NCM 109- HIGH RISK PEDIATRIC NURSING

LECTURE NO. 1

DAREN G. LINATOC, RN, RM, LPT, MAN, MAEd

Health Problems of Newborns/ High Risks Newborns

I. Birth Injuries
II. Cranial Deformities
III. Common Problems in the Newborn

I. BIRTH INJURIES- Several factors predispose an infant to birth injuries. Maternal

factors include uterine dysfunction that leads to prolonged or precipitous labor,
preterm or postterm labor, and cephalopelvic disproportion. Injury may result from
dystocia caused by fetal macrosomia, multifetal gestation, abnormal or difficult
presentation (not caused by maternal uterine or pelvic conditions), and congenital
anomalies. Intrapartum events that can result in scalp injury include the use of
intrapartum monitoring of fetal heart rate and collection of fetal scalp blood for acid–
base assessment. Obstetric birth techniques can cause injury. Forceps birth, vacuum
extraction, version and extraction, and cesarean birth are potential contributory
factors. Often more than one factor is present, and multiple predisposing factors may
be related to a single maternal condition.

I.1. SOFT TISSUE INJURY- Various types of soft tissue injury may be sustained
during the process of birth, primarily in the form of bruises or abrasions secondary to
dystocia. Soft tissue injury usually occurs when there is some degree of disproportion
between the presenting part and the maternal pelvis (cephalopelvic disproportion). The
use of forceps to facilitate a difficult vertex delivery may produce bruising or abrasion
on the sides of the neonate's face. Petechiae or ecchymoses may be observed on the
presenting part after a breech or brow delivery. After a difficult or precipitous delivery,
the sudden release of pressure on the head can produce scleral hemorrhages or
generalized petechiae over the face and head. Petechiae and ecchymoses may also
appear on the head, neck, and face of an infant born with a nuchal cord, giving the
infant's face a cyanotic appearance. A well-defined circle of petechiae and ecchymoses
or abrasions may also be seen on the occipital region of the newborn's head when a
vacuum suction cup is applied during delivery. Rarely, lacerations occur during
cesarean section. These traumatic lesions generally fade spontaneously within a few
days without treatment. However, petechiae may be a manifestation of an underlying
bleeding disorder or a systemic illness (such as an infection) and should be further
evaluated as to their origin. Nursing care is primarily directed toward assessing the
injury and providing an explanation and reassurance to the parents.

I.2. HEAD TRAUMA- Trauma to the head and scalp that occurs during the birth
process is usually benign but occasionally results in more serious injury. The injuries
that produce serious trauma, such as intracranial hemorrhage and subdural
hematoma, are discussed in relation to neurologic disorders in the newborn. Skull
fractures are discussed in association with other fractures sustained during the birth
process. The three most common types of extracranial hemorrhagic injury are caput
succedaneum, cephalhematoma, and subgaleal hemorrhage.
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I.2.a. CAPUT SUCCEDANEUM- The most commonly observed scalp lesion is caput
succedaneum, a vaguely outlined area of edematous tissue situated over the portion
of the scalp that presents in a vertex delivery. The swelling consists of serum, blood,
or both accumulated in the tissues above the bone, and it often extends beyond the
bone margins. The swelling may be associated with overlying petechiae or ecchymoses.
No specific treatment is needed, and the swelling subsides within a few days. Careful
observation for signs of infection is needed if the skin over the caput is abraded or
broken down.
I.2.b. CEPHALHEMATOMA- Infrequently, a cephalhematoma is formed when blood
vessels rupture during labor or delivery producing bleeding into the area between the
bone and its periosteum. The injury occurs most often with primiparous delivery and
is more likely with forceps delivery and vacuum extraction. Unlike caput
succedaneum, the boundaries of the cephalhematoma are sharply demarcated and do
not extend beyond the limits of the bone (suture lines). The cephalhematoma may
involve one or both parietal bones. The occipital bones are less commonly affected, and
the frontal bones are rarely affected. The swelling is usually minimal or absent at birth
and increases in size on the second or third day. Blood loss is usually not significant.
No treatment is indicated for uncomplicated cephalhematoma. Most lesions are
absorbed within 2 weeks to 3 months. Lesions that result in severe blood loss to the
area or that involve an underlying fracture require further evaluation.
Hyperbilirubinemia may result during resolution of the hematoma. A local infection
can develop and is suspected when a sudden increase in swelling occurs. Parents
should be counseled that, in some cases, a small area of calcification may develop and
persist.

I.2.c. SUBGALEAL HEMORRHAGE- Subgaleal hemorrhage is bleeding into the

subgaleal compartment. The subgaleal compartment is a potential space that contains
loosely arranged connective tissue; it is located beneath the galea aponeurosis, the
tendinous sheath that connects the frontal and occipital muscles and forms the inner
surface of the scalp. The injury occurs as a result of forces that compress and then
drag the head through the pelvic outlet. Instrumented delivery, particularly vacuum
extraction and forceps delivery, increases the risk of subgaleal hemorrhage. Additional
risk factors include prolonged second stage of labor, prolonged rupture of membranes,
fetal distress, failed vacuum extraction, and maternal primiparity. The bleeding
extends beyond bone, often posteriorly into the neck, and continues after birth with
the potential for serious complications, such as anemia or hypovolemic shock.
I.3. FRACTURES- The clavicle, or collarbone, is the bone most frequently fractured
during the birth process. Clavicular fracture is more common with shoulder dystocia
or a difficult vertex or breech delivery of infants who are large for gestational age.
Crepitus (the coarse crackling sensation produced by the rubbing together of fractured
bone fragments) may be felt or heard on examination. A palpable, spongy mass,
representing localized edema and hematoma, may also be a sign of a fractured clavicle.
The infant may be reluctant to move the arm on the affected side, and the Moro reflex
may be asymmetric. Radiographs usually reveal a complete fracture with overriding of
the fragments. Fractures of long bones, such as the femur or the humerus, are
sometimes difficult to detect by radiographic examination in infants. Although

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osteogenesis imperfecta is a rare finding, a newborn infant with a fracture should be
assessed for other evidence of this congenital disorder.
I.4. PARALYSIS

I.4.a. FACIAL PARALYSIS- Pressure on the facial nerve (cranial nerve VII) during
delivery may result in injury to that nerve. The primary clinical manifestations are loss
of movement on the affected side, such as an inability to completely close the eye,
drooping of the corner of the mouth, and absence of wrinkling of the forehead and
nasolabial fold. The paralysis is most noticeable when the infant cries. The mouth is
drawn to the unaffected side, the wrinkles are deeper on the normal side, and the eye
on the involved side remains open. No medical intervention is necessary. The paralysis
usually disappears spontaneously in a few days but may take as long as several
months.

I.4.b. BRACHIAL PALSY- Plexus injury results from forces that alter the normal
position and relationship of the arm, shoulder, and neck. Erb palsy (Erb-Duchenne
paralysis) is caused by damage to the upper plexus. and usually results from
stretching or pulling away of the shoulder from the head, as might occur with shoulder
dystocia or with a difficult vertex or breech delivery. Other identified risk factors
include an infant with birth weight of more than 4000 g (8.8 pounds), multiparous
pregnancy, a vacuum-assisted extraction, prolonged labor, and a previous history of
brachial plexus injury. The less common lower plexus palsy, or Klumpke palsy,
results from severe stretching of the upper extremity while the trunk is relatively less
mobile.

The clinical manifestations of Erb palsy are related to the paralysis of the affected
extremity and muscles. The arm hangs limp alongside the body while the shoulder and
arm are adducted and internally rotated. The elbow is extended, and the forearm is
pronated, with the wrist and fingers flexed; a grasp reflex may be present because
finger and wrist movement remain normal. In lower plexus palsy, the muscles of the
hand are paralyzed, with consequent wrist drop and relaxed fingers. In a third and
more severe form of brachial palsy, the entire arm is paralyzed and hangs limp and
motionless at the side. The Moro reflex is absent on the affected side for all forms of
brachial palsy.

Treatment of the affected arm is aimed at preventing contractures of the paralyzed

muscles and maintaining correct placement of the humeral head within the glenoid
fossa of the scapula. Complete recovery from stretched nerves usually takes 3 to 6
months. Full recovery is expected in 88% to 92% of infants. However, avulsion of the
nerves (complete disconnection of the ganglia from the spinal cord that involves both
anterior and posterior roots) results in permanent damage. For injuries that do not
improve spontaneously by 3 to 6 months, surgical intervention may be needed to
relieve pressure on the nerves or to repair the nerves with grafting. In some cases,
injection of botulinum toxin A into the pectoralis major muscle may be effective in
reducing muscle contractures after birth-related brachial plexus injuries.
I.4.c. PHRENIC NERVE PARALYSIS- Phrenic nerve paralysis results in
diaphragmatic paralysis as demonstrated by ultrasonography, which shows paradoxic
chest movement and an elevated diaphragm. Initially, radiography may not

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demonstrate an elevated diaphragm if the neonate is receiving positive-pressure
ventilation. The injury sometimes occurs in conjunction with brachial palsy.
Respiratory distress is the most common and important sign of injury. Because injury
to the phrenic nerve is usually unilateral, the lung on the affected side does not
expand, and respiratory efforts are ineffectual. Breathing is primarily thoracic, and
cyanosis, tachypnea, or complete respiratory failure may be seen. Pneumonia and
atelectasis on the affected side may also occur.

II. CRANIAL DEFORMITIES

In a normal newborn, the cranial sutures are separated by membranous seams several
millimeters wide. Up to 2 days after birth, the cranial bones are highly mobile, which
allows them to mold and slide over one another, adjusting the circumference of the
head to accommodate to the changing shape and character of the birth canal. The
principal sutures in the infant's skull are the sagittal, coronal, and lambdoidal sutures,
and the major soft areas at the juncture of these sutures are the anterior and posterior
fontanels. After birth, growth of the skull bones occurs in a direction perpendicular to
the line of the suture, and normal closure occurs in a regular and predictable order.
Although there are wide variations in the age at which closure takes place in individual
children, normally all sutures and fontanels are ossified by the following ages:

Eight weeks: Posterior fontanel closed

Six months: Fibrous union of suture lines and interlocking of serrated edges

Eighteen months: Anterior fontanel closed

After 12 years: Sutures unable to be separated by increased ICP

Solid union of all sutures is not completed until late childhood. Craniostenosis, closure
of a suture before the expected time, inhibits the perpendicular growth. Because
normal increase in brain volume requires expansion, the skull is forced to grow in a
direction parallel to the fused suture. This alteration in skull growth always produces
a distortion of the head shape when the underlying brain growth is normal. A small
head with closed and normal shape is a result of deficient brain growth; the suture
closure is secondary to this brain growth failure. Failure of brain growth is not
secondary to suture closure.

Various types of cranial deformities are encountered in early infancy. These include an
enlarged head with frontal protrusion (bossing; characteristic of hydrocephalus),
parietal bossing that is seen in chronic subdural hematoma, a small head, and a
variety of skull deformities. Some occur during prenatal development; in others, head
circumference is usually within normal limits at birth, and the deviation from normal
development becomes apparent with advancing age.

III. COMMON PROBLEMS IN THE NEWBORN

III.1. ERYTHEMA TOXICUM NEONATORUM- Erythema toxicum neonatorum, also

known as flea-bite dermatitis or newborn rash, is a benign, self-limiting eruption of
unknown cause that usually appears within the first 2 days of life. The lesions are

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firm, 1- to 3-mm, pale yellow or white papules or pustules on an erythematous base;
they resemble flea bites. The rash appears most commonly on the face, proximal
extremities, trunk, and buttocks, but it may be located anywhere on the body except
the palms and soles. The rash is more obvious during crying episodes. There are no
systemic manifestations, and successive crops of lesions heal without pigmentation
changes. The rash usually lasts about 5 to 7 days. The etiology is unknown. However,
a smear of the pustule will show numerous eosinophils and a relative absence of
neutrophils. When the diagnosis is questionable, bacterial, fungal, or viral cultures
should be obtained. Although no treatment is necessary, parents are usually
concerned about the rash and need to be reassured of its benign and transient nature.

III.2. Candidiasis- Candidiasis, also known as moniliasis, is not uncommon in

newborns. Candida albicans, the usual organism responsible, may cause disease in
any organ system. It is a yeastlike fungus (it produces yeast cells and spores) that can
be acquired from a maternal vaginal infection during delivery; from person-to-person
transmission (especially from poor hand-washing technique); or from contaminated
hands, bottles, nipples, or other articles. Mucocutaneous, cutaneous, and
disseminated candidal infections are all observed in this age group. Candidiasis is
usually a benign disorder in neonates, often confined to the oral and diaper regions.
In extremely preterm infants, there is an increased risk of serious systemic infections
caused by Candida. Diaper dermatitis caused by Candida organisms manifests as a
moist, erythematous eruption with small white or yellow pebbly pustules. Small areas
of skin erosion may also be seen.

Oral candidiasis (thrush) is characterized by white, adherent patches on the tongue,

palate, and inner aspects of the cheeks. It is often difficult to distinguish from
coagulated milk. The infant may refuse to suck because of pain in the mouth. This
condition tends to be acute in newborns and chronic in infants and young children.
Thrush appears when the oral flora is altered as a result of antibiotic therapy or poor
hand washing by the infant's caregiver. Although the disorder is usually self-limiting,
spontaneous resolution may take as long as 2 months, during which time lesions may
spread to the larynx, trachea, bronchi, and lungs and along the gastrointestinal tract.
The disease is treated with good hygiene, application of a fungicide, and correction of
any underlying disturbance. The source of infection should be treated to prevent
reinfection. Topical application of 1 ml nystatin (Mycostatin) over the surfaces of the
oral cavity four times a day, or every 6 hours, is usually sufficient to prevent spread of
the disease or prolongation of its course. Several other drugs may be used, including
amphotericin B (Fungizone), clotrimazole (Lotrimin, Mycelex), fluconazole (Diflucan),
or miconazole (Monistat, Micatin) given intravenously, orally, or topically. To prevent
relapse, therapy should be continued for at least 2 days after the lesions disappear.
Gentian violet solution may be used in addition to one of the antifungal drugs in
chronic cases of oral thrush; however, the former does not treat gastrointestinal
Candida infection.
Oral candidiasis can be distinguished from coagulated milk when attempts to remove
the patches with a tongue blade are unsuccessful. The primary caregiver may also
report that the infant does not nurse well or bottle feed as previously.
III.3. HERPES SIMPLEX VIRUS

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Neonatal herpes is one of the most serious viral infections in newborns, with a
mortality rate of up to 60% in infants with disseminated disease. Approximately 86%
to 90% of herpes simplex transmission occurs during passage through the birth canal.

Neonatal herpes manifests in one of three ways: (1) with skin, eye, and mouth (SEM)
involvement; (2) as localized central nervous system (CNS) disease; or (3) as
disseminated disease involving multiple organs.

III.4. BIRTHMARKS

Discolorations of the skin are common findings in newborn infants. Most, such as
mongolian spots or telangiectatic nevi, involve no therapy other than reassurance to
parents of the benign nature of these discolorations.

Darker or more extensive lesions demand further scrutiny, and excision of the lesion
is recommended when feasible. Such lesions include a reddish brown solitary nodule
that appears on the face or upper arm and usually represents a spindle and epithelioid
cell nevus (juvenile melanoma); a giant pigmented nevus (or bathing trunk nevus),
a dark brown to black, irregular plaque that is at risk of transformation to malignant
melanoma; and the dark brown or black macules that become more numerous with
age (junctional or compound nevi).
Vascular birthmarks may be divided into the following categories: vascular
malformations, capillary hemangiomas, and mixed hemangiomas.

III.4.a. Vascular stains (malformations) are permanent lesions that are present at
birth and are initially flat and erythematous. Any vascular structure, capillary, vein,
artery, or lymphatic may be involved. The two most common vascular stains are the
transient macular stain (stork bite, salmon patch, or angel kiss) and the port-wine stain,
or nevus flammeus. The port-wine lesions are pink, red, or, rarely, purple stains of the
skin that thicken, darken, and proportionately enlarge as the child grows.

Port-wine stains may also be associated with structural malformations, such as

glaucoma or leptomeningeal angiomatosis (tumor of blood or lymph vessels in the pia-
arachnoid) (Sturge- Weber syndrome) or bony or muscular overgrowth (Klippel-
Trenaunay-Weber syndrome). Children with port-wine stains on the eyelids, forehead,
or cheeks should be monitored for these syndromes with periodic ophthalmologic
examination, neurologic imaging, and measurement of extremities.

The treatment of choice for port-wine stains is the use of the flashlamp-pumped
pulsed-dye laser. A series of treatments is usually needed. The treatments can
significantly lighten or completely clear the lesions with almost no scarring or pigment
change.

III.4.b. Capillary hemangiomas, sometimes referred to as strawberry hemangiomas,

are benign cutaneous tumors that involve only capillaries. These hemangiomas are
bright red, rubbery nodules with a rough surface and a well-defined margin.
Strawberry hemangiomas may not be apparent at birth but may appear within a few
weeks and enlarge considerably during the first year of life and then begin to involute
spontaneously. It may take 5 to 12 years for complete resolution, and a significant
number of patients may be left with residual findings, such as telangiectasia,

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redundant fatty tissue, or skin atrophy. Topical or systemic propranolol may be used
in some cases to shrink the lesions. Cavernous venous hemangiomas involve deeper
vessels in the dermis and have a bluish red color and poorly defined margins. These
latter forms may be associated with the trapping of platelets (Kasabach-Merritt
syndrome) and subsequent thrombocytopenia.
Hemangiomas may also occur as part of the PHACE syndrome:

Posterior fossa brain malformation

Hemangiomas (segmental cervicofacial)

Arterial anomalies

Cardiac defects, including coarctation of the aorta

Eye anomalies
Although most hemangiomas require no treatment because of their high rate of
spontaneous involution, some vision and airway obstruction may necessitate therapy.
Systemic propranolol or prednisone may deter further growth.