYANOTIC TYPE
A. TRANSPOSITION OF GREAT VESSELS
○ Aorta arises from right ventricle, pulmonary artery arises from left ventricle oxygenated blood therefore circulates
through left side of heart to lungs and back to left side
○ unoxygenated blood enters the right atrium from body ,goes back to right ventricle and back to circulation without
being oxygenated
○ S/S:
 Blueness of the skin
 Shortness of breath
 Poor feeding
 Clubbing of the fingers or toes
 peripheral hypoxemia
 severe progressive pulmonary hypertension.
○ Complications:
 Arrythmias
 Heart failure
○ Mgt: Balloon Atrial Septostomy (Rashkind Procedure)
B. TETRALOGY OF FALLOT
○ This condition is characterized by the following four defects:
 an abnormal opening, or ventricular septal defect, that allows blood to pass from the right ventricle to the left
ventricle without going through the lungs
 a narrowing (stenosis) at or just beneath the pulmonary valve that partially blocks the flow of blood from the
right side of the heart to the lungs
 the right ventricle is more muscular than normal
 the aorta lies directly over the ventricular septal defect
○ Tetralogy of Fallot results in cyanosis (bluish color of the skin and mucous membranes due to lack of oxygen).
○ Cyanosis develops within the first few years of life.
○ First presentation may include poor feeding, fussiness, tachypnea, and agitation.
○ Cyanosis occurs and demands surgical repair.
○ Dyspnea on exertion is common.
○ Hypoxic "tet" spells are potentially lethal, unpredictable episodes that occur even in noncyanotic patients with TOF.
These spells can be aborted with relatively simple procedures.
○ Birth weight is low.
○ Growth is retarded.
○ Development and puberty may be delayed.
○ Right ventricular predominance on palpation
○ May have a bulging left hemithorax
○ Systolic thrill at the lower left sternal border
○ Single S2 - Pulmonic valve closure not heard
○ Systolic ejection murmur
○ Cyanosis and clubbing - Variable
○ Squatting position
○ Scoliosis - Common
○ Retinal engorgement
○ Hemoptysis
○ Mgt: Tet Spells
 Knee-chest position: This provides a calming effect, reduces systemic venous return.
 Oxygen therapy
 Morphine sulfate - decrease systemic venous return.
 Surgery: Blalock Taussig Shunt
High Risk Infant
Monday, 31 January 2022 12:54 pm

COMMON HEALTH PROBLEM DURING INFANCY

FAILURE TO THRIVE
• A condition in which a child fails to gain weight and is persistently less than the fifth percentile on standard growth
chart
• Persistent deviation from established growth curve.
• Delay in physical growth and weight gain might lead to cognitive impairment or even death
• 4 principal factors for human growth:
1. Food
2. Rest and activity
3. Adequate secretions of hormones
4. Satisfactory relationship with care giver
• Classified as:
1. Organic (OFTT) - due to pathologic condition such as problem in absorption and hormonal dysfunction
2. Nonorganic (NFTT) – due to psychosocial factor disrupted maternal child relationship
3. Idiopathic(IFTT) - Unexplained by the usual organic and environmental etiologies but usually classified as NFTT
• A thorough history is the best guide to establishing the etiology of the failure to thrive:
○ Poverty is the greatest single risk factor worldwide and in the United States
○ Nutritional deficiency is the fundamental cause
• Assessment findings
○ Poor muscle tone, loss of subcutaneous fats, skin breakdown
○ Rumination – common
○ characteristic; voluntary regurgitation
○ Lethargic- unresponsive
○ Positive delay in growth and development
○ Signs of disturbed maternal – child interaction
○ Diminished or nonexistent crying
○ Radar gaze - wide-eyed gaze and continual scan of environment
• Characteristics of the individual providing care:
1. Difficulty perceiving and assessing the infant’s needs
2. Frustrated and angered at the infant’s dissatisfied response
3. Frequently under stress and in crisis, with emotional, social and financial problems
• All children with failure to thrive need additional calories for catch-up growth :
○ Treatment depends on the cause
○ Medical disorder - specific treatment is given Parent-child relationship - Family counseling
○ Nutritious, high-calorie feedings
• Nursing Interventions
○ Provide consistent caregiver.
○ Provide sufficient nutrients.
 Make feeding a priority intervention.
 Keep an accurate record of intake.
 Weigh daily.
○ Introduce positive feeding environment
 Establish a structured routine
 Hold the young child for feeding
 Maintain eye-to-eye contact
 Maintain a calm, even temperament
 Provide a quiet, non stimulating environment
 Talk to child giving appropriate directions and praise for eating
 Increase stimulation appropriate to the child’s present developmental level.
 Provide the parent an opportunity to talk.
 When necessary, relieve the parent of childrearing responsibilities until able and ready emotionally to
support the child.
 Demonstrate proper infant care by example, not lecturing.
 Supply the parent with emotional support with fostering dependency.
 Promote the parent’s self-respect and confidence by praising achievements with child.

HYDROCEPHALUS
• An imbalance of cerebrospinal fluid (CSF) absorption or production caused by: malformations, tumors, hemorrhage,
infections, or trauma
• Results in head enlargement and increased ICP
• Types:
○ COMMUNICATING- occurs as a result of impaired absorption within the subarachnoid space.
○ NONCOMMUNICATING- blockage in the ventricular system that prevents CSF from entering the subarachnoid
space
• Assessment:
1. Increased head circumference
2. Thin, widely separated bones of the head that produce a cracked pot sound (Macewen's sign) on percussion
3. Anterior fontanel tense, bulging, and non pulsating
4. Dilated scalp veins
 5. Sunsetting eyes
6. Behavior changes, such as irritability and lethargy
7. Headache on awakening
8. Nausea and vomiting
9. Ataxia- lack of coordination of muscle movement
10. Nystagmus- involuntary movement of the eyes
11. Late signs: High, shrill cry and seizures.
• Diagnostic Test: CT scan, MRI, Skull X-ray
○ Transillumination- holding a bright light such as a flashlight or specialized light (Chun gun) against the skull in a
darkened room; a skull filled with fluids rather than solid brain substance
• Management - treatment depends to cause
○ Surgical interventions
 GOAL: Prevent further CSF accumulation by bypassing the blockage and draining the fluid from the
ventricles to a location where it may be reabsorbed.
a. Ventriculoperitoneal shunt - the CSF drains into the peritoneal cavity
b. Atrioventricular shunt - CSF drains into the right atrium of the heart
c. Acetazolamide (Diamox)- promote the excretions of excess fluids
 Preoperative interventions
a. Give small frequent feedings as tolerated until a preoperative NPO status is prescribed.
b. Reposition head frequently and use an egg crate mattress under the head to prevent pressure sores.
c. Prepare the child and family for diagnostic procedures and surgery
 Postoperative interventions
a. Monitor vital signs and neurological signs.
b. Position the child on the unoperated side
c. Observe for signs of increased ICP
d. elevate head 15-30 degrees
e. Monitor for signs of infection
f. Measure head circumference.
g. Provide comfort measures; expected level of functioning
h. Administer medications as prescribed, diuretics, antibiotics, or anticonvulsants.
i. Instructions on parents re: wound care, shunt revision
j. Availability of support groups; community agencies
k. Instruct the parents on how to recognize shunt infection or malfunction
 In an infant- irritability, lethargy, and feeding poorly
 In a toddler- headache and a lack of appetite
 In older children- an alteration in the child's level of consciousness.

SPINA BIFIDA
• A central nervous system defect results from failure of the neural tube to close during embryonic development generally
in the lumbosacral region
• Causes:
○ Actual cause is unknown; multiple factors
○ Genetic – if a sibling has had neural tube defect
○ Environmental factors
○ Medications , viral infection and radiation
• Types:
1. Spina bifida occulta- Posterior vertebral arches fail to close in the lumbosacral area.
 Spinal cord and meninges remains in the normal anatomic position
 Defect may not be visible dimple or a tuff of hair on the spine
 Asymptomatic may have slight neuromuscular deficits
 No treatment if asymptomatic aimed at specific symptoms
2. Spina bifida cystica- Protrusion of the spinal cord and/or its meninges with varying degrees of nervous tissue
involvement.
a. Meningocele
• part of spinal protrudes through opening in the spinal canal
• sac is covered with thin skin no nerve roots involved
• no motor or sensory loss Good prognosis after surgery
b. Myelomeningocele (meningomyelocele)
• with spinal nerves roots in the sac
• have sensory or motor deficit
• below site of the lesion
• 80% have multiple handicaps
• Assessment- Depends on the spinal cord involvement
1. Visible spinal defect
2. Motor/sensory involvement
a. Flaccid paralysis of the legs
b. Altered bladder and bowel function
c. Hip and joint deformities
d. Hydrocephalus
• Diagnostics:
○ Prenatal- ultrasound, amniocentesis
○ Postnatal
 x-ray of spine
 CT scan
 myelogram-uses a special dye and an X-ray (fluoroscopy) to provide a very detailed picture of the spinal cord
 and spinal column
 encephalogram
 urinalysis, BUN, Creatinine clearance
• Management:
1. Surgery- closure of sac within 48 hours, shunt, orthopedic
2. Drug therapy- Antibiotic, Anticholinergic
• Nursing Management:
1. Prevent trauma to the sac
a. cover with a sterile, moist (normal saline), non adherent dressing
b. change the dressing every 2 to 4 hours as prescribed, keep area free from contamination
c. place in a prone position to minimize tension on the sac
d. head is turned to one side for feeding
e. Administer meds
2. Prevent Complication
a. Use aseptic technique to prevent infection.
b. Assess the sac for redness, clear or purulent drainage, abrasions, irritation, and signs of infection.
c. Clean intermittent catheterization
d. Perform neurological assessment
e. Assess for physical impairments such as hip and joint deformities
3. Provide adequate nutrition
4. Provide sensory stimulation
5. Provide emotional support to parents and family
6. Provide discharge teachings
 wound care
 ROM, PT
 signs of complications
 medication regimen
 positioning – feeding ,diaper change

MENINGITIS
• inflammations of meninges of the brain and spinal cord
• Cause by bacteria, viruses, other microorganism
• as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic
infections.
• H Influenzae Meningitis – the most common form; between 6 to 12 months
○ Bacterial meningitis - Hemophilus influenza type B, Streptococcus pneumoniae, or Neisseria meningitidis
○ Viral meningitis is associated with viruses such as mumps, herpesvirus, and enterovirus.
• Assessment
○ Fever, chills, headache,
○ high-pitched cry, irritability
○ Vomiting, Poor feeding or anorexia
○ bulging anterior fontanel in the infant
○ Signs of meningeal irritations
 nuchal rigidity – stiff neck
 Positive Kernig sign- Severe stiffness of the hamstring muscle causes an inability to straighten the leg when
the hip is flexed to 90 degrees.
 Opisthotonos
a. arching of the back
b. head and heels bent backward
c. and body arched forward
 Brudzinski sign - Flexion at the hip in response to forward flexion of the neck
• Interventions
1. Provide isolation and maintain it for at least 24 hours after antibiotics are initiated.
2. Administer antibiotics and antipyretics as prescribed.
3. Perform neurological assessment and monitor for seizures and complications
4. Assess for changes in level of consciousness and irritability.
5. Monitor intake and output.
6. Assess nutritional status.
7. Determine close contacts of the child with meningitis because the contacts will need prophylactic treatment.
8. Meningococcal vaccine is recommended to protect against meningitis.
a. Monitor for signs of infection
b. Measure head circumference.
c. Provide comfort measures; expected level of functioning
d. Administer medications as prescribed, diuretics, antibiotics, or anticonvulsants.
e. Instructions on parents re: wound care, shunt revision
f. Availability of support groups; community agencies
g. Instruct the parents on how to recognize shunt infection or malfunction
□ In an infant- irritability, lethargy, and feeding poorly
□ In a toddler- headache and a lack of appetite
□ In older children- an alteration in the child's level of consciousness.

SEIZURES
• Recurrent sudden changes in consciousness, behavior, sensations and or muscular activities beyond voluntary control
cause by excess neuronal discharge
• Normally the neuron sends out messages in electrical impulses periodically and the firing individual neuron is regulated
 by an inhibitory feedback loop mechanism
• With seizures many more neurons than normal fire in a synchronous fashion in a particular area of the brain; the
energy generated overcomes the inhibitory feedback mechanism

FEBRILE SEIZURES
• Description
○ Common in children between 6mos – 3yrs old
○ Common in 5% of population under 5 years old, familial
○ Nonprogressive, does not generally result in brain damage
○ Commonly associated with high fever – 38.9 to 41.1 Celsius
○ Some appear to have a low seizure threshold and convulse when a fever of 37.8 to 39.8
• Classification:
1. Partial seizure
a. Simple – localized motor activity
□ shaking of arm or leg
□ limited to one side of the body
b. Complex – psychomotor seizure
□ memory loss and staring
□ non purposeful movements
 AURA – sensation that signals an attack
 After – sleep or confuse; unaware of the seizure
2. Generalized
a. Tonic – clonic
□ prodromal
□ AURA
□ tonic
□ post ictal
b. Absence - rarely 20 seconds
□ stares straight, does not fall
 Status Epilepticus
• Contributing factors: seizure disorder
1. Intracranial infection
2. Space occupying lesion
3. CNS defects
• Assessment findings
1. Restlessness/irritability
2. Body stiffens and loss of consciousness
3. Clonic movements – quick, jerking movements of arms, legs, and facial muscle
4. Pupils dilate and roll up
• Diagnostic Test:
○ Blood studies
 to rule out lead poisoning,
 hypoglycemia
 infection
 Electrolytes imbalance
 EEG – to detect abnormal wave
• Treatment:
1. Drug Therapy
a. Diazepam
b. Phenobarbital
c. Dilantin
2. Surgery – for tumor and hematoma
• Interventions
1. Reduce fever with antipyretics.
2. Give prescribed medication
3. Generalized seizure precautions
4. Do not restrain; pad crib rails; do not use tongue blade
5. Observe and record the time of seizure, duration, and body parts involved.
6. Suction and administer oxygen after the seizure as required.
7. Observe the degree of consciousness and behavior after seizure
8. Provide rest after the seizure.

OTITIS MEDIA
• Description
○ Bacterial or viral infection of the middle ear
○ Common in infants and preschoolers
○ Eustachian is shorter, wider, and straighter thereby, allowing nasopharyngeal secretion to enter middle ear more
easily
• Assessment Findings
1. Behavior that would indicate pain
• restless and repeatedly shakes the head
• frequently pulls or tugs at affected ear
2. Irritability, cough, nasal congestion, fever
3. Hearing impairment
4. Purulent discharges
 • Diagnosis
1. Examination of ear with otoscope – reveals bright red bulging eardrum
2. Culture and sensitivity of ear discharges
• Possible Complication
○ permanent hearing loss
○ mastoiditis
• Management
1. Antibiotics, analgesics
2. Myringotomy incision into the tympanic membrane to relieve pressure and drain the fluid with /without tube
• Postoperative Interventions
3. Wear earplugs while bathing, shampooing, and swimming,
4. Diving and submerging under water are not allowed.
5. Child should not blow his or her nose for 7 to 10 days after surgery.
• Interventions
1. Encourage fluid intake.
2. Teach the parents to feed infants in upright position, to prevent reflux.
3. Instruct the child to avoid chewing as much as possible during the acute period because chewing increases pain.
4. Provide local heat and have the child lie with the affected ear down.
5. Instruct the parents in the appropriate procedure to clean drainage from the ear with sterile cotton swabs.
6. Instruct the parents in:
• Administration of analgesics or antipyretics
• Administration of the prescribed antibiotics, emphasizing that the 10- to 14-day period is necessary to
eradicate infective organisms.
• Screening for hearing loss may be necessary
• Administering ear medications.
□ Younger than age 3, pull the lobe down and back.
□ Older than 3 years, pull the pinna up and back.

CLEFT LIP AND CLEFT PALATE

• Description
○ Nonunion of the tissue and bone of the upper lip and hard/soft palate during embryonic development
○ Failure of the maxillary and premaxillary processes to fuse during fetal development
○ Etiology – primarily genetic
 environmental factors
 viral infection
 exposure to radiation
 Folic acid deficiency
 teratogenic factors
• Assessment Findings
1. Facial abnormality
2. Difficulty sucking and swallowing
3. Milk escapes through nose
• Assessment
○ Cleft lip
 can range from a slight notch to a complete separation from the floor of the nose.
○ Cleft palate
 nasal distortion
 midline or bilateral cleft
 variable extension from the uvula and soft and hard palate.
• Associated Problems
1. Feeding problems
2. URTI
3. Ear infection
4. Speech defect, dental malformation
5. Body image
• Management
1. Surgical correction (Rule of Ten)
 Cheiloplasty – Correction of cleft lip
 Palatoplasty – Cleft palate surgery
□ Done before speech development
□ Allow for palatal changes
 Logan bar/steri strips- to take the tension off the sutures
2. Team Approach Therapy – Dentist and orthodontist
 Audiologist
 Speech Therapist
 Pediatrician
• Nursing Intervention (Pre-op Cleft Lip)
1. Feed in upright position’ in small frequent feedings
2. Burp frequently
3. Use large-holed nipples
4. Use rubber-tipped syringe – if unable to suck
5. Gavage feeding as ordered
6. Finish feeding with water
7. Provide emotional support for parents and family
• Nursing Intervention (Post-op Cleft Lip)
 1. Maintain patent airway
2. Assess color; monitor for frequent swallowing
3. Do not place in prone position
4. avoid straining suture lines
5. Use elbow restraints
6. Resume feedings as ordered (Haberman feeder)
7. Provide pain control as ordered
• Nursing Intervention (Pre-op Cleft Palate)
1. Prepare parents to care for child after surgery
2. Instruct concerning feeding methods and positioning
• Nursing Intervention (Post-op Cleft Palate)
1. Suction mucus and saliva gently and do not touch the sutures
2. Incision care
3. Clean suture with sterile cotton swab with half strength hydrogen peroxide followed by saline
4. Apply antibiotic ointment
5. Do not displace Logan bar
6. Do not place in prone position, Place in side lying position
7. Keep spoons, pacifier, straws, away from child’s mouth for 7 to 10 days post op
8. Elbow strain
9. Special feeder – syringe with rubber tubing into side of mouth, Breck feeder

ESOPHAGEAL ATRESIA/TEF
• Description
○ The esophagus terminates before it reaches the stomach, ending in a blind pouch, and/or a fistula is present that
forms an unnatural connection with the trachea.
 Type I/A - lower segments of the esophagus are blind;
 Type II/ B – upper end of esophagus opens into the trachea; blind lower segment
 Type III/ C – upper end blind; lower end connects into trachea
• Clinical Manifestation
1. Excessive amount of secretions constant drooling large secretion from the nose
2. Intermittent/unexplained cyanosis
3. Coughs and chokes
4. Fluids returns through nose and mouth
5. Regurgitation & vomiting
6. Abdominal distention
7. Inability to pass a small catheter through
8. The mouth or nose into the stomach.
• Diagnostic Evaluation
1. X-ray of abdomen and Chest X-ray
2. X-ray with radiopaque catheter
3. Insertion of a catheter
• Management
○ Includes maintenance of :
 a patent airway
 prevention of aspiration pneumonia
 gastric or blind pouch decompression
 supportive therapy
 surgical repair
○ Drug Therapy
 Antibiotics – for respiratory infection
○ Surgery
 Primary repair – esophageal anastomosis
 Gastrostomy - feeding
 Esophagostomy- drain secretions
Pre-operative Interventions
1) The infant may be placed in an incubator or radiant warmer with high humidity (intubation and mechanical
ventilation may be necessary if respiratory distress occurs).
2) Upright position
3) Maintain an NPO status.
4) Regular suctioning
5) Maintain IV fluids or hyperalimentation as prescribed.
6) Observe closely for:
- vital signs; respiratory behavior
- amount of secretions
- abdominal distention
- skin color
Post-operative Interventions
1) Monitor respiratory status.
2) Maintain patent airway; continued use of incubator
3) Suction as needed, change position frequently; avoid hyperextension of neck
4) Maintain IV fluids, antibiotics, and parenteral nutrition as prescribed.
5) Maintain adequate nutrition – gastrostomy
6) Monitor strict intake and output.
7) Monitor daily weight.
8) Inspect the surgical site for signs and symptoms of infection.
 9) Monitor for anastomotic leaks as evidenced by purulent drainage from the chest tube, increased temperature,
and increased white blood cell count.
10) Observe for signs of stricture at the anastomosis site (e.g., poor/refusal to feed, dysphagia, drooling,
regurgitated undigested food).

HYPERTROPHIC PYLORIC STENOSIS

• Description
○ Congenital hypertrophy of the circular muscles of the pylorus in the stomach; the muscle becomes progressively
thickened and elongated with narrowing of the pyloric canal.
○ The stenosis usually develops in the first few weeks of life, causing projectile vomiting, dehydration, metabolic
alkalosis, and failure to thrive.
• Assessment
1. Vomiting that progresses from mild regurgitation to forceful and projectile vomiting
2. Vomitus contains gastric contents such as milk or formula, may contain mucus, may be bloodùtinged, and does not
usually contain bile.
3. Exhibits hunger and irritability.
4. Peristaltic waves are visible from left to right across the epigastrium during or immediately following a feeding.
5. Olive-shaped mass is in the epigastrium just right of the umbilicus.
6. On barium enema, string sign can be seen
7. Dehydration and malnutrition can occur.
8. Electrolyte imbalances can occur.
• Management
○ Fredet-Ramstedt Pyloromyotomy
 plits the hypertrophic pyloric muscle down to the submucous, allowing pylorus to expand so that food may
pass
• Nursing Interventions
1. Monitor vital signs.
2. Monitor strict intake and output.
3. Obtain daily weights.
4. Monitor for signs of dehydration and electrolyte imbalances.
5. Feed by gavage
 Thickened feeding
 Slowly upright
 Burp frequently
6. Prepare the child and parents for surgery if prescribed.
 Pyloromyotomy
□ Pre op
▪ Monitor hydration status
▪ Correct F/E imbalances
▪ NPO
▪ Monitor character of stool
▪ NGT
□ Post operative
▪ Monitor intake and output
▪ Start SFF
▪ Feed slowly, upright
▪ Monitor for abdominal distention
▪ Monitor for signs of infection
▪ Instruct parents on wound care and feeding

HIRSCHSPRUNG’S DISEASE (AGANGLIONIC MEGACOLON)

• Description
○ Absence of ganglion cells in a portion of the large intestine
○ Is a parasympathetic nerve cells that regulates peristalsis in the intestine
○ The absence of the ganglion cells would result to absence peristalsis and affected colon becomes dilated and filled
with feces and gas
○ The disease may be a familial congenital defect or may be associated with other anomalies, such as Down
syndrome and genitourinary abnormalities.

• Assessment Findings
○ Newborn
 Failure to pass meconium stool
 Refusal to suck
 Abdominal distention
 Bile-stained vomitus
○ Children
  Failure to gain weight and delayed growth
 Abdominal distention
 Vomiting
 Constipation alternating with diarrhea
 Ribbon-like and foul-smelling stools
• Diagnostic Studies – Rectal biopsy
• Management
○ Surgery
 Temporary colostomy
□ A portion of the large intestine is brought through the abdominal wall to carry stool out of the body
 Bowel repair
□ Dissection and removal of the affected section with anastomosis of intestine
□ Abdominal – perineal pull through
• Nursing Management
1. Administer enema as ordered with Isotonic solution only
2. Do not treat loose stools – child is constipated
3. Administer TPN
4. Instruct parents on colostomy care, correct diet

INTUSSUSCEPTION
• Description
○ Invagination or telescoping of a portion of the small intestine into a more distal segment of the intestine
○ 3 times more likely in boys than girls and the common cause of intestinal obstruction in childhood
○ Cause is unknown
• Factors
1. Hyperperistalsis and unusual mobility of cecum and ileum
2. Lesion such as polyp and tumor
○ It is considered a surgical abdominal emergency in children
○ Mechanical Bowel Obstruction Occurs intestinal walls press against each other causing inflammation, edema and
decreased blood flow.
○ May progress to necrosis, perforation and peritonitis.
○ Gangrene of the bowel
• Clinical Presentation
1. Sudden onset of abdominal pain (in a healthy baby)
2. Infant cries out sharply and draws knees up to abdomen
3. Vomiting occurs and increases overtime (Bile stained vomitus)
4. Currant jelly stool
5. Signs of shock
6. (+) for Occult blood in stools
7. Sausage-shaped mass in RLQ
• Diagnosis
○ Often based on history and physical examination alone
1. Barium enema
 Is definitive (in 75% of cases)
 It is therapeutic and curative in most cases with less than 24-hour duration
2. Digital rectal exam
 reveals mucous, blood
• Immediate Treatment
○ IV fluids
○ NPO status
○ Diagnostic barium enema
○ Surgery
 manual reduction of invagination
 resection with anastomosis
 possible colostomy (gangrenous)
• Nursing Management
1. Provide routine pre- and post-operative care for abdominal surgery
2. Monitor fluid and electrolyte status
3. Maintain nutrition and hydration
4. Resume feedings 24 hours post operative

IMPERFORATE ANUS
• Description
○ Congenital malformation in which there is no anal opening or there is stricture of the anus
○ Etiology is unknown
○ An arrest in embryonic development on 7th to 8th week of intrauterine lif
○ A membrane remains and blocks the union between the rectum and the anus
○ Blind rectal pouch with normal anus
• Clinical Presentation
1. No stool passage with in 24 hours after birth
2. Meconium stool from other orifice
3. Only a dimple indicates the site of the anus
4. Inability to insert thermometer
• Diagnosis
○ Digital rectal exam
 ○ Ultrasound
○ Abdominal X-rays
• Management
1. If suspected, do not take rectal temperature
2. Pre-operative care
 Monitor for the presence of stool in the urine and vagina (indicates a fistula) and report immediately.
 Administer IV fluids as prescribed
 Prepare the child and parents for the surgical procedures, including the potential for colostomy.
3. post-operative Care
 Expose perineum to air
 Check bowel sounds
 NGT for gastric decompression
 Change position frequently
 Oral feeding started gradually as soon as peristalsis function returned
 Instruct the parents to use only a water-soluble lubricant and to insert the dilator no more than 1 to 2cm

DISPLACED URETHRAL OPENINGS

• HYPOSPADIAS
○ Males: urethra opens on the lower surface of the penis
○ Females: urethra opens into the vagina
• EPISPADIAS
○ Only in males
○ Urethra opens on the dorsal surface of the penis
○ Congenital absence of the upper wall of the urethra
• Procreation may be interfered with in severe cases
• Increased risk of urinary tract infection
• MANAGEMENT
1. Circumcision is delayed until surgical repair
2. Surgical repair
 Meatotomy

DOWN SYNDROME
• Description
○ Chromosomal disorder caused by the presence of all or part of an extra 21st chromosome.
○ It is named after John Langdon Down, the British doctor who described the syndrome in 1866.
○ The disorder was identified as a chromosome 21 trisomy
• Assessment Findings
1. Small head, flat facial profile
2. Low-set ears
3. Simian creases
4. 40% congenital heart defects
5. With moderate retardation
6. Wide space between 1st – 2nd toes
7. Lax muscle tone
• Management
1. Prevent respiratory infections
 Clearing the nose
 Cool mist vaporizer
 Chest physiotherapy
 Handwashing and avoiding exposure to infection.
2. When feeding infants and young children, use a small, straight-handled spoon to push food to the side and back of
the mouth.
3. Encourage fluids and foods rich in fiber.
4. Constipation results from decreased muscle tone, which affects gastric motility.
5. Provide good skin care because the skin is dry and prone to infection.
6. Family education – counseling
7. developmental progress

AUTISM
• Description
○ Severe mental disorder beginning in infancy or toddlerhood
○ Pervasive developmental disorder
○ Disorder apparent to the parents before the child is 3 years old
• Characterized by
○ Severe deficit in language,
○ perceptual and motor development
○ Defective reality testing
○ Inability to function in social setting
• The cause is unknown and the prognosis may be poor.
• Possible causes
1. Unsatisfactory mother-child relationship
2. CNS abnormalities
• Diagnosis is established based on symptoms and the use of specialized autism assessment tools
• Categories
 1. Inability to relate with others
2. Inability to communicate
3. Obvious limited activities/interest
• Clinical presentation
1. Infant not responsive to cuddling
2. No eye contact or facial responsiveness
3. Impaired/no verbal communication
4. Echolalia
5. Inability to tolerate change
6. Fascination with movement
7. Labile moods
• Assessment
1. Bizzare responses to the environment
 Intense reaction to minor changes
 Attachment to objects
 Intensely preoccupied to moving object
2. Self-absorbed and unable to relate to others.
3. Repetitive hand movement, rocking, and rhythmic body movement
4. Hitting, head banging, and biting
5. Music often holds a special interest for them
6. No delusions, hallucinations, or incoherence
7. Excellent long-term memory
8. May play happily alone for hours but have temper tantrums if interrupted.
• Nursing intervention
1. Provide parents /family with support and information about the disorder
2. Assist child with ADL
3. Promote reality testing
4. Encourage the child to develop relationship with another person
5. Maintain regular schedule of activities
6. Provide constant routine for child
7. Protect from self injury
8. Provide safe environment
9. Provide seizure precaution

ATTENTION DEFICIT HYPERACTIVITY DISORDER

• Description
○ Developmental disorder characterized by inappropriate degrees of inattention, overactivity, and impulsivity
○ One of the most common reasons for referral of children to mental health services
○ Childhood problems include lowered intellectual development, some minor physical abnormalities, sleeping
disturbances, behavioral or emotional disorders, and difficulty in social relationships.
• Diagnosis
○ Established on:
 parent and teachers reports
 psychological assessments
○ Diagnosable by 36 months
○ 3 major characteristics revealed before 7 years of age
• Assessment
1. Fidgets with hands or feet or squirms in the seat
2. Easily distracted with external or internal stimuli
3. Difficulty with following through on instructions
4. Poor attention span
5. Shifting from one uncompleted activity to another
6. Talking excessively
7. Interrupting or intruding on others
8. Engaging in physically dangerous activities without considering the possible consequences
• Therapeutic Management
○ Environment
 construction of stable environment
 special instruction free from distractions
 fair but firm and set consistent limits
○ Medications
 controls excessive activity
 lengthening the attention span
 decreasing the distractibility
• Interventions
1. Provide environmental and physical safety measures.
2. Encourage support groups for parents.
3. Administer prescribed medication; some commonly prescribed medications that include:
 methylphenidate hydrochloride (Ritalin),
 pemoline (Cylert), and
 dextroamphetamine sulfate (Dexedrine).
4. Inform the child and parents that positive effects of the medication may be seen within 1 to 2 weeks